“The four most beautiful words in our common language: I told you so.”—Gore Vidal (1925-2012)

Editor-In-Chief, Chester “Trip” Buckenmaier III, MD, COL (ret.), MC, USA

I wrote an editorial in U.S. Medicine on June 10, 2018, entitled “If you tell a big enough lie and tell it frequently enough, it will be believed.” This was a quote from one of the most infamous villains of the 20th century, Adolf Hitler. The hate, death and evil that this individual inflicted upon the world are of such magnitude that I was somewhat sheepish about using the quote in this forum. Readers of this column for any length of time are aware that I try to walk a fine line to express my opinions in a socially and politically appropriate way. Some might even suggest I have tripped over that notional “line” but, in my defense, if I have been crass or uncouth in my oration, it has been with the best intentions to better the care of our servicemembers.

The topic of the editorial where I invoked Hitler dealt with the uncomfortable emergence of the vaping phenomenon that has been penetrating deep into the country’s school-age population as a modern method for using the highly addictive drug nicotine. According to the national Centers for Disease Control and Prevention, a single JUUL pod (the most prolific manufacturer of the liquid packs used in electronic vaping devices) contains as much nicotine as a pack of 20 regular cigarettes. Juul, the Silicon Valley startup that services three-quarters of the vaping market, aggressively marketed their products to youth, according to a Stanford University research study into the companies selling ads. Ads featured young people in exciting situations using Juul products, and Juul pod flavors were explicitly designed so appeal a younger population.

It appears the campaign has been thriving, since cigarette smoking among young people continues to decline, while vaping has increased exponentially. Unlike regular cigarettes that have been exhaustively studied—and the risks extensively documented—the impact of e-cigarettes and vaping on human physiology is mostly unknown. Notwithstanding the paucity of information regarding vaping health risks, many manufacturers of these products, to include Juul, have suggested vaping is a “safer” alternative to cigarette smoking. Further complicating the issue is the emergence of other substances, most notably tetrahydrocannabinol, the principal psychoactive molecule in cannabis, that are being vaped.

In my original editorial, I asked the following rhetorical questions: “What consequences will arise for the next generation from the marketing tall tales of the vaping industry? The power of lies to negatively impact society has been a reverberating theme throughout human history. For this reason, we cannot passively accept claims of safety from the e-cigarette industry, particularly since these claims appear to be directed at the most vulnerable segment of our society, our impressionable youth.”

Horrifyingly, this question has been answered in the past few weeks, as a sixth young person died from lung disease linked to vaping, and many others are being treated for severe respiratory illness. While the CDC has yet to determine a clear cause or definitive link to explain this deadly respiratory illness, all these young people had vaping use in common. Recently the American Lung Association warned that “e-cigarettes are not safe” and can cause irreversible lung damage and disease. The American Medical Association is urging the public to avoid e-cigarettes until more is understood regarding the recent outbreak of lung disease linked to vaping. Dr. Patrice Harris, the current AMA president, further stated, “We must not stand by while e-cigarettes continue to go unregulated. We urge the U.S. Food and Drug Administration (FDA) to speed up the regulation of e-cigarettes and remove all unregulated products from the market.”1 I could not agree more.

As federal medicine providers, we need to ensure this message is being expressed to our patients, especially our younger patients. Nicotine—in any form—is an extremely addictive and dangerous substance. Smoking anything is not consistent with a healthy lifestyle. Federal providers should never miss an opportunity to explain and expound upon this message. I take no pride in being prescient on the issue of vaping. Sadly, I must disagree with Gore Vidal regarding the pleasure of being correct, for, in this case, it truly sucks to be right.

1https://www.cnn.com/2019/09/10/health/vaping-outbreak-2019-explainer/index.html. Accessed September 13th, 2019.