TEMPLE, Texas (KWTX) The answer to questions about the safety of vaping ultimately lies in the mix of chemicals in the liquid that e-cigarettes and vaping devices use, but so far the mix has proven to be something of a mystery because "vape juice" comes from so many different sources with no manufacturing standards.
Nearly 2,300 cases of lung injury and 47 deaths associated with e-cigarette or vaping product use had been reported to the U.S. Centers for Disease Control and Prevention as of Nov. 20 and researchers are trying to find a common link. (CDC image)
But a researcher at Scott & White Medical Center in Temple says some of the substances he's found in vape juice are toxic to humans.
"I got started with the study after a number of friends' kids were experiencing problems with vaping," said Dr. Carl Boethel, chief of the hospital's Division of Pulmonary, Critical Care and Sleep Medicine.
The issue only heightened when he made a trip to New Mexico with some Boy Scouts.
"I went on a Boy Scout trip to Philmont and while I was there I talked with the scouts about vaping and they told me vaping was rampant in their schools. All over," he said.
"It's almost epidemic," Boethel said.
"In the past couple of years there's been a dramatic increase in use of vaping products in middle and high schools."
Boethel has been studying the effects of vaping for some time, but he pointed out, that unlike tobacco, which has been studied for decades, scientists and doctors say there is no way for them to predict what issues vaping could cause users 30 or 40 years down the road.
"We just don't know," Boethel said, "and that's what's scary.
Part of the scientific effort now is to find out what is in vape juice and how it's manufactured and mixed.
E-liquid, or e-juice, is the name for the solution that's heated up and converted to an aerosol, which e-cigarette users inhale.
The primary ingredients of vape juice include vegetable glycerin and propylene glycol but the juice may contain many other substances that haven't been adequately studied, Boethel said.
Joshua Knight, 33, said he started vaping two and a half years ago when his son was born.
"People seem to think that smokers and vapers don't think about what they're doing, but a lot of vapers are the intelligent people who are getting away from smoking that being said younger kids looking at 'oh my God this is a fad I want to do it with my friends' aren't checking and that's probably why they are going out to their local quickie mart picking up a Juul because it's cool and that's what's killing them."
The biochemistry major said, he knows some of the products on the market can be unsafe, which is why he mixes his own vape juice.
He said it contains pure nicotine, food-grade flavoring, vegetable glycerin, and propylene glycol.
AMA calls for a total ban
The American Medical Association, on Nov. 19, called for a total ban "on all e-cigarette and vaping products that do not meet Food and Drug Administration approval as cessation tools."
"The recent lung illness outbreak has alarmed physicians and the broader public health community and shined a light on the fact that we have very little evidence about the short- and long-term health consequences of e-cigarettes and vaping products," said AMA President Dr. Patrice A. Harris.
"It's simple – we must keep nicotine products out of the hands of young people and that's why we are calling for an immediate ban on all e-cigarette and vaping products from the market."
In the meantime, some colleges and universities are banning vaping on altogether.
McLennan Community College in Waco, for example, announced that starting Jan. 1, 2020, it will no long allow smoking or vaping on campus.
Right now the school has several designated smoking areas away from the entrances to any building.
Psychology major, John James said he's been vaping for nearly three years.
He started as an alternative to smoking cigarettes.
He said he has quit before but the stress of a new job encouraged him to pick up the habit again.
He said he realizes the psychology of smoking, curbing the nicotine appetite and the repeated movement of taking those routine drags is difficult.
Because of the rule change on his campus, he is considering quitting again.
"So MCC has starting the first of the year what will be a complete ban on campus so it would probably be a lot easier for me to quite instead of trying to sneak around I don't know I do enjoy it but I don't like the fact that I have a chemical addiction."
Pieces of the puzzle
Nearly 2,300 cases of lung injury and 47 deaths associated with e-cigarette or vaping product use had been reported to the U.S. Centers for Disease Control and Prevention as of Nov. 20 and researchers are trying to find a common link.
"The CDC has identified vitamin E acetate as a chemical of concern among people with e-cigarette, or vaping, product use associated lung injury," the agency said.
The CDC is recommending that people not use e-cigarette or vaping products that contain THC and that vitamin E acetate should not be added to the products.
"The latest national and state findings suggest THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, or family, or in-person or online dealers, are linked to most of the cases and play a major role in the outbreak," the CDC said.
The U.S. Food and Drug Administration is following the same path.
"The FDA has not found one product or substance that is involved in all of the cases; however, we do know that THC is present in most of the samples being tested," the agency said.
The FDA also found vitamin E acetate in 48 percent of the THC products it tested in concentrations ranging from 23% to 88%.
The substance is used in as a thickening agent in vaping fluid.
But 24% contained other thickeners such as medium chain triglycerides, the FDA said.
An analysis of samples from 70 patients with U.S. Centers for Disease Control and Prevention case numbers finds 79% of the patients are linked to THC products, 76% of the cases included products in which vitamin E acetate was used, 31% included products that used aliphatic esters as thickeners and 6 percent included products that used polyethylene glycol.
"It is important to stress that identifying any compounds present in the samples linked to patient cases is but one piece of the puzzle and will not necessarily answer questions about causality, which makes ongoing work critical at both the state and federal levels," the FDA said.
State and federal efforts, so far, however, are mainly focused at addressing the use of e-cigarettes and vaping products by children.
Congress moves to ban online sales
On Oct. 28 Congress passed the U.S. House of Representatives' "Preventing Online Sales of E-Cigarettes to Children Act," which aims to prevent online sales of electronic cigarettes to minors by applying the same safeguards already in place for regular cigarettes and smokeless tobacco products.
But the legislation does not address e-liquids or their regulation.
The measure is pending in the U.S. Senate.
"I applaud the House for passing this legislation to reduce underage smoking by treating a child's attempted purchase of e-cigarettes online the same as other tobacco products, and I look forward to bringing it to the Senate floor soon," U.S. Sen. John Cornyn, R-Texas said.
If it becomes law, the measure will require age verification, an adult with ID to receive the delivered package, clearly label shipping packages to reflect they contain tobacco products and comply with all state and local tobacco tax requirements.
"The most common way for children to purchase e-cigarettes is to buy them online. We need to stop that from happening," said Sen. Dianne Feinstein, D-Calif.
"I'm pleased to see the House pass this bill with broad bipartisan support and I urge the Senate to do the same swiftly so we can curb children's access to these addictive and harmful devices."
In mid-November the U.S. House Energy and Commerce Committee passed a bill banning flavored tobacco products including flavored e-cigarettes and menthol cigarettes.
The president ponders a response
On Nov. 22 President Donald Trump met with representatives of the vaping industry and public health advocate to discuss possible solutions to the vaping epidemic, the impact of vaping on children, banning the sale of flavored vaping products and raising age limits.
In September Mr. Trump announced his administration would work to remove flavored products from the market.
U.S. Sen. Mitt Romney, R-Utah, who participated in the meeting, called vaping among children "a health emergency."
"We've got almost 6 million kids addicted to nicotine and they are getting addicted to nicotine because of flavors. Sixty-six percent of the kids addicted to these products are saying they didn't even know they had nicotine in it. They thought it was just a candy type product. It's the flavor that's drawn the kids in," he said.
The president, however, questioned whether outlawing flavored vaping products might lead to worse problems.
"If you don't give it to them it's going to come here illegally. They're going to be selling stuff on the street corner that's going to be horrible," he said.
Some states tread where feds fear to go
Michigan Gov. Gretchen Whitmer announced in early September that she would issue an emergency ban on the online retail sale of flavored nicotine vaping products, but a court issued a temporary injunction against the ban in October.
New York implemented a statewide ban on most flavored nicotine vaping products in mid-September and a week later Massachusetts Gov. Charlie Baker declared a public health emergency and announced a four-month statewide ban on online and retail sales of all vaping products.
Rhode Island Gov. Gina Raimondo has signed an order directing the state's Department of Public Health to ban the sale of flavored e-cigarettes.
A judge temporarily blocked an attempt to implement similar rules in Montana.
Utah officials instituted a policy that allows the sale of e-cigarettes and vaping products only in tobacco specialty shops whose owners agree to place warnings about the dangers of vaping unregulated THC.
In Washington state an emergency 120-day rule is in effect that bans all flavored vaping products.
Oregon has implemented a six-month rule banning the sale of flavored nicotine and cannabis.
Officials in California stopped short of banning vaping products, but Gov. Gavin Newsom has issued an order aimed at curtailing youth vaping.
(Ke'Sha Lopez contributed to this story)