Vapes and Lung Disease: The CDC’s Lesson in How Not to Handle an Illness Outbreak

    Optimally resolving a nationwide outbreak of any illness involves the cooperation of not only countless local, state and federal agencies, but the media, medical providers and private industry as well. Above all, it involves cooperation from the public. Regardless of how an illness is spread or manifested, how quickly an outbreak can be brought to an end often depends on the public complying with public health messaging. This compliance, in turn, requires trust.

    To maintain the trust of an anxious public, the public health system must remain objective. Unfortunately, the messaging regarding the current outbreak of lung injuries associated with the use of vapor products provides a discouraging case study in how public health can be conscripted as a political tool.

    The trouble began at the outset. On August 17, the Centers for Disease Control issued its initial statement on the outbreak, announcing, “While some cases […] appear to be linked to e-cigarette product use, more information is needed to determine what is causing the illnesses.” By mentioning a link to e-cigarettes before stating that the cause of the illnesses was unknown, the CDC’s statement primed the public and the media to associate the outbreak with nicotine vapes. This then became the context in which all future messages were interpreted, even after the evidence implicated only illicit cannabis products. 

    The CDC’s biggest failure in this outbreak to date has been that, beginning with its first statement, it referred to “e-cigarettes” generally.

    The CDC did not make it adequately clear that its use of the term “e-cigarettes” encompasses not only legal vaping products containing only nicotine, but illegal ones containing cannabis derivatives. With increases in youth vaping as a backdrop, the statement sparked a firestorm of inaccurate messaging that continues to this day. 

    As the investigation progressed and the number of cases increased, the CDC released few additional details other than case counts and deaths. Then on September 6, after the media reported that researchers had found a suspicious chemical agent—Vitamin E acetate—in cannabis product samples, the CDC announced that “no one substance, including Vitamin E acetate, has been identified in all of the samples tested,” continuing the trend of downplaying the outbreak’s connection to unregulated cannabis products. 

    It was not until September 27 that the CDC announced that “THC products may play a role in outbreak of lung injury.” Nevertheless, its preventative recommendations maintained that nicotine vapor products could also be implicated. 

    Meanwhile, toxicology tests began identifying potentially harmful chemical compounds in cannabis vapor products. The proportion of afflicted patients reporting use of cannabis surpassed 75 percent, while those who used only nicotine hovered around 10 percent. By this time, it should have become clear to the CDC that legal nicotine vapor products were not at the root of this illness. And indeed, as of October 28, the CDC has concluded, “The latest national and state findings suggest products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak.” 

    Yet the agency’s recommendation continues to hold that “the only way to assure that you are not at risk […] is to consider refraining from use of all e-cigarette and vaping products.” The CDC’s unwavering message that “no one compound or ingredient has emerged as the cause of these illnesses to date” is true, but they seem to be using it as an excuse to stall for as long as possible before exonerating nicotine products.

    The CDC’s biggest failure in this outbreak to date has been that, beginning with its first statement, it referred to “e-cigarettes” generally. Its continued reliance on the term represents a missed opportunity to distinguish the elevated risk—or lack thereof—between illegal, unregulated products containing cannabis derivatives and legal, regulated products containing nicotine. What’s more, its continued reluctance to state definitively that regulated, legal e-cigarettes are not the cause of the illnesses only compounds the communication failures that began with that initial statement.

    The truth is that real-world outbreaks are messy. Self-reported data, dose-response relationships, inconsistent data collection methods, and other factors obscure the connections between cases and exposures. Yet this does not mean that public health agencies should withhold information or obscure messages until every potential variable is accounted for.

    Consider the Salmonella outbreak that the CDC is currently investigating. The agency has definitively linked this outbreak to ground beef, based on the fact that 75 percent of those diagnosed reported eating ground beef (as opposed to 40 percent among the general public). Despite a quarter of the afflicted patients reporting that they did not eat ground beef, the CDC did not delay announcing the culpable product. And unlike its messaging about vaping products, in this case, the CDC “is not advising that consumers stop eating thoroughly cooked ground beef, or that retailers stop selling ground beef.”

    The CDC’s failure … makes it difficult to believe its actions are not politically motivated.

    In the case of novel disease outbreaks like these lung injuries, even if the source is identified, it may take many months or years to sort out the specifics of the disease process and causes. This was evident in the investigation of the first cases of HIV, Legionnaires’ disease and Ebola virus disease, and will likely be the reality for these types of lung injuries. In fact, between 2002 and 2011, the CDC identified both the source and the pathogen in only 38 percent of foodborne outbreaks reported. Nevertheless, it is possible for the CDC to help prevent new cases of the disease in the interim by providing timely and actionable safety recommendations to the public.

    The CDC’s failure to differentiate between e-cigarettes that deliver nicotine and those that deliver cannabis compounds, coupled with the insistence that legal nicotine products are involved, despite the lack of compelling publicly available evidence, makes it difficult to believe its actions are not politically motivated.

    As lawmakers continue to propose and adopt increasing numbers of bans on vaping products, the fact that neither the CDC nor the Food and Drug Administration has mentioned that the evidence from this outbreak does not support bans of registered, legal nicotine vapor products becomes increasingly disappointing.

    Given the CDC’s disapproval of any non-pharmaceutical product that contains nicotine, it may be unrealistic to expect it to defend e-cigarettes. However, for the sake of the current adult smokers and former smokers who benefit from the availability of e-cigarettes, the agency should not encourage the conscription of an outbreak for political purposes—especially when the facts do not support the policies so many are pushing in response to the messaging.

    By allowing baseless fears to circulate, the CDC is using the outbreak as a political chess piece in a game that will sacrifice the health of millions.


    CDC logo via Wikimedia Commons. 

    The Influence Foundation, which operates Filter, has received a restricted grant from the author’s employer, the R Street Institute, to support production of two reports about harm reduction subjects.

    • Chelsea Boyd

      Chelsea Boyd, MS is a research associate in harm reduction policy at the R Street Institute. Her work focuses on applying harm reduction to tobacco control, substance use and sexual health policy to improve public health. She received her master’s degree in epidemiology from the George Washington University Milken Institute School of Public Health and her bachelor’s degree in liberal arts, concentrating on economics, from Colorado State University.

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