It said it had received reports about three confirmed deaths and a fourth under investigation. In addition, 450 cases of lung disease were under investigation. On Monday, the number of reported deaths was five. Another day later, a sixth death was reported. By late last week, however, the number of cases had been revised downwards, to 380.
The news sparked widespread panic last week, with media headlines connecting e-cigarettes to a “mysterious lung disease” and both the CDC and the American Medical Association (AMA) recommending that all of the more than 10 million US vapers quit immediately – until the cause of the illnesses is understood. Similar calls were made in other countries.
By Wednesday, the panic, fuelled by preliminary new data that shows an increase in vaping among US high school students, prompted the Trump administration to propose a ban on all flavoured e-cigarettes.
That is an ignorant response and a dangerous one, which will cost more lives than it saves.
The facts, such as they are, point to a very specific cause, and not to a problem with vaping in general.
The CDC said that no definitive cause for the deaths or lung disease cases had been determined. However, the disease is not mysterious, as numerous publication of greater and lesser repute have claimed. The disease is called lipoid pneumonia, a non-contagious form of pneumonia that can occur when either oils or lipid-containing substances enter the lungs, according to Dr Daniel Fox, who participated in the CDC’s conference call with the media.
Even though the modern vaping trend has been around for well over a decade, and there are between 35 million (in 2016) and 55 million (projected for 2021) vapers in the world, nobody seems to have noticed this very noticeable side-effect before. This raises the question, what changed? And why is this only happening in the US?
In 80% of the cases under investigation, the patients admitted to vaping THC oil. THC, short for tetrahydrocannabinol, is the principal psychoactive constituent of cannabis. It is plausible that the other 20%, who admitted to vaping nicotine-containing liquid only, simply did not care to disclose their use of THC oil.
The CDC also made a curiously specific recommendation to avoid vaping products “off the street”, and pointed to the presence of vitamin E acetate in many of the THC oil samples it took. This substance has also been fingered by the US Food and Drug Administration (FDA) as a likely cause of the observed lipoid pneumonia.
UPI reported that tocopheryl acetate, an agent used to dilute THC oil more commonly known as vitamin E acetate or simply vitamin E oil, was identified by the New York State Department of Health in nearly all the cases it was investigating. Reuters narrowed it down to two illicit brands of THC oil which had been diluted with vitamin E acetate. The brands, Dank Vapes and Chronic Carts (THC oil is often sold in cartridges for vape pens), were until recently available for sale via Amazon.com.
On the black market, drugs are routinely cut with other substances – some benign and some toxic – to make dealers more money. In legal markets, however, this practice is rare. Leading makers of nicotine e-cigarettes, including Juul Labs, British American Tobacco and Imperial Brands, told Reuters their products contain neither vitamin E compounds nor THC.
So far, then, it looks like we’re dealing with people who vape improperly prepared THC oils, mostly bought off the street. There appear to be no new health problems associated with products available on the ordinary, commercial, non-cannabis vaping market.
Barring new information that implicates regular e-cigarettes, there is absolutely no justification in calling for a ban on any or all of them. Yet by Monday 16 September, New York State had banned flavoured e-cigarette products, which appear to have had nothing to do with the outbreak of lung disease.
“Tobacco companies have been touting vaping as the answer to old fashioned nicotine-filled cigarettes. This new form of smoking has been directed at nicotine addicts, struggling to give up the habit. But now the American Medical Association has issued a warning, urging smokers to stop using e-cigarettes or face the risk of lung cancer.”
This is a gross overstatement of what the AMA actually said. It did take a strong stance against vaping, and urged doctors to advise patients of “the dangers of e-cigarettes, including toxins and carcinogens”. It wants e-cigarettes to be regulated, unregulated products to be removed from the market, and flavours to be banned, to “prevent potentially significant illness”.
The AMA itself also overstates the threat dramatically and proposes remedial measures that do not have any evidence to support them. It doesn’t even mention that a large majority of the cases under investigation involve users who admitted to having vaped THC oil, and not only ordinary vape liquid.
eNCA interviewed the national chairperson of the South African Medical Association (SAMA), Angelique Coetzee, who said that her organisation had released a document in 2015 in which it cautioned against the use of e-cigarettes. I haven’t been able to find such a document, but I did find a 2013 article in the South African Medical Journal which declared that the risks of e-cigarettes outweighed the benefits, “based on the currently available evidence”. Of course, that was then. This is now.
Coetzee told eNCA that there is no evidence showing that e-cigarettes help people to quit smoking. But this is wrong.
As I documented before, there are several studies that show exactly that. A large cross-sectional study of 5,863 adults in the UK in 2014 found that smokers who tried quitting by using an e-cigarette were substantially more likely to succeed than those who used over-the-counter nicotine replacement therapies, or those who used no aids at all.
A review of the evidence in 2014, as well as an expanded review in 2016, both found that vaping does help smokers to quit, helps heavy smokers to reduce their cigarette consumption, and was not associated with significant adverse events. This 2016 study found e-cigarettes were positively correlated with the success of quit attempts. A 2019 study found e-cigarette users were twice as likely to quit cigarettes as users of conventional quit aids.
If you ignore all these studies and assume that e-cigarettes do not help people quit, then you could argue that there is no benefit to vaping, and any risk, however low, would weigh against it. This is what Coetzee would have you believe, but the medical literature contradicts her claim.
She continued by saying that all e-cigarettes contain nicotine, which is false. Many don’t, and a smoker who wants to quit will typically start with a high-nicotine liquid, and gradually use lower concentrations until they’re on a nicotine-free liquid.
She said that the problem lies with nicotine, which is also false. Cigarette smoke contains thousands of chemicals, of which at least 70 are known carcinogens, and it isn’t even clear that nicotine is one of them.
“At present, it is not possible to draw a conclusion whether nicotine itself may act as a complete carcinogen,” declared a recent academic paper that looked into potential effects of nicotine on cancer development and treatment.
She said e-cigarettes give you bronchitis, pneumonia or “popcorn lung”. This is also a gross generalisation. It can in theory do so, but actual cases are rare. In the case of the ominous-sounding popcorn lung, properly called bronchiolitis obliterans, there have been exactly zero cases reported as a result of e-cigarette use.
The only link is that some flavours of vaping liquid have been found to contain diacetyl, as disclosed on the labels. Diacetyl can cause bronchiolitis obliterans in people exposed to substantial amounts, which workers in popcorn factories used to be, hence the nickname.
Even in the few liquids that do contain diacetyl, however, levels are only 1% of the diacetyl levels in cigarette smoke, so the notion that e-cigarette use inevitably, or even sometimes, leads to the disease is baseless.
The same is true for Coetzee’s claim that e-cigarettes have been linked to cancer. They haven’t. That something contains trace amounts of a potential carcinogen says nothing about the risk of it actually causing cancer. Many vegetables contain carcinogenic compounds. It’s the dose that makes the poison.
“We know it, it’s to prove it, that’s where the difficulty lies,” she says. But that’s not how science works. You don’t know things without evidence, especially if you’re the chairperson of the SAMA.
She said they aren’t sure what chemicals are in e-cigarette vapour because there have been no studies. That’s utter nonsense. I’ve cited numerous studies in two previous columns on vaping on the composition of vape liquids and their potential health effects. Those columns also point to studies that show extremely few people who have never smoked (less than 1% in almost all countries) regularly vape, and vaping is not a gateway to smoking tobacco.
It appears, however, that South African health authorities are simply not interested in reading the academic literature.
On the specific chemical composition, of which Coetzee claimed ignorance, a 2016 experiment found 31 distinct substances in e-cigarette vapour, which compares highly favourably to the 4,000 chemicals Coetzee said are in cigarette smoke. It also found far lower concentrations of harmful chemicals than those found in tobacco smoke. This, despite the fact that the experiment went out of its way to simulate worst-case-scenario vaping, assuming one cigarette was equivalent to as many as 20 puffs on an e-cigarette at 30-second intervals (adding up to 10 minutes of continuous vaping). It deliberately overheated the coil and used devices for a staggering 450 puffs without being cleaned. Vaping like that would taste absolutely awful, so it is unlikely that anyone would voluntarily do so.
Coetzee is either unaware of the literature on vaping, or she’s deliberately lying. She then promptly says that inhaling the vapour is dangerous to your lungs, and that “we are going to see a lot of lung diseases increasing in future”. How would she know, if by her own admission she has no clue what the vapour contains?
That this gross display of ignorance and outright misinformation passes as expert commentary in the media is mind-boggling. I’d rather take health advice from the car guard outside my local pharmacy.
Ultimately, it’s about the numbers, however. Nobody ever claimed that e-cigarettes were entirely harmless. We know that potentially toxic or carcinogenic substances can be released and that the risk increases the hotter and dirtier the coil gets. It stands to reason that not inhaling vapour is likely better for you than doing so.
In my previous two vaping columns, I discussed the safety evidence of e-cigarettes, and while further research is undoubtedly needed, all the evidence points to a fraction of the risk of smoking tobacco.
The claim has always been that e-cigarettes reduce the risk of harm when compared with cigarettes. Even if we suppose, implausibly, that all the recent deaths and cases of lipoid pneumonia were linked to ordinary non-cannabis vaping, it still pales by comparison with the 480,000 annual deaths in the US because of smoking. If we count in deaths per million users, we get 1,400 deaths per million smokers, compared to 0.5 deaths per million vapers.
That is what “harm reduction” looks like and it should be public policy to encourage smokers to take up vaping. In an ideal world, of course, we’d want everyone to quit smoking altogether. In the real world, however, people need ways to help them do that, and e-cigarettes offer perhaps the best possible way to do so. It should be hailed as the best thing ever to happen to the anti-smoking cause.
Yet the South African government, without having done any studies whatsoever on the safety or otherwise of e-cigarettes, has already written the rules. In the Control of Tobacco Products and Electronic Delivery Systems Bill, published in 2018, though not yet signed into law, it rejected the lobbying of the pharmaceutical industry to hobble the competition for quit-smoking aids by regulating e-cigarettes as medical products, and instead bowed to the lobbying of the tobacco industry to hobble the competition for cigarettes by subjecting e-cigarettes to the same onerous restrictions as tobacco products. That means no advertising, no retail display, no online sales, and no vaping in public places. It’s a travesty born of ignorance and will do grave harm to public health.
Even if one did not take into account the evidence that vaping can help smokers quit, thereby reducing the harm of tobacco products, everyone, in any case, has the right to consume products that pose some health risks.
Every time we eat or drink anything we’re taking risks, including the risk of ingesting low levels of toxic substances, disease-causing pathogens or carcinogens. In the case of some foods, we risk obesity, diabetes and other adverse consequences. In the case of some drinks, we risk drunkenness, heart disease and stroke.
If we had to ban everything that posed a small risk to our health, we’d have to ban, well, everything.
The current health scare around vaping probably has nothing to do with ordinary vaping liquids, whether or not they contain nicotine. It appears to be linked to THC oils diluted with vitamin E oils.
Although vaping is not entirely risk-free, it is vastly safer than smoking tobacco. For this reason alone, any regulation of e-cigarettes ought to increase public confidence in vaping. It should not fan and exploit public hysteria to blindly restrict or ban vaping without any regard for facts or science. DM