lung illness associated with vaping in canada was reported. a high school student in ontario needed to be put on life support. the person had been vaping every day. his health improved and he was released from the hospital. this case has not been confirmed, as 27 september 2019. he vaped intensively, adding thc to his devices. he initially showed symptoms aligning with bronchiolitis, but many patients that have vape-related illnesses in the united states have experienced damage to the pulmonary alveoli; this type of injury was not found. instead, his case aligned more with an injury called popcorn lung, an ailment most commonly seen in factory workers of microwave popcorn plants more than 20 years ago. on 27 september 2019, the first confirmed case of a vaping-related lung illness was announced in canada. a montreal resident in quebec in their 50s was admitted to a hospital with breathing difficulties. the person had been vaping to help them give up smoking. chief public health officer of canada announced on 11 october 2019, that they are aware of the initial cases of vaping-associated lung illness, and they stated that a few other occurrences are being investigated. three probable cases have been reported in british columbia as of 7 november 2019, and other cases are under investigation in british columbia. two probable cases have been reported in new brunswick as of 16 october 2019. a case in newfoundland and labrador was reported as a probable case of a lung illness tied to vaping in january 2020. a person became sick in late 2019 following the routine use of a cannabis product, and has since been released from the hospital. as of 4 february 2020, 17 cases of lung injuries have been reported to the public health agency of canada. reported cases were from alberta (1), british columbia (3), new brunswick (2), newfoundland and labrador (1), ontario (4), and quebec (6). 14 people required hospitalization. other countries what has occurred in the united states has not occurred in other places where vaping is frequent, such as the uk. in european countries such as france, there is no evidence of an outbreak of the vaping-associated lung illness that occurred in the us. investigation us fda's forensic chemistry center. investigators from multiple states in the us are collaborating with the centers for disease control and prevention (cdc) and the us food and drug administration (us fda) to determine the cause of the lung illnesses associated with the use of vaping products. on 6 september 2019, dr. dana meaney-delman, serving as the incident manager of cdc's response to this outbreak, said that "based on the clinical and laboratory evidence to date, we believe that a chemical exposure is likely associated with these illnesses. however, and i really want to stress this, more information is needed to determine which specific products or substances are involved. we are aware that some laboratories have identified vitamin e acetate in product samples, and we have connected those laboratories with the fda forensic laboratories to compare results. at this time, no one device, product, or substance has been linked to all cases. continued investigation is needed to better understand if a true relationship exists between any specific product or substance and the illnesses observed in patients. to find the answer we will need to combine information about e-cigarette use, and product sample testing and the clinical information from patients." many patients have acknowledged recent use of tetrahydrocannabinol (thc)-containing e-cigarette products while speaking to healthcare personnel, or in follow-up interviews by health department staff. on 6 september 2019, the new england journal of medicine reported that "information on product use is based on reports by the patients, and patients may be reluctant to report illicit drug use." on 2 october 2019, the new england journal of medicine reported that the histologic evidence suggests that the "vaping-associated lung injury represents a form of airway-centered chemical pneumonitis from one or more inhaled toxic substances rather than exogenous lipoid pneumonia as such, but the agents responsible remain unknown." they also stated that this "finding should be interpreted with caution." on 17 october 2019, the american journal of clinical pathology reported that lung biopsies from eight patients with vaping-associated lung injury show acute lung injury patterns, not exogenous lipoid pneumonia. of the 2,506 reported cases, information is available in the three months prior to symptom onset for 1,782 of them as of 3 december 2019. 80% reported thc use, 35% reported exclusive thc use, about 54% reported using nicotine-containing products, and 13% reported exclusive use of nicotine-containing products. the cdc reported that their findings suggest vaping products containing thc, particularly those obtained off the street or from other informal sources (e.g. friends, family members, or illicit dealers), are linked to most of the cases, and play a major role in the outbreak. on 8 november 2019, dr. anne schuchat, principal deputy director of the cdc, said, "for the first time we have detected a potential toxin of concern — vitamin e acetate — in biologic samples from patients with lung injuries associated with the use of e-cigarette or vaping products." the sample types were bronchoalveolar lavage (bal) fluid samples (fluid samples collected from the lungs). the chemical was found in samples collected from ten different states, from the lungs of 29 patients with the disease. "these findings provide direct evidence of vitamin e acetate at the primary site of injury within the lungs," said dr. schuchat. the cdc tested for a wide range of substances that might be found in e-cigarette or vaping products including plant oil, petroleum distillates like mineral oil, medium-chain triglyceride oils – or mct oils – and terpenes which are compounds found in or added to thc products. no other potential toxicants were detected in the testing conducted so far. the cdc did not rule out other possible compounds or ingredients that may be causing the lung injuries. no one compound or ingredient has emerged as the cause of these illnesses so far; and it may be that there is more than one cause of this outbreak. many of the samples tested by the states or by the us fda, as part of the 2019 investigation, have been identified as vaping products containing tetrahydrocannabinol (or thc, a psychoactive component of the cannabis plant) and further, most of those samples with thc tested also contained significant amounts of vitamin e acetate. vitamin e acetate is a substance present in topical consumer products or dietary supplements, but data is limited about its effects after inhalation. while the us fda does not have enough data presently to conclude that vitamin e acetate is the cause of the lung injury in these cases, the agency believes it is prudent to avoid inhaling this substance. the us fda's forensic chemistry center serves as the fda's national laboratory, and is playing a critical role in fact-gathering and analysis for the incidents of lung illnesses following vaping product use. illicit vaping some of the vaping products analyzed by the wadsworth center contained exceedingly high amounts of vitamin e acetate, including those pictured here. frequently reported brand names of thc and nicotine-containing e-cigarette or vaping products reported by patients with lung injury — illinois and wisconsin, 2019. inhalation of chemicals or substances is considered to be the main cause of the lung illnesses. counterfeit cannabis cartridges are being sold to users at a reduced cost. dank vapes is an illicit brand that uses a cartridge. there is no singular company that owns dank vapes. dank vapes appears to be the most prominent in a class of largely counterfeit brands, with common packaging that is easily available online, and that is used by distributors to market thc-containing cartridges with no obvious centralized production or distribution. some of the vaping products that contained exceedingly high amounts of vitamin e acetate include chronic carts and dank vapes. illicit vape brands have been sold across multiple states in the us. as of 27 august 2019, the most frequently used product reported by patients experiencing respiratory, gastrointestinal, and/or constitutional symptoms in illinois and wisconsin was the thc product called dank vapes. dank vapes was the most commonly reported product brand used by patients nationwide, although there are regional differences. while dank vapes was most commonly reported in the northeast and south, tko and smart cart brands were more commonly reported by patients in the west, and rove was more common in the midwest. the composition of thc based oils is, to a large extent, unknown. public health recommendations the cdc recommends that the public should consider not using any vaping products during their investigation, particularly those containing thc from informal sources like friends, or family, or in-person or online dealers as of 20 november 2019. the us fda considers it prudent to avoid inhaling vitamin e acetate. on 6 september 2019, the us fda stated that because consumers cannot be sure whether any thc vaping products may contain vitamin e acetate, consumers are urged to avoid buying vaping products on the street, and to refrain from using thc oil or modifying/adding any substances to products purchased in stores. the cdc recommends that e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products, according to the cdc. various diluent thickening products were sold online via wholesale suppliers. there has been an increase in attention to companies that sell diluent products that are made with vitamin e acetate. a lot of speculation has focused on honey cut. honey cut, used as a diluent thickener, became widely used in los angeles' vape pen manufacturing plants in late 2018. after honey cut became widely used in thc vape cartridges many other similar products from other companies were introduced into the market in early 2019. the maker of honey cut's product is not known, and the only way to purchase the product was from the company's website. in early september 2019, the honey cut website went offline and honey cut told sellers in the toy district, los angeles area to discontinue offering its products for sale. counterfeit products from china that look like honey cut products were being sold, which increased the confusion in regard to which products people may have been vaping. the company floraplex in michigan has shutdown the buyers page for their uber thick brand. the diluent products called clear cut were sold by connoisseur concentrates from tigard, oregon. clear cut is no longer available from the company's website. the company acknowledged the products contained vitamin e acetate. the company stated that it began selling the products in may 2019 and was reviewed by the oregon liquor control commission. as of 10 september 2019, mass terpenes' pure thickener diluent is no longer available on its website. a cache of the product on its website stated, "a proprietary formula composed simply of flavorless terpenes and a derivative of vitamin e (to preserve color and consistency)." aaron riley, ceo of cannasafe, stated that likely about 75-80% of illicit vapes use some type of diluent agent. drew jones of mr extractor stated in september 2019 that as high as 70% of illicit cannabis vape cartridges in the us contain vitamin e acetate. it is estimated that at least 40 companies in the us sold a cutting agent containing vitamin e acetate. thickening agents have been sold online as a less costly and safer substitute. thickening agents were used to water down and bulk up vape oils. thickening agents were used mostly in thc vape products. vitamin e acetate was used to cut thc oil to dilute it. vitamin e acetate dilutes vape oil without making it look like the oil was watered down. previously, vitamin e was used in low concentrations, or lower than 20% of the formula in vape cartridges. as a result of a limited availability of cannabis in california as well as high demand, illicit sellers had used about 50% or higher of diluent thickeners in their formulas to bulk up tiny potency vape cartridges. thomas whitten, a consultant at weedrar, said to rolling stone that "there's so much cutting agent even the people who made the cutting agent didn't expect it