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Photo courtesy of New York State Department of Health
Governor Andrew M. Cuomo directed the New York State Department of Health Monday to take a series of measures to address two emerging public health crises: the increasing number of cases of vaping-associated respiratory illnesses and the increasing number of youth that are using vape products and developing lifelong nicotine addictions. The Governor directed the Department of Health to issue subpoenas to companies marketing and selling 'thickening agents' used in black market vaping products and to issue emergency regulations mandating that warning signs must be posted in all vape and smoke shops in New York State. Additionally, the Governor announced that he will advance new legislation to ban flavored e-cigarettes.

"Common sense says if you do not know what you are smoking, don't smoke it, and right now we don't know what you are smoking in a lot of these vaping substances," Cuomo said. "The rise in vaping-associated illnesses is a frightening public health phenomenon and I am directing the Department of Health to take several actions to address this crisis, including starting an investigation into some of these companies that produce vaping substances to find out what's in it and requiring that smoke and vape shops post a warning that lets people know that this is a risky activity. I am also going to propose new legislation that will ban flavored e-cigarettes. In the meantime our advice is quite simple: don't do it because we don't know if it's safe."

Cuomo ordered the Department of Health to issue subpoenas to three companies that the Department has identified as marketing thickening agents to companies that manufacture vape liquids. These thickeners are being marketed and readily available on the internet as a cheaper, safer alternative that does not negatively impact flavoring or odor of existing products and can be used to cut vape products to any level of THC. The Department is ordering them to provide additional information to aid its investigation of this public health crisis. The Wadsworth Center has obtained samples of thickeners from these three companies and determined that they are nearly pure vitamin E acetate oil. The companies being served with this subpoena and their product names are: Honey Cut Diluting Agent by Honey Cut Labs LLC in Santa Monica, California; Uber Thick by Floraplex Terpenes in Ypsilanti, Michigan, and Pure Diluent by Mass Terpenes in Amherst, Massachusetts. These three companies are the first to be subpoenaed, but more companies are likely to be ordered to provide samples as the investigation continues.

While the investigation is still ongoing, laboratory results have shown very high levels of vitamin E acetate in nearly all cannabis-containing samples analyzed by the Wadsworth Center. Vitamin E acetate is a commonly available nutritional supplement that is not known to cause harm when ingested as a vitamin supplement or applied to the skin. However, the Department continues to investigate its health effects when inhaled because its oil-like properties could be associated with the observed respiratory symptoms.

In addition, Cuomo directed the Department of Health to issue emergency regulations, subject to approval by the Public Health and Health Planning Council (PHHPC), to require entities in New York State that sell vaping products to post signage on the dangers of vaping. The Department is also launching a public service campaign to further educate the public on the numerous risks involved with vaping.

Finally, the Governor said he will advance legislation to prohibit the possession, manufacture, distribution, sale or offer for sale of flavored electronic liquids to discourage electronic cigarette use in New York State.

According to Department of Health data, nearly 40 percent of 12th grade students and 27 percent of high school students in New York State are now using e-cigarettes, and this increase is largely driven by flavored e-liquids. High school use in 2018 (27.4%) is 160 percent higher than it was in 2014 (10.5%). While New York's high school student smoking rate dropped from 27.1% in 2000 to a record low of 4.3% in 2016, aggressive marketing promoting flavored e-cigarettes stands to turn that trend. Flavoring is a key youth marketing strategy of the vaping/aerosol industry just as it is in the cigarette, cigar, and smokeless tobacco markets. E-cigarette marketing highlights flavors such as mint chocolate, bubblegum and cherry cola, and creates a mistaken belief that they are not harmful to users. Studies show nearly 78% of high school students, and 75% of middle school students report being exposed to pro-tobacco marketing in 2016.

New York State Department of Health Commissioner Dr. Howard Zucker said, "The current outbreak of vaping-associated illnesses and the increasing number of young people using vape products and developing lifelong addictions are two serious public health crises."

On Saturday, the Governor announced that the Department of Health was issuing guidance to New Yorkers to stop vaping during this investigation into vaping-associated illnesses. As of September 9, 2019, the Department has received 41 reports from New York State physicians of severe pulmonary illness among patients ranging from 15 to 46 years of age who were using at least one cannabis-containing vape product before they became ill. However, all patients reported recent use of various vape products.

Rigorous testing also continues on all vape products currently authorized in the state's highly regulated Medical Marijuana Program. There have been no adverse events related to vaping among certified patients in this program since this investigation began. However, out of an abundance of caution, we are also urging patients in the medical marijuana program to consult with their health care providers on potential alternatives to vaping products while the investigation continues.

Patients using vape products reported a variety of symptoms, developing over a period of days to weeks, including:

• Pulmonary symptoms (cough, shortness of breath, chest pain)
• Gastrointestinal symptoms (nausea, vomiting, diarrhea)
• Fatigue
• Fever
• Headache
• Weight loss

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