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By Lisa Profera MD

For many years, vaping has been touted as a safer alternative to smoking cigarettes. In the fall of 2019, the “vape crisis” hit the media when a significant number of people experienced serious and (sometimes deadly) lung damage due to vaping. 

“Vaping” is slang for the practice of inhaling tobacco or other plant-based substances via a portable device (e-cigarette) that produces an inhalable vapor or aerosol by heating it up. The problem is that most of the liquid oils (e-liquids) that are vaporized also contain additives, flavorings, and/or other solvents that are potentially harmful.

Everyone knows that smoking cigarettes causes cancer. Nicotine alone, although highly addictive, does not cause cancer. When e-cigarettes were first introduced in 2003, they were marketed as a safer alternative to smoking cigarettes for people already addicted to nicotine. Unfortunately, the marketing extended to non-smokers, and a new, younger generation of people became dependent on vaping nicotine. Additives and flavorings enhanced palatability, increasing the appeal of e-cigarettes. Specific brands and flavors targeted young people in the past several years and usage increased exponentially around the world.

There is no safe tobacco product; nicotine, however “pure” the delivery system is, is still a highly addictive substance with its own set of effects and side-effects on several body systems (nervous, endocrine, gastrointestinal, and cardiovascular). Like heroin and cocaine, it causes a surge in dopamine levels, which affects pleasure and reward responses in the brain. Once the effects wear off, the user wants more. Nicotine also reduces anxiety through the release of beta-endorphin. There are certainly safer ways to obtain positive effects on brain neurotransmitters. 

The performance of vape devices can vary widely; most are made in China. Many vape pens work with a battery that powers a heating element. Some of these devices not only vaporize the e-liquid, they reach high enough temperatures to combust it. These higher temperatures can convert chemicals such as solvents, flavorings, and other additives into potentially harmful substances. Heavy metals and other toxins can also be present as contaminants.

There are several different types of vaping devices. Some use convection or combustion of dry plant material, and others heat up and aerosolize the e-liquid. Even though investigators at the CDC suspect the lung injury to be caused by chemicals in the e-liquid, they are still recommending that people refrain from any type of vaping until they have more information.

For several years, we have known about the presence of certain harmful chemicals in vape cartridges. Historically, the three main culprits have been diacetyl, polyethylene glycol (PEG), and propylene glycol (PG). The new kid on the block, the substance causing the very severe lung disease that caught the attention of the media and the CDC, is vitamin E acetate — more on that later.

Diacetyl is an organic compound with a buttery taste — it’s a common flavoring used in the popcorn industry. It is also present in some foods and alcohol, but we typically don’t inhale it. When added to vape products it offers an appealing flavor, but it is also heated and inhaled into the lungs. 

PEG and PG are used as thinning agents in nicotine and marijuana vape cartridges. These chemicals are also found in many household items such as cosmetics, baby wipes, hair sprays, and pet food. After heating and inhalation, the PG cools down deep inside the lungs. As it cools, it can polymerize, and form deposits that act as plastic-like plugs inside the bronchioles, causing irreversible lung damage. It’s commonly used in antifreeze. 

PEG is the active ingredient in the popular laxative Miralax. When heated to a temperature of 480º F, PEG undergoes a chemical reaction and becomes acrolein (propenal). Both acrolein and diacetyl are known to cause lung damage and are potential carcinogens. Thus, one can argue that e-liquids containing these chemicals are no safer than smoking regular tobacco cigarettes.

We know from the experience of the popcorn industry that PEG and diacetyl are linked to a debilitating lung condition called bronchiolitis obliterans, also known as “popcorn lung.” This is a serious, irreversible disease caused by direct injury to the bronchioles (the smallest airway passages in the lungs). It was first documented as many workers in popcorn-making facilities started to develop this uncommon condition more frequently than what had been documented in the general population. Although these chemicals were identified as being potentially harmful in the popcorn industry, they are being used in the vape industry. Concerns about these chemicals in e-cigarettes were expressed to the FDA (Food and Drug Administration). In July of 2017, the FDA decided to delay investigation into the e-cigarette industry until 2022, despite opposition from the American Lung Association. 

Fast forward to late summer 2019, when an unusually high number of people were experiencing severe respiratory compromise due to vaping — most notably, a condition called EVALI (e-cigarette- or vaping-associated lung injury). The initial symptoms of EVALI are common in many other respiratory diseases and may be difficult to diagnose immediately. Patients can present with cough, shortness of breath, chest pain, and gastrointestinal symptoms. Other symptoms that may occur are fever, chills, and weight loss. Severe symptoms and/or hypoxia (low oxygen saturation) warrant hospitalization. Respiratory failure and death occurred in some patients.

As of late November 2019, there were over 2,200 cases of EVALI and 47 deaths, according to the CDC. According to an official statement: “Recent CDC laboratory testing of bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs) from 29 patients with EVALI submitted to CDC from 10 states found vitamin E acetate in all of the samples.”

Vitamin E acetate is used as a thickening agent in THC vaping devices. Some patients with EVALI also used nicotine-containing vape products. The CDC recommends that people refrain from all e-cigarette or vaping products. Cases of EVALI peaked in mid-September, and are thankfully on the decline. 

The CDC delineated vitamin E acetate as “a chemical of concern.” It is unclear whether vitamin E acetate is the sole cause of EVALI in this recent health scare, or if there are other chemicals or factors involved. Investigation by the CDC is ongoing. The most recent updates are posted on their website,

The CDC and FDA are working together to analyze the chemical components in both e-liquids and their vapors to better understand the cause and mechanism of lung injury. Until we have more information, the existence of a “safe vape” is unknown.



Owner and Founder of PROJUVU MD

Aesthetics and Lifestyle Medicine in Ann Arbor, MI

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