The U.S. Centers for Disease Control and Prevention reports that large numbers of e-cigarette users have been hospitalized with severe lung disease. Since June 28, there have been at least 450 cases reported across 33 states and one U.S. territory. Most were teens and young adults. Most worrying: There have been five deaths.
“So far, no definitive causes have been established,” said Dana Meaney-Delman. She is part of the lung-injury-response group at the CDC in Atlanta, Ga. She spoke at a September 6 news conference.
At the briefing, federal and state health authorities said the outbreak might trace to some particular substance vaped. Or, they noted, it might be due to some special type of vaping device. For now, they don’t know.
Health officials, including those with the CDC and the U.S. Food and Drug Administration, began issuing periodic updates on the outbreak on August 23. These agencies are working with state health departments to better understand what’s behind the outbreak.
Symptoms have included shortness of breath and chest pain. Some people had diarrhea. Others complained of being tired or having gut distress, including vomiting.
Even though the cases appear similar, CDC cautions that “it is not clear if these cases have a common cause or if they are different diseases with similar [symptoms].” All patients had used e-cigs before falling ill.
For now, federal health officials urge people not to vape. They point out that vaping can be especially harmful to kids, young adults and pregnant women.
Not the first sign of risks
Vaping’s link to lung risks should comes as little surprise. Earlier studies had shown that e-cig use can lead to chronic lung symptoms and worsened asthma in teens. Some high-school vapers developed “smoker’s cough,” including chronic bronchitis (Bron-KY-tis) and wheezing.
Teen vaping has sparked alarm among health professionals. Last year, 1 in 5 high schoolers reported recent e-cig use. That’s a 78 percent jump over the year before. That finding comes from the National Youth Tobacco Survey. And it prompted FDA to restrict the sale of certain flavors of e-cig liquids — ones with flavors that appeal to teens.
Many of the recently hospitalized e-cigarette users reported having recently vaped THC. It’s the ingredient in marijuana that makes people “high.” Little research has been done on the lung impacts of vaping pot. However, the American Lung Association suspects that marijuana may produce lung effects similar to what has been seen with typical e-cigarette use.
On September 6, doctors and health officials from several U.S. states released a series of studies describing the new cases. Officials in Wisconsin and Illinois described 53 vapers who had developed severe lung illness. Most were young people who had been otherwise healthy. More than eight in every 10 were male. Nearly one in every three were 17 or younger.
Almost all of the patients were hospitalized. Roughly one-third needed a ventilator to help them breathe. Of 41 patients who gave detailed interviews, 61 percent had vaped liquids containing nicotine. Eight in every 10 had vaped THC products. Nearly half had used both, according to a September 6 report in the New England Journal of Medicine.
Possible suspects eyed in new outbreak
The New York State Department of Health is eyeing one suspect substance. On September 5, it reported that high levels of vitamin E acetate had been found in some vape products containing marijuana. Vitamin E acetate is a dietary supplement. It’s also used in some skin care products.
Illona Jaspers studies inhalation toxicology at the University of North Carolina School of Medicine in Chapel Hill. The lungs aren’t designed to handle the range of chemicals and toxic materials that can be released by e-cigarettes, she says. Substances that are safe to eat, such as vitamin E acetate or the flavors added to vaping liquids, can pose risks to the lungs. “When you change the route of exposure, you are changing the potential for toxicity,” she says.
However, Jaspers notes, even if vitamin E acetate were behind the new outbreak, there are other chemicals released by vaping that could also harm the lungs. “Heavy vapers who got scared by all of this may now have this false sense of security, saying ‘Oh, I’m not doing the vitamin E stuff. So I can continue.’” That, she warns, “is a bad idea.”
In North Carolina, five patients with illnesses potentially linked to vaping developed a noninfectious form of pneumonia. CDC shared details September 6 in the Morbidity and Mortality Weekly Report. All five said that they had vaped THC concentrates or oils purchased on the street. Doctors diagnosed lipoid pneumonia in the patients. It occurs when oils or fat-containing substances enter the lungs and provoke inflammation.
FDA is testing more than 120 samples of vaping products for a broad range of chemicals. These include nicotine and THC. “The samples we’re continuing to evaluate show a mix of results,” said Mitch Zeller. He directs FDA’s Center for Tobacco Products in Silver Spring, Md. He notes that “no one substance or compound, including vitamin E acetate, has been identified in all of the samples tested.”
Lungs are not the only organs at risk
Even before the latest hospitalizations, there were concerns about risks of lung disease. Cell studies pointed to possible immune problems and dental problems. Some studies turned up signs of impaired wound healing, genetic changes and heart risks. In addition, studies have warned of the possibility in teen vapers of nicotine addiction or a transition to smoking conventional cigarettes.
Some health risks being linked to vaping are similar to those seen with smoking conventional cigarettes. Other risks, such as seizures, may be novel and unique to the unusual liquids and high-nicotine exposures possible with certain newer types of e-cigs.
“We do know that e-cigarettes do not emit a harmless aerosol,” said Brian King at a press briefing August 23. He works in CDC’s Office on Smoking and Health. It’s in Atlanta, Ga. The available evidence, he says, indicates that chemicals in an e-cig’s vapors “could be problematic” when it comes to lung disease.
acetate (also called acetic acid) A short-chained fatty acid that is a common byproduct of fiber fermentation in the gut.
aerosol A group of tiny particles suspended in air or gas. Aerosols can be natural, such as fog or gas from volcanic eruptions, or artificial, such as smoke from burning fossil fuels.
asthma A disease affecting the body’s airways, which are the tubes through which animals breathe. Asthma obstructs these airways through swelling, the production of too much mucus or a tightening of the tubes. As a result, the body can expand to breathe in air, but loses the ability to exhale appropriately. The most common cause of asthma is an allergy. Asthma is a leading cause of hospitalization and the top chronic disease responsible for kids missing school.
bronchitis A disease caused when the airways that move oxygen to the lungs become irritated and inflamed. The germs that cause colds, flu and bacterial infections can sometimes trigger bronchitis. So can breathing in heavily polluted air, tobacco smoke or certain chemical fumes. Bronchitis may cause wheezing, too, and coughs that bring up thick mucus known as phlegm.
Centers for Disease Control and Prevention, or CDC An agency of the U.S. Department of Health and Human Services, CDC is charged with protecting public health and safety by working to control and prevent disease, injury and disabilities. It does this by investigating disease outbreaks, tracking exposures by Americans to infections and toxic chemicals, and regularly surveying diet and other habits among a representative cross-section of all Americans.
chemical A substance formed from two or more atoms that unite (bond) in a fixed proportion and structure. For example, water is a chemical made when two hydrogen atoms bond to one oxygen atom. Its chemical formula is H2O.
chronic A condition, such as an illness (or its symptoms, including pain), that lasts for a long time.
compound (often used as a synonym for chemical) A compound is a substance formed when two or more chemical elements unite (bond) in fixed proportions. For example, water is a compound made of two hydrogen atoms bonded to one oxygen atom. Its chemical symbol is H2O.
diarrhea (adj. diarrheal) Loose, watery stool (feces) that can be a symptom of many types of microbial infections affecting the gut.
e-cigarette (short for electronic cigarette) Battery-powered device that disperses nicotine and other chemicals as tiny airborne particles that users can inhale. They were originally developed as a safer alternative to cigarettes that users could use as they tried to slowly break their addiction to the nicotine in tobacco products. These devices heat up a flavored liquid until it evaporates, producing vapors. People use these devices are known as vapers.
federal Of or related to a country’s national government (not to any state or local government within that nation). For instance, the National Science Foundation and National Institutes of Health are both agencies of the U.S. federal government.
Food and Drug Administration (or FDA) A part of the U.S. Department of Health and Human Services, FDA is charged with overseeing the safety of many products. For instance, it is responsible for making sure drugs are properly labeled, safe and effective; that cosmetics and food supplements are safe and properly labeled; and that tobacco products are regulated.
genetic Having to do with chromosomes, DNA and the genes contained within DNA. The field of science dealing with these biological instructions is known as genetics. People who work in this field are geneticists.
gut An informal term for the gastrointestinal tract, especially the intestines.
immune (adj.) Having to do with the immunity. (v.) Able to ward off a particular infection. Alternatively, this term can be used to mean an organism shows no impacts from exposure to a particular poison or process. More generally, the term may signal that something cannot be hurt by a particular drug, disease or chemical.
inflammation (adj. inflammatory) The body’s response to cellular injury and obesity; it often involves swelling, redness, heat and pain. It also is an underlying feature responsible for the development and aggravation of many diseases, especially heart disease and diabetes.
inhalation A term for breathing in.
link A connection between two people or things.
marijuana A mind-altering drug. It is made from the leaves (and sometimes stems or seeds) of the Cannabis sativa plant. This drug also goes by the colloquial terms pot and weed.
morbidity The prevalence of illness; the share of people having a particular sickness at some particular time or in some particular place.
mortality Deaths. From mortal, meaning deadly.
nicotine A colorless, oily chemical produced in tobacco and certain other plants. It creates the “buzz” associated with smoking. Highly addictive, nicotine is the substance that makes it hard for smokers to give up their use of cigarettes. The chemical is also a poison, sometimes used as a pesticide to kill insects and even some invasive snakes or frogs.
novel Something that is clever or unusual and new, as in never seen before.
organ (in biology) Various parts of an organism that perform one or more particular functions. For instance, an ovary is an organ that makes eggs, the brain is an organ that makes sense of nerve signals and a plant’s roots are organs that take in nutrients and moisture.
outbreak The sudden emergence of disease in a population of people or animals. The term may also be applied to the sudden emergence of devastating natural phenomena, such as earthquakes or tornadoes.
pneumonia A lung disease in which infection by a virus or bacterium causes inflammation and tissue damage. Sometimes the lungs fill with fluid or mucus. Symptoms include fever, chills, cough and trouble breathing.
pot A slang term for marijuana.
range The full extent or distribution of something. For instance, a plant or animal’s range is the area over which it naturally exists. (in math or for measurements) The extent to which variation in values is possible. Also, the distance within which something can be reached or perceived.
risk The chance or mathematical likelihood that some bad thing might happen. For instance, exposure to radiation poses a risk of cancer. Or the hazard — or peril — itself. (For instance: Among cancer risks that the people faced were radiation and drinking water tainted with arsenic.)
seizure A sudden surge of electrical activity within the brain. Seizures are often a symptom of epilepsy and may cause dramatic spasming of muscles.
smoking A term for the deliberate inhalation of tobacco smoke from burning cigarettes.
supplement (verb) To add to something. (in nutrition) Something taken in pill or liquid form — often a vitamin or mineral — to improve the diet. For instance, it may provide more of some nutrient that is believed to benefit health. It may also provide some substance to the diet that is claimed to promote health.
survey To view, examine, measure or evaluate something, often land or broad aspects of a landscape. (with people) To ask questions that glean data on the opinions, practices (such as dining or sleeping habits), knowledge or skills of a broad range of people. Researchers select the number and types of people questioned in hopes that the answers these individuals give will be representative of others who are their age, belong to the same ethnic group or live in the same region. (n.) The list of questions that will be offered to glean those data.
symptom A physical or mental indicator generally regarded to be characteristic of a disease. Sometimes a single symptom — especially a general one, such as fever or pain — can be a sign of any of many different types of injury or disease.
technology The application of scientific knowledge for practical purposes, especially in industry — or the devices, processes and systems that result from those efforts.
tobacco A plant cultivated for its leaves, which many people burn in cigars, cigarettes, and pipes. Tobacco leaves also are sometimes chewed. The main active drug in tobacco leaves is nicotine, a powerful stimulant (and poison).
toxic Poisonous or able to harm or kill cells, tissues or whole organisms. The measure of risk posed by such a poison is its toxicity.
toxicology The branch of science that probes poisons and how they disrupt the health of people and other organisms. Scientists who work in this field are called toxicologists.
transition The boundary where one thing (paragraphs, ecosystems, life stage, state of matter) changes or converts into another.
unique Something that is unlike anything else; the only one of its kind.
vaping (v. to vape) A slang term for the use of e-cigarettes because these devices emit vapor, not smoke. People who do this are referred to as vapers.
vapors Fumes released when a liquid transforms to a gas, usually as a result of heating.
ventilator (in medicine) A device used to help a person breathe — take in oxygen and exhale carbon dioxide — when the body cannot effectively do that on its own.
vitamin Any of a group of chemicals that are essential for normal growth and nutrition and are required in small quantities in the diet because either they cannot be made by the body or the body cannot easily make them in sufficient amounts to support health.
wheezing (v. wheeze) Chest sounds associated with labored breathing. They can sound like a whistling or rattling, and develop when something obstructs some of the air passages.
Journal: J.E. Layden et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin – preliminary report. New England Journal of Medicine. Published online September 6, 2019. doi: 10.1056/NEJMoa1911614.
Journal: K. Davidson et al. Outbreak of electronic-cigarette–associated acute lipoid pneumonia — North Carolina, July–August 2019. Morbidity and Mortality Weekly Report. Published online September 6, 2019. doi: 10.15585/mmwr.mm6836e1.
Report: Indiana State Department of Health. Indiana health officials report first vaping-related death. September 6, 2019.
Report: Minnesota Department of Health. Health officials report death in a patient hospitalized for vaping-related lung injury. September 6, 2019.
Report: Los Angeles County Department of Health. Public Health Investigates First Death Associated with E-Cigarettes in LA County. September 6, 2019.
Report: New York State Department of Health. New York State Department of Health announces update on investigation into vaping-associated pulmonary illnesses. September 5, 2019.
Report: Statement from CDC Director Robert R. Redfield, M.D., and Acting FDA Commissioner Ned Sharpless, M.D., on federal and state collaboration to investigate respiratory illnesses reported after use of e-cigarette products. August 30, 2019.
Report: U.S. Centers for Disease Control and Prevention. Update on severe pulmonary disease associated with e-cigarettes. August 23, 2019.
Report: Illinois Department of Public Health. Illinois resident experiencing respiratory illness after vaping dies. August 23, 2019.
Journal: K.F. Trivers et al. Prevalence of cannabis use in electronic cigarettes among US youth. JAMA Pediatrics. Published online September 17, 2018. doi:10.1001/jamapediatrics.2018.1920.
Journal: T.W. Wang et al. Tobacco product use among middle and high school students – United States, 2011-2017. Morbidity and Mortality Weekly Report. Vol. 67, June 8, 2018, p. 629. doi: 10.15585/mmwr.mm6722a3.