After more than a thousand respiratory illnesses throughout the United States were linked to nicotine and cannabis vaping products, the Centers for Disease Control and Prevention (CDC) has launched an investigation into the cause of the issue.
The investigation has centered on additives in vape cartridges and additives in vape cartridges, and focusing in particular on vitamin E acetate, a thickening agent used in street-market THC cartridges made by unknown manufacturers.
As of Oct. 3, 2019, there have been 18 reported deaths and 1,080 confirmed and probable cases of vape-related illnesses traced to both nicotine e-cigarettes and cannabis vape products reported in 48 states, including states with adult-use and medical cannabis laws as well as states that prohibit cannabis products, according to the CDC.
Those who have vaped products associated with the illnesses reported dizziness, nausea, fatigue, and shortness of breath, symptoms of acute lipoid pneumonia. Public health officials have warned against purchasing vape pens off the street. The New York Department of Health (NYDOH) found that many of these products contained vitamin E acetate.
Investigation into Vitamin E Acetate
While the CDC is still investigating the cause of the outbreak, on Sept. 5, 2019, the NYDOH announced that vitamin E acetate was the focus of its investigation after “laboratory test results showed very high levels of vitamin E acetate in nearly all cannabis-containing samples analyzed.”
On the other hand, “No single device, ingredient or additive has been identified,” according to Dana Meaney-Delman, an incident manager with the CDC.
On Sept. 9, the NYDOH issued subpoenas to three companies, Honey Cut Labs LLC, Floraplex Terpenes, and Mass Terpenes, which make thickening agents and market them to companies that manufacture vape oils. The samples the NYDOH received were determined to be “nearly pure vitamin E acetate oil.”
Does vitamin E acetate cause distress when vaporized and inhaled, and is it the lone culprit of these vape-related lung illnesses? The short answer: Doctors are still unsure of the cause and the CDC investigation is still ongoing. In the meantime, consumers should know more about vitamin E acetate and other potentially harmful additives and cutting agents.
What is Vitamin E Acetate?
Vitamin E is a nutrient that dissolves in fat, found in a wide variety of foods including vegetables and other oils, fruit juices, green vegetables, cereals, eggs, nuts, meat and poultry. It's also commonly taken as a supplement.
According to the National Institutes of Health (NIH) Office of Dietary Supplements, vitamin E functions as an antioxidant and immune booster for those with a vitamin E deficiency and it can also help prevent blood clots. When eaten, vitamin E is safe in doses of up to 1,000 milligrams per day. Both vitamin E and vitamin E acetate have been deemed safe for cosmetic and topical applications by the Cosmetic Ingredient Review Expert Panel.
As reported by the NYDOH, the form of vitamin E found in each of the vape products tested during its investigation was vitamin E acetate. Dr. Jeffrey C. Raber, Chief Executive Officer and Chief Visionary Officer of Los Angeles-based lab testing facility The Werc Shop, told Weedmaps News that vitamin E acetate, or alpha-tocopherol acetate, is an ester of alpha-tocopherol — one of eight compounds in the vitamin E class.
“Although the names 'vitamin E' and 'vitamin E acetate' sound similar, each are different molecules with different properties,” Raber said. “[Vitamin E acetate] is not naturally produced by plants or animals. In addition, it's much less effective as an antioxidant. Both are used and generally recognized as safe additives for food as fat-soluble anti-oxidizing and spoilage agents.”
Vitamin E is an approved additive by the Food and Drug Administration (FDA), generally regarded as safe in the doses we're all typically used to consuming in food. In high doses, however, a vitamin E supplement can become toxic. When taken in high doses, vitamin E can cause “nausea, diarrhea, stomach cramps, fatigue, weakness, headache, blurred vision, rash, and bruising and bleeding,” according to WebMD. As a natural blood thinner, high doses of vitamin E may increase the risk of excessive bleeding from an injury, as well as hemorrhaging in the brain.
“We know that vitamin E is present in cannabis,” Raber added. “So traditional cannabis use has not caused concerns, but again that is to be taken in context with concentration (i.e. dosage) and type of use. Again, we need to really stress the importance of recognizing the difference in these two molecules [...] Vitamin E is not the same as vitamin E acetate.”
Is it Dangerous to Vape Vitamin E Acetate?
If vitamin E can be harmful in higher-than-recommended doses, can vitamin E acetate also be harmful when inhaled as a vape additive?
According to NBC News, in 2000 an Ontario, Canada, woman was admitted to McMaster University Medical Center for a lung infection that was causing trouble breathing, coughing, fatigue, vomiting, fever, and diarrhea. The woman had lipoid pneumonia, the same lung illness that some of the recent vape users have been diagnosed with. The woman admitted to “inhaling home brews of marijuana oil made with either petroleum jelly or vitamin E oil,” as reported by NBC News. The case, published in the Canadian Respiratory Journal in 2000, revealed that the woman smoked homemade cannabis oil two to 10 times a day for more than a decade.
As of 2019, the effects of inhaled vitamin E acetate haven't really been studied enough to identify it as the definitive culprit of the vape lung crisis. Furthermore, the FDA only approved vitamin E as safe when eaten, with an understandable lack of foresight that people would be breathing it in.
“There is very little toxicological and safety data available for the inhalation of [vitamin E acetate]. Aside from use in some hairsprays with no apparent effect, there appears to be little else.” Raber said. “There is even less, if any, data available about the chemical fate of [vitamin E acetate] that is first heated to high temperatures and then inhaled like would occur in a vape cartridge.”
With a lack of tangible data, it is possible that vitamin E acetate and other vape additives found in THC carts — like the ones that are the only common denominator in the current outbreak of lung illnesses — may break down into toxic chemicals that can cause irreparable lung damage.
“When you apply enough heat to just about anything, the substance will break down into smaller pieces, known as degradation products,” said Adie Rae, Ph.D., a neuroscientist and instructor at Washington University in St. Louis, and a scientific adviser to Weedmaps. “Some of those smaller degradation products can be extremely toxic.”
Rae added that there are two reasons why something could be safe to eat, but not to inhale: 1) the liver is good at filtering out toxicants, but the lungs are not, and 2) edible vitamin E acetate contains no degradation products, which are plausibly abundant in superheated vapor.
“It is very likely that [a degradation product] is the culprit. Benzene rings are very common degradation products; they are known carcinogens. Methacrolein is another one; it is extremely toxic and burns the skin and lungs when inhaled,” Rae said.
Studies have shown that tocopherol quinones, a common family of degradation product molecules, are extremely toxic to human cells.
“It is also totally plausible that these vape products produced ALL of these aforementioned toxins, plus others,” Rae said.
Cannabis Industry is Responding
Many cannabis companies have been quick to respond with statements to confirm that they do not use additives, including vitamin E acetate, in their cannabis vape products.
In a released statement to Weedmaps News, manufacturer Cobra Extracts said it “always produce[s] natural cannabis products without any additives or cutting agents” and that their products do not contain vitamin E acetate, propylene glycol (PG), vegetable glycerin (VG), polyethylene glycol (PEG), coconut oil, medium-chain triglyceride (MCT) oils, or any other cutting agents. Binske, TribeTokes, and Vapen MJ provided a similar statement.
Weedmaps News has also received statements from Dosist, Beboe, Pure Vape, and Select, each brand stating that no vitamin E acetate or any other cutting agents are used in its products. Brands such as AbsoluteXtracts, Flav, LucidMood, Jetty Extracts and others have posted statements to Instagram to assure consumers their products don't contain vitamin E acetate or other cutting agents.
Vitamin E Acetate Found in Vape Products
Public health officials at the state and federal level have repeatedly warned of the dangers of purchasing vape products on the street or from untraceable sources, as counterfeits have been known to thrive.
Along with the announcement to focus its search into vitamin E acetate, the NYDOH also released photos of vape pens found to have vitamin E acetate, which included “Dank Vapes,” a vape brand that in August 2019, news site Inverse.com labeled “the 'biggest conspiracy' in pot that can put you in a coma.”
The next day, the New England Journal of Medicine released a report that found that of the patients who became ill from vape-related lung injuries in Illinois and Wisconsin, 24 of 41 interviewed patients [59%] used “Dank Vapes.”
That same day, the Food and Drug Administration (FDA) released a consumer update on Sept. 6, 2019, advising that consumers “avoid buying vaping products on the street” and avoid “modifying/adding any substances” to store-bought products.
On Sept 15, 2019, The New York Times reported that police raided an underground operation that made approximately 3,000 counterfeit vape cartridges a day. These underground manufacturers are believed to run mature operations that make and distribute vape cartridges that are diluted with cutting agents, some of which could contain vitamin E acetate.
It should be noted that public health officials have yet to confidently determine the cause of these illnesses. “At this time, no one device, product, or substance has been linked to all cases,” said Dr. Ileana Arias, the Principal Deputy Director for CDC, in a Sept. 6 press briefing. “Continued investigation is needed to better understand if a true relationship exists between any specific product or substance and the illnesses observed in patients.”
Feature image: Health officials have recorded 1,080 confirmed and probable cases of respiratory illnesses linked to THC and tobacco vapes. Eighteen people have died. (Gina Coleman/Weedmaps)
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