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Research

Life-threatening bronchiolitis related to electronic cigarette use in a Canadian youth

Simon T. Landman, Inderdeep Dhaliwal, Constance A. Mackenzie, Tereza Martinu, Andrew Steele and Karen J. Bosma
CMAJ December 02, 2019 191 (48) E1321-E1331; DOI: https://doi.org/10.1503/cmaj.191402
Simon T. Landman
Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steele), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont.
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Inderdeep Dhaliwal
Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steele), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont.
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Constance A. Mackenzie
Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steele), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont.
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Tereza Martinu
Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steele), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont.
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Andrew Steele
Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steele), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont.
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Karen J. Bosma
Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steele), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont.
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  • RE: Lack of supplied information
    Sean Rankin
    Posted on: 22 November 2019
  • RE: Vape related "Popcorn Lung" debunked years ago
    Jason R. Haney
    Posted on: 22 November 2019
  • RE: "Popcorn lung", diacetyl and vaping
    Marion C Burt
    Posted on: 22 November 2019
  • RE: Lack of data
    Luke W. Marshall
    Posted on: 21 November 2019
  • RE: broncholitis and vaping
    Stuart Eberhard
    Posted on: 21 November 2019
  • Posted on: (22 November 2019)
    RE: Lack of supplied information
    • Sean Rankin, Vaping advocate and user, Haze Vape Co., Calgary, AB

    This report is incredibly vague, while at the same time incriminating vaping products with little evidence.
    A background on Diacetyl:
    - A butter flavoured compound used in artificial flavourings, and was once commonly used in e-cigarette flavours. Risks were known, and it was used in limited capacity.
    - Harvard Medical School published a study stating to have found Diacetyl in eliquids (1). This was no surprise, it was never intended to be a secret. The Harvard Study also failed to disclose within their study, a control group to compare their findings - the most important being that tobacco cigarettes produce more than 100x times more Diacetyl than even the most offending eliquid (2).
    There are no records of bronchiolitis obliterans on record as a result of smoking.
    With over 15 years of use worldwide, there have been no reports whatsoever of any ecigarette user contracting the disease.
    Use of the ingredient was almost completely eliminated from eliquids in North America, regardless.
    - With nearly zero likelihood of a North American product containing any significant amount of Diacetyl, the chances of anyone contracting Bronchiolitis Obliterans due to vaping is infinitesimal.
    During a time where thousands of cases of lung damage are being clearly and undeniably linked to illegal THC products tainted by either Vitamin E Acetate or Myclobutanil, this study purports that regulated products, produced with common knowledge of the...

    Show More

    This report is incredibly vague, while at the same time incriminating vaping products with little evidence.
    A background on Diacetyl:
    - A butter flavoured compound used in artificial flavourings, and was once commonly used in e-cigarette flavours. Risks were known, and it was used in limited capacity.
    - Harvard Medical School published a study stating to have found Diacetyl in eliquids (1). This was no surprise, it was never intended to be a secret. The Harvard Study also failed to disclose within their study, a control group to compare their findings - the most important being that tobacco cigarettes produce more than 100x times more Diacetyl than even the most offending eliquid (2).
    There are no records of bronchiolitis obliterans on record as a result of smoking.
    With over 15 years of use worldwide, there have been no reports whatsoever of any ecigarette user contracting the disease.
    Use of the ingredient was almost completely eliminated from eliquids in North America, regardless.
    - With nearly zero likelihood of a North American product containing any significant amount of Diacetyl, the chances of anyone contracting Bronchiolitis Obliterans due to vaping is infinitesimal.
    During a time where thousands of cases of lung damage are being clearly and undeniably linked to illegal THC products tainted by either Vitamin E Acetate or Myclobutanil, this study purports that regulated products, produced with common knowledge of the issues surrounding Diacetyl and restricted use of Diacetyl as a result, are somehow to blame.
    With no toxicology reports to demonstrate any connection to any product whatsoever.
    This is not a scientific conclusion, this is simply biased guesswork at best, nothing more than an accusation that should never have been published in any capacity, anywhere. An agenda that has been condoned by the CMAJ, one which will continue scaring vaporizer users away from their devices, and back to smoking tobacco. This is simply irresponsible work by all parties involved.
    Yes, I am a vaper, yes, I am a vaping industry business owner. I spend nearly every day studying the subject of vaping. I put my own life on the line by testing the products I sell, before I sell them. Vaping knowledge is what I do.
    My stores alone have helped thousands wean themselves not only from tobacco, but with nicotine adjustment in our products, my customers have also been able to wean themselves from vaping when they choose to do so.
    References
    1. Allen JG, Flanigan SS, LeBlanc M, et al. Flavoring chemicals in e-cigarettes: diacetyl, 2,3-pentanedione, and acetoin in a sample of 51 products, Including fruit-, candy-, and cocktail-flavored e-cigarettes. Environ Health Perspect 2016;124:733-9.
    2. Fujioka K, Shibamoto T. Determination of toxic carbonyl compounds in cigarette smoke. Environ Toxicol 2006;21:47-54.

    Show Less
    Competing Interests: Yes, I am a vaper, yes, I am a vaping industry business owner. I spend nearly every day studying the subject of vaping. I put my own life on the line by testing the products I sell, before I sell them. Vaping knowledge is what I do. My stores alone have helped thousands wean themselves not only from tobacco, but with nicotine adjustment in our products, my customers have also been able to wean themselves from vaping when they choose to do so.
  • Posted on: (22 November 2019)
    RE: Vape related "Popcorn Lung" debunked years ago
    • Jason R. Haney, Owner, County Computers and Apothic Vapes, None

    Bronchiolitis Obliterans (popcorn lung) is indeed real though extremely rare. It is caused by accute exposure to Diacetyl, a chemical used to enhance buttery and custard flavors in the food industry (and the vape industry for a short time ending 2014/2015). Diacetyl is also a naturally occuring chemical produced in various fruits, vegetables and plants. The most notable of which is Tobacco. More on that in a minute.

    I think it is quite questionable for any educated health professional to pin the blame on this youth's lung injury on popcorn lung, as there has been a plethora of scientific data negating the possibility. I assume willful ignorance is to blame here, an utter failure to research the plethora of available data. There is 750x more diacetyl in a pack of cigarettes than there is in a days worth of vaping nicotine fluid, and to date we have no confirmation that smokers are getting popcorn lung.

    To put that into perspective: A vaper is exposed to 9mcg of Diacetyl (study by Allen et al., [https://ehp.niehs.nih.gov/doi/10.1289/ehp.1510185]) per day whereas a pack a day smoker is exposed to 6718mcg (Fujioka and Shibamoto study, [https://onlinelibrary.wiley.com/doi/abs/10.1002/tox.20153]) per day. Yet popcorn lung has only been diagnosed in those popcorn factory workers almost 20 years ago, there can be no...

    Show More

    Bronchiolitis Obliterans (popcorn lung) is indeed real though extremely rare. It is caused by accute exposure to Diacetyl, a chemical used to enhance buttery and custard flavors in the food industry (and the vape industry for a short time ending 2014/2015). Diacetyl is also a naturally occuring chemical produced in various fruits, vegetables and plants. The most notable of which is Tobacco. More on that in a minute.

    I think it is quite questionable for any educated health professional to pin the blame on this youth's lung injury on popcorn lung, as there has been a plethora of scientific data negating the possibility. I assume willful ignorance is to blame here, an utter failure to research the plethora of available data. There is 750x more diacetyl in a pack of cigarettes than there is in a days worth of vaping nicotine fluid, and to date we have no confirmation that smokers are getting popcorn lung.

    To put that into perspective: A vaper is exposed to 9mcg of Diacetyl (study by Allen et al., [https://ehp.niehs.nih.gov/doi/10.1289/ehp.1510185]) per day whereas a pack a day smoker is exposed to 6718mcg (Fujioka and Shibamoto study, [https://onlinelibrary.wiley.com/doi/abs/10.1002/tox.20153]) per day. Yet popcorn lung has only been diagnosed in those popcorn factory workers almost 20 years ago, there can be no credible argument that someone vaping nicotine e-liquids had their lungs damaged by diacetyl. This youth would have had to vape 746 days worth of nicotine vape liquids in just one day in order to be exposed to as much diacetyl as one gets from smoking 1 pack of cigarettes.

    This is all quite public and scientific knowledge, if I could link websites here I would have included those as citations. But I am sure the esteemed writers of this article know how to use the google and find research and studies done and/or referenced by the likes of; Dr. Micheal Seigel and Professor David Sweanor (North America's anti-tobacco champions) as well as Dr. Konstantinos Farsalinos and Riccardo Pelosa just for starters.

    Bottom line: Consider that the FDA issued a warning well over a month ago in relation to the danger of vaping black market THC oils (https://www.fda.gov/consumers/consumer-updates/vaping-illness-update-fda...). And the patient himself admitted to vaping such, while the chief medical officer of the Middlesex-London Health Unit admitted knowing the youth had purchased his product from the U.S.A.

    It is an extreme stretch to blame this youth's issues on a much fabled yet obscure disease, when the symptoms match perfectly with those suffering and dying in the U.S. due to Vitamin E Acetate contaminated THC vape carts. Had a direct and clear warning gone out at the end of August when Leafly sounded the alarm about THC vape carts being the cause, we might not have 42 dead and over 2000 hospitalized. Public Health England and it's media partners nipped their THC vape cart scare in the bud back in July by doing exactly that (https://www.bbc.com/news/uk-england-manchester-49001669). No one died, crisis averted.

    It is my opinion that the misinformation being bandied around by our health officials, media and politicians for the last 3 months is nothing less than reckless endangerment, responsible in large part for the 42 dead and counting, this article is just as bad. As if it is not bad enough that 600 people will die today in North America from tobacco use when there is a far less harmful alternative, an excellent gateway to living smoke free.

    Show Less
    Competing Interests: I own a vape shop set up to help smokers transition to the harm reduction product that ended my 25yr tobacco addiction.
  • Posted on: (22 November 2019)
    RE: "Popcorn lung", diacetyl and vaping
    • Marion C Burt, retired, None

    It should be noted that the Harvard study from 2017 that identified diacetyl in several samples of nicotine-based e-liquid did not compare the levels to that of tobacco cigarettes. In fact, tobacco cigarettes contain 700 times the amount of diacetyl found in any of the samples.
    The vaping "community" communicates constantly, and when this study's results appeared, most manufacturers removed diacetyl from their recipes in the interest of safety. Further, in developing the TVPA in 2018 to regulate the vaping industry, Health Canada guidance strongly advised against the use of diacetyl in vaping e-liquid (1). The government monitors the manufacture of this liquid to ensure compliance.
    According to press reports, the patient bought his e-liquid from a Canadian online vendor whose inventory would be controlled by these regulations.
    The statement in this paper that diacetyl is present in many flavours is therefore incorrect and misleading.
    Reference
    1. Flavourants and other additives. In Guidance on Vaping Products not Marketed for a Therapeutic Use. Ottawa: Health Canada; modified 2019 Jan. 15. Available: www.canada.ca/en/health-canada/services/publications/product-safety/vapi... (accessed 2019 Nov. 25).

    Competing Interests: None declared.
  • Posted on: (21 November 2019)
    RE: Lack of data
    • Luke W. Marshall, Entrepreneur, County Vape by L&M Supplies Limited.

    It's interesting that I see no mention of THC products that were determined to be the cause of the issue of the cases throughout the United States. With the teen here getting their products online from an American company. Maybe the evidence hadn't been announced at the time of writing but this article should be amended to reflect this. The broad use of the word Vaping as a reason or cause in and of itself is misleading and uninformative. Its like blaming the needle a heroin junkie uses when the overdose on bad product. And it is the bad unregulated product in the US that is the Issue. THC oils cut with vitamin E acetate and laced with toxic pesticides that has been on only common factor found. This might have been learned earlier had the medical establishment taken appropriate steps to gather evidence and take a proper history. unfortunately by the CDCs own admission this didn't even begin to happen till after the 9th person died. The rampant misunderstanding that is being spread thanks to the general term of vaping has become so widespread that the doctors themselves failed to do their duty and thus the American public was mislead with false data often leaving people taking precautions from the wrong product.and ultimately dying. We Must do better to ensure that this kind of behavior is not condoned or even given enough weight to get off the ground lest we find cause to over regulate one product that halps while trying to safeguard against something else e...

    Show More

    It's interesting that I see no mention of THC products that were determined to be the cause of the issue of the cases throughout the United States. With the teen here getting their products online from an American company. Maybe the evidence hadn't been announced at the time of writing but this article should be amended to reflect this. The broad use of the word Vaping as a reason or cause in and of itself is misleading and uninformative. Its like blaming the needle a heroin junkie uses when the overdose on bad product. And it is the bad unregulated product in the US that is the Issue. THC oils cut with vitamin E acetate and laced with toxic pesticides that has been on only common factor found. This might have been learned earlier had the medical establishment taken appropriate steps to gather evidence and take a proper history. unfortunately by the CDCs own admission this didn't even begin to happen till after the 9th person died. The rampant misunderstanding that is being spread thanks to the general term of vaping has become so widespread that the doctors themselves failed to do their duty and thus the American public was mislead with false data often leaving people taking precautions from the wrong product.and ultimately dying. We Must do better to ensure that this kind of behavior is not condoned or even given enough weight to get off the ground lest we find cause to over regulate one product that halps while trying to safeguard against something else entirely.

    Show Less
    Competing Interests: I am in the business of selling vaping product for the purposes of helping people to quit.
  • Posted on: (21 November 2019)
    RE: broncholitis and vaping
    • Stuart Eberhard, physician (retired), (formerly) London Health Sciences Centres

    As previous chief of Internal Medicine at a large academic hospital about two years ago at a medical conference I said residents interested in entering a subspecialty should think about respiratory medicine as with the legalization of marijuana and vaping there will be lots of work for chest doctors.
    I was correct.

    Competing Interests: None declared.
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Canadian Medical Association Journal: 191 (48)
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Life-threatening bronchiolitis related to electronic cigarette use in a Canadian youth
Simon T. Landman, Inderdeep Dhaliwal, Constance A. Mackenzie, Tereza Martinu, Andrew Steele, Karen J. Bosma
CMAJ Dec 2019, 191 (48) E1321-E1331; DOI: 10.1503/cmaj.191402

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Life-threatening bronchiolitis related to electronic cigarette use in a Canadian youth
Simon T. Landman, Inderdeep Dhaliwal, Constance A. Mackenzie, Tereza Martinu, Andrew Steele, Karen J. Bosma
CMAJ Dec 2019, 191 (48) E1321-E1331; DOI: 10.1503/cmaj.191402
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