Monday, September 30, 2019

To Protect Youth from Progression to Cigarette Smoking, Truth Initiative Wants to Ban the Fake Ones But Let Real Cigarettes Remain on the Shelves

In an op-ed piece published by CNN last Friday, the president of the Truth Initiative bemoaned the "epidemic" of vaping among our nation's youth, arguing that electronic cigarette use leads to smoking. She cited research which shows "that young people who vape are more likely than their peers who don't vape to smoke traditional cigarettes in the future."

And what does the Truth Initiative propose should be done to prevent a massive youth migration to cigarette smoking?

A. Ban or severely restrict the sale of cigarettes.
B. Ban or severely restrict the sale of both cigarettes and e-cigarettes.
C. Neither of the above.

The answer ...

... C. Neither of the above.

Instead, the Truth Initiative is calling for option D:

D. Only ban flavored e-cigarettes, but leave cigarettes on the shelves, easily accessible to youth in every convenience store and gas station in the country.

The Rest of the Story

I'm sorry, but there is simply no justification for banning the sale of most electronic cigarettes but allowing real cigarettes, which kill more than 400,000 Americans each year, to remain on the shelves, almost completely unregulated.

One of the major arguments that the Truth Initiative CEO offers to support her call for a ban on all flavored e-cigarettes is that when JUUL pulled its flavors other than mint and menthol from store shelves, youth simply switched to mint and menthol flavors. But if that's true, then shouldn't we be concerned that if flavored e-cigarettes are banned, youth will simply switch to tobacco-flavored e-cigarettes?

If the Truth Initiative is genuinely concerned about youth vaping, then there is no justification for it failing to call for a ban on all e-cigarettes. By its own logic, leaving tobacco-flavored e-cigarettes will simply result in youth switching to tobacco-flavored e-cigarettes.

OK, so you're thinking that kids are not going to switch from a candy- or fruit-flavored e-liquid to a tobacco-flavored one? Fine, but if that's the case, then it's even less logical to argue that kids are going to switch from fruit-flavored e-cigarettes to the harsh, tobacco-flavored real ones. You can't credibly make the argument that youth will avoid the tobacco flavor of e-cigarettes, but get hooked on the tobacco flavor of real cigarettes.

The truth, of course, is that kids are not getting hooked on flavored e-cigarettes and then progressing to tobacco-flavored real cigarettes. They are using flavored e-cigarettes specifically because they want to avoid the health consequences that they all know are associated with the tobacco-flavored real cigarettes.

So if youth are not going to switch from flavored e-liquids to tobacco-flavored e-liquids, what are they going to switch to?

The answer is THC e-liquids, many of which are packaged in kid-friendly brands like "Apple Jacks," "Banana OG," "Birthday Cake," "Black Berry Kush," "Blue Dream," "Blueberry Kush," "Bubble Gum," "Candy Land," "Cherry Pie," "Cotton Candy," "Fruity Pebbles," "Gelato," "Grape Ape," "Grape Stomper," "Green Crack," "Honey Berry," "Honey Dew," "Ice Blue Raspberry," "Key Lime Pie," "Lemon Berry," "Lemon Head," "Lemon Slushie," "LSD," "Mai Tai," "Mango Kush," "Maui Wowie," "Mimosa," "Mojito," "Orange Chai," "Orange Cookies," "Orange Daiquiri," "Peach," "Pineapple Express," "Pot of Gold," "Purple Punch," "Rose Gold," "Russian Cream," "Sour Apple," "Strawberry Shortcake," "Sweet Aromatic," "Tangie," "Vanilla Kush," "Water Melon," "Wedding Cake," and "Zskittlez."

These are precisely the black market products that have led to more than 800 cases of severe respiratory failure, most among young people, with 13 fatalities.

The Truth Initiative's proposal to ban all flavored e-cigarettes would result in a shift from flavored e-liquids to the increased use of flavored e-joints, and it would make the current respiratory disease outbreak much worse, potentially resulting in more deaths. Does the Truth Initiative really want those severe illnesses and deaths on its hands?

This is before we even get to talking about the effects that a flavored e-cigarette ban would have on adults, which include a mass return to cigarette smoking or entrance into a new black market for flavored e-liquids, which might eventually result in an even worse disease outbreak in the future, since the number of adults using these products and thus subject to any contaminant that may arise in these black market products will be immense.

The Truth Initiative has apparently written off adult smokers completely at this point. The op-ed views them as being expendable: "the current environment is not about providing well-regulated e-cigarette technology for adult smokers who otherwise won't quit." This is a complete betrayal of a central part of the mission of the Truth Initiative, which was to "reduce tobacco use" by "increasing successful quit rates, and reducing disparities in access to prevention and cessation services."

The rest of the story is that the Truth Initiative has steered away from its original mission and its policy proposal to ban flavored e-cigarettes would severely harm the health of both youth and adults across the nation.

There is a better alternative, and it involves Option B above; specifically, restrict the sale of all tobacco products, including cigarettes and e-cigarettes to stores that can only sell these products and are only open to people ages 21+. Ironically, it is the nation's vape shops and most of the vaping industry -- and not health groups -- that are pushing for such a policy change.

In Response to Two Deaths Due to Marijuana Vaping, Oregon Health Department Recommends Ban on Nicotine-Containing Electronic Cigarettes

In response to two deaths that it says were attributable to vaping cannabis purchased from legal state dispensaries and three additional cases that were linked to cannabis products purchased from state dispensaries, the Oregon Health Authority is recommending that all nicotine-containing (non-cannabis) electronic cigarettes should be banned for six months.

According to an article by Oregon Public Broadcasting: "Officials with the Oregon Health Authority recommended Gov. Kate Brown ban vaping products in the state for six months, following a second vaping-related death Thursday." This recommendation is for a ban on all vaping products, both THC and nicotine e-liquids.

Later in the same article, we learn that: "the most recent death followed the same pattern as past cases: an adult, who experienced severe respiratory injuries after vaping cannabis products purchased from a licensed retailer." And in an article published in the Salem Reporter, we learn that all five of the reported cases in Oregon are associated with the use of "licensed cannabis products."

The Oregon state health department warned the public against any vaping: "At a press conference Thursday announcing the latest death, health officials were adamant: No one in Oregon should still be vaping. “No level of vaping is safe,” Sidelinger said. “With these acute respiratory injuries and deaths, we do urge all individuals to stop vaping, whether that’s nicotine-based products, cannabis products or other products.”"

The state health officer closed by saying that: "With the root cause of these vaping-related illnesses still unknown, Sidelinger said it’s likely health officials are going to see “increased number of cases and, tragically, more deaths.”"

The Rest of the Story

Actually, the reason that health officials are going to see increased number of cases and more deaths is not that the root cause of these vaping-related illnesses is still unknown, but because the root cause is known but officials like Dr. Sidelinger are disregarding this critical information.

Even after the CDC has finally admitted that vaping THC, potentially contaminated with vitamin E acetate oil, is the chief culprit in the outbreak, and even after the Oregon Health Authority itself admits that all five of the state's outbreak cases are associated with the vaping of cannabis products purchased from state dispensaries, the Oregon state health department is still ignoring, undermining, and hiding that critical information from the public by claiming that we still have no idea what is going on and that people should stop vaping anything, no matter the situation, no matter what the ingredients are, no matter how long they have been using these products without a problem and without changes in their ingredients, and no matter where they are obtaining those vaping products.

The health department's warning is so vague and so general that people - especially young people - are not going to take it seriously.

By not issuing an explicit warning against vaping marijuana, the Oregon Health Authority is hiding critical information and undermining the known role that THC vape cartridges are known to be playing in this outbreak. And that is going to lead to people, especially youth, continuing to vape marijuana as the warning is just not specific enough.

In fact, the health warning issued by the Oregon Health Authority specifically mentions not vaping e-cigarettes, but does not specifically caution against vaping THC vape cartridges.

This all-too-vague warning is irresponsible not only because it is going to make the outbreak worse, not better, but because it is also going to cause enormous health damage to former smokers in the state who have quit smoking by switching to electronic cigarettes. The health department is telling them in no uncertain terms to discontinue the use of their e-cigarettes, which is tantamount to telling them to go back to smoking.

Ironically, after the first death in Oregon occurred and was linked to THC vaping of a product purchased at a licensed state dispensary, the Oregon Health Authority decided not to close down the two dispensaries whose products were implicated, defending its decision by arguing that it would be unfair to close down a business without clear evidence that its products were implicated.

According to an article in Willamette Week:

"Jonathan Modie, spokesman for the OHA, says just because the person bought products from these two stores doesn't mean it was necessarily the stores' products that killed the person."It doesn't necessarily mean the individual got sick from products that they had purchased at these dispensaries, we just know that the individual shopped at a couple of dispensaries prior to getting ill," says Modie. "We're still waiting to get samples of the products and then we send that off for testing." 

"When WW asked if it wouldn't be better to shut down a store that potentially sold a lethal product to a customer, Modie replied, "How do you think the dispensary operator would feel if it turned out that the product wasn't theirs? We wouldn't want to name or point to a specific dispensary before we have all of the information that says unequivocally that that was the dispensary where the product was sold that made the individual sick," says Modie."

So let's get this straight: When the Oregon Health Authority had a direct link between a death from the outbreak and cannabis vaping cartridges purchased at two dispensaries that they regulate, they emphasized that they didn't want the dispensary operators to feel bad if it turned out that the product wasn't responsible for the death, but weeks later - when it appears much clearer that vaping marijuana and not store-bought nicotine e-liquids is the primary culprit in the outbreak - they are perfectly OK with shutting down every vape shop in the state, even the hundreds that don't sell THC vape cartridges in the first place and whose products have not been implicated in the slightest way. 

There is now even more evidence that THC vaping products are playing a major role (if not the only role) in the outbreak. Iowa has now reported that of 23 cases in the state, 18 patients have admitted to using THC vapes. Officials in Texas have now reported that at least 75% of the case patients in that state have admitted to vaping THC. And it has now been revealed that the death reported in Indiana, which was previously not attributed to any particular product, was associated with THC vaping.

Thus, every death for which information has been released about the products used has been associated with vaping marijuana. And more importantly, every single reported case in Oregon has been associated with vaping cannabis purchased at state dispensaries.

The rest of the story is that the Oregon Health Authority appears to have a vendetta against nicotine-containing e-cigarettes, and it is going to great lengths to protect marijuana dispensaries that it regulates and whose products appear to be responsible for two deaths and three life-threatening cases, while attacking retail stores and vape shops whose products have not been implicated with even the slightest bit of evidence.

In some ways, the Oregon Health Authority actually bears some responsibility for these two deaths because it apparently failed to properly regulate the state's marijuana dispensaries. It appears that the health department failed to require testing of dispensary vaping liquids for vitamin E acetate oil and other cutting agents. This is what led to the sale of an oil-based e-liquid that should never have been on the shelves in the first place. 

Rather than pointing the finger at every retail store and vape shape in the state that is selling water-based e-liquids, the Oregon Health Authority should first be pointing the finger at itself and apologizing to the victims' families for not properly regulating the state's marijuana dispensaries and allowing them to sell oil-laden THC liquids that have no business being sold anywhere.

Sunday, September 29, 2019

CDC Finally Admits that Black Market THC Vape Carts are a Major Culprit in Respiratory Disease Outbreak

The CDC has finally admitted that black market THC vape carts are a major culprit in the respiratory disease outbreak that has affected 805 people and resulted in 13 deaths. Instead of continuing to emphasize that "no single product" is linked to all the cases, the CDC clearly stated yesterday that "THC is the most prominent link across patients" and the agency changed its warning to specifically mention THC: "While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC."

Because of the CDC's long overdue acknowledgment of the primary role of illicit THC vape carts, newspaper headlines are finally telling the story like it should be told. For example, the headline of an article in the Regina Leader-Post reads: "CDC recommends against using vapes with THC due to lung illnesses." An article by NASDAQ is entitled: "U.S. CDC recommends against using vapes with marijuana ingredient." And the headline of a New York Times article reads: "Dank Vapes, TKO and Other THC Vaping Brands Are Linked to Illnesses, C.D.C. Says."

These are the kinds of clear, specific messages that we should have seen in newspapers two months ago.

In an emergency MMWR publication, the CDC reported that of cases in which there was information on the products used, 84% of patients admitted to vaping THC. But in contrast to previous publications, instead of immediately undermining this important finding by emphasizing that "no single product" can be linked to all the cases, the CDC instead emphasized that there are multiple reasons why many patients might not report using THC even if they did: "patients might not always know what substances they use or might be hesitant to reveal use of substances that are not legal in their state."

In a separate article covering patients from Illinois and Wisconsin, the CDC revealed that: "Use of tetrahydrocannabinol (THC)-containing e-cigarette products, the majority of which were prefilled cartridges obtained from informal sources, was reported by 87% of patients during the 3 months preceding illness." Importantly, CDC finally admitted that: "the predominant use of prefilled THC-containing cartridges among patients with lung injury associated with e-cigarette use suggests that they play an important role."

The CDC also reported that: "In Wisconsin, eight patients initially denied using THC-containing products in interviews, but five (63%) were later found to have used THC through review of medical charts, reinterview, or cross-referencing with friends who were also interviewed as patients."

Finally, the CDC finally provided very specific information about the black market THC vape carts that were used: "Although no single brand name was reported by all patients, a prefilled THC cartridge sold under the brand name Dank Vapes was reported by 57 (66%) patients. In Wisconsin, two groups of friends (two patients in one group and three in the second group) who became ill after using THC-containing cartridges specifically reported sharing Dank Vapes cartridges. Dank Vapes was the only e-cigarette product reported by one of the patients."

The Rest of the Story

I checked my blog and Twitter feed to determine when I first issued an explicit warning for people to avoid vaping black market THC vape cartridges. I issued such a warning on my blog on August 25th and on Twitter the same day. On August 28th, I tweeted the following: "The CDC isn't warning the public, so I'll do it myself: PLEASE do not vape THC oils that were purchased from any unlicensed seller. And spread the word to youth who might be at risk. Hiding the truth is not an effective public health strategy."

It took five weeks (35 days) after my warning before the CDC finally announced the major role of THC vape carts in the outbreak. During those 35 days, how many young people continued to use THC vape carts who might have stopped if the CDC had announced this connection 35 days earlier? How many people developed respiratory illness because of this failure?

Now that it is clear that the outbreak is not being caused by store-bought electronic cigarettes, but by THC vaping cartridges and perhaps other counterfeit black market products, it is critical that the five states which have banned e-cigarettes or flavored e-cigarettes (Massachusetts, Rhode Island, Michigan, New York, and Washington) rescind these bans and focus on limiting the illegal distribution of THC vaping products.

Friday, September 27, 2019

CDC's Failure to Demand Urine THC Testing of All Outbreak Patients is Inexcusable and is Putting the Entire Nation at Risk

The CDC has irresponsibly botched its entire investigation of vaping-associated respiratory illness (VARI) by failing to recommend or demand that clinicians perform a urine THC drug test on every case patient, and this is putting the entire nation at risk while leading to terrible public policies that are causing immediate harm to thousands of people.

The CDC continues to insist that we have no idea what is causing this "mystery illness" and that "no single product" has been identified that explains all of the cases. This statement, which violates basic principles of epidemiological outbreak investigations, is the single communication that has confused policy makers and the public and hindered the ability of state health agencies to issue appropriate recommendations to the public to actually curtail this epidemic of life-threatening respiratory failure.

Contrary to what the CDC seems to be insisting, this outbreak is not going to be solved by identifying a single product common to every patient. Like all outbreak investigations, it is going to be solved by identifying a type of product that is common to an overwhelming majority of patients. And frankly, we already have that and it's called marijuana. There is just far too high a proportion of case patients who have admitted to using THC or CBD oils for this to be merely a coincidence.

Just overnight it was announced that a second Oregon patient has died. The reported cause? Vaping of THC oils. Of course, this didn't stop the Oregon Health Authority from recommending that Oregonians stop vaping nicotine-containing e-liquids. This non sequiter is striking: "A second Oregonian has died from a lung illness after vaping cannabis products, and state health authorities Thursday urged people to immediately stop using all vaping products." This is like reporting a series of deaths from eating Romaine lettuce and advising people to immediately stop eating all lettuce and cabbage. Except it's a lot worse because no harm comes from people stopping eating cabbage. Severe harm is already resulting from ex-smokers stopping vaping and returning to smoking or to the black market.

There are simply too many cases of patients who were vaping for years without a problem and then decided to try THC vape carts and then suddenly getting sick to dismiss the central role of marijuana vaping in this outbreak.

So why aren't the CDC and in turn, state health authorities issuing very clear warnings to the public to stop vaping marijuana, especially THC vape pens or vape carts that are purchased on the street?

It's because the CDC keeps repeatedly issuing the irresponsible mantra of this botched investigation: "No single product" has been linked to all cases. While I was working at CDC, I was not aware of a single Epi-Aid in which a single exposure was linked to all cases of an outbreak. There are always going to be a small proportion of people who forgot that they did have a little potato salad at the church picnic. And in this investigation, the problem is far worse. There are no legal implications and no stigma attached to admitting that you ate some potato salad. But for a youth to admit that they were using illicit marijuana vaping carts purchased off the street from drug dealers could have substantial consequences, not only legal ones but stigma-related ones as well as affecting their relationships with their parents.

The CDC itself admits that about 80% of the outbreak patients admit to using THC oils. My count from media reports puts that figure closer to 90%. How high does that proportion have to go before the CDC issues a clear recommendation not to vape THC and stops undermining its own findings by emphasizing the failure to find a common product in every single case? Apparently, it's 100% before they will take the appropriate actions and enable health authorities to put an end to the tremendous morbidity and mortality this outbreak is causing.

The Rest of the Story

The sentinel failure of the CDC in investigating this outbreak is its failure to recommend or demand that all case patients be screened (via urine drug testing) for THC. In people who vape marijuana regularly, THC can be detected in the urine for at least 4-6 weeks following the last exposure. Even in people who don't vape marijuana regularly, THC can be detected for between 7 and 10 days after the most recent use. This is not going to be 100% sensitive in detecting all THC use but it would certainly help detect a large proportion of the cases where a patient is using THC but did not report it.

Even if a small proportion of patients were screened for THC, it would provide valuable information. 

The recommendation to test for THC does not need to be justified based on the premise that youth patients are "lying" about their drug use:

1. There are thousands of counterfeit products on the market that are packaged to look like legitimate nicotine-containing products but which may contain cheaply made THC oils. There are even counterfeit JUUL-compatible pods that appear to be JUUL but are actually bootleg products and could contain THC oils. So youth may simply have no idea that they are using THC. This alone makes it inexcusable for clinicians not to test for THC in every patient.

2. Many youth simply don't know what they are vaping in the first place. Data from the Monitoring the Future study and other national surveys reveal that youth are unable to accurately report what they are vaping. They may not actually know what is in the cartridges that they are using. Youth are most commonly obtaining their vaping liquids from other kids at their schools, not directly from a retail store. So they are not getting an ingredient list or being told exactly what is in the liquid. They truly may not be aware of exactly what they are vaping. Under these circumstances, it is bordering on public health negligence for the CDC not to recommend that patients be screened for THC use.

The CDC has been insisting that a small proportion of cases have occurred among patients who did not use THC. The truth is that they have no way of knowing that. Unless the patients have been tested for THC, it simply cannot be said that cases have occurred among patients who only used nicotine-containing e-liquids. This is why I believe it is so irresponsible that the CDC has repeatedly given the impression that it knows that a substantial proportion of cases do not involve THC. They actually have no way of verifying their contention that "no single product" ties together all the cases. It is entirely possible that a single product - marijuana and counterfeit vapes - does tie together all the cases.

The CDC's failure to conduct this investigation properly (as outlined above) is not only putting the entire public at risk because we are failing to properly communicate the role of black market THC vape carts, but it is also leading to bad public policy that is already having devastating public health consequences as well as putting hundreds of vape shops out of business and creating massive job loss and financial harm for small business owners.

The final question that I want to tackle in this commentary is why the CDC is failing to recommend THC testing of every case patient. There is no legitimate public health justification for this failure. The only explanation is that the CDC does not actually want to tie all the cases together by detecting marijuana use in a large proportion of patients who reported using only nicotine-liquids because that would let legally sold, store-bought nicotine-containing e-cigarettes off the hook. The CDC's actions tell me that they actually desire to be able to tie these cases to traditional e-cigarette use. They are apparently going to hold out as long as possible before admitting clearly that THC carts are playing a major role in this epidemic.

The CDC's irresponsibility is perhaps best demonstrated by the testimony of a CDC deputy director at this week's Congressional hearing. She testified that one possible cause of the outbreak is something about the act of vaping itself. In other words, she testified that something about the process of vaping itself may be causing this outbreak, rather than the specific products that are being vaped.

Sorry - I hate to have to use this type of language but my conscience does not allow me to express it any other way:

This is complete bullshit.

People have been vaping for the past 12 years without any problems. Millions of smokers who quit smoking by switching to vaping have experienced dramatic improvement in their respiratory health, not rapid progression to respiratory failure. The act of vaping is not causing this outbreak. It is something in the e-liquid or that results from the heating of the e-liquid that is responsible.

At an August 23rd press briefing, one CDC official had this to contribute to a reporter's question about why there has been an upsurge in cases: "We do know that e-cigarettes do not emit a harmless aerosol."

Instead of that meaningless observation, the official could have instead explained that one major change we do know about is the use of a new thickening agent that had not been used previously - vitamin E acetate oil - and could have pointed out that the overwhelming majority of cases were associated with vaping black market THC cartridges. But he was apparently more concerned about creating the perception that e-cigarette companies continue to insist that their products are harmless and then attacking this straw man than actually providing a useful answer to the question.

I get the idea that the CDC really doesn't know anything about vaping. They keep talking about it as if it is some great "mystery" and we don't have any clues about what may be going on. The truth is that we have an immense amount of information, but they are just not putting it together. They keep discounting the information that they do have. The cannabis experts actually know far more about the outbreak and its potential causes than the CDC does. In fact, some cannabis experts actually predicted this outbreak before it occurred because of the changes they were observing in the production of black market THC vape carts and the counterfeiting of legitimate products that they observed.

Although I'm convinced that the CDC's failure to recommend THC testing, its failed communication on the potential causes of the outbreak, and the actions of policy makers to ban electronic cigarettes are all contributing towards making the outbreak worse by obscuring the potential role of marijuana vaping, it is not too late to prevent further deaths by initiating THC testing of case patients. I hope that the CDC will institute this recommendation immediately.

Thursday, September 26, 2019

Using Its Emergency Powers, Rest of the Story Issues Four-Month Temporary Ban on Further E-Cigarette Bans

Today, I am bypassing the usual rulemaking process and using my emergency powers to declare a public health emergency and accordingly, I am issuing a four-month, temporary ban on politicians enacting further electronic cigarette bans.

The purpose of this public health emergency is to temporarily pause all knee-jerk reaction e-cigarette bans so that we can work with our vaping and cannabis market experts to identify what is actually making people sick and how to better regulate these products to protect the health of our residents without putting thousands of small business owners out of work, forcing thousands of ex-smokers to return to smoking, and creating a massive new or expanded black market for illicit THC and nicotine e-liquids.

Why is This a Public Health Emergency?

This is a public health emergency because starting today, ex-smokers in Massachusetts began a wholesale return back to smoking tobacco cigarettes as the stores carrying the electronic cigarettes which were keeping them away from smoking were boarded up and emptied of merchandise, causing tens of thousands of dollars of lost expenditures and putting hundreds of vape shops out of business. 

I have already heard many stories of ex-smokers who today lit up their first cigarette in months or years, thanks to the governor and the Public Health Council's ban on the sale of electronic cigarettes. In addition, I have already heard many stories of medical marijuana patients who are now turning to dangerous, unregulated, black market THC vaping products because they are unable to switch to combustibles or edibles for medical reasons.

Furthermore, hundreds of smoking cessation clinics (i.e., vape shops) have boarded up their windows, eliminating in one fell swoop one of the most successful anti-smoking interventions in the state of Massachusetts.

Worst of all, with the elimination of nicotine-containing e-liquids, youth are going to begin switching over to illicit THC vaping carts which are associated with most of the cases of severe respiratory failure that are sweeping the country.

In addition, since public health officials have told us that youth vapers are at high risk of transitioning to smoking (e-cigarettes are a gateway to smoking, they say), it is a public health disaster for real cigarettes to remain on the shelves of convenience stores, gas stations, and pharmacies while electronic cigarettes are nowhere to be found.

Reason for Temporary Ban

I am issuing a temporary ban on further e-cigarette bans for 4 months so that it provides enough time to educate policy makers about what we already know regarding the probable causes of the respiratory disease outbreak, information that the CDC has been hiding from health officials and the public for several weeks.

Since the agency readily admits that no fewer than 80% of the cases are associated with the use of black market THC vape carts and in states that have tested the THC vape carts that have been recovered, between 90% and 100% of those carts were "contaminated" with vitamin E acetate oil, there is no justification for shutting down stores selling nicotine-containing e-liquids whose only ingredients are propylene glycol, glycerin, water, nicotine, and flavorings, all of which have been around for years and not caused any problems. It will take 4 months to educate public officials about the differences between a water-based e-liquid and an oil-based e-liquid and the fact that oil-based e-liquids are the ones that are causing lipoid pneumonia.

The ban will be rescinded in four months, after which time I reserve the right to use a formal rule-making process to permanently remove e-cigarette bans from the marketplace of stupid policy proposals should the facts of the situation not sink in.

Criminal Proceedings Against Illicit Drug Dealers

Unlike Governor Baker's emergency order, which leaves illicit drug dealers off the hook, my emergency order is going to go after the source of the products that are causing so many young people to suffer life-threatening respiratory illnesses. My order also includes an injunction so that vape shops can remain open to continue to save the lives of thousands of Massachusetts residents who are depending on e-cigarettes to remain smoke-free and much healthier than they were when they smoked tobacco cigarettes.

Legal cannabis dispensaries and medical marijuana providers will be allowed to continue to sell legal, regulated cannabis vaping products, but only after certifying that the products were manufactured safely and without any vitamin E acetate or non-cannabis oils.


As in Michigan, the penalty for violation of this emergency order will be $200 per ex-smoking vaper who is forced to go back to smoking or to turn to the black market and up to six months of jail time. Lawmakers will also be liable for four-months worth of revenues for each vape shop that shuts down in their state to any enacted e-cigarette or flavored e-cigarette bans.

Reaction from the National Lung Association

"In the absence of strong federal action especially by the FDA, states are being forced to make decisions to protect the health of children and adults from an electronic cigarette-ban-related public health emergency," said the National Lung Association National President and CEO. "The Rest of the Story's announcement reinforces the need for the FDA and CDC to confront the illicit production and distribution of oil-laden THC vape carts and bootleg or counterfeit "nicotine" cartridges that are being sold on the black market or through shady internet sites. While the Centers for Disease Control and Prevention and state and local departments of health continue to investigate the hundreds of cases of lung injury from black market vape cartridges, the National Lung Association once again urges all Americans to stop using cigarettes and to stop vaping marijuana unless it is purchased from a legal dispensary that has certified the absence of added oils, such as vitamin E acetate oil."

Disposition of Legislative Proposals and Bills Currently Under Consideration

Because this is a temporary ban, at this time politicians are not being asked to destroy their bills, however, the bills need to be taken off of the shelves immediately.

Politicians Continue to Destroy Hundreds of Small Businesses as More Drug Busts Reveal Thousands More Illicit THC Vape Carts

Yesterday, the governor of yet another state - Rhode Island - announced that he would be directing the Department of Health to ban the sale of all flavored e-liquids. This now makes four states which either have banned or will imminently ban the sale of either all nicotine-containing e-cigarettes or all flavored, nicotine-containing e-cigarettes. This, along with the resignation of the CEO of JUUL, gained widespread media attention yesterday, dominated on the air waves only by a presidential impeachment inquiry.

What flew off the radar screen and is being completely ignored by those very same politicians who are banning nicotine-containing e-cigarettes is that yesterday, authorities in both Virginia and Minnesota conducted raids on makeshift residential marijuana vaping product manufacturing facilities and seized more than 76,000 illegal THC vape carts - the products that are almost certainly responsible for most of the hundreds of cases of severe, acute respiratory disease that are occurring across the nation.

In Virginia, officials seized more than 1,000 "Dank" vape cartridges which have been linked to at least some cases of the respiratory illness. Since these cartridges typically sell for about $35, the estimated street value of the seized products is more than $35,000.

In Minnesota, officials seized more than 75,000 illicit THC vape carts, "in flavors like Fruity Pebbles, Cherry Kush and Candy Land."

The Rest of the Story

It is telling that while drug enforcement authorities are actually starting to get to the root of the problem by interfering with distribution channels of the illicit THC vape carts and counterfeit or bootleg "nicotine" vaping cartridges that appear to be causing the vaping-associated respiratory disease outbreak, politicians are instead trying to win political points by putting hundreds of small businesses - vape shops which are essentially smoking cessation clinics - out of business.

As I have emphasized, this is not going to curtail the outbreak. It is going to make it worse. My opinion echoes that of former FDA commissioner Dr. Scott Gottlieb, who in recent days has been outspoken in pointing out the folly of the CDC's communications as well as policy makers' responses to the outbreak.

As Dr. Gottlieb wrote yesterday: "Reading transcripts, it seems there’s too much conflating these tragic lung injuries with store bought brands of regulated, legal e-cigs like Juul and NJOY; and far too little blaming THC, CBD, and bootleg nicotine vapes - where so far, the only available hard evidence points."

Sadly, Dr. Gottlieb appears to be the only (former) public official who knows what he is talking about because he actually knows something about the vaping industry. If he were still the commissioner, we would probably not be in the unfortunate situation we are today.

Instead of going after flavored nicotine e-liquids sold legally by retail stores, policy makers should be going after the attractive, flavored, bootleg THC vape carts - in flavors like Fruity Pebbles, Cherry Kush and Candy Land - that are being sold and distributed to our nation's youth on the black market by drug dealers.

By diverting attention away from the real problem, policy makers are actually making the problem much worse. There are going to be more severe illnesses and deaths, not fewer, because of these misguided and completely unjustified electronic cigarette bans. 

If you really want to have a better understanding of the true nature of the problem, read this article by the folks at Leafly. In my opinion, they are the ones who should be conducting the outbreak investigation, not the CDC which has already completely botched the investigation and the communication of the truth to the public.

Wednesday, September 25, 2019

Massachusetts Governor's Emergency Order Protects Drug Dealers at the Expense of Hundreds of Life-Saving Small Businesses

In a move that is a huge victory for the state's drug dealers, Massachusetts Governor Charlie Baker has instituted a 4-month ban on the sale of all vaping products in the state, including both nicotine-containing electronic cigarettes sold at retail stores and vape shops and cannabis vaping products sold at legal cannabis dispensaries. The ban, which was approved by the state Public Health Council on Tuesday, goes into effect immediately and was motivated by the recent emergence of an outbreak of vaping-associated respiratory illness (VARI) that has affected more than 530 people across the United States and has resulted in nine deaths.

The primary suspected cause of this outbreak of severe, acute respiratory failure which often takes the form of lipoid pneumonia or an eosinophilic chemical pneumonitis is the widespread black market sale of illicit marijuana vape cartridges, many of which contain a viscous oil that is used as a thickening agent to help drug dealers obtain a higher price for the THC vape carts they are selling. There were recently two major drug busts which recovered thousands of oil-laden THC vape carts, and testing of THC vape carts provided by numerous case patients in New York State revealed that all of them contained high levels of vitamin E acetate oil, the thickening agent that has recently come into widespread use by illicit drug manufacturers (as well as some legal manufacturers).

Although the CDC has misled the public into thinking that nicotine-containing e-cigarettes like JUUL are causing the outbreak, the application of basic epidemiology principles should tell us that this cannot be the case. Since JUUL and many other nicotine-containing e-cigarettes sold at retail stores have been on the market for at least several years, it does not make sense that we would all of the sudden see these products causing severe respiratory failure. Moreover, since there are millions of adult JUUL users, we would be seeing a lot more adult cases of this disease if it were being caused by JUUL or similar products.

Clearly, whatever is going on is affecting primarily youth and primarily males. What kind of vaping products are used primarily by youths? The answer is black market products. Since adults can legally access cannabis vaping products in states with legalized recreational or medical cannabis, it is primarily going to be youth who use the black market THC oils that are being distributed by the drug dealers.

The strongest evidence that the primary culprit is black market THC oils is the fact that the most common presentation of the illness is a lipoid pnemonia. This is a disease that is known to be caused by oil inhalation. Virtually all, if not all, nicotine-containing electronic cigarettes sold at stores are made with water/alcohol-based e-liquids, which do not cause lipoid pneumonia. In contrast, the THC vape carts that are in wide circulation are loaded with a viscous oil. When this oil is heated and then cools when it reaches the lungs, it solidifies and basically cakes the alveoli and also induces severe inflammation (as the body's immune cells try to get rid of the oil). This explains the typical radiographic appearance in the cases, which is actually part of the case definition.

If there are any nicotine-containing e-liquids that are using an oil-base, they are almost certainly being sold online, not by retailers or vape shops. But Governor Baker's order focuses on the latter.

The Rest of the Story

So why, in the face of this severe epidemic of respiratory disease that has been associated with the widespread use of oil-laden THC vape cartridges sold on the black market, is the governor banning the sale of legally produced and sold nicotine-containing e-liquids that have not been confirmed to be causing any cases?

The answer, I believe, is that this is an easy political victory. It looks great to upper middle class suburban parents (voters) that politicians are stepping in to protect their children. And it takes no political courage to go after hundreds of small business owners who don't have the political power to put up a legal fight. It would be far more difficult to actually confront the real problem, which would require the governor to go after the drug dealers who are distributing illicit THC vape carts that are winding up in the hands of youth throughout the state.

Sadly, Governor Baker's action is going to make this problem much worse, not better. Eliminating nicotine-containing e-liquids is not going to prevent further cases from occurring because those are not the products which appear to be causing the outbreak in the first place. Moreover, the kids who are selling e-liquids in our middle schools and high schools are not going to simply shut down their operations. They are going to switch over to selling the e-liquids that remain available, which will be the black market THC vape carts that are actually causing this outbreak.

This emergency order is also going to have other severe adverse health consequences. It is going to shut down hundreds of vape shops which are literally life-saving businesses: they are helping tens of thousands of smokers to quit smoking and to remain off of cigarettes. Essentially, vape shops are smoking cessation clinics. Most of the owners have themselves quit smoking by switching to e-cigarettes, and they can provide personal advice and counseling to their customers. This is much more effective smoking cessation counseling than most physicians can provide. And that's why it's been so widely successful.

Don't be fooled. A four-month temporary suspension of e-cigarette sales is, for most small businesses, a permanent ban because they are going to have to shut down. Most small businesses can simply not survive having no revenue for four months. And if they have a large supply of e-liquids in inventory, they could be out hundreds of thousands of dollars. They will never recover.

This ban is also going to lead many ex-smokers to return to smoking as their e-liquids disappear and it becomes too inconvenient to obtain them. In addition, this order is going to create a new, unregulated black market for e-liquids.

But the worst outcome, by far, will be the misdirection caused by this move. It takes our attention off the widespread problem of marijuana vaping among middle and high school youth in Massachusetts. That is the public health emergency we face, but apparently, we're not willing to face up to it because it's a lot more politically expedient to go after small businesses than drug dealers.

Tuesday, September 24, 2019

Arizona Detectives Bust Illegal THC Vape Cart Operation and Butane Hash Oil Lab; CDC Continues to Go After Legal Manufacturers and Downplay the Role of these Black Market Marijuana Products

Two weeks ago, detectives with the Maricopa County Drug Suppression Task Force busted an illegal THC vape cart operation in Phoenix. They found more than 1,000 THC vape carts worth an estimated $55,000 along with a butane hash oil manufacturing lab and 300 pounds of mid-grade marijuana used to manufacture butane hash oil. The vape carts they found were packaged as the "Dank" brand, which has been associated with some of the recent vaping illnesses and deaths.

This is at least the second bust of an illegal THC vape cart manufacturing facility in as many weeks, as Wisconsin drug enforcement officials raided a similar operation in Kenosha County and found more than $1.5 million worth of illegal THC vape cartridges.

The CDC continues to claim they we don't yet know whether black market THC vape cartridges are involved in the outbreak at all, insisting that "We do not yet know the specific cause of these lung injuries." Instead of explicitly warning youth in no uncertain terms that THC oils are causing deaths, the CDC continues to invoke legally sold electronic cigarettes and to warn against any use of electronic cigarettes at all.

The CDC's official recommendation remains: "If you are concerned about these specific health risks, CDC recommends that you consider refraining from using e-cigarette or vaping products."

The Rest of the Story

Given the fact that close to 90% of cases and 100% of the deaths for which products have been reported are associated with marijuana vaping, it is inexcusable that the CDC fails to distinguish between the products being vaped. It is also inexcusable that CDC has failed to distinguish between the vaping of oil-based e-liquids (which are typically used in TC carts) and water/alcohol-based e-liquids (as are used in virtually all e-cigarettes).

The scare that CDC has caused is associated with a sharp decline in e-cigarette use and in fact, financial analysts are predicting that we are going to see an increase in cigarette consumption, especially if policy makers follow through with their plans to ban flavored e-cigarettes.

Even worse, there is no doubt in my mind that the CDC's botched warning is leading to more cases of severe respiratory illness. Youth are reportedly getting scared of e-cigarettes and are destroying JUUL pods, but they don't appear to understand that vaping marijuana is the real severe risk here.

Dr. Stan Glantz today tweeted that propylene glycol and glycerin might be the cause of the respiratory disease outbreak. This is ridiculous. These excipients have been used in e-liquids for the past 12 years without a problem. Moreover, if PG/VG were the problem, then there would be a huge number of cases occurring among adults, much less of a differential by gender, and much less of an age gradient in the reported cases.

The most important fact that is being ignored is that the bulk of these cases are presenting as lipoid pneumonia. Exogenous lipoid pneumonia is caused by oil inhalation. PG/VG are not going to cause an outbreak of lipoid pneumonia. But the widespread use of THC oils, which is running rampant among youth, could very well be causing this outbreak.

We don't have all the facts we need, but the pieces are all starting to fit together. And we know enough right now to explicitly warn youth against vaping marijuana. I remain convinced that the CDC's conflation of the problem of youth e-cigarette use and the problem of this respiratory disease outbreak is going to have devastating public health consequences.

Monday, September 23, 2019

CDC Investigation into Respiratory Disease Outbreak Has Contributed Absolutely Nothing to the Public's Knowledge So Far

Before the CDC initiated its investigation of vaping-associated respiratory illness (VARI) on August 1, here is what we knew about the outbreak:

This outbreak is associated with vaping. If you want to avoid getting sick, you should avoid vaping.

After nearly eight weeks of CDC investigation, here is what the CDC's current conclusion is about the outbreak:

This outbreak is associated with vaping. If you want to avoid getting sick, you should avoid vaping.

In other words, the investigation has added nothing in terms of public knowledge. Most importantly, it has added nothing in terms of specific steps that the public can take to avoid this life-threatening illness.

Frankly, it didn't take a rocket epidemiologist to issue the same warning that the CDC is now issuing. Any guy off the street could tell the public that the outbreak is associated with vaping and that to avoid it, you should refrain from vaping. After all, the name itself tells you that: "vaping-associated respiratory illness."  

The Rest of the Story

In distinct contrast to most of its investigations, it appears that the CDC has lost sight of the purpose of this particular investigation. It appears that the driving purpose of the investigation is to do everything possible to demonize electronic cigarettes, holding out as long as possible to continue to invoke legally sold, nicotine-containing e-liquids as being responsible for the outbreak, even in the face of contradicting information.

The CDC might defend itself by arguing that until it can identify with exact certainty what all the causes of the outbreak are, it must err on the side of caution and not draw any conclusions.

But that shows a misunderstanding of the purpose of an outbreak investigation. The primary purpose, beyond anything else, is to prevent further cases from occurring. By the precautionary principle, this means that you do not wait until you have a definitive and comprehensive, detailed understanding of exactly what is causing the outbreak and until you know all of the causes. Instead, it means that if you have reasonable evidence even of one particular cause, you need to explicitly warn the public to avoid that exposure.

Sadly, the CDC's communications regarding the investigation have added literally nothing to the public's knowledge of how to avoid this disease. Based on the CDC's communications, the public doesn't really have any more knowledge today about how to avoid the disease than virtually any guy off the street could be telling us. The CDC's message remains: "If you're concerned, then don't vape."

Any sixth-grade student, without any training in epidemiology, could have told us that all the way back on August 1. After all, the case definition requires that a patient must have a history of vaping. So by definition, every case that occurs is going to be associated with vaping, and if you don't vape, you cannot - by definition - get the disease.

I think that the CDC is not doing its job if after eight weeks of investigation, it cannot tell us anything more than some guy off the street.

We are trained in epidemiology for a reason. And I'd like to think that my years of training in epidemiology allows me to offer the public more specific than what some guy on the street can offer. If not, then why am I being paid all this money?

Although conducting scientific research, reviewing the scientific literature, and attending scientific conferences are all a part of how I have gained specific knowledge regarding vaping that allows me to hopefully contribute something meaningful to the public's understanding of this outbreak, what has by far prepared me the most is the fact that I have spoken to thousands of actual vapers. This is something that, frankly, the CDC has simply not been doing.

Instead of talking to vapers, they have dismissed the knowledge and experiences of vapers as being nothing other than "anecdotes." This is the term that previous CDC director Dr. Thomas Frieden used to describe vapers in 2014. Perhaps the CDC should have been spending less time belittling vapers and more time listening to them!

One of the things I learned very early on in talking to vapers, and in reviewing the literature, is that oil-based liquids should never be vaped. This was widely known to vapers back in 2012, a full seven years ago. The CDC should have known this going into the investigation but it appears that it still doesn't understand this critical concept. In fact, the CDC has yet to issue any warning against the use of oil-based e-liquids when vaping.

Both the epidemiological and clinical evidence point strongly to the likelihood that what is causing most (if not all) of the cases to become so sick is that the lungs simply cannot handle being doused with oil. Since virtually all nicotine-containing e-liquids are water/alcohol-based, not oil-based, this is not a problem with the overwhelming majority of traditional electronic cigarettes. That there may be a few rogue companies or suppliers selling oil-based nicotine e-liquids remains a possibility and cannot be ruled out. However, we do know that in the overwhelming majority of cases, the affected patients were vaping THC oils, not water-based e-liquids. And the primary manifestations of the syndrome - lipoid pneumonia and eosinophilic pneumonitis - are completely consistent with THC vape oil poisoning.

Perhaps the most important principle of risk communication in outbreak investigations that the CDC is violating is being honest and open.

As CDC itself writes in a manual called "Communicating During an Outbreak or Public Health Investigation":

"Risk communication literature identifies four factors that determine whether an audience, including journalists, will perceive a messenger as trusted and credible, including
  • Empathy and caring,
  • Honesty and openness,
  • Dedication and commitment, and
  • Competence and expertise."
There's no question that the CDC investigation is marked by high levels of empathy and caring, dedication and commitment, and competence and expertise. However, the one thing it appears to be missing is honesty and openness.

The CDC has been reluctant to tell the public that the majority of cases are associated not with vaping e-cigarettes, but with vaping marijuana. Where the agency has mentioned that "many" cases report vaping marijuana, it has immediately undermined that connection by stressing that no single cause has been identified for all cases, something that almost never happens in an outbreak investigation (not everyone remembers having eaten some of the potato salad).

The rest of the story is that any guy on the street could look at the information available today and conclude that these cases of vaping-associated respiratory illness are associated with vaping and that to avoid the illness, people should consider not vaping.

But I think we know a heck of a lot more than that and can do much better than that guy on the street because of our training in epidemiology.

Sunday, September 22, 2019

Results from National Survey Show that CDC's Communication about Respiratory Disease Outbreak Has Been a Public Health Disaster

A newly released, national public opinion survey conducted by Morning Consult reveals that twice as many U.S. adults believe that JUULs, as opposed to marijuana vape carts, are associated with the outbreak of deaths from respiratory disease. The survey also reveals that U.S. adults are no more likely to believe that marijuana vape carts are associated with the deaths as to think that marijuana vape carts are not associated with the deaths.

Specifically, 58% of the adults surveyed attribute the outbreak deaths to the use of "e-cigarettes such as JUUL," while only 34% attribute these deaths to "marijuana or THC" vaping. And an almost equal proportion of adults believe that the deaths are not associated with marijuana or THC vaping (32%) as believe that the deaths are associated with marijuana or THC vaping.

The truth is that of the five reported deaths in which the product being used has been revealed, all five (5/5, or 100%) are associated with the use of marijuana or THC vape carts while none are associated with the use of JUUL.

It isn't even plausible that these deaths could be associated with JUUL because there are millions of JUUL users who have been using the products for several years without any reported problems. Moreover, we would be seeing a lot more cases among adults if JUUL was the culprit.

In contrast, there are very strong reasons to believe that marijuana vape carts are the primary culprits. More than 80%, and probably closer to 90% of the cases involve patients who admitted to vaping THC. Of the remaining 10%, it is highly likely that many (if not all) of them are simply not reporting THC use because many youth would not want to admit to the use of illicit THC vape carts purchased off the black market from drug dealers. Furthermore, I am not aware of a single case in which a negative THC urine screen was obtained, meaning that we can't rule out the use of a THC cart in any of the cases. And finally, all five of the deaths for which products were reported involve patients who vaped cannabis.

The Rest of the Story

These results demonstrate how awful the CDC's risk communication has been around this outbreak. Despite the fact that close to 90% of the cases are associated with the use of THC oils, the public is much more likely to attribute the outbreak to the use of legally sold and rigorously lab-tested JUUL than to the use of illicit and completely untested and unregulated THC vape carts. This is truly a public health disaster!

It is a disaster because it means that the CDC has failed to properly communicate the severe risks of vaping marijuana. Instead, the CDC has successfully scared the public into thinking that e-cigarettes like JUUL could almost instantly kill you. Undoubtedly, this means that many of the continuing cases that we now observe and will observe moving forward are being caused by the failed, if not fraudulent, CDC warning.

People who otherwise might have been dissuaded from vaping marijuana if the CDC had been honest are likely continuing to do so and are at great risk of suffering respiratory failure or even death.

The rest of the story is that the CDC has not been transparent, forthcoming, or honest in its communications regarding the outbreak of vaping-associated respiratory illness. It has gone out of its way to hide the fact that most of these cases were associated with the use not of legal electronic cigarettes, but of illicit THC vape carts. And sadly, the misinformation campaign is working. The public is completely misinformed about the outbreak and is not in a position to make informed, rational decisions to take action to avoid this life-threatening disease.

In its apparent zeal to demonize electronic cigarettes, the CDC has put the lives of the public at risk.

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.