Juul Labs, Inc. launched its vaping products in 2015. These products quickly became the most popular vaping products in the United States eventually accounting for 75% of the U.S. e-cigarette market. Juul’s products differed as they came in a variety of different flavors such as “Cool Mint” and “Mango.”
The flavored pods along with the belief that vaping was safer than smoking, led to a significant rise in vaping among teenagers, with the rate of teen e-cigarette use more than doubling from 2017 to 2019 alone. During this same period, a large number of teens suffered serious pulmonary injury and death caused by vaping.
The increasing number of teen deaths and injuries ultimately led the FDA to step in and issue a ban on certain vaping products and flavors. On February 6, 2020, a nationwide ban on all non-menthol or tobacco flavored pods or cartridges.
Juul targeted teens and young adults in its marketing campaigns which included the use of social media “influencers,” persistent instagram, facebook and twitter advertisements, pop-up “Juul Bar,” and sampling events in most major cities. Not only was the marketing targeted to teens, but the design of the Juul device, which is shaped like a USB flash drive and the variety of sweet and fruity flavors were also clearly targeted at teens.
Many lawsuits followed, consisting primarily of personal injury cases but also a variety of class action cases based on Juul’s marketing activity. The cases were initially scattered across the United States but most Juul cases filed in the U.S. are now pending in the United States District Court for the Northern District of California or the Superior Court of the State of California for the County of Los Angeles.
All federal cases were consolidated before the Hon. William Orrick of the Northern District of California and California State Court cases were consolidated before the Hon. William Highberger of the Los Angeles County Superior Court. There are over 350 cases pending before Judge Orrick and hundreds of additional cases pending in Los Angeles County Superior Court before Judge Highberger.
Injuries From Juul and E-Cigarette Use
Serious injuries from vaping have skyrocketed in the past few years as scientists and researchers learn more about the short and long-term health effects of e-cigarette use. From August 2019 to January 2020, over 2,668 hospitalized cases of vaping related lung injuries, causing at least 55 deaths, were reported to the Centers for Disease Control.
These E-cigarette or Vaping use Associated Lung Injuries (“EVALI”) include bronchiolitis obliterans (a/k/a “Popcorn Lung”), lipoid pneumonia, organizing pneumonia, diffuse alveolar damage, acute eosinophilic pneumonia and interstitial pneumonia. Because the symptoms of EVALI can be very similar to influenza and other respiratory viruses, it is likely that the true number of EVALI cases is significantly higher.
JUUL, which is partially owned by tobacco giant Altria Group, is by far the best-selling e-cigarette in the U.S. market. Nicotine concentration in JUUL e-liquids is higher than other e-cigarette brands. Until August 2018, when JUUL lowered the concentration of nicotine to 3%, the nicotine concentration in JUUL brands was 5%, significantly higher than other brands which ranged from 0.3% to 2.4%.
As of 2018, over 3.62 million middle- and high-school students were e-cigarette users with almost 21% of high-school and 5% of middle-school students actively vaping. The number of school age e-cigarette users is increasing exponentially with the number doubling from 2017 to 2018.
Until 2018, when the FDA was confronted with frightening numbers showing the dramatic increase in the number of middle- and high-school students using e-cigarettes, there was almost no federal regulation of these devices. Compounding the lack of regulation into these devices, there was almost no research on the long-term health effects of vaping.
While more research into the potential long-term health effects are ongoing, the short-term health effects are becoming clearer and clearer. As one member of a team of Johns Hopkins School of Public Health researchers studying e-cigarettes noted, “I thought we would start seeing some of these effects years from now and I’m disturbed that we are starting to see them so soon.” E-cigarette use has been linked to the following serious and potentially deadly health complications.
Popcorn Lung or Bronchitis Obliterans
Popcorn lung, a/k/a bronchiolitis obliterans, is a potentially fatal lung disease caused by the chemical diacetyl. Popcorn lung was discovered over a decade ago after workers in a microwave popcorn factory came down with serious pulmonary problems. It was revealed these workers developed bronchiolitis obliterans, which is an inflammatory obstruction of the lung’s smallest airways, called bronchioles. These airways become inflamed and damaged due to chemicals like diacetyl. Diacetyl was commonly used as a flavoring agent in microwave popcorn. After researchers discovered it was linked to several deaths and hundreds of cases of bronchiolitis obliterans, the major popcorn manufacturers removed diacetyl from their products.
Despite the well-known fact that diacetyl causes bronchiolitis obliterans, some manufacturers of e-cigarettes put this dangerous chemical in their vaping products as a means of “flavoring.”
A June 2016 study funded by the National Institute of Health tested 51 types of flavored e-cigarettes for the presence of diacetyl, acetoin and 2,3-pentanedione, two other chemicals strongly linked to lung disease. The study results, appearing in Environmental Health Perspectives, found that at least one of the three chemicals were present in 47 of the 51 flavors tested. Diacetyl was found in 39 of the 51 flavors and acetoin and 2,3-pentanedione were detected in 46 and 23 of the flavors, respectively.
There is currently no cure for “popcorn lung,” although the use of antibiotics, immuno-suppressants, cough suppressants and oxygen may help alleviate some symptoms. In severe cases a lung transplant may be required. It should be noted that the cases of bronchiolitis obliterans found in popcorn manufacturing workers were indirect, i.e., the result of employees inhaling the chemical into their lungs from the surrounding air. In contrast, when vaping, diacetyl and other chemicals are directly inhaled into the lungs.
In addition to diacetyl, acetoin and 2,3-pentanedione, e-cigarettes were found to contain a number of carcinogens and other chemicals linked to lung damages such as nitrosamines, formaldehyde (embalming fluid), toluene and acrolein. Vaping liquids also contain a number of metals such as nickel, chromium, manganese, arsenic and lead.
A study by researchers at Johns Hopkins University, investigating whether metals from the e-cigarette heating coils would also be found in the aerosol generated by the heating coils, found high levels of these metals in the aerosol. The adverse and potentially deadly affects of heavy metals in the bloodstream is widely known.
Lipoid Pneumonia and Other Rare Pneumonias
Vaping has been linked to lipoid pneumonia is a rare infection caused by lipids (fatty acids) that enter the lungs and cause them to become inflamed. When the oil within the vaping cartridge is heated up it produces a vapor, which may include small, aerosolized droplets of lipids. When enough of these lipid droplets are inhaled into the lungs, it can lead to irritation of the lungs and then to lipoid pneumonia.
Vaping cartridges contain significant portions of glycerol (“vegetable glycerine”) and propylene glycol which are lipids. Lipoid pneumonia can cause chest pain, difficulty breathing, chronic coughing and coughing up blood.
Vaping has also been linked to a variety of other rare pneumonias such as acute eosinophilic pneumonia and interstitial pneumonia. Acute eosinophilic pneumonia (AEP) is a potentially fatal but uncommon pneumonia that is caused by the rapid accumulation of eosinophils, a type of white blood cells, in the lungs.
AEP can present with varying levels of severity but the most severe from presents as acute respiratory distress syndrome with commonly fatal results. Interstitial pneumonia affects the walls of the alveoli which becomes inflamed. It can rapidly develop over 1 to 2 weeks to acute respiratory failure which is fatal. More than 60% of people with interstitial pneumonia die within 6 months.
Seizures From Vaping
In April 2019, the FDA announced it was investigating a disturbing trend of seizures among e-cigarette users after receiving 32 reports of seizures. Over the following 4 months, the FDA received an additional 92 reports of e-cigarette related seizures in the U.S.
Although a causal connection between e-cigarette use and seizures has not yet been confirmed, the lack of any prior seizure history, the young age of the subjects along with their exposure to high levels of nicotine from e-cigarettes has caused great concern about the healthcare industry.
The FDA urges the public and all healthcare workers to report any seizure cases among younger individuals that are current or former e-cigarette users, especially if there is no prior history of seizures. The FDA and various research institutions are currently investigating the causal link, if any, between e-cigarette use and seizures.
Cardiovascular Problems and E-Cigarette Use
A 2019 study by researchers at the Stanford School of Medicine, found that certain e-liquid flavors (fruit, tobacco, sweet tobacco with caramel and vanilla, sweet butterscotch, cinnamon, and menthol) might increase the risk of cardiovascular disease when inhaled. In particular, the study found that these e-cigarette flavors can adversely impact the endothelial cells that line the interior of blood vessels.
Interestingly, the amount of the damage to endothelial cells varied among the flavors with menthol and cinnamon flavors found to be especially damaging. Nicotine, which is a vaso-constrictor, was excluded as the cause of the damage because the damage was found irrespective of the nicotine levels of the e-cigarette flavor tested (flavors with 0, 6 and 18 mg per ml were tested). The long-term effects of this damage to the endothelial cells is not yet known but is expected to be the focus of additional future studies.
Nicotine Overdose and Poisoning
While it is common knowledge that nicotine is the addictive ingredient in tobacco products, many are not aware that too much nicotine can lead to adverse health affects and can even be fatal. Nicotine is a central nervous system stimulant and can result in nausea, vomiting, abnormal heart rate, dizziness, increased blood pressure and hearing and vision changes, when large quantities are ingested.
Liquid nicotine and e-cigarette use are more likely to result in nicotine toxicity than traditional tobacco products like cigarettes. This is primarily due to the fact the nicotine in these products is purer as opposed to nicotine found in cigarettes and cigars where it is a naturally occurring substance.
Vaping is the leading cause of nicotine poisoning in the United States. While nicotine toxicity has historically been relatively rare, it has become much more prevalent in recent years due to vaping. For example, in 2011, there were only 269 cases of nicotine poisoning from vaping reported to US. Poison control centers. As e-cigarette use increased, so did the number of nicotine poisoning cases with 5,183 cases reported in 2019, an increase of almost 2000% from 2011.
The lethal dose of nicotine has been reported to be approximately 60 mg in adults. Fatalities from nicotine toxicity are rare, with one cigarette equivalent to about 2mg of nicotine in the bloodstream, however adverse events such as vomiting, tachycardia, chest pain, hypertension and nausea are common. Treatment for nicotine toxicity depends upon the amount of nicotine in the body and can range from the ingestion of charcoal to help absorb the nicotine to the use of a ventilator for more serious cases.
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