The caution has taken on new urgency in recent months as authorities scramble to understand a rash of mysterious vaping-linked illnesses that have put healthy people in the hospital with serious lung diseases. The latest federal data show there are more than 2,600 cases reported from all 50 states, the District of Columbia and the two U.S. territories (Puerto Rico and U.S. Virgin Islands) connected to vaping or e-cigarettes, which are battery-powered devices that can look like flash drives and pens and that mimic smoking by heating liquids containing substances such as nicotine and marijuana. At least 57 deaths have been confirmed in 27 states and the District of Columbia, according to the Centers for Disease Control and Prevention.

On Nov. 8, CDC officials announced a “breakthrough” discovery, saying they identified vitamin E acetate in the lung fluids of 29 people sickened in the outbreak of dangerous vaping-related lung injuries. The finding points to the oil as a likely culprit in the outbreak, a top official said. Cases have been declining since a peak in September. While the number of new hospitalized cases are dropping, they have not returned to levels before June 2019 and public health officials remain worried about the disease.

How did the concerns start?

E-cigarettes have been sold for more than a decade, but reports of vaping-linked illness started proliferating this year. An investigation by state health departments in Illinois and Wisconsin traced the first signs of illness among 53 tracked patients to April. The victims — mostly young men with a median age of 19 — overwhelmingly ended up in the hospital, many under intensive care. A third went on respirators.

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Patients typically experienced coughing, chest pain or shortness of breath before their health deteriorated to the point that they needed to be hospitalized, according to the CDC. Other reported symptoms include nausea, vomiting, diarrhea, fatigue, fever and weight loss.

Many victims have ended up with acute respiratory distress syndrome, a life-threatening condition in which fluid builds up in the lungs and prevents the oxygen people’s bodies need to function from circulating in the bloodstream.

The Washington Post’s Lena Sun chronicled one Utah man’s experience with the disease:

Within days, Alexander Mitchell had gone from being a 20-year-old hiking enthusiast to being kept alive by two machines forcing air into and out of his lungs and oxygenating his blood outside of his body. “He went from being sick to being on death’s door in literally two days,” recalled his father, Daniel Mitchell, as he struggled to grasp the unthinkable. “The doctor said he was dying. In all honesty, I was preparing to plan a funeral for my child. I wept and wept for this boy.” ... Six weeks after he left the hospital, Mitchell has resumed hiking. But with his lung capacity diminished by 25 percent, he doesn’t go for long or as often as he used to. He also struggles with his short-term memory. Doctors say they’re not sure whether he will fully recover.

The first death from a vaping-related illness was reported Aug. 23 in Illinois. At that time, federal and state officials were investigating almost 200 cases of the baffling sickness in 22 states, according to the CDC.

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Oregon officials announced a second death, saying a middle-aged adult fell seriously ill after vaping with marijuana oil. It was the first casualty linked to a store-bought product.

The list of states with deaths has grown quickly since. Initials, officials weren’t sure why the injuries were surfacing this year. “We’re all wondering if this is new or just newly recognized,” the CDC’s Dana Meaney-Delman said earlier this summer.

Some argue that doctors may have missed previous cases: Susan Walley, chair of the tobacco control section of American Academy of Pediatrics, told BuzzFeed News that based on her experience, young people might not recognize their use of common e-cigarette brands such as Juul as “vaping” when pediatricians ask.

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Others are skeptical that older cases could have gone under the radar.

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“You have a lot of otherwise healthy young people suddenly arriving with fast-developing pneumonia in emergency rooms — that will raise red flags in a hurry,” Sean Callahan, a physician at the University of Utah, told BuzzFeed. “This is new.”

Who is affected?

As of Jan. 7, 2020, officials counted 2,602 cases. The 57 deaths have been confirmed in 27 states and the District of Columbia: Alabama, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Illinois, Indiana, Kansas, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, and Virginia.

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The median age of deceased patients was 51 years and they ranged from 15 through 75 years. The youngest patient to die was a 15-year-old in Dallas County, Texas. The county health department said the teen, a Dallas county resident, had a chronic underlying medical condition. A health department spokeswoman said she could not disclose whether the teen had been vaping marijuana or nicotine.

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In New York, a 17-year-old male from the Bronx was hospitalized in early September with a vaping-related respiratory illness and readmitted in late September. He died Oct. 4.

The U.S. Army is tracking two cases in active-duty soldiers, according to a statement from the U.S. Army Public Health Center. The soldier in the United States has been treated and released. The other soldier, stationed overseas, is still being treated. The statement provided no additional details.

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Most of the patients who have fallen sick and for whom officials have demographic information are male and young: Almost 80 percent of the patients are under 35, and their median age is 24, according to the CDC. But until the report of the New York teen’s death, the deaths were older adults. The median age of patients who died is 53. Their ages range from 17 to 75.

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A handful of known patients have recovered only to be quickly readmitted to the hospital, the CDC has said. Such relapses have occurred between five and 55 days after the discharge, according to the agency’s principal deputy director, Anne Schuchat. While some of those rehospitalized had started vaping again, others may have faced a heightened risk of illness due to their lung injuries or steroid treatments, she said.

What do we know about the cause of the illnesses?

Officials are still trying to figure out what, exactly, is causing people to fall ill. But growing evidence points to products with THC, the psychoactive component of marijuana.

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“The latest national and state findings suggest products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak,” the CDC has said.

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About 83 percent of 1,184 patients for whom relevant data is available reported using THC-containing products in the three months before their symptoms, the CDC said. Slightly more than a third of patients said they used those products exclusively.

Thirteen percent said they had only vaped nicotine.

The nationwide investigation has found no particular vaping devices or products linked to all cases and is looking into potential contamination or counterfeits. Many have also used multiple products, according to the CDC.

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Officials in Illinois and Wisconsin provided some of the strongest clues so far into what might be making people sick. They conducted in-depth interviews with 86 of their patients. The vast majority reported using illicit THC-containing prefilled vape cartridges and bought them from informal sources.

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Officials said they don’t have test results yet on what was in those illicit THC products.

Is vitamin E acetate the culprit?

The Post reported in early September that investigators at the Food and Drug Administration found the same vitamin E-derived oil in marijuana products vaped by multiple people sickened around the country.

The chemical, vitamin E acetate, was present in almost all of the cannabis samples from victims identified in New York, according to the state’s health department. New York Gov. Andrew M. Cuomo (D) has directed his health department to subpoena three companies selling “thickening agents” used to adjust THC levels in products found on the black market. The thickening agents are “nearly pure” vitamin E acetate, officials say.

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Vitamin E acetate has also been found in samples collected from across the country and tested by the FDA. FDA testing has found THC in 70 percent of samples linked to patients. Half of those THC samples also contained vitamin E acetate in concentrations as high as 88 percent.

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On Nov. 8, Anne Schuchat, CDC’s principal deputy director, said the discovery of vitamin E acetate in the lung fluids of 29 people sickened in outbreak "provide direct evidence of vitamin E acetate at the primary site of injury, within the lungs.” It points to growing evidence of vitamin E acetate as “a very strong culprit of concern,” she said in a briefing with reporters.

The findings don’t rule out other possible compounds or ingredients that may be causing the lung injuries. But CDC tested for a wide range of substances that might be found in patients’ lung fluids, including plant oils and petroleum distillates, such as mineral oil. None of the others were detected.

Some patients have said they vaped only nicotine products, even though urine tests have showed the presence of THC, authorities said. Doctors say patients may be hesitant to admit to using marijuana.

The FDA disclosed that it has launched a criminal investigation with the Drug Enforcement Administration. That is happening alongside the probe by the CDC into the cause of the illnesses. Federal officials are not pursuing individual vapers. But if the FDA determines “someone is manufacturing or distributing illicit, adulterated vaping products that caused illness and death for personal profit, we would consider that to be a criminal act,” said then-acting FDA commissioner Norman “Ned” Sharpless.

In testimony before a House panel, Sharpless said the FDA has received 300 samples from vaping-related injury patients and tested 150. About 70 percent are products containing THC, and about half of those contain vitamin E oil, which Sharpless said has “no business” being in the lungs.

New York’s health commissioner, Howard Zucker, has urged medical marijuana patients to discuss alternatives with their doctors, although no sicknesses have been reported among patients in the state’s medical marijuana program.

Black market marijuana products, which industry experts say are typically cheaper than legally sold items, are drawing increasing scrutiny. California, home to the largest legal marijuana market in the world, has a black market three times that size. Changes in the ingredients used in popular marijuana vaping devices in the state could be making people sick, according to experts of the legal and illicit cannabis markets, as well as doctors and health officials. They say black market operators are using more thickening agents to dilute THC oil because of a crackdown by state authorities that has made the oil scarcer on the black market.

THC oil is used to fill tiny disposable containers known as vape cartridges, which are heated to create vapor that can be inhaled. Vaping cartridges are among the most popular items in the legal and illicit markets, industry analysts said.

Are certain brands implicated?

The CDC has identified a number of brands as “largely counterfeit,” saying distributors use packaging easily purchased online to “market THC-containing cartridges with no obvious centralized production or distribution,” as one report from the agency states.

Authorities in Wisconsin and Illinois, where the earliest illness reports emerged, say most of their interviews with patients point to illicit THC products with Dank Vapes cartridges. They also reported using THC products under the brands TKO, Off White, Moon Rocks, Chronic Carts, Cookies, Smart Carts, Kingpen, Dabwoods, Rove, Mario Carts, California Confidential and Supreme G.

Patients in those two states reported using nicotine e-cigarettes named Juul, Smok, Suorin Drop, Naked, Solace, Mr Salt-E, Salt Nic, Air Factory and Vuse Alto, the CDC report states.

How are authorities and policymakers responding?

Officials are imposing tough new sales restrictions and declaring public health emergencies, advising people to put away their e-cigarettes while investigators try to get to the bottom of the illnesses.

The CDC — which is leading inquiries into the illnesses and working with state authorities — has told doctors to ask patients about e-cigarettes when they arrive with symptoms resembling the vaping-linked afflictions and to report the cases to health departments.

The agency said recently that it is expanding its lab testing as it looks for harmful chemicals in e-cigarette liquids, in the vapor the devices emit and in samples from patients’ bodies.

Some lawmakers have called for more urgent action from the federal government. Sen. Richard J. Durbin (D-Ill.) had accused then-FDA chief Sharpless of “sitting on his hands,” tweeting that he would call for the leader’s resignation if he did not “take action in the next 10 days.”

Durbin’s calls for increased e-cigarette regulation came two years after the FDA pushed back its deadline to review the products, which the agency has yet to approve.

A plan for stricter regulations materialized Sept. 11, as Health and Human Services Secretary Alex Azar announced at a White House gathering with the president and other top officials that the FDA is working to outlaw sales of most flavored vaping products. The policy, which would upend the e-cigarette market, will be finalized in a few weeks and then go into effect 30 days later, Azar said. The restrictions would be lifted only for products that the FDA approves. Tobacco-flavored e-cigarettes will not be affected, officials said.

Although the move came amid the growing concern over vaping-linked illnesses, the Trump administration pointed to a broader rise in teen vaping as its motivation.

But in early November, Trump reversed course because of worries that angry vape shop owners and their customers might hurt his reelection prospects, said White House and campaign officials.

On Jan. 2, 2020, the Food and Drug Administration ordered companies to stop manufacturing, distributing and selling most cartridge-based e-cigarette flavors — including mint and fruity flavors — by early February, saying the crackdown is urgently needed to stem a surge in teen vaping.

The deadline was announced as the Trump administration officially unveiled its long-debated vaping policy. Its approach targets disposable pods that have soared in popularity among young people and are sold in tens of thousands of convenience stores across the country. But it excludes menthol- and tobacco-flavored cartridges and exempts e-liquids and devices used in open-tank systems, which typically are sold in vape shops that cater to adults but also can be purchased elsewhere.

Federal health officials also said they would pursue companies that promote any kind of vaping product to minors or fail to take steps to keep the items away from them.

Michigan, New York, Rhode Island and Washington have enacted similar bans on flavored vaping sales over industry protests, and Massachusetts recently announced the strictest statewide regulations to date: a four-month halt to sales of all vaping products, effective immediately. Lawmakers elsewhere are mulling similar actions.

“We’re seeing more and more states exploring what emergency powers they have,” said Michael Seilback, assistant vice president for state public policy at the American Lung Association.

But the new policies face legal challenges. On Oct. 15, a Michigan judge halted the state’s flavor ban about two weeks after it took effect, ruling that the damage to vape businesses outweighs government’s interest in decreasing youth vaping, according to the Detroit Free Press.

Michigan Gov. Gretchen Whitmer (D) has pledged to appeal the decision.

Local policymakers are acting, too. San Francisco — home to Juul Labs — was the first city to ban all e-cigarette sales in June, a year after it outlawed flavored products.

How common is vaping?

Vaping has risen dramatically in popularity around the world — from 7 million users in 2011 to 35 million a few years ago — as smoking rates decline.

Tobacco and cigarette company Altria Group estimated nearly 14 million nicotine e-cigarette users in the United States earlier this summer. Another study found last year that more than half of American adult e-cigarette users are under 35 years old, stoking concerns about vaping among young people.

Studies showing vaping’s growing popularity among teens sparked particular worry last year. About 37 percent of 12th-graders in the United States reported vaping over the past year in one government-funded survey released in December — nearly a 10 percentage-point increase from 2017. Nicotine vaping rates among high school seniors doubled in the past month, and younger students also reported higher use; marijuana vaping rose, too. A CDC report found last year that e-cigarettes were the most popular product among the nearly 5 million high school and middle school students who used tobacco within a 30-day period.

Vaping’s popularity among students continued to increase this year, according to preliminary data that found 1 in 9 high school seniors say they vape near-daily — a figure that researchers say suggests nicotine addiction.

Why were e-cigarettes controversial before the vaping-linked illness reports?

Mysterious illnesses aside, many have accused e-cigarette manufacturers of exposing young people to addictive nicotine and luring them toward smoking. The National Academies of Science, Engineering and Medicine say they found “substantial evidence” that youths who try vaping are more likely to use conventional cigarettes. Advocates of vaping sales bans also cite research on nicotine’s effects on youth brain development.

Last year, then-FDA Commissioner Scott Gottlieb called teenage vaping an “epidemic” as he announced a crackdown on more than 1,300 entities allegedly selling e-cigarettes to minors. He threatened to ban the flavored vaping liquids that have drawn so much scrutiny for their appeal to young people — unless e-cigarette manufacturers such as Juul Labs worked to substantially curb underage use.

E-cigarette makers have lobbied aggressively against new regulations making good on that threat and argue that their products can help smokers quit while giving those addicted to nicotine a safer option than burning tobacco. They say they’re working to address underage vaping and warn that an outright ban could just replace regulated sales with a black market.

The CDC agrees that e-cigarettes can help smokers who substitute them for regular tobacco products, and health professionals say vaping to be safer than traditional smoking, which kills 8 million people per year, according to the World Health Organization. The debate over vaping regulations has split the public health community, experts say, as some cite harm reduction for smokers while others emphasize the threat to youths. England’s public health agency cites estimates that the practice is 95 percent less harmful than smoking.

But given that the FDA has yet to vet vaping products, experts caution that the long-term consequences of using e-cigarettes remain unclear.

Marisa Iati contributed to this report.