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The number of people stricken by acute lung disease linked to e-cigarettes continues to grow, with nearly 500 suspected cases reported across the U.S. as of this week, along with two more deaths in Oregon and Indiana. But while the Centers for Disease Control and Prevention and others are still saying there are multiple reasons why these products could be hurting people, health officials in New York have pointed to one ingredient in particular: vitamin E oil.

In a press conference Friday, CDC officials provided an update on the situation. There were 450 suspected or confirmed cases across 33 states reported to the CDC as of Thursday.

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In Wisconsin, the first state to report the cluster back in July, there have been 34 confirmed cases, with an additional 12 being investigated. Illinois, with 49 currently confirmed or suspected cases, was the first state to report a death likely linked to vaping. On Wednesday, health officials in Oregon reported that a middle-aged man with severe respiratory disease linked to vaping succumbed to his injuries in July, and on Friday, another death was reported by Indiana officials. Yet another death possibly related to vaping is also being investigated, according to the CDC.

The condition still has no official name, but the CDC has created a standard guideline definition for doctors to diagnose and report cases. Sufferers are said to experience worsening symptoms like cough, fatigue, and trouble breathing in the days and weeks following vaping, while some have also had stomach issues like vomiting and diarrhea. Nearly all of the victims have been hospitalized, sometimes for weeks at a time, and some have had ongoing heart and lung problems even after treatment. In many cases, their lungs also have evidence of lipid pneumonia, a type of inflammation linked to inhaling oils.

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In its briefing on Friday, CDC officials again stressed these cases aren’t tied to a single e-cigarette product or ingredient. But a majority of victims have reported using products containing THC, such as waxes and oils that are heated and inhaled. Oftentimes, people have bought these products off the black market rather than through legal vape shops. These products have included counterfeit versions of cannabis-containing e-cigarettes available in some states where recreational cannabis is legal.

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On Thursday, the New York State Department of Health announced an update on its own investigation, stating that officials had detected vitamin E acetate—an oily compound form of the vitamin commonly used in skin creams or supplements—in nearly all of their samples of products containing cannabis or THC that had been used by sick patients. The agency said vitamin E would now be a key focus of its investigation. Also on Thursday, the Washington Post reported that the Food and Drug Administration had found vitamin E in THC-containing products taken from patients across the country.

According to Sven-Eric Jordt, a Duke University researcher who has studied the potential harms of nicotine vaping, vitamin E has never turned up in the “regular” nicotine products that he or other researchers have studied. Nor does vitamin E appear to have been found in any of the legal nicotine-based e-cigarettes taken from patients.

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That means there’s little research on how vitamin E could affect our lungs when heated and inhaled. But there’s definitely a reason to think its effects on the lung could be disastrous, even if it’s safe to apply on our skin.

“If inhaled at sufficient amounts, it could certainly cause respiratory problems, maybe even lipid pneumonia, a lung inflammation associated with inhalation of oils,” he told Gizmodo via email. “It is an antioxidant, and may burn and disintegrate when heated in an e-cigarette, releasing toxicants.”

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What’s unclear at this point, though, is exactly why vitamin E is in these products. Jordt noted some vitamin E is naturally found in cannabis, so there’s a chance the compound can be found in the largely unadulterated cannabis oil that many vaping products use.

“On the other hand, it is entirely possible that the illegal products contained added vitamin E acetate to increase volume or dissolve THC/CBD better—or that a skin care oil was mixed in,” he added. “For example, there are many CBD skin care oils marketed online that contain vitamin E acetate and other oils in addition to CBD.”

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There are still many unanswered questions, though. Black market products are now a common link between patients, but there are a minority of sickened people who reported using only nicotine products (of course, it’s possible these patients are reluctant to admit cannabis or THC use). In the Oregon death, the patient did report using cannabis oil, but it was purchased from a legal vape shop.

One major problem is that e-cigarette liquid can contain such a large number of ingredients, especially if it’s illicitly made. We’re still barely scratching the surface of how these chemicals interact with one another or our lungs.

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Jordt pointed out that some companies—billing themselves as the healthy alternative to nicotine vaping—are selling e-cigarette products that explicitly let people vape vitamins, including vitamin E. Neither the CDC nor other health agencies have implicated these kinds of products in the illness cluster, but regardless, it’ll take a long time before we can be sure of what any of these products can do to our health.

In the meantime, the CDC has one clear piece of advice: Avoid buying any vaping products sold through the black market, including online.

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