The number of illnesses and deaths in the country tied to vaping – or using electronic cigarettes - continues to rise.
The Centers for Disease Control and Prevention now says there have been over 1,000 cases, and over 20 deaths.
And they still don’t know exactly why or what is causing it. The majority of those who have gotten sick have been because of vaping THC, the psychoactive ingredient in marijuana.
But local governments have started to take action.
Washington and Massachusetts instituted emergency bans on vaping products, and Los Angeles is considering a measure to ban the sale of electronic cigarettes entirely.
After the first death in the state, Utah is launching a criminal investigation.
In Nevada, marijuana is legal. There are vape shops on seemingly every corner, so, what role should governments and public health advocates play when people are getting sick and the cause is unknown?
Kimberly Hertin is the disease surveillance supervisor for the Southern Nevada Health District. She said there have been four confirmed cases of the vaping illness and no deaths about which the district knows.
However, Hertin pointed out that those numbers might be under-reported because without a specific test people may not know if they have the illness connected to vaping.
In addition, she said the people impacted reported they got their vaping products from various places and used various products. Three of the people did report using THC or CBD oil use. CBD oil is the non-psychoactive ingredient found in marijuana.
The type of product and where it is purchased are key points in the discussion about the illnesses.
Gregory Conley is the president of the American Vaping Association, which is a nonprofit dedicated to making sure vaping products continue to stay legally available to adults.
He said the problem isn't vaping itself but illegal products, especially illegal THC cartridges.
"I think it is important to know that Nevada and other states that have wide-open legal recreational marijuana markets have not seen these sorts of illnesses unless and except from people that are buying off the black market," he said.
Conley said patients diagnosed with the vaping illness are reluctant to tell authorities they are vaping an illegal drug that they purchased illegally.
He backed up that idea with the fact that Nevada has the largest number of daily users of vaping products but has only four cases of the illness. While Utah has a smaller number of daily users but reports 76 cases.
However, Hertin disputed that take on the issue.
"We have not identified that this is strictly just a black market problem," she said.
Hertin said the SNHD is working with the FDA and CDC to determine what is behind the illness. The district has obtained the vaping products from three of the four people who have been diagnosed with the illness.
State Senator Joe Hardy, who is also a physician, told KNPR's State of Nevada that determining the cause of the outbreak is tough because it is not a bacteria or virus.
"What you have to do, you have to look at ruling out a bacteria pneumonia. You have to rule out a virus and viruses can be a whole host of different viruses," he said, "Is it a chemical, for instance."
Hardy said there is evidence of patients having chemical burns on their lungs similar to the burns produced by mustard gas, which was used in World War I.
The soldering used to put the vape pens together maybe the cause of those burns but right now, Hardy said, the investigation into what's causing the problem is still underway.
Getting to the bottom of the problem is a priority for the SNHD because vaping has been a growing trend.
Malcolm Ahlo is the tobacco control coordinator for the district. He said about 5.4 percent of teenagers in Nevada report using combustible cigarettes but about 15 percent - more than double - report using vaping products.
Conley, who used vaping to stop smoking, argued that keeping vaping products on the shelves is a good thing - even if there is a risk of exposing people to an unknown illness - because it keeps people away from regular cigarettes, which are far more dangerous.
Ahlo has a different take on the issue.
"Electronic cigarettes may be more healthy but it's not a healthy alternative to quitting smoking," he said, "So, we think if you want to quit smoking you need to call 1-800-QUIT-NOW."
Ahlo pointed out that e-cigarettes are not approved or monitored by the FDA. He believes some kind of regulation on vaping products needs to be put into place.
However, former state lawmaker and current county commissioner, Tick Segerblom, who helped get legalized cannabis passed in Nevada, said it is up to the state to determine those regulations - not the local jurisdictions.
Until that happens, Segerblom has some simple advice for people who are vaping THC.
"The best solution you have is to go to a dispensary," he said, "Everything we do sell in our dispensaries has been fully tested and so the best quality product this there."
Joe Hardy, Nevada State Senator; Tick Segerblom, Clark County Commissioner; Malcolm Ahlo, Tobacco Control Coordinator, Southern Nevada Health District, Kimberly Hertin, Disease Surveillance Supervisor, Southern Nevada Health District; Gregory Conley, president, American Vaping Association
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