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Cannabis shops around Washington state are now required to hang signs warning customers of 鈥渟evere lung injuries鈥� and 鈥渄eaths鈥� associated with vaping.

, a co-owner of one such shop, Tacoma House of Cannabis, argues the government response to vaping illnesses should focus instead on the black market.

鈥淪omething has just changed, and no one really knows what it is,鈥� he said.

Still, Heiderich supports more rigorous testing so the regulated market is perceived as safer. This summer, his shops began contacting their suppliers to verify what鈥檚 in their products.

He acknowledged that some 鈥渂ad actors鈥� could be selling products on the legal market in Washington.

鈥淗opefully, that is the exception to the rule, and any regulation that does come down puts an end to those sort of business practices,鈥� he said. 鈥淲e don鈥檛 need those people in the market.鈥�

Health officials nationwide are still puzzling over why some who vape come down with a severe respiratory illness and, in some cases, die. So far, the Centers for Disease Control and Prevention鈥檚 investigation has identified , but has yet to pinpoint a lone cause that explains all cases.

Many cases have been traced to vape cartridges filled with THC (the psychoactive ingredient in cannabis) 鈥� cartridges the users found on the black market. Some who have gotten ill were vaping both THC and nicotine, according to CDC reports. A smaller percentage report using only nicotine.

鈥淭he data do continue to point to THC-containing products as the source of the vast majority of individuals鈥� lung injury,鈥� Dr. Anne Schuchat, the CDC鈥檚 principal deputy director, told reporters at a press briefing Oct. 25.

鈥淭here are continuing cases that do not report that history,鈥� she said, 鈥渂ut I鈥檇 like to stress that we don鈥檛 know what the risky material or substance is, and THC may be a marker for a way that cartridges are prepared or the way devices are producing harm.鈥�

Schuchat said it remains to be seen if that is also happening with devices that contain nicotine 鈥� not just THC.

鈥淲e are seeing the THC as a marker for products that are risky,鈥� she said, 鈥渂ut at this time, because of the continued presence of cases that only report exclusive nicotine-containing e-cigarette or vaping product use, we feel that it is very important for people to consider refraining from use of any kind of e-cigarette.鈥�

In response to the CDC鈥檚 ongoing investigation, a handful of states have banned certain vaping products. States where recreational marijuana is legal are also taking a second look at their regulations.

Massachusetts moved to temporarily stop the sale of all vaping products. Oregon and Washington have enacted emergency bans on flavored vaping products. (A judge in Oregon has since put a stay on the temporary ban of flavored nicotine vapes but allowed the ban on flavored vapes containing THC to stand.)

Some cases of lung injury in聽听补苍诲听 may be linked to products from the regulated cannabis market, according to local health agencies, raising questions about the safeguards for consumers who vape legal products.

鈥業 Could Barely Breathe鈥�

Charles Wilcoxen, a police officer for the Puyallup Tribe in Washington state, turned to vaping cannabis nearly two years ago. The 44-year-old U.S. Army veteran says he assumed it was a safer alternative to smoking the plant.

Wilcoxen said he would buy the vape cartridges from Washington鈥檚 legal marijuana shops and use them on his off-duty days to relieve stress.

There was nothing unusual about his vaping routine in September he said 鈥� 鈥淚 used the same device and the same cartridges as I had in the past.鈥�

But this time Wilcoxen very quickly became sick. Shortly after vaping, he began wheezing heavily. Soon he was nauseated and running a fever.

鈥淚 just felt horrible,鈥� he remembered. 鈥淚 tried to get through the weekend and tough it out.鈥�

In September, Charles Wilcoxen was hospitalized for three days with a severe respiratory illness after vaping cannabis cartridges he bought at a legal shop.(Photo by Will Stone)

At first, Wilcoxen thought it could be the flu. But then he started to suspect his illness might be related to his vaping. When Wilcoxen woke up one morning and could barely breathe, he decided to go to the emergency room.

鈥淟iterally, I would take five steps and have to hunch over and try to catch my breath,鈥� he said.

He spent three days in the hospital.

Doctors found a strange build-up in his lungs and sent it for analysis. The results came back positive for聽聽鈥� a rare respiratory illness caused by oils or fats entering the lungs. It鈥檚 one of the vaping-related conditions researchers have聽 in other vape-users hospitalized in recent months.

Wilcoxen is still recovering and has decided to sue.

His lawsuit alleges that defects in the vaping products led to his illness. He鈥檚 going after six companies that have a role in manufacturing or distributing the cartridges or the vaping device.

鈥淏uy something off the black market, you are taking your chances,鈥� said Mark Lindquist, Wilcoxen鈥檚 attorney. But customers who buy their vape products from a state-licensed store, he said, should be able to count on getting a safe product.

States Look To New Rules

Testing standards for cannabis vary across the legalized market in the U.S.

The state of Washington requires that vape products sold in stores be checked for, among other things, potency, toxins and residual solvents used in the extraction process. Some states, including California, go even further and mandate 聽for other substances, such as pesticides.

These regulations, however, don鈥檛 necessarily require checking for other potentially harmful chemicals that sometimes find their way into vape cartridges on the black market and could, conceivably, turn up in legal cartridges, too.

The ongoing聽 into vaping-related illnesses has revealed that illicit THC cartridges sometimes contain so-called 鈥渃utting agents鈥� like vitamin E acetate, which isn鈥檛 safe to inhale.

, laboratory director for Confidence Analytics, which has a state license to test cannabis products in Washington, said a cutting agent is typically used to dilute the THC oil in the black market supply.

But state labs in Washington aren鈥檛 necessarily looking for vitamin E acetate.

鈥淭here is no requirement to test for any sort of cutting agent,鈥� Stevens said.

In recent months, more customers have been asking her laboratory to test for vitamin E, out of concern for its possible role in the vaping-illness outbreak.

Stevens said she鈥檇 be 鈥渟urprised鈥� to discover vitamin E in one of the products sold in Washington鈥檚 legal retail stores. 鈥淏ut I definitely wouldn鈥檛 exclude the possibility,鈥� she said, 鈥渂ecause there are no checks on that right now.鈥�

Shannon Stevens is laboratory director for Washington-based Confidence Analytics, which tests cannabis products before they are solid in licensed retail shops.(Photo by Will Stone)

Washington State Bans Flavors

In an effort to identify harmful chemicals, Washington state regulators are collecting information from cannabis companies that make vaping products.

In the meantime, the Washington State Board of Health recently聽聽a four-month emergency ban on flavored vaping products, which applies to both nicotine and THC.

鈥淲e aren鈥檛 waiting for Big Tobacco to tell us what is in their products,鈥� Gov. Jay Inslee said, in announcing his executive order to prohibit the sale of certain vaping products.

Inslee鈥檚 administration is framing the outbreak as yet another symptom of the rise in youth vaping.

, the state health officer for Washington, said a ban on flavored products will discourage young people from vaping in the first place.

鈥淲hile we don鈥檛 know yet exactly what is causing severe lung injury, we did like the option of banning flavors because we know the youth are very attracted to flavors,鈥� she said.

But the state鈥檚 public health leaders also acknowledge the ban isn鈥檛 necessarily a remedy to the current outbreak of illnesses.

鈥淲e are not saying that the flavors are what are causing this current lung injury or illness,鈥� said Washington鈥檚 Secretary of Health John Wiesman before voting in favor of the ban. 鈥淲e obviously don鈥檛 yet know what that is.鈥�

Before Washington passed its flavor ban, many from the vape industry criticized the move as heavy-handed and misguided. And some public health experts warn the ban could backfire.

鈥淭here is this risk when you ban something [legal] that people will be driven to the black market,鈥� said , director of the UCLA Cannabis Research Initiative.

Cooper says the regulated cannabis market is already fraught with problems. People walk into a cannabis shop with neatly packaged products and believe everything has undergone rigorous safety testing, she said.

鈥淭hey think they can trust what鈥檚 on the labels,鈥� said Cooper, 鈥渂ut the truth is the labels don鈥檛 necessarily accurately portray what鈥檚 actually in the products.鈥�

She said it doesn鈥檛 help that the public health messaging is all over the place 鈥� often lumping together cannabis and nicotine products.

Given all the unknowns about the vaping illnesses, the CDC continues to issue broad warnings about the risks of vaping.

Schuchat said vapers can鈥檛 assume that some states have a better handle on quality than other states.

鈥淲hether the substances that are in products that are completely unregulated by the states are riskier than the products that are regulated by the states,鈥� Schuchat recently told reporters, 鈥淚 don鈥檛 think we have good data either way.鈥�

This story is part of a partnership that includes and Kaiser Health News.