Vaping and prescription opioids: limbic capitalism in action

Have you ever written something and sent it off, only to encounter a perfect example of what you wanted to say? That happened to me.

I had just finished a new book on addiction when the vaping crisis erupted. The gist of the book is that that globalization, industrialization, mass marketing, digitization, and social media have turned the ancient human preoccupation with disreputable, potentially addictive pleasures into lucrative, commercially normal enterprises. Bad habits have been McDonaldized.

Vaping couldn’t have been a more perfect example of this.

I call those who help make bad habits routine “limbic capitalists,” a reference to their products’ neural common denominator. Whether they sell junk food, porn, slots, computer games, alcohol, or drugs, they target the limbic system, the brain networks responsible for pleasure, motivation, long-term memory, and other survival functions linked to emotions.

Biological evolution shaped the limbic system, which is indispensable for life and reproduction. But cultural evolution and technological change created a trapdoor. The same neural pathways can be exploited — lethally — by entrepreneurs of brain-rewarding products that foster excessive consumption and addictive behavior.

I analyzed several categories of mortality data from the World Health Organization and found that, for every premature death from homicide or war-related violence, there were 30 premature deaths from unhealthful practices such as smoking, overeating, or distracted driving. Bad habits may be big business, but they are also big killers.

The surest way to recruit the heavy, regular users who provide the bulk of limbic capitalists’ profits is to entice them at an early age. With e-cigarettes, the incentive to do so was especially strong. Reducing harms by substituting nicotine vapor for tobacco smoke, though a promising idea, had an obvious economic downside. Adult vapers would eventually die or wean themselves away from nicotine. They could be replaced but, beginning in the late 1990s, smoking among U.S. teens began a sustained decline.

Given that the U.S. was easily the world’s largest e-cigarette market, and given that the odds of smoking diminish rapidly as nonsmokers mature through their 20s, the future looked like it would be filled with millennials with no need of e-cigarettes and no association of “pods” with anything other than sci-fi movies.

Unless, of course, vaping became the new original source of nicotine dependency.

In hindsight, the temptation for e-cigarette pioneers resembled the one that faced opioid manufacturers and distributors. Before the 1990s, when physicians prescribed narcotics for cancer, surgery, and trauma, the licit market for these painkillers was ethical and self-limiting. Patients died or recovered.

But then the industry’s patiently orchestrated campaign to liberalize opioid prescribing for chronic non-cancer pain, and the ensuing overpromotion and oversupply of drugs like OxyContin and Roxicodone, greatly expanded the market and triggered the entwined epidemics of iatrogenic and diversion-based opioid addiction. The latter disproportionately involved young males, the same demographic most prone to vaping-based nicotine addiction.

The limbic-capitalist moment for e-cigarettes arrived in 2015, just as the prescription opioid addiction crisis was transitioning to its heroin-and-fentanyl phase. In June of that year, Pax Labs launched Juul, a compact, concealable, and customizable e-cigarette ideally suited to an adolescent marketing campaign.

Some early Juul promotions were conventional: samples doled out at movies and concerts, glam ads featuring the ripped-jean young. But the startup’s biggest marketing assets were the internet and social media. Juul, whose vaporizer resembles a USB drive, took advantage with a barrage of tweets, Instagram posts, YouTube videos, and paid media influencers like Christina Zayas. “They really wanted to appeal to the younger market,” Zayas said. “And they did.”

Juul had another hook for youths: fruity flavors. These reflect an older tactic I call blending. Economists tend to miss its significance because they slot limbic capitalists into categories like Big Tobacco. But their actual products involve artful hedonic manipulation. Think of menthol, aromatics, and nicotine-enhancing ammonia in cigarettes. Some additives, such as sugar in cereals and sodas, have the further benefit of enticing young consumers. Juul worked the trick with mango and cool mint. Recording vaping tricks and uploading them for fun, instruction, and likes provided a juvenile sweetener of another variety.

Then Juul ran into two problems inherent to commercialized vice. One hitch was that other limbic capitalists, including counterfeiters and black marketeers, could also play the additives game. Skip the nicotine, advised a 2018 High Times article, and fill your Juul pods with THC oil (assuming it really was THC oil). Any enhancement or substitution increases the risk of toxic adulteration, suspected as a contributor to the 2019 outbreak of acute lung injuries among those who make or buy customized cartridges with alternative flavors and drugs. As with prescription opioids, many of the knockoffs could be traced back to Chinese manufacturers and internet vendors.

That so many hospitalized vapers — current median age of 24 years — were young aggravated a second threat facing the industry. In December 2018, news broke that rates of self-reported vaping had jumped from 11% to 21% among high school seniors, the biggest one-year increase in drug use ever recorded in the Monitoring the Future survey.

An estimated 1.3 million more high school students were vaping in 2018 than in 2017. By mid-2019, parents had begun filing lawsuits on behalf of their addicted minor children, while federal regulators proposed banning e-cigarettes of the flavored variety. In September, Massachusetts Gov. Charlie Baker went further, imposing a four-month ban on sales of all vaping products.

The legal blowback is consistent with the history of limbic capitalism. Societies reserve their strongest condemnations for addictive products that target the young, on whose health the future depends. Nothing scandalizes the public like hooked teenagers on respirators or morgue slabs.

Knowing how sensitive this nerve is, limbic capitalists have often countered with strategic walk backs and PR buys. This year, Juul ran a series of full-page ads in the Wall Street Journal advocating raising the age of legal purchase and tougher ID checks for vaping products. Attentive readers could not help but notice how closely the newly vigilant tone of the Juul ads echoed those that Purdue Pharma — “We Make Prescription Opioids. And We Want to Limit Their Use” — ran in the Journal in late 2018.

If the ads were too late for Purdue, they were nonetheless instructive for historians looking for patterns in the distant and more recent past. The pattern for the vaping scandal, and for the opioid crisis, and for proliferating addictions generally, is that of limbic capitalism. Step away from the headlines, take a closer look at vaping, and you will see but the latest blossom on the prettified thorn bush of commercialized vice.

David T. Courtwright, Ph.D., is professor emeritus at the University of North Florida who has written several books on the history of addictive substances. His latest is “The Age of Addiction: How Bad Habits Became Big Business” (Harvard University Press, May 2019). He has testified as an expert witness for plaintiffs in litigation against prescription opioid manufacturers.