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

Overview

• CDC, FDA, and state health authorities have made progress in identifying the cause of EVALI.
• 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.What We Know

About the Outbreak:

• As of February 4, 2020, a total of 2,758 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).
  • Sixty-four deaths have been confirmed in 28 states and the District of Columbia (as of February 4, 2020).
• 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.
• 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.
• 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 studyexternal icon 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).

What CDC Recommends

• 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 medicationsexternal icon. 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.

Latest Information

• 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 4, 2020, a total of 2,758 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-four deaths have been confirmed in 28 states and the District of Columbia (as of February 4, 2020):
  • Alabama, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, and Virginia
  • The median age of deceased patients was 51 years and ranged from 15-75 years (as of January 14, 2020).
  • More deaths are currently under investigation.
• 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.

What CDC is Doing

Public Health Response:

• CDC’s Lung Injury response efforts are committed to:
  • Detect new cases and track progress in controlling the outbreak.
  • Identify and define the risk factors for EVALI.
  • Conduct laboratory testing that can assist with identifying chemicals of concern.
  • Communicate actionable recommendations to clinicians, public health professionals, and the general public.

Partnerships:

• CDC continues to work closely with FDA, states, public health partners, and clinicians by providing consultation and technical assistance on communication, health alerts, public outreach, and surveillance.
• CDC continues to communicate with international public health partners. Currently, there is a very small number of similar lung injuries outside the U.S. and not close to the magnitude in the U.S.

Media and Communication:

• CDC is maintaining an EVALI webpage with key messages and updates on case counts, deaths, and resources available to healthcare providers, health departments, and the public.

Laboratory Testing:

• CDC developed guidance documents to assist public health laboratories, healthcare providers, pathologists, and others with specimen collection, storage, and submission to CDC for testing.
• CDC is testing bronchoalveolar lavage (BAL) fluid samples as well as blood or urine samples paired to BAL fluid samples.
• CDC is evaluating autopsy tissue specimens associated with individuals with suspected EVALI. CDC is also evaluating biopsy specimens on a case-by-case basis.
• CDC is conducting aerosol emissions testing of case-associated product samples from e-cigarette, or vaping, products, and e-liquids paired to BAL fluid samples.

For more information and resources for key stakeholders, visit For Healthcare Providers and For State and Local Health Departments. General resources are also available.

A possible culprit has been found in a recent string of vaping-related hospitalizations and deaths.

At least 39 people have died of a mysterious lung illness linked to e-cigarettes and approximately 2,050 people in 49 states have suffered vaping-related respiratory illnesses, including many teens and young adults who had to be hospitalized, according to the Centers for Disease Control and Prevention.

On Nov. 8, the CDC announced a breakthrough in identifying the cause: Vitamin E acetate was found in all 29 samples of lung fluid tested from patients with vaping illness across 10 states.

“These findings provide direct evidence of vitamin E acetate at the primary site of injury within the lungs,” said Dr. Anne Schuchat, the CDC’s principal deputy director, who called vitamin E acetate “a very strong culprit” behind the illnesses.

Vitamin E acetate is found in foods, supplements and cosmetic products like skin creams. But when inhaled, “it may interfere with normal lung function,” Dr. Schuchat said. Another CDC official described vitamin E acetate as “enormously sticky” and “just like honey,” when it goes into the lung. Vitamin E acetate is used as an additive in some vaping products.

The CDC cautioned, however, that there may be more than one cause of the outbreak and that it is investigating other substances as well. It continued to recommend that people refrain from using all e-cigarette or vaping products as the investigation continues.

State and federal officials have issued warnings about the dangers of e-cigarettes in the wake of the hospitalizations.

“While many people consider vaping to be a less dangerous alternative to smoking cigarettes, it is not risk-free,” New York State Health Commissioner Dr. Howard Zucker said in a statement in August, noting that the Health Department is actively investigating cases of vaping-related lung-disease in New York State. “These latest reports of pulmonary disease in people using vaping products in New York and other states are proof that more study is needed on the long-term health effects of these products.”

More than 3.6 million young people in the United States use e-cigarettes, according to the Centers for Disease Control and Prevention, far more than the 280,000 estimated in 2011. The U.S. Surgeon General’s Office declared the situation a public health epidemic among youth, and, like the American Lung Association and other major organizations, has issued warnings about the dangers of e-cigarettes.

E-cigarettes are battery-operated devices with a heating element that turns liquid from a refillable cartridge into an aerosol that the user inhales. The aerosol is often filled with nicotine and other substances, and may contain flavorings and coloring. E-cigarettes are also known as vape pens, hookah pens, vaporizers and e-pipes. The American Lung Association says inhaling ingredients found in e-cigarettes may expose people to high levels of toxins, which can cause irreversible lung damage and lung diseases. Also, the nicotine found in many e-cigarettes is an addictive drug, just as it is in regular cigarettes, and can stunt the development of the adolescent brain and increase the risk for future drug addiction.

To better understand how vaping can affect your health, Health Matters spoke with Dr. Brendon Stiles, an associate attending cardiothoracic surgeon at NewYork-Presbyterian/Weill Cornell Medical Center and an associate professor of cardiothoracic surgery at Weill Cornell Medicine.

What do people need to know about the health risks of vaping?
We still have very little knowledge about the health consequences of vaping and e-cigarettes. However, a recent study shows precancerous changes in airway cells after e-cigarette use. Also, the New England Journal of Medicine recently published national estimates showing increased rates of vaping and nicotine use in adolescents.

What does vaping do to your lungs?
It still isn’t entirely clear. But what is clear is that e-cigarettes have been found to have chemicals and particles that have been linked experimentally to lung disease, including asthma and chronic obstructive pulmonary disease (COPD). Vaping can also cause lung inflammation, which has been linked to chronic lung disease as well.

“Dangerous chemicals found in e-cigarettes include acetaldehyde and formaldehyde, which have been associated with heart disease in addition to lung disease.”

— Dr. Brendon Stiles

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Could it cause permanent lung damage? What about your heart?
It still isn’t known. However, teens may be most at risk for long-term effects since their lungs are still developing. Dangerous chemicals found in e-cigarettes include acetaldehyde and formaldehyde, which have been associated with heart disease in addition to lung disease .

Are there other health impacts of vaping?
There is certainly a real possibility that vaping could increase a person’s cancer risk. Studies have already shown that e-cigarettes can induce DNA damage and mutations in normal airway cells, which are precursor events to cancer. E-cigarette vapor may also adversely affect immune cells in the lung environment, leading to lung inflammation, another precursor to cancer.

Is there a secondhand impact?
Potentially, although this hasn’t been well studied.

Is there anything else you think is important for people to know?
The industry is poorly regulated and it is not entirely clear what is in different e-cigarette products, although harmful chemicals have been found in some. The recent hospitalizations are an unfortunate example of that. Certainly, this adds to the growing number of reports that vaping is not “harmless.”

Brendon Stiles, M.D., is an associate attending cardiothoracic surgeon at NewYork-Presbyterian/Weill Cornell Medical Center and an associate professor of cardiothoracic surgery at Weill Cornell Medicine. Dr. Stiles is an advocate for lung cancer patients and for cancer research in general. He is chair of the Lung Cancer Research Foundation’s Board of Directors. Dr. Stiles can be found on Twitter, @BrendonStilesMD, where he frequently comments on lung cancer, engaging directly with patients and advocacy groups.

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Over 2500 Confirmed Injuries and 34 Deaths linked to Vaping

Vaping and E-Cigarette Lawsuits

The number of people, especially young people, who “vape” has skyrocketed in recent years. Indeed, electronic cigarettes made by JUUL® and other companies have become part of everyday life for many people. But, though they had been advertised as a safer alternative to traditional cigarettes, e-cigarettes have now been tied to serious health issues.

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What Happens Next?

Any lawyer you decide to hire will want to collect as much information about your case as you can offer. Medical records will be high on the list.

In discussing your case, the lawyer will probably explain that you will not owe anything for representation if there isn’t a settlement or trial verdict in your favor. In other words, any payment for the attorney will come out of and be determined by the amount you ultimately receive.

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I want to share this article I found on KQED ARTS https://www.kqed.org/arts/13870538/the-black-community-a-target-for-the-tobacco-industry-since-slavery

“Children smoking Carolina Brights.” Photo by Bayard Wootten (“Children smoking Carolina Brights.” Photo by Bayard Wootten)

Have you ever looked at the Center for Disease Control’s web page that highlights the tobacco industry’s impact on African Americans? It’s horrifying.

According to the data, black folks say they want to quit smoking more than other demographic, but fail more often. We are more readily exposed to second hand smoke than other groups. And we live in communities where smoking advertisements disproportionately saturate the market—especially ads for menthols.

And in big bold letters, in the middle of the page, it says, “Tobacco use is a major contributor to the three leading causes of death among African Americans—heart disease, cancer, and stroke.”

Yeah, the numbers are up to date. And at the same time, this issue isn’t anything new. It’s been like this for ages. Some might say it’s been like this since our ancestors were enslaved on the tobacco farms in the Carolinas.

“I’m looking at it from slavery to vaping,” says Tracy Brown, lead artist and curator of the Same Game Different Smokers, an exhibition sponsored by The African American Tobacco Contol Leadership Council (AATCLC) and the African American Center at the San Francisco Library, which is running at the San Francisco Main Library from Dec. 7 through the first week of February.

An exhibition about the tobacco industry preying on African Americans isn’t new—there have been many others. But many of them look at the 1950s and ’60s, according to Brown. “I make the case that the tobacco industry has been targeting the black community since the 1600s,” she says.

Brown uses archival images, depictions of black people from the last decade as well as from the last century. She compares the posture of people in the photos, combines that with data collected from industry documents, and shows it all as evidence why 45,000 African Americans die from smoking every year.

But Brown, who works with the African American Tobacco Control Leadership Council, says San Francisco’s recent passage of legislation banning the sale of e-cigarettes is a glimmer of hope, and may be a sign that Big Tobacco is losing control.

A New Exhibition Sheds Light On How Big Tobacco Targeted Generations Of Black Americans

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KQED’s Brian Watt visited Same Game Different Smokers, an exhibition at the San Francisco Public Library that sheds light on how big tobacco companies have historically preyed on African American communities. Tap play above to listen to the segment. 

She adds it’s unfortunate that change has been spawned by headline after headline of vaping deaths, largely in white communities. But maybe it’ll open the conversation to smoking’s impacts, past and preset, on the black community.

“We know that menthol products have been used to target the black community,” says Brown. “The makers of Newport, for example.”

According to the CDC, “Over 7 out of 10 African American youth ages 12-17 years who smoke use menthol cigarettes.”

I asked the dumb question that needed to be asked: why do black folks like menthol?

Brown says, “We tend to lean toward menthol, not because of a natural inclination, but what happens with menthol when you smoke it. It sweetens the taste of tobacco, cools down and numbs your mouth and throat. The kids like menthol and mint flavors.”

But the black community isn’t unique in liking menthol products, says Brown. “What’s unique is the tobacco industry using JET magazine and Ebony, and attaching them to images of us that are very attractive.”

There was a time when I smoked menthols as a teen. But during that short stint, on one fateful day, I put a partially lit Newport into my pants pocket while rushing to jump the 58 bus in downtown Oakland. Yup, that’s all it took for me to kick the habit.

Some people aren’t as lucky to feel the pain of smoking so acutely. For most of my friends, at this age, it’s habitual. But at one time, I recall them telling me it was about a feeling, or just about access, or simply an aesthetic thing.

Brown says that aesthetic—that attractive image, which the big tobacco companies successfully sold—was strategic. But it goes beyond advertising. “They sponsored events, they work with black leaders… the tobacco industry has been very cunning in getting support of the black community,” says Brown.

There are reportedly documents  that show  that show tobacco companies, like Phillip Morris, have been “engaged” with the NAACP the National Urban League and The United Negro College Fund since the 1950s.

Prior to doing any research, Brown already presumed the people who run the industry were “shiesty.” Digging into old reports and data confirmed that assumption, and talking to people about firsthand experiences brought further revelations about the size of the tobacco industry’s target on the black community.

“One guy told me his mom would leave a lit cigarette in each room so she’d have something to smoke as she walked thru the house,” says Brown.

She’s been impacted by smoking on a personal level, too. She’s lost six close family members from tobacco. “One of my favorite aunts died this year,” she says, “and she was a chain smoker.”

She told me her aunt’s name was Victoria—Aunt Vicky—who loved gardening and watching movies, “and she could talk mess with the best of them,” said Brown, who used to visit her all the time in Florida.

Brown says she has family roots down there, as well as Mississippi and South Carolina. She’s traced her lineage, and has found the family that enslaved her paternal grandfather’s side. “My great-great-great grandfather was able to buy the land.”

Of course, it was “40 acres and a mule,” supposedly granted to formerly enslaved folks by the Freedman’s Bureau. And, of course, it was agricultural land in South Carolina—where they most likely grew tobacco.

But Brown, a proud San Francisco native, says San Francisco is doing something significant with its e-cigarette ban, hence her desire to hold the opening here. Ultimately, she wants to spread the word, bring the exhibit to other cities, get the FDA to step to the plate, and see something happen on a federal level.

At the same time, Brown isn’t waiting on elected officials. She wants families to be proactive, too. And she’s extending an invitation to all school districts to take a school trip or tell the friends and family about the exhibition. “I’ve talked to every child in my life about these products,” she says.

It’s a drastic shift from when I was a kid. Just a few decades ago, smoking was everywhere. Joe Camel was a cool-ass smoking cartoon. The fly guys all smoked in movies. There were billboards and bus benches. Not to mention ads in the corner stores—and there were stores on every corner. Hell, one of the coldest lines of all time is Richie Rich’s: “Where you from? Oakland, smokin’!“

Of course, Rich was talking about smoking marijuana. But even that usually came rolled in tobacco.

By Marisa Cohen

Electronic cigarettes were originally designed as a healthier alternative to traditional cigarettes. But it turns out smoking e-cigarettes — commonly known as vaping — has its own risks.

In August 2019, the CDC began tracking cases of severe lung problems in people who vape. Thousands had lung damage that needed treatment in hospitals, and several died from the condition. Eventually, researchers tied these cases to vaping. The illness is now called e-cigarette or vaping product use-associated lung injury (EVALI).

Doctors and researchers are still working to learn more about this condition, including its exact causes and long-term effects. But there are early signs of EVALI to watch for so you know when to get help.

Early Symptoms of EVALI

Although researchers know the condition is tied to vaping, they’re not yet clear how it happens.

“We’re still not exactly sure the exact cause of it, but there is an inflammatory response that occurs in the lung presumed due to something in the aerosol from vaping,” says Joanna Tsai, MD, a pulmonologist at the Ohio State University Wexner Medical Center.ADVERTISEMENT

Someone with EVALI may have breathing and digestive problems, along with other symptoms, including:

• Fever
• Chills
• Cough
• A hard time breathing
• Shortness of breath
• Chest tightness
• Belly pain
• Loss of appetite (not hungry)
• Nausea and vomiting
• Diarrhea
• Weight loss

Some people say their symptoms formed over a few days, while others say it took several weeks. Those affected seem to have serious lung damage. They may even need intensive care and support with a ventilator, a machine that helps you breathe.

Who’s Most at Risk

Anyone who’s vaped in the last 90 days is at risk for EVALI. You don’t have to be older or already sick.

“Many of these patients were normal, healthy people,” Tsai says.

The average age of people with EVALI is 24, and almost 4 out of 5 are younger than 35. Rachel Boykan, MD, a clinical associate professor of pediatrics at the Renaissance School of Medicine at Stony Brook University, says that might be because vaping products are most popular with younger people.

You may be more at risk if the product you’re vaping has vitamin E acetate. The CDC says it’s the common chemical found in the lungs of people who’ve gotten sick. Vitamin E acetate comes from vitamin E. It’s generally used to thicken liquids, particularly in e-cigarette or vaping products that have THC. THC is the psychoactive ingredient in marijuana that gets you high.

It also seems many of the people who’ve gotten sick weren’t just vaping nicotine.

“[W]hen the outbreak of EVALI occurred with multiple deaths noted, we have learned that the majority of the individuals involved vaped THC, although there were still reports of people who vaped exclusively nicotine,” says Tsai.

But that doesn’t mean vaping nicotine is safer. There’s still a lot to learn. And Tsai says the industry is “basically unregulated,” which means there’s no set standard manufacturers have to follow. So buyers don’t always know what they’re getting.

What to Do if You Have Symptoms

See your doctor right away if you vape any kind of product and get any of the above symptoms. They’ll do a full exam and evaluation to rule out other illnesses, such as bacterial or viral pneumonia. You might get a chest X-ray or CT scan. Healthy lungs are filled with air and appear dark. The scan will show hazy-looking spots (opacities) if you have EVALI.

You may be given corticosteroids to lessen inflammation in the lungs. Or you might be put on a ventilator in severe cases. But it’s still not safe to go back to vaping if your doctor says it’s just a cold or stomach bug. While the CDC has several precautions for people who continue to use e-cigarettes or vape, it says the best way to avoid risk of EVALI is to quit vaping altogether.

Information for the Public, FDA Actions, and Recommendations

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FDA Statement on consumer warning to stop using THC vaping products amid ongoing investigation into lung illnesses – October 4, 2019

Background

FDA-CDC Statement on Investigating
Lung Illnesses

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
• FDA Actions
• FDA Preliminary Lab Analysis
• Information & Resources for Consumers
• Information for Healthcare Providers
• Information for State Health Departments
• FDA Resources
• CDC Resources

Incident Overview

CDC Outbreak Info

• 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.

FDA Sample Collection Criteria
and Information for Vaping Related Incidents

• 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 1,070 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 Jan. 22, 2020, 814 of the 1,070 samples connected to patients (76%) have undergone some level of testing and additional testing is likely to be conducted on many of these products.
  • 503 of these samples have been found to contain THC
    • 51% 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%
    • 24% 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 Jan. 22, 2020, approximately 649 samples are directly linked to 88 patients with CDC case numbers and samples from 86 of these patients have been analyzed.
  • 74% of these 86 patients were connected to products containing THC.
    • Of these:
      • 80% of cases included products with vitamin E acetate as a diluent
      • 31% 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

Vaping Illness Update:
FDA Warns Public to Stop Using
Tetrahydrocannabinol (THC)-Containing
Vaping Products and Any Vaping Products
Obtained Off the Street

• 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.

Robert H. Shmerling, MD
Faculty Editor, Harvard Health Publishing

The Centers for Disease Control and Prevention has created a web page with the latest information and recommendations about what is now being called EVALI (for e-cigarette, or vaping, product use associated lung injury).

The rising popularity of vaping has been dramatic, especially among teenagers. According to a recent study, about 37% of high school seniors reported vaping in 2018, up from 28% the year before. An estimated 2.1 million middle school and high school students reported using e-cigarettes in 2017; that number jumped to 3.6 million in 2018. Certainly, age restrictions — it’s illegal to sell e-cigarettes to anyone under 21 (18 or 19 in some states) — aren’t preventing use among teens and young adults. And nearly seven million adults 18 or older use e-cigarettes, according to a 2017 survey by the CDC.

E-cigarettes use a battery-powered device that heats a liquid to form vapors — or, more accurately, aerosol — that the user can inhale (thus “vaping”). These devices heat up various flavorings, nicotine, marijuana, or other potentially harmful substances. Nicotine is addictive, of course. And while that fact is prominently displayed in advertising, we know from experience with regular cigarettes that warnings don’t always work!

Recent reports link vaping to lung disease

You may have seen news reports of lung problems, including two deaths — one in Illinoisand another in Oregon— linked to vaping. According to the CDC:

• Nearly 200 e-cigarette users have developed severe lung disease in 22 states (and the numbers keep rising — a Washington Post story put the number at 354). Most cases were among teens and young adults.
• Experts aren’t sure if vaping actually caused these lung problems, but believe the most likely culprit is a contaminant, not an infectious agent. Possibilities include chemical irritation, or allergic or immune reactions to various chemicals or other substances in the inhaled vapors.
• Typically, symptoms have started gradually, with shortness of breath and/or chest pain before more severe breathing difficulty led to hospital admission.
• The lung disease has not been linked to a specific brand or flavor of e-cigarette.
• The FDA, CDC, and state health officials are investigating these cases to determine the specific cause(s) and how to prevent and treat them.

What we don’t know about vaping and lung disease

It’s not clear how often vaping might lead to lung trouble or who is at highest risk. For example, are lung problems more common among vapers who already have breathing problems (such as asthma) or who use marijuana? Is it more common among younger individuals? Does use of e-cigarettes cause the lung disease? Or is an added substance (such as marijuana) or another contaminant the culprit? Since the FDA’s regulation of e-cigarettes is still evolving, it’s particularly difficult to get answers.

Other health risks of vaping

The recent tragic and alarming cases of severe lung disease are clearly cause for concern. A number of other health effects are also worrisome:

• Nicotine is highly addictive and can affect the developing brain, potentially harming teens and young adults. Even some “nicotine-free” e-cigarettes have been found to contain nicotine.
• Some substances found in e-cigarette vapor have been linked to an increased risk of cancer.
• Teens who vape are more likely to begin smoking cigarettes.
• Explosions and burns have been reported with e-cigarettes while recharging the devices, due to defective batteries.
• Accidental exposure to liquid from e-cigarettes has caused acute nicotine poisoning in children and adults.
• Vaping during pregnancy could harm a developing fetus.

How vaping affects our overall health is uncertain.

But what about the benefits?

In addition to whatever enjoyment vaping brings, some evidence suggests vaping helps some people stop smoking. However, how it compares to a nicotine patch or other methods of smoking cessation is not clear. So far, the FDA has not approved vaping as a method of smoking cessation. And many smokers who vape continue to use both cigarettes and e-cigarettes.

The CDC’s position is that “E-cigarettes have the potential to benefit adult smokers who are not pregnant if used as a complete substitute for regular cigarettes and other smoked tobacco products.” Meanwhile, the FDA warns that vaping is “not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.”

The true balance between the benefits and risks of vaping remains impossible to assess. We don’t always know what’s in e-cigarettes. The FDA does not regulate these products. And there is no information available about long-term health impact.

The bottom line

Perhaps vaping should be viewed as a “lesser of evils” for current cigarette smokers. Still, it’s clear that there is a lot about vaping we don’t know. One way we’ll learn more is by people reporting possible vaping-related health problems to the FDA — you can let them know if you’ve had such problems.

Until we know more, think twice about vaping. Federal and state authorities recommend avoiding all vaping until more is known. If you do decide to vape, avoid e-cigarettes bought “off the street” and stick with brand name e-cigarette products without modification (such as adding marijuana or other drugs).

These cases of severe lung disease among people who vape raise important questions about the safety of vaping. Perhaps we shouldn’t be surprised that lung problems might develop in people who vape: our lungs were meant to inhale clean air and nothing else. It took many years to recognize the damage cigarettes can cause. We could be on a similar path with vaping.

Follow me on Twitter @RobShmerling

Home » Harvard Health Blog » Can vaping damage your lungs? What we do (and don’t) know – Harvard Health Blog

A hookah is a water pipe used to smoke specially-made tobacco. The tobacco usually comes in different flavors, such as mint, cola, cherry, lemon-lime, coffee, chocolate, coconut, apple, licorice, and other fruity blends.

Hookahs vary in size, shape, and style. The set-up of a typical hookah water pipe includes a bowl for the coal and tobacco, an ashtray to catch the ashes, a hose with a mouthpiece to draw the smoke into and allow it to cool, and a water bowl to cool and humidify the tobacco smoke.

Hookah smoking is often a social activity in Hookah Bars, particularly with young adults, with users passing the same mouthpiece around the group.

While many believe hookah smoking to be safer than cigarette smoking, it actually is just as dangerous to your health, if not more so.

Other names for hookah include shisha, narghi, bute, argileh, shisha, hubble-bubble, and goza.

How many cigarettes equal an hour of hookah smoking?

Hookah smoke that you inhale can contain 36 times more tar than cigarette smoke, 15 times the carbon monoxide, and 70% more nicotine than one cigarette.

Hookah smokers may absorb more toxins and cancer-causing chemicals than cigarette smokers. An hour of hookah tobacco smoking is equal to smoking 40 to 400 cigarettes, depending on frequency of puffing, the depth of inhalation, and how long the hookah session lasts.

Are hookahs safer than smoking cigarettes?

•  Share Your Story

Many people who use hookahs believe hookah smoking is safer than smoking cigarettes, thinking that the tobacco smoke is filtered through water making it cleaner. This is not true. Inhaled hookah smoke contains the same toxins as cigarette smoke such as tar, nicotine, carbon monoxide, heavy metals, and other cancer-causing chemicals.

Like cigarette smoking, smoking hookah has been associated with health effects and problems such as lung cancer, respiratory illness, low birth weight, and periodontal disease. The World Health Organization (WHO) reports a hookah smoking session can expose smokers to more smoke over a longer period of time than cigarette smoking, exposing the users to possibly higher concentrations of the same toxins and carcinogens as cigarette smoke.

Are hookahs addictive like cigarettes?

•  Share Your Story

Many people think that hookah smoking is safer than cigarette smoking. It’s not. Both hookah and cigarettes contain nicotine from the tobacco, which is an addictive drug. Inhaling hookah smoke has the same addictive properties as inhaling cigarette smoke. Hookah is generally not used to get high.

Are hookah smoking and vaping the same thing?

A hookah is not the same thing as a vaping cigarette (e-cigarette, vape), which is a smaller, individual-use device that burns substances at high temperatures to make them into a vapor.

Smoking Quiz: How to Quit Smoking

Which of these are not signs of cigarette addiction?

1. Smoking even when you’re sick in bed
2. Smoking more than three cigarettes a day
3. Smoking within 30 minutes after you wake up in the morning
4. Having difficulty snuffing out that first cigarette of the day

Click to take the rest of the How to Quit Smoking Quiz »

What are the health risks of hookah and cigarette smoking (including secondhand smoke)?

People who smoke hookahs and cigarette smokers are at risk for some of the same diseases and health problems, including:

• Lung cancer
• Oral cancer
• Stomach cancer
• Esophageal cancer
• Bladder cancer
• Reduced lung function leading to chronic lung disease
• Heart disease
• Peripheral vascular disease
• Periodontal disease
• Decreased fertility
• Low birth weight babies
• Babies with respiratory disease
• Exposure to infection (from sharing the hookah mouthpiece)
• Carbon monoxide exposure (headache, dizziness, nausea, confusion)
• Secondhand smoke from hookahs can be a health risk for nonsmokers, just as is secondhand cigarette smoke.

If you feel you may be addicted to smoking hookahs or cigarettes, contact your doctor or other health care professional for advise on smoking cessation.SLIDESHOW25 Effects of Smoking on Your Looks and LifeSee Slideshow