Concerns about the outbreak have since diminished, but there continues to be some confusion about the causes of EVALI. Additionally, there has been some confusion about the dangers of using e-cigarettes and similar “vaping” technologies that have been developed within the cannabis industry. This post hopes to describe the most current information about the EVALI epidemic, as well as to provide some clarity concerning vaping devices.
Before delving in, there is a lesson from history that is pertinent here. Approximately 2500 years ago, Kamarina, a town in Sicily was plagued by a mysterious illness. Eventually, the leaders of the town determined that the cause of the disease was a swamp that surrounded the settlement, and that the swamp should be drained. Before beginning this task, however, they consulted the oracle of Apollo. The oracle said that the swamp should remain because the disease would eventually pass. The leaders decided to drain the swamp anyway. Soon after, an invading Carthaginian army effortlessly traversed the dried swamp and razed the town.
What Are Electronic Cigarettes?
Electronic cigarettes (e-cigarettes or e-cigs) have become ubiquitous. These devices allow users to inhale a vapor created by heating nicotine, flavorings, and other substances (such as glycerin or propylene glycol) that typically come in a prepackaged, liquid solution often known as vape juice or e-juice. The act of using an electronic device to inhale vapors has become known as vaping.
As vaping liquids containing nicotine became more common, so too did the vaping of oils rich in cannabinoids. In most cases, these devices resemble pens and are consequently known as vape pens. Products that contain either tetrahydrocannabinol (THC), which produces intoxicating effects, or cannabidiol (CBD), which does not, also contain thickening agents like vegetable glycerin or propylene glycol. This is true for those who vape cannabis recreationally, as well as those who participate in state medical cannabis programs. (The vaping devices described in this post should not be confused with devices that heat herbal cannabis to the point where the cannabinoids vaporize but stop short of bringing the plant matter to the point of combustion.)
Though vape juice and cannabis oils appear to be similar, they are not interchangeable. One cannot use the same device for both without making significant modifications, as the two preparations have different chemistries. Simply put, cannabinoids are highly lipophilic and highly hydrophobic, whereas nicotine is soluble in both water and in lipids.
The Promise of Electronic Cigarettes
The dangers of smoking are very well documented. Cigarettes that contain tobacco can lead to significant health problems such as heart disease, cancer, and chronic obstructive pulmonary disease (COPD), and are especially hazardous because of the addictive nature of nicotine, which is found in tobacco. It should also be emphasized that cigarettes can lead to low birth weights, birth defects, and preterm birth, and that it is highly recommended that pregnant women abstain from smoking.
For these reasons, many medical professionals were cautiously optimistic about the potential benefits of electronic cigarettes as a tool for smoking cessation when they first entered markets in the United
States in 2007. There continues to be a strong consensus among medical professionals that e-cigarettes are less dangerous than conventional cigarettes, and that electronic cigarettes can be an enormous benefit if they help individuals quit smoking.
Additionally, evidence shows that vaping is more effective than other cessation tools when it comes to getting people to quit smoking. Recently, 900 people who wanted to quit smoking were recruited to take part in a study. Half were given e-cigarettes and half were given other nicotine replacement products like patches or gum. One year later, 18% of those assigned e-cigarettes had stopped smoking. Among the other group, only 10% had successfully quit.
Unfortunately, the same study showed that many individuals may use electronic cigarettes not as a means to quit, but as a substitution for conventional cigarettes. Of those within the e-cigarette group who had quit smoking, 80% were still using them a year later. Of those within the group who had been assigned gum or patches, only 9% were still using the other nicotine replacement products. In other words, it appears that many individuals who stop smoking and start vaping merely change the delivery mechanism through which they satisfy their addiction to nicotine.
To reiterate, most medical professionals would agree that vaping is preferable to smoking, and that e-cigarettes are beneficial as a cessation tool, but they are not harmless. They still contain nicotine, and nicotine has been shown to increase the risk of cardiovascular, respiratory, and gastrointestinal disorders.
Moreover, it seems as though the market for vaping devices is changing in a manner that indicates e-cigarettes are no longer being marketed as a cessation tool, but rather as a novel means of delivering nicotine to new users. At the time they were introduced, in 2007, e-cigarettes resembled conventional tobacco cigarettes and were typically disposable. In time, the devices became more permanent and reusable (as their batteries can be charged using a USB cable), thereby encouraging users to purchase more disposable cartridges containing the nicotine-rich liquid. Additionally, many of the devices, most notably the “pods” manufactured by JUUL, ceased to resemble traditional cigarettes physically. Flavors also proliferated, many of which were ostensibly intended for younger users—for anyone to maintain that there is a large adult market for cotton candy-flavored vape juice seriously stretches credulity.
This evolution in appearance has led to a far more dangerous psychological divorce between conventional cigarettes and e-cigarette: many younger vapers fail to recognize that they are using a product that contains nicotine. Though this may seem ridiculous to previous smokers or even older non-smokers, surveys show that this disconnect is real and extremely common. The Centers for Disease Control and Prevention report that two-thirds of JUUL users between the ages of 15 and 24 do not know that JUUL products contain nicotine.
This is shocking, but far less alarming than the figures describing the rapid rise of vaping among high school students. A CDC survey shows that, while conventional cigarette use has declined among U.S. high school students throughout the 2010s (from around 16% in 2011 to 6% in 2019), e-cigarette use has skyrocketed from 3% in 2011 to 27.5% in 2019. Also shocking: 10.5% of middle school students reported current use.
The original impetus to use vaping devices to consume cannabis is not the same. The goal of the user is not to quit smoking. Rather, these individuals prefer vaping to smoking for other reasons. For some, vaping is a more discreet alternative, it is easier to calculate one’s dose, and the act of inhalation is less harsh than smoking.
Vaping can also allow one to purchase distillates that contain extremely high concentrations of THC. This has become a growing concern among many medical professionals, as extremely high doses of THC can send individuals to the emergency room and lead to acute cannabis-induced psychosis.
Acute cannabis-induced psychosis is not permanent. It dissipates as the THC is metabolized or eliminated. Additionally, it is a separate issue from the argument that cannabis use may play a role in triggering severe mental illnesses such as bipolar disorder or schizophrenia. The debate on that matter is ongoing and beyond the parameters of this post.
Within this post, I have noted two public health issues:
1. Tobacco use among teens—via devices like those manufactured by JUUL—is on the rise after years of decline;
2. Increasingly high concentrations of THC are leading to more hospitalizations for acute cannabis-induced psychosis.
While both are public health concerns, neither one is behind the outbreak of EVALI cases in the United States. They are concurrent public health issues and should not be conflated.
What is EVALI?
Since the beginning of August 2019 and through January 7, 2020, the CDC has reported 2602 cases of EVALI. In that time, 57 deaths have been confirmed. EVALI patients typically experience symptoms that look like pneumonia. This includes shortness of breath, coughing, chest pain, fever, and even nausea. Many of those who are stricken with EVALI are otherwise young and healthy.
In all EVALI cases, patients reported using vaping products. Most claimed they vaped cannabis. Some did not. Lab results seemed to corroborate many of these claims. In most cases, THC was present; in a few, it was not. What was present in all samples of bronchoalveolar lavage (BAL) fluids taken was a substance known as vitamin E acetate. This suggests that the common denominator is vitamin E acetate.
Vitamin E acetate closely resembles vegetable glycerol—the substance found in most cannabis vape cartridges and some vape juices—but is significantly cheaper to produce. Additionally, vitamin E acetate is a common ingredient in cosmetics and balms, as it has numerous benefits when applied topically. It has been used for a long time and is not considered dangerous so long as it is not vaporized and inhaled. When this happens, it can coat the lungs as if in honey.
Though more evidence needs to emerge before any definitive conclusions are made, it seems as though the cause of the EVALI outbreak can be traced back to illicit manufacturers who use vitamin E acetate to cut costs. Consequently, only those who used cannabis or nicotine products obtained from illicit sources should have been exposed to vitamin E acetate. This seems to be the case.
This suggests (though it does not prove) that vaping is not to blame for EVALI per se; rather, the problem is that individuals are obtaining vaping products that have been adulterated with vitamin E acetate. In other words, the rising use of products like JUUL pods among teenagers is a major problem, but it has very little to do with EVALI. Additionally, the rising strength of cannabis products is a concern, but it has virtually nothing to do with EVALI.
Most importantly, if our fervor to end teen smoking and to restrict high-potency cannabis makes it more difficult to obtain unadulterated products, this could push people to seek out vaping products via the illicit market—the source of products that contain vitamin E acetate. We need to be judicious and base our decisions on sound evidence. We do not want to invite another Kamarina.
Dr. Ahmad reports no conflict of interest. He is not a speaker, advisor, or consultant and has no financial or commercial relationship with any biopharmaceutical entity whose product/device may have been mentioned in this article.