by Carl V Phillips

The Centers for Disease Control and Prevention finally acknowledged on September 27 that contaminated liquids containing tetrahydrocannabinol (THC) and cannabinoid (CBD) oils are the likely cause of the recent outbreak of lung injuries.  The agency said that “Most patients report a history of using THC-containing products. The latest national and regional findings suggest products containing THC play a role in the outbreak.” As of October 1, there were 1,080 cases and 18 deaths.  Unfortunately, the lung injuries and deaths have been conflated with the so-called teen vaping epidemic, which I have put into perspective in this blog (here, here, here and here).  Federal officials, however, continue to ignore one critical link: teen marijuana use.  Government surveys document that the prevalence of current (past 30 days) marijuana use has been high among high schoolers for 25 years.  The link is further demonstrated in the 2018 National Youth Tobacco Survey.  Although officials portray current high school vapers as caught up in a tobacco/nicotine epidemic, they rarely acknowledged that the students had vaped marijuana, as shown in the chart that I presented on September 25 at the Global Tobacco and Nicotine Forum in Washington, DC.  Of the 3.1 million high school vapers in 2018, over half had vaped marijuana.  The more teens vaped, the more likely they had used marijuana.  It is therefore not surprising that 16% of the lung injuries occurred in high schoolers. Although the new CDC statement about THC is helpful, it over-emphasizes e-cigarettes, and it came weeks after state health authoritiesand the FDA implicated illicit liquids related to marijuana.  The CDC’s slow-walking and its continued conflation of e-cigarette use and nicotine vaping have had significant consequences.  First, officials have eroded the commitment of vapers who quit smoking, which may lead them to return to smoking.  Second, the CDC is discouraging current smokers from switching to e-cigarettes, even though such products have been used by millions of consumers nationwide for over a decade with no acute lung injuries.  Third, the CDC failed to warn consumers about using illicit THC liquids.  Earlier, more detailed warnings from the CDC might have save lives and limited injuries. The vaping-related injuries and deaths are clearly tragic, but so are the deaths from smoking: nearly a half million annually for the past 30+ years, or more than 1,300 every single day. Original author: Brad Rodu

Unlike most other state health departments, which are conflating the respiratory disease outbreak associated with black market (and a few legal dispensary-sold) THC vaping products and the general problem of youth e-cigarette use, the Utah Department of Health has issued a report which unequivocally concludes that vaping marijuana is causing severe respiratory illness, which has now affected 71 residents in the state.Unlike the CDC and many state health departments, which are doing everything they can to undermine the observed connection between outbreak cases and marijuana vaping, the Utah Department of Health concluded that: "Given the evidence outlined below, vaping THC cartridges or “carts” is likely the driver of this outbreak of severe lung injury. The UDOH recommends people do not vape THC cartridges until we learn more."The evidence presented in the report is overwhelming:Of 36 cases who reported on product usage, 34 (94%) admitted to vaping THC cartridges.  Of 19 THC cartridges tested, 17 (89%) contained vitamin E acetate oil.No contaminants or abnormalities were detected in any of the 20 nicotine cartridges tested.Most of the THC cartridges were purchased illegally on the black market.At least one of four black market THC vape cart "brands" were mentioned by all 34 of the cases who reported using THC: Dank Vapes, Rove, Golden Gorilla, and Smart Cart.These brands are consistent with those reported by case patients in other states and with those confiscated in drug busts of large, illegal THC vape cart production operations.  The Rest of the StoryIn contrast, take a look at the health advisory issued by the Michigan Department of Health and Human Services. Its recommendation to the public is: "Individuals should consider refraining from vaping until the specific cause of the vaping-related lung injuries has been identified."This is completely irresponsible in three respects:It makes absolutely no mention of avoiding THC vape carts.It is unnecessarily vague and invokes legally sold nicotine e-cigarettes that are being purchased from retail stores, none of which have been implicated in the outbreak.Given the severity of this disease, how can the Department merely urge people to "consider" refraining from vaping. That's hardly a warning at all. In fact, it absolutely minimizes the severity of the disease and undermines the seriousness of the entire warning. Even worse, the Department apparently changed this advisory, which previously did specifically mention THC vape carts. In other words, they made a conscious decision to remove the mention of THC entirely from the warning.This is completely irresponsible and inexcusable. It puts Michigan youth and the entire public at risk by hiding from them the fact that most of the observed cases have been specifically associated with the use of black market THC vape carts.In my view, the Michigan Department of Health and Human Services should be held responsible for future cases of respiratory disease or death among state residents who were not adequately and properly warned against the specific dangers of vaping THC oils.Original author: Michael Siegel

October 7th, 2019

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A new survey released yesterday by the National Opinion Research Center (NORC) at the University of Chicago found that the public believes that vaping nicotine-based e-liquids is much more harmful than vaping THC e-liquids.While 54% of the public believes that vaping nicotine is very harmful, only 38% believe that vaping THC is very harmful. And while just 16% of the public does not believe that nicotine vapes are harmful, an amazing one-third (33%) of the public does not believe that vaping marijuana carries any risk.These data are shocking in light of the fact that we are a good two months into an outbreak of severe respiratory failure and death, affecting more than 1,000 people, in which the overwhelming majority of cases vaped THC oils and contaminated, bootleg THC vape cartridges have been clearly tied to the outbreak, while there is currently no evidence that nicotine vapes are involved at all.Given the life-threatening risks associated with vaping black market THC oils at this time, it is simply devastating to find that the public has very little appreciation of the severe risks associated with marijuana vaping and thinks that vaping nicotine e-liquids is much more harmful. This result is almost certainly related to the CDC's failure to clearly communicate to the public the extremely high level of risk associated with vaping THC and its concerted effort to try to blame traditional, legal, store-bought nicotine-containing electronic cigarettes for the outbreak.The evidence that contaminated THC oils are linked to the outbreak continues to get stronger every day. Today it was revealed that 10 of the 11 reported outbreak case patients in Delaware admitted to the use of THC vapes. The other patient apparently did not admit to vaping marijuana but the results of a THC urine screen were either not announced or the test was not conducted.Also today, a North Carolina Health News article revealed that early this summer, physicians at a North Carolina hospital observed the first three cases of the outbreak in the state and noticed that all three patients had vaped THC oils. The physicians immediately notified the CDC. Later, the same physicians published an article reporting five patients with lipoid pneumonia that was related to the use of THC oils.Even though 100% of these patients were vaping black market THC, the CDC made nothing of that information and refused to warn the public not to vape black market THC, instead remaining deliberately vague in its warning in order to be able to implicate nicotine electronic cigarettes, which it has despised ever since they came on the market.The authors of that article explicitly noted that their findings "highlight the importance of awareness of a potential association between use of marijuana oils or concentrates in e-cigarettes and lipoid pneumonia." Two weeks later, the CDC had yet to have clearly communicated that information to the public. And now, a full three weeks later, the CDC still stated (in today's North Carolina Health News article) that they just don't have any answers.The CDC might not have any answers, but any guy off the street could have told you back in early September that if five young patients present with a severe, newly seen respiratory disease and all five report having vaped THC oils that the outbreak likely has something to do with vaping THC oils. It is incredible that the CDC hasn't advanced beyond that obvious conclusion after two months of investigation and has in fact gone backwards from that conclusion, trying to convince the public that we really don't know if THC oils have any involvement in the outbreak in the first place. We just don't have any answers, they continue to say.I cannot overemphasize the level of irresponsibility that we are witnessing from the CDC. I can assure you that if I still worked at the CDC (I worked in the office that is leading this investigation), I would never have allowed this to occur.After seeing this new survey results, I am now convinced beyond a doubt that this failed communication is making the outbreak worse than it would have been had the CDC clearly communicated to the public the connection that the guy on the street realized weeks ago. The message has simply not come across because the CDC, and in turn state health departments, are more concerned about implicating nicotine-containing electronic cigarettes than in actually trying to prevent further cases of this severe illness.Original author: Michael Siegel

The Journal of the American Heart Association on June 5, 2019, published an article, “Electronic cigarette use and myocardial infarction among adults in the US Population Assessment of Tobacco and Health [PATH],” by Dharma N. Bhatta and Stanton A. Glantz (here).  In reading the article, I discovered that the authors misrepresented the research record;  presented a grossly inaccurate analysis of PATH Wave 1 survey data, and omitted critical information with respect to (a) when survey participants were first told that they had a heart attack, and (b) when participants first started using e-cigarettes.  The article reflected a significant departure from accepted research practices.  The authors reported that current e-cigarette users were twice as likely as never users to have had a heart attack, based on information from 38 survey participants.  They reported odds ratios (ORs) of 2.25 (95% confidence interval, CI = 1.23 – 4.11) for 19 daily vapers, and 1.99 (CI = 1.11 – 3.58) for 19 some-day users (Abstract, Table 3 and Table S6).  Drs. Bhatta and Glantz claimed that their study confirmed that “e-cigarette use is an independent risk factor for having had a myocardial infarction…”  In a blog post on the University of California San Francisco website, Dr. Glantz cited the study as “more evidence that e-cigs cause heart attacks” (here). I have extensive experience conducting research on the PATH data files.  I conducted an analysis of the Public Use Wave 1 data, which has no restrictions on release of results.  I found that at least 11 of the 38 current e-cigarette users were first told that they had a heart attack years before they first started using e-cigarettes.  My research team conducted further analyses that were discussed in letters we sent to JAHAeditors on July 11 and July 18; these letters were never acknowledged.  At the instruction of the Inter-university Consortium for Political and Social Research, I am not able to share those letters with you.Original author: Brad Rodu

A study published yesterday in the New England Journal of Medicine by a team of researchers at the Mayo Clinic provides further evidence that contaminated THC oils are likely playing a major role in the vaping-associated respiratory disease outbreak and makes it even less likely that store-bought nicotine e-liquids are playing any role at all. Here is the key evidence provided by the paper:1. The overwhelming majority of patients admitted to vaping THC oils.Approximately 76% of the patients studied who reported on product use admitted to vaping marijuana (13 out of 17 patients). Because urine THC testing was either not conducted or not reported, it is not possible to state that any of these cases occurred in a patient who had not vaped a marijuana-based product. In one case, a patient had been vaping nicotine e-liquids for five years, but then tried vaping marijuana and was in the hospital with respiratory distress within a few days. His vaping history was reported as: "vaping nicotine for 5 years; on weekend prior to presentation, started vaping nicotine with marijuana for the first time."2. The study authors suspect a direct chemical injury to the lungs, suggesting that a new contaminant, not traditional nicotine e-liquids, is the most likely cause.After examining the lung biopsies, the authors concluded that the most likely explanation for these cases is "direct lung toxicity from an inhaled noxious agent or agents." The ingredients of store-bought nicotine e-liquids is quite standard. These e-liquids contain propylene glycol, glycerin, water, nicotine, and flavorings. This formula is ubiquitous for all store-sold nicotine e-liquids and there have not been any recent changes to these ingredients. The FDA's testing of the recovered nicotine e-liquids from case patients have so far not revealed any contaminants. These products have been sold for years without reported problems of lung toxicity.In contrast, black market THC products and counterfeit vape cartridges sold over the internet and by street dealers are very susceptible to contamination. Unlike legal THC oils, the black market products are not tested, and therefore might contain pesticides, residual solvents, other noxious chemicals, or synthetic cannabinoids, each of which could potentially cause a direct chemical injury to the lung.In fact, acute respiratory toxicity from synthetic cannabinoids has been observed. So has acute alveolar hemorrhage and a more subacute lung injury characterized radiographically by diffuse hazy densities. Moreover, just lack week, testing of a large number of black market THC vape cartridges revealed that they "all contained myclobutanil, a fungicide that can transform into hydrogen cyanide when burned," which can have severe respiratory toxicity. It was also recently shown that vaping butane hash oil can result in severe lung toxicity that presents in a similar fashion to the current outbreak cases.3. The study findings are not necessarily inconsistent with lipoid pneumonia.Although the study authors opine that the pathological findings are not indicative of exogenous lipoid pneumonia, the basis for this conclusion is not clear. The authors' assertion seems to be based primarily on their failure to find "coalescent of lipid into large droplets." However, there are many previous reports of exogenous lipoid pneumonia in which the pathology examination did not report finding a coalescence of lipid into large droplets in the lung. The main finding in these previous studies (example) was the presence of lipid-laden macrophages, just as the primary finding in the current study was the presence of foamy (lipid-laden) macrophages. The radiographic findings in many of the cases and the finding of lipid-laden macrophages are consistent with a diagnosis of lipoid pneumonia in at least some of the observed cases. I think it is premature to rule out the significance of the inhalation of large quantities of viscous oil in the pathogenesis of the disease.The results of this study add to the growing evidence that contaminated black market THC oils or counterfeit, bootleg vape cartridges are the primary, if not sole, cause of the outbreak. In two cases, legally purchased THC oils from dispensaries in Oregon were implicated. However, there are no cases that have been shown to be associated with the use of store-purchased nicotine e-liquids and it seems extremely unlikely that these products have any involvement in the outbreak.Original author: Michael Siegel

While the CDC and many health groups have been obsessed with youth e-cigarette use, an even more troubling epidemic has been spreading among our nation’s youth. In contrast to the e-cigarette use explosion, which has not caused any significant disease or deaths, this other, ignored epidemic has caused hundreds of youth to develop life-threatening respiratory failure and has been responsible for 13 deaths. What is this “other” vaping epidemic?It’s not vaping of e-cigarettes. It’s the vaping of marijuana. In my analysis of data from the 2018 National Youth Tobacco Survey, I found that the majority of youth who currently use e-cigarettes also report having vaped marijuana or THC vape cartridges.Specifically:Of ever e-cigarette users, 41.8% report having vaped marijuana or THC.Of current e-cigarette users (those who used in the past 30 days), 51.9% report having vaped marijuana or THC.Of regular e-cigarette users (those who used at least 10 days in the past 30 days), 63.1% report having vaped marijuana or THC.Of heavy and potentially addicted e-cigarette users (those who used every day in the past 30 days), 66.8% report having vaped marijuana or THC.While the CDC and many state health departments have focused on the fact that many youth are vaping e-cigarettes with “kid-friendly” flavors, they have all overlooked the fact that the majority of these youth are also vaping marijuana vape carts or vape pens with even more “kid-friendly” flavors, including:         "Apple Jacks,"          "Banana OG,"          "Birthday Cake,"          "Black Berry Kush,"          "Blue Dream,"          "Blueberry Kush,"          "Bubble Gum,"          "Candy Land,"          "Cherry Pie,"          "Cotton Candy,"          "Fruity Pebbles,"          "Gelato,"          "Grape Ape,"          "Grape Stomper,"          "Green Crack,"          "Honey Berry,"          "Honey Dew,"          "Ice Blue Raspberry,"          "Key Lime Pie,"          "Lemon Berry,"          "Lemon Head,"          "Lemon Slushie,"          "LSD,"          "Mai Tai,"          "Mango Kush,"          "Maui Wowie,"          "Mimosa,"          "Mojito,"          "Orange Chai,"          "Orange Cookies,"          "Orange Daiquiri,"          "Peach,"          "Pineapple Express,"          "Pot of Gold,"          "Purple Punch,"          "Rose Gold,"          "Russian Cream,"          "Sour Apple,"          "Strawberry Shortcake,"          "Sweet Aromatic,"          "Tangie,"          "Vanilla Kush,"          "Water Melon,"          "Wedding Cake," and          "Zskittlez."In fact, this year, marijuana use among college-age students reached a 35-year high! According to an articlein The Hill: “43 percent of full-time college students ages 19-22 reported using marijuana at least once in the previous 12 months. One-quarter of students reported using marijuana at least once in the last 30 days.” Both “the annual and 30-day "prevalence levels" are at historic highs since 1983.”"In particular, there was a dramatic increase in marijuana vaping during the past year: “The number of students who said they vaped marijuana in the last 30 days rose by 5.7 percentage points between 2017 and 2018, according to the study, with 5.2 percent of college students saying they vaped marijuana in 2017 compared with 10.9 percent of students who said the same in 2018. ‘This doubling in vaping marijuana among college students is one of the greatest one-year proportional increases we have seen among the multitude of substances we measure since the study began over 40 years ago,’ said John Schulenberg, principal investigator of the Monitoring the Future Panel Study."So while anti-nicotine groups obsess over cotton candy and bubble gum e-cigarettes, they have paid no attention to cotton candy and bubble gum THC vape carts, which are in fact far more dangerous.Original author: Michael Siegel

In an op-ed piece published by CNN last Friday, the president of the Truth Initiative bemoaned the "epidemic" of vaping among our nation's youth, arguing that electronic cigarette use leads to smoking. She cited research which shows "that young people who vape are more likely than their peers who don't vape to smoke traditional cigarettes in the future."And what does the Truth Initiative propose should be done to prevent a massive youth migration to cigarette smoking?A. Ban or severely restrict the sale of cigarettes.B. Ban or severely restrict the sale of both cigarettes and e-cigarettes.C. Neither of the above.The answer ...... C. Neither of the above.Instead, the Truth Initiative is calling for option D:D. Only ban flavored e-cigarettes, but leave cigarettes on the shelves, easily accessible to youth in every convenience store and gas station in the country.The Rest of the Story I'm sorry, but there is simply no justification for banning the sale of most electronic cigarettes but allowing real cigarettes, which kill more than 400,000 Americans each year, to remain on the shelves, almost completely unregulated.One of the major arguments that the Truth Initiative CEO offers to support her call for a ban on all flavored e-cigarettes is that when JUUL pulled its flavors other than mint and menthol from store shelves, youth simply switched to mint and menthol flavors. But if that's true, then shouldn't we be concerned that if flavored e-cigarettes are banned, youth will simply switch to tobacco-flavored e-cigarettes?If the Truth Initiative is genuinely concerned about youth vaping, then there is no justification for it failing to call for a ban on all e-cigarettes. By its own logic, leaving tobacco-flavored e-cigarettes will simply result in youth switching to tobacco-flavored e-cigarettes.OK, so you're thinking that kids are not going to switch from a candy- or fruit-flavored e-liquid to a tobacco-flavored one? Fine, but if that's the case, then it's even less logical to argue that kids are going to switch from fruit-flavored e-cigarettes to the harsh, tobacco-flavored real ones. You can't credibly make the argument that youth will avoid the tobacco flavor of e-cigarettes, but get hooked on the tobacco flavor of real cigarettes.The truth, of course, is that kids are not getting hooked on flavored e-cigarettes and then progressing to tobacco-flavored real cigarettes. They are using flavored e-cigarettes specifically because they want to avoid the health consequences that they all know are associated with the tobacco-flavored real cigarettes.So if youth are not going to switch from flavored e-liquids to tobacco-flavored e-liquids, what are they going to switch to?The answer is THC e-liquids, many of which are packaged in kid-friendly brands like "Apple Jacks," "Banana OG," "Birthday Cake," "Black Berry Kush," "Blue Dream," "Blueberry Kush," "Bubble Gum," "Candy Land," "Cherry Pie," "Cotton Candy," "Fruity Pebbles," "Gelato," "Grape Ape," "Grape Stomper," "Green Crack," "Honey Berry," "Honey Dew," "Ice Blue Raspberry," "Key Lime Pie," "Lemon Berry," "Lemon Head," "Lemon Slushie," "LSD," "Mai Tai," "Mango Kush," "Maui Wowie," "Mimosa," "Mojito," "Orange Chai," "Orange Cookies," "Orange Daiquiri," "Peach," "Pineapple Express," "Pot of Gold," "Purple Punch," "Rose Gold," "Russian Cream," "Sour Apple," "Strawberry Shortcake," "Sweet Aromatic," "Tangie," "Vanilla Kush," "Water Melon," "Wedding Cake," and "Zskittlez."These are precisely the black market products that have led to more than 800 cases of severe respiratory failure, most among young people, with 13 fatalities.The Truth Initiative's proposal to ban all flavored e-cigarettes would result in a shift from flavored e-liquids to the increased use of flavored e-joints, and it would make the current respiratory disease outbreak much worse, potentially resulting in more deaths. Does the Truth Initiative really want those severe illnesses and deaths on its hands?This is before we even get to talking about the effects that a flavored e-cigarette ban would have on adults, which include a mass return to cigarette smoking or entrance into a new black market for flavored e-liquids, which might eventually result in an even worse disease outbreak in the future, since the number of adults using these products and thus subject to any contaminant that may arise in these black market products will be immense. The Truth Initiative has apparently written off adult smokers completely at this point. The op-ed views them as being expendable: "the current environment is not about providing well-regulated e-cigarette technology for adult smokers who otherwise won't quit." This is a complete betrayal of a central part of the mission of the Truth Initiative, which was to "reduce tobacco use" by "increasing successful quit rates, and reducing disparities in access to prevention and cessation services."The rest of the story is that the Truth Initiative has steered away from its original mission and its policy proposal to ban flavored e-cigarettes would severely harm the health of both youth and adults across the nation.There is a better alternative, and it involves Option B above; specifically, restrict the sale of all tobacco products, including cigarettes and e-cigarettes to stores that can only sell these products and are only open to people ages 21+. Ironically, it is the nation's vape shops and most of the vaping industry -- and not health groups -- that are pushing for such a policy change.Original author: Michael Siegel

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In response to two deaths that it says were attributable to vaping cannabis purchased from legal state dispensaries and three additional cases that were linked to cannabis products purchased from state dispensaries, the Oregon Health Authority is recommending that all nicotine-containing (non-cannabis) electronic cigarettes should be banned for six months.According to an article by Oregon Public Broadcasting: "Officials with the Oregon Health Authority recommended Gov. Kate Brown ban vaping products in the state for six months, following a second vaping-related death Thursday." This recommendation is for a ban on all vaping products, both THC and nicotine e-liquids.Later in the same article, we learn that: "the most recent death followed the same pattern as past cases: an adult, who experienced severe respiratory injuries after vaping cannabis products purchased from a licensed retailer." And in an article published in the Salem Reporter, we learn that all five of the reported cases in Oregon are associated with the use of "licensed cannabis products." The Oregon state health department warned the public against any vaping: "At a press conference Thursday announcing the latest death, health officials were adamant: No one in Oregon should still be vaping. “No level of vaping is safe,” Sidelinger said. “With these acute respiratory injuries and deaths, we do urge all individuals to stop vaping, whether that’s nicotine-based products, cannabis products or other products.”"The state health officer closed by saying that: "With the root cause of these vaping-related illnesses still unknown, Sidelinger said it’s likely health officials are going to see “increased number of cases and, tragically, more deaths.”"The Rest of the StoryActually, the reason that health officials are going to see increased number of cases and more deaths is not that the root cause of these vaping-related illnesses is still unknown, but because the root cause is known but officials like Dr. Sidelinger are disregarding this critical information.Even after the CDC has finally admitted that vaping THC, potentially contaminated with vitamin E acetate oil, is the chief culprit in the outbreak, and even after the Oregon Health Authority itself admits that all five of the state's outbreak cases are associated with the vaping of cannabis products purchased from state dispensaries, the Oregon state health department is still ignoring, undermining, and hiding that critical information from the public by claiming that we still have no idea what is going on and that people should stop vaping anything, no matter the situation, no matter what the ingredients are, no matter how long they have been using these products without a problem and without changes in their ingredients, and no matter where they are obtaining those vaping products.The health department's warning is so vague and so general that people - especially young people - are not going to take it seriously.By not issuing an explicit warning against vaping marijuana, the Oregon Health Authority is hiding critical information and undermining the known role that THC vape cartridges are known to be playing in this outbreak. And that is going to lead to people, especially youth, continuing to vape marijuana as the warning is just not specific enough.In fact, the health warning issued by the Oregon Health Authority specifically mentions not vaping e-cigarettes, but does not specifically caution against vaping THC vape cartridges.This all-too-vague warning is irresponsible not only because it is going to make the outbreak worse, not better, but because it is also going to cause enormous health damage to former smokers in the state who have quit smoking by switching to electronic cigarettes. The health department is telling them in no uncertain terms to discontinue the use of their e-cigarettes, which is tantamount to telling them to go back to smoking.Ironically, after the first death in Oregon occurred and was linked to THC vaping of a product purchased at a licensed state dispensary, the Oregon Health Authority decided not to close down the two dispensaries whose products were implicated, defending its decision by arguing that it would be unfair to close down a business without clear evidence that its products were implicated.According to an article in Willamette Week:"Jonathan Modie, spokesman for the OHA, says just because the person bought products from these two stores doesn't mean it was necessarily the stores' products that killed the person."It doesn't necessarily mean the individual got sick from products that they had purchased at these dispensaries, we just know that the individual shopped at a couple of dispensaries prior to getting ill," says Modie. "We're still waiting to get samples of the products and then we send that off for testing." "When WW asked if it wouldn't be better to shut down a store that potentially sold a lethal product to a customer, Modie replied, "How do you think the dispensary operator would feel if it turned out that the product wasn't theirs? We wouldn't want to name or point to a specific dispensary before we have all of the information that says unequivocally that that was the dispensary where the product was sold that made the individual sick," says Modie."So let's get this straight: When the Oregon Health Authority had a direct link between a death from the outbreak and cannabis vaping cartridges purchased at two dispensaries that they regulate, they emphasized that they didn't want the dispensary operators to feel bad if it turned out that the product wasn't responsible for the death, but weeks later - when it appears much clearer that vaping marijuana and not store-bought nicotine e-liquids is the primary culprit in the outbreak - they are perfectly OK with shutting down every vape shop in the state, even the hundreds that don't sell THC vape cartridges in the first place and whose products have not been implicated in the slightest way. There is now even more evidence that THC vaping products are playing a major role (if not the only role) in the outbreak. Iowa has now reported that of 23 cases in the state, 18 patients have admitted to using THC vapes. Officials in Texas have now reported that at least 75% of the case patients in that state have admitted to vaping THC. And it has now been revealed that the death reported in Indiana, which was previously not attributed to any particular product, was associated with THC vaping.Thus, every death for which information has been released about the products used has been associated with vaping marijuana. And more importantly, every single reported case in Oregon has been associated with vaping cannabis purchased at state dispensaries.The rest of the story is that the Oregon Health Authority appears to have a vendetta against nicotine-containing e-cigarettes, and it is going to great lengths to protect marijuana dispensaries that it regulates and whose products appear to be responsible for two deaths and three life-threatening cases, while attacking retail stores and vape shops whose products have not been implicated with even the slightest bit of evidence.In some ways, the Oregon Health Authority actually bears some responsibility for these two deaths because it apparently failed to properly regulate the state's marijuana dispensaries. It appears that the health department failed to require testing of dispensary vaping liquids for vitamin E acetate oil and other cutting agents. This is what led to the sale of an oil-based e-liquid that should never have been on the shelves in the first place. Rather than pointing the finger at every retail store and vape shape in the state that is selling water-based e-liquids, the Oregon Health Authority should first be pointing the finger at itself and apologizing to the victims' families for not properly regulating the state's marijuana dispensaries and allowing them to sell oil-laden THC liquids that have no business being sold anywhere.Original author: Michael Siegel

The CDC has finally admitted that black market THC vape carts are a major culprit in the respiratory disease outbreak that has affected 805 people and resulted in 13 deaths. Instead of continuing to emphasize that "no single product" is linked to all the cases, the CDC clearly stated yesterday that "THC is the most prominent link across patients" and the agency changed its warning to specifically mention THC: "While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC."Because of the CDC's long overdue acknowledgment of the primary role of illicit THC vape carts, newspaper headlines are finally telling the story like it should be told. For example, the headline of an article in the Regina Leader-Post reads: "CDC recommends against using vapes with THC due to lung illnesses." An article by NASDAQ is entitled: "U.S. CDC recommends against using vapes with marijuana ingredient." And the headline of a New York Times article reads: "Dank Vapes, TKO and Other THC Vaping Brands Are Linked to Illnesses, C.D.C. Says."These are the kinds of clear, specific messages that we should have seen in newspapers two months ago.In an emergency MMWR publication, the CDC reported that of cases in which there was information on the products used, 84% of patients admitted to vaping THC. But in contrast to previous publications, instead of immediately undermining this important finding by emphasizing that "no single product" can be linked to all the cases, the CDC instead emphasized that there are multiple reasons why many patients might not report using THC even if they did: "patients might not always know what substances they use or might be hesitant to reveal use of substances that are not legal in their state."In a separate article covering patients from Illinois and Wisconsin, the CDC revealed that: "Use of tetrahydrocannabinol (THC)-containing e-cigarette products, the majority of which were prefilled cartridges obtained from informal sources, was reported by 87% of patients during the 3 months preceding illness." Importantly, CDC finally admitted that: "the predominant use of prefilled THC-containing cartridges among patients with lung injury associated with e-cigarette use suggests that they play an important role."The CDC also reported that: "In Wisconsin, eight patients initially denied using THC-containing products in interviews, but five (63%) were later found to have used THC through review of medical charts, reinterview, or cross-referencing with friends who were also interviewed as patients."Finally, the CDC finally provided very specific information about the black market THC vape carts that were used: "Although no single brand name was reported by all patients, a prefilled THC cartridge sold under the brand name Dank Vapes was reported by 57 (66%) patients. In Wisconsin, two groups of friends (two patients in one group and three in the second group) who became ill after using THC-containing cartridges specifically reported sharing Dank Vapes cartridges. Dank Vapes was the only e-cigarette product reported by one of the patients."The Rest of the StoryI checked my blog and Twitter feed to determine when I first issued an explicit warning for people to avoid vaping black market THC vape cartridges. I issued such a warning on my blog on August 25th and on Twitter the same day. On August 28th, I tweeted the following: "The CDC isn't warning the public, so I'll do it myself: PLEASE do not vape THC oils that were purchased from any unlicensed seller. And spread the word to youth who might be at risk. Hiding the truth is not an effective public health strategy."It took five weeks (35 days) after my warning before the CDC finally announced the major role of THC vape carts in the outbreak. During those 35 days, how many young people continued to use THC vape carts who might have stopped if the CDC had announced this connection 35 days earlier? How many people developed respiratory illness because of this failure? Now that it is clear that the outbreak is not being caused by store-bought electronic cigarettes, but by THC vaping cartridges and perhaps other counterfeit black market products, it is critical that the five states which have banned e-cigarettes or flavored e-cigarettes (Massachusetts, Rhode Island, Michigan, New York, and Washington) rescind these bans and focus on limiting the illegal distribution of THC vaping products.Original author: Michael Siegel

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The CDC has irresponsibly botched its entire investigation of vaping-associated respiratory illness (VARI) by failing to recommend or demand that clinicians perform a urine THC drug test on every case patient, and this is putting the entire nation at risk while leading to terrible public policies that are causing immediate harm to thousands of people.The CDC continues to insist that we have no idea what is causing this "mystery illness" and that "no single product" has been identified that explains all of the cases. This statement, which violates basic principles of epidemiological outbreak investigations, is the single communication that has confused policy makers and the public and hindered the ability of state health agencies to issue appropriate recommendations to the public to actually curtail this epidemic of life-threatening respiratory failure.Contrary to what the CDC seems to be insisting, this outbreak is not going to be solved by identifying a single product common to every patient. Like all outbreak investigations, it is going to be solved by identifying a type of product that is common to an overwhelming majority of patients. And frankly, we already have that and it's called marijuana. There is just far too high a proportion of case patients who have admitted to using THC or CBD oils for this to be merely a coincidence.Just overnight it was announced that a second Oregon patient has died. The reported cause? Vaping of THC oils. Of course, this didn't stop the Oregon Health Authority from recommending that Oregonians stop vaping nicotine-containing e-liquids. This non sequiter is striking: "A second Oregonian has died from a lung illness after vaping cannabis products, and state health authorities Thursday urged people to immediately stop using all vaping products." This is like reporting a series of deaths from eating Romaine lettuce and advising people to immediately stop eating all lettuce and cabbage. Except it's a lot worse because no harm comes from people stopping eating cabbage. Severe harm is already resulting from ex-smokers stopping vaping and returning to smoking or to the black market.There are simply too many cases of patients who were vaping for years without a problem and then decided to try THC vape carts and then suddenly getting sick to dismiss the central role of marijuana vaping in this outbreak.So why aren't the CDC and in turn, state health authorities issuing very clear warnings to the public to stop vaping marijuana, especially THC vape pens or vape carts that are purchased on the street?It's because the CDC keeps repeatedly issuing the irresponsible mantra of this botched investigation: "No single product" has been linked to all cases. While I was working at CDC, I was not aware of a single Epi-Aid in which a single exposure was linked to all cases of an outbreak. There are always going to be a small proportion of people who forgot that they did have a little potato salad at the church picnic. And in this investigation, the problem is far worse. There are no legal implications and no stigma attached to admitting that you ate some potato salad. But for a youth to admit that they were using illicit marijuana vaping carts purchased off the street from drug dealers could have substantial consequences, not only legal ones but stigma-related ones as well as affecting their relationships with their parents.The CDC itself admits that about 80% of the outbreak patients admit to using THC oils. My count from media reports puts that figure closer to 90%. How high does that proportion have to go before the CDC issues a clear recommendation not to vape THC and stops undermining its own findings by emphasizing the failure to find a common product in every single case? Apparently, it's 100% before they will take the appropriate actions and enable health authorities to put an end to the tremendous morbidity and mortality this outbreak is causing.The Rest of the StoryThe sentinel failure of the CDC in investigating this outbreak is its failure to recommend or demand that all case patients be screened (via urine drug testing) for THC. In people who vape marijuana regularly, THC can be detected in the urine for at least 4-6 weeks following the last exposure. Even in people who don't vape marijuana regularly, THC can be detected for between 7 and 10 days after the most recent use. This is not going to be 100% sensitive in detecting all THC use but it would certainly help detect a large proportion of the cases where a patient is using THC but did not report it.Even if a small proportion of patients were screened for THC, it would provide valuable information.  The recommendation to test for THC does not need to be justified based on the premise that youth patients are "lying" about their drug use:1. There are thousands of counterfeit products on the market that are packaged to look like legitimate nicotine-containing products but which may contain cheaply made THC oils. There are even counterfeit JUUL-compatible pods that appear to be JUUL but are actually bootleg products and could contain THC oils. So youth may simply have no idea that they are using THC. This alone makes it inexcusable for clinicians not to test for THC in every patient.2. Many youth simply don't know what they are vaping in the first place. Data from the Monitoring the Future study and other national surveys reveal that youth are unable to accurately report what they are vaping. They may not actually know what is in the cartridges that they are using. Youth are most commonly obtaining their vaping liquids from other kids at their schools, not directly from a retail store. So they are not getting an ingredient list or being told exactly what is in the liquid. They truly may not be aware of exactly what they are vaping. Under these circumstances, it is bordering on public health negligence for the CDC not to recommend that patients be screened for THC use.The CDC has been insisting that a small proportion of cases have occurred among patients who did not use THC. The truth is that they have no way of knowing that. Unless the patients have been tested for THC, it simply cannot be said that cases have occurred among patients who only used nicotine-containing e-liquids. This is why I believe it is so irresponsible that the CDC has repeatedly given the impression that it knows that a substantial proportion of cases do not involve THC. They actually have no way of verifying their contention that "no single product" ties together all the cases. It is entirely possible that a single product - marijuana and counterfeit vapes - does tie together all the cases.The CDC's failure to conduct this investigation properly (as outlined above) is not only putting the entire public at risk because we are failing to properly communicate the role of black market THC vape carts, but it is also leading to bad public policy that is already having devastating public health consequences as well as putting hundreds of vape shops out of business and creating massive job loss and financial harm for small business owners.The final question that I want to tackle in this commentary is why the CDC is failing to recommend THC testing of every case patient. There is no legitimate public health justification for this failure. The only explanation is that the CDC does not actually want to tie all the cases together by detecting marijuana use in a large proportion of patients who reported using only nicotine-liquids because that would let legally sold, store-bought nicotine-containing e-cigarettes off the hook. The CDC's actions tell me that they actually desire to be able to tie these cases to traditional e-cigarette use. They are apparently going to hold out as long as possible before admitting clearly that THC carts are playing a major role in this epidemic.The CDC's irresponsibility is perhaps best demonstrated by the testimony of a CDC deputy director at this week's Congressional hearing. She testified that one possible cause of the outbreak is something about the act of vaping itself. In other words, she testified that something about the process of vaping itself may be causing this outbreak, rather than the specific products that are being vaped.Sorry - I hate to have to use this type of language but my conscience does not allow me to express it any other way:This is complete bullshit.People have been vaping for the past 12 years without any problems. Millions of smokers who quit smoking by switching to vaping have experienced dramatic improvement in their respiratory health, not rapid progression to respiratory failure. The act of vaping is not causing this outbreak. It is something in the e-liquid or that results from the heating of the e-liquid that is responsible. At an August 23rd press briefing, one CDC official had this to contribute to a reporter's question about why there has been an upsurge in cases: "We do know that e-cigarettes do not emit a harmless aerosol."Instead of that meaningless observation, the official could have instead explained that one major change we do know about is the use of a new thickening agent that had not been used previously - vitamin E acetate oil - and could have pointed out that the overwhelming majority of cases were associated with vaping black market THC cartridges. But he was apparently more concerned about creating the perception that e-cigarette companies continue to insist that their products are harmless and then attacking this straw man than actually providing a useful answer to the question.I get the idea that the CDC really doesn't know anything about vaping. They keep talking about it as if it is some great "mystery" and we don't have any clues about what may be going on. The truth is that we have an immense amount of information, but they are just not putting it together. They keep discounting the information that they do have. The cannabis experts actually know far more about the outbreak and its potential causes than the CDC does. In fact, some cannabis experts actually predicted this outbreak before it occurred because of the changes they were observing in the production of black market THC vape carts and the counterfeiting of legitimate products that they observed.Although I'm convinced that the CDC's failure to recommend THC testing, its failed communication on the potential causes of the outbreak, and the actions of policy makers to ban electronic cigarettes are all contributing towards making the outbreak worse by obscuring the potential role of marijuana vaping, it is not too late to prevent further deaths by initiating THC testing of case patients. I hope that the CDC will institute this recommendation immediately.Original author: Michael Siegel

Today, I am bypassing the usual rulemaking process and using my emergency powers to declare a public health emergency and accordingly, I am issuing a four-month, temporary ban on politicians enacting further electronic cigarette bans.The purpose of this public health emergency is to temporarily pause all knee-jerk reaction e-cigarette bans so that we can work with our vaping and cannabis market experts to identify what is actually making people sick and how to better regulate these products to protect the health of our residents without putting thousands of small business owners out of work, forcing thousands of ex-smokers to return to smoking, and creating a massive new or expanded black market for illicit THC and nicotine e-liquids.Why is This a Public Health Emergency? This is a public health emergency because starting today, ex-smokers in Massachusetts began a wholesale return back to smoking tobacco cigarettes as the stores carrying the electronic cigarettes which were keeping them away from smoking were boarded up and emptied of merchandise, causing tens of thousands of dollars of lost expenditures and putting hundreds of vape shops out of business. I have already heard many stories of ex-smokers who today lit up their first cigarette in months or years, thanks to the governor and the Public Health Council's ban on the sale of electronic cigarettes. In addition, I have already heard many stories of medical marijuana patients who are now turning to dangerous, unregulated, black market THC vaping products because they are unable to switch to combustibles or edibles for medical reasons.Furthermore, hundreds of smoking cessation clinics (i.e., vape shops) have boarded up their windows, eliminating in one fell swoop one of the most successful anti-smoking interventions in the state of Massachusetts.Worst of all, with the elimination of nicotine-containing e-liquids, youth are going to begin switching over to illicit THC vaping carts which are associated with most of the cases of severe respiratory failure that are sweeping the country.In addition, since public health officials have told us that youth vapers are at high risk of transitioning to smoking (e-cigarettes are a gateway to smoking, they say), it is a public health disaster for real cigarettes to remain on the shelves of convenience stores, gas stations, and pharmacies while electronic cigarettes are nowhere to be found.Reason for Temporary BanI am issuing a temporary ban on further e-cigarette bans for 4 months so that it provides enough time to educate policy makers about what we already know regarding the probable causes of the respiratory disease outbreak, information that the CDC has been hiding from health officials and the public for several weeks.Since the agency readily admits that no fewer than 80% of the cases are associated with the use of black market THC vape carts and in states that have tested the THC vape carts that have been recovered, between 90% and 100% of those carts were "contaminated" with vitamin E acetate oil, there is no justification for shutting down stores selling nicotine-containing e-liquids whose only ingredients are propylene glycol, glycerin, water, nicotine, and flavorings, all of which have been around for years and not caused any problems. It will take 4 months to educate public officials about the differences between a water-based e-liquid and an oil-based e-liquid and the fact that oil-based e-liquids are the ones that are causing lipoid pneumonia.The ban will be rescinded in four months, after which time I reserve the right to use a formal rule-making process to permanently remove e-cigarette bans from the marketplace of stupid policy proposals should the facts of the situation not sink in.Criminal Proceedings Against Illicit Drug DealersUnlike Governor Baker's emergency order, which leaves illicit drug dealers off the hook, my emergency order is going to go after the source of the products that are causing so many young people to suffer life-threatening respiratory illnesses. My order also includes an injunction so that vape shops can remain open to continue to save the lives of thousands of Massachusetts residents who are depending on e-cigarettes to remain smoke-free and much healthier than they were when they smoked tobacco cigarettes.Legal cannabis dispensaries and medical marijuana providers will be allowed to continue to sell legal, regulated cannabis vaping products, but only after certifying that the products were manufactured safely and without any vitamin E acetate or non-cannabis oils.PenaltiesAs in Michigan, the penalty for violation of this emergency order will be $200 per ex-smoking vaper who is forced to go back to smoking or to turn to the black market and up to six months of jail time. Lawmakers will also be liable for four-months worth of revenues for each vape shop that shuts down in their state to any enacted e-cigarette or flavored e-cigarette bans.Reaction from the National Lung Association"In the absence of strong federal action especially by the FDA, states are being forced to make decisions to protect the health of children and adults from an electronic cigarette-ban-related public health emergency," said the National Lung Association National President and CEO. "The Rest of the Story's announcement reinforces the need for the FDA and CDC to confront the illicit production and distribution of oil-laden THC vape carts and bootleg or counterfeit "nicotine" cartridges that are being sold on the black market or through shady internet sites. While the Centers for Disease Control and Prevention and state and local departments of health continue to investigate the hundreds of cases of lung injury from black market vape cartridges, the National Lung Association once again urges all Americans to stop using cigarettes and to stop vaping marijuana unless it is purchased from a legal dispensary that has certified the absence of added oils, such as vitamin E acetate oil."Disposition of Legislative Proposals and Bills Currently Under ConsiderationBecause this is a temporary ban, at this time politicians are not being asked to destroy their bills, however, the bills need to be taken off of the shelves immediately.Original author: Michael Siegel

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Yesterday, the governor of yet another state - Rhode Island - announced that he would be directing the Department of Health to ban the sale of all flavored e-liquids. This now makes four states which either have banned or will imminently ban the sale of either all nicotine-containing e-cigarettes or all flavored, nicotine-containing e-cigarettes. This, along with the resignation of the CEO of JUUL, gained widespread media attention yesterday, dominated on the air waves only by a presidential impeachment inquiry.What flew off the radar screen and is being completely ignored by those very same politicians who are banning nicotine-containing e-cigarettes is that yesterday, authorities in both Virginia and Minnesota conducted raids on makeshift residential marijuana vaping product manufacturing facilities and seized more than 76,000 illegal THC vape carts - the products that are almost certainly responsible for most of the hundreds of cases of severe, acute respiratory disease that are occurring across the nation.In Virginia, officials seized more than 1,000 "Dank" vape cartridges which have been linked to at least some cases of the respiratory illness. Since these cartridges typically sell for about $35, the estimated street value of the seized products is more than $35,000.In Minnesota, officials seized more than 75,000 illicit THC vape carts, "in flavors like Fruity Pebbles, Cherry Kush and Candy Land."The Rest of the StoryIt is telling that while drug enforcement authorities are actually starting to get to the root of the problem by interfering with distribution channels of the illicit THC vape carts and counterfeit or bootleg "nicotine" vaping cartridges that appear to be causing the vaping-associated respiratory disease outbreak, politicians are instead trying to win political points by putting hundreds of small businesses - vape shops which are essentially smoking cessation clinics - out of business.As I have emphasized, this is not going to curtail the outbreak. It is going to make it worse. My opinion echoes that of former FDA commissioner Dr. Scott Gottlieb, who in recent days has been outspoken in pointing out the folly of the CDC's communications as well as policy makers' responses to the outbreak.As Dr. Gottlieb wrote yesterday: "Reading transcripts, it seems there’s too much conflating these tragic lung injuries with store bought brands of regulated, legal e-cigs like Juul and NJOY; and far too little blaming THC, CBD, and bootleg nicotine vapes - where so far, the only available hard evidence points."Sadly, Dr. Gottlieb appears to be the only (former) public official who knows what he is talking about because he actually knows something about the vaping industry. If he were still the commissioner, we would probably not be in the unfortunate situation we are today.Instead of going after flavored nicotine e-liquids sold legally by retail stores, policy makers should be going after the attractive, flavored, bootleg THC vape carts - in flavors like Fruity Pebbles, Cherry Kush and Candy Land - that are being sold and distributed to our nation's youth on the black market by drug dealers.By diverting attention away from the real problem, policy makers are actually making the problem much worse. There are going to be more severe illnesses and deaths, not fewer, because of these misguided and completely unjustified electronic cigarette bans. If you really want to have a better understanding of the true nature of the problem, read this article by the folks at Leafly. In my opinion, they are the ones who should be conducting the outbreak investigation, not the CDC which has already completely botched the investigation and the communication of the truth to the public.Original author: Michael Siegel

In a move that is a huge victory for the state's drug dealers, Massachusetts Governor Charlie Baker has instituted a 4-month ban on the sale of all vaping products in the state, including both nicotine-containing electronic cigarettes sold at retail stores and vape shops and cannabis vaping products sold at legal cannabis dispensaries. The ban, which was approved by the state Public Health Council on Tuesday, goes into effect immediately and was motivated by the recent emergence of an outbreak of vaping-associated respiratory illness (VARI) that has affected more than 530 people across the United States and has resulted in nine deaths.The primary suspected cause of this outbreak of severe, acute respiratory failure which often takes the form of lipoid pneumonia or an eosinophilic chemical pneumonitis is the widespread black market sale of illicit marijuana vape cartridges, many of which contain a viscous oil that is used as a thickening agent to help drug dealers obtain a higher price for the THC vape carts they are selling. There were recently two major drug busts which recovered thousands of oil-laden THC vape carts, and testing of THC vape carts provided by numerous case patients in New York State revealed that all of them contained high levels of vitamin E acetate oil, the thickening agent that has recently come into widespread use by illicit drug manufacturers (as well as some legal manufacturers).Although the CDC has misled the public into thinking that nicotine-containing e-cigarettes like JUUL are causing the outbreak, the application of basic epidemiology principles should tell us that this cannot be the case. Since JUUL and many other nicotine-containing e-cigarettes sold at retail stores have been on the market for at least several years, it does not make sense that we would all of the sudden see these products causing severe respiratory failure. Moreover, since there are millions of adult JUUL users, we would be seeing a lot more adult cases of this disease if it were being caused by JUUL or similar products.Clearly, whatever is going on is affecting primarily youth and primarily males. What kind of vaping products are used primarily by youths? The answer is black market products. Since adults can legally access cannabis vaping products in states with legalized recreational or medical cannabis, it is primarily going to be youth who use the black market THC oils that are being distributed by the drug dealers.The strongest evidence that the primary culprit is black market THC oils is the fact that the most common presentation of the illness is a lipoid pnemonia. This is a disease that is known to be caused by oil inhalation. Virtually all, if not all, nicotine-containing electronic cigarettes sold at stores are made with water/alcohol-based e-liquids, which do not cause lipoid pneumonia. In contrast, the THC vape carts that are in wide circulation are loaded with a viscous oil. When this oil is heated and then cools when it reaches the lungs, it solidifies and basically cakes the alveoli and also induces severe inflammation (as the body's immune cells try to get rid of the oil). This explains the typical radiographic appearance in the cases, which is actually part of the case definition. If there are any nicotine-containing e-liquids that are using an oil-base, they are almost certainly being sold online, not by retailers or vape shops. But Governor Baker's order focuses on the latter.The Rest of the Story So why, in the face of this severe epidemic of respiratory disease that has been associated with the widespread use of oil-laden THC vape cartridges sold on the black market, is the governor banning the sale of legally produced and sold nicotine-containing e-liquids that have not been confirmed to be causing any cases?The answer, I believe, is that this is an easy political victory. It looks great to upper middle class suburban parents (voters) that politicians are stepping in to protect their children. And it takes no political courage to go after hundreds of small business owners who don't have the political power to put up a legal fight. It would be far more difficult to actually confront the real problem, which would require the governor to go after the drug dealers who are distributing illicit THC vape carts that are winding up in the hands of youth throughout the state.Sadly, Governor Baker's action is going to make this problem much worse, not better. Eliminating nicotine-containing e-liquids is not going to prevent further cases from occurring because those are not the products which appear to be causing the outbreak in the first place. Moreover, the kids who are selling e-liquids in our middle schools and high schools are not going to simply shut down their operations. They are going to switch over to selling the e-liquids that remain available, which will be the black market THC vape carts that are actually causing this outbreak.This emergency order is also going to have other severe adverse health consequences. It is going to shut down hundreds of vape shops which are literally life-saving businesses: they are helping tens of thousands of smokers to quit smoking and to remain off of cigarettes. Essentially, vape shops are smoking cessation clinics. Most of the owners have themselves quit smoking by switching to e-cigarettes, and they can provide personal advice and counseling to their customers. This is much more effective smoking cessation counseling than most physicians can provide. And that's why it's been so widely successful.Don't be fooled. A four-month temporary suspension of e-cigarette sales is, for most small businesses, a permanent ban because they are going to have to shut down. Most small businesses can simply not survive having no revenue for four months. And if they have a large supply of e-liquids in inventory, they could be out hundreds of thousands of dollars. They will never recover.This ban is also going to lead many ex-smokers to return to smoking as their e-liquids disappear and it becomes too inconvenient to obtain them. In addition, this order is going to create a new, unregulated black market for e-liquids.But the worst outcome, by far, will be the misdirection caused by this move. It takes our attention off the widespread problem of marijuana vaping among middle and high school youth in Massachusetts. That is the public health emergency we face, but apparently, we're not willing to face up to it because it's a lot more politically expedient to go after small businesses than drug dealers.Original author: Michael Siegel

Two weeks ago, detectives with the Maricopa County Drug Suppression Task Force busted an illegal THC vape cart operation in Phoenix. They found more than 1,000 THC vape carts worth an estimated $55,000 along with a butane hash oil manufacturing lab and 300 pounds of mid-grade marijuana used to manufacture butane hash oil. The vape carts they found were packaged as the "Dank" brand, which has been associated with some of the recent vaping illnesses and deaths.This is at least the second bust of an illegal THC vape cart manufacturing facility in as many weeks, as Wisconsin drug enforcement officials raided a similar operation in Kenosha County and found more than $1.5 million worth of illegal THC vape cartridges.The CDC continues to claim they we don't yet know whether black market THC vape cartridges are involved in the outbreak at all, insisting that "We do not yet know the specific cause of these lung injuries." Instead of explicitly warning youth in no uncertain terms that THC oils are causing deaths, the CDC continues to invoke legally sold electronic cigarettes and to warn against any use of electronic cigarettes at all.The CDC's official recommendation remains: "If you are concerned about these specific health risks, CDC recommends that you consider refraining from using e-cigarette or vaping products."The Rest of the StoryGiven the fact that close to 90% of cases and 100% of the deaths for which products have been reported are associated with marijuana vaping, it is inexcusable that the CDC fails to distinguish between the products being vaped. It is also inexcusable that CDC has failed to distinguish between the vaping of oil-based e-liquids (which are typically used in TC carts) and water/alcohol-based e-liquids (as are used in virtually all e-cigarettes).The scare that CDC has caused is associated with a sharp decline in e-cigarette use and in fact, financial analysts are predicting that we are going to see an increase in cigarette consumption, especially if policy makers follow through with their plans to ban flavored e-cigarettes.Even worse, there is no doubt in my mind that the CDC's botched warning is leading to more cases of severe respiratory illness. Youth are reportedly getting scared of e-cigarettes and are destroying JUUL pods, but they don't appear to understand that vaping marijuana is the real severe risk here.Dr. Stan Glantz today tweeted that propylene glycol and glycerin might be the cause of the respiratory disease outbreak. This is ridiculous. These excipients have been used in e-liquids for the past 12 years without a problem. Moreover, if PG/VG were the problem, then there would be a huge number of cases occurring among adults, much less of a differential by gender, and much less of an age gradient in the reported cases.The most important fact that is being ignored is that the bulk of these cases are presenting as lipoid pneumonia. Exogenous lipoid pneumonia is caused by oil inhalation. PG/VG are not going to cause an outbreak of lipoid pneumonia. But the widespread use of THC oils, which is running rampant among youth, could very well be causing this outbreak.We don't have all the facts we need, but the pieces are all starting to fit together. And we know enough right now to explicitly warn youth against vaping marijuana. I remain convinced that the CDC's conflation of the problem of youth e-cigarette use and the problem of this respiratory disease outbreak is going to have devastating public health consequences.Original author: Michael Siegel