Clusters of Serious Illnesses Nationwide Raise More Concerns About Vaping

Aug 20, 2019

Credit wikimedia commons

Federal health officials are tracking clusters of serious health issues among mostly young people.  Analysts have linked these lung conditions and breathing problems with vaping.

But some health officials suspect certain unlicensed vaping substances that included contaminated liquids. The Exchange on Wednesday gets the latest on what we know and what we don't about vaping.  As of Tuesday, Aug. 20, N.H. health officials said they were not aware of any cases in the Granite State but they are monitoring the situation.


GUESTS:

Lena Sun - National reporter for the The Washington Post, with a focus on public health and infectious disease.

Patricia Tilley - Deputy Director, Division of Public Health Services at the N.H. Dept. of Health and Human Services.

Related Reading

Lena Sun's health reporting, including recent news of a mysterious lung illness that has been linked to vaping.    Also from The Washington Post: Concerns about a new form of addiction among teens, e-cigarettes.

In Kings County, California, where seven people suffered acute respiratory distress, a public health official warned against buying vaping products from unlicensed street sellers or "pop-up" shops that could contain contaminants. 

As reported in The New York Times, doctors in several states suspected the emergency admissions were related to vaping certain cannabis products, even illegal street drugs or contaminated liquids laced with T.H.C., the ingredient that produces marijuana's high. 

In his op-ed for The New York Times,  Harvard researcher Joseph Allen reports finding formaldehyde in e-cigarette emissions. Allen's research has also indicated that common e-cigarette flavorings may impair lung function. 

Michael Siegel, professor with the Boston University School of Public Health strongly opposes a ban on e-cigarettes. 

A 2018 report from the National Academies of Sciences, Engineering, and Medicine found that using e-cigarettes may lead youth to start smoking, adults to cease smoking. 

Transcript:

This is a computer-generated transcript, and may contain errors. 

Laura Knoy:
From New Hampshire Public Radio, I'm Laura Knoy and this is The Exchange.

Electronic cigarettes are supposed to be for adults only, often marketed as devices that help adults quit traditional tobacco products. But their popularity among children is undeniable. A U.S. surgeon general report last year said e-cigarette use among middle and high school students surged 900 percent between 2011 and 2015. And now the Centers for Disease Control reports a new cluster of serious lung related illnesses among mostly young adults, including some who had such difficulty breathing, had to be put on ventilators. The CDC has linked these cases to vaping while investigations continue. And today, in exchange, what we know and what we don't about the health effects of vaping. Let's hear from you.Laura

Laura Knoy:
With me in studio, Patricia Tilley, deputy director at the Division of Public Health Services at the New Hampshire Department of Health and Human Services. And Patricia, good to see you. Thank you for being here.

Patricia Tilley:
Good morning. Thanks so much.

Laura Knoy:
Also with us from D.C., Lena Sun, a health reporter for The Washington Post with a focus on public health and infectious disease. And Lena Sun, really good to have you to thank you for your time.

Lena Sun:
Nice to be here.

Laura Knoy:
So, Lena, you wrote the article that described this. What are state and federal health officials seeing in these clusters that they described?

Lena Sun:
So they have been puzzled by this mysterious or unexplained illnesses, lung illnesses that all have been linked to e-cigarette use. And in some cases, the people who have been using the devices have been using nicotine, and in some cases they've been using marijuana based products. And they also suspect there might be some cases where it's do it yourself home brewers of the substance that's being inhaled. But the only commonality is the e-cigarette device and the vaping, and they don't really know what's causing it.

Lena Sun:
They have ruled out infectious agents like viruses or bacteria. I don't know how deeply they've gone into fungal infectious agents, but they've basically come to the conclusion, not the conclusion, the deep suspicion, that it is something related to the vaping that is causing these people to be sick.

Lena Sun:
There are 94 is that they're looking at in 14 states and that was last week. I'm sure it is more since then, because I have talked to other physicians who haven't even reported their cases to their local health department yet.

Laura Knoy:
Wow. And in a moment, Lena, maybe you can help us figure out sort of how the CDC investigates these clusters and the interaction there. But I'm just curious about what these people are experiencing.

Laura Knoy:
Lena, what are some of the symptoms?

Lena Sun:
Shortness of breath, difficulty breathing, vomiting, in some cases diarrhea and chest pain before they're hospitalized. And in Wisconsin, for example, they had 30 cases, 15 confirmed, 15 suspected. All of them were hospitalized in Minnesota. They had four cases of patients, 16 to 19 years old, all hospitalized. And they were so sick in some cases that they had to be on ventilators. They weren't able to breathe for themselves.

Laura Knoy:
Ok, that's terrifying. And if anybody's ever experienced shortness of breath, it's very scary. And it's just so sad. Lena, to think about these young people being put on ventilators. My goodness, what are doctors doing for these folks? What are they able to do for these folks?

Lena Sun:
Well, when I was talking to doctors, they were explaining to me that, you know, when you when you can't breathe, and you know, when people have pneumonia, you know, those little air sacs in your lungs fill up with fluid or things that are not oxygen. And in some cases, what they try to do is to get additional oxygen into the patient. And what they've also told me is that in many of these cases, these patients are young, 21, 20, you know, in their 20s. And that is what is they have going for them, otherwise healthy young people. If it wasn't an older person, they said that the chances of survival would be much less.

Laura Knoy:
Wow. Patricia, has any of this been reported in New Hampshire yet?

Patricia Tilley:
We are so lucky that we have had no known cases yet in New Hampshire, but we're monitoring this very closely right now and we are providing education and outreach to clinicians and others as we learn more from the CDC and from the other states that have seen this before. We have.

Laura Knoy:
So vaping is very popular in New Hampshire, right. Patricia, there was some recent numbers that showed that among young people we have even higher rates than the national average.

Patricia Tilley:
You know.

Patricia Tilley:
Adolescent e-cigarette use is on the rise across the country and New Hampshire is no different. You know, we are facing an epidemic of youth e-cigarette use, which has threatened a whole new generation with nicotine addiction, you know, in New Hampshire. Almost a quarter of all high school age kids report using one of these devices in the past 30 days. The U.S. average is only around 13 percent.

And what's I think even more troubling is you certainly see the rise as kids get older. So by 12th grade, by your senior year, especially if you're a boy, we're inching towards their, you know, a third of high school students using these products. Why? Especially boys? You know, it's unclear right now. We've always seen a little bit of a discrepancy between boys and girls and their use of regular combustible cigarettes. And, you know, we've been lucky with lots of policy interventions and education that we've seen regular cigarette use really go down.

Patricia Tilley:
Over the years, we've had long trends of reduced rates of regular cigarette tobacco use. But with the introduction of e-cigarettes and vaping and their ability to be small and discreet, the the rates in which we've seen the increase are really astonishing.

Laura Knoy:
And I have heard from young people that they would never dream of picking up regular cigarettes. They think they're smelly, they think they're dirty. But e-cigarettes, like they taste good and they smell good and they're kind of sleek and attractive, like you said.

Patricia Tilley:
Absolutely. And there's clearly a marketing effect of bringing those two to young smokers. And once you get that nicotine, you become addicted. And we know that those adolescent brains are really primed for addiction. So it's really a convergence of all the wrong things together. You know, they're small. They're attractive. You don't smell anymore.

Patricia Tilley:
You know, when you or I were in high school and you went into the girls room or the boys room and you smell like cigarettes, that was really obvious. And now we have a product that's completely can be hidden from teachers, from moms, from dads and from everyone else.

Laura Knoy:
As we've said, federal health officials are tracking clusters of very serious health issues among mostly young people, lung conditions, breathing problems they believe are linked to vaping. So, Lena, we talked about the seriousness of the illnesses that the CDC has been tracking. We talked about how some of these other young, otherwise healthy people who have been put on ventilators, what other treatments have doctors been using, steroids or other sorts of medications that that can help?

Lena Sun:
They have been using steroids in some cases because that's to help with reducing inflammation, because there's a lot of inflammation in the lung. But in some cases, they are just hoping that they can if they can get the oxygen somehow into the body and keep the body from getting worse, that, you know, that that that the patient themselves will heal.

Lena Sun:
So I was talking to a young man last night who was in the hospital for nine days, and they had to use two different kinds of life support systems. He was 20 years old and one was the ventilator that people can think of.

Lena Sun:
The other was a device that, because his lungs were no longer working... How can I describe it? They put a tube in him. It's like a surgery to put this tube in so that they can pump the blood out that doesn't have oxygen. Use the machine to add blood and take out CO2, pump that back into his body. And his dad told me that it was looking at him on these machines. Bright red coming out of one side, dark red on the other side. And at any one time, one third of his blood was outside his body. And if the kid pulled out the tubing, he would be dead in 30 seconds.

Laura Knoy:
Wow. So very serious. Very serious.

Lena Sun:
He almost died. And but over time, as the lungs got, the more oxygen was going in, his lungs began to heal slowly. And also the people have been on narcotics, because when you have all this stuff in you, your instinct is to pull it out. Right. And so they are often restrained and. Put into medical comas so that they don't pull out all this equipment. It sounded very, very scary.

Laura Knoy:
That's horrific. And the narcotics and the steroids you mentioned earlier, all powerful medicines. So even if you save your life from being on these ventilators and so forth, Lena, you're going to have some health problems getting off of the medications that were used to save you.

Lena Sun:
Well, they are there. I mean, it's so early in the investigation, as Dr. Tilley, I'm sure it knows that they're still don't know what the culprit is. They don't know if everybody will recover fully what the long term effects are, just like there's not a lot of information long term about harm of e-cigarettes.

Laura Knoy:
So Patricia for people listening who think e-cigarettes, vaping. How does that work? I've seen them. I've smelled the, you know, the blueberry puff of smoke walking down the street. Just remind us how these work. And if you could also, Patricia, just add a note about the addictive nature, because the health consequences that Lena mentions are so severe, so dire in these cases that it makes me think this must be a pretty powerful addiction. So just remind us how these work. First of all, please.

Patricia Tilley:
Absolutely. So e-cigarettes are really a device group of battery power devices that mimic the act of smoking by producing this vapor, this puff that contains the nicotine flavoring and a whole host of other chemicals. And it's all inhaled. So this is part of the problem that we're learning about what the short and long term effects are of inhaling this type of aerosol.

Patricia Tilley:
You know, we've had generations to learn about what combustible cigarettes do to us and the health outcomes around heart disease and cancer and diabetes that that produces what we're now learning, what the inhaling this aerosol does to us, including the flavors, you know, the flavors that they use our food grade. So they could be used to flavor your food.

Patricia Tilley:
But there really hasn't been a lot of experience of what that means when you when you bring that into your lungs. So those are the things that our scientists are really trying hard to to study. So not only these devices come in all different shapes and sizes, some of them look like regular cigarettes. Some of them like cigars.

Patricia Tilley:
But often right now what we're seeing is they look like computer USP drives, like flash drives. They're small. They could look like pens. They could look like any everyday item.

Patricia Tilley:
You know, I've heard from one teacher that there's an item that when kids are wearing their hoodies and they have little strings that come out of them, there's a device that sits sort of at the end of the string. So it looks like the kid's just chewing on the string.

Laura Knoy:
Well, there's a whole line of clothing called vaporware. So go ahead, Patricia.

Patricia Tilley:
So, absolutely. And. And they come with these thousands of different flavors. And the flavors we know from our experience with tobacco, traditional tobacco are really what attract youth because they taste good and they're. And you double that with the nicotine, a JUUL pod. So JUUL is one particular brand.

Laura Knoy:
That's the biggest brand. Dominates the market.

Patricia Tilley:
And you can find it in every convenience store and every place you go. And one of those pods that they call it, which is where the juice lives, the e-cigarette juice lids, those pods contain enough nicotine that you would find in 20 regular cigarette. Oh, my goodness. Well, it's a lot of nicotine. Huge punch. So what is the impact of nicotine on the body? Patricia? Sure. So what we find, especially among adolescents, that nicotine can affect brain development and it can lead to issues with attention, behavior, cognition and mood.

Patricia Tilley:
These are issues that we know that as the synapses are developing and adolescent brains, that's really priming them for a lifetime of addiction. What we know, again, from traditional tobacco cigarettes, original combustible cigarettes is that the likelihood of you being addicted to that nicotine just rises exponentially. If you start using these products before you're 18 years old.

Patricia Tilley:
Once you're after 18, the likelihood of becoming addicted while you still may, that likelihood goes down. So we know there's something about the adolescent brain that really just primes them. And again, we have these devices that are are really cool looking and they taste good. And they they don't seem to be harmful.

Patricia Tilley:
They certainly don't smell. And so for whatever reason, youth, they're starting to use them. And there's a sense, again, because it's just a puff, that there's really no damage. There's really a sense that they're there can't be risk. And the other pieces is that I'm not sure that all parents have had the information or the education to actually. Have this conversation with their kids. And so that's what we're really promoting right now, is an ongoing for parents to educate themselves, understand what those products are, and really talk about those risks with their kids.

Laura Knoy:
For parents, a lot of them are just. They don't know what these things are. They look like pens. They look like flash drives. There isn't the telltale smell and so forth. What about the flavors? Lena, this has been a big issue and the big company JUUL that dominates this market has been sort of pulling back on the flavors. Can you tell us a little bit more about that, Lena?

Lena Sun:
Well, I know my colleague has written a lot about the flavors and as as Dr. Tilley said, that the flavorings are what attract the youngsters. And in talking to some of the patients who have been using this, they say that, you know, that's what appeals to them. I talked to the young man that I was telling you about was they being peach menthol. And his parents really didn't know that the dangers he the dad was a former smoker. And he was telling me that this is the kind of thing that he would have used back in the day if it was around. And I think I think the attraction for it for the young people is exactly what Dr. Tilley said.

Lena Sun:
And it would be interesting to know how whether physicians or health systems are aware that this is going on and what kind of alarm is being raised.

Lena Sun:
Some health departments have sent out advisories to all the health care providers in their state. I don't know if this is something that New Hampshire has done or is thinking about, even though you don't have any cases. But that that is that is something that, you know, when you talk to parents of patients who have gotten so sick, that's what they want people to know, to raise awareness that this could be this could happen to their child hasn't happened yet.

Laura Knoy:
Patricia, in our state?

Patricia Tilley:
So, in New Hampshire, we're still taking the lead from CDC and from those other states and and discovering what what type of education would be most effective for our clinicians out in the community. But what we have been doing for a long time right now is talking, especially with pediatricians, especially with family care providers, to talk to young adults about the issues related to e-cigarettes and e-cigarettes Use that really to highlight how that the use of these products can impact their health of what we do know and what we don't know about long term use and really need to encourage them to use our quit line and others if if they're using them now.

Laura Knoy:
Ok, after a short break, we will talk a lot more and we'll start taking your questions and comments.

Laura Knoy:
This is The Exchange I'm Laura Knoy today. Federal health officials are tracking a cluster of serious lung illnesses among young people they believe are related to vaping. We're finding out more.Our guests are Lena Sun, health reporter for The Washington Post with a focus on public health and infectious disease. And Patricia Tilley, deputy director at the Division of Public Health Services at the New Hampshire Department of Health and Human Services. By the way, lots of extra reading and resources on our Web site today and each prawns slash exchange. And Lena and Patricia, let's go right to our listeners. And Tom is calling in. Hi, Tom. Go ahead. You're on the air. Welcome.

Caller:
Hi, Laura. It's Tom Sherman, the state senator and also chair of Health and Human Services. Hi, Trish.

Laura Knoy:
Hey there. And a physician yourself, Tom, correct.

Caller:
Yeah, I'm a gastroenterologist at Exeter, VA. The work that's been done. If I could ask a quick question, the work that has been done on tobacco use, one of the major drivers of giving teenagers away from tobacco has been the price of the product.

Caller:
And so it's one of the actual beneficial roles of taxing tobacco products as that tends to keep teenagers away.

Caller:
But one of the things you mentioned in terms of regulatory is the concentration of nicotine and how high the concentration is in a lot of vape products. Do you happen to know if any states have tried to regulate concentration of nicotine as a way of decreasing toxicity of vape products?

Laura Knoy:
Oh, that's interesting. Yeah, it might be difficult for a company to do that on a case by case, a state by state basis. But do you know, Patricia?

Patricia Tilley:
You know, so I think states are trying lots of ways to try and crack this, not I'm not aware of any state right now that is looking at regulating the concentration of nicotine. Again, because a lot of these products can be bought in individual vape shops. You make year wear where the vape shops make their own e juice as well as the big corporate big tobacco companies like JUUL. You know, the big corporate world might be easier to regulate in that way, but we have so many again of these vape shops that we see on all the corners in all of our towns. And that's what makes this really difficult to to regulate at a policy level.

Yeah. Lena, do you know, would that even be something that would be possible to regulate the amount of nicotine, given the highly addictive nature, as Patricia described?

Lena Sun:
I don't know. I would have to turf this to the folks who follow that regulatory procedure. You know, I don't you know, the problem is that when you talk to these individuals, they are showing you the different products. And some of the warning labels are clearly, as some are made in the U.S.

Lena Sun:
But if they are making it on their own or if they are buying the oil, for example, the oil is that's in many, many of these products. This must be pharmaceutical grade. But if you're buying a food grade oil, then that is a different level. And those tiny particles get into your lung and you get this thing called lip void pneumonia, where that lipid or oil particles are in your lung. And it is those deep those things are not supposed to be in your lungs. That's what causes inflammation.

Laura Knoy:
Yeah. And JUUL, again, the big company and there's other companies besides Jill, but they dominate. They have said that these problems that the CDC is tracking are likely due to, you know, on the street non authorized homebrew type products. JUUL says it's strictly monitors, you know, the purity of of its products, although there are a lot of chemicals, as you described, even in these, you know, official products from a company. But, Tom, it sounded like you had a question also that you want to jump in there or comment as a state senator. Towards policy?

Caller:
Well, yeah. This is a huge challenge, you know, not only in the vape shops and but also the online accessibility that's very difficult to regulate. And a lot of people are reluctant to start regulating online sales, especially in New Hampshire. So it's it's a it's an exploding health problem, not just from the standpoint of addiction issues in young people, but I would hope that we can start looking at and working with trash, which I do often work on, on this as a public health problem, which is, I think, the appropriate approach to it.

Laura Knoy:
Tom, I'm glad you called, since you're a state senator. I did ask you about policy. A couple cities. Keene, Dover come to mind have passed ordinances saying you have to be 21 to buy tobacco products. The age overall in the state is 18. What is the latest with efforts to raise that statewide age to 21 across the state?

Caller:
Well, there have been bills and efforts to put that in the budget. They have not succeeded. There have also been bills that have been trying to tell towns that they can't do that. Those also have not succeeded. So at this point, the legislature is somewhat split on what regulation can be imposed and whether there should be state wide regulation. But I think most states are moving towards 21, especially in New England. And I but I think New Hampshire is still an active debate in the legislature on both sides, whether towns can act individually to do it or whether at the state level we want to be imposing those kind of regulations. And, you know, it's it's really an issue of developing the consensus that this is a public concern.

Caller:
I think one thing that a lot of people forget is that it while it is an individual decision, it's also addiction, which is a medical illness.

Caller:
And on top of that, there is a public cost to this. And tobacco alone is up in the billions in the state of New Hampshire alone. So lots of issues probably worthy of a another show. But on the legislative side, the state is split.

Laura Knoy:
And lastly, why was this Tobacco 21 initiative put in the budget, Tom? That seems an odd place to put it.

Caller:
Well, the budget can be placed to put things that are that have not succeeded in the legislature. And and as you're aware, they often don't succeed in the budget either. So that is a way of trying to get something through as our amendment.

Laura Knoy:
Ok, well, Tom, I'm glad you called in both as a state senator and a and a physician yourself. So thank you very much. and to Concord, where Sarah is on the line. Hi, Sarah. Thanks for being with us. Go ahead.

Caller:
Hi. Can you hear me?

Laura Knoy:
Sure can. Yeah. Go ahead.

Caller:
Hi, so I am a researcher, I work for Dartmouth and I have a large randomized controlled trial that examining the appeal and effective, you figure out in chronic smokers a serious mental illness. I'm a clinical psychologist by training. Sure. And I just I wanted I've done a lot of research on e-cigarettes, a lot of reading, and I wanted to make sure that your listeners didn't end up feeling like we need to just demonize the entire category of electronic nicotine delivery system. I agree that they should not be used with young people, that we shouldn't be encouraging young people to use and we should be discouraging them. And I'm trying to set up a system where youth are not using them. But the fact is, what's dangerous about smoking is the smoke, not the nicotine.

Caller:
So people you know, oftentimes there's this misconception that nicotine causes cancer. It's not it's the process of burning. And because e-cigarettes is vaporizing a liquid, all those byproducts somebody mentioned all the chemicals in e-cigarettes, there's way more chemicals and cigarettes. And the byproduct of burning is what's really dangerous.

Caller:
There is an international scientific panel in 2014 that rated nicotine containing products on a scale from zero to 100, with 100 being the most harmful combustible cigarettes, of course, get 100 e-cigarettes got a 4, which is the same as a nicotine patch. So I have a place here for chronic smokers who have tried everything they can to quit. And there's not a lot of resources for people who are trying to quit.

Caller:
New Hampshire does a terrible job of not sending their tobacco settlement money on actual cessation treatment. There's not much that people have, but these can be a really useful tool for somebody who's like an entrenched smoker and cannot quit. And they can use this device to wean themselves off of cigarettes and then eventually off nicotine. So anyway, I just want to make sure people don't just demonize them and say we should just throw this product out because they are much, much safer than a combustible cigarette.

Laura Knoy:
Yeah. No, Sarah, I'm really glad you called. Can you stand in line for a minute? Because I do have a question or two for you as a researcher on this. And you're right, the advertising campaign for these products is, you know, make the switch. And there is evidence that this is a whole lot safer for people who are currently smoking to switch to e-cigarettes. I think that's you know, that's been made pretty clear. What does the research that you've looked at, Sarah, say, though, about this large number of young adults, teenagers who never would've picked up a cigarette but are picking up these vaping products and as we heard from Lena Sun earlier, are developing serious health issues? I just wonder what what research you've looked at with that.

Caller:
Yeah, the problem with the research on youth... It's very hard to conclude that a young person would never have picked up a cigarette. It's just hard if you can't design a longitudinal study and randomly assigned people to be exposed to cigarettes or so, you know, it's just it's impossible to design a study that would really answer that question with this with this young person have smoked. If vape wasn't around mean they are an appealing product. You know, the flavors are obviously targeting youth. So that's a huge problem.

Caller:
And in my field, you know, we advise people stay away from flavors. We don't really know enough about them. You're better off just sticking with tobacco flavor. I mean, some of these e-cigarettes really only have nicotine, propylene glycol and tobacco flavor. That's it. They don't have a lot of other chemicals. The other thing just I want to quickly mention is the FDA has published its intention to reduce the content of nicotine in cigarettes down to almost nothing. By law, they can't reduce it to nothing. And then, you know, chronic smokers are going to need to get their nicotine in some way. And getting it from a patch or a large intercom just doesn't work for a really chronic smoker. So I know I know your focus is on youth and I'm totally on board with doing everything we can to keep young people from using these things because it's a slippery slope then to use a combustible, which is even worse for them.

Laura Knoy:
Yeah. No, I am really glad you called. And I wanted to ask you also about the flavor Sarah. If you don't know, it's totally fine. I was looking at some research from Harvard yesterday which looked at some of the flavors and I think Patricia alluded to this earlier, that the flavors are approved for eating, but no one has any idea what the flavors do to your lungs, which is obviously a completely different process, breathing versus digesting. So. Have you looked at some of the issues around these flavoring agents, Sarah, and what they might do to the lungs, young or old?

Caller:
Yep, yep. Yep. The flavors that the most research that's been done is on cinnamon for whatever reason. And that one seem to not be good in the same way that menthol is much worse in regular cigarette. You know, that's a flavor that you're adding to your regular cigarette. So you're right. We don't know a ton about flavors, but they seem to it seems to be even more dangerous to put a flavor in a in a regular cigarette or an e-cigarette.

Laura Knoy:
Well, lastly, Sarah, and again, I'm so glad you called. What else would you like to know about the impact of e-cigarettes on young people? Sounds like most your research is focused on existing adult smokers and I get that. But there is so much that we don't know because this is relatively new. So as a researcher, what else would you like to know?

Caller:
Specifically about vaping in young people.

Laura Knoy:
Yeah.

Caller:
Boy, I mean,.

Laura Knoy:
Where to start, right?

Caller:
I just think I mean, they just shouldn't be doing it.

Caller:
You know, I have I have a 13 year old and I ask him, you know, do you see these things around? And even at, you know, run lit and concrete. He sees them.

Caller:
And my message to him is, don't get started with them. They're they're not something you want to get involved with.

Laura Knoy:
So that's interesting. Even as someone who thinks that they are effective for helping adults.

Caller:
Right. I think they have a place idea, a place that that they hold for me as an I have a close colleague who works on all my studies, who was a smoker for 30 years, and she finally has passed by over a year, not smoking combustible.

Caller:
But she's still using her JUUL. And she's kind of... her attitude. It's like, well, I'm going to keep with this for a little while because keeping me away from regular cigarettes. But eventually I would be off this, too. But she never thought she'd quit smoking ever.

Laura Knoy:
Okay. Well, Sara, thank you for calling. And I'm going to put you on hold so we can get your information because we might want to follow up with you on a future show. Wow. Patricia, really interesting. And Lena, you, too. But, Patricia, you first. We haven't talked about, you know, the other side of this story, which is that some adult smokers say, you know, these things save their life.

Patricia Tilley:
Absolutely. So I think that's one of the places where we're drawing a real line around the difference between youth access and youth use of these products versus older adults that have been lifetime smokers. You know, I really appreciate the callers comments and her research is very important. One of the things I would note, though, is, you know, I you can underscore that we would have never known whether an adolescent would have picked up a combustible cigarette or an e-cigarette.

Patricia Tilley:
But what we do know is that the use of these e-cigarettes is way higher than the use of combustible cigarettes. So there's something very different about these products. And we do also know that once they transition, as you know, as they get a little bit older, they're out and about as a young and as a young adult. The e-cigarettes are expensive. And to be honest, it's sometimes a little cheaper to just go back and start using the combustible cigarettes again. So we have young adults that are using both products.

Laura Knoy:
So even though no, that individual person, we don't know if they never would've picked up a cigarette. You're saying, Patricia, the numbers do show given levels of traditional cigarette smoking among middle school and high schoolers versus cigarette use a middle schoolers in high school as it's out of the park out different.

Patricia Tilley:
Absolutely.

Patricia Tilley:
I mean, there's been a 78 percent increase in the use of electronic devices among high school students between 2017 and 2018. The rate of use is really exponential.

Laura Knoy:
Well, and on this point, though, that Sarah and I'm so glad she called Lena, a recent comprehensive National Academy of Sciences study seems to offer contradictory findings. On the one hand, it does find that e-cigarettes do help adults switch. Like Sarah said, for more harmful traditional cigarettes. But this same study also find e-cigarettes may lead youth to actually start smoking traditional tobacco cigarettes. A new touched on this, too, Patricia. How do you sort this out? Lena?

Lena Sun:
Well, I mean, I think it's really hard and I think that evidence... The problem is that this is relatively recent. And the FDA, former FDA commissioner Scott Gottlieb has referred to this as an epidemic among, you know, of e-cigarettes, among teenagers. And, you know, when he was in office, he was really trying to sort of get his hands around this. That report from the National Academies was one of the most comprehensive studies done on health effects of e-cigarettes.

Lena Sun:
And, you know, and they went down category by category in terms of exposure to nicotine, for example. They said there is conclusive evidence that exposure to nicotine from e-cigarettes is highly variable and depends on the device and the liquid, and that there is substantial evidence that nicotine intake from E e-cigarettes among experienced adult e-cigarette users can be comparable to that of conventional cigarettes.

Lena Sun:
But at the same time, most e-cigarettes contain and emit numerous potentially toxic substances substances. And these are the things that haven't been really studied in depth. And when they talk about public benefit and public harm, this is what they they have to put into the pictures. How did this compare to somebody who, like the previous caller was saying, has been smoking regular cigarettes all their lives?

Lena Sun:
Right. so it's tricky.

Laura Knoy:
Yeah. It's two different people. Somebody who's been smoking their whole life and has been desperate to quit versus a 13 year old who, again, picks it up because it smells like bubblegum. So we will talk a lot more after a short break.

Laura Knoy:
This is The Exchange, I'm Laura Knoy. Today. Federal health officials are tracking reports of serious lung conditions among young people that they linked to vaping.

Laura Knoy:
This hour, we're getting the latest. What we know, what we don't know and we've been hearing from you. Our guest in studio is Patricia Tilley, deputy director of the Division of Public Health Services at the New Hampshire Department of Health and Human Services. And on the phone from D.C., Lena Sun, a health reporter for The Washington Post with the focus on public health and infectious disease. And both of you, right back to the phones. Eric is calling in from Laconia. Hi, Eric. You're on the air. Thanks for calling in.

Caller:
All right. Thanks for having me.

Laura Knoy:
Sure. Go ahead.

Caller:
My comment was that your average cigarette runs somewhere between 9 mg and 15 mg of nicotine and the E juices that are out there, for most starters, is somewhere between 3 and 9 milligrams. But they do offer salt based nicotine that run between 20 and 50 milligrams salt.

Laura Knoy:
Salt based is what you said Eric? You said salt based?.

Caller:
Salt based liquids is what they call it.

Laura Knoy:
Okay. Go ahead, sorry. Yeah.

Caller:
And for some, that's just starting out. I mean, one cigarette. I know a lot of kids that'll tell you. They got noxious the first time they smoked a cigarette. Adults as well. And that's only Max 15. You can imagine putting something 50 milligrams into your body. You're going to get very sick and puffing on it all day. That's the equivalent of a heavy smoker that goes through two packs a day. And these kids are starting out on this. I think your policymakers are right on track with restricting the amount of nicotine that's available in these tapes.

Laura Knoy:
Do you have personal experience with this, Eric?

Caller:
I absolutely do. I ended up getting one of the salt nicotine vapes. It was only 20 milligrams and I'm a smoker about a pack a day. Wow. And I would say four or five pops in and I ended up experiencing nausea, diarrhea, vomiting. I was shaky, had a headache. Pretty much everything except for the lung issues that were described.

Laura Knoy:
Wow. That's really interesting. And this is coming from you as a regular smoker. So the jewelry. I'm calling it a JUUL, even though, Neal, there are no no other companies. So the heavy concentration of nicotine had a real impact on you, Eric. Yes, ma'am, what's been helpful in terms of you quitting? Several people have already said today that there's not a lot of effective mechanisms and that some people feel like vaping isn't effective medicine. What's helped you quit? Eric?

Caller:
What's helped me is a product that's similar to JUUL, but it's produced by a camel called an Alto, and I came to that because I went into the hospital to have a surgery and they gave me a nicotine inhaler. Now there is no exhale to it. There is no baby, but it's the same general principle. You're inhaling nicotine straight into your lungs. And that's what helped me to not smoke. And that's how I got into using the Alto instead.

Laura Knoy:
Okay. Eric, thank you very much for calling in. Patricia, do you wanna jump in on that? She experienced that. He told us about.

Patricia Tilley:
Yeah. You know, I mean, this is what we're hearing around the country. And certainly because the E juice is so variable, so you don't always know what you're getting and youth don't always know what you're getting because you can imagine being a party where somebody is vaping and they just sort of handoff to somebody else to take another rep on the on the vape. And so we see this sort of these health effects from the material. And that's what again, in the past we had big tobacco.

Patricia Tilley:
We understood it was a regulated market. And here we have a much more unregulated market. The other thing that I just want to underscore is while we certainly could use more resources in the state for prevention and helping folks quit. We do have resources available right now. Something called 1 800 Quick Net quit now.

Patricia Tilley:
So I encourage any of your listeners who are currently using e-cigarettes or combustible cigarettes to call in 1 800 Quit now and talk to the coaches there who could really walk you through what the quitting process is like. We know it's hard. We know that most smokers, whether if combustible or e-cigarettes, are going to have to try to quit multiple times before it it takes.

Laura Knoy:
Wow. OK.

Laura Knoy:
Well, Erica was really interesting to hear your story. Thank you very much for calling in. Lena, I know we've been talking about, you know, the nicotine levels a lot. And Eric mentioned that there was a very powerful story in terms of this cluster of serious lung illnesses that, again, you've been reporting on from the CDC. How much have doctors been reporting? Federal health officials been reporting that the people having problems were using vapes that might have included. You know, I think you mentioned this before, sort of home brews and THC, which is the psychoactive component of marijuana, street drugs and so forth. Just remind us how much that might be a factor in terms of these illnesses that the CDC is tracking.

Lena Sun:
Well, that's exactly the disease Detective part of of the investigation. Right. They suspect that there is some e-cigarette product is the cause behind these illnesses.

Lena Sun:
So they're trying to figure out how much of it is the patients using some kind of commercially available device, whether they're sharing e-cigarette products like the refill pods or cartridges with other people or whether they're reusing old cartridges or pods with homemade or commercially bought products or whether they're doing something to the drug to concentrate it and then using a specific kind of device to inhale it. So they're asking the health care providers, the doctors and others to ask patients about anything that they still have at home in terms of the device or the liquid. This the young man that I spoke to yesterday was using a device and he just switched to a different brand of nicotine.

Lena Sun:
Peach, peach, menthol, I think. And he was starting to puff on that. And that made him violently sick, vomiting. He just couldn't stop vomiting. Oh, he said.

Lena Sun:
And he had been puffing before other things. And he said that he switched to this particular other product and that's what made him sick. So, you know, what they have to do is in each one of these cases. Right. They have to narrow down what was used. See what the commonalities are and try to figure this out. And some of the commercial manufacturers like JUUL are saying, well, you know, they're monitoring their use and they're trying to shift the focus to people who have been vaping illicit drugs.

Lena Sun:
But in this case, at this young man was using a nicotine product that he bought in a vape shop.

Laura Knoy:
Yeah. Well, and here's a question from Michael that gets to this. Michael says, What role does THC vaping products play in vape popularity with adolescents? What percentage of adolescents use their vape pens for THC in addition to nicotine? Patricia, you might not know the exact numbers, but I'm guessing this is a a concern.

Patricia Tilley:
This has been an ongoing concern and it's really a concern of educators because not only are kids using these products in school, but they have no idea what's in the product. This year, the legislature passed a bill called HB 511, and so what that did was clarify in our current youth access laws that not only is the wealth tip that the device is illegal for minors to have in any EE juice in it is illegal. Prior to that, our youth access law that we had written it a long time ago at several years ago now, and the way the legislation had read was that it required that nicotine be in the E juice that was within the definition of our law. And we found that we needed go back on with our tobacco advocates and legislators and policymakers across the aisle say, you know what, we don't need to define illiquid that way.

Patricia Tilley:
We simply need to say that those devices and any other e liquid should not be in the hands of kids because we simply add it. That gives the tools to our regulatory partners, folks at law enforcement and within schools to be able to say that that product should not be allowed. We're also seeing certainly the use of illicit THC or cannabis vapes that has also become ubiquitous among a young adult population. And certainly for my understanding of the the cases that are in the rest of the country, there is often been this co use of both e-cigarettes with nicotine, with a vape product that might have had THC. But really the one common denominator has been the e-cigarettes with nicotine.

Laura Knoy:
All right. Well, let's go back to our listeners. Michael, thank you for that e-mail. Jonathan's calling from Tilton. Hi, Jonathan. You're on the air. Welcome. Go ahead.

Caller:
Hi. Good morning. Morning.

Caller:
I'm 34 years old and I started smoking when I was basically gone to college. So around 17 or so. And I continued that for about 10 years. I was also an athlete, so I did a lot of mountain biking and I definitely noticed a pinch in my lungs when I would really try to exert myself. And so around the time I was 28 is when I decided to try to switch vaping. 2015 was kind of just starting to get popular. And I immediately realized how complicated it was. And it seems more expensive because I had to make an initial investment. And these things have just come down so much as the availability for these kids is it's just too much and they don't know the complicated aspects of how they work. I went to school for engineering and so my first thought was, is it bad to be breathing, override a hot metal element? You know, so. And I don't know what the difference really is with these dual devices versus a real, you know, kind of like a higher grade option. It's a tank and a battery with sophisticated controls for how whether you want to do pure wattage or an actual temperature control.

Laura Knoy:
And there's a lot of equipment. Jonathan. Yeah. Yeah.

Caller:
The benzo is the acid that's in the door.

Caller:
It's something that I'm not quite sure why it's there, because every, you know, quality is used from companies that have been around for, you know, 10 to 15 years that I see that I use contains just propane glycol and vegetable glycerin and food grade. I buy only natural flavoring.

Caller:
Yeah. Though. And I use grade is having no ill effects. OK. I you know, I just I think it's a case of just, you know, lack of understanding and abuse rather than the products themselves being not harmful. Of course, nothing is as good as breathing in pure air, but compared to a cigarette, these things are safer.

Caller:
And I just I feel like there's so much doom and gloom surrounding them that it just contributes to the counterculture kind of aspects of the lifestyle. And, you know, kids are making more of a sport out of it than, you know, than than what it was really intended for. Had to try to get people to stop smoking.

Laura Knoy:
Well, it does. It's great to hear from you. And I hope you heard earlier Sarah, who called in, who's a researcher at Dartmouth, and she had similar things to say about let's not forget the benefits in helping adult smokers quit. And Lena, to you first. What also strikes me about Jonathan's Colin, I'm so glad to call Jonathan is as he said, it's complicated. There's a lot of different delivery devices. There's some products, as Jonathan said, or I won't use the word pure, but simple. Just a couple compounds. Others have all sorts of stuff in it. So I just wonder if you can reflect Lena on how complicated it is, especially for you as a reporter trying to figure this out.

Lena Sun:
It is very complicated because they are. I think there are there is many, many different types of devices. And as Dr. Tilley said, some look like pens and USP sticks. And there are larger devices like these tank systems or mods. This young man who I was talking to yesterday sent me a video of how he would use his system and the the product that he used. And, you know, it has to be heated.

Lena Sun:
And he said that sometimes that kids who are trying to save a little bit money of money might try to go elsewhere and get a cheaper version or mix the some of the, you know, the oil themselves. And so this is the part where if you are vaping and you are doing on a regular basis and you're using a product that nobody really knows what's in it, those. The bottom line is those substances get into your lung, which aren't supposed to be there. And it's causing what these doctors are very, very worried about.

Lena Sun:
And it is probably underreported because often the people who are presenting to their urgent care clinics and the emergency rooms have symptoms of what could be flu or pneumonia. And this is not something that people are not adding, you know, two and two together and thinking of the vaping products.

Laura Knoy:
Sure. Especially it doesn't get to those severe cases that you mentioned earlier, where people have had to be put on ventilators. Go ahead, Patricia. I can see you want to jump in.

Patricia Tilley:
Sure. I just want to also note that we've seen that defective e-cigarettes, batteries have caused fires, they've caused little explosions and a few of which have resulted in really serious industrial injuries. You know, children and adults have been poisoned by swallowing, breathing or absorbing the E! Liquid through their skin or their eyes. And so this is another really important thing for parents who may be using these products because perhaps they were a lifetime smoker, but they really need to be kept far away out of the hands of kids, especially those products that are not fully contained. So the JUUL products, they're fully contained, but the ones where you have cartridges, where you mix your own or add your own liquid, really need to be kept far away from the hands of kids.

Laura Knoy:
So what's the latest? If you can tell us, Patricia, on sort of the regulatory aspect of this JUUL, for example, has cut back on the flavors, at least in stores. Been a lot of changes, so it's hard to keep track. JUUL also has new beefed up online checks that you are as old as you say you are, although from what I read, that involves giving them your Social Security number, which doesn't sound great. So what's the latest in terms of the regulatory landscape, especially here in New Hampshire, for sure.

Patricia Tilley:
So at the federal level, the FDA is really trying to figure this out. So they've they've honed in right on the flavors, as you know, as you noted. So and JUUL and they've they've set a little note out to all the manufacturers, too, that they're going to be addressing these flavors in a much more substantive way. JUUL, as a large company has seen that, seen the writing on the wall and has pulled those started to pull those products off the shelves.

Laura Knoy:
And by the way, I've seen huge ads in newspapers from JUUL saying adults only and look at all these adults and they're so happy that they quit smoking.

Patricia Tilley:
Absolutely. And, you know, but at the local level, at the local regulatory level, and that's where, you know, we looked at partners like Senator Sherman and others in the legislature to help us really figure out this complex issue.

Lena Sun:
Lena, last question. What more do you want to be looking on this, at this with this topic? Research from Harvard. The CDC, I guess I'm just wanting what's next for you after you did this story about the CDC?

Lena Sun:
Well, this is still an ongoing investigation. So, I would really like to know if at some they're getting these products for people who still have the samples at home.

Lena Sun:
They're getting tested at FDA labs. And I would I want to stay on top and figure out whether there is a common product or substance, you know, to get to the bottom of what is what is causing this. And also to figure out the range of illness. So far, people have been seriously ill. But, you know, hopefully nobody will die because of a respiratory condition that they won't be able to deal with. And I think not all states are maybe being as proactive as they could be to get the message out to their clinicians and their health system.

Laura Knoy:
Well, Lena, I really appreciate you taking time out for us this morning. Thank you very much. Thank you. That's Lena Sun, a health reporter for The Washington Post and voters. Tilley. Thank you so much for being here. Thank you. Patricia Until You is deputy director at the Division of Public Health Services at the New Hampshire Department of Health and Human Services. And you're listening to The Exchange on New Hampshire Public Radio.