2019–2020 vaping lung illness outbreak

2019–2020 vaping lung illness outbreak
Some of the Illegal and unregulated (black market) cannabis vaping products were found to contain large amounts of vitamin E acetate, including Dank Vapes pictured here.[1]
Map of reported hospitalized cases or deaths in the US and US territories.[2]
DiseaseVaping-associated pulmonary injury
LocationUnited States
First outbreak2019 (2019)
First reportedApril 2019 (2019-04)
Confirmed cases2,711
Deaths
61

An outbreak of vaping-associated pulmonary injury (VAPI), dubbed e-cigarette, or vaping, product use-associated lung injury (EVALI) by the U.S Centers for Disease Control (CDC), started in 2019[3] among users of illegal, unregulated cannabis vaping products,[2] almost exclusively in the United States.[4] The first cases were identified in Illinois and Wisconsin in April 2019; as of 21 January 2020, a total of 2,711 hospitalized cases, including 60 deaths, have been confirmed. According to the CDC, "Vitamin E acetate is strongly linked to the EVALI outbreak...Evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases"..[2]

Cases peaked in September 2019, and have slowly declined since. The CDC stopped reporting on EVALI cases in February 2020 due to the decline in cases, but as of December 2020 continues to monitor cases that may arrive in emergency departments.[5]

CDC investigators identified direct exposure to chemicals present in illegal cannabis vaping products as responsible for the outbreak.[6] Vitamin E acetate is a very strong culprit of concern in the lung illnesses related to THC-based vaping products, but the CDC did not rule out other chemicals as possible causes. According to the CDC, "No specific e-cigarette device or substance has been linked to all cases, and e-cigarette include a variety of chemical and additives; consumers may not know what these products contain."[2] Though patients have reported using vaping products containing THC, nicotine, or both types, about 36% of patients studied by the CDC admitted THC use.[5][2] The majority of those affected were young adults 18–34, which is the group with the greatest prevalence of cannabis use in the U.S.[7]

Nicotine-containing products are regulated in the U.S. by the Food and Drug Administration (FDA); THC products are illegal under federal law, but allowed and regulated by some states. Prior to the outbreak, vitamin E acetate was used in low concentrations, lower than 20% of the formula in vape cartridges, as a thickening agent.[8] As a result of a limited availability of cannabis in California as well as high demand, illicit sellers had used about 50% or higher of diluent thickeners in their formulas to bulk up tiny potency vape cartridges to create the illegal and dangerous products,[8] and vitamin E acetate is a common choice because it resembles THC oil.[2] Some jurisdictions took action to restrict the sale of products containing vitamin E acetate and other chemicals in response to the outbreak, but THC products in states where it is illegal are produced illegally (and sometimes obtained illegally in jurisdictions where legal, by uninformed consumers).

Public health recommendations

The CDC recommends that the public should consider not using any vaping products during their investigation, particularly those containing THC from informal sources like friends, or family, or in-person or online dealers as of 20 November 2019.[2] The U.S. FDA considers it prudent to avoid inhaling vitamin E acetate.[9] On 6 September 2019, the U.S. FDA stated that because consumers cannot be sure whether any THC vaping products may contain vitamin E acetate, consumers are urged to avoid buying vaping products on the street, and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.[9] The CDC recommends that e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant.[2] Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products, according to the CDC.[2]

Background

Though this is the first time that vaping products have been linked to an outbreak of lung illness,[10] at least 19 cases of vaping-associated pulmonary injuries had been reported worldwide prior to 2019.[11] The first case of e-cigarettes inducing lipoid pneumonia was documented in the medical literature in 2012,[12] though the causative agent was identified as glycerin, not vitamin E acetate. Glycerin was long thought to be a safe additive in e-cig liquid. However, the carcinogen formaldehyde is known as a product of propylene glycol and glycerol vapor degradation,[13] these ingredients may also cause lung inflammation.[14]

Lipoid pneumonia is known for its lung inflammation towards a period of time with exogenous and endogenous factors that cause this disease.[15]

United States

Cases involved in the outbreak of severe vaping-associated pulmonary injury associated with vaping products were first identified in Illinois and Wisconsin in April 2019.[3] As of 21 January 2020, a total of 2,711 hospitalized cases of lung illness associated with the use of vaping products have been reported to the Centers for Disease Control and Prevention (CDC) from 50 states, the District of Columbia, and two US territories (Puerto Rico and US Virgin Islands).[2] The potential cases of severe lung illness have been associated with the use of vaping products such as devices, liquids, refill pods, and cartridges.[16] On 12 September 2019 the CDC no longer reported possible cases.[17] The CDC changed its reporting methodology from counting possible cases to reporting probable and confirmed cases where patients recently vaped, developed a breathing illness, and either had some tests were performed to rule out infection or testing did not show an infection.[17] The CDC stated the possible cases are still under investigation at the state level.[17] As of 3 December 2019, the CDC is only reporting hospitalized vaping-associated lung illness cases and vaping-associated lung illness deaths regardless of hospitalization status.[2] As of 15 October 2019, the CDC has reported on 1,358 people with data on age and gender: 70% of people are male.[2] The median age of persons is 24 years and ages range from 13 to 75 years.[2] 79% of persons are under 35 years old.[2] Prevalence of lung disease attributable to vaping is likely under reported as cases brought to the CDC are some of the most severe.[18]

Symptoms typically develop over a period of days but sometimes can manifest over several weeks.[19] Many cases, patients reported a gradual start of symptoms, including: breathing difficulty, shortness of breath, and/or chest pain before hospitalization.[20] Based on reports from several states, patients have experienced respiratory symptoms (cough, shortness of breath, or chest pain), and some have also experienced gastrointestinal symptoms (nausea, vomiting, or diarrhea) or non-specific symptoms (fatigue, fever, or weight loss).[2] Some cases reported mild to moderate gastrointestinal illness.[20] Some patients have reported that their symptoms developed over a few days, while others have reported that their symptoms developed over several weeks.[2] Some patients have reported gastrointestinal symptoms began before respiratory symptoms.[2] Fever, elevated heart rate, and elevated white blood cell count have been reported, even though no infectious disease has been identified.[2] Many patients sought medical care in ambulatory settings, sometimes over several visits, before they were admitted to the hospital.[2]

Percentage of persons needing intubation and hospitalization among persons with vaping-associated lung injury.
Percentage of persons needing intubation and hospitalization among persons with vaping-associated lung injury.[21]

Many patients have required medical treatment with supplemental oxygen.[2] Some required assisted ventilation.[2] Some patients have been treated with corticosteroids with demonstrated improvement.[2] Evidence does not suggest an infectious disease is the cause of the severe pulmonary disease.[2] Antibiotic therapy alone has not consistently been associated with clinical improvement.[2] A handful of individuals have been re-admitted for clinical care after discharge for lung injury.[22] The CDC does not know whether individuals who were re-admitted continued or restarted use.[22] The range of time that the CDC is aware of for these re-admissions ranges from approximately five days after discharge to 55 days after discharge.[22]

As of 5 September 2019, the New York State Department of Health reported 34 cases of severe lung illness in patients who were reportedly using different vaping products.[1] Tests conducted by the Wadsworth Center found exceedingly high amounts of vitamin E acetate in most of the cannabis e-cigarette products.[1] "At least one vape product containing vitamin E acetate has been linked to each patient who submitted a product for testing," the New York State Department of Health stated.[23] None of the nicotine-based product samples contained vitamin E acetate.[1] According to the reports from Illinois and Wisconsin, the onset of respiratory findings appeared to have occurred over several days to several weeks before hospitalization.[16] As of 5 September 2019, the Illinois Department of Public Health reported 42 cases of lung illness, seven that were still being investigated, and one death.[24] Severe lung illness among young adults and youth who used vaping products required hospitalization in 11 cases in Wisconsin and others were being investigated in August 2019.[25] Symptoms were difficulty breathing, tiredness, chest pain, cough, and reduced weight.[25] Some required help to breathe.[25]

On 9 August 2019, the California Department of Public Health issued a statement regarding a cluster of seven healthy adults in Kings County, California, all of whom required hospitalization.[26] Since June 2019, at least seven cases of severe acute pulmonary illness in previously healthy adults were reported from a hospital in Kings County, California.[26] Cases were among residents of multiple counties.[26] The patients presented with progressive respiratory distress, sometimes initially diagnosed with pneumonia or bronchitis, and some with preceding fevers and gastrointestinal symptoms.[26] All cases failed to respond to an initial course of antibiotic treatment.[26] All patients required admission to the hospital with significant respiratory support, including high-flow oxygen, bilevel positive airway pressure (BIPAP), or intubation with mechanical ventilation.[26] Diagnoses included pneumonitis and acute respiratory distress syndrome (ARDS).[26] Several cases of vaping-associated pulmonary injury (VAPI) and acute respiratory distress syndrome (ARDS) in California were connected to vaping cannabis products that were traced back to pop-up retailers.[27] Patients have improved with systemic steroids.[26] Evaluation for infectious etiologies has been negative to date in all patients.[26] All patients reported vaping in the weeks prior to hospital admission, and a reported common exposure among these patients is that they have been vaping cannabis or CBD oils.[26]

Deaths

A total of 60 deaths linked to vaping products have been confirmed among 27 states and the District of Columbia: Alabama, California (4), Connecticut, Delaware, District of Columbia, Florida, Georgia (3), Illinois (5), Indiana (4), Kansas (2), Louisiana, Massachusetts (3), Michigan, Minnesota (3), Mississippi, Missouri (2), Montana, Nebraska, New Jersey, New York (2), Oregon (2), Pennsylvania, Rhode Island, South Carolina, Tennessee (2), Texas, Utah, and Virginia.
A total of 60 deaths linked to vaping products have been confirmed as of January 21, 2020 among 27 states and the District of Columbia.[2]
  At least one death linked to a vaping product.
  At least two deaths linked to a vaping product.
  At least three deaths linked to a vaping product.
  At least four deaths linked to a vaping product.
  At least five deaths linked to a vaping product.
  Hospitalizations but no confirmed deaths.

As of 21 January 2020, a total of 60 deaths linked to illegal (Black market) cannabis vaping products have been confirmed in 27 states and the District of Columbia: Alabama, California (4), Connecticut, Delaware, District of Columbia, Florida, Georgia (3), Illinois (5), Indiana (4), Kansas (2), Louisiana, Massachusetts (3), Michigan, Minnesota (3), Mississippi, Missouri (2), Montana, Nebraska, New Jersey, New York (2), Oregon (2), Pennsylvania, Rhode Island, South Carolina, Tennessee (2), Texas, Utah, and Virginia.[2] The median age of deceased persons was 51 years and ranged from 15 to 75 years, as of 14 January 2020.[2]

Canada

On 18 September 2019, a case of severe lung illness associated with vaping in Canada was reported.[28] A high school student in Ontario needed to be put on life support.[28] The person had been vaping every day.[29] His health improved and he was sent home.[28] This case has not been confirmed, as 27 September 2019.[30] He vaped intensively, adding THC to his devices.[18] He initially showed symptoms aligning with bronchiolitis (lung condition normally caused by a bacterial or viral infection), but many patients that have vape-related illnesses in the United States have experienced damage to the alveoli; this type of injury was not found.[18] Instead, his case aligned more with an injury called popcorn lung, an ailment most commonly seen in factory workers of microwave popcorn plants nearly 20 years ago.[18]

On 27 September 2019, it was announced the first confirmed case of a vaping-related lung illness in Canada.[30] A Montreal resident in Quebec in their 50s was admitted to a hospital with breathing difficulties.[30] The person had been vaping to help them give up smoking.[30] Chief Public Health Officer of Canada announced on 11 October 2019 that they are aware of the initial cases of vaping-associated lung illness and they stated that a few other occurrences are being investigated.[31] Three probable cases have been reported in British Columbia as of 7 November 2019[32] and other cases are under investigation in British Columbia.[33] Two probable cases have been reported in New Brunswick as of 16 October 2019.[34]

A case in Newfoundland and Labrador was reported as a probable case of a lung illness tied to vaping in January 2020.[35] A person became sick in late 2019 following the use of a cannabis product.[35] The person has since been released from the hospital.[35] As of 4 February 2020, 17 cases of lung injuries have been reported to the Public Health Agency of Canada.[36] Reported cases were from Alberta (1), British Columbia (3), New Brunswick (2), Newfoundland and Labrador (1), Ontario (4), and Quebec (6).[36] 14 people needed to be hospitalized.[36]

Other countries

What has occurred in the US has not occurred in other places where vaping is frequent such as the UK.[4] In European countries such as France, there is no evidence of an outbreak of the vaping-associated lung illness that occurred in the US.[37]

Investigation

US FDA's Forensic Chemistry Center.
US FDA's Forensic Chemistry Center.[39]

Investigators from multiple states in the US are collaborating with the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration (US FDA) to determine the cause of the lung illnesses associated with the use of vaping products.[40]

On 6 September 2019, Dr. Dana Meaney-Delman, serving as the incident manager of CDC's response to this outbreak, said that "Based on the clinical and laboratory evidence to date, we believe that a chemical exposure is likely associated with these illnesses. However, and I really want to stress this, more information is needed to determine which specific products or substances are involved. We are aware that some laboratories have identified vitamin E acetate in product samples, and we have connected those laboratories with the FDA Forensic laboratories to compare results. At this time, no one device, product, or substance has been linked to all cases. Continued investigation is needed to better understand if a true relationship exists between any specific product or substance and the illnesses observed in patients. To find the answer we will need to combine information about e-cigarette use, and product sample testing and the clinical information from patients."[6]

Patients have acknowledged recent use of tetrahydrocannabinol (THC)-containing e-cigarette products while speaking to healthcare personnel, or in follow-up interviews by health department staff.[20] On 6 September 2019, The New England Journal of Medicine reported that "Information on product use is based on reports by the patients, and patients may be reluctant to report illicit drug use."[3] On 2 October 2019, The New England Journal of Medicine reported that the histologic evidence suggests that the "vaping-associated lung injury represents a form of airway-centered chemical pneumonitis from one or more inhaled toxic substances rather than exogenous lipoid pneumonia as such, but the agents responsible remain unknown."[41] They also stated that this "finding should be interpreted with caution."[41] On 17 October 2019, the American Journal of Clinical Pathology reported that lung biopsies from eight patients with vaping-associated lung injury show acute lung injury patterns, not exogenous lipoid pneumonia.[42]

Of the 2,506 reported cases, information is available in the three months prior to symptom onset for 1,782 of them as of 3 December 2019.[2] 80% reported THC use, 35% reported exclusive THC use, about 54% reported using nicotine-containing products, and 13% reported exclusive use of nicotine-containing products.[2] The CDC reported that their findings suggest vaping products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak.[2]

On 8 November 2019, Dr. Anne Schuchat, principal deputy director of the CDC, said, "for the first time we have detected a potential toxin of concern — Vitamin E acetate — in biologic samples from patients with lung injuries associated with the use of e-cigarette or vaping products."[43] The sample types were bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs).[2] The chemical was found in samples collected from ten different states from the lungs of 29 patients with the disease.[43] "These findings provide direct evidence of Vitamin E acetate at the primary site of injury within the lungs," said Dr. Schuchat.[43] The CDC tested for a wide range of substances that might be found in e-cigarette or vaping products including plant oil, petroleum distillates like mineral oil, medium-chain triglyceride oils – or MCT oils – and terpenes which are compounds found in or added to THC products. No other potential toxicants were detected in the testing conducted so far.[43] The CDC did not rule out other possible compounds or ingredients that may be causing the lung injuries.[43] No one compound or ingredient has emerged as the cause of these illnesses so far; and it may be that there is more than one cause of this outbreak.[2]

Many of the samples tested by the states or by the US FDA as part of the 2019 investigation have been identified as vaping products containing tetrahydrocannabinol (or THC, a psychoactive component of the cannabis plant) and further, most of those samples with THC tested also contained significant amounts of vitamin E acetate.[9] Vitamin E acetate is a substance present in topical consumer products or dietary supplements, but data is limited about its effects after inhalation.[9] While the US FDA does not have enough data presently to conclude that vitamin E acetate is the cause of the lung injury in these cases, the agency believes it is prudent to avoid inhaling this substance.[9] The US FDA's Forensic Chemistry Center serves as the FDA's national laboratory and is playing a critical role in fact-gathering and analysis for the incidents of lung illnesses following vaping product use.[39]

Illicit vaping

Some of the vaping products that contained exceedingly high amounts of vitamin E acetate, including those pictured here.
Some of the vaping products analyzed by the Wadsworth Center contained exceedingly high amounts of vitamin E acetate, including those pictured here.[1]
Frequently reported brand names of THC and nicotine-containing e-cigarette or vaping products reported by patients with lung injury — Illinois and Wisconsin, 2019.
Frequently reported brand names of THC and nicotine-containing e-cigarette or vaping products reported by patients with lung injury — Illinois and Wisconsin, 2019.[44]

What people are inhaling is causing the lung illnesses.[45] The lung illnesses are likely to be caused by a chemical exposure.[23] Counterfeit cannabis cartridges are being sold to users at a reduced cost.[46] Dank Vapes is an illicit brand that uses a cartridge.[47] There is no singular company that owns Dank Vapes.[48] There have been hundreds of people selling Dank Vapes cartridges.[48] Dank Vapes appears to be the most prominent in a class of largely counterfeit brands, with common packaging that is easily available online and that is used by distributors to market THC-containing cartridges with no obvious centralized production or distribution.[44] Some of the vaping products that contained exceedingly high amounts of vitamin E acetate include Chronic Carts and Dank Vapes.[1] Illicit vape brands have been sold across multiple states in the US.[49] As of 27 August 2019, the most frequently used product reported by patients experiencing respiratory, gastrointestinal, and/or constitutional symptoms in Illinois and Wisconsin was the THC product called Dank Vapes.[3] Dank Vapes was the most commonly reported product brand used by patients nationwide, although there are regional differences.[2] While Dank Vapes was most commonly reported in the Northeast and South, TKO and Smart Cart brands were more commonly reported by patients in the West and Rove was more common in the Midwest.[2] The composition of THC based oils is to a large extent not known.[3]

Public health recommendations

The CDC recommends that the public should consider not using any vaping products during their investigation, particularly those containing THC from informal sources like friends, or family, or in-person or online dealers as of 20 November 2019.[2] The US FDA considers it prudent to avoid inhaling vitamin E acetate.[9] On 6 September 2019, the US FDA stated that because consumers cannot be sure whether any THC vaping products may contain vitamin E acetate, consumers are urged to avoid buying vaping products on the street, and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.[9] The CDC recommends that e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant.[2] Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products, according to the CDC.[2]

Various diluent thickening products were sold online via wholesale suppliers.[50] There has been an increase in attention to companies that sell diluent products that are made with vitamin E acetate.[8] A lot of speculation has focused on Honey Cut.[51] Honey Cut, used as a diluent thickener, became wildy used in Los Angeles' vape pen manufacturing plants in late 2018.[47] After Honey Cut became widely used in THC vape cartridges many other similar products from other companies were introduced into the market in early 2019.[52] The maker of Honey Cut's product is not known, and the only way to purchase the product was from the company's website.[53] In early September 2019, the Honey Cut website went offline[8] and Honey Cut told sellers in the Toy District, Los Angeles area to discontinue offering its products for sale.[54] Counterfeit products from China that look like Honey Cut products were being sold, which increased the confusion in regard to which products people may have been vaping.[55]

The company Floraplex in Michigan has shutdown the buyers page for their Uber Thick brand.[53] The diluent products called Clear Cut were sold by Connoisseur Concentrates from Tigard, Oregon.[50] Clear Cut is no longer available from the company's website.[50] The company acknowledged the products contained vitamin E acetate.[50] The company stated that it began selling the products in May 2019 and was reviewed by the Oregon Liquor Control Commission.[50] As of 10 September 2019, Mass Terpenes' Pure Thickener diluent is no longer available on its website.[8] A cache of the product on its website stated, "a proprietary formula composed simply of flavorless terpenes and a derivative of Vitamin E (to preserve color and consistency)."[8] Aaron Riley, CEO of CannaSafe, stated that likely about 75-80% of illicit vapes use some type of diluent agent.[8] Drew Jones of Mr Extractor stated in September 2019 that as high as 70% of illicit cannabis vape cartridges in the US contain vitamin E acetate.[56] It is estimated that at least 40 companies in the US sold a cutting agent containing vitamin E acetate.[52] Thickening agents have been sold online as a less costly and safer substitute.[57]

Thickening agents were used to water down and bulk up vape oils.[8] Thickening agents were used mostly in THC vape products.[8] Vitamin E acetate was used to cut THC oil to dilute it.[58] Vitamin E acetate dilutes vape oil without making it look like the oil was watered down.[59] Previously, vitamin E was used in low concentrations, or lower than 20% of the formula in vape cartridges.[8] As a result of a limited availability of cannabis in California as well as high demand, illicit sellers had used about 50% or higher of diluent thickeners in their formulas to bulk up tiny potency vape cartridges.[8] Thomas Whitten, a consultant at WeedRAR, said to Rolling Stone that "there's so much cutting agent even the people who made the cutting agent didn't expect it to be cut that much."[8] Some cannabis laboratories began making arrangements in September 2019 to provide testing services for vitamin E.[60]

Regulations in legal markets for cannabis use allow the use of many additives such as tocopherols (various forms of vitamin E).[52] However, regulators may be considering banning such substances in the near future, as of September 2019.[52] As of December 2019, Washington state has now banned vape products containing vitamin E acetate, thought to be linked to illness.[18] Although the substance is not banned in the United States and has not been officially declared as a deadly substance, many states are making advances to ban the use of the chemical in vape products.[18] States like Massachusetts are considering a ban on flavored tobacco and vape products, and in New York, Manhattan is expected to become the largest city to ban all vaping flavors except tobacco.[18] Other states that have already banned the use of vitamin E acetate in vape products include Colorado and Ohio.[18]

Subpoenas

In September 2019, New York Governor Andrew Cuomo instructed the state health department to issue subpoenas against three sellers of thickening agents used in illicit vaping products.[61] The subpoenas are being served against Honey Cut Labs in Santa Monica, California, for its Honey Cut product; Floraplex Terpenes in Ypsilanti, Michigan, for its Uber Thick product; and Mass Terpenes in Amherst, Massachusetts, for its product.[62] All three firms sell a product used as a thickener in vape liquids.[63] The thickeners from all three firms were found to contain mostly vitamin E acetate, according to test results from the Wadsworth Center.[57]

Criminal cases

On 5 September 2019, Tyler Huffhines and Jacob Huffhines were arrested.[64] Search warrants were served on a house at their place of residence and at a leased condominium.[64] In September 2019, an investigation in Kenosha County, Wisconsin, is underway to determine whether a major operation ran by the Huffhines brothers for purportedly making illicit THC vape cartridges, which were packed in containers to resemble candy and were thought to have been marketed to youth, could be related to a series of vaping-induced lung illness and deaths in the US.[64] The purportedly candy-themed containers used names such as Sour Patch.[65] In January 2018, Tyler Huffhines purportedly began the operation.[65] The vape cartridges purportedly contained as high as 1,000 milligrams of THC,[65] when the packaging stated it was just 5 milligrams.[66] Roughly $1.5 million worth of THC products were seized during the raid.[67] 57 mason jars containing THC oil were also seized during the raid.[68] Each jar was worth about $6,000.[68]

An initial appearance in Kenosha County court was held for both brothers on 16 September 2019.[69] Tyler Huffhines is facing multiple drug-related charges including possession with intent to deliver THC.[69] Jacob Huffhines is facing charges including being a felon in possession of a firearm and possession of THC.[69] Bond for Tyler Huffhines was set $500,000.[69] Bond for Jacob Huffhines was set at $50,000.[69] Both are scheduled to return to court on 26 September 2019.[69] The Huffhines brothers pleaded not guilty on 23 October 2019.[70]

Courtney Huffhines, the mother of Jacob and Tyler Huffhines, was charged with assisting her sons run the illegal THC vape operation.[71] A woman was arrested in connection with the THC vape operation.[71] On 3 October 2019, Hannah Curty was charged with making THC, as a party to an offense against the law.[72] She is scheduled to return to court on 11 October 2019.[72] Courtney Huffhines and Hannah Curty were in court on 11 October 2019.[73] Both women are due to return to court on 23 October 2019.[73] Courtney Huffhines and Hannah Curty pleaded not guilty on 23 October 2019.[70]

On 17 October 2019, 22-year-old Jordan Lynam was charged with making THC vape cartridges in relation to the Huffhines's purportedly illicit vaping operation.[74]

Daniel Graumenz, Wesley Webb, and Tarail King are facing charges in relation to the illicit vaping operation.[75]

Civil lawsuits

On 23 September 2019, a product liability lawsuit, Charles Wilcoxson v. Canna Brand Solutions LLC et al., was filed in Superior Court of Pierce County, Washington, against makers of THC vape cartridges.[76] Wilcoxson, a peace officer, had used THC vape products between January 2018 and September 2019.[76] He bought cannabis products that included Conscious Cannabis, Rainbows Aloft, Leafwerx, MFused, and Jane's Garden, and a Canna Brand Solutions vaporizer, all of which were cited as defendants.[76] The plaintiff was hospitalized for three days in September 2019 with wheezing and lipoid pneumonia as a result of his vaping, according to the complaint.[76]

In September 2019, 35-year-old Erin Gilbert from Virgin Islands filed a lawsuit against Just CBD in a Broward County, Florida court, contending that her sickness was the result of a CBD vape oil containing mango flavor that she had purchased from a merchant in Saint Croix.[77] After just a few days of using the vape oil, she had severe respiratory problems, multiple organ failure, and deficient supply of oxygen, resulting in necrosis of her legs, both of which had to be amputated.[77]

In May 2019, a 21-year-old was hospitalized for more than two weeks due to fluid in his lungs and was in a medically induced coma for 8 days.[78] He had purportedly developed an addiction to Juul mint pods, which he had been using since age 19.[79] In October, the patient sued Juul, complaining the company did not disclose the dangers of its pod system and deceptively advertised its products as being safer than combustible cigarettes.[78] The suite also claimed Juul advertised its products to intentionally entice underage individuals and young adults as well as people who are never frequent smokers.[78]

In September 2019, a lawsuit was brought on behalf of an 18-year-old from Illinois who had been hospitalized with lung damage from vaping. The sued charged Juul with targeting teens with false marketing of a dangerous product, and a gas station for allowing him to buy vaping products as a minor.[80]

On 29 October 2019, the Los Angeles Unified School District, the second largest district in the nation filed a class action suit against Juul for creating an epidemic of youth vaping that impedes student learning and risking the health and safety of more than 600,000 students in the Los Angeles School District.[81] As of January 2020, a total of 10 California school districts have filed a lawsuit against Juul Labs, Inc. The suit seeks injunctive relief and abatement remedy to fight against the vaping epidemic in the California school districts.[82]

Responses

E-cigarette industry

The e-cigarette industry is placing the blame on illicit vaping liquids for the lung injuries.[83] "Each day of this crisis brings more evidence that street vapes containing THC or other illegal drugs are responsible for these illnesses, not nicotine vaping products," said Gregory Conley of the American Vaping Association, in August 2019.[83] "Like any health-related events reportedly associated with the use of vapor products, we are monitoring these reports," Juul Labs stated to Reuters in August 2019.[84] The company also stated that some news reports state that several cases of lung illness are associated with vaping THC, found in cannabis, "a Schedule 1, controlled substance that we do not sell."[84]

United States

The CDC recommends that people should not use e-cigarette, or vaping, products that contain THC, particularly from informal sources like friends, or family, or in-person or online dealers.[2] Until the relationship of vitamin E acetate and lung health is better understood, vitamin E acetate should not be added to e-cigarette, or vaping, products.[2] In addition, people should not add any substance to e-cigarette or vaping products that are not intended by the manufacturer, including products purchased through retail establishments.[2] CDC also recommends that people should not modify or add any substances such as vitamin E acetate to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments.[2] According to the CDC, if you are an adult using e-cigarettes, or vaping, products, to quit smoking, do not return to smoking cigarettes.[2] Adults addicted to nicotine using e-cigarettes should weigh all risks and benefits, and consider utilizing FDA-approved nicotine replacement therapies.[2]

The US FDA considers it prudent to avoid inhaling vitamin E acetate.[9] On 6 September 2019, the US FDA stated that because consumers cannot be sure whether any THC vaping products may contain vitamin E acetate, consumers are urged to avoid buying vaping products on the street, and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.[9] On 4 October 2019, the US FDA strengthened its warning to consumers to stop using vaping products containing THC amid more than 1,000 reports of lung injuries—including some resulting in deaths—following the use of vaping products.[85]

"The legal vapes have been actively regulated by FDA since Aug 2017. FDA has conducted thousands of inspections of manufacturers and vape stores, published manufacturing guidance, sought product removals etc. These tragedies point to illegal vapes and THC," former FDA Commissioner Scott Gottlieb tweeted in August 2019.[86] During an interviewed on CNBC's Squawk Box on 9 September 2019, Gottlieb said that "the current belief is the illnesses are linked to illegal vapes containing vitamin E oil."[87] He also stated that cannabis products in the US should be regulated.[87]

"The e-cigarette-related lung illnesses currently sweeping across the country reaffirm our belief that the use of e-cigarettes and vaping is an urgent public health epidemic that must be addressed. We must not stand by while e-cigarettes continue to go unregulated. We urge the U.S. Food and Drug Administration (FDA) to speed up the regulation of e-cigarettes and remove all unregulated products from the market. We also call on the FDA to immediately ban flavors, as well as marketing practices, that enhance the appeal of e-cigarette products to youth," Patrice A. Harris, the president of the American Medical Association, stated on 9 September 2019.[88] On 19 November 2019, the American Medical Association urged for a complete ban on all types of vaping products that are not approved by the US FDA as quitting smoking aids.[89]

Various states have banned vitamin E acetate in vaping products, including Colorado, Ohio,[90] and Washington.[91]

The governor of Massachusetts declared a public health emergency on 24 September 2019, and ordered a 4-month moratorium on the sale of all vaping products, both for nicotine and THC.[92] After courts determined it had sole jurisdiction over THC products, the Massachusetts Cannabis Control Commission quarantine all THC vape products until they could be screened for vitamin E acetate and other chemicals.[93][94] A Massachusetts testing lab offering tests to consumers found vitamin E acetate was widespread in unlicensed products but not in licensed products.[95] The nicotine vaping ban was also challenged and ended early, but prompted the state legislature to ban flavored nicotine products to reduce underage vaping, among other new measures.[96]

The federal government has been criticized for instituting bans on flavored products rather than passing caps on nicotine concentrations and establishing accountability measures for negligent marketing.[97]

Canada

Health Canada, the responsible government agency, responded to the US cases of potentially deadly lung illness by issuing a warning on 4 September 2019.[98] They advise that Canadians consider not using vaping products, monitor for symptoms, get a medical attention quickly if they have concerns, tell their doctor if and what they vape or have vaped, avoid the illegal and unregulated markets, avoid modifying vaping products, report adverse reactions, and monitor their advisory for updates.[98] They also stated for those who are vaping to watch for symptoms such as cough, shortness of breath, or chest pain.[98] On 11 October 2019, Chief Public Health Officer of Canada recommended to Canadians to consider holding back from vaping.[31] Health Canada started a $766,000 advertisement campaign to curb underage vaping in part in response to the US and Canadian outbreak.[99]

Europe

"What little we know of recent reports from the U.S. is that the devices used appear to be linked to 'home brews' of illicit drugs and not legitimate vaping products," Martin Dockrell, overseer of tobacco control at Public Health England, stated in September 2019.[37]

Australia

As a result of a potential link between vaping and lung illness in the US, the Australian Medical Association stated on September 18, 2019, that they reiterate a precautionary approach for the use of vaping products.[100]

India

Following a string of deaths tied to vaping in the US, India has banned the sales of vaping products in September 2019.[101]

World Health Organization

Dr. Vinayak Prasad, overseer of tobacco control at World Health Organization, told CNN on September 12, 2019, that WHO was observing the events in the US and abroad and will provide information to governments at the appropriate time.[102] Prasad also stated that its member states have not made any announcements of lung illnesses that resemble those that were observed in the US.[102]

Hospitalized patients

News media featured hospitalized lung vaping illness patients in narratives including the following:

See also

Notes

    References

    1. 1 2 3 4 5 6 "New York State Department of Health Announces Update on Investigation into Vaping-Associated Pulmonary Illnesses". New York State Department of Health. 5 September 2019.
    2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 "Outbreak of Lung Injury Associated with (black market) E-Cigarette Use, or Vaping". Centers for Disease Control and Prevention. 28 January 2020.Public Domain This article incorporates text from this source, which is in the public domain.
    3. 1 2 3 4 5 Layden, Jennifer E.; Ghinai, Isaac; Pray, Ian; et al. (2019). "Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report". New England Journal of Medicine. 382 (10): 903–916. doi:10.1056/NEJMoa1911614. ISSN 0028-4793. PMID 31491072.
    4. 1 2 Kelland, Kate (14 October 2019). "Vaping illness, deaths likely very rare beyond U.S., experts say". Reuters.
    5. 1 2 "New CDC Report Provides First Analysis of Lung Injury Deaths Associated with Use of illegal (Black market) cannabis E-cigarette, or Vaping, Products | CDC Online Newsroom | CDC". www.cdc.gov. 28 October 2019. Retrieved 19 June 2020.
    6. 1 2 "Transcript of September 6, 2019, Telebriefing: Investigation of Pulmonary Disease Among People Who Use E-cigarettes". Centers for Disease Control and Prevention. 6 September 2019.Public Domain This article incorporates text from this source, which is in the public domain.
    7. ↑ King, Brian A.; Jones, Christopher M.; Baldwin, Grant T.; Briss, Peter A. (2020). "The EVALI and Vaping Epidemics — Implications for Public Health". New England Journal of Medicine. 382 (8): 689–691. doi:10.1056/NEJMp1916171. ISSN 0028-4793. PMC 7122126. PMID 31951683.
    8. 1 2 3 4 5 6 7 8 9 10 11 12 Dickson, EJ (10 September 2019). "Three Companies Subpoenaed in Weed Vape Illness Investigation". Rolling Stone.
    9. 1 2 3 4 5 6 7 8 9 "Tetrahydrocannabinol (THC)-containing Vaping Products: Vaping Illnesses". United States Food and Drug Administration. 6 September 2019.Public Domain This article incorporates text from this source, which is in the public domain.
    10. ↑ Hammond, David (2019). "Outbreak of pulmonary diseases linked to vaping". BMJ. 366: l5445. doi:10.1136/bmj.l5445. ISSN 0959-8138. PMID 31506254. S2CID 202553770.
    11. ↑ Langreth, Robert; Etter, Lauren (30 September 2019). "How Early Signs of Lung Effects of Vaping Were Missed and Downplayed". Insurance Journal.
    12. ↑ Eissenberg, Thomas (5 September 2019). "Vaping is risky. Do not do it if you care about your lungs". The Guardian.
    13. ↑ Lestari, Kusuma S.; Humairo, Mika Vernicia; Agustina, Ukik (11 July 2018). "Formaldehyde Vapor Concentration in Electronic Cigarettes and Health Complaints of Electronic Cigarettes Smokers in Indonesia". Journal of Environmental and Public Health. 2018: 9013430. doi:10.1155/2018/9013430. ISSN 1687-9805. PMC 6076960. PMID 30105059.
    14. ↑ "Vaping propylene glycol and vegetable glycerine may lead to lung inflammation". News-Medical.net. 18 October 2019.
    15. ↑ "Lipid pneumonia", Wikipedia, 2 August 2021, retrieved 28 October 2021
    16. 1 2 Schier, Joshua G.; Meiman, Jonathan G.; Layden, Jennifer; Mikosz, Christina A.; VanFrank, Brenna; King, Brian A; Salvatore, Phillip P.; Weissman, David N.; Thomas, Jerry; Melstrom, Paul C.; Baldwin, Grant T.; Parker, Erin M.; Courtney-Long, Elizabeth A.; Krishnasamy, Vikram P.; Pickens, Cassandra M.; Evans, Mary E.; Tsay, Sharon V.; Powell, Krista M.; Kiernan, Emily A.; Marynak, Kristy L.; Adjemian, Jennifer; Holton, Kelly; Armour, Brian S.; England, Lucinda J.; Briss, Peter A.; Houry, Debra; Hacker, Karen A.; Reagan-Steiner, Sarah; Zaki, Sherif; Meaney-Delman, Dana; et al. (CDC 2019 Lung Injury Response Group) (2019). "Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance". MMWR. Morbidity and Mortality Weekly Report. 68 (36): 787–790. doi:10.15585/mmwr.mm6836e2. ISSN 0149-2195. PMC 6755818. PMID 31513561.Public Domain This article incorporates text from this source, which is in the public domain.
    17. 1 2 3 "CDC, states update number of cases of lung disease associated with e-cigarette use, or vaping" (Press release). Centers for Disease Control and Prevention. 12 September 2019.Public Domain This article incorporates text from this source, which is in the public domain.
    18. 1 2 3 4 5 6 7 8 Boudi, F Brian; Patel, Sonia; Boudi, Ava; Chan, Connie (2019). "Vitamin E Acetate as a Plausible Cause of Acute Vaping-related Illness". Cureus. 11 (12): e6350. doi:10.7759/cureus.6350. ISSN 2168-8184. PMC 6952050. PMID 31938636. This article incorporates text by F Brian Boudi, Sonia Patel, Ava Boudi, Connie Chan available under the CC BY 3.0 license.
    19. ↑ "Severe Pulmonary Disease Associated with Using E-Cigarette Products". Centers for Disease Control and Prevention. 30 August 2019.Public Domain This article incorporates text from this source, which is in the public domain.
    20. 1 2 3 "E-Cigarette Products: Safety Communication - Due to the Incidents of Severe Respiratory Disease Associated with Use of an E-Cigarette Product". United States Food and Drug Administration. 30 August 2019.Public Domain This article incorporates text from this source, which is in the public domain.
    21. ↑ Siegel, David A.; Jatlaoui, Tara C.; Koumans, Emily H.; Kiernan, Emily A.; Layer, Mark; Cates, Jordan E.; Kimball, Anne; Weissman, David N.; Petersen, Emily E.; Reagan-Steiner, Sarah; Godfred-Cato, Shana; Moulia, Danielle; Moritz, Erin; Lehnert, Jonathan D.; Mitchko, Jane; London, Joel; Zaki, Sherif R.; King, Brian A.; Jones, Christopher M.; Patel, Anita; Delman, Dana Meaney; Koppaka, Ram; Griffiths, Anne; Esper, Annette; Calfee, Carolyn S.; Hayes, Don; Rao, Devika R.; Harris, Dixie; Smith, Lincoln S.; Aberegg, Scott; Callahan, Sean J.; Njai, Rashid; Adjemian, Jennifer; Garcia, Macarena; Hartnett, Kathleen; Marshall, Kristen; Powell, Aaron Kite; Adebayo, Adebola; Amin, Minal; Banks, Michelle; Cates, Jordan; Al-Shawaf, Maeh; Boyle-Estheimer, Lauren; Briss, Peter; Chandra, Gyan; Chang, Karen; Chevinsky, Jennifer; Chiang, Katelyn; Cho, Pyone; DeSisto, Carla Lucia; Duca, Lindsey; Jiva, Sumera; Kaboré, Charlotte; Kenemer, John; Lekiachvili, Akaki; Miller, Maureen; Mohamoud, Yousra; Perrine, Cria; Shamout, Mays; Zapata, Lauren; Annor, Francis; Barry, Vaughn; Board, Amy; Evans, Mary E.; Gately, Allison; Hoots, Brooke; Pickens, Cassandra; Rogers, Tia; Vivolo-Kantor, Alana; Cyrus, Alissa; Boehmer, Tegan; Glidden, Emily; Hanchey, Arianna; Werner, Angela; Zadeh, Shideh Ebrahim; Pickett, Donna; Fields, Victoria; Hughes, Michelle; Neelam, Varsha; Chatham-Stephens, Kevin; O'Laughlin, Kevin; Pomeroy, Mary; Atti, Sukhshant K.; Freed, Jennifer; Johnson, Jona; McLanahan, Eva; Varela, Kate; Layden, Jennifer; Meiman, Jonathan; Roth, Nicole M.; Browning, Diane; Delaney, Augustina; Olson, Samantha; Hodges, Dessica F.; Smalley, Raschelle (2019). "Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019". MMWR. Morbidity and Mortality Weekly Report. 68 (41): 919–927. doi:10.15585/mmwr.mm6841e3. ISSN 0149-2195. PMC 6802682. PMID 31633675.Public Domain This article incorporates text from this source, which is in the public domain.
    22. 1 2 3 4 5 "Transcript of CDC Telebriefing: Lung Injury Investigation". Centers for Disease Control and Prevention. 11 October 2019.Public Domain This article incorporates text from this source, which is in the public domain.
    23. 1 2 Tanne, Janice Hopkins (2019). "Don't vape, CDC says, as US lung disease epidemic grows". BMJ. 366: l5479. doi:10.1136/bmj.l5479. ISSN 0959-8138. PMID 31501087. S2CID 202414987.
    24. ↑ "2019 Respiratory Illnesses in Illinois". Illinois Department of Public Health. 5 September 2019.
    25. 1 2 3 "New Cases Identified in Investigation of Lung Disease Among Teens and Young Adults Who Reported Vaping". Wisconsin Department of Health Services. 2 August 2019.
    26. 1 2 3 4 5 6 7 8 9 10 "Severe Acute Pulmonary Disease Associated with Cannabis or Cannabidiol Oil Vaping" (PDF). California Tobacco Control Program. California Department of Public Health. 9 August 2019. pp. 1–4.Public Domain This article incorporates text from this source, which is in the public domain.
    27. ↑ "Health Officials Report Death in Vaping Related Lung Disease". Tulare County Health & Human Services Agency. 16 September 2019. Archived from the original on 10 October 2019.
    28. 1 2 3 Gillies, Rob (18 September 2019). "Youth in Canada is diagnosed with illness related to vaping". Associated Press.
    29. ↑ Dubinski, Kate (18 September 2019). "Ontario teen was on life-support after respiratory illness linked to vaping". CBC.ca.
    30. 1 2 3 4 "Quebec resident confirmed as first Canadian case of vaping-related illness". CBC.ca. 27 September 2019.
    31. 1 2 Public Health Agency of Canada (11 October 2019). "Statement from the Council of Chief Medical Officers of Health on vaping in Canada". Chief Public Health Officer of Canada.
    32. ↑ "2 more probable cases of vaping-related illness confirmed in B.C." CBC.ca. 7 November 2019.
    33. ↑ Ross, Andrea (11 October 2019). "6 people in B.C. have reported illnesses potentially related to vaping since June". CBC.ca.
    34. ↑ Lindsay, Bethany (16 October 2019). "First probable case of vaping-related illness confirmed in B.C." CBC.ca.
    35. 1 2 3 "First probable vaping-related illness reported in Newfoundland and Labrador". The Canadian Press. 17 January 2020.
    36. 1 2 3 "Vaping-associated lung illness". Public Health Agency of Canada. 5 February 2020.
    37. 1 2 Wheaton, Sarah (12 September 2019). "Europe's missing 'vaping sickness'". Politico.
    38. ↑ "Hearing on "Sounding the Alarm: The Public Health Threats of E-Cigarettes"". 25 September 2019.
    39. 1 2 "Lung Illnesses Associated with Use of Vaping Products". United States Food and Drug Administration. 18 October 2019.Public Domain This article incorporates text from this source, which is in the public domain.
    40. ↑ Richtel, Matt; Grady, Denise (7 September 2019). "What You Need To Know About Vaping-Related Lung Illness". The New York Times.
    41. 1 2 Butt, Yasmeen M.; Smith, Maxwell L.; Tazelaar, Henry D.; Vaszar, Laszlo T.; Swanson, Karen L.; Cecchini, Matthew J.; Boland, Jennifer M.; Bois, Melanie C.; Boyum, James H.; Froemming, Adam T.; Khoor, Andras; Mira-Avendano, Isabel; Patel, Aiyub; Larsen, Brandon T. (2019). "Pathology of Vaping-Associated Lung Injury". New England Journal of Medicine. 381 (18): 1780–1781. doi:10.1056/NEJMc1913069. ISSN 0028-4793. PMID 31577870.
    42. ↑ Mukhopadhyay, Sanjay; Mehrad, Mitra; Dammert, Pedro; Arrossi, Andrea V; Sarda, Rakesh; Brenner, David S; Maldonado, Fabien; Choi, Humberto; Ghobrial, Michael (2019). "Lung Biopsy Findings in Severe Pulmonary Illness Associated With E-Cigarette Use (Vaping): A Report of Eight Cases". American Journal of Clinical Pathology. 153 (1): 30–39. doi:10.1093/ajcp/aqz182. ISSN 0002-9173. PMID 31621873.
    43. 1 2 3 4 5 "Transcript of CDC Telebriefing: Update on Lung Injury Associated with E-cigarette Use, or Vaping". Centers for Disease Control and Prevention. 8 November 2019.Public Domain This article incorporates text from this source, which is in the public domain.
    44. 1 2 Ghinai, Isaac; Pray, Ian W.; Navon, Livia; O'Laughlin, Kevin; Saathoff-Huber, Lori; Hoots, Brooke; Kimball, Anne; Tenforde, Mark W.; Chevinsky, Jennifer R.; Layer, Mark; Ezike, Ngozi; Meiman, Jonathan; Layden, Jennifer E. (2019). "E-cigarette Product Use, or Vaping, Among Persons with Associated Lung Injury — Illinois and Wisconsin, April–September 2019". MMWR. Morbidity and Mortality Weekly Report. 68 (39): 865–869. doi:10.15585/mmwr.mm6839e2. ISSN 0149-2195. PMC 6776374. PMID 31581166.Public Domain This article incorporates text from this source, which is in the public domain.
    45. ↑ Furlow, Bryant (2019). "US state governments investigate suspected vaping-associated severe lung disease". The Lancet Respiratory Medicine. 7 (11): 934–935. doi:10.1016/S2213-2600(19)30303-0. ISSN 2213-2600. PMID 31477520.
    46. ↑ Greene, Tristan (28 August 2019). "Bootleg vape cartridges linked to outbreak of potentially fatal lung illness". The Next Web.
    47. 1 2 Downs, David (30 August 2019). "Vape Pen Lung Disease Has Insiders Eyeing Misuse of New Additives". Leafy.
    48. 1 2 Betuel, Emma (19 August 2019). "Dank Vapes Is the "Biggest Conspiracy" in Pot That Can Put You in a Coma". Inverse.
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    50. 1 2 3 4 5 Peel, Sophie (9 September 2019). "Leading Oregon Cannabis Extractor Pulls Line of Vape Products Off Its Website as Health Questions Swirl". Willamette Week.
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    52. 1 2 3 4 Downs, David (11 September 2019). "Amid Vape Pen Lung Disease Deaths: What Exactly Is Vitamin E Oil?". Leafy.
    53. 1 2 Downs, David (6 September 2019). "Vape Cart Additive Makers Pull Products as Others Go Dark". Leafy.
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    55. ↑ Kuznia, Rob; Sun, Lena H. (24 September 2019). "Potential culprits in mystery lung illnesses: Black-market vaping products". The Washington Post.
    56. ↑ Downs, David (9 September 2019). "Regulators, Industry React to Vitamin E-Tainted Vape Carts". Leafy.
    57. 1 2 "Governor Cuomo Takes Aggressive Action to Protect New Yorkers from Harmful and Addictive Vaping Products Following Rise in Vaping-Associated Illnesses Nationwide". Governor of New York. 9 September 2019.
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    60. ↑ Lotus, Jean (12 September 2019). "Vaping lung disease: Legal pot labs start testing for vitamin E in cannabis oil". United Press International.
    61. ↑ Goldman, Henry (9 September 2019). "Cuomo Signals N.Y. Crackdown on Vaping Products After Illnesses". Bloomberg News.
    62. ↑ H. Sun, Lena (9 September 2019). "New York to subpoena firms selling substances linked to illicit vaping products". The Washington Post.
    63. ↑ Klepper, David (9 September 2019). "New York to Require Health Warnings in Vape Shops". U.S. News & World Report. Associated Press.
    64. 1 2 3 Smith, Deneen (11 September 2019). "Authorities investigating whether Paddock Lake brothers drug operation related to vape illnesses". Kenosha News.
    65. 1 2 3 Winsor, Morgan (13 September 2019). "Wisconsin brothers accused of running illegal THC vape cartridge 'empire'". ABC News.
    66. ↑ Mole, Beth (12 September 2019). "Black-market THC-vape operation busted in Wisconsin, police say". Ars Technica.
    67. ↑ Pelisek, Christine (11 September 2019). "Wisconsin Man, 20, Accused of Running Large-Scale Counterfeit THC Vaping Scheme: 'National Epidemic'". People.
    68. 1 2 Jewell, Hannah (11 September 2019). "Brothers accused of operating 'empire of illegal drugs' in Kenosha County". FOX6 News.
    69. 1 2 3 4 5 6 Williams, Derica (16 September 2019). "Kenosha County brothers charged, accused of running massive drug operation". FOX6 News.
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    71. 1 2 Smith, Deneen (3 October 2019). "Racine woman, 20, in custody related to large Kenosha County THC vaping case; mother posts bond". Wisconsin State Journal.
    72. 1 2 Abad, Jacquelyn (3 October 2019). "19-year-old worker arrested in connection with Huffhines' family THC cartridge investigation". WDJT-TV.
    73. 1 2 Abad, Jacquelyn (11 October 2019). "2 women accused in THC vape ring will stand trial". WISN-TV.
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    76. 1 2 3 4 "The First of the Vape-Lung Product Liability Cases Has Been Filed". Lexology. 2 October 2019.
    77. 1 2 Kapnick, Izzy (25 October 2019). "Vaping Companies Brace for Wave of Lawsuits Over Lung Illness". Courthouse News Service.
    78. 1 2 3 Bernabe, Angeline Jane; Wagschal, Andgerry (22 October 2019). "Former Juul user, 21, sues company after being hospitalized, placed in coma for 8 days". ABC News.
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    80. ↑ Dampier, Cindy (13 September 2019). "A Gurnee teen hospitalized for a vaping-related illness is suing e-cigarette company Juul". Chicago Tribune.
    81. ↑ "Los Angeles Unified School District Files Class Action Lawsuit Against E-Cigarette Manufacturer JUUL Labs, Inc". Panish Shea & Boyle LLP. 29 October 2019. Retrieved 6 April 2020.
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    90. ↑ People are vaping a deadly substance along with THC. Why isn't vitamin E acetate illegal?
    91. ↑ Washington state bans vape products that contain vitamin E acetate
    92. ↑ https://www.bostonglobe.com/news/marijuana/2019/09/24/governor-baker-make-vaping-announcement-amid-spate-lung-illnesses/o8sO6mf3GOmX4mOpLLtcEL/story.html Baker declares public health emergency, orders 4-month ban on all vaping products
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    95. ↑ Massachusetts Lab Offers First Two Vitamin E Acetate Screenings Free
    96. ↑ Ban on vape sales in Massachusetts ends Wednesday — what happens next?
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    101. ↑ Robertson, Adi (18 September 2019). "India bans e-cigarette sales and says there's an 'epidemic' of kids vaping". The Verge.
    102. 1 2 Hunt, Katie (17 September 2019). "The US and UK see vaping very differently. Here's why". CNN.
    103. ↑ Harmata, Claudia (20 September 2019). "Texas Mom Speaks Out After Almost Dying from Vaping-Related Illness: 'My Lungs Were Full of Fluid'". People.
    104. ↑ Bojórquez, Kim (6 August 2019). "What Utah doctors are saying about vaping". Deseret News.
    105. ↑ H. Sun, Lena (24 August 2019). "He went from hiking enthusiast to 'on death's door' within days. Doctors blamed vaping". The Washington Post.
    106. ↑ Crash, Melissa (12 September 2019). "Marion family warns about vaping dangers after teen suffers double lung collapse: 'It was traumatic'". WTTV.
    107. ↑ Dillon, Dominique (13 September 2019). "Man fighting vaping-related lung illness: "If I die, let somebody else live off of my mistake"". WSYR-TV.
    108. ↑ Van Hagen, Isobel (8 August 2019). "Florida Teenager Warns Against Juuling After His Lung Collapsed". Newsweek.
    109. ↑ Bonilla, Alex; Blair, Alexander J.; Alamro, Suliman M.; Ward, Rebecca A.; Feldman, Michael B.; Dutko, Richard A.; Karagounis, Theodora K.; Johnson, Adam L.; Folch, Erik E.; Vyas, Jatin M. (2019). "Recurrent spontaneous pneumothoraces and vaping in an 18-year-old man: a case report and review of the literature". Journal of Medical Case Reports. 13 (1): 283. doi:10.1186/s13256-019-2215-4. ISSN 1752-1947. PMC 6732835. PMID 31495337. This article incorporates text by Alex Bonilla, Alexander J. Blair, Suliman M. Alamro, Rebecca A. Ward, Michael B. Feldman, Richard A. Dutko, Theodora K. Karagounis, Adam L. Johnson, Erik E. Folch, and Jatin M. Vyas available under the CC BY 4.0 license.
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    111. ↑ Ben-Moche, Erin (11 September 2019). "Local Teen 'Lucky to Be Alive' After Vaping Incident". Jewish Journal.
    112. ↑ Wadas, Amy (12 September 2019). "Local Teenager Recovering From Lung Disorder Due To Vaping". KDKA-TV.
    113. ↑ Cipriani, Marcie (10 September 2019). "Beaver County teenager hospitalized, suffering effects of vaping". WTAE-TV.
    114. ↑ Grady, Denise (15 October 2019). "A Young Man Nearly Lost His Life to Vaping". The New York Times.
    115. ↑ Shanes, Alexis (10 October 2019). "'My lungs were chemically burned': NJ victim speaks out against vaping". North Jersey Media Group.
    116. ↑ Haskell, Peter (10 October 2019). "'Most Miserable Time Of My Life': NJ Woman Speaks Out After Nearly Dying From Vaping". WCBS (AM).
    117. ↑ Farber, Madeline (4 November 2019). "Indiana teen says he was expelled after suffering vaping illness at school". Fox News.
    118. ↑ Martinez, Jennifer (15 October 2019). "Valley teen hospitalized after being found unresponsive due to vaping-related illness". KSAZ-TV.
    119. ↑ Williams, Corey (13 November 2019). "Michigan Teen Receives Double Lung Transplant After 'Enormous' Damage From Vaping". Time (magazine). Archived from the original on 13 November 2019.
    120. ↑ McCall, Rosie (12 November 2019). "Man Receives Double Transplant After Lungs 'Irreparably Damaged' by Vaping". Newsweek.
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