Throughout 2019 many individuals suffered from vaping illnesses – or EVALI – which cased a number of injuries and deaths across the United States. Governments around the world began taking action to protect their citizens by banning vaping as a whole. We have compiled a timeline of the incidents that lead to the many bans in countries, states, and cities. However, what is thought to be the leading cause may not be what many suspected.

Vaping Illness Timeline

On August 17, 2019, the CDC announced that they would be actively investigating approximately 94 cases of vaping-related illnesses in 14 states. That number would soon grow to 200 cases in 22 states, officially kicking off the vaping crisis. At the time, CDC officials had not yet determined the cause of the illness and instead accused THC, CBD, and nicotine vaporizers as the primary culprits.

While this was not the first time vaping had been accused as a cause of illness, the scale and magnitude of the new cases brought a significant amount of attention to the vaping industry as a whole. In a short span of time, vaping has become the subject of more intense criticism and has drawn the ire from lawmakers and government officials. This wave of backlash has resulted in an increased amount of regulation directed towards nicotine-based vaporizers and e-cigarette flavours.

Not long after on August 23, health officials announced the death of an Illinois patient that could be the first in the US linked to vaping. The patient was hospitalized after falling ill after vaping Illinois Department of Public Health stated, but offered no other information.

As the CDC continued its investigation, the public health institute “took the unusual step” of issuing recommendations regarding vaping and e-cigarette products. This is the first time the CDC has done something like this and was made with information gathered from the general public, clinicians, and public health officials. Among the recommendations made by the CDC:

“Anyone who uses e-cigarette products should not buy these products off the street (e.g., e-cigarette products with THC, other cannabinoids) and should not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer.”

In the same statement, the CDC reiterated its existing stance on vaping, noting that “e-cigarette products should not be used by youth, young adults, pregnant women, as well as adults who do not currently use tobacco products.”

Despite the CDC’s warnings to avoid illicit products, on September 4, 2019, an unidentified person was hospitalized after vaping a THC product. This person later died and the product he used was linked to a recreational marijuana shop in Oregon. Prior to his admittance to the hospital, the patient was “otherwise healthy and quickly became ill,” according to the lead investigator and public health physician assigned to the patient.

This would be the second death to come out of the vape crisis, with a third life claimed the day after in Indiana. After these recent deaths, federal health authorities urged people to stop using e-cigarette products while they continued to investigate the now 450 cases in 33 states. Interestingly, while the CDC warned consumers about THC products, several other government agencies chose to place restrictions and warnings on nicotine-containing e-cigarettes.

On September 6, 2019, two more deaths occurred, one in Minnesota and the other in Los Angeles county. It should be noted that the patient in Minnesota had a history of underlying lung disease, however, the illness that claimed their life was related to vaping illicit THC products.

On the same day, the CDC released a statement about its investigations, stating that no single product was responsible for all the vaping related illnesses. While many of the patients did report using primarily THC products, some did note that they only consumed nicotine or products with both THC and nicotine.

Following these two deaths, Illinois Sen. Dick Durbin tweeted to Ned Sharpless, acting commissioner for the U.S Food and Drug Administration, demanding action in regards to vaping related illnesses. In his tweet, Durbin pressed the FDA to send letters to all schools in America warning them of the health consequences related to vaping. He also urged the FDA to ban e-cigarette flavours, other than tobacco, and to ban e-cigarettes that had not been approved by the FDA. Senator Durbin ended his tweet by stating “If Dr. Sharpless doesn’t take action in the next 10 days, I plan to call for his resignation. Enough is enough.”

With the vaping illness toll on the rise, reaching 530 across 38 states by September 19, 2019, the FDA announced that it would begin a criminal investigation into the outbreak. Seven people were now dead from the vaping illness, and the FDA finally decided to collect samples for more than 150 patients to analyze them for the presence of cutting agents and other substances.

In response to the uptick in vaping lung illnesses, the California Department of Public Health released a health advisory on September 24, 2019. In this advisory, the California Department of Public Health warned citizens of the “imminent public health risks posed by vaping any product.” The advisory also added that everyone should stop vaping “no matter what the substance or source.”

By September 26, 2019, 805 cases of the vaping lung illness were reported, with at least 12 known deaths, according to the CDC. Patients could now be found in 46 states, and deaths included two in California, two in Kansas, and one each in Georgia, Florida, Illinois, Indiana, Minnesota, Missouri, Mississippi and Oregon. At this point, the median age of patients was 23 years old, and two-thirds of the patients were male.

On October 9, 2019, with the death toll reaching 18, the Washington State Board of Health voted in a temporary ban on the sale of nicotine and THC-flavoured products. This was enacted just two weeks after Gov. Jay Inslee asked for the emergency rule in an executive order. The vote was unanimous and the band was scheduled to last four months.

During this vaping illness outbreak, Washington was not the only state to ban flavoured e-cigarettes. New York State, Massachusetts, and Michigan also instituted their own state-wide bans, many of which were enacted to limit the sales of vaping products and their supposed appeal to children.

While the CDC had previously placed warnings on both THC products and e-cigarettes, on October 17, 2019, the public health institute announced that the majority of illnesses had been linked to vaping products containing THC. Unfortunately, by this point, there had been 33 deaths across 24 states and 1,479 lung injury cases, involving every state except Alaska. It should also be noted that by this point, the illness had been deemed EVALI (E-cigarette or Vaping product use Associated Lung Injury).

In response to the increasing amount of EVALI patients, the Trump administration reports that they’re considering a ban on all flavoured vaping products. The ban would still allow the sale of tobacco and menthol flavours, under the assumption that they’re less appealing to minors. After making this statement, the Trump administration receives a wave of backlash from pro-vaping advocates, many of whom consider this reason to not vote for President Trump in the upcoming election.

Despite the CDC’s statement that the source of EVALI had come primarily from THC-based products, almost all e-cigarette bans remain in place and JUUL begins to face even more pressure from government entities and anti-vaping advocates. As the largest e-cigarette company in the world, JUUL was placed under heavy scrutiny and is still currently battling lawsuits aimed towards the company from multiple sources.

After months of research, on November 8, 2019, the CDC finally announces that vitamin E is the likely cause of EVALI and calls on prossesors to cease adding it to products. The CDC conducted tests on the lung fluid of 29 EVALI patients. In all the samples, vitamin E acetate was present and no other potential toxins were detected in the tests. In response to these findings, the CDC continues to warn people to not use e-cigarettes or vaping products that contain THC.

In response to the CDC’s vitamin E acetate findings, Washington State’s Department of Health and its Liquor and Cannabis Board called on all cannabis processing companies to “immediately stop adding vitamin E acetate to vapor products and distributing any vapor products containing vitamin E acetate.” The DOH and LCB went on to further state that “All products available for retail sale are required to have documentation available that lists ingredients.”

On November 18, 2019, the CDC reports that the death toll has risen to 42 in 24 states. The CDC also reported that there have been over 2,172 cases of EVALI across the country. On the same day, President Trump backs down from his flavoured vaping ban. According to The New York Times, Trump chose not to go forward with the ban, due to “potential pushback from his supporters.”

According to Judd Deere, a spokesperson for the White House, “President Trump and this administration are committed to responsibly protecting the health of children.” He went on to further state “at this time, we are in an ongoing rulemaking process, and I will not speculate on the final outcome.”

That being said, on November 22, 2019, the same day the EVALI death toll reached 47, President Donald Trump hosted a roundtable at the White House on vaping. The discussion centred around whether methol should be banned alongside other flavours. While these discussions took place, the CDC reported that the 47 deaths had been confirmed in 25 states and the District of Columbia. The CDC also reported that there have been 2,290 cases of EVALI in every state, except Alaska, and in two U.S territories, Puerto Rico and the U.S. Virgin Islands.

After a two-week Thanksgiving break, the CDC announced that as of December 5, 2019, the death toll reached 48 people. These deaths come from 25 different states, including Alabama, California, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Kansas, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon, Pennsylvania, Tennessee, Texas, Utah, Virginia, and in the District of Columbia. In addition to an increase in deaths, the CDC also reported 2,291 cases of EVALI, but they did note that it has removed non-hospitalized cases from its previous numbers.

The Key Culprit of the EVALI Outbreak

As the outbreak of EVALI has affected over 2,000 people across the US, it’s been made quite clear that THC vape products are playing a major role. As the CDC reported, vitamin E acetate — an oily chemical added to some THC vaping liquids as a thickener or to dilute the liquid — is a “strong culprit of concern.”

The chemical itself is a synthetic form of vitamin E and is often used in nutritional supplements and skin creams. While it is safe to use in these instances, the chemical is not safe to inhale. The chemical itself is incredibly viscous and sticky, and can easily hang around in the lungs after it is inhaled. According to health officials, the presence of vitamin E acetate can interfere with how the lungs function.

The CDC first identified vitamin E acetate as a key culprit in EVALI cases after investigating samples taken from 29 patients in 10 states. In all of the samples, vitamin E acetate was present, while other potential toxins — such as plant and mineral oils — were not. According to Anne Schuchat, principal deputy director of the Centers for Disease Control and Prevention, “direct evidence of vitamin E acetate at the primary site of injury within the lungs.”

That being said, Schuchat did emphasize that the CDC’s investigation isn’t over. While vitamin E acetate has been identified as a key culprit in the EVALI outbreak, officials at the CDC still can’t say for certain that vitamin E acetate is the source of harm in all cases.

What is certain, is that both state and federal investigations have found that many of the THC products patients used were purchased through informal or black market sources. It has also been reported that vitamin E acetate has been used as a cheap cutting agent by illicit cannabis suppliers.

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