As the number of vaping-related illnesses and deaths in the U.S. continues to rise, government officials at the federal, state and local levels have focused on curbing – and, in some cases, banning – the sale of e-cigarette and vaping products, especially those appealing to minors.

On Nov. 5, federal health officials identified vitamin E acetate -- an oily, sticky substance sometimes used as a thickening agent in vaping products -- as a possible cause of the illnesses; the substance was found in 29 samples of lung fluid from patients who had fallen ill after vaping.

The Centers for Disease Control and Prevention has warned consumers to stop vaping . "While the investigation is ongoing, CDC has advised that individuals consider not using e-cigarettes because as of now, this is the primary means of preventing this severe lung disease," Dr. Dana Meaney-Delman, who is managing the CDC's response to the outbreak, said in a call with reporters and other federal officials.

E-cigarettes and vape pens go by many names, including e-cigs, e-hookahs, mods, vapes, tank systems and electronic nicotine delivery systems, or ENDS. They come in many shapes and sizes, but all have three main components: a heating element, a liquid that typically contains flavorings and nicotine, and a mouthpiece.

While alternatives to traditional cigarettes have been around since the late 1800s, the first "smokeless non-tobacco cigarette" was patented in August 1965, according to the U.S. surgeon general's report on e-cigarettes . The modern e-cigarette was originally developed to help smokers avoid some of the health problems associated with traditional tobacco cigarettes, and the first type was patented by Hon Lik – a Chinese pharmacist whose father died from smoking-related illness – in 2003. A year later, Stanford Universit y graduate students Adam Bowen and James Monsees independently created what eventually became the Juul, a device intended to "disrupt the tobacco industry" and deliver "a nicotine level found in no other alternative on the market."

Sales of e-cigarettes have surged since they entered the U.S. market around 2007, according to a recent surgeon general's advisory . The devices have been the most popular tobacco product among U.S. youth since 2014, with youth more likely than adults to use e-cigarettes. Nearly 3% of U.S. adults were current e-cigarette users in 2017.

What is vaping?

Vaping is the act of inhaling a vaporized liquid. When using an e-cigarette or vape pen, liquid in the device is heated to produce vapor that the user inhales. Many e-cigarettes contain nicotine; some contain THC, the psychoactive ingredient in marijuana, or CBD oil, a cannabis-derived analgesic. The liquids come in different flavors, including mint , apple pie, mango or watermelon, which critics say are intended to appeal to kids.

What is an electronic cigarette?

Cigarette-styled vapes – also known as e-cigarettes or e-cigs – are battery-powered devices that tend to look and feel like traditional cigarettes. E-cigs consist of three parts : a battery, a cartomizer – a cartridge, which stores the e-liquid, and an atomizer, which heats the e-liquid, vaporizing it when in use – and a silicone mouthpiece. When a user inhales from an e-cig, an LED light on the end of the battery can glow.

Though some manufacturers market them as smoking-cessation devices, e-cigarettes are considered tobacco products because they are typically used to deliver nicotine, an addictive, natural compound found in tobacco. The e-liquid can also contain other harmful ingredients , however, such as volatile organic compounds and heavy metals such as nickel, tin and lead.

What is a vape pen? How does it work?

Vaporizer pens – commonly called vape pens – are stylized tubes that range in size from a standard pen to a cigar and come in a variety of colors. Similar to e-cigarettes, vape pens hold a cartridge filled with vaping liquid, which can come in multiple flavors and may contain nicotine, THC or CBD oil; a heating element known as the atomizer; and a rechargeable battery that powers the atomizer. When a person uses a vape pen, the atomizer turns on, heating up the e-liquid until it vaporizes and is then inhaled by the user.

What is a Juul? What is Juuling?

Juul is the top-selling e-cigarette brand in the U.S. The cartridge looks like a USB flash drive and gives off very little vapor and odor when used. A single Juul contains about as much nicotine as 20 tobacco cigarettes.

Juuling is used as a synonym for vaping using a Juul or another brand, such as PHIX or Suorin, which look similar. Since they are small and produce very little vapor, they have become popular with teenagers ; multiple media outlets have reported increased use of these devices in classrooms across the U.S.

What is in vaping liquid?

The ingredients in vaping liquid – also called e-juice, vape juice and e-liquid – vary depending on the brand, but most contain about 90% propylene glycol or vegetable glycerin, which helps distribute the flavor and nicotine, if included, throughout the liquid. The other 10% consists of flavoring, water and, depending on the product, nicotine, THC or CBD oil. Most e-cigarettes contain nicotine – even some products that advertise otherwise, the Centers for Disease Control and Prevention reports. The CDC has also identified harmful substances in some vaping liquids:

Ultrafine particles that can be inhaled deep into the lungs

Diacetyl, a chemical linked to a serious lung disease

Volatile organic compounds

Cancer-causing chemicals

Heavy metals such as nickel, tin and lead



Products purchased "on the street" or from unauthorized vendors may be even more risky. In August, officials at the CDC and the FDA warned people to avoid such products .

"Anyone who uses e-cigarette products should not buy these products off the street (e.g., e-cigarette products with THC, other cannabinoids) and should not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer," officials said in a joint statement at the time.

Is vaping safer than smoking traditional cigarettes?

Vaping is safer than smoking traditional tobacco cigarettes in that vaping limits a user's exposure to particulate matter and the 7,000 chemicals, many of which are toxic, found in traditional cigarettes. But the chemicals used to create vaping liquid can vary , and the short- and long-term health impacts of inhaling them are largely unknown.

Is secondhand smoke or vapor from e-cigarettes harmful?

Even if you're not using the product yourself, inhaling the vapor exhaled by others who are using e-cigarettes can be dangerous to your health.

While research is limited, some shows secondhand "smoke" exposure from vaping could cause asthmatic and other respiratory reactions, as well as eye and throat irritation. Possibly hazardous chemicals released by e-cigarettes – such as nicotine, heavy metals, volatile organic compounds, cancer-causing chemicals and ultrafine particles – can end up deep in the lungs.

"The majority of studies have concluded that passive exposure may pose a health risk to bystanders, particularly vulnerable populations such as children and teens," Andy Tan, an investigator at the Center for Community-Based Research at the Dana-Farber Cancer Institute in Boston, told HealthDay .

Is vaping addictive?

While not all vaping products contain nicotine, those that do expose users to the highly addictive and toxic chemical . Nicotine can raise an individual's blood pressure and adrenaline levels, heightening his or her heart rate and risk of having a heart attack. Some cartridges marked "extra-strength" or used with Juuls expose users to as much nicotine as an entire package of 20 tobacco cigarettes. Increasing the voltage of the e-cigarette's battery could also result in a stronger "hit" of the e-liquid.

Is vaping or are e-cigarettes regulated?

The FDA finalized a rule in 2016 that extended the Family Smoking Prevention and Tobacco Control Act to give its Center for Tobacco Products regulatory authority over electronic nicotine delivery systems – including e-cigarettes, vapes, e-liquids, e-cigars, e-pipes and e-hookahs – that meet the definition of a tobacco product. By extending the rule, the FDA regulates "the manufacture, import, packaging, labeling, advertising, promotion, sale and distribution of ENDS, including components and parts of ENDS but excluding accessories," according to the agency's website , though its policies, procedures and reviews of e-cigarette products are still developing. The agency allowed existing products to stay on the market while pursuing FDA clearance, a maneuver known as "enforcement discretion."

Thousands of products remain on the market without formal guidelines or product standards as FDA staff, as well as e-cigarette and flavoring manufacturers and retailers , have claimed more time is needed to prepare for regulation. The FDA previously said e-cigarette manufacturers would not be required to submit their products for review until 2021, but a federal judge intervened to move that deadline to May 2020. If the Trump administration's proposed ban on flavored e-cigarettes goes into effect, however, most flavored nicotine vaping products would be banned before then, and subject to FDA review before re-entering the market.

As of Aug. 8, 2016, it is illegal to sell e-cigarettes and other ENDS products to people younger than 18, and retailers, both online and in brick-and-mortar stores, are responsible for verifying the age of individuals under 27 who are interested in buying any tobacco product, according to the FDA .

Why were e-cigarettes allowed on the market without FDA approval?

The FDA does not approve any tobacco product ; rather, the agency regulates tobacco products.

E-cigarettes entered the U.S. marketplace around 2007. In 2008, the FDA tried to establish authority over e-cigarettes as drugs or drug-delivery devices – which it has authority to do under the Food, Drug and Cosmetic Act – by blocking new shipments into the U.S. In 2010, a federal court ruled that the FDA could not regulate e-cigarettes as drugs or drug-delivery devices if they were not marketed as tools to help people quit smoking, as nicotine gum and patches are. But the agency could regulate e-cigarettes as tobacco products.

In the meantime, Congress passed a sweeping tobacco-control law in 2009 to more thoroughly regulate the sale and use of tobacco products. Following the 2010 court ruling, the FDA decided to regulate e-cigarettes as tobacco products, but it took until 2016 for the agency to issue its new rules detailing e-cigarettes as tobacco products and consequently banning their sale to anyone under 18.

E-cigarette manufacturers have had the opportunity since 2007 to apply to the FDA's Center for Drug Evaluation and Research or its Center for Devices and Radiological Health for clearance of e-cigarettes for therapeutic purposes, such as potential use for smoking cessation, but as of August 2016 , no e-cigarette manufacturer had received approval this way, according to a U.S. surgeon general report.

Is it safe for kids, teens or young adults to vape?

The use of any tobacco product – including e-cigarettes – is unsafe for young people, the CDC says. Most e-cigarettes contain nicotine, which can be particularly harmful to children and teens because the brain continues to develop until about the age of 25, and younger brains are particularly sensitive to nicotine and developing an addiction. Research also shows that using e-cigarettes may be a gateway to using traditional tobacco products.

While scientists are still learning about the potential long-term health impacts of e-cigarettes, some of the ingredients in the aerosol may be harmful to the lungs. There have also been cases of defective batteries causing fires and explosions, as well as cases of poisoning through the absorption of the aerosol through individuals' skin and eyes, the CDC reports .

Federal officials also advise women who are pregnant and adults who do not currently use tobacco products to not start using e-cigarettes.

How can I tell if my kid is vaping?

Some signs your child may be vaping include, but are not limited to:

Increased thirst

Desire for flavor

Nosebleeds

Acne

Cutting back on caffeine

Pneumonia

Unfamiliar USB drives, battery chargers or spare parts in their rooms, clothing, bags, school lockers and around the home

What are the health risks of vaping?

While scientists are still learning about the long-term health effects of vaping, e-cigarette vapor may contain substances that can cause serious lung disease , heart disease and cancer, according to the American Cancer Society . For pregnant women, exposure to nicotine in these products could lead to premature births and low-birthweight babies.

The vapor from e-cigarettes may also contain volatile organic compounds, flavoring chemicals and formaldehyde. According to the surgeon general , volatile organic compounds may cause eye, nose and throat irritation, headaches, nausea and damage to the liver, kidneys and brain. Some flavorings contain high levels of diacetyl, which has been linked to bronchiolitis obliterans, a serious lung disease.

Does vaping cause cancer?

The CDC reports that cancer-causing chemicals have been found in vape liquids. The American Cancer Society notes that inhaling from an e-cigarette product low on e-liquid or from a device that overheats e-liquid (known as a "dry puff") could cause formaldehyde to form. Formaldehyde exposure has been linked to short-term health effects – including watery eyes; burning sensations in the eyes, nose, and throat; coughing; wheezing; nausea; and skin irritation – as well as leukemia, according to the National Cancer Institute .

Are there any benefits to vaping?

E-cigarettes may have the potential to reduce risk for current smokers who completely transition from using traditional tobacco products to the vaping devices, and they have been marketed as a way to help smokers kick their nicotine habit. However, research shows that a majority of adults who use e-cigarettes also smoke traditional cigarettes, and they have not officially been approved by the Food and Drug Administration as a smoking-cessation tool .

What are the symptoms of the lung disease people are getting from vaping?

Reported symptoms of the lung disease cases tied to vaping range from the gradual start of breathing difficulty, shortness of breath or chest pain before hospitalization to some cases reporting mild to moderate gastrointestinal illness, including nausea, vomiting and diarrhea. Other symptoms reported include fever or fatigue, according to the CDC and FDA .

Is the government doing anything to stop vaping?

As the FDA waits for e-cigarette manufacturers and retailers to submit their products for review, federal officials announced on Sept. 11 their intent to ban all non-tobacco flavors for e-cigarette products in an effort to curb what officials have called an epidemic of youth vaping. The FDA has also cracked down on retailers in undercover blitz operations to eliminate youth access to e-cigarette products. Meanwhile, the CDC activated its Emergency Operations Center on Sept. 16 to expedite and strengthen interagency responses across the U.S. to its investigations of severe lung disease associated with vaping or e-cigarette use. The CDC and FDA are also working together to investigate recent e-cigarette product use among patients and to test the substances or chemicals within e-cigarette products used by case patients, and they have warned consumers not to buy their e-cigarette products off the streets .

Meanwhile, authorities in Oregon's legal marijuana market have asked store owners to review the products on their shelves and pull any they think may be harmful to users' health, while authorities in New York and North Carolina have pursued legal action against vaping product companies to learn more about what's in their products, what safety regulations are in place and to stop their marketing and sales of e-cigarettes to teens. Several state health departments, including Massachusetts ', are also working to collect data tied to potential cases of lung disease related to the use of e-cigarettes.

On the local level, San Francisco became the first U.S. city to ban the sale and distribution of e-cigarettes in June – the ban would take effect in early 2020 but is being challenged by a November ballot measure backed by Juul Labs . More than a dozen states, as well as hundreds of cities and communities , also have moved to raise the legal age for buying tobacco products to 21.

Is it still safe to vape?

Vaping is substantially less harmful to individual health than smoking a regular cigarette, which exposes the user to more than 7,000 harmful chemicals. But e-cigarettes are not harmless because they allow users to inhale chemicals that can have adverse health impacts. While the CDC says e-cigarettes have the potential to help adult smokers who are not pregnant to transition away from regular cigarettes and other smoked tobacco products, it warns that the use of e-cigarettes is unsafe for kids, teens, young adults, pregnant women and adults who do not currently smoke any tobacco products.