U.S. health officials are looking closely at vitamin E acetate as a potential cause of the severe lung injuries that have sickened thousands of Americans who have used vaping devices, including more than three dozen who died as a result.

A study of fluid taken from the lungs of 29 patients battling the condition found all of them had signs of vitamin E acetate, according to a report from the U.S. Centers for Disease Control and Prevention on Friday.

Vitamin E acetate is a thick and gummy syrup, similar in consistency to honey, that some illegal makers of vaping liquids use to dilute their product in order to reduce the amount of active ingredients they need to add.

“These new findings are significant,” said Anne Schuchat, principal deputy director of the CDC, in a conference call, declaring the discovery a breakthrough in the investigation. “For the first time we have identified a potential toxin of concern, in biologic samples. These findings provide direct evidence of vitamin E acetate at the primary site of injury.”

Vitamin E acetate is widely used in food and skin care products, where it is safe, Schuchat said. There is a distinct difference, however, between inhaling something and swallowing it. Previous studies have found that when vitamin E acetate is inhaled, it may affect lung function, she said. New York state officials identified it as a possible culprit in September.

The number of Americans sickened in the outbreak of vaping-related lung injuries has been steadily increasing. As of Nov. 5, there were 2,051 cases reported in 49 states, the District of Columbia and one U.S. territory, the CDC said on Thursday, with 39 confirmed deaths.

Regulators had signaled in recent weeks that the outbreak was likely tied to the use of black-market vaping products containing THC, the psychoactive ingredient in marijuana, though they hadn’t drawn a direct link to any one product, behavior or ingredient. The CDC has said that in a small percentage of confirmed illnesses, patients had reported using nicotine-only products.

There are hundreds of devices and ingredients at play in the vaping market, and not all are legal, which has made identifying the source of the outbreak much more difficult.

The rash of illnesses has coincided with increasing alarm about use of e-cigarettes and vaping devices by teens. According to the 2019 National Youth Tobacco Survey, about 4.1 million high-school students and 1.2 million middle school students will have used vaping products at some point this year.

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