10 things we know about vaping-related lung illnesses

New York: Medical experts and federal health officials have warned the public about the dangers of vaping and discouraged using the devices as the number of people with a severe lung illness linked to vaping more than doubled to 450 possible cases in 33 states and the number of deaths rose to five.

The Indiana Department of Health announced the third death on Friday, and hours later, officials in Minnesota confirmed that a fourth person had died. The Los Angeles County Department of Public Health is investigating a fifth death, and an official said that “vaping is a probable potential cause”.

Two other deaths, one in Illinois, the other in Oregon, had been announced previously.

Amid the surge in cases, physicians and health officials in states with the earliest and largest number of cases published detailed descriptions of the acute lung disorder in people who vape in a series of articles in the New England Journal of Medicine and described the trend as “worrisome”.

“There is clearly an epidemic that begs for an urgent response,” Dr David Christiani of the Harvard T.H. Chan School of Public Health wrote in the New England Journal of Medicine.

Here are 10 things we know so far about the sudden surge in vaping-related lung illnesses:

1. Although federal and state officials said the definitive cause of the illness remains unknown, “the severity of the illness and the recent increase in the incidence of this clinical syndrome indicates that these cases represent a new or newly recognised and worrisome cluster of pulmonary disease related to vaping,” according to health department officials in Wisconsin and Illinois, who conducted a joint investigation of 53 patients.

2. The Centers for Disease Control and Prevention warned that no consistent e-cigarette products have been linked to the disorder, and that while some victims used marijuana-based products, some reported using marijuana and nicotine products, and a smaller group reported using nicotine only. “We are getting a clearer focus, and the investigation is narrowing,” said Ileana Arias, the acting deputy director for non-infectious diseases at CDC.

3. No specific device or substance has been linked to all the cases, officials said. The Food and Drug Administration is analysing samples collected from patients across the country who have fallen ill and is testing them for a broad range of chemicals, including nicotine, THC — the active ingredient in marijuana — and “cutting agents” to dilute solutions and other substances. “We believe chemical exposure is likely associated with the illnesses,” said Dana Meaney-Delman, who is heading CDC’s lung injury response.

4. New York state and FDA labs told officials they found vitamin E acetate, an oil derived from vitamin E, in samples of products collected from patients who had been sickened by vaping. New York state officials have said the oil is a key focus of the state’s investigation. FDA officials have stressed, however, that no one substance, including vitamin E acetate, has been identified in all samples. Identifying compounds in samples won’t necessarily answer questions about causality, they said.

5. Even though the definitive cause remains unknown, the mysterious lung illness is coming into focus as officials and clinicians identified clinical similarities in illnesses among people who use e-cigarettes, or vape. Preliminary reports from clinicians and state health departments in Wisconsin, Illinois, North Carolina and Utah confirm and strengthen patterns that individual doctors treating patients have described.

6. Most patients have been young and healthy. They had similar symptoms, including cough, chest pain or shortness of breath that appeared to take place over several days to several weeks before hospitalisation. All patients reported using e-cigarettes, which officials define as battery-operated devices that heat a liquid and deliver an aerosolised product.

7. Clinicians in Utah and North Carolina said they had identified the presence of abnormal immune cells in the lungs of some patients, which could be a “useful marker” for a diagnosis of a rare form of pneumonia known as lipoid pneumonia. “That can occur when either oils or lipid-containing substances enter the lungs,” said Daniel Fox, a pulmonologist and critical care physician at WakeMed Health and Hospitals in North Carolina. Fox said he had treated five patients, and those cases are being reported by North Carolina’s health department.

8. Health officials have said they are focusing on contaminants and counterfeit substances as a likely cause, narrowing the possible culprits to adulterants in vaping products purported to have THC, although they have not ruled out adulterants in nicotine vaping products. E-cigarette aerosol generally contains fewer toxic chemicals than conventional cigarette smoke, officials have said. But e-cigarette aerosol is not harmless and can expose consumers to substances known to damage health, including ultra-fine particles, heavy metals, volatile organic compounds and other harmful ingredients.

9. Many of the chemicals in e-cigarette liquids may “undergo thermal degradation” when they are heated, producing new compounds with potentially harmful consequences. “Alone or in combination, these substances could result in a variety of pulmonary illnesses,” the authors of the NEJM paper on the Wisconsin and Illinois investigation wrote. The illnesses could include lipoid pneumonia and could result in severe lung injury and a very serious condition known as acute respiratory distress syndrome.

10. E-cigarettes are commonly used to inhale nicotine but can also be used to deliver THC, CBD and butane hash oils known as “dabs.” Although previous reports have detailed severe lung illnesses among people who have used nicotine or cannabis extracts in e-cigarettes, there haven’t been large clusters of pulmonary illnesses occurring at the same time that have been linked to e-cigarettes, the Wisconsin and Illinois authors wrote.

WHAT ARE E-CIGARETTES?

Electronic cigarettes: An electronic cigarette or e-cigarette is a hand-held battery-powered vaporiser that simulates smoking by providing some of the behavioural aspects of smoking but without burning tobacco.

Vaping: The action or practice of inhaling and exhaling the vapour produced by an electronic cigarette or similar device. The user of a vaping device is referred to as a vaper.