Vaping Outbreak: Update

Timothy Byars

President, Chief Education Officer

Radicle Health

Presently, there is an outbreak in the U.S. of lung injury of unknown source associated with electronic smoking devices. As of today, the Center for Disease Control and Prevention has reported a total number of 1,299 cases of vaping-related lung injuries. Two thirds of these cases are people between the ages of 18 and 34. To date, there have been 28 deaths.

The symptoms include shortness of breath, cough, chest pain, nausea, fever, fatigue, and abdominal pain.[1] For some patients, the symptoms developed within days; for others, symptoms developed over several weeks.[2]

Currently, the CDC believes that these illnesses are not caused by infection by direct tissue damage from chemical contaminants or other noxious agents. However, the causes remain unknown. It remains unclear whether the causes are from cannabis products, from nicotine products, from products with synthetic cannabinoids, from flavored e-liquids, or from some combination of these products.

Health officials from several states are working with CDC to determine the causes of the outbreak. For example, in July of this year, the Illinois Department of Public Health and the Wisconsin Department of Health Services launched an investigation with 86 of the 127 patients with lung injury in Wisconsin and Illinois. [3]

Among the 86 interviewed patients:

• 75 (87%) reported using cannabis products during the 3 months preceding illness

• 61 (71%) reported using nicotine products

• 50 (58%) reported using both THC and nicotine products

• 25 (29%) reported using only THC products

• 11 (13%) reported using only nicotine products

The interviewers asked these patients about specific brands that they were using and the where the patient obtained the products. Patients reported using 155 different cannabis brands.

Interviewers were able to obtain the source information from 112 of these cannabis products:

• 100 (89%) were acquired from informal sources (from an illicit market or from an acquaintance)

• 6 were bought at an out-of-state cannabis dispensary (but the state was not specified, so it's not clear whether these products were purchased in states that have mandatory product testing)

• 5 were bought online

• 1 was bought at a tobacco shop

It should be noted that the five products bought online and the product bought at a tobacco shop should also be considered illicit market purchases, as regulated cannabis products can be sold only through state-licensed dispensaries.

The CDC Principal Deputy Director Dr. Anne Schuchat has stated that the CDC now has product information from 578 patients. 78% of patients reported using cannabis products and 37% reported using only cannabis products. 58% of these patients reported using nicotine products and 17% reported using only nicotine products.[4]

On October 2, doctors at the Mayo Clinic published a report in the New England Journal of Medicine detailing their findings from lung tissue samples that they studied from 17 patients with lung injury (two samples were from patients who had died).

Dr. Brandon Larsen stated that all 17 specimens demonstrated “a pattern of injury in the lung that looks like a toxic chemical exposure, a toxic chemical fume exposure, or a chemical burn injury.” Dr. Larsen also stated the injuries were similar to those sustained by people who have been exposed to mustard gas during World War I.[5]

The CDC stated that no single compound has been found to link all the suspected cases.

Officials from the New York State Department of Health have suggested that one ingredient that might be causing the injuries is vitamin E acetate, which researchers detected in nearly all of the samples they analyzed that were linked to lung injury.

Vitamin E acetate is commonly used in topical products and dietary supplements. There is no data to study its effects when inhaled. Moreover, fats or oils that enter into the lungs can be highly toxic can lead to a condition called lipoid pneumonia.

NBC News commissioned a cannabis testing facility to test a sample cannabis cartridges (18 in total were purchased). Three of these were purchased from legal dispensaries and the remaining 15 unlicensed companies.

• No heavy metals, pesticides, residual solvents, or other potentially problematic toxins (like Vitamin E) were found in the cartridges obtained from the legal dispensaries.

• Of the 15 obtained from the illicit market, 13 contained Vitamin E and 10 contained pesticides (they only tested 10 and all tested positive).

All of the illicit market products contained myclobutanil, a fungicide that converts into hydrogen cyanide when burned and can have a toxic effect on the lungs.

A testing company in Colorado has suggested that the issue might be in the cartridges themselves. To cut production costs, some unscrupulous companies use a type of solder that contains cadmium, and this solder is on the heating element. Cadmium is toxic to multiple organ systems and exposure can produce fever, headache, and joint pain. Cadmium can injure lung cells, can cause fluid in the lungs and can impair function, and can lead to respiratory failure. [6]

Until more information becomes available, the CDC recommends:

• Refraining from using electronic smoking devices.

• If you are using electronic smoking devices, buy these products only from licensed dispensaries.

Radicle Health has always recommended that patients:

• Never purchase or inhale concentrates that contain additives such as Vitamin E acetate, polyethylene glycol (PEG), propylene glycol (PG), coconut oil, MCT oil, or any other emulsifiers or synthetic agents.

• Purchase cannabis products only through state-licensed cannabis retailers or licensed delivery services.

• Never purchase products sold through an illicit market or from any non-licensed dispensary or delivery service. These products are likely not tested and can be easily counterfeited.

Questions or feedback? Leave a comment below or contact Timothy Byars at tim@radiclehealthcare.com

References

[1] Karlamangla S. FAQ: What we know about the deadly lung illnesses tied to vaping. Los Angeles Times. https://www.latimes.com/california/story/2019-10-03/vaping-deaths-lung-illness-cdc-faq. Published October 3, 2019. Accessed October 7, 2019.

[2] For the Public: What You Need to Know. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/need-to-know/index.html. Published October 3, 2019. Accessed October 7, 2019.

[3] E-cigarette Product Use, or Vaping, Among Persons with Associated Lung Injury - Illinois and Wisconsin, April–September 2019 | MMWR. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/68/wr/mm6839e2.htm?s_cid=mm6839e2_w. Accessed October 7, 2019.

[4] Reuters. U.S. Vaping-Related Deaths Rise to 18, Illnesses Surpass 1,000: CDC. The New York Times. https://www.nytimes.com/reuters/2019/10/03/us/03reuters-usa-vaping-cdc.html. Published October 3, 2019. Accessed October 8, 2019.

[5] Grady D. Lung Damage From Vaping Resembles Chemical Burns, Report Says. The New York Times. https://www.nytimes.com/2019/10/02/health/vaping-illnesses.html?action=click&module=RelatedLinks&pgtype=Article. Published October 2, 2019. Accessed October 7, 2019.

[6] Metal Fume Zebra. Colorado Green Lab. http://www.coloradogreenlab.com/blog/part-1-metal-fume-zebra?fbclid=IwAR290zkIsHpxiN9dFCD1Ljatw_sCdCXzrAe4UiqANjEplnjyPEJIJFk6X9A. Published October 5, 2019. Accessed October 7, 2019.