DENVER, Sept. 10 (UPI) -- Illicit THC vape cartridges being cut with a thickening agent may be the cause of the severe lung condition linked to vaping, some cannabis industry sources believe.
A joint investigation by the Centers for Disease Control and Prevention and the Food and Drug Administration has listed vitamin E oil, or tocopheryl acetate, as one of the compounds potentially linked to six deaths and the hospitalization of some 450 people in 33 states who used some type of e-cigarette.
The New York State Department of Health last week first identified "very high levels of vitamin E acetate" showing up in nearly all the cannabis-containing vape cartridges linked to 34 patients who submitted a product for testing, the agency said.
Vitamin E acetate is not an approved additive for New York's medical marijuana program-authorized vape products, and was not found in the nicotine-based products that were tested, a statement from the health department said last week.
Raw vitamin E acetate can be purchased "for pennies" from lotion ingredient wholesalers, said Peter Hackett, CEO of Concord, Calif.-based Air Vapor, a vape hardware distributor. While vitamin E is sold as a nutritional supplement and is safe for topical uses and ingestion, it has a boiling point of 455 F and is not recommended to be inhaled.
"The lab recommendations are you should be using a mask when it is heated, but now it's being found in vape products," Hackett said.
THC vape cartridges, both legal and illegal, have been sold for years. They are filled with extracted cannabis oil that vaporizes when it comes in contact with heated coils from a vape pen or e-cigarette.
But because of a crackdown on illegal marijuana cultivation by California, Hackett believes illegal THC vape cartridge producers are having a harder time obtaining cannabis oil and are adding more thickeners, including vitamin E acetate.
In the illicit market, customers use an "air bubble test" to tell if a THC vape cartridge has good quality, high-viscosity cannabis oil, Hackett said.
Oils that seem runny or have an air bubble that shoots around the cartridge might not be high-quality. It's also possible that the oil has additives that act like cannabis oil, but could be doctored with thickeners.
"I believe the supply chain shortage in California has something to do with it," Hackett said, adding that California has been the source of most of the illegal cannabis vaping cartridges sold throughout the United States.
"The black-market producers can't find enough oil, so they're filling cartridges with high percentages of thickening agent," he said.
Hackett's company imports vape cartridges, which are a legal, FDA-regulated product for nicotine, but he said most of his buyers are using the cartridges to make THC vapes, both legal and illicit.
"I have to compete with them. We lose a lot of business to the illicit market," he said.
Customers asked for a thickening agent, but the company passed on supplying it, he said.
Vitamin E is added to cosmetic products and lotions as an antioxidant, but if introduced into the lungs as a heated vapor, it can cool to a greasy substance that could interfere with a person's absorption of oxygen.
On Sunday, former FDA Commissioner Scott Gottlieb identified three different vaping-associated lung diseases that had been found by researchers: lipoid pneumonia, alveolar hemorrhage and cryptogenic organizing pneumonia.
"Most of these severe cases, so far, appear to be symptoms that can occur when either oils or lipid-containing substances enter lungs," Gottlieb tweeted. "This points to illegal products that are being cut with dangerous chemicals as a culprit."
Hospitalized patients have experienced coughing, shortness of breath or chest pains, and some have also experienced nausea, vomiting, or diarrhea, as well as fatigue, fever or weight loss, the CDC said.
Symptoms could develop over a period of days, but sometimes show up over several weeks. In a joint statement last week the CDC and FDA said they were investigating multiple causes for the new lung disease, and vitamin E acetate was one of them.
More than 120 samples of vape cartridges were being analyzed by the two agencies, acting FDA Commissioner Ned Sharpless said.
"The FDA is analyzing these for a broad range of chemicals, but no one substance, including vitamin E acetate, has been identified in all of the samples tested. Importantly, identifying any compounds present in the samples will be one piece of the puzzle but won't necessarily answer questions about causality, which makes our ongoing work critical," Sharpless said in a statement.
One problem is that patients don't always tell the truth about using illicit THC vapes, medical professionals say.
California reported 57 potential cases of the lung disease, plus one death. Kings County, Calif., where legal cannabis sales are prohibited, was one of the first locations where health officials identified patients as having bought illegal vape products at "pop-up shops."
"Under no circumstances should you vape cannabis or CBD oils obtained from a 'pop-up shop,'" a statement from the health department said.
So far, 34 cases were identified in Wisconsin, among mostly young male patients with an average age of 19. Illinois identified 25 patients, including one who died. Other deaths occurred in Indiana -- where 30 cases of severe lung injury were identified -- and Minnesota. One adult patient died in Oregon, where a vape was purchased at a legal dispensary, said Jonathan Modie, of the Oregon Health Authority.
In the legal cannabis market, tests exist for heavy metals, pesticides and other impurities, but vape cartridges are not tested for thickening additives, Hackett said. "There's no test for vitamin E, so it could be there in the legal market, too."
In Colorado, where two people have been hospitalized with severe lung problems, the state Department of Public Health and Environment said more testing still had to be done, and the agency characterized vitamin E oil as a "lead and not a definite answer," said Tony Cappello, director of the Disease Control and Environmental Epidemiology Division, in an email.
"We are aware of the discovery of vitamin E oil as a common ingredient in some of the samples that were tested from cases of this illness in other states," Cappellow said.
"We are aware that vitamin E acetate may be used as a thickening ingredient in vaping liquids, but we do not have much information on what happens when vitamin E acetate is actually vaporized and inhaled.
"We continue to work with the CDC and FDA to look at all possible links to the illness, including nicotine, THC, CDB, synthetic marijuana, and other compounds."
Meanwhile, the FDA and CDC have recommended that more scrutiny be given to vapes and e-cigarettes, and that they should be avoided by pregnant women and teens.
These lung disease outbreaks are likely an unintended result of a lack of legalization on the federal level, said Morgan Fox, spokesperson for the National Cannabis Industries Association.
"Anybody can order a big batch of vape carts in bulk from China and elsewhere. Then they can be filled with whatever happens to be on hand in an illegal lab," Fox said. "These products are only popular because cannabis is illegal and because people can't buy from from legal tested products.
"You should not be using vape products that you bought on the illicit market. Changes in federal law to sensible cannabis policies could help legal businesses displace the illegal market."