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What You Should Know About E-cigarettes and EVALI

A January 2020 poll by Morning Consult of 2,200 adults found that 66% mistakenly believe that nicotine e-cigarettes are the cause of the EVALI outbreak. Despite the fact that the CDC announced January 16, 2020 that the strongest link to the outbreak was illicit THC vapor products tainted with vitamin E acetate, the number of adults who believe nicotine products are the cause has risen 8 percentage points since the height of the outbreak in September 2019. Here’s what you need to know about EVALI.

What does EVALI mean?

EVALI is an acronym coined by the CDC for “Electronic Cigarette, or Vaping, product use-Associated Lung Injury.”

How is EVALI diagnosed?

Patients present flu- or pneumonia-like symptoms that don’t respond to traditional treatment.

Symptoms may include:
  • Coughing
  • Chest pain
  • Shortness of breath
  • Abdominal pain
  • Nausea
  • Vomiting
  • Diarrhea
  • Fever
  • Chills
  • Weight loss

If the patient reports current or past use of vaping products, the diagnosis is a matter of excluding other illnesses and diseases. Medical professionals will do a physical exam, which includes taking the patient’s vital signs and pulse-oximetry (a test to measure oxygen levels in the blood). A respiratory virus panel is also recommended to rule out other illnesses, and a chest CT scan.1

Why do researchers think this outbreak is related to vaping?

In these cases, the patients involved reported a history of vaping, and testing found no evidence of a known illness or disease that could explain the symptoms. The correlation of current or past vaping among these patients was strong evidence that something in the vapor products might be causing the illness.

What type of vapor product were the patients using?

The CDC investigation found that 82% of the patients self-reported using THC (tetrahydrocannabinol, the main psychoactive chemical in cannabis) products, while 14% self-reported only using products containing nicotine. Of those reporting vaping THC products, 78% reported acquiring products only from informal sources (family/friends, dealers, online, or other sources).2 Patients used many different brands and products, so the outbreak has not been narrowed down to a specific brand or product.

What does the CDC suspect is causing the illness from vapor products?

Among patients who reported vaping THC products, the CDC found that the patients were exposed to vitamin E acetate. The tests found vitamin E acetate either in the product the patients were using, or vitamin E acetate was found in the patient’s lungs. Among patients who reported exclusively vaping nicotine, the CDC has not reported finding any vitamin E acetate or any other contaminants in the products those patients used, nor has CDC reported finding vitamin E acetate in their lungs.

What is vitamin E acetate?

Vitamin E is the common name for several similar types of chemicals called “tocopherols.” Chemists extract oils from plants and then fractionate (similar to distilling alcohol) tocopherols from the oil. Vitamin E acetate, also known as “tocopheryl acetate,” is a synthetic form of vitamin E. It is often found in skin care products and dietary supplements. While vitamin E is claimed to have antioxidant properties for skin, it has not been studied for inhalation.

Why is vitamin E acetate being used in vapor products?

Vitamin E acetate is considered a contaminant in vapor products containing THC.

THC vapor products are filled with a liquid that consists of cannabinoids (including THC,) terpenoids (aromatic oils) and flavonoids (pigments) that have been extracted from marijuana flowers. According to Leafly.com3:

Pure THC extract is a thick amber oil, and traditional THC oil cutting agents thin the oil. In response, customers learned to detect cut oil by flipping over vape cartridges to see how the air bubble moves inside the tank—much like the bubble in a carpenter’s level. A fast-moving bubble means the oil had been thinned with a cutting agent and wouldn’t deliver the high THC potency a consumer desires.

Manufacturers of illicit THC cartridges use vitamin E acetate as a “thick cutting agent” to thin the THC oil without affecting the “bubble test” mentioned above. Cutting THC oil with vitamin E acetate means that illicit cartridges can be sold at sometimes half the price of legal products. Manufacturers of legal, regulated THC vapor products are less likely to have used vitamin E acetate to dilute their products because they are often legally required to undergo testing for potency and purity.4

Is vitamin E acetate used in commercial nicotine vapor products?

No. The ingredients of commercially-available nicotine vapor products may include: propylene glycol, vegetable glycerine, food-grade flavorings and USP-grade nicotine, but they do not contain vitamin E acetate. Nicotine vaping liquids are alcohol-based and water soluble, not “oil.” Nicotine strengths are adjusted by using more or less propylene glycol or vegetable glycerine. There is simply no cost benefit for manufacturers to use vitamin E acetate in nicotine liquids. In fact, oil-based liquids are not even compatible with devices designed to vaporize water-based nicotine liquids.

Why does vitamin E acetate harm the lungs?

Researchers and medical professionals aren’t exactly sure why, but they have some theories. For example, tocopherols adhere to the lung surfactant, which is a fluid that lines the surface of the lungs. The fluid allows oxygen to transfer from the air into the rest of the body. Tocopherols can block that transfer from happening, causing the difficulty in breathing.

Are THC vapor products commonly referred to as “e-cigarettes” by the THC vapor industry or consumers?

No. Cannabis and THC vapor products are most commonly referred to as “vape pens” or “vape carts” (short for “cartridges.”) The term “e-cigarette” is almost exclusively used to refer to nicotine vapor products.

Commercially-available nicotine vapor products don’t contain vitamin E acetate, so how are they linked to EVALI?

For most of the outbreak medical professionals and the CDC have relied on self-reported information from the patients to determine what products were being used. CDC reports that in 14% of the suspected EVALI cases, patients reported that they did not use THC vapor products and exclusively used nicotine vapor products.

However, in many of these cases, patients who denied using THC either eventually admitted to using illicit THC products, were found to have THC in their system or THC products were found in their home by friends or family members. CDC has acknowledged that many may have feared legal repercussions of admitting to using an illegal substance.

Not all of the EVALI patients were tested for THC, but of those who were, some test results came back negative for THC. However, those patients were still found to have vitamin E acetate in their lungs. Experts suggest that the THC could have been purged from their system by the time they were tested, while the vitamin E acetate remained in their lungs. As vitamin E acetate isn’t found in nicotine vapor products, it’s more likely that the patients were exposed to illicit THC vapor products.

Furthermore, the CDC has not reported any contaminants found in commercially-available nicotine products used by the suspected EVALI patients. The products the patients used contained the same ingredients as products used by millions of unaffected vapers. This raises serious doubt as to whether nicotine products can be implicated in the outbreak at all. Those who claimed to have not used illicit THC vapor products are more likely either misleading authorities about their use, or their condition is unconfirmed as EVALI.

Why did the CDC emphasize “e-cigarettes” instead of tainted, illicit THC vapor products when naming the outbreak?

Because so few cases have involved exclusive use of e-cigarettes, it is unclear why CDC chose to emphasize the word “e-cigarettes” when naming the illness. Some suspect it may have been intentional to conflate the outbreak with commercial nicotine vapor products as an attempt to reduce youth experimentation. Others believe it was simply a lack of understanding popular terminology on the part of agency officials. Unfortunately, we may never know.

Does the CDC still advise consumers to stop using any vapor product, including nicotine vapor products?

In January of 2020, the CDC finally moved away from the broad recommendation that people consider refraining from vaping altogether. The web site currently advises that youth, pregnant women and non-tobacco users shouldn’t vape. The CDC guidance also states that former smokers using nicotine e-cigarettes should not go back to smoking.

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