Experimental Forum 2: Two Years After the 2020 Food and Drug Administration Guidance on E-Cigarette Flavors

Putatively, flavorings afford adult cigarette smokers options to switch to vaping.1 But the flavorings are also perceived to be attractive to people who have never smoked cigarettes, with particular concern about nicotine initiation by underage youths.2 In particular, the flavor and type of device on which nicotine use is initiated may influence later nicotine dependence in young adults.3 In the United States, three broad classes of vaping device are common: (1) single-unit disposable devices roughly equivalent to a pack of cigarettes;(2) homemade devices with, for example, customizable nicotine liquid tanks, batteries, and mouthpieces;and (3) devices with a rechargeable battery and replaceable cartridges containing nicotine liquid. Creating complicated relationships, and further limiting possible benefits to smoking cessation in the public health audience's eyes, Altria (formerly Philip Morris) purchased a major stake in JUUL in 2018. In addition to stay-at-home mandates, fear of contracting the respiratory illness was noted to increase motivation to quit cigarette smoking.8 Interestingly, e-cigarette users also reported greater quit attempts (41 %) than did cigarette smokers (26%) because of COVID-19 fears.9 In addition, various state and local prohibitions against public vaping and fluctuations in product cost have also occurred. Because of changes in sampling necessitated by the COVID-19 pandemic, data quality in large population-based surveys remains an area of active investigation, including potential discontinuities that could limit comparisons overtime. [...]we note that one or two time points since the Guidance was released may not portend sustained changes in behavior.

The US Public Health Service House-to- House Canvass Survey of the Morbidity and Mortality of the 1918 Influenza Pandemic

Between November 20, 1918, and March 12, 1919, the US Public Health Service carried out a vast population-based survey to assess the incidence rate and mortality of the influenza pandemic among 146 203 persons in 18 localities across the United States. The survey attempted to retrospectively assess all self-reported or diagnosed cases of influenza since August 1, 1918. It indicated that the cumulative incidence of symptomatic influenza over 6 months had been 29.4% (range = 15% in Louisville, KY, to 53.3% in San Antonio, TX). The overall case fatality rate (CFR) was 1.70%, and it ranged from 0.78% in San Antonio to 3.14% in New London, Connecticut. Localities with high cumulative incidence were not necessarily those with high CFR. Overall, assuming the survey missed asymptomatic cases, between August 1, 1918, and February 21, 1919, maybe more than 50% of the population was infected, and about 1% of the infected died. Eight months into the COVID-19 pandemic, the United States has not yet launched a survey that would provide population-based estimates of incidence and CFRs analogous to those generated by the 1918 US Public Health Service house-to-house canvass survey of influenza. (Am J Public Health. 2021;111: 438-445 https://doi.org/10.2105/AJPH.2020.306025)

The US Public Health Service House-to-House Canvass Survey of the Morbidity and Mortality of the 1918 Influenza Pandemic.

Between November 20, 1918, and March 12, 1919, the US Public Health Service carried out a vast population-based survey to assess the incidence rate and mortality of the influenza pandemic among 146 203 persons in 18 localities across the United States. The survey attempted to retrospectively assess all self-reported or diagnosed cases of influenza since August 1, 1918. It indicated that the cumulative incidence of symptomatic influenza over 6 months had been 29.4% (range = 15% in Louisville, KY, to 53.3% in San Antonio, TX). The overall case fatality rate (CFR) was 1.70%, and it ranged from 0.78% in San Antonio to 3.14% in New London, Connecticut. Localities with high cumulative incidence were not necessarily those with high CFR. Overall, assuming the survey missed asymptomatic cases, between August 1, 1918, and February 21, 1919, maybe more than 50% of the population was infected, and about 1% of the infected died. Eight months into the COVID-19 pandemic, the United States has not yet launched a survey that would provide population-based estimates of incidence and CFRs analogous to those generated by the 1918 US Public Health Service house-to-house canvass survey of influenza.

The Public Health We Need

Natural disasters, including this pandemic, hurricanes, flooding, fires, and earthquakes, have become the new public health normal.1 AJPH, in collaboration with the Centers for Disease Control and Prevention, has strived to make the evidence and the history available in regular issues and supplements (https://am. ajph.link/Emergency-Management_2017, https://am.ajph. link/Medical-Countermeasures_2018, https://am.ajph.link/ Community-Preparedness_2019). Workers in the health care, mail and delivery, food establishment and restaurant, retail, warehouse, and transportation sectors are taking huge risks to keep the economy and public health functioning, but they have been neglected-because of the gig economy, precarious jobs, endemic poverty, lack of access to care, insufficient wages and benefits, andso on-fora decade or more. The evidence supporting this is overwhelming.7 The pandemic, compounded or not by natural disasters, hasn't put an end to the epidemics of opioid addiction, deaths ofdespair, mass incarceration, punitive immigration policies, vaping among youths, gun violence and other forms of violence exacerbated by the quarantine, lack of access to food locally and globally, and wide disparities in health between rural and urban regions.