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U.S. public health officials warned Americans who aren’t already smokers to avoid e-cigarettes and other vaping devices after a mysterious outbreak of a severe lung disease emerged in recent weeks, which has sickened at least 215 people across 25 states and been linked to at least one death.

The U.S. Centers for Disease Control and Prevention and the Food and Drug Administration are working with state health departments to try to figure out what is causing the damage, which they say has been tied to vaping. In many cases, patients reported using products that included cannabis or THC, the active ingredient in marijuana, before falling ill. The agencies also cautioned against altering commercial devices or consuming home-brew substances.

“Anyone who uses e-cigarette products should not buy these products off the street and should not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer,” CDC Director Robert Redfield and acting FDA Commissioner Ned Sharpless said in the statement. “Regardless of the ongoing investigation, e-cigarette products should not be used by youth, young adults, pregnant women, as well as adults who do not currently use tobacco products.”

The recommendation echoes that of Kevin Burns, the chief executive officer of Juul Labs Inc., who was blunt in his advice to current non-smokers in an interview with CBS This Morning.

“Don’t vape,” he said earlier this week, addressing people who don’t currently use tobacco. “Don’t use Juul. Don’t start using nicotine if you don’t have a pre-existing relationship with nicotine. Don’t use the product. You are not our target consumer.”

Many people believe vaping is safer than traditional cigarettes and tobacco, which kill 8 million people each year due to cancer, health disease and other conditions, according to the World Health Organization. E-cigarettes are seen as an alternative that could help smokers quit and save lives, though health officials are still working to understand their side effects and risks as they become more and more popular.

Altria Group Inc., the tobacco company that sells Marlboro cigarettes, is a major investor in closely held Juul. Shares of Altria were down 1.5% at 1:46 p.m. in New York.

Lung symptoms

The emergence of symptoms in patients with severe lung damage hasn’t always followed a consistent pattern. Many reported a slow buildup before they were hospitalized, including difficulty breathing, shortness of breath and chest pain. Others appeared to have a virus, including fevers and fatigue, or gastrointestinal issues like vomiting and diarrhea.

It’s not yet clear if there is a common cause or if patients are suffering from different conditions with similar symptoms, the officials said.

Public health authorities are investigating the brands and types of e-cigarette products used by the patients, where they were obtained, and whether any of them would fall under the FDA’s regulatory authority. They asked health-care providers to report any cases of severe pulmonary disease in patients who had used e-cigarettes within the past three months to state or local health departments.

“More information is needed to better understand whether there’s a relationship between any specific products or substances and the reported illnesses,” the officials said. “At this time, there does not appear to be one product involved in all of the cases, although THC and cannabinoids use has been reported in many cases.”

The lung illnesses aren’t the only health concerns being investigated that are linked to e-cigarettes. The FDA is probing 127 reports it’s received of vaping associated with seizures, an inquiry the agency started after receiving reports from a young adult and the parents of two teens who used devices they said were sold by Juul Labs Inc.

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