Characteristics of E-cigarette, or Vaping, Products Used by Patients With Associated Lung Injury and Products Seized by Law Enforcement

Minnesota, 2018 and 2019

Joanne Taylor, PhD; Terra Wiens, MPH; Jason Peterson, MS; Stefan Saravia, MPH; Mark Lunda; Kaila Hanson, MS; Matt Wogen; Paige D'Heilly, MPH; Jamie Margetta, MPH; Maria Bye, MPH; Cory Cole, MPH; Erica Mumm, MPH; Lauren Schwerzler, MPH; Roon Makhtal; Richard Danila, PhD; Ruth Lynfield, MD; Stacy Holzbauer, DVM

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(47):1096-1100. 

In This Article

Abstract and Introduction

Introduction

During August 9–October 31, 2019, 96 patients were classified as having e-cigarette, or vaping, product use–associated lung injury (EVALI) by the Minnesota Department of Health (MDH); other patients are being investigated for case classification and exposures. Among 58 patients interviewed, 53 (91%) reported obtaining tetrahydrocannabinol (THC)–containing products from informal sources such as friends, family members, or in-person or online dealers. Using gas chromatography–mass spectrometry (GCMS), the MDH Public Health Laboratory (PHL) analyzed 46 THC-containing e-cigarette, or vaping, products obtained from 12 EVALI patients for various potential toxicants, including vitamin E acetate, which has recently been detected in some THC-containing products and in samples of lung fluid from EVALI patients.[1–4] To explore whether vitamin E acetate is a recently added component in THC-containing products, MDH tested ten products seized by law enforcement in 2018, before the EVALI outbreak, and 20 products seized in 2019, during the outbreak. Twenty-four products obtained from 11 EVALI patients from 2019 contained vitamin E acetate. Among the seized products tested by MDH, none seized in 2018 contained vitamin E acetate, although all tested THC-containing products seized in 2019 tested positive for vitamin E acetate. These chemical analyses of products obtained from EVALI patients and of products intended for the illicit market both before and during the outbreak support a potential role for vitamin E acetate in the EVALI outbreak; however, the number of products tested was small, and further research is needed to establish a causal link between exposure to inhaled vitamin E acetate and EVALI. Collaboration between public health jurisdictions and law enforcement to characterize THC-containing products circulating before the recognition of the EVALI outbreak and during the outbreak might provide valuable information about a dynamic market. These Minnesota findings highlight concerns about e-cigarette, or vaping, products that contain THC acquired from informal sources. Because local supply chains and policy environments vary, CDC continues to recommend not using e-cigarette, or vaping, products that contain THC or any e-cigarette, or vaping, products obtained from informal sources. E-cigarette, or vaping, products should never be used by youths, young adults, or pregnant women.* Until the relationship between inhaled vitamin E acetate and lung health is better characterized, vitamin E acetate should not be added to e-cigarette, or vaping, products.

On August 12, the Minnesota Commissioner of Health requested that patients with EVALI be reported. Medical records of suspected cases were reviewed, and patients were classified using CDC case definitions. EVALI patients or their proxies (e.g., parents) were interviewed using an adaptation of a structured questionnaire developed in Illinois and Wisconsin in consultation with CDC during investigation of cases in those states. Patients were asked to provide product samples to MDH for testing. In addition, to explore whether the content of the local supply of illicit e-cigarette, or vaping, products was different before the outbreak, local law enforcement provided products to MDH from a raid of unregulated manufacturers and distributors of e-cigarette, or vaping, products in 2018 and a comparison sample of products from a raid in 2019 that coincided with the current outbreak.

Product samples from EVALI patients and from the two law enforcement seizures were analyzed at MDH PHL using internally developed headspace GCMS and nontargeted GCMS methods and purchased reference materials. MDH PHL tested for active compounds (cannabidiol [CBD], nicotine, and THC), toxicants of concern (glycerin, medium-chain triglyceride [MCT], propylene glycol, and vitamin E acetate), and three vitamin E forms (alpha, beta, and gamma tocopherol).

Bronchoalveolar lavage (BAL) fluid samples from five EVALI patients were analyzed at CDC for active compounds and toxicants. MDH collaborated with the Minnesota Bureau of Criminal Apprehension Forensic Drug Chemistry Department, which had obtained six containers of bulk liquids, each labeled with a different flavor, and 100 cartridges (all labeled "Cali Plugs Grape Punch") from a spring 2018 raid. PHL tested five bulk liquid samples and five cartridges held by the Minnesota Bureau of Criminal Apprehension. In September 2019, local law enforcement seized 75,000 cartridges intended for the illicit THC market.[5] These cartridges were packaged inside boxes bearing two market labels: "Dank Vapes" and "31 Flavors." Investigators used labeling to identify 31 different flavors of Dank Vapes and 19 different flavors of 31 Flavors. PHL evaluated 10 different flavor cartridges labeled "Dank Vapes" and 10 different flavor cartridges labeled "31 Flavors."

As of October 31, 2019, 96 patients were classified as having confirmed or probable EVALI in Minnesota, and additional cases are being investigated. The median age of patients was 21 years (range = 15–71 years), and 58 (60%) were male. Eighty-seven (91%) patients were hospitalized, including 26 (27%) in intensive care units. Three (3%) patients died. Among 58 (60%) interviewed EVALI patients, 53 (91%) reported using illicit THC-containing products obtained from informal sources in the 3 months before illness onset,§ 41 (71%) used nicotine-containing products, and 14 (24%) used CBD oil products (Table). Two patients reported using illicit THC, medical cannabis, and nicotine-containing products. Thirty-nine (67%) patients reported using Dank Vapes.

Sixteen (28%) patients submitted 265 products, 67 of which were selected for testing because of available product volume and features that physically differentiated the cartridges; 46 contained THC, and 21 contained nicotine. Among the 46 assessed THC-containing products submitted by 12 patients, the most commonly detected compounds were vitamin E acetate (24, 52%), MCT (20, 43%), CBD (20, 43%), and alpha tocopherol (17, 37%). Eight (17%) THC-containing products did not contain either vitamin E acetate or MCT. THC-containing products used by 11 of 12 (92%) patients contained vitamin E acetate, and products from seven (58%) patients contained MCT. One patient who used medical cannabis submitted illicit THC-containing products; one tested product contained vitamin E acetate and another contained MCT. THC-containing products from one patient did not contain vitamin E acetate; however, this patient reported using multiple products daily, including Dank Vapes, which were not included among the products submitted for testing. Among 21 nicotine-containing products submitted by eight patients, 20 contained propylene glycol, and 15 contained glycerin but not the other analytes.

Among the 21 patient-submitted THC-containing products that were categorized by identifiable brands, two of two Dank Vapes samples contained vitamin E acetate (Figure). In five products labeled "Dr. Zodiak" and six labeled "TKO Extract," vitamin E acetate, MCT, and alpha tocopherol were variably detected.

Figure.

Detection of vitamin E acetate and medium chain triglyceride (MCT) by mass spectrometry methods in tetrahydrocannabinol (THC)– containing products obtained from e-cigarette, or vaping, product use–associated lung injury patients (N = 46) and law enforcement raids (N = 27) — Minnesota, 2018 and 2019

Vitamin E acetate was detected in all five patient BAL fluid specimens. One of these patients submitted four THC-containing cartridges labeled "TKO Extract" (two), "Rove" (one), or "Dr. Zodiak" (one), all of which contained vitamin E acetate. Although the other patients were known to be exposed to THC based on interview or testing of the BAL fluid, none of the other patients whose BAL fluid specimens were tested submitted THC-containing products for testing.

Among products seized during the 2018 raid, all five bulk liquid samples tested negative for vitamin E acetate and MCT; two tested positive for THC (Figure). The bulk liquids appeared to be flavoring agents. All five Cali Plug cartridges tested contained THC and MCT, but not vitamin E acetate. Among the 20 tested cartridges seized during September 2019, all contained THC, vitamin E acetate, and MCT. In addition, five cartridges of 31 Flavors also contained gamma tocopherol.

*https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf.
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/assets/2019-Lung-Injury-Surveillance-Case-Definition-508.pdf.
§THC-containing products were obtained from informal sources such as friends, family members, or in-person or online dealers, and were not obtained from the Minnesota medical cannabis program (https://www.health.state.mn.us/people/cannabis/).

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