State and local officials in New Jersey are grappling with reports of severe lung disease in 15 relatively young patients with a history of e-cigarette use, part of a growing concern that has involved more than 200 patients in at least two dozen states.
Garden State officials are working with county and municipal health departments, healthcare providers and other groups to learn more about 13 of the reports; two others have been confirmed as aligning with a specific case description created by national experts for “severe pulmonary disease associated with using e-cigarette products,” according to the Department of Health, which is overseeing the state investigation.
The DOH is seeking more information from healthcare providers to determine if there are other reports that require investigating. E-cigarettes, or vapes, are battery operated-devices used to heat flavored oil infused with nicotine, or THC, the active ingredient in marijuana, to create a vapor that users inhale. (Most young people use vapes for nicotine.)
The New Jersey patients — who reported a mix of coughing, chest pain, trouble breathing and other symptoms, like vomiting or diarrhea — are from the central and northern parts of the state, range between 17 and 45 years of age, and had no history of serious health issues, DOH said. All were hospitalized at some point and some were put on ventilators to help them breathe.
Doctors have been unable to identify an infection or other likely cause of their lung problems but found they all had one thing in common: the use of e-cigarettes. That said, they used different devices and products and some industry experts and health officials have suggested the devices may have been altered or used with substances sold on the street, not purchased from a licensed company.
Nicotine and cannabis
“This outbreak of severe pulmonary disease appears to be connected with e-cigarettes being used to inhale either cannabis-infused oils (containing THC) or nicotine-containing e-cigarette juices,” said Dr. Cristine Delnevo, director of the Center for Tobacco Studies at Rutgers University. “A lot of attention is given to the e-cigarettes and [their] use by young people in the context of tobacco; we don’t talk a lot about vaping marijuana, but we should.”
In response, the DOH issued a public health alert in mid-August to healthcare providers and local departments notifying them of these cases — nine of which had been identified at that time — and urging them to carefully assess patients with similar symptoms for vaping use. The providers were urged to ask about how often patients with those symptoms use e-cigs, what specific products and devices they prefer, as part of the traditional screening on drug and alcohol use.
If providers identify a patient with serious pulmonary problems that have no obvious explanation, other than a possible link to vape use, the DOH wants doctors to report the case to their local health department or the state’s Communicable Disease Service. The state is hoping to use this information to help build a more complete picture of the problem.
“Although the specifics of the illnesses are not well understood, so far, the cases in New Jersey have similar characteristics as seen in other states,” said Dr. Michael Steinberg, chief of general internal medicine at Robert Wood Johnson Medical School and director of the Tobacco Dependence Program at the center. “But until we know more about these illnesses, it is important for healthcare providers to gather as much information and medical history as possible to try and better understand the causes and associations.”
This process is essential, in part to ensure providers rule out all potential causes for the condition, Steinberg said. “It is particularly important to ascertain what type of e-cigarettes or vaping devices were used and what specifically was being vaped,” he added.
Nationwide, some 215 “possible cases” of vape-associated lung disease have been reported, according to the federal Centers for Disease Control and Prevention, and other potential cases are under investigation. One adult in Illinois died after being hospitalized for a respiratory illness that developed after using e-cigarettes.
Vaping industry resists the charge
The American Vaping Association, a nonprofit industry group, has stressed that there is no concrete evidence linking the patient’s death to vaping. It also noted that a number of the cases under federal review have involved “black market” products, including those infused with THC.
“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, AVA president, in late August. He also criticized health officials and the media for conflating the issues. The AVA points to some research that suggests vaping may be less harmful for adults than traditional cigarettes, since it doesn’t produce the same cancer-causing tar.
But anti-smoking advocates are concerned that the rise in vape use is leading to a new generation of nicotine addicts, in numbers not seen in the past; in addition, they note that little is known about the oils and flavorings involved, which could lead to other problems when inhaled. Some are also calling for the federal government to take a more active role in overseeing these devices.
“We desperately need the (U.S. Food and Drug Administration) to exercise its authority to regulate e-cigarettes comprehensively,” said Kevin Schroth, a member of Rutgers’ Center for Tobacco Studies, noting that the devices have been in use for a dozen years and the FDA has had the authority to regulate them for a decade. “But we still have very few regulations in place, even for commercially sold e-cigarette products. The FDA is trying to be cautious and evidence-based, but common-sense regulations need to be put in place as soon as possible.”
Use of e-cigarettes on the rise
To address the increase in e-cigarette use, and help those who work with young people to better understand the dangers involved, the state DOH also launched a new website last week with information for parents, teachers and coaches; it describes the look and operation of various vapes, outlines the known risks, and provides links to news accounts, CDC information, and other resources.
While traditional smoking has declined in New Jersey — less than 14 percent of adults and 12 percent of high school students smoke cigarettes — the use of e-cigarettes is on the rise. The DOH found one in five high school student here vaped regularly during the 2016-2017 school year, and federal surveys show that nationwide, e-cigarette use grew 78 percent among that age group in 2018. In middle school, vaping ticked up 48 percent that year.
To counter this trend, the department has taken steps to combat e-cigarette use among young people, committing $7 million in tobacco-tax revenue to address vaping through a variety of regional and community programs. Lawmakers have also introduced bills seeking to make it harder for young people to obtain these products, sale of which is banned to minors. In addition, anti-smoking advocates like the Campaign for the Tobacco Free Kids have turned their attention to vaping in recent years, promising to use the same techniques they used to battle big tobacco.