The emotional and irrational hysteria in the US about the “vaping-related” (or cannabis-related?) lung disease that goes far beyond confirmation bias
- Thursday, 05 September 2019 14:59
By Dr Farsalinos
I have been following the recent developments and announcements in the US on the serious, acute cases of respiratory failure which have been presented as “vaping related”. It would not be a hyperbole to characterize the reactions, announcements and statements of some authorities, regulators and scientists as hysterical. There is no doubt that they are emotional, inaccurate and without any scientific and epidemiological basis.
Almost all announcements, whether from health organizations or from local public health authorities refer to the cases as “vaping related”. In no announcement do they mention in the title that many cases have been confirmed (and others are simply not confirmed yet) as related to the use of cannabis (and/or THC) inhalation using a battery-and-resistance device (i.e. an e-cigarette device). In no announcement do they mention that these cases are in fact THC/cannabis-related and not vaping-related.
Let’s start with the basics. Why is the term “vaping-related” cases wrong?
Let’s assume we have no information about the use of cannabis and/or THC (legal or illegal). So, let’s use simple principles of epidemiology to understand the recent outbreak. E-cigarettes have been popular in the US and globally since 2009-2010. There are approximately 10 million vapers in the US today, many of whom have been using e-cigarettes for years, and many more millions worldwide. The average age of adult vapers in the US is approximately 40 years (data from my study on the NHIS surveys that will be published soon). Until this summer, there were no reports of any outbreaks of disease (in the respiratory system or elsewhere), in any age group, in any part of the world. Suddenly, within a short period of time (few weeks), in a specific geographic region (e-cigarettes are available worldwide, not only in the US) and in a specific age group (adolescents or young adults) there are cases of severe, acute respiratory dysfunction that has resulted in 2 deaths and several hospitalizations. What does this tell us from an epidemiological perspective (again, without considering any information about cannabis/THC use)?
- That these cases are not related to long-term use of e-cigarettes. The authorities have clarified that these are acute cases. Despite various media presenting this as a mysterious lung disease, it is in fact poisoning of the lungs which is clinically manifested as serious respiratory failure (perhaps ARDS, perhaps some form of severe lung inflammation leading to respiratory failure).
- That these cases are not related to vaping products that have been available for years in the US and global market. It makes absolutely no sense that the same products that have been used for several years by millions and never caused any disease outbreak are only today causing acute disease.
- That these cases are not related to products that are generally used by the average vaper. The average age of adult vapers in the US is different from the average age of adults that have suffered from this acute condition. Also, the number of cases is very low considering the millions of vapers in the US and the many more millions globally.
- That these cases are related to the recent release of new products (that were not previously available in the market), or to a recent modification in the composition of products previously available in the market, or to a recent problem in the manufacturing process or raw materials of products that were previously available in the market. This explains the timing of the outbreak. These products could be nicotine-containing or nicotine-free products (remember, we assume there is no information on THC/cannabis).
All these conclusions, derived from applying simple principles of epidemiology, have been largely ignored by most authorities, regulators and scientists. Instead, we are witnessing a persistent, frantic, unprecedented campaign against conventional vaping, which in fact delivers a clear message to consumers that it is preferable to relapse back to smoking (or keep on smoking) rather than use (or switch to) e-cigarettes. The media campaign is so intense and so epidemiologically unjustified that it exceeds the definition of confirmation bias.
Now, let’s consider the reports that THC/cannabis vaping is implicated in the outbreak. While this is mentioned in several reports and announcements from health authorities, none has characterized the cases are “THC/cannabis-related”. Why? Well, it seems that some of the states with cases of acute respiratory failure have already legalized THC/cannabis. In fact, there is at least one report of a death related to the use of products obtained from a legal cannabis shop. As everyone may understand, state authorities that have legalized a product cannot suddenly admit that they were wrong and their decision caused an outbreak of acute disease. It is by far “easier” (and more “convenient”) to blame the “evil” e-cigarette for everything.
But should they have blamed THC/cannabis in general for the outbreak and call it “THC/cannabis-related disease”? In my opinion, no. If THC/cannabis does not cause acute respiratory failure from smoking it, it is very unlikely (if not impossible) to cause disease from vaping it. The culprit is not THC/cannabis per se. Most likely (but this has not been proven yet), the cases are related to other compounds used in the preparation of THC/cannabis containing liquids or contaminants in these liquids. While there are reports of vegetable oils being used as solvents (that would certainly be consistent with cases of lipoid pneumonia) or a fungicide, we cannot determine the cause yet. However, if this is the case, then this can also happen with nicotine-containing liquids, if someone is ignorant enough to use oils to dissolve flavorings in a nicotine-containing liquid. If the case is about use of illicit products containing illegal substances that were obtained in the black market, this would be no different than blaming syringes for the deaths cause by intravenous drug use; or like blaming whiskey for the deaths and blindness caused by illicit alcohol containing methanol. Sounds silly, right?
But all these are still assumptions. At this time, there is no clearly defined cause for the reported cases. Thus, we should focus on the epidemiological principles mentioned above, which makes it virtually impossible that products available and used for many years by millions of consumers are now causing acute lung failure. While I understand the cautious approach of the CDC, I am certain they fully understand the epidemiology behind this outbreak and they should have done more to identify the cause more rapidly. Other organizations have used this outbreak to support that none should use e-cigarettes, with this statement referring (among others) to millions of former smokers who now use e-cigarettes and to millions of smokers who cannot quit with other methods and would have considered e-cigarettes as an option to quit smoking. What a public health service…
There have been several health crises in the past, with chicken contaminated with dioxins (few years ago in Europe), mad cow disease, and a recent outbreak of Salmonella infections from chicken (again) that resulted in 2 deaths and 175 hospitalizations in the US. For the latter, I am sure all these people were not only eating backyard poultry but also poultry from the market or fast food stores. Still, none presented it as chicken-related illness in general and there were no generalized recommendations that none should eat poultry (despite eating it safely for decades). I wonder if the “passionate” statements mentioned by the media, scientists and authorities will ever be corrected once the exact cause of this outbreak has been firmly established. I even wonder if the media will cover the story at that time with the same “passion” as they are doing today.
In conclusion, from an epidemiological perspective, the current situation with cases of acute respiratory failure reported in the US, is extremely unlikely (I would say, certainly not) attributed to products that have been available in the worldwide market for years and have been used by millions of consumers. The exact cause for these conditions should be urgently determined, and the emotional, irrational hysteria against e-cigarettes (in general) needs to stop as soon as possible.