What’s Behind the Mysterious Illnesses and Deaths Linked to Vapes and E-Cigs?

What you need to know about Vaping-Associated Pulmonary Injury and Trump’s proposed flavored e-cig ban

A newly identified ailment, known as Vaping-Associated Pulmonary Injury (VAPI), is being diagnosed across the country, with vapes and e-cigarettes linked to illness and even death. On September 6, Los Angeles County reported its first VAPI fatality, one of six recorded so far nationwide. But, even as cases pile up, the exact causes of VAPI remain unknown.

Symptoms of VAPI can include coughing, chest pain, and shortness of breath. Some studies have also connected vaping to lipoid pneumonia, in which fat particles enter the lungs.

“As we work to identify what is causing otherwise healthy young people to become ill, state health officials and doctors are finding clinical similarities that will help doctors identify patients more quickly,” Dr. Dana Meaney Delman, the incident manager overseeing the Center for Disease Control’s response to the vaping illness, said in a press briefing on the matter.

Among the patterns they have begun to trace are that the majority of patients are young men, with a median age of 19, who are described as “generally healthy.” Typically they report respiratory problems, fever, and other symptoms, and all reported using a vape product within the last 90 days–nearly all vaped within the last seven days–with a majority of those afflicted using both what they believed to be nicotine and THC products within that time period.

“The bottom line is everyone should think twice about vaping until more is known about their impacts”

“As their popularity rises, especially among teens and young adults, we are compelled to warn our 10 million residents that the risks of using these devices–with or without nicotine, marijuana, CBD, or some street concoction–may now include severe lung injury,” says Los Angeles County Health Officer Dr. Muntu Davis. “The bottom line is everyone should think twice about vaping until more is known about their impacts on the health of their users, and the role they play as a contributor to lung damage.”

Nicotine vapes, sold under brand names like Juul, NJOY, and blu, have been seen as an alternative to traditional tobacco cigarettes, with many users under the impression that they were a “healthier” option. It’s an impression that some officials believe was spread by e-cigarette marketers themselves. On Monday, the FDA formally accused Juul, the largest brand in the marketplace, of illegally marketing their products as safer than traditional cigarettes, and revealed details of an 18-month long probe of the company over allegations that Juul withheld pertinent documents from authorities.

The technology in the typical modern, portable vaporizer, was patented in 2003. In her 2018 New Yorker feature on the vaping phenomenon, journalist Jia Tolentino suggests readers “imagine a handheld humidifier that’s hot and full of nicotine.” They may come as pre-filled disposables, or as units which can be refilled. Those refills (often called “carts,” short for cartridge) seem to be a prime suspect in the search for a cause of VAPI–specifically illicit cartridges sold on the black market.

As the New York Times reports, several cases in New York have been at least tentatively linked to “juice” cartridges containing vitamin E oil or synthetic vitamin E oil (also known as tocopheryl-acetate). The vitamin E oil was detected in samples of illicitly produced vape cartridges containing both nicotine and marijuana. Recreational-use marijuana is still prohibited in New York state, so many users go to the black-market to obtain product, rather than visiting regulated dispensaries; only one death, reported in Oregon on September 5, has yet been connected to a marijuana vape product purchased at a licensed cannabis dispensary.

But even if vitamin E oil explains some of cases, health officials don’t think that any one additive alone is the whole answer. Concerns have also been raised about the vape devices themselves, particularly the temperatures to which the “juice” is heated in order to become vapor; a fully operational vape may heat to over 200 degrees and illicitly-made devices or cartridges can cause inconsistencies and spikes. Another line of inquiry focuses heavily on the solvents some operations, particularly illicit or simply disreputable marijuana dealers use to extract active ingredients from plant matter.

“At this time, no one device, product, or substance has been linked to all cases”

“Based on the clinical and laboratory evidence to date, we believe that a chemical exposure is likely associated with these illnesses,” Dr. Delman of the CDC said. “However, and I really want to stress this, more information is needed to determine which specific products or substances are involved. We are aware that some laboratories have identified vitamin E acetate in product samples, and we have connected those laboratories with the FDA forensic laboratories to compare results. At this time, no one device, product, or substance has been linked to all cases.”

The current rash of vaping illnesses appears to have started in mid-July, but concerns about what may be in vape cartridges isn’t entirely new. As far back as October 2018, studies were published describing chemicals appearing in Juul and other major-brand e-cigarettes, as NPR reported. E-cigarette brands are not required to disclose their ingredients lists, so a team of Yale scientists “reverse engineered” several formulas to determine what might be inside. They found a number of acetals, aldehydes, and other potential lung irritants.

On Wednesday, with concerns about VAPI increasing, the Trump administration announced a proposal to ban sales of nicotine products with “non-tobacco” flavorings. While legitimately produced and sold e-cigarette cartridges are not directly implicated in a large number of VAPI cases diagnosed to date, the proposed ban also seems motivated by a more general desire to curb the popularity of e-cigarettes with teens, which has grown rapidly, and is often linked to developing an addiction to traditional cigarettes later in life.

“We intend to clear the market of flavored e-cigarettes to reverse the deeply concerning epidemic of youth e-cigarette use,” Health and Human Services Secretary Alex Alzar wrote in a statement regarding the move.

Marijuana vape products sold on the regulated market in California have, to date, not been linked to cases of VAPI–and some in the cannabis industry are scrambling to educate consumers about the distinctions between buying legitimate marijuana products versus those sold on the black market.

“If a consumer purchases on the black market, it is like anything else. You don’t know what is inside–or what cartel you are supporting”

When it comes to purity, the state guidelines are very strict,” says Cody Sadler, co-founder of Platinum, a cannabis brand that produces vape products. “California’s regulated cannabis and cannabis products are rigorously tested for residuals, toxins, solvents, pesticides, and heavy metals, above and beyond the testing required for any other manufactured product sold in California.”

So far, Sadler reports his company hasn’t noticed any sales fluctuations related to VAPI fears–and he’s still confidently using his own vape himself–but he warns that consumers should do their research, talk to trusted authorities, and most of all, avoid illicit products. 

“If a consumer purchases on the black market, it is like anything else,” he says. “You don’t know what is inside–or what cartel you are supporting.”

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