When the first reports of a mysterious illness striking people who used electronic cigarettes started to trickle out in the media, there were more questions than answers. What was causing this illness? Was it associated with only certain devices, or certain types of vaping? Did it affect vapes that contained nicotine, THC, or both?
As researchers struggled to find answers, the first reports turned into a torrent and the health authorities began to report fatalities associated with vaping. By late October 2019, the CDC had tracked 34 confirmed deaths associated with vaping, and there was no clear pattern:
- 84% reported using THC-containing vapes
- 37% reported using nicotine-containing vapes
- 63% reported using only THC vapes
- 16% reported using only nicotine vapes
A month later, as the death toll continued to climb, a clearer picture emerged: the CDC identified an additive in vape liquid that was associated with lung injury. The chemical, vitamin E acetate, was found in lung samples obtained from people who had died from vaping-related illness. In general, this chemical is not used in nicotine e-cigarettes, but is typically used in THC-containing e-cigarettes as a thickener. In particular, the CDC singled out “home brew” THC vaping liquid and urged that people should avoid all THC-containing e-cigarettes, especially those obtained from friends or informal sources.
While researchers narrow down on the causes of this outbreak, the fact that it happened at all raises larger questions about the rapid and mostly unregulated rise of e-cigarettes. At the beginning of this decade, e-cigarettes were rare—according to the U.S. Surgeon General, less than 3% of adolescents had tried vaping. At the time, e-cigarette companies were touting their products as smoking cessation tools, a claim that was unproven. It didn’t take long, however, before e-cigarette companies recognized a new market and began to aggressively target adolescents and young people with flavors like bubble gum and cotton candy and advertising campaigns modeled after the same approach Big Tobacco historically used to recruit young, new smokers. And it worked: by 2018, the latest year for which there are figures, the U.S Surgeon General estimated that almost 20% of girls and 23% of boys had tried vaping, and the vast majority used fruity or sweet flavors. Powered by omnipresent brands like Juul, e-cigarettes quickly grew to a multi-billion industry.
All of this happened in the face of murky science and legislative inaction. Vaping products remained unregulated, while public health researchers race to answer myriad questions about this explosive new trend. Did vaping cause harm to users, either through the nicotine or chemicals present in the vaping liquid? Was vaping really a successful smoking-cessation strategy? Was the explosion youth vaping leading more kids to try tobacco, a product with well-known health risks?
Unfortunately, many of these questions remain wholly or partially unanswered. And the picture is complicated by the intersection of nicotine-based vapes and those that offer THC, the psychoactive product in marijuana. In the majority of states where marijuana is legal, either for recreational or medicinal use, THC vapes are common delivery systems—and in many cases, these products are formulated by amateurs working in an unregulated environment. In 2019, this combustible mixture of loosely regulated products, explosive growth, and a murky scientific picture finally resulted in the tragic situation we are experiencing now.
What Patients Need to Know
Without a uniform set of guidelines to rely on, communicating with patients about vaping can be difficult. However, a number of medical bodies have released points that can be useful in any conversation about vaping. These include:
- The American Medical Association supports the ban on sale and distribution of all e-cigarette and vaping products unless they have been approved by the FDA for smoking-cessation and are available by prescription only.
- E-cigarettes contain nicotine, which is an addictive chemical and has been shown to be harmful for developing babies and create addiction.
- E-cigarettes are not FDA approved as smoking cessation tool. There are other approved and proven smoking cessation tools.
While these positions may change as more research comes in, the best approach toward e-cigarettes right now is caution.
 Centers for Disease Control and Prevention. New CDC Report Provides First Analysis of Lung Injury Deaths Associated with Use of E-cigarette, or Vaping, Products.
 Centers for Disease Control and Prevention. Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping.
 American Medical Association. AMA: Stop sales of e-cigarettes that lack FDA approval.
 Food & Drug Administration. Fact of Fiction: What to Know About Smoking Cessation.