EXPERT REACTION: First death related to vaping reported in the US

The health risks of e-cigarette use are not yet fully understood. These products contain potentially harmful chemicals which could damage the small air spaces and blood vessels in the lungs leading to irreversible lung and heart disease. There is evidence that these inhaled substances can cause the airways to constrict which could be fatal in someone susceptible to asthma.

Due to the very delicate nature of lung tissue, inhalation of any foreign substance is a bad idea and should be avoided especially by young people whose lungs are still developing and by pregnant women because of risk to the foetus.

The potential for harm is further increased due to the possibility of contamination of vaping liquids by more toxic substances which could be delivered in high concentrations.

The reports from the US support the careful evidence-based approach that Australia has taken in relation to e-cigarettes. Fortunately, use in youth has been much lower than in the US or Canada. Nonetheless, non-nicotine e-liquids can be sold legally and there is some use in young people. There are reports of on-shore, retail sales of popular e-cigarettes with claims, as yet unconfirmed, that they contain nicotine.

These reports from the US of 200 or more cases of serious and fatal acute lung injury, an extremely rare event in other circumstances, should be a wake-up call. By way of comparison, during the SARS epidemic, there were 27 cases in the US and no deaths. The absence of a specific pattern of product or use is concerning and it is equally worrying that these reports have come from a range of US states so that local contamination is unlikely. It is possible that the link to e-cigarettes is coincidental in some cases but also likely that other cases have not been attributed to e-cigarette use as the link was never contemplated.

These cases have not emerged in a knowledge vacuum. E-cigarettes are harmful to the lung and have a range of other adverse effects. The majority of e-cigarette users experience cough and this is a common reason for ceasing use. Those who report continued use as infrequently as three days per month are twice as likely to have bronchitis symptoms.  

Unless and until they become an approved therapeutic product, there is no regulatory agency in Australia with responsibility for consumer safety in relation to e-cigarette liquids and devices; including analysis of reported adverse events associated with their use. It is timely for governments to define and support a relevant agency.

In the meantime, vendors of e-cigarette liquids should be held liable for harms that the products they sell cause.

"There is insufficient evidence to show that e-cigarettes help people quit smoking or that they are safe.

On the contrary, the evidence we do have indicates that the potential harms outweigh any benefits.

Australian data show that the number of children aged 12 to 17 years, who are non-smokers, and have tried e-cigarettes, has almost tripled between 2013 and 2016.  And the evidence is growing that e-cigarettes can drive young adults to take up smoking, and that their use is associated with a higher risk of respiratory disease, heart disease and the precursors to cancer.”

For these reasons, the Heart Foundation is calling for strict regulation of e-cigarettes and the stipulation that e-cigarette producers provide evidence of the safety and efficacy of their products.

We also recommend that governments remain cautious. We support the current regulation, which bans the sale of e-cigarettes containing nicotine unless they have been approved by the Therapeutic Goods Administration (TGA).

This process allows the TGA to review product safety and efficacy before granting marketing approval. We also support State and Territory-based laws that ban their advertising and promotion including the restrictions on their use in smoke-free areas. These laws help to reduce the marketing and promotion of e-cigarette use to non-smokers, especially children.

This tragic news highlights the need for vaping product standards and regulation.

Most of the reports about these hospitalisations and death suggest that THC vaping products, particularly backyard-produced liquids, are involved, rather than mainstream nicotine vaping products.

Hopefully. the US health authorities will quickly identify the exact products that are involved in each case and what the cause of this illness is.

People who are using cannabis products should be advised about this potential risk of vaping THC liquids or cannabis oils. 

We need to monitor this situation closely, but at this stage it is unclear whether there are any implications for people using standard commercial nicotine vaping products to quit smoking, such as products that comply with the European Union regulations.

Media reports of outbreaks of a serious lung illness in the US and the death of a man have been linked to vaping and are currently being investigated.

However, vaping nicotine to quit smoking is highly unlikely to be the cause. Nicotine vaping is an effective quitting aid and has not yet been linked to any serious respiratory harm.

A much more likely explanation is the use of contaminated black-market THC liquids (the active ingredient in cannabis or marijuana) or synthetic cannabis, which have been reported as being used by many of those affected.

Vapers in Australia who are using nicotine from a reputable source to quit smoking should not panic. It is important not to stop vaping if you might relapse to smoking. Non-smokers and young people should not vape.

The public should also avoid the use of black-market products, especially THC liquids or synthetic cannabis and even black-market nicotine. Street drugs are entirely unpredictable and can be very toxic.

The full disaster of smoking’s health effects did not become apparent for 40 years after smoking became widespread. With vaping only being widespread in some countries for 10 years, it is far too early to know the full risks of e-cigarettes. But 160 serious cases of lung disease in 15 US states, including one death may be an ominous 'canary in the coalmine' of what lies ahead.

This death and the 160 other serious cases of lung disease being investigated underscore just how prudent Australia’s precautionary approach to e-cigarette regulation is. Evil genies are very, very hard to get back in their bottles.

The average daily vaper inhales a cocktail of vapourised nicotine, propylene glycol ad chemical flavouring agents deep into their lungs 200 times a day or 73,000 times a year. We have no idea what the long term consequences of this are. Vapers are being treated like human lab rats by the vaping and tobacco industries which have all now bought into e-cigs.

The cause of these reported cases of serious illness need to be thoroughly investigated but they point to the risks of young people using vaporisers to consume illicit drugs, such as synthetic cannabis products and methamphetamine. This also includes vaporising illicitly-produced tobacco extracts that are reportedly being sold.

Smokers using vaporisers that contain approved nicotine products obtained on prescription are unlikely to be at risk of these serious health consequences.

Unfortunately, I am not surprised by the news. Many public health advocates have known about the harms associated with vaping for quite some time.

Contrary to what the vaping industry has led consumers to believe, these devices are not harmless. The flavourings and other chemicals that are added to e-liquids have been linked to numerous health harms.

The vaping industry is now largely funded by the tobacco industry and they are undermining public health efforts to protect individuals from unnecessary exposure to a toxic product.

It is important that the Australian Government maintain the current strict regulation of e-cigarettes and consider federal legislation banning flavoured e-liquids and recreational use of these devices.

If the vaping industry would like to market their products as ‘therapeutic’, they should be subject to the same conditions as every other therapeutic good in Australia and submit their product to the Therapeutic Goods Administration for immediate and independent testing.