The Great American Smoke Out – Understanding the Vaping Crisis
It’s been all over the news – as of November 13th, 2019, a nationwide outbreak of EVALI, formally known as E-cigarette or Vaping Product Use Associated Lung Injuries, has resulted in 2,172 cases and 42 deaths in 49 US states, according to the CDC. With case reports spiking in September and continuing steadily throughout ongoing months, the outbreak has induced nationwide panic as the CDC and FDA continue investigating the potential causes.
The CDC recently reported a new breakthrough in lab testing, identifying vitamin E acetate, an oil form of vitamin E, as being a “chemical of concern” in the investigation. Vitamin E acetate is being found in many bootleg THC vaping products as a cutting agent to thicken or dilute the product. THC is the psychoactive chemical in cannabis that gives you the high, and with the majority of THC vaping products being unregulated and illegal, the FDC and CDC are “recommending that people do not use THC-containing e-cigarette or vaping products.” While vitamin E acetate is typically found in supplements, beauty products, and foods, in which it’s generally considered safe, when inhaled it is proving to function as a dangerous “sticky,” honey-like substance that clings to the lungs. Dr. Anne Schuchat, the principal deputy editor of the CDC, is identifying vitamin E acetate as a “very strong culprit” in the EVALI outbreak.
As reported by NBC News, a new study from CannaSafe lab has revealed that a number of illicit THC vaping cartridges are tainted with “a toxic stew of dangerous chemicals” including pesticides, vitamin E acetate, and formaldehyde. One, in particular, is Dank Vapes, a brand of illegal vaping products that many EVALI patients consumed, which was found to have high traces of all three in its products.
So, is it just THC vaping products I have to be worried about? What about e-cigarettes containing only nicotine?
This, in my opinion, has been the biggest point of confusion for those trying to navigate the EVALI crisis, at least judging from conversations I’ve had with friends, family, and colleagues. With tons of headlines reporting the latest news on potential bans of flavored e-cigarettes, lawsuits against leading e-cigarette brand JUUL, and the teenage vaping epidemic that is rampant in schools – it’s hard to decipher what exactly is going on, and how it all relates to EVALI outbreak reports.
Let’s dive in:
It’s important to note that results from the CDC lab testing of 29 patients’ lung fluid samples indicated that vitamin E acetate was present in all samples. A press release published by the CDC announced that “We do know that THC is present in most of the samples tested to date, and most patients report a history of THC-containing products. The latest national and state findings suggest products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak.”
As of November 5th, according to the CDC website, of 1,184 surveyed patients with EVALI:
- 83% reported using THC-containing products; 35% reported exclusive use of THC-containing products.
- 61% reported using nicotine-containing products; 13% reported exclusive use of nicotine-containing products.
- 48% reported both THC- and nicotine-containing product use.
- 4% reported no THC- or nicotine-containing product use.
However, the CDC reports that it is still too soon to rule out additional chemicals or identify that this is only related to THC vaping as well, especially being that 13% of surveyed patients reported using nicotine-only products.
Dr. Schuchat announced at a recent press briefing that, “Lab testing is providing important new information, but no single product, brand, substance or additive has been identified in all of the cases at this point. It may be that there is one cause or that there are many problematic substances causing lung injury. And there may be complex root causes for this outbreak.”
So how is JUUL involved?
JUUL, the brand accounting for almost 70% of the e-cigarette market, has skyrocketed in popularity in part for its discreet, sleek look, resembling a USB. JUUL creates nicotine-only products, known as JUUL pods, with “one Juul pod containing 20 cigarettes worth of nicotine.” This is pretty scary, considering that a 2018 study from Truth Initiative reported that “nearly two-thirds – 63 percent – of JUUL users between 15 and 24 years old did not know that the product always contains nicotine.” The study also provides evidence that “the majority of youth e-cigarettes users think they vaped only flavoring, not nicotine” (Truth Initiative).
The brand has become highly popular with Gen Z’s and Millennials. A 2019 National Youth Tobacco Survey indicated that 27.5 percent of high school students and over 5 million youth are currently e-cigarette users and that from 2017 to 2019, e-cigarettes have increased by 135 percent for high schoolers (Tobacco Free Kids). JUUL is under fire for appealing to youths through their popular flavored pods and is currently facing lawsuits from California, North Carolina and New York for conducting marketing campaigns allegedly aimed at teens. President Trump made strong motions toward banning all flavored e-cigarettes nationwide, but decided against it at the last minute, reportedly due to fear of mass unemployment and voter-loss.
In 2018, the U.S. Surgeon General declared an e-cigarette epidemic among youth, with the CDC indicating that “one in five high schoolers and one in 20 middle schoolers currently use e-cigarettes.” As a (semi) recent college grad, I can definitely say that JUUL and other e-cigarette products maintained a huge presence on campus, turning people who have never smoked nicotine products, and who perhaps otherwise wouldn’t have, onto addictive nicotine habits.
It should also be noted that many black-market companies have created THC pods that can fit into the JUUL device, which poses another threat to the EVALI crisis. While, according to JUUL’s website, e-cigarette products like theirs were developed “as a satisfying alternative to cigarettes” to help existing smokers ween off cigarettes, it seems to be turning a whole new generation onto its products along the way.
But does JUUL correlate to the EVALI outbreak?
As mentioned, although findings are showing vitamin E acetate as being associated with EVALI, it’s too soon to rule out additional chemicals and causes. However, vitamin E acetate is not found in nicotine e-cigs, like JUUL, that have been tested.
As reported by ABC News, Dr. Michael Siegal, professor at Boston University School of Public Health, commented that “this outbreak does not appear to be associated with traditional legally-sold e-cigarettes, but with illicit and sometimes counterfeit THC vaping cartridges.”
The Bottom Line: While the majority of EVALI patients reportedly used THC-containing products, around 10 – 13 percent of patients have indicated exclusively vaping only nicotine-containing products. Until there is more research reported, no definitive conclusions can be made at this time.
But what are the Risks of E-Cigarettes?
According to the FDA website:
“E-cigarette aerosol is not harmless. It can contain harmful substances, including:
- Cancer-causing chemicals
- Volatile organic compounds
- Ultrafine particles
- Flavorings that have been linked to lung disease
- Heavy metals such as nickel, tin, and lead “
“There is no FDA oversight of the manufacturing of these products—which means there is no oversight regarding potentially harmful ingredients.” – Lung.Org
Who is EVALI affecting?
Around 80% of patients are reportedly under 35 years old, and of this, the median age is 24. The largest demographic of patients EVALI has affected are young white males, and the youngest death reported is a 17-year old boy from New York. One patient, who is 17- year- old male from Michigan, had to undergo a double lung transplant to survive.
Symptoms of EVALI, according to Yale Medicine, include difficulty breathing, shortness of breath, chest pain, coughing, gastrointestinal symptoms such as nausea, diarrhea and vomiting, rapid heartbeat, and rapid, shallow breathing.
What action is being taken?
Many states have enacted bans on vaping and flavored e-cigarettes. Massachusetts immediately placed a temporary ban on all e-cigarettes and is voting on if this should be made permanent. Michigan and New York are also among states that have announced bans on flavored e-cigarettes. Walmart announced they will stop selling e-cigarettes, and on November 15th, Apple announced it was removing all vaping-related apps. As mentioned, New York, California and North Carolina are suing JUUL for targeting youths in their marketing efforts.
The American Medical Association is calling for a total ban of vaping and e-cigarette products that are not FDA approved, and currently, no products have been reviewed or approved for use by the FDA. The CDC and FDA are currently “working tirelessly to investigate the distressing incidents” associated with vaping, and are “working closely with their federal and state partners to identify the products or substances that may be causing the illness.”
For now, the CDC is urging people to avoid using THC-containing e-cigarettes or vaping products and recommends they not buy these products from “informal sources” such as friends, family or online/in-person dealers.
What does this mean for Marijuana Vapes?
There are strong debates regarding the federal legalization and regulation of marijuana, leaving many questioning if the EVALI outbreak would have occurred if there were regulations that could have prevented black-market, bootleg THC-vape cartridges from becoming so widespread. With Canada working toward marijuana legalization and regulating cannabis vape cartridges so they can be sold legally, the US will have to take notes on how this impacts their population.
In order to ameliorate this crisis, impactful action and regulation need to occur. Hopefully, the best and most effective solution will become apparent, and in my opinion, must come from the top-down, at the federal level.