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Vaping is hailed as the go-to alternative for the one billion nicotine-addicted smokers globally, not safe but 95% safer than tobacco, according to experts. Now with the number of vapers worldwide predicted to reach 55 million by 2021, the September 2019 reports by the Centers for Disease Control and Prevention (CDC) about an outbreak of severe lung disease linked to vaping has put vaping under scrutiny. What is behind these latest vaping scares in the US?

In the latest update, the CDC reports, there are now 2,290 confirmed and probable lung injury cases linked to the e-cigarette, or vaping products use in 49 US states. Forty-seven people are said to have died on EVALI short for ‘E-cigarette, or Vaping product use Associated Lung Injury.’

The culprit

CDC identified vitamin E acetate as the chemical of concern, after laboratory testing of bronchoalveolar lavage (BAL) fluid samples from the lungs from 29 patients with EVALI from 10 states.

Among all registered EVALI patients, 95% of patients ended up in the hospital. The demographic characteristics of patients were similar; most were male, and most were younger than 35 years old. These patients also reported identical use of tetrahydrocannabinol (THC)-containing products. (83% of hospitalized versus 84% of nonhospitalized patients).

What's Behind the Latest Vaping Scare in the US

Among all registered EVALI patients, 95% of patients ended up in the hospital (image source – Unsplash

Patients in the CDC investigation reported symptoms such as:

  • cough, shortness of breath, or chest pain
  • nausea, vomiting, abdominal pain, or diarrhea
  • fever, chills, or weight loss

CDC found vitamin E acetate in all of these samples. It was the first time oil has been detected directly in the lungs of patients, near the inflamed areas of the lung.

What is Vitamin E acetate?

Vitamin E acetate is a popular thickener found mostly in illicit market THC vape carts.

Vitamin E is the common name for several similar types of chemicals called “tocopherols.” Alpha-tocopherol contained in corn and other vegetable oil. Tocopherol can also be made synthetically from petroleum. We often eat tocopherols as a dietary supplement, and manufacturers put tocopherols in food and cosmetics. Vaping looks to lead to the oil coating of the lungs and so hindering the exchange of oxygen. As the lungs attempt to free themselves of the oil, they become inflamed, which impede the breathing process even more. The reaction of the lung to it is the primary concern.

Other issues could be related to the purity of Vitamin E acetate; this is conjecture at this point, as we need further research on the subject. When chemists extract tocopherols from vegetable oil using fractionation there is a chance that trace food allergens like soy and nut can remain in tocopherol mixtures.

Lung reaction to inhaling an oil, is it new?

No. Records show documented cases of people inhaling oils leading to lipoid pneumonia in medical journals over the last decade. Individual cases included children inhaling oil or Vaseline products applied to their noses or adults smoking oil moistened tobacco. So while case studies exist, more systematic scientific research is still to be conducted. Scientists note that while FDA regulation covers what is safe or allowed to consume via food intake, inhaling vape form of substances is a new area, with heating temperatures and hardware material also needing consideration.

Vapes on the market include next to nicotine, flavors, also caffeine products or other energizers, essential oils, CBD, or a variety of vitamin vapes not containing vitamin E acetate.

Scrutiny of ‘illegal’ unregulated vapes

Tetrahydrocannabinol (THC) was in most of the 26 EVALI samples tested to date. Most of the 26 patients reported a history of using THC-containing e-cigarette or vaping products. Many bought from informal sources like friends, or family, or in-person or online dealers. Questions arise regarding how far unregulated production, so-called ‘homebrews,’ might play some role in the outbreak, raising questions about the purity of the products and compounds vaped.

When analyzing the risks of vaping, one has to consider that there are two vape systems on the market. Closed system vapes have ready-made refills screwing directly onto the e-cigarette’s battery. Here a producer controls what goes into the vape. In an open system, the liquid can be refilled manually by the user, using a variety of products not controlled by one producer.

Currently, CDC is still collecting data till the end of November and plans to release the next update and findings by December 5, 2019.

Unanswered questions

So far, the sample of 26 people seems quite small given the nearly 2300 cases of EVALI. A question remains as to why was the outbreak mainly occurring in the US, and not other big vaping markets like the UK or Germany?

Some other obstacles

While most patients have acknowledged the recent use of tetrahydrocannabinol (THC)-containing e-cigarette products when speaking to healthcare personnel, or in follow-up interviews by health department staff. The New England Journal of Medicine reported that “Information on product use is based on reports by the patients, and patients may be reluctant to report illicit drug use.”

Vaping Scare

The market increase of vaping worldwide from about seven million in 2011 to 41 million in 2018 (image source Unsplash)

The market increase of vaping worldwide from about seven million in 2011 to 41 million in 2018 is a business opportunity for many. Global production by small businesses and increasing online availability make oversight and quality control a challenge, price competition, and lack of knowledge might lead to the production and distribution of unsafe vape juice. Further, the open systems might lead to people, not chemists, creating their personalized mix. Given that people continue to vape only increased awareness and information on substances, dos and don’ts can address existing risks.

So far, most of the vape carts seized in the ongoing investigation into the lung injuries have come from the illicit market. Stringent testing in markets deters additive use—but doesn’t assure its absence. Regulations in legal adult-use cannabis markets do not explicitly ban many additives, including tocopherols. But they may soon.

Keeping it real

FDA has actively regulated the legal vapes since Aug 2017. FDA has conducted thousands of inspections of manufacturers and vape stores, published manufacturing guidance, sought product removals, etc. The EVALI tragedies point to illegal vapes and THC. While more remains to do in regards to researching the health consequences of vaping of certain substances, awareness-raising about risks, and regulating a growing industry, this should be done based on scientific facts. This is why it is so important to purchase safe vapes.

Experts are pointing out that vaping remains much safer than smoking, with some concern that the current vaping scare might lead to nicotine-addicted people going back to the more dangerous tobacco. As the CDC acknowledges, ‘Cigarette smoking is responsible for more than 480,000 deaths per year in the United States’. Adults who are using an e-cigarette, or vaping, products for smoking cessation should be advised not to return to smoking cigarettes.

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