Study Shows EVALI Linked To Unregulated, Contaminated Vaping Products

Prior to our deep descent into COVID-19 lockdown, a different pulmonary threat was grabbing headlines. A mysterious and deadly respiratory ailment emerged among users of e-cigarettes and cannabis concentrates.

Eventually, a link to an additive in unregulated marijuana vape cartridges was identified as the catalyst for these health developments, widely known as e-cigarette and vaping-associated lung injury (EVALI). The Centers for Disease Control and Prevention (CDC) released data that shows nearly 3,000 people in the U.S. got sick from this illness and 68 people unfortunately passed away. The culprit in causing EVALI was determined to be vitamin E acetate, a chemical contaminant uses as a cutting agent in unregulated cannabis vape cartridges.

A recent study of the outbreak was published in the journal Drug and Alcohol Dependence that revealed some interesting findings. Apparently, EVALI was less prevalent in states where adult-use cannabis was legal – 42% lower, in fact, than those states that probit it. States allowing home cultivation for medical marijuana patients experienced a 60% lower incidence rate of EVALI.

“States in the highest EVALI-quintile tended to either ban all marijuana use or have [medical cannabis] laws prohibiting home cultivation,” says the report, authored by Yale School of Public Health professor Abigail Friedman and Meghan Morean, a psychiatry research scientist at the Yale School of Medicine. 

Cannabis legalization advocates have long argued that access to safe, legal cannabis is more beneficial from a public health standpoint than illicit, untested, and unregulated products. The authors said their analysis “is the first to show a relationship between MM [medical marijuana] policy and EVALI.”

“Simply put,” the study says, “if the public can obtain products legally from reputable sources, there is less demand for illicit products. EVALI incidence was about 40% lower in states with [recreational marijuana] legalization.”

A top CDC official suggested in 2019 that “labeling and information can help people know what they’re getting and then the systems that are there to enforce that the product is what it says it is can also help the consumer.”

Massachusetts was in the highest EVALI quintile and the lone exception to the trend. The researchers noted that “Massachusetts’s [recreational marijuana] law went into effect almost two years before its first licensed dispensary opened, a delay that could have strengthened the informal market in the interim.”

The study also pointed out that forbidding smokable cannabis correlated with a general increase in EVALI prevalence. States that prohibited smoking cannabis but sold smokable cannabis flower in dispensaries fared better. 

“Marijuana policies may offer a means to reduce the scale of such outbreaks if they impede the market penetration of contaminated products or affect the types of marijuana products consumers use.”

The study admittedly had some limitations, however. Researchers relied on state-reported EVALI data that can be inconsistent from one state to another. Also, trying to distinguish different types of cannabis use was challenging. While both flower and concentrate can be consumed in a vape, only concentrates were implicated in the outbreak. (The complications mount from there when factoring in dabbing via a dab pen vs. dabbing with a dab nail.)

The authors point out that the findings are not causal but they do provide helpful information and direction for states considering legalization. They also wrote that they could not assess policy differences within the ten states that had implemented adult-use marijuana laws before 2020. None prohibited smokable marijuana, for example, and only Washington State forbids home cultivation for personal use.

“Specifically, to the extent that such policies affect licit and illicit marijuana use, policymaking not only must ensure the safety of legal products but also should consider potential impacts on illicit market offerings,” the report says. “To the extent that policymakers seek to leverage marijuana policies as a means to reduce the risk of future outbreaks,” it concludes, “close attention to these laws’ details, particularly those expected to affect mode of use, will be critical.”