The Texas Department of State Health Services is looking to pinpoint the cause of severe lung disease in those who have reported vape use.
At press time, 82 cases had been reported in North Texas this year, including one death in October, the only reported death in the state. North Texas cases make up a little less than half of the 165 total cases for the state since mid-August.
While highly populated areas like North Texas typically see a high number of cases, department spokesperson Chris Van Deusen said a common cause for the region’s high case count has not been identified.
“There’s not really a way to speculate at this point as to why North Texas might be seeing an outsized proportion,” he said.
The multistate “outbreak” of vaping-associated lung injuries has killed 37 people in 24 states between Aug. 1 and Oct. 29, per the Centers for Disease Control and Prevention’s website. This includes North Texas’s first death, which was reported in October, per the state health department’s site.
A developing story
Vaping, which is the inhalation of vapor from e-cigarettes, is still in the early stages of medical research, said Omar Awad, a medical doctor and pulmonologist in the Baylor Scott & White Health system. There are few answers as to what is causing vaping-related lung injury and illness, he said.
“We don’t know what compound in the e-cigarette or in the vape is doing it,” Awad said.
Unknown substances in liquid nicotine could be the culprit for respiratory illness, said Nicole Rogers, emergency department medical director at Medical City Frisco.
“We’re thinking there’s an oil that’s in the liquid nicotine that’s causing toxicity to the lungs,” she said. “[There are] multiple chemicals in this; they’re not pure substances.”
A vaping device contains a higher concentration of nicotine as compared to a cigarette, Rogers said, which increases the potential for nicotine addiction in users.
However, some users are adding THC, the active ingredient of cannabis, to their vape devices. THC is present in most vape samples causing injury tested by the U.S. Food and Drug Administration, according to the CDC site. The latest national and state findings suggest products with THC, particularly those not sold in stores, are linked to most lung injury cases and have played a “major” role in the outbreak, per the site.
A patient with vaping-related illness will typically arrive at an emergency room unaware that their symptoms are due to vaping, Rogers said. Symptoms could include cough, fever, shortness of breath, chest pain, nausea and vomiting, she said.
The long-term effects of vaping are still mostly unknown, Awad said.
“It’s usually decades in the making,” Awad said. “I don’t think we’ve even scratched the surface in knowing the potential harmful effects in vaping or e-cigarettes yet.”
Effect on youth
Rogers said a variety of e-cigarette liquid flavors have drawn teenagers to pick up vaping.
“Now, there’s a lifetime of these children, young adults and adolescents that are now becoming addicted to nicotine,” Rogers said.
Since Texas raised the age to purchase, consume and possess nicotine from 18 to 21, effective Sept. 1, Rogers said those younger than age 21 are likely obtaining nicotine from alternative sources, increasing the likelihood that unknown substances will be present in their vapes.
Toddlers and infants could be subjected to one deadly drawback of vaping. Rogers said there have been increases in poison control calls for a toddler or an infant accidentally drinking liquid nicotine because of the colorful appearance of a e-cigarette liquid cartridge. “A sip” of liquid nicotine can kill a child age 1 or 2, she said.
Those who vape to kick a cigarette habit could see less carcinogenic impact on their lungs, Rogers said.
“People that are trying to use vaping as an excuse to stop smoking—most of them end up doing both,” she said.
Awad said he addresses cigarette cessation by vaping on a “case-by-base” basis.
“There is more success for cigarette users to stay off cigarettes with vaping than with other nicotine replacement products,” Awad said. But they may continue vaping instead, he said.
If someone quits cigarettes with alternative products, such as a nicotine patch or gum, they have a higher likelihood to permanently stay off nicotine, Awad said.
“There might be a role for vaping in smoking cessation,” Awad said, “but not the way it is now. It is unregulated; it is uncontrolled.”
For vaping to be used as a cigarette cessation aid, Awad said vaping products must be manufactured and regulated as pharmaceutical drugs.
Some Frisco vapor stores are reporting declining sales with rising reports of vaping-related illnesses, injuries and deaths nationwide.
Three days after the first reported U.S. vaping death in August, Artisan Vapor & CBD, which has five shops, including one in Frisco, started seeing a drop in customer traffic, according to district manager Vincent Kilgore.
“It has very negatively impacted business,” Kilgore said. “People are coming into the stores left and right and asking if vapes are killing people.”
Kilgore said he responds by educating customers on how to use vapes properly to avoid injury.
Artisan Vapor & CBD, founded in 2013, has seen an approximate 20% decrease in sales across the company nationwide since the first reported vaping death, Kilgore said.
This decline is not uncommon, said Schell Hammel, president of The Vapor Bar, which has a Frisco location on Stonebrook Parkway. Hammel is also the director of state chapter relations for the Smoke Free Alternative Trade Association for the U.S. and vice president of the American E-liquid Manufacturing Standards Association.
“It has not only affected my business but businesses across the country,” Hammel said.
Vapor stores nationwide have seen a 25%-75% decrease in sales between August and October, Hammel said. Texas stores have taken a 34%-75% hit, she said.
The Vapor Bar stores, which first opened in McKinney in 2012, have seen a 19%-35% drop in sales, Hammel said. All its locations in Texas, West Virginia and Virginia are reducing costs and store hours to compensate for decreased sales, she said.
The global e-cigarette and vape market was valued at $10.2 billion in 2018, according to a Grand View Research market research report.
“There was pretty good money in this field just a few months ago,” Kilgore said.
Some business managers say the decline is inhibiting vapor stores from their goal of helping customers break their cigarette addictions.
“We’re losing our vapers back to smoking,” Hammel said.
Vaping and cigarette cessation
Kilgore and Hammel said their businesses aim to use vaping as a tool to quit smoking, but the negative attention around vaping has caused some of their customers to return to cigarettes.
“Our job isn’t just to sell as many vapes as possible,” Kilgore said. “Our job is to get people off of nicotine.”
Artisan Vapor & CBD does this by reducing its vapes’ nicotine content over time, he said.
The U.S. Food and Drug Administration plans to clear the market of unauthorized, non-tobacco-flavored e-cigarette products, including mint and menthol, according to a U.S. Department of Health & Human Services news release in September.
This move is intended to “reverse the deeply concerning epidemic of youth e-cigarette use,” Health and Human Services Secretary Alex Azar said in the release.
The FDA aims to do this with a policy that would require non-tobacco-flavored e-cigarettes to be authorized by the FDA before being sold on the market.
But Hammel said she believes vape flavors play a role in nicotine cessation for adults.
“[Flavors are] a necessary process for these individuals to be able to move into as their taste buds regenerate,” Hammel said.
Flavors are not intended to attract youth to use e-cigarettes, Hammel said. The Vapor Bar’s customers range between the ages of 33 and 75, she said.
The typical customer at Artisan Vapor & CBD is between ages 25 and 40, Kilgore said.
THC and black market products
The cause behind the recent spate of injuries and deaths is still being investigated by health departments. But according to the Centers for Disease Control and Prevention’s website, THC, the active ingredient of cannabis, has been linked to most lung injury cases and has played a “major” role in the recent health outbreak.
Hammel said she believes there is confusion surrounding vaping products sold in stores and products sold on the black market or illegally. THC is not part of the vaping industry, she said.
According to Kilgore, some vape users who illegally obtain THC products add Vitamin E acetate—a compound typically found in skin-care products—to their devices to enhance the THC by thinning THC oil. However, the acetate is not meant to be inhaled and can inhibit oxygen production, he said.
To shift public perspective on the vaping industry, Kilgore and Hammel said they are rolling out education about unregulated THC along with laws and guidelines.
“We’ve been doing this for a decade now,” Hammel said of running vaping stores. “Nothing has ever come like this, and why in the world would they think, all of a sudden, that [THC] started coming out of our shops?”