COLUMBUS, Ohio - Cough, shortness of breath and fatigue can be the first symptoms in people who have been hospitalized with severe lung damage likely due to vaping.

All the patients have a history of vaping, but doctors can't find any infections. Therefore, public health officials suspect the cause of the illnesses is chemical exposure, likely due to their e-cigarette use.

But what exactly is that chemical? Does it come from vaping nicotine or THC, the active ingredient in marijuana? What about flavors?

Details seem as clear the clouds that vapers create. But some information has been gleaned by public health officials. Read on for more.

A: A review of cases in Wisconsin and Illinois was published in the New England Journal of Medicine. It found people who became sick reported vaping nicotine, THC and cannabidiol or CBD products. CBD is an ingredient in marijuana and hemp that doesn't produce a high but is thought to have medicinal benefits.

“It doesn’t mean nicotine is safe, but a lot of these patients vaping THC is a concern,” said Joanna Tsai, a physician and researcher who studies vaping at Ohio State University.

James Jarvis, president of the Ohio Vapor Trade Association, a vaping industry trade group, notes that the research is based on patients reporting what they vaped.

That may not reflect what the patients actually vaped, said Jarvis, who believes there is an overreaction to the illnesses and that the nicotine vaping shops his group represents don't sell harmful products.

A: Michigan and New York have banned flavored vaping products. The Trump administration is working on curtailing flavors. And other states are also considering flavor bans, including in Ohio.

Gov. Mike DeWine's team is looking into whether he has the authority to ban flavored products. In the General Assembly, House Bill 346 would ban flavors except for tobacco.

With flavors such as cotton candy and bubble gum, conventional thinking is that vaping companies use them to market their products to young people.

From 2017 to 2018, daily e-cigarette use among high schoolers increased from 11.7 percent to 20.8 percent, according to federal research.

That's a national average. There aren't yet numbers for Ohio, although the median age of people who have been hospitalized in the state with vaping-related illnesses is 21, according to the Ohio Department of Health.

In 2015, Harvard University researchers found flavoring chemical diacetyl in more than 75% of nicotine e-cigs and refill liquids. That chemical has been associated with a respiratory illness commonly called "popcorn lung," because it first appeared in workers who inhaled artificial butter flavor in microwave popcorn processing facilities.

Additionally, flavor bans will reduce the number of number of chemicals in vape juice, which may be useful as researchers determine what exact chemicals are causing the sickness, said Scott Perlmuter, a Cleveland attorney who has represented clients in vaping lawsuits.

“The science is so incomplete on this, the danger of e-cigarettes," he said. "So there are suspicions that will probably bear out in 10 years as to why people are having lung injuries."

A: The New York State Department of Heath has found vitamin E acetate in samples of THC vaping oils that it has tested, believed to have been used as a cutting agent because it is cheaper than cannabis oil and has a similar viscosity. In Utah, 90 percent of THC vaping cartridges provided by sick patients had vitamin E oil, according to the Utah Department of Health. 

“The lung is really kind of designed to be breathing air, we’re not supposed to be breathing in chemicals, oils or flavors,” said Tsai, the OSU physician.

"All vitamins at really high levels can be toxic," he said. "Vitamin E is just like anything else. If you have too high of levels of ingestion, it can cause injury.”

A: Public health officials are concerned about people becoming sick from THC products purchased on the black market. Patients have reported them going by different names, including the Dank Vape and Chronic Carts labels.

The federal government has opened a criminal investigation into the illnesses and deaths. The Washington Post reported that unfilled vape cartridges manufactured in China are sent to the U.S., looking like legitimate brands. Black market operators purchase the counterfeit "carts" and fill them with THC oil -- mixed with vitamin E acetate and other chemicals to dilute the amount of expensive THC each contains -- and sell them to distributors.

New York health officials have subpoenaed a Santa Monica, California company that sells an additive used in cartridges -- wanting to learn more about the ingredients.

Nonetheless, the Post reported that "no one product or substance, including vitamin E acetate, has been conclusively identified as the cause of the lung injuries" at this point.

A: The federal Centers for Disease Control and Prevention says adults who've used e-cigs to quit smoking should "not return to cigarettes."

"Until we know more, if you are concerned about these specific health risks, CDC recommends that you consider refraining from using e-cigarette or vaping products," it says in a recommendation.

Brad Lander, an OSU psychologist who specializes in addiction medicine, used to tell smokers to switch to e-cigs, believing they could lower their level of nicotine intake over time and they could eventually stop vaping and be off nicotine completely.

Some of e-cigs contain twice the amount of nicotine as a full cigarette, which meant that people continued to be addicted, he said.

"I thought they were mainly inhaling water vapor," he said. "I was basically wrong with that. The things in the fluids are causing a lot of health problems. The actual fluid isn't what we thought it was. Of course, they didn't tell us that."

The vaping industry says e-cigs are an alternative to smoking, though none of its products have received approval by the Food and Drug Administration as cessation devices. 

Yet Jarvis, of the Ohio Vapor Trade Association, noted that two hospitals in the U.K. opened vape shops, after they instituted strict smoking bans that even prohibited cigarette use in people's vehicles.

A. The harmful health effects of smoking have been well-documented over the decades. There just isn't the same amount of vaping research right now.

Tsai, the OSU doctor, said research has shown an increase in blood pressure briefly after using e-cigarettes. Vaping can increase aortic stiffness.

“I do think that if you're looking at the composition of smoke from traditional cigarettes and the e-cig vapors, (vapors have)  less toxic chemicals in comparison," she said. "But at the same time you can’t completely (be sure) that e-cigarettes are safe.”

But vape juice isn't chemical-free, said Ohio Department of Health Director Amy Acton, who is also a physician.

She said e-cigarette aerosols can contain cancer-causing chemicals, heavy metals such as nickel, tin and lead, volatile organic compounds, ultrafine particles that can reach deep into lungs and flavorings such as diacetyl, which has caused popcorn lung.

“What does 'safer than smoking' mean?" asked Case Western Reserve University law professor Katharine Van Tassel, who specializes in U.S. Food and Drug Administration regulation. "Every cigarette has a different formula. You’re inhaling the nicotine but you’re also getting the tar and other ingredients that goes with it. We absolutely cannot say that vaping is safer than smoking because all these formulas have different ingredients.”

“The long-term effects of cigarettes you don’t see until you see a lifetime of exposure," she said. "We won’t know for a long time that vaping nicotine, just itself without all (the extra) ingredients, is safer than smoking nicotine. We just can’t say that.”

A. Jarvis of the Ohio Vapor Trade Association expects many small businesses will shutter if flavors are banned.

He said reputable vaping shops in Ohio and elsewhere have high standards, but will likely be the ones to suffer. Meantime, people will continue to get flavored nicotine and THC products on the black market, he said.

Jarvis said the businesses in his association check IDs to ensure people are old enough to purchase product. Beginning on Oct. 17, the minimum age to purchase tobacco products in Ohio, including vape pens and liquids, increases from 18 to 21.

"If people are waiting in the car, we've gone so far as to look out the window and see younger people and the business is not making that sale," Jarvis said.

“But it’s going to be the small manufacturers, probably through a trade association, who are going to object to this,” she said. “Someone like Juul, the big businesses, they’re going to benefit if the small ones go out of business.”

Juul has announced a corporate shakeup, with a new CEO in K.C. Crosthwaite from the tobacco giant Altria -- who has experience with working closely with regulators, according to the Wall Street Journal. 

The company is also pausing all advertising. However, it has been in trouble with federal regulators in the past over product marketing, Van Tassel said.

"Juul had a warning letter from the FDA because Juul's marketing campaign was talking about how can you switch to a Juul so you can stop using tobacco," she said. "They’re using the language ‘switch’ instead of 'stop.'"

A. Under Ohio's medical marijuana law, cannabis cannot be smoked. It can be vaped. Patients vape plant material or THC oil.

There is no known connection between any of the severe lung illnesses and legal Ohio medical marijuana, said Kelly Whitaker, a spokeswoman for the Ohio Department of Commerce, which is a state marijuana regulator.

State regulations allow additives in vaping oil. Ingredients must be licensed and regulated in compliance with state and federal laws, as well as nontoxic and safe for human consumption, Whitaker said in an email.

"Additionally, characterizing flavors, except those intended to mimic marijuana strains, are prohibited from all products intended for use in the vaporization of medical marijuana," she said.

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