How to Protect Yourself

Since the specific compounds or ingredients causing lung injury associated with the use of electronic cigarettes or vaping products are not yet known, the only way to assure that you are not at risk while the investigation continues is to consider refraining from use of all e-cigarette, or vaping, products. There is no safe tobacco product – all tobacco products, including e-cigarettes, carry a risk.

No one compound or ingredient has emerged as the cause of these illnesses to date; and it may be that there is more than one cause of this outbreak. Many different substances and product sources are still under investigation. While it appears that vitamin E acetate is associated with EVALI, evidence is not yet sufficient to rule out contribution of other chemicals of concern to EVALI. The only commonality among all cases is that patients report the use of e-cigarette, or vaping, products, including nicotine, tetrahydrocannabinol (THC), and cannabinoid (CBD)-containing products.

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 a number of the cases and play a major role in the outbreak. However, many cases, including some of the patient deaths, have been a associated with vaping nicotine only products.

If you use electronic cigarettes or vaping products and you experience any of the symptoms below, you should seek immediate medical care.

• Cough, shortness of breath, or chest pain
• Nausea, vomiting, abdominal pain, or diarrhea
• Fever, chills, night sweats, fatigue, or weight loss

Some patients have reported their symptoms developed over a few days, while others have reported their symptoms developed over several weeks. When seeking medical care, tell your health care provider about what vaping products you have used.

What is an e-cigarette?

• Electronic cigarettes – or e-cigarettes – work by heating a liquid to produce an aerosol that users inhale into their lungs.
• The liquid can contain: nicotine, tetrahydrocannabinol (THC) and cannabidiol (CBD) oils, and other substances, flavorings, and additives.
• E-cigarettes are also called vapes, e-hookahs, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS).

What is vaping?

• Using an e-cigarette is commonly called vaping.
• Vaping can refer to using e-cigarettes to inhale many substances, including nicotine, and THC or CBD oils.

Recommendations

DHSS recommends that while this outbreak is ongoing, people should not:

• Use e-cigarette, or vaping, products that contain THC.
• Buy any type of e-cigarette, or vaping, products, particularly those containing THC, off the street.
• Modify or add any substances to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments.
• THC use has been associated with a wide range of health effects, particularly with prolonged heavy use. The best way to avoid potentially harmful effects is to not use THC, including through e-cigarette, or vaping, products. Persons with marijuana use disorder should seek evidence-based treatment by a health care provider.

What is marijuana (THC)?

• Marijuana, which can also be called weed, pot, dope, or cannabis, is the dried flowers and leaves of the cannabis plant.
• Marijuana contains mind-altering (e.g., psychoactive) compounds like tetrahydrocannabinol, or THC, as well as other active compounds like cannabidiol, or CBD, that are not mind-altering.
• For help to quit vaping marijuana, consult a doctor; visit the Substance Abuse and Mental Health Services Administration’s Treatment Locator to locate treatment in your area; or call 1-800-662-HELP (4357).

What are the health risks of marijuana (THC)?

• Marijuana use has been associated with a wide range of health effects, particularly with prolonged heavy use.
• These effects range from short-term problems with attention, memory, learning, to longer-term problems such as psychosis, anxiety, suicidal ideation and attempts, depression, and substance use disorder. It is not known whether these are causal relationships or simply associations.
• Marijuana use can lead to the development of problem use, known as a marijuana use disorder, which takes the form of addiction in severe cases. Recent data suggest that 30 percent of those who use marijuana may have some degree of marijuana use disorder.¹
• The best way to avoid potentially harmful effects is to not use marijuana.
• For more information visit the CDC web page Marijuana and Public Health.

How does marijuana use during adolescence affect youth?

• Marijuana use, including through the use of cigarettes or vaping, is associated with a broad range of health effects. Regardless of the substance used, e-cigarette, or vaping, products should never be used by youth.
• Marijuana use can harm the developing adolescent brain and impact attention, learning, and memory.
• People who begin using marijuana before the age of 18 are four to seven times more likely to develop a marijuana use disorder than adults.²
• Youth marijuana use has also been associated with antisocial and oppositional behaviors, nicotine use, poor school performance, use of other illicit substances and the development of substance use disorders, and impairments in social relationships. See the recent Surgeon General’s Advisory: Marijuana Use and the Developing Brain.
• Regardless of the substance used, e-cigarette or vaping products should never be used by youth or pregnant women. It is important for parents to communicate with their child about the risks of nicotine, THC, or other substance use. CDC offers a Talk with Your Teen About E-cigarettes tip sheet to help parents talk with their children about why e-cigarettes are harmful for them.

What should I do if I am currently vaping marijuana/THC for medical use?

• Many people who vape THC, do so to treat other medical conditions, although there is currently little scientific evidence that vaping THC is helpful for diverse health issues for which it is being used. DHSS’ advice to medical cannabis patients is to refrain from vaping THC products while this outbreak is ongoing. If there are other THC products that have been effective in treating your medical condition, you should use those products until the outbreak has ended.
• If medical cannabis patients choose to continue vaping THC to treat their medical conditions, they should consider the following guidelines:
  • Only purchase THC vape cartridges from reputable, licensed dispensaries.
  • Do not modify or add any substances to the cartridges.
  • Know the symptoms of vaping-related lung injuries and seek immediate medical care if you experience any of them.

References

1. Hasin DS, Saha TD, Kerridge BT, et al. Prevalence of Marijuana Use Disorders in the United States Between 2001-2002 and 2012-2013. JAMA Psychiatry. 2015;72(12):1235-1242. doi:10.1001/jamapsychiatry.2015.1858
2. Winters KC, Lee C-YS. Likelihood of developing an alcohol and cannabis use disorder during youth: Association with recent use and age. Drug Alcohol Depend. 2008;92(1-3):239-247. doi:10.1016/j.drugalcdep.2007.08.005
3. What Are Marijuana’s Long-Term Effects on the Brain? National Institute on Drug Abuse. Retrieved from “What are Marijuana’s Long-Term Effects on the Brain?”.

What is vitamin E acetate and why might it be in e-cigarette, or vaping, products?

• Vitamin E is a vitamin found in many foods, including vegetable oils, cereals, meat, fruits, and vegetables. It is also available as a dietary supplement and in many cosmetic products, like skin creams.
• Vitamin E acetate is used as an additive in the production of e-cigarette, or vaping, products, because it resembles THC oil. Vitamin E acetate is also used as thickening ingredient in e-liquids.

Why might vitamin E acetate be harmful?

• Vitamin E acetate usually does not cause harm when ingested as a vitamin supplement or applied to the skin. However, previous research suggests when vitamin E acetate is inhaled, it may interfere with normal lung functioning.

• While, vaping has been promoted as a safer alternative to smoking, the CDC says e-cigarettes are not safe for:
  • Youth
  • Young adults
  • Pregnant women
  • Adults who do not currently use tobacco products
• If you’ve never smoked or used other tobacco products or e-cigarettes, you should not start. E-cigarettes are devices that deliver an aerosol to the user by heating a liquid that usually contains nicotine, flavorings, and other chemicals. E-cigarettes are still a relatively new tobacco product, and additional research is needed to better understand the dangers and long-term risks of using them.
• If you are an adult using e-cigarettes, or vaping, products to quit cigarette smoking, do not return to smoking cigarettes. Use evidence-based treatments, including healthcare provider counseling and FDA approved medications.
• Adult smokers who are attempting to quit should use evidence-based treatments, including counseling and FDA-approved medications. If you need help quitting tobacco products, including e-cigarettes, contact your health care provider.
• If you are a youth using e-cigarettes, or vaping, products or any other nicotine containing products (e.g. cigarettes, smokeless tobacco, etc.) and need help quitting, talk to your healthcare provider, or utilize any of the free resources below for help to quit.
• Information about e-cigarettes and vapes can be found on the CDC website.

For information about how you can help yourself or a loved one quit tobacco, including e-cigarettes, visit YouCanQuit.org, or call 1-800-QUIT-NOW (1-866-784-8669).

Smokefree.gov
Free tools and tips to help you quit including, texting and apps.

Smokefreeteen
Free tools and tips to help you quit including, texting and apps.

TEXT-DITCHJUUL
Free text–to-quit vaping service to help adolescents quit using electronic cigarettes. Text DITCHJUUL to 88709

Questions?

MOTobaccoProgram@health.mo.gov