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Update 11/8/2019: The CDC has confirmed that out of 29 samples of lung fluid from affected patients all samples tested positive for Vitamin E acetate. This has led the CDC to consider Vitamin E acetate to be a "chemical of concern."
Over the past two months, the Centers for Disease Control and Prevention (CDC) has been working with state and local departments of health around the country to identify cases of what has come to be known as Vaping-Associated Pulmonary Illness (VAPI). As of 5:00 PM on September 25, the CDC had confirmed 805 cases of lung injury in 46 states and one U.S. territory. The CDC also confirmed a total of 12 deaths in 10 states.
While several states have issued recommendations to quit using vapes, other states have banned, or are currently looking into banning, vaporization products (for both nicotine and cannabis) altogether. Massachusetts has banned the sale of all vaporization products for four months, and New York and Michigan are banning sales of flavored vaping products. Other jurisdictions, such as Los Angeles, are considering bans as well.
What Patients Should Know
First, it is important to note that this illness is not caused by anything intrinsic to cannabis. Of the 514 patients for whom CDC has data, 16% reported the exclusive use of nicotine-containing products in the 30 days prior to symptom onset. Second, the available evidence indicates that the vast majority of those who were sickened after using a vaporizer cartridge purported to contain THC purchased their cartridges not through legally licensed stores, but through unregulated, illicit channels. However, there are indications that some individuals may have been sickened, and at least one person has been killed, by a product or products purchased at one or more licensed stores in Oregon. Given this information, along with the varied experiences of those who have fallen ill as a result of vaping, the CDC investigation is focusing its investigation on electronic nicotine delivery systems (ENDS), which include vape/dab pens, electronic cigarettes, and the liquids they contain, which can include nicotine, cannabis oil, and other substances and additives.
As yet, investigators have not been able to pin down one factor or set of factors that is likely to result in illness. Vitamin E (tocopherol) acetate has been implicated as a potential cause of illness and injury in many of the cases involving illicit cannabis cartridges, but it has not been present in all samples. CannaSafe, a PFC-certified lab in California, recently revealed results from a small study that showed black market cartridges can contain extremely high concentrations of other dangerous chemicals, such as myclobutanil, a pesticide routinely found in cannabis samples that is converted to the poison hydrogen cyanide when heated to 400 °F (204.4 °C). CannaSafe tested 10 illicit cartridges for myclobutanil and found it in each one, highlighting the need for patients and consumers to purchase products that have been subjected to mandatory testing for dangerous chemicals and other hazards. Additionally, such cartridges can contaminate their contents with heavy metals like arsenic and lead. However, the recent disclosure that at least one death has been linked to a legally purchased product underscores that this risk is not just confined to the illicit market.
Whether due to better healthcare surveillance and reporting, the addition of new cutting agents or other additives, the presence of pesticides or other contaminants, issues with certain types, brands, or manufacturers of cartridges and other delivery mechanisms, a combination of these factors, or something else, it is clear that the use of ENDS is not without risk. ASA strongly recommends patients and consumers stop using cannabis-containing cartridges entirely (or at least to the extent possible) until there is clarity as to what is causing these illnesses and deaths.
ASA does not support outright bans on cannabis-containing cartridges or devices intended for the consumption of cannabis concentrates, which could simply drive more people to the unregulated market and exacerbate the spread of VAPI. Rather, we recommend bans on the inclusion of any additives (e.g., diluents, thickeners, flavoring agents) not derived from cannabis. Additionally, we recommend patients and consumers only purchase cannabis products that have undergone testing at an independent, third-party laboratory that has verified composition and potency and screened for adulterants, contaminants, heavy metals, residual solvents, chemical residues, and other health concerns, such as mold and dangerous bacteria.
We understand that for many patients, inhalation may be the preferred - or the only effective - method of delivery. Historically, inhaling cannabis vapor has been considered a safer alternative to inhaling cannabis smoke because the toxic byproducts of combustion are avoided. While this is still believed to hold true for dry herb (flower) vaporizers, vape pens, though convenient and easy to use, should be avoided at this time. ASA recommends that patients and consumers who currently use a vape pen instead use other delivery mechanisms, such as dry herb vaporizers, tinctures, edibles, or topicals. Patients who must be able to medicate discreetly and rely on vape pens because they don’t produce cannabis’ signature scent may find combining the use of a flower vaporizer and a personal smoke filter to be a workable solution.
Americans for Safe Access started out in 2002 with the mission to not just ensure access to medical cannabis to patients across the county, but to ensure safe access. As a patient-focused organization, we take the safety of patients very seriously, and the emergence of VAPI has caused us great concern. The current health crisis that is being linked to the use of illicit concentrate vaporization products highlights the importance of legalization, regulation, laboratory testing of all cannabis and cannabis-derived products (most critically when they are in their final form), and third-party certification, such as that offered through ASA's Patient Focused Certification (PFC) program.
Since 2014, ASA has urged the industry to adopt third-party certification for all cannabis businesses. Through the PFC program, companies are required to adhere to safety, quality, manufacturing, testing, packaging, and labeling standards beyond those set by most jurisdictions where the medical and/or adult use of cannabis has been legalized. PFC companies are subject to both routine and unannounced inspections by independent auditors, which is especially important in light of the fact that jurisdictions may not have enough inspectors to ensure that all licensed operators are complying with all regulations. Patients and consumers may wish to encourage the dispensaries they patronize and the brands that produce the products they use to explore PFC certification to ensure patient and consumer safety and product quality. We will continue to do our part for patients, who are and always will be our highest priority, by keeping up the pressure on industry to adopt regulations that promote patient and consumer safety and by persisting in our advocacy for safe access to cannabis for patients everywhere.