E-cigarette Product Use, or Vaping, Among Persons with Associated Lung Injury - Illinois and Wisconsin, April-September 2019

Blunt and non-blunt cannabis use associated with cigarette, e-cigarette, and cigar initiation: Findings from the population assessment of tobacco and health (PATH) study

BACKGROUND

Smoking cannabis using a tobacco-derived cigar shell or wrap, called blunt smoking, exposes individuals to non-trivial amounts of nicotine. The extent smoking blunts impact the risk of initiating other tobacco products is not well understood. We investigated if past-year blunt smoking is related to the risk of initiating cigarettes, e-cigarettes, and cigars.

METHODS

We obtained data on a nationally representative, non-institutionalized, civilian cohort of US residents aged 12 years and older who had never used cigarettes, e-cigarettes, or any cigar at baseline and surveyed annually for three years from the Population Assessment of Tobacco and Health Study. We estimated the proportional hazard (odds) of initiating these tobacco products associated with past-year blunt smoking, non-blunt cannabis use, or neither using discrete-time survival analyses.

RESULTS

Smoking blunts increased the risk of starting cigarettes (OR = 4.5), e-cigarettes (OR = 3.7), and cigars (OR = 6.7) compared to using neither blunts nor cannabis. Non-blunt cannabis use also increased the risk of starting cigarettes (OR = 4.0) but moderately for e-cigarettes (OR = 2.8) and any cigar (OR = 2.2). Blunt use was strongly related to starting combustible tobacco (cigarettes or cigars; OR = 9.0) and any three tobacco products (OR = 10.9). Exploratory findings showed that cigarillos drove cigar results and effect modification by age, race/ethnicity, and sex.

CONCLUSIONS

People who smoke blunts risk starting cigarettes, e-cigarettes, and cigars more than those who abstain from cannabis. Blunts may contribute to tobacco initiation above cannabis alone.

Misconceptions of Vaping Among Young Adults

Background Vaping is growing in popularity worldwide, especially among young adults. To develop effective tobacco prevention interventions, first, there must be an understanding of the attitudes and perceptions of young adults toward the use of vaping. Highlighting perception discrepancies between races may allow physicians to more effectively counsel their patients regarding the risks of vaping. Methodology We conducted an online survey using Amazon Mechanical Turk (MTurk, https://www.mturk.com/) to identify misconceptions about vaping among adults aged 18 to 24 years who currently vape. The survey consisted of 18 questions evaluating reasons for vaping, history of tobacco use, and thoughts on the adverse effects of vaping. The Penn State Electronic Cigarette Dependence Index was implemented to assess dependence. Exclusion criteria comprised respondents who did not vape and were under the age of 18 or over the age of 24. Results A total of 1,009 responses were received with 66% identifying as male (n = 667) and 33% (n = 332) identifying as female. Sixty-nine percent of patients smoked cigarettes or used another form of tobacco previously (n = 692). Of those respondents, 81% indicated that they had since quit using tobacco products (excluding vaping). Switching to vaping was the most common reason for quitting cigarettes or other forms of tobacco, with health concerns and social purposes being the second and third most common reasons provided, respectively. When asked whether vaping had negative health impacts, only 238 (24%) participants strongly agreed with this statement, while a majority (64%) neither agreed nor disagreed or only somewhat agreed. Most participants were white or Caucasian (n = 777). When asked whether smoking or vaping had more severe health implications, 55% of white or Caucasian participants, 41% of Asian participants, and 32% of black or African American participants indicated that vaping was worse than smoking cigarettes. The average Penn State dependence score was 8.7, suggesting medium dependence. Conclusions Our survey sample of 1,006 young adults who vape indicated that the majority did not perceive vaping as significantly harmful. A comprehensive smoking prevention policy, educational interventions, and quit support are needed to enhance awareness among young adults about the health effects associated with vaping. Such interventions should also consider the novel shift toward the replacement of smoking with vaping.

E-cigarette or Vaping product use Associated Lung Injury (EVALI) in a 15 year old female patient - case report

BACKGROUND

E-cigarettes are devices which allow to aerosolize liquids containing nicotine or other substances. Ever since they were released on the market in 2006, the number of users have been constantly increasing, especially among adolescents, ranging from 7,6% to 9,3% in the age group 18-24 years old from 2014 to 2019. Hand in hand with the spread of E-cigarettes many have been the efforts to understand their impact on health. EVALI (E-cigarette or Vaping product use Associated Lung Injury) is an emerging condition with a heterogeneous presentation with several reported cases worldwide. We mean to report a case of EVALI in a 15-year-old female Caucasian patient, who's currently attending her clinic follow-up at Bambino Gesù Pediatric Hospital in Rome.

CASE PRESENTATION

The patient was admitted to the Emergency Room due to acute respiratory failure in November 2020. At admittance, she was severely dyspneic (HR 120 bpm, SatO2 75%). As she was hospitalized amid the COVID-19 pandemics, she underwent a nasopharyngeal swab for SARS-CoV2, which turned out negative, and a chest CT scan. Chest CT scan showed a central ground grass pattern with peripheral sparing. At the anamnestic recall, it was disclosed she was an e-cigarette smoker and occasional marijuana user. The microbiological work-up proved only positive for Rhinovirus. Her clinical and radiological case was discussed with our radiologist who suspected EVALI. She was assisted through HFNC, antibiotical therapy and corticosteroids with a dramatic recovery within the first 48 h.

CONCLUSIONS

EVALI started being recognized a specifically nosological entity in summer 2019, with increasing cases being reported. No diagnostic criteria have been agreed upon yet, but its usual presentation includes respiratory, gastrointestinal and systemic symptoms of different degree and the diagnosis can be hypothesised in case the patient has an evocative clinical and radiological presentation and has been an E-cigarette smoker in previous 90 days. Due to the novelty of the condition and its heterogeneous presentation it is of interest to report the cases in which EVALI is identified to raise awareness about this emerging new-age disease.

Characteristics of Adults Who Use Both Marijuana and E-Cigarette, or Vaping, Products: A Cross-Sectional Study, Utah, 2018

OBJECTIVES

Among young people, dual use of marijuana and e-cigarette, or vaping, products (EVPs) is linked with using more inhalant substances and other substances, and poorer mental health. To understand antecedents and potential risks of dual use in adults, we analyzed a representative adult population in Utah.

METHODS

We used data from the 2018 Utah Behavioral Risk Factor Surveillance System (n = 10 380) and multivariable logistic regression to evaluate differences in sociodemographic characteristics, comorbidities, and risk factors among adults aged ≥18 who reported currently using both EVPs (any substance) and marijuana (any intake mode), compared with a referent group of adults who used either or neither.

RESULTS

Compared with the referent group, adults using EVPs and marijuana had greater odds of being aged 18-29 (adjusted odds ratio [aOR] = 12.44; 95% CI, 6.15-25.14) or 30-39 (aOR = 3.75; 95% CI, 1.73-8.12) versus ≥40, being male (aOR = 3.29; 95% CI, 1.82-5.96) versus female, reporting ≥14 days of poor mental health in previous 30 days (aOR = 2.30; 95% CI, 1.23-4.32) versus <14 days, and reporting asthma (aOR = 2.09; 95% CI, 1.02-4.31), chronic obstructive pulmonary disorder (aOR = 2.94; 95% CI, 1.19-7.93), currently smoking cigarettes (aOR = 4.56; 95% CI, 2.63-7.93), or past-year use of prescribed chronic pain medications (aOR = 2.13; 95% CI, 1.06-4.30), all versus not.

CONCLUSIONS

Clinicians and health promotion specialists working with adults using both EVPs and marijuana should assess risk factors and comorbidities that could contribute to dual use or associated outcomes and tailor prevention messaging accordingly.

Exposure to e-cigarette vapor extract induces vocal fold epithelial injury and triggers intense mucosal remodeling

Vaping has been reported to cause acute epiglottitis, a life-threatening airway obstruction induced by direct epithelial injury and subsequent inflammatory reaction. Here, we show that we were able to recapitulate this phenomenon in vitro. Exposure of human engineered vocal fold (VF) mucosae to 0.5% and 5% electronic cigarette (e-cigarette) vapor extract (ECVE) for 1 week induced cellular damage of luminal cells, disrupting homeostasis and innate immune responses. Epithelial erosion was likely caused by accumulation of solvents and lipid particles in the cytosol and intercellular spaces, which altered lipid metabolism and plasma membrane properties. Next, we investigated how the mucosal cells responded to the epithelial damage. We withdrew the ECVE from the experimental system and allowed VF mucosae to regenerate for 1, 3 and 7 days, which triggered intense epithelial remodeling. The epithelial changes included expansion of P63 (TP63)-positive basal cells and cytokeratin 14 (KRT14) and laminin subunit α-5 (LAMA5) deposition, which might lead to local basal cell hyperplasia, hyperkeratinization and basement membrane thickening. In summary, vaping presents a threat to VF mucosal health and airway protection, thereby raising further concerns over the safety of e-cigarette use.

This article has an associated First Person interview with the first author of the paper.

Editor's choice: Exposure of vocal fold mucosae to e-cigarette vapor extract induces lipid-mediated epithelial injury that disrupts vocal fold mucosal homeostasis and innate barrier function and triggers intense mucosal remodeling.

Health effects of electronic cigarettes

E-cigarettes cause harm to adolescent users. The devices and constituents create multiple substances which are toxic on inhalation, including nicotine, metallic nanoparticles, particulate matter, and carbonyls. In addition, there is a robust relationship between youth vaping and use of combustible cigarettes as adults. This finding is based on longitudinal research and is found among youth who were at low risk for use of combustible cigarettes. Therefore, the most substantially confirmed health hazard of youth vaping is creating a new generation of smokers of combustible cigarettes and the documented health risks of such use. The physiological and psychological harms of nicotine dependence during adolescence also have been well documented. Additionally, population-based research has shown a consistent link between current vaping and respiratory issues during adolescence itself. Significant lung disease (EVALI) has occurred in adolescents and not all cases are linked to vitamin E acetate. Finally, extrapolating research on adults to adolescents raises the possibility that e-cigarette use is linked to pre-symptomatic cardiovascular dysfunction and may have a significant health impact during adulthood. The combination of this evidence, from pre-clinical to population-based longitudinal studies, conclusively demonstrates that e-cigarettes are not safe for youth.

Vaping-Induced Sepsis and Rapidly Evolving Pleural Effusion in a Young, Otherwise Healthy Male

There have been increasing reports of electronic cigarette (e-cigarette) or vaping use-associated lung injury (EVALI), and the evolving literature demonstrates that the solvents used to dissolve flavors, including vitamin E, may be responsible, at least in part, for the injuries associated with this form of smoking. We present the case of a 26-year-old, otherwise healthy, African American male with a history of heavy use-cigarette use who presented with pleuritic chest pain. He was found to be septic and developed a rapidly accumulating pleural effusion with loculations during his hospitalization. He eventually underwent a thoracotomy due to his deteriorating respiratory status. This case highlights the importance of physician awareness regarding the growing evidence base suggesting that electronic cigarettes and vaporized tobacco products are not as safe as they have been perceived to be. Physicians should screen for and advise patients regarding the risks associated with the use of such products.

Vaping-Associated Lung Injury: A Review

Since commercial development in 2003, the usage of modern electronic cigarette (e-cigarette) continues to increase amongst people who have never smoked, ex-smokers who have switched to e-cigarettes, and dual-users of both conventional cigarettes and e-cigarettes. With such an increase in use, knowledge of the irritative, toxic and potential carcinogenic effects on the lungs is increasing. This review article will discuss the background of e-cigarettes, vaping devices and explore their popularity. We will further summarise the available literature describing the mechanism of lung injury caused by e-cigarette or vaping use.

E-cigarette vaping associated acute lung injury (EVALI): state of science and future research needs

"E-Cigarette (e-cig) Vaping-Associated Acute Lung Injury" (EVALI) has been linked to vitamin-E-acetate (VEA) and Δ-9-tetrahydrocannabinol (THC), due to their presence in patients' e-cigs and biological samples. Lacking standardized methodologies for patients' data collection and comprehensive physicochemical/toxicological studies using real-world-vapor exposures, very little data are available, thus the underlying pathophysiological mechanism of EVALI is still unknown. This review aims to provide a comprehensive and critical appraisal of existing literature on clinical/epidemiological features and physicochemical-toxicological characterization of vaping emissions associated with EVALI. The literature review of 161 medical case reports revealed that the predominant demographic pattern was healthy white male, adolescent, or young adult, vaping illicit/informal THC-containing e-cigs. The main histopathologic pattern consisted of diffuse alveolar damage with bilateral ground-glass-opacities at chest radiograph/CT, and increased number of macrophages or neutrophils and foamy-macrophages in the bronchoalveolar lavage. The chemical analysis of THC/VEA e-cig vapors showed a chemical difference between THC/VEA and the single THC or VEA. The chemical characterization of vapors from counterfeit THC-based e-cigs or in-house-prepared e-liquids using either cannabidiol (CBD), VEA, or medium-chain triglycerides (MCT), identified many toxicants, such as carbonyls, volatile organic compounds, terpenes, silicon compounds, hydrocarbons, heavy metals, pesticides and various industrial/manufacturing/automotive-related chemicals. There is very scarce published toxicological data on emissions from THC/VEA e-liquids. However, CBD, MCT, and VEA emissions exert varying degrees of cytotoxicity, inflammation, and lung damage, depending on puffing topography and cell line. Major knowledge gaps were identified, including the need for more systematic-standardized epidemiological surveys, comprehensive physicochemical characterization of real-world e-cig emissions, and mechanistic studies linking emission properties to specific toxicological outcomes.

Cannabis Vaping Among Youth and Young Adults: a Scoping Review

Purpose of Review

The purpose of this review was to describe the state-of-the-literature on research specific to cannabis vaping among youth and young adults.

Recent Findings

Out of 1801 records identified, a total of 202 articles met eligibility criteria for inclusion in this review. Most of this literature (46.0% of studies) was specific to the health effects of cannabis vaping, particularly EVALI (e-cigarette and vaping associated lung injury). Other research areas identified in the review included the etiology (24.3%) and epidemiology (24.8%) of cannabis vaping, in addition to articles on regulation (8.4%) and marketing (5.5%) of the same.

Summary

Cannabis vaping is increasingly common among youth and young adults and more prevalent is settings where recreational use for adults has been legalized. The literature documents a number of negative health effects of cannabis vaping for young people, along with risk factors and reasons for the same.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40429-022-00413-y.

Profiles of Nicotine and Cannabis Exposure among Young Adults with Asthma

There is a paucity of data on nicotine and cannabis use among young adults (YAs) with asthma. This study aimed to do the following among YAs with asthma: (1) describe YAs' active and passive exposure to nicotine and cannabis; (2) identify latent classes of active use of nicotine and cannabis; and (3) explore predictors of class membership (i.e., demographics, parental and friend use of nicotine and cannabis, and hours of environmental exposure to tobacco smoke, e-cigarette vapor, and marijuana smoke). YAs with asthma (N = 178) self-reported on nicotine and cannabis exposure and the included covariates. Latent class analysis was used to identify latent classes of lifetime nicotine and cannabis use. High rates of nicotine and cannabis use among YAs with asthma were found: 37% reporting a lifetime history of using both nicotine and cannabis. Regarding past year use, 25% had smoked cigarettes, 40% had used e-cigarettes, and 35% had used cannabis. Five classes of lifetime use were identified. The largest class was a non-user class (53%); the other four classes indicate concerning patterns of nicotine and cannabis use. The most consistent predictor of being in a class characterized by more nicotine and cannabis exposure (versus being in the non-user class) was past week exposure to cannabis smoke. This is the first study to identify classes of lifetime nicotine and cannabis use, and examine predictors of class membership, among YAs with asthma. There is a critical need to address environmental and active tobacco and marijuana exposure among YAs with asthma.

Can social media monitoring help identify the next EVALI? An examination of Reddit posts about vitamin E acetate and Dank Vapes

BACKGROUND

Scientists identified vitamin E acetate (VEA) and "Dank Vapes" (a fake brand of tetrahydrocannabinol [THC] vaping products) as contributors to the 2019-2020 outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). On social media, people who post about vaping or THC discussed the causes of EVALI. We examined whether Reddit conversations may have served as early signals of the outbreak.

METHODS

We collected Reddit posts from March 2018 to February 2020 on vaping- and THC-related subreddits that mentioned VEA or Dank Vapes. We identified peaks in post volume, examined post content, and used natural language processing to identify terms most characteristic of posts.

RESULTS

There were almost no posts about VEA before EVALI. Subsequently, there were two peaks, both referencing media coverage of scientific findings that linked VEA to EVALI. Discussion regularly referenced concerns about the legitimacy of Dank Vapes before EVALI; peaks in posts were largely unrelated to scientific findings or media coverage of those findings. The terms most characteristic of VEA posts were EVALI-related; those most characteristic of Dank Vapes posts were about quality or legitimacy.

CONCLUSIONS

Although posts about VEA and Dank Vapes did not predict the outbreak, the public health community could use social media to encourage people who vape or use THC to report future health concerns (e.g., through FDA's Safety Reporting Portal). Researchers and regulators could also use social media to see if potentially problematic products, such as Dank Vapes, have a history of concern among individuals who use those products.

The EVALI outbreak and tobacco sales in the USA, 2014-2020

BACKGROUND

The E-cigarette, or Vaping Product-Use Associated Lung Injury (EVALI) Outbreak of 2019 hospitalised thousands and killed dozens of people in the USA and raised perceptions of the dangers posed to health by electronic cigarettes (e-cigarettes). These illnesses along with continued increases in youth vaping rates lead to the passage of many state and federal laws intended to curtail the sale of flavoured e-cigarettes. Little is known about the impact of these events on US e-cigarette and cigarette retail sales.

METHODS

Using Nielsen Scantrack sales data from January 2014 to January 2020 for 23 US states, we evaluate the effect of the EVALI outbreak. First-differenced state-panel regressions tracking unit sales of total-level and category-level e-cigarettes and cigarette sales controlling for price, Tobacco 21 policy coverage, product distribution, seasonality, EVALI-attributable deaths, and state-level e-cigarette policies affecting the availability of e-cigarettes (non-tobacco flavoured and total) were employed.

RESULTS

Dollar sales of e-cigarettes declined 29% from their pre-EVALI peak by January 2020. Total sales of e-cigarettes declined in response to EVALI deaths and the total e-cigarette sales ban put in place in Massachusetts adopted in its wake. Cigarette sales were largely unchanged by either the direct or indirect policy effects of the EVALI outbreak, except for in Massachusetts, where cigarette sales-particularly those smoked by young people-rose temporarily after a total ban on e-cigarette sales.

CONCLUSION

Sales of e-cigarettes declined in response to the EVALI outbreak and from the most restrictive regulatory policies that were adopted in response, while sales of cigarettes were affected less.

Modeled Respiratory Tract Deposition of Aerosolized Oil Diluents Used in Δ9-THC-Based Electronic Cigarette Liquid Products

Electronic cigarette, or vaping, products (EVP) heat liquids ("e-liquids") that contain substances (licit or illicit) and deliver aerosolized particles into the lungs. Commercially available oils such as Vitamin-E-acetate (VEA), Vitamin E oil, coconut, and medium chain triglycerides (MCT) were often the constituents of e-liquids associated with an e-cigarette, or vaping, product use-associated lung injury (EVALI). The objective of this study was to evaluate the mass-based physical characteristics of the aerosolized e-liquids prepared using these oil diluents. These characteristics were particle size distributions for modeling regional respiratory deposition and puff-based total aerosol mass for estimating the number of particles delivered to the respiratory tract. Four types of e-liquids were prepared by adding terpenes to oil diluents individually: VEA, Vitamin E oil, coconut oil, and MCT. A smoking machine was used to aerosolize each e-liquid at a predetermined puff topography (volume of 55 ml for 3 s with 30-s intervals between puffs). A cascade impactor was used to collect the size-segregated aerosol for calculating the mass median aerodynamic diameter (MMAD) and geometric standard deviation (GSD). The respiratory deposition of EVP aerosols on inhalation was estimated using the Multiple-Path Particle Dosimetry model. From these results, the exhaled fraction of EVP aerosols was calculated as a surrogate of secondhand exposure potential. The MMAD of VEA (0.61 μm) was statistically different compared to MCT (0.38 μm) and coconut oil (0.47 μm) but not to Vitamin E oil (0.58 μm); p < 0.05. Wider aerosol size distribution was observed for VEA (GSD 2.35) and MCT (GSD 2.08) compared with coconut oil (GSD 1.53) and Vitamin E oil (GSD 1.55). Irrespective of the statistical differences between MMADs, dosimetry modeling resulted in the similar regional and lobular deposition of particles for all e-liquids in the respiratory tract. The highest (~0.08 or more) fractional deposition was predicted in the pulmonary region, which is consistent as the site of injury among EVALI cases. Secondhand exposure calculations indicated that a substantial amount of EVP aerosols could be exhaled, which has potential implications for bystanders. The number of EVALI cases has declined with the removal of VEA; however, further research is required to investigate the commonly available commercial ingredients used in e-liquid preparations.

Feasibility of a Traceback Approach for Using Pathology Specimens to Facilitate Genetic Testing in the Genetic Risk Analysis in Ovarian Cancer (GRACE) Study Protocol

Guidelines currently state that genetic testing is clinically indicated for all individuals diagnosed with ovarian cancer. Individuals with a prior diagnosis of ovarian cancer who have not received genetic testing represent missed opportunities to identify individuals with inherited high-risk cancer variants. For deceased individuals, post-mortem genetic testing of pathology specimens allows surviving family members to receive important genetic risk information. The Genetic Risk Assessment in Ovarian Cancer (GRACE) study aims to address this significant healthcare gap using a "traceback testing" approach to identify individuals with a prior diagnosis of ovarian cancer and offer genetic risk information to them and their family members. This study will assess the potential ethical and privacy concerns related to an ovarian cancer traceback testing approach in the context of patients who are deceased, followed by implementation and evaluation of the feasibility of an ovarian cancer traceback testing approach using tumor registries and archived pathology tissue. Descriptive and statistical analyses will assess health system and patient characteristics associated with the availability of pathology tissue and compare the ability to contact and uptake of genetic testing between patients who are living and deceased. The results of this study will inform the implementation of future traceback programs.

Tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, product use behaviors among adults after the onset of the 2019 outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI)

INTRODUCTION

During the E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) outbreak, patient data on tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, product (EVP) use was collected, but data on non-affected adult product use after the onset of the EVALI outbreak is limited. This study describes adult THC-EVP use after EVALI began.

METHODS

THC-EVP use data came from an 18-state web-based panel survey of adult THC- and nicotine-containing EVP users conducted February 2020. Unweighted descriptive statistics were calculated; logistic regression assessed correlates of use.

RESULTS

Among 3,980 THC-EVP users, 23.5% used THC-EVPs daily. Common brands of THC-EVPs used were Dank Vapes (47.7%) and Golden Gorilla (38.7%). Reported substances used included THC oils (69.6%), marijuana herb (63.6%) and THC concentrate (46.4%). Access sources included: recreational dispensaries (41.1%), friend/family member (38.6%) and illicit dealers (15.1%). Respondents aged 45-64 years had lower odds for daily use compared with those aged 25-34 years (aOR = 0.73; 95% CI = 0.60, 0.90). Compared with White respondents, Asian respondents had lower odds (aOR = 0.55; 95% CI = 0.36, 0.84) and Black respondents higher odds (aOR = 1.48; 95% CI = 1.17, 1.86) of daily use. Respondents odds of daily use and accessing THC-EVPs through commercial sources were higher among states with legalized nonmedical adult marijuana use compared to states without.

CONCLUSIONS

Almost half of respondents reported daily or weekly THC-EVP use, and accessed products through both informal and formal sources, even after EVALI began. Given the potential for future EVALI-like conditions to occur, it is important to monitor the use of THC-EVPs and ensure effective education activities about associated risk.

Environmental Factors

The acute respiratory distress syndrome (ARDS) remains a major cause of morbidity and mortality in the intensive care unit. Improving outcomes depends on not only evidence-based care once ARDS has already developed but also preventing ARDS incidence. Several environmental exposures have now been shown to increase the risk of ARDS and related adverse outcomes. How environmental factors impact the risk of developing ARDS is a growing and important field of research that should inform the care of individual patients as well as public health policy.

The chemistry and toxicology of vaping

Vaping is the process of inhaling and exhaling an aerosol produced by an e-cigarette, vape pen, or personal aerosolizer. When the device contains nicotine, the Food and Drug Administration (FDA) lists the product as an electronic nicotine delivery system or ENDS device. Similar electronic devices can be used to vape cannabis extracts. Over the past decade, the vaping market has increased exponentially, raising health concerns over the number of people exposed and a nationwide outbreak of cases of severe, sometimes fatal, lung dysfunction that arose suddenly in otherwise healthy individuals. In this review, we discuss the various vaping technologies, which are remarkably diverse, and summarize the use prevalence in the U.S. over time by youths and adults. We examine the complex chemistry of vape carrier solvents, flavoring chemicals, and transformation products. We review the health effects from epidemiological and laboratory studies and, finally, discuss the proposed mechanisms underlying some of these health effects. We conclude that since much of the research in this area is recent and vaping technologies are dynamic, our understanding of the health effects is insufficient. With the rapid growth of ENDS use, consumers and regulatory bodies need a better understanding of constituent-dependent toxicity to guide product use and regulatory decisions.

Advancing the science on cannabis concentrates and behavioural health

ISSUES

The Cannabis sativa L. plant contains hundreds of phytocannabinoids, but putatively of highest importance to public health risk is the psychoactive cannabinoid delta-9-tetrahydrocannabinol (THC), which is associated with risk for cannabis use disorder, affective disturbance, cognitive harm and psychomotor impairment. Recently, there has been an increase in the use and availability of concentrated cannabis products (or 'concentrates') that are made by extracting cannabinoids from the plant to form a product with THC concentrations as high as 90-95%. These products are increasingly popular nationwide. The literature on these widely available high potency concentrates is limited and there are many unknowns about their potential harms.

APPROACH

This review covers the state of the research on cannabis concentrates and behavioural health-related outcomes and makes recommendations for advancing the science with studies focused on accurately testing the risks in relation to critical public and behavioural health questions.

KEY FINDINGS

Data point to unique behavioural health implications of concentrate use. However, causal, controlled and representative research on the effects of cannabis concentrates is currently limited.

IMPLICATIONS

Future research is needed to explore chronic, acute and developmental effects of concentrates, as well as effects on pulmonary function. We also highlight the need to explore these relationships in diverse populations.

CONCLUSION

While the literature hints at the potential for these highly potent products to increase cannabis-related behavioural health harms, it is important to carefully design studies that more comprehensively evaluate the impact of concentrates on THC exposure and short- and long-term effects across user groups.

Inhalants

Toxic inhalants include various xenobiotics. Irritants cause upper and lower respiratory tract injuries. Highly water-soluble agents injure the upper respiratory tract, while low water-soluble inhalants injure the lower track. Asphyxiants are divided into simple asphyxiants and chemical asphyxiants. Simple asphyxiants displace oxygen, causing hypoxia, while chemical asphyxiants also impair the body's ability to use oxygen. Cyanide is a classic chemical asphyxiant. Treatment includes hydroxocobalamin. Electronic cigarette or vaping use-associated lung injury (EVALI) is a relatively new illness. Patients present with respiratory symptoms and gastrointestinal distress. EVALI appears to be associated with vaping cannabinoids. Treatment is supportive and may include steroids.

A qualitative examination of e-cigarette use among California young adults during the EVALI outbreak

The 2019 outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) increased awareness of potential health risks associated with vaping among the general public. Little is known, however, about how unfolding information regarding EVALI affected knowledge, attitudes, and behaviors among e-cigarette users, particularly among young adults. This study describes attitudinal and behavioral responses to EVALI among young adult e-cigarette users. In October and November 2019, seven focus groups were held with college-going young adult tobacco users from two four-year public universities in California. Focus groups included questions regarding knowledge of and reaction to EVALI news, and how the news affected product use. Text from current e-cigarette users was extracted to develop individual phenomenological textural-structural descriptions of e-cigarette use for 38 individuals which were used to create a composite experience of e-cigarette use in light of EVALI. Experiences indicated that e-cigarette users were aware of information regarding EVALI and received information from numerous sources. Information was filtered for legitimacy of EVALI claims and causes of EVALI. Risk rationalizations were developed to assess potential harm of continued e-cigarette use and provided reasoning for behavioral responses to EVALI. The emerging harm associated with EVALI prompted e-cigarette users to engage in a cognitive process resulting in employment of a range of rationalities to justify continued use. These results suggest how environmental, cognitive, and behavioral factors may interact as young adults negotiate e-cigarette-related harms.

“Vaping”- a Trojan Horse Against Fight Toward Tobacco Use and Cancer: A Systematic Review of the Existing Evidence

The purpose of this systematic review is to understand many aspects of vaping, like what is vaping, why it is more enticing to adolescents and young adults, what makes it more harmful than regular smoked tobacco products, subsequent health consequences, and what measures are currently being taken against this activity. A literature search was conducted in online database PubMed using search string “(((((Lung injury*[Title/Abstract]) AND Vaping[Title/Abstract]) OR electronic nicotine delivery device[Title/Abstract]) OR electronic cigarette*[Title/Abstract]) AND e-cigarettes liquid) AND electronic cigars and search filter used were “published in the last 5 years” and “Human Studies.” Similar search terms were used to search EMBASE, Web of Science, Google Scholar, and the CENTRAL database of the Cochrane Library with the help of Boolean terms. Thirty-six articles were included for a final systematic review. Many of the known brands use additives such as flavoring and thickening agents that, when used even for the short term, can cause toxicity to human lung tissues. This toxicity depends not only on the extent of the habit, but also on the variable susceptibility to lung damage, dual use with cigarettes, variability in the product design of different brands, and the liquid content used in them. Vaping may be linked with significant health issues, including respiratory diseases such as asthma, very severe forms of bronchitis such as popcorn lung, or E-cigarette, or vaping, product use-associated lung injury, and cardiovascular illnesses such as atherosclerotic plaque and myocardial ischemia. From the current systematic review, we would like to emphasize that no long-term toxicological and health studies have been carried out in humans using these vaping products and their constituents to date. Although cessation should be strongly encouraged in smokers for better quality of life, it is uncertain whether it is a universally safer option to replace cigarettes with these vaping devices.

Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine

Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population. E-cigarettes have become the most commonly used tobacco products among youth in the United States. Fruit and mint flavors and additives such as marijuana have enticed children and adolescents. E-cigarette, or vaping, product use-associated lung injury (EVALI) is a newly identified lung disease linked to vaping. Clinical presentation of EVALI can be varied, but most commonly includes the respiratory system, gastrointestinal (GI) tract, and constitutional symptoms. Clinical management of EVALI has consisted of vaping cessation and supportive therapy, including supplemental oxygen, noninvasive ventilation, mechanical ventilation, glucocorticoids, and empiric antibiotics, until infectious causes are eliminated, and in the most severe cases, extracorporeal membrane oxygenation (ECMO). Currently, although there is an insufficient evidence to determine the safety and the efficacy of e-cigarettes for perioperative smoking cessation, EVALI clearly places these patients at an increased risk of perioperative morbidity. Given the relatively recent introduction of e-cigarettes, the long-term impact on adolescent health is unknown. As a result, the paucity of postoperative outcomes in this potentially vulnerable population does not support evidence-based recommendations for the management of these patients. Clinicians should identify "at-risk" individuals during preanesthetic evaluations and adjust the risk stratification accordingly. Our societies encourage continued education of the public and health care providers of the risks associated with vaping and nicotine use and encourage regular preoperative screening and postoperative outcome studies of patients with regard to smoking and vaping use.

E-cigarette, or Vaping, Product Use-Associated Lung Injury: Looking Back, Moving Forward

Implications In this commentary, we describe the evidence-based approach used to identify the primary cause of EVALI and to curb the 2019 outbreak. We also discuss future research opportunities and public health practice considerations to prevent a resurgence of EVALI.

Electronic Cigarettes and Their Impact on Allergic Respiratory Diseases: A Work Group Report of the AAAAI Environmental Exposures and Respiratory Health Committee

The explosive rise in popularity of electronic cigarette (e-cig) devices over the past decade has led to controversies over the role of these devices in smoking cessation and harm reduction from combustible cigarette smoking. Increased recognition of potential direct harms of e-cigs, including life-threatening and fatal cases of e-cig and vaping product use-associated lung injury, has emphasized the need to curb use until safety can be established. Of particular concern is the steep rise in e-cig use among teenagers and young adults who have never smoked and among individuals with underlying lung disease, such as asthma. In this report, we describe the different types of e-cig devices available, summarize the available data on the potential health benefits and detriments of e-cig use, and highlight the findings of studies examining e-cigs as smoking cessation tools. Because e-cigs have only gained popularity in the last few years, very few studies have been able to demonstrate an impact of e-cig use on harm reduction related to combustible cigarettes. Moreover, the health effects of e-cigs at a population level must be balanced against the harms of e-cig use, which include nicotine dependence and promoting initiation of cigarette use amongst "never smokers." With respect to smoking cessation, e-cigs appear to serve as switching products that may help individuals reduce or quit cigarette use, but do not address nicotine addiction. Finally, we discuss our recommendations for ways that health care providers can screen and counsel patients on e-cig use. The goal of this report is to provide health care providers with the most recent information on this topic so that they can educate patients on the potential pros and cons of e-cig use.

A 23-year-old man with acute lung injury after using a tetrahydrocannabinol-containing vaping device: a case report

Background

Vaping-associated lung injury is a newly emerging disease process with the potential for serious health implications and high mortality, even despite the lack of underlying lung disease. We present a case of a young, otherwise healthy patient with tetrahydrocannabinol vaping-associated lung injury.

Case presentation

A 23-year-old Caucasian man with a past history of tetrahydrocannabinol vaping and benzodiazepine and methamphetamine abuse presented to the emergency department of our institution with a complaint of “feeling malnourished” over the past 5 days, along with associated fevers, cough, and vomiting. His past medical, surgical, family, and social histories were significant only for the recent use of marijuana vaping pens. Upon initial presentation, the patient appeared to be in significant respiratory distress. A computed tomographic scan of his chest demonstrated diffuse central predominant interstitial opacities, and he was admitted to the medical intensive care unit, where he was eventually intubated for hypoxic respiratory failure. No other cause of his respiratory failure was found, and it was ultimately believed that the patient had sustained a vaping-associated lung injury.

Conclusion

Tetrahydrocannabinol-containing vaping-associated lung injury is still poorly understood overall and is currently being investigated by the Centers for Disease Control and Prevention. In the meantime, physicians should consider vaping to be a public health emergency. We summarize the appropriate history, physical examination, appropriate workup, and therapies that physicians should be aware of in order to appropriately manage and treat patients presenting with suspected vaping-associated lung injury.

Knowledge, attitudes, and practices of young adults regarding the impact of electronic cigarette use on oral health

BACKGROUND

The popularity and prevalence of electronic cigarette (EC) usage has continued to surge to 35 million worldwide, with one-half of users younger than 34 years. Despite emerging research suggesting deleterious oral health effects, the perceptions of EC users concerning oral health effects remain unknown. The purpose of this study was to explore knowledge, attitudes, and practices of young adults regarding the impact of EC use on oral health.

METHODS

A cross-sectional survey used a validated tool to investigate vaping and oral health knowledge, attitudes, and practices among a convenience sample of EC users (N = 220). Outcomes were analyzed using descriptive and inferential statistics.

RESULTS

People 18 through 24 years (N =168) indicated a lack of knowledge (mean [standard deviation {SD}], 2.9 [1.7]) and familiarity with oral health effects of vaping (mean [SD], 2.7 [1.7]). Participants expressed willingness to discuss oral health effects of vaping with dental care professionals (n = 111 [66%]), and most (n = 109 [65%]) would potentially reduce (30%) or quit (24%) if they believed it was harmful to their oral health. Participants 18 through 24 years were more likely to agree they would quit (n = 54 [68%]) than those 25 through 34 years (n = 36 [42%]; χ² = 11.03; P = .004; φ = 0.26). Those who visit their dental care professional every 6 months (n = 82 [57%]) agreed they would quit vaping versus those who do not (n = 26 [37%]; χ² = 9.84; P = .007; φ, 0.22).

CONCLUSIONS

Respondents reported low knowledge regarding the implications of vaping on oral health but expressed a willingness to discuss vaping with their dental care professionals.

PRACTICAL IMPLICATIONS

Most EC users are willing to accept guidance from dental care professionals regarding quitting use.

Reduction of bronchial response to mannitol after partial switch from conventional tobacco to electronic cigarette consumption

BACKGROUND

Regarding the multiple health effects of e-cigarettes, there are insufficient data on potential effects on bronchial reactivity (BHR). In the present study, we assessed the impact of a switch from conventional to e-cigarettes on BHR under realistic conditions over a period of 3 months.

METHODS

Sixty subjects who declared to reduce or stop their tobacco consumption by inhalation of nicotine-containing liquids via e-cigarette, and 20 volunteers participating in a stop-smoking program were included. Data was analysed using parametric and non-parametric statistical procedures. Spirometry, determinations of exhaled carbon monoxide (eCO) and nitric oxide (FeNO), provocation testing with mannitol as an indirect bronchial stimulus, and cotinine measurements were used to investigate BHR and nicotine abstinence.

RESULTS

BHR to mannitol significantly decreased in the group using e-cigarettes and nicotine-containing liquids over a period of three months in this real-life setting. Participants reduced their tobacco consumption to about 25% or lower, confirmed by a reduction in eCO. Changes in lung function and FeNO were small and not statistically significant, and changes in the stop-smoking group were similar to those in the e-cigarette group.

CONCLUSION

The reduction in BHR that can be expected after a reduction of cigarette consumption was not abolished by the concomitant use of e-cigarettes. Whether the decrease in BHR observed after 3 months is maintained when using e-cigarettes over longer time periods or has an individual prognostic value, must be clarified in long-term studies.

E-cigarette use and respiratory disorders: an integrative review of converging evidence from epidemiological and laboratory studies

Background

Use of electronic cigarettes (e-cigarettes) is prevalent among adolescents and young adults, but there has been limited knowledge about health consequences in human populations. We conduct a systematic review and meta-analysis of results on respiratory disorders from studies of general-population samples and consider the mapping of these results to findings about biological processes linked to e-cigarettes in controlled laboratory studies.

Method

We conducted a literature search and meta-analysis of epidemiological studies on the association of e-cigarette use with asthma and with COPD. We discuss findings from laboratory studies about effects of e-cigarettes on four biological processes: cytotoxicity, oxidative stress/inflammation, susceptibility to infection and genetic expression.

Results

Epidemiological studies, both cross-sectional and longitudinal, show a significant association of e-cigarette use with asthma and COPD, controlling for cigarette smoking and other covariates. For asthma (n=15 studies), the pooled adjusted odds ratio (aOR) was 1.39 (95% CI 1.28–1.51); for COPD (n=9 studies) the aOR was 1.49 (95% CI 1.36–1.65). Laboratory studies consistently show an effect of e-cigarettes on biological processes related to respiratory harm and susceptibility to illness, with e-cigarette conditions differing significantly from clean-air controls, although sometimes less than for cigarettes.

Conclusions

The evidence from epidemiological studies meets established criteria for consistency, strength of effect, temporality, and in some cases a dose–response gradient. Biological plausibility is indicated by evidence from multiple laboratory studies. We conclude that e-cigarette use has consequences for asthma and COPD, which is of concern for respirology and public health.

Epidemiological studies show a relationship of e-cigarette use with asthma and COPD, and laboratory studies show their adverse effects on four biological processes. It can be concluded that e-cigarette use is of significant concern for public health.https://bit.ly/3drH4pj

Characterizing and assessing compliance of online vendors to the state of Massachusetts ENDS product sales ban

INTRODUCTION

Recent reports of lung injury associated with Electronic Nicotine Delivery System (ENDS) products precipitated by increasing vaping prevalence and interest in flavors among adolescents has led to policies that restrict the sale, distribution, and accessibility of ENDS products. This study assessed compliance of online ENDS vendors to the Massachusetts temporary sales ban.

METHODS

The study involved structured web surveillance for online ENDS vendors using keyword searches on Google search engine (October to November 2019.) Once vendors were identified, we conducted simulated online purchases, defined as placing an order for an ENDS product by putting it in the website shopping cart without finalizing payment. Simulated purchases and content analysis of websites was conducted to determine compliance characteristics. Fisher’s exact test was used to identify associations between compliance and website characteristics such as location and age verification requirements.

RESULTS

Simulated online purchases from 50 identified ENDS vendors yielded 72% (n=36) stores that were non-compliant and allowed placement of ENDS product orders, without restrictions, to a Massachusetts address. The remaining 14 websites had processes in place to prevent orders from buyers located in Massachusetts. Other characteristics of interest, including use of age verification, location data, and web registrar/registrant data were collected and reported.

CONCLUSIONS

The September 2019 Massachusetts executive order was a comprehensive ban on selling ENDS products both online and offline. However, our study found that close to three-fourths of the vendors appeared to be non-compliant, indicating that implementation and enforcement are ongoing challenges for future tobacco control efforts on the internet. Policymaking needs to be specifically tailored to address the unique challenges of online environments, particularly in the context of identifying non-compliant sites, ensuring age verification, and addressing non-US sellers.

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

CONTEXT.—

Vaping is the inhalation of heated aerosol from a small battery-powered device as a method to deliver nicotine or other substances. A recent outbreak of severe respiratory illness primarily in the United States has put a spotlight on vaping and its potential risks.

OBJECTIVE.—

To familiarize pathologists with vaping, the cytologic and histopathologic features of vaping-associated acute lung injury, and the role of pathology in this diagnosis.

DATA SOURCES.—

A targeted literature review was performed.

CONCLUSIONS.—

Most cases of vaping-associated lung injury have been linked to vaping products containing tetrahydrocannabinol or other cannabinoids. Lung biopsies show a spectrum of nonspecific acute lung injury patterns (organizing pneumonia, diffuse alveolar damage, acute fibrinous, and organizing pneumonia, or combinations of the above), accompanied by prominent, foamy macrophage accumulation. Injury is usually accentuated around small airways. Lipid-laden macrophages can be identified in bronchioloalveolar lavage fluid in most patients and these can be highlighted using lipid stains, such as oil red O, but the clinical utility of this finding remains unclear, as lipid-laden macrophages can be seen in a wide variety of processes and should not be relied upon to make the diagnosis. Classic histologic features of exogenous lipoid pneumonia have not been identified in tissue samples. Lightly pigmented macrophages, similar to those seen with traditional cigarette smoking, are present in some cases but are usually a minor feature. To date, no specific pathologic features for vaping-related injury have been identified, and it remains a diagnosis of exclusion that requires clinicopathologic correlation.

Examining the temporality of vitamin E acetate in illicit THC-containing e-cigarette, or vaping, products from a public health and law enforcement response to EVALI - Utah, 2018-2020

BACKGROUND

In the summer of 2019, e-cigarette, or vaping, product use-associated lung injury (EVALI) was detected in the United States. Multiple agencies reported illicit tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products containing vitamin E acetate (VEA) as a substance of concern.

METHODS

As an expansion of the Utah Department of Health's response to EVALI, the Utah Public Health Laboratory and the Utah Department of Public Safety screened 170 products from 96 seizures between October 2018 and January 2020. Using Pearson's correlation coefficient, we analyzed the temporal correlation of national, and Utah specific case counts, and the percentage of seizures indicating VEA by month.

RESULTS

The findings indicate strong and significant correlations between seizures indicating VEA and both the national (r = 0.70, p = 0.002) and Utah specific (r = 0.78, p < 0.001) case counts.

CONCLUSION

These findings underscore that VEA should not be added to e-cigarettes, or vaping, products and the importance of collaboration with law enforcement when responding to outbreaks associated with illicit substances.

E-Cigarette or Vaping Product Use-associated Lung Injury: Developing a Research Agenda. An NIH Workshop Report

The NHLBI convened a working group on October 23, 2019, to identify the most relevant and urgent research priorities and prevailing challenges in e-cigarette or vaping product use-associated lung injury (EVALI). Experts across multiple disciplines discussed the complexities of the EVALI outbreak, identified research priorities, and recommended strategies to address most effectively its causal factors and improve diagnosis, treatment, and prevention of this disease. Many research priorities were identified, including the need to create national and international registries of patients with EVALI, to track accurately those affected and assess outcomes. The group concluded that biospecimens from subjects with EVALI are urgently needed to help define EVALI pathogenesis and that vaping has disease risks that are disparate from smoking, with the occurrence of EVALI highlighting the importance of broadening e-cigarette research beyond comparators to smoking-related diseases.

E-cigarette use and respiratory disorders: an integrative review of converging evidence from epidemiological and laboratory studies

BACKGROUND

Use of electronic cigarettes (e-cigarettes) is prevalent among adolescents and young adults, but there has been limited knowledge about health consequences in human populations. We conduct a systematic review and meta-analysis of results on respiratory disorders from studies of general-population samples and consider the mapping of these results to findings about biological processes linked to e-cigarettes in controlled laboratory studies.

METHOD

We conducted a literature search and meta-analysis of epidemiological studies on the association of e-cigarette use with asthma and with COPD. We discuss findings from laboratory studies about effects of e-cigarettes on four biological processes: cytotoxicity, oxidative stress/inflammation, susceptibility to infection and genetic expression.

RESULTS

Epidemiological studies, both cross-sectional and longitudinal, show a significant association of e-cigarette use with asthma and COPD, controlling for cigarette smoking and other covariates. For asthma (n=15 studies), the pooled adjusted odds ratio (aOR) was 1.39 (95% CI 1.28-1.51); for COPD (n=9 studies) the aOR was 1.49 (95% CI 1.36-1.65). Laboratory studies consistently show an effect of e-cigarettes on biological processes related to respiratory harm and susceptibility to illness, with e-cigarette conditions differing significantly from clean-air controls, although sometimes less than for cigarettes.

CONCLUSIONS

The evidence from epidemiological studies meets established criteria for consistency, strength of effect, temporality, and in some cases a dose-response gradient. Biological plausibility is indicated by evidence from multiple laboratory studies. We conclude that e-cigarette use has consequences for asthma and COPD, which is of concern for respirology and public health.

Occupational Bronchiolitis: An Update

Occupational bronchiolitis is characterized by inflammation of the small airways, and represents a heterogeneous set of lung conditions that can occur following a range of inhalation exposures related to work. The most common clinical presentation includes insidious onset of exertional dyspnea and cough. Multiple reports in recent years have drawn attention to previously unrecognized risk factors for occupational bronchiolitis following exposures in several settings. Both current and past occupational exposures, including prior military deployment-related exposures, should be considered in patients undergoing evaluation for unexplained dyspnea. Diagnostic testing for potential bronchiolitis should include a thorough assessment of the small airways.

E-cigarette, or vaping, product use-associated lung injury: a review

Background

E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) is a disease entity related to the use of battery-operated or superheating devices that create an aerosolized form of nicotine and tetrahydrocannabinol (THC) and/or other substances for inhalation.

Methods

We performed a literature review to document epidemiology, pathogenesis and risk factors, diagnosis, clinical presentation, evaluation and management of EVALI.

Results

In the summer of 2019, an outbreak of EVALI cases brought this disease entity into the national spotlight. Since being recognized as a serious pulmonary disease with public health implications, more than 2600 cases have been reported to CDC with 68 deaths as of February 2020. The pathophysiology of EVALI remains unknown. Substances such as Vitamin E acetate have been implicated as a possible causes of lung injury. The CDC has established case definitions of “confirmed EVALI” cases to help guide identification of the disease and assist in surveillance. While clinical judgement by healthcare providers is imperative in the identification of EVALI cases, the heterogeneous presentations of EVALI make this difficult as well. Ultimately most investigative studies should be aimed at ruling out other disease processes that can present similarly. Treatment is centered around removing the offending substance and providing supportive care.

Conclusions

EVALI is a serious pulmonary disease with public health implications. Diagnosis requires a high degree of suspicion to diagnose and exclusion of other possible causes of lung disease. It may be beneficial to involve a pulmonary specialist early in the management of this disease which is generally supportive care.

E-Cigarette Use Associated With Asthma Independent of Cigarette Smoking and Marijuana in a 2017 National Sample of Adolescents

PURPOSE

Knowledge about the health consequences of e-cigarette use in adolescence remains limited. Available studies of asthma among adolescents are based on data collected five or more years ago, and evidence from more recent generations of e-cigarette products is needed.

METHODS

We analyzed data from the 2017 Youth Risk Behavior Survey, a cross-sectional study with a representative U.S. national sample of high school students. Multivariable analyses tested for associations of ever and 30-day e-cigarette use with asthma controlling for cigarette smoking, marijuana use, demographics, and obesity.

RESULTS

A significant association with asthma was found for ever use of e-cigarettes, adjusted odds ratio (AOR) = 1.15 (confidence interval [CI], 1.02-1.30; p = .02) and for currently using e-cigarettes, AOR = 1.30 (CI, 1.10-1.53; p = .002). Also related to asthma were current cigarette smoking, AOR = 1.24 (CI, 1.03-1.51; p = .03) and obesity, AOR = 1.48 (CI, 1.30-1.68; p < .0001). E-cigarettes had an additive effect for asthma beyond smoking (p = .03). Differentials in asthma prevalence by race/ethnicity were found, with lower prevalence of asthma for non-Hispanic Asian (p = .02) and Hispanic (p = .03) and higher prevalence for non-Hispanic black (p < .0001) and non-Hispanic multirace (p < .0001) relative to non-Hispanic white populations.

CONCLUSIONS

E-cigarette use was significantly associated with asthma in recent data on adolescents, controlling for several disease-relevant covariates. The results are consistent with studies based on previous generations of e-cigarettes and support the significance of e-cigarettes as a continuing public health concern.

Demographics, Substance Use Behaviors, and Clinical Characteristics of Adolescents With e-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) in the United States in 2019

IMPORTANCE

To date, limited information is available on the characteristics of adolescents with e-cigarette, or vaping, product use-associated lung injury (EVALI).

OBJECTIVE

To inform public health and clinical practice by describing differences in demographics, substance use behaviors, and clinical characteristics of EVALI among adolescents compared with adults.

DESIGN, SETTING, AND PARTICIPANTS

Surveillance data reported to the Centers for Disease Control and Prevention during the 2019 EVALI outbreak were used to calculate adjusted prevalence ratios (aPRs) with 95% CIs and to test differences between 360 hospitalized or deceased adolescents vs 859 young adults and 936 adults with EVALI (N = 2155).

MAIN OUTCOMES AND MEASURES

Demographics, substance use behaviors, and clinical characteristics.

RESULTS

Included in this cross-sectional study were 360 hospitalized or deceased adolescents (age range, 13-17 years; 67.9% male) vs 859 young adults (age range, 18-24 years; 72.4% male) and 936 adults (age range, 25-49 years; 65.6% male) with EVALI. Adolescents diagnosed as having EVALI reported using any nicotine-containing (62.4%), any tetrahydrocannabinol (THC)-containing (81.7%), and both (50.8%) types of e-cigarette or vaping products. Informal sources for obtaining nicotine-containing and THC-containing e-cigarette or vaping products were more commonly reported by adolescents (50.5% for nicotine and 96.5% for THC) than young adults (19.8% for nicotine [aPR, 2.49; 95% CI, 1.78-3.46] and 86.9% for THC [aPR, 1.11; 95% CI, 1.05-1.18]) or adults (24.3% for nicotine [aPR, 2.06; 95% CI, 1.49-2.84] and 75.1% for THC [aPR, 1.29; 95% CI, 1.19-1.40]). Mental, emotional, or behavioral disorders were commonly reported; a history of attention-deficit/hyperactivity disorder was almost 4 times more likely among adolescents (18.1%) than adults (4.9%) (aPR, 3.74; 95% CI, 1.92-7.26). A history of asthma was more likely to be reported among adolescents (43.6%) than adults (28.3%) (aPR, 1.53; 95% CI, 1.14-2.05). Gastrointestinal and constitutional symptoms were more common in adolescents (90.9% and 97.3%, respectively) than adults (75.3% and 94.5%, respectively) (aPR, 1.20; 95% CI, 1.13-1.28 and aPR, 1.03; 95% CI, 1.00-1.06, respectively). Because of missing data, percentages may not be able to be calculated from data provided.

CONCLUSIONS AND RELEVANCE

Public health and clinical professionals should continue to provide information to adolescents about the association between EVALI and THC-containing e-cigarette or vaping product use, especially those products obtained through informal sources, and that the use of any e-cigarette or vaping product is unsafe. Compared with adults, it appears that adolescents with EVALI more frequently have a history of asthma and mental, emotional, or behavioral disorders, such as attention-deficit/hyperactivity disorder, and report nonspecific problems, including gastrointestinal and constitutional symptoms; therefore, obtaining a confidential substance use history that includes e-cigarette or vaping product use is recommended.

Severe Lung Injury Associated With Use of e-Cigarette, or Vaping, Products-California, 2019

IMPORTANCE

Since August 2019, more than 2700 patients have been hospitalized with e-cigarette, or vaping, product use-associated lung injury (EVALI) across the United States. This report describes the outbreak in California, a state with one of the highest case counts and with a legal adult-use (recreational) cannabis market.

OBJECTIVE

To present clinical characteristics and vaping product exposures of patients with EVALI in California.

DESIGN, SETTING, AND PARTICIPANTS

Case series describing epidemiologic and laboratory data from 160 hospitalized patients with EVALI reported to the California Department of Public Health by local health departments, who received reports from treating clinicians, from August 7 through November 8, 2019.

EXPOSURES

Standardized patient interviews were conducted to assess vaping products used, frequency of use, and method of product acquisition. Vaping products provided by a subset of patients were tested for active ingredients and other substances.

MAIN OUTCOMES AND MEASURES

Demographic and clinical characteristics, level of care, and outcomes of hospitalization were obtained from medical record review.

RESULTS

Among 160 patients with EVALI, 99 (62%) were male, and the median age was 27 years (range, 14-70 years). Of 156 patients with data available, 71 (46%) were admitted to an intensive care unit, and 46 (29%) required mechanical ventilation. Four in-hospital deaths occurred. Of 86 patients interviewed, 71 (83%) reported vaping tetrahydrocannabinol (THC)-containing products, 36 (43%) cannabidiol (CBD)-containing products, and 39 (47%) nicotine-containing products. Sixty-five of 87 (75%) THC-containing products were reported as obtained from informal sources, such as friends, acquaintances, or unlicensed retailers. Of 87 vaping products tested from 24 patients, 49 (56%) contained THC. Vitamin E or vitamin E acetate was found in 41 (84%) of the THC-containing products and no nicotine products.

CONCLUSIONS AND RELEVANCE

Patients' clinical outcomes and vaping behaviors, including predominant use of THC-containing products from informal sources, are similar to those reported by other states, despite California's legal recreational cannabis market. While most THC products tested contained vitamin E or vitamin E acetate, other underlying cause(s) of injury remain possible. The California Department of Public Health recommends that individuals refrain from using any vaping or e-cigarette products, particularly THC-containing products from informal sources, while this investigation is ongoing.

Vaping-Related Acute Parenchymal Lung Injury: A Systematic Review

The outbreak of vaping-related acute lung injury in the United States, named EVALI (e-cigarette or vaping product use associated acute lung injury), has reignited concerns about the health effects of vaping. Initial case reports of vaping-related lung injury date back to 2012, but the ongoing outbreak of EVALI began in the summer of 2019 and has been implicated in 2,807 cases and 68 deaths as of this writing. Review of the scientific literature revealed 216 patient cases that spanned 41 reports of parenchymal lung injury attributed to vaping. In this review, we detail the clinical, radiographic, and pathologic patterns of lung injury that are attributable to vaping and provide an overview of the scientific literature to date on the effects of vaping on respiratory health. Tetrahydrocannabinol was the most commonly vaped substance, and vitamin E acetate was found in BAL specimens from many affected individuals. However, no specific component or contaminant has been identified conclusively to date as the cause for the injury. Patients present with cough, dyspnea, constitutional symptoms, and GI symptoms. Radiologic and histopathologic findings demonstrate a spectrum of nonspecific acute injury patterns. A high index of suspicion combined with a good history are the keys to an accurate diagnosis. Treatment is supportive; the mortality rate is low, and most patients recover. Corticosteroids have been used with apparent success in patients with severe disease, but more rigorous studies are needed to clarify their role in the treatment of vaping-related lung injury.

Hospitalizations and Deaths Associated with EVALI

BACKGROUND

As of January 7, 2020, a total of 2558 hospitalized patients with nonfatal cases and 60 patients with fatal cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) had been reported to the Centers for Disease Control and Prevention (CDC).

METHODS

In a national study, we compared the characteristics of patients with fatal cases of EVALI with those of patients with nonfatal cases to improve the ability of clinicians to identify patients at increased risk for death from the condition. Health departments reported cases of EVALI to the CDC and included, when available, data from medical-record abstractions and patient interviews. Analyses included all the patients with fatal or nonfatal cases of EVALI that were reported to the CDC as of January 7, 2020. We also present three case reports of patients who died from EVALI to illustrate the clinical characteristics common among such patients.

RESULTS

Most of the patients with fatal or nonfatal cases of EVALI were male (32 of 60 [53%] and 1666 of 2498 [67%], respectively). The proportion of patients with fatal or nonfatal cases was higher among those who were non-Hispanic white (39 of 49 [80%] and 1104 of 1818 [61%], respectively) than among those in other race or ethnic groups. The proportion of patients with fatal cases was higher among those 35 years of age or older (44 of 60 [73%]) than among those younger than 35 years, but the proportion with nonfatal cases was lower among those 35 years of age or older (551 of 2514 [22%]). Among the patients who had an available medical history, a higher proportion of those with fatal cases than those with nonfatal cases had a history of asthma (13 of 57 [23%] vs. 102 of 1297 [8%]), cardiac disease (26 of 55 [47%] vs. 115 of 1169 [10%]), or a mental health condition (32 of 49 [65%] vs. 575 of 1398 [41%]). A total of 26 of 50 patients (52%) with fatal cases had obesity. Half the patients with fatal cases (25 of 54 [46%]) were seen in an outpatient setting before hospitalization or death.

CONCLUSIONS

Chronic conditions, including cardiac and respiratory diseases and mental health conditions, were common among hospitalized patients with EVALI.

A Systematic Literature Review of E-Cigarette-Related Illness and Injury: Not Just for the Respirologist

Following the recent electronic cigarette (e-cigarette) illness outbreak, the current review aimed to collect all related clinical cases for study and analysis and provide a critical synopsis of the proposed injury mechanism. Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines, e-cigarette-related clinical cases were identified via Google Scholar and PubMed databases. Additionally, references of published case reports and previous review papers were manually searched, revealing 159 publications presenting e-cigarette-related case reports and 19 reports by the Centers for Disease Control and Prevention. 238 individual cases were identified; 53% traumatic injuries due to e-cigarette explosion or self-combustion, 24% respiratory cases, and 12% poisonings. Additional cases pertained to oral, cardiovascular, immunologic, hematologic, allergic reactions, infant complications, and altered medication levels. Case reports were mainly published between 2016-2019 (78%). The oldest case, a lipoid pneumonia, was published in 2012. The current review showed that e-cigarette-related health effects extend beyond the acute lung injury syndrome, including traumatic, thermal injuries and acute intoxications. Physicians should be aware of the distinct clinical presentations and be trained to respond and treat effectively. Regulators and public health authorities should address the regulatory gap regarding electronic nicotine delivery systems (ENDS) and novel tobacco products.