Cloudy with a Chance of Death

Illustrated by Victoria Xu

Over the last few months, news stories about vaping illnesses and deaths have spread like wildfire, with each story portraying a grim picture of a method of inhalation once thought to be safe by design. As a result, a sort of panic has ensued, with federal and state administrations threatening to ban the sale of e-cigarette devices while vape-centric businesses scramble to protect their revenue stream. Public perception of vaping products is wavering as users, advocates and those opposed to the practice receive a hazy picture of the health facts underlying the issue.

As with any drug-related policy consideration, the situation is much more complicated and much less concrete than at first glance. Despite the abundance of eye-catching vaping-related stories, there are very few verifiable conclusions that can be drawn. Nevertheless, public sentiment and even government action are already outrunning scientific research in the race to a solution.

According to the Centers for Disease Control and Prevention (CDC), as of Oct. 1, 2019, there have been 1080 lung injury cases and 18 deaths linked to vaping. But what exactly is vaping? The CDC defines it as the use of electronic cigarettes (or e-cigarettes, for short) that “work by heating a liquid to produce an aerosol that users inhale into their lungs(1). The liquid in question can contain a variety of substances, but the active ingredients are typically either nicotine—the addictive drug derived from the tobacco plant that is at the center of traditional cigarette use—or tetrahydrocannabinol (THC)—the psychoactive drug derived from the cannabis plant commonly known as marijuana.

The CDC goes on to say that, while no particular substance or chemical can yet be attributed to the morbidity of e-cigarettes, 36% of patients report exclusively vaping THC while only 16% report exclusively vaping nicotine in the 30-day period before their symptoms arose (1). The instinct, perhaps, is to interpret this data to conclude that THC is more dangerous than nicotine, at least when inhaled via e-cigarette, but this is not a conclusion supported by enough evidence as of yet. In fact, while THC and nicotine are both addictive substances with their own fair share of reported health drawbacks, there has been some evidence to suggest that neither of these active ingredients are causing the current outbreak. 

Recall that e-cigarettes work by heating a liquid containing a drug into an aerosol to be inhaled. These liquids are sold in disposable, replaceable cartridges alongside the e-cigarettes themselves. Cartridges containing THC are, of course, still illegal under federal law, so—even in states where marijuana use is decriminalized or fully legalized for recreational use—they are likely to be manufactured on the black market. The manufacturing process calls for the use of oils as a thickening agent for the liquid in THC cartridges. In an effort to reduce the illicit production of these cartridges, authorities in several states have cracked down on these thickening oils (2). The result? There has been a recent change in the composition of substances found in illicit THC cartridges.

One of the new stars of the show is a chemical called vitamin E acetate, an oil with similar physical properties to THC oil that is used to dilute the cartridges. While vitamin E acetate is a legal compound incorporated into many safe products, experts believe that it may be dangerous to inhale—causing symptoms like coughing, shortness of breath and chest pain (2). Critically, these are three of the most common symptoms reported by the thousand patients identified by the CDC.

In Illinois and Wisconsin, these illicit, black-market cartridges are used by a majority of people vaping THC, and a brand called “Dank Vapes” is leading the pack of counterfeit e-cigarette products (3). Physicians in New York State have reported over thirty cases of patients with symptoms of a vaping-related illness between August and September of 2019, all of whom were “using at least one cannabis-containing vape product before they became ill(4). For all vaping products submitted for testing as part of this investigation, at least one vape containing vitamin E acetate was linked to each patient.

On the other hand, the New York State investigators did not find any vitamin E acetate when testing nicotine-containing vapes, so perhaps this new cartridge additive cannot account for the 16% of CDC patients who do not report using THC e-cigarettes. An editorial in the New England Journal of Medicine might explain this discrepancy, stating that the “mixing of multiple ingredients with primary compounds and potential contaminants may result in in vitro (or even in vivo) production of new agents that may be toxic(5). So, in short, while vitamin E acetate may play a role in the recent uptick of vaping-related illnesses, it is likely not the full story. The full story, again, is unknown, which is why the CDC has not definitively identified any specific substance that is causing the illnesses.

What the CDC has done definitively, though, is to urge the public to refrain from the use of e-cigarettes, especially those containing THC. In accordance, the Trump administration has decided to enact a ban of flavored vape products nationwide, implicating companies like Juul that sell nicotine e-cigarettes criticized for being marketed towards kids (6). But, while avoiding e-cigarette use may be a surefire way to decrease vaping-related illnesses, banning e-cigarette products may do exactly the opposite. 

Countless research has demonstrated that, when it comes to addictive substances like nicotine or THC, users tend to seek out drugs whether they are legal or not, whether they are sold legitimately or on the black market (7). Therefore, the consequence of a ban may not be a decrease in vaping, but an increase in black-market vaping. And if the main suspect of the recent illnesses is the illicit manufacturing processes employed in the world of black-market cartridges, then pushing more products underground—away from the regulatory oversight of legal sales—may only exacerbate the problem.

Certainly, there are legitimate health concerns associated with nicotine and THC, even when consumed using the safest possible methods. However, if the goal is to mitigate the current health crisis, then banning a significant subset of e-cigarettes is likely not the most effective solution. Instead, more resources should be dedicated to the investigation of e-cigarettes, so that the culprit of the recent illnesses can be identified. At that point, regulation in the legal market can ensure that e-cigarette cartridges are manufactured safely, and legalization can ensure that users buy from these legal markets instead of the unregulated ones.

It is undoubtedly shocking to see article after article about each new patient suffering from vaping-related illnesses, and headlines like the one used here certainly do not help assuage public anxiety. Nevertheless, considering the facts at play, we should devote our energy to solving the problem in a responsible, data-driven way, instead of letting reactionary policy proposals further cloud our collective judgment.

Edited by: Edward Toderescu-Stavila

Illustrated by: Victoria Xu

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