An exercise in spotting agenda journalism: dissecting a 2022 New York Times article on teen vaping sentence by sentence to show how it pins an EVALI hospitalization on legal nicotine vapes while never quite saying so—since the actual cause was illegal THC products. Every misleading sentence is technically true.

The 2019 EVALI outbreak was caused by illicit THC vapes adulterated with vitamin E acetate, but it became a public justification for restrictions on legal nicotine vaping.

This essay looks at a 2022 New York Times article about teenage vaping which juxtaposes synthetic nicotine, flavored vapes, Lizzie Burgess’s hospitalization, and nicotine addiction without ever quite saying that legal flavored nicotine vapes caused her lung injury.

Sentence by sentence, the article’s misleading effect comes from technically true phrasing: “vaping”, “vaping THC and nicotine”, “vaping-related lung injury”, and post-hoc narrative order.

The case is a useful example because the ground truth is clear, the article was high-profile and edited, and the manipulation is grammatical and selection rather than simple falsehoods.

The 2019 nicotine vaping moral panic was one of the more striking ones of our era, where illegal black-market THC marijuana vapes poisoned with vitamin E acetate that caused severe “EVALI” lung injuries were a major justification for unprecedented bans on legal nicotine vaping products. Despite no lab-verified instance of a nicotine product with the vitamin E acetate adulteration (only THC products), and nicotine vapes produced by large businesses which had sold countless billions of doses to millions of people beforehand, with no EVALI epidemic before (or since), and the phenomenon subsiding after lawsuits and prosecutions of vitamin E acetate sellers, it somehow became common knowledge that nicotine vapes were deadly.

How did this happen?

Media Coverage

One way it happened was via a conflation of THC and nicotine vaping, driven in part by inaccurate reporting by victims and by the difficulty of proving a negative—after all, any given case could have been due to nicotine vaping, somehow, how would one prove it wasn’t? This was then amplified by activists and journalists working together to selectively report and describe true facts.

I was particularly struck by an instance in the New York Times in March 2022, which paints a compelling picture of legal nicotine vapes causing severe lung problems in one young woman, Lizzie Burgess:

[The Lizzie Burgess excerpt]

This article appears to have been successful in persuading readers. In the NYT comment section (mirrored below in full), most comments agreed with the article, often going as far as to claim that “addict and kill people—including children”/“here they are exploiting a legal loophole to addict millions more young adults to their lethal products” or “Young people especially become easily addicted to the nicotine…The damage to their lungs resembles the worst pneumonia you can get and still be alive.” or “The purveyors of these drug delivery systems are killing our children with intent. They should all be thrown in jail, and the import of these products should be banned.” (The import of THC vapes contaminated with vitamin E acetate is, of course, already banned or adult ID required etc.) Indeed, only a single NYT commenter (who no one responded to) appeared to get it right in their reply a quarter down the comment section:

The illness described in the article was clearly caused by using an adulterated, illegal, THC-containing vaping product, not the nicotine-based e-cigarettes being criticized here. That should have been made clearer.

The article might have convinced me too if I hadn’t already known better.

I was perplexed why the NYT would lie like that, as the article clearly said repeatedly that nicotine vaping was to blame. I had thought that it was now uncontroversial and consensus that the moral panic had framed nicotine vaping (albeit unpopular to acknowledge now that the ‘issue-attention cycle’ had moved on and the activists gotten what they wanted). Was it just wrong, or had I misunderstood something? Perhaps I had skimmed over a smoking gun, like finally finding fatal levels of vitamin E acetate in lab testing of a Juul pod?

Rhetoric

So I went back to excerpt the article—and while rereading, realized that in every case I thought might be a lie, rereading showed it had been so carefully worded as to be technically correct and to simply be misleading.

After this, I was in awe of the rare artistry of the piece, which elevated it from merely misleading to a wonderful example of “bounded distrust” in journalism and how selective quotation and mere juxtaposition can lead astray the insufficiently skeptical reader.

It’s a great example because it is:

1. Ground-truth objective answer, known then, and even more clearly confirmed by years of followup:

   EVALI was caused by THC products. There is no hard lab-tested evidence that any legal nicotine products, the subject of the article, caused EVALI.

2. Longform (~1,800 words) high-profile piece in one of the most prestigious newspapers in the world:

   meaning that it passed editing and fact-checking

3. Purely textual/grammatical:

   phrases like “vaping products” or “vaping THC and nicotine” are suspiciously worded and violate ordinary norms of writing to be specific and informative—if a young woman has been hospitalized by a nicotine vaping product, why not say just so? If vitamin E acetate had been found in legal nicotine vaping products, why not just name the test result and product specifically?

4. Unnecessary to the core of the article:

   it would be possible to write this story without bringing in irrelevant THC-contaminated anecdotes or EVALI, by focusing on legitimate criticisms of nicotine vaping. (You could discuss teen access, flavor marketing, age checks, FDA jurisdiction, statutory drafting, the economics of disposable devices, and the adult harm-reduction case without ever mentioning EVALI which you know is not related to teen access to legal anything.)

5. Deliberate: the phrasing is so consistently and carefully done that the author almost certainly knew what they were doing—if they hadn’t, they would have slipped up at least once, and joined two sentences with a comma, or some other easy writing mistake which would have been incorrect.

I kept thinking about what a great example it was and that at some point I should fisk it. Finally, I did.

The article’s misleading chain of logic is synthetic nicotine → vaping flavors → “vaping-related lung injury” → Lizzie Burgess; and in an anecdote demonstrating this: “flavored vapes” → “vaping THC and using a device” → “vaping-related lung injury” → “nicotine addiction” → ban “flavored vapes”.

But nowhere does it say anything like:

Her lung injury was caused by legal flavored nicotine vapes.

It is always ‘vaping caused lung injury’ (true! vaping THC products did) or ‘vaping THC and nicotine’ (the ‘and’ does a lot of work there), or juxtaposition like ‘she was soon in the ICU…She’s struggled to end her nicotine addiction’.

It just carefully arranges the sequence of facts to encourage the ordinary causal inference of post hoc ergo propter hoc, downplaying or omitting the THC, while using supersets like ‘vaping’ or ‘vaping THC and nicotine’ so the article technically contains the relevant information (the informed reader would interpret this correctly as Lizzie Burgess having almost surely been hospitalized by the THC vaping, but the ordinary reader has already been led down the wrong path—and confirmation bias does the rest).

It serves as a good exercise for the reader: how do you handle science journalism like this, where the author is not careless or egregiously lying, but where the author appears to know exactly where the line is and never quite crosses it? Or readers who ask only, “is each sentence technically true and lets me believe what I want to believe?” Would you have noticed the suspiciously specific wording, or the omission of how it never quite says, despite its length, a simple statement like “nicotine vapes caused EVALI”? Or the implied (and falsified) predictions like “EVALI will continue until legal vaping products are fully banned”? Or would you have fallen for a good Narrative?

Excerpts

Below are some key excerpts, with weasel words or rhetoric highlighted in bold:

Scientists are just beginning to look at the unknown health impacts of new, tobacco-free nicotine products, even as research is expanding into the harmful effects of vaping and its flavor ingredients.

…Scientists are just beginning to study the unknown health effects of synthetic nicotine, even as research is expanding into the harm caused by vaping and flavor ingredients alongside continuing cases of devastating vaping-related lung injury. To many public health advocates, new trends in the vaping industry are thwarting the FDA’s efforts to protect a new generation from nicotine addiction.

…FDA enforcement actions have had little effect on Lizzie Burgess’s ability to get vapes over the last 4 years. “I think the FDA should take it all off the market now”, she said.

…Vaping is still popular among teenagers. Rani Dhiman, 16, said it is highly visible in the bathrooms and stairwells of her high school in the Detroit suburbs.

…She said the stress and loneliness of the pandemic might have been a trigger for some teenagers to start. It’s also portrayed glamorously, she pointed out, in “Euphoria”, a popular HBO series about a teenager kicking drug addiction.

…The FDA’s efforts to limit teenagers’ access to flavored vapes had little effect on Lizzie Burgess’s ability to get them over the last 4 years in the Indianapolis suburbs. Within weeks of starting to vape at 16, she said, she was addicted. There was always a gas station, older friend or website selling e-cigarettes in flavors like banana ice cream or sour apple, she said.

…At 19, she said, she was vaping THC and using a device—now advertising tobacco-free nicotine—that has as much nicotine as two packs of cigarettes, every 2–3 days. She said she fell ill with what started like a cold, which progressed to rapid breathing, almost-gray lips and feeling depleted. By the time she went to the emergency room, her oxygen saturation was 67, far below the normal range of 95 or higher. Burgess said she was soon in the ICU with vaping-related lung injury.

[photo of young woman in ICU with face covered by a medical ventilation mask]

[Burgess in the ICU last year. When she arrived at the hospital, her oxygen saturation was 67, far below the normal range of 95 or higher. Credit: Lizzie Burgess]

[X-ray scan of two pairs of lungs. Top: “Liz’s Lungs”, off-color and shrunken. Bottom: “Healthy Lungs”, white and large.]

…She’s struggled to end her nicotine addiction and is down to two cigarettes a day.

…“I think the FDA should take it all off the market now”, Burgess said of the flavored vapes. “I think it will be very very hard for them to reel it all in. It’s so big and there are so many companies now.”

…[Sales data] released by the CDC Foundation shows that since the FDA stepped up e-cigarette enforcement in February 2020, sales of disposable fruit-flavored and candy-flavored devices have grown by 290%, to 6.46 million devices a month by November 2021. Sales of the FDA-targeted flavored pod and cartridge devices have nearly vanished.

…The unregulated vaping market at this point is a problem of the FDA’s making, said Gregory Conley, president of the American Vaping Association, an industry trade group. He said the agency fueled the problem by over-regulating a product used by millions of adults who find vaping a safer alternative to smoking.

…“This country should learn some lessons from past prohibitions that failed miserably”, Conley said. “If you don’t fairly regulate a market where there is a great deal of demand from legal adults, you will fuel gray and black markets where the operators are not concerned with checking IDs before selling.”

…Recent research has focused in on the chemicals used to simulate butter, which is linked to lung damage, and vanilla, which is associated with birth defects in zebrafish.

Appendix

The NYT Article

By Christina Jewett

March 8, 2022

[image of assorted vaping products on a white table]

Scientists are just beginning to look at the unknown health impacts of new, tobacco-free nicotine products, even as research is expanding into the harmful effects of vaping and its flavor ingredients.

The Food and Drug Administration’s crackdown on flavored e-cigarettes in 2020 was meant to be a comprehensive, aggressive strategy to curtail the epidemic of teenage vaping.

But two years later, sales of disposable, flavored e-cigarettes have soared. Some companies have moved just beyond the reach of the FDA by swapping out one key ingredient. They have circumvented federal oversight of tobacco plant-derived nicotine by using an unregulated synthetic version.

The agency had nearly wiped out the use of flavors in devices like Juul, once the teenage favorite, that could be refilled with pods in flavors like creme brûlée and mango. Jumping into the breach, though, companies like the teen favorite Puff Bar are selling disposable devices filled with candy flavors and tobacco-free or synthetic nicotine.

Scientists are just beginning to study the unknown health effects of synthetic nicotine, even as research is expanding into the harm caused by vaping and flavor ingredients alongside continuing cases of devastating vaping-related lung injury. To many public health advocates, new trends in the vaping industry are thwarting the FDA’s efforts to protect a new generation from nicotine addiction.

“These companies like Puff Bar and others are deliberately driving their trucks of poison through this huge loophole”, said Meredith Berkman, a founder of Parents Against Vaping E-Cigs. She recently hosted a webinar about synthetic nicotine attended by 700 people. “We think we need to regulate these products.”

Lawmakers on Tuesday proposed language that they want inserted in the Congressional omnibus budget bill that would give the FDA authority to regulate synthetic nicotine, although it is unclear if the issue will be included in the final bill.

Representative Frank Pallone Jr. Democrat of New Jersey and chairman of the House Energy and Commerce Committee, said the provision would be a public health victory over “bad actors” who circumvented the FDA’s authority.

“That ends with passage of this bill, which will close this loophole and clarify FDA’s authority to regulate all tobacco products, including those containing synthetic nicotine”, Pallone said in a statement on Tuesday.

Sales of synthetic or tobacco-free nicotine went from virtually nonexistent in 2020 to taking up shelf space in 2⁄3rds of US vape shops in 2021, according to market research. Those stores said such products accounted for nearly 20% of sales, according to ECigIntelligence, which surveys hundreds of the shops each year. The company projected that the US vape market, web sales included, would be nearly $6 billion this year.

FDA enforcement actions have had little effect on Lizzie Burgess’s ability to get vapes over the last 4 years. “I think the FDA should take it all off the market now”, she said.

[Photo of young white woman in a bomber jacket and jeans, looking sad.]

[Credit: Lee Klafczynski for The New York Times]

Federal officials have been in a cat-and-mouse game with some e-cigarette makers. Spurred by a court order, the FDA forced thousands of e-cigarette companies, including Juul, to apply in 2020 for authorization to remain on the market. With the agency focused on the most popular devices, like Juul’s, that used insertable cartridges, makers of disposable vape pens in flavors like gummy bear and candy cane flooded the market. The agency then responded with a stern warning and even product seizures aimed at some of those companies, including Puff Bar.

By late last year, more than a million tobacco-sales applications had been denied. Applications to remain on the market by Juul and myriad other companies are pending.

By early 2021, Puff Bar returned to the market with “tobacco-free” or synthetic nicotine that didn’t fall under FDA oversight, loaded with the fruity flavors prohibited in vapes with tobacco-based nicotine. Other companies imported similar devices containing synthetic or tobacco-free nicotine from factories in Shenzhen, China, according to industry experts.

Patrick Beltran, who has identified himself in news reports as one of two executives of Puff Bar, did not respond to requests for comment.

Sales data released by the CDC Foundation shows that since the FDA stepped up e-cigarette enforcement in February 2020, sales of disposable fruit & candy-flavored devices have grown by 290%, to 6.46 million devices a month by November 2021. Sales of the FDA-targeted flavored pod and cartridge devices have nearly vanished.

Since early 2020, overall e-cigarette sales are up nearly 50% to about 22 million units per month, according to Information Resources, a data tracking consultant. The National Youth Tobacco Survey conducted in early 2021, when many students were learning via Zoom, reported that, overall, about 11% of high school students used e-cigarettes.

New e-cigarette suppliers can go into business easily: They contract with a manufacturer in China, set up a website and get space in a warehouse to store and ship devices, said Samantha Shusterman, a senior counsel supervising e-cigarette enforcement for the Massachusetts attorney general’s office. They use shell companies and can quickly withdraw the profits if they face scrutiny.

“It’s a whack-a-mole situation”, said Shusterman, whose state banned all flavored e-cigarettes, except in licensed smoking bars. “They’re not following any of the laws.”

Mitch Zeller, director of the FDA’s Center for Tobacco Products, said the agency recognized the problem.

“Disposable e-cigarettes made only with synthetic nicotine pose a particular challenge for the FDA when it comes to our tobacco authorities”, Zeller said in an email. “The FDA is actively investigating this issue and considering how to best address such products.”

[photo of young woman in ICU with face covered by a medical ventilation mask]

[Burgess in the ICU last year. When she arrived at the hospital, her oxygen saturation was 67, far below the normal range of 95 or higher. Credit: Lizzie Burgess]

[X-ray scan of two pairs of lungs. Top: “Liz’s Lungs”, off-color and shrunken. Bottom: “Healthy Lungs”, white and large.]

[A scan of Burgess’s lungs, top, compared with healthy lungs. Credit: Lizzie Burgess]

Vaping is still popular among teenagers. Rani Dhiman, 16, said it is highly visible in the bathrooms and stairwells of her high school in the Detroit suburbs.

She said the stress and loneliness of the pandemic might have been a trigger for some teenagers to start. It’s also portrayed glamorously, she pointed out, in Euphoria, a popular HBO series about a teenager kicking drug addiction.

“Sometimes so many people are vaping in the bathrooms, it’s hard to do anything about it”, Dhiman said, adding that she doesn’t vape.

The FDA’s efforts to limit teenagers’ access to flavored vapes had little effect on Lizzie Burgess’s ability to get them over the last 4 years in the Indianapolis suburbs. Within weeks of starting to vape at 16, she said, she was addicted. There was always a gas station, older friend or website selling e-cigarettes in flavors like banana ice cream or sour apple, she said.

At 19, she said, she was vaping THC and using a device—now advertising tobacco-free nicotine—that has as much nicotine as two packs of cigarettes, every two → 3 days. She said she fell ill with what started like a cold, which progressed to rapid breathing, almost-gray lips and feeling depleted. By the time she went to the emergency room, her oxygen saturation was 67, far below the normal range of 95 or higher. Burgess said she was soon in the ICU with vaping-related lung injury.

She’s struggled to end her nicotine addiction and is down to two cigarettes a day.

“I think the FDA should take it all off the market now”, Burgess said of the flavored vapes. “I think it will be very very hard for them to reel it all in. It’s so big and there are so many companies now.”

Synthetic nicotine remains far more expensive than the tobacco-derived product, leading some industry experts to question whether a device label of “synthetic” is accurate.

The unregulated vaping market at this point is a problem of the FDA’s making, said Gregory Conley, president of the American Vaping Association, an industry trade group. He said the agency fueled the problem by over-regulating a product used by millions of adults who find vaping a safer alternative to smoking.

“This country should learn some lessons from past prohibitions that failed miserably”, Conley said. “If you don’t fairly regulate a market where there is a great deal of demand from legal adults, you will fuel gray and black markets where the operators are not concerned with checking IDs before selling.”

[Photo of professorial old white man sitting on desk]

[Dr. Robert Jackler of Stanford University created a “synthetic teenager” named Joe, who used gift cards to buy flavored synthetic nicotine products online and have them shipped. Credit: Ian C. Bates for The New York Times]

Dr. Robert Jackler, who studies tobacco company advertising at Stanford University, has also noted major tobacco retailers entering the synthetic nicotine market with flavored gums called “pouches.” He said his tobacco research group could pose as a teenager and use gift cards to easily buy the flavored synthetic nicotine gums from major retailers and have them shipped to a home in California.

“When we buy them, there’s no age gating”, Dr. Jackler said.

The loopholes are many with synthetic nicotine, he said, allowing the products to avoid hefty tobacco taxes and remain affordable and to evade the algorithms that online retailers use to weed out underage sales of tobacco products. The ease of purchasing was also concerning, Dr. Jackler said, given how little is known about the health effects of flavored, synthetic nicotine.

Recent research has focused in on the chemicals used to simulate butter, which is linked to lung damage, and vanilla, which is associated with birth defects in zebrafish.

Dr. Sven-Eric Jordt, an associate professor at Duke University who has studied synthetic nicotine, said it posed many unknowns.

About 99% of tobacco-derived nicotine is a psychoactive molecule called S-nicotine, he said. But a mirror-image molecule, known as R-nicotine, makes up 50% of most types of synthetic nicotine. He said the R-nicotine molecule appears to be less addictive, but very little research has been done on it in animals or humans.

“It could alter nerve transmission in the brain in different ways from classic nicotine”, Dr. Jordt said, “but we don’t understand that at this time.”