What is it?

If you’ve seen the news lately, you’re probably aware of a few hundred people across the country who have experienced vaping sickness. Unfortunately, one person has died from it. The individuals involved are young and healthy, but have a sudden onset of breathing problems. The common factor is that they all vape. Why is this happening all of sudden? What is being done to address it? If you vape, should you be concerned?


0909 Vaping Sickness TNIf you’ve been following the news over the summer, you’ve probably heard about the mysterious and life-threatening vaping-related illnesses that are sweeping across the country. As of last week, a fifth person has died and there are now 450 possible cases in 33 states and one territory. The scary thing is that the definitive cause of the illness remains unknown. For the most part, the patients are healthy and in their late teens and 20s. They’re showing up at hospitals with severe shortness of breath, often after suffering for several days with vomiting, fever and fatigue. Due to the gravity of their symptoms, some have ended up in the intensive care unit and on a ventilator for weeks. The doctors treating these patients say that the lung scans of the patients look like there is a serious viral or bacterial pneumonia, but other tests show no signs of infection. Several patients were diagnosed with a rare condition known as lipoid pneumonia. This occurs when the cells in the lung are filled with lipids (fat). While your digestive tract can break down and get rid of lipids, your lungs aren’t designed to handle anything except gases. Your lungs are filters that are supposed to take the air you breathe, clean it and deliver oxygen to the blood in exchange for carbon dioxide. When you inhale particles, whether it’s from air pollution, cigarettes or vaping, your lungs have to work harder to filter out the bad stuff. As your body tries to clear these particles, it creates inflammation, which in your lungs appears as fluid. If your lungs get so inflamed that they can’t take in oxygen, you end up on a ventilator. If the ventilator isn’t enough to support your lungs, you can ultimately die.

Where are these oils coming from? What other chemicals are in e-juice? Many of the e-cigarette companies promote the idea that consumers should do their own research regarding vapor products. However, many of the ingredients are protected as trade secrets, so individuals are unable to find this information readily. Considering that most other products that are used for human consumption have to list their ingredients, this seems odd. Aren’t there rules that these companies should be following?

The problem is that when e-cigarettes came to market about ten years ago, they end up in a regulatory no man’s land, which meant there was no oversight. This is because they aren’t considered a food, drug nor medical device. If they were classified as any of these, they would have immediately been placed under the control of the Food and Drug Administration (FDA). It wasn’t until a few years ago they were classified as being tobacco products. Due to this, billions of dollars of vaping products have been sold and consumed without going through the FDA’s arduous review process to assess their safety. In 2009, Congress passed the Family Smoking Prevention and Tobacco Control Act, which gave the FDA the power to oversee the safety and sale of tobacco products. However, e-cigarettes weren’t classified as a tobacco product until 2010 when a federal judge ruled that the FDA should regulate them as tobacco products. Even after that ruling, it took the agency six years to finalize its guidelines to use in regulating e-cigarettes and e-liquids. By then, it was 2016 and the e-cigarette market had swelled to an estimated $4.1 billion. The scary thing is that current projections by market researchers state that it could reach $48 billion by 2023. One of the first things that the agency did was ban e-cigarette sales to minors. Also, it’s requiring all new vaping products to submit applications for authorization before they can come to market. For companies and retailers who already have products on the market, they were granted two years to submit applications and the FDA would get an additional year to evaluate them. During this time, existing products could still be sold. When Dr. Scott Gottlieb arrived as the new FDA commissioner in 2017, he pushed the deadline back to 2022. The following year, the Center for Disease Control (CDC) released a report that showed in 2011 only 1.5% of high school students were vaping, but by 2018, that number had risen to 20.8%. The FDA published its own report that showed between 2017 and 2018 alone e-cigarette use among high school students rose 78%. According to the National Academy of Sciences, when teens use e-cigarettes, it increases the risk of them using traditional cigarettes. This information changed Gottlieb’s thinking, but the deadline didn’t change. As of July 2019, a judge ruled that e-cigarette makers only have 10 more months to submit applications, making them due in May 2020. Since starting to regulate the e-cigarette industry, the agency has conducted thousands of inspections of manufacturers and retailers. It has taken enforcement actions against companies selling e-cigarettes that look like juice boxes and one that was putting the ingredients found in erectile dysfunction drugs into its e-liquid. Companies are now required to label their products as potentially addictive, sell them only to adults and comply with all manufacturing standards. Since e-cigarettes never went through the FDA’s “gold standard” approval process, doctors can’t readily look up a detailed list of known side effects, which is making it incredibly hard to treat the patients who are developing vaping illnesses.

E-cigarettes were invented as a way to quit smoking, but some recent research has called that into question. There’s no question that cigarette smoke contains a much larger number of toxins and cancer-causing chemicals than e-liquid. So, if someone is a heavy smoker and transitions to e-cigarettes before quitting altogether, there is some benefit. The problem is people who give up cigarettes but vape instead. It’s becoming clearer that e-cigarettes aren’t harmless and can actually expose consumers to substances known to damage health, such as ultra-fine particles, heavy metals, volatile organic compounds and toxic chemicals, such as formaldehyde. As more studies are being done, many of the chemicals in the e-liquids are shown to undergo thermal degradation when they’re heated, which produces new compounds with potentially harmful consequences. In 2018, a report by the National Academies of Sciences, Engineering, and Medicine reviewed over 800 studies on the health effects of e-cigarettes. It found e-cigarettes produce a large amount of potentially toxic substances, including some that are known to damage DNA. The other problem is that alone, or in combination, these substances could result in a variety of pulmonary illnesses. The type and amount of the toxic substances vary with each device and e-liquid. Another factor is how the device is used. Some of the studies did lung biopsies done on young healthy people who have been vaping for a couple of years. The results are astounding. Many of them show signs of significant lung damage that resembles the type of lung damage in an elderly patient who has smoked for decades.

While we’re just beginning to understand the possible long-term health consequences of vaping. The primary concern is these individuals who are developing acute respiratory problems. What has caused this sudden increase? There are several factors. According to the CDC, the recent dramatic increase in reported cases is the result of increased awareness. Many doctors are now coming forward and describing earlier cases of severe lung problems linked to vaping that were not officially reported or included in the current CDC count due to the lack of regulation and having nowhere to report it to until now. Unlike certain infectious diseases, which are required to be reported to federal authorities, this doesn’t fall into that category. Also, unlike infectious disease outbreaks, this investigation has been more difficult because there isn’t a specific culprit, an established national system of collecting information or even a consistent definition of the illness. Another issue is the assortment of state and federal regulatory authorities involved in the process. The CDC and FDA are investigating these cases in conjunction with state and local health officials. An added problem is the sheer number and kinds of businesses, legal and illicit, selling the products. While nicotine vaping products are lightly regulated, with tougher rules coming in the near future, marijuana vaping products aren’t regulated because they’re illegal under federal law.

Due to the nature of the suddenness of the onset of symptoms, the primary focus of the investigation is to look everything that is in the e-liquids from THC, CBD and nicotine to solvents and possible contaminants. Samples from the patients and the products they used have been sent to the FDA’s forensic laboratory in Cincinnati. One of the main things that they are looking at is the amount of oils in the products. This is because oils are often used as solvents to dissolve the nicotine or THC making them easier to vaporize. The problem is that some oil droplets may be left over as the liquid cools back down. When you inhale these droplets, it coats the inside of your lungs and may result in breathing problems and lung inflammation. One ingredient that has appeared in several of the samples is Vitamin E oil. Vitamin E is sometimes advertised as a supplement in cannabidiol oil, which is not designed for vaping but has been used that way. Vitamin E is found in certain foods, such as canola oil, olive oil and almonds. The oil comes from the vitamin, known as vitamin E acetate, is commonly available as a nutritional supplement and is used in topical skin treatments. It’s not known to cause harm when ingested or applied to the skin. However, its molecular structure could make it hazardous when inhaled. Another common ingredient that is being found in e-liquid is vegetable glycerin, which is made from vegetable oil. An additional concern is that black-market dealers appear to be using new substances to thin out THC oil, which is thick, odorless and colorless. They mix in unknown oils, that are also colorless and odorless, in order to give the appearance of purity.

A hinderance to the investigation is that many victims have reported vaping different products, purchased in different places and used for different lengths of time. This means that there isn’t a common source. It also means that people are putting whatever concoction of different chemicals and different amounts into their e-cigarettes. Some say they vaped products containing marijuana. Others say they only used products containing nicotine. Still others reported using both. There are too many variables to precisely pinpoint the exact cause of the illness. Furthermore, each person reacts differently to irritants. The one thing that is known for sure is that the more you smoke, the higher the concentration of chemicals in your lungs, the more likely you’ll see an ill effect, and the more severe that effect will be. One reason there isn’t an accurate idea of what people are using is because vaping habits aren’t talked about the same way smoking and drinking habits are medical appointments. Part of the problems is that many doctors haven’t been asking patients about e-cigarette use. It’s something that should be addressed, just like smoking, drinking, diet and exercise. Another issue is that some patients don’t know, or deny knowing, the actual substances they might being inhaling. The idea that people don’t know what they’re inhaling has many doctors and researchers concerned about how little the public knows about the ingredients in e-cigarettes and the risks of smoking them. Countless number of doctors have said that they’ve seen the warning signs for years that vaping could be hazardous, but that message isn’t getting to the public soon enough. Parents should definitely rethink letting their kids vape because it’s not a safer alternative to cigarettes and it will not keep them from smoking. The CDC recently issued a health advisory that people should refrain from using e-cigarette products and, if you are going to use them, avoid buying the modified devices or products.

There’s no question that vaping products are not as safe or benign as they were initially thought to be. Unfortunately, the problem is most likely going to get worse before it gets better. The sad thing is that we already have a case study on this—traditional cigarettes. It took us more than 20 years to realize that they were harmful to our health. We are repeating the same mistake right now with e-cigarettes. While it may have taken the FDA far too long to initially act, we need to do everything we can to catch up to not only prevent e-cigarettes from following in the steps of cigarettes, but to prevent more people from becoming critically ill due to vaping sickness.