On September 18, a regional medical center in London, Ontario, held a press conference to report that a 17-year-old patient had almost died of a lung condition that doctors believed was caused by vaping.
The Middlesex-London Health Unit doctor, Dr Chris Mackie, told the assembled reporters that he knew what products the patient had used, but „We don't give out any information about the brand information because that would mean that this is something that comes from a brand, if you look closely at the international evidence, that's not the case“.
The US news media at the time was already urging the CDC to admit that the outbreak of steam-induced lung injury was primarily (though not entirely) caused by black market THC cartridges, but Mackie didn't want to discuss what the teen had taken in during the press conference. Two days later, he denied that the teen had even been vaporizing THC products and blamed it directly on nicotine vaping.
„This person did not use any[THC] products“, Mackie told the CBC. „The person has been quite heavily vaperting with a nicotine-based product.“
The Canadian press spread the story dutifully, and Vaper was understandably outraged. If a commercial vaping product caused this nightmare, why shouldn't he call the product? Dr. Mackie's Twitter feed was full of outraged nicotine addicts who called him a liar. He said they were „malignant“.
Between the London teenager and growing fears of an „epidemic“ of teenage American-style vaping, Canada has had its own moral panic in recent months. And then came the report from doctors who had treated the London teenager.
Popcorn lung!
The press release appeared on November 21. The patient was finally identified as male, and the authors admitted that he regularly vaped THC products (Dr. Mackie never apologized, by the way, for lying about it.) Since his condition was marked with certain characteristics, the doctors of Ontario said he was different from the American cases they „postulated“ he could have been caused by bronchiolitis obliterans (popcorn lung).
Popcorn lung is a unicorn for anti-vaping activists. Since some E fluids contain diacetyl and acetylpropionyl, substances known to cause bronchiolitis obliterans in flavour factories, it has long been believed that vaping could cause popcorn lungs, but studies have shown that the amount of diacetyl consumed by vapers is very small (or non-existent) and unlikely to cause the disease. And in fact, it has never been the case that diacetyl and acetylpropionyl are present.
„Recently, several cases of „E-cigarette or Vaping Product Use – Associated Lung Injury“ (EVALI) have been described“, according to the Canadian press release „However, this patient presented a new type of steam-related injury similar to popcorn lung, a disease occurring in workers that has the chemical aroma of diacetyl, a component of microwaves, in the chemical aroma of diacetyl, a component of microwaves;
They wanted to write: „If inhaled in large quantities“, but probably forgotten. There is no evidence that commercial E fluid contains enough diacetyl to cause bronchiolitis obliteran – or even that cigarettes containing a hundred times more of the chemical than E fluid have ever caused a case.
With the press release came a case study published in the Canadian Medical Association Journal (CMAJ). The case study was much less convincing than the press release. In fact, the Canadian physicians in the case study admit that they cannot prove that it is a case of bronchiolitis obliterans at all.
What prevented the doctors from making a definite diagnosis of the popcorn lung or from excluding another case of EVALI?
No surgical biopsy was performed to examine the patient's bronchioles, the small airways that are diagnostically damaged and scarred by bronchiolitis obliterans.
However, the „Tree-in-bud“ injury pattern they identified as diagnostic for the broad category of lung diseases summarized as bronchiolitis is not unique to the specific conditions of bronchiolitis obliterans. Some EVALI patients in whom bronchiolitis obliterans was excluded also showed this pattern.
They did not test for lipoid pneumonia, so this could not be ruled out.
They never tested the products the teenager was using: „Our patient's vaping fluid was not available for analysis, but similarly flavoured products have been shown to contain flavourings including diacetyl.“
They have not measured how much diacetyl is contained in „similar products“. Did they contain enough that a vaper would exceed the limits for diacetyl in the workplace?
The doctors admitted that they could not localise „the pathogen responsible for our patient's lung disease because he had ingested a variety of substances, more than one of which could be a pathogen for damage“.
Just because the case seems to be superficially different from most US cases does not prove that it is a popcorn lung – or even that the causative factors were different from the typical American EVALI cases that seem to be associated with vitamin E acetate used to dilute illegal cannabis oil.
„[There are many ways in which patients' lungs have responded to inhalation of vitamin E acetate oil and all impurities it contains“, wrote Boston University Professor of Public Health Michael Siegel, who is also a physician. „ These presentations ranged from lipid pneumonia to chemical pneumonia to crypotogenic organizing pneumonia and acute eosinophilic pneumonia. The point is that various different presentations ranged from crypotogenic organizing pneumonia to acute eosinophilic pneumonia. The point is that various different lungs reacted to inhalation of vitamin E acetate oil and all impurities it contains“, wrote Michael Siegel, Professor of Public Health at Boston University, who is also a physician. „ These presentations ranged from lipid pneumonia to chemical pneumonia to crypotogenic organizing pneumonia and acute eosinophilic pneumonia;
The end result is that there is not enough evidence to call this case popcorn lung, and the doctors' decision to „postulate“ that it was popcorn lung was ill-considered. The lung injuries that the CDC summarizes as EVALI have a wide range of characteristics, and the victims seem to suffer from a variety of different types of injuries or diseases. This case is probably just another variant.
But deputy CMAJ editor Dr. Matthew Stanbrook, respirologist at the University of Toronto and a long-time committed opponent of vaping, really wants you to believe that Stanbrook apparently waited ten years to find a popcorn lung related to steaming, and through the chewing gum, here it was in his own backyard! He wasn't about to let it escape. His editorial on the horrors of vaping appears in the magazine next to the case study. Read his editorial on the horrors of vaping.
„Although the case reported by Landman and colleagues shares many characteristics with those described so far in the EVALI epidemic, several differences make the case unique and outstanding“, Stanbrook wrote. „Clinical characteristics suggest a form of bronchiolitis – possibly bronchiolitis obliterans, a pathology not previously described with the use of e-cigarettes, but long considered a probable consequencea long time ago𔄚 was considered a probable consequence“.
It was never considered a likely sequel by anyone who had studied the history of popcorn lung and earlier diacetyl studies that showed that vaping products contained only small amounts of the substance, but that did not stop Stanbrook.
„Most e-cigarette fluids contain or produce the flavourings diacetyl“, Stanbrook continued, „Diacetyl is a known cause of bronchiolitis obliterans, an association first described among workers in a factory producing butter-flavoured popcorn („popcorn worker's lung“). This case may therefore be the first direct proof of lung disease, this case may be the first direct evidence of lung disease.
Although the „postulation“ of the London doctors for the popcorn lung was full of powers and Maybes, Dr. Stanbrook wants you to know that this is the vaping danger that has always been expected and long been considered probable, practically ignoring the fact that tens of millions of people, mostly ex-smokers with already weakened lungs, have been consuming commercial nicotine products daily for more than a decade without consequences.
Why should this „otherwise healthy“ (the doctors' words) teenager be beaten down by the disease alone? Frankly, very few products offer such reassuring opportunities! Aspirin kills thousands every year, and driving cars is even more difficult.
Bronchiolitis obliterans develops rapidly – like the lung condition of the Canadian teenager - but it doesn't stay halfway through its natural progression. Doctors report that the teenager still has signs of severe lung damage, but improves slightly. He has been discharged from hospital for months. The cases of bronchiolitis obliterans are usually not that severe – but it is typical of EVALI patients who have survived.
Stanbrook called for a complete ban on flavoured vaping products and noted that the CMAJ had always supported such a ban. „The logical and responsible measure against toxic, harmful products is to recall them and ban them“, he wrote.
There is no reason to „postulate“ that an unusual event caused this teenager's lung injury when the same substance that the CDC blames for the American „EVALI“ cases is available everywhere. Vitamin E acetate is an easy-to-buy chemical compound commonly used in the manufacture of cosmetics and dietary supplements.
I don't know these doctors, so I can't judge their motives, but it seems they, like Dr. Stanbrook, don't like to vapour and they don't want teenagers to do it, so they deliberately ignored the obvious cause of this boy's tragic lung injury and used an improbable one to help solve their anti-vaping case. At best, it's the result of a distortion of variety confirmation in the garden and a motivated argumentation. At worst, this effort was driven from the start by the intention to deceive from the worst case scenario.
