The Centers for Disease Control and Prevention has updated and revised the national tally of illnesses linked to the use of e-cigarettes, aka vaping, dropping the count from 450 possible cases to 380 confirmed and probable cases, the agency announced late Thursday.

The new figure follows a clearer clinical definition for the illness as well as further investigation into individual cases. The 380 confirmed and probable cases now span 36 states and still include six deaths, as reported earlier. The CDC added that the current number of cases “is expected to increase as additional cases are classified.”

While health investigators are clearing the air around the clinical aspect of the cases, the cause is still foggy. Though all the cases are associated with vaping, investigators have struggled to identify specific vape products or ingredients that tie all the cases and symptoms together.

So far, investigations have narrowed to focusing on contaminants in counterfeit, black-market, and home-mixed vape liquids, particularly ones containing THC. Many people sickened reported using vape liquids containing THC (tetrahydrocannabinol, the primary psychoactive ingredient in cannabis) prior to falling ill. But the culprit or culprits are still under investigation.

Other problems

Meanwhile, the issue of e-cigarette regulation became blurred this week as well. On Wednesday, President Donald Trump announced intentions to ban flavored e-cigarette products. During the announcement he referenced the current outbreak of vaping-related illnesses, saying:

“We have a problem in our country. It’s a new problem. It’s a problem nobody really thought about too much a few years ago, and it’s called ‘vaping’… There have been deaths and there have been a lot of other problems.”

Flavored, nicotine-based vape products have generally not been eyed as a suspect in the vaping-related illnesses and deaths—particularly those products made by mainstream manufacturers, such as Juul and Blu.

Such a ban appears unlikely to impact the current outbreak—but it may help combat another public health concern: teen vaping. The Food and Drug Administration and the CDC have long blamed flavored products for the sharp uptake of e-cigarette use in children and teens. The products include fruity, candy, alcohol, and dessert flavors, which are thought to be targeted directly to youth, echoing the tactics that tobacco companies used to entice and hook customers long ago.

E-cigarette use among middle and high school students rose from 2.1 million in 2017 to 3.6 million in 2018, according to the CDC. As such, the CDC and FDA have described youth vaping as an “epidemic.”

Dark episode

Vaping industry groups and proponents, however, argue that it’s dangerous to demonize vaping generally and combine the vaping-related illness outbreak with the issue of teen e-cigarette use.

“You’re terrifying people who are benefiting from vaping by not smoking,” Clive Bates, a former chief of the UK charity Action on Smoking and Health (ASH), told Politico.

ASH and government health agencies in the UK have embraced e-cigarettes as a way to wean people off traditional cigarettes. As such, Bates and others think that US authorities should have more nuanced messaging on vaping dangers, particularly those from the unregulated products linked to the illnesses and deaths. Bates added that the current stance by US agencies is creating one of the “darkest episodes in American public health... They have lost all their moorings with evidence and good practice,” he said.

(While the UK has a high uptake of e-cigarette use, the country has not seen a similar rash of vaping-related illnesses.)

Still, while vaping advocates oppose the ban on flavored products, it’s unclear when or if it will go into effect. The FDA still has to finalize the regulation and experts expect that e-cigarette makers will challenge the legality of the ban in courts.