View source for 2019–2020 vaping lung illness outbreak

{{Short description|Outbreak of vaping-associated pulmonary injury}}
{{Use dmy dates|date=July 2022}}
{{Infobox outbreak
| name            = 2019–2020 vaping lung illness outbreak
| width           = 
| image           = NYSDOH Announces Update on Investigation into Vaping-Associated Pulmonary Illnesses (48683410542).jpg
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| caption         = Some of the 
Illegal and unregulated (black market) cannabis [[electronic cigarette|vaping products]] were found to contain large amounts of [[tocopheryl acetate|vitamin E acetate]], including Dank Vapes pictured here.<ref name=NSDH2019/>
| map1            = Map of Cases or Deaths Reported to CDC Jan 2020.jpg
| legend1         = Map of reported hospitalized cases or deaths in the US and US territories.<ref name=CDC2020/>
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| disease         = [[Vaping-associated pulmonary injury]]
| virus_strain    = <!-- or | bacteria_strain = -->
                 <!-- or | parasite_strain = -->
                 <!-- or | pathogen_strain = -->| location        = [[United States]]
| first_outbreak  = {{start date and age|2019}}
| first_reported  = {{start date and age|2019|4}}
| index_case      = <!-- National or international depending on article level -->
| arrival_date    = <!-- or | dates = -->
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| source          = <!-- Animal or other reservoir -->
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| confirmed_cases = 2,711
| active_cases    = 
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| severe_cases    = 
| recovery_cases  = 
| deaths          = 61
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| total_ili       = 
| website         = 
}}
An [[outbreak]] of [[vaping-associated pulmonary injury|e-cigarette, or vaping, product use-associated lung injury]] (EVALI) started in 2019<ref name=LaydenGhinai2019>{{cite journal |last1=Layden |first1=Jennifer E. |last2=Ghinai |first2=Isaac |last3=Pray |first3=Ian |last4=Kimball |first4=Anne |last5=Layer |first5=Mark |last6=Tenforde |first6=Mark W. |last7=Navon |first7=Livia |last8=Hoots |first8=Brooke |last9=Salvatore |first9=Phillip P. |last10=Elderbrook |first10=Megan |last11=Haupt |first11=Thomas |last12=Kanne |first12=Jeffrey |last13=Patel |first13=Megan T. |last14=Saathoff-Huber |first14=Lori |last15=King |first15=Brian A. |last16=Schier |first16=Josh G. |last17=Mikosz |first17=Christina A. |last18=Meiman |first18=Jonathan |title=Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Final Report |journal=New England Journal of Medicine |date=5 March 2020 |volume=382 |issue=10 |pages=903–916 |doi=10.1056/NEJMoa1911614|display-authors=3|issn=0028-4793|pmid=31491072|doi-access=free}}</ref> among users of [[Illegal drug trade|illegal]], unregulated [[Cannabis (drug)|cannabis]] [[electronic cigarette|vaping products]],<ref name="CDC2020">{{cite web|date=28 January 2020|title=Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping|url=https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html|publisher=[[Centers for Disease Control and Prevention]]}}{{PD-notice}}</ref> almost exclusively in the United States.<ref name="Kelland2019">{{cite news|url=https://www.reuters.com/article/us-health-vaping-britain-idUSKBN1WT1XP|title=Vaping illness, deaths likely very rare beyond U.S., experts say|first=Kate|last=Kelland|publisher=[[Reuters]]|date=14 October 2019}}</ref> The first cases of this particular outbreak were identified in Illinois and Wisconsin in April 2019; as of 18 February 2020, a total of 2,807 hospitalized cases, including 68 deaths, have been confirmed. According to the U.S [[Centers for Disease Control and Prevention|Centers for Disease Control]] (CDC), "[[Vitamin E acetate]] is strongly linked to the EVALI outbreak...Evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either [[Tetrahydrocannabinol|THC]] or non-THC products, in some of the reported EVALI cases".<ref name=CDC2020/>

Cases peaked in September 2019, and have slowly declined since. The CDC stopped reporting on EVALI cases in February 2020, due to the decline in cases, but as of December 2020, continues to monitor cases that may arrive in emergency departments.<ref name=":0" /> Some states continue to record new EVALI cases. As of January 2022, the state of California has reported at least 40 cases on their update page, that were diagnosed after February 2020.<ref> {{cite web|url=https://www.cdph.ca.gov/Programs/CCDPHP/Pages/EVALI-Weekly-Public-Report.aspx |title=E-cigarette, or Vaping, Associated Lung Injury (EVALI) California Brief Update|date=4 January 2022|website= cdph.ca.gov |access-date=3 June 2022}}</ref> According to an article in the Radiological Society of North America news published in March 2022, EVALI cases continue to be diagnosed. "EVALI has by no means disappeared," Dr. Kligerman said. "We continue to see numerous cases, even during the pandemic, many of which are initially misdiagnosed as COVID-19."<ref>{{cite web |url=https://www.rsna.org/news/2022/march/EVALI-Diagnosis |title=Differentiating EVALI from COVID-19 on Imaging Proves Challenging |work=[[Radiological Society of North America]] |date=March 10, 2022 |first=Nick |last=Klenske |access-date=August 1, 2022 }}</ref> There have been at least 73 cases diagnosed in Utah after the last CDC update of February 2020.<ref>{{cite journal |last1=Blagev |first1=Denitza P |last2=Callahan |first2=Sean J |last3=Harris |first3=Dixie |last4=Collingridge |first4=Dave S. |last5=Hopkins |first5=Ramona O |last6=Eve |first6=Jacqueline R. |last7=Waddoups |first7=Lindsey |last8=Aston |first8=Valerie |last9=Brown |first9=Samuel |last10=Lanspa |first10=Michael J |title=Prospectively Assessed Long-Term Outcomes of Patients with E-cigarette or Vaping-associated Lung Injury (EVALI) |journal=Annals of the American Thoracic Society |date=9 May 2022 |volume=19 |issue=11 |pages=AnnalsATS.202201–049OC |doi=10.1513/AnnalsATS.202201-049OC|pmid=35533314 |pmc=9667811 |s2cid=248669259 |pmc-embargo-date=November 1, 2023 }}</ref>

CDC investigators identified direct exposure to chemicals present in illegal cannabis vaping products as a likely culprit for the outbreak, but the CDC did not rule out other chemicals in nicotine vapes as possible causes.<ref name="CDC-Press-Briefing-Transcript-2019" /> Vitamin E acetate is a very strong culprit of concern in the lung illnesses related to THC-based vaping products but according to the CDC, "No specific e-cigarette device or substance has been linked to all cases, and e-cigarettes include a variety of chemical and additives; consumers may not know what these products contain."<ref name="CDC2020" /> Though patients have reported using vaping products containing THC, [[nicotine]], or both types, 84% of patients studied by the CDC admitted THC use.<ref name=":0">{{cite web|date=28 October 2019|title=New CDC Report Provides First Analysis of Lung Injury Deaths Associated with Use of E-cigarette, or Vaping, Products {{!}} CDC|url=https://www.cdc.gov/media/releases/2019/p1028-first-analysis-lung-injury-deaths.html|access-date=19 June 2020|website=www.cdc.gov}}</ref><ref name="CDC2020" /> The majority of those affected were young adults aged 18–34, which is the group with the greatest prevalence of cannabis use in the U.S.<ref name="KingJones2020">{{cite journal|last1=King|first1=Brian A.|last2=Jones|first2=Christopher M.|last3=Baldwin|first3=Grant T.|last4=Briss|first4=Peter A.|title=The EVALI and Vaping Epidemics — Implications for Public Health|journal=New England Journal of Medicine|volume=382|issue=8|pages=689–691|year=2020|issn=0028-4793|doi=10.1056/NEJMp1916171|pmid=31951683|pmc=7122126|doi-access=free}}</ref>

Nicotine-containing products are regulated in the U.S. by the [[Food and Drug Administration]] (FDA) which has not approved any vape product for sale; THC products are illegal under federal law, but allowed and regulated by some states. Prior to the outbreak, vitamin E acetate was used in low concentrations, lower than 20% of the formula in vape cartridges, as a [[thickening agent]].<ref name="Dickson-2019" /> As a result of a limited availability of cannabis in California, as well as high demand, illicit sellers had used about 50% or higher of diluent thickeners in their formulas to bulk up tiny potency vape cartridges to create the illegal and dangerous products,<ref name="Dickson-2019" /> and vitamin E acetate is a common choice because it resembles THC oil.<ref name="CDC2020" />  Some jurisdictions took action to restrict the sale of products containing vitamin E acetate and other chemicals in response to the outbreak, but THC products in states where it is illegal are produced unlawfully (and sometimes obtained illegally in jurisdictions where legal, by uninformed consumers).

In 2021, researchers at Johns Hopkins University analyzed the vape aerosols of popular brands such as Juul and Vuse, and found "nearly 2,000 chemicals, the vast majority of which are unidentified."<ref>{{cite web| url= http://www.https://releases.jhu.edu/2021/10/06/johns-hopkins-finds-thousands-of-unknown-chemicals-in-e-cigarettes/ |title= Johns Hopkins Finds Thousands of Unknown Chemicals in E-Cigarettes |date= 6 October 2021|website= Johns Hopkins|access-date= 13 April 2022}}</ref> The CDC has not ruled out nicotine vapes as a possible additional cause of some cases of EVALI.<ref name=CDC2020/>

==Public health recommendations==
The CDC recommends that the public should consider not using any vaping products during their investigation, particularly those containing THC from informal sources like friends, family, or in-person or online dealers as of 20 November 2019.<ref name=CDC2020/> The U.S. FDA considers it prudent to avoid inhaling vitamin E acetate.<ref name=FDA-2019/> On 6 September 2019, the U.S. FDA stated that because consumers cannot be sure whether any THC vaping products may contain vitamin E acetate, consumers are urged to avoid buying vaping products on the street, and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.<ref name=FDA-2019/> The CDC recommends that e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant.<ref name=CDC2020/> Adults who do not currently use [[List of tobacco products|tobacco products]] should not start using e-cigarettes or vaping products, according to the CDC.<ref name=CDC2020/>

==Background==
According to a systematic review article, "Initial case reports of vaping-related lung injury date back to 2012, but the ongoing outbreak of EVALI began in the summer of 2019..."<ref>{{cite journal |last1=Jonas|first1=Andrea M |last2= Raj |first2=Rishi |title= Vaping-Related Acute Parenchymal Lung Injury: A Systematic Review|journal=Chest |date=18 May 2020 |volume= 158 |issue=4 |pages=1555–1565 |doi=10.1016/j.chest.2020.03.085 |pmid=32442559 |s2cid=218857503 }}</ref>  At least 19 cases of vaping-associated pulmonary injuries had been reported worldwide prior to 2019.<ref name=Langreth2019>{{cite news|url=https://www.insurancejournal.com/news/national/2019/09/30/541486.htm|title=How Early Signs of Lung Effects of Vaping Were Missed and Downplayed|last1=Langreth|first1=Robert|last2=Etter|first2=Lauren|work=Insurance Journal|date=30 September 2019}}</ref> The first case of [[electronic cigarette|e-cigarettes]] inducing [[lipid pneumonia]] was documented in the medical literature in 2012,<ref name=Eissenberg2019>{{cite news|url=https://www.theguardian.com/commentisfree/2019/sep/05/vaping-risk-regulation-lungs|title=Vaping is risky. Do not do it if you care about your lungs|last=Eissenberg|first=Thomas|work=[[The Guardian]]|date=5 September 2019}}</ref> though the causative agent was identified as [[glycerol|glycerin]], not vitamin E acetate. Glycerin was long thought to be a safe additive in e-cig liquid. However, the [[carcinogen]] [[formaldehyde]] is known as a product of [[propylene glycol]] and glycerol vapor degradation,<ref>{{cite journal |last1=Lestari |first1=Kusuma S. |last2=Humairo |first2=Mika Vernicia |last3=Agustina |first3=Ukik |title=Formaldehyde Vapor Concentration in Electronic Cigarettes and Health Complaints of Electronic Cigarettes Smokers in Indonesia |journal=Journal of Environmental and Public Health |date=11 July 2018 |volume=2018 |pages=9013430 |doi=10.1155/2018/9013430 |pmid=30105059 |pmc=6076960 |issn=1687-9805|doi-access=free }}</ref> and these ingredients may also cause lung inflammation.<ref>{{cite web |title=Vaping propylene glycol and vegetable glycerine may lead to lung inflammation |url=https://www.news-medical.net/news/20191018/Vaping-propylene-glycol-and-vegetable-glycerine-may-lead-to-lung-inflammation.aspx |website=News-Medical.net |date=18 October 2019}}</ref>

[[Lipid pneumonia]] is known to cause lung inflammation, with exogenous and endogenous factors that cause this disease.

== United States ==

Cases involved in the outbreak of severe vaping-associated pulmonary injury were first identified in Illinois and Wisconsin in April 2019.<ref name=LaydenGhinai2019/> As of 18 February 2020, a total of 2,807 hospitalized cases of lung illness associated with the use of vaping products have been reported to the [[Centers for Disease Control and Prevention]] (CDC) from 50 states, the [[Washington, D.C.|District of Columbia]], and two US territories ([[Puerto Rico]] and [[United States Virgin Islands|US Virgin Islands]]).<ref name=CDC2020/> The potential cases of severe lung illness have been associated with the use of vaping products such as devices, liquids, refill pods, and cartridges.<ref name=SchierMeiman2019/> On 12 September 2019, the CDC no longer reported possible cases.<ref name=CDC-2019/> The CDC changed its reporting methodology from counting possible cases, to reporting probable and confirmed cases where patients recently vaped, developed a breathing illness, and either had some tests that were performed to rule out infection, or testing did not show an infection.<ref name=CDC-2019/> The CDC stated the possible cases are still under investigation at the state level.<ref name=CDC-2019>{{cite press release|url=https://www.cdc.gov/media/releases/2019/s0912-update-cases-vaping.html|title=CDC, states update number of cases of lung disease associated with e-cigarette use, or vaping|publisher=Centers for Disease Control and Prevention|date=12 September 2019}}{{PD-notice}}</ref> 

As of 3 December 2019, the CDC is only reporting hospitalized vaping-associated lung illness cases and vaping-associated lung illness deaths, regardless of hospitalization status.<ref name=CDC2020/> As of 15 October 2019, the CDC has reported on 1,358 people with data on age and gender: 70% of people are male.<ref name=CDC2020/> The median age of persons is 24 years, and ages range from 13 to 75 years.<ref name=CDC2020/> 79% of persons are under 35 years old.<ref name=CDC2020/> Prevalence of lung disease attributable to vaping is likely [[under-reporting|under reported]], as cases brought to the CDC are some of the most severe.<ref name=BoudiPatel2019/>

Symptoms typically develop over a period of days, but can sometimes manifest over several weeks.<ref name=CDC-HAN-2019>{{cite web|url=https://emergency.cdc.gov/han/han00421.asp|title=Severe Pulmonary Disease Associated with Using E-Cigarette Products|publisher=Centers for Disease Control and Prevention|date=30 August 2019}}{{PD-notice}}</ref> In many cases, patients reported a gradual start of symptoms, including: breathing difficulty, [[shortness of breath]], and/or [[chest pain]] before hospitalization.<ref name=FDA2019/> Based on reports from several states, patients have experienced respiratory symptoms (cough, shortness of breath, or chest pain), while some have also experienced gastrointestinal symptoms (nausea, vomiting, or diarrhea) or non-specific symptoms (fatigue, fever, or weight loss).<ref name=CDC2020/> Some cases reported mild to moderate gastrointestinal illness.<ref name=FDA2019/> Some patients have reported that their symptoms developed over a few days, while others have reported that their symptoms developed over several weeks.<ref name=CDC2020/> Some patients have reported that their gastrointestinal symptoms began before their respiratory symptoms.<ref name=CDC2020/> Fever, elevated heart rate, and elevated white blood cell count have been reported, even though no infectious disease has been identified.<ref name=CDC2020/> Many patients sought medical care in ambulatory settings, sometimes over several visits, before they were admitted to the hospital.<ref name=CDC2020/>

[[File:Percentage of persons needing intubation and hospitalization among patients with e-cigarette, or vaping, product use associated lung injury.png|thumb|right|Percentage of persons needing intubation and hospitalization among persons with vaping-associated lung injury.<ref name=SiegelJatlaoui2019>{{cite journal|last1=Siegel|first1=David A.|last2=Jatlaoui|first2=Tara C.|last3=Koumans|first3=Emily H.|last4=Kiernan|first4=Emily A.|last5=Layer|first5=Mark|last6=Cates|first6=Jordan E.|last7=Kimball|first7=Anne|last8=Weissman|first8=David N.|last9=Petersen|first9=Emily E.|last10=Reagan-Steiner|first10=Sarah|last11=Godfred-Cato|first11=Shana|last12=Moulia|first12=Danielle|last13=Moritz|first13=Erin|last14=Lehnert|first14=Jonathan D.|last15=Mitchko|first15=Jane|last16=London|first16=Joel|last17=Zaki|first17=Sherif R.|last18=King|first18=Brian A.|last19=Jones|first19=Christopher M.|last20=Patel|first20=Anita|last21=Delman|first21=Dana Meaney|last22=Koppaka|first22=Ram|last23=Griffiths|first23=Anne|last24=Esper|first24=Annette|last25=Calfee|first25=Carolyn S.|author-link25=Carolyn Calfee|last26=Hayes|first26=Don|last27=Rao|first27=Devika R.|last28=Harris|first28=Dixie|last29=Smith|first29=Lincoln S.|last30=Aberegg|first30=Scott|last31=Callahan|first31=Sean J.|last32=Njai|first32=Rashid|last33=Adjemian|first33=Jennifer|last34=Garcia|first34=Macarena|last35=Hartnett|first35=Kathleen|last36=Marshall|first36=Kristen|last37=Powell|first37=Aaron Kite|last38=Adebayo|first38=Adebola|last39=Amin|first39=Minal|last40=Banks|first40=Michelle|last41=Cates|first41=Jordan|last42=Al-Shawaf|first42=Maeh|last43=Boyle-Estheimer|first43=Lauren|last44=Briss|first44=Peter|last45=Chandra|first45=Gyan|last46=Chang|first46=Karen|last47=Chevinsky|first47=Jennifer|last48=Chiang|first48=Katelyn|last49=Cho|first49=Pyone|last50=DeSisto|first50=Carla Lucia|last51=Duca|first51=Lindsey|last52=Jiva|first52=Sumera|last53=Kaboré|first53=Charlotte|last54=Kenemer|first54=John|last55=Lekiachvili|first55=Akaki|last56=Miller|first56=Maureen|last57=Mohamoud|first57=Yousra|last58=Perrine|first58=Cria|last59=Shamout|first59=Mays|last60=Zapata|first60=Lauren|last61=Annor|first61=Francis|last62=Barry|first62=Vaughn|last63=Board|first63=Amy|last64=Evans|first64=Mary E.|last65=Gately|first65=Allison|last66=Hoots|first66=Brooke|last67=Pickens|first67=Cassandra|last68=Rogers|first68=Tia|last69=Vivolo-Kantor|first69=Alana|last70=Cyrus|first70=Alissa|last71=Boehmer|first71=Tegan|last72=Glidden|first72=Emily|last73=Hanchey|first73=Arianna|last74=Werner|first74=Angela|last75=Zadeh|first75=Shideh Ebrahim|last76=Pickett|first76=Donna|last77=Fields|first77=Victoria|last78=Hughes|first78=Michelle|last79=Neelam|first79=Varsha|last80=Chatham-Stephens|first80=Kevin|last81=O'Laughlin|first81=Kevin|last82=Pomeroy|first82=Mary|last83=Atti|first83=Sukhshant K.|last84=Freed|first84=Jennifer|last85=Johnson|first85=Jona|last86=McLanahan|first86=Eva|last87=Varela|first87=Kate|last88=Layden|first88=Jennifer|last89=Meiman|first89=Jonathan|last90=Roth|first90=Nicole M.|last91=Browning|first91=Diane|last92=Delaney|first92=Augustina|last93=Olson|first93=Samantha|last94=Hodges|first94=Dessica F.|last95=Smalley|first95=Raschelle|title=Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019|journal=MMWR. Morbidity and Mortality Weekly Report|volume=68|issue=41|pages=919–927|year=2019|issn=0149-2195|doi=10.15585/mmwr.mm6841e3|pmid=31633675|pmc=6802682}}{{PD-notice}}</ref>|alt=Percentage of persons needing intubation and hospitalization among persons with vaping-associated lung injury.]]
Many patients have required medical treatment with supplemental oxygen.<ref name=CDC2020/> Some required assisted ventilation.<ref name=CDC2020/> Some patients have been treated with [[corticosteroid]]s with demonstrated improvement.<ref name=CDC2020/> Evidence does not suggest an infectious disease is the cause of the severe pulmonary disease.<ref name=CDC2020/> Antibiotic therapy alone has not consistently been associated with clinical improvement.<ref name=CDC2020/> A handful of individuals have been re-admitted for clinical care after discharge for lung injury.<ref name=CDC---2019/> The CDC does not know whether individuals who were re-admitted continued or restarted use.<ref name=CDC---2019/> The range of time that the CDC is aware of for these re-admissions ranges from approximately five days after discharge, to 55 days after discharge.<ref name=CDC---2019>{{cite web|url=https://www.cdc.gov/media/releases/2019/t1011-lung-injury-investigation.html|title=Transcript of CDC Telebriefing: Lung Injury Investigation|publisher=Centers for Disease Control and Prevention|date=11 October 2019}}{{PD-notice}}</ref>

As of 5 September 2019, the [[New York State Department of Health]] reported 34 cases of severe lung illness in patients who were reportedly using different vaping products.<ref name=NSDH2019/> Tests conducted by the [[Wadsworth Center]] found exceedingly high amounts of [[tocopheryl acetate|vitamin E acetate]] in most of the cannabis e-cigarette products.<ref name=NSDH2019/> "At least one vape product containing vitamin E acetate has been linked to each patient who submitted a product for testing," the New York State Department of Health stated.<ref name="Tanne2019">{{cite journal |last1=Tanne |first1=Janice Hopkins |year=2019 |title=Don't vape, CDC says, as US lung disease epidemic grows |journal=BMJ |volume=366 |pages=l5479 |doi=10.1136/bmj.l5479 |issn=0959-8138 |pmid=31501087 |s2cid=202414987}}</ref> None of the [[nicotine]]-based product samples contained vitamin E acetate.<ref name=NSDH2019>{{cite web|url=https://www.health.ny.gov/press/releases/2019/2019-09-05_vaping.htm|title=New York State Department of Health Announces Update on Investigation into Vaping-Associated Pulmonary Illnesses|publisher=[[New York State Department of Health]]|date=5 September 2019}}</ref> According to the reports from Illinois and Wisconsin, the onset of respiratory findings appeared to have occurred over several days to several weeks before hospitalization.<ref name=SchierMeiman2019>{{cite journal|last1=Schier|first1=Joshua G.|last2=Meiman|first2=Jonathan G.|last3=Layden|first3=Jennifer|last4=Mikosz|first4=Christina A.|last5=VanFrank|first5=Brenna|last6=King|first6=Brian A|last7=Salvatore|first7=Phillip P.|last8=Weissman|first8=David N.|last9=Thomas|first9=Jerry|last10=Melstrom|first10=Paul C.|last11=Baldwin|first11=Grant T.|last12=Parker|first12=Erin M.|last13=Courtney-Long|first13=Elizabeth A.|last14=Krishnasamy|first14=Vikram P.|last15=Pickens|first15=Cassandra M.|last16=Evans|first16=Mary E.|last17=Tsay|first17=Sharon V.|last18=Powell|first18=Krista M.|last19=Kiernan|first19=Emily A.|last20=Marynak|first20=Kristy L.|last21=Adjemian|first21=Jennifer|last22=Holton|first22=Kelly|last23=Armour|first23=Brian S.|last24=England|first24=Lucinda J.|last25=Briss|first25=Peter A.|author26-link=Debra Houry |last26=Houry|first26=Debra|last27=Hacker|first27=Karen A.|last28=Reagan-Steiner|first28=Sarah|last29=Zaki|first29=Sherif|last30=Meaney-Delman|first30=Dana|collaboration=CDC 2019 Lung Injury Response Group|title=Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance|journal=MMWR. Morbidity and Mortality Weekly Report|volume=68|issue=36|pages=787–790|year=2019|issn=0149-2195|doi=10.15585/mmwr.mm6836e2|pmc=6755818|pmid=31513561}}{{PD-notice}}</ref> As of 5 September 2019, the [[Illinois Department of Public Health]] reported 42 cases of lung illness, seven that were still being investigated, and one death.<ref name=IDPH-2019>{{cite web|url=http://dph.illinois.gov/topics-services/prevention-wellness/tobacco/e-cigarettes-and-vapes|title=2019 Respiratory Illnesses in Illinois|publisher=[[Illinois Department of Public Health]]|date=5 September 2019}}</ref> Severe lung illness among young adults and youth who used vaping products required hospitalization in 11 cases in Wisconsin, and others were being investigated in August 2019.<ref name=WDHS2019/> Symptoms were difficulty breathing, tiredness, chest pain, cough, and reduced weight.<ref name=WDHS2019/> Some required assistance to breathe.<ref name=WDHS2019>{{cite web|url=https://www.dhs.wisconsin.gov/news/releases/080219.htm|title=New Cases Identified in Investigation of Lung Disease Among Teens and Young Adults Who Reported Vaping|publisher=[[Wisconsin Department of Health Services]]|date=2 August 2019}}</ref>

On 9 August 2019, the [[California Department of Public Health]] issued a statement regarding a cluster of seven healthy adults in [[Kings County, California]], all of whom required hospitalization.<ref name=CDPH2019/> Since June 2019, at least seven cases of severe acute pulmonary illness in previously healthy adults were reported from a hospital in Kings County, California.<ref name=CDPH2019/> Cases were among residents of multiple counties.<ref name=CDPH2019/> The patients presented with progressive respiratory distress, sometimes initially diagnosed with pneumonia or bronchitis, and some with preceding fevers and gastrointestinal symptoms.<ref name=CDPH2019/> All cases failed to respond to an initial course of antibiotic treatment.<ref name=CDPH2019/> All patients required admission to the hospital with significant respiratory support, including high-flow oxygen, [[non-invasive ventilation|bilevel positive airway pressure]] (BIPAP), or intubation with [[mechanical ventilation]].<ref name=CDPH2019/> Diagnoses included [[pneumonitis]] and [[acute respiratory distress syndrome]] (ARDS).<ref name=CDPH2019/> Several cases of vaping-associated pulmonary injury (VAPI) and acute respiratory distress syndrome (ARDS) in California were connected to vaping cannabis products that were traced back to [[pop-up retail]]ers.<ref name=TCHHSA2019>{{cite web|url=http://hhsawebdocs.tchhsa.org/questys.cmx.hhsawebdocs/File.ashx?id=5092|archive-url=https://web.archive.org/web/20191010172121/http://hhsawebdocs.tchhsa.org/questys.cmx.hhsawebdocs/File.ashx?id=5092|url-status=dead|archive-date=10 October 2019|title=Health Officials Report Death in Vaping Related Lung Disease|publisher=Tulare County Health & Human Services Agency|date=16 September 2019}}</ref> Patients have improved with systemic steroids.<ref name=CDPH2019/> Evaluation for infectious etiologies has been negative to date in all patients.<ref name=CDPH2019/> All patients reported vaping in the weeks prior to hospital admission, and a reported common exposure among these patients is that they have been vaping [[cannabis]] or [[cannabidiol|CBD oil]]s.<ref name=CDPH2019>{{cite web|url=http://publichealth.lacounty.gov/eprp/Health%20Alerts/CDPHPulmonaryDiseaseandVaping081219.pdf|title=Severe Acute Pulmonary Disease Associated with Cannabis or Cannabidiol Oil Vaping|publisher=[[1988 California Proposition 99|California Tobacco Control Program]]|agency=[[California Department of Public Health]]|pages=1–4|date=9 August 2019}}{{PD-notice}}</ref>

=== Deaths ===

[[File:2019 US vaping lung disease outbreak - fatalities.svg|thumb|right|450px|A total of 68 deaths linked to [[electronic cigarette|vaping products]] have been confirmed as of 18 February 2020 among 27 states and the District of Columbia.<ref name=CDC2020/>{{legend|#e98dc1|At least one death linked to a vaping product.}}
{{legend|#a23d97|At least two deaths linked to a vaping product.}}
{{legend|#da2636|At least three deaths linked to a vaping product.}}
{{legend|#f58219|At least four deaths linked to a vaping product.}}
{{legend|#eec500|At least five deaths linked to a vaping product.}}
{{legend|#bfbebe|Hospitalizations but no confirmed deaths.}}
|alt=A total of 68 deaths linked to vaping products have been confirmed among 27 states and the District of Columbia: Alabama, California (4), Connecticut, Delaware, District of Columbia, Florida, Georgia (3), Illinois (5), Indiana (4), Kansas (2), Louisiana, Massachusetts (3), Michigan, Minnesota (3), Mississippi, Missouri (2), Montana, Nebraska, New Jersey, New York (2), Oregon (2), Pennsylvania, Rhode Island, South Carolina, Tennessee (2), Texas, Utah, and Virginia.]]

As of 18 February 2020, a total of 68 deaths, many linked to illegal ([[black market]]) cannabis vaping products have been confirmed in 27 states and the District of Columbia: Alabama, California (4), Connecticut, Delaware, District of Columbia, Florida, Georgia (3), Illinois (5), Indiana (4), Kansas (2), Louisiana, Massachusetts (3), Michigan, Minnesota (3), Mississippi, Missouri (2), Montana, Nebraska, New Jersey, New York (2), Oregon (2), Pennsylvania, Rhode Island, South Carolina, Tennessee (2), Texas, Utah, and Virginia.<ref name=CDC2020/> The median age of deceased persons was 51 years, and ranged from 15 to 75 years, as of 14 January 2020.<ref name=CDC2020/>

==Canada ==

On 18 September 2019, a case of severe lung illness associated with vaping in Canada was reported.<ref name=Gillies2019/> A high school student in Ontario needed to be put on [[life support]].<ref name=Gillies2019/> The person had been vaping every day.<ref name=Dubinski2019>{{cite news|url=https://www.cbc.ca/news/canada/london/vaping-respiratory-illness-london-1.5288065|title=Ontario teen was on life-support after respiratory illness linked to vaping|last=Dubinski|first=Kate|publisher=CBC.ca|date=18 September 2019}}</ref> His health improved and he was released from the hospital.<ref name=Gillies2019>{{cite news|url=https://www.apnews.com/ec8cd33f6cfb4af7b66a3850e9097516|title=Youth in Canada is diagnosed with illness related to vaping|last=Gillies|first=Rob|work=Associated Press|date=18 September 2019}}</ref> This case has not been confirmed, as 27 September 2019.<ref name=CBC.ca/> He vaped intensively, adding THC to his devices.<ref name=BoudiPatel2019/> He initially showed symptoms aligning with [[bronchiolitis]] (lung condition normally caused by a bacterial or viral infection), but many patients that have vape-related illnesses in the United States have experienced damage to the [[Pulmonary alveolus|pulmonary alveoli]]; this type of injury was not found.<ref name=BoudiPatel2019/> Instead, his case aligned more with an injury called [[Bronchiolitis obliterans|popcorn lung]], an ailment most commonly seen in factory workers of microwave popcorn plants nearly 20 years ago.<ref name=BoudiPatel2019/>

On 27 September 2019, it was announced the first confirmed case of a vaping-related lung illness in Canada.<ref name=CBC.ca/> A Montreal resident in Quebec in their 50s was admitted to a hospital with breathing difficulties.<ref name=CBC.ca/> The person had been vaping to help them [[smoking cessation|give up smoking]].<ref name=CBC.ca>{{cite news|url=https://www.cbc.ca/news/canada/montreal/vaping-related-illness-quebec-1.5299487|title=Quebec resident confirmed as first Canadian case of vaping-related illness|publisher=[[CBC.ca]]|date=27 September 2019}}</ref> [[Chief Public Health Officer of Canada]] announced on 11 October 2019, that they are aware of the initial cases of vaping-associated lung illness, and they stated that a few other occurrences are being investigated.<ref name=PHAC2019/> Three probable cases have been reported in [[British Columbia]] as of 7 November 2019,<ref name=CBC.ca-2019>{{cite news|url=https://www.cbc.ca/news/canada/british-columbia/bc-vaping-illness-2-more-confirmed-1.5352421|title=2 more probable cases of vaping-related illness confirmed in B.C.|publisher=CBC.ca|date=7 November 2019}}</ref> and other cases are under investigation in British Columbia.<ref name=Ross2019>{{cite news|url=https://www.cbc.ca/news/canada/british-columbia/vaping-illnesses-bc-1.5319214|title=6 people in B.C. have reported illnesses potentially related to vaping since June|last=Ross|first=Andrea|publisher=CBC.ca|date=11 October 2019}}</ref> Two probable cases have been reported in [[New Brunswick]] as of 16 October 2019.<ref name=Lindsay2019>{{cite news|url=https://www.cbc.ca/news/canada/british-columbia/bc-vaping-illness-confirmed-1.5323647|title=First probable case of vaping-related illness confirmed in B.C.|last=Lindsay|first=Bethany|publisher=CBC.ca|date=16 October 2019}}</ref>

A case in [[Newfoundland and Labrador]] was reported as a probable case of a lung illness tied to vaping in January 2020.<ref name=TCP2020/> A person became sick in late 2019 following the use of a cannabis product.<ref name=TCP2020/> The person has since been released from the hospital.<ref name=TCP2020>{{cite news|url=https://www.msn.com/en-ca/news/canada/first-probable-vaping-related-illness-reported-in-newfoundland-and-labrador/ar-BBZ3XNl|title=First probable vaping-related illness reported in Newfoundland and Labrador|publisher=[[The Canadian Press]]|date=17 January 2020}}</ref> As of 4 February 2020, 17 cases of lung injuries have been reported to the [[Public Health Agency of Canada]].<ref name=PHAC2020/> Reported cases were from Alberta (1), British Columbia (3), New Brunswick (2), Newfoundland and Labrador (1), Ontario (4), and Quebec (6).<ref name=PHAC2020/> 14 people required hospitalization.<ref name=PHAC2020>{{cite web|url=https://www.canada.ca/en/public-health/services/diseases/vaping-pulmonary-illness.html|title=Vaping-associated lung illness|publisher=[[Public Health Agency of Canada]]|date=5 February 2020}}</ref>

== Other countries ==

What has occurred in the United States has not occurred in other places where vaping is frequent, such as the UK.<ref name="Kelland2019" /> In European countries such as France, there is no evidence of an outbreak of the vaping-associated lung illness that occurred in the US.<ref name=Wheaton2019>{{cite news|url=https://www.politico.eu/article/us-vaping-illness-death-toll-rises-fear-reversals-anti-smoking-campaigns/|title=Europe's missing 'vaping sickness'|last=Wheaton|first=Sarah|work=[[Politico]]|date=12 September 2019}}</ref>

== Investigation ==

[[File:Telebriefing Vaping 10112019.ogg|thumb|right|11 October 2019 [[Centers for Disease Control and Prevention]] audio of the telebriefing conference call with reporters.<ref name=CDC---2019/> An update into the cases of lung injury linked to vaping.<ref name=CDC---2019/>|alt=11 October 2019 audio of the telebriefing Centers for Disease Control and Prevention conference call with reporters. An update into the cases of lung injury linked to vaping.]]

[[File:Sounding the Alarm - The Public Health Threats of E-Cigarettes.webm|thumb|right|Sounding the Alarm: The Public Health Threats of E-Cigarettes.<ref name=EC2019>{{cite web|url=https://energycommerce.house.gov/committee-activity/hearings/hearing-on-sounding-the-alarm-the-public-health-threats-of-e-cigarettes|title=Hearing on "Sounding the Alarm: The Public Health Threats of E-Cigarettes"|date=25 September 2019}}</ref>|alt=Sounding the Alarm: The Public Health Threats of E-Cigarettes.]]

[[File:FDA’s Forensic Chemistry Center.jpg|thumb|right|US FDA's Forensic Chemistry Center.<ref name=FDA---2019/>|alt=US FDA's Forensic Chemistry Center.]]

Investigators from multiple states in the US are collaborating with the [[Centers for Disease Control and Prevention]] (CDC) and the US [[Food and Drug Administration]] (US FDA) to determine the cause of the lung illnesses associated with the use of vaping products.<ref name=Richtel2019>{{cite news|url=https://www.nytimes.com/2019/09/07/health/vaping-lung-illness.html|title=What You Need To Know About Vaping-Related Lung Illness|last1=Richtel|first1=Matt|last2=Grady|first2=Denise|work=[[The New York Times]]|date=7 September 2019}}</ref>

On 6 September 2019, Dr. Dana Meaney-Delman, serving as the incident manager of CDC's response to this outbreak, said that "Based on the clinical and laboratory evidence to date, we believe that a chemical exposure is likely associated with these illnesses. However, and I really want to stress this, more information is needed to determine which specific products or substances are involved. We are aware that some laboratories have identified vitamin E acetate in product samples, and we have connected those laboratories with the FDA Forensic laboratories to compare results. At this time, no one device, product, or substance has been linked to all cases. Continued investigation is needed to better understand if a true relationship exists between any specific product or substance and the illnesses observed in patients. To find the answer we will need to combine information about e-cigarette use, and product sample testing and the clinical information from patients."<ref name=CDC-Press-Briefing-Transcript-2019>{{cite web|url=https://www.cdc.gov/media/releases/2019/t0906_telebriefing_investigation_pulmonary_disease_e-cigarettes.html|title=Transcript of September 6, 2019, Telebriefing: Investigation of Pulmonary Disease Among People Who Use E-cigarettes|publisher=Centers for Disease Control and Prevention|date=6 September 2019}}{{PD-notice}}</ref>

Many patients have acknowledged recent use of [[tetrahydrocannabinol]] (THC)-containing e-cigarette products while speaking to healthcare personnel, or in follow-up interviews by health department staff.<ref name=FDA2019>{{cite web|url=https://www.fda.gov/safety/medical-product-safety-information/e-cigarette-products-safety-communication-due-incidents-severe-respiratory-disease-associated-use-e|title=E-Cigarette Products: Safety Communication - Due to the Incidents of Severe Respiratory Disease Associated with Use of an E-Cigarette Product|publisher=United States Food and Drug Administration|date=30 August 2019}}{{PD-notice}}</ref> On 6 September 2019, ''[[The New England Journal of Medicine]]'' reported that "Information on product use is based on reports by the patients, and patients may be reluctant to report illicit drug use."<ref name=LaydenGhinai2019/> On 2 October 2019, ''The New England Journal of Medicine'' reported that the histologic evidence suggests that the "vaping-associated lung injury represents a form of airway-centered chemical pneumonitis from one or more inhaled toxic substances rather than exogenous lipoid pneumonia as such, but the agents responsible remain unknown."<ref name=ButtSmith2019/> They also stated that this "finding should be interpreted with caution."<ref name=ButtSmith2019>{{cite journal|last1=Butt|first1=Yasmeen M.|last2=Smith|first2=Maxwell L.|last3=Tazelaar|first3=Henry D.|last4=Vaszar|first4=Laszlo T.|last5=Swanson|first5=Karen L.|last6=Cecchini|first6=Matthew J.|last7=Boland|first7=Jennifer M.|last8=Bois|first8=Melanie C.|last9=Boyum|first9=James H.|last10=Froemming|first10=Adam T.|last11=Khoor|first11=Andras|last12=Mira-Avendano|first12=Isabel|last13=Patel|first13=Aiyub|last14=Larsen|first14=Brandon T.|title=Pathology of Vaping-Associated Lung Injury|journal=New England Journal of Medicine|volume=381|issue=18|pages=1780–1781|year=2019|issn=0028-4793|doi=10.1056/NEJMc1913069|pmid=31577870|doi-access=free}}</ref> On 17 October 2019, the ''[[American Journal of Clinical Pathology]]'' reported that lung [[Biopsy|biopsies]] from eight patients with vaping-associated lung injury show acute lung injury patterns, not exogenous lipoid pneumonia.<ref name=MukhopadhyayMehrad2019>{{cite journal|last1=Mukhopadhyay|first1=Sanjay|last2=Mehrad|first2=Mitra|last3=Dammert|first3=Pedro|last4=Arrossi|first4=Andrea V|last5=Sarda|first5=Rakesh|last6=Brenner|first6=David S|last7=Maldonado|first7=Fabien|last8=Choi|first8=Humberto|last9=Ghobrial|first9=Michael|title=Lung Biopsy Findings in Severe Pulmonary Illness Associated With E-Cigarette Use (Vaping): A Report of Eight Cases|journal=American Journal of Clinical Pathology|volume=153|issue=1|pages=30–39|year=2019|issn=0002-9173|doi=10.1093/ajcp/aqz182|pmid=31621873|doi-access=free}}</ref>

Of the 2,506 reported cases, information is available in the three months prior to symptom onset for 1,782 of them as of 3 December 2019.<ref name=CDC2020/> 80% reported THC use, 35% reported exclusive THC use, about 54% reported using nicotine-containing products, and 13% reported exclusive use of nicotine-containing products.<ref name=CDC2020/> The CDC reported that their findings suggest vaping products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, or illicit dealers), are linked to most of the cases, and play a major role in the outbreak.<ref name=CDC2020/>

On 8 November 2019, Dr. Anne Schuchat, principal deputy director of the CDC, said, "for the first time we have detected a potential toxin of concern — Vitamin E acetate — in biologic samples from patients with lung injuries associated with the use of e-cigarette or vaping products."<ref name=CDC----2019/> The sample types were [[bronchoalveolar lavage]] (BAL) fluid samples (fluid samples collected from the lungs).<ref name=CDC2020/> The chemical was found in samples collected from ten different states, from the lungs of 29 patients with the disease.<ref name=CDC----2019/> "These findings provide direct evidence of Vitamin E acetate at the primary site of injury within the lungs," said Dr. Schuchat.<ref name=CDC----2019/> The CDC tested for a wide range of substances that might be found in e-cigarette or vaping products including [[types of plant oils|plant oil]], [[petrochemical|petroleum distillates]] like [[mineral oil]], [[medium-chain triglyceride|medium-chain triglyceride oils]] – or MCT oils – and [[terpene]]s which are compounds found in or added to THC products. No other potential [[toxicant]]s were detected in the testing conducted so far.<ref name=CDC----2019/> The CDC did not rule out other possible compounds or ingredients that may be causing the lung injuries.<ref name=CDC----2019>{{cite web|url=https://www.cdc.gov/media/releases/2019/t1108-telebriefing-vaping.html|title=Transcript of CDC Telebriefing: Update on Lung Injury Associated with E-cigarette Use, or Vaping|publisher=Centers for Disease Control and Prevention|date=8 November 2019}}{{PD-notice}}</ref> No one compound or ingredient has emerged as the cause of these illnesses so far; and it may be that there is more than one cause of this outbreak.<ref name=CDC2020/>

Many of the samples tested by the states or by the US FDA, as part of the 2019 investigation, have been identified as vaping products containing tetrahydrocannabinol (or THC, a [[psychoactive drug|psychoactive]] component of the [[cannabis|cannabis plant]]) and further, most of those samples with THC tested also contained significant amounts of vitamin E acetate.<ref name=FDA-2019/> Vitamin E acetate is a substance present in topical consumer products or dietary supplements, but data is limited about its effects after inhalation.<ref name=FDA-2019/> While the US FDA does not have enough data presently to conclude that vitamin E acetate is the cause of the lung injury in these cases, the agency believes it is prudent to avoid inhaling this substance.<ref name=FDA-2019/> The US FDA's Forensic Chemistry Center serves as the FDA's national laboratory, and is playing a critical role in fact-gathering and analysis for the incidents of lung illnesses following vaping product use.<ref name=FDA---2019>{{cite web|url=https://www.fda.gov/news-events/public-health-focus/lung-illnesses-associated-use-vaping-products|title=Lung Illnesses Associated with Use of Vaping Products|publisher=United States Food and Drug Administration|date=18 October 2019}}{{PD-notice}}</ref>

== Illicit vaping ==

{{multiple issues|section=1|{{tone|section|date=February 2020}}{{cleanup rewrite|section=yes|date=February 2020}}}}

[[File:NYSDOH Announces Update on Investigation into Vaping-Associated Pulmonary Illnesses (48683410247).jpg|thumb|right|250px|Some of the [[electronic cigarette|vaping products]] analyzed by the [[Wadsworth Center]] contained exceedingly high amounts of [[tocopheryl acetate|vitamin E acetate]], including those pictured here.<ref name=NSDH2019/>|alt=Some of the vaping products that contained exceedingly high amounts of vitamin E acetate, including those pictured here.]]

[[File:Frequently reported brand names of THC and nicotine-containing e-cigaretteor vaping products reported by patients with lung injury — Illinois and Wisconsin, 2019.jpg|thumb|right|Frequently reported brand names of THC and nicotine-containing e-cigarette or vaping products reported by patients with lung injury — Illinois and Wisconsin, 2019.<ref name=GhinaiPray2019/>|alt=Frequently reported brand names of THC and nicotine-containing e-cigarette or vaping products reported by patients with lung injury — Illinois and Wisconsin, 2019.]]

Inhalation of chemicals or substances is considered to be the main cause of the lung illnesses.<ref name=Furlow2019>{{cite journal|last1=Furlow|first1=Bryant|title=US state governments investigate suspected vaping-associated severe lung disease|journal=The Lancet Respiratory Medicine|volume=7|issue=11|pages=934–935|year=2019|issn=2213-2600|doi=10.1016/S2213-2600(19)30303-0|pmid=31477520|doi-access=free}}</ref> [[Counterfeit]] cannabis cartridges are being sold to users at a reduced cost.<ref name=Greene2019>{{cite web|url=https://thenextweb.com/insights/2019/08/29/bootleg-vape-cartridges-linked-to-outbreak-of-potentially-fatal-lung-illness/|publisher=[[The Next Web]]|title=Bootleg vape cartridges linked to outbreak of potentially fatal lung illness|first=Tristan|last=Greene|date=28 August 2019}}</ref> [[Dank Vapes]] is an [[black market|illicit]] brand that uses a cartridge.<ref name=Downs2019/> There is no singular company that owns Dank Vapes;<ref name=Betuel2019/> there have been hundreds of people selling Dank Vapes cartridges.<ref name=Betuel2019>{{cite news|url=https://www.inverse.com/article/58581-dank-vapes|title=Dank Vapes Is the "Biggest Conspiracy" in Pot That Can Put You in a Coma|last=Betuel|first=Emma|work=[[Inverse (website)|Inverse]]|date=19 August 2019}}</ref> Dank Vapes appears to be the most prominent in a class of largely counterfeit brands, with common packaging that is easily available online, and that is used by distributors to market THC-containing cartridges with no obvious centralized production or distribution.<ref name=GhinaiPray2019>{{cite journal|last1=Ghinai|first1=Isaac|last2=Pray|first2=Ian W.|last3=Navon|first3=Livia|last4=O'Laughlin|first4=Kevin|last5=Saathoff-Huber|first5=Lori|last6=Hoots|first6=Brooke|last7=Kimball|first7=Anne|last8=Tenforde|first8=Mark W.|last9=Chevinsky|first9=Jennifer R.|last10=Layer|first10=Mark|last11=Ezike|first11=Ngozi|last12=Meiman|first12=Jonathan|last13=Layden|first13=Jennifer E.|title=E-cigarette Product Use, or Vaping, Among Persons with Associated Lung Injury — Illinois and Wisconsin, April–September 2019|journal=MMWR. Morbidity and Mortality Weekly Report|volume=68|issue=39|year=2019|pages=865–869|issn=0149-2195|doi=10.15585/mmwr.mm6839e2|pmid=31581166|pmc=6776374}}{{PD-notice}}</ref> Some of the vaping products that contained exceedingly high amounts of vitamin E acetate include [[Chronic Carts]] and Dank Vapes.<ref name=NSDH2019/> Illicit vape brands have been sold across multiple states in the US.<ref name=Downs--2019>{{cite news|url=https://www.leafly.com/news/health/vape-pen-lung-disease-advice-consumers|title=Vape Pen Lung Disease: Here's What You Need to Know|first=David|last=Downs|publisher=Leafy|date=9 September 2019}}</ref> As of 27 August 2019, the most frequently used product reported by patients experiencing respiratory, gastrointestinal, and/or constitutional symptoms in Illinois and Wisconsin was the THC product called Dank Vapes.<ref name=LaydenGhinai2019/> Dank Vapes was the most commonly reported product brand used by patients nationwide, although there are regional differences.<ref name=CDC2020/> While Dank Vapes was most commonly reported in the Northeast and South, TKO and Smart Cart brands were more commonly reported by patients in the West, and Rove was more common in the Midwest.<ref name=CDC2020/> The composition of THC based oils is, to a large extent, unknown.<ref name=LaydenGhinai2019 />

==Public health recommendations==
The CDC recommends that the public should consider not using any vaping products during their investigation, particularly those containing THC from informal sources like friends, or family, or in-person or online dealers as of 20 November 2019.<ref name=CDC2020/> The US FDA considers it prudent to avoid inhaling vitamin E acetate.<ref name=FDA-2019/> On 6 September 2019, the US FDA stated that because consumers cannot be sure whether any THC vaping products may contain vitamin E acetate, consumers are urged to avoid buying vaping products on the street, and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.<ref name=FDA-2019/> The CDC recommends that e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant.<ref name=CDC2020/> Adults who do not currently use [[tobacco products]] should not start using e-cigarette, or vaping, products, according to the CDC.<ref name=CDC2020/>

Various diluent thickening products were sold online via wholesale suppliers.<ref name=Peel2019/> There has been an increase in attention to companies that sell diluent products that are made with vitamin E acetate.<ref name=Dickson-2019>{{cite magazine|url=https://www.rollingstone.com/culture/culture-features/vaping-honey-cut-mystery-thickener-vitamin-e-acetate-vapes-881896/|title=Three Companies Subpoenaed in Weed Vape Illness Investigation|last=Dickson|first=EJ|magazine=[[Rolling Stone]]|date=10 September 2019}}</ref> A lot of speculation has focused on Honey Cut.<ref name=Dickson2019>{{cite magazine|url=https://www.yahoo.com/entertainment/vitamin-e-oil-behind-vaping-193531987.html|title=Is Vitamin E Oil Behind the Vaping Crisis?|last=Dickson|first=EJ|magazine=Rolling Stone|publisher=Yahoo! Entertainment|date=6 September 2019}}</ref> Honey Cut, used as a diluent thickener, became widely used in [[Los Angeles]]' vape pen manufacturing plants in late 2018.<ref name="Downs2019">{{cite news|url=https://www.leafly.com/news/health/vape-pen-lung-disease-thc-oil-additive-investigation|title=Vape Pen Lung Disease Has Insiders Eyeing Misuse of New Additives|first=David|last=Downs|publisher=Leafy|date=30 August 2019}}</ref> After Honey Cut became widely used in THC vape cartridges many other similar products from other companies were introduced into the market in early 2019.<ref name="Downs---2019" /> The maker of Honey Cut's product is not known, and the only way to purchase the product was from the company's website.<ref name="Downs-2019" /> In early September 2019, the Honey Cut website went offline<ref name="Dickson-2019" /> and Honey Cut told sellers in the [[Toy District, Los Angeles]] area to discontinue offering its products for sale.<ref name="DownsHoward2019">{{cite news|url=https://www.leafly.com/news/politics/vape-pen-injury-supply-chain-investigation-leafly|title=Journey of a tainted vape cartridge: from China's labs to your lungs|first1=David|last1=Downs|last2=Howard|first2=Dave|last3=Barcott|first3=Bruce|publisher=Leafy|date=24 September 2019}}</ref> Counterfeit products [[made in China|from China]] that look like Honey Cut products were being sold, which increased the confusion in regard to which products people may have been vaping.<ref name="Kuznia2019">{{cite news|url=https://www.washingtonpost.com/health/potential-culprits-in-mystery-lung-illnesses-black-market-vaping-products/2019/09/24/cb5b708e-d98d-11e9-ac63-3016711543fe_story.html|title=Potential culprits in mystery lung illnesses: Black-market vaping products|first1=Rob |last1=Kuznia |first2=Lena H.|last2=Sun|newspaper=[[The Washington Post]]|date=24 September 2019}}</ref>

The company Floraplex in Michigan has shutdown the buyers page for their Uber Thick brand.<ref name=Downs-2019>{{cite news|url=https://www.leafly.com/news/health/some-vape-cart-additive-makers-pull-products-others-go-dark|title=Vape Cart Additive Makers Pull Products as Others Go Dark|first=David|last=Downs|publisher=Leafy|date=6 September 2019}}</ref> The diluent products called Clear Cut were sold by Connoisseur Concentrates from [[Tigard, Oregon]].<ref name=Peel2019/> Clear Cut is no longer available from the company's website.<ref name=Peel2019/> The company acknowledged the products contained vitamin E acetate.<ref name=Peel2019/> The company stated that it began selling the products in May 2019 and was reviewed by the [[Oregon Liquor Control Commission]].<ref name=Peel2019>{{cite news|url=https://www.wweek.com/news/state/2019/09/09/leading-oregon-cannabis-extractor-pulls-line-of-vape-products-off-its-website-as-health-questions-swirl/|title=Leading Oregon Cannabis Extractor Pulls Line of Vape Products Off Its Website as Health Questions Swirl|last=Peel|first=Sophie|publisher=[[Willamette Week]]|date=9 September 2019}}</ref> As of 10 September 2019, Mass Terpenes' Pure Thickener diluent is no longer available on its website.<ref name=Dickson-2019/> A cache of the product on its website stated, "a proprietary formula composed simply of flavorless terpenes and a derivative of Vitamin E (to preserve color and consistency)."<ref name=Dickson-2019/> Aaron Riley, CEO of [[CannaSafe]], stated that likely about 75-80% of illicit vapes use some type of diluent agent.<ref name=Dickson-2019/> Drew Jones of Mr Extractor stated in September 2019 that as high as 70% of illicit cannabis vape cartridges in the US contain vitamin E acetate.<ref name=Downs----2019>{{cite news|url=https://www.leafly.com/news/industry/vapi-vape-pen-lung-disease-regulators|title=Regulators, Industry React to Vitamin E-Tainted Vape Carts|first=David|last=Downs|publisher=Leafy|date=9 September 2019}}</ref> It is estimated that at least 40 companies in the US sold a cutting agent containing vitamin E acetate.<ref name=Downs---2019/> [[Thickening agent]]s have been sold online as a less costly and safer substitute.<ref name=NSOG2019>{{cite web|url=https://www.governor.ny.gov/news/governor-cuomo-takes-aggressive-action-protect-new-yorkers-harmful-and-addictive-vaping|title=Governor Cuomo Takes Aggressive Action to Protect New Yorkers from Harmful and Addictive Vaping Products Following Rise in Vaping-Associated Illnesses Nationwide|publisher=[[Governor of New York]]|date=9 September 2019}}</ref>

Thickening agents were used to water down and bulk up vape oils.<ref name=Dickson-2019/> Thickening agents were used mostly in THC vape products.<ref name=Dickson-2019/> Vitamin E acetate was used to cut THC oil to dilute it.<ref name=Kirkham2019>{{cite news|url=https://www.reuters.com/article/us-health-vaping-industry-explainer-idUSKCN1VY2ET|title=Explainer: One possible culprit in vaping lung illnesses - 'Dank Vapes'|first1=Chris|last1=Kirkham|first2=Jeffrey|last2=Dastin|publisher=Reuters|date=13 September 2019}}</ref> Vitamin E acetate dilutes vape oil without making it look like the oil was watered down.<ref name=Johnson2019>{{cite news|url=https://abcnews.go.com/Health/wireStory/us-vaping-illness-outbreak-65576094|title=What we know about the US vaping illness outbreak|last=K. Johnson|first=Carla|work=[[ABC News]]|date=12 September 2019}}</ref> Previously, vitamin E was used in low concentrations, or lower than 20% of the formula in vape cartridges.<ref name=Dickson-2019/> As a result of a limited availability of cannabis in California as well as high demand, illicit sellers had used about 50% or higher of diluent thickeners in their formulas to bulk up tiny potency vape cartridges.<ref name=Dickson-2019/> Thomas Whitten, a consultant at WeedRAR, said to ''[[Rolling Stone]]'' that "there's so much cutting agent even the people who made the cutting agent didn't expect it to be cut that much."<ref name=Dickson-2019/> Some cannabis laboratories began making arrangements in September 2019 to provide testing services for vitamin E.<ref name=Lotus2019>{{cite news|url=https://www.upi.com/Top_News/US/2019/09/12/Vaping-lung-disease-Legal-pot-labs-start-testing-for-vitamin-E-in-cannabis-oil/8491568299191/|title=Vaping lung disease: Legal pot labs start testing for vitamin E in cannabis oil|last=Lotus|first=Jean|publisher=[[United Press International]]|date=12 September 2019}}</ref>

Regulations in legal markets for cannabis use allow the use of many additives such as tocopherols (various forms of vitamin E).<ref name=Downs---2019/> However, regulators may be considering banning such substances in the near future, as of September 2019.<ref name=Downs---2019>{{cite news|url=https://www.leafly.com/news/health/vape-pen-lung-disease-vitamin-e-oil-explained|title=Amid Vape Pen Lung Disease Deaths: What Exactly Is Vitamin E Oil?|first=David|last=Downs|publisher=Leafy|date=11 September 2019}}</ref> As of December 2019, Washington state has now banned vape products containing vitamin E acetate, thought to be linked to illness.<ref name=BoudiPatel2019/> Although the substance is not banned in the United States and has not been officially declared as a deadly substance, many states are making advances to ban the use of the chemical in vape products.<ref name=BoudiPatel2019/> States like Massachusetts are considering a ban on flavored tobacco and vape products, and in New York, Manhattan is expected to become the largest city to ban all vaping flavors except tobacco.<ref name=BoudiPatel2019/> Other states that have already banned the use of vitamin E acetate in vape products include Colorado and Ohio.<ref name=BoudiPatel2019>{{cite journal|last1=Boudi|first1=F Brian|last2=Patel|first2=Sonia|last3=Boudi|first3=Ava|last4=Chan|first4=Connie|title=Vitamin E Acetate as a Plausible Cause of Acute Vaping-related Illness|journal=Cureus|volume=11|issue=12|pages=e6350|year=2019|issn=2168-8184|doi=10.7759/cureus.6350|pmc=6952050|pmid=31938636}}{{CC-notice|cc=by3|url=https://www.cureus.com/articles/25498-vitamin-e-acetate-as-a-plausible-cause-of-acute-vaping-related-illness|author(s)=F Brian Boudi, Sonia Patel, Ava Boudi, Connie Chan}}</ref>

== Legal proceedings ==

=== Subpoenas ===

In September 2019, New York Governor [[Andrew Cuomo]] instructed the state health department to issue [[subpoena]]s against three sellers of thickening agents used in illicit vaping products.<ref name=Goldman2019>{{cite news|url=https://www.bloomberg.com/news/articles/2019-09-09/ny-s-cuomo-signals-crackdown-on-vaping-products-after-illnesses|title=Cuomo Signals N.Y. Crackdown on Vaping Products After Illnesses|last=Goldman|first=Henry|publisher=[[Bloomberg News]]|date=9 September 2019}}</ref> The subpoenas are being served against Honey Cut Labs in Santa Monica, California, for its Honey Cut product; Floraplex Terpenes in Ypsilanti, Michigan, for its Uber Thick product; and Mass Terpenes in Amherst, Massachusetts, for its product.<ref name=Sun2019>{{cite news|url=https://www.washingtonpost.com/health/2019/09/09/new-york-subpoena-firms-selling-substances-linked-illicit-vaping-products/|title=New York to subpoena firms selling substances linked to illicit vaping products|last=H. Sun|first=Lena|newspaper=The Washington Post|date=9 September 2019}}</ref> All three firms sell a product used as a thickener in vape liquids.<ref name=Klepper2019>{{cite news|url=https://www.usnews.com/news/best-states/new-york/articles/2019-09-09/new-york-to-require-health-warnings-in-vape-shops|title=New York to Require Health Warnings in Vape Shops|last=Klepper|first=David|work=[[U.S. News & World Report]]|agency=Associated Press|date=9 September 2019}}</ref> The thickeners from all three firms were found to contain mostly vitamin E acetate, according to test results from the [[Wadsworth Center]].<ref name=NSOG2019/>

=== Criminal cases ===
On 5 September 2019, Tyler Huffhines and Jacob Huffhines were [[arrest]]ed.<ref name=Smith2019/> [[Search warrant]]s were served on a house at their place of residence and at a leased condominium.<ref name=Smith2019/> In September 2019, an investigation in [[Kenosha County, Wisconsin]], is underway to determine whether a major operation ran by the Huffhines brothers for purportedly making illicit THC vape cartridges, which were packed in containers to resemble candy and were thought to have been [[electronic cigarette and e-cigarette liquid marketing#Marketing to youth|marketed to youth]], could be related to a series of vaping-induced lung illness and deaths in the US.<ref name=Smith2019>{{cite news|url=https://www.kenoshanews.com/news/crime/investigators-say-paddock-lake-brothers-drug-operation-was-aimed-at/article_4560c684-38be-573c-8b94-5ce17c9e57e2.html|title=Authorities investigating whether Paddock Lake brothers drug operation related to vape illnesses|last=Smith|first=Deneen|work=[[Kenosha News]]|date=11 September 2019}}</ref> The purportedly candy-themed containers used names such as Sour Patch.<ref name=Winsor2019/> In January 2018, Tyler Huffhines purportedly began the operation.<ref name=Winsor2019/> The vape cartridges purportedly contained as high as 1,000&nbsp;milligrams of THC,<ref name=Winsor2019>{{cite news|url=https://abcnews.go.com/US/wisconsin-brothers-accused-running-illegal-thc-vape-cartridge/story?id=65558903|title=Wisconsin brothers accused of running illegal THC vape cartridge 'empire'|last=Winsor|first=Morgan|work=ABC News|date=13 September 2019}}</ref> when the packaging stated it was just 5&nbsp;milligrams.<ref name=Mole2019>{{cite news|url=https://arstechnica.com/science/2019/09/black-market-thc-vape-operation-busted-in-wisconsin-police-say/|title=Black-market THC-vape operation busted in Wisconsin, police say|first=Beth|last=Mole|work=[[Ars Technica]]|date=12 September 2019}}</ref> Roughly [[United States dollar|$]]1.5 million worth of THC products were seized during the raid.<ref name=Pelisek2019>{{cite news|url=https://people.com/crime/wisconsin-man-20-accused-of-running-large-scale-counterfeit-thc-vaping-scheme-national-epidemic/|title=Wisconsin Man, 20, Accused of Running Large-Scale Counterfeit THC Vaping Scheme: 'National Epidemic'|last=Pelisek|first=Christine|work=[[People (magazine)|People]]|date=11 September 2019}}</ref> 57 mason jars containing THC oil were also seized during the raid.<ref name=Jewell2019/> Each jar was worth about $6,000.<ref name=Jewell2019>{{cite news|url=https://fox6now.com/2019/09/11/2-men-accused-of-operating-empire-of-illegal-drugs-in-kenosha-county/|title=Brothers accused of operating 'empire of illegal drugs' in Kenosha County|last=Jewell|first=Hannah|publisher=[[WITI (TV)|FOX6 News]]|date=11 September 2019}}</ref>

An initial appearance in [[Kenosha County Courthouse and Jail|Kenosha County court]] was held for both brothers on 16 September 2019.<ref name=Williams2019/> Tyler Huffhines is facing multiple drug-related charges including possession with intent to deliver THC.<ref name=Williams2019/> Jacob Huffhines is facing charges including being a [[felony|felon]] in possession of a firearm and possession of THC.<ref name=Williams2019/> Bond for Tyler Huffhines was set $500,000.<ref name=Williams2019/> Bond for Jacob Huffhines was set at $50,000.<ref name=Williams2019/> Both are scheduled to return to court on 26 September 2019.<ref name=Williams2019>{{cite news|url=https://fox6now.com/2019/09/16/kenosha-county-brothers-now-charged-accused-of-running-massive-drug-operation/|title=Kenosha County brothers charged, accused of running massive drug operation|last=Williams|first=Derica|publisher=FOX6 News|date=16 September 2019}}</ref> The Huffhines brothers pleaded not guilty on 23 October 2019.<ref name=FOX6News2019/>

Courtney Huffhines, the mother of Jacob and Tyler Huffhines, was charged with assisting her sons run the illegal THC vape operation.<ref name=Smith-2019/> A woman was arrested in connection with the THC vape operation.<ref name=Smith-2019>{{cite news|url=https://madison.com/news/local/crime-and-courts/racine-woman-in-custody-related-to-large-kenosha-county-thc/article_e3d87372-1ea8-53a7-95b9-05d533ee894c.html|title=Racine woman, 20, in custody related to large Kenosha County THC vaping case; mother posts bond|last=Smith|first=Deneen|work=[[Wisconsin State Journal]]|date=3 October 2019}}</ref> On 3 October 2019, Hannah Curty was charged with making THC, as a party to an offense against the law.<ref name=Abad2019/> She is scheduled to return to court on 11 October 2019.<ref name=Abad2019>{{cite news|url=https://www.cbs58.com/news/19-year-old-woman-arrested-in-connection-with-huffhines-family-thc-cartridge-investigation|title=19-year-old worker arrested in connection with Huffhines' family THC cartridge investigation|last=Abad|first=Jacquelyn|publisher=[[WDJT-TV]]|date=3 October 2019}}</ref> Courtney Huffhines and Hannah Curty were in court on 11 October 2019.<ref name=WISN-TV2019/> Both women are due to return to court on 23 October 2019.<ref name=WISN-TV2019>{{cite news|url=https://www.wisn.com/article/two-women-accused-in-thc-vape-ring-will-stand-trial/29443086|title=2 women accused in THC vape ring will stand trial|last=Abad|first=Jacquelyn|publisher=[[WISN-TV]]|date=11 October 2019}}</ref> Courtney Huffhines and Hannah Curty pleaded not guilty on 23 October 2019.<ref name=FOX6News2019>{{cite news|url=https://fox6now.com/2019/10/23/not-guilty-pleas-entered-by-4-of-5-suspects-in-massive-thc-vape-operation/|title=Not guilty pleas entered by 4 of 5 suspects in massive THC vape operation|publisher=FOX6 News|date=23 October 2019}}</ref>

On 17 October 2019, 22-year-old Jordan Lynam was charged with making THC vape cartridges in relation to the Huffhines's purportedly illicit vaping operation.<ref name=WDJT-TV2019>{{cite news|url=https://www.cbs58.com/news/authorities-make-5th-arrest-in-kenosha-county-thc-vaping-business|title=Authorities make 5th arrest in Kenosha County THC vaping business|publisher=WDJT-TV|agency=Associated Press|date=17 October 2019}}</ref>

Daniel Graumenz, Wesley Webb, and Tarail King are facing charges in relation to the illicit vaping operation.<ref name=WDJT--TV2019>{{cite news|url=https://www.cbs58.com/news/3-more-people-charged-in-wisconsin-thc-vape-manufacturing|title=3 more people charged in Kenosha County THC vape manufacturing|publisher=WDJT-TV|agency=Associated Press|date=22 October 2019}}</ref>

=== Civil lawsuits ===
{{See also|Vail v. Juul Labs, Inc.}}
On 23 September 2019, a [[product liability]] lawsuit, ''Charles Wilcoxson v. Canna Brand Solutions LLC et al.'', was filed in [[List of Superior Court Districts in Washington|Superior Court of Pierce County, Washington]], against makers of THC vape cartridges.<ref name=L2019/> Wilcoxson, a peace officer, had used THC vape products between January 2018 and September 2019.<ref name=L2019/> He bought cannabis products that included Conscious Cannabis, Rainbows Aloft, Leafwerx, MFused, and Jane's Garden, and a Canna Brand Solutions vaporizer, all of which were cited as defendants.<ref name=L2019/> The plaintiff was hospitalized for three days in September 2019 with [[wheeze|wheezing]] and [[lipid pneumonia|lipoid pneumonia]] as a result of his vaping, according to the complaint.<ref name=L2019>{{cite news|url=https://www.lexology.com/library/detail.aspx?g=917722ad-b0f0-4437-bd55-05a4516ae589|title=The First of the Vape-Lung Product Liability Cases Has Been Filed|publisher=Lexology|date=2 October 2019}}</ref>

In September 2019, 35-year-old Erin Gilbert from [[Virgin Islands]] filed a lawsuit against Just CBD in a [[Broward County, Florida]] court, contending that her sickness was the result of a [[cannabidiol|CBD]] vape oil containing mango flavor that she had purchased from a merchant in [[Saint Croix]].<ref name=Kapnick2019/> After just a few days of using the vape oil, she had severe respiratory problems, multiple organ failure, and [[asphyxia|deficient supply of oxygen]], resulting in [[necrosis]] of her legs, both of which had to be amputated.<ref name=Kapnick2019>{{cite news|url=https://www.courthousenews.com/vaping-firms-brace-for-wave-of-lawsuits-over-lung-illness/|title=Vaping Companies Brace for Wave of Lawsuits Over Lung Illness|last=Kapnick|first=Izzy|publisher=[[Courthouse News Service]]|date=25 October 2019}}</ref>

In May 2019, a 21-year-old was hospitalized for more than two weeks due to fluid in his lungs and was in a [[induced coma|medically induced coma]] for 8 days.<ref name=Bernabe2019/> He had purportedly [[nicotine dependence|developed an addiction]] to Juul mint pods, which he had been using since age 19.<ref name=Balk2019>{{cite news|url=https://www.nydailynews.com/news/national/ny-juul-coma-lawsuit-20191023-ejq4iezkozgm7ptiyy6ygyszbi-story.html|title=Pennsylvania man, 21, sues Juul after spending week in medically induced coma|last=Balk|first=Tim|work=[[New York Daily News]]|date=22 October 2019}}</ref> In October, the patient sued Juul, complaining the company did not disclose the dangers of its pod system and deceptively advertised its products as being safer than combustible [[cigarette]]s.<ref name=Bernabe2019/> The suit also claimed Juul aimed to intentionally entice underage individuals and young adults with their product, as well as individuals who had never been smokers in the firm place.<ref name=Bernabe2019>{{cite news|url=https://abcnews.go.com/GMA/News/juul-user-21-sues-company-hospitalized-coma-days/story?id=66431800|title=Former Juul user, 21, sues company after being hospitalized, placed in coma for 8 days|last1=Bernabe|first1=Angeline Jane|last2=Wagschal|first2=Andgerry|work=[[ABC News]]|date=22 October 2019}}</ref>

In September 2019, a lawsuit was brought on behalf of an 18-year-old from Illinois who had been hospitalized with lung damage from vaping. The plaintiff charged Juul with targeting teens with false marketing{{clarify|date=October 2022}} of a dangerous product, and a gas station for allowing him to buy vaping products as a minor.<ref name=Dampier2019>{{cite news|url=https://www.chicagotribune.com/lifestyles/ct-life-vaping-illness-lawsuit-hergenreder-tt-0913-20190913-biuvgihs55hmfnu3ab7td5rhoa-story.html|title=A Gurnee teen hospitalized for a vaping-related illness is suing e-cigarette company Juul|last=Dampier|first=Cindy|work=[[Chicago Tribune]]|date=13 September 2019}}</ref>

On 29 October 2019, the Los Angeles Unified School District, the second largest district in the nation filed a class action suit against Juul for creating an epidemic of youth vaping that impedes student learning and endangers the health and safety of more than 600,000 students in the Los Angeles School District.<ref>{{cite web|url=https://www.psblaw.com/2019/10/29/los-angeles-unified-school-district-files-class-action-lawsuit-against-e-cigarette-manufacturer-juul-labs-inc/|title=Los Angeles Unified School District Files Class Action Lawsuit Against E-Cigarette Manufacturer JUUL Labs, Inc.|date=29 October 2019|website=Panish Shea & Boyle LLP|access-date=6 April 2020}}</ref> As of January 2020, a total of 10 California school districts have filed a lawsuit against Juul Labs, Inc. The suit seeks injunctive relief and abatement remedy to fight against the vaping epidemic in California school districts.<ref>{{cite web|url=https://www.psblaw.com/2020/01/22/10-california-school-districts-file-suit-against-juul-for-vaping-epidemic-impeding-student-education/|title=10 California School Districts File Suit Against JUUL for Vaping Epidemic Impeding Student Education|date=23 January 2020|website=Panish Shea & Boyle LLP|access-date=6 April 2020}}</ref>

== Responses ==

=== E-cigarette industry ===

The e-cigarette industry is placing the blame on illicit vaping liquids for the lung injuries.<ref name=Vergano2019/> "Each day of this crisis brings more evidence that street vapes containing THC or other illegal drugs are responsible for these illnesses, not nicotine vaping products," said Gregory Conley of the [[American Vaping Association]], in August 2019.<ref name=Vergano2019>{{cite news|url=https://www.buzzfeednews.com/article/danvergano/vaping-illness-outbreak-spread|title=The Vaping Lung Illness Outbreak Has Now Spread To 25 States|last=Vergano|first=Dan|work=[[BuzzFeed News]]|date=30 August 2019}}</ref> "Like any health-related events reportedly associated with the use of vapor products, we are monitoring these reports," [[Juul|Juul Labs]] stated to ''[[Reuters]]'' in August 2019.<ref name=Joyner2019/> The company also stated that some news agencies report that several cases of lung illness are associated with vaping THC, found in cannabis, "a [[Schedule 1 controlled substance]] that we do not sell."<ref name=Joyner2019>{{cite news|url=https://www.reuters.com/article/us-health-vaping-cdc/cdc-investigates-lung-illnesses-linked-to-e-cigarette-use-idUSKCN1V80MA|title=CDC probes lung illnesses linked to e-cigarette use|first=April|last=Joyner|publisher=[[Reuters]]|date=18 August 2019}}</ref>

However recent research using commercially sourced JUUL nicotine vape products has documented harms from these devices. A February 2022 research article on vape aerosol from JUUL products showed "Profound pathological changes to upper airway, lung tissue architecture, and cellular structure," of mice exposed for as little as 9 weeks. "This vaping-induced pulmonary injury model demonstrates mechanistic underpinnings of vaping-related pathologic injury." <<ref>{{cite journal |last1=Esquer|first1=Carolina|last2= Echeagaray |first2=Oscar | last3=Firouzi |first3= Fareheh |last4= Savko | first4= Clarissa |last5= Shain |first5 = Grant | last6= Bose |first6 = Pria | last7= Rieder | first7= Abigail | last8= Rokaw | first8= Sophie | last9 = Witon-Paulo | first9= Andrea |last10= Gude | first10= Natalie | last11= Sussman | first11= Mark | title= Fundamentals of vaping-associated pulmonary injury leading to severe respiratory distress |journal= Life Science Alliance |date= Feb 2022 |volume= 5 |issue=2 |pages=1555–1565 |doi=10.26508/lsa.202101246 |url=https://www.life-science-alliance.org/content/5/2/e202101246 |pmid=34810278 |pmc=8616545 }}</ref>

=== United States ===

The CDC recommends that people should not use e-cigarette, or vaping, products that contain THC, particularly from informal sources like friends, or family, or in-person or online dealers.<ref name=CDC2020/> Until the relationship of vitamin E acetate and lung health is better understood, vitamin E acetate should not be added to e-cigarette, or vaping, products.<ref name=CDC2020/> In addition, people should not add any substance to e-cigarette or vaping products that are not intended by the manufacturer, including products purchased through retail establishments.<ref name=CDC2020/> CDC also recommends that people should not modify or add any substances such as vitamin E acetate to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments.<ref name=CDC2020/> According to the CDC, if you are an adult using e-cigarettes, or vaping, products, to [[smoking cessation|quit smoking]], do not return to [[tobacco smoking|smoking cigarettes]].<ref name=CDC2020/> Adults addicted to nicotine using e-cigarettes should weigh all risks and benefits, and consider utilizing FDA-approved [[nicotine replacement therapy|nicotine replacement therapies]].<ref name=CDC2020/>

The US FDA considers it prudent to avoid inhaling vitamin E acetate.<ref name=FDA-2019/> On 6 September 2019, the US FDA stated that because consumers cannot be sure whether any THC vaping products may contain vitamin E acetate, consumers are urged to avoid buying vaping products on the street, and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.<ref name=FDA-2019>{{cite web|url=https://www.fda.gov/safety/medical-product-safety-information/tetrahydrocannabinol-thc-containing-vaping-products-vaping-illnesses|title=Tetrahydrocannabinol (THC)-containing Vaping Products: Vaping Illnesses|publisher=[[Food and Drug Administration|United States Food and Drug Administration]]|date=6 September 2019}}{{PD-notice}}</ref> On 4 October 2019, the US FDA strengthened its warning to consumers to stop using vaping products containing THC amid more than 1,000 reports of lung injuries—including some resulting in deaths—following the use of vaping products.<ref name=FDA--2019>{{cite web|url=https://www.fda.gov/consumers/consumer-updates/vaping-illness-update-fda-warns-public-stop-using-tetrahydrocannabinol-thc-containing-vaping|title=Vaping Illness Update: FDA Warns Public to Stop Using Tetrahydrocannabinol (THC)-Containing Vaping Products and Any Vaping Products Obtained Off the Street|publisher=United States Food and Drug Administration|date=4 October 2019}}{{PD-notice}}</ref>

"The legal vapes have been actively regulated by FDA since Aug 2017. FDA has conducted thousands of inspections of manufacturers and vape stores, published manufacturing guidance, sought product removals etc. These tragedies point to illegal vapes and THC," former FDA Commissioner [[Scott Gottlieb]] [[Twitter|tweeted]] in August 2019.<ref name=Fordham2019>{{cite news|url=https://finance.yahoo.com/news/former-fda-head-blames-counterfeit-170844233.html|title=Former FDA head blames counterfeit e-cigarettes for rise in vape-related lung disease|first=Evie|last=Fordham|publisher=[[Fox Business Network]]|agency=[[Yahoo! Finance]]|date=28 August 2019}}</ref> During an interviewed on [[CNBC]]'s ''[[Squawk Box]]'' on 9 September 2019, Gottlieb said that "the current belief is the illnesses are linked to illegal vapes containing vitamin E oil."<ref name=Bursztynsky2019/> He also stated that [[legal history of cannabis in the United States|cannabis products in the US]] should be regulated.<ref name=Bursztynsky2019>{{cite news|url=https://www.cnbc.com/2019/09/09/scott-gottlieb-federal-reckoning-needed-after-vaping-linked-deaths.html?recirc=taboolainternal|title=It's time for a 'federal reckoning' in the wake of vaping-linked deaths, says former FDA chief|last=Bursztynsky|first=Jessica|publisher=[[CNBC]]|date=9 September 2019}}</ref>

"The e-cigarette-related lung illnesses currently sweeping across the country reaffirm our belief that the use of e-cigarettes and vaping is an urgent public health epidemic that must be addressed. We must not stand by while e-cigarettes continue to go unregulated. We urge the U.S. Food and Drug Administration (FDA) to speed up the regulation of e-cigarettes and remove all unregulated products from the market. We also call on the FDA to immediately ban flavors, as well as marketing practices, that enhance the appeal of e-cigarette products to youth," Patrice A. Harris, the president of the [[American Medical Association]], stated on 9 September 2019.<ref name=AMA2019>{{cite web|url=https://www.ama-assn.org/press-center/ama-statements/ama-urges-public-avoid-e-cigarette-use-amid-lung-illness-outbreak|title=AMA urges public to avoid e-cigarette use amid lung illness outbreak|last=Harris|first=Patrice A.|publisher=[[American Medical Association]]|date=9 September 2019}}</ref> On 19 November 2019, the American Medical Association urged for a complete ban on all types of vaping products that are not approved by the US FDA as quitting smoking aids.<ref name=AMA-2019>{{cite web|url=https://www.ama-assn.org/press-center/press-releases/ama-calls-total-ban-all-vaping-products-not-approved-fda|title=AMA calls for total ban on all vaping products not approved by FDA|publisher=American Medical Association|date=19 November 2019}}</ref>

Various states have banned vitamin E acetate in vaping products, including Colorado, Ohio,<ref>[https://www.usatoday.com/story/news/health/2019/11/15/vitamin-e-acetate-deadly-thc-vape-additive-no-regulations-cdc/2569828001/ People are vaping a deadly substance along with THC. Why isn't vitamin E acetate illegal?]</ref> and Washington.<ref>[https://www.foxnews.com/health/washington-state-vape-products-vitamin-e-acetate-ban Washington state bans vape products that contain vitamin E acetate]</ref>

The governor of Massachusetts declared a public health emergency on 24 September 2019, and ordered a 4-month moratorium on the sale of all vaping products, both for nicotine and THC.<ref>{{cite news |url=https://www.bostonglobe.com/news/marijuana/2019/09/24/governor-baker-make-vaping-announcement-amid-spate-lung-illnesses/o8sO6mf3GOmX4mOpLLtcEL/story.html |title=Baker declares public health emergency, orders 4-month ban on all vaping products |date=24 September 2019 |access-date=1 August 2022 |work=Boston Globe |first=Matt |last=Stout }}</ref> After courts determined it had sole jurisdiction over THC products, the Massachusetts Cannabis Control Commission quarantine all THC vape products until they could be screened for vitamin E acetate and other chemicals.<ref>[https://www.bizjournals.com/boston/news/2019/11/12/massachusetts-regulators-quarantine-medical-vape.html Massachusetts regulators quarantine medical vape products as ban expires]</ref><ref>{{cite web |url=https://mass-cannabis-control.com/commission-amends-quarantine-order-to-permit-sale-of-marijuana-vaporizer-devices-and-newly-manufactured-marijuana-vaping-products/ |title=Commission Amends Quarantine Order to Permit Sale of Marijuana Vaporizer Devices and Newly Manufactured Marijuana Vaping Products |access-date=24 February 2020 |archive-date=18 February 2020 |archive-url=https://web.archive.org/web/20200218073336/https://mass-cannabis-control.com/commission-amends-quarantine-order-to-permit-sale-of-marijuana-vaporizer-devices-and-newly-manufactured-marijuana-vaping-products/ |url-status=dead }}</ref> A Massachusetts testing lab offering tests to consumers found vitamin E acetate was widespread in unlicensed products but not in licensed products.<ref>[https://greenrushdaily.com/health/massachusetts-lab-offers-first-two-vitamin-e-acetate-screenings-free/ Massachusetts Lab Offers First Two Vitamin E Acetate Screenings Free]</ref> The nicotine vaping ban was also challenged and ended early, but prompted the state legislature to ban flavored nicotine products to reduce underage vaping, among other new measures.<ref>[https://www.bostonglobe.com/news/marijuana/2019/12/10/mass-vape-sales-ban-lifts-wednesday-what-happens-next/LkJQ6cOvB3b2X9trN01o6M/story.html Ban on vape sales in Massachusetts ends Wednesday — what happens next?]</ref>

The federal government has been criticized for instituting bans on flavored products rather than passing caps on nicotine concentrations and establishing accountability measures for negligent marketing.<ref>{{cite web|title=US Policymakers are Failing to End the Vaping Public Health Crisis. Here's How We Can Stop It|url=https://www.crossfirekm.org/articles/us-policymakers-are-failing-to-end-the-vaping-public-health-crisis-heres-how-we-can-stop-it|access-date=30 June 2020|website=Crossfire KM}}</ref>

=== Canada ===

[[Health Canada]], the responsible government agency, responded to the US cases of potentially deadly lung illness by issuing a warning on 4 September 2019.<ref name=HC2019/> They advise that Canadians consider not using vaping products, monitor for symptoms, get a medical attention quickly if they have concerns, tell their doctor if and what they vape or have vaped, avoid the illegal and unregulated markets, avoid modifying vaping products, report adverse reactions, and monitor their advisory for updates.<ref name=HC2019/> They also stated for those who are vaping to watch for symptoms such as cough, shortness of breath, or chest pain.<ref name=HC2019>{{cite web|url=http://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2019/70939a-eng.php|title=Update on the potential risk of pulmonary illness associated with vaping products|author1=Government of Canada|publisher=[[Health Canada]]|date=9 September 2019}}</ref> On 11 October 2019, Chief Public Health Officer of Canada recommended to Canadians to consider holding back from vaping.<ref name=PHAC2019>{{cite web|url=https://www.canada.ca/en/public-health/news/2019/10/statement-from-the-council-of-chief-medical-officers-of-health-on-vaping-in-canada.html|title=Statement from the Council of Chief Medical Officers of Health on vaping in Canada|author1=Public Health Agency of Canada|publisher=[[Chief Public Health Officer of Canada]]|date=11 October 2019|author1-link=Public Health Agency of Canada}}</ref> Health Canada started a $766,000 advertisement campaign to curb underage vaping in part in response to the US and Canadian outbreak.<ref name=Pinkerton2020>{{cite news|url=https://ipolitics.ca/2020/02/03/health-canada-rolled-out-766000-emergency-ad-campaign-to-combat-youth-vaping/|title=Health Canada rolled out $766,000 emergency ad campaign to combat youth vaping|last=Pinkerton|first=Charlie|work=[[iPolitics]]|date=3 February 2020}}</ref>

=== Europe ===

"What little we know of recent reports from the U.S. is that the devices used appear to be linked to 'home brews' of illicit drugs and not legitimate vaping products," Martin Dockrell, overseer of [[tobacco control]] at [[Public Health England]], stated in September 2019.<ref name=Wheaton2019/>

=== Australia ===

As a result of a potential link between vaping and lung illness in the US, the [[Australian Medical Association]] stated on 18 September 2019, that they reiterate a [[precautionary principle|precautionary approach]] for the use of vaping products.<ref name=AMA--2019>{{cite web|url=https://ama.com.au/media/ama-backs-strong-response-vaping-deaths|title=AMA Backs Strong Response to Vaping Deaths|publisher=[[Australian Medical Association]]|date=18 September 2019}}</ref>

=== India ===

Following a string of deaths tied to vaping in the US, India has [[regulation of electronic cigarettes|banned the sales of vaping products]] in September 2019.<ref name=Robertson2019>{{cite news|url=https://www.theverge.com/2019/9/18/20872967/india-e-cigarette-vaping-ban-epidemic-health-risks|title=India bans e-cigarette sales and says there's an 'epidemic' of kids vaping|last=Robertson|first=Adi|work=[[The Verge]]|date=18 September 2019}}</ref>

=== World Health Organization ===

Dr. Vinayak Prasad, overseer of tobacco control at [[World Health Organization]], told [[CNN]] on 12 September 2019, that WHO was observing the events in the US and abroad and will provide information to governments at the appropriate time.<ref name=Hunt2019/> Prasad also stated that its member states have not made any announcements of lung illnesses that resemble those that were observed in the US.<ref name=Hunt2019>{{cite news|url=https://edition.cnn.com/2019/09/17/health/vaping-us-uk-e-cigarette-differences-intl/|title=The US and UK see vaping very differently. Here's why|last=Hunt|first=Katie|publisher=[[CNN]]|date=17 September 2019}}</ref>

== Hospitalized patients ==

News media featured hospitalized lung vaping illness patients in narratives including the following:
* Dehydration from nausea, [[pneumonia|multifocal pneumonia]], [[sepsis]], [[respiratory failure|acute respiratory failure]] with [[hypoxemia]], and [[thrombus|blood clot]]s, necessitating a [[induced coma|medically induced coma]] and removal of fluid from the lungs.<ref name=Harmata2019>{{cite news|url=https://people.com/health/texas-mom-almost-died-from-vaping-related-lung-illness/|title=Texas Mom Speaks Out After Almost Dying from Vaping-Related Illness: 'My Lungs Were Full of Fluid'|last=Harmata|first=Claudia|work=[[People (magazine)|People]]|date=20 September 2019}}</ref>
* Vomiting, coughing up blood, and [[lipoid pneumonia|lipid pneumonia]]<ref name="Bojórquez2019">{{cite news|url=https://www.deseret.com/utah/2019/8/6/20797673/what-utah-doctors-are-saying-about-vaping|title=What Utah doctors are saying about vaping|last=Bojórquez|first=Kim|work=[[Deseret News]]|date=6 August 2019}}</ref>
* Nausea, chest pains, shortness of breath, and acute respiratory distress syndrome necessitating [[extracorporeal membrane oxygenation]] (ECMO)<ref name=Sun2019a>{{cite news|url=https://www.washingtonpost.com/health/one-mans-near-death-experience-with-vaping-related-lung-failure/2019/08/24/ca8ce42c-c5b4-11e9-9986-1fb3e4397be4_story.html|title=He went from hiking enthusiast to 'on death's door' within days. Doctors blamed vaping.|last=H. Sun|first=Lena|newspaper=[[The Washington Post]]|date=24 August 2019}}</ref> 
* Shoulder and back pain, double lung collapse<ref name=Crash2019>{{cite news|url=https://cbs4indy.com/2019/09/12/marion-family-warns-about-vaping-dangers-after-teen-suffers-double-lung-collapse-it-was-traumatic/|title=Marion family warns about vaping dangers after teen suffers double lung collapse: 'It was traumatic'|last=Crash|first=Melissa|publisher=[[WTTV]]|date=12 September 2019}}</ref> 
* Vomiting, fever, sweating, painful coughing, [[bronchitis]], and [[classification of pneumonia#Double pneumonia (bilateral pneumonia)|double pneumonia]] in a patient who had vaped [[Tetrahydrocannabinol|THC]]<ref name=DownsHoward2019/>
* Vomiting up food, oil and water in the lungs, requiring supplemental oxygen for daily activities<ref name=Dillon2019>{{cite news|url=https://www.localsyr.com/news/man-fighting-vaping-related-lung-illness-if-i-die-let-somebody-else-live-off-of-my-mistake/|title=Man fighting vaping-related lung illness: "If I die, let somebody else live off of my mistake"|last=Dillon|first=Dominique|publisher=[[WSYR-TV]]|date=13 September 2019}}</ref>
* Severe pain in the side, lung collapse, "black spots" on the lungs in a patient using about half a [[Juul]] mint pod a day for about 18 months.<ref name=Hagen2019>{{cite news|url=https://www.newsweek.com/florida-teenager-warns-against-juuling-after-his-lung-collapsed-1453253|title=Florida Teenager Warns Against Juuling After His Lung Collapsed|last=Van Hagen|first=Isobel|work=[[Newsweek]]|date=8 August 2019}}</ref>
* Chest and back pain from recurrent [[Pneumothorax|pneumothoraces]] (air in the chest outside of the lungs)<ref name=BonillaBlair2019>{{cite journal|last1=Bonilla|first1=Alex|last2=Blair|first2=Alexander J.|last3=Alamro|first3=Suliman M.|last4=Ward|first4=Rebecca A.|last5=Feldman|first5=Michael B.|last6=Dutko|first6=Richard A.|last7=Karagounis|first7=Theodora K.|last8=Johnson|first8=Adam L.|last9=Folch|first9=Erik E.|last10=Vyas|first10=Jatin M.|title=Recurrent spontaneous pneumothoraces and vaping in an 18-year-old man: a case report and review of the literature|journal=Journal of Medical Case Reports|volume=13|issue=1|pages=283|year=2019|issn=1752-1947|doi=10.1186/s13256-019-2215-4|pmc=6732835|pmid=31495337}}{{CC-notice|cc=by4|url=https://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-019-2215-4|author(s)=Alex Bonilla, Alexander J. Blair, Suliman M. Alamro, Rebecca A. Ward, Michael B. Feldman, Richard A. Dutko, Theodora K. Karagounis, Adam L. Johnson, Erik E. Folch, and Jatin M. Vyas}}</ref>
* Trouble breathing, necessitating a [[mechanical ventilation|ventilator]] and medically induced coma.<ref name=Hawkins2019>{{cite news|url=https://abcnews.go.com/US/teen-put-life-support-vaping-didnt-smoker/story?id=65522370|title=Teen who was put on life-support for vaping says 'I didn't think of myself as a smoker' |last1=Hawkins |first1=Sally |last2=Walker |first2=Knez |last3=Riegle |first3=Ashley |last4=Rivas |first4=Anthony |work=ABC News |date=11 September 2019}}</ref> The 18-year-old patient says she bought vaping products from a [[tobacconist|smoke shop]] that did not ask for her [[identity document|ID card]], enabling her to lie and claim that she was 22.<ref name=Ben-Moche2019>{{cite news|url=https://jewishjournal.com/news/los_angeles/community/304290/local-teen-lucky-to-be-alive-after-vaping-incident/|title=Local Teen 'Lucky to Be Alive' After Vaping Incident|last=Ben-Moche|first=Erin|work=[[The Jewish Journal of Greater Los Angeles|Jewish Journal]]|date=11 September 2019}}</ref>  
* Dizziness, vomiting, abdominal pain, difficulty breathing, necessitating supplemental oxygen.<ref name=Wadas2019>{{cite news|url=https://pittsburgh.cbslocal.com/2019/09/12/local-teenager-lung-disorder-vaping/|title=Local Teenager Recovering From Lung Disorder Due To Vaping|last=Wadas|first=Amy|publisher=[[KDKA-TV]]|date=12 September 2019}}</ref><ref name=Cipriani2019>{{cite news|url=https://www.wtae.com/article/beaver-county-teenager-hospitalized-suffering-effects-of-vaping/28986432|title=Beaver County teenager hospitalized, suffering effects of vaping|last=Cipriani|first=Marcie|publisher=[[WTAE-TV]]|date=10 September 2019}}</ref>
* Breathing problems mistaken for the flu or [[gastroenteritis|stomach virus]], eventually requiring [[extracorporeal membrane oxygenation|ECMO]]<ref name=Grady2019>{{cite news|url=https://www.nytimes.com/2019/10/15/health/vaping-thc-illness.html|title=A Young Man Nearly Lost His Life to Vaping|last=Grady|first=Denise|work=The New York Times|date=15 October 2019}}</ref>
* Difficulty breathing, requiring supplemental oxygen and steroids,<ref name=Shanes2019>{{cite news|url=https://www.northjersey.com/story/news/2019/10/10/vaping-juul-damaged-nj-woman-lungs-left-her-hospitalized/3932942002/|title='My lungs were chemically burned': NJ victim speaks out against vaping|last=Shanes|first=Alexis|publisher=[[North Jersey Media Group]]|date=10 October 2019}}</ref> diagnosed as [[Obliterative bronchiolitis|popcorn lung]].<ref name=Haskell2019>{{cite news|url=https://wcbs880.radio.com/articles/nj-woman-speaks-out-after-nearly-dying-vaping|title='Most Miserable Time Of My Life': NJ Woman Speaks Out After Nearly Dying From Vaping|last=Haskell|first=Peter|publisher=[[WCBS (AM)]]|date=10 October 2019}}</ref>
* Dizziness and vomiting, problems breathing diagnosed as [[pneumonitis]]<ref name=Farber2019>{{cite web|url=https://www.foxnews.com/health/indiana-teen-vaping-illness-expelled-report|title=Indiana teen says he was expelled after suffering vaping illness at school|last=Farber|first=Madeline|publisher=Fox News|date=4 November 2019}}</ref>
* Patient discovered unresponsive in bedroom, mucus and blood coming from lungs, [[cardiac arrest]]<ref name=Martinez2019>{{cite news|url=https://www.fox10phoenix.com/news/valley-teen-hospitalized-after-being-found-unresponsive-due-to-vaping-related-illness|title=Valley teen hospitalized after being found unresponsive due to vaping-related illness|last=Martinez|first=Jennifer|publisher=[[KSAZ-TV]]|date=15 October 2019}}</ref>
* [[Lung transplantation#Double-lung|Double lung transplant]] for a 17-year-old from Michigan on 15 October 2019,<ref name=Corey2019>{{cite magazine|url=https://time.com/5726491/michigan-teen-vaping-damage-lung-transplant/|archive-url=https://web.archive.org/web/20191113133804/https://time.com/5726491/michigan-teen-vaping-damage-lung-transplant/|url-status=dead|archive-date=13 November 2019|title=Michigan Teen Receives Double Lung Transplant After 'Enormous' Damage From Vaping|last=Williams|first=Corey|magazine=[[Time (magazine)|Time]]|date=13 November 2019}}</ref> believed to be the first such procedure due to vaping<ref name=McCall2019>{{cite news|url=https://www.newsweek.com/man-receives-double-transplant-after-lungs-irreparably-damaged-vaping-1471133|title=Man Receives Double Transplant After Lungs 'Irreparably Damaged' by Vaping|last=McCall|first=Rosie|work=Newsweek|date=12 November 2019}}</ref>

==Criticism of vaping bans== 
Critics of vaping bans state that vaping is a much safer alternative to smoking tobacco products and that vaping bans incentivize people to return to smoking cigarettes.<ref>{{cite web |title=California Is Forcing Smokers To Buy More Dangerous Products |url=https://reason.com/2022/05/06/californias-is-forcing-smokers-to-buy-more-dangerous-products/|date=6 May 2022 |work=[[Reason (magazine)|Reason]]}}</ref> For example, critics cite the British Journal of Family Medicine in August 2015 which stated, "E-cigarettes are 95% safer than traditional smoking."<ref>{{cite web |title=Vaping 95% less harmful than smoking |url=https://www.gmjournal.co.uk/vaping-95-less-harmful-than-smoking#:~:text=E%2Dcigarettes%20are%2095%25%20safer,help%20people%20give%20up%20smoking.|date=August 2015}}</ref>  Additionally, San Francisco's chief economist, Ted Egan, when discussing the San Francisco vaping ban stated the city's ban on e-cigarette sales will increase smoking as vapers switch to combustible cigarettes.<ref>{{cite web |title=San Francisco's Top Economist Confirms Vape Ban Means More Smoking |url=https://reason.com/2019/07/15/san-franciscos-top-economist-confirms-vape-ban-means-more-smoking/ |work=[[Reason (magazine)|Reason]] |date=15 July 2019}}</ref>  Critics of smoking bans stress the absurdity of criminalizing the sale of a safer alternative to tobacco while tobacco continues to be legal. Prominent proponents of smoking bans are not in favor of criminalizing tobacco either, but rather allowing consumers to have the choice to choose whatever products they desire.<ref>{{cite web |title=California Is Forcing Smokers To Buy More Dangerous Products |url=https://reason.com/2022/05/06/californias-is-forcing-smokers-to-buy-more-dangerous-products/ |work=[[Reason (magazine)|Reason]] |date=6 May 2022}}</ref>

In 2022, after two years of review, the [[Food and Drug Administration]] (FDA) denied [[Juul|Juul's]] application to keep its tobacco and menthol flavored vaping products on the market.<ref>{{cite web |title=FDA to Order Juul E-Cigarettes Off U.S. Market |url=https://www.wsj.com/articles/fda-to-order-juul-e-cigarettes-off-u-s-market-11655904689 |newspaper=The Wall Street Journal |access-date=1 August 2022 |date=22 June 2022}}</ref>  Critics of this denial note that research published in Nicotine and Tobacco Research found that smokers who transitioned to Juuls in North America were significantly more likely to switch to vaping than those in the United Kingdom who only had access to lower-strength nicotine products.<ref>{{cite journal |title=Differences in Switching Away From Smoking Among Adult Smokers Using JUUL Products in Regions With Different Maximum Nicotine Concentrations: North America and the United Kingdom |url=https://academic.oup.com/ntr/article/23/11/1821/6276234?login=false|date=18 May 2021 |doi=10.1093/ntr/ntab062 | last1=Goldenson | first1=Nicholas I. | last2=Ding | first2=Yu | last3=Prakash | first3=Shivaani | last4=Hatcher | first4=Cameron | last5=Augustson | first5=Erik M. | last6=Shiffman | first6=Saul | journal=Nicotine & Tobacco Research | volume=23 | issue=11 | pages=1821–1830 | pmid=34002223 | pmc=8653762 }}</ref> This happens as the Biden Administration seeks to mandate low-nicotine cigarettes which, critics note, is not what makes cigarettes dangerous.<ref>{{cite web |title=Mandating Low-Nicotine Cigarettes Could Make Smoking More Dangerous|url=https://reason.com/2022/06/22/mandating-low-nicotine-cigarettes-could-make-smoking-more-dangerous/ |date=22 June 2022 |work=[[Reason (magazine)|Reason]] }}</ref> They also note that vaping does not contain many of the components that make smoking dangerous such as the combustion process and certain chemicals that are present in cigarettes that are not present in vape products.

In 2022, Brian King, the head of the FDA's Center for Tobacco Products, has stated, "We do know that e-cigarettes — as a general class — have markedly less risk than a combustible cigarette product."<ref>{{cite web |title=Insider Q&A: FDA official on vaping's "promise or peril"|url=https://apnews.com/article/science-health-public-tobacco-industry-regulation-6af0d635d7859bab914cc249ef43b6e2|date=September 26, 2022 |work=[[Associated Press]]}}</ref> When asked by [[Reason (magazine)|Reason]] whether the FDA is going to commit any resources to correct misperceptions about e-cigarettes, King responded with "I can't commit to any specific actions."<ref>{{cite web |title=FDA Admits Vaping Is Safer Than Smoking But Refuses To Correct the Record|url=https://reason.com/2022/09/29/fda-admits-vaping-is-safer-than-smoking-but-refuses-to-correct-the-record/|date=September 29, 2022 |work=[[Reason (magazine)|Reason]]}}</ref>

== See also ==
* [[Adverse effects of electronic cigarettes]]
* [[Safety of electronic cigarettes]]
*[[Juul]]

== Notes ==
{{reflist|group=notes}}

== References ==
{{reflist}}

== External links ==

* {{cite web|url=https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html|title=Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products|publisher=[[Centers for Disease Control and Prevention]]|year=2020}}

{{Electronic cigarettes}}

{{DEFAULTSORT:Vaping lung illness outbreak, 2019-2020}}
[[Category:2019 disease outbreaks]]
[[Category:2020 disease outbreaks]]
[[Category:2019 controversies in the United States]]
[[Category:2020 controversies in the United States]]
[[Category:2019 disasters in the United States]]
[[Category:2020 disasters in the United States]]
[[Category:Electronic cigarettes]]
[[Category:United States lawsuits]]
[[Category:Disease outbreaks in the United States]]
[[Category:Product safety scandals]]
[[Category:2019 beginnings|Vaping lung illness outbreak]]
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