In the summer of 2019, months before the word “coronavirus” meant anything to most people, a mysterious respiratory illness began popping up around the U.S., ultimately sending over 2,700 primarily young and healthy people to the hospital and dozens to an early grave. The culprit wasn’t an infectious disease, but a poison: THC vaping devices sold on the black market that were filled with oily contaminants that suffocated and burned victims’ lungs once inhaled.
More than a year later—and what a year it’s been—Gizmodo decided to take a look back at this crisis. Did it truly end, as you might assume from the shrinking media coverage dedicated to it? If so, why? How did it play into a still contentious debate over the health risks of vaping and the need for regulation? And what lessons, if any, have we learned?
The first reported cases of the illness came in late July from Wisconsin, when teens in the state began coming down with symptoms like coughing, shortness of breath, and fatigue, along with severe lung damage visible on medical imaging. Reported cases steadily increased throughout the summer in states around the country, while further investigation found that some people had experienced the illness as early as March. By late fall 2019, new reported cases began significantly dropping, even as more doctors were now aware of the problem. In the last week of December, only 29 cases were reported to the Centers for Disease Control and Prevention—a sharp drop off from the over 200 cases reported in a week during September. All told, as of February 2020, at least 2,807 people are known to have had this vaping-related lung illness, and 68 people died.
As for why these poisonings slowed down, there’s no single answer. It was apparent early on that many victims had recently used vaping products with THC, a psychoactive ingredient of cannabis, that also contained vitamin E acetate, an oily form of the vitamin commonly found in household products like skin creams. This ingredient was often used as a filler to reduce the amount of THC needed per product or to fool customers into thinking the THC in the product was better quality by making the vaping fluid thicker. Importantly, vitamin E was readily found in illicit vaping products—usually disposable THC cartridges—and these products were clearly responsible for most cases of the illness.
By the fall, public health agencies were explicitly warning people to stay away from buying products off the street or from friends, as were vape users and influencers. At least one company that appeared to legally sell vitamin E as a cutting agent in Oregon pulled its product off the market. And there may have been pressure on the manufacturers of illicit devices and cartridges to remove or reduce the vitamin E they used. All of these factors probably contributed to the decline of cases.
“We had close to 40 cases altogether, between the months of June to December of 2019. And then, just like with the rest of the country, we then saw a pretty rapid decrease, even starting around September, October,” said Aleksandr Kalininskiy, a pulmonary and critical care fellow at the University of Rochester Medical Center in New York. Kalininskiy and his colleagues were some of the first doctors to publish case reports on the patients afflicted with the condition.
But according to David Downs, the California bureau chief of cannabis-focused website and news outlet Leafly, the underlying factors that gave rise to these cases in the first place haven’t really gone away. Perhaps more than any outlet, Leafly has investigated these poisonings extensively.
“What we found was that the structure of the market and the incentives to adulterate products had not changed. The profit motive still exists, you still make more money, fooling consumers and being unfair to them, such that the promise of injury was still there,” Downs said.
Though the CDC said it would stop tracking the reporting of vaping-related illness in February 2020, local public health agencies and doctors continue to report their own cases. In June, doctors from California described eight patients who became sick from vaping in April. In July, Minnesota health officials sent out a warning to health care providers, after 11 suspected victims had recently been identified. And Kalininskiy says that the University of Rochester Medical Center has seen at least six probable cases this year.
These newer cases have been harder to find in part due to the covid-19 pandemic, since the two conditions can present similar symptoms. The pandemic is also likely one reason why the CDC decided to stop tracking these cases, constrained by limited resources. The situation has even spawned its own fringe conspiracy theory, with some people arguing that the vaping cases last year were actually covid-19 in disguise (no expert or source I spoke to endorsed that idea).
In addition to the illness caused by these tainted products, the resulting public health response has in many ways deepened the divide between vaping consumers, manufacturers, and some public health agencies and experts. This divide is evident even in attempts to name what exactly happened to victims.
Early on, doctors and others often used the term “vaping-associated pulmonary injury,” or VAPI, to describe the condition. But by October, the CDC adopted the term EVALI, short for “e-cigarette, or vaping, product use associated lung injury.” The CDC also continued to recommend that people stay away from all vaping products to be safe as possible, though it did emphasize the added risk of using black market products. By then, it was obvious that electronic cigarettes, or e-cigarettes—a term used for nicotine-based vaping products sold legally—had no substantial role in the poisonings. Some people were understandably confused and upset at the CDC for the decision.
“There have been broader issues with quality control of electronic cigarettes and their flavorings, but [the name] was distracting from this acute injury problem and where it was coming from in the market, such that it was doing a disservice to readers who need to be able to make a rational choice about their health and what they’re consuming,” said Downs. Leafly continues to only use the term VAPI in its articles.
The name change was only the latest signal to vaping consumers, people in the industry, and public health experts who see vaping as a healthier alternative to cigarette smoking that the crisis was being used to crack down on the industry without justification. As more and more cases of VAPI/EVALI were emerging last year, states, cities and eventually the federal government began passing down more restrictive policies, including raising the age limit to buy to 21 and outright bans on legally sold vaping products such as flavored e-cigarettes. Sometimes, officials would even directly cite these illnesses as one reason for the bans, despite there clearly being no connection to the majority of cases.
The framing seems to have worked a bit too well. A Morning Consult poll in February 2020 found that two-thirds of Americans at least partly blamed e-cigarettes for the recent vaping-related deaths caused by lung damage, while only 28 percent correctly pointed the finger at tainted THC products. These results were actually worse than a poll taken in September 2019, when a smaller percentage blamed e-cigarettes and more blamed THC.
This isn’t to say that legally sold e-cigarettes and cannabis-based products don’t carry their own risks. There have been reports of serious injuries predating or unrelated to VAPI/EVALI linked to e-cigarettes and legal products, and many experts are worried about the long-term health effects of e-cigarettes, even if it’s not the same level of harm caused by tobacco cigarettes. The rise in teen vaping has also alarmed the public health community, since we don’t know what will happen to them years from now if they become chronic users. Companies like Juul have since been federally investigated and sued for slyly marketing their products to teens, despite their insistence that they’re only meant for adult cigarette users hoping to wean off tobacco.
But even some researchers and public health experts have worried about the conflation of these other real concerns with VAPI/EVALI.
“From the start, I was like, wait a minute. This isn’t the regulated, well-manufactured products that we’re talking about here,” said Terry Gordon, an air pollution researcher and professor at NYU’s Department of Environmental Medicine who studies e-cigarettes. “E-cigarettes aren’t safe, but they’re safer than cigarettes.”
If there is common ground to be found between vape enthusiasts and critics of the practice, it’s likely in regulation. Downs and his team at Leafly have found that VAPI/EVALI cases were substantially lower in states where cannabis was legally available and sold, a finding supported by other research. And though there are a minority of cases where victims have not reported a history of THC use, Leafly’s investigation so far hasn’t been able to conclusively trace any single case to legal products, nicotine-based or not.
“We’ve seen aspects of the industry raise their hand and say, ‘We invite scrutiny, we invite regulation. We are tired of counterfeiters and poisoners running circles around our good-faith efforts,’” Downs said.
This November, five states became the latest to legalize cannabis in some form, while three—Arizona, New Jersey, and South Dakota—legalized recreational use. Sixteen states now have full legalization. Some local regulatory agencies have started to implement stricter rules on the quality control of legal cannabis products, not just in the ingredients that are included but in the chemicals that products are actually emitting when used. The cannabis industry has also begun to create its own best practices in the wake of these cases. But if cannabis remains illegal federally for the foreseeable future, it will be that much harder for agencies like the FDA to implement universal regulatory guidelines. Downs notes that other agencies, like the Federal Trade Commission, could likely do more to crack down on illicit products being shipped in the U.S. from overseas (often from China), but they simply lack the political will or resources.
As long as the black market has a large consumer base in states where cannabis is illegal, cases of VAPI/EVALI will continue to appear, even if vitamin E acetate is removed entirely from the supply. Scientists have found other chemicals in (largely illicit) vaping products and flavorings that could plausibly cause the same sort of lung damage seen in victims, such as squalene, as has Leafly. The potential for other contaminants being introduced down the road is always there.
While it might be ideal to want young people who have never smoked to not start vaping, that genie has left the bottle for millions of people. So, at the very least, users should be steered to legally regulated products that can be made safer still, Downs said, instead of taking a gamble on the street. “I’ve landed on the note that this technology is too useful to ever go away,” he said. “The question is: how clean is it going to be—how regulated?”
As for the survivors of VAPI/EVALI, the news is good and bad. Most of the patients that doctors like Kalininskiy have seen months after their initial symptoms seem to have recovered without lingering problems. Yet, he notes that other researchers have found reduced lung function in recovered patients—the sort of disrepair that could raise survivors’ risk of future health problems. According to Matthew McGraw, a doctor and pediatric pulmonologist at the University of Rochester Medical Center, it’s almost certainly in the best interest of VAPI/EVALI patients to never pick up vaping again.
“I think that’s the biggest message to convey is, if you stop, there’s a good chance that you won’t have persistent lung function changes,” McGraw said. “One thing that we’ve been great about here is getting our patients to quit the use of e-cigarettes. But in other places, I’m skeptical as to whether they’ve had as good success in trying to get users off e-cigarettes.”