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Most US States with Recreational Cannabis Access Had Fewer EVALI Cases, Study Finds

By Leo Bear-McGuinness

Published: Aug 27, 2020   
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E-cigarette or vaping-associated lung injury (EVALI) cases were significantly less common in US states with access to legal recreational cannabis, according to a new study published in Addiction.

Conversely, the study found that states without a legal recreational marijuana market were more likely to have more EVALI cases per capita.

The EVALI outbreak emerged around last August and has been strongly linked to vitamin E acetate, a cutting agent commonly found in illicit cannabis vape products

The study’s findings thus add to the growing weight of evidence that the illicit cannabis vape cartridge market – not its legal, regulated counterpart – was the prime source of the vaping-related disease.

A reversed trend

To make their conclusions, the author of the new study scoured through data on EVALI cases recorded up to mid-January (sourced from state websites) and current US vaping rates (sourced from recently conducted surveys).

They found that the five earliest states to legalize recreational marijuana – Alaska, California, Colorado, Oregon, and Washington – all had less than one EVALI case per 100,000 residents aged 12-to-64.

On the other hand, not one of states with the highest EVALI-prevalence rates – Utah, North Dakota, Minnesota, Delaware, and Indiana – permitted recreational cannabis consumption.

Of all ten states where recreational cannabis use was legal prior to 2020, only Massachusetts was in the top cluster of states with high proportions of EVALI cases. Several states with recreational access, such as Nevada, Washington, Colorado, and Alaska, were among the regions with the lowest cases of EVALI per capita.

“If e-cigarette or marijuana use per se drove this outbreak, areas with more engagement in those behaviors should show a higher EVALI prevalence,” Abigail Friedman, an assistant professor at the Yale School of Public Health and the study’s author, said in a statement. “This study finds the opposite result.”

From her data, Friedman concluded that neither higher adult vaping rates nor higher rates of recent cannabis use predicted increased EVALI prevalence. Indeed, an increase in these behaviors was actually associated with a significant decrease in the prevalence of EVALI.

Instead, the more likely culprit was again deemed to be vitamin E acetate, which is often found in informally purchased and modified THC e-liquids.

“Alongside geographic clusters of high EVALI prevalence states,” Friedman added, “these findings are more consistent with locally available e-liquids or additives driving the EVALI outbreak than a widely used, nationally-available product.”

Good vape, bad vape

Friedman’s findings chime with those of another recent study published in JAMA Network Open. That research found that the average recreational cannabis state had 1.7 EVALI cases per million people, while the average figure in medical cannabis states was 8.8 cases per million.

As of February 18, 2020, over 2,800 people had been hospitalized from EVALI and 68 had died from the disease, according to the US Centers for Disease Control and Prevention (CDC). The outbreak appeared to abate from November onwards; the proportion of hospitalized EVALI patients reported to the CDC declined from 58 percent on November 12, 2019, to 30 percent on December 3.

Back in December, the CDC claimed that it was “unlikely” that a single brand of vaping products was responsible for the vaping crisis. Instead, the agency strongly linked the EVALI cases to the illicit vaping market; it found that one counterfeit THC brand, Dank Vapes, was used by 56 percent of hospitalized EVALI patients nationwide.

And after conducting its own research to find the cause of the disease, the US Food and Drug Administration (FDA) announced in February that “the presence of the compound vitamin E acetate in vaping products is strongly linked to the outbreak.”

Speaking to Analytical Cannabis last October, Dr Swetha Kaul, vice president of the board of directors at the California Cannabis Industry Association, concurred that the illicit vape market was the main source of the contaminant.

“Vitamin E acetate is extremely viscous and it’s cheaply available, so it makes a perfect cutting agent,” she said. “[…]20, 30, 60 percent of a cartridge could be vitamin E acetate.”

“The safer option is to shop [for] legal, tested products. I feel like that's the messaging that might resonate,” she added. “Because if you just tell people to stop vaping, they're just going to ignore the entire message. So how about giving them a route where at least their chances of staying safe are higher and better?”


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