Report details vaping products used by Minnesota patients with lung injury
Vitamin E acetate appears to be a common link among the products containing THC used by patients with electronic cigarette- or vaping-associated lung injury, or EVALI, in Minnesota, according to a report published in Morbidity and Mortality Weekly Report.
Sixteen of the 96 patients with confirmed or probable EVALI identified from Aug. 9 to Oct. 31, 2019, in Minnesota provided samples from 265 products for testing to the Minnesota Department of Health. Of the 67 products selected for testing, 46 contained THC and 21 contained nicotine. Samples were evaluated using gas chromatography-mass spectrometry.
Commonly detected compounds
In the products containing THC, which were submitted by 12 patients, the most commonly detected compounds included vitamin E acetate (52%), medium chain triglyceride (MCT; 43%), CBD (43%) and alpha tocopherol (37%). THC-containing products used by 11 of the 12 patients contained vitamin E acetate and products from seven patients contained MCT. Seventeen percent of products containing THC did not contain vitamin E acetate or MCT.
Notably, one patient who used medical cannabis submitted illicit THC-containing products, with one containing vitamin E and another containing MCT. Vitamin E acetate was not found in THC-containing products submitted by one other patient, but this patient also reported using multiple products daily, including “Dank Vapes,” which were not provided for testing.
Eight patients also submitted 21 nicotine-containing products — of which 20 contained propylene glycol and 15 contained glycerin.
Twenty-one products containing THC were categorized according to identifiable brands. Of these, two of two Dank Vapes samples contained vitamin E acetate. Five products labeled “Dr. Zodiak” and six labeled “TKO Extract” also contained vitamin E acetate, MCT and alpha tocopherol.
Vitamin E as a new additive
To determine whether vitamin E acetate is a newer additive to THC-containing products, the researchers compared samples from e-cigarette or vaping products seized by law enforcement before the EVALI outbreak in spring 2018 with those seized after the outbreak began in September 2019.
Products seized in 2018 included six containers of bulk liquids, each labeled with a different flavor, and 100 cartridges — of which five liquid samples and five cartridges were tested. Those seized in 2019 included 75,000 cartridges intended for the illicit THC market, including Dank Vapes and “31 Flavors.” Ten different flavor cartridges from each label were tested.
Samples from all five bulk liquids from 2018 tested negative for vitamin E acetate and MCT and two tested positive for THC. All five “Cali Plug” cartridges tested positive for THC and MCT but not vitamin E acetate. In contrast, all 20 cartridges seized in 2019 tested positive for THC, vitamin E acetate and MCT and five of the 31 Flavors cartridges tested positive for gamma tocopherol.
These findings suggest that vitamin E acetate may be a more recent diluent or filler, the researchers noted.
“The ongoing investigation in Minnesota has shown that collaborating with law enforcement to obtain and test products confiscated before and during the current outbreak can provide valuable information on the potential changes in these products in a dynamic market,” they wrote.
However, the researchers added that further testing of more products from Minnesota from before 2019 and testing of products from other states are necessary to confirm these conclusions.
Moreover, although these data implicate vitamin E acetate as a potential contributor to the EVALI outbreak, the number of samples tested was small and the products submitted for testing did not represent the spectrum of products used by all patients with EVALI, they noted.
“According to these and other published data, using THC-containing products with vitamin E acetate appears to be associated with EVALI; however, it is possible that more than one compound or ingredient could be a cause of lung injury, and evidence is not yet sufficient to rule out contribution of other toxicants,” the researchers wrote. – by Melissa Foster
Disclosures: The authors report no relevant financial disclosures.