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Everything you ever wanted to know about the vaping health crisis

Wait, which one?

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Illustration by Alex Castro / The Verge

The past year has seen a skyrocketing rate of teen vaping, an outbreak of lung injuries, some serious regulatory shake-ups in the e-cigarette industry, and a whole lot of panic. With so many different vaping crises going on right now, we thought we’d provide a vaping roundup.

This post will be updated as new information emerges. 

I keep hearing about illnesses and injuries. What’s going on with vaping right now? 

In the United States, regulatory and public health agencies are looking into these three different public health-related problems: 

  • Exploding e-cigarettes
  • Seizures
  • Lung injuries

Did you say exploding e-cigarettes? 

Exploding e-cigarettes have shattered peoples’ jaws (warning: there’s a graphic picture in that linked story) and even killed people. There’s no single identified cause of these explosions, but according to the Food and Drug Administration (FDA), they appear to be associated with “battery-related issues.” The FDA even has a list of “Tips to Help Avoid “Vape” Battery Explosions” and asks that people report any e-cigarette explosions to it directly. A study published in the journal Tobacco Control found that emergency rooms saw “an estimated 2035 e-cigarette explosion and burn injuries” from 2015–2017.

the FDA also has other vaping worries on its collective mind

The FDA also has other vaping worries on its collective mind at the moment. 

Like the seizures? 

That’s one of them. As of August 2019, the FDA had received 127 reports of seizures or other neurological symptoms. That’s over the course of about a decade, but it’s still pretty alarming. That investigation kicked off in April 2019, after three cases involving both seizures and Juul use were brought to the attention of the FDA in the fall of 2018. That investigation is still ongoing.

There’s not a ton of data about the seizures, and the FDA isn’t completely sure that e-cigarettes are at the root of the problem. One of the reasons that the FDA is looking into this is that seizures have been linked to nicotine poisoning in the past. They’ll still need a lot more data before they can definitively draw a link between the two.     

But the seizures and explosions aren’t related to the terrifying cases of lung injuries I’ve been seeing this summer, right?

“these numbers may change frequently.”

Right. The lung injuries seem to be a completely different scary thing. So far, the Centers for Disease Control and Prevention (CDC) has identified 2,172 probable cases of these injuries in 49 states, the District of Columbia, and the US Virgin Islands. The only state that has not yet reported a case is Alaska. As the CDC notes, “these numbers may change frequently.” Authorities are still gathering information, but based on early data, patients with the condition seem to be overwhelmingly male (around 70 percent) with 79 percent of patients under age 35. 

On October 4th, the FDA warned consumers not to use THC vapes. As of November 13th, 2019, 42 people have died of these injuries.

Image: CDC

Wait, you keep saying “injuries,” but I remember hearing about this as a disease or illness. Are those different things? 

No, those things are the same. There was just some confusion at first about what was going on, which led to some imprecision with language. The CDC did refer to the condition as a disease early on, but it quickly ruled out infectious diseases like viruses or bacterial infections. It kept referring to it as a disease or illness until recently. “We’re calling it lung injury associated with e-cigarettes or vaping,” Anne Schuchat, principal deputy director of the CDC, said in a congressional hearing, acknowledging that “it’s not particularly catchy.” 

“It’s not particularly catchy.” 

During a press call on October 25th, Schuchat said that they were now calling the injury EVALI, an acronym for “e-cigarette, or vaping, product use associated lung injury.” It’s still not particularly catchy, but slightly better than the longer version.

The CDC is saying “injury” because “it really does look like an injury, not a long-term disease like emphysema,” Schuchat explained. Though there may be long-term consequences from the injuries, she notes. Right now, it’s too early to tell.  

House Oversight and Reform Committee Holds Hearing On Outbreak Of Lung Disease Associated With Vaping
Dr. Anne Schuchat, principal deputy secretary of the Centers for Disease Control and Prevention, at a congressional hearing on vaping.
Photo by Mark Wilson / Getty Images

What are the symptoms of the lung injuries?   

Symptoms could include a cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fatigue, fever, or abdominal pain, according to the CDC. Some people developed the symptoms suddenly, over a few days, while with others it was a slow buildup over a few weeks. 

Do we know why this lung injury outbreak is happening? Is it THC?

All the cases involve e-cigarettes, but beyond that, investigators don’t know much. The FDA has gotten nervous enough about THC vapes to warn consumers not to use them at all, and to avoid any nicotine vapes they might get on the street.

Counterfeit products are common, making life difficult for people buying THC cartridges who might think they’re getting a brand typically sold in places where THC is legal. The decentralized market also adds another hurdle to an already complicated and sprawling investigation.

The CDC says that most patients — 86 percent — had a history of either using e-cigarette products containing tetrahydrocannabinol, aka THC, or using both THC and nicotine. But products containing THC (the chemical in weed that makes you high) aren’t the sole focus of the investigation. As of October 15th, about 11 percent of patients reportedly limited their e-cigarette use to nicotine products only. 

“Remember that these are self reports, so it’s the person saying, ‘I only use the nicotine containing product’” Mitch Zeller, director of the Center for Tobacco Products at the FDA said in a press call on October 25th. Zeller said that there may be some question as to whether what patients are reporting is actually the case, “especially if that report is coming from a teen, or someone living in a state where the use of any of the potential compounds is illegal,” Zeller said.

The scale of the problem becomes visible when you take a look at the investigation in Wisconsin and Illinois. Investigators there talked to 86 patients and identified 234 different products and 87 different brands that the group had used before getting ill. One brand name, Dank Vapes, had been used by 57 patients. But researchers found that the label didn’t mean much. The CDC found that the Dank Vapes packaging is easily found online, and production is not centralized at all. It’s mostly a marketing tool for people manufacturing and selling THC vape cartridges. 

Dank Vapes packaging is easily found online, and production is not centralized at all

“We don’t have full data yet,” Schuchat said at the hearing. Investigators at the FDA are trying to test many substances that could potentially be linked to those hundreds of cases. But actually gathering the evidence isn’t easy. For one thing, the cases are spread across nearly the entire country, meaning that coordinators are dealing with dozens of different health organizations and jurisdictions. Not to mention, Schuchat explained, in many instances, there might not be much of the substance left — if it’s still available at all. People could have thrown it out or used up the entire pod before they got sick. 

Products involved in the New York investigation in to vaping-related lung injuries.
Products involved in the New York investigation in to vaping-related lung injuries.
Photo by Mike Wren / NYS Department of Health

Then there’s the fact that the chemicals that you put into an e-cigarette might change as you heat it. That means investigators need to test the chemical suspects under a lot of different conditions to get an accurate picture of how they might affect the lungs. “There are sophisticated studies going on to try to analyze both the product and potentially the vapor or aerosol as well,” Schuchat said.

One chemical, vitamin E acetate, was identified as a key focus of an investigation in New York where researchers found that it could coat the insides of lungs like grease, potentially damaging them. The CDC announced a breakthrough in early November when it found vitamin E acetate in lung fluid taken from 29 patients with the lung injury across 10 states. The substance is now considered to be a “chemical of concern” by the CDC.

But vitamin E acetate has not been found in all samples that the FDA is examining. A different study, published in the New England Journal of Medicine found that injuries in several cases were more like chemical burns than the injuries linked to vitamin E acetate. Both federal agencies continue to cast a wide net as the investigation continues.  

What about the youth vaping epidemic that all of the politicians are talking about? 

Way before the first cases of lung injuries were reported, kids vaping was the big health concern across the country, especially after the US surgeon general declared it to be an epidemic in November.  

Last year’s data showed a spike in youth vaping, with 3.6 million kids having used e-cigarettes. There has been a similar rise in 2019’s data, with one in four high school students reporting e-cigarette use. In 2018, the surgeon general specifically called out Juul, mentioning the products’ high nicotine content as a worry. Young people who tried products with high concentrations of nicotine were more likely to keep smoking and vaping later, too. 

kids vaping was the big health concern across the country

Juul uses nicotine salts in its products, which give a more pleasant feeling than freebase nicotine and helps account for its popularity.   

Anecdotally, it seems like Juul’s popularity is waning — at least on social media where people are publicly posting about trying to quit Juul. As The Verge’s Ashley Carman has reported, some people have taken extreme measures, throwing their Juuls out windows or turning to sugar snap peas to fend off the cravings.

So what are people doing about it? 

There’s almost as much going on in the regulatory space as there is in the health space. Concerned by the rise in youth vaping, lawmakers have tried to write laws restricting flavored vapes since last year. That push didn’t really take off until the summer of 2019 when states, including Michigan and New York, announced bans on flavored vapes.  

President Trump even called for the FDA to ban flavored e-cigarettes entirely. The FDA announced more limited age restrictions related to flavors last year, but the proposed ban is expected to go further.   

Then there’s the lung injury outbreak. In the wake of that, a few states decided to either temporarily ban all e-cigarettes (Massachusetts) or target counterfeit and black market products (California). As the case count rose, companies like Walmart decided to stop selling e-cigarettes, and major media companies decided to stop showing ads relating to e-cigarettes. On November 15th, Apple announced that it was removing all vaping-related apps from its App Store.  

Juul, which is a dominant player in the industry in the US, announced on September 25th that it would stop advertising in the US and that it would not fight the FDA’s latest effort to regulate the industry. The company is facing several open investigations and lawsuits into its marketing practices.

As Vaping Became Widespread With Little Known About Health Effects, US Gov. Delayed Key Regulations
Pediatricians hold vaping products in a bag outside the Massachusetts State House. The doctors were asking legislators to increase regulations.
Photo by David L. Ryan / The Boston Globe via Getty Images

Will vaping bans actually work? 

It depends on what you want them to do. If you want to cut down on youth vaping and plan to ban flavors, that might work. But it probably won’t help with the lung injuries. It could also backfire and end up being a boon for traditional cigarette companies. And banning e-cigarettes entirely in an effort to crack down on the injuries... well, we still don’t know what that might do, in part because we know so little about the injuries. 

No ban will be perfect. Makers are going to keep right on DIYing their own vaping liquids. Teens will keep finding ways to get their fix, like they did earlier this year when a round of age restrictions sent them to eBay and Alibaba to buy knock-off pods, vapes, and cigarettes.

No ban will be perfect

That doesn’t mean regulations are worthless. But it does mean that regulators are in a research arms race to figure out what might actually be the best way to reduce the harms caused by vaping. 

“We need to jump-start the research necessary to guide regulation in the future,” Thomas Eissenberg, co-director of the Center for the Study of Tobacco Products at Virginia Commonwealth University, told The Verge in September. “I think a valuable side effect of a very unfortunate cluster of disease is that more attention and resources will be put behind the work.”

Is vaping safe? 

Really, “safe” is way too imprecise to cover all the possible e-cigarettes, vape pens, liquids, juice, pods, mods, and other stuff on the market, not to mention the vast demographic diversity of people who might be vaping. The CDC’s website points out that while e-cigarettes are considered to be less harmful than regular cigarettes, “that doesn’t mean e-cigarettes are safe.”

Researchers have learned a few things over the years. Vaping at high voltages can release formaldehyde-causing chemicals. It could increase your risk of heart disease. That being said, it’s probably better than smoking. Then again, even though it may be less terrible than cigarettes, vaping does expose you to more toxic chemicals and heavy metals than if you didn’t vape at all. Oh, and many e-cigarette products still contain nicotine, which is still addictive

vaping might be safer than some choices you can make, it’s definitely worse than others, but beyond that, it’s still a crapshoot

The industry is moving so quickly that by the time studies come out, they might not even be applicable to what’s popular now, and long-term effects are really difficult to judge. Bottom line: vaping might be safer than some choices you can make, it’s definitely worse than others, and beyond that, it’s still a crapshoot when it comes to health risks. 

The CDC says that youth, young adults, and pregnant people should not use e-cigarettes, period. It recommends that people “consider refraining from using e-cigarette or vaping products” while the lung injury investigation is ongoing, “particularly those containing THC.” If you don’t currently vape, it also gently suggests that this isn’t the time to pick it up. However, it also says that people using e-cigarettes to move away from traditional cigarettes should not go back to smoking. 

Unsurprisingly, the American Lung Association has one of the most definitive statements out there. “E-cigarettes are not safe and can cause irreversible lung damage and lung disease,” ALA president Harold Wimmer said in a statement. “No one should use e-cigarettes or any other tobacco product.”

Though there may be long-term consequences from these lung injuries, Schuchat notes, right now, it’s too early to tell.