To Vape or Not to Vape
With all recent reports of lung disease and several deaths and more than 450 hospitalizations attributed to vaping, I thought it was time to give an opinion on the subject.
Vape products for smokers as an alternative nicotine source has been around since 2004, starting in China and spreading throughout Europe and the west by 2006. Vaping has been primarily used by smokers and ex-smokers and it is estimated that 17% of the adult population in Great Britain have used vape products for tobacco. In the USA, more than 9 million people vape nicotine products. With the widespread use of "e-cigarettes" (EC), especially in the United Kingdom, studies have been performed to determine the safety of the product. A comprehensive review study funded by the Crown in 2015 determined that "While vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent and the chemicals that are present pose limited danger. It had previously been estimated that EC are around 95% safer than smoking." Followup reviews in the UK this year again confirm this estimate as likely accurate.
Something's Going On
We would not usually expect to see a spike in an unusual disease as a consequence of everything being constant. To attribute it simply to vaping, as much of the press and politic has, is really not logical. Something is different.
I am reminded of something I learned in my second year of medical school. In the early 1980's, there was a large spike in young people being diagnosed with full blown Parkinson's Disease. The kind of symptoms it takes a decade or more to develop in most patients. The only factor they had in common is the abuse of IV narcotics. Well, people had been abusing heroin for many years prior to this. Something was different. It was eventually traced back to a contaminant from a clandestine drug laboratory making fentanyl which was toxic to the same nerve cells that are lost over the long term in Parkinson’s Disease.
Although it has not been determined definitively what caused the lung injury in these patients, all evidence points to some type of "chemical exposure" according to the CDC. Most of the cases involved black market cannabis vape cartridges or nicotine "vape juice" bought off the street. The evidence to date strongly argues this is a contaminant from clandestine drug synthesis.
Safe or Deadly?
As with everything in medicine, determining treatment requires breaking out the scales and seeing how the risks versus benefits balance. The risk for vaping is estimated to be 5% of that of tobacco smoking for legitimate nicotine products with chemicals because of potentially toxic chemicals produced in the vaporization process. We are talking cannabis here, so we can decrease this percentage further as cannabis vaping involves much less frequent and smaller volumes of vape compared to nicotine replacement use. The benefits of cannabis are many and add significant weight to that side of the scales. Vaping is a discreet and convenient way for many patients to dose which would be another one for the plus side if important to you. It looks like the benefits outweigh the risks for patients who require or prefer this route of administration with one important caveat. Source matters. Cartridges obtained from the black market are always suspect. You can not rely on packaging or lab stickers to determine if it is a legitimate product smuggled into Arkansas or a nicely forged copy. The bad guys have become good at mimicking the real thing as far as packaging and labeling go. We have seen how good the quality control is with hundreds of illnesses and several deaths most likely caused by contaminated product. Both Bold Cultivation and Natural State Medicinals use no additional additives other than cannabis extract in the vape cartridges they produce. They should be as safe as any legitimate nicotine vape product and are likely safer.
For patients who do not really need the convenience and stealth of vape cartridges, skip them. No exposure eliminates that small risk. If vaping is a route of administration you do well with, than the benefits seem to outweigh the risks but only if you obtain your cartridges directly from a dispensary. Any other source is rolling the dice with your health.
Brian Nichol MD