Queensland man Peter Hansen died of a severe lung injury which was probably caused by a decade of vaping.
7.30 can exclusively reveal the autopsy results for Mr Hansen, conducted at the request of his family following his death in October.
The autopsy found the death of the 71-year-old was due to an acute lung injury, and his condition met most of the criteria for EVALI, a new lung illness emerging among vape or e-cigarette users.
EVALI stands for e-cigarette or vaping product use-associated lung injury.
The ABC has previously reported on the only other documented case of EVALI in Australia, a 15-year-old girl from Sydney who ended up in intensive care.
Mr Hansen's wife Pam Ashdown said she wanted to warn other vape users about the possibility of serious lung injuries.
"It's just coming out now how harmful it can be, so I think we just need to push and let people know that it can cause death," she said.
"If somebody does suddenly pass away and they have been vaping, find out why they died … I don't want his death to be in vain."
Vaping 'seemed to be better for him'
Over a decade ago, Mr Hansen quit smoking and started vaping at the request of his step-daughter Kellie Butterworth.
She was about to give birth and told him she did not want second-hand smoke around.
"That was his real turning point of going, 'OK, I'm going to ring the Quitline and get some help and make a change,' because he desperately wanted to hold this baby," Ms Butterworth said.
Mr Hansen saw a doctor with the telehealth company Quit Clinics, which provided him with a prescription so he could begin importing nicotine vaping products.
After his death, his family discovered he had been using a third-party website hosted overseas to buy products made by UK manufacturer Liberty Flights.
Ms Ashdown said her husband was constantly vaping.
"This vaping thing that he was using, it seemed to be better for him," she said.
"I don't think he used it as much as he [used to] smoke a cigarette but it was always there."
'It's very sad'
In October, Mr Hansen was at the Airlie Beach holiday resort in the Whitsundays that he ran with Ms Ashdown when he began feeling short of breath.
They called an ambulance and Mr Hansen was taken to a nearby hospital before being transferred to the larger Mackay Base Hospital.
Intensive care doctor Sean McManus was there to treat him.
"It was quite a striking scene … [he was] clearly in severe distress, taking huge gasps of air, had that real hunger and distress," Dr McManus said.
It was a confronting sight for his family.
While he was heavily sedated, they comforted Mr Hansen by playing him his favourite 70s rock music and videos from his beloved grandsons.
A medical investigation brought further bad news.
A CT scan showed severe damage to Mr Hansen's lungs, including ground glass opacities in the lung — a possible sign of EVALI.
Although he also had a history of cigarette smoking prior to vaping, Dr McManus suspected that had not caused his hospitalisation.
"I just saw these quite huge cystic lesions in the apex of his lung," Dr McManus said.
"I've seen lots of results of smoking-related lung injury — we call that emphysema or chronic obstructive pulmonary disease … it's generally sort of much more even throughout the lungs.
"Peter was the first older patient that had had a significant history of e-cigarettes."
After three days in intensive care, Ms Ashdown and her family had to make the heartbreaking decision to take Mr Hansen off life support.
They had been married for 32 years.
"It's very sad, very lonely, and I miss him every day," Ms Ashdown said.
"Everyone should have a Peter Hansen in their life."
Autopsy report 'very significant'
Mr Hansen's family gave permission for an autopsy to be conducted into his death.
The autopsy described his lungs as red, airless and very heavy, with a weight more than double what was expected.
The presence of foreign body-type granulomas, or areas of inflammation, are "consistent with a reaction to an inhaled agent".
While there was some lung damage caused by cigarette smoking, the pathologist concluded that the cause of death was an acute lung injury superimposed on chronic lung disease and a probable case of EVALI — meeting three of the four key criteria.
Dr McManus supports the autopsy's findings.
"In the absence of anything else, my feeling was that, well, certainly in the history and the presentation of Peter, it was obvious that the e-cigarettes was a large part of it."
He is now part of a group of doctors who have submitted a case report to a medical journal.
Sukhwinder Sohal is a respiratory scientist at the University of Tasmania who researches the impact of vaping on lung health and is a board member of the Thoracic Society.
He reviewed the autopsy report for 7.30 and supports its findings.
"I think that autopsy report was very significant," Dr Sohal said.
"There was evidence for toxic inhalation, which was related to vaping, then there was pulmonary infiltration as well.
"They found significantly increased numbers of foamy macrophages or inflammatory cells, and there was a lot of fluid build-up in the lungs, which again indicates a strong, strong EVALI case."
More evidence needed on vaping, say health authorities
But Colin Mendelsohn, who has also seen the autopsy report, is urging caution.
He is the founding chairman of the Australian Tobacco Harm Reduction Association (ATHRA) and is an advocate for vaping as an aid for smoking cessation. He believes it to be less harmful than cigarettes.
The National Health and Medical Research Council says that is a widely held belief because e-cigarettes are thought to expose users to fewer toxic chemicals. However, it says there is insufficient evidence to quantify the reduction in risk.
Dr Mendelsohn was sceptical of the autopsy's findings about whether Mr Hansen's severe lung injury was caused by vaping.
"I think the explanation that we already have from the post-mortem of emphysema, fibrosis and respiratory failure is a very good fit with what we see with smokers who have a long history of smoking," he said.
"Even if in the worst-case scenario, [that] this was the case of the EVALI, I think we need to keep it in perspective and look at the huge benefits to other smokers from vaping."
He conducts telehealth consultations with patients who are looking to stop smoking and need a prescription to start vaping.
"I've seen many hundreds of smokers who switch to vaping," he said.
"It's not successful for everyone but there are many smokers who have made the switch and quit smoking, who hadn't been able to quit with other methods."
ATHRA received funding from vaping companies when it was first established, but Dr Mendelsohn said that was no longer the case.
He stopped being a director of the association last year.
"ATHRA received unconditional start-up funding from two vape companies, Nicopharm and Nicovape, to help cover the initial legal and website costs of establishing the charity in 2018," Dr Mendelsohn said in a statement.
"Since March 2019, ATHRA has no longer accepted any donations from the vaping industry."
The federal health department says there is not enough evidence to promote e-cigarettes for smoking cessation.
A recent Cochrane Review looked at the medical evidence around whether vaping helped people quit smoking.
It found there were only a small number of studies and there was a wide variety in data.
There was moderate confidence that nicotine e-cigarettes helped more people stop smoking than other methods, but more research was needed to confirm that.
"Look, I think we can always do with more evidence; we haven't had a lot of trials on vaping," Dr Mendelsohn said.
"It's a slow and expensive process.
'Lungs are not designed for any of these toxic agents'
Health authorities in Australia have taken a cautious approach to vaping because the long-term health impacts are unknown.
Access to nicotine products is restricted and can only be obtained with a doctor's prescription, and they are either imported from overseas or purchased from a pharmacy.
Authorities are concerned about the rapid surge in take-up, with half a million regular users in Australia. And they have warned e-cigarettes are not risk free and may expose users to chemicals and toxins that can cause negative health effects, including in the lungs.
Dr Sohal said he was concerned about some vaping products being toxic to the lungs.
"I think there are huge concerns about vaping and electronic cigarettes when people are exposing their lungs to these dangerous electronic smoking devices," he said.
One of the reasons health authorities are being cautious is because of the dramatic spike in lung-injury cases that occurred in the United States between March 2019 and February 2020.
More than 2,800 people were admitted to hospital and 68 died with EVALI.
However, most of those cases involved people using products with an additive called vitamin E acetate as well as cannabis oils, in particular the psychoactive compound tetrahydrocannabinol known as THC.
The US health protection agency, the CDC, said in a statement there had been a considerable decline in cases since the 2019 peak and the data did "not suggest a resurgence of EVALI cases at this time".
Mr Hansen's family is unaware of him using products with vitamin E acetate and says he did not use cannabis oils or products with THC.
Toxicology researcher Jody Morgan tested six products Mr Hansen was using before his death.
"None of the six samples that were analysed had anything that was obviously a toxic molecule, and also none of them had any of the eight compounds that are now banned by the Australian Therapeutic Goods Administration (TGA), and that included no evidence of Vitamin E acetate," Dr Morgan said.
Dr Morgan has tested ingredients in hundreds of other vaping products at the University of Wollongong.
She recently moved to the University of Sydney.
"Some of the things of concern that we have found is that nicotine concentrations are very rarely the concentration that they say on the label," she said.
"We also have found a number of products that contain some of the … substances that are now banned from the TGA in Australia, and they include things like 2,3-pentanedione, which is a butter-type of flavouring, which has been associated with popcorn lung."
She is also particularly concerned about the sudden appearance of a cooling agent called WS 23.
"Pretty much every single disposable e-cigarette sample that we analyse contains this particular molecule in quite high concentrations," she said.
"Why are we concerned about that? One, its recent rapid appearance, and also there's no data on what the inhalation toxicity of this particular compound is."
'More research needed'
Ms Ashdown wants health authorities to review the current system of how vaping products are provided to patients.
7.30 requested an interview with Samuel Murray, the managing director of Quit Clinics, the telehealth company that provided Mr Hansen with a prescription to vape, but he declined.
In a statement, Dr Murray said he was "shocked to learn about the death of Mr Peter Hansen" and expressed his condolences.
"Prior to being contacted by 7.30 we were unaware of any Quit Clinics patient having significant adverse impacts from nicotine vaping," the statement said.
It also said Quit Clinics believes "current medical research suggests that vaping is significantly safer than smoking", but it is not risk-free.
Dr Murray said patients were told Quit Clinics could not guarantee the safety of any vaping product.
"Quit Clinics and its doctors continually review the latest research in this space, and we will continue to review our procedures and prescribing practices as research continues to emerge."
Liberty Flights, the UK manufacturer of products being used by Mr Hansen, said Mr Hansen had ordered its products through a third-party website and it had not dealt with Mr Hansen directly.
Liberty Flights said its products were subjected to "rigorous screening and testing protocols" in accordance with the UK Medicinal Healthcare Regulatory Authority.
The manufacturer also said it had never used vitamin E acetate in its products.
Editor's note 07/04/22: After this story was published it was brought to our attention that the Australian Tobacco Harm Reduction Association (ATHRA) received funding from an organisation called the Knowledge Action Change group in 2018. Knowledge Action Change had itself at that time accepted funding from a group called Foundation for a Smoke Free World which received funding from Philip Morris International. In response, 7.30 sent written questions to ATHRA and Dr Colin Mendelsohn. Dr Mendelsohn responded to say he had nothing further to add. ATHRA's statement is now available here.
