Too Cool to Juul

On Friday, August 23, 2019, the Centers for Disease Control and Prevention (CDC), released a statement regarding the first death linked to e-cigarettes or “vaping” devices [1]. While the exact cause of death is unknown, the CDC reports that they are investigating e-cigarettes at the state and local level to learn the “causes or cause of this ongoing outbreak.” 

At least 215 cases of vaping related lung disease in 22 states are under investigation by the CDC [2]. The first death occurred late August in Illinois. State officials from Illinois reported that cases of respiratory illness secondary to vaping doubled in one week—with most cases occurring in individuals between 17 and 38 years of age [3]. Symptoms have been relatively nonspecific, including shortness of breath, cough, and fatigue. Furthermore, symptoms progressively worsened over the course of a few days before patients sought medical attention. 

While the cases are linked to e-cigarettes, officials have not identified a specific ingredient or contaminant that may cause these symptoms. Furthermore, e-cigarettes have been on the market for at least a decade, which further adds to the mystery of these recent outbreaks. Currently, e-cigs like Juul, are the most commonly used tobacco product among adolescents [4]. In 2018, more than 30 million U.S. middle school and high school students reported using e-cigarettes. In contrast, only 2.8% of adults reported e-cigarette use. Proponents of e-cigarettes report that vaping devices benefit public health by helping current cigarette smokers quit smoking. E-cigarettes are not currently approved by the Food and Drug Administration as a quit-smoking aid because of the lack of research evidence. 

Suspicious Ingredients 

E-cigarettes aerosolize an oil that usually contains nicotine, flavoring, propylene glycol, vegetable glycerin, and other chemicals [4]. This liquid, known as “vape juice,” may serve as a culprit to the recent outbreak of lung disease. Specifically, the surge in cases may be caused by the addition of a new ingredient used to dilute the oil or make it stronger [3]. When the liquid is heated, the aerosol can contain fine and ultrafine particles linked to bronchiolitis obliterans, or “popcorn lung.” Furthermore, inhaling left over oil drops after the liquid has cooled can cause lung inflammation [2]. In New York, health officials report that vitamin E oil may be associated with acute respiratory distress [2]. Other health officials report that novel methods to deliver THC through flavoring or emulsification may be to blame. 

Doctors from Utah, Illinois, and other states report similar patterns in identifying these cases. While lung scans suggest serious viral or bacterial pneumonia, bloodwork shows no signs of infection [2]. Other patients have been diagnosed with lipoid pneumonia—an immune reaction mediated by lung tissue to foreign objects, leading to inflammation and buildup of liquids. In Utah, a 20-year-old man woke up with chest pain, nausea, and shortness of breath [5]. The patient suffered from acute respiratory distress syndrome, which required ECMO (extracorporeal membrane oxygenation) life support. During ECMO, the patient’s blood is pumped to an artificial lung, which adds oxygen and removes carbon dioxide from the blood. Fortunately, the patient survived and did not need a lung transplant, as doctors had anticipated. Unfortunately, he did lose his lung capacity by 25%. While this patient presented with a more severe case of lung illness, his findings could be vital to understanding the pathogenesis of the disease.

E-Cigs, Juul, and Policy 

The Vapor Technology Association, an interest group representing the vaping trade industry, released a statement urging, “public officials to thoroughly investigate the circumstances which might have led to each reported hospitalization before making statements to the public as to whether certain products are implicated in these incidents” [2]. 

Public health’s battle with Big Tobacco has shaped public health policy over the last few decades. Earlier this summer, San Francisco became the first major city to ban e-cigarettes—unanimously voting to ban their sale and distribution [6]. Interestingly, SF is home to Juul Labs, the largest producer of e-cigarettes in the country. The company, which started in 2015, now own 70% of the vaping market. The reason for the ban came second to the lax regulation of e-cigs and vaping products by the FDA. A spokesman from Juul responded by saying that banning e-cigarettes denies current smokers an avenue for quitting, and the ban will create a black market among underage individuals. San Francisco’s city attorney stated that the ban is pivotal in preventing a new generation of children addicted to nicotine. 

The ban also prevents the manufacturing, distribution, or sale of e-cigarettes in the city. This would pose as a serious problem for Juul Labs; however, the ordinance is not retroactive. This means the law does not apply to existing companies like Juul, but it will prevent new companies from setting up shop in the city. On their website, Juul says they have made it harder for underage individuals to buy products by deleting company accounts on Facebook and Instagram. Juul is currently petitioning to override the ban on a November ballot initiative. 

The future of e-cigarettes remains unclear—it marks new territory from the perspective of public health and federal oversight. Understanding the cause of these acute lung attacks will serve as an important guide in how the public moves forward. It will be interesting to see if other cities follow San Francisco’s lead in banning e-cigarettes, especially in the wake of the current outbreak. In the meantime, it is up to the CDC to get to the bottom of this mysterious disease, sooner rather than later.

Tina Samsamshariat

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Tina Samsamshariat is a member of the class of 2022 at the University of Arizona College of Medicine - Phoenix. She received her Bachelor of Science from the University of California, Los Angeles and her MPH from the University of Southern California. She enjoys surfing, climbing, and rap music. Twitter: @TSamsamshariat

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