‘The Haymaker’ is Leafly Deputy Editor Bruce Barcott’s opinion column on cannabis politics and culture.
If 2019 was the year of the vaping health crisis, 2020 will be a year of reckoning. The first question that must be asked is this: Why did American public health officials fail so spectacularly?
Let me say that again clearly: The VAPI/EVALI emergency represents one of the greatest derelictions of duty on the part of American public health leaders that I’ve seen in my lifetime.
Here at Leafly, we witnessed the train wreck firsthand.
Evidence existed in late summer
On August 23, officials at the federal Centers for Disease Control and Prevention (CDC) announced that they had identified 193 potential cases of a new and mysterious lung illness linked to vaping across 22 states. One adult in Illinois died after being hospitalized for the condition, CDC leaders said.
Public health officials consciously ignored market-based information while the death toll mounted.
One week later Leafly published the first story exposing the frightening rise of a new street-market cutting agent, vitamin E oil (tocopheryl acetate). David Downs, our California bureau chief, drew upon his extensive contacts and years of experience covering the state’s cannabis industry to ask a basic question: People have been vaping cannabis oil and nicotine for years without suffocating to death—what changed?
Hey, look into this vitamin E oil
The answer, Downs found, was the introduction of vitamin E oil specifically into illicit THC vape cartridges. The oil wasn’t in legal cartridges because state regulators require manufacturers to label every cartridge with its lab-verified THC content. A legal cart heavily cut with vitamin E oil would test out at 25% THC or lower—a mark of shame that consumers would shun. (Most legal cannabis cartridges contain 70% to 90% THC.)
Nicotine carts weren’t cut with the stuff because it makes no economic sense to do so. Nicotine extract is cheap; THC extract is expensive. THC vape consumers in prohibition states had no lab-verified label on their carts, so they bought into a myth: The thicker the oil, the higher the THC content. Vitamin E oil took over the street market because it “thickened” the cart while actually reducing the THC content—and the cost to the manufacturer.
Public health officials, and especially leaders at the federal Centers for Disease Control, consciously ignored all of this market-based information.
CDC focused on patients, ignored the supply chain
Instead, they insisted on solving the VAPI mystery by relying on honest responses from patients affected by the tainted cartridges. For months, CDC officials told the public it was impossible to know what kind of vapes were killing people.
In fact, public health leaders were so desperate to cast blame on nicotine vape devices (which they insisted on calling “e-cigarettes,” a term absolutely nobody who vapes ever uses) that they changed their original term, VAPI (Vaping Associated Pulmonary Injury), to the more cumbersome EVALI (E-cigarette or Vaping Product Use-Associated Lung Injury) in order to put the focus on e-cigarettes.
Research has found that a certain percentage of patients will bend the truth to avoid exposure or embarrassment.
The data told a different story. Nearly all of the VAPI cases emerged from patients who vaped illicit THC cartridges. A stubborn percentage of patients insisted they had only vaped legal nicotine products—around 10 to 15%.
In a late October report on Utah EVALI victims, 92% of the 53 patients interviewed said they’d vaped THC in the three months prior to their lung injury. Cannabis is outlawed in Utah, so their vape cartridges were obtained from the illegal market. After testing, 89% of them were found to contain vitamin E oil. Similar percentages attended other patient populations.
What was happening was clear to anyone familiar with human psychology and the history of cannabis. In a certain number of VAPI cases, shamed and embarrassed patients probably lied to their doctors.
“THC? Not me, doc.”
In any situation where public health authorities rely on patient self-reporting, a certain percentage of patients will bend the truth to avoid exposure or embarrassment. It’s such a common phenomenon that social scientists have a name for it: socially desirable responding.
In 2015, public health researcher Dana Eser Hunt looked into the reliability of self-reported responses “when the questions involve reporting behaviors which threaten the respondent with exposure, embarrassment or both.”
Hunt’s findings were critically pertinent to the VAPI crisis. In one study of adults tested for cannabis consumption, only 84% were willing to admit to past use—even after they were presented with a positive drug test result that showed otherwise.
Other studies have found that truthfulness of patient responses depends on factors including privacy of the interview, anonymity and confidentiality of the information, sensitivity or embarrassment of the information, and perceptions of normative behavior.
CDC officials should have known
Federal and state health officials seemed to treat VAPI as if it were a judgment-neutral outbreak, like the Legionnaires’ Disease mystery of the 1970s. But it wasn’t. It involved a highly stigmatized and illegal activity: consuming cannabis.
As CDC officials continued to cling to the fiction of nicotine-cause VAPI, state leaders panicked.
As CDC officials continued to cling to the fiction of nicotine-cause VAPI, state leaders panicked.
In late September, Massachusetts Gov. Charlie Baker outlawed all vaping products. Washington Gov. Jay Inslee, who’d been crusading for years to kill the nicotine vape industry, spotted a political opportunity and pounced. He banned flavored vapes and blasted vaping companies. “Look, when you addict a 12-year-old kid to nicotine, you’re just wrong,” he roared. Never mind that Juuling seventh-graders, concerning as they are, were not suffocating from vitamin E poisoning.
State officials ignored illegal THC, blasted nicotine
I attended Inslee’s Sept. 27 press conference. During and after the conference, I asked what state officials were doing about vitamin E oil. Rick Garza, director of Washington’s Liquor and Cannabis Board (LCB), said his agency would require cannabis vape makers to disclose their ingredients. In other words, he asked them to send him a recipe list. That’s it.
When I pressed Garza on the troubling vitamin E oil reports, one of his staff members shot me a dirty look. “We think there’s a lot of…inaccurate information being published right now,” she said.
It was clear who she blamed for spreading it. For weeks, Leafly had been publishing in-depth investigations of the role of vitamin E oil in the unregulated THC vape street market. We all but rented billboards calling attention to the vitamin E thickening additives that entered the illegal market in 2018.
“What kind of inaccuracies?” I asked.
“We’re on the weekly calls with the CDC,” she said. “They think it could be a lot of things.”
State health officials made horribly wrong decisions. But they wouldn’t have made them without the stalling and dithering of CDC leaders.
UK health leaders endorse nicotine vaping
Gov. Inslee’s presser was marked by a heated exchange between him and a nicotine vaping advocate. Things got loud. The man nearly had to be escorted out of the room. He kept shouting about “British studies.” Most of the reporters—who had zero experience with vaping—dismissed him as a nutter.
I was curious, so I dug into the idea of “British studies.” And you know what? The nutter was right.
Research out of the UK has consistently shown nicotine vaping to be one of the most successful harm reduction tools of modern times. Public Health England has found that vaping is 95% safer than smoking cigarettes. A 2017 study in the Annals of Internal Medicine found that adult nicotine vaping was associated with “substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes.”
Saving thousands of lives every year
Roughly 480,000 Americans are killed by tobacco smoking every year. If the cancer risk dropped 95%, that would mean about 456,000 Americans might not die in a future year.
BMJ considers the rise of nicotine vaping as a substitute for tobacco smoking to be one of the decade’s great public health victories.
Nicotine vaping saves lives—thousands of them, possibly millions. Earlier this month BMJ, one of the world’s most respected medical journals, ran a summation of wins and losses for British public health in the 2010s. The rise of nicotine vaping as a substitute for tobacco smoking was ranked as one of the decade’s great public health victories.
“Credit should go to Public Health England for championing electronic cigarettes,” wrote BMJ’s Nigel Hawkes, “which has given tobacco cessation a boost at no cost to the public purse.” Hawkes noted that “if somebody could come up with a similar technological fix for obesity they would be the hero of the 2020s.”
CDC’s conclusion: too little, too late
Finally, in late December, CDC officials admitted what the data had shown for months: Street-market THC vape carts cut with vitamin E oil were the cause of the VAPI outbreak. The Washington Post reported:
With the latest data, “we are of the belief that vitamin E acetate has caused” the vaping-related lung illnesses “in the vast majority of patients,” [CDC principal deputy director Anne] Schuchat said. Although other studies are ongoing to understand the specific mechanisms of the harm to lungs, “we don’t have to hold our breath to go deeper.”
By then the damage had been done. The narrative had already been set in the minds of millions.
Even experienced science reporters and editors couldn’t be bothered to revise their erroneous takeaway: Vaping kills. Science News, an otherwise solid and trusted information source, ran a year-in-review piece a few days ago. Headline: Vaping’s dangers loom large amid more than 50 U.S. deaths this year.
The Science Newsstory contained no mention of the role that labeling and lab testing regulations played in keeping the state-legal THC vape supply safe and untainted. There was no distinction between legal and illegal products. Or mention of the fact that, as David Downs reported here, legal cannabis vape cartridges have been found to be 1,000% safer than street-market vapes. The author said nothing about the millions of adults whose lives will be saved by switching from smoking to vaping.
This is the real and tragic legacy of the VAPI crisis of 2019. As we sail into 2020, it is time to reckon with the damage done and to redouble the fight to reduce harm and save lives. Here at Leafly, we will continue to attack the hard questions and uncover critical data. The fight for cannabis legalization isn’t just about changing laws. It’s about repairing past harms, fighting ignorance and stigma, implementing sensible policies, and improving the health, wellness, and happiness of every single individual. Happy new year, everybody.