Citation

Cirulis MM, Callahan SJ, Aberegg SK. JAMA Netw. Open 2020; 3(4): e202238.

Affiliation

Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City.

Copyright

(Copyright © 2020, American Medical Association)

DOI

10.1001/jamanetworkopen.2020.2238

PMID

32250430

Abstract

In JAMA Network Open, Wing et al1 report an intriguing and insightful analysis of state-level incidences of electronic cigarette (e-cigarette)– or vaping–associated lung injury (EVALI), determined from case rates from the Centers for Disease Control and Prevention and Surveillance, Epidemiology, and End Results estimates of state populations. They found that the incidence of EVALI is lower in states that have legalized recreational marijuana and its active ingredient, tetrahydrocannabinol (THC), compared with states where it remains illegal or available only for medicinal uses. This finding withstood adjustment for variation in vaping rates among states. The cross-sectional nature of the analysis and inherent limitations of the available data mean that the ecological fallacy and other sources of confounding may be at play. In part because of its preliminary nature, interesting questions arise from the analysis, answers to which are likely to ultimately be found at the intersection of sociology, public health, and the law. It is illuminating to examine some of these questions through a wide historical lens.

One hundred years ago, on January 17, 1920, the Eighteenth Amendment of the US Constitution went into effect, prohibiting the manufacture, sale, or transport of intoxicating liquors. Moral and social sentiments, rather than a concern for public health per se, were the impetus for the amendment. Nonetheless, the desired but imperfectly realized result of Prohibition—curtailment of alcohol consumption—brought welcome salutary effects, some recognized only in retrospect. Rates of liver cirrhosis,2 psychiatric admissions for alcoholic psychosis,3 and infant mortality4 declined, as did arrests for drunkenness and related offenses.3 Not all secondary effects were positive, however. Bootlegging was rampant and criminal syndicates proliferated, fueling a wave of organized crime. Bootleggers fortified their distillates with methanol to increase apparent potency, causing blindness and death in unwary consumers.5 They also procured industrial ethanol, exempted from Prohibition and mass produced cheaply, as raw material for alcoholic beverages. In response, at the behest of the US government, industrial ethanol stocks were intentionally adulterated with methanol, benzene, and other poisonous substances to deter their consumption. The resulting concoctions, known as denatured alcohol, were responsible for thousands of deaths during the 14 years that Prohibition was in effect.5 The history of Prohibition thus serves as a cautionary tale about unintended and unforeseen consequences of legislation regulating substances that affect public health.

Nearly 100 years later, in 2012, Colorado became the first of several states to enact legislation serving as a de facto override of a federal ban on marijuana that has been in effect since shortly after the repeal of Prohibition. These laws form the basis of the analysis reported by Wing ...

Language: en