Europe does not appear to be experiencing an outbreak of the “vaping sickness” gripping the U.S.

It’s not clear anyone would know if it was.

U.S. President Donald Trump on Wednesday moved to finalize a ban on flavored e-cigarettes in light of the country’s outbreak of a vaping-related illness that’s made 450 people sick and resulted in at least six deaths. With the U.S. Food and Drug Administration urging people to avoid buying unregulated vape products, other U.S. experts say people should avoid all e-cigarettes until the cause is clear.

In European countries like the U.K. and France, which have voluntary reporting systems, there’s not much evidence of this problem, and experts cite tighter e-cigarette regulations in Europe than the U.S.

“We have not seen anything like what we’ve seen in the U.S. recently in Europe, to my knowledge as a scientist, and I’m pretty aware of the field,” said Constantine Vardavas, the European Respiratory Society’s scientific relations director with the EU.

“You’re terrifying people who are benefiting from vaping by not smoking.” — Clive Bates, former chief of the U.K. charity Action on Smoking and Health

But while several EU and national agencies said they are monitoring the U.S. situation, they weren’t always able to say who’s keeping track on this side of the Atlantic. An EU-wide reporting system is still in the works, and a broad analysis of e-cigarette safety is only due in the fall of 2020.

Some EU experts say there’s no reason to think this side of the Atlantic will be immune.

Though the cases are currently limited to the U.S., the Portuguese Society of Pulmonology said in a statement Wednesday that “they are likely to arise in other countries, including Portugal,” given the widespread availability of e-cigarettes.

“The use of electronic cigarettes is dangerous and not recommended,” the society said.

The lesser evil

This debate has extra resonance in the U.K., where the government has embraced e-cigarettes as a way to wean people off tobacco.

There, officials say the worst thing people could do is go back to regular cigarettes out of fears that vapes could land them in the hospital with a major lung malfunction.

“You’re terrifying people who are benefiting from vaping by not smoking,” said Clive Bates, a former chief of the U.K. charity Action on Smoking and Health (ASH) and a strong defender of e-cigarettes as a smoking cessation tool.

Bates argued that authorities should be delivering more targeted warnings about unregulated products. Instead, he said the U.S. medical establishment is creating one of the “darkest episodes in American public health ... They have lost all their moorings with evidence and good practice.”

The U.K. has the world’s third-highest uptake of e-cigarettes, and government health officials promote vapes as a way to wean people off more harmful tobacco. Over the past year, according to the country’s Medicines and Healthcare products Regulatory Agency (MHRA), only 12 incidents of health problems with nicotine-containing e-cigarettes have been reported to the regulator’s voluntary system.

Among those, seven involved respiratory problems, and none of the cases were considered serious or required hospitalization. (Even in these cases, it’s not known if the e-cigarette was the cause of the reported problems.)

But there are some major caveats that leave room for concern. The U.K. has seen at least one case that has key similarities with the U.S. “vaping sickness,” which is essentially lipoid pneumonia — the accumulation of fat particles in the lungs. Doctors suspected the patient’s vaping liquid was to blame.

The case, discussed in the BMJ, does not appear to have been logged with the U.K. regulator. A separate system to report problems with illicit drugs is still in a pilot phase.

EU regulations also put the burden on manufacturers and importers to look out for health problems and address them.

Meanwhile, the cases in the U.S. increasingly appear to involve vape liquid containing THC, which is still illegal in the majority of EU countries (as well as most U.S. states). That may mean reporting systems aren’t taking all the products people actually use into account. The MHRA's system accounts only for nicotine-based vapes.

Martin Dockrell, head of tobacco control at Public Health England, was quick to offer reassurances about the safety of legal vapes. “What little we know of recent reports from the U.S. is that the devices used appear to be linked to ‘home brews’ of illicit drugs and not legitimate vaping products,” he said. “Unlike the U.K., which has strict regulation ... on e-cigarette safety, the U.S. has no regulation.”

Only in America?

U.S. regulators inspect some vape manufacturing sites and bar some ingredients from e-cigarette liquids. But that oversight is considerably less comprehensive than the EU’s Tobacco Products Directive, which restricts ingredients and limits the level of nicotine in products.

EU regulations also put the burden on manufacturers and importers to look out for health problems and address them.

Manufacturers have to notify in advance the contents of e-liquids — meaning officials at least know which legal products contain oils that could collect in the lungs, making them easier to recall if necessary.

Yet when it comes to home brews, “that of course is difficult to regulate,” said Vardavas.

Around the EU, poison control centers seem to be the most regular go-to outlet for documenting safety concerns. A 2017 analysis of 10 countries found that kids ingesting the vape liquid is the most commonly reported problem.

“People are dying from vaping, so we’re looking at it very closely.” — Donald Trump

In France, “investigations are underway” to determine whether there are any cases similar to the U.S., a spokesperson for the ministry of health said. So far, there’ve been no reports. Professional societies have been asked to trace cases, the spokesperson said in an email.

The EU is gearing up for a more coordinated approach. Vardavas is involved in an EU-funded project to help countries enforce the Tobacco Products Directive, and among their goals is to create a common reporting sheet for adverse events, he said.

The European Commission said it has asked a panel of outside scientific advisers to issue an opinion about the health risks of e-cigarettes to feed into a report due in May 2021 — making that the earliest date at which data is likely to be available.

In announcing his plans Wednesday, Trump said, “We can’t allow people to get sick and we can’t have our youth be so affected.”

“People are dying from vaping, so we’re looking at it very closely,” he said during an Oval Office appearance with senior U.S. health officials.

Deborah Arnott, ASH’s chief executive, noted that 480,000 people die in the U.S. each year from tobacco-related conditions.

While Public Health England wouldn’t comment directly on U.S. recommendations, John Newton, its director of health improvement, stressed: “There is no situation where it would be better for your health to continue smoking rather than switching completely to vaping.”