Wednesday, September 18, 2019

As Another Person Dies from Using Illicit THC Vape Carts, Health Authorities Still Insist that We Have No Idea What is Causing the Problem

Yesterday we learned that a seventh person has died from the growing epidemic of "vaping-associated respiratory illness" that is sweeping the country. In the six previous deaths, authorities released information about the products used in three of them, each of which involved vaping marijuana, not electronic cigarettes.

Although authorities did not release information about what caused this seventh death, family members apparently attribute it to the use of an illicit THC vape cart. It's not clear, however, whether the brand used - a Lucky Charms CUREpen - was real or whether it was a counterfeit product that was packaged in the same packaging. Cannabis insiders have been warning us since last January about the dangers of counterfeit THC vape carts that started to go into wide distribution around that time. How prescient they were!

All in all, marijuana vaping has been associated with approximately 90% of the cases. Although about 10% of cases reported using only nicotine-based e-liquids, we know that there is significant under-reporting of THC use by youth. In addition, many youth may actually not know what is in their cartridges. Moreover, we know that there are many counterfeit cartridges on the market. Finally, the CDC has not recommended that case patients be tested for THC so its use cannot be ruled out. In fact, unless THC testing was conducted, the use of THC oils cannot be ruled out in any of the cases.

Given these facts, you would think that health authorities would issue very clear warnings to youth to avoid vaping marijuana, especially illicit THC vape carts that are purchased off the street.

The Rest of the Story

Instead, here is what one physician is telling the public in an article published by The Mighty:

"The Mighty spoke to Meghan Cirulis, M.D., a physician and researcher at the University of Utah. She has led a number of studies on lung diseases and was recently involved in research for the New England Journal of Medicine identifying markers physicians could use to diagnose vaping-induced lung injury. Is there a safe way to vape? “At this stage, I would say no,” Dr. Cirulis said. “Until we figure this out, I think vaping puts people at immediate risk of health consequences that can be severe, even fatal.”

"She added that while some vape products may seem safer than others, we can’t make reliable risk assessments until these products are studied more. Cirulis said that while a “higher proportion of cases” have been linked to e-cigarettes containing CBD and THC, she “wouldn’t consider any product higher or lower risk” until more information is available. “We have definitely seen cases in patients only using nicotine products,” she noted. A lot of discussion has centered on legal versus illegal e-cigarettes, but Cirulis said that at the moment, it’s not clear commercial vapes are safer than “street” vapes. “Some of the cases have reported use of only commercial e-liquids — so I wouldn’t say any product is ‘safe’ currently,” she told us."

"This is in part because even legally sold vape products are subject to very little government oversight. “I have found it interesting that we still don’t really know exactly what is causing the issue,” said Cirulis. “I think [it] speaks to how poorly regulated the e-cigarette market really is — we have no idea what is in even the commercially sold e-liquids.”"

So the main points this physician is making are:

1. The vaping of any e-liquid, even if it is a product that has been on the market for ten years and has caused no problems, is dangerous and could be fatal.

2. No e-liquids are any safer than any others. They are all equally risky. Vaping illicit THC carts purchased off the black market is no more dangerous than vaping a nicotine-containing e-cigarette purchased from a reputable retailer and made by a reputable company.

3. It is no riskier to buy a vaping cartridge off the street where you have no idea what is in the e-liquid than to purchase an e-cigarette from a retail store made by a reputable manufacturer where you know exactly what is in the e-liquid.

This is just crazy. And irresponsible.

There is no way I would give the public advice that buying a THC vape cart from some drug dealer on the street is just as safe as buying an electronic cigarette from a reputable retailer. Or for that matter, that buying a THC vape cart from some drug dealer on the street is just as safe as buying a THC vaping liquid sold at a licensed dispensary.

As inaccurate, uninformed, and irresponsible is this advice, I don't completely blame the physician. I think that physicians are relying on the CDC to do its job and they listen to what the CDC has to say. And so far, the CDC has essentially been saying the same thing. They have lumped all vaping together and have not clearly stated that using THC vape carts is more risky than using traditional e-cigarettes.

I have never seen such a dismissal of the idea that there are gradations in risk. Apparently, I missed the memo that told us that from now on, everything is either dangerous or not. There is no middle ground and everything gets lumped together.

Unfortunately, whoever sent that memo is endangering the lives of our nation's youth.

Tuesday, September 17, 2019

Despite Increasing Clarity in Role of Illicit THC Vape Carts in Lung Injury Outbreak, CDC Violating Its Own Principles to Blame E-Cigarettes

The role of illicit THC vape carts in the lung injury outbreak --which has now caused 7 deaths--continues to become clear. Yesterday, Dallas County reported 14 new cases ranging in age from 16 to 44 with a median age of 19, all of whom were hospitalized with severe respiratory distress. Although the news headline mentions only that these cases were associated with "vaping," if you read down to the 11th paragraph, you find out that "Ninety percent of the Dallas County cases reported vaping THC products."

The CDC has continually downplayed the role of THC vape carts in the outbreak and even today, continues to blame it on electronic cigarettes generally. Most revealing is the fact that every time the CDC even mentions a potential role of THC, it immediately undermines it by emphasizing that "The investigation has not identified any specific e-cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases."

The Rest of the Story

Don't let the CDC fool you. What they're not telling you is that in epidemiological outbreak investigations, we almost never identify a single exposure that ties together all of the cases. This is why we calculate odds ratios to estimate the strength of association between the exposure and the cases. If every single case was associated with a single exposure, then it wouldn't take an epidemiological analysis to identify the source of the outbreak.

I defy you to find a single other CDC outbreak investigation in which the agency emphasized that "the investigation has not identified any specific exposure that is linked to all cases." The failure to find a 100% link between a single exposure and every single case is the norm in outbreak investigations and never precludes the CDC from concluding that a highly common exposure is a likely source. Except in this investigation.

For example, consider the CDC's investigation of an outbreak of severe ocular and respiratory illness following exposure to a contaminated hotel swimming pool. The investigation identified 24 cases of disease. What percentage of the cases had gone swimming or entered the pool area?

If you are thinking 100%, you are wrong. It was just 83%. But that didn't preclude the CDC from concluding that the swimming pool was implicated in the outbreak. They didn't issue a statement saying:

"While 83% of the cases reported spending time in the pool area, 17% did not. The investigation has not identified any specific exposure that is linked to all cases."

Consider the CDC's investigation of a Salmonella outbreak caused by contaminated beef sold in the U.S. Of the 73 cases who did not visit Mexico, what percentage reported eating beef?

If you are thinking 100%, you are wrong. It was 93%. Again, that didn't cause CDC not to warn the public about the dangers of eating contaminated beef. They didn't issue a statement saying:

"While 93% of the cases reported eating beef, 7% did not. The investigation has not identified any specific exposure that is linked to all cases."

In the current outbreak investigation, there are many reasons why one would not expect to be able to tie every reported case to the use of THC vape carts:

1. The primary affected demographic group is youth. About half of the cases are ages 19 and below. Thus, many of the cases are minors and would be expected to under-report their use of illicit marijuana vape cartridges that by definition were obtained from black market drug dealers.

2. The CDC did not recommend that clinicians test patients for THC. In the absence of this testing, there is no way to validly conclude that a youth who doesn't report using THC products actually did not use those products.

3. Not every youth may know exactly what is in the e-liquid cart they are using. It is entirely possible that some of the youths were vaping THC e-liquids but didn't know it.

Frankly, given the consequences of admitting to illicit marijuana use for minors, it is quite remarkable that 90% the cases have admitted to using THC vape carts. 

Given these basic principles of outbreak investigation, why would the CDC violate its own principles in an effort to try to implicate legal electronic cigarettes and to take the focus off marijuana vaping?

It is clear to me that the agency has a pre-existing bias against electronic cigarettes and really wants to be able to implicate these products.

The CDC might attempt to defend itself by saying that they are simply trying to be extra cautious. But the truth is that if they wanted to be cautious, they would immediately issue a very clear and explicit warning to youth not to vape marijuana, period. That they have failed to do this indicates that they are playing with children's health and lives.

The rest of the story is that the CDC is playing with children's health and lives in order to try to further demonize electronic cigarettes.

Monday, September 16, 2019

Under Michigan's New E-Cigarette Flavor Ban, a Youth Caught With a Juul Four-Pack Could Be Put in Prison for Six Months

Michigan's governor is prepared to issue an emergency executive order that would ban the sale of flavored electronic cigarettes effective immediately (once the order is filed). I have already explained why this law will be a public health disaster. It will have three major deleterious health effects:

1. It will cause many ex-smokers to return to smoking as their vaping products are taken off the market.

2. It will create a new black market for flavored e-liquids that does not exist today. As we are finding out, black market products can be extremely dangerous.

3. It will cause many youths who are currently vaping e-liquids to switch to vaping marijuana e-joints that are purchased off the black market (and which are likely responsible for the current epidemic of severe respiratory disease).

The law is also unjustified because it bans flavored e-cigarettes while leaving flavored real cigarettes on the shelves (in the name of menthol cigarettes). So while menthol fake cigarettes will be banned, selling menthol real cigarettes will be just fine. This will certainly harm menthol smokers who want to quit smoking by switching to menthol e-cigarettes.

The Rest of the Story

On top of all of the above, the law will criminalize the mere possession of four or more flavored e-cigarettes. Thus, a high school kid who is caught with a four-pack of flavored Juul pods will be guilty of a crime. An that crime is punishable by up to six months in state prison.

The part of the law that criminalizes the possession of four or more flavored e-cigarettes reads as follows:

"A person who possesses four or more flavored vapor products, or flavored alternative nicotine products is rebuttably presumed to possess said items with the intent to sell."

The rest of the story is that Michigan's proposed flavored e-cigarette ban is terrible public policy that will have terrible public health consequences. It will also potentially criminalize any vaper who possesses four or more flavored e-liquid cartridges or pods. It has taken years to start the process of decriminalize the possession of small amounts of marijuana. Are we now going to have to do the same thing for the possession of life-saving e-liquids?

Thursday, September 12, 2019

E-Cigarettes are a Gateway to Smoking, so as Teen Vaping Dramatically Increased from 21% to 28%, Smoking Plummeted to Lowest Historical Level

Countering the claims of anti-nicotine groups that electronic cigarettes are a gateway to smoking, data released yesterday from the National Youth Tobacco Survey indicate that while the rates of teen vaping continued to increase dramatically (from 21% in 2018 to 28% in 2019 and from 12% to 28% from 2017-2019), the rate of decline in youth smoking accelerated in 2019, dropping to its lowest level in recorded history.



If vaping was a gateway to smoking among youth, one would expect to see some sort of positive correlation between youth vaping rates and youth smoking rates. And in fact, there is a HUGE correlation between the rates of youth vaping and youth smoking during the period 2011-2019.

The Rest of the Story

To cut to the chase, the rest of the story is that there is indeed a huge correlation between the rates of youth vaping and the rates of youth smoking, which is at the very high level of 0.89. In fact, this is about as close to a perfect correlation as you can get with public health surveillance data.

So, you say, this proves - beyond a doubt - that the anti-nicotine groups were right and that e-cigarettes are a gateway to youth smoking.

There's just one thing I forgot to tell you ...

... I forgot the minus sign.

The correlation between the youth vaping and youth smoking rates during this decade is actually --0.89 (that's NEGATIVE 0.89).

Here is the scatter plot (the smoking rate is the x-axis; the vaping rate is the y-axis):



As you can see, there is a dramatic relationship here. The lower the vaping rate, the higher the smoking rate. And the higher the vaping rate, the lower the smoking rate.

In other words, these data show that vaping is supplanting smoking, not supporting it. Vaping culture is not being transformed into smoking culture. It's exactly the opposite. Vaping culture is almost completely replacing smoking culture.

Thus, the truth is that e-cigarettes are not leading to an increase in youth smoking. E-cigarettes are actually accelerating the trend of declining youth smoking.

If you actually stop to talk to kids, they will tell you this. I do educational workshops with youths who are caught vaping or Juuling. And they repeatedly tell me - especially the Juulers - that they wouldn't even think about putting a cigarette in their mouths. They think it's disgusting. And that's a huge part of the appeal of the Juul - a cutting edge, modern, cool device that looks like a flash drive and allows you to emit a cool vapor cloud that dissipates almost instantly.

The rest of the story is that vaping is not leading youth to smoking. Instead, what the data tell us is that a vaping culture is further decimating a smoking culture that is already on the decline.

Tobacco Financial Analysts: Flavored E-Cigarette Ban Will Substantially Boost Cigarette Sales

Due primarily to the CDC's hiding the fact that the overwhelming majority, if not all of the cases of "vaping-associated pulmonary illness (VAPI)" are most likely caused by vaping marijuana, not e-cigarettes, the Trump Administration and the FDA are poised to ban all flavored e-cigarettes.

This obviously makes no sense at all.

The logic is basically: Product X is causing a severe disease outbreak. Product Y is not. So we are going to immediately ban Product Y.

The CDC has taken it a step further. They are essentially warning the public not to use "products," rather than telling them not use Product X.

I have argued that a flavored e-cigarette ban would drive masses of ex-smokers from vaping back to smoking. This prediction now seems to be confirmed by a number of tobacco financial analysts, who are alerting investors that such a ban would substantially boost the sale of cigarettes while decimating the e-cigarette market, which has nearly doubled in the past year. It is predicted that nearly all of the declines in vaping will be translated into cigarette smoking.

The Rest of the Story

This may be the best evidence yet that the FDA's flavored e-cigarette ban will result in a substantial increase in smoking-related morbidity and mortality.

There is no question that there is a direct link between the level of cigarette consumption in the U.S. and the number of smoking-related deaths. If cigarette consumption rises, then so does the number of deaths.

The rest of the story is that the health groups calling for a ban on flavored e-cigarettes are also calling for a dramatic increase in smoking rates and in the number of smoking-related deaths.

Wednesday, September 11, 2019

In Completely Irresponsible and Negligent Message, American Lung Association Warns against E-Cigarette Use, but Not against Vaping THC

In response to the alarming outbreak of severe, acute respiratory disease that has now affected more than 450 people in 33 states and has killed six people, the American Lung Association issued a statement yesterday stating that no one should continue using electronic cigarettes, which it says can cause "irreversible lung damage." According to the statement: "E-cigarettes are not safe and can cause irreversible lung damage and lung disease. No one should use e-cigarettes or any other tobacco product. This message is even more urgent today following the increasing reports of vaping-related illnesses and deaths nationwide."

The Rest of the Story

This is an irresponsible and I believe negligent message that is going to cause a lot of harm. By hiding from the public the fact that the overwhelming majority of cases have been associated not with electronic cigarettes, but with the vaping of marijuana, this message is actually going to result in many youth continuing to vape THC products.

Rather than tell the truth and issue a clear and unequivocal warning that people should stop vaping THC vape cartridges, this message to avoid e-cigarettes is not only failing to prevent further cases of the disease, but it is essentially going to cause more diseases because youth are going to be misled into thinking that the risk is associated with e-cigarettes, not vaped marijuana.

Furthermore, banning flavored e-cigarettes, as the White House is apparently considering, would not doing anything to stem the outbreak, since e-cigarettes do not appear to be causing the outbreak. Instead, a ban on flavored e-cigarettes would lead many ex-smokers to go back to smoking.

Tuesday, September 10, 2019

Mayor Michael Bloomberg and the Campaign for Tobacco-Free Kids are Lying to the Public

Whether one supports or opposes a ban on flavored e-cigarettes, I would hope we would all agree that it is unethical to lie to the public in order to support one's position. But that is exactly what Mayor Bloomberg and the Campaign for Tobacco-Free Kids have done in an op-ed they published today in the New York Times.

The op-ed states: "Any adult knows that if you want to get a child’s attention, there is no enticement like candy. This currency of youth has become the weapon of choice for tobacco companies. They are making huge investments in nicotine-loaded e-cigarettes and selling them in a rainbow of sweet and fruity flavors like cotton candy, gummy bear, mango and mint."

It is simply not true that the tobacco companies are selling electronic cigarettes in cotton candy or gummy bear flavors. Those flavors are certainly on the market, but they are not being sold by tobacco companies. 

In the U.S., there are four major brands of electronic cigarettes that are sold, at least in part, by tobacco companies: Juul, blu, Logic, and Vuse. While each of these brands has flavored e-liquids or pods, none of them sells gummy bear or cotton candy flavors.

The Rest of the Story

Why is it necessary to lie to make the point that tobacco companies are selling e-liquids in flavors that are attractive to youth?

I don't understand this. I have worked in the tobacco control movement for 34 years and have been involved in numerous public campaigns against the tobacco industry and tobacco products. But never have I lied about the facts in order to try to support my policy positions.

Honesty and transparency are important ethical values in the practice of public health. We shouldn't flush them down the sink just to try to make a more jarring appeal to the public. The truth should be enough.

Beyond this lie, the piece is misleading in tying the respiratory disease outbreak that has affected more than 450 people and caused five deaths to electronic cigarettes. By the CDC's own admission, 80% of the cases have been tied to vaping illicit marijuana/THC cartridges, not legal e-cigarettes. It is disingenuous and frankly, dishonest, to suggest to the public that this terrible outbreak is being caused by e-cigarettes, when there is no solid evidence to back up that claim.

As I have pointed out before, youth are understandably reluctant to report illicit use of marijuana vape cartridges purchased off the black market, so it is quite possible that there is a significant amount of under-reporting. Because of this under-reporting, it is possible that all of the cases are associated with e-cannabis rather than e-cigarettes.

We live at a time when some politicians have no trouble simply making up the facts as they go along to support their positions. Public health organizations should not be doing the same thing.

Pieces of the Mysterious Lung Disease Puzzle Starting to Come Together, But CDC Continues to Endanger Health by Hiding the Critical Pieces

The pieces of the puzzle of what is causing the "mysterious" outbreak of acute, severe lung disease among more than 450 people--mostly youth and young adults--are starting to come together. Yesterday, new cases of this illness were reported in at least three states. They were said to be associated with "vaping." However, if you read the fine print, it turns out that all of these cases were associated with the use of black market THC vaping cartridges.

Georgia Public Radio announced two new cases of "vaping-related illness" in the state of Georgia. If you read down further in the article, you'll find out that "Both cases have a history of vaping, including THC."

The Lake County News-Sun announced a new case of respiratory illness in Illinois caused by the use of "electric cigarettes." If you read further down, you'll find out that the patient admitted that last year, he "began smoking sold-on-the-street 'dab sticks,' THC-filled devices made for e-cigs."

WSB-TV in Atlanta reported a new case of "vaping-related" respiratory illness in Georgia. If you read a little further down in the article, you'll find out that "he had recently vaped a liquid cannabis product."

The more cases that are closely examined, the more clear it becomes that this outbreak is primarily, if not entirely, explained by the vaping of illicit, black market THC cartridges.  

Importantly today, another piece of the puzzle came together. One of the inconsistent pieces of the puzzle was that although most of the cases appeared to be associated with black market THC cartridges, there was one death in Oregon that was reportedly associated with a THC vaping product purchased from a licensed dispensary. How could that have happened?

Well today that mystery may have been solved. A leading Oregon cannabis extraction company revealed that just this spring, it began selling THC cartridges that had been cut with vitamin E acetate oil. The product was apparently approved by the Oregon Liquor Control Commission (OLCC) for use in legal recreational marijuana products sold at licensed dispensaries in the state.

Furthermore, the owner of this company explained that recently, there was a "revolutionary" change: the widespread introduction of a new diluent thickening agent (a vitamin E acetate oil) that was soon adopted "everywhere."

As explained in Willamette Week: "Jones is a leading figure in one of the most lucrative segments of the cannabis industry: butane hash oil, the honeylike distilled essence of cannabis plants. That extract can be used in vaporizer pens. He claimed in 2017 that he was making millions of dollars from the machine, called "Mr. Extractor," used to extract the hash oil. ... Jones writes that a Los Angeles-based company called HoneyCut first revolutionized diluent thickeners. He writes that these products have become hugely popular. "Through our research and testing we have found that almost every terpene and flavor manufacturer in the country is selling their version of Tocopheryl Acetate," Jones writes. Jones writes that when he met with the OLCC in the spring, he expressed to them that these additives would be "everywhere" within the next six months. ... Jones also writes that many of these diluent thickening products are now available through wholesale retailers online."

In light of the recent outbreak, Jones' company has discontinued the use of its vitamin E acetate product and apparently all other diluents. 

The Rest of the Story

Although the cause of this outbreak is becoming clearer and clearer, the CDC's messages to the public are becoming vaguer and vaguer. Instead of honing in on the importance of youth immediately stopping the use of black market THC vape cartridges, the CDC is instead continuing to put the blame on vaping in general, including electronic cigarettes manufactured by legally by reputable companies. 

The CDC is deviating from standard protocol used in disease outbreak investigations and health emergencies, and I believe this is because they have such a bias against electronic cigarettes that they refuse to let this opportunity to further demonize e-cigarettes go by, even though the evidence points in a completely different direction.

Not only is this putting the lives of our nation's youth at risk because the CDC is not warning them about the risks of using THC vape cartridges, but it is leading to irresponsible and irrational public policy. Within the past few days, the governor of Michigan implemented a ban on all flavored e-cigarettes, and politicians in the states of New York and Delaware announced that they will introduce similar legislation in those states.

These proposed flavored e-cigarette bans would be a public health disaster. They would result in thousands of ex-smokers returning to smoking as the products that are keeping them smoke-free are taken off the shelves. It would also create a new black market for e-cigarette products where one does not currently exist. And the most ironic result would be that in May 2020, when e-cigarettes in all of the other states fall under the jurisdiction of the FDA, these states' vaping products would be the only ones in the country that are unregulated. If this outbreak has taught us anything, it is the dangers posed by the black market. Who knows what kind of public health disasters lie ahead in Michigan and other states that ban e-cigarettes and then are hit with a huge black market for vaping products that are in extremely high demand by smokers and ex-smokers who want to protect their health.

Monday, September 09, 2019

CDC's Obfuscation of Link Between Illicit THC Carts and Lung Disease Outbreak is Worsening the Situation and Probably Leading to More Cases

Instead of simply acknowledging that a large number of cases in the recent outbreak of severe, acute respiratory failure are due to black market THC vape carts, the Centers for Disease Control and Prevention (CDC) is undermining that key information and continuing to do everything it can to pin the outbreak on the use of traditional, nicotine-containing electronic cigarettes. Today, I provide three examples to show how the CDC's fraudulent conduct is causing state officials to issue inappropriate warnings that are almost certainly worsening the situation and leading to more cases of disease.

1. Montana: Today, health officials in Montana issued a warning to state residents concerning the disease outbreak. This warning was reported by the state's Public News Service. Instead of informing the public that oil-laden THC vape carts are associated with most of the cases and should absolutely be avoided, the state health department's medical director told the public that we have no idea what is causing the outbreak and that everyone should simply stop vaping. According to the article, the state medical director stated: "We have something that has serious consequences and we don't know what's exactly going on. Protect yourself and stay away from these products at this time, until we have a better understanding. And hopefully, this would be a good time to stop using the products completely."

This is not only blatantly inaccurate information but it is highly irresponsible. However, I don't completely blame the Montana health department because they are simply relaying information that originates from the top: from the CDC.

Inexplicably and inexcusably, the warning does not even mention the words marijuana or THC. Hiding the fact that oil-laden THC vape carts are right now extremely dangerous to use is going to result in the continued use of these products by young people and result in further cases of the disease that could be prevented by simply telling the public the truth. Again, this stems from the CDC's obfuscation of the observed link between marijuana vaping and most of the cases. By hiding the truth, the CDC is essentially lying to the public. It is a lie of omission. And it is endangering the health of our nation's young people.

2. Ohio: Mirroring a line that it obtained directly from the CDC, a Cincinnati public radio story informed the public that: "no specific e-cigarette device or substance has been linked to the illnesses. While some patients used marijuana-based products, others used marijuana and nicotine products, and a smaller group reported using nicotine products only." This statement deliberately obscures the role of marijuana-based products with high oil content in inducing the majority of the observed cases, many of which have been confirmed to have been caused by lipoid pneumonia due to oil inhalation. Again, the media are simply mimicking what they are hearing from CDC, so I'm not blaming them. It is the CDC that is to blame for this inaccurate and irresponsible information.

3. Tennessee: A story run by the NBC News Knoxville affiliate reports that six cases of the disease have been reported in the state. The story reports only that these cases are associated with the use of e-cigarettes. Nothing more specific than that. However, if you dig in more closely, you'll find that (in small print in a different article) a Knox County teenager who was hospitalized for a "vape-related" illness actually reported that what he was using was an illicit THC vape cart. As the teen explained: "You buy these from people off the streets. Anywhere. You can find these anywhere. People make these. They put, what I've heard, butane, lighter fluid, other chemicals and stuff inside of these."

It is a shame that this teen appears to know more about the outbreak than the Centers for Disease Control and Prevention and that the warning he is giving is far more accurate and effective than the CDC's.

I'm sure we could go down the list of all 50 states and demonstrate that they are all putting out inaccurate and irresponsible warnings. But this all stems from the top - from the CDC. That is why it is absolutely inexcusable that the agency continues to try to blame the outbreak on traditional, legal e-cigarettes, even in the face of overwhelming and compelling evidence that the primary (if only) culprit is illegal, black market marijuana vaping products being made by an illicit drug cartel that is making millions of dollars spreading this poison to our nation's youth through an elaborate distribution of network of drug dealers.

Sunday, September 08, 2019

A Flood of Irresponsible Actions and Advice on Respiratory Disease Outbreak

There is a wave of irresponsible recommendations and actions that are taking place in response to the outbreak of more than 400 cases of severe, acute respiratory disease and five deaths that have occurred in the United States. Since there are far too many to write an individual commentary on each, I am combining three of the most important examples in this post.

1. Dr. Thomas Eissenberg Implies that the Respiratory Disease Outbreak is being Caused by Traditional (nicotine-containing) Electronic Cigarettes

In an op-ed piece in The Guardian entitled "Vaping Is Risky: Do Not Do It If You Care About Your Lungs," Dr. Thomas Eissenberg--a professor at Virginia Commonwealth University--advises the public to discontinue all vaping and ties the recent outbreak of severe, acute respiratory disease to nicotine-containing electronic cigarettes. He writes: "For the past seven years, a steady stream of scientific studies has uncovered potential health risks associated with vaping. These risks include nicotine dependence, airway injury, and cardiovascular disease. Now we must add debilitating lung disease to that list. Lipoid pneumonia is one such disease, probably caused by inhalation of oil-containing vapor: the body’s immune response to oil in the lungs involves inflammation that can be fatal."

I find this to be irresponsible. It implies that lipoid pnemonia is being caused by traditional, nicotine-containing electronic cigarettes and that these products are implicated in the respiratory disease outbreak. Most if not close to all traditional, nicotine-containing electronic cigarette liquids are not oil-based, but water and alcohol-based. They are nearly uniformly made up of some combination of propylene glycol, glycerin, water, nicotine, and flavorings. Thus, there is little risk of lipoid pneumonia associated with traditional e-cigarettes.

What is almost certainly causing the recently reported rash of lipoid pneumonia cases is the vaping of THC oils, which are - as the description suggests - oil-based products. While the regulated dispensaries that produce legal, recreational THC e-liquids for vaping generally implement complex procedures to eliminate oils from their products, black market manufacturers do not. This means that there are many bootleg marijuana vape pens and vape carts on the market that contain oils. These oils are not vaporized when heated because their boiling point tends to be above the temperatures achievable with the vaping pens. Instead, the liquid oil droplets are inhaled into the lung. This is a disastrous situation as the oil essentially coats the alveoli in the lungs and makes it impossible for the lungs to work. Macrophages (scavenger cells) try their best to get rid of the oil by encircling the droplets but not before the patient may experience respiratory failure. This is why when a patient with lipoid pneumonia undergoes a bronchoalveolar lavage, pathologists are able to detect "lipid-laden macrophages" in the lung cells. This has been a common feature of a large number of the observed cases in the outbreak, and the overwhelming majority of these cases are due to the vaping of illicit THC oils purchased off the black market.

Lipoid pneumonia does not need to be added to the list of diseases caused by legal electronic cigarettes sold by stores or e-cigarette companies. It needs to be added to the list of diseases caused by vaping marijuana carts purchased from illegal drug dealers.

Furthermore, the recommendation that every ex-smoker stop vaping if they care about their lungs is exactly the opposite of what we should be telling them. The most important thing you can do if you are an ex-smokers who has quit smoking is to not go back to smoking. But that is exactly what is going to happen to the overwhelming majority of ex-smoking vapers if they follow the advice provided in this op-ed. Yes, in an ideal world, one free of addiction, we would simply advise anyone using any drug to stop. But that doesn't really help us in the real world. In the real world of drug addiction, we have something called harm reduction. For people who are unable to immediately stop their drug use, we (public health practitioners) advise them to switch to an alternative that is much safer, even if it still involves addiction. For heroin users, it would be irresponsible to put out an op-ed saying: "Shooting Up with Heroin is Risky: Don't Do It If You Care About Your Health." Instead, what we do is everything in our power to recruit and encourage people addicted to heroin to get into treatment programs, most of which work by providing a safer alternative, such as methadone or another opiate agonist. For people who are addicted to smoking and cannot quit using traditional NRT or other drugs, we should be encouraging them to, not dissuading them from, switching to electronic cigarettes.

2. New York Governor Andrew Cuomo Urges All New Yorkers to Halt Vaping

In an alert issued today, New York governor Andrew Cuomo urged everyone in the state to immediately stop vaping. As quoted in an NBC News article, Governor Cuomo stated: "There is an investigation ongoing. Nobody knows exactly what it is. There is some suggestion that is linked to Vitamin E, et cetera. Our health guidance is no one should be using vaping products, period, until we know what it is."

This is inexcusably irresponsible in two ways:

First, the governor completely undermines what we do know about the causes of the disease outbreak by substituting an explanation of the link between marijuana vaping and most of the disease cases and replacing it with a dismissive "et cetera." No - it is not "et cetera." It is the terribly serious and important information that the vast majority of cases of lung disease have been caused by vaping illicit THC oils purchased off the black market. There is simply no excuse for the governor to be hiding this information from the public.

Second, for the reasons stated above, it is terrible advice to tell everyone to immediately stop vaping. Ex-smokers who have quit smoking by switching to vaping should absolutely continue vaping, because if they don't, they will almost certainly return to deadly cigarette smoking. These are people who are addicted to nicotine and are not simply going to stop using nicotine overnight because the governor tells them to. If they heed his advice, we are going to have a large increase in the number of smokers in the state of New York.

Although the New York State Department of Health also issued the same warning, I am not blaming the department because it is quite clear that they were forced to do so by the governor. If there are any additional cases of respiratory disease in New York that result from young people using black market THC vape carts or vape pens, it is - as far as I'm concerned - partly on the shoulders of the governor, who bears some responsibility for those illnesses and if they occur, deaths.

3. Senator Dick Durbin Blames the Outbreak on the FDA and Believes that the FDA Should Be Controlling and Preventing these Diseases

According to an article in The Hill, Senator Dick Durbin (D-IL) has told the FDA commissioner to "stop this vaping epidemic" or resign. He was apparently referring to an alarming outbreak of severe respiratory diseases that have affected more than 400 (mostly) young people and caused five deaths. Durbin pointedly asked the FDA commissioner: "Will FDA act now that 193 people across 22 states have severe lung illness associated with e-cigarettes? Will FDA act now that a person in Illinois has died?"

I think Senator Durbin should have done his homework and examined the scientific evidence regarding the cause of the 193 people having severe lung illnesses and the person in Illinois who has died. Right now, it appears that the major cause of this outbreak is the production and distribution by a small cartel of illegal drug manufacturers of illicit, bootleg THC oil-containing vape pens and carts. Thus, the FDA likely has nothing to do with this outbreak and there is really nothing that the FDA can do to prevent further cases. Why? Because the FDA does not have jurisdiction over the illegal production, distribution, and sale of illicit drugs. The FDA has jurisdiction over legal drugs, not illegal ones.

In other words, Senator Durbin is turning his ire against the wrong person. Who Senator Durbin should be angry at, and who he should call into his office for an explanation, are the drug manufacturers and distributors who are running a multi-million dollar business out of producing and selling illicit THC cartridges for vaping that are being used by thousands of young people across the country who are obtaining these products on the black market.

The FDA does not currently have any jurisdiction over these dealers. To the best of my knowledge, the DEA (Drug Enforcement Agency) is probably the government agency with the most direct jurisdiction at this time. If Senator Durbin wants the FDA to try to get to the bottom of this, then what he should do is immediately introduce legislation to give the FDA jurisdiction over illicit cannabis product manufacturing, distribution, and sale. That's the only way that we are truly going to get to the bottom of this, unless the DEA is able to put an end to it.

The Most Telling Sign that CDC is Protecting Illicit Marijuana Drug Dealers While Doing Everything it Can to Pin this Outbreak on Traditional E-Cigarettes

It is clear to me that in its investigation of more than 400 cases of acute respiratory failure tied to the vaping of certain products, the CDC is doing everything it can to undermine the proven connection between most of these cases and illicit marijuana vape carts, while exaggerating a potential, but completely unproven connection with traditional electronic cigarettes.

This was highlighted last Friday with the complete split between the FDA and CDC with respect to their public communications and warnings regarding the disease outbreak.

The CDC is undermining the observed connection between black market THC/CBD oils and the majority of the reported cases as well as the finding of high levels of tocopherol acetate in many of the product samples provided by affected patients. The CDC's primary warning is to avoid electronic cigarettes and vaping altogether. This is tantamount to advising ex-smokers who quit by switching to vaping to return to smoking. This irresponsible advice completely ignores the principle of addiction and the lack of a clear and unambiguous warning not to use black market marijuana vape carts is inexcusable and puts youths' lives at risk.

In contrast, the FDA has issued a specific and unequivocal warning not to use THC/CBD oils, especially black market vape carts. The FDA stated that: "consumers are urged to avoid buying vaping products on the street, and to refrain from using THC oil or modifying/adding any substances to products purchased in stores." Although the FDA noted that youth should not vape at all, they did not back down from or undermine the finding of tocopherol acetate in many of the tested samples. Unlike the CDC, the FDA did not issue a recommendation that ex-smokers who vape should return to smoking.

Former FDA commissioner Dr. Scott Gottlieb has also been very clear in his Twitter communications, warning that: "Based on current reports it’s likely to be case most of the vaping injuries are related to illegal products and mostly THC and CBD." He also astutely pointed out that "permissive state laws on recreational THC and our conflicted attitude toward cannabis create a lot of risk. These products and vape pens sold to aerosolize stuff other than nicotine (and thus probably not regulated by FDA) fall into dangerous gap where there’s no proper oversight."

Dr. Gottlieb also noted that: "Legitimate e-liquids are generally based on chemicals that are water soluble, not oils that can cause acute lung injury. High levels of vitamin E acetate were found in nearly all cannabis-containing vapes tested by NYS Department of Health. Nobody should use illegal vape products." I applaud Dr. Gottlieb for stepping in where CDC failed and providing helpful and specific recommendations based on the best available information at the present time.

In contrast to Dr. Gottlieb, the CDC is actually undermining the connection between illicit THC oils and the outbreak. For example, they relentlessly emphasize that many of the patients who reported using THC oils also used "nicotine-containing products": "While many of the patients, but not all, reported recent use of THC-containing products, some reported using both THC- and nicotine-containing products." This completely undermines the previous phrase and downplays the connection between THC oils and the disease, while implying that traditional e-cigarettes are still a likely cause. They also mention that although vitamin E acetate was found in many of the samples, it was not found in every single one of them. Again, this undermines this important finding.

Both of these examples of undermining the role of illegal THC vaping products are completely unnecessary and irrelevant. If THC oils are related to the disease, then it doesn't matter whether the patients also vaped traditional e-cigarettes. If THC oils are causing a large number of cases, then there is no need to invoke the traditional e-cigarettes, even though some patients are using multiple products. In addition, the CDC should know full well that in a disease outbreak investigation, you almost never find a single exposure that ties together every case. The fact that vitamin E acetate was not found in every sample does not eliminate its potential role. Nor does the fact that not every patient reported using THC oils eliminate the possibility that THC oils are responsible for the entirety of the outbreak.

Despite the sharp deviation between CDC and FDA, the most telling sign that the CDC is intentionally protecting illicit marijuana drug dealers in its zeal to go after the legal e-cigarette industry is a glaring omission from its recommendations to clinicians that no one seems to have picked up on.

The Rest of the Story

The CDC issued a Health Alert Network alert which advises clinicians of what they should do with every suspected case. 


Here is the entirety of the CDC's recommendations for clinicians:

Recommendations for Clinicians
  1. Report cases of severe pulmonary disease of unclear etiology and a history of e-cigarette product use within the past 90 days to your state or local health department. Reporting of cases may help CDC and state health departments determine the cause or causes of these pulmonary illnesses.
  2. Ask all patients who report e-cigarette product use within the last 90 days about signs and symptoms of pulmonary illness.
  3. If e-cigarette product use is suspected as a possible etiology of a patient’s severe pulmonary disease, obtain detailed history regarding:
    • Substance(s) used: nicotine, cannabinoids (e.g., marijuana, THC, THC concentrates, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), flavors, or other substances
    • Substance source(s): commercially available liquids (i.e., bottles, cartridges, or pods), homemade liquids, and re-use of old cartridges or pods with homemade or commercially bought liquids
    • Device(s) used: manufacturer; brand name; product name; model; serial number of the product, device, or e-liquid; if the device can be customized by the user; and any product modifications by the user (e.g., exposure of the atomizer or heating coil)
    • Where the product(s) were purchased
    • Method of substance use: aerosolization, dabbing, or dripping
    • Other potential cases: sharing e-cigarette products (devices, liquids, refill pods, or cartridges) with others
  4. Determine if any remaining product, including devices and liquids, are available for testing. Testing can be coordinated with the local or state health departments.
  5. Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms and of e-cigarette product use. Evaluate and treat for other possible causes of illness (e.g., infectious, rheumatologic, neoplastic) as clinically indicated. Consider consultation with specialists (pulmonary, infectious disease, critical care, medical toxicology) as appropriate.
  6. Clinical improvement of patients with severe pulmonary disease associated with e-cigarette use has been reported with the use of corticosteroids. The decision to use corticosteroids should be made on a case-by-case basis based on risks and benefits and the likelihood of other etiologies.
  7. Lipoid pneumonia associated with inhalation of lipids in aerosols generated by e-cigarettes has been reported based on the detection of lipid-laden alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining (e.g., oil red O). The decision about whether to perform a BAL should be based on individual clinical circumstances.
  8. Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining may be considered during pathologic examination, and is best performed on fresh tissue. Routine pathology tissue processing (including formalin-fixation and paraffin-embedding) can remove lipids. Conducting routine tissue processing and histopathologic evaluation is still important. Consider consultation with specialists in pulmonary medicine and pathology to help inform any evaluation plan.
  9. Patients who have received treatment for severe pulmonary disease related to e-cigarette product use should undergo follow-up evaluation as clinically indicated to monitor pulmonary function.
Do you see the glaring omission here? Do you see the omission that I think demonstrates that the CDC is actively attempting to decrease its ability to conclude that THC oils are causing these reported cases?

The glaring omission in the CDC's recommendations for clinicians is that they failed to recommend that clinicians conduct a sensitive urine drug screen for THC in every patient.

This is the only way to determine with reasonable accuracy whether a patient used a THC-containing product. Simply relying on self-reports is not sensitive enough because many youth will understandably hide the fact that they were using an illicit, black market drug that was essentially obtained from drug dealers. Every patient needs to be tested for THC.

The failure to recommend this testing indicates to me that the CDC is not serious about really wanting to be able to invoke THC oils as a cause of these illnesses if they truly are the cause. By not recommending this testing, the CDC is ensuring that there is no way that THC will be implicated in every case. This, by definition, will leave open the possibility that traditional e-cigarettes are causing some of the cases, allowing the CDC to emphasize that people should not use e-cigarettes!

The rest of the story is that the parameters that the CDC has established for its investigation will ensure that it has the ability to invoke electronic cigarettes as being a possible cause for the outbreak. This tells me that the CDC is more interested in protecting the illicit, underground THC vape cart black market than truly protecting the health of our nation's youth. Apparently, being able to continue to demonize electronic cigarettes is more of a priority. 

Friday, September 06, 2019

American Lung Association Criticizes CDC for Giving a Vague Warning on Respiratory Disease Outbreak; Then Issues a Warning that is Even More Vague

In a Politico article published today, the American Lung Association criticized the CDC for issuing too vague a warning regarding what people should do to avoid the "vaping"-associated outbreak of acute, severe respiratory disease.

The American Lung Association was quoted as stating: "We know that it’s important with health communication to deliver very clear messaging, unambiguous meaning."

The Rest of the Story

At first, when I saw this quote, I thought that the American Lung Association was absolutely on-point with its criticism because the CDC has been far too vague by warning people not to use "e-cigarettes" generally instead of focusing on the illicit, bootleg marijuana vape carts that have been associated with the vast majority of the cases. However, I then read what the American Lung Association suggested as a less vague and more appropriate warning.

It was: "Don't use these products."

"These" products? What products? Ironically, while criticizing the CDC for being too vague and ambiguous, the American Lung Association is issuing a warning that is even more vague and more ambiguous. At least with the CDC warning, we have some idea of what products they are talking about, even though they are lumping together products that are clearly not responsible for the observed cases with those that are. But with the American Lung Association's warning, it is not even clear what products they are talking about. It would hard to be more vague or more ambiguous if you tried.

In fact, the most recent warning posted on the American Lung Association's web site is almost as ambiguous. It states: "The American Lung Association has been raising the alarm about e-cigarettes and their use for more than a decade, and reiterates the recommendation that the public should not use any tobacco product, including e-cigarettes." Essentially, the American Lung Association's warning is "don't use e-cigarettes."

The warning does not even mention that the majority of cases are linked not to e-cigarettes, but to e-marijuana. The words marijuana and THC do not even appear anywhere in the statement.

Since the American Lung Association still seems to believe that we have no idea what is causing this outbreak, perhaps they should make their warning even more ambiguous:

"Don't use products."

This would actually be quite funny, except for the fact that people's lives are at risk, especially young people, among whom the prevalence of vaping marijuana is quite high.

The American Lung Association is quite right when it states that "it’s important with health communication to deliver very clear messaging, unambiguous meaning." But maybe it should examine its own messages before criticizing others.

CDC Has No Problem Attacking Vaping Companies so Why are They Protecting the Marijuana Drug Cartel?

We now know that the majority of cases of the severe respiratory disease outbreak that has affected more than 300 people and resulted in three deaths across the United States are associated with the use of illicit, bootleg marijuana vape carts that are produced by what is most likely a relatively small cartel of illegal manufacturers. E-liquid samples from patients across multiple states have tested positive for tocopherol acetate and at high levels, with at least one sample reported to be comprised of 50% tocopherol acetate. The CDC itself reported today that a cluster of cases of lipoid pnemonia in North Carolina were all associated with the use of bootleg THC oils.

In spite of this information, the CDC continues to avoid clearly warning the public not to vape
THC oils! Instead, they are continuing to focus on all vaping products and their primary advice is still: "don't vape."

Shockingly, in the CDC's most recent alert, the recommendations to the public do not include a specific warning against vaping marijuana vape carts. The CDC's primary warning is: "While this investigation is ongoing, people should consider not using e-cigarette products." Moreover, nowhere in the paragraph that contains the CDC's recommendations do the words "marijuana" or "THC" even appear! Not even once.

The CDC's failure to warn the public about vaping bootleg marijuana carts is unfortunately filtering down to nearly all reports regarding this outbreak. Even in the prestigious New England Journal of Medicine, today's featured article mimicked CDC in its recommendations. The primary recommendation was that the public should consider not using e-cigarettes. There was not a clear and specific warning to stringently avoid vaping illegal marijuana.

The Rest of the Story

Given what we now know, I find it completely irresponsible for the CDC to continue to obscure the truth and to continue to try to blame this outbreak on legal, nicotine-containing e-cigarettes that have been on the market for years and have not caused any previous problems, rather than to acknowledge that the vast majority of the cases seem to be due to the use of illegal marijuana vape carts.

Why is the CDC going to such great lengths to try to demonize the vaping industry while protecting the illegal marijuana cartel that is producing and widely distributing unregulated THC carts that are apparently contaminated with high levels of a thickening agent that likely coats the lungs with oil and prevents the lungs from working?

We do know that many of the cases are presenting as lipoid pneumonia, that lipid-laden macrophages are being detected in most of these presentations, and that recent changes in illicit vaping marijuana production has apparently resulted in the introduction of a large amount of an oil into THC vape carts that does not vaporize (except at extreme temperatures not achievable with most vape pens) and therefore, youth are inhaling liquid oil into their lungs which is retained. No wonder this is such an extremely dangerous situation and no wonder we are seeing such unexpectedly severe lung failure in these patients. I don't think this can be said to be a complete "mystery" any longer.

In today's New England Journal article, it reports that of all reported cases in Illinois and Wisconsin in which patients were rigorously interviewed, 87% eventually admitted to vaping marijuana, not (just) nicotine e-liquids. It is certainly possible that most or all of the others were just reluctant to admit buying bootleg vape carts from drug dealers.

While the CDC and other health groups are still trying as hard as they can to blame legal, retail e-cigarettes, it is difficult to understand two things: (1) what changed such that we are seeing such an enormous outbreak at this particular time? (2) since there is not one product implicated, how could there possibly be contamination of multiple brands of e-liquids when they are all manufactured at different facilities?

We can potentially explain both of these with marijuana vaping. First, there was apparently a change made by the illicit marijuana vape cart manufacturers late last year and it appears that they started to use tocopherol acetate as a new thickening agent. One would expect that they would put a large amount of the agent into the cart because their chief goal is to make money. Second, the bootleg vape carts are apparently made by a very small number of manufacturers (possibly by one very large production in the Los Angeles area) and then distributed widely throughout the country. This would explain why we are seeing a multi-state outbreak with multiple products and brands. It is thought that the same contaminated THC oil may be used in multiple products, just packaged differently.

I am by no means arguing that we can explain every single case and that no nicotine-containing e-liquid is involved. However, it is clear that this outbreak is primarily related to the illicit, wide distribution of dangerous THC oils by an illegal drug operation.

The rest of the story is that the CDC is doing everything in its power to protect this illegal operation and to deflect blame onto the vaping companies. And the end result is that it is putting the lives of our youth at risk.

Thursday, September 05, 2019

ALERT: Major Breakthrough in Investigation of "Mysterious" Lung Disease Outbreak

There has been a major breakthrough in the investigation of the outbreak of more than 300 cases of a "mysterious" lung disease that the CDC and many other health agencies have told the public is due to the vaping of electronic cigarettes. And now, everything is starting to make some sense.

Illicit THC vape carts that were obtained from a number of case patients that were tested in federal and state laboratories have tested positive for vitamin E acetate, an oil that just started to be used late last year as a thickening agent in bootleg THC vape carts. Apparently, for every single case in New York State for which testing is complete, vitamin E acetate was found in at least one of the THC vape carts that were used by the patient. Almost simultaneously, testing of recovered THC vape carts by the FDA revealed vitamin E acetate in 10 of 18 tested samples. Importantly, the FDA reported that it found no contamination in any of the nicotine e-liquids tested.

The Rest of the Story

While there are still a lot of unknowns, the pieces of the puzzle are just beginning to fit together. One the great mysteries about this outbreak is "Why now?" Nicotine e-liquids have been on the market for many years and are being used by millions of vapers but there has never been a problem. Something must have changed to result in the outbreak occurring at this time. But what?

Now there is a possible explanation: it turns out that there was a major change made in the bootleg THC vape cart drug dealing industry late last year. It appears that a new thickening agent started to be used in bootleg THC vape carts. Very possibly, that new agent was vitamin E acetate. Tocopherol acetate (the fancy name for vitamin E acetate) is a thickening agent that is typically used in cosmetics like skin cleansers. But late last year, it apparently began to be used for thickening the THC oil (presumably to hide the fact that it had been highly diluted, which is a clue to some buyers that they are not getting much product). Here is what leafly.com has to say:

"Peter Hackett of Air Vapor Systems and Disinger and Heldreth of True Terpenes both mentioned the recent introduction of a novel diluent thickener called Honey Cut. The product swept through LA’s pen factories late last year. Honey Cut maintains a website, but the identity of the product manufacturer remains unknown, as does the chemical makeup of the substance. Leafly has made many attempts to reach officials at Honey Cut, but they have chosen not to respond.
Honey Cut’s introduction last year proved so popular that competing products by other diluent makers soon began appearing."

What was the new diluent thickener in Honey Cut?

You guessed it ... tocopherol acetate.

An insightful article at WebMD adds this information:

"Investigators are also trying to figure out what may have changed in vape cartridges that could have triggered this rash of respiratory illnesses. According to David Downs, writing in the publication Leafly.com, a marijuana information source, underground sellers began using a new tasteless and odorless thickening agent in late 2018. Buyers often judge THC potency by its thickness.
'This new additive may or may not play a role in the current health crisis,' writes Downs, Leafly's California bureau chief. 'But it is one of the major new ingredients in illegal vape cart oil in widespread use this summer.'"

If tocopherol acetate is playing a role in the outbreak, it would help to explain why the observed lung illnesses are so severe and why the patients' lungs basically stop working. As explained in the Washington Post:

"Vitamin E acetate is basically grease, said Michelle Francl, a chemistry professor at Bryn Mawr College. Its molecular structure means that “you have to heat it up pretty hot” for it to vaporize. Its boiling point is 363 degrees Fahrenheit, which is well above the 212 degree F boiling point for water, and nearly four times higher than normal human body temperature. Once the oil is heated hot enough to vaporize, it can potentially decompose and “now you’re breathing in who-knows-what,” Francl said. When that vapor cools down in the lungs, it returns to its original state at that temperature and pressure, she said, which means “it has now coated the inside of your lungs with that oil,” she said.
It is not difficult to imagine why the lungs would stop working if they became coated with grease or oil.

It will be interesting to see how long it takes the CDC to issue an unequivocal warning to the public that they should absolutely not vape marijuana using THC vape carts obtained off the street.

This emerging story shows the dangers of bias in public health. The long-standing bias of the CDC against vaping has resulted in the agency failing to warn the public in clear and specific terms about the risks associated with the use of bootleg THC vape carts and instead, issuing warnings against "vaping" and "e-cigarettes" generally and making meaningless statements like "e-cigarette aerosol is not harmless water vapor."

On my blog, I first issued a warning about the use of black market THC oils on August 25, and then on August 28 I blogged and tweeted an unequivocal warning, since the CDC had failed to do so. It is now 11 days later, and we are still waiting for the CDC, HHS, and other health groups to issue a clear and specific warning against the use of bootleg THC vape carts. We are still waiting for these groups to stop blaming the outbreak on vaping or on e-cigarettes. Although we cannot completely rule out any role of e-cigarettes, it now appears very unlikely that they have anything to do with the outbreak, which appears to be due to e-cannabis, not e-cigarettes.

The truly unfortunate rest of the story is that in their zeal to demonize e-cigarettes, the CDC and other health agencies have put the lives of our nation's youth at risk. They should have issued a warning 11 days ago. During the past 11 days, how many youth continued to vape THC oils because of the failure of health agencies to accurately convey the known information about the potential causes of the outbreak? The CDC and other health agencies and some anti-tobacco groups have gone to great lengths to protect the illicit cannabis industry. But they have no problem with attacking the e-cigarette companies and telling ex-smokers to return to smoking rather than continuing to vape. Why?

Health Officials Continue to Warn People Not to Use E-Cigarettes While Youth Get Life-Threatening Diseases from Vaping Marijuana

There is a complete disconnect between the facts regarding the investigation of the "mysterious" illness that is affecting more than 300 people in the U.S. (mostly youth and young adults) and the health warning messages that are being communicated by public health officials. The majority of the cases have been associated not with the use of electronic cigarettes (which use nicotine-containing e-liquids) purchased at stores, but with the use of marijuana (THC) vaping carts purchased from drug dealers.

I have already reported that across California, New Mexico, and Wisconsin, 54 of the 57 cases that were reported as of last week were confirmed to have been associated with the use of THC oil (California: 21 of 21 cases; New Mexico: 8 of 8 cases; Wisconsin: 24 of 27 cases).

Yesterday, it was reported that of eight case patients interviewed in Minnesota, every single one of them reported having vaped THC, not nicotine. According to a state health department official quoted in a Minneapolis Star-Tribune article: "All of the ones we’ve interviewed, eight of eight, said they used an illegal THC product."

In addition, the second death caused by the outbreak, which occurred in Oregon, was also associated with the vaping of cannabis, although the product was apparently purchased at a licensed dispensary, not on the black market. 

So we now have five states, widely separated geographically, in which the vaping of THC oils or marijuana vape carts has been identified as the primary cause of the outbreak.

In light of this information, you would think that health officials would be issuing very clear warnings to our nation's youth not to vape marijuana, especially THC oils purchased off the street. Instead, health officials continue to emphasize that the primary risk factor for these severe illnesses is "vaping" or "e-cigarettes" generally.

This stark contrast is evidenced in an article reporting the death of a person in Oregon from vaping marijuana. After readers are informed about this marijuana-related death, they are given a CDC warning "that people who vape consider avoiding e-cigarettes while they investigate." Don't consider avoiding vaping marijuana, just avoid using an e-cigarette. Since many youth do not associate e-cigarettes with marijuana, even this broad recommendation is likely to go unheeded.

Michigan Ban on Flavored E-Cigarettes is a Terrible Policy with Devastating Public Health Consequences

Yesterday, Michigan Governor Gretchen Whitmer signed into law an executive order that bans the sale of all flavored e-cigarettes in the state. The ban includes both retail sales and online sales of all e-cigarettes, with the sole exception of tobacco-flavored products. In doing so, Michigan becomes the first state in the nation to promulgate a complete ban on the sale of the overwhelming majority of vaping products.

In defending the ban, state health officials "pointed to studies indicating that young people who vape are more likely to start smoking regular cigarettes."

The Rest of the Story

I cannot overemphasize how insane this policy is. From a public health perspective, it makes absolutely no sense to ban these fake cigarettes, but to allow the real ones to remain on the shelves. If electronic cigarettes, which have not been confirmed to have caused a single death, are so dangerous that they cannot be sold anywhere in the state, then certainly real tobacco cigarettes which kill more than 400,000 Americans each year should not be sold in Michigan.

And if the chief concern of the governor and health officials is that e-cigarette use may lead to youth smoking, then how ludicrous is it to allow the sale of cigarettes to continue while thousands of kids in the state are apparently at high risk of starting to smoke?

Certainly, if youth vaping is a public health emergency then youth smoking is even more of an emergency and so is youth alcohol use, especially youth binge drinking. But the governor is not banning the sale of cigarettes or alcohol. Why? There is simply no public health justification for this selective ban on the sale of electronic cigarettes.

Not only is this terrible public policy, but it is going to have a devastating effect on the health of Michiganders. Tens of thousands of ex-smokers in Michigan rely upon flavored e-cigarettes to remain off of cigarettes. They successfully quit smoking completely by switching to vaping. When these products are taken off the market, they are not going to drive down to Ohio to purchase their favored vaping products. Instead, most of the them are going to simply go back to smoking. It's simply too inconvenient for them to have to drive long distances to continue vaping. And if you think that these tends of thousands of vapers are going to quit nicotine cold turkey, then you don't know anything about nicotine addiction.

The other thing that some vapers will do is to start purchasing their products off what will be a new black market in Michigan. Unlike all other vaping products in the nation, these products will be the only ones that are completely unregulated. As of May 2020, the FDA will have complete scrutiny over every electronic cigarette device and e-liquid on the market throughout the nation, except for those in Michigan, which will be completely unregulated. This makes no sense at all. Given the outbreak of severe respiratory disease we are now seeing due to black market marijuana vaping products, the last thing we need is to have a new black market of nicotine e-liquids being developed. But vapers in Michigan will have no choice. For the overwhelming majority, it will be either returning to smoking or purchasing off the black market.

I hope that the state legislature will override this completely irresponsible decision by the governor, but if not, I think there are strong grounds for a lawsuit to enjoin this regulation from taking effect. By banning electronic cigarettes but not real cigarettes, which are similarly situated with regards to their public health consequences (actually, not similarly situated but much more deadly), this is an arbitrary and capricious action and is therefore not justified as a health regulation.

The rest of the story is that Michigan's ban on flavored e-cigarettes is an irresponsible and unjustified public health policy that is going to have devastating public health consequences. This is an example to the nation of exactly what not to do to respond to the epidemic of youth vaping.

Instead, the state should simply restrict the sale of all tobacco products - including cigarettes and vaping products - to adult-only (age 21+) establishments that only sell these products. This would help to reduce youth vaping while at the same time allowing ex-smokers to continue accessing the vaping products that are literally saving their lives. And it would save thousands of small businesses - the vaping shops in Michigan that are essentially acting as smoking cessation clinics for the state's smokers. It's like having a statewide smoking cessation program without having to put out a penny in funding. Now why would you want to get rid of that?