Although the topic has died down after reaching a crescendo in the fall of 2019, reports are still trickling in of people who’ve contracted a lung illness, and of some who’ve even died, as a result of vaping. Not only is this rightly terrifying, it begs the question: if vaping has been around for more than a decade, why is it only now that we’re getting all of these reports about severe lung disease and sudden death?
The answer is actually fairly simple, though unfortunately it’s not one that’s often accurately reported by major media sources. Let’s dive in and explore the root cause of what the federal Centers for Disease Control and Prevention (CDC) somewhat confusingly terms “E-cigarette, or Vaping, Product Use-Associated Lung Injury,” or EVALI.
In mid-2019, patients began showing up at hospitals showing signs of a mysterious lung infection cropping up in otherwise healthy patients. By August, the CDC had established a link between the disease and use of a variety of vapor products. Fast forward to October and, with nearly 1300 cases reported, the EVALI name was coined.
At this time, the CDC warned against using any type of e-cigarette or vapor product, advice they’d later retract only after serious damage was done with regard to public perception of vaping. The number of reported EVALI cases eventually topped 2500, with more than 50 deaths related to the illness.
News media, conditioned by a scare years ago related to the flavor extract diacetyl, quickly responded to the newest potential vaping threat. Diacetyl is a compound that creates a buttery note and is used heavily in the manufacture of microwave popcorn. Exposure to high concentrations of the chemical has led to a condition known colloquially as “popcorn lung” in factory workers, and its presence in some bakery and dessert e-liquids was presented as proof in the mid-2010s that e-cigarettes were dangerous to their users. Although diacetyl is found in much higher concentrations in cigarette smoke than vapor and only one case of popcorn lung has ever been reported outside a factory setting (not vaping-related), e-liquid manufacturers have largely changed their recipes to avoid exposure to the substance.
But as it would turn out, the primary culprit behind EVALI, and in fact the only one identified to date, has absolutely nothing to do with nicotine vaping at all.
A New Kind of Vape
As we know, e-cigs and liquid vapor devices have been around for well over a decade at this point. Why, then, has the EVALI scare only come to light in the last six months or so? It turns out that there is a completely new player in the vape scene that’s only rose to prominence within the last couple years: marijuana.
Many states have moved within the last decade to legalize cannabis consumption either for personal or medical reasons. Eleven states now allow adults to consume marijuana for any reason, and 33 in total allow it for medicinal use – that number could jump to 40 by the end of the year. With laws and social norms surrounding the substance relaxing across the nation, many users have looked for less-harmful ways to consume it, including by vaping.
Liquid marijuana vaping is very different from nicotine e-liquid, however. Unlike the water-soluble base ingredients propylene glycol and vegetable glycerin that make up most of what goes into an e-liquid, cannabis extract is oil-based. Since oil and water don’t mix, different base ingredients are used to formulate the much-thicker cannabis liquids that go into marijuana vape cartridges than into e-liquids or pre-filled nicotine pods.
The Culprit Emerges
Oils have always been somewhat of a bogeyman in nicotine vaping circles, and for years both amateur and professional e-liquid mixers have advised complete avoidance of any oil-based flavorings when making vape liquid. The reason for this is that oils are essentially fats, and fat deposits in the lungs can lead to a condition called lipoid pneumonia, a serious lung condition very closely aligned with EVALI symptoms.
Some fats, it seems, are even more harmful than others. Of particular concern is vitamin E acetate, an oil similar in appearance and viscosity to oils extracted from the marijuana plant. While not often an ingredient in cannabis vapor cartridges from responsible manufacturers, it became popular for use by unregulated distributors preparing cartridges for sale on the black market in states where marijuana remains illegal or in legal states to consumers trying to avoid taxes.
As the CDC investigated the outbreak of EVALI, it became clear that the vast majority of people who contracted the illness admitted to using marijuana vapes, either exclusively or in combination with legal nicotine vapor products. Public health officials acknowledge that it’s possible even more of the cases are marijuana-linked but that users were fearful of acknowledging their cannabis use.
Testing of patients further proved out what the CDC calls a “strong” link between vitamin E oil and EVALI, with 48 of 51 patients in a study having the compound present in lung fluid drawn as a sample. The evidence was so strong that, earlier this month, the CDC reversed its position of advising consumers to avoid all vapor products and instead now cautions specifically against the use of black market marijuana vapes.
Following the initial panic, new cases of EVALI have dropped dramatically. Over the last two years, more than 100 people have been arrested for manufacturing and distributing illegal marijuana vape cartridges, of which more than a half million have been seized – most of this activity has come since the initial disease scare.
That’s good news. But an unfortunate side effect of the controversy has been the continued demonization of the legal nicotine vapor industry and an unnecessary panic that’s caused an unknown number of people to switch from vaping back to smoking, a practice that’s undeniably more harmful. Even worse, the panic has caused even more people to believe (incorrectly) that vaping is worse than smoking, and lent momentum to a host of vaping bans working their way through all levels of government including a ban on flavored pods that takes effect next month.
Remember: vaping is not “safe” or without risks of its own, some of which we still don’t understand and likely won’t for years to come. If you don’t vape and don’t smoke, you shouldn’t start. But if you are a current or former smoker, it’s important to know that there’s a large and growing body of evidence that nicotine vaping is preferable to continuing smoking, and that to date no ingredient in a nicotine e-liquid has been tied to EVALI, even in those instances where no one died.