2019 outbreak of lung illness linked to vaping products

In 2019, an outbreak of severe vaping-associated lung illness affected users in most states in the US.[notes 1][5] Cases involved in the outbreak of lung illness were first identified in Illinois and Wisconsin in April 2019.[6] Similar cases of vaping-associated lung illness were reported in the UK and Japan before the outbreak occurred.[7] 2,290 cases have been reported to the Centers for Disease Control and Prevention (CDC) from 49 states, the District of Columbia, and two US territories (Puerto Rico and US Virgin Islands), as of November 20, 2019.[5] 47 deaths have been confirmed in the US, as of November 20, 2019.[5] Based on reports from several states, symptoms typically develop over a period of days but sometimes can manifest over several weeks.[2]

Some of the cannabis vaping products were found to contain large amounts of Vitamin E acetate, including Dank Vapes pictured here.[1]

On September 6, 2019, Dr. Dana Meaney-Delman, serving as the incident manager of the CDC's response to this outbreak, said that "Based on the clinical and laboratory evidence to date, we believe that a chemical exposure is likely associated with these illnesses."[8] Of the 2,290 reported cases, information is available in the three months prior to symptom onset for 1,184 of them as of November 5, 2019, 2019.[5] 86% reported THC use, 35% reported exclusive THC use, about 61% reported using nicotine-containing products, and 13% reported exclusive use of nicotine-containing products.[5] Many of the samples tested by the states or by the US Food and Drug Administration (US FDA) as part of the 2019 investigation have been identified as vaping products containing tetrahydrocannabinol (or THC, a psychoactive component of the cannabis plant).[9] Most of those samples with THC tested also contained significant amounts of Vitamin E acetate.[9] The CDC reported that their findings suggest vaping products containing THC are linked to most of the cases and play a major role in the outbreak.[5] The CDC stated that the chemical Vitamin E acetate is a very strong culprit of concern in the lung illnesses related to THC-based vaping products, but did not rule out other chemicals as possible causes.[notes 2][10]

Thickening agents were used to dilute vape oils.[11] There has been an increase in attention to companies that sell diluent products that are made with Vitamin E acetate.[11] Previously, Vitamin E was used in low concentrations, or lower than 20% of the formula in vape cartridges.[11] As a result of a limited availability of cannabis in California as well as high demand, illicit sellers had used about 50% or higher of diluent thickeners in their formulas to bulk up tiny potency vape cartridges.[11] In September 2019, New York Governor Andrew Cuomo instructed the state health department to issue subpoenas against three sellers of thickening agents used in illicit vaping products.[12]

The e-cigarette industry is placing the blame on illicit vaping liquids for the lung injuries.[13] Juul Labs stated that some news reports state that several cases of lung illness are associated with vaping THC, found in cannabis, "a Schedule 1, controlled substance that we do not sell."[14] The CDC recommends that the public should consider not using any vaping products during their investigation, particularly those containing THC from informal sources like friends, or family, or in-person or online dealers as of November 20, 2019.[5] The US FDA considers it prudent to avoid inhaling Vitamin E acetate.[9] On September 6, 2019, the US FDA stated that because consumers cannot be sure whether any THC vaping products may contain Vitamin E acetate, consumers are urged to avoid buying vaping products on the street, and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.[9]

History

United States
Confirmed or probable cases have been reported in 49 states, the District of Columbia, Puerto Rico, and the US Virgin Islands.[5]
CT scan showing diffuse lung infiltrates in three cases with acute lipid pneumonia.[15]
Lipid-laden alveolar macrophages in a case of vaping-associated lung injury. Left: Papanicolaou stain; right: Oil Red O stain.[15]
Percentage of persons needing intubation and hospitalization among persons with vaping-associated lung injury.[16]

Cases involved in the outbreak of severe lung illness associated with vaping products were first identified in Illinois and Wisconsin in April 2019.[6] As of November 20, 2019, 2,290 confirmed or probable cases of lung illness associated with the use of vaping products have been reported to the Centers for Disease Control and Prevention (CDC) from 49 states (all except Alaska), the District of Columbia, and two US territories (Puerto Rico and US Virgin Islands).[5] The potential cases of severe lung illness have been associated with the use of vaping products such as devices, liquids, refill pods, and cartridges.[17] The CDC is no longer reporting possible cases as of September 11, 2019.[18] The CDC stated the possible cases are still under investigation at the state level.[18] As of October 15, 2019, the CDC has reported on 1,358 people with data on age and gender: 70% of people are male.[5] The median age of persons is 24 years and ages range from 13 to 75 years.[5] 79% of persons are under 35 years old.[5]

Symptoms typically develop over a period of days but sometimes can manifest over several weeks.[2] Many cases, patients reported a gradual start of symptoms, including: breathing difficulty, shortness of breath, and/or chest pain before hospitalization.[19] Based on reports from several states, patients have experienced respiratory symptoms (cough, shortness of breath, or chest pain), and some have also experienced gastrointestinal symptoms (nausea, vomiting, or diarrhea) or non-specific symptoms (fatigue, fever, or weight loss).[5] Some cases reported mild to moderate gastrointestinal illness.[19] Some patients have reported that their symptoms developed over a few days, while others have reported that their symptoms developed over several weeks.[5] Some patients have reported gastrointestinal symptoms began before respiratory symptoms.[5] Fever, elevated heart rate, and elevated white blood cell count have been reported, even though no infectious disease has been identified.[5] Many patients sought medical care in ambulatory settings, sometimes over several visits, before they were admitted to the hospital.[5]

Many patients have required medical treatment with supplemental oxygen.[5] Some required assisted ventilation.[5] Some patients have been treated with corticosteroids with demonstrated improvement.[5] Evidence does not suggest an infectious disease is the cause of the severe pulmonary disease.[5] Antibiotic therapy alone has not consistently been associated with clinical improvement.[5] A handful of individuals have been re-admitted for clinical care after discharge for lung injury.[20] The CDC does not know whether individuals who were re-admitted continued or restarted use.[20] The range of time that the CDC is aware of for these re-admissions ranges from approximately five days after discharge to 55 days after discharge.[20]

As of September 5, 2019, the New York State Department of Health reported 34 cases of severe lung illness in patients who were reportedly using different vaping products.[1] Tests conducted by the Wadsworth Center found exceedingly high amounts of Vitamin E acetate in most of the cannabis e-cigarette products.[1] "At least one vape product containing vitamin E acetate has been linked to each patient who submitted a product for testing," the New York State Department of Health stated.[21] None of the nicotine-based product samples contained vitamin E acetate.[1] According to the reports from Illinois and Wisconsin, the onset of respiratory findings appeared to have occurred over several days to several weeks before hospitalization.[17] As of September 5, 2019, the Illinois Department of Public Health reported 42 cases of lung illness, seven that were still being investigated, and one death.[22] Severe lung illness among young adults and youth who used vaping products required hospitalization in 11 cases in Wisconsin and others were being investigated in August 2019.[23] Symptoms were difficulty breathing, tiredness, chest pain, cough, and reduced weight.[23] Some required help to breathe.[23]

On August 9, 2019, the California Department of Public Health issued a statement regarding a cluster of seven healthy adults in Kings County, California, all of whom required hospitalization.[24] Since June 2019, at least seven cases of severe acute pulmonary illness in previously healthy adults were reported from a hospital in Kings County, California.[24] Cases were among residents of multiple counties.[24] The patients presented with progressive respiratory distress, sometimes initially diagnosed with pneumonia or bronchitis, and some with preceding fevers and gastrointestinal symptoms.[24] All cases failed to respond to an initial course of antibiotic treatment.[24] All patients required admission to the hospital with significant respiratory support, including high-flow oxygen, bilevel positive airway pressure (BIPAP), or intubation with mechanical ventilation.[24] Diagnoses included pneumonitis and acute respiratory distress syndrome (ARDS).[24] Several cases of vaping-associated pulmonary injury (VAPI) and acute respiratory distress syndrome (ARDS) in California were connected to vaping cannabis products that were traced back to pop-up retailers.[25] Patients have improved with systemic steroids.[24] Evaluation for infectious etiologies has been negative to date in all patients.[24] All patients reported vaping in the weeks prior to hospital admission, and a reported common exposure among these patients is that they have been vaping cannabis or CBD oils.[24]

Deaths
A total of 47 deaths linked to vaping products have been confirmed among 25 states and the District of Columbia.[5]
  Indicates at least one death linked to a vaping product.
  Indicates at least two deaths linked to a vaping product.
  Indicates at least three deaths linked to a vaping product.
  Indicates at least four deaths linked to a vaping product.
  Indicates at least five deaths linked to a vaping product.

As of November 20, 2019, a total of 47 deaths linked to vaping products have been confirmed in 25 states and the District of Columbia: Alabama, California (4), Connecticut, Delaware, District of Columbia, Florida, Georgia (3), Illinois (5), Indiana (4), Kansas (2), Louisiana, Massachusetts (3), Michigan, Minnesota (3), Mississippi, Missouri (2), Montana, Nebraska, New Jersey, New York (2), Oregon (2), Pennsylvania, Tennessee (2), Texas, Utah, and Virginia.[5] The median age of deceased persons was 53 years and ranged from 17 to 75 years.[5]

In August 2019, the Illinois Department of Public Health (IDPH) reported the first death in the US linked to vaping products.[26] The deceased individual had been recently vaping and was hospitalized with serious respiratory sickness.[26] On September 6, 2019, the Minnesota Department of Health announced the death of a Minnesota resident that appears to have been related to illicit THC vaping products.[27] The second vaping-induced lung illness death in the US and the first death of its kind in Oregon had used a vaping product containing cannabis oil that was legally purchased from a cannabis shop.[28] It is the first death in the US linking a vaping product to a purchase from a licensed dispensary.[28] On September 10, 2019, the Kansas Department of Health and Environment announced the death of a Kansas resident that was related with the cases of severe lung illness linked to vaping products.[29] The patient was admitted to the hospital with symptoms that worsened rapidly.[29] On September 16, 2019, the Tulare County Health & Human Services Agency in California announced the death of a Tulare County resident that resulted from complications linked to vaping.[25] On September 19, 2019, the Missouri Department of Health and Senior Services announced the death of a Missouri man that was due to vaping.[30] He began vaping in May 2019 for his chronic pain.[30] On August 22, 2019, he required hospitalization.[30] He developed acute respiratory distress syndrome which resulted in his death.[30] On September 23, 2019, Kansas governor Laura Kelly announced the second death in Kansas due to vaping.[31] On September 26, 2019, Oregon Health Authority announced the second death in Oregon which was the result of vaping cannabis products.[32]

On October 3, 2019, the Connecticut State Department of Public Health announced the first death in Connecticut that was associated with vaping.[33] On October 9, 2019, the Utah Department of Health announced the first death in Utah that was associated with vaping.[34] The Salt Lake County resident was less than 30 years old and died at home.[34] On October 24, 2019, the District of Columbia Department of Health announced the first death in the District of Columbia that was caused by vaping.[35] On October 24, 2019, the Tennessee Department of Health reported the second death in Tennessee that was caused by vaping.[36] On October 30, 2019, the Massachusetts Department of Public Health (DPH) reported the second death in Massachusetts due to nicotine vaping.[37] Earlier in October 2019 they reported the first death due to nicotine vaping in Massachusetts.[37] On October 24, 2019, the Illinois Department of Public Health (IDPH) reported the second death in Illinois due to vaping.[38] On October 31, 2019, the Illinois Department of Public Health (IDPH) reported the third death in Illinois due to vaping.[39] On November 6, 2019, the Massachusetts Department of Public Health (DPH) reported the third death in Massachusetts due to vaping.[40] The Worcester County resident in his 50s was vaping both nicotine and THC.[40] The fourth death linked to vaping in California occurred on November 7, 2019.[41] On November 14, 2019, the Missouri Department of Health and Senior Services reported the second death in Missouri due to vaping.[42] On November 14, 2019, the Illinois Department of Public Health (IDPH) reported the fourth death in Illinois due to vaping.[43] On November 20, 2019 New York governor Andrew Cuomo reported the second death in New York state connected with vaping.[44] On November 21, 2019, the Illinois Department of Public Health (IDPH) reported the fifth death in Illinois linked to vaping.[45]

Canada

On September 18, 2019, a case of severe lung illness associated with vaping in Canada was reported.[46] A high school student in Ontario needed to be put on life support.[46] The person had been vaping every day.[47] His health improved and he was sent home.[46] This case has not been confirmed, as September 27, 2019.[4] On September 27, 2019, it was announced the first confirmed case of a vaping-related lung illness in Canada.[4] A Montreal resident in Quebec in their 50s was admitted to a hospital with breathing difficulties.[4] The person had been vaping to help them give up smoking.[4] Chief Public Health Officer of Canada announced on October 11, 2019 that they are aware of the initial cases of vaping-associated lung illness and they stated that a few other occurrences are being investigated.[48] Three probable cases have been reported in British Columbia as of November 7, 2019[49] and other cases are under investigation in British Columbia.[50] Two probable cases have been reported in New Brunswick as of October 16, 2019.[51]

Europe

Similar cases of vaping-associated lung injury were reported in the UK before the US outbreak occurred.[7] One death in the UK was associated with e-cigarette use in 2010[52] and a second death in the UK was associated with e-cigarette use in 2012.[53] 18-year-old Raphaël Pauwaert from Brussels died in less than 30 days after developing pneumonia.[54] He received an e-cigarette as a gift for his 18th birthday.[54] He was placed in a medically induced coma.[54] He died on November 6, 2019.[55] His doctors believe the cause of death was probably a result of his vaping.[55]

International

Similar cases of vaping-associated lung injury were reported in Japan before the US outbreak occurred.[7] This indicates that this has the possibility to be a more pervasive phenomenon.[7] However, the prevalence of lung injuries in various countries is unknown as of September 2019.[7] The first case of e-cigarettes inducing lipoid pneumonia was documented in 2012.[56] A 42-year-old woman was suffering from lipoid pneumonia in 2012.[57] She was using e-cigarettes for seven months.[57] Doctors believed the glycerin in the e-liquid caused her illness.[57] The first case of a vaping-related lung illness in the Philippines was reported in November 2019.[58] A 16-year-old girl from central Philippines was vaping e-cigarettes for half a year.[58] She had difficulty breathing and was admitted to the hospital in October 2019.[58] She was discharged after she received treatment from a pediatric pulmonologist.[58]

Investigation
Sounding the Alarm: The Public Health Threats of E-Cigarettes.[59]
US FDA's Forensic Chemistry Center.[60]

Investigators from multiple states in the US are collaborating with the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration (US FDA) to determine the cause of the lung illnesses associated with the use of vaping products.[61]

On September 6, 2019, Dr. Dana Meaney-Delman, serving as the incident manager of CDC's response to this outbreak, said that "Based on the clinical and laboratory evidence to date, we believe that a chemical exposure is likely associated with these illnesses. However, and I really want to stress this, more information is needed to determine which specific products or substances are involved. We are aware that some laboratories have identified Vitamin E acetate in product samples, and we have connected those laboratories with the FDA Forensic laboratories to compare results. At this time, no one device, product, or substance has been linked to all cases. Continued investigation is needed to better understand if a true relationship exists between any specific product or substance and the illnesses observed in patients. To find the answer we will need to combine information about e-cigarette use, and product sample testing and the clinical information from patients."[8]

Patients have acknowledged recent use of tetrahydrocannabinol (THC)-containing e-cigarette products while speaking to healthcare personnel, or in follow-up interviews by health department staff.[19] On September 6, 2019, The New England Journal of Medicine reported that "Information on product use is based on reports by the patients, and patients may be reluctant to report illicit drug use."[6] On October 2, 2019, The New England Journal of Medicine reported that the histologic evidence suggests that the "vaping-associated lung injury represents a form of airway-centered chemical pneumonitis from one or more inhaled toxic substances rather than exogenous lipoid pneumonia as such, but the agents responsible remain unknown."[62] They also stated that this "finding should be interpreted with caution."[62] On October 17, 2019, the American Journal of Clinical Pathology reported that lung biopsies from eight patients with vaping-associated lung injury show acute lung injury patterns, not exogenous lipoid pneumonia.[63]

Of the 2,290 reported cases, information is available in the three months prior to symptom onset for 1,184 of them as of November 5, 2019, 2019.[5] 86% reported THC use, 35% reported exclusive THC use, about 61% reported using nicotine-containing products, and 13% reported exclusive use of nicotine-containing products.[5] The CDC reported that their findings suggest vaping products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak.[5]

On November 8, 2019, Dr. Anne Schuchat, principal deputy director of the CDC, said, "for the first time we have detected a potential toxin of concern — Vitamin E acetate — in biologic samples from patients with lung injuries associated with the use of e-cigarette or vaping products."[10] The sample types were bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs).[5] The chemical was found in samples collected from ten different states from the lungs of 29 patients with the disease.[10] "These findings provide direct evidence of Vitamin E acetate at the primary site of injury within the lungs," said Dr. Schuchat.[10] The CDC tested for a wide range of substances that might be found in e-cigarette or vaping products including plant oil, petroleum distillates like mineral oil, medium-chain triglyceride oils – or MCT oils – and terpenes which are compounds found in or added to THC products. No other potential toxicants were detected in the testing conducted so far.[10] The CDC did not rule out other possible compounds or ingredients that may be causing the lung injuries.[10] No one compound or ingredient has emerged as the cause of these illnesses so far; and it may be that there is more than one cause of this outbreak.[5]

Many of the samples tested by the states or by the US FDA as part of the 2019 investigation have been identified as vaping products containing tetrahydrocannabinol (or THC, a psychoactive component of the cannabis plant) and further, most of those samples with THC tested also contained significant amounts of Vitamin E acetate.[9] Vitamin E acetate is a substance present in topical consumer products or dietary supplements, but data is limited about its effects after inhalation.[9] While the US FDA does not have enough data presently to conclude that Vitamin E acetate is the cause of the lung injury in these cases, the agency believes it is prudent to avoid inhaling this substance.[9] The US FDA's Forensic Chemistry Center serves as the FDA's national laboratory and is playing a critical role in fact-gathering and analysis for the incidents of lung illnesses following vaping product use.[60]

Illicit vaping
Some of the vaping products analyzed by the Wadsworth Center contained exceedingly high amounts of Vitamin E acetate, including those pictured here.[1]
Frequently reported brand names of THC and nicotine-containing e-cigarette or vaping products reported by patients with lung injury — Illinois and Wisconsin, 2019.[64]

What people are inhaling is causing the lung illnesses.[65] The lung illnesses are likely to be caused by a chemical exposure.[21] Counterfeit cannabis cartridges are being sold to users at a reduced cost.[66] Dank Vapes is an illicit brand that uses a cartridge.[67] There is no singular company that owns Dank Vapes.[68] There have been hundreds of people selling Dank Vapes cartridges.[68] Dank Vapes appears to be the most prominent in a class of largely counterfeit brands, with common packaging that is easily available online and that is used by distributors to market THC-containing cartridges with no obvious centralized production or distribution.[64] Some of the vaping products that contained exceedingly high amounts of vitamin E acetate include Chronic Carts and Dank Vapes.[1] Illicit vape brands have been sold across multiple states in the US.[69] As of August 27, 2019, the most frequently used product reported by patients experiencing respiratory, gastrointestinal, and/or constitutional symptoms in Illinois and Wisconsin was the THC product called Dank Vapes.[6] The composition of THC based oils is to a large extent not known.[6]

Various diluent thickening products were sold online via wholesale suppliers.[70] There has been an increase in attention to companies that sell diluent products that are made with Vitamin E acetate.[11] A lot of speculation has focused on Honey Cut.[71] Honey Cut, used as a diluent thickener, became wildy used in Los Angeles' vape pen manufacturing plants in late 2018.[67] After Honey Cut became widely used in THC vape cartridges many other similar products from other companies were introduced into the market in early 2019.[72] The maker of Honey Cut's product is not known, and the only way to purchase the product was from the company's website.[73] In early September 2019, the Honey Cut website went offline[11] and Honey Cut told sellers in the Toy District, Los Angeles area to discontinue offering its products for sale.[74] Counterfeit products from China that look like Honey Cut products were being sold, which increased the confusion in regard to which products people may have been vaping.[75]

The company Floraplex in Michigan has shutdown the buyers page for their Uber Thick brand.[73] The diluent products called Clear Cut were sold by Connoisseur Concentrates from Tigard, Oregon.[70] Clear Cut is no longer available from the company's website.[70] The company acknowledged the products contained Vitamin E acetate.[70] The company stated that it began selling the products in May 2019 and was reviewed by the Oregon Liquor Control Commission.[70] As of September 10, 2019, Mass Terpenes' Pure Thickener diluent is no longer available on its website.[11] A cache of the product on its website stated, "a proprietary formula composed simply of flavorless terpenes and a derivative of Vitamin E (to preserve color and consistency)."[11] Aaron Riley, CEO of CannaSafe, stated that likely about 75-80% of illicit vapes use some type of diluent agent.[11] Drew Jones of Mr Extractor stated in September 2019 that as high as 70% of illicit cannabis vape cartridges in the US contain Vitamin E acetate.[76] It is estimated that at least 40 companies in the US sold a cutting agent containing Vitamin E acetate.[72] Thickening agents have been sold online as a less costly and safer substitute.[77]

Thickening agents were used to water down and bulk up vape oils.[11] Thickening agents were used mostly in THC vape products.[11] Vitamin E acetate was used to cut THC oil to dilute it.[78] Vitamin E acetate dilutes vape oil without making it look like the oil was watered down.[79] Previously, Vitamin E was used in low concentrations, or lower than 20% of the formula in vape cartridges.[11] As a result of a limited availability of cannabis in California as well as high demand, illicit sellers had used about 50% or higher of diluent thickeners in their formulas to bulk up tiny potency vape cartridges.[11] Thomas Whitten, a consultant at WeedRAR, said to Rolling Stone that "there's so much cutting agent even the people who made the cutting agent didn't expect it to be cut that much."[11] Some cannabis laboratories began making arrangements in September 2019 to provide testing services for vitamin E.[80] Regulations in legal markets for cannabis use allow the use of many additives such as tocopherols (various forms of Vitamin E).[72] However, regulators may be considering banning such substances in the near future, as of September 2019.[72]

Subpoenas

In September 2019, New York Governor Andrew Cuomo instructed the state health department to issue subpoenas against three sellers of thickening agents used in illicit vaping products.[12] The subpoenas are being served against Honey Cut Labs in Santa Monica, California, for its Honey Cut product; Floraplex Terpenes in Ypsilanti, Michigan, for its Uber Thick product; and Mass Terpenes in Amherst, Massachusetts, for its product.[81] All three firms sell a product used as a thickener in vape liquids.[82] The thickeners from all three firms were found to contain mostly Vitamin E acetate, according to test results from the Wadsworth Center.[77]

Criminal cases

On September 5, 2019, Tyler Huffhines and Jacob Huffhines were arrested.[83] Search warrants were served on a house at their place of residence and at a leased condominium.[83] In September 2019, an investigation in Kenosha County, Wisconsin, is underway to determine whether a major operation ran by the Huffhines brothers for purportedly making illicit THC vape cartridges, which were packed in containers to resemble candy and were thought to have been marketed to youth, could be related to a series of vaping-induced lung illness and deaths in the US.[83] The purportedly candy-themed containers used names such as Sour Patch.[84] In January 2018, Tyler Huffhines purportedly began the operation.[84] The vape cartridges purportedly contained as high as 1,000 milligrams of THC,[84] when the packaging stated it was just 5 milligrams.[85] Roughly $1.5 million worth of THC products were seized during the raid.[86] 57 mason jars containing THC oil were also seized during the raid.[87] Each jar was worth about $6,000.[87]

An initial appearance in Kenosha County court was held for both brothers on September 16, 2019.[88] Tyler Huffhines is facing multiple drug-related charges including possession with intent to deliver THC.[88] Jacob Huffhines is facing charges including being a felon in possession of a firearm and possession of THC.[88] Bond for Tyler Huffhines was set $500,000.[88] Bond for Jacob Huffhines was set at $50,000.[88] Both are scheduled to return to court on September 26, 2019.[88] Tyler and Jacob Huffhines were bound over for the duration of the trial on September 26, 2019.[89] Both are scheduled to return to court on October 23, 2019.[89] The Huffhines brothers pleaded not guilty on October 23, 2019.[90]

Courtney Huffhines, the mother of Jacob and Tyler Huffhines, was charged with assisting her sons run the illegal THC vape operation.[91] A woman was arrested in connection with the THC vape operation.[91] On October 3, 2019, Hannah Curty was charged with making THC, as a party to an offense against the law.[92] She is scheduled to return to court on October 11, 2019.[92] Courtney Huffhines and Hannah Curty were in court on October 11, 2019.[93] Both women are due to return to court on October 23, 2019.[93] Courtney Huffhines and Hannah Curty pleaded not guilty on October 23, 2019.[90]

On October 17, 2019, 22-year-old Jordan Lynam was charged with making THC vape cartridges in relation to the Huffhines's purportedly illicit vaping operation.[94]

Daniel Graumenz, Wesley Webb, and Tarail King are facing charges in relation to the allicit vaping operation.[95]

Civil lawsuit
See also: Media reports of persons hospitalized involving the 2019 vaping lung illness outbreak § Lawsuits after discharge; and Vail v. Juul Labs, Inc.

On September 23, 2019, a product liability lawsuit, Charles Wilcoxson v. Canna Brand Solutions LLC et al., was filed in Superior Court of Pierce County, Washington, against makers of THC vape cartridges.[96] Wilcoxson, a peace officer, had used THC vape products between January 2018 and September 2019.[96] He bought cannabis products that included Conscious Cannabis, Rainbows Aloft, Leafwerx, MFused, and Jane's Garden.[96] All of these companies are cited as defendants, according to the compliant.[96] The supplier of plaintiff's vaporizer was Canna Brand Solutions, which was also cited as a defendant.[96] On September 11, 2019, the plaintiff was vaping and that night he was wheezing very badly.[96] By Monday morning he was taken to the emergency room and was told he has lipoid pneumonia as a result of his vaping, according to the complaint.[96] He was in the hospital for three days.[96]

Responses

E-cigarette industry

The e-cigarette industry is placing the blame on illicit vaping liquids for the lung injuries.[13] "Each day of this crisis brings more evidence that street vapes containing THC or other illegal drugs are responsible for these illnesses, not nicotine vaping products," said Gregory Conley of the American Vaping Association, in August 2019.[13] "Like any health-related events reportedly associated with the use of vapor products, we are monitoring these reports," Juul Labs stated to Reuters in August 2019.[14] The company also stated that some news reports state that several cases of lung illness are associated with vaping THC, found in cannabis, "a Schedule 1, controlled substance that we do not sell."[14]

United States

The CDC recommends that the public should consider refraining from use of all e-cigarette, or vaping, products during their investigation.[5] CDC also recommends that people should not use e-cigarette, or vaping, products that contain THC, particularly from informal sources like friends, or family, or in-person or online dealers.[5] Until the relationship of vitamin E acetate and lung health is better understood, vitamin E acetate should not be added to e-cigarette, or vaping, products.[5] In addition, people should not add any substance to e-cigarette or vaping products that are not intended by the manufacturer, including products purchased through retail establishments.[5] CDC also recommends that people should not modify or add any substances such as vitamin E acetate to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments.[5] According to the CDC, if you are an adult using e-cigarettes, or vaping, products, to quit smoking, do not return to smoking cigarettes.[5] Adults addicted to nicotine using e-cigarettes should weigh all risks and benefits, and consider utilizing FDA-approved nicotine replacement therapies.[5]

The US FDA considers it prudent to avoid inhaling Vitamin E acetate.[9] On September 6, 2019, the US FDA stated that because consumers cannot be sure whether any THC vaping products may contain Vitamin E acetate, consumers are urged to avoid buying vaping products on the street, and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.[9] On October 4, 2019, the US FDA strengthened its warning to consumers to stop using vaping products containing THC amid more than 1,000 reports of lung injuries—including some resulting in deaths—following the use of vaping products.[97]

"The legal vapes have been actively regulated by FDA since Aug 2017. FDA has conducted thousands of inspections of manufacturers and vape stores, published manufacturing guidance, sought product removals etc. These tragedies point to illegal vapes and THC," former FDA Commissioner Scott Gottlieb tweeted in August 2019.[98] During an interviewed on CNBC's Squawk Box on September 9, 2019, Gottlieb said that "the current belief is the illnesses are linked to illegal vapes containing vitamin E oil."[99] He also stated that cannabis products in the US should be regulated.[99]

"The e-cigarette-related lung illnesses currently sweeping across the country reaffirm our belief that the use of e-cigarettes and vaping is an urgent public health epidemic that must be addressed. We must not stand by while e-cigarettes continue to go unregulated. We urge the U.S. Food and Drug Administration (FDA) to speed up the regulation of e-cigarettes and remove all unregulated products from the market. We also call on the FDA to immediately ban flavors, as well as marketing practices, that enhance the appeal of e-cigarette products to youth," Patrice A. Harris, the president of the American Medical Association, stated on September 9, 2019.[100] On November 19, 2019, the American Medical Association urged for a complete ban on all types of vaping products that are not approved by the US FDA as quitting smoking aids.[101]

On September 10, 2019, the American Lung Association issued a statement in light of the upsurge in reported illnesses and deaths associated with vaping: "E-cigarettes are not safe and can cause irreversible lung damage and lung disease. No one should use e-cigarettes or any other tobacco product. This message is even more urgent today following the increasing reports of vaping-related illnesses and deaths nationwide."[102]

"Vaping has become a very big business, as I understand it. Like, a giant business. In a very short period of time. But we can't allow people to get sick and we can't have our youth be so affected. And I'm hearing it. And that's how the first lady got involved. She's got a son, together, that is a beautiful young man and she feels very, very strongly about it. She's seen it, and we're both reading it. A lot of people are reading it. But people are dying, from vaping. So we're looking at it very closely," Donald Trump said to news reporters on September 11, 2019.[103]

Canada

Health Canada, the responsible government agency, responded to the US cases of potentially deadly lung illness by issuing a warning on September 4, 2019.[104] They advise that Canadians consider not using vaping products, monitor for symptoms, get a medical attention quickly if they have concerns, tell their doctor if and what they vape or have vaped, avoid the illegal and unregulated markets, avoid modifying vaping products, report adverse reactions, and monitor their advisory for updates.[104] They also stated for those who are vaping to watch for symptoms such as cough, shortness of breath, or chest pain.[104] On October 11, 2019, Chief Public Health Officer of Canada recommended to Canadians to consider holding back from vaping.[48]

Europe

"What little we know of recent reports from the U.S. is that the devices used appear to be linked to "home brews' of illicit drugs and not legitimate vaping products," Martin Dockrell, overseer of tobacco control at Public Health England, stated in September 2019.[105] What has occurred in the US has not occurred in other places where vaping is frequent such as the UK, John Britton, the director of the UK Centre for Tobacco and Alcohol Studies, stated in October 2019.[106] In European countries such as France, there is no evidence of an outbreak of the vaping-associated lung illness that occurred in the US.[105]

International

Dr. Vinayak Prasad, overseer of tobacco control at World Health Organization, told CNN on September 12, 2019, that WHO was observing the events in the US and abroad and will provide information to governments at the appropriate time.[107] Prasad also stated that its member states have not made any announcements of lung illnesses that resemble those that were observed in the US.[107] As a result of a potential link between vaping and lung illness in the US, the Australian Medical Association stated on September 18, 2019 that they reiterate a precautionary approach for the use of vaping products.[108] Following a string of deaths tied to vaping in the US, India has banned the sales of vaping products in September 2019.[109]

Patients
Main article: Media reports of persons hospitalized involving the 2019 vaping lung illness outbreak § Responses after discharge

In September 2019, 45-year-old Scott Goldstein from Shreveport, Louisiana, was struggling to stay alive after he says he was sickened from a vaping-induced lung illness.[110] On September 13, 2019, it was reported that Goldstein, in his hospital bed, said, "Now I have oil and water in my lungs that my lungs can't get rid of. Making them crystallize. They're rock hard."[110] He stated that he did not have any symptoms other than not being able to keep food down.[110]

18-year-old student, Chance Ammirata from Florida was using about half a Juul mint pod a day.[notes 3][112] This is equivalent to a nicotine dose of 10 combustible cigarettes a day.[113] He was vaping for about 18 months.[114] After presenting to the hospital with intense chest pain,[115] he was found to have had a collapsed left lung and needed surgery to repair it.[114] In August 2019, he posted an image of his lungs on social media.[116] On Twitter he explained the black dots on his lungs were from strictly Juul use.[114] He cautioned others to quit vaping.[117] He said, "It's so f***ing scary."[114]

In August 2019, 18-year-old Simah Herman was quickly taken to the UCLA Medical Center after she had trouble breathing.[118] After she was hospitalized her condition worsened.[119] After being hooked up to a ventilator and waking up from a medically induced coma, Herman wrote: "I want to start a no-vaping campaign."[118] She posted photos of herself on Instagram and started an anti-vaping campaign from her hospital bed.[119]

In August 2019, Herman thought she was going to die.[118] Doctors originally thought she had pneumonia.[120] She was in a medically induced coma for four days[120] and on a ventilator for almost a week.[121] She was in the hospital for almost ten days.[120] At 15, Herman started vaping and within two years her health deteriorated.[118] The smoke shop she bought the products from in North Hollywood did not ask for her ID card.[120] She told the shop she was 22, she said.[120] She was vaping every day.[118] After leaving the hospital she has given up vaping.[120] Before ending up in the hospital, doctors were unable to tell her the reason she felt sick even though she told them she was vaping, she said.[118]

Notes
  1. All patients have reported using vaping products.[2] The outbreak has raised concern among public health officials, and revived the debate regarding the effects of vaping.[3] This is the first time that vaping products has been linked to an outbreak of lung illness.[3] Except for one confirmed case in Canada,[4] it seems to be occurring only in the US.[3]
  2. Research suggests when vitamin E acetate is inhaled, it may interfere with normal lung functioning.[5] Vitamin E acetate is used as an additive in the production of e-cigarette, or vaping, products, because it resembles THC oil.[5] Vitamin E acetate is also used as a thickening ingredient in e-liquid.[5]
  3. In sampling multiple e-cigarette delivery systems, a 2019 study found Juul pods were the only product to demonstrate in vitro cytotoxicity from both nicotine and flavor content, in particular ethyl maltol.[111]

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