Pandemic of the unregulated

A study finds 2019’s EVALI outbreak wasn’t caused by vaping mainstream nicotine or cannabis products—but by vaping informal alternatives


In 2019 there was a different pandemic sweeping the nation, wreaking havoc on people’s lungs, putting some in the hospital and others in early graves.

Rates of the mysterious “E-cigarette or Vaping-product Associated Lung Illness” (aka EVALI) spiked in August of 2019 and the Centers for Disease Control and Prevention (CDC) launched an investigation into the outbreak the same month. As of February 18, 2020 (when they stopped recording cases), EVALI had hospitalized 2,807 people—68 of whom had died as a result. By September, CDC officials were holding press conferences suggesting that THC products were largely behind the outbreak. 

Fingers were pointed, blame was cast, both federal and local legislation started passing to restrict the sale of vape products, and criticisms were levelled against state cannabis policies. 

But that blame was misplaced, according to Abigail Friedman, lead author of a study published in, [[I]]Addiction[[I]], titled “Association of vaping-related lung injuries with rates of e-cigarette and cannabis use across US states.” Her research indicates that the root cause of EVALI actually wasn’t correlated to legalized cannabis or higher rates of nicotine vape use at all. In fact, she found the correlation went the opposite direction: States with legal cannabis (and higher rates of vape use) were seeing [[I]]fewer[[I]] cases of EVALI than states upholding prohibition.

This suggests that the problem was tied to illicit or “informally sourced” products—not those coming from commercial manufactures. 

For her analysis, Friedman collected data from every state on the total number of EVALI cases they’d reported as of the second week of January 2020. She then compared those against state policies concerning cannabis legalization and vape restrictions, prior to August 1 (the day when the CDC initiated its formal investigation into EVALI).  

“I wanted to look at policies that couldn’t possibly have been passed in response to the outbreak because they preceded the CDC’s recognition that something was going wrong in the greater public,” she says. 

Friedman explains that vaporizing cannabis is the second most popular form of cannabis consumption (smoking flower being the first), meaning states with legal cannabis have overall higher rates of vape use than those that don’t. So if commercial vapes (for either THC or nicotine) were driving the outbreak of EVALI, she would have expected the rates of EVALI hospitalizations to be higher in states where people had access to legal cannabis. 

However, that was not what she observed.  

“There are fewer cases [of EVALI] per capita in states that have recreational marijuana,” Friedman states. “If [users in those states] are more likely to vape as their primary mode of use, then it had to be that they were less likely to be exposed to a tainted product.”

The data backed that up: States with the strictest cannabis laws and vape restrictions—like Utah, North Dakota, Minnesota, Delaware, and Indiana—all had some of the highest rates of EVALI hospitalizations in the country. By contrast, the five earliest states to legalize recreational cannabis (Colorado, California, Oregon, Washington, and Alaska) all had less than one EVALI case per 100,000 residents between the ages of 12 and 64. 

Friedman also looked at states that allow for medical marijuana patients to grow their own cannabis, compared to those that prohibit home cultivation. 

“We thought that if [states] permit home cultivation, people would actually show lower rates of vaping and higher rates of smoking marijuana,” she says, adding that was exactly what they found. “Consequently, if you permit home cultivation, you see a lower EVALI incidence relative to medical marijuana states that prohibit home cultivation.”

All of that information, data, and patterns observed seemed to indicate strongly to Friedman that the root source of America’s EVALI outbreaks was not coming from the legal market. 

“We were dealing with an informally sourced or illicit market product,” Friedman says. “That is what creates the danger: if it’s easy to adulterate products on the illicit market, then it’s more likely that product gets into the hands of someone who uses it and then gets sick.”

Instead of legal cannabis or commercial e-cigarettes causing the health crisis, it was actually prohibition policy driving it.

“When we’re talking about drug policy . . . whether it’s tobacco or marijuana or other products, we need to be thinking about the effects that a policy targeting one thing will have on both the licit and illicit market for those products,” Friedman says. 

If people have the option to buy reliable cannabis, or commercially produced cannabis concentrate or nicotine cartridges, they typically will, she says. She explains, the phenomenon is known as “crowding out” where—the introduction of a new market, forces the old market out via consumer preference. Safer, higher quality cannabis products will always be preferable to consumers. 

“This outbreak was not about vaping mainstream nicotine or cannabis products. It was never about vaping mainstream products,” Friedman says. “[It’s] about how state regulations are going to affect the illicit market and how that’s introducing new risks.”