--:-- Sean Rameswaram: Before we start our show, a quick note about another show. There's these two ladies who host a podcast called By the Book. Their names are Jolenta Greenberg and Kristen Meinzer, and I can personally attest they're very fine people. I used to work with them over at WNYC. By the Book is a show in which they talk about different self-help books, but they got this new show where they take everything they learn making By the Book and channel it into basically their own self-help podcast where they sort of usher people through personal self-help journeys. It's called We Love You and So Can You. Kristen and Jolenta send listeners on their own self-help journeys and help them make over a big part of their life, like jumping back into dating or starting a new career. You'll laugh. You'll cry. You'll subscribe, maybe? We Love You and So Can You. It's playing now wherever your podcasts are playing.
--:-- Sean Rameswaram: Back in May of last year, we made an episode about vaping. The FDA had just sent these warning letters to a dozen or so companies like Juul that looked to be marketing their nicotine devices to kids. Get your cotton candy flavored nicotine, that kind of thing. The episode mentioned that these devices were dangerous, that they were untested, that they were powerful. It even ended with a public service announcement about the dangers at play here. Don't go vape your jewel, it's really not cool. But even so, after we published a bunch of listeners told us the episode made them want to go out and buy a Juul. One of our co-workers definitely did just that. Today's episode is about vaping, but I can almost guarantee you it won't make you want to vape because now people are dying.
--:-- Sean Rameswaram: The Centers for Disease Control is warning people to stop using e-cigarettes. The reason? The number of possible cases of vaping-related lung illnesses has more than doubled in a month. Right now, there are more than 450 possible cases in 33 states. Health officials say at least five deaths are likely linked to vaping. 18-year-old Piper Johnson was on her way to college when she wound up in a Colorado intensive care unit. Had I waited 36 hours longer, I probably would have died or been put on a ventilator. I didn't think that that little pod could do so much damage on my body.
--:-- Julia Ballou: What's going on is that there's an outbreak of a mysterious vaping-related respiratory illness that's sweeping across the U.S. I'm Julia Ballou, and I'm reporting on Health for Vox. Today I spoke to you from Vienna. That's Vienna, Austria, not Vienna, Virginia.
--:-- Sean Rameswaram: Starting around April, doctors started to see young, otherwise healthy people show up in their offices and hospitals with difficulty breathing. And they do CT scans and x-rays and look at their lungs and notice that they had these abnormalities. Something was causing inflammation in the lungs. And when they'd start to try to search for what that was, a bacterium or virus, they didn't find anything. Which is really unusual to see young, healthy people show up in hospital who don't have any sign of infection but have difficulty breathing.
--:-- Chance Amarada: It felt like I was genuinely having a heart attack. That's how I describe the feeling when my medical emergency began about three weeks ago. I would say, like, my chest felt like it was collapsing and tightening up, and I couldn't breathe. And they said, your lung has collapsed. You have to go to surgery right now.
--:-- Julia Ballou: And only a few months later, when more and more of these cases started to show up, did they realize what was linking them was that all of the patients vaped. Every single one of them reported using e-cigarettes in the last 90 days. So by the end of August, there were about 200 possible cases in 22 states. And on Friday, the CDC announced that that number has risen to 450 possible cases in more than 30 states.
--:-- Polly Hergenrader: My 18-year-old son, Adam, has been in the hospital since Saturday, when he was rushed to the ER with chills, shortness of breath, and vomiting. He's now relying on a supplemental breathing mask, steroids, and antibiotics as he battles a lung infection.
--:-- Julia Ballou: What was the first case in which we know someone died from vaping here? So in August, we learned of a woman in Illinois who was hospitalized with this unexplained illness, and she died and she was only in her 30s. And she's now thought to be the first person in the U.S. who's died because of vaping. And on Friday, we learned about the fifth death, which happened in L.A. And that person was over the age of 55.
--:-- Julia Ballou: So we've got a woman in her 30s, but also an older guy who died from vaping. Is everyone who vapes getting sick right now? Or is this like limited to a certain type of person? No, not at all. And yeah, it's important to remember there are many, many people across the country. And right now we're talking about 450 cases. So this is definitely a subset of the population using e-cigarettes.
--:-- Julia Ballou: What we know now is that most of the people who have been diagnosed are actually in their late teens and 20s. So on Friday the New England Journal of Medicine a medical journal came out with a series of reports on this outbreak. And one of them was a study in Wisconsin and Illinois. And they found that the median age of the patients in those states is 19. So that means that half of the people who are getting sick with this illness are younger than 19.
--:-- Tristan Zofield: I woke up just throwing up everywhere and my heart was just pounding out of my chest going 100 miles an hour.
--:-- Julia Ballou: Are all these people who are getting sick getting better? I mean, obviously, five or so have died, but how's everyone else doing? Yeah, so one of the doctors I spoke to who's been treating patients with illness said that when she's followed up with people who have recovered from the breathing difficulties in particular, their lungs still appear to be damaged, so there seems to be some long-lasting impact on the lungs.
--:-- Alexander: The doctors told me my lungs are diminished by 25 percent. I don't have the stamina that I used to. I don't have the strength that I used to. They're hopeful I'll recover.
--:-- Julia Ballou: But the long-term health effects of people with the illness, we don't know them yet. Is there any particular type of vape device? I mean, we talked a lot about the Juul back in our episode about vaping in May of last year. Is it a type of nicotine or THC that people are inhaling? Do we know that there's one thing to stay away from here?
--:-- Julia Ballou: So unfortunately, it's still not clear. And that's why the CDC and FDA are telling people just don't use e-cigarettes until we know what's going on. Right now, the FDA is analyzing hundreds of samples from the products that people who have gotten sick have been using. And they think that there's a chemical in some of them that might be what's causing the illness, but they're still considering everything from nicotine to THC to pesticides, additives, all the chemicals that come in flavors.
--:-- Julia Ballou: And yeah, one thing that does link many of the cases is that people had been using THC in their e-cigarette devices. How do you get that? You know, the THC. I got it from like a drug dealer or whatever. Did he assure you it was okay? Sure, yeah. But you don't know whether it was okay or not.
--:-- Julia Ballou: Right. But then there are also people who got sick who had only been using nicotine e-cigarettes and then some people use both so marijuana and nicotine containing liquids in their in their devices so it's possible that we'll learn that this sickness is caused by an exposure to like a couple of chemicals or that the chemicals are working together in a way that's making people sick or it's also possible some people who are saying they only use nicotine are lying because right now I think the data that we have ourself reported and maybe and again it's a lot of young people, maybe they don't want to admit that they were using marijuana.
--:-- Julia Ballou: So it's really not clear yet, and it's going to take some time to find out. But it is worth noting that on Friday, the State Health Department of New York announced that an investigation of the cases there found that vitamin E acetate was a chemical that turned up in the products that people who have been sickened in New York had been using. But then the feds on Friday in a press briefing walked back from that and said that, you know, while New York has had that finding, it's still not clear that vitamin E is really the culprit and they're considering many, many different potential causes.
--:-- Julia Ballou: What is vitamin E acetate exactly? It sounds mostly healthy. It is, yeah. So it's something that's found in nutritional supplements and it's completely safe in those, but it does have these oily, greasy properties that when you're inhaling it into your lungs, it can cause some of the symptoms and inflammation that the people who are sick have been experiencing.
--:-- Julia Ballou: What other chemicals or ingredients are in these vape cocktails? Do we know? So, so, so many. So flavorings and additives and toxins that are in the mix. So nicotine, heavy metals like mercury and aluminum. Yum. Formaldehyde has been found in e-cigarettes. And then yeah and then the flavorings like you know strawberry lemonade and butter rum and all the Oreo flavor or whatever all the different flavors that are available now they also made of many different types of chemical combinations.
--:-- Julia Ballou: So it's important to remember there are hundreds of different ingredients in the vape juices people are using. As delicious as that sounds, I mean, all of these ingredients have been in these vape cocktails for years now. Why are people getting sick all of a sudden? What's interesting is that it's not entirely clear that this is a new phenomenon. So it's possible this has been going on for some time, but because e-cigarette use has only soared recently that we're actually detecting these links now.
--:-- Julia Ballou: It's also possible that there's something that's been introduced on the market or black market products that people are accessing that are introduced more recently that are making people sick. Why is there a black market for these devices when you see like vape stores on like every corner and they're being sold in convenience stores? It's not like there's like a black market for like Miller Lite.
--:-- Julia Ballou: Why are people buying vape devices on the streets? Well, remember in this case, a lot of the patients had reported using THC, which is the psychoactive ingredient in marijuana. And as we know, marijuana is illegal in every state. So it's possible that people are just purchasing these devices off of whoever is dealing to them. Or it's also possible that they have a, you know, black market source that's cheaper than what's on the market.
--:-- Julia Ballou: So I think there's lots of reasons why people might be turning to black market sources. Do we know if the CDC's warnings have worked, if people are going to ease up off the vaping, or are we likely to see more hospitalizations, more injuries, more deaths as a result of people using these devices in the coming weeks and months?
--:-- Julia Ballou: I have noticed just on social media and talking to people that there seems to be more awareness about the potential dangers of these devices as a result of this outbreak. So maybe it is scaring people off of them. To the people who are vaping underage, knock it off. Don't do that to your parents.
--:-- Julia Ballou: As for people who are of legal smoking age, if you want to vape, vape. Just, you know the risks. It almost killed me. But whether anyone's actually measuring, yeah, whether e-cigarette use is going down as a result, I don't know.
--:-- Julia Ballou: Juul markets itself as an alternative to traditional cigarettes. And the e-cigarette giant says its mission is to improve the lives of the world's 1 billion adult smokers by eliminating cigarettes. And the goal appears to be paying off. In recent weeks, cigarette sales volume declined more than 7 percent. That is more than twice the historic rate of decline.
--:-- Julia Ballou: Balooz, I think, you know, people thought I'm going to vape instead of smoke cigarettes because it seemed like the healthier alternative. Do all these recent illnesses and even deaths suggest that that might not be true? I think we still don't know enough to say anything definitively. Definitively, but we do know that regular cigarettes are the deadliest products that have ever been introduced to the consumer market. So that's a pretty tough thing to beat.
--:-- Julia Ballou: Obviously, one of the dangers here is that teens have really glommed on to vaping, the Juul in particular. All right, so I have my brother here who is of age, and he's going to teach me how to do some vape tricks. So here, show me some of your best tricks.
--:-- Julia Ballou: When you breathe in, don't inhale it. Like, breathe in like... Uh-uh. Oh, shit.
--:-- Julia Ballou: So there's this national survey called the National Institutes of Health Survey, and they track how American youth are using substances. And the number of high school seniors who said they vaped nicotine in the past 30 days had doubled between 2017 and 2018. So it went from 11% to nearly 21%. This survey is like more than 40 years old, and it was the largest increase they'd ever seen of any substance in the history of the survey.
--:-- Julia Ballou: What that means is that a quarter of 12th graders are now using the e-cigarettes at least at some point in the last month. And we have no idea what the long-term health effects of that will be. A quarter of all 12th graders in the United States are vaping at some point every month. Yeah, so what they track is 30-day use in the past 30 days.
--:-- Julia Ballou: And just for comparison, so adult use, it's like fewer than 5% of adults are currently using e-cigarettes. And we don't have any more of an idea of what this might be doing to not even fully formed adults yet.
--:-- Julia Ballou: Well, we thought until this outbreak that the diseases that would be related to e-cigarettes would take a long time to turn up. In the same way, smoking doesn't kill you two days after you smoke a cigarette. It kills you after many years of use and the accumulation of that toll on the body.
--:-- Julia Ballou: So what that means is that there might be these potential cardiovascular effects like heart disease and high blood pressure, heart attacks, things like that. Then we've also seen these rare cases of seizures related to nicotine containing e-cigarettes and also of e-cigarette explosions. So when these vape devices have exploded in people's mouths and broken their jaws and whatnot.
--:-- Julia Ballou: So we still definitely learning about what the longer term consequences of some of these short shorter term health effects are going to be. And I mean the last time we spoke about this you also mentioned that there this ability to take these like super hyper mega doses of nicotine when you have a vaping device. Whereas when you're smoking a cigarette, you're a little more limited to, you know, a single cigarette at a time, obviously.
--:-- Julia Ballou: What do we know about the health impacts of just taking a lot of nicotine? So I think it's important to say that that was about Juul, right? So Juul does deliver this like crazy dose of nicotine. I think it's as much as, so one Juul pod delivers as much nicotine as up to two packs of cigarettes. So they're definitely in the addiction business, but that's not all e-cigarettes.
--:-- Julia Ballou: But Juul does control like this market. It's the biggest player, right? Absolutely. Yeah, they have the greatest share of the e-cigarette market for sure. And these are similar to the health effects of nicotine in cigarettes. So raising blood pressure, speeding up the heart rate, causing the arteries to narrow.
--:-- Julia Ballou: We know that nicotine can increase the adrenaline that circulates in our bodies. So that activates this fight or flight response. And in young people, we know that nicotine can rewire the brain. So there are questions about what that means for addiction and susceptibility to addiction later if you've been juuling every day in your teens.
--:-- Julia Ballou: Are e-cigarettes regulated the same way as regular cigarettes? I know this is sort of a new wild west of smoking or vaping, but is the government staying on top of it? So yeah, only in 2009 did the FDA get regulatory authority over the tobacco industry, and e-cigarettes were left out of it until that finally changed in 2016.
--:-- Julia Ballou: And so the Fed started to regulate e-cigarettes then, and it meant that they could do things like banning sales to minors and making sure that the ingredients were listed on packages and stuff like that. But they've also delayed some big compliance deadlines as part of the regulation.
--:-- Julia Ballou: So, for example, companies that have entered the market after February 2007 have more time to get FDA approval to sell their products. So they push back a deadline for these companies that came on the market after 2007. In the context of this outbreak, it's worth noting that FDA doesn't regulate THC since it's illegal under federal law.
--:-- Julia Ballou: So there are certainly some gaps still in the regulation of the products that seem to be causing this outbreak. Is the vaping industry responding to this at all? Are they saying, hey, our bad, we're going to make sure these things are a little safer, anything like that? So the line from the vaping industry seems to be that federal officials are unnecessarily frightening the population.
--:-- Julia Ballou: Oh. So the Vapor Technology Association, which is this big e-cigarette vaping industry trade group, so they released a statement recently urging, quote, public officials to thoroughly investigate the circumstances which might have led to each reported hospitalization before making statements to the public about whether certain products are implicated in these incidences.
--:-- Julia Ballou: And how much would scaring people off e-cigarettes cost the vaping industry? So we know that Juul is now valued at $38 billion. Yeah, so it was a massive valuation when it was purchased by the parent company of Philip Morris, one of the world's largest tobacco companies, which now owns more than a third of Juul.
--:-- Julia Ballou: So yeah, the company is hugely valuable. Big Tobacco clearly sees a future with them. And yeah, if this outbreak were to turn those trends around that we were talking about, there would be a lot of money lost. And so anyone thinking, oh, I got this cool vape device that's not really a part of this big old cigarette tobacco machine that dates back to slavery in the United States, that isn't the case anymore.
--:-- Julia Ballou: That's not the case. And it hasn't been for a while. Many of the e-cigarette companies are controlled by tobacco companies. Is this like a huge moment for vaping where whatever happens in the next few months or year might decide the future of this potentially very, very harmful trend?
--:-- Julia Ballou: You know, like you said, when e-cigarettes were introduced to the market, they were really framed as these stop-smoking devices. And then there was this youth boom and lots of marketing around that and social media use around vaping. And now we're seeing this outbreak that seems to be directly linked to the e-cigarette industry.
--:-- Julia Ballou: And I think that might indeed be this turning point in the conversation. Julia Blues covers health for Vox. Shortly after she and I spoke this morning, the FDA sent a stern warning letter to Juul Industries for illegally marketing its vaping products as safer than cigarettes. The FDA says that Juul has 15 days to take corrective action.
--:-- Sean Rameswaram: I'm Sean Rameswaram. This is Today Explained.
