In August, the Centers for Disease Control and Prevention (CDC) began investigating reports of severe respiratory problems appearing to stem from the vaping of unknown substances. There are now more than 450 such cases and six deaths have reportedly been associated with vaping.
While vaping is often characterized as the common association in these cases it should be understood that vaping is a process, not a product. The vapor from e-cigarettes is produced using a heating element that turns the e-liquid contained in the cartridge, tank, or pod into a vapor. The level of risk posed to the user lies in the substances that are being vaped, rather than the process itself.
Tobacco cigarettes contain more than 7,000 chemicals; e-cigarettes have a fraction of this number and in dramatically lower concentrations. E-cigarettes are around 95 percent safer than combustible cigarettes and are the most popular and effective tool used to quit smoking.
Nicotine containing e-cigarettes have been available in developed markets such as the U.S. and the U.K. for well over a decade, with tens of millions of users. The U.K. government actively promotes vaping as a route to smoking cessation.
According to modeling conducted by David Levy and colleagues at Georgetown University Medical Center, replacement of cigarette with e-cigarette use over a 10-year period would yield 6.6 million fewer premature deaths, with 86.7 million fewer life years lost.
The sudden outbreak of severe lung problems and fatalities being associated with vaping have left the general public and health authorities confused as to what is the cause of these illnesses. In the recent past, similar cases have been reported in both in the U.S. and the U.K. but all appeared to be related to synthetic cannabis oils or other illegal cannabinoid products.
The exact cause of this outbreak has yet to be determined but a clear pattern has emerged in terms of what these patients have been vaping and the common factor appears to be cannabis oils and other contaminants, not legal e-cigarette products.
Here is a series of quotes from public health experts who have been examining this issue and what may be causing it:
What’s causing this outbreak?
Professor Ray Niaura, College of Global Public Health at New York University:
“It is unlikely it is e-cigarettes that have been on the market for a long time” unless “something was either changed or a new product was introduced into marketplaces.”
“More likely, it’s what others are saying and people are vaping a lot of other things besides nicotine, such as synthetic cannabis or contaminated THC that is making an appearance and leading to these bad consequences.”
Dr. Sarah Jackson, a senior research fellow at the Tobacco and Alcohol Research Group at University College London:
“The recent cluster of vapers developing lung problems follows a decade of widespread e-cigarette use without reports of similar adverse effects. The majority of cases appear to have been vaping illicit e-liquids containing THC. E-cigarettes are the most popular quitting aid used by smokers – and among the most effective. Advice to discourage people from vaping legal, regulated e-liquids appears to be unwarranted and risks pushing people back to smoking.”
Professor Peter Hajek, director of the Tobacco Dependence Research Unit, Queen Mary University of London:
“The mystery seems to have been resolved now, with cases being traced to a contaminated marijuana extract. Although the scare is being used to put smokers off switching from cigarettes to much less risky vaping, it has nothing to do with e-cigarettes as they are normally used in this country.
“E-cigarettes have been around for over a decade now and are used by millions of people, with no such cases occurring. The outbreak is similar to methanol poisonings that kill people every now and then when contaminated alcohol is sold.”
Linda Bauld, professor of health policy at the University of Edinburgh:
“We have no evidence that they are linked to the types of e-cigarettes used by over 3 million people in the UK. Details from the USA are sketchy and clearly further investigation is needed, but these cases appear to be linked to contaminated or black market e-liquids. They may also be linked to vaping substances other than nicotine including cannabis oils that have been tampered with or modified.”
Dr. Konstantinos Farsalinos, research fellow Onassis Cardiac Surgery, Department of Pharmacology, University of Patras:
“In conclusion, from an epidemiological perspective, the current situation with cases of acute respiratory failure reported in the US, is extremely unlikely (I would say, certainly not) attributed to products that have been available in the worldwide market for years and have been used by millions of consumers. The exact cause for these conditions should be urgently determined, and the emotional, irrational hysteria against e-cigarettes (in general) needs to stop as soon as possible.”
Peter Openshaw, professor of experimental medicine at Imperial College London:
“It seems possible that these case clusters are related to inhalation of oil or oil/water mixtures that cause immune activation and trigger both local inflammation in the lung (pneumonitis) and, in some cases, systemic inflammation. Exactly why and how remains to be determined.
“The risk seems especially great in those adding substances to the manufacturer’s nicotine-containing products. While the exact causes are being investigated, it is vital that home-made mixtures of commercial and other products (especially containing any form of oil) are not used in vaping devices.”
The New England Journal of Medicine, “Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report”:
“Although the cause or causes of the reported illnesses remain under investigation, products containing THC are the most commonly reported e-cigarette product exposure among these case patients (84 percent). However, 17 percent of the patients reported using only nicotine-based products, and 44 percent reported using both THC-based and nicotine-based products. Information on product use is based on reports by the patients, and patients may be reluctant to report illicit drug use.”
Are legal e-cigarettes to blame?
Dr. Scott Gottlieb, former commissioner of the Food and Drug Administration:
“We should acknowledge and incorporate into our policy response three facts about the current tragedies related to vaping and kids. 1) Many are likely caused by illegal and counterfeit products, some laced with THC…2) Legal vapes while not safe are subject to regulation on manufacturing, sales, marketing, ingredients, warnings. These regs took effect Aug 2017; and 3) If we outlaw all vapes, and pull legal products off the market, problems with illegal and counterfeit products will get worse.”
Dr. Michael Siegel, professor in the Department of Community Health Sciences, Boston University School of Public Health:
“I find it completely irresponsible for the CDC to continue to obscure the truth and to continue to try to blame this outbreak on legal, nicotine-containing e-cigarettes that have been on the market for years and have not caused any previous problems, rather than to acknowledge that the vast majority of the cases seem to be due to the use of illegal marijuana vape carts.”
Christopher Snowdon, head of lifestyle economics at the Institute of Economic Affairs:
“The CDC is playing a dangerous game. When a bad batch of drugs appears on the streets of Britain, the police do not issue a general warning against taking drugs. Instead, they describe what the bad batch looks like so that drug users can avoid it. Why? Because telling people not to take drugs doesn’t work. Telling people to avoid a particular bunch of green Ecstasy pills does. By the same token, the CDC’s policy of telling people not to vape is not only a tacit instruction to smokers to keep smoking, but is a less effective way of tackling the current spate of hospitalizations than telling people to steer clear of black market THC cartridges.”
“The FDA also told state officials Wednesday that its lab tests found nothing unusual in nicotine products that had been collected from sick patients, according to another person who took part in the call.”
The tragic cases of deaths and respiratory illnesses being reported across the country are a matter of urgent concern for public health officials. But politicians, journalists, and others should take care not to conflate the use of legal, regulated e-cigarette products with illegal and contaminated products. Otherwise, smokers looking for healthier alternatives and current e-cigarette users may garner the impression that it would be beneficial or otherwise not as harmful to return to smoking cigarettes, which remain the most dangerous consumer product on the market and are responsible for 480,000 deaths per year.
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