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Vitamin E acetate found in lungs of vaping victims – Expert Reaction

The Centers for Disease Control and Prevention (CDC) is narrowing in on vitamin E acetate as a potential cause of vaping illnesses and deaths in the US, with confirmation the chemical has been found in all 29 lung tissue samples taken from patients.

Previously, the CDC determined that most patients with vaping-related lung injuries appeared to have bought either cannabis or tobacco vaping liquid containing vitamin E acetate.

As of November 5th, there have been 2,051 cases and 39 deaths. So far, the outbreak appears to be restricted to the US.

The SMC asked experts to comment on the laboratory testing – experts also contributed to a Q&A on vaping in October. Feel free to use these comments in your reporting.

Professor Chris Bullen, Professor of Public Health, School of Population Health, The University of Auckland, comments:

“The response from US authorities has been slow – it was widely known that the ‘acute vaping illness’ problem seen in the US was associated with a contaminant in black market sourced e-cigarette THC cartridges a month ago.

“Vitamin E acetate may be the causal agent (or a marker for the presence of another toxicant).

“In the US what is described is typical of a point-source mass poisoning event, not a generic issue with all e-cigarettes or their liquids.

“To my knowledge, no cases have been found in people who vape regular main brand e-liquid or pod-based products such as JUUL.

“Further, to my knowledge, no such problem has been documented in anyone in New Zealand to date. Neither the National Poisons Centre nor the Centre for Adverse Reactions Monitoring have reported such cases in New Zealand, at least when I enquired two weeks ago.”

No conflict of interest.

Dr Kelly Burrowes, Auckland Bioengineering Institute, University of Auckland, comments:

“There is a mounting body of evidence to suggest that electronic cigarettes come with considerable risks and can no longer be considered as harmless.

“The aerosol inhaled when vaping penetrates deep into the gas exchange surface of the lungs and contains a raft of different chemicals. The lungs are the largest organ within our bodies – with the gas exchange surface being the size of around 20 king-sized beds – and are constantly exposed to the external environment via what we breathe. When we inhale foreign particles, such as pollutants, cigarette smoke, or e-cigarette aerosol, our cells are exposed to this material and the body’s natural inflammatory response is triggered. Inflammation is designed to protect our body by using different inflammatory cells within the body to remove this material.

“Acute lung injury is a disorder of acute inflammation that causes damage to the cells lining the gas exchange surface. The recent cases of the newly-coined ‘electronic-cigarette or vaping associated lung injury’ (EVALI) show patterns of acute lung injury including various types of pneumonitis (which refers to lung inflammation caused by inhaling irritants – compared to pneumonia which is caused by an infection). The most common symptoms of pneumonitis are shortness of breath, which may be accompanied by a dry cough and eventually could lead to severe respiratory distress as seen in the cases in the USA.

“A recent assessment of the pathology (looking at the cells of lung tissue from electronic-cigarette or vaping associated lung injury patients) in the New England Medical Journal suggests that the disorder represents a form of chemical pneumonitis due to one or more inhaled toxic substances contained within e-cigarette aerosol. There have been lots of different types of lung damage observed in these cases and so far there is no standardised case definition for electronic-cigarette or vaping associated lung injury.

“Vitamin E acetate is being proposed as the culprit behind electronic-cigarette or vaping associated lung injury. Vitamin E acetate is a synthetic form of Vitamin E and is often used as an antioxidant in supplements and skincare products to prevent oils from going rancid. In the case of e-liquids, it is thought that this chemical is added to act as a thickener, particularly in pods containing THC. But, there is still a lot to be learnt and this outbreak of respiratory disease could be caused by any one of a number of chemicals present in the inhaled vapour.

“The issue with determining adverse health effects of vaping is the huge variation in products on the market with >400 brands and >15,500 flavours available (although this number is constantly evolving). This heterogeneity of both the construction of e-cigarettes and the substances aerosolised could mean that many other pulmonary manifestations have not yet been uncovered.

“For example, as well as different additives like vitamin E acetate, there is a huge range of flavouring chemicals used – some known to irritate the lungs and others with unknown impacts. Different types of metals can be used in the device itself and these are known to enter the aerosol being inhaled. So far, several carcinogens have been found in e-cigarette aerosols, including formaldehyde, acetaldehyde, acrolein, and heavy metals (we have found lead, copper, nickel and zinc in our samples) to name a few. And finally, customisable temperatures, devices and e-liquids mean that there is no way to know or control the chemicals being inhaled from these devices.

“There is no point continuing to debate whether e-cigarettes are more or less harmful than conventional cigarettes; this is only delaying the implementation of vital regulations – needed now – and increasing our understanding of the long term effects of vaping. It is clear that there is a large population of youth starting to use e-cigarettes worldwide and it is, or should be, hard to ignore that many scientific studies are showing cytotoxic, pro-inflammatory, genotoxic effects and effects on the respiratory function of users.”

No conflict of interest.

Dr George Laking, Medical Oncologist and Chair, End Smoking New Zealand, comments:

“Pretty much the whole vaping community knew it was Vitamin E acetate two months ago, we learnt of this via Michael Siegel.

“It’s taken the CDC two months to catch up, during which time speculation and misinformation have thrived.  In particular, people were advised to abandon their established nicotine vaping devices and liquids because of this.

“Concerning New Zealand, it does reinforce the need for people to be able to trust their supplier of vaping products, and by implication, the desirability of a regulatory framework for product quality assurance.

“These reports should not raise concern for New Zealanders who vape nicotine. The reports relate to some people in the USA who have vaped THC, i.e. cannabis products. The reports don’t mean there will never be an acceptable way to vape THC, but they certainly reinforce advice to not vape vitamin E acetate as part of a THC mix.”

Conflict of interest statement: End Smoking New Zealand supports harm reduction approaches to tobacco control; I have no financial links to vaping or tobacco industries.

Dr Murray Laugesen MBChB, Adjunct Professor, University of Canterbury, comments:

“I published the only New Zealand report on e-cigarette content and toxicity in 2015 in the New Zealand Medical Journal. Based on Canadian research we commissioned, we found that New Zealand available e-cigarettes (measuring the most toxic aldehydes) had 0.5% the toxicity of a Marlboro e-cigarette.

“No reports have been registered on the content of Vitamin E acetate in New Zealand cigarettes. However, New Zealand legislation is likely to require such proof in future if this is now known to be a factor. However the Associate Minister has not got any order paper listed in the current order paper of Parliament, and legislation is much desired.”

No conflict of interest.

Professor Julian Crane, Director of the Wellington Asthma Research Group, University of Otago, Wellington, comments:

“Vitamin E acetate found in lung fluids of all US deaths so far tested. This oil was suggested as a possibility at the beginning of the problem.

“New Zealand vapers not using illegal or home made products can be assured that this oil won’t be present in nicotine e-cigarettes. Its use has been to dilute cannabis oil products.”

No conflict of interest.