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Outbreak of Lung Illness Associated with Using E-Cigarette Products (cdc.gov)
56 points by colund 38 days ago | hide | past | web | favorite | 73 comments

I've been following this for months and New York State seems to be reporting the most accurate information.



The sickness is suspected to be caused by blackmarket THC vape cartridges which have been cut with Vitamin E Acetate.

There is a huge problem with black market / counterfeit THC vape products.

There are two communities tracking this on Reddit:



Is it worse than regular smoking? or how about the new IQOS type?

Obviously not smoking is the best option but assuming smokers will continue smoking even knowing the risks - which is the case unfortunately for a big majority, i believe the best thing to do is give them a way to get their fix that poses the smallest risk.

As others have said this "outbreak" is likely due to dodgy thc capsules so doesn't impact anyone but a very niche group

Surely there are several ways to deliver nicotine that are far safer than electronic cigarettes. There is mounting evidence that these are worse than tobacco.

Disclaimer: I'm Swedish so I guess you could say I'm culturally biased, but I have no economic interest in this.

You can always try "snus". Snuff has a bad rep in the US because of the association with chewing tobacco and old westerns, but snus in a pouch under your lip is actually very hygienic, easily disposable, practically invisible and obviously spares your lungs, while still giving you a nicotine buzz.

Obviously no way of consuming nicotine is risk free, but I use it every now and then and I enjoy it, especially with beer or coffee.

I think Swedish Match is attempting to market snus in the US under the "General" brand[1], might be worth checking out if you want to try an alternate way of consuming tobacco.

[1]: https://www.generalsnus.com

A lot of hockey players here in Canada use snus and even after learning how to do it properly it still makes me want to vomit. Plus the idea of a 'spit bottle' is even more anti-social than massive vape clouds (which are entirely unnecessary and becoming taboo).

There's no such thing as a "spit bottle" required for "proper" usage of snus. Perhaps if you are using snus that isn't portioned in bags and you wish to keep it in for a long time, you'll need to spit at some point -- but the vast majority of people do use portioned snus, and it is normally discarded before it starts running in a dedicated part of the box you took it from.[1]

[1]: https://proxy.duckduckgo.com/iu/?u=https%3A%2F%2Fd13o5qkgojw...

Strange, I wonder why all the hockey players I know used one. I'll ask them next time, I'm not much an expert on the subject. But I do know one gets his from Europe.

> I wonder why all the hockey players I know used one.

My guess would be that they did not use "portioned" snus. It's a bit of a macho thing, so the prevalence of the loose kind that you have to bake into a ball yourself and get your hands dirty is much higher among professional athletes, car mechanics and the like, while most regular consumers prefer the portioned bags. If you're interested in the statistics, about 77% prefer portioned snus.[1]

I believe one of the major reasons that people prefer to take their snus "straight" is because it's stronger, but the whole thing about dirtying your hands, making a mess when discarding it, going around spitting etc. creates some obvious issues for regular office workers or other consumer groups with similar opinions.

[1]: https://news.cision.com/se/nordic-snus/r/hur-snusar-svenskar...

Snus you do not spit

It’s my impression snuff and chewing tobacco beside being a bit gross (spittoons) it causes mouth cancer in some fraction of users.

It did prior to the early 2000's, I've read (but cant find the source) that they changed the manufacture to reduce the number of nitrotessamines to be in the same range as the swedish style.

I think you're referring to nitrosamines, and according to Robert Nilsson who is a professor at Stockholm University, there is "no proof of correlation between snus and cancer"[1] and indeed in 2002, the warning labels had to be changed,[2] and today "only" reads (my translation): "This tobacco product harms your health and is addictive", which is a far cry from the EU mandated warning on cigarettes that goes more like "Smoking kills", with some variants.

[1]: https://www.dagensmedicin.se/artiklar/2012/05/26/snus-bor-in...

[2]: https://www.snusbolaget.se/snusjournalen/snus-och-halsa-del-...

I'm sure that the risk of cancer isn't negligible, but again, spitting is not something that users of portioned snus do, the bags are normally discarded way before they turn runny.

What is the effect on your teeth though? How would you deal with it?

I haven't personally noticed any effect, but I'm sure it does affect your teeth in a similar way to drinking tea and coffee in the long run. Beyond that, it creates temporary irritation on your gums (temporary meaning it goes away if you stop and doesn't damage your gums permanently), and over a long period of time it can cause a permanent effect of receding your gum line, which of course isn't great. I'm no authority on how serious these effects are, how common they are etc. but I would imagine that they would require some pretty heavy usage under a long period of time, and that "loose" (un-portioned) snus probably affects your gums much harder than the more popular portioned variant in small bags, since the un-portioned variant is pure tobacco with no material in between it and your gums.

(And, on the topic, I am quite sure that in addition to the comparably low health risks of snus in contrast to e/cigarettes, the trust in the origin and the quality of the raw material used is rightfully so higher than that of the materials used in after market vape juice.)

Thanks, I did not know snus was used in those bags. I always thought it was akin to what I know as "pruimtabak" [1]. I've since learned (via Wikipedia) that there is original snus or "lössnus" and "Portionssnus" with "White portion" being a variant. It makes a lot of sense now.

[1] https://nl.wikipedia.org/wiki/Pruimtabak

>There is mounting evidence that these are worse than tobacco.

No there isn't. The evidence overwhelmingly indicates that e-cigarettes are far, far safer than any form of tobacco.


That article is from 2015. The exotic pneumonias and other respiratory diseases that have sickened hundreds and killed 10s have been linked to electronic cigarettes only in the past few months. Tobacco, bad as it is, does not cause these catastrophic outcomes within just months of beginning habitual use. And evidence more recent than 2015 shows that electronic cigarettes are not very effective in weaning people away from tobacco. We now know, from longer term studies, that many of these people return to cigarettes. These products have not been around very long and 2015 is ancient history. I stand by my comment.

In Vienna, the shop I bought my supplies had all products tested by local TÜV NORD and they mixed liquids on site. Nowadays I buy and mix myself from standard 50/50 PG/VG mix from known source. I had mixed results with imported premixed liquids (off smell, not consistent viscosity - went to bin) and that promptly stopped me from buying more of premixed stuff (along with problematic regulations of container sizes).

Anything you add to the liqiud other than nicotine and PG/VG may be problematic. You never really know what is in imported premixed liquid, what cutting agents were used, what purity of source material was.

It seems that CDC is seeing some results of cost cutting, using stuff that was not really meant to be vaped mixed to keep margins better.

I have asthma and have lived in Denver since before legalization.

When vape pens first came out I never had any issues. In the last few years I very well could have easily been one of those statistics.

Vape pens make my lungs hurt and I have to use my rescue inhaler for days afterwards. It’s terrible. I don’t know if they changed how they make the oil but I completely gave up on vaping. I tried one with pineapple flavoring and man... it almost was the death of me.

Shouldn't any kind of smoking be a big no-no with ashtma? Really curious because I have rhinitis and can't stand smoke around me.

I mean, probably. Cigarettes make me hurt (haven’t smoked one in a decade at least). Vapes make me hurt. Smoking weed from a clean pipe gives me almost zero negative effects unless I smoke significantly more than usual over the course of a few days.

What's the effect of not smoking anything?

Sorry, but I had to back up and re-read this. I guess I just assumed you were exposed to second-hand vapor, so I was very sympathetic to your plight (and quite shocked that you could detect the change in second-hand vapor!) until I got to "I completely gave up on vaping". My mis-reading of the post actually had me laughing out loud.

I've never used the pens and only use a "mod" with nicotine base mixed with 50% VG/PG at a local shop and haven't had any issues. In fact, I use my rescue inhaler far less since I've started vaping, which I only picked up after 3 years of being unable to quit the nicotine lozenges I originally used to quit cigarettes.

All the recent fear aside, I think we can form and do deserve a well regulated market for these products.

You are having a reaction to nicotine salts. Juul started the trend of using nicotine-salts rather than nicotine. It has much less throat burn so you can get a higher dose, but it makes some people wheeze.

Sorry I should have been more specific. I only vaped THC.

My guess would be too many terpenes (or extra added terpenes). A recent trend has been adding massive amounts of these volatiles to the mix (purchased in bulk from places like trueterpenes[0] - which has warnings all over it) to create "flavor profiles" or to more closely mimic the effects of smoking flower. These are the same as the toxic essential oils that people overdo. Some are far more potent than others and definitely can cause reactions (even in non-asthmatics).

Stick to unflavored distillates.

[0] https://trueterpenes.com/

i said right at the beginning when people were starting to recommend e-cigarettes as a replacement for cigarettes that they should keep the good old 'unknown unknowns' in mind and that a recommendation without knowledge of long term risk is dangerous.

This should maybe be a general lesson when people advocate unproven replacements for unhealthy habits.

Yet all we know is that these people vape and many of them were vaping black market THC oil with high levels of vitamin E. An estimated 10M people vape in the US and here we have an acute health issue with a few hundred people.


Right now there are literally 100s of millions of people vaping.

A small percentage of Americans, who mainly smoke THC, are suffering.

Sounds like someone in America is doing something dodgy.

To be clear, only a small percentage are showing critical damage (breathing trouble, death).

What percentage is not showing life-threatening issues yet, but are slowly building up accumulated damage?

Same. Call me in 50 years when they've had as long to examine the effects of vaping as we needed to definitively establish the lung cancer link to smoking. It amazes me that people hear "no known, proven side effects" with a technology that never existed before and read that as "safe".

The alternative for most is cigarettes. Do you really believe that vaping is worse than that? Are you going to wait another 30 years before picking up a cell phone? What about GMO's? New medicines?

Waiting to prove a negative is a silly stance when you know the alternative will kill you and severely lower your quality of life until that day comes.

The alternative is quitting. Only a lack of willpower and predatory marketing lets anyone fool themselves into thinking otherwise. Cigarettes used to be advertised as healthy, too.

I believe cell phones may have negative health effects that we have not yet discovered. They offer considerable convenience and that's worth it for me, but I know people who don't use them for that reason.

I'm skeptical about GMOs in general as they have potentially unknown environmental risks that we are poorly equipped to reverse or undo once we discover them.

New medicines obviously must be weighed against the disease they treat and the existing standard of care.

Waiting is exactly the wise choice, and acting like the alternative is cigarettes is nonsense when there's a perfectly available, free, harmless alternative that works for billions of people all over the world and has done for all time, which is simply not smoking.

As for your actual question, whether vaping is worse than cigarettes, I don't know and wouldn't guess, but I wouldn't quit smoking to take up vaping.


> abstinence approach

Smoking is not sex, don't be a fool.

> You don't know what you're talking about.

I actually do.

> So you "don't know" if something known to cause cancer and respiratory disease is worse than something not known to cause any disease?

That's correct. And neither do you, because the history isn't there.

Now, please go back and look at the history of cigarette smoking in the US if you want to continue this discussion further on an equal footing.

> I actually do.

You, and millions of others who have managed to quit smoking. I'm one of them.

Don't hate the user/addict though; hate the industry who use shady marketing to influence young people (children) to start smoking, who influence our MPs with shady lies and trickery. They are the servants of death.


>Smoking is not sex, don't be a fool.



the fact or practice of restraining oneself from indulging in something, typically alcohol.

>That's correct. And neither do you, because the history isn't there.

No, it's not correct. We don't prove things safe, we attempt to show, with reasonable certainty, that something is not harmful. Those are not equivalent. We have no reason to believe that vaping is dangerous. That's not a statement that it is safe, but to equate it to cigarettes is asinine.

>Now, please go back and look at the history of cigarette smoking in the US if you want to continue this discussion further on an equal footing.

Judging from your tone and opinions I don't think we'll ever be "on equal footing". This subject seems to draw out the most pompous, ignorant people.

OK, thanks for the definition.

Now, to restate my point:

The abstinence approach works for those who choose to improve their health by not smoking. If you don't make that choice, fine. But it's irresponsible to suggest that vaping is a safer alternative to smoking when we simply do not and cannot know that to be the case.

The jury will continue to be out until vaping has a long enough history for the long-term effects to become clear. So again: call me in 50 years.

If I had to gamble and pick which of the two is less unhealthy? I wouldn't gamble. Nobody is being forced to make that choice.

>But it's irresponsible to suggest that vaping is a safer alternative to smoking when we simply do not and cannot know that to be the case.

Ok. I also argue that laptops are potentially as dangerous as smoking. Call me in 20 years and I'll let you know how it turned out.

Great! I'm curious what you think the mechanism is, since laptops aren't a mechanism for inhaling addictive chemicals into your lungs, but hey, you might be right! Wanna make a bet?

Good, we're getting closer now; objective evidence should be the only thing that matters here, not unfounded fear.

There's nothing unfounded about extreme caution with a new, addictive product that has not existed long enough for the effects on human health to be known.

Bear in mind their invention was, I believe, a positive. That by adjusting the nicotine in the vape you could ease off smoking. The goal was not for vaping to become a cool thing to do. (Although I'm certain once e-cig companies realized the market they were encroaching on, they capitalized as capitalists do.)

at the same time it's entirely possible if not likely the issue is with some additive which needs to be banned and all other additives highly regulated and logged so these sorts of issues can properly be attributed to those problematic additives.

If we replaced large increasing lung cancer rates with acute respiratory issues for some people vaping fake products I say we're much better off.

Pretty certain I've had lipid pneumonia through vaped bad oils; but the gastrointestinal involvement and elevated heart rate and white blood cell count sound like there might be something more specific happening? Please someone educate us further?

I thc vaped for a little while. Everything seemed fine till the next batch which was a cough factory. It is unregulated and blackmarket. For all I know huffing paint is safer.

I'm another person who for whatever reason was never able to adjust to vaping. It quite literally hurts, even with modest inhales, despite trying numerous models (disposables, cartridges, expensive sub ohm systems, you name it). This applies both for nicotine and thc vaping. I just wrote it off as something that was a personal eccentricity.

Honestly it was for the best - I ended up using gum and eventually just quitting, and stopped using thc for other reasons.

Related discussion yesterday:


Bit confused how they've got 450 cases but no certainty?

Surely 1 out of 450 has a sample left that can be tested thoroughly?

Hasn't stopped them from making completely generic recommendations against vaping when most information points to specific kinds of THC pens.

Well no. As I pointed out in another comment. All have vaping in common...only some have THC associations (with some allowance for underreporting).

So they're right to ere on the side of caution here. The CDC isn't exactly incompetent...if they could pin this down to THC pens only they would.

I do think you're right in that this is probably some dodgy THC solvent, but based on current known info I think CDC called it cautiously...but right.

Recommendation is to not use e cig until they finish investigating but I wonder if a real cig is a worse alternative still?

It’s hard to imagine anything worse than a real cig with regard to the wide scale negative effects it has on nearly every system in the body. Maybe inhaling plutonium. :)

The most harmful part about cigarettes is inhaling byproducts from something burning. I'm even mildly allergic to pretty much every vape product, and I'd acknowledge that provided there is nothing toxic in vape juice, it has to be much less harmful than smoking - simply because of the lack of combustion products.

You already inhale polonium when you smoke a regular cigarette. :)

Whelp, there go my plans of pissing off Putin

I'm not a doctor but are there any theories on how one might die from vaping?

I have asthma. Even legal dispensary bought THC cartridges put my lungs in such a bad spot that my rescue inhaler barely brings relief. If I wasn’t well aware of that and hit one a dozen times over the course of the day I would be in serious trouble.

The way this is being reported, I feel quite confident that this is some sort of a deliberate propaganda campaign.

The two biggest red flags for me:

1) Language used in official press releases, weasel wording like:

a) "over 450 possible cases of lung illness associated with the use of e-cigarette products"

b) "The investigation has not identified any [single - my addition] specific substance or e-cigarette product that is linked to all cases. Many [how many? do you have no statistics on that? why?] patients report using e-cigarette products with liquids that contain cannabinoid products, such as tetrahydrocannabinol (THC)".

It seems written in a manner to maximize plausible deniability, hinting at one thing strongly [but not saying it outright], and making an extremely subtle acknowledgement of alternative causes [in the spirit of professionalism and "full disclosure"], but not reporting the magnitude of the "many", which could very well be 100%.

That's the beauty (and shortcoming) of written language for communication - when something is written in a seemingly deceitful style like this, there's no way for sure of knowing whether it is accidental or not. Unnecessary vagueness from a facts based organization like the CDC and #2 (below) make me lean strongly towards the deliberately deceitful interpretation.

2) Vaping has been extremely widespread for years, with few reports like these. And then out of the blue, 450 cases (5 deaths) occur in one country. No curiosity whatsoever about why everything is fine for years and then a massive spike in a very short period of time, in one country.

I could very well be wrong, but I will make a prediction: this will play heavily in the media for a few more weeks and then subtly degrade to a "gee, we don't really know what the real issue was, but our research is ongoing", and we won't hear about it again.

EDIT: From another HN comment:



New York State Department of Health Announces Update on Investigation into Vaping-Associated Pulmonary Illnesses

Department Warns Against Use of Black Market Vaping Products

Lab Test Results Show High Levels of Vitamin E Acetate, Now Focus of Investigation

The Department issued a health advisory in August, alerting health care providers of this emerging health threat and listing symptoms they should look for in patients. As of September 5, 2019, the Department has received 34 reports from New York State physicians of severe pulmonary illness among patients ranging from 15 to 46 years of age who were using at least one cannabis-containing vape product before they became ill. However, all patients reported recent use of various vape products.

Laboratory test results showed very high levels of vitamin E acetate in nearly all cannabis-containing samples analyzed by the Wadsworth Center as part of this investigation. At least one vitamin E acetate containing vape product has been linked to each patient who submitted a product for testing. Vitamin E acetate is not an approved additive for New York State Medical Marijuana Program-authorized vape products and was not seen in the nicotine-based products that were tested.

As a result, vitamin E acetate is now a key focus of the Department's investigation of potential causes of vaping-associated pulmonary illnesses. Vitamin E acetate is a commonly available nutritional supplement that is not known to cause harm when ingested as a vitamin supplement or applied to the skin. However, the Department continues to investigate its health effects when inhaled because its oil-like properties could be associated with the observed symptoms.

The Wadsworth Center is testing both cannabis and nicotine-containing vape products as part of this investigation and continues testing the purity of New York's approved medical marijuana products. More than a dozen product samples, in some cases multiple samples from a single product, from patients reporting symptoms have been tested. These samples have been tested for a range of substances, including THC and other cannabis-derived cannabinoids, nicotine, synthetic cannabinoids, opioids and pesticides. Products tested include a variety of labels and packaging. Many are suspected to be counterfeits of recreational cannabis-containing vape products available in other states.


It's rather interesting that absolutely none of these extra details, which have been available for quite some time now, appear in any official CDC reports.

Lungs were made for air, not smoke or atomized vapor (aside from drugs meant to be administered as a vapor).

Is this really that hard for people to figure out?

> air, not ...

Relevant: https://simple.wikipedia.org/wiki/Air

I am not surprised at all, and I'm surprised that anyone is surprised. The idea that one can breathe particulate or droplet matter into their lungs without causing problems seems absurd on its face given everything we've known about the effects of air pollution for decades. Tobacco is not special.

The more I read the comments of any discussion about e-cigarettes, the more I am convinced that there is a dedicated astroturfing campaign so any real discussion of the possible risks of e-cigarettes is derailed.

Any suggestion that e-cigarettes could be dangerous at all is instantly downvoted into oblivion or shouted down with, "you want me to smoke? It's deadly!"

Well, either a dedicated campaign or just a lot of addicts with their head firmly buried in the sand.

Is there any real chance that e-cigs could be more dangerous, or comparable to smoking? Would we even know yet? It can take decades for smokers to start developing bad symptoms, could vaping be similar?

It's possible. I would go further and say that the idea that smoke and vapor -of any kind- might not be great for your lungs is also suppressed by people who want marijuana legalized. I'm one of them, but the idea that breathing non-gaseous things doesn't have negative health effects is just weird.

There's also edibles if people don't want to smoke or vape.

Let's fast forward a few years from now to the point where we determine that e-cigarettes contain some sort of cancer or lung disease-causing product / additive, just like we figured out with cigarettes decades ago.

What I don't understand is why the FDA will not outright ban them immediately. (Well I probably do, and the answer is lobbying.)

Regardless of your stance on whether or not the FDA _should_ ban ingredients that pose health risks (government intervention on liberties et cetera), the fact is that this is the FDA's policy. It bans harmful ingredients (usually).

So with that policy in place, what's the deal here? If and when e-cigarettes are found to contain a chemical that is directly linked to cancer or lung disease, will the FDA ban it? Or will it conspicuously let it slide, and just slap a warning on it, like it did cigarettes?



There's no evidence that any of the ingredients of e-cigarette vapour are significantly carcinogenic. That may well continue to be true; there is no natural law saying that a habit you dislike must be carcinogenic.

There are many possible formulations of e-cigarette liquid, with the only common factor being nicotine. We are extremely confident that nicotine isn't carcinogenic, although it may cause mild cardiovascular harm. If we find out that some of the other ingredients in e-cigarette vapour are toxic or carcinogenic, the industry will voluntarily stop using those ingredients immediately; they already did so with diacetyl.

"We are extremely confident that nicotine isn't carcinogenic"

I would not say that's the case. This article is a good place to start:


It's probably better not to create a black market for an existing, addictive product by banning it outright.

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