Can vaping cause sudden death?

Vaping, or the use of electronic cigarettes, has become increasingly popular in recent years, especially among youth and young adults. E-cigarettes heat a liquid, often containing nicotine and flavorings, into an aerosol that the user inhales. While touted by some as a safer alternative to traditional cigarettes, concerns have been raised about the potential health risks of vaping. One of the most serious potential risks is whether vaping can cause sudden, unexpected death.

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What do we know about vaping-related deaths so far?

In recent years, a concerning pattern of vaping-related lung injuries and deaths has emerged:

As of February 2020, 68 deaths and over 2,800 hospitalizations due to vaping-related lung injury have been reported to the CDC.

The exact cause of the severe lung injuries is still under investigation, but vitamin E acetate, an additive sometimes used in THC-containing vaping products, has been identified as a chemical of concern.
Most patients reported vaping THC products, although some reported vaping only nicotine or a combination of THC and nicotine.

This outbreak of severe, and in some cases fatal, lung disease indicates that vaping carries serious health risks that are still not fully understood.

What is known about vaping and cardiovascular effects?

Beyond the acute lung injuries that have been reported, there is concern that vaping may have negative cardiovascular effects that could raise the risk of sudden death:

Nicotine is known to temporarily raise blood pressure and heart rate. The high nicotine concentrations in some e-cigarettes could increase cardiovascular strain.
Studies have found that e-cigarette aerosol exposure can reduce blood flow and stiffen arteries, which increases cardiovascular risk.

Animal studies have shown that nicotine and aerosol exposure from e-cigarettes can cause damage and dysfunction to blood vessels.
Some flavorings used in e-cigarettes have been linked to endothelial cell dysfunction in blood vessels.

These cardiovascular effects provide biological plausibility for why vaping could potentially increase the risk of sudden death in some individuals. More research is still needed, however, on the long-term cardiovascular impacts of e-cigarette use.

Have any vaping-related deaths involved sudden, unexpected death?

While most reported vaping-related deaths appear to have resulted from severe lung injuries, investigations have identified some cases that involved sudden cardiovascular events:

A 39-year old man in Minnesota collapsed and died unexpectedly after vaping THC oil.
A 17-year old male in New York City died after vaping nicotine due to a lung obstruction that triggered a fatal cardiac event.

A 16-year-old female in Belgium died suddenly after three weeks of vaping nicotine and THC. While she had lung damage, it was not deemed severe enough to be the cause of death.

These cases raise concern that for some vaping could trigger sudden cardiovascular complications resulting in death. However, the rarity of these events compared to the much larger number of severe lung injury cases makes drawing conclusions difficult. More research is needed to determine if vaping truly raises the risk of sudden fatal cardiovascular events.

Can vaping worsen pre-existing cardiovascular conditions?

Experts warn that vaping may significantly increase risk when individuals already have underlying cardiovascular conditions, such as:

Hypertension – Nicotine from vaping can cause spikes in blood pressure.
Arrhythmias – Vaping may trigger irregular heart rhythms.
Coronary artery disease – Vaping may worsen blood flow obstruction.

Congenital heart defects – Increased strain on the cardiovascular system from vaping could be dangerous.

Past case reports have linked vaping to acute cardiovascular events in individuals with pre-existing conditions, such as ST-elevations in a patient with vasospastic angina and ventricular fibrillation in a patient with a left ventricular aneurysm.

The American Heart Association warns individuals with cardiovascular disease against using e-cigarettes, as the safety risks are currently unknown. More research is needed on this population.

Have any population studies linked vaping and sudden death?

Drawing definitive links between vaping and sudden, unexpected death is challenging due to the rarity of these events and difficulty controlling for other risk factors. However, some larger population analyses have found associations:

A study of over 10,000 Americans found daily e-cigarette use was associated with significantly higher odds of having a heart attack.
Data analysis of the 2016 Behavioral Risk Factor Surveillance Study found that daily vaping was associated with increased odds of both heart attack and stroke.

A study in the Journal of the American Heart Association linked e-cigarette smoking with higher risk of coronary artery disease.

These population studies suggest potential relationships between regular vaping and cardiovascular events. However, more research is needed to confirm direct causal links.

What are the proposed mechanisms relating vaping to sudden death?

There are a few proposed mechanisms by which vaping could theoretically trigger sudden death in some individuals:

Nicotine toxicity – High doses of nicotine could overstimulate the cardiovascular system.
Aldehyde exposure – Aldehydes like acrolein in e-cigarette aerosol may damage endothelial cells lining blood vessels.
Imbalance in autonomic nervous system – Nicotine overstimulation could imbalance the parasympathetic and sympathetic nervous pathways that control heart function.

Increased thrombotic tendencies – Nicotine-induced catecholamine release could promote clot formation, obstructing blood flow.
Impaired vascular function – Vaping could reduce nitric oxide-induced vasodilation, increasing risk of hypertension or coronary events.

However, more research is needed to provide robust evidence for these proposed mechanisms in humans and to rule out alternative explanations.

Do flavors or other e-liquid ingredients raise risk?

Concerns have been raised that certain e-liquid flavorings or ingredients could increase the cardiovascular toxicity of vaping:

Some flavorings like cinnamaldehyde have been shown to damage endothelial cell function.
Studies on cardiac tissue indicate that flavorings such as vanillin and cinnamaldehyde can be metabolized into toxic aldehydes.

E-liquids containing the emulsifying agent PEG have been linked to vacuole formation and damage in endothelial cells.

However, research is limited on the cardiovascular effects of specific vaping flavorings and ingredients. More study is required to determine if certain product formulations carry higher risks. Analyzing the compounds present in e-liquids associated with cardiovascular events could help identify hazardous chemical culprits.

What type of vaping carries the highest risk?

Based on current evidence, vaping products most strongly linked to cardiovascular issues and sudden death include:

THC oil vaping – Nearly all reported cases of EVALI lung injury involved vaping THC oil, sometimes in combination with nicotine.
High nicotine concentrations – Vaping e-liquids with nicotine salts or high nicotine levels (over 20 mg/mL) may carry higher risk.
Modifications like dabbing – Modified vaping techniques like ‘dripping’ or ‘dabbing’ can expose users to more concentrated toxic doses and larger inhaled volumes of e-liquids.

Frequent, chronic use of these high-risk vaping products is most strongly associated with vaping-related medical complications based on current data. More research is still needed though.

Who may be at highest risk of sudden death from vaping?

Some groups may face particularly elevated risk of experiencing serious cardiovascular events from vaping based on current knowledge:

Individuals with pre-existing cardiovascular conditions – These individuals are more vulnerable to effects of nicotine and aerosol exposure on the cardiovascular system.

Pregnant women – Nicotine and toxins from vaping could impact fetal development and maternal health.
Adolescents and young adults – Their cardiovascular systems are still developing and may be more susceptible to damage.
Individuals with mental health conditions – They have higher rates of tobacco use and may engage in riskier vaping behaviors.

More research is needed though to confirm whether these populations definitively have elevated risk compared to the general population.

Conclusion

In summary, while vaping is often perceived as safer than smoking, emerging evidence indicates it carries real health risks, including the potential for sudden death in some users. Serious lung injuries and fatal cardiovascular complications linked to vaping demonstrate it is not a harmless habit. Certain high-risk vaping behaviors, formulations, and populations may face greater likelihood of adverse events. However, significant research gaps remain in understanding the mechanisms relating vaping to sudden death and confirming causal links suggested by case reports and population studies. Rigorous longitudinal studies tracking health outcomes in vapers over time are critical for elucidating lasting cardiovascular impacts. For now, the safest choice is to avoid vaping altogether until more definitive data is available.

Key Points	Summary
– Over 60 deaths have been linked to vaping as of early 2020	A pattern of severe, sometimes fatal, lung injuries and cardiovascular complications associated with vaping has emerged in recent years.
– Vaping may increase cardiovascular strain and damage blood vessels	Biological mechanisms like increased hypertension and arterial stiffness provide plausibility for vaping increasing sudden death risk.
– Links found between vaping and heart attacks/stroke in population data	Some large population studies have found associations between frequent vaping and increased cardiovascular events.
– High doses of nicotine and certain flavorings may increase risk	The risk of sudden death from vaping may be highest with THC vaping, modified techniques, and high nicotine levels.

Key References

Layden JE, Ghinai I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Final Report. New England Journal of Medicine. 2020.

Viswam D, Trotter S, Burge PS, Walters GI. Respiratory failure caused by lipoid pneumonia from vaping e-cigarettes. BMJ Case Reports. 2018.
Bhatta DN, Glantz SA. Electronic Cigarette Use and Myocardial Infarction Among Adults in the US Population Assessment of Tobacco and Health. Journal of the American Heart Association. 2019.
Alzahrani T, Pena I, Temesgen N, Glantz SA. Association Between Electronic Cigarette Use and Myocardial Infarction. American Journal of Preventive Medicine. 2018.

Krishnasamy VP, Hallowell BD, Ko JY, et al. Update: Characteristics of a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — United States, August 2019–January 2020. MMWR Morb Mortal Wkly Rep. 2020