“It’s fair to say that there were early warning signs that were missed,” said Stanton Glantz, a tobacco researcher at the Center for Tobacco Control Research and Education at the University of California, San Francisco. “These cases have been reported for several years but nobody put two and two together because they were too isolated.”
Back in 2011 a woman presented at Legacy Good Samaritan Medical Center in Portland, Oregon, with breathing problems, cough and fever, with hazy white patches covering a third of her lungs on chest scans, and white strange deposits clotted her lung’s immune cells. Pulmonologist concluded she had a form of pneumonia more commonly seen in those who have inhaled mineral oil such as fire breathers.
In 2014 a man from northwestern Spain presented at hospital with very similar symptoms, the doctors there blamed his condition on pneumonia and the incident was referenced in a presentation given at the nicotine conference that year, though never formally published.
In 2016 in Roanoke, Virginia doctors reported treating a man who used e-cigarettes who required mechanical ventilation due to his rapidly worsening breathing problems. This case was also presented at a medical meeting in that year and his condition was called vapor lung.
Jump to present day and officials are trying to understand the cause of 8 deaths and over 530 cases of acute lung injuries which are linked to vaping that have happened in 2019, most of which in more recent months. While there are many speculated causes officials have not been able to determine the exact cause of the outbreak or identify a single product or substance responsible for causing these injuries.
Juul Labs Inc recently announced its Chief Executive Officer Kevin Burns would be stepping down, and the company is effectively ending all marketing and lobbying of the current administration.
“We don’t know enough about the aerosol that vaping produces and its health effects,” said Anne Schuchat, principal deputy director of the U.S. Centers for Disease Control and Prevention, at a hearing before the House Committee on Oversight and Reform. “It may be that the process itself is risky.”
This new cluster of diseases highlights a debate over the advantages of e-cigarettes over regular cigarettes in days of the past, and it has complicated efforts to understand whether and how inhaling vapor could harm the lungs. As vaping became popular hints were missed by regulators and scientists that vaping may not be as benign as proponents hoped, they focussed on vaping reducing the exposure to cancer causing compounds in regular cigarettes, while key questions were largely sidestepped about whether these e-cigarettes posed new risks.
Researchers and doctors who tried to publish journal articles about their findings or publicize their patient’s illnesses were subject to attacks on social media, letters to editors, and smeared at conferences by vaping advocates and those with ties to the industry. Others stayed silent or said they weren’t sure where to report suspected vaping related illnesses given the green light of the industry deep pockets. Within the governments researchers clashed over the safety of these products which slowed down new regulations and opened the door for companies to expand their reach before a consensus could be reached.
“We’re conducting a big, uncontrolled and poorly documented set of chemistry experiments inside people’s lungs,” said Alan Louis Shihadeh, an aerosol scientist at American University of Beirut, part of the U.S.-government funded Center for the Study of Tobacco Products. “Researchers know very little about the safety of it.”
Doctors who treated some of the earlier cases suggest that it is possible that there were even more cases which were overlooked. In 2011 Danielle Hosmer, a pulmonologist and occupational medicine specialist who treated the patient in Portland questioned the patient for over a half hour about possible exposure including vaping, which at the time most doctors likely would not have thought to ask. “It would be completely easy to miss,” said Dr. Hosmer. “This has been going on for a longer period of time than people realize.” The case was published in a medical journal, but the authorities were not alerted.
Schuchat of the CDC told lawmakers that evidence suggests this disease started picking earlier this year. “It is less likely that large-scale we have been seeing this and missed it,” she said.
The number of reported cases is expected to rise sharply, as the health effects of inhaling the base components of vaping fluids propylene glycol and glycerin are not fully understood. They have been deemed safe to eat, but vaping delivers large doses over long periods of time of the compounds that have been heated at high temperatures; this changes their composition into something new, which is then delivered in ultrafine particles to the deepest parts of the lungs, without fully understanding the effects.
Still some with vested interests are sticking to their guns. “Science has demonstrated that vaping as a substitute for smoking saves lives, and is at least 95% safer than combustible cigarettes,” said Tony Abboud, executive director of the Vapor Technology Association. “That level of harm reduction potential should not be dismissed — especially when combustible cigarettes remain the No. 1 cause of preventable deaths in the U.S.”
Producers and manufacturers have discussed the potential of adverse health effects such as Riccardo Polosa a researcher and advocate who presented a study in 2014 at the Global Forum on Nicotine in Warsaw, Poland, titled “Harmful and potentially harmful constituents in e-Cigarettes.” The presentation contained a cache of records that were given to the FDA by Juul Labs and mentions a case of a man in the hospital for non-respiratory symptoms before the company began selling products in 2015, but Juul was not connected to the man’s condition. After a series of tests he was concluded to have lipoid pneumonia.
“Unfortunately we are re-writing history,” said Ana Souto Alonso, a doctor at the Complejo Hospitalario Universitario de A Coruña, where the patient was treated. “With tobacco it took many years to know the toxic effects. Now we’re learning with vaping — we don’t really know the effects on health.”
“There is no way vaping could put people at risk for lipoid pneumonia,” Polosa wrote in a March 2014 response to the Spanish case on a website called the “Ashtray Blog.” In an interview, Polosa said at the time that he was asked to review the clinical notes and concluded that his lung illness was linked not to vaping, but to a series of unrelated medical procedures.
In 2015, a researcher from the National Institute for Occupational Safety and Health sounding warnings to FDA officials that diacetyl and pentanedione commonly found in some e-cigarette flavorings had been found to be potentially harmful. “Safe enough to eat does not mean it is safe to breathe,” said the researcher, named Ann Hubbs, according to a copy of a presentation she gave at an FDA hearing on e-cigarette safety.
Hubbs warned, “…the inhalation toxicity of most flavorings is a major concern that has not been investigated. The base fluid ingredients may elicit pathophysiological and/or pathological changes in lung function…”
Cases of vaping related lung injuries continued, and in 2015 a woman presented with respiratory failure after using e-cigarettes at Birmingham Heartlands Hospital in England. Deposits in her lung immune cells were detected and she was concluded to have contracted lipoid pneumonia from vaping. Consulting pulmonologist Gareth Walters sent a letter to the manufacturer of the patient’s product to ask for a list of ingredients but got no response.
A fatal case of hemorrhage in air sacs in the lungs was attributed in vaping in 2016 by doctors at West Virginia University. That same year, one of the doctors who treated the Portland patient 5 years prior saw another case of pneumonia in which the patient spent prolonged time vaping in her room after fighting with a roommate.
In 2017, scientists who had been conducting animal experiments with vaping substances for months began to see troubling results. Telethon Kids Institute in Perth, Australia published a study showing that glycerin made animals airways hyper responsive, the vaping aerosols were concluded to cause “significant impairments in lung function.” This caused vaping proponents to attack the study saying there were various problems and raised questions about accuracy.
“Breathing anything into the lungs other than air is probably not going to be good in the long term,” said lead researcher Alexander Larcombe.
In 2016 Baylor College of Medicine tested the most popular mixture of glycerin and propylene glycol in mice for 4 months with and without nicotine using no flavorings; key immune cells in the animals appeared to become highly abnormal and jammed with fat in the same way Portland doctors had observed their patient.
“I won’t forget it,” says Farrah Kheradmand, a physician researcher at Baylor College of Medicine recalls. “In 15 years of doing this, I had never seen anything like this.”
In a published study Baylor researchers showed that the deposits were coming from inside of the lungs; vaping solvents are suspected to disrupt the ability of the cells to recycle lung surfactant, which is an oil protein substance required to keep air sacs open.
If vaping products had been a drug detailed human studies on their safety would have been required to be performed and validated before they were allowed to enter the market. Those studies are only beginning to be done now after the fact, including a 100 patient lung safety trial of e-cigarettes being conducted by Maciej Goniewicz, a pharmacologist at Roswell Park Comprehensive Cancer Center in Buffalo, New York.
