Vaping-Induced Acute Pulmonary Toxicity: An update

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"Now, another study has just been published which sheds new light on the vaping scare from last year, and so it is time to revisit that outbreak, and see what has changed in 12 months."

Just one year ago the media was in a frenzy about the dangers of vaping and e-cigarettes (remember those nice times before COVID)? But where did all that enthusiasm go, and why was it that just last September it seemed that an outbreak was occurring in which all our children where going to die from vaping-related lung injuries, then we heard nothing? It is not only due to the rise of bigger issues like the pandemic, but the fact that those incidences largely went away. As we reported last year, the majority of those cases where caused by an additive to oil based vape cartridges primarily purchased from the black market. Now, another study has just been published which sheds new light on the vaping scare from last year, and so it is time to revisit that outbreak, and see what has changed in 12 months.

The 2019 outbreak of vaping related injuries

According to the CDC, the first incidences of Vaping Associated Lung Injury (VALI) were reported on March 31st, 2019. The e-cigarettes and vapes implicated had been on the market since the early 2000’s, and the first scientific studies had concluded that they were a relatively safe alternative to smoking cigarettes, and could act as an effective Nicotine Replacement Therapy (NRT).  These studies where backed up by a major review published in 2015 by the UK government. So it was a major surprise to many folks when the media started to go after vaping, with the president even making plans to ban flavored vape ‘juices,’ which was later abandoned. But the cases of injury kept being recorded, in what looked to be a problem that was quickly spiraling out of control.

Between 2006 and 2018 the CDC had no reports of injuries or deaths resulting from the use of e-cigarettes or vapes. The number of reported injuries and hospitalizations started to rise rapidly in June of 2019, peaking on September 15th with 237 hospitalizations reported in a single day across the US. Most cases were attributed not to e-cigarettes, but to cannabis oil (THC) vape cartridges. As we also reported at the time, it was suspected that the additive Vitamin E Acetate was to blame, which had only recently been introduced to the market.


As quickly as the number of cases rose, it began to fall. By December 29th, 2019, the numbers had reduced to just 13 incidents per day, and have stayed at less than 10 cases per day since. It would appear that the CDC stopped tracking cases on February 9th, 2020, or was not receiving anymore reports of VALI. The states with the greatest number of total cases were Texas, Illinois, and New York (all states which did not have legal cannabis sales at the time). As of February 19th, 2020, a total of 68 deaths had been reported due to VALI in the US and its territories, with Georgia and Indiana reporting the most deaths, at 6 each. States with legal cannabis showed lower rates, with Oregon and Washington having only 2, and Colorado having 0 deaths.

Dates of symptom onset and hospital admission for patients with lung injury associated with e-cigarette use, or vaping — United States, March 31, 2019–February 15, 2020
Dates of symptom onset and hospital admission for patients with lung injury associated with e-cigarette use, or vaping — United States, March 31, 2019–February 15, 2020

All of this data shows two clear conclusions, the first being that the vaping-related injuries were primarily related to cannabis oil vape cartridges, and that banning flavored vape juices (as the Trump administration desired) would not have any impact on the outbreak. Second, that something was different about the vape cartridges sold primarily on the black market then those sold through state licensed suppliers, which is most likely Vitamin E Acetate. So, what about the new study published just days ago?

Updates to this ‘outbreak’ of vaping injuries

The new study, published in the Journal of Investigative Medicine looks at case studies of 7 of the patients for which accurate patient history and medical records were available. The study did not go into any detail about how these 7 case studies where chosen out of the 2,800 that were potentially available. What is did point out were the similarities between each case, which can help both doctors and users better identify the symptoms related to VALI, and treat them adequately.

All seven patients showed up to the ER with similar, flu-like symptoms. This included persistent fever (100-103°F), difficulty breathing (O2 saturation between 87-96%), and most (84%) having elevated white blood cell counts. A few also had GI issues, including nausea, vomiting, and diarrhea. CT scans of the lungs showed what is called ‘diffuse ground glass opacities,’ which is often associated with acute atypical pneumonia. In the PCR tests, generally no viruses, bacteria, or fungi where detected that would signal typical pneumonia.


In most cases, treatment was relatively similar, and involved a combination of strong antibiotics and the corticosteroid methylprednisolone, often prescribed to relieve inflammation and auto-immune disorders. All the patients described in the study recovered, and were able to taper off of the steroids in a matter of several weeks post-hospitalization. Their hospitalizations generally lasted between 6 and 16 days.

The study did not, however, conclude that these injuries were due exclusively to Vitamin E Acetate, nor did it go very much in depth on the science of what could be causing these incidents and injuries. It did theorize as to the various mechanisms of injury, including solvents left over form the extraction process such as butane and possibly the biproducts from heating plant terpenes including benzene. However, there was no laboratory studies to back-up any of these claims, and only 1 case study regarding BHO was cited, in which a 19-year old was treated for butane exposure after attempting to make his own extracts (not using a vape). Overall, the analysis as to the causes of these injuries was much less science and much more non-evidence backed conjecture. Although they did mention the problems of Vitamin E Acetate, they did not attempt to conclude whether that was the cause of the injuries described. Which would seem like the logical culprit because once it was made publicly aware that unlicensed or illegal producers where using the ‘Honey Cut’ oils then the injuries stopped.

Even though those authors did not want to point to Viatamin E acetate as the casue, and instead made the concious decision to mislead their readers into thinking the casue was still completely unknown, previously published studies did point in that directioin. According to the Utah State Board of Health, over 90% of the THC cartridges sampled over the last few months contained Vitamin E Acetate. The New York State Department of Health has reported similar findings when investigating the substances vaped by patients reporting to emergency rooms. So, although none of the federal level organization wants to make any conclusions yet, most of the evidence points towards the Vitamin E Acetate content in the product Honey Cut as the primary cause of the recent epidemic, and not traditional nicotine or THC based products that have been on the market for more than a decade.

So, what do we know?

Based on all the data we currently have, it would appear that the ‘outbreak’ of vaping related injuries in 2019 was due primarily to Vitamin E acetate. and entitlement and possibly mental health issues, it had only recently been on the market, and was being sold out of China as a product called ‘Honey Cut.’ This product allowed producers to reduce the amount of cannabis oil in their products, while still providing a product that looks and tastes like the more pure cannabis oils. This product was distributed to a small number of legal dispensaries, but was more so adopted by money-saving entrepreneurs who were producing cartridges for the black market. Once the problem was reported on, the product was avoided, and the number of cases started to decline rapidly. Now, that most producers and many users know the risks of Vitamin E Acetate the number of acute vaping related lung injuries has decreased to (presumably) zero, based on CDC data.

This would imply that users have little to worry about in terms of acute damage or lung injury due to vaping. However, this does not mean that vaping is 100% safe, it does still carry real risks to health for all users. While vaping may be a good alterative or NRT for cigarettes and other forms of tobacco, it is not advised that anybody begin vaping, especially teens and children.

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