12 October 2019
With at least 26 deaths linked to vaping in the US, Australian doctors are being urged to question patients about their use of e-cigarettes
Australian health departments are on alert for lung injuries caused by vaping after the national health protection agency in the US confirmed 26 deaths and 1,300 injuries have been associated with the use of vaping products and e-cigarettes.
As of Friday, figures from the US Centers for Disease Control and Prevention (CDC) revealed 80% of those affected by the vaping crisis so far are younger than 35. The CDC’s investigation has so far failed to find any specific chemical causing the deaths and illnesses. The NSW government has subsequently sent a form to health departments across that state asking doctors to report any suspected cases of vaping-associated respiratory disease.
Professor Matthew Peters, a respiratory physician, said it was good to see Australian health departments being proactive. While the US outbreak dates back to March, Peters said it’s likely other cases occurring earlier may have been misdiagnosed. In a study published this month by the New England Journal of Medicine, a team led by doctors from the Mayo Clinic in the US examined lung tissue biopsies from 17 people suspected to have vaping-associated injuries. All 17 were found to have injuries in their lungs consistent with chemical burns, similar to those seen in the lungs of people exposed to mustard gas in the second world war.
Doctors in Australia needed to start routinely asking their patients with lung-related issues about whether they were vaping, Peters said.
“Most doctors have not been doing this, they might only ask about smoking,” Peters said. “There are so many reassuring messages out their about e-cigarette use and vaping, such as the statistic that vaping is 95% safer than smoking, and messages that vaping can help people quit smoking. So patients aren’t always telling doctors that they’ve started vaping either, because they don’t see it as a concern. We need to change the questions we are asking as physicians, because the world is different now.”
So far the CDC has interviewed 573 patients affected by the recent spike in respiratory illnesses about their e-cigarette and vaping use in the three months prior to the onset of their symptoms. Those affected have reported coughing, shortness of breath, chest pain, nausea, vomiting, abdominal pain, diarrhoea, fatigue, fever, and weight loss. About 76% of those affected reported using products containing THC, one of the chemicals in cannabis.
Associate Professor Coral Gartner, a tobacco control researcher with the University of Queensland’s school of public health, said it appeared that a contaminant associated with THC, rather than vaping in and of itself, was the culprit for the deaths and injury in the US.
“While not everyone has admitted to the use of THC, a number of these have subsequently been found to be lying, which is completely understandable given the potential ramifications for use of illicit substances,” Gartner said. “Investigators are still not 100% sure on the chemical agent that is responsible for the acute lung damage, but cutting agents containing vitamin E oil have been implicated.
“Certainly it is reasonable to assume that illicit THC oil products are sold in Australia. It is less clear if they are likely to contain the chemical agent responsible for the acute lung damage in the USA.”
She added that while there may be some lung disease risk associated with standard nicotine vaping products, this was most likely to be different from what was being seen in the US, which she said seemed to be more of an acute poisoning scenario rather than a chronic exposure issue.
Dr Miranda Ween, a cancer biologist with Adelaide Medical School, agreed that the US crisis was likely a case of contaminants in a reagent going to many suppliers, or contaminants found in cheap knock-off versions of the big brands.
“This has been possible because of the lack of regulation around quality control in e-liquids to ensure users are safe,” Ween said. “Australia suffers the same lack of regulations and thus it is entirely possible that we could see a similar situation arise here as well. For example, a batch of seized counterfeit product in the US was found to contain a pesticide which when heated turned into cyanide, which is clearly not something we should be inhaling.”
The crisis comes as a report released by Australia’s independent chemical regulator, the National Industrial Chemicals Notification and Assessment Scheme (Nicnas), found many of the 243 chemicals identified as ingredients used in e-cigarette liquids “are of concern to human health”, though not all ingredients used in vaping products have been identified. Nicnas found while e-cigarette emissions contained contaminants mostly derived from the e-cigarette liquid, some came from the device.
Quit Victoria director Dr Sarah White said while this evidence combined with the US cases showed Australian regulators correct to be taking a cautious approach to e-cigarettes, more needed to be done. She agreed with Peters that doctors and researchers needed to be routinely examining people’s vaping history, not just their smoking history.
“If there are vaping-related injuries being seen in Australia, we probably aren’t picking them up,” White said. “The frightening evidence coming out at the moment absolutely justifies the careful approach being taken by Australia.”
While laws around e-cigarettes do vary between states and territories, generally the sale, possession and use of nicotine in the form of an electronic cigarette is illegal. Professor Billie Bonevski, the interim president of the Society for Research in Nicotine and Tobacco Oceania Chapter, says the growing community of vapers in Australia was being pushed underground because of these tight restrictions, and were sourcing products from illegal vendors and online.
“There is the risk there you could end up with street vendors who create their own solutions and tap into these communities,” Bonevski said. “I certainly am not for nicotine vaping solutions being sold on every street corner, but I don’t support making it so hard people have to buy products underground.”
While many public health experts and doctors are calling for stronger evidence that e-cigarettes are a safe and effective smoking cessation product before being made more readily available, Bonevski said with so many variables between products and solutions, it would always be difficult to identify good quality studies with reliable data to support the products being approved by the Therapeutic Goods Administration and sold in pharmacies. “But anyone who tries to say smoking e-cigarettes are just as bad as smoking are wrong and should be struck off,” she said.
White disagrees, and says the products should be taken off the shelves altogether, for not just medical but consumer safety reasons. She said there had been cases of the devices exploding, causing deaths. She also cited the death of a toddler in Melbourne after he consumed his mother’s e-nicotine liquid. Consumer safety standards were sorely lacking, she said.
“I can’t buy a bicycle helmet or toys from shops that don’t meet consumer safety standards, but I can go and buy a device for heating up liquids and inhale from that device for hours on end,” she said. “We have taken other products off the shelves that have less issues with them than e-cigarettes.”
She acknowledged her position had resulted in backlash from pro-vaping lobbyists in Australia, many of whom are supported by the tobacco companies that have bought a stake in the e-cigarette market.
“There are people who so passionately believe in e-cigarettes that they’re evangelical about it,” White says. “There is a divide across public health and tobacco control on this which is no doubt being fed by vested interests, and no-one is backing down.”
On Saturday, the international medical journal the Lancet published an editorial in the wake of the US deaths, and said the positioning of e-cigarettes as a quit-aid had been “vastly overstated”.
“Data also suggest that smokers switch to e-cigarettes, then remain dependent long term,” the editorial said. “No solid evidence base underpins the marketing claims that e-cigarettes are healthier than cigarettes or that they can support quitting, but lax regulation has allowed e-cigarette manufacturers to pervert the success of antismoking public health messages and position e-cigarettes as healthy.”
For Professor Mike Daube, who has been researching tobacco control for almost 50 years, one of the most worrying aspects of the debate around the efficacy and safety of e-cigarettes was that it had taken the pressure off the big tobacco companies to be accountable for tobacco-related deaths and harm.
“Tobacco is still killing eight million people each year [globally],” Daube said. “It’s an interesting time as it feels like there is now a complacency around the issue of smoking prevention, which is worrying as many of the people still smoking in Australia now are the most disadvantaged groups.”