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Vaping in adolescents: epidemiology and respiratory harm

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Vaping in adolescents: epidemiology and respiratory harm

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This article talks about the risk factors for adolescents that use vape products.

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Vaping in adolescents: epidemiology and respiratory harm

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This review highlights epidemiologic changes in e-cigarette use in adolescents, discusses recent advances in aerosolized nicotine delivery, and provides and updated profile of research related to the lung-specific harm of e-cigarettes. In the past…

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Virchows Archiv on vape-related lung injury

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Virchows Archiv on vape-related lung injury

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This article presents an overview on the increase of electronic nicotine over the past decade and the related diseases that have come with it.

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Vaping-related lung injury - Virchows Archiv

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The use of electronic nicotine delivery systems has increased in popularity dramatically over the past decade. Although lung diseases caused by vaping have been reported since the modern invention of the electronic cigarette, in the summer of 2019, patients began to present to health care centers at…

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Cleveland Clinic Journal of Medicine addresses vaping

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Cleveland Clinic Journal of Medicine addresses vaping

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This journal gives a full overview of what vaping is. It also goes into different aspects of lung injury outbreak.

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ABSTRACT

Vaping devices, introduced to the US market in 2007 as aids for smoking cessation, have become popular among youth and young adults because of their enticing flavors and perceived lack of negative health effects. However, evidence is emerging that vaping may introduce high levels of dangerous chemicals into the body and cause severe lung injury and death. This article reviews the history and prevalence of vaping and available research on its health effects and efficacy in smoking cessation, and proposes recommendations for clinicians and legislators to reduce harms associated with vaping.

KEY POINTS

Vaping is a common gateway to tobacco and marijuana use for adolescents and adults.

The Juul vaping device delivers high nicotine concentrations that may pose a higher risk of nicotine addiction.

Vaping has had unintended consequences that include poisoning of children who swallowed liquid nicotine, fires and explosions from defective batteries in the devices, and effects on the developing brain.

Vaping is associated with respiratory illness and, in rare cases, death, likely due to vaporized agents introduced into the lungs. Small amounts of heavy metals, acetone, and other carcinogenic compounds in the vaping aerosol may cause lung damage.

YOUTH AT RISK

Youth are particularly at risk. In a 2018 survey, 20.8% of high school students reported using e-cigarettes on more than 1 day in the previous 30 days ( Table 1), a significant increase from 1.5% in 2011. Additionally, 11.3% of high school students reported using 2 or more types of tobacco products; in middle school students, the number was 4.9%-nearly 1 in 20-up from 0.6% in 2011.

In 2014, for the first time, e-cigarette use became more common among US youth than traditional cigarettes.

The odds of taking up vaping are higher among minority youth in the United States, particularly Hispanics. This trend is particularly worrisome because several longitudinal studies have shown that adolescents who use e-cigarettes are 3 times as likely to eventually become smokers of traditional cigarettes compared with adolescents who do not use e-cigarettes.

If US youth continue smoking at the current rate, 5.6 million of the current population under age 18, or 1 of every 13, will die early of a smoking-related illness.

RECENT OUTBREAK OF VAPING-ASSOCIATED LUNG INJURY

Most of these patients had been vaping tetrahydrocannabinol (THC), though many used both nicotine-and THC-containing products, and others used products containing nicotine exclusively. Thus, it is difficult to identify the exact substance or substances that may be contributing to this sudden outbreak among vape users, and many different product sources are currently under investigation.

One substance that may be linked to the epidemic is vitamin E acetate, which the New York State Department of Health has detected in high levels in cannabis vaping cartridges used by patients who developed lung injury. The US Food and Drug Administration (FDA) is continuing to analyze vape cartridge samples submitted by affected patients to look for other chemicals that can contribute to the development of serious pulmonary illness.

WHAT IS AN E-CIGARETTE? WHAT IS A VAPE PEN?

E-cigarettes, the most common type of electronic nicotine delivery system, look like conventional cigarettes. Designs vary, but the devices generally contain a power source (typically a lithium battery), a heating element, and a reservoir for the "e-liquid" ( Figure 1). The e-liquid typically consists of a solvent (propylene glycol or vegetable glycerin), flavorings (eg, tobacco, mint, fruit, bubblegum), and, often, nicotine in various doses. When the user inhales, the negative pressure closes a switch, turning on the heater, which turns some of the liquid into an aerosol, which is inhaled. The aerosol may contain nicotine, but formulations are proprietary and not currently regulated.

Vape pens consist of similar elements but are not necessarily similar in appearance to a conventional cigarette, and may look more like a pen or a USB flash drive. In fact, the Juul device is recharged by plugging it into a USB port.

Vaping devices have many street names, including e-cigs, e-hookahs, vape pens, mods, vapes, and tank systems.

The first US patent application for a device resembling a modern e-cigarette was filed in 1963, but the product never made it to the market. Instead, the first commercially successful e-cigarette was created in Beijing in 2003 and introduced to US markets in 2007.

Newer-generation devices have larger batteries and can heat the liquid to higher temperatures, releasing more nicotine and forming additional toxicants such as formaldehyde. Devices lack standardization in terms of design, capacity for safely holding e-liquid, packaging of the e-liquid, and features designed to minimize hazards of use.

WHAT IS JUUL?

The Juul device (Juul Labs, www.juul.com) was developed in 2015 by 2 Stanford University graduates. Their goal was to produce a more satisfying and cigarette-like vaping experience, specifically by increasing the amount of nicotine delivered while maintaining smooth and pleasant inhalation. They created an e-liquid that could be vaporized effectively at lower temperatures.

While more than 400 brands of vaping devices are currently available in the United States, Juul has held the largest market share since 2017, an estimated 72.1% as of August 2018. The surge in popularity of this particular brand is attributed to its trendy design that is similar in size and appearance to a USB flash drive, and its offering of sweet flavors such as "crème brûlée" and "cool mint."

On April 24, 2018, in view of growing concern about the popularity of Juul products among youth, the FDA requested that the company submit documents regarding its marketing tactics, as well as research on the effects of this marketing on product design and public health impact, and information about adverse experiences and complaints. The company was forced to change its marketing to appeal less to youth. Now it offers only 3 flavors: "Virginia tobacco," "classic tobacco," and "menthol," although off-brand pods containing a variety of flavors are still available. And some pods are refillable, so users can essentially vape any substance they want.

BAD THINGS IN E-LIQUID AEROSOL

Studies of vape liquids consistently confirm the presence of toxic substances in the resulting vape aerosol. Depending on the combination of flavorings and solvents in a given e-liquid, a variety of chemicals can be detected in the aerosol from various vaping devices. Chemicals that may be detected include known irritants of respiratory mucosa, as well as various carcinogens. The list includes:

Organic volatile compounds such as propylene glycol, glycerin, and toluene

Aldehydes such as formaldehyde (released when propylene glycol is heated to high temperatures), acetaldehyde, and benzal-dehyde

Acetone and acrolein

Carcinogenic nitrosamines

Polycyclic aromatic hydrocarbons

Particulate matter

Metals including chromium, cadmium, nickel, and lead; and particles of copper, nickel, and silver have been found in electronic nicotine delivery system aerosol in higher levels than in conventional cigarette smoke.

E-CIGARETTES AND SMOKING CESSATION

Conventional cigarette smoking is a major public health threat, as tobacco use is responsible for 480,000 deaths annually in the United States.

There are currently 5 types of FDA-approved nicotine replacement therapy products (gum, patch, lozenge, inhaler, nasal spray) to help with smoking cessation. In addition, 2 non-nicotine prescription drugs (varenicline and bupropion) have been approved for treating tobacco dependence.

Can vaping devices be added to the list of nicotine replacement therapy products? Although some manufacturers try to brand their devices as smoking cessation aids, in one study, one-third of e-cigarette users said they had either never used conventional cigarettes or had formerly smoked them.

Bullen et al randomized smokers interested in quitting to receive either e-cigarettes, nicotine patches, or placebo (nicotine-free) e-cigarettes and followed them for 6 months. Rates of tobacco cessation were less than predicted for the entire study population, resulting in insufficient power to determine the superiority of any single method, but the study authors concluded that nicotine e-cigarettes were "modestly effective" at helping smokers quit, and that abstinence rates may be similar to those with nicotine patches.

Hajek et al randomized 886 smokers to e-cigarette or nicotine replacement products of their choice. After 1 year, 18% of e-cigarette users had stopped smoking, compared with 9.9% of nicotine replacement product users. However, 80% of the e-cigarette users were still using e-cigarettes after 1 year, while only 9% of nicotine replacement product users were still using nicotine replacement therapy products after 1 year.

While quitting conventional cigarette smoking altogether has widely established health benefits, little is known about the health benefits of transitioning from conventional cigarette smoking to reduced conventional cigarette smoking with concomitant use of e-cigarettes.

Campagna et al found no beneficial health effects in smokers who partially substituted conventional cigarettes for e-cigarettes.

As with safety information, long-term outcomes regarding the use of vape devices for smoking cessation have not been yet established, as this option is still relatively new.

VAPING AS A GATEWAY DRUG

Another worrisome trend involving electronic nicotine delivery systems is their marketing and branding, which appear to be aimed directly at adolescents and young adults. Juul and other similar products cannot be sold to anyone under the age of 18 (or 21 in 18 states, including California, Massachusetts, New York, and now Ohio). Despite this, Juul and similar products continue to increase in popularity among middle school and high school students.

While smoking cessation and health improvement are cited as reasons for vaping among middle-aged and older adults, adolescents and young adults more often cite flavor, enjoyment, peer use, and curiosity as reasons for use.

In September 2019, Michigan became the first state to ban the sale of flavored e-cigarettes in stores and online. Similar bills have been introduced in California, Massachusetts, and New York.

SECONDHAND VAPEAND OTHER EXPOSURE RISKS

Accidental nicotine poisoning in children as a result of ingesting e-cigarette liquid is also a major concern, particularly with sweet flavors such as bubblegum or cheesecake that may be attractive to children.

Device malfunctions or battery failures have led to explosions that have resulted in substantial injuries to users, as well as house and car fires.

HOW DO WE DISCOURAGE ADOLESCENT USE?

There are currently no established treatment approaches for adolescents who have become addicted to vaping. A review of the literature regarding treatment modalities used to address adolescent use of tobacco and marijuana provides insight that options such as nicotine replacement therapy and counseling modalities such as cognitive behavioral therapy may be helpful in treating teen vaping addiction. However, more research is needed to determine the effectiveness of these treatments in youth addicted to vaping.

Given that youth who vape even once are more likely to try other types of tobacco, we recommend that parents and healthcare providers start conversations by asking what the young person has seen or heard about vaping. Young people can also be asked what they think the school's response should be: Do they think vaping should be banned in public places, as cigarettes have been banned? What about the carbon footprint? What are their thoughts on the plastic waste, batteries, and other toxins generated by the e-cigarette industry?

New US laws ban the sale of e-cigarettes and vaping devices to minors in stores and online. These policies are modeled in many cases on environmental control policies that have been previously employed to reduce tobacco use, particularly by youth. For example, changing laws to mandate sales only to individuals age 21 and older in all states can help to decrease access to these products among middle school and high school students.

As with tobacco cessation, education will not be enough. Support of legislation that bans vaping in public places, increases pricing to discourage adolescent use, and other measures used successfully to decrease conventional cigarette smoking can be deployed to decrease the public health impact of e-cig arettes. We recommend further regulation of specific harmful chemicals and clear, detailed ingredient labeling to increase consumer understanding of the risks associated with these products. Additionally, we recommend eliminating flavored e-cigarettes, which are the most appealing type for young users, and raising prices of e-cigarettes and similar products to discourage use by youth.

If current cigarette smokers want to use e-cigarettes to quit, we recommend that clinicians counsel them to eventually completely stop use of traditional cigarettes and switch to using e-cigarettes, instead of becoming a dual user of both types of products or using e-cigarettes indefinitely. After making that switch, they should then work to gradually taper usage and nicotine addiction by reducing the amount of nicotine in the e-liquid. Clinicians should ask patients about use of e-cigarettes and vaping devices specifically, and should counsel nonsmokers to avoid initiation of use.

EVIDENCE OF HARM CONTINUES TO EMERGE

Data about respiratory effects, secondhand exposure, and long-term smoking cessation efficacy are still limited, and it remains as yet unknown what combinations of solvents, flavorings, and nicotine in a given e-liquid will result in the most harmful or least harmful effects. In addition, while much of the information about the safety of these components has been obtained using in vitro or mouse models, increasing reports of serious respiratory illness and rising numbers of deaths linked to vaping make it clear that these findings likely translate to harmful effects in humans.

E-cigarettes may ultimately prove to be less harmful than traditional cigarettes, but it seems likely that with further time and research, serious health risks of e-cigarette use will continue to emerge.

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Vaping: The new wave of nicotine addiction

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Vaping devices, introduced to the US market in 2007 as aids for smoking cessation, have become popular among youth and young adults because of their enticing flavors and perceived lack of negative health effects. However, evidence is emerging that vaping may introduce high levels of dangerous chemicals into the body and cause severe lung injury and death.

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NBC News presents study from Stanford University

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NBC News presents study from Stanford University

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This news article provides us with a study from Stanford that claims teens that vape care 7 times more like;y to get COVID-19.

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Teen vapers up to 7 times more likely to get COVID-19: Stanford study

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“Being a 21-year-old, I should not be spending six days in the hospital for lung complications,” said one young vaper who survived coronavirus.

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Non-profit Organization- Truth Initiative 

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Non-profit Organization- Truth Initiative 

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An article published by Truth Initiative which is an organization committed to making nicotine and tobacco use a thing of the past.

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Nicotine levels in e-cigarettes are highly variable, with some reaching levels near combustible cigarettes. Nicotine is harmful to developing brains: younger users are more likely to become addicted, have more difficulty quitting and may be at higher risk for addiction to other substances in the future. While we endorse the important public health strategy of harm minimization and these new products may be beneficial to smokers who completely switch from combustible tobacco, they still pose health risks and nonsmokers should never use them.

E-cigarettes are threatening to addict a new generation to nicotine, and we are committed to research and actions that protect today's young people. We have conducted studies on e-cigarettes, especially the leading brand that is driving the epidemic of youth e-cigarette use, JUUL, and helped lead efforts to call on regulatory action needed to protect youth. We have also been at the forefront of public education and community engagement efforts focused on e-cigarettes, including our Safer ≠ Safe campaign and the first-of-its-kind program to help young people quit vaping, This is Quitting.

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Nicotine levels in e-cigarettes are highly variable, with some reaching levels near combustible cigarettes. Nicotine is harmful to developing brains: younger users are more likely to become addicted, have more difficulty quitting and may be at higher risk for addiction to other substances in the future.

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In this video, a pulmonary specialist Dr. Aldarondo, speaks about acute lung injury associated with vaping.

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What Are the Effects of Vaping? | Sigfredo Aldarondo, M.D.

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This article talks about lung injury (EVALI) associated with vaping.

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In the summer of 2019, the Centers for Disease Control and Prevention (CDC) began to investigate a steep rise in hospitalizations linked to the use of vaping products. The patients complained of a host of respiratory symptoms including shortness of breath, cough, and chest pain. They all shared one thing in common: They had used vaping products within the previous three months.

The condition came to be called "e-cigarette, or vaping, product use associated lung injury," or EVALI. By February 2020, the CDC had recorded over 2800 hospitalizations due to EVALI along with 68 deaths caused by the condition.

Fortunately, there has been a substantial drop in cases since they peaked in August and September of 2020. What's more, researchers have also identified vitamin E acetate, a chemical added to some THC-containing vaping products, as the main-but possibly not the only-cause of the illness. The outbreak of EVALI cases emerged against a backdrop of an ongoing vaping epidemic among youth. According to the CDC, 15% of EVALI patients were less than 18 years old.

At Yale Medicine, most pediatricians have started asking middle- and high school-age patients about their exposure to vaping, in large part to identify patients who might be at higher risk for developing related problems.

"I screen all of my patients, any child over age 12, since [vaping] can exacerbate underlying conditions like asthma," says Yale Medicine pediatric pulmonologist Pnina Weiss, MD.

EVALI is a serious medical condition in which a person's lungs become damaged from substances contained in e-cigarettes and vaping products.

Vaping involves using a device known as an e-cigarette-also called a vape pen, mod, or tank-to heat up a small amount of liquid, turning it into a vapor that can be inhaled. Most vape liquids contain substances such as propylene glycol and glycerol as base ingredients that create the vapor. But they may also contain other compounds including artificial flavors, nicotine, THC, and cannabinoid (CBD) oil.

EVALI may cause the following symptoms:

Shortness of breath

Cough

Chest pain

Fever and chills

Diarrhea, nausea, vomiting, and abdominal pain

Rapid heartbeat

Rapid and shallow breathing

Researchers have linked vitamin E acetate, a synthetic form of vitamin E found in some THC-containing vaping products, to EVALI. When inhaled, the chemical can damage the lungs. One study detected vitamin E acetate in the lung fluid of 48 out of 51 EVALI patients sampled across 16 states. By contrast, lung fluid samples taken from healthy people did not contain the vitamin.

Because of this and other studies, vitamin E acetate is considered the main cause of EVALI. Other chemicals found in nicotine- and THC-containing vaping products may also play a role in the condition.

The primary risk factor for EVALI is current or previous use of a vaping device.

In particular, use of vaping devices that contain THC have been associated with the condition. According to the CDC, over 80% of people hospitalized due to EVALI reported use of vaping products that contained THC, though many also said they used nicotine-containing products. The CDC further notes that nearly 80% of EVALI patients who used THC-containing e-cigarettes obtained their vaping products from "informal sources" including family, friends, dealers, or online sources, rather than commercial outlets.

Diagnosing EVALI can be challenging because the symptoms of this lung condition are similar to those of other respiratory illnesses, like pneumonia and even the seasonal flu virus.

There is no single test for EVALI; it's what is known as a "diagnosis of exclusion," which means that a doctor will conduct tests to rule out other potential diseases and conditions.

Your doctor will begin his or her diagnosis by asking you about your use of e-cigarettes within the past three months and whether you vaped a product containing nicotine, THC, or both. During the physical exam, your doctor will use a stethoscope to listen to your lungs, check your heartrate, and measure your blood oxygen saturation using a pulse oximeter. A chest X-ray or computed tomography (CT) scan is usually necessary for diagnosis and will show hazy looking spots (called opacities) in the lungs. This contrasts with a clear back space in healthy lungs. Your doctor may also order bloodwork to rule out other possible causes of your illness.

Many people diagnosed with EVALI need to be treated in a hospital where medications can be closely monitored, and respiratory support is readily available.

Treatments may include:

Corticosteroids. A type of medication that reduces inflammation in the lungs and throughout the body.

Supportive care. Patients may receive supplemental oxygen through a nasal cannula. In more severe cases, they may be put on a mechanical ventilator or an extracorporeal membrane oxygenation machine.

Antibiotics. These drugs may be given to the patient while diagnostic test results are being finalized as it's difficult to distinguish EVALI from bacterial infections.

Antivirals. Because EVALI causes similar symptoms to some viral infections, antivirals may be used, especially during influenza season.

Because the illness is so new, there is no way to predict how patients will fare after being released from the hospital following treatment. Dr. Weiss says that some have become ill again after steroid treatment is stopped, so follow-up care is vital.

"We recommend that patients see a pulmonologist within one to two weeks after being discharged to undergo testing of lung function and pulse oximetry [level of oxygen in the blood]," she says.

Because of the lack of long-term data and the fact that patients have died from EVALI, the prognosis for those affected remains uncertain. Researchers are working hard to learn as much as possible about the illness, its causes, and the odds for making a full recovery.

"Yale physicians have been at the forefront in identifying EVALI cases," Dr. Weiss says. She explains that even before CDC guidelines on treating the illness were released, Yale doctors were successfully treating patients with a combination of antibiotics and steroids. Doctors at Yale Medicine also collaborate with researchers in the fields of tobacco and addiction medicine to provide care for patients with EVALI.

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E-cigarette, or Vaping Product, Use Associated Lung Injury (EVALI)

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E-cigarette, or vaping product, use-associated lung injury, or EVALI, is the term for the lung disease that can develop due to vaping. Learn about symptoms and treatment.

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The FDA gives an overview and studies on respiratory illness related to the use of vape products.

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FDA is seeking unpublished data and information related to the use of vaping products associated with recent lung injuries. FDA is seeking information on product design and potential ways to prevent consumers from modifying or adding substances to these products that are not intended by the manufacturers.

Submit a public comment to docket FDA-2020-N-0597 by June 19, 2020.

Background

Both the U.S. Food and Drug Administration and the U.S. Centers for Disease Control and Prevention are working tirelessly to investigate the distressing incidents of severe respiratory illness associated with use of vaping products. The FDA and CDC are working closely with state and local health officials to investigate these incidents as quickly as possible, and we are committed to taking appropriate actions as a clearer picture of the facts emerges.

While the work by federal and state health officials to identify more information about the products used, where they were obtained and what substances they contain is ongoing, the FDA is providing consumers with some information to help protect themselves.

Incident Overview

The Centers for Disease Control and Prevention (CDC) is working with states to determine if cases are confirmed or probable after examining the medical records of suspected cases.

Please see the CDC's website for updated cases. These numbers may change frequently.

While some cases in each of the states are similar and appear to be linked to vaping product use, more information is needed to determine what is causing the respiratory illnesses.

In many cases, patients reported a gradual start of symptoms, including breathing difficulty, shortness of breath, and/or chest pain before hospitalization. Some cases reported mild to moderate gastrointestinal illness including vomiting and diarrhea, or other symptoms such as fevers or fatigue.

In many cases, patients told healthcare personnel or health department staff of recent use of vaping products containing tetrahydrocannabinol (THC, a psychoactive component of the marijuana plant).

Even though cases appear similar, it is not clear if they have a common cause or if they involve different diseases with similar presentations, which is an issue central to our investigation.

CDC and the FDA are providing consultation to state health departments and are working closely with them to gather information on any products or substances used.

For example, our agencies are working to standardize information collection at the state level to help build a more comprehensive picture of these incidents. This includes investigating the brand, manufacturer and types of vaping products, whether any of them are products that would fall within the FDA's regulatory authority, as well as where they were obtained.

FDA Actions
Former Acting FDA Commissioner Ned Sharpless, M.D. takes a tour of the FDA's Forensic Chemistry Center. The Center serves as the FDA's premier national laboratory and is playing a critical role in fact-gathering and analysis for the ongoing incidents of lung illnesses following vaping product use.

The FDA remains deeply concerned about these respiratory illnesses and deaths and is working closely with the CDC, as well as state and local public health partners, to investigate them as quickly as possible.

To help gather and analyze as much information as possible, the FDA's laboratory is working closely with our federal and state partners to identify the products or substances that may be causing the illnesses.

The FDA is analyzing samples submitted by a number of states for the presence of a broad range of chemicals, including nicotine, THC and other cannabinoids, along with cutting agents/diluents and other additives, pesticides, opioids, poisons, heavy metals and toxins.

No one substance has been identified in all of the samples tested. Importantly, identifying any compounds that are present in the samples will be one piece of the puzzle but will not necessarily answer questions about what is causing these illnesses.

Federal and state partners are following any potential leads, and the FDA is committed to taking appropriate actions as the facts emerge and keeping the public informed as we have more information to share.

FDA Preliminary Lab Analysis

To date, the FDA has received over 1,300 samples from 31 states and one territory with roughly 1,090 of these samples connected to patients. These samples have been collected directly from consumers, hospitals, and state offices. They have included vaping devices and products containing varied levels of liquid as well as packaging and other documentation. Many samples have contained little to no liquid, which limits the number and types of tests that can be conducted on each submission. The FDA has not found one product or substance that is involved in all of the cases; however, we do know that THC is present in most of the samples being tested. The following is a snapshot of lab activities most relevant to the samples containing THC, as of the date noted.

As of Feb. 12, 2020, 843 of the 1,090 samples connected to patients (77%) have undergone some level of testing and additional testing is likely to be conducted on many of these products.
511 of these samples have been found to contain THC

50% of the THC products have been found to contain vitamin E acetate as a diluent. The concentration of vitamin E acetate determined in a subset of these samples has ranged from 23% to 88%

29% of the THC products have been found to contain another diluent such as medium chain triglycerides

The FDA labs are also doing work to focus on connecting the analysis of samples to particular patients with assigned CDC case numbers. As of Feb 12, 2020, approximately 677 samples are directly linked to 95 patients with CDC case numbers and samples from 93 of these patients have been analyzed.
73% of these 93 patients were connected to products containing THC.
Of these:

81% of cases included products with vitamin E acetate as a diluent

32% included products with aliphatic esters as diluent (e.g., triglycerides)

9% included products with polyethylene glycol as diluent

It is important to stress that identifying any compounds present in the samples linked to patient cases is but one piece of the puzzle and will not necessarily answer questions about causality, which makes ongoing work critical at both the state and federal levels. Every day the FDA and partners are gathering more information and seek to use that information to better understand the relationship between any specific products or substances and the reported illnesses. Importantly, the variations of use patterns, products or substances reportedly used and the samples being tested may mean there are multiple causes of these injuries.

Information & Resources for Consumers

CDC, FDA, and state health authorities have made progress in identifying substances of concern in e-cigarette, or vaping, product use-associated lung injury (EVALI), and in characterizing the outbreak.

National emergency department data and active case reporting from state health departments around the country show a sharp rise in symptoms or cases of EVALI in June 2019, a peak in September 2019, and a gradual, but persistent decline since then.

Although cases related to the outbreak are decreasing, new cases continue to be reported to CDC by state health departments and samples connected to EVALI patients continue to be tested by both CDC and FDA.

National and state data from patient reports and product sample testing suggest THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, or family, or in-person or online dealers, are linked to most EVALI cases and play a major role in the outbreak.

Vitamin E acetate is strongly linked to the EVALI outbreak. Vitamin E acetate has been found in product samples tested by FDA and state laboratory and in patient lung fluid samples tested by CDC from geographically diverse states. Vitamin E acetate has not been found in the lung fluid of people that do not have EVALI.

However, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases.

FDA and CDC recommend that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, or family, or in-person or online dealers.

Vitamin E acetate should not be added to any e-cigarette, or vaping, products. Additionally, people should not add any other substances not intended by the manufacturer to products, including products purchased through retail establishments.

Adults using nicotine-containing e-cigarette or vaping products as an alternative to cigarettes should not go back to smoking; they should weigh all available information and consider using FDA-approved smoking cessation medications. They should contact their healthcare professional if they need help quitting tobacco products, including e-cigarettes, as well as if they have concerns about EVALI.

E-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products.

THC use has been associated with a wide range of health effects, particularly with prolonged frequent use. The best way to avoid potentially harmful effects is to not use THC-containing e-cigarette, or vaping, products.

Persons engaging in ongoing cannabis use that leads to significant impairment or distress should seek evidence-based treatment by a health care professional.

If you are concerned about your health after using a vaping product, contact your health care provider, or you can also call your local poison control center at 1-800-222-1222 .

If you experience vaping-associated respiratory illness, the FDA also encourages you to report this information, including providing any associated product, to your state or local health departments. Reporting to your state or health departments is crucial as federal and state partners work together to have accurate case identification and reported case counts. For more information regarding state and local health department directories, please refer to:
https://www.cdc.gov/publichealthgateway/healthdirectories/index.html

If you experience a problem with any tobacco product, such as an unexpected health or safety issue, report it online using the Safety Reporting Portal. You may submit reports about any tobacco product, including cigarettes, roll-your-own cigarettes, cigars, smokeless tobacco, electronic cigarettes and waterpipe tobacco. You can also report problems with the components and parts of tobacco products. The FDA website has more information on what to include in a report.

Information for Healthcare Providers

As this investigation continues, CDC and the FDA encourage clinicians to report possible cases of vaping-associated respiratory illness to their local or state health department for further investigation. Reporting to your state or health departments is crucial as federal and state partners work together to have accurate case identification and reported case counts.

If vaping product use is suspected as a possible cause for a patient's lung illness, a detailed history of the substances used, the sources, and the devices used should be obtained, as outlined in the CDC Health Advisory, and efforts should be made to determine if any remaining product, devices, and liquids are available for testing. Health care providers also can contact their local poison control center.

Product-specific information related to possible cases may be submitted to the FDA online using the Safety Reporting Portal. The FDA website also has more information on what to include in a report to the SRP.

Information for State Health Departments

FDA would like to thank all State Departments of Health (and other partners) for their ongoing efforts, collaboration and communications on the recent respiratory illnesses associated with e-cigarettes and vaping products.

CDC and FDA are working together to coordinate analysis of e-cigarette, or vaping, products to provide insight into the nature of the chemical exposure(s) contributing to the lung injury outbreak.

As of Dec. 19, 2019, CDC and FDA are accepting case-associated product samples for aerosol or e-liquid testing if corresponding bronchoalveolar lavage (BAL) fluid samples are submitted to CDC (samples do not need to be submitted at the same time to meet this requirement). CDC and FDA will no longer be accepting isolated case-associated product samples.
In EVALI-related death cases, CDC and FDA will continue to accept product samples for testing even if no BAL fluid sample is available for testing.

This change does not mean that the investigation has concluded. The extensive product testing conducted by both FDA and CDC to date has provided critical information regarding potential chemicals of concern. At this time, additional focused testing is needed for paired specimen testing (i.e., both product and BAL fluid samples) in order to continue to further inform the investigation.

Additionally, CDC and FDA are streamlining the sample collection process to reduce the burden on state partners. All product samples and corresponding BAL fluid samples will be submitted to CDC. CDC and FDA will coordinate sample testing and transfer to testing laboratories as appropriate.

CDC will conduct aerosol emissions testing of e-cigarette, or vaping, products. FDA is analyzing e-liquids for the presence of a broad range of chemicals. Analysis of both aerosol emissions and e-liquids will complement each other, and together will help improve our understanding of exposures among case patients associated with the lung injury outbreak.

The graphic below outlines the process for states to submit product samples to CDC for routing and testing in coordination with FDA. Upon receipt of product samples, CDC will determine whether sufficient liquid product is available to perform aerosol and e-liquid analysis and coordinate testing with FDA.

For information about collection and submission of e-cigarette or other vaping products, including e-liquids, associated with confirmed or probable cases for possible testing by FDA, contact: FDAVapingSampleInquiries@fda.hhs.gov.

For information about collection and submission of e-cigarette or other vaping products' e-liquids associated with confirmed or probable cases for possible aerosol emissions testing by CDC, contact IncidentResponse@cdc.gov.

FDA Resources

CDC Resources

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Respiratory Illnesses Associated with Use of Vaping Products

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FDA is seeking unpublished data and information related to the use of vaping products associated with recent lung injuries. FDA is seeking information on product design and potential ways to prevent consumers from modifying or adding substances to these products that are not intended by the manufacturers.

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This article from the CDC goes in depth about lung injury associated to the use of E-cigarettes and vaping products.

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Centers for Disease Control and Prevention

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CDC, the U.S. Food and Drug Administration (FDA), state and local health departments, and other clinical and public health partners are continuing to monitor e-cigarette, or vaping, product use-associated lung injury (EVALI).

Updated February 25, 2020, at 1:00 PM EST

Emergency department (ED) visits related to e-cigarette, or vaping, products continue to decline, after sharply increasing in August 2019 and peaking in September.

National and state data from patient reports and product sample testing show tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers, are linked to most EVALI cases and play a major role in the outbreak.

Vitamin E acetate is strongly linked to the EVALI outbreak. Vitamin E acetate has been found in product samples tested by FDA and state laboratories and in patient lung fluid samples tested by CDC from geographically diverse states. Vitamin E acetate has not been found in the lung fluid of people that do not have EVALI.

Evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases.

CDC will continue to update guidance related to EVALI as appropriate.

About the Outbreak:

As of February 18, 2020, a total of 2,807 hospitalized EVALI cases or deaths have been reported to CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands).

Emergency department (ED) visits related to e-cigarette, or vaping, products continue to decline, after sharply increasing in August 2019 and peaking in September.

National ED data and active case reporting from state health departments around the country show a sharp rise in symptoms or cases of EVALI in August 2019, a peak in September 2019, and a gradual, but persistent decline since then.

Reasons for the decline are likely multifactorial and may be related to the following:

Increased public awareness of the risk associated with THC-containing e-cigarette, or vaping, product use as a result of the rapid public health response.

Removal of vitamin E acetate from some products.

Law enforcement actions related to illicit products.

Laboratory data show that vitamin E acetate, an additive in some THC-containing e-cigarette, or vaping, products, is strongly linked to the EVALI outbreak.

A recent study analyzed samples from 51 EVALI cases from 16 states and a comparison group of samples from 99 comparison individuals without EVALI for vitamin E acetate, plant oils, medium chain triglyceride (MCT) oil, coconut oil, petroleum distillates, and diluent terpenes.

Vitamin E acetate was identified in bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs) from 48 of the 51 EVALI patients, but not in the BAL fluid from the healthy comparison group.

No other toxicants were found in BAL fluid from either group, except for coconut oil and limonene (1 EVALI patient each).

In August 2019, CDC started collecting data from states on EVALI cases using a standardized case report form. The data were voluntarily collected and submitted by each state to CDC on a routine basis. Due to the subsequent identification of the primary cause of EVALI, and the considerable decline in EVALI cases and deaths since a peak in September 2019, CDC stopped collecting these data from states as of February 2020.

However, CDC continues to monitor EVALI-related trends using emergency department data from the National Syndromic Surveillance Program's BioSense/ESSENCE platform. These data do not suggest a resurgence of EVALI at this time.

CDC encourages clinicians to continue to report possible cases of EVALI to their local or state health department for further investigation.

CDC will continue to provide assistance to states, as needed, related to EVALI and will provide any updates at: www.cdc.gov/EVALI.

CDC and FDA recommend that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers.

Vitamin E acetate should not be added to any e-cigarette, or vaping, products. Additionally, people should not add any other substances not intended by the manufacturer to products, including products purchased through retail establishments.

Adults using nicotine-containing e-cigarette, or vaping, products as an alternative to cigarettes should not go back to smoking; they should weigh all available information and consider using FDA-approved smoking cessation medications. If they choose to use e-cigarettes as an alternative to cigarettes, they should completely switch from cigarettes to e-cigarettes and not partake in an extended period of dual use of both products that delays quitting smoking completely. They should contact their healthcare professional if they need help quitting tobacco products, including e-cigarettes, as well as if they have concerns about EVALI.

E-cigarette, or vaping, products (nicotine- or THC-containing) should never be used by youths, young adults, or women who are pregnant.

Adults who do not currently use tobacco products should not start using e-cigarette, or vaping, products.

THC use has been associated with a wide range of health effects, particularly with prolonged frequent use. The best way to avoid potentially harmful effects is to not use THC-containing e-cigarette, or vaping, products.

Persons engaging in ongoing cannabis use that leads to significant impairment or distress should seek evidence-based treatment by a healthcare professional.

Key Facts about Use of E-Cigarette, or Vaping, Products

Electronic cigarettes-or e-cigarettes-are also called vapes, e-hookahs, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS).

Using an e-cigarette is commonly called vaping.

E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs.

The liquid can contain: nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances, flavorings, and additives. THC is the psychoactive mind-altering compound of marijuana that produces the "high."

Key Facts about Vitamin E Acetate

Vitamin E acetate is used as an additive, most notably in THC-containing e-cigarette, or vaping, products.

Vitamin E is a vitamin found in many foods, including vegetable oils, cereals, meat, fruits, and vegetables. It is also available as a dietary supplement and in many cosmetic products, like skin creams.

Vitamin E acetate usually does not cause harm when ingested as a vitamin supplement or applied to the skin. However, previous research suggests that when vitamin E acetate is inhaled, it may interfere with normal lung functioning.

If you have questions about CDC's investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact CDC-INFO or call 1-800-232-4636 .

As of December 3, 2019, CDC is only reporting hospitalized EVALI cases and EVALI deaths regardless of hospitalization status. CDC has removed nonhospitalized cases from previously reported case counts. See Public Health Reporting for more information.

As of February 18, 2020, a total of 2,807 hospitalized e-cigarette, or vaping, product use-associated lung injury (EVALI) cases or deaths have been reported to CDC from 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands).

Sixty-eight deaths have been confirmed in 29 states and the District of Columbia (as of February 18, 2020):

Alabama, California (4), Connecticut, Delaware, District of Columbia, Florida (2), Georgia (6), Illinois (5), Indiana (6), Kansas (2), Kentucky, Louisiana (2), Massachusetts (5), Michigan (3), Minnesota (3), Mississippi, Missouri (2), Montana, Nebraska, New Jersey, New York (4), Oregon (2), Pennsylvania, Rhode Island, South Carolina, Tennessee (2), Texas (4), Utah, Virginia and Washington (2).

The median age of deceased patients was 49.5 years and ranged from 15-75 years (as of February 18, 2020).

Among the 2,668 hospitalized EVALI cases or deaths reported to CDC (as of January 14, 2020):

66% were male

The median age of patients was 24 years and ranged from 13-85 years.

By age group category:

15% of patients were under 18 years old;

37% of patients were 18 to 24 years old;

24% of patients were 25 to 34 years old; and

24% of patients were 35 years or older.

2,022 hospitalized patients had data on substance use, of whom (as of January 14, 2020):

82% reported using THC-containing products; 33% reported exclusive use of THC-containing products.

57% reported using nicotine-containing products; 14% reported exclusive use of nicotine-containing products.

50% of EVALI patients who reported using THC-containing products provided data on product source (as of January 7, 2020):

16% reported acquiring products only from commercial sources (recreational and/or medical dispensaries, vape or smoke shops, stores, and pop-up shops).

78% reported acquiring products only from informal sources (family/friends, dealers, online, or other sources).

6% reported acquiring products from both commercial and informal sources.

54% of EVALI patients who reported using nicotine-containing products provided data on product source (as of January 7, 2020):

69% reported acquiring products only from commercial sources.

17% reported acquiring products only from informal sources.

15% reported acquiring products from both commercial and informal sources.

Number of Hospitalized EVALI Cases or Deaths Reported to CDC as of February 18, 2020

Dates of symptom onset and hospital admission for patients with lung injury associated with e-cigarette use, or vaping - United States, March 31, 2019-February 15, 2020

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Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products

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CDC is investigating an outbreak of e-cigarette, or vaping, product use associated lung injury (EVALI). Learn CDC's recommendations, and the latest outbreak information.

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ABC News on life threatening vape incident

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ABC News on life threatening vape incident

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This news article gives a look into a real life teen who was put on life support due to using vape products.

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Though she might not look like it today, Simah Herman said she was sure she was going to die last month as she sat in the car unable to breathe, her father racing her to the hospital.

"I just remember feeling like absolute...nothing. Like I just couldn't do anything," Herman, 18, said. "I couldn't drink water. I couldn't move. Like, I literally just wanted to crawl out of my skin."

The doctors looking after Herman at Los Angeles' Ronald Reagan UCLA Medical Center were also stumped. On that day, Aug. 15, a chest X-ray showed white hazy areas at the bottom of her lungs, which her pulmonologist, Dr. Kathryn Melamed, said could potentially be pneumonia. Less than 48 hours later, chest X-rays showed that her lungs were filled with white - they were inflamed and full of fluid, Melamed said.

"My best guess since we're still learning about what is really going on in the lungs is [it's a] profound inflammatory reaction to the vape products or some...component of the vape products," Melamed told ABC News' Adrienne Bankert for "Nightline."

Still unable to breathe after two days, Herman had to be put on a ventilator, and shortly afterward, a medically induced coma. It was while she was in the coma that her cousin revealed a secret that Simah had been keeping from her parents that helped lead to some answers.

"She said, 'You know she smokes every day?'" said Stacy Herman, Simah Herman's mother. "I said, 'What? What are you talking about?' And she said, 'She smokes every day. She smokes that vape.' I said, 'You tell the doctors right now. You go tell the doctors right now.'"

By the time that Simah Herman had emerged from her coma, she had been in the hospital for five days. With a ventilator still pumping oxygen into her failing lungs, the teen who said she would vape every 10 to 15 minutes decided to become an advocate against vaping.

"I asked for, like, a pen and paper because that was the only way I could communicate," Simah Herman said. "And I wrote, 'I want to start a no-vaping campaign.' That was the first thing I did when I opened my eyes."

Simah Herman's story is one of the latest in a string of cases of serious - sometimes even life-threatening - illnesses linked to vaping.

As of Sept. 10, there have been six confirmed deaths and over 450 possible cases of lung illness in 33 states associated with e-cigarette products, according to the Centers for Disease Control and Prevention (CDC), which noted that in addition to nicotine, patients also reported using e-cigarette products with liquids containing cannabinoids like THC, the active compound in marijuana.

Many of the cases involve teens. Just last month, 17-year-old Trystan Zohfeld spent 18 days in the hospital after suffering from a vaping-related illness, during which he said he was "throwing up everywhere." On Monday night, a Texas high schooler was also rushed to the hospital after vaping.

Melomed is one of countless health officials who fear that vaping-related illnesses are an emerging crisis. Among high school students, there was a 78% increase in e-cigarette use between 2017 and 2018, according to the Food and Drug Administration's (FDA) National Youth Tobacco Survey.

Simah Herman said she first started vaping at age 15, and that she'd buy the cartridges from a smoke shop despite being a minor.

"I went in and I was like, 'Can I get a pack of Juul pods?' And they were like, 'How old are you?' And I said, '22,' and they were just like, 'OK,'" Simah Herman said.

Just this week, the FDA sent a warning letter to Juul, the industry leader for vape products, accusing it of illegally marketing its nicotine vape products as safer than traditional cigarettes without proof.

In a statement to ABC News, Juul said it was reviewing the FDA letter and that it would "fully cooperate."

"We share these concerns about youth vaping, which is why we have taken the most aggressive actions of anyone in the industry to combat youth usage," Juul said. "We strongly advocate for Tobacco 21 legislation, we stopped the sale of non-tobacco and non-menthol-based flavored JUULpods to our traditional retail store partners, enhanced our online age-verification process, strengthened our retailer compliance program with over 2,000 secret shopper visits per month and shut down our Facebook and Instagram accounts while working constantly to remove inappropriate social media content generated by others on those platforms.

"Most recently, we announced the deployment of technology at retail stores that automatically restricts the sale of JUUL products until a government-issued ID is electronically scanned to verify age and ID validity," the company continued. "This technology also limits the amount of JUUL products that can be purchased to prevent reselling or sharing to those underage, and it will soon be mandatory for all JUUL product sales across the country."

Simah Herman was healthy and active when she first started vaping. She had been a dancer for years, even making the dance team during her freshman year of college. But she said her abilities started to diminish as her vaping habit increased and she began vaping cannabis as well.

Eventually, she was vaping a nicotine cartridge a day, with the total amount of nicotine in one cartridge the same as that in a pack of cigarettes.

"I didn't think of myself as a smoker. Like, it's just a different kind of smoke," Simah Herman said. "The vaping just makes it seem like nothing. Like you're doing nothing wrong."

In the two years that she had been vaping, Simah Herman said she lost 50 pounds "without trying" because she felt sick all the time. She said she often felt nauseous and dizzy, too, and that she didn't notice how her appearance had changed.

As her health issues worsened, she also stopped going to classes. Doctors, meanwhile, weren't able to offer any solid answers, even though she would tell them that she vaped, she said.

"I told every doctor that I went to just because I had such severe issues," she said. "I wanted to make sure that...wasn't making anything worse, but no doctor ever said, like, 'Maybe you should stop vaping.'"

Melamed said there is a lot that's still unknown about the consequences of vaping. "We don't know which components - if it's a certain component or certain product [or] certain brand that is responsible for both the short- and long-term effects of vaping," she said.

Stacy Herman, however, believes the whole industry - not just Juul - markets to minors purposely. After she discovered that her daughter was hiding her vape addiction, she said she "ransacked her room" and "found all the vapes."

"The fact that they market this crap to children, and they turn it into pink, pretty purple packaging [kind of] pisses me off," Stacy Herman said. "I'm so angry that [Simah] can get a hold of this thinking it's nothing wrong with it because everyone's doing it. ... It looks and smells like mango, and it looks and smells like bubblegum and her room smells delicious. I smell[ed] the packages. They smell great."

Although Simah Herman has stopped vaping, she said she still feels compelled to pick one up.

"Now I don't necessarily crave the nicotine. I don't necessarily crave the weed. It's just craving, like, the act of smoking," she said. "So that's been the hardest thing...staying away from it."

Hoping that her story going public will help to discourage e-cigarette use, she said that she'd tell teens who want to try vaping that she once wanted to try it just once, too.

But then "I tried it another time and then another time. It's just remembering that you don't need it. Like, it's going to kill you."

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centers for disease control and prevention

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Teen who was put on life-support for vaping says 'I didn't think of myself as a smoker'

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Though she might not look like it today, Simah Herman said she was sure she was going to die last month as she sat in the car unable to breathe, her father racing her to the hospital. "I just remember feeling like absolute...nothing. Like I just couldn't do anything," Herman, 18, said.

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Global Organization End Vaping- Working To End the Teen Vaping Epidemic. This website gives resources to receive help on ending the vape addiction.

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A variety of advocacy groups on the state, national and global level aim to inform the public about tobacco products, e-cigarettes, and vaping. Whether you're the parent of a young person who vapes, an engaged community member, or someone trying to quit, these organizations may offer the support and facts you need.

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A variety of advocacy groups on the state, national and global level aim to inform the public about tobacco products, e-cigarettes, and vaping. Whether you're the parent of a young person who vapes, an engaged community member, or someone trying to quit, these organizations may offer the support and facts you need.

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Northwestern Medicine explains lung illness related to vaping

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Northwestern Medicine explains lung illness related to vaping

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This video talks about the affects of vaping on an individuals lungs.

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When Smoke Means Fire | Symptoms of a Disturbing Lung Illness No One Should Ignore