KOJO NNAMDIYou're tuned in to The Kojo Nnamdi Show on WAMU 88.5, welcome. The Centers for Disease Control and Prevention has recorded at least 215 cases of severe pulmonary disease or lung illness in patients with a history of vaping since August 22nd with cases reported in 25 states. Maryland Public Health officials identified five individuals, who have developed severe lung illness, severe enough to require hospitalization for their symptoms. Officials in Virginia have confirmed three similar cases so far. They're still investigating others. All of these patients have a history of using e-cigarettes leading doctors to believe that the mysterious illnesses are related to vaping.

KOJO NNAMDIVaping has surged in popularity in recent years especially among teenagers and young adults. So this latest development is alarming on many fronts. Joining me in studio is Dr. Clifford Mitchell. He is the Director of the Environmental Health Bureau at Maryland Department of Health and Mental Hygiene. Dr. Mitchell, thank you for joining us.

CLIFFORD MITCHELLThank you very much.

NNAMDIWhat does the CDC mean when they say severe pulmonary disease and is this widespread enough to be considered an outbreak?

MITCHELLWell, there are two questions there Kojo. The first is these cases have been quite severe many requiring hospitalization, some actually requiring time in the intensive care unit or intubation and assistance with oxygenation. So this would be considered very severe pulmonary disease, and something that we take quite seriously.

NNAMDIWhat can you tell us about the patients in Maryland? For instance, we just got an email from Mills who says, I'm writing this outside my son's room at Fair Oaks Hospital where he has been since Friday. He has acute bilateral pneumonia caused by impurities in what he was vaping. Had we not brought him to the ER when we did in all likelihood he would have died. Ask any pulmonologist in the area and they'll tell you that this is not an emerging threat. It has emerged. So tell us about the patients in Maryland. What kind of symptoms are they experiencing?

MITCHELLWell, they're very similar to the patients that have been observed nationally. In many cases these patients have started off with what appears to be flu-like symptoms. So high fevers, some gastrointestinal symptoms like nausea, and then they've progressed to have severe shortness of breath, cough and problems maintaining the body's oxygenation and that has brought them to the emergency room and to hospitals. So something that I think we are all taking very very seriously across the country. And the CDC, FDA and other national organizations are also very concerned about this.

NNAMDIAnd what do you know about the demographics of the patients?

MITCHELLWell, they are very similar to the demographics of the people that we know are vaping. So they tend to be younger adults. In some cases across the country and in Maryland we have seen people, who are under the age 18. But for the most part the majority are in sort of the young adult range of over 18 to mid-40s-50s.

NNAMDIDo we know what is causing these illnesses? Have health officials been able to make the direct link to vaping?

MITCHELLSo I think that that's the question that is on everybody's mind. At this point we don't know what's causing it. We have associations. We know that many of these individuals have used a combination of products. Some of them have reported using nicotine containing products, but have also contained in many cases products that contain THC products. And at this point we do not have a single agent or even group of agents that we could point to and say, that's what's actually causing this.

NNAMDISo officials are not yet ready to make the declaration that vaping is causing these illnesses, but you found a strong association between vaping and these symptoms in patients correct?

MITCHELLWell, I think that at this point we've ruled out all the other or many of the other possible explanations. So we've looked at things like infectious agents and these folks have not. These patients have not had infectious agents that we've been able to identify. And they've all got a strong association with vaping. So while we can't say for sure what it is in the vaping that's causing the problem, we are all very concerned that vaping is the most likely explanation for what is causing the problem.

NNAMDIJoining us in studio is Moriah Balingit. Moriah is the National Education Reporter at The Washington Post. Moriah, thank you for joining us.

MORIAH BALINGITThank you for having me.

NNAMDIOne of the major concerns cited by the CDC and other public health officials about this outbreak is the fact that vaping is extremely popular among teenagers and young adults. So they are at risk. You've been writing about this trend for The Washington Post. What can you tell us about the popularity of vaping among teenagers?

BALINGITSo it has really exploded over the last couple of years. In 2018, something like 37 percent of 12th graders reported that they had vaped at least once in the previous month. And that was something like double the rate from the previous year. And it's become very pervasive in teen culture. Some teens refer to the bathroom now as the JUUL room, because JUUL, a lot of teens are using it to use e-cigarettes. There's all kind of memes and language and lingo that's associated with e-cigarettes now. One term that I heard from an addiction specialist is "nic sick" and that's a term that refers to when somebody vapes so much that they become physically ill. They get nausea. And some addiction specialists have also said that they're seeing people with symptoms of nicotine toxicity disorder, which is something that was previously found in, for example, if a kid got a hold of nicotine gum.

NNAMDISo this is an indication that this may have crossed over from just being a trendy thing to an addiction among some young people?

BALINGITYes. And there's a lot of concern that there are a lot more teens addicted than we really realize or know, because it's very easy to conceal e-cigarette use especially JUUL use. Teens have gotten away with juuling in classrooms, in their bedrooms, obviously in school bathrooms. And so it's a lot easier for a teen to hide that they're addicted to juuling or that they're using e-cigarettes regularly than it would be if they were using regular cigarettes, for example, which obviously carry a pretty strong smell.

NNAMDIThe surprising thing, Moriah, is that smoking has lost some of its luster as the cool thing to do among teenagers in recent years. That's for smoking traditional cigarettes, but vaping is extremely popular. What did the kids you spoke with tell you about why they do it and are they aware of the health risks?

BALINGITI think for the large part they're not aware of the health risks. And part of the reason is because as a poll we're not aware of the health risks as we've seen. There's these illnesses that are linked to vaping that we weren't previously aware of, and I think the message that a lot of teens got is that vaping is safer than cigarettes. And even if that is the case, that doesn't mean that it's safe. And I don't know if that was a message that they got. The funny thing is that I talked to teens, who were vaping up to a pack or like a pod a day, which is about equivalent to one to two packs of cigarettes worth of nicotine. They think that cigarettes are disgusting, and they never ever want to smoke. So even though they were basically addicted to e-cigarettes they still found combustible tobacco use to be really gross.

BALINGITSo maybe I'm not exactly sure why they get into it. I think part of it -- a lot of them were attracted to the flavors. They thought it looked cool. They thought it was sleek. So I think that was a large part of it, and the fact that it's really easy to conceal could also play a role in why teens are attracted to the product.

NNAMDILet's go to the phones where David in Plainfield, Indiana awaits us. David, you're on the air. Go ahead, please.

DAVIDThank you, Kojo. My wife has vaped for years and I think her big thing is talk to the store you're buying your stuff from. She uses the same store every time. She's tried a couple others. She doesn't like them. Doesn't go back to them. She talks to the guys. Got good information on her kit, the actual vaping machine. You know, the type of battery she wanted, the type of tank, coil. And she keeps it clean. She cleans out the device, the coil changes it regularly. Buys liquid from the store where she can talk to the guys and say, hey, you know, what's in it? You know, what kind of things did you do to make it?

DAVIDAnd I think that one thing that I hope they look at in this problem that people are having is that people, who get stuff from like a well-established store, was it more underground? Did they add something to the liquid themselves? And I think that that's a big thing is that getting it from a professionally done place would make it, you know, a lot better. And I hope that that's -- I don't want people to demonize vaping. It's actually quite good for her. And when she switched from cigarettes to vaping a lot of stuff came out of her lungs and she's been a lot healthier ever since.

NNAMDIWell, there's still obviously a lot that we don't know, Cliff Mitchell, but to what extent have you been talking or listening or hearing about the fact that it has to do with, well, maybe where it comes from?

MITCHELLSo this is a complicated question, but I want to go back to something that Moriah talked about, which is that, you know, we do know that cigarettes pose significant health risks. They're associated with cancer. They're associated with strokes, hypertension, cardiovascular disease. And so we certainly want people to quit smoking. I do, however, want to stress that there is a lot that we don't know about even the chronic use of vaping devices. And so while we're very concerned about the disease risk associated with the severe pulmonary diseases and we can talk a little bit about sort of what we know about that. At this point, I do want to emphasize that the long term health consequences of vaping itself are unknown.

MITCHELLThere are a significant number of chemicals that are in the aerosol that's produced by vaping devices. And they include aldehydes, ketones, acetyls and a bunch of other things as well as nicotine itself, which is both addictive and has cardiovascular effects. And the other thing is that we have just started this experiment with -- on the large scale population bases exposing people to vaping. And we do not know at this point that it is safe by any means. So I do want to stress that even if we weren't talking about these significant pulmonary risk associated with this lung disease, there's a lot we don't know about the long term health consequences of vaping.

NNAMDIMoriah, you also spoke with addiction specialists and clinicians, who are treating kids for vaping addiction. So allow me to ask if there's a relationship between these two things. One is it more difficult for teens to quit once they're addicted and two are there resources for them to turn to?

BALINGITIt appears to be a very different kind of addiction than tobacco addiction. The teens that have been presented -- or the teens that end up with these addiction specialists often have really strange symptoms that we don't typically associate with combustible cigarettes. They're stealing to fuel their JUUL habits or their e-cigarette habits. They're developing really really extreme mood swings. Far more extreme than we typically see with, you know, in normal adolescence. I talked to teens, who couldn't sleep at night who developed very severe anxiety, grew violent at times. I talked to a mother, who said that she would have thought that her son was addicted to heroin, because his addiction JUUL was so extreme. She at one point told me that she went into his bedroom and he was curled up on the floor crying and saying, "I just can't stop."

BALINGITSo the symptoms that have been associated with some of these teens with addiction to e-cigarettes are far more acute and far more severe than we've typically seen with tobacco. And the doctors I spoke to believe that it may be linked to the fact that a person can JUUL or they can vape far more nicotine than they might be able to with cigarettes. So, for example, because JUUL manufactured its product to be smoother to be easier on the throat, it's possible for a teenager, who would never be able to chain smoke a pack of cigarettes to JUUL an entire pod, which is about equivalent to that amount of nicotine. So we're starting to see for the first time what are the impacts of these extremely high levels of nicotine on an adolescent brain.

NNAMDIAnd since we still know so little about vaping, what about the resources available for these young people who might be addicted to vaping to turn to?

BALINGITI spoke to a couple of parents, who said they had a lot of trouble finding counselors, addiction specialists who would treat their kids. One mother I knew actually ended up sending her child to an inpatient drug rehabilitation center, and she had trouble finding a place where they didn't allow tobacco use because she's trying to get her son to quit nicotine. Some counselors don't take it seriously. And I think the bigger problem is a lot of pediatricians don't know about it and don't know to ask about it.

BALINGITOne addiction specialist I talked to she had a patient referred to her, who was describing things like dissociation disorder where he was sort of not realizing -- he would, you know, blink and not realize where he was. And she swore -- she was like, this kid has to be lying. He's got to be on other drugs. They screened him. He was just using e-cigarettes. He just had nicotine in his system and she was really appalled to find out that -- how extreme these symptoms can get with e-cigarette usage.

NNAMDIWhat are schools doing to reduce or present vaping by students?

BALINGITSo a lot of schools have started out with sort of a punitive scheme. They have treated e-cigarettes just like they treat cigarettes. So sometimes that means a suspicion or it means other consequences. Some kids have gotten kicked out of sports. But other schools are starting to look at this more as an addiction problem and realize that sending a kid home for a day might just mean that that kid is going to, you know, use e-cigarettes all day. So they're trying to either match or replace that with education, because they're really trying to slow this trend. But, you know, for some parents they feel that the punitive aspect doesn't really work, because taking their kids out of their communities out the extracurriculars that might keep them from vaping in the first place ends up being very counterproductive.

NNAMDICliff Mitchell.

MITCHELLYeah, and I would add to that in Maryland there is a new law which as of October of this coming year will actually make it illegal to sell these products as well as all tobacco products to people under the age of 21. So I think we are beginning to see states also recognize the risks associated with this especially with young people. I just learned this morning that Michigan is now banning for a six month period the use of e-cigarettes while they look at the potential harm associated with these. So I think that you are seeing an increasing recognition, partly because of the health risks that we've identified just recently, but also because of the things that Moriah's talked about.

NNAMDIMoriah, what stance is the industry taking here? What are the manufacturers of e-cigarettes and vaping devices saying regarding the health risks and the fact that vaping has surged among young people?

BALINGITYou know, they often really defend their products and their product design saying that these products were designed as tobacco satiation products. These were designed for adults, who are addicted to smoking. And they say they manufactured their products to make them attractive to those adults so that they could transition from traditional combustible tobacco products to e-cigarettes, which they view and defend as safer than combustible tobacco products. And they've, you know, partially because of the FDA JUUL, the company that has 70 percent of the market share has actually taken some of it's more popular flavors out of retail outlets. So they had a flavor called crème brulee and another one called mango, and mango -- I talked to teenagers was wildly popular among teenagers. So they can no longer buy those in retail outlets, but they can still buy them online.

BALINGITSo those are a couple of things that have been done. I think the problem is that either they didn't anticipate or they didn't think about the fact that some people are moving immediately to e-cigarettes. They're not viewing this as a tobacco satiation product. They're viewing this as a nicotine -- like a way to ingest nicotine.

NNAMDIHere is Nicole in Olney, Maryland. Nicole, you're on the air. Go ahead, please.

NICOLEHi. I'm a former smoker. Occasionally have, you know, vaped some of the flavorful nicotine ones. And they're way stronger than a normal cigarette. And what I promote with my children is safe cannabis use. As a parent I do vape cannabis. I have a pen with me currently. I would not recommend the vaping of the nicotine to the children, because nicotine -- it's almost like alcohol to me. I'm absolutely shocked that we promote it the way that we do. And I agree with the statement from the other mother that I have friends that are in rehab. And I don't see how they're in rehab, because all they do is sit there and smoke a carton of cigarettes all day. And I'm like, you're not in rehab. You're now just seriously addicted to nicotine and that's just as bad.

NICOLEAnd so with my kids, I've educated them since they were young about cannabis. And they're familiar with it. And neither of them use at this point. But I think it's because they're aware of -- okay some of this stuff is really bad. And, you know, if you're going to go for it, you're going to do something, you know, you don't want to get stuck on something that you're going to be addicted to the rest of your life. And nicotine is so highly addictive. So I would just maybe -- we should look at cannabis as an option more so than, you know, nicotine and things like that and alcohol.

NNAMDICliff Mitchell.

MITCHELLSo thank you for that comment, Nicole. I do want to stress, however, that one of the things that we're looking at with a strong potential association is the possibility that at least some of this problem is related to THC containing products that are being vaped. Now there's a lot we do not know. We haven't identified a product, whether it's an actual product being marketed legally in some states or it's a counterfeit product. At this point nobody knows, but there is at least some reason to be suspicious and concerned about the possibility of THC containing products being related to in some way the ongoing problem associated with pulmonary disease. So I would be very very cautious and hesitant to promote in any way the use of vaping of cannabis products as safer in any way to the concerns with respects to vaping of nicotine.

NNAMDIThe email I read earlier about an individual whose son is in Fair Oaks Hospital was apparently from Theodore in Fairfax, Virginia. Theodore is now on the air. Theodore, go ahead, please.

THEODOREYeah, hey, Kojo. And this is in many ways a response to the most recent call there, because my son who is critically ill, it's from vaping THC products. And what his pulmonologist has said is that they're seeing a tremendous rise in problems associated with that, because A, it's unregulated and B, these products contain all sorts of strange oils and so his lungs are just a complete wreck as a result. So, you know, who knows how long it's going to take before he gets well. And so anybody who's vaping these products is just -- they should watch a video of somebody on a ventilator and then ask themselves, do I really want to be that person?

NNAMDIOkay. Thank you very much for your call. Finally, Cliff Mitchell, where do we go from here?

MITCHELLWell, I think there are really two issues. Obviously everybody is very concerned about finding the cause and preventing this ongoing problem with lung disease. I think a second and equally compelling question are some of the issues that Moriah has raised and that the callers have raised about the long term consequences and risks associated with vaping particularly in young people. And so I think that as we move forward we will have to be very concerned about stopping the ongoing problem with pulmonary disease. Beyond that I think that there are real questions about who and how we should be allowing the use of vaping in the general population.

NNAMDIDr. Clifford Mitchell is the Director of the Environmental Health Bureau at the Maryland Department of Health and Mental Hygiene. Thank you for joining us.

MITCHELLThank you very much, Kojo.

NNAMDIMoriah Balingit is the National Education Reporter at The Washington Post. Moriah, thank you for joining us.

BALINGITThank you for having me.

NNAMDIShort break, when we come back a new report out today calls for an all hands on deck approach to solving the affordability problem in this region. I'm Kojo Nnamdi.