Ask any vaper why they do it, and you'll probably hear a similar answer: "It's not a lifestyle choice. It's life or death."
That phrase, for all its political hokiness, has become something of their refrain—chanted at protests, shouted at speeches, plastered all over their insular Twitter world. It's a sentiment, they know, not everybody shares. Just last week, U-Haul announced that it would be implementing a new policy not to hire nicotine users, regardless of how they consumed it. But there's a distinction between vaping and smoking, vapers say; that's precisely their point.
That lack of distinction among employers has raised a related issue: Vapers are also getting lumped in with cigarette users when it comes to health insurance penalties.
Health insurers, following the lead of the U.S. Food and Drug Administration (FDA), do not qualify e-cigarettes or vapes as cessation or harm-reduction tools, even though many of them offer programs to help smokers ditch their habit or additional incentives to keep them healthy. Little discussion has yet been had about how health insurance companies explicitly deal with vapers, but respected scientists have come out in favor of exploring vaping products as a means of substantially improving public health, should smokers swap their cigarettes for vapes.
Vaping, of course, has recently been associated with 2,591 illnesses and deaths, according to the latest tally from the Centers for Disease Control and Prevention (CDC). But nearly all of those cases have been tied to a thickening agent sometimes found in illicit THC cartridges, not e-liquids containing nicotine. There is reasonable evidence, at least in the short term, that well-regulated nicotine vapes are better for your health than smoking cigarettes, and many harm-reduction proponents here and abroad have lauded the technology as an avenue for smokers to quit. One such statistic, from Public Health England (PHE), a government agency similar to the U.S.'s CDC, has asserted that vaping is "95 percent less harmful than smoking." The U.K., for its part, does not have anywhere near the crisis that the U.S. does.
Despite this, in the American healthcare world, if you vape, you are really no different from a smoker.
"If you have any belief, even given all the uncertainties, that vaping can be a form of harm reduction, from a public-health and ethical standpoint, the answer to this question is obvious," said Ronald Bayer, a professor of sociomedical sciences at Columbia. "People," he continued, "should be encouraged to go from one to the other, not discouraged."
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Currently, under the Affordable Care Act, people who buy non-group health insurance and indicate that they consume tobacco products could face a tobacco-use surcharge, which can jack up a premium by 50 percent. After August 2016, when the FDA officially got regulatory power over vapes and e-cigarettes, "tobacco products" started to include them as well. States—like employers—can set their own policies on this, and not every state allows for these surcharges, as anti-cancer activists, along with Big Tobacco, have said that it would disproportionately affect lower-income groups. A small company with fewer than 50 people employed also must provide workplace wellness initiatives in order to levy a tobacco-use surcharge.
The whole point of a vape is that it employs an e-liquid with nicotine rather than tobacco and the deadly toxins produced from burning and ingesting it. But practically, from the point of view of the health insurer, the two could be extremely difficult to separate.
"I think it would be hard for an insurance company to differentiate between electronic cigarettes and vaping versus traditional cigarette use," said Michael Ong, a tobacco control expert and a professor in residence of medicine and health policy and management at the University of California, Los Angeles. "While a survey question response might help, the traditional way of checking via cotinine levels [essentially the amount of nicotine in the body] wouldn't be able to differentiate between the two products."
It's also likely that "group health insurance plans follow the FDA's lead in determining what is and isn't a tobacco product"—a consequence that could affect not just a single person, but their entire family, said Michael Pesko, an assistant professor of economics at Georgia State University.
"Medicaid programs provide free use of other FDA-approved forms of nicotine replacement therapy like gum and patches," Pesko continued. "Would it be reasonable to consider subsidizing e-cigarettes for long-term smokers that haven't quit smoking in another way? I think that's a reasonable debate we could have."
Harm-reduction advocates and public-health scholars have compared this approach from health insurers to other similar strategies employed by lawmakers and public officials, those who have often acted like vaping and smoking were synonymous. Or that vaping was actually worse. It's been evident with taxes—and a heavy vape tax could, as the New York Times reported, prevent smokers from transitioning to vaping. And it's been clear with life insurance over the past few months, as there have been several reports that people who vape might have more difficulty obtaining these policies, because major reinsurers—those companies that insure the insurers—have been worried following the spate of illnesses in the U.S.
The bigger question, of course—and one that applies to the cigarette surcharge too—is how we want to treat people, and if companies should truly be allowed to charge more for health insurance based on risky behavior they partake in outside the office.
"To me, the entire issue with healthcare is one of simple justice," said Bayer. "Half of the U.S. population is going to be obese soon, according to a new study, and it's primarily going to affect lower-income Americans. Is that what we're planning on doing? Are we really going to charge the poor more for their health insurance?"
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This article originally appeared on VICE US.