Boston Pulmonologist Provides Misinformation About the Cause of Severe Lung Disease Associated with "Vaping"

In an article published today in the Boston Herald, a Boston pulmonologist attributed the growing number of cases of severe, acute respiratory disease to "vaping" in general, giving the impression that the risk factor for these illnesses is any type of e-cigarette use and implying that any youth who uses electronic cigarettes is at risk. She hyped up this claim about calling vaping "the number one respiratory public health concern in youth and young adults worldwide."

The more than 200 cases of severe lung illness that have been reported in 22 states is indeed an important public health concern. But it is misleading, alarmist, and irresponsible to tell the public that these cases are being caused by retail e-cigarette products generally. Moreover, it is damaging misinformation because it does nothing to prevent further cases from occurring. The attribution for these cases is so broad that it is tantamount to giving no advice at all. Scaring people into believing that any vaping could cause you to die of respiratory failure is not only untrue, but it is not going to result in any change in behavior because it is far too vague.

This is a public health crisis and I think that any physician who makes public statements about these cases has a responsibility to provide accurate information that will actually help to prevent further cases from occurring. Scaring people into thinking that any vaping product can cause respiratory failure is not only inaccurate, but it is irresponsible because it doesn't provide useful information that can help youth avoid the specific products that are responsible for the observed cases.

The Rest of the Story

As an trained epidemiologist, it was immediately clear to me that these cases are not being caused by vaping products generally because these products have been on the market for years without any significant problems and because the reports are clustered in specific geographic areas. Now that further information is available, it is clear that the majority of the observed cases are associated with the use of THC oils that were obtained from unlicensed sellers. It is also likely that cases occurring among people using nicotine-containing e-liquids without THC are due to a contaminant that is appearing in products being sold on the black market, not in retail stores.

According to an article in yesterday's Washington Post, "Officials are narrowing the possible culprits to adulterants in vaping products purported to have THC, the component in marijuana that makes users high, as well as adulterants in nicotine vaping products."

The article also states that: "The sudden onset of these mysterious illnesses and the patients’ severe and distinctive symptoms have led investigators to focus on contaminants, rather than standard vaping products that have been in wide use for many years" and that "The investigation is “starting to point to what solvents are being used, and that can vary a lot” — especially in counterfeit or black-market products, including potentially mislabeled solvents that consumers buy themselves to make do-it-yourself “home brews,” said an official at the Centers for Disease Control and Prevention, which is heading the investigation."

The Boston pulmonologist quoted in the Boston Herald story is telling the public just the opposite, as she is attributing these cases to standard vaping products. This undermines the warnings that several state health departments have given to avoid black market products, especially THC oils. It also unduly scares parents into thinking, for example, that if their child is JUULing, they may die of acute respiratory distress syndrome. There is plenty for a parent of a youth who is JUULing to worry about (namely, the fact that it is addictive), but there is no reason to believe that acute respiratory disease is one of them.

In a disease outbreak such as this one, responsible public warnings need to be as specific as possible about the risk. In an outbreak of E. coli caused by a contaminated batch of lettuce, we don't tell the public that the disease is associated with eating, or even that it is associated with eating lettuce. People need much more specific guidance if they are to take appropriate action to avoid or reduce the risk of further spread of the outbreak.

Here, we need to start telling the public the truth. However much physicians or anti-nicotine groups may not like it, the truth is that the outbreak we are seeing is not due to the risks of using standard vaping products. It appears much more likely that the outbreak is mostly, if not completely attributable to illicit products--especially THC extracts--that are being sold by unlicensed sellers on the black market. Unless people are provided with this specific information, they will not take action to avoid the products that could put them at risk.

Why is the American Lung Association More Interested in Demonizing Electronic Cigarettes than Saving Kids' Lives?

In response to former FDA Commissioner Scott Gottlieb's warning that the spike in vaping-related lung disease among young people appears to be largely associated with counterfeit e-liquid products, especially THC oils, the American Lung Association contradicted Dr. Gottlieb and tried to cast the blame on traditional nicotine-containing e-cigarettes instead.

The spokesperson for the American Lung Association was quoted as saying: "With all due respect to former FDA Commissioner Gottlieb, I think it's too soon to speculate about the cause or the reason why we're seeing this ... I firmly believe that had FDA not delayed the oversight of these products in July of 2017 that we would be in a much different position than we are today. ... The tobacco industry has long been happy to place fingers when there have been issues of counterfeit cigarettes … The bottom line is that e-cigarettes are not safe, and from the American Lung Association’s perspective, no one should be using e-cigarettes."

The Rest of the Story

Alas, the truth is revealed. At the end of the day, the American Lung Association's chief aim is to demonize e-cigarettes and anyone who is using them.

What's astounding to me is that the American Lung Association is actually undermining Dr. Gottlieb's warning to the public to avoid vaping THC oils and counterfeit e-liquids purchased off the street. Moreover, Dr. Gottlieb is not "speculating." At least five different health departments and the CDC itself have stated that many of the reported cases appear to be associated with the use of THC oils purchased off the street. We don't need to wait until there is absolute certainty about the cause of every single case. There is enough information to warn people not to use THC oils or any e-liquids purchased from unlicensed sellers or pop-up shops. That's exactly what Dr. Gottlieb was doing and it's deplorable that the American Lung Association would attempt to undermine his warning just to get in a jab against vapers.

Seriously, it's very clear to me that the American Lung Association truly hates vapers and wishes them nothing but the worst. It's almost as if they are hoping that the cases end up being tied to traditional vaping products so they can say "We told you so."

Ironically, while the American Lung Association castigated Dr. Gottlieb for jumping to conclusions, it then proceeded to jump to conclusions itself, asserting that the cause of these cases is the failure of the FDA to implement the pre-market tobacco application requirement. But that presupposes that the cases are due to e-liquids being manufactured by legitimate companies that would be complying with the FDA regulations. If the cause of many or most of these cases is THC oils, then those wouldn't be subject to FDA regulation in the first place. The ALA's statement is essentially concluding that the THC oils are not a major cause. This is irresponsible and dangerous and threatens the health and lives of the nation's young people.

Marijuana Reform Organization Issues Warning Against Vaping THC Oils Obtained from Unlicensed Sellers; CDC Does Not

It is a sad state of affairs in public health when we have to rely upon a marijuana law reform organization to issue a critical health warning on the severe risks of vaping unlicensed THC oils, while the CDC remains silent.

According to an article in USA Today, the National Organization for the Reform of Marijuana Laws (NORML) warned consumers "not to buy THC vape products from unlicensed retailers." The organization's Deputy Director--Paul Armentano--explained the danger associated with the use of illicit THC vaping products: "Unregulated illicit market cannabis products, like products in any unregulated marketplace, are of variable quality and may put some consumers at risk. These incidents linked to the use of unregulated, illicit market vapor cartridges reinforce the need for greater market regulation, standardization, and oversight ... Consumers must also be aware that not all products are created equal; quality control testing is critical and only exists in the legally regulated marketplace."

In response to the occurrence of seven cases of acute respiratory distress syndrome that were linked to the use of THC or CBD oil extracts purchased from the illicit market, the Hanford (CA) health department issued a very specific warning to the public not to vape cannabis or CBD oils obtained from an unlicensed seller. The warning was issued in no uncertain terms: "Under no circumstances should you vape cannabis or CBD oils obtained from a “pop-up shop."

The Rest of the Story

The CDC continues to remain silent, even though it has become clear that vaping THC oils, particularly those obtained on the street from unlicensed sellers, is a risk factor for the "mysterious" respiratory illness that has affected close to 200 individuals. The CDC has yet to issue any kind of warning, preferring instead to continue to scare people about the dangers of all vaping products, making no distinctions whatsoever between the myriad types of vaping products on the market.

The Office on Smoking and Health continues to hammer home its meaningless mantra that e-cigarette aerosol is "not harmless." In its August 23rd media briefing, the Office on Smoking and Health not once but twice reiterated the earth-shattering statement that "e-cigarettes do not emit a harmless aerosol."

And then once again in the excellent USA Today article from yesterday, the Office on Smoking and Health once again offered the extremely helpful information that "e-cigarette aerosol is not harmless."

In addition, the Office on Smoking and Health continued to harp on the dangers of "traditional nicotine vape liquid." And even when given the opportunity to emphasize the dangers of vaping THC oil, the Office on Smoking and Health tried to divert attention from that concern back to the thousands of other vaping products that are not causing any problem: "Though the government knows people use substances including THC in vape pens, King said, "the bottom line is there’s a variety of things in e-cigarette aerosol that could have implications for lung health."

This is completely irresponsible. People are dying or having severe, life-threatening illnesses and instead of warning people about the risks of using illicit THC oils that have been linked to many of the cases, CDC is more concerned about making a political statement demonizing e-cigarette aerosol without any evidence that traditional e-cigarette aerosol has been associated with any of the reported cases.

In fact, it appears that the Office on Smoking and Health tried to imply that traditional nicotine e-liquids could cause respiratory disease before acknowledging that none of the cases has been linked to traditional nicotine e-liquids but then warning anyway about the respiratory risks of the traditional vaping of retail e-cigarette products: "Dr. Brian King of the CDC's Office on Smoking and Health told reporters that harmful ingredients in traditional nicotine vape liquid had been identified that included ultrafine particulates, heavy metals such as lead, cancer-causing chemicals and flavoring used in e-cigarettes to give it a buttery flavor. Those ingredients had been related to severe respiratory illness, he said. While they haven't been linked to the current cases, 'we know that e-cigarette aerosol is not harmless,' King said." 

Why is the CDC pointing the finger at every constituent in normal e-cigarette aerosol, implying that any of these chemicals could be the cause of acute respiratory distress syndrome, but protecting illicit cannabis vaping?

The rest of the story is that in its zeal to demonize electronic cigarettes, the CDC is actually protecting illegal drug dealers at the expense of the protection of the health of our nation's youth.

IN MY VIEW: CDC and Health Groups' Bias Against E-Cigarettes is Putting Kids' Lives at Risk

According to the Centers for Disease Control and Prevention (CDC), there have now been 153 reported cases of severe, acute lung disease caused by "vaping" across 19 states. Tragically, one of these cases resulted in a death. Most of the cases are occurring among youth or young adults. The acute disease appears to be taking the form of lipoid pnemonia, acute respiratory distress syndrome, and/or chemical pneumonitis.

Physicians, health departments, and the CDC have almost uniformly informed the public that these cases are caused by "vaping" and have advised youth and young adults to avoid using "e-cigarettes."

The Rest of the Story

The advice from health agencies, including the CDC, to avoid using "e-cigarettes" is irresponsible. This is such a broad category of products that it doesn't really give people any guidance whatsoever in terms of what to avoid. There are millions of people who are vaping nicotine-containing e-liquids and it would not be prudent for these millions of people to return to smoking in order to avoid the risk of this "unknown" and "mysterious" medical condition. Moreover, with such vague advice, no one is likely to change their behavior because they are not being warned about any specific, identifiable risk.

The truth is that in every case so far in which a specific e-liquid has been identified, that product has been a THC-containing e-liquid, typically purchased off the street and often in open cartridges such that they could contain a contaminant or other drug. In at least some of the cases, the use of a THC oil, such as butane hash oil, has been implicated. In January of this year, there was a published case report of a severe, acute respiratory illness attributable to the use of butane hash oil. Apparently, all 21 cases in California were attributed to vaping of marijuana with all the THC e-liquids being purchased on the street.

Since lipoid pneumonia is caused by oil inhalation, it seems pretty clear that those cases diagnosed as lipoid pneumonia are being caused by the use of e-liquids that are oil-based, not alcohol-based. Most nicotine-containing e-liquids are alcohol-based, meaning that they contain as excipients some combination of propylene glycol and glycerin. These products do not pose a risk of lipoid pneumonia. There are some nicotine-containing e-liquids that are oil-based, and these should absolutely be avoided.

Although we do not have a single common link between all the reported cases, there are useful recommendations that the CDC could be giving. At a minimum, they should be telling the public not to vape THC oils, including butane hash oil. Second, they should be telling people not to use any oil-based vaping e-liquid product. Third, they should be telling people not to use any e-liquid unless you know what is in it -- that is, do not buy products off-the-street and stick to products being sold at retail stores, especially closed cartridges where there is no risk of contamination or the presence of unknown drugs.

These would actually be useful recommendations that could possibly help prevent further cases. Instead, the CDC and other health groups are providing such generalized and vague advice that it is essentially meaningless.

Sadly, the failure of CDC and other health agencies to provide appropriate recommendations is putting kids' lives at risk. Since there has been no admonition to avoid the use of THC oils, kids are going to continue to use these products. This is why the CDC's recommendations are irresponsible.

The question is: why are the CDC and other health groups being so broad in their statements, warning broadly against "vaping" or using "e-cigarettes" but failing to warn against the use of THC oil?

The answer, I believe, is that these organizations have such a pre-conceived conclusion that vaping is hazardous and such a bias against the use of e-cigarettes for smoking cessation that they are hoping to be able to attribute these cases to traditional nicotine vaping.  

By no means are we in a position currently to be able to conclude that vaping THC oils or other oil-based e-liquids is solely responsible for the observed cases nor are we sure that street-purchased products are solely to blame. However, I think we know enough to be able to offer a specific recommendation that people not use these products. That CDC has failed to do this is irresponsible, putting lives at risk, and demonstrating the agency's bias in its views of the science around smoking and vaping.