By Samantha Aman

This time last year, Ryan McLaughlin was spending $220 a month on his vaping habit.

“I found out because I had to do a spending report for one of my classes, and that’s what I was spending just on Juul pods,” said McLaughlin, a sophomore at Temple University. “In my mind, that was like, ‘What the heck?’ So I stopped with Juul, but I just got another device that was cheaper.”

McLaughlin, who started vaping while he was in high school, said he was an “aggressive” electronic cigarette user by the time he got to college.

“I tried quitting twice before, and I would just get a constant craving,” he said. “I didn’t get headaches or anything like that. There was just a constant need to [vape], right now.”

But after hearing about the outbreak of vaping-related illnesses and deaths being reported around the country, McLaughlin successfully quit vaping for the first time.

“When I heard about it, I had one more pod left,” he said. “I decided I was going to finish that and just be done. And I haven’t bought a pack since.”

McLaughlin is just one of the many e-cigarette users who seemed surprised by news of the mysterious and life-threatening vaping-related illnesses.

Nearly 11 million American adults use e-cigarettes, and more than half of those users are under 35, according to a 2018 study published in the Annals of Internal Medicine.

To date, the Centers for Disease Control and Prevention has reported 19 deaths and 1,080 cases of lung injury related to vaping, with numbers expected to rise as more incidents are classified. Cases have been reported from 48 states, including Pennsylvania, New Jersey, and Delaware, as well as the U.S. Virgin Islands.

“The symptoms are general at first,” explained James Mearns, director of clinical education for DCCC’s School of Respiratory Therapy. “It’s basically a fever, a cough, and shortness of breath.”

Mearns acknowledged that these symptoms are hardly rare, especially during cold and flu season. “What happens [in cases of vaping-related illnesses] is that it starts to get worse,” he said. “Shortness of breath gets progressively worse to the point where oxygen is needed or there’s even respiratory failure and the patient needs to be put on a respirator.”

Despite the growing number of severe illnesses, the CDC has yet to identify specifically what is causing the outbreak beyond general exposure to vaping-related chemicals. According to their website, “No consistent e-cigarette or vaping product, substance, or additive has been identified in all cases, nor has any one product or substance been conclusively linked to lung disease in patients.”

“I started because everyone else had it…”

– Ryan McLaughlin

The lack of research on e-cigarettes and their effects on the lungs is complicating efforts to identify a specific chemical responsible for the illnesses, Mearns explained.

“As far as long-term data [on vaping], there is none,” Mearns said. “There’s just incidental information right now.”

Mearns also pointed to the wide range of chemicals a person inhales through e-cigarette use. This can include heavy metals, like lead and tin, as well as chemicals such as diacetyl, which is considered safe to ingest but has been linked to high rates of lung disease when inhaled.

“The lungs are made to take in oxygen and get rid of carbon dioxide, and anything else you inhale into your lungs is going to cause some destruction to the lung tissue,” Mearns said. “I think that’s what we’re seeing now with vaping.”

One possible chemical culprit behind the rash of illnesses and deaths is vitamin E acetate. The New York State Department of Health announced in early September they had found “very high levels of vitamin E acetate in nearly all cannabis-containing samples,” and that at least one product containing the chemical had been “linked to each patient who submitted a product for testing.”

Elias Argyris, DCCC assistant professor of biology, anatomy, physiology, and microbiology, said in an email that vitamin E acetate is a “more stable, chemically synthesized form of vitamin E, [often used] in skincare products and dietary supplements.”

Argyris explained that the chemical, also called alpha-tocopheryl acetate (ATA), was never considered for use as an inhalant.
“Its inhalation toxicity is not known, but in general inhaling oil is a bad idea,” he said. “Lipids (i.e. oils) in the lung are toxic and have been associated with lung injury.”

According to Argyris, inhaling the acetate form of vitamin E oil may be particularly dangerous. “When ATA oil is inhaled, it can coat the lungs and cause symptoms such as cough, shortness of breath and chest pain,” he said. “Furthermore, at higher doses, when inhaled it can worsen lung reactions, disrupt oxygen exchange, and destroy lung cells.”

Vitamin E acetate can be used as a thickening agent in vape oil, and in the wake of the New York Health Department’s announcement, New York Governor Andrew Cuomo confirmed that the state had issued subpoenas to three companies that sold thickening agents containing the chemical.

The vitamin E derivative is particularly associated with THC vaping oil; the CDC reports that in most cases, patients who have contracted vaping-related illnesses have used vaping products containing THC.

But Ned Sharpless, acting commissioner for the Food and Drug Administration, cautioned against jumping to conclusions before the FDA and CDC had completed their testing, stating in a press release that “…no one substance, including Vitamin E acetate, has been identified in all of the samples tested. Importantly, identifying any compounds present in the samples will be one piece of the puzzle but won’t necessarily answer questions about causality.”

Still, the rise of vaping-related illnesses has coincided with growing concern about vaping’s popularity, particularly among children.

Preliminary data from the 2019 National Youth Tobacco Survey suggests that the rate of e-cigarette use among high school students is much higher than among adults. One in four of the students surveyed reported having used an e-cigarette in the previous 30 days.

Dr. Anne Schuchat, principal deputy director for the CDC, recently testified before Congress that fourth-generation vaping devices, including Juul products, also use nicotine salts that contain incredibly high doses of nicotine and may be particularly harmful to children.

“The product can cross the blood-brain barrier and lead to potentially more effects on the developing brain in adolescents,” Schuchat told Congress, adding that in addition to priming the brain and body for addiction to other substances, higher levels of nicotine in the brain may increase a child’s risk of developing difficulties with attention, learning, and memory.

In response to the outbreak of illnesses and the rising rates of youth vaping, a growing number of government and state officials have begun to call for vaping bans or restrictions.

San Francisco, where Juul Labs Inc. is located, passed a law in June that will ban the sale of all e-cigarettes when it takes effect in 2020.

More recently, Michigan and New York have taken steps to ban sales of flavored vaping products. President Donald Trump has also spoken out against flavored e-cigarettes, claiming that his administration is working toward instituting a nationwide ban.

The focus on flavored products is at least partially due to concerns that they are more attractive to children, experts said.

“Flavors are a big attractor for teenagers, and usually the first product people are using is flavored,” Schuchat testified.

One 2017 study found that children who used flavored vaping products were significantly more likely than those who used non-flavored products to progress to smoking cigarettes.

There’s also concern that flavored vaping products are more dangerous, as multiple studies have suggested that various chemicals used to flavor the products may be particularly harmful to the lungs.

Proponents of vaping, however, maintain that it’s a safer alternative to smoking cigarettes and point out that the rise in youth vaping coincided with a sharp reduction in rates of youth smoking.

For his part, Mearns isn’t sure that this distinction between smoking and vaping is valid.

“You’re going to destroy your lung tissue whether you smoke or vape,” he said. “It’s just a matter of whether you know what you’re getting or not. For those people who do vape, the best I could tell you is they should at least look into what chemicals they’re inhaling. And that isn’t always spelled out in the fine print.”

As for McLaughlin, he hasn’t used an e-cigarette in over a month and believes he has successfully quit vaping.

“I started because everyone else had it, and I was just like, ‘Oh, let me see what it is,’” he said. “Over like a year, vaping for me went from pretty casual to pretty aggressive. At one point, I was going through like a pod a day almost.”

When asked if he regrets starting to use e-cigarettes, McLaughlin’s answer is instantaneous: “Yes. It was a waste of money and, I guess I know now, detrimental to my health. Now, it’s like a switch flipped in my brain, and it’s just not worth it at all.”