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.
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 brand information because that would imply 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 individual was not using any [THC] products," Mackie told the CBC. "This individual was vaping pretty heavily with a nicotine-based product."
The Canadian press dutifully spread the story, and vapers were understandably outraged. If a commercial vaping product caused this nightmare, why wouldn't he name the product? Dr. Mackie's Twitter feed was full of outraged nicotine addicts calling him a liar. He said they were "vicious."
Between the London teen and growing fears of an American-style "epidemic" of teen vaping, Canada has had its own moral panic in recent months. And then came the report from doctors who had treated the London teen.
The press release appeared on November 21. The patient was eventually identified as male, and the authors admitted that he regularly vaped THC products. (Dr. Mackie never apologized for lying about this, by the way). Because his condition was marked with certain characteristics, Ontario doctors said he was different from American cases, they "postulated" he might 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 vapor-related injury similar to popcorn lung, a condition that occurs in workers exposed to the chemical flavoring of diacetyl, an ingredient in microwave popcorn. When inhaled, the chemical causes bronchiolitis, which is characterized by the small airways of the lungs becoming inflamed and clogged."
They meant to write, "When inhaled in large quantities," but probably forgot. There is no evidence that commercial e-liquid contains enough diacetyl to cause bronchiolitis obliteran - or even that cigarettes, which contain hundreds of times more of the chemical than e-liquid, 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 recognized as diagnostic of the broad category of lung diseases grouped as bronchiolitis is not unique to the specific conditions of bronchiolitis obliterans. Some EVALI patients in whom bronchiolitis obliterans had been 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 teen used: "Our patient's vaping liquid was not available for analysis, but similarly flavored products have been shown to contain flavorings including diacetyl."
They didn't measure how much diacetyl was in the "similar products". Did they contain enough that a vaper would exceed the workplace limits for diacetyl?
The doctors admitted that they "cannot locate the agent(s) responsible for our patient's lung disease because he ingested a variety of substances, more than one of which may be an agent of harm."
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.
"[T]here are a variety of ways in which patients' lungs have responded to inhalation of vitamin E acetate oil and all the contaminants it contains," wrote Boston University public health professor Michael Siegel, who is also a physician. "These presentations ranged from lipoid pneumonia to chemical pneumonia to crypotogenic organizational pneumonia to acute eosinophilic pneumonia. The point is that different people react differently to whatever in vitamin E acetate oil is causing this outbreak. There's a variety of presentations and although this presentation has some different functions than many earlier ones, it's not clear that this is a completely different entity because it's a completely different cause."
The bottom line 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 poorly considered. The lung injuries that the CDC groups together 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 features with those previously described in the EVALI epidemic, several differences make the case unique and outstanding," Stanbrook wrote. "The clinical features suggest a form of bronchiolitis - possibly bronchiolitis obliterans, a pathology not previously described with e-cigarette use but long considered a likely consequence" (emphasis mine).
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 liquids contain or produce the flavoring agents diacetyl," Stanbrook continued. "Diacetyl is a known cause of bronchiolitis obliterans, an association first described in workers at a butter-flavored popcorn manufacturing plant ("popcorn worker's lung"). This case may therefore represent the first direct evidence of the lung disease most expected to result from e-cigarette use" (again, my emphasis).
Although the London doctors' "postulation" for popcorn lung was full of powers and maybes, Dr. Stanbrook wants you to know that this is the vaping danger that was always expected and long thought likely. He virtually ignores the fact that tens of millions of people, mostly ex-smokers with already weakened lungs, have consumed commercial nicotine products daily for more than a decade without consequence.
Why should this "otherwise healthy" (the doctors' words) teenager be beaten down with the disease alone? Frankly, very few products offer such reassuring odds! 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 flavored vaping products, noting that the CMAJ has always supported such a ban. "The logical and responsible action against toxic, harmful products is to recall and ban them," he wrote.
It would be wise to advocate for a ban on vitamin E acetate instead. There is no reason to "postulate" that an extraordinary event caused this teenager's lung injury when the same substance the CDC blames for American "EVALI" cases is available everywhere. Vitamin E acetate is an easily acquired 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.