State health officials said Friday that many patients sickened with mysterious lung injuries used black market marijuana vaping devices marketed under a counterfeit brand, offering the strongest clues so far into what might be making people sick.

Officials in Wisconsin and Illinois, the states that were the first to report cases, conducted in-depth interviews with 86 patients who said they used a wide range of e-cigarette products. The vast majority reporting using illicit products containing THC, the psychoactive component of marijuana, according to a report released Friday. The products were sold as prefilled vape cartridges – tiny disposable containers – and obtained from informal sources, officials said.

A high percentage of patients said they used Dank Vapes cartridges. According to a report released by the Centers for Disease Control and Prevention Friday, Dank Vapes appears to be the most prominent in a class of “largely counterfeit brands with common packaging that is easily available online and that is used by distributors to market THC-containing cartridges with no obvious centralized production or distribution.”

Vaping cartridges are among the most popular items in both the legal and illicit marijuana markets, industry analysts have said.

Officials have said there is no single e-cigarette or vaping product, brand or specific substance that has been definitively linked to the outbreak. Patients have used many kinds of products with a wide array of ingredients, some of which may have been mixed with potentially illicit substances, such as marijuana.

But the predominant use of prefilled THC-containing cartridges among patients who have been sickened “suggests that they play an important role” in causing the outbreak, the report said.

Nationally, CDC officials said most of the people in the outbreak, or 77%, reported using THC-containing products or both THC and nicotine-containing products. That has prompted CDC to modify its warning Friday, urging people to consider refraining from using any e-cigarette products, especially those containing THC.

So far, 805 cases have been reported in 46 states and one U.S. territory and at least 12 people have died.

“We are in the midst of a complex investigation that is encompassing nearly all states, and involves serious, life-threatening disease in young health people who have reported the use of a wide variety of substances and products,” said Anne Schuchat, CDC’s principal deputy director.

Officials have said they suspect the cause of the lung disease to be some kind of chemical exposure. One substance that is a key focus of investigators is vitamin E oil, known as vitamin E acetate. Experts in the legal marijuana industry have said it has been used to stretch out THC oil that is used to fill vape cartridges. It is colorless and odorless, has similar viscosity to THC oil, and is much cheaper.

Vitamin E acetate, which is sold legally, is commonly used as a nutritional supplement and in skin-care products. It’s not harmful when ingested or applied to the skin. But health officials have warned it could be hazardous when inhaled, potentially causing the sorts of symptoms many patients have reported: cough, shortness of breath and chest pain.

Vitamin E acetate has been found in THC products taken from sickened patients and tested by state labs and the FDA’s forensic lab, officials have said.

The U.S. Food and Drug Administration and the Drug Enforcement Administration have launched a criminal investigation. That is happening alongside the probe by the Centers for Disease Control and Prevention into the cause of the illnesses that began being tracked in April. Officials are not pursuing individual vapers. But if the FDA determines “someone is manufacturing or distributing illicit, adulterated vaping products that caused illness and death for personal profit, we would consider that to be a criminal act,” FDA acting commissioner Norman “Ned” Sharpless said this week.

Initial data from two states showed that most patients reported a history of using e-cigarette products containing THC, the psychoactive ingredient found in marijuana. Some said they used both THC and nicotine products, and some have reported using only nicotine products. But officials and clinicians have said patients, particularly younger ones, are often reluctant to share information about their use of illicit substances, such as marijuana.

In a second report released Friday, CDC officials provided more detail about that breakdown. Among 805 cases of lung injury from 46 states and one U.S. territory that have been reported to CDC, officials have received information for 771 patients. Nearly 70% were male, with a median age of 23. Most were younger than 34.

Of 514 patients for whom officials had information on what available substances or products they vaped:

– 395, or about 77%, said they used THC-containing products

– 292, or about 57%, said they used nicotine-containing products

– 210 patients, or 41%, said they used both THC and nicotine-containing products

– 82, or 16%, said they exclusively used nicotine-containing products.

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