Patients, mostly otherwise healthy and in their late teens and 20s, are showing up in emergency rooms with severe shortness of breath, often after suffering for several days with vomiting, fever and fatigue
Some have wound up in the intensive care unit or on a ventilator for weeks. Treatment has been complicated by patients’ lack of knowledge — and sometimes outright denial — about the actual substances they might have used or inhaled.
Health investigators are now trying to determine whether a particular toxin or substance has sneaked into the supply of vaping products, whether some people reused cartridges containing contaminants, or whether the risk stems from a broader behavior, like heavy e-cigarette use, vaping marijuana or a combination.
On Friday, the Centers for Disease Control and Prevention issued a warning to teenagers and other consumers, telling them to stop buying bootleg and street cannabis and e-cigarette products, and to stop modifying devices to vape adulterated substances.
The illnesses have focused attention on a trend that has been overshadowed by the intense public concern about soaring teenage use of e-cigarettes, with its potential for hooking a new generation on nicotine: the rise of the vaping device itself. It has introduced a wholesale change in how people consume nicotine or marijuana, by inhaling vaporized ingredients.
Vaping works by heating liquid and turning it into steam to be inhaled. Broadly speaking, e-cigarettes are considered less harmful than traditional cigarettes, which work through the combustion of tobacco that sends thousands of chemicals, many carcinogenic, into the lungs.
But vaping has its own problems: To become inhalable, nicotine or THC, the high-inducing chemical in marijuana, must be mixed with solvents that dissolve and deliver the drugs. The solvents, or oils, heat up during aerosolization to become vapor. But some oil droplets may be left over as the liquid cools back down, and inhaling those drops may cause breathing problems and lung inflammation.
“Inhaling oil into your lungs is extremely dangerous behavior that could result in death,” said Thomas Eissenberg, who studies vaping at Virginia Commonwealth University. “That is probably the biggest message we can get out of this.”
Many vaping ingredients are not listed on the products. Vitamin E oil appears to have been a common substance associated with the severe and sudden respiratory problems in some of the New York cases, according to state health officials. It is not known how it was used. Vitamin E is sometimes advertised as a supplement in cannabidiol oil, which is not designed for vaping but has been used that way.
Dr. Scott Gottlieb, the former commissioner of the Food and Drug Administration, said he suspected a link to illicit products — perhaps related to ingredients including THC — because the main manufacturers of e-cigarettes had not suddenly altered their ingredients on a wide scale. “It’s probably something new that has been introduced into the market by an illegal manufacturer, either a new flavor or a new way to emulsify THC that is causing these injuries,” he said.
The outbreaks have created a crisis for two emerging industries — e-cigarettes and legal cannabis — that have pitched themselves as beneficial to public health. E-cigarette supporters consider the technology a safer alternative to smoking, while cannabis has been sold politically as “medical marijuana” and as a substitute for tobacco growers.
Now some subset of these products is causing a serious lung disease that even cigarettes, while lethal in the long run, don’t cause in young people. Lobbyists and company officials in both industries are scrambling to blame unregulated products.
The spate of illnesses has made news again of Juul Labs, maker of the blockbuster e-cigarette device blamed for the surge in teenage vaping. In a television interview, Kevin Burns, the company’s chief executive, said he did not know of evidence linking the recent cases to Juul’s products.
On lung scans, the illnesses look at first like a serious viral or bacterial pneumonia, but tests show no infection. “We’ve run all these tests looking for bacteria, looking for viruses and coming up negative,” said Dr. Dixie Harris, a critical care pulmonologist in Salt Lake City, who has consulted on four such patients and reviewed case files of nine others in the state.[…]
The Vapor Technology Association, an e-cigarette and vaping industry trade group, asked “public officials to thoroughly investigate the circumstances which might have led to each reported hospitalization before making statements to the public as to whether certain products are implicated in these incidents.”
The regulation and study of the marijuana industry is particularly complex. Even though the federal government still considers cannabis a controlled substance, 33 states now allow it to be sold for either recreational or medicinal purposes or both. Hundreds of cannabis products are sold, legally and illegally, such as THC oil, or cannabis oil with THC.
The Food and Drug Administration has warned some sellers of cannabis product supplements not to make health claims, but more are doing so than the agency can keep up with. The F.D.A. oversees CBD products sold as dietary supplements, but does not regulate THC, which is illegal under federal law. Liquid nicotine and THC, sometimes sold in cartridges for use in vaping devices, can each contain oils that may be safe to swallow but can damage the lung when vaporized into a mix of unknown chemicals.
While e-cigarettes have been presumed less harmful over the long run than cigarettes, the ultimate impact from years of vaping is simply not yet known.
Mr. Eissenberg, director of the Center for the Study of Tobacco Products at Virginia Commonwealth University, said seven cases of similar lung injuries from e-cigarette vaping had been reported in previous years.
“A common ingredient was vegetable glycerin, which is made from vegetable oil,” he said. “If there is some incomplete process, there can be oil left in the vegetable glycerin when that person is using it, and inhaling oil and getting oil into your lungs is what is causing some of the lung injuries we see.”
“Basically what the F.D.A. should be doing is testing every one of these liquids to see if they have any oil at all and making a regulation that would ban oil in any of these products, whether it is a THC product or a nicotine product,” said Mr. Eissenberg, who is researching vaping with a grant from the agency.