The disease is clinically distinct from lipoid pneumonia, a disease diagnosed in other patients with purported vaping-caused illnesses.
Juul has not responded to a request for comment. A kind of vaporizer product, Juul's e-cigarettes warm up liquids in a chamber to temperatures that are too low to burn the material, but high enough to volatilize it for inhalation.
The Food and Drug Administration in September admonished the company for advertising its products as a safer than cigarettes without the FDA's approval of that claim.
Juul for more than a year has been slammed with lawsuits over its alleged use of trendy ads and flavored products to rope youths into using its products. The deceptive trade lawsuits, now being filed in state and federal courts on a daily basis, claim the company concealed the addictiveness of Juul e-cigarettes and under-represented nicotine doses.
The company has publicly denied that it targeted teens in its advertising.
Notwithstanding the long-running cascade of nicotine-addiction lawsuits against Juul, civil cases attempting to link Juul pods to acute respiratory failure and other life-threatening sicknesses are a relatively new phenomenon.
Over the summer, a California federal court complaint attempted to connect plaintiff Maxwell Berger's stroke to his use of Juul e-cigarettes.
Berger and Gluch's pleadings both draw heavily from the language and background information in the nicotine-addiction-centered lawsuits against Juul. These plaintiffs say Juul portrayed its products as safe despite evidence that nicotine vaping carries a risk of respiratory and cardiovascular illness.
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Conley of the American Vaping Association said smaller vaping liquid producers are ill-equipped to shoulder the legal fees that will come with years of personal injury litigation.
"You can almost never look at the e-cigarette industry as a whole. You can look at it as two divisions," Conley said. "You have Wall Street-backed companies that have the ability to raise capital, along with Juul, which is more than one-third owned by a big tobacco company with a rich history of defending lawsuits. Then you have the rest of the industry."
The big tobacco company Conley was referencing is Altria, which recently acquired a multibillion-dollar, 35% stake in Juul. Altria owns Philip Morris USA, maker of Marlboro cigarettes.
Conley said that with financial resources aplenty, the big e-cigarette corporations' lawyers are free to adopt a strategy of squashing as many personal injury cases as possible with settlement money.
"They eventually may just try to settle, pay everything out and make people go away for low amounts of money," Conley said. "If they actually fight [in court], I don't believe these lung illness cases will be shown to be caused by nicotine vaping products."
He said the cost of litigation, combined with a new FDA regulatory scheme, could reshape the vaporizer industry and put many of the smaller vaporizer companies out of business in the next few years.
The FDA asserted dominion over the regulation of e-cigarette producers and vape shops in 2016 when it deemed e-cigarettes to be tobacco products under the Family Smoking Prevention and Tobacco Control Act.
A deadline for submitting e-cigarette product applications to the FDA has been extended until 2022, giving small-scale nicotine cartridge producers a sigh of relief. The application process involves extensive safety reviews meant to show the FDA that a given product will be marketed in a manner that protects public health.
The FDA meanwhile is considering a regulation to prohibit the use of fruity flavorings in e-cigarette liquids.
Industry advocates have warned that a flavor ban -- combined with new regulatory roadblocks to selling modular vaporizer devices -- could create a large black market for nicotine vaping items, similar to what's going on in the THC oil arena.
"Grey and black markets just create consumer safety issues. And we know prohibition in this country does not work. There are 14 million people who vape. You can't put this genie back in the bottle," Conley said.
States and cities across the nation have moved fast to ban fruit flavored e-cigarettes on the grounds that they appeal to teens.
Michigan was the first state to institute a flavor ban. But after vape shops sued, a judge issued a preliminary injunction blocking the state from enforcing it. New York State's flavored e-cigarette ban was likewise temporarily blocked in court.
Massachusetts has instituted a four-month ban on all vaping product sales. A judge in Suffolk County on Monday allowed the ban to remain in place, provided that the governor's office submits a formal emergency regulation.
Meanwhile San Francisco, where Juul maintains its headquarters, has an upcoming moratorium on all vaping products sales pending FDA review.
Juul for its part has announced that it will no longer sell fruit-flavored products anywhere in the U.S.
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As for contaminants in the THC vaping oil market -- the list of suspect substances is long.
Dr. Ruth Lynfield of the Minnesota Health Department said in an interview that Vitamin E, used to thicken THC vaping oil, is being investigated as a possible contributor to the wave of vaping-linked lung illnesses.
Health officials are focusing on vitamin E oil in part because it has become one of the most widely used diluting agents in THC vape liquids, especially in illegal products. And its inhalation safety profile is not well-developed.
Other substances, including pesticides, thermal decomposition products of propylene glycol, heavy metals from heating elements, and various solvents have been suggested as possible contributors to the outbreak.
There have been isolated hospitalization reports indicating that some black market vaping oils contained powerful research chemicals, synthetic cannabinoids, in place of naturally derived THC.
Lynfield said it "paints a pretty frightening picture" when droves of previously healthy vaporizer users in their 20s and 30s fall ill and end up in hospitals on mechanical ventilation. She said what is happening appears to be a true large-scale outbreak, not some statistical fluke or mass misattribution of infectious illness to vaping habits.
CDC data, which includes "confirmed and probable" cases of vaping-related lung injury, indicates that nearly 80% of patients are under the age of 35.
Confounding efforts to make the THC oil distribution chain safe, empty counterfeit vaporizer cartridges can be readily purchased online and in retail shops in California. Unscrupulous profiteers buy the cartridges, fill them with potentially unsafe diluents and distribute them on a mass scale.
According to Conley, high state taxes on vaping and THC products are creating a breeding ground for illicit products.
"When you put big taxes on legitimate vaping cartridges, and you combine that with a lackadaisical attitude towards black market sales, we end up with people avoiding high prices by buying something from the guy down the street. And the packaging looks like it came from a dispensary," he said. "A consumer thinks, 'Well maybe it just fell off the back of a truck.' And that's why he's getting a THC oil for $30 instead of $60.'"
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