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Following a mysterious outbreak of vaping-linked illnesses and deaths on the mainland over the past few months, Hawaii health officials are investigating the first severe respiratory illness possibly related to e-cigarette use.

The Hawaii island minor is still hospitalized and receiving treatment for a serious lung injury, the Hawaii Department of Health reported. The department has not yet determined an official cause and would not disclose further details, including the age of the patient.

“We’re sad to hear it, but it’s not surprising based on what’s happening across the country,” said Jessica Yamauchi, executive director of the Hawaii Public Health Institute. “With our vaping rates being so high, it was probably just a matter of time before Hawaii had its first case.”

Since April, the national Centers for Disease Control and Prevention has reported among patients of all ages in 33 states and one U.S. territory. All reported cases of severe pulmonary disease were from patients who had a history of vaping. At least six people have died.

The medical cases in question have been predominantly among young people and more than half of patients have needed intensive care.

“Some had to be put on ventilators, some had to go to extra measures for oxygenation, so all in all, these patients are very sick,” said Alvin Bronstein, a physician and the chief of the Hawaii Department of Health Emergency Medical Services and Injury Prevention System Branch. “When you see the X-rays it looks like snow in the lungs.”

A Youth ‘Epidemic’

When the number of American teens who smoke e-cigarettes surpassed 2 million, U.S. Food and Drug Administration Commissioner Scott Gottlieb

But vaping rates among Hawaii youth have long surpassed national rates.

Kevin Ramirez, coordinator of Hawaii’s Youth Electronic Smoking Devices Prevention Project, says Hawaii students have been using e-cigarettes more than their mainland peers since the first statistics were published in 2011.

The Hawaii high school youth vaping rate rose from 5% in 2011 to 25.5% in 2017.

More specifically, the 2017 survey found more than a quarter of Hawaii high schoolers had smoked an e-cigarette at least once within the past month — twice the national average, according to the state health department.

By comparison, fewer than 5% of Hawaii adults used e-cigarettes in 2017.

“I think if you look on the street you’d see it’s the young people vaping, not older people,” Bronstein said.

E-cigarettes are widely available in stores and online, and kids find creative ways of getting ahold of them, Ramirez says.

“We’ve heard reports from principals who are catching students who are collecting money from their peers, going to Longs, buying a prepaid credit card, ordering online, and once they get the goods they take it back to school,” he said. “They’re doing this through Snapchat or Instagram.”

Vaping rates are much higher on neighbor islands compared to Oahu, according to Yamauchi, who said a recent survey found more than a third of all Big Island high schoolers currently use e-cigarettes.

Students as young as 11 years old are vaping as well. It’s estimated that 16% of Hawaii middle schoolers smoke e-cigarettes, which is three times the national middle school average, according to Scott Stensrud, the Hawaii Public Health Institute’s Statewide Youth Coordinator.

“It’s not like the old days where it’s the bad kids smoking,” Stensrud said. “It’s the athletes, the student body presidents — it’s crossing all spectrums of students. I’ve heard the story enough times to know it’s across all types of schools, public and private.”

Ongoing Investigation

The Hawaii Department of Health has published an official advisory to physicians, urging them to pay closer attention for respiratory symptoms such as chest pain, cough or shortness of breath among patients who report using vaping products, such as e-cigarettes that harbor nicotine or THC.

Other symptoms include weight loss, dizziness, nausea, abdominal pain and fever.

Last month, the CDC launched an investigation into the lung illnesses and has partnered with state health departments and the U.S. Food and Drug Administration to analyze the effects of using a variety of e-cigarette products, whether they are liquids, refill pods or cartridges. Investigators believe the illnesses are sparked by chemical exposure, but federal health officials still won’t point to a single substance as the culprit.

E-cigarette devices may carry nicotine, marijuana or other chemicals. The is an oil derived from Vitamin E.

“Our biggest concern is off-the-street illicit types of products,” said DOH spokeswoman Janice Okubo. “People who add or change the products that they use or mix in different things, that’s a concern as well. I don’t think they’ve had an actual definitive finding from the investigation yet, but those are the issues that are concerning.”

Hawaii Medical Cannabis Industry Reacts

State law allows licensed medical marijuana dispensaries to sell vaping cartridges, but their products are closely regulated and tested.

The Hawaii Association of Licensed Therapeutic Healthcare, the trade association for Hawaii’s medical cannabis dispensaries, released a statement on Sept. 2 to remind patients that state law requires dispensaries “to submit every batch of flower and manufactured product for analysis by a third party lab regulated by the state.”

“This mandatory analysis includes screening for the presence of solvent residues and any additives,” the association said.

Any product that fails those state laboratory tests must be destroyed.

Noa Botanicals, an Oahu medical cannabis dispensary, reiterated that in a statement Tuesday.

“We never add artificial ingredients such as propylene glycol or vegetable glycerin,” the company said.