E-Cigarettes, Wet Lung, and the US vs the UK

Yet again, the US news media over-hypes a story and uses it to peddle a narrative about e-cigarettes being “just as bad” as analog cigarettes. They are evil, dangerous, and should be banned. And this obsession in the US with e-cigarettes being somehow terrible is very strange to me, seeing as how other countries (such as the UK), are actually quite happy with e-cigarettes as smoking cessation devices.

E-cigarettes are in the news again because of a Pennsylvania woman with a history of mild asthma going to the hospital after having developed a cough, chest pains, and difficulty breathing. After attempts to control these symptoms, all of which failed, she went into respiratory failure, needing a machine to help her breathe and tubes inserted into her chest to drain fluids from her lungs. She was diagnosed with hypersensitivity pneumonitis.

According to Cleveland Clinic, hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis) is “a complex condition of varying intensity, clinical presentation, and natural history. It is the result of an immunologically induced inflammation of the lung parenchyma in response to inhalation exposure to a large variety of antigens. These are primarily organic antigens to which patients have been previously sensitized and are hyperresponsive.”

Wikipedia gives a less technical definition, calling it “an inflammation of the alveoli within the lung caused by hypersensitivity to inhaled organic dusts. Sufferers are commonly exposed to the dust by their occupation or hobbies.”

What does this have to do with vaping?

So the woman, as you can see from the CBS article linked to above, had started vaping 3 weeks prior to developing the symptoms. The American Academy of Pediatrics put out a case study implicating the woman’s electronic cigarette use. And as you can imagine, the media ran wild with this.

An 18-year-old woman working as a hostess in a rural Pennsylvania restaurant decided to try e-cigarettes, perhaps another of the innumerable bistro workers hoping to calm frayed nerves with a smoke — or in this case, a vape.

This hostess, though, paid an unusual price for her e-cig use, according to a case study published Thursday in the medical journal Pediatrics. As usual for a patient report, the authors did not disclose the young woman’s name to protect her privacy.

E-cigarettes heat liquid and turn it into vapor, which a user inhales and then exhales in a large puffy cloud. The liquid is known as e-juice, and it contains flavorings, propylene glycol, glycerin and often nicotine — though many users are unaware of this final addictive ingredient.

Okay hold on… wait a minute… I’m sorry for the sudden detour, but…


“The liquid is known as e-juice, and it contains flavorings, propylene glycol, glycerin and often nicotine — though many users are unaware of this final addictive ingredient.”

Excuse me… uh… CNN? On what planet is anyone unaware of the fact that devices advertised as nicotine inhalation devices contain… you know… nicotine? Who is unaware of that fact?


Clearly, the author of that article was unaware of that fact… why else would they write such an ignorant sentence?

What most people are unaware of is the fact that you can get e-liquid without nicotine. I use nicotine-free e-liquid myself, now, and I love it.

Anyways… back to the main story…

So the big thing now is “wet lung”. That’s what the media is calling it. This poor woman, who I would argue likely has an allergy to an ingredient or perhaps several ingredients in e-liquid (could be the propylene glycol, vegetable glycerin, or whatever was in the flavorings her e-liquid had), is being used by the media for sensationalism.

I’m going to copy the statement made by Dr Konstantinos Farsalinos (yes, he is a real person and that is his real name) in response, although I would like him and his team to look closer at the data and perform their own study.

This was a case report of hypersensitivity pneumonitis. Most commonly an allergic reaction that causes inflammation in the lung. Any inflammation in the lungs (could be caused by pneumonia, bacteria, and more) can result in pleural effusion. This is irrelevant to the “wet lung” that implies ecig use results in liquid accumulation in the lungs. The authors of the study only suggest that vaping caused hypersensitivity pneumonitis providing absolutely no scientific data to back this theory except mentioning that the girl vaped.

The use of the term “Wet Lung” is a deliberate attack on vaping and an attempt to fearmonger & spread misinformation once again forcing smokers away from using this product to quit smoking.

The sad thing is I can’t call this the “definitive statement” on the subject, which is why I’d like to see some peer review on that case study. The authors of the case study clearly believe that vaping is what caused her hypersensitivity pneumonitis, and they do put forward a compelling argument.

Look… the reality I have no interest in denying here is that vaping is still young. There are no long-term studies, and thus no long-term understanding of any potential long-term health risks. It really could turn out that vaping is, indeed, a cancer risk. It really could turn out that vaping deteriorates lungs to a horrible, fluid-filled state, meaning that while they may not do to your lungs what cigarettes do to them, it’s only a different way to kill yourself.

I acknowledge all of that.

On the other hand, however, back in 2015, Public Health England issued a report finding that electronic cigarettes were 95% safer than analog cigarettes (PDF). The part I’m quoting is the summary of Chapter 10 (Safety of e-cigarettes in the light of new evidence), on page 80.

Two recent worldwide media headlines asserted that EC use is dangerous. These were based on misinterpreted research findings. A high level of formaldehyde was found when e-liquid was over-heated to levels unpalatable to EC users, but there is no indication that EC users are exposed to dangerous levels of aldehydes; stressed mice poisoned with very high levels of nicotine twice daily for two weeks were more likely to lose weight and die when exposed to bacteria and viruses, but this has no relevance for human EC users. The ongoing negative media campaigns are a plausible explanation for the change in the perception of EC safety (see Chapter 8).

None of the studies reviewed above alter the conclusion of Professor Britton’s 2014 review for PHE. While vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent and the chemicals that are present pose limited danger. It had previously been estimated that EC are around 95% safer than smoking [10, 146]. This appears to remain a reasonable estimate.

Here’s that 2014 report for anyone who’s interested in reading that (PDF).

Of course, that has been disputed, in part by an article published in the Lancet

It is worth reading the paper on which PHE has based its latest advice carefully. Nutt and colleagues describe how the Independent Scientific Committee on Drugs, which Nutt founded in 2010, convened an international expert panel to consider the “relative importance of different types of harm related to the use of nicotine-containing products”. During a two-day workshop in July, 2013, the panel met in London to review the context of perceived harms from nicotine products, the range of products (including “electronic nicotine delivery system products”), and the criteria of harms. The group scored the products for harm, and weightings were applied to the results. Based on the opinions of this group, cigarettes were ranked as the most harmful nicotine product with a score of 99·6. E-cigarettes were estimated to have only 4% of the maximum relative harm. It is this result that yields the “95% less harmful” figure reported last week.

But neither PHE nor McNeill and Hajek report the caveats that Nutt and colleagues themselves emphasised in their paper. First, there was a “lack of hard evidence for the harms of most products on most of the criteria”. Second, “there was no formal criterion for the recruitment of the experts”. In other words, the opinions of a small group of individuals with no prespecified expertise in tobacco control were based on an almost total absence of evidence of harm. It is on this extraordinarily flimsy foundation that PHE based the major conclusion and message of its report.

But Public Health England has continued to review the evidence each and every year as new evidence comes out, most recently published on March 2, 2018. According to Chapter 9, “Health risks of e-cigarettes”…

One assessment of the published data on emissions from cigarettes and e-cigarettes calculated the lifetime cancer risks. It concluded that the cancer potencies of e-cigarettes were largely under 0.5% of the risk of smoking.

Comparative risks of cardiovascular disease and lung disease have not been quantified but are likely to be also substantially below the risks of smoking. Among e-cigarette users, 2 studies of biomarker data for acrolein, a potent respiratory irritant, found levels consistent with non-smoking levels.

There have been some studies with adolescents suggesting respiratory symptoms among e-cigarette experimenters. However, small scale or uncontrolled switching studies from smoking to vaping have demonstrated some respiratory improvements.

E-cigarettes can release aldehydes if e-liquids are overheated, but the overheating generates an aversive taste.

To date, there is no clear evidence that specific flavourings pose health risks but there are suggestions that inhalation of some could be a source of preventable risks.

It cannot be stressed enough that analog cigarettes kill over 480,000 people per year in the United States alone. The first documented death from an electronic cigarette in the United States happened recently. And yeah… it’s pretty horrific…

A US man died when a vape pen blew up and projected fragments into his skull, a post-mortem examination has found.

Tallmadge D’Elia also suffered burns over 80% of his body in a fire on 5 May caused by the exploding e-cigarette, according to forensic officials.

The 38-year-old’s body was discovered by firefighters in the burning bedroom of his family home in the beach resort of St Petersburg, Florida.

It is believed to be the first US death from a vape pen explosion.

The television producer’s death has been ruled an accident.

It’s a really terrible situation. See… with mechanical mods, there are no safety features. There’s no automatic shut-off, no short protection, no over-heating protection, no battery runaway protection, no firing cut-off… when you use mechanical mods, your safety is entirely up to you.

Now, I started my vaping journey with mechanical mods, and I had no incidents. The reason is because I was tutored every step of the way, and watched over, by people obsessed with battery safety. They made me get to know Ohm’s Law, and then when Steam Engine came out, it became my best friend. I was introduced to Battery Mooch, and used his early tests to make sure I never built my coils outside the limits the batteries I was using could handle… and then I would only buy the strongest, highest-rated batteries on the market for vaping. Plus, I made sure my batteries were always wrapped… I never vaped if there was even the slightest tear on the battery’s wrap. I got an ohm reader, and did everything in my power to make sure I was safe.

And the worse, most terrifying thing that would happen to me with my mech mods was the occasional hot button. Never once did I have a battery severely overheat, go into thermal runaway, or explode.

But then I got a regulated mod, and all I have to worry about is keeping my batteries married (I have a mod that uses three 18650 batteries, so I make sure they charge and discharge at the same time and roughly the same rates; and obviously I never pair batteries from different brands; they’re all the same brand with the same specs) and wrapped. The chipset on the mod does mostly everything else.

I don’t see the point of using mechanical mods anymore, and I would never recommend them to beginners or smokers looking to make the switch.

The unfortunate man above was using a mechanical mod, and for some reason, it exploded while he was asleep. And this could be for a couple reasons:

1. His battery wasn’t wrapped properly, causing a short which caused a runaway

2. His button was being pushed down, firing the device for too long, causing it to get too hot and explode.

Regardless of why, this man tragically and needlessly lost his life.

But US media (I linked to the BBC, which is not US media) wants to use this as a reason that electronic cigarettes are bad. It’s sad and unfortunate, but the cause of the explosion was user error.

If there is one advantage to mechanical mods over regulated mods, at least in the eyes of manufacturers, it’s that many of the problems encountered with mech mods can be blamed on user error. There are no chips or other electronics installed in mech mods that can go wrong. Mech mods are purely metal tubes that a battery is put into, an atomizer is screwed on the top, and a button is screwed on the bottom. The button is used to basically push the battery into the bottom of the atomizer, closing the circuit and allowing the user to vape. The safety of the user is almost entirely up to the user. The manufacturer is, at most, responsible for the size of the metal tube (for example… if you want your tube to be used with a single 18650 battery, you better make sure that the tube is big enough and round enough to accommodate said battery with a bit of room to spare). The advantage here, obviously, is to the manufacturer.

Regulated mods, on the other hand, offer more advantage to the user, but there’s a lot more put in these boxes that can fail, and that failure will be the manufacturer’s fault (usually… the user can still be blamed in some scenarios, like dropping the mod, getting it wet, running over it with their car, letting their kids get ahold of it… you know… stuff like that).

The man who died was using a mechanical mod. So whatever caused the explosion was, sadly, because of user error. It’s an argument against mechanical mods (or, at the very least, against inexperienced vapers using mechanical mods), yes, but not against electronic cigarettes as a whole.

So what about the US vs the UK? Read that article from the BBC again. Notice the way the article handles the story? Now look at those two studies I posted from Public Health England.

The United States would never put out such studies. The Royal College of Physicians of London damn near demands that smokers switch to vaping. Now compare that to the US’s Surgeon General warnings against electronic cigarettes.

What exactly is going on here?

Back in 2016, Wired put out an article saying the difference is priorities.

It is indeed true that e-cigs lack the black tar that makes cigarettes so bad for your lungs. But the kind of math that goes into calculating individual health effects doesn’t necessary apply when you’re talking about a group of people. To craft public health policy, you have to ask three questions. 1) How many smokers are trading cigarettes for e-cigs? 2) How many non-smokers are getting addicted to nicotine thanks to e-cigs, whose many candy flavors seem to teenagers? And 3) Which number is bigger?

Because e-cigs are so new, nobody knows the answer. One side will publish an analysis that says one thing, and the other will criticize their statistics. They go back and forth and back and forth. Neither side has enough data to draw irrefutable conclusions.

But neither side is budging—just look at their response to the FDA’s new rule to regulate e-cigarettes as tobacco products. “It makes no sense,” says Michael Siegel, a public health researcher at Boston University, who has been a proponent of e-cigs for harm reduction. “They’re essentially favoring cigarettes over e-cigarettes.” Siegel is referring to a particular quirk of US tobacco regulation: The 2009 Tobacco Control Act grandfathered in all products on the market before 2007, which includes virtually no e-cigarettes. E-cigs will now have to go through an approval process to get to market that old cigarettes did not.

To the other side though, the FDA’s rule is a bare minimum. “All they really do is assert jurisdiction,” says Stanton Glantz, a vocal anti-tobacco advocate who is a professor of medicine at UCSF. “The best evidence that this rule represents a step (albeit small) forward,” he wrote on his blog, “is the fact that Mike Siegel has described it as “‘a disaster for public health.'” Siegel has since responded with a comment on the blog. (Glantz was actually a mentor to Siegel years ago).

(I should probably let all of you know that Stanton Glantz is embroiled in a second sexual harassment scandal. I know I’m biased against him, being a vaper and all, but the dude is a scumbag. Is that an ad hominem to dismiss his anti-vaping arguments? Sure… if you want to say that, then go ahead. I also happen to think that the science out of the UK refutes him pretty definitively, regardless, so I don’t have to engage in an ad hominem against him. But the fact that he’s been accused of sexual harassment twice certainly biases me even more against him.)

And you know… that article by Wired makes a good point. In the UK, health is a national priority. Because they have the NHS, they have a strong monetary incentive to support any and all harm reduction methods they can. In effect, vaping saves them money. In the US, on the other hand, health care is private. Here, money is made on people getting sick. So, smoking makes us money. So we’re not going to be so supportive of harm reduction.

In the end, as I’ve already stated in this very post, and will always state… we don’t know the long-term effects of vaping yet. So yes, it could turn out to be… well… not safe. However, what we do know, and what I am 100% convinced of, is that no matter how you look at it, electronic cigarettes are much safer than analog cigarettes. What I also personally know is that I would still be smoking an average of 2.5 packs a day if not for electronic cigarettes. I breathe better, I sleep easier, and… recently… I gave up nicotine itself entirely, all thanks to electronic cigarettes.

Yes, we should be cautious. Yes, regulation should exist. But electronic cigarettes have real benefits with regard to harm reduction and smoking cessation. We in the US ignore that at our own peril. I know that, if you follow me in any measure, you’ll realize that I’m repeating myself… I’m becoming a broken record.

But I will continue to be a broken record about this until the US catches up with the rest of the world. No one, and I do mean no one, has claimed that electronic cigarettes are safe. The claim, backed up by science, has always been that they are safer than analog cigarettes, and that they are a very good method of cessation and harm reduction.

But only in the US can that be seen as a bad thing…

Leave a Reply