Despite the fact that the vaping crisis headlines are fading, the numbers on usage and lung illnesses are still concerning.
Data on Usage - Cannabis and Nicotine Vaping
According to the University of Michigan/NIDA Monitoring the Future Survey released on
December 20, 2019, current (past month) cannabis vaping among high school seniors nearly doubled in just one year (from 7.5% to 14%), which was the largest one-year jump of any drug in the 45-year history of the survey. Seniors' past-year cannabis vaping more than doubled in two years (from 9.5% in 2017 to 20.8%) in 2019 and their lifetime cannabis vaping nearly double (from 11.9% to 23.7%).
Cannabis vaping doubled and tripled in two years among 10th and 8th grade students as well. Among 10th grade students, past-month use rose from 4.3% in 2017 to 12.6% in 2019 and among 8th grade students, it rose from 1.6% to 3.9%. For past year use, cannabis vaping for 10th graders was not far behind from 12th graders at 19.4% and for 8th graders it was 7%.
For the first time, the Monitoring the Future survey measured near daily cannabis vaping (more than 20 days a month). Some 3.5% of 12th graders vape marijuana that often on a national basis.
Nicotine vaping among adolescents similarly increased, threatening to undo the significant gains in reducing cigarette smoking among youth. The survey found that 35% of 12th graders vaped nicotine in the past year, as did 31% of 10th graders and 17% of 8th graders. For past month use, the numbers were 25% for 12th graders, 20% for 10th graders and 9% for 8th graders.
Marin’s tobacco vaping rates are less recent (2017-18) and for different grades (odd versus even) but are even higher than these national Monitoring the Future averages. For example in the Tamalpais Union High School in Marin County, 33% of 11th graders and 24% of 9th graders were currently (past 30 days) vaping nicotine.
Adolescents and young adults who have smoked e-cigarettes are more than three times more likely to move on to cannabis than youth who never try vaping, according to a research review study, as published in JAMA Pediatrics in August 2019. Researchers examined data from 21 previously published studies with more than 128,000 participants ages 10 to 24. Overall, young people who used e-cigarettes were 3.5 times more likely to use cannabis, the analysis found.
Teen vapers were most at risk for cannabis use. Among adolescents ages12 to 17, e-cigarette users were 4.3 times more likely to use cannabis.
And a new study by Oregon State University published on January 15, 2020 in the Journal Addiction found that college students in states that had legalized recreational use of cannabis by 2018 were 18% more likely than students in other states to have engaged in past-month cannabis use. These students also were 17% more likely to be frequent users of cannabis (defined as use on at least 20 of the past 30 days).
Moreover, this gap between cannabis use in legalization and non-legalization states widened over time, the researchers at Oregon State University found. Six years after legalization in the earliest-adopting states, college students were 46% more likely to be cannabis users.
Another Oregon State study, published in November in Addictive Behaviors, found that students ages 21 and older in recreational cannabis legalization states showed a greater decline in binge drinking than their peers in non-legalization state.
EVALI (E-Cigarette or Vaping Product Use-Associated Lung Injury)
Hospitalizations and Deaths
While the outbreak of severe lung injuries may have peaked in September 2019, new cases are still surfacing at a pace of roughly 100 a week.
As of January 14, 2020, a total of 2,668 hospitalizations from vaping-related severe lung disease have been reported to the CDC from 50 states, Puerto Rico, and the U.S. Virgin Islands, along with 60 deaths from 27 states and the District of Columbia.
Some 82% of patients reported using THC-containing products and 37% did so exclusively. 57% percent used nicotine-containing products and 13% did so exclusively. More than 152 different THC-containing products were used by patients.
New data from the CDC shows that half of patients who used THC-containing products reported where they obtained THC vaping cartridges. Of these,131 or 16% bought them only from legal commercial sources, such as legal recreational dispensaries, medical dispensaries or both, as well as vape or smoke shops, stores and pop-up shops. 78% bought them from informal sources, defined as family/friends, dealers, online or other. And 6% brought them from both commercial and informal sources. Accordingly, these products have not come exclusively from the black market.
While the CDC concluded that Vitamin E Acetate is “strongly linked” to the outbreak of the recent lung illness and deaths, it has cautioned that the “evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products.”
Dr. Anne Schulchat, principal deputy director of the CDC, said that even if THC suppliers stopped adding Vitamin E Acetate, that would not necessarily make illicit THC safe because providers could switch to other dangerous substances to extend the THC and increase their profits.
The patients monitored used over 150 different THC brands, including Smart Carts and
TKO in the western U.S., Rove in the Midwest and Dank Vapes in the Northeast. Accordingly, there may well be more than one cause of the illnesses.
Moreover, new findings indicate that many have relapsed and had to be re-hospitalized or died shortly after being sent home from the hospital. Their median time to winding up back in the hospital was four days and the median time to death after hospital discharge was three days.
Trump Administration Partial Ban
Retreating from Trump's initial promise to ban all flavored vaping products, including
menthol pods, on January 2, 2020, the FDA announced it would ban mint- and fruit-flavored vaping products but exempt menthol and tobacco flavored pods. It also did not ban flavors sold mostly in vape shops for use in tank vaporizer systems. And the flavor-cartridge ban may not hold if manufacturers are able to obtain FDA authorization to sell such products. A federal court order set May 12, 2020 as the date by which all e-cigarette and vaporizer manufacturers must obtain such authorization from the FDA or be removed from the market.
2019 survey data shows an increase in menthol flavored JUUL pods and together with mint JUUL pods are at levels near that of fruit flavored pods.
The FDA announced on December 20, 2019 that 44 websites had been seized by the agency and the Drug Enforcement Agency (DEA) for marketing illicit THC vaping cartridges.
More Trouble for JUUL
Meanwhile, according to a former top executive of JUUL, at least one million contaminated mint-flavored nicotine pods were sold by the e-cigarette giant company last year. As reported in a New York Times article, the company refused to recall them when told about the problem.
The executive, formerly the JUUL senior vice president for global finance, has filed a lawsuit accusing the company of firing him after he learned of the contamination. He claims that he was told to charge the supplier $7 million so that JUUL could recover from the contaminate
batches of flavored pods. He also claims that then-CEO Kevin Burns commented at a company meeting that “half of our customers are drunk and vaping” and wouldn’t “notice the quality of our pods.
According to the former executive, Burns also pressured suppliers to hurriedly come up with more mint-flavored product. Burns, he said, also exhorted employees, saying, “You need to have an IQ of 5 to know that when customers don’t find mango they buy mint.” Burns denies the allegations.
Approximately 50 lawsuits are currently pending against JUUL for vaping illnesses and false marketing claims. At a recent hearing in the Georgia state legislature, one doctor witness told the story of a 17-year old teen treated by her colleagues who had been JUULing for six months. He woke up one morning with severe pain in his chest. It turned out that his left lung had collapsed. Treatment included inserting a tube into his chest to remove air that had leaked from his lung into his chest cavity, pushed against his lung and collapsed it. He was hospitalized for several days and then released, but soon after work up with a similar pain in his chest. His other lung had collapsed. The doctor said her hospital has treated four collapsed lungs in teens in just the past two months. She pleaded with the legislators to not forget the collapsed lungs, exacerbation of asthma increasing in the nation, popcorn lung, nicotine addiction and brain rewiring.
Successors to JUUL - Puff Bars
Cheaper, disposable vapes pens such as Puff Bars were gaining in popularity. Puff Bars come in flavors such as Banana Ice, Sour Gummy and Cool Mint. Not surprisingly other companies have rushed in such as Fotem which makes
blu, another popular disposable with flavors such as Melon Time, Honeymoon, Mint-sation or other soon-to-be-banned flavors. Similarly Posh and Stig are pre-charged pre-filled disposable vaping devices made by domestic companies and imported from China. Despite some having higher nicotine levels than JUUL, our youth report that many of their peers think that because these vape pens are cheaper and disposable they have less nicotine than JUULs.
Moreover, Trump's prohibition on fruit flavors only extends to refillable cartridge based e-cigarettes - and not disposable cigarettes. This means there is a huge loophole in the vaping ban which teens have caught onto fast. As quoted in a New York Times article dated February 1, 2020 entitled "Savvy Teens Find Loophole in Vaping Ban and Dive Through for Flavors", one principal of a Seattle high school stated, "We're still back on JUUL" but her students tell her "JUUL's so yesterday; we've moved on".
New Cannabis Vaping Products
Notwithstanding the hit to JUUL Labs, Pax Labs, the company which created the JUUL e-cigarettes (from which JUUL was spun off) recently introduced a new THC vaporizer that looks a lot like JUUL. It is called the Era Pro.
The Monitoring the Future Survey released on December 18th shows the number of teens
vaping cannabis nearly tripled in two years. Kids switched out pods containing nicotine with pods containing THC.
According to a recent Nielsen survey of over 200,000 adults nationally, San Francisco, Seattle and Portland were the three cities past-month cannabis use among those age 18 and older now tops tobacco use, including e-cigarettes. In San Francisco, past-month use was 16% versus past month tobacco use at 13%.
New Research on Cannabis: Cardio-vascular Disease, Head and Neck Cancer
Two new areas of research are of note that point to health risks of cannabis use:
Increased Heart Problems. A paper published in the Journal of the American College of Cardiology on January 20, 2020 suggests an association between cannabis use and a range of heart problems. The paper reviewed data showing that smoking cannabis was linked with increased heart rate and blood pressure, altered heart muscle and blood vessel and an increased risk of abnormal heart rhythms (arrhythmias). The paper also noted that cannabis can interfere with commonly used cardiac medicines including some blood pressure drugs and cholesterol lowering statins. According to one cardiologist, vaping increases the delivery of cannabis and it is anticipated that the cardiovascular effects are enhanced with vaping cannabis.
Earlier presentations in November 2019 at the American Heart Association Scientific Sessions pointed to observational studies of youth ages 15-24 with a cannabis use disorder and an increased risk of heart arrhythmia problems and those who are frequent cannabis users at ages 18-44 with a higher risk for stroke.
Head and Neck Cancer. A study out of UC San Diego finds that THC in cannabis
accelerates growth of HPV-related head and neck cancer, which are the fastest growing
cancers in the U.S. This is occurring at the same time that exposure to cannabis is accelerating with smoking and vaping cannabis. Read about it here.
While more study is needed in these and other areas, it is becoming increasingly clear that there is much that we don't know about the effects of smoking and vaping cannabis and both involve significant health risks.