What’s Known and Not Known About the Mysterious Vaping Illness

More deaths, few clues, and a sense of emergency as e-cig use soars and the black market thrives

A closeup photo of a man exhaling smoke from an electronic cigarette in Washington, DC on September 12, 2019.
Photo: Eva Hambach/AFP/Getty

AsAs the death toll from a respiratory illness tied to vaping reached eight last week and the number of total cases in the crisis climbed to 530 across 38 states, the mystery began to take on Hollywood qualities. The U.S. Centers for Disease Control and Prevention activated its emergency operations center while scrambling to find a cause, or even just some clues, in a health crisis that has officials baffled. Unlike with salmonella or E. coli outbreaks, experts have no idea what substance is behind this public health nightmare.

States with reported cases of the mysterious vaping illness. Image: CDC

“I wish we had more answers,” Anne Schuchat, the CDC’s principal deputy director, said in a press briefing. “We’re working closely with state and local health departments, FDA, and the clinical community to learn as much as we can to try to stop this outbreak.”

Here are some things that are known about the crisis, according to the CDC:

  • More than half the illnesses involve people under the age of 25, and 16% are younger than 18.
  • The overall age range of victims extends up to 65 years old.
  • Some 75% of the people afflicted are men.
  • The total number of cases includes both individuals with newly reported symptoms as well as some with previously identified sicknesses that are only now being counted as part of this outbreak.
  • Symptoms include coughing, shortness of breath, chest pain, nausea, vomiting, diarrhea, fatigue, fever, and abdominal pain.
  • Most of the patients report a history of vaping with products that contain tetrahydrocannabinol (THC), the psychoactive compound found in marijuana.
  • Some, but not all, of the patients report using e-cigs with nicotine.

Officials don’t yet know if the illnesses are tied to commercial vaping products or black market alternatives, let alone which substances might be the culprits. Schuchat had much more to say about the investigation’s process, and about what’s not known, than about what is known.

“CDC is working 24/7 with the states to try to find answers,” she said. “I’d like to stress how challenging this situation is, as patients may have been exposed to a variety of products and substances, may not know the contents or sources of these products, and in some instances may be reluctant or too ill to fully disclose all the details of interest.”

While it would be convenient to point the finger at black market vaping products, and instructive to determine whether the illnesses are tied to one substance or another, the CDC has not been able to zero in on any cause beyond vaping in general.

“No consistent e-cigarette or vaping product, substance, additive, or brand has been identified in all cases, nor has any single product or substance been conclusively linked to lung injury in patients,” Schuchat said.

Of the rising death toll, she said, “we do expect others.”

The Food and Drug Administration is on the case, too. But Mitch Zeller, director of the FDA Center for Tobacco Products, had no more definitive information on the cause than what the CDC offered, calling it an “ongoing investigation that has way more questions than answers.”

The FDA “has now collected more than 150 vaping product samples from a number of states for analysis in our forensic chemistry center,” Zeller said. “FDA is analyzing these samples for the presence of a broad range of chemicals, including nicotine, THC, and other cannabinoids, along with opioids, cutting agents, or dilutants and other additives, pesticides, poisons, and toxins.”

The FDA has also launched a criminal investigation, not to make life difficult for vapers, but “to identify what is making people sick,” and to “focus on the supply chain,” Zeller said.

Black market crimes and complications

The contents of home-brewed vaping cartridges are anyone’s guess. Schuchat hinted at the possible additional risk posed by using cartridges made by users themselves or by opportunistic sellers. “Anyone who uses an e-cigarette or vaping product should not use or buy these products off the street and should not modify or add any substances to these products,” she said.

Vaping cartridges being manufactured at a North Phoenix home were seized by detectives. It’s not known if black market products like these are involved in the current health crisis, but the brand — Dank — has been used by some of those reporting the mysterious lung affliction. Photo: Maricopa County Sheriff’s Department

Last week, detectives in Arizona arrested two men in a Phoenix home for allegedly making vaping cartridges packaged with child-friendly graphics and a brand name of Dank. In a statement, the Maricopa County Sheriff’s Department said the same brand had been found in illegal vape product operations elsewhere in the country. Dank was reportedly used by 24 of 41 patients at the beginning of the lung illness outbreak, as detailed in a paper published September 6 in the New England Journal of Medicine.

The Phoenix bust seized 300 pounds of marijuana, 1,100 vape cartridges, cash, guns, and manufacturing equipment. Image: MCSO

The Phoenix bust seized 300 pounds of marijuana, 1,100 vape cartridges, cash, guns, and manufacturing equipment. The Arizona arrests came just a few days prior to the Arizona Department of Health Services announcing the first three cases of the vaping-related illness in that state.

A larger series of busts were made in Wisconsin earlier this month, which — along with Illinois — was ground zero for the vaping illnesses that began cropping up in July. Officials in Wisconsin seized 57 Mason jars filled with THC-laced liquid, 31,200 vape cartridges (each filled with 1 gram of THC), and 98,000 unfilled cartridges, along with cash and guns in a stockpile worth $1.5 million, according to the local sheriff’s department. These, also, were the Dank brand, the New York Times reported.

Popularity soars among kids

The mystery illnesses coincide with the surging popularity of electronic cigarettes. Vaping among adolescents and teens doubled over the past two years, the National Institute on Drug Abuse (NIDA) announced this week.

“With 25% of 12th graders, 20% of 10th graders, and 9% of 8th graders now vaping nicotine within the past month, the use of these devices has become a public health crisis,” NIDA’s director, Nora Volkow, said in a statement. “These products introduce the highly addictive chemical nicotine to these young people and their developing brains, and I fear we are only beginning to learn the possible health risks and outcomes for youth.”

Researchers who crunched the numbers said the increase in adolescent vaping between 2017 and 2018 was “the largest for any substance tracked” by the group over the past 44 years.

Juul, the most popular commercial maker of e-cigs and vaping products, has been targeted by the CDC for marketing to kids, and for the high nicotine content of its products. A single pod, or cartridge, can contain as much nicotine as 20 cigarettes, the CDC says. Studies have shown that the flavorings alone can be harmful, breaking down into dangerous chemicals like formaldehyde.

Michigan and New York have banned the sale of flavored e-cigarettes, and the Trump administration is also considering a similar nationwide ban.

Known and emerging risks of e-cigarettes

Whether the current nationwide health crisis involves black market or commercially available vaping products, it’s becoming increasingly clear that vaping is not the safe alternative to smoking that proponents have advocated.

E-cigs don’t create smoke. They heat a soup of liquid chemicals in a cartridge to create an aerosol, or vapor, whose properties are not yet well studied. The liquid can contain marijuana, nicotine, flavorings, and other substances. As I reported last month, studies are finding that this stuff is far from innocuous after it’s combined in a vapor.

A brief summary of the research:

  • E-cig vapor contains lead, nickel, cancer-causing materials, and fine particulate matter that seeps deep into the lungs, says the CDC.
  • What happens when chemicals mix in the vaporizing process is not entirely known.
  • The vapor can inflame the lungs in ways similar to asthma, one study finds, and another study shows the vapor can kill white blood cells, which are key to the body’s immune system.
  • Another new study finds that a single session of vaping significantly reduces blood flow to the femoral artery, choking off the supply of oxygen and nutrients to the lower body. It’s not known if the effect will recur with perpetual vaping, but if it does, it would raise the risk of atherosclerosis, which can lead to stroke or heart attack, says the study’s lead researcher, Felix Wehrli, a professor at the University of Pennsylvania’s Perelman School of Medicine.
  • Critically, research shows that some of the harmful effects of the vapor seem to be related to what happens when various chemicals — including the flavorings — are vaporized together. More research is needed to figure all that out, including what unhealthy role the vaporized flavorings might play.

Health experts say vaping is particularly bad for young brains, which are vulnerable to nicotine addiction and can be harmed irreparably while in the formation stages.

But it will be years — after longitudinal studies can be done — before the long-term effects of this relatively new habit are known.

Meantime, Schuchat has some advice. Anyone who uses e-cigs to avoid regular cigarettes should not return to their old habits; they should see their doctor about other options. For everyone else, she said this: “Until we know more, if you are concerned about these specific health risks, CDC recommends that you consider not using e-cigarette or vaping products.”

Explainer of things, independent health and science journalist, author, former editor-in-chief of LiveScience and Space dot com.

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