Long-term outcomes of EVALI: a 1-year retrospective study

E-Cigarette or Vaping Product Use-Associated Lung Injury: A Comprehensive Review

E-cigarette or vaping product use-associated lung injury (EVALI) is a critical and potentially fatal form of lung injury that gained considerable public health concern in 2019. The use of e-cigarettes and vaping products is causally associated with EVALI, a condition characterized by a constellation of respiratory symptoms, such as coughing, shortness of breath, and chest pain. This comprehensive narrative literature review explores the complexities of EVALI, including its association with the structure and composition of e-cigarettes and its epidemiology, pathogenesis, clinical and radiological manifestations, management strategies, and public health implications. Moreover, it uncovers the long-term repercussions of EVALI and underscores the ongoing research endeavors designed to mitigate and comprehend the risks associated with using e-cigarettes.

Prospective follow-up of New York City residents with e-cigarette, or vaping product use-associated lung injury-2020-2021

BACKGROUND

A multistate outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) occurred in 2019. Because of EVALI's novelty and severity, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) prospectively assessed sequelae among NYC residents who received an EVALI diagnosis in 2019.

METHODS

Using existing NYC EVALI surveillance data, DOHMH attempted contact with all living residents who received an EVALI diagnosis in 2019 and conducted 3 waves of telephone interviews during April 2020-March 2021. Interview questions were adapted from the Centers for Disease Control and Prevention's EVALI case report form and validated surveys. Baseline differences between respondents and nonrespondents were assessed with Chi-square and Fisher's exact tests; clinical and behavioral characteristics and open-ended responses were summarized.

RESULTS

In 2019, 53 NYC residents received an EVALI diagnosis; 33 (67%), 14 (29%), and 18 (37%) of 49 living residents participated in the first, second, and third interviews, respectively. Interviews occurred after outpatient diagnosis (6%) or hospital discharge (94%), at a median of 8, 11, and 17 months for each wave. Respondents (N = 33) and nonrespondents (N = 16) did not differ by sex, age, hospitalization status or length. Respondents were mostly male (70%), had a median age of 23 years (range: 16-63 years), and all reported using vaping or e-cigarette products (vaping) with tetrahydrocannabinol (88%), nicotine (49%), or cannabidiol (9%) before diagnosis. Respiratory (first and second interviews) and gastrointestinal (third interviews) symptoms were most commonly reported. Sixteen respondents (49%) reported any new diagnosis during follow-up. Fifteen to 29% of respondents reported vaping at each interview; 58%-93% reported recent non-vaped cannabinoid use.

CONCLUSION

NYC residents with EVALI reported symptoms throughout the follow-up period, and approximately half reported newly diagnosed health conditions. Further studies are needed to understand EVALI's relationship with symptoms and health conditions.

Oxidized phospholipid and transcriptomic signatures of THC-related vaping associated lung injury

E-cigarette/vaping-associated lung injury (EVALI) is strongly associated with vitamin E acetate and often occurs with concomitant tetrahydrocannabinol (THC) use. To uncover pathways associated with EVALI, we examined cytokines, transcriptomic signatures, and lipidomic profiles in bronchoalveolar lavage fluid (BALF) from THC-EVALI patients. At a single center, we prospectively enrolled mechanically ventilated patients with EVALI from THC-containing products (N = 4) and patients with non-vaping acute lung injury and airway controls (N = 5). BALF samples were analyzed by Luminex multiplex assay, RNA sequencing, and mass spectrometry. After treating BEAS-2B lung epithelial cells with vaping and non-vaping BALF, LDH release was quantified. THC-EVALI BALF had significant increases in IFNγ, CCL2, CXCL5, and MMP2 relative to non-vaping patients. RNA sequencing showed enrichment for biological oxidation, glucuronidation, and fatty acid metabolism pathways. Oleic acid and arachidonic acid metabolites were increased in THC-EVALI, as were oxidized phosphatidylethanolamines (PE) such as PE(38:4). THC-EVALI BALF induced more LDH release compared to BALF from non-vaping patients. Thus, THC-EVALI is characterized by altered phospholipid composition, accumulation of lipid oxidation products, and increased pro-inflammatory mediators that may contribute to epithelial cell death. These findings serve as a framework to study novel oxidized phospholipids implicated in the pathogenesis of EVALI.

"Better Than Any DARE Program": Qualitative Analysis of Adolescent Reactions to EVALI Television Storylines

Introduction. Research suggests that awareness of e-cigarette, or vaping, product-use associated lung injury (EVALI) among adolescents is associated with increased harm perception of e-cigarettes. The depiction of EVALI on three primetime medical dramas offers an opportunity to examine the use of these storylines for tobacco prevention education. Methods. We conducted four focus groups with seventh- and eighth-grade students at an urban middle school. Participants viewed three clips of scenes followed by a facilitated discussion as to the influence of the clips on knowledge and perceptions of e-cigarettes and the use of clips for tobacco prevention education. Two research assistants double-coded notes from the focus groups using a qualitative content analysis approach. Results. Our final sample included 78 adolescents; we obtained self-reported demographic information for 75. The majority of participants were 13 to 14 years of age (82.7%) and identified as cisgender female (52.0%) and Black (52.0%). No participants had knowledge of EVALI prior to viewing the clips. Comments made both during and after watching suggest the clips may have reinforced knowledge and perceptions of harm; participants stated that the clips could be a useful intervention tool. Viewing the clips also generated unprompted discussion about flavored products, tobacco advertising, other television programs, and marijuana. Conclusions. Clips featuring the depiction of EVALI on medical dramas may be an effective tool for raising awareness of e-cigarette use-related harms. These results offer a promising first step for future collaborative research between public health, adolescents, and schools to develop tobacco prevention education utilizing these clips.

E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Continues: An Opportunity for Pharmacist Intervention

Electronic cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) was first identified and reported in 2019, but media coverage and reporting of cases drastically decreased when the COVID-19 pandemic started in early 2020. The syndrome has continued to occur since that time and it is critical that pharmacists are aware of how EVALI presents, and when it should be considered as a potential diagnosis. Inpatient and outpatient pharmacists play a vital role in the treatment of EVALI, and should be knowledgeable of the utility of corticosteroids, even though data are extremely limited. Pharmacists should understand the importance of collecting detailed and accurate information about vaping from patient interviews. Pharmacists also play a leading role in cessation counseling and treatment, selecting medications that can be used to treat nicotine addiction from vaping, and assisting with transitions of care and follow-up.

Cardiopulmonary Impact of Electronic Cigarettes and Vaping Products: A Scientific Statement From the American Heart Association

Vaping and electronic cigarette (e-cigarette) use have grown exponentially in the past decade, particularly among youth and young adults. Cigarette smoking is a risk factor for both cardiovascular and pulmonary disease. Because of their more limited ingredients and the absence of combustion, e-cigarettes and vaping products are often touted as safer alternative and potential tobacco-cessation products. The outbreak of e-cigarette or vaping product use-associated lung injury in the United States in 2019, which led to >2800 hospitalizations, highlighted the risks of e-cigarettes and vaping products. Currently, all e-cigarettes are regulated as tobacco products and thus do not undergo the premarket animal and human safety studies required of a drug product or medical device. Because youth prevalence of e-cigarette and vaping product use was as high as 27.5% in high school students in 2019 in the United States, it is critical to assess the short-term and long-term health effects of these products, as well as the development of interventional and public health efforts to reduce youth use. The objectives of this scientific statement are (1) to describe and discuss e-cigarettes and vaping products use patterns among youth and adults; (2) to identify harmful and potentially harmful constituents in vaping aerosols; (3) to critically assess the molecular, animal, and clinical evidence on the acute and chronic cardiovascular and pulmonary risks of e-cigarette and vaping products use; (4) to describe the current evidence of e-cigarettes and vaping products as potential tobacco-cessation products; and (5) to summarize current public health and regulatory efforts of e-cigarettes and vaping products. It is timely, therefore, to review the short-term and especially the long-term implications of e-cigarettes and vaping products on cardiopulmonary health. Early molecular and clinical evidence suggests various acute physiological effects from electronic nicotine delivery systems, particularly those containing nicotine. Additional clinical and animal-exposure model research is critically needed as the use of these products continues to grow.

The E-cigarette or Vaping Product Use-Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report

E-cigarette or vaping product use-associated lung injury (EVALI) is a severe pulmonary illness associated with the use of e-cigarettes or vaping products that was officially identified and named in 2019. This American Thoracic Society workshop was convened in 2021 to identify and prioritize research and regulatory needs to adequately respond to the EVALI outbreak and to prevent similar instances of disease associated with e-cigarette or vaping product use. An interdisciplinary group of 26 experts in adult and pediatric clinical care, public health, regulatory oversight, and toxicology were convened for the workshop. Four major topics were examined: 1) the public health and regulatory response to EVALI; 2) EVALI clinical care; 3) mechanisms contributing to EVALI; and 4) needed actions to address the health effects of EVALI. Oral presentations and group discussion were the primary modes used to identify top priorities for addressing EVALI. Initiatives including a national EVALI case registry and biorepository, integrated electronic medical record coding system, U.S. Food and Drug Administration regulation and enforcement of nicotine e-cigarette standards, regulatory authority over nontobacco-derived e-cigarettes, training in evaluating exogenous exposures, prospective clinical studies, standardized clinical follow-up assessments, ability to more readily study effects of cannabinoid e-cigarettes, and research to identify biomarkers of exposure and disease were identified as critical needs. These initiatives will require substantial federal investment as well as changes to regulatory policy. Overall, the workshop identified the need to address the root causes of EVALI to prevent future outbreaks. An integrated approach from multiple perspectives is required, including public health; clinical, basic, and translational research; regulators; and users of e-cigarettes. Improving the public health response to reduce the risk of another substantial disease-inducing event depends on coordinated actions to better understand the inhalational toxicity of these products, informing the public of the risks, and developing and enforcing regulatory standards for all e-cigarettes.

Prospectively Assessed Long-Term Outcomes of Patients with E-Cigarette- or Vaping-associated Lung Injury

Rationale: E-cigarette- or vaping-associated lung injury (EVALI) was first identified in 2019. The long-term respiratory, cognitive, mood disorder, and vaping behavior outcomes of patients with EVALI remain unknown. Objectives: To determine the long-term respiratory, cognitive, mood disorder, and vaping behavior outcomes of patients with EVALI. Methods: We prospectively enrolled patients with EVALI from two health systems. We assessed outcomes at 1 year after onset of EVALI using validated instruments measuring cognitive function, depression, anxiety, post-traumatic stress, respiratory disability, coronavirus disease (COVID-19) infection, pulmonary function, and vaping behaviors. We used multivariable regression to identify risk factors of post-EVALI vaping behaviors and to identify whether admission to the intensive care unit (ICU) was associated with cognitive, respiratory, or mood symptoms. Results: Seventy-three patients completed 12-month follow-up. Most patients were male (66.7%), young (mean age, 31 ± 11 yr), and White (85%) and did not need admission to the ICU (59%). At 12 months, 39% (25 of 64) had cognitive impairment, whereas 48% (30 of 62) reported respiratory limitations. Mood disorders were common, with 59% (38 of 64) reporting anxiety and/or depression and 62% (39 of 63) having post-traumatic stress. Four (6.4%) of 64 reported a history of COVID-19 infection. Despite the history of EVALI, many people continued to vape. Only 38% (24 of 64) reported quitting all vaping and smoking behaviors. Younger age was associated with reduced vaping behavior after EVALI (odds ratio, 0.93; P = 0.02). ICU admission was not associated with cognitive impairment, dyspnea, or mood symptoms. Conclusions: Patients with EVALI, despite their youth, commonly have significant long-term respiratory disability; cognitive impairment; symptoms of depression, anxiety, post-traumatic stress; and persistent vaping.

Recurrent spontaneous pneumothorax in a 15-year-old female associated with electronic cigarettes

Pneumothorax as a sequela of vaping is a relatively recent complication being described in the literature. Smoking has classically been associated with an increased risk of pneumothorax, and emerging evidence is showing that electronic cigarettes (e-cigarettes) likely carry some of the same risks. Since e-cigarettes increased in popularity, especially among the adolescent population, there has been a reported increased incidence of lung injury, including pneumothorax. We present a case of a 15-year-old female with a history of e-cigarette use admitted for recurrent pneumothorax with failure to re-expand requiring surgical intervention.