photo by jaroslav devia on unsplash
Although Tryston Zohfeld — with a head full of wavy locks and an athletic build — was seemingly the picture of perfect health, he was keeping a years-long secret from his parents that would turn out to be near fatal.
A 17-year-old graduate of Weatherford High School, who has a penchant for dirt bikes, Zohfeld woke up on the morning of July 26 with chills, vomiting, chest pain, shortness of breath, and a racing heart.
Assuming he had the flu, doctors treated him with a concoction of antibiotics and other medications, but his symptoms only got worse; within 24 hours, Zohfeld was checked into a hospital.
His initial X-rays revealed something that looked like pneumonia on both sides of his chest, but having already ruled out the infection, the specialists couldn’t figure out the cause.
“When Tryston first came in, I interviewed him,” Dr. Suzanne Whitworth, medical director of Infectious Diseases at Cook Children’s Hospital, says. “He was very distressed and having difficulty breathing. And, he continued to deteriorate over the next 48 hours without any plausible cause.
“He required more and more support, and we didn’t know the reason for it. This is not normal in a healthy teenager. We were all worried for him as we continued to explore every possible cause, but he just continued to get worse.”
Blood drawn, machines hooked up, and a mass of internal photographs taken, doctors ran every test imaginable. But as physicians thumbed through the index of possible causes — each one getting rarer and more obscure — every test returned nothing conclusive. And Zohfeld continued to deteriorate, his lungs failing.
“It’s really weird for an otherwise healthy kid to walk into a hospital and go into complete respiratory failure,” Dr. Diane Arnaout, a pediatrician with Cook Health Network and Zohfeld’s regular doctor, says. “That amount of inflammation doesn’t usually happen.”
Zohfeld’s breathing had become so labored that he had to be intubated — a tube inserted down his windpipe with a machine attached to breathe for him. Even then, his lungs could not perform a regular inhale and exhale, so they had to use a technique known as high-frequency ventilation when only short and rapid puffs of air can be tolerated.
“They had me on this big machine that was pretty much breathing for me,” Zohfeld told CNN in an interview following his release. “If that didn’t work out, then nothing else was going to work out.”
Finally, he was placed in a medically induced coma for 10 days. “When you’re in respiratory distress, your body begins to fatigue. It just wears you out when you are constantly gasping, in desperation for air,” Arnaout says.
Cause for Concern
Having been Arnaout’s patient for about a year, Zohfeld had seemed in good health at his checkup appointment last fall. At that time, Zohfeld had confided to his doctor about his vaping, and she had warned him of its unknown effects. “He used it as a coping mechanism, like most people,” Arnaout says. But Zohfeld had no plans of quitting and no related complaints at the time.
Those began in earnest in July when he noticed some alarming changes. “I was tired all the time. My energy was low. I was losing some weight,” he said.
That quickly progressed. “He started having chills,” says Arnaout. “He was feeling really exhausted all the time, was nauseous, and had some fevers.”
When the pathology came back, the only thing that could explain his lung inflammation was chemical pneumonitis — damage from some chemical exposure. It was termed diffuse alveolar damage — meaning Zohfeld’s lungs were inflamed by some unidentified trigger that led to lung tissue damage.
Zohfeld had been vaping since eighth grade, without his parent’s knowledge, and while a clear answer for why his lungs failed him was never found, the specialists that treated him feel vaping could have played a role. “We’ll never be able to prove it, but I think vaping was definitely related,” Dr. Whitworth says.
“Damage to the air sacks in the lungs can be caused by a lot of things,” says Dr. Karen Schultz, medical director of Pulmonology and Respiratory Therapy at Cook Children’s. “But as we ruled possible causes out one by one, we were only left with chemical exposure.”
As a pulmonologist at Cook Children’s Hospital, when faced with lung failure, Schultz is typically caring for patients with underlying pulmonary histories, most commonly asthma patients. That’s why Zohfeld’s case was all the more unusual.
“We don't know for sure,” Whitworth says. “But there are literature reports of hypersensitivity pneumonitis from vaping. I told him, ‘No inhaling anything again, ever.’”
With steroids to reduce the inflammation, Zohfeld’s lung function slowly improved to the point that he could be removed from the ventilator.
“He declined very rapidly. At times we weren’t sure he was going to live through this episode,” Schultz says. But he also improved more rapidly than most patients typically would. It was not “the norm” for someone who had been this ill and unable to breathe on his own, to rebound in such a way.
Zohfeld continues to heal and has become the subject of much media attention following an Aug. 20 blog post written by Arnaout on the Cook Children’s Checkup Newsroom. Local and national news outlets (CNN and ABC News among them) scrambled to cover the story in the days that followed. And, as it turns out, Zohfeld is only one of many cases that have put the dangers of vaping in the spotlight.
Safer Does Not Mean Safe
By early September, the Centers for Disease Control and Prevention (CDC) was investigating some 450 medical cases potentially caused by vaping, including many with severe lung damage. New headlines and articles are exploring the probable links and updating the growing story on a daily basis.
Vaping advocates have long touted the benefits of vaping (opposed to cigarette smoking) in helping people kick their tobacco habit.
One of the leading organizations for vaping proponents is Consumer Advocates for Smoke-free Alternatives Association (or CASAA). Formed in 2009, the organization promotes the benefits of what they call “reduced harm alternatives” to cigarette smoking (or combustible tobacco).
“Though we are uncertain as to how safe they are, we are fairly sure that they are safer than smoking cigarettes,” the CASAA website states. “Part of our certainty derives from knowing how harmful regular smoking is. Almost anything is certain to be safer.”
There’s no refuting the dangers of cigarette smoke. According to the American Lung Association, when burned, cigarettes produce at least 69 cancer-causing chemicals. But, in 2011 the FDA warned e-cigarette producers from advertising claims of helping the user to stop smoking or providing any other health benefit or else it would be more strictly regulated as a drug or medical device. Health claims for e-cigarettes have since all but disappeared.
“We do not know the exact mechanism of how vaping damages the lungs,” Schultz says. “The CDC is currently examining around 215 cases (it has since increased to 450, as stated above). In Zohfeld’s case, as with all the others, when everything else gets ruled out, we are left with vaping as the only thing in common.”
According to an Aug. 30 CNN article by Michael Nedelman: “In Tryston's home state of Texas, there are more than a dozen such cases. But some states have potentially several times that — with at least 38 in California, 35 in Illinois, and 32 in Wisconsin — state health departments announced this week. These include a number of cases still under investigation.”
In fact, the Milwaukee Health Department notified its community about 16 people it said had been hospitalized with chemical pneumonia, which caused inflammation of the lungs. This alarming increase in vape-related injuries prompted it to issue a warning just prior to the Labor Day weekend. “Stop using any vape and/or e-cigarette devices immediately,” the department said.
The American Lung Association echoed the Milwaukee Health Department’s warning: “Stop using any vape and/or e-cigarette devices immediately,” the group said in a statement to the local WISN 12 News. “E-cigarettes contain toxic chemicals, heavy metals, and fine particles, and the inhalation of these chemicals can cause irreversible lung damage and lung disease. The developing lungs of youth may be more at risk.”
Due to a lack of data and controlled studies, there’s no way to confirm what many suspect — that vaping is leading to serious health consequences. “We don’t know what’s in the stuff, because it’s not well-regulated,” Arnaout says. “It’s only a matter of time before we’ll know the harm they cause.” And vaping proponents are quick to point out that at least some of these cases involved inhaling THC (the main active ingredient in marijuana and the cannabis plant) rather than traditional nicotine-based vape liquids.
Hospital statistics are not good at tracking the data yet either, since some vape-related injuries (like younger children ingesting the liquid in the flavored “pods”) are not coded as pulmonary issues but rather as accidental poisonings. The guidelines are being updated currently for health departments across the country and the CDC to get a better handle on all the data that is pouring in.
Targeting Teens
While cases of lung disorders and even seizures are being identified and studied, one thing is for certain — vaping among our teens is on the rise. While vape has been billed a “safer” option, there’s growing concern that this new form of nicotine consumption is getting a new generation hooked.
According to the CDC website: “Recent increases in the use of e-cigarettes is driving increases in tobacco product use among youth. The number of middle and high school students using e-cigarettes rose from 2.1 million in 2017 to 3.6 million in 2018 — a difference of about 1.5 million youth.”
The FDA and the CDC are synchronized in calling the rise of vaping among teens an epidemic.
“The recent surge in e-cigarette use among youth, which has been fueled by new types of e-cigarettes that have recently entered the market, is a cause for great concern,” Jerome Adams, Surgeon General of the United States Health Services, said via the CDC website. “We must take action now to protect the health of our nation’s young people.”
And, recent headlines harken back to the days when tobacco companies aggressively marketed their addictive products to a targeted teen market.
Many of the marketing tactics are ones we have grown wary of over the past few decades; teen-enticing packaging, flavorings, and imagery may call into question the industry’s intentional targeting of youth.
“Youth use of tobacco products in any form is unsafe,” the CDC says. Its statistics from 2018 confirm that nearly one in five high school students (20.8%) and one in 20 middle schoolers (4.9%) reported vaping in the past month.
Teens commonly refer to all brands of e-cigarettes (or e-cigs) by the most popular brand name on the market, JUUL, in much the same way that many brands of soda are referred to as a Coke. The popularity of the brand, with its style and slick advertising, has made “Juuling” so trendy among the nation’s youth that the term transcends brands and encapsulates the vaping experience for their age group.
Founded in 2015, JUUL uses nicotine salts (also known as protonated nicotine) from leaf-based tobacco for its key ingredient. And, in just three short years, the company, valued at $15 billion, has captured 72% of the market share, according to The Wall Street Journal.
The techy-appeal of JUUL has a lot to do with its staggering success. JUUL is shaped to resemble a USB device for ease of transport and the ability to hide it in plain sight at both school and home.
Many have argued that the packaging alone targets younger users. Where older smokers and vape-users might not know a USB from a VHS, teens get it immediately. And, based upon the sheer market share and dollar signs connected to JUUL, teens have helped catapult the brand into a commanding lead.
Critics have pointed out similarities between the e-cigarette’s marketing efforts and that of Camel cigarettes’ in the early to mid-’90s, when it launched its infamous Joe Camel advertisements, which is credited with quadrupling the number of underage smokers who preferred the Camel brand.
Due to increased FDA pressure, JUUL has closed its social media accounts, begun using “real” product users, rather than paid models in its advertising, and has updated its age-verification policies for purchase [requiring an ID check].
While we may never know the exact cause of Zohfeld’s failing lungs, for many, the rise of vaping and subsequent growing nicotine dependency among youth remain a cause for concern.
“When I saw [Zohfeld] looking completely defeated, barely able to hop up on the examination table after his release, the comparison was so striking, he seemed very humbled by the experience,” Arnaout says. “I hope everybody can learn from this. I am proud of him for sharing his story.”
What Are E-cigarettes?
E-cigarettes are electronic devices that heat a liquid and produce an aerosol or mix of small particles in the air.
Some e-cigarettes look like regular cigarettes, cigars, or pipes. Some look like USB flash drives, pens, and other everyday items. Larger devices such as tank systems, or “mods,” do not look like other tobacco products.
E-cigarettes come in many shapes and sizes. Most have a battery, a heating element, and a place to hold a liquid.
They are sometimes called e-cigs, e-hookahs, mods, vape pens, vapes, tank systems, and electronic nicotine delivery systems (ENDS).
Using an e-cigarette is sometimes called vaping or juuling.
Statistics About E-cigarette Use Among U.S. Youth
Among middle and high school students, 3.62 million were current users of e-cigarettes in 2018.
E-cigarette use from 2017 to 2018 increased 78% among high school students (11.7% to 20.8%) and 48% among middle school students (3.3% to 4.9%) from 2017 to 2018.
According to a 2013 – 2014 survey, 81% of current youth e-cigarette users cited the availability of appealing flavors as the primary reason for use.
