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A woman smokes a Juul e-cigarette in this posed picture. Photo by Ronen Zvulun/Reuters

What are symptoms of vaping-related lung disease? Answers to your e-cigarette questions

In recent months, hundreds of people across the United States have gotten sick and a handful have died, and all of them have had one thing in common: They used e-cigarettes. While the federal government has taken steps to restrict these devices, the exact source of the outbreak remains unclear, raising questions and concerns about safety among the public.

Since June, 530 probable or confirmed cases have been tied to vaping e-cigarettes, the Centers for Disease Control and Prevention said Thursday. Investigators said seven people have died in California, Illinois, Indiana, Kansas, Minnesota, and Oregon, according to the latest CDC data released on Sept. 11. A seventh U.S. death possibly linked to e-cigarettes is being investigated in California, according to health officials there. Overall, federal officials have identified possible and confirmed cases in 38 states and the U.S. Virgin Islands.

Among the 530 cases, three-quarters are male, and more than half are under 25-years-old — that includes 16 percent who are under age 18.

“If you are concerned about these health risks, we recommend refraining from using these e-cigarette or vaping products,” said Dr. Anne Schuchat, the CDC’s principal deputy director.

This latest figure marks a rise in the number of cases federal officials have reported so far, including a mix of cases reported retrospectively and with people who have fallen ill in recent days and weeks.

Part of what complicates the investigation is people who have gotten sick may not have known the true nature of what they were vaping, and are reluctant to disclose that information or are too ill to speak, Schuchat said.

The Food and Drug Administration has enlisted the help of the Office of Criminal Investigations to determine what is happening, said Mitch Zeller, who directs the agency’s Center for Tobacco Products. But he said the agency is not pursuing prosecution of those who use vaping products.

“Getting to the bottom of these respiratory illnesses is a top priority,” Zeller said on the call with reporters Thursday.

On Sept. 6, the CDC asked people to stop using e-cigarettes until investigators determine a cause. Laboratories from the FDA have tested samples for nicotine, opioids, poisons, toxins and tetrahydrocannabinol, also known as THC — the primary psychoactive component in marijuana.

The Trump administration moved to ban flavored e-cigarettes nationwide on Sept. 11, after Michigan made similar overtures a week earlier. The state banned these types of e-cigarettes Wednesday. The FDA was moving to remove all non-tobacco flavored e-cigarette products from the market, Health Secretary Alex Azar said in a White House appearance.

In addition to an estimated 8 million adults, 5 million children also use e-cigarettes in the U.S., according to Azar.

Most teens know there is a health risk associated with vaping, but they do not want to admit they might be vulnerable to the pulmonary disease that is on the rise, said 17-year-old Rebecca Williamson, a senior at Forest Hills High School in Sidman, Pennsylvania.

“They think, ‘Oh, that won’t happen to me. I’m just a kid,’” said Williamson, who spoke to PBS NewsHour Student Reporting Labs.

The American Lung Association has described teen use of e-cigarettes as an “epidemic,” and the organization has lobbied to end the sale of flavored tobacco products, as well as any vaping products that illegally entered the market after Aug. 8, 2016, and to raise the federal age for tobacco sales to 21.

In the dozen days since the CDC told Americans to stop using e-cigarettes until more is known about why people are getting sick, the PBS NewsHour asked its audience for their questions about e-cigarettes and vaping. For two perspectives, we got answers from the FDA, as well as Erika Sward, the American Lung Association’s national assistant vice president for advocacy.

Do we know what vaped substance or device was used by people who got sick?

ERIKA SWARD: The CDC, with state and local health departments, are investigating all of the different reports of death or illness caused by vaping. They have not yet determined if there is a particular chemical or a particular product, that is associated with the pulmonary outbreak.

FOOD AND DRUG ADMINISTRATION: 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. We do not yet know the specific cause of these illnesses. The investigation has not identified any specific e-cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases.

Do we know if it’s the mechanism (vaping) or the liquid that is causing the problem?

ERIKA SWARD: Well, it’s both. Inhaling anything into your lungs that is not clean air or a medication that has been found safe and effective by the FDA is not a good idea. People are inhaling chemicals into their lungs here. The liquid is also causing the problem.

Why are products for human consumption allowed on the market without more testing?

ERIKA SWARD: That’s a good question. That really has to do with the failure of both the Obama and Trump administrations from fully implementing the Tobacco Control Act. This has to do with the fact that these products essentially came on and created a wild, wild west, as we waited for two different administrations to bring them under their authority…before bringing them onto the market. They were out there for a long time without any sort of oversight. That’s why the American Lung Association sued the FDA, and we won. That’s why we have the president’s bold announcement as a critical first step.

FOOD AND DRUG ADMINISTRATION: When FDA’s foundational “deeming rule” went into effect on Aug. 8, 2016, it gave the agency’s Center for Tobacco Products regulatory authority over all ENDS [electronic nicotine delivery systems], including e-cigarettes, e-liquids, e-cigars, e-pipes, and e-hookahs. Leading up to that milestone and since then, FDA has worked quickly to develop regulations, policies, and procedures to regulate this rapidly evolving class of new tobacco products. FDA’s oversight of these products is a top priority for the agency.

Why does the U.S. research draw different conclusions from research in the U.K.?

FOOD AND DRUG ADMINISTRATION: Due to the epidemic of youth e-cigarette use in the United States, FDA needs to ensure e-cigarettes are not an on-ramp to nicotine addiction for millions of youth. The regulation of e-cigarettes and other tobacco products may vary across countries for a variety of reasons. In the United States, for example, while FDA believes that certain products may have the potential to provide a benefit to some addicted adult cigarette smokers, any given product may not have an overall net population health benefit if, for example, it leads to increased tobacco product initiation or dual use. Evaluating and regulating tobacco products according to a public health standard based on population health impacts may lead to different actions in the United States than in other countries that apply a different standard.

ERIKA SWARD: I think this [question] has to do with a Royal College of Physicians’ conclusion that e-cigarettes are 95 percent safer than cigarettes. The bottom line is that e-cigarettes are regulated in the U.K. They are not regulated here…. They’re a much different product here in the U.S than what’s in the U.K. I would also say the Royal College underestimated the potential damage, especially when you consider the public health.

Why did it take years to address the industry’s marketing and availability to teens?

ERIKA SWARD: A lack of political will by two administrations — both the failure of the Obama administration to assert its authority over these products and remove products from the market, and from the Trump FDA. …What everyone is trying to do now is close the barn door after the horses went out. The surgeon general has rightly made the point — it is not too late to act. The historic announcement last week from the president is really important to beginning to address that.

FOOD AND DRUG ADMINISTRATION: FDA is deeply concerned about the epidemic of youth e-cigarette use. The agency will continue to use the full scope of its regulatory authority thoughtfully and thoroughly to keep e-cigarettes out of the hands of America’s kids and tackle this mounting public health crisis.

On Aug. 8, 2016 when the deeming rule went into effect, it became immediately illegal to sell e-cigarettes to people younger than 18. Retailers also became legally responsible for requiring age verification by photo ID for individuals under 27 to purchase a tobacco product.

On April 24, 2018, FDA published a statement that included the announcement of a Youth Tobacco Prevention Plan. FDA’s Youth Tobacco Prevention Plan is a series of actions to stop youth use of tobacco products, especially e-cigarettes, with special focus on three key areas: Preventing youth access to tobacco products, curbing marketing of tobacco products aimed at youth; and educating teens about the dangers of using any tobacco product, including e-cigarettes, as well as educating retailers about their key role in protecting youth

If your teen or young adult did not experience immediate health problems from vaping, and has since quit, can there still be problems later on? If so, what are the symptoms?

FOOD AND DRUG ADMINISTRATION: All reported cases of the current lung illnesses under investigation have a history of vaping within the 90 days before first experiencing symptoms. Some patients have reported that their symptoms developed over a few days, while others have reported that their symptoms developed over several weeks. Anyone who has recently used an e-cigarette or vaping product and develops symptoms like those reported on the CDC website should see a health care provider.

ERIKA SWARD: There certainly can be ongoing consequences of inhaling these kinds of chemicals into lungs. The most important signs parents should watch for is difficulty breathing, shortness of breath, chest pains, [gastrointestinal] sickness — those are all signs of the broader pulmonary outbreak we’re seeing now.

Why are e-cigarette commercials allowed on TV?

FOOD AND DRUG ADMINISTRATION: Any person who manufactures, packages, or imports for sale or distribution of cigarettes within the United States must comply with the requirements under the Federal Cigarette Labeling and Advertising Act (FCLAA). This Act prohibits any advertising of cigarettes and little cigars on radio, television, or other media regulated by the Federal Communications Commission. E-cigarettes are not addressed in the FCLAA.

ERIKA SWARD: There are very few restrictions on any sort of marketing and advertising for tobacco companies. The law that prohibits the marketing of cigarette ads does not apply to any other tobacco product.

Why aren’t e-cigarette ingredients listed?

FOOD AND DRUG ADMINISTRATION: Manufacturers of all tobacco products, including e-cigarettes, are required to submit to FDA a listing of all ingredients and additives that are added by the manufacturer to the tobacco, paper, filter, or other part of each tobacco product.

The Food, Drug and Cosmetic Act (FD&C Act) also requires tobacco manufacturers and importers to report the levels of harmful and potentially harmful constituents (HPHCs) found in their tobacco products. The law also requires FDA to publish HPHC quantities in each brand and subbrand of tobacco product, but not until it can do so in a way that people find understandable and not misleading. There are several efforts under way at FDA to make progress toward that goal.

ERIKA SWARD: Manufacturers just had to submit their ingredients to the FDA in June. In general, tobacco product ingredients are not listed. We want to see that the FDA reviews each of these products in advance to make sure they are appropriate for public health. These are pretty potent chemical cocktails. Vegetable glycerine and propylene glycol are on FDA’s list and are generally safe for ingesting them, for eating them. It’s completely different when they’re inhaled. Sometimes, chemicals mix and match with each other in ways that we as consumers do not realize, in ways that are dangerous to your lungs. Simply listing the ingredients is not enough for us to understand what these products are doing to our bodies.

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