About six years ago, a consumer group supporting smoke-free alternatives to cigarettes began collecting stories from longtime smokers happy they'd switched to vaping.
Those smokers spoke of how they'd beaten their addiction to traditional cigarettes by using electronic cigarettes, and said even though they were still inhaling nicotine through those devices, they felt they'd made a healthier choice.
But now the dangers of vaping are becoming more clear.
Last week, the Centers for Disease Control and Prevention reported there have been 805 confirmed and probable cases of vaping-linked lung illness — including 12 deaths — nationwide this year.
Those who got sick included several from Berks County, and while none of those patients died, their illnesses were serious, and at least two required treatment in local intensive care units, doctors said.
"We're still learning the harms of vaping, but it's not a safe alternative to smoking," said Dr. David Young, a pulmonary, lung and ICU doctor who works at both Penn State Health St. Joseph and Reading Hospital. "With vaping you have no idea what you're smoking."
Young knows of two young adults who required ICU stays in Berks after suffering lung damage related to vaping, and neither had any previous medical problems, he said.
Pain, trouble breathing
Both had pain and significant trouble breathing, he said. One needed a ventilator and the other a breathing tube in their lungs, and additional therapy to treat the infections they'd acquired, he said.
They were very sick," Young said.
Among the questions doctors have is whether pulmonary damage related to vaping will be permanent, he said.
E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs. What's difficult for doctors is that there are so many types of e-cigarette devices now, which can be used at different settings and voltages, he said. And there are also so many types of liquid that can be heated in them, all sold with very little government oversight, he said.
So when treating patients who got sick from vaping, it's tough to know what exactly made them ill, he said.
"There are 5,000 different liquids out there and 400 types of devices," he said. "No one knows who is manufacturing what."
THC plays a role
But CDC said its investigation into lung injuries associated with vaping suggest products containing THC play a role in the outbreak.
CDC has received data on 514 of the patients in its report, and about 77% reported using THC-containing products, with 36% of them using THC products exclusively.
While the CDC's investigation is ongoing, the agency recommends that people consider refraining from using vaping products, particularly those containing THC.
Part of the initial draw to vaping was that it didn't expose users to some of the harmful chemicals that traditional cigarettes do, said Dr. Sarah Luber, Wellness Program director for Tower Health (which owns Reading Hospital) and who is part of the internal medicine faculty.
Those chemicals included tar and carbon monoxide, she said.
But the liquids used in vaping contain other dangerous chemicals, which vary from product to product, but could include things like lead and formaldehyde, she said.
Popular with teenagers
Part of the concern is that vaping is especially popular with teenagers, in part because it's usually cheaper than cigarettes, and because the liquids include interesting flavors such as bubblegum and pink lemonade, she said. The chemicals involved could be particularly harmful to their developing brains, she said.
"There could be long-lasting effects," she said.
And while some smokers switched from regular cigarettes to e-cigarettes, many of those who started vaping did not quit cigarettes, meaning they're now dual users, Luber said.
Doctors have studied the effects of cigarettes for more than a half-century to learn about the harm they cause, but the study of vaping-related illnesses is a much more recent phenomenon, meaning doctors are learning as they go, Young said.
In the meantime, Luber said, better alternatives to smoking are nicotine replacement therapies such as nicotine gum, patches, inhalers, sprays, and lozenges, behavioral therapies or prescription medicines bupropion and varenicline (Chantix) that can help with cravings and withdrawal symptoms.
Anyone with concerns about their health related to vaping should talk to their primary care provider, she said.
And doctors will continue to study the effects of vaping and track illnesses connected to it, Luber said.
"It's a rapidly changing area," she said. "We're trying to get a grip on it."