Is Vitamin E Acetate Killing Vapers?

Officials at the U. S. Centers for Disease Control announced Friday that they may have found a cause for the lung injuries and deaths in people who use e-cigarettes.  Since the problem arose last March, a total of 39 people have died from what is now being called "e-cigarette, or vaping, product use associated lung injury," (EVALI for short) and over 2,000 more have become ill or hospitalized.  A report by National Public Radio says that a compound called vitamin E acetate (tocopheryl acetate) has been found in lung-fluid samples from 29 individuals who were hospitalized as a result of vaping.  While the CDC has not reached any definite conclusions that vitamin E acetate is the sole cause of EVALI, the fact that it has been found in all 29 samples is significant.  The compound is known to be used by off-label manufacturers who sell vaping products containing THC—the active ingredient in marijuana.  Most but not all EVALI victims admit using vaping mixtures containing THC.

Vitamin E acetate is a more stable form of pure vitamin E (tocopherol), and the acetate is used in a wide variety of consumer products meant to be applied to the skin or swallowed.  It is an oil-like substance that is innocuous in these applications, but inhaling vaporized oily materials can lead to serious lung problems.  The syndrome called "lipoid pneumonia" can strike people whose job involves breathing vaporized oils.  For example, a performer who "eat sfire" by sticking flaming objects in his mouth will often prepare for his stunt by coating his mouth with a petroleum-jelly-like substance called kerdan.  If the hot object happens to vaporize some of the kerdan and the unfortunate performer breathes the vapor, the oil can coat the inside of his lungs and cause lipoid pneumonia.  A less exotic way of getting the disease is to take a mineral-oil laxative and have it go down your trachea instead of your esophagus (the wrong way.)  So it's entirely reasonable to believe that lipoid pneumonia is what the sick vapers are getting, and that vitamin E acetate may be the cause.

This situation is beginning to resemble another famous incident in which manufacturers involved in making a psychoactive substance turned to what they thought was a harmless chemical in order to cut corners, only to find that it poisoned their customers. 

During Prohibition in the U. S. (1919-1933), it was illegal to sell intoxicating beverages containing more than a few percent of ethyl alcohol.  One of the few exceptions was made for extracts of essential oils such as vanilla and ginger, which were typically 70% alcohol.  When sales of such products boomed and it became clear that people weren't just making lots of vanilla ice cream and gingerbread cookies with the extracts, the Food and Drug Administration required makers of these extracts to adjust their formulas so that they were undrinkable in concentrated form, a process called denaturing.  In particular, makers of Jamaica ginger had to add bitter-tasting substances like castor oil that would not interfere with the intended use for ginger flavoring, but would discourage would-be alcohol consumers from drinking the stuff just to get a buzz.  In order to enforce these rules, the FDA would audit samples of Jamaica ginger to make sure that when the alcohol boiled off, the remaining solids were heavy enough to satisfy the auditors that the makers were still denaturing their product properly.

Thus the matter stood until the price of castor oil went up in the late 1920s.  One Jamaica-ginger maker named Harry Gross looked around for a substitute chemical and found one called tri-ortho cresyl phosphate (TOCP for short).  He asked the manufacturer, Celluloid Corporation, if the chemical was toxic, and they told him they didn't think so.  But this was simply based on the fact that no one involved in the making of the chemical had become seriously ill, not that any tests on animals or humans had been made.  TOCP had a suitable specific gravity to be substituted for castor oil, so Gross made up a large batch of several barrels and sold it to retailers, who in turn sold it to their mostly poor customers who couldn't afford good bootleg liquor.

In a few months, doctors in the poorer areas of cities, especially in the South, began seeing patients whose legs were not working right.  It turned out that TOCP was a slow-acting neurotoxin that selectively attacked the nerves going to the leg muscles.  Over the next year or so, thousands of victims of what came to be called "jake-leg syndrome" turned up.  Many were permanently paralyzed and spent the rest of their lives in wheelchairs, if they could afford one. 

Gross eventually served a two-year jail sentence for adulterating his product, but there were no other major legal consequences for the manufacturers, or compensation benefits for the thousands of mostly poor victims of the syndrome. 

The parallels to the current vaping crisis may not be as obvious as they seem.  But in both cases, there is a chemical being sold under dubious circumstances by shady operators.  In both cases, the chemical involved was not previously suspected of being harmful.  And in both cases, serious injuries occurred to thousands of people before anything substantial was done to get to the source of the problem.

In contrast to the jake-leg episode, the CDC has been issuing warnings about vaping products almost since the first victims of EVALI were identified.  But the drive that some people feel to get high can overpower caution and common sense, and there will always be those around who are willing to cater to such desires with a potentially dangerous product.

It looks like the CDC may be getting to the bottom of the problem, and if they do, we can expect quick action against anyone selling vaping products that can harm users.  While the free market has its uses, regulations to protect the public typically arise only after serious widespread harm has been done due to lack of regulation, and that may be what happens in this case. 

Sources:  The NPR article "CDC Finds Possible Culprit In Outbreak Of Vaping-Related Lung Injuries" appeared on Nov. 8, 2019 at https://www.npr.org/sections/health-shots/2019/11/08/777646890/cdc-finds-possible-culprit-in-outbreak-of-vaping-related-lung-injuries.  I also used material from the health website Healthline at https://www.healthline.com/health/lipoid-pneumonia#causes.  I blogged on this matter on September 9, 2019 at https://engineeringethicsblog.blogspot.com/2019/09/vaping-turns-deadly.html.  And an excellent longer article detailing the saga of jake-leg syndrome ("Jake Leg" by Dan Baum) appeared in The New Yorker magazine's Sept. 15, 2003 issue beginning on p. 50, to which I referred for some of the information above, as well as Wikipedia articles on Jamaica ginger and vitamin E.