This article was first published in The Montreal Gazette.
According to the U.S. Centers for Disease Control and Prevention (CDC), there are currently six deaths and 380 confirmed or probable cases of severe lung disease due to vaping. As one editorial writer in a medical journal put it, “there is clearly an epidemic that begs for an urgent response.”
E-cigarettes have exploded in popularity in recent years, especially among teens. Between 2011 and 2018, the percentage of U.S. high school students using them skyrocketed from 1.5 percent to 20.8 percent.
This surge in popularity is probably explained by a combination of factors.
A marketing strategy geared toward teens and making effective use of social media has clearly played a role. Just recently, the U.S. Food and Drug Administration sent a warning letter to JUUL about their advertising, citing a school visit where a representative allegedly claimed that their product was “totally safe” and stated that a student “should mention JUUL to his (nicotine-addicted) friend …because that’s a safer alternative than smoking cigarettes, and it would be better for the kid to use.”
Another reason that e-cigarettes have become so popular is that they come in a variety of flavours, unlike regular tobacco products. Flavoured cigarettes were made illegal in Canada in 2009. According to one analysis, nearly one-third of users started vaping because of e-cigarette flavours, and these flavours, particularly fruit flavours, were more likely to influence younger adults 18-24 years old than older ones. Given their role in encouraging vaping, and the suggestion that the flavourings themselves might be dangerous, Michigan recently banned flavoured e-cigarettes. Other jurisdictions may soon follow.
While many people use e-cigarettes as a means to quit smoking, the evidence for their effectiveness is somewhat underwhelming. A 2013 Lancet study found that e-cigarettes performed about as well (or as poorly) as the nicotine patch, with quit rates of 7.3 percent vs. 5.8 percent at six months. A more recent New England Journal of Medicine study found that e-cigarettes outperformed other nicotine replacement products with quit rates of 18 percent vs. 9.9 percent. However, an important caveat to the NEJM study is that 80 percent of patients who “quit” smoking were still using e-cigarettes at one year, whereas most people (over 90 percent) who quit with something like the nicotine patch ultimately stop using it. Thus, e-cigarette users did not so much quit smoking as switch from cigarettes to e-cigarettes.
The tendency to use e-cigarettes indefinitely is why this recent cluster of vaping-related lung disease is such a concern. Why this sudden uptick of cases has come about is not entirely clear. Case reports of severe respiratory failure from vaping are not new. Some date as far back as 2015. Thus, it’s possible that cases were going undiagnosed or unappreciated until the current episode made everyone take notice.
Another potential culprit is tetrahydrocannabinol (THC), the psychoactive ingredient in cannabis. Many, though not all, of the e-cigarette samples tested by the FDA contained THC. Another interesting finding is that many, but again, not all, of the samples, contained high levels of Vitamin E acetate, which has led to suspicions that it might be responsible.
While it might seem implausible that a vitamin or its derivative could cause hundreds of cases of lung disease, it is worth remembering two important points. Taking something orally is not the same as inhaling it into your lungs. Second, vitamin E is not a benign substance, and a meta-analysis of 19 trials found that high doses of vitamin E increased mortality.
For now, no single cause can be blamed for these cases and the best advice is probably that issued by the CDC. Consider not using e-cigarette products and, irrespective of the investigation, remember that the use of e-cigarettes is unsafe for children, teens, and young adults.
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