Vaping: A Public Health Analysis

Madison Skye - The Art of Vapor
Madison Skye - The Art of Vapor

In early September 2019, the US Center for Disease Control issued a press release reporting an investigation into a recent increase in lung injuries associated with the use of electronic cigarettes, sometimes called e-cigarettes or “vapes.” President Trump issued a statement along with Health and Human Services Secretary Alex Azar and FDA Commissioner Ned Sharpless vowing to take action in response to the incoming reports. By the end of the month, the CDC investigation turned into an “outbreak,” prompting a frenzy of media activity announcing a new vaping health crisis facing the American public. Government agencies and politicians scrambled to come with a response, with the FDA summoned before a congressional committee to explain themselves.

At the time, FDA officials prepared regulations that would ban the sale of flavored electronic cigarette products across the nation, touting it as the way to combat the increasing trend of underage electronic cigarette use. Local governments reacted to the anticipated changes, with state and city leaders rushing to address voter concerns by initiating legislation to ban vaping products in their jurisdictions, condemning flavored tobacco products and the companies that market them to youths as the cause for increased usage among underage users. Bearing the brunt of the blame was San Francisco-based JUUL Labs, a popular e-cigarette brand that in 2018 had sold a 35% stake in the company to Altria, a large tobacco corporation. Multiple lawsuits were filed in federal court against the company, which already was under investigation for multiple claims that the company targeted its advertisements at potential underage customers, and whose CEO had recently resigned amid these accusations. Hundreds of vape-related small businesses were affected by the changes, with many choosing to lay off their staff and close up shop due to local restrictions making it impractical to continue.

For many politicians, it was a big win: they had a chance to prove they could stand up for their voters against the greed of Big Tobacco that had addicted a new generation of children smokers at the expense of their health. And there was evidence for the cause, as survey data supported that underage vaping had increased significantly over the last few years.

Youth Vaping Trends

As more and more reports of injuries and deaths due to vaping were reported in the media, the condition was given a name, EVALI: e-cigarette or vaping associated lung injury. With little resistance, regulations and lawsuits continued to make progress in reaction to increasing public attention, and with traditional cigarette smoking among US adults also reaching an all time low at the time, many activists declared a victory for public health.

Then, as EVALI data was analyzed to understand the cause of the outbreak, new evidence began to emerge that made an understanding the situation more complicated. A report was released explaining that the majority of reported cases of vape-related lung injuries involved the use of devices containing THC, not nicotine. Furthermore, the majority of the THC-containing products consumed in these cases were either illicit cannabis brands or counterfeit replicas of state-licensed cannabis brands, not obtained from a state-regulated retailer. Because these statistics depend on voluntary statements from EVALI patients, the reported use of THC may be understated due to patient concern of criminal, social, or job-related repercussions. In other words, it is possible that some EVALI patients lied about using THC to protect themselves from losing their job or getting arrested.

These illicit products were submitted for testing, and as laboratory results came in, a likely culprit for the injuries began to emerge, a compound called vitamin E acetate. A synthetic form of vitamin E called an ester, it is sometimes used in skin creams, where it can penetrate skin cells and provide purported antioxidant effects. However, its use as an inhalant was not tested or approved by any scientific or regulatory agency, and limited existing research suggested that inhaling vitamin E acetate would interfere with lung function. The CDC published its results along with a reported decline in reported EVALI cases, eventually rescinding their original recommendation to cease all vaping activities, a statement that had implied that the use of any electronic cigarette could result in acute lung injury or death.

CDC EVALI Cases
Source: CDC

This data created a serious conundrum. There was plenty of evidence that youth vaping was on the rise for the last 5 years, but the most recent spike in EVALI cases did not seem to be directly caused by that trend. Between 2018 and 2019, reported EVALI cases increased by more than 1,000 percent, but overall vape usage increased by less than 10 percent. This means that if typical nicotine e-cigarettes (which had been sold in the US for at least 10 years) were the direct cause of the spike in injuries, something between 2018 and 2019 changed in those devices that caused a hundredfold statistical increase in acute lung disease. But there were no dramatic changes to the ingredients in these devices over the last year, and based on the evidence it was highly unlikely that these new injuries were caused by nicotine-based electronic cigarettes, and instead pointed to the presence of vitamin E acetate in counterfeit THC products. In addition, in the United Kingdom, which has about 3.6 million regular vaping consumers, no significant increase in vaping related injuries was reported.

President Trump reversed his position on the original proposed ban, refusing to sign a memorandum that would have imposed broad restrictions on the vape industry, calling for a more detailed analysis of the situation. With an election year looming, some political and anti-vaping activists quickly billed this move as a scheme to win votes and get cozy with Big Tobacco. The president hosted a roundtable session with industry members, cabinet members, and members of Congress to hear various arguments surrounding the proposed bans, with no specific decisions being made other than a promise to come up with a solution that addresses industry and public health concerns.

Trump Vaping & E-Cigarettes Roundtable. Courtesy: C-SPAN

The full transcript from the meeting raises (and somewhat confuses) two very distinct and very different public health issues, both of which had already been brewing unchecked for years. First, a significant rise of underage electronic nicotine use, and second, a proliferation of unregulated cannabis products across the nation.

History of Vaping

The concept of electronic vaporizers was patented in 1930, but no commercially viable products gained traction from those designs until 2004, when an inventor named Hon Lik released an electronic cigarette to the Chinese domestic market based on a patent he had filed a year before. Eventually these products made their way to the European and US markets, with early designs being disappointing to many prospective customers and consumption limited mainly to hobbyists. Inventions in vaporizer design and general advances in battery technology led to improvements to e-cigarette products that resulted in some early commercial success, but at the time most traditional tobacco companies regarded the category as an enthusiast market and not a mainstream opportunity. Additional improvements such as replaceable coils, configurable power supplies (called “box mods”), and a variety of new flavors were developed that resulted in the growth of the enthusiast market into a subculture known as “the vaping community.”

As the community grew, tobacco companies began to notice, with some of the larger e-cigarette brands such as blu being acquired by larger tobacco companies, beginning their entry into the market. Meanwhile, two Stanford graduate students met at school and began to work on a new design that resulted in the development of a variety of vaporizer devices, one of which became JUUL. JUUL is one of several pod-based vaping devices that are popular because of their size and convenience. Customers purchase a small handheld rechargeable battery device and install disposable cartridges called “pods.” The pods are sealed and contain a flavored liquid that is vaporized and inhaled.

JUUL
JUUL, a popular pod-based electronic cigarette

Electronic cigarettes function using a relatively simple design. By applying electrical power to a bundle of wire (called a “coil”) inside of a cartridge, the resistance in the wire creates heat, similar to the way a light bulb produces light and heat as electricity is applied to the bulb’s filament. By regulating the amount of heat inside the cartridge using specially designed electronic chips within the device, the coil heats the liquid in the cartridge to a temperature high enough to covert the liquid into an inhalable vapor, but not hot enough to burn it. Some devices are activated with a button, and others have sensors that automatically detect when the user is inhaling from the device and activate the coils. This action delivers a flavored vapor along with the active ingredient: nicotine.

Thank You For Smoking

Nicotine is an organic compound that naturally occurs in tiny concentrations in a variety of plants such as potatoes, tomatoes, and eggplant, but in the tobacco plant, a crop indigenous to North America, it can occur in much higher concentrations, up to 3 percent. Native Americans smoked tobacco for years, and as European countries colonized North America, an industry developed around the cultivation and trade of tobacco. Tobacco became wildly popular in Europe, which led to it becoming a major agricultural cash crop in the American South. With little understanding of the health effects of smoking and tobacco’s massive economic potential, the industry flourished for years, even using images of doctors in advertisements to encourage consumption.

R.J. Reynolds

Then in 1950, a preliminary report was filed in the British Medical Journal providing evidence that smoking was linked to a significant increase in cancer. This led to a 1964 report from the US Surgeon General recognizing the link between smoking and lung cancer, resulting in the requirement of health warnings on cigarette packaging. For the next 45 years, the tobacco industry would find themselves at odds with health officials and local governments, as cigarette lobbyists fought off regulation and restrictions despite the growing pile of evidence accumulating indicating the negative health effects of smoking. Ultimately, the Family Smoking Prevention and Tobacco Control Act was passed in 2009, granting the FDA oversight of tobacco products, treating nicotine as a drug.

Nicotine is a nervous system stimulant that has the potential to affect mood, anxiety levels, cognition, and sleep, with many consumers developing an reliance on it for relaxation, clarity of mind, or stress reduction. It also has a very strong dependence potential due to its neurological stimulant effects and its strong withdrawal symptoms. However although nicotine has these well documented physiological effects, by itself it is not the leading cause of lung cancer among smokers.

When burning tobacco leaves within a cigarette, thousands of chemical compounds are generated as the components of tobacco smoke. Nicotine is one of those chemicals. However, along with it comes at least 70 other carcinogenic (cancer-causing) compounds such as benzene, aromatic amines, polyaromatics, heavy metals, as well as compounds from incomplete combustion such as carbon monoxide and acrolein. It is comparable to inhaling wood smoke on a regular basis.

https://www.cancer.ie/reduce-your-risk/smoking/health-risks/whats-in-cigarettes

Despite the known health effects, public educational material, a lingering odor, and the irritation from inhaling smoke from burning leaves, the addictive nature of nicotine makes quitting smoking very difficult.

An Alternative Emerges

Various processes to chemically extract nicotine from tobacco plants have existed for years. Smoking cessation products such as nicotine gum and nicotine patches use extracted nicotine to help customers satiate smoking cravings and ease withdrawal symptoms. On the tobacco plant, nicotine is bound to the leaves as ionic compounds with various organic acids, known as its naturally occurring salt nicotine form. In chemistry terms, a salt is a stable, solid compound held together by electrostatic forces (an “ionic bond”); common table salt is a salt composed of sodium and chlorine ions, and nicotine salt is composed of nicotine and acid ions. If you neutralize the acid with a base such as ammonia, you can break this ionic bond and liberate the nicotine from the plant into a solution, and then by utilizing a hydrocarbon extraction process, produce a purified form of nicotine called freebase nicotine. The word “freebase” has an unfortunate association with illicit drugs, but its scientific meaning is to describe the chemical separation of an amine (such as nicotine) from its acid form (nicotine salt).

Early electronic cigarettes mixed freebase nicotine with vegetable glycerine, propylene glycol, and flavorings to produce e-juice: a liquid mixture that when vaporized, delivered a flavorful hit of nicotine carried along by a large volume of relatively harmless vapor. However, since freebase nicotine had its naturally occurring acid ions removed through the extraction process, its pH is slightly basic, which can cause irritation to tissues in the throat. But by introducing a mild acid (such as benzoic acid) back into freebase nicotine, it can be turned back into a salt, not perfectly identical to its original natural form, but a similar chemically created representation. By recreating nicotine salt, electronic cigarettes could deliver almost exactly the same form of nicotine that comes from smoking tobacco, while also producing a smoother, less irritating vapor without the carcinogens generated from burning leaves. Also, since some studies indicated that nicotine salt was more readily absorbed by the lungs, a larger dose of nicotine could be delivered with each electronic puff.

A typical nicotine salt product. Source: Naked100

A Tale of Two Countries

Many electronic cigarette manufacturers such as JUUL capitalized on this technology, delivering compact, stylish devices that contained a pod with a smooth flavor and a high concentration of salt nicotine. As the social stigma of smoking cigarettes continued to grow, these slick devices offered a way to consume nicotine in a flavorful package and not end up smelling like a campfire. In the United States, which had a general lack of e-cigarette regulations, pods were filled with high amounts of nicotine and aggressively marketed to new users. Attractive models and social media influencers marketed the devices as a safer, more socially acceptable alternative to smoking, offering flavors that taste great in a format that looks cool.

Early ad for JUUL

America’s youth ate it up. JUUL’s sales skyrocketed up to more than $1 billion in 2018, and investors clamored to invest in the business, ultimately resulting in tobacco giant Altria paying $12.8 billion to acquire 35 percent of the company in December of 2018. But the demographic metrics that also began to emerge were troubling: a huge amount of these new users were underage. With a online age verification at the time relatively easy to bypass, and many older adults viewing the devices as a fad, minors could easily obtain these devices through the Internet or an adult proxy purchase. Nicotine’s strong addiction potential was delivered along with these new, modern devices that looked good, tasted good, were easy to obtain, and (supposedly) didn’t cause cancer. Even Leonardo DiCaprio vaped. And with some of these pods containing high concentrations of more than 5% nicotine salt and no lower options, a new public health problem emerged: the kids were now hooked.

With no meaningful federal regulations in place, local governments reacted. The city of San Francisco passed an ordinance that banned the sale of any vaping products not reviewed by the FDA. Since there were no FDA reviews of electronic cigarettes, that amounted to a ban of all vaping products in the city. The state of Massachusetts declared a public health emergency and issued a ban on flavored tobacco and vaping products. Lawmakers, some armed with misinformation that nicotine vaping was the cause of the spike in vitamin E acetate related injuries, rushed to pass laws to broadly outlaw and condemn electronic cigarettes to pacify concerned voters. Opponents argued that cigarette smokers who were using vaping as a tool to quit tobacco would return back to cigarettes, but had little support. JUUL, already the defendant in a variety of class action cases and criminal lawsuits, pulled their fruit flavored products off the US market since the FDA seemed convinced it was the flavors that were enticing underage users. But there was a problem with that position: adults who had quit smoking cigarettes in favor of vaping liked those fruit flavors too. They didn’t want their vape to take like cigarette smoke.

Meanwhile, across the Atlantic in the United Kingdom, electronic cigarettes had been virtually embraced by the government, but not as a fad for children. Recognizing the difficulty of quitting cigarettes due to the addictive properties of nicotine, and with a scientific understanding that electronic cigarettes contain far less harmful chemicals than tobacco smoke, the UK House of Commons adopted a policy of harm reduction and passed resolutions that promoted vaping as a useful tool for existing smokers to quit cigarettes, while establishing regulations around product content and marketing to prevent it from attracting children. While US sold JUUL pods contained more than 50 milligrams per milliliter of nicotine, JUUL pods sold in the UK only contained 20 mg/ml due to established regulatory limits.

So far, it seems to be working, as evidence exists that thousands of cigarette smokers in the UK who were unable to quit using other means were able to quit by taking up vaping.

NHS – Using E-Cigarettes/Vapes To Quit Smoking

The policy of harm reduction recognizes that individuals may continue certain destructive behaviors despite the risks due the addictive nature of that behavior. By offering a path that reduces the risks from from that behavior, it can improve the quality of life of those individuals, decrease their mortality rate, and increase the probability of complete abstinence. By transitioning an existing tobacco smoker to vaping, although they still consume nicotine, that person is no longer exposed to all the carcinogens that came with burning tobacco.

Also, there was no youth vaping crisis in the UK. As part of the vaping policy, UK laws strictly restricted marketing and sales to potential underage customers, and the surge of youth vaping that swept the US did not take hold in the UK.

Source: ash.org.uk

And so, the evidence seems to point to the youth vaping crisis in the US being a self-inflicted wound. With a lack of policies restricting sales and marketing of a highly addictive substance, businesses will do what they do best: push attractive products, acquire new loyal customers, and optimize for profits.

That explains the story of youth vaping in America, but the original CDC report is not yet fully explained: how did thousands of people end up with serious lung injuries after consuming illegal cannabis products containing questionable ingredients?

The Cannabis Story

Besides the vape industry, there is another industry that has been growing like a weed. Already decriminalized in more than 40 states, and recreationally legal in at least 10, the cannabis industry has risen from a community of marijuana enthusiasts into a high growth commercial industry that has also enticed investors looking for the next big win. The ambiguous legal status of cannabis is often confusing: it’s a multi-billion dollar industry in states like California, and yet its a Schedule I illegal controlled substance according to the US federal government. Some states like Colorado and California have embraced the industry, offering resources and assistance to potential entrepreneurs looking to build the next cannabis empire in their state, while other states have remained opposed to any legalization effort, punishing possession of small amounts as a serious crime.

Colorado Medical Cannabis
A medical marijuana collective. By © O’Dea at Wikimedia Commons

And since the federal government does not recognize the legal status of marijuana, the FDA also does not regulate it. Instead, the Justice Department is tasked with enforcing its status as a Schedule I controlled substance. Legally, federal law enforcement has the right to seize cannabis products and prosecute related activities anywhere in the United States as a violation of the Controlled Substances Act, but in practice, in cannabis-legal states they take very little action, because those states have already indicated that they will vigorously defend their cannabis industries in federal court.

With the state government in their corner, licensed cannabis operators have been more or less able to operate in the open as they legally desire, albeit without full access to some federal services such as traditional banking. State-level health regulations impose restrictions on product quality, to ensure that standards are met and that products are tested in laboratories to identify harmful chemicals, heavy metals, and microorganisms. Products purchased from state licensed retailers have a “chain of custody” that can show lab testing results and track the product’s origin all the way back to its beginning as a seedling, giving buyers a degree of confidence in the quality of their purchase.

SC Labs
SC Labs, a cannabis testing company

And just like vaping grew from a hobbyist market to an enthusiast subculture, and from there into a worldwide phenomenon, the culture of cannabis has its own different story of how it exploded on the worldwide stage.

Cannabis Culture

Cannabis has been consumed by humans for thousands of years, with records reporting its use in ancient India and China. A plant indigenous to central Asia, it made its way via traders to Africa and the Caribbean by the 8th century. There is considerable history documenting the medical use of cannabis for treating inflammation, nausea, and lack of appetite, and because of its potent psychoactive effects, there is also a long history of recreational consumption. In US history, in the 1850s medical cannabis preparations were sold by pharmacies and recreational hashish parlors were common in the cities.

A cannabis tincture from the 1850s

The Pure Food and Drug act of 1906, a law intended to protect consumers from polluted substances, classified cannabis as a controlled substance, with some states such as California considering it to be a poison, passing laws to make its possession a crime. The Federal Bureau of Narcotics was formed in 1930, and it took a firmer stance, stating that cannabis caused people to commit violent crimes and act irrationally. The Marihuana Tax Act of 1937 made possession of cannabis illegal excluding medical and industrial use, until it was overturned in 1969 by the Supreme Court determining the law to be unconstitutional. In reaction to that judgment, Congress passed the Controlled Substances Act in 1970, and cannabis became a Schedule I controlled substance. President Richard Nixon, who had signed the act, declared a “war on drugs” the next year in 1971.

Meanwhile, during the counterculture (“hippie”) movement of the 1960s, many Americans experimented with various drugs and documented their experiences. Many hippies consumed cannabis and became advocates for its medical benefits as well as its pleasurable effects, and an enthusiast market began to grow, giving rise to the stoner culture. Around the same time, hip hop music began to emerge from New York, and by the 1990s it had become a mainstream commercial success. Many hip hop artists were also avid cannabis enthusiasts, and as those artists gained commercial success, so did public awareness of cannabis, particularly among youth. Over time, the cannabis enthusiast community grew into a subculture of its own.

Snoop Dogg
Snoop Dogg, a popular hip hop artist and cannabis enthusiast. Source: Jason Persse

Then in 1996, California passed Proposition 215, the Medical Marijuana Initiative, the first state to legalize cannabis activities for medical purposes. Since the medical applications of cannabis were not well defined, any resident could easily obtain a prescription, effectively making the product readily accessible to any adult in the state. With easy product access in California and the continued growth of hip hop influence, cannabis culture began to expand its borders across the country and into other parts of the world. A new industry was about to be born.

But if a new cannabis enthusiast found themselves living in a state where marijuana was still criminalized, they were faced with the dilemma of obtaining a product they desire in a state where it was illegal.

Prohibition 2: The Sequel

And so, just like Prohibition in the 1930s, the modern bootlegger emerged. Smuggling products from cannabis-friendly states into prohibitive states across the country, marijuana made its way across the nation and into the hands of eager enthusiasts ready to buy. Despite the legal risks, enterprising traffickers pursued the opportunity because the demand was there. Cannabis products that were grown and sourced in California under medical marijuana laws and intended for sale within state borders, instead were transported across the nation, turning the state into the largest marijuana exporter in the world.

Marijuana Seizure
An example of unregulated cannabis transport

But just as the vaping industry was very lightly regulated by health departments during its early days, the medical cannabis industry was hardly regulated at all. Because of cannabis’ ambiguous status as a federally-illegal-state-medical product, regulatory health standards were not strictly established or enforced. Many cannabis operators were avid enthusiasts that self-regulated themselves to high standards to produce high quality products. But others prioritized profits, even if it came with health risks. Less principled cultivators sprayed cannabis plants with pesticides that had known harmful effects on humans to protect their crops, and others used chemicals such as plant growth retardants that increased product yield but had long-term negative health effects on whoever consumed it. Crops that had mold or mildew overgrowth were sold at a lower prices or exported instead of being destroyed.

Sophisticated buyers, mostly concentrated in cannabis-friendly states, were educated enough to know how to avoid such products. But the much larger amateur market across the nation, facing restrictive laws, limited product access, and fewer educational resources, purchased whatever was available. And there was little recourse: a cannabis smoker falling ill from pesticide exposure in a state where marijuana possession is a felony will be extremely unlikely to report their consumption, and even if they did, there was no way to track such product back to its source. It was likely purchased from a local connection in cash, and that local connection likely purchased it in cash from a distributor that transported it in bulk from another state, with no record of its origin.

As a result, in some parts of the country the darker side of the cannabis industry is very real: products are more dangerous to consume, criminal activities are increased and organized, courts and prisons are flooded with cases, and law enforcement agencies spend more money without an increase in tax revenues. Research by economist Mark Thornton demonstrated that an increase in drug law enforcement budgets has always resulted in the creation of higher potency forms of that drug. Cannabis is no exception, and as some states intensified their efforts on marijuana crackdowns, stronger cannabis products began to emerge.

Look At My Dab

Just as the active ingredient in tobacco is nicotine, the primary active ingredient in cannabis is tetrahydrocannabinol (THC). THC is the most famous of hundreds of active compounds contained in marijuana known as cannabinoids. And similar to smoking tobacco in cigarettes, smoking cannabis flowers in a joint, a blunt, or a bong involves inhaling hundreds of other byproducts produced by burning the plant material, some of which are known carcinogens.

Like nicotine, THC can be extracted from the cannabis plant. But while nicotine is an alkaloid that can be freed from the plant using a base such as ammonia, THC is a complex fatty molecule that requires additional processing. Cannabis plants have tiny growths called trichomes that contain concentrations of THC in an stable form called tetrahydrocannabinolic acid (THCa). But THCa is not biologically active, it must be heated to a sufficient temperature to decarboxylate it, which removes a hydroxyl (OH) group and releases CO2 gas, turning the THCa into delta-9-tetrahydrocannabinol (delta 9 THC), one of the biologically active isomers of THC. The process of burning cannabis flowers introduces enough temperature to decarboxylate the THCa on the plant material, so that when the smoke is inhaled, it contains biologically active delta 9 THC.

By following one of several methods, a highly concentrated THC oil can be extracted from cannabis plant material, resulting in an active substance that can be used to create edibles, tinctures, and other concentrated products. The concentrated oil can also be vaporized and inhaled, and many cannabis enthusiasts select this as their preferred means of consumption, using a device called a “dab rig” to vaporize and inhale the concentrate, which comes in various forms such as “shatter,” “crumble,” or “dabs.”

An example of THC concentrate. By Andres Rodriguez

Vaping Weed

With electronic cigarette innovations progressing about the same time as cannabis industry growth, it didn’t take long before THC oil was filled in electronic cartridges to produce a convenient, highly concentrated product. But pure THC is very viscous and by itself has no flavoring, so flavorings are added that decrease the thickness of the oil and add taste. The mixture is filled in specialized electronic cigarette cartridges and produces a simple, convenient format to vape THC.

Brass Knuckles, a popular California-regulated cannabis vape brand

The convenience and simplicity resulted in enormous growth, with multiple successful brands emerging that offered high quality, concentrated cannabis vaping products. Guided by an enthusiast community that was mostly self-regulating, these brands imposed their own quality controls to ensure that the finished products were high in potency and free from harmful chemicals. Independent testing labs emerged that were able to provide third party confirmation to educated consumers that they were purchasing a clean and safe product. By the time recreational cannabis legislation came into effect years later, many of these self-imposed regulations became incorporated into state health policies.

Crisis Waiting To Happen

As the popularity of cannabis concentrates grew, so did demand. Customers everywhere wanted the latest products, but if they lived in states with restrictive cannabis laws, they turned to local connections to bring it to them, and were willing to pay much more than the retail cost. These connections would turn to their distribution contacts, who would source the products in medical marijuana markets and bring them to their buyers. Despite the legal risks, it was a lucrative market.

Then some distributors, who made profits by acquiring products from cannabis-friendly states and transporting them into more restrictive states where they could be sold for higher prices, realized they could make more money by manufacturing the products themselves. But clients often requested specific brands that were popular or known for consistent quality. So some began to manufacture counterfeit cannabis products, meticulously duplicating the same packaging and hardware of popular brands that were in high demand.

Motivated by profits, counterfeiters diluted their THC oil, introducing additives that would increase the volume of the liquid as much as possible and reduce costs. The replica packaging, which had claims of potency and quality, referenced authentic test results from the original brand, but were not real. Concerned about brand perception, licensed manufacturers tried to make more complicated packaging to discourage counterfeits, launching a cat and mouse game where each new iteration would get cloned within weeks. Licensed brands had limited resources available to them for protection, with federal services such as copyrights, trademarks, and customs protections all unavailable to them.

Empty replica packaging sold online for Dank Vapes, a popular unregulated cannabis brand

Customers became aware of the counterfeits, but many distributors pushed their own replicas as legitimate, so it became difficult to determine if a product was real. Because pure THC oil is highly viscous, some consumers adopted a crude measure for cartridge potency by examining the thickness of the oil inside it: the logic being that a runny liquid meant the cartridge was diluted or “cut”, had low potency, and therefore a fake. In response, some replica makers that had been diluting their THC oil to maximize profits began to add artificial thickeners to their products to raise the fluid’s viscosity, and thus give the perception of a highly concentrated vaping liquid. The worst of them, either ignorant of organic chemistry or bad actors unconcerned about their own client’s health, added thickening substances like vitamin E acetate that were never tested, never approved, and should never have even been considered.

These thickeners (sometimes called emulsifiers) increase the viscosity of the oil in the cartridge, which helps to sell them, but once inhaled, instead of being absorbed by the lungs they harden, clogging the alveoli, sacs that absorb oxygen for the body. Heavy usage caused some consumers to overwhelm their lungs, ultimately sending them to the hospital with life threatening injuries. With the country flooded with black market replicas, many tainted by untested thickeners, health cases continued to pour in, and as of January 14, 2020, 2,668 EVALI injuries and 60 deaths have been reported in the US, a public health tragedy.

Another Tale of Two Countries

But in Canada, America’s neighbor to the north, as of January 21, 2020, only 17 EVALI cases and no deaths were reported. After taking the differences between the two countries of total cannabis consumer population into account, the US still reported 18 times more EVALI cases per cannabis consumer than Canada. Why the drastic difference? Are US products that much more dangerous?

On June 18, 2018, Canada passed the Cannabis Act, a landmark law which legalized recreational cannabis nationwide in Canada. While the law made consumption and possession (within legal limits) of cannabis no longer a crime, it also established restrictions on its production, distribution, and marketing. Celebrity endorsement, event sponsorship, or any marketing activities that could appeal to youth are not allowed. Enthusiasts are free to cultivate and manufacture products in small quantities for personal use.

A cannabis dispensary in Vancouver, British Columbia. By Mike

The stark difference in EVALI case data provides supporting evidence that Canadian cannabis policy has contributed to protecting its citizens from illegal, hazardous products. Cannabis products, including vapes, are available in Canada from state-licensed retailers along with a chain of custody tracing back to its originating producer. While black market products will always exist and could be responsible for the reported cases in Canada, the data suggests a dramatic reduction in consumption of these illicit products is due to the legal availability of regulated products.

Improving Public Health

Public health agencies like the FDA are responsible for protecting and improving the health of its citizens, and there are many examples where the FDA’s testing process has prevented harmful substances from being sold to the American public as medicine. But there are also failures, and in the cases of vaping and cannabis, US health policy is sorely out of date, and this exposes the American public additional risks that can be mitigated.

  • Statistics indicate that by not restricting the nicotine content and advertising practices of nicotine vaping companies such as JUUL, youth vaping consumption in the US skyrocketed, while in the UK where these practices were highly regulated, youth consumption remained relatively constant. Flavored vapes were sold in both markets, suggesting that the primary driver for youth adoption was not the availability of flavored products, but rather the high nicotine content and targeted marketing practices allowed in the US.
  • In the UK, accepting and promoting vaping as a form of harm reduction for cigarette smokers to improve their quality of life had a positive statistical effect on smoking reduction. Harsh vaping bans by US local governments could have long term negative health effects, such as driving some adult vaping consumers back to cigarettes or the creation of black market nicotine products.
  • It is important to address the youth vaping problem with the vaping industry, and the black market cannabis product issue with the cannabis industry. While there is minor overlap, they should be handled as separate industries with separate leaders that deal with two different substances.
  • Although state-regulated cannabis agencies provide services to manage health risks and regulate products within their borders, a lack of federal policy actually stimulates the interstate black market, exposing the public to dangerous products from bad actors. The black market also threatens the reputation and economic growth of the legitimate cannabis market. The stark statistical difference of EVALI cases between US and Canada indicates that putting an appropriate federal policy in place can help to shield the public from these threats.
  • Harsh criminal bans of vaping or cannabis will result in deleterious effects to the economy and to public health. Increasing law enforcement spending to enforce criminal penalties will also result in increased spending for courts and prisons, with no supporting tax revenue. The black market will grow, exposing the public to stronger more dangerous products with no health standards to protect them.

Learning More

There are multiple resources to learn more about harm reduction principles and how they can be used to improve public health and quality of life.