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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).