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Vape pen lung injury: Here’s what you need to know

January 10, 2020
vape pen lung disease
A suspected tainted black market vape cart seized in New York. (Courtesy of New York State Department of Health)
As of Tuesday, Jan. 7, the CDC has reported 2,602 confirmed and probable cases in all 50 states of severe acute respiratory distress syndrome associated with a recently inhaled drug aerosol (commonly known as vaping). As many as 57 deaths across 27 states may be directly or indirectly related to the seven-month-old injury series. Here’s what you need to know.

Should I stop vaping?

What is the suspected diagnosis?

  • In many cases, symptoms and treatment mirror a condition called lipoid pneumonia, previously found in patients who inhaled mineral oil.
  • Subsequent biopsies of 17 victims indicate “airway-centered chemical pneumonitis from one or more inhaled toxic substances rather than exogenous lipoid pneumonia as such, but the agents responsible remain unknown.”
  • A third biopsy series looked similar to the first two, adding organizing pneumonia to the diagnosis cluster.
Sickened lungs show up as cloudy on the left x-ray, and clear after treatment of one suspected VAPI patient in Utah. (Courtesy University of Utah)

Sickened lungs show up as cloudy on the left X-ray, and clear after treatment of one suspected VAPI patient in Utah. (Courtesy University of Utah)

What’s causing it?

  • The contamination is emanating out of the supply chain for illicit market THC vape carts, the CDC said Oct. 30. “The latest national and state findings suggest products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak.”
  • There are multiple known contaminants in illicit vape carts that could cause lung injury. But on Nov. 8, the CDC announced a “very strong culprit of concern”—vitamin E oil, (aka tocopheryl-acetate). Lung fluid analyses of 29 victims from 10 states tested positive for the substance, “The samples,” said CDC Dr. Anne Schucat, “provided evidence of vitamin E acetate at the primary site of injury in the lungs. … “No other potential toxins were detected.”
  • New York health authorities have confirmed that synthetic vitamin E (tocopheryl-acetate) is tainting most seized vape carts in that state. Utah officials concurred Oct. 25. Pen makers report using it because it’s a cheap thickener. The FDA is now specifically looking at tocopherols. New York has subpoenaed three thickener-makers—Floraplex, Honey Cut, and Mass Terpenes—after tests showed all three products were tocopheryl-acetate. On Sept. 13, SC Labs of California found Floraplex’s Uber Thick to be almost totally tocopheryl-acetate.
  • The FDA has received about 900 samples for testing. So far, they’ve found vitamin E acetate in 47% of the 225 THC carts tested. The FDA is testing seized carts for THC, nicotine, cutting agents called diluents, additives, pesticides, opioids, poisons, and toxins. One New York patient who tested his cart found it contained formaldehyde, pesticide, vitamin E oil, and “a little dab of THC.” The California lab Cannasafe reports ten out of ten vape carts from California illicit stores tested positive for tocopheryl-acetate, some as high as 40%. FDA testing has confirmed tocopheryl-acetate cuts of 31% to 88%, the mean average is 50%.
  • Health officials have confirmed that among the tainted carts are ones with the illicit market brand names Dank Vapes, TKO, Off White, Moon Rocks, Chronic Carts, and West Coast Carts, but the condition is linked to multiple illicit market brands across multiple states. One Tulare County, CA victim’s family member confirmed the presence of a “black and gold” cart labeled “Lucky Charms” from the brand “West Coast Cure”. (Matching that description is both counterfeit packaging and authentic packaging for a popular, illicit market brand in California called West Coast Cure.)
  • Beyond unsafe additives, at least one woman may have suffered “cobalt lung” from heavy metal exposure via vaping.

Why vitamin E oil?

  • As Leafly reported in early September, a new diluent known as Honey Cut entered the illicit vape cart market in late 2018. The product, which dilutes THC oil without thinning the viscosity, is manufactured by Honey Cut LLC registered to a Joshua Temple of Los Angeles. Officials at the terpene manufacturer True Terpenes, based in Portland, OR, told Leafly they tested Honey Cut earlier this year and found it to contain Vitamin E oil, aka tocopheryl-acetate. Two brands—Mr. Extractor of Oregon and Constance Therapeutics of California—told Leafly they’ve been selling forms of vitamin E oil into the vape cart market. Mr Extractor’s Drew Jones told Leafly he believes up to 40 companies sold a copycat oil, and the oil is in 60% of carts in the US. Lab tests have found the oil in multiple thickener products, including Peak Terpenes’ Thicc Stretch.

Amid vape pen lung disease deaths: What exactly is vitamin E oil?

What are the symptoms?

What are the latest numbers?

  • This man-made mass poisoning event is akin to bathtub gin under alcohol prohibition. Prohibition states have ten times more VAPI per capita than legalization states.  It is generally a creature of unlicensed markets where consumers have no legal alternative. It’s akin to recent Spice/K2 poisonings, as well as unregulated CBD market poisonings. The first reports came out of the prohibition state of Wisconsin, which has 103 hospitalized, and Kings County, CA, which has banned legal access to tested cannabis, alongside 60% of local cities and counties. California has 178 hospitalizations and four suspected deaths. Illinois has 214 hospitalized and five dead. New York reports 150 hospitalized and two deaths. Texas has 236 confirmed cases and three dead. Minnesota has 141 cases and three dead. Florida reports 110 hospitalized and a death.
  • In contrast, Oregon has two suspected deaths and 18 suspected illnesses. Colorado has 11 suspected cases. The state of Washington may have 18 cases, with one allegedly linked to a store. California’s second and third suspected deaths occurred in Tulare County and Kings County, where purchasing tested, legal cannabis from a store is banned in all areas other than the city of Woodlake. The victim’s family said he was using illicit market THC cartridges. California officials said Oct. 23 that just one of the 79 victims interviewed so far reported exclusive use of tested vapes. California lab Anresco announced Oct. 28 that no tocopheryl-acetate has been found in tests of over 200 licensed cartridges. Of Ohio’s 17 confirmed cases, 90% are black market THC cart-related, and none are medical cannabis system-related.
  • Injury rates appear to be on the decline since September, the CDC said Oct. 25. But tens of millions of tainted vape carts remain on the street.

Why is this happening now?

  • Leafly has reported that a new ingredient—next-generation cutting agents (thickeners)—are being misused in THC vape carts. Legal chemical thickener makers said they do not approve of use in vape carts. Chemical thickener makers also do not approve of dilutions greater than 10%. However, their web sites are unclear about the products’ approved and unapproved uses. The chemical makers have no information on what inhaling thickener aerosol does to your lungs, especially if it is heated or burned.
An oil-laden immune cell extracted from a VAPI patient in Utah (left). On the right, a normal macrophage. (Courtesy Andrew Hansen, Jordan Valley Medical Center)

An oil-laden immune cell extracted from a VAPI patient in Utah (left). On the right, a normal macrophage. Doctors have found lipid-laden macrophages in some but not all patients. Biopsies of 17 patients found “foamy macrophages and pneumocyte vacuolization” in all 17 samples. (Courtesy Andrew Hansen, Jordan Valley Medical Center)

How can I protect myself?

  • Only buy tested, regulated adult-use and medical cannabis products in legal stores like California, Washington, Oregon, and Colorado. Licensed supply chains are much harder to contaminate. By contrast, street traffickers are filling carts with harmful chemicals, and they go straight into your lungs. Here’s how to spot an illicit market, or counterfeit THC vape cart.
  • Though licensed markets have more safeguards, suspicious additives are not yet banned in California. Washington and Oregon banned tocopheryl acetate in vapes mid-November. Colorado intends to ban tocopheryl-acetate, MCT oil, and PEG this winter.
  • Cheap illicit market vape carts also routinely malfunction. Malfunctioning carts can get very hot, and burn additives and thickeners, releasing an unknown noxious gas. Run them at low, controlled temperatures.
  • If you’re concerned about additives in your cannabis, stick to tested flowers from licensed adult-use stores. Check store licenses on regulators’ websites, like California’s license lookup tool. In terms of extracts, additive-free extract is called “rosin”, and it also comes in vape carts in mature adult-use markets. There’s also tinctures, sublinguals, edibles, topicals, and transdermals, for those who want to avoid all cannabinoid inhalation products.

Leafly originally published this story Sept. 6. We updated it again Jan. 10 at 3:20 p.m. PST.

David Downs's Bio Image

David Downs

David Downs directs news and lifestyle coverage as the California Bureau Chief for He's written for WIRED, Rolling Stone and Billboard, and is the former cannabis editor of the San Francisco Chronicle, as well as the author of several cannabis books including 'Marijuana Harvest' by Ed Rosenthal and David Downs. He co-hosts The Hash podcast. TW: @davidrdowns | IG @daviddowns

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  • Neuro

    Reports in Oregon suggest that the death here was an individual buying tested product from a legitimate dispensary. Any further news on this front? Presumably these products would not have been adulterated.

    • John Keller

      Unfortunately, that presumption would be false, because a minority of dispensaries, while licensed, don’t hold to the same standards of excellence most do. The product bought at the “legitimate” dispensary could very well be gray or even black market.

    • Anon

      Here in OK, I’ve seen Mario Carts, Cereal Carts, and Dank Vapes on shelves in a few dispensaries. Not everyone plays by the rules.

  • Fam Highs

    What are some of the brand names associated with black market/fake THC cartridges? And is there a way to test the ones I currently have to see if they’re legit? Any info on the Cannaclear brand carts?

  • Gammorean Barr

    Buy legit products from legit sources people. if it tastes or feels off don’t finish it.

  • Johnny Falcon

    There’s not one word in this piece about the Oregon case involving a legally purchased vape. Meanwhile, the two dispensaries that sold the victim cartridges remain open with not one word of explanation forthcoming from the Oregon officials. How difficult is it to check their vape carts for metals, vitamin E oils, etc?

    Meanwhile, employees at Michigan dispensaries (where I live) keep telling me that their products are safe yet I can’t even access information from regulators about what chemicals and additives are tested for. I love vaping weed but for now I’m sticking to flower and dabbing concentrates that do not use carrier fluid. It would be great if we coud get enough information to make and informed decision. I know we don’t have all the answers yet, but it seems reckless to leave products on the shelves of dispensaries that might have already killed someone.

    • call your local cannabis lab – and they will confirm that they do NOT test for vitamin e or any of these new cutting agents… a very large reputable CA cannabis lab confirmed with me that a vape cartridge filled with pure vitamin e or even 100% cutting agent would PASS lab testing and be on a legit dispensary shelf the next day…. the California labs have zero instructions or guidelines from the state on testing for vitamin e or cutting agents… really scary

    • Because at this point its still just conjecture, they haven’t released any information whether those carts were actually used, involved, or tampered with, etc.

    • mommadog1

      @Johnny Falcon , I couldn’t agree more. Very well said!

  • Etidorhpa

    I don’t see why anyone wants to vape oils or waxes anyways. Stick with plant material only, you’ll be better off.

    • For some of us, the smell of cannabis on our clothing or transferred to our vehicle can be a death sentence even as medical use in a medical state if we’re pulled over. Some demographics are looked at as maybe a stoner, pothead, hippy, whatever, but usually, it’s in jest or with a laugh, they are considered relatively non-threatening. Darker-skinned folks however if they smell like weed or their vehicle smells like weed, they are thugs, drug dealers, gang members, etc. If they are pulled over an officer can realistically murder them and simply say they smelled the scent of weed on their victim or their vehicle and it’s written off as if the person murdered deserved it.

    • Randall Buss

      convenience. discretion. ease. not having to live in an apartment/ house that permanently smells like a college dorm. yeah, fuck anyone who wants options in how they get high. this guy knows everything.

    • Larry Megugorac

      The reason….it’s so convenient!!! With a PAX ERA you buy their PAX PODS and you literally can enjoy anywhere! No Lighters, No messy ashes…and way less smell than smoking flower…works great at Concerts!

    • Gerry Dempsey-Patch

      @etidorhpa:disqus I agree that flower is always best. However, I am a quadriplegic and cannot fill or load my own pipe or dry herb vape, so it’s so much easier to just get a pre-filled oil cart. Also, I am not in a legal state, so I don’t have the benefit of dispensaries that have texted carts. So, I’m in a catch 22 here, but since all of this stuff has been coming out, I stopped using my vape and have been having my aides load my pipe before they leave me alone for the day and/or night and just have to hope that there’s enough to last me till they return. I guess that’s just one of the reasons why I /people use oil vapes. ☺

  • Highway 69

    Where did all the comments go?

  • Jesus Sanchez
  • So far all reports claim the problems are with black market carts…. but the regulated market is NOT testing for vitamin e or other chemicals that may be the culprit. So it is entirely possible that many fully white market and lab tested carts are on dispensary shelves – and they could easily contain vitamin e or other chemicals – because the current lab testing does not test for vitamin e or these other new cutting agents.

    • It’s also a matter of how much they are “cutting” the product, not only that the product is in the cart. A legit cart wouldn’t dilute their product as much as the black market because it would affect the effects of the cartridge. No one would buy their carts in an actual dispensary if they are consistently under-performing.

    • Jim McDonald

      That is exactly my concern.

  • Will from Daytona

    Agreed…Some folks shy away from vaporizers. In my case, it took a couple of weeks to properly use my Pax 3. I only buy flower and extract from CO2 or zero solvent. Medicinal users will find that vaporizing dry herb is safer, wastes less active ingredient, and works beyond their expectations.

    • Larry Megugorac

      Hey Will,

      I just love my PAX 3! Works great on ground flower…i like being able to use either half oven loads or full oven loads depending on your needs! But I have been also vaping oils PAX ERA w/PAX PODS….only bought from Oakland’s Harborside…the largest dispo in the world! While I am very concerned about all this vaping news, I have been using their oils for almost 3 years with no problems….Harborside tests are way stricter than is required by Law…But Just be safe…I’ll stick to flower while this crap is all sorted out!

      • Will from Daytona

        You summed it up quite well…Know where your product started out, and whose hands touched it until yours. If I were a betting man, I’d be looking at certain countries in the East. If the carts aren’t coming from there, the ingredients may be. In Florida, for good and bad, our system is vertically integrated, by law. The growers process and sell. Having only one hand to slap is good, in regards to product quality and safety. As you, I’ll stick to flower for the time being.

    • Bec Jenn

      I have a firefly2 that I’m in love with. However, I will say that the vape carts are more portable and provide a stronger, quicker punch. I use carts for when I’m out and about and in quite a bit of pain. If I’m at home and the pain is severe, I start with a cart, have an edible and finish off with my firefly 2. I don’t do any combustion as my heart and lungs are one of the few organ systems that are in good shape right now.

  • Cin Abington

    And so it goes when humans think they can make a better product than Mother Nature. I just knew when cannabis was taken into the lab for dissection and chemical tweaking it would inevitably end up in the same ranks as big pharma’s poison pills and all the other assorted crap that has been hawked to unsuspecting patients for at least the last three decades. The plant, in its totally un-raped form, is where the medicine is. Once in the hands of the chemist it loses its healing qualities and becomes poisonous, just like all the rest of the garbage available in our “medical” market of synthetic “medicines”. Just grow your own plants and learn how to cook with it. Or smoke it in its natural form if you are not afraid of contracting lung ailments such as emphysema. But get it out of the laboratories, please! We have come so far… lets not lose any more ground!

    • ultima9

      “Once in the hands of the chemist it loses its healing qualities and becomes poisonous” What a load of garbage. Obviously posted by someone who has no idea how chemistry works. Without those “rapist chemists” as you so colorfully put it, we wouldn’t have nearly enough food to feed the world’s population, nor would we have 80% of the luxuries you take for granted today – such as the computer you typed this asinine post with.

  • Fun Please

    Trusted users list me please

  • Funky Bluester

    There are enough Senators and Congressmen personally invested in the cannabis industry to forestall any negative legislation on vaping. They won’t walk away from the money.

  • rick rod

    If I smoked a couple of these vape carts about 1 1/2 year ago (from Colorado) and haven’t noticed any of these side effects by now, should I be safe or should I see my doctor? They are long gone so testing is not possible.

    • Nothing to do with older vape carts, it was new ones from late 2018 until recently on the illicit black market that to thicken and cut the product to make more profits, the black market added vitamin e based thickeners which cannot be heated up and inhaled. I would advise to not smoke black market carts at all, now or in the future, but if you did that far back you’re safe.

  • Highway 69

    Take a look at these comments and you’ll see a common misunderstandings that usually only the non-cannabis-using crowds make. It involves the very definition of what vaping is. The term “vaping” is problematic because even pro-cannabis folks here seem to think that vaping only involves using a pen type device that uses cartridges.

    That’s why I try to differentiate between vaporizing dry herb (aka flower) and “vaping” using carts. Vaporizing flower does not smell because you don’t burn anything. It’s pure plant vapor. And because your herb is never lit — there are no ashes, only plant material that you can use in edibles if you are so inclined. Try to do that with a bong!

    The bottom line is that while “vaping” is a popular choice to consume cannabis — “vaporizing” flower is another choice to consider.

  • Northern Mushroom

    Great article on vaping! This is part of the reason why I avoid vaping in the first place,


  • Never_Speechless

    If youre afraid to smoke your carts I’ll take em!

  • Didn’t say anything about smoking while driving, maybe you should ask questions before just spouting nonsense.

    • 360dunk

      First off, I don’t need to ask questions….you’re just yet another poster bringing race into a non-racial story. (boring)
      Secondly, you saying that ‘their vehicle smells like weed’ absolutely indicates smoking while driving.

      Are you just going to argue everything? Seems sad and miserable.

  • GFY.

    • Fun Please


  • Highway 69

    You’re probably OK. The distinction is not 100%, but the licensed stores aren’t going to risk selling products that haven’t also been licensed and/or certified.
    But to even more confident that what you inhale is safe(r) — buy flower and a quality convection vaporizer. You’ll be glad you did!

  • Highway 69

    That’s a good idea! At least it would make people ask you what the difference was.

  • Highway 69

    Hey, speaking of vaporizing… have you ever known anybody who “vaporizes” loose leaf tobacco? (Vaporizers can be used on other dried herbs e.g. lavender, chamomile, etc.) My son rolls his own cigarettes and I would love for him to quit smoking, which gave me the idea to buy him a vaporizer.

  • GFY twice. And I’m a guy, next time don’t try to bully people you think are women, moron.

  • Michael Lindenmaier

    The problem is that even legal vapes are pulled from the market. As the OLC stated, they are not testing for any additives. Flavorings can contribute to lung inflammation; they might be approved (GRAS) for food products, but not as inhalants. We would like to think that only illegal products are contributing to these cases. Artificial terpenes, or other flavorings are added, laboratories can’t really figure out retrospectively what the reasons for the illnesses were (menthol is the least concerning). Historically, THC products have not led to any deaths or serious illness. People should use organically grown cannabis, and experiment with different regional cannabis varieties. Patients should be able to obtain medical products for their ailments. According to the Arthritis Foundation, CBD should not be vaped at all.

  • If you want to really protect yourself *do not* buy any vape, illegal or legal, with thinning agents, thickeners, or other cutting agents like PEG, PG, VG, MCT oil, or even insane amounts of terpenes. Every single one of those cutting agents, even terpenes, has been shown to produce negative health outcomes in conditions present in so-called vape pens (which often are vapes in name only, and actually are combusting oils around the coil but might be vaporizing the oils further away from the coil).

    The doctors that I have interviewed, like Dr. Jeffrey Raber at the WercShop, have been clear that inhaled MCT oil may lead to lipid pneumonia, when it comes to terpenes we do not know what is “too much,” and broadly, when it comes to vapes, we are all test subjects in an experiment since none of these devices have previously been tested.

  • SmartCart

    Scared to use your cartridge. Wish there was a way to test for lipids such as vitamin e from the privacy of your home. check out smartcart.

  • GTG

    Dr. Zodiak’s Moon Rocks are a legal company. It should have been pointed out in the article, that they were referring to counterfeit Moon Rocks:

  • GTG

    There have been no reported issues with the Kurvana brand of products.

    Legal dispensaries will not give refunds on cannabis based products, though some may allow you store credit or a discount on your next visit.

  • sanele morgan


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  • BruceIshikawa

    With dry herb vaporizers readily available, there is no reason to use liquid vape cartridges.

  • catherine yronwode

    Rather than comparing the effect of Honey Cut on the THC Oil market to “bathtub gin” under alcohol prohibition, i suggest that you please look up Jake Leg paralysis and the cutting of Jamaica Gin Extract with toxic tri-ortho-cresyl phosphate in 1930. I have published (on my Facebook timeline) some of the parallels between the two cases, with high praise to the Pulitzer-Prize-worthy Leafly investigative reportage of David Downs and associates. Additionally, in my posts you will also see my discovery of a previously unreported “coincidental” chemical link between tri-ortho-cresyl phospahte and tocopherol acetate. I wish you all the best in your continued investigations.

  • Highway 69

    See my older comment.

  • CrowSenji

    Just bought a CBD pen with MCT oil and terpenes, I hope I don’t die but I need it for my asthma since unfortunately it’s not a qualifying condition to get actual legal cannabis in Connecticut, and adult use is also illegal. Wish me luck!

  • Christy Mahmood

    Why buy cheap vape carts if your health will be put in line? I’d rather go to legal weed dispensaries than buy cheap on illegal markets. I wouldn’t put my life in danger.