Every week the number jumps. The epidemic of a mysterious lung illness, first reported this spring, has swept across the nation, jumping from a few to more than 1,000 cases in 48 states and the U.S. Virgin Islands, according to a Centers for Disease Control and Prevention report released in early October.
Some patients have had such severe lung damage that they’ve been sent to intensive care units and placed on ventilators to keep them alive while their lungs recover during days-long hospital stays. To date, 18 people have died. And, because the cause and scope of the illness is unknown, more cases are expected. Researchers have observed that it disproportionately affects the young—80 percent of patients are 35 years old or younger—and that it is linked to vaping tobacco and THC, the main psychoactive ingredient in cannabis. Otherwise, precious little is known about what, exactly, is the root cause of this ballooning outbreak.
“We have a situation—and this is true of both nicotine and of cannabis—where you’ve got products that are being sold, they’re on the market, and consumers are basically paying to be the guinea pigs for the industry,” says Pamela Ling, a professor of medicine at UCSF. In the years since e-cigarettes first came on the market and through the current wave of illnesses, scientists have been trying “to play catch up,” says Ling who received her MPH from UC Berkeley. “But science is a slow process,” especially in cases like this where the drugs in question haven’t gone through the usual testing before being released into the market.
Suzaynn Schick, an associate professor of medicine at UCSF, says this dilemma is especially worrisome for cannabis products. “In both cases you’re inhaling something that is very poorly studied, but especially poorly studied for cannabis e-cigarettes, because it’s literally forbidden research.” Marijuana is a Schedule I drug, and “the only cannabis that researchers can get their mitts on to study—no matter how reputable, no matter how many times they’ve done the kind of research, no matter how expert they are—is cannabis grown on one farm and distributed through the [Drug Enforcement Administration],” says Schick. It’s a low-percentage THC marijuana that bears little resemblance to the “juice” that comes in vape pens, mixed as it is with a host of other chemicals and diluents to make the substance vapable. “So basically,” says Schick, “researchers are going damn near blind trying to figure out what the hell’s going on.”
In a race to understand the phenomenon, the CDC, the Food and Drug Administration, and state health departments are conducting independent investigations. Some theories have been floated. E-cigarettes are loaded with a liquid cartridge containing THC or nicotine, which, when heated, turns to vapor that the user inhales. There’s speculation that one or more ingredients in the mixtures may be causing the damage.
For example, health officials have found the presence of vitamin E acetate in many of the marijuana products used by affected patients. It’s not yet known if the oil is the cause of the illness, but there are reasons to believe it might be associated with some of the respiratory symptoms patients have suffered, including chest pains, shortness of breath, and coughing. Vitamin E acetate is commonly found in supplements and topical skin treatments and isn’t known to cause harm when ingested––but when heated and inhaled? That’s a completely different, poorly understood, story. The same questions apply to the flavoring in many e-cigarettes, another category of under-researched chemicals.
Schick says product developers start with a chemical flavoring that’s “generally recognized as safe” for consumption, like bubble gum. But then they put it into a product that you heat, vaporize, and inhale. “So you’re doing something different to it and putting it in a different part of your body,” she says. Similarly, while there are lower levels of carcinogens in e-cigarettes than regular cigarettes, other potentially harmful chemical reactions may be occurring as a result of vaporization. Schick says we the developers, the users, the researchers are complicit in a “great big, huge, messy public experiment with zero controls.”
There are plenty other complications: So many different types of vaping devices are in use, from both the licit and illicit market and from all over the country, with some users even mixing their own juice. Plus, when it comes to cannabis vaping, there’s the question of whether patients are honestly reporting their drug habits (especially in states where weed is illegal). So while the CDC is publicizing the problem and encouraging doctors to collect and share their data, their findings make “a very messy data set,” says Ling. What’s more, the CDC’s principal deputy director, Dr. Anne Schuchat, said during a recent briefing with reporters, the data set is only getting messier. “The data we are getting does not suggest [the epidemic] has peaked.”
A look at past research can provide some insight into the dangers of vaping, however. In 2016, chemist and researcher Hugo Destaillats and his team at the Berkeley Lab found that, despite the broad public view that they’re a relatively safe alternative to smoking, e-cigarettes indeed contain many toxins. Destaillants and his team found 31 potentially toxic substances in e-cigarette vapors, some of which produce acrolein, a powerful irritant when heated, as well as propylene oxide, a potential carcinogen and respiratory irritant. Toxin levels, they discovered, increased alongside the voltage used to power vaping devices. “The way you heat the liquid drastically determines if you produce a lot of compounds or just a few. As you increase the voltage, toxic byproduct concentrations increase exponentially,” Destaillats said.
Schick primarily focuses on the potential health consequences of e-cigarette vapor on nonusers. “I know that when you release nicotine into the room and it settles on a surface, it reacts with normal gases in the air to form carcinogens,” she says. As Destaillats put it before the current outbreak: “Regular cigarettes are super unhealthy. E-cigarettes are just unhealthy.” Even that, we’re finding now, may have been an understatement.
In theory, the FDA could more aggressively control the e-cigarette industry, but in practice, it gets bogged down. “The FDA could enforce their own rules, and say, ‘You can’t sell these e-cigarettes until they’ve gone through the FDA approval process,’” Ling notes. “Technically, all e-cigarettes are illegal right now—they’re just not enforcing it.” It may be a bit murkier even than that, however. Although tobacco products cause proven harm, they’re not technically classified as drugs and “exist in this weird nether-zone between drug and ordinary consumer product,” says Schick. “So the FDA does have a mandate to regulate them, but they are super constrained.” While they’re currently in the process of conducting research to determine how best to regulate the products, “it’s all very slow, expensive, and vulnerable to political interference and under-funding.”
As Schick hinted, some of the FDA’s lack of enforcement can be explained by the influence of vaping industry lobbyists. A Los Angeles Times exposé published early this month revealed that four years ago, the FDA had a plan to ban vaping flavors to protect kids from getting hooked. Then, after vaping industry lobbyists went on the offensive, senior Obama officials killed the plan and erased much of the evidence supporting it.
Meanwhile, state and local authorities from New York and Missouri to Michigan and Washington have banned certain types of e-cigarettes. In August, Alameda County and the City of Berkeley issued a joint health advisory warning about the pulmonary illnesses, and the month prior, Berkeley banned flavored tobacco and vape pods—although this was mostly an effort to curb teen vaping, another issue the current outbreak has helped highlight. According to the most recent data from a national “Monitoring the Future” survey, this year 25 percent of high school seniors admitted to vaping in the previous month, compared to 11 percent in 2017.
If the known health effects from vaping are cause for concern, the unknowns surrounding the rise of acute lung illness are forcing health departments throughout the nation to urge people to stop vaping entirely, at least until a cause is found. But how long that will take is anyone’s guess. “I think folks are mostly looking to CDC for even just a summary of what we know about the cases—how many are using what substance, how many are cannabis versus nicotine vaping or both,” says Ling. But she’s not holding her breath. “The CDC is pretty conservative. They’re not going to jump to a particular cause right away.”