Iowa may soon join 13 other states that prohibit vaping and the use of e-cigarettes in public.

Iowa’s Smokefree Air Act, enacted in 2008, prohibits smoking in almost all public places — including offices, restaurants, bars and outdoor entertainment venues. Under new legislation proposed by the Iowa Department of Public Health, the law would be expanded to apply those same prohibitions to vaping and the use of e-cigarettes.

The proposal comes in the midst of the ongoing EVALI outbreak that has sickened at least 2,500 people in 50 states. The EVALI acronym stands for e-cigarette or vaping associated lung injury.

The Centers for Disease Control and Prevention says that as of earlier this month, 57 EVALI-related deaths have been confirmed in 27 states and the District of Columbia. Many of those who have been sickened report vaping THC, or tetrahydrocannabinol, which is the psychoactive element found in marijuana.

In Iowa, the Department of Public Health has reported 56 EVALI-related illnesses since Aug. 30, 2019. Of those 56 cases, 43 — or 77% — appear to have involved the use of THC products.

“The body of literature, as it stands right now, indicates there is a lot we don’t know about the effects of vaping in general — including the effects of secondhand exposure,” said Dr. Caitlin Pedati, Iowa’s state medical director and state epidemiologist. “There is quite a range of these devices in terms of how they are manufactured. And there’s also quite a range in terms of the liquids you can put into them.”

The lack of reliable data has prompted the American Medical Association to call for a ban on all vaping and e-cigarette products.

“We have very little evidence about the short- and long-term health consequences of e-cigarettes and vaping products,” AMA President Dr. Patrice Harris said in November. “We must keep nicotine products out of the hands of young people, and that’s why we are calling for an immediate ban on all e-cigarette and vaping products from the market.”

The Iowa Department of Public Health has taken the position that because the specific vaping ingredients that cause lung injuries have yet to be identified, the only way to eliminate all risk at this point is to refrain from using e-cigarettes and vaping products.

Nationally and in Iowa, the uncertainty over the health effects of vaping has led to a debate over its regulation. Some argue that because vaping is a relatively safe alternative to tobacco use, it should be lightly regulated. Others say that because vaping is addictive and e-cigarettes contain known carcinogens, the products should be tightly regulated if not banned altogether.

Nebraska increased the legal age for buying and using cigarettes and vaping products to 19 on Jan 1. But that new legal age will be short-lived. A federal law boosted the age to 21, with enforcement beginning this summer.

Iowa Attorney General Tom Miller, a Democrat, has repeatedly expressed reservations about certain regulatory schemes, including a proposed federal ban on flavored e-cigarette products. For now, at least, Miller isn’t backing or opposing the bill that would expand Iowa’s Smokefree Air Act.

“We’re a little concerned about the language,” said Miller’s spokesman, Lynn Hicks, referring to the proposed changes to the Smokefree Air Act. “Saying that ‘the General Assembly finds that vapor products cause and exacerbate diseases in nonsmoking adults and children’ — well, we’d like to see more data on that. Generally, the attorney general is concerned with equating smoking combustible products — and the secondhand smoke associated with that — with vaping.”

Last October, Miller wrote to the U.S. Office of Management and Budget to argue that a federal ban on flavored vaping products for adults would be detrimental to public health.

“We believe the United States is heading for a crisis in this field in 2020 with potentially millions of Americans facing life-threatening regulation imposed by the federal government,” Miller wrote.

He added that a ban on flavored vaping products would generate a wave of unintended consequences, including the closure of thousands of retail stores; a migration of customers from legitimate American businesses to Chinese, Internet-based suppliers; the development of a black market in flavored products; and a reversal of the trend that has seen former tobacco users take up vaping as a less risky alternative.

In Iowa, vaping is already prohibited in state offices, in foster homes and in any vehicle where a foster child is present. In addition, the cities of Coralville, North Liberty, Iowa City and Ames have banned vaping in enclosed workplaces, bars and restaurants.

Nationally, 13 states and at least 840 cities have banned vaping in public establishments that were already treated as smoke-free public areas. Other states have gone even further.

In October, Montana Gov. Steve Bullock ordered the state’s Department of Public Health and Human Services to enact emergency rules prohibiting the sale of flavored e-cigarettes as well as flavored nicotine and THC vaping products. The ban, which includes a sunset provision that causes the ban to expire after 120 days, was temporarily blocked by the courts, but last month a judge cleared the way for it to take effect.

In November, Massachusetts became the first state in the nation to ban all flavored tobacco and vaping products, including menthol cigarettes. The move came after Gov. Charlie Baker declared a public health emergency and imposed a temporary ban on the sale of all such products. The ban was later set aside when Baker signed into law new legislation that limits the sale of flavored vaping products to licensed smoking bars where the products can be smoked only on-site.

E-cigarettes consist of a battery, a liquid-filled cartridge and an LED light. The liquid in the cartridge produces a vapor or mist when heated, which the user inhales. The ingredients of the liquid vary, but often include nicotine, flavoring and a range of chemicals that cause the nicotine to vaporize.

In April 2019, the National Institute for Public Health and the Environment published its findings of a study related to the effects of secondhand vapor. Researchers collected the breath of 17 vaping volunteers and found increased levels of propylene glycol, copper and TSNAs, which stands for tobacco-specific nitrosamines, which are considered some of the most potent carcinogens in tobacco products.

From those measurements, the researchers calculated the effect on bystanders in two different scenarios — a non-ventilated car with two e-cigarette users inside, and a ventilated office with one e-cigarette user. Researchers concluded that in addition to the predictable increased risk of respiratory-tract irritation, the bystanders — particularly those in the enclosed car — could face an increased risk of tumors due to the TSNAs.

World-Herald staff writer Martha Stoddard contributed to this report.

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