Vape Pen Lung Disease: Here’s What You Need to Know

As of Thursday, Sept. 19, the CDC has reported 530 confirmed and probable cases in 38 states of severe acute respiratory distress syndrome possibly associated with a recently inhaled drug aerosol (commonly known as vaping). As many as eight patients may have died from the condition. The deaths occurred in Illinois, Oregon, Indiana, California (2), Minnesota, Kansas, and Missouri. Here’s what you need to know.

Should I Stop Vaping?

If you own illicit vape cartridges, throw them away immediately. The CDC, FDA, and HHS advised consumers Thursday to avoid buying cannabis vapes or using products off the street. They are unregulated, untested, and are often contaminated.
If you purchase an illicit market disposable vaporizer cartridge—either THC or nicotine—and it’s filled with the wrong additive at the wrong amount, using it carries the risk of immediately injuring your lungs. Up to eight patients may have died as a result of tainted cartridges.
More broadly, the American Medical Association said Sept. 9 to stop vaping any e-cigarette. And Sept. 10, President Trump mulled banning flavorings in legal e-cigarettes.

What Is the Suspected Diagnosis?

In many cases, symptoms and treatment mirror a condition called lipoid pneumonia, previously found in patients who inhaled mineral oil.

Sickened lungs show up as cloudy on the left x-ray, and clear after treatment of one suspected VAPI patient in Utah. (Courtesy University of Utah)

What’s Causing It?

The contamination is emanating out of the supply chain for illicit market THC vape carts, the CDC said Sept. 19. “Most patients have reported a history of using e-cigarette products containing THC. Many patients have reported using THC and nicotine. Some have reported the use of e-cigarette products containing only nicotine.”
We don’t know for certain, but New York health authorities have confirmed that synthetic vitamin E oil (tocopheryl-acetate) is tainting most seized vape carts in that state. Pen makers report using it because it’s a cheap thickener. The FDA is now specifically looking at forms of vitamin E oil. New York has subpoenaed three thickener-makers—Floraplex, Honey Cut, and Mass Terpenes—after tests showed all three products were tocopheryl-acetate. On Sept. 13, SC Labs of California found Floraplex’s Uber Thick to be almost totally tocopheryl-acetate.
The FDA has received about 120 samples for testing. So far, they’ve found vitamin E acetate in 10 of the 18 THC samples. The FDA is testing seized carts for THC, nicotine, cutting agents called diluents, additives, pesticides, opioids, poisons, and toxins. One New York patient who tested his cart found it contained formaldehyde, pesticide, vitamin E oil, and “a little dab of THC.”
Health officials have confirmed that among the tainted carts are ones with the illicit market brand names Chronic Carts, Dank Vapes, and West Coast Carts, but the condition is linked to multiple illicit market brands across multiple states. One Tulare County, CA victim’s family member mentioned a “black and gold” cart labeled “Lucky Charms”. (Matching that description is both counterfeit packaging and authentic packaging for a popular, illicit market brand in California called West Coast Cure.)

Why Vitamin E Oil?

As Leafly reported last week, a new diluent known as Honey Cut entered the illicit vape cart market in late 2018. The product, which dilutes THC oil without thinning the viscosity, is manufactured by Honey Cut LLC registered to a Joshua Temple of Los Angeles. Officials at the terpene manufacturer True Terpenes, based in Portland, OR, told Leafly they tested Honey Cut earlier this year and found it to contain Vitamin E oil, aka tocopheryl-acetate. Two brands—Mr. Extractor of Oregon and Constance Therapeutics of California—told Leafly they’ve been selling forms of vitamin E oil into the vape cart market. Mr Extractor’s Drew Jones told Leafly he believes the oil is in 60% of carts in the US.

What Are the Symptoms?

Any who has vaped a black market cart in recent days or weeks and subsequently developed shortness of breath, dizziness, nausea, weakness, and tiredness should see a physician. Bring the cart.

What Are the Latest Numbers?

This mass poisoning event is akin to bathtub gin under alcohol prohibition. It is generally a creature of unlicensed markets where consumers have no legal alternative. It’s akin to recent Spice/K2 poisonings, as well as unregulated CBD market poisonings. The first reports came out of the prohibition state of Wisconsin, which has 35 cases, and Kings County, CA, which has banned legal access to tested cannabis, alongside 60% of local cities and counties. California has 81 potential cases and two suspected deaths (all illicit market-related). Illinois has 69. New York reports 78 cases. Texas has 25 confirmed cases. On Sept. 9, Kansas reported one suspected death. Minnesota has 36 cases. Missouri reported one related death Sept. 19, and 22 possible cases.
In contrast, Oregon has one suspected death and one suspected illness. Colorado has six suspected cases. The state of Washington may have three cases. California’s second suspected death occurred in Tulare County, where purchasing tested, legal cannabis from a store is banned in all areas other than the city of Woodlake. The victim’s family said he was using illicit market THC cartridges. Of Ohio’s 17 confirmed cases, 90% are black market THC cart-related, and none are medical cannabis system-related.
Wisconsin police announced one related arrest Sept. 10. California officials raided two unlicensed cannabis stores selling THC carts Sept. 13.

Why Is This Happening Now?

Leafly has reported that a new ingredient—next-generation cutting agents (thickeners)—are being misused in THC vape carts. Legal chemical thickener makers said they do not approve of use in vape carts. Chemical thickener makers also do not approve of dilutions greater than 10%. However, their web sites are unclear about the products’ approved and unapproved uses. The chemical makers have no information on what inhaling thickener aerosol does to your lungs, especially if it is heated or burned.

An oil-laden immune cell extracted from a VAPI patient in Utah (left). On the right, a normal macrophage. (Courtesy Andrew Hansen, Jordan Valley Medical Center)

How Can I Protect Myself?

Only buy tested, regulated adult use and medical cannabis products in legal stores like California, Washington, Oregon, and Colorado. Street traffickers are filling carts with harmful chemicals, and they go straight into your lungs. Here’s how to spot an illicit market, or counterfeit THC vape cart.
Though licensed markets have more safeguards, suspicious additives are not yet banned in California, Washington, and Oregon. On Thursday, Oregon regulators told stores to post vape warnings and hold suspicious products, and told licensed cart markers to immediately admit any “undisclosed agents” or face “legal consequences.” Oregon retailers have begun pulling suspicious products.
Cheap illicit market vape carts also routinely malfunction. Malfunctioning carts can get very hot, and burn additives and thickeners, releasing an unknown noxious gas. Run them at low, controlled temperatures.
If you’re concerned about additives in your cannabis, stick to tested flowers from licensed adult use stores. In terms of extracts, additive-free extract is called “rosin”, and it also comes in vape carts in mature adult use markets. There’s also tinctures, sublinguals, edibles, topicals, and transdermals, for those who want to avoid all cannabinoid inhalation products.