E-cigarette Use, or Vaping, Practices and Characteristics Among Persons with Associated Lung Injury - Utah, April-October 2019

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.

An assessment of vaping-induced inflammation and toxicity: A feasibility study using a 2-stage zebrafish and mouse platform

It is currently understood that tobacco smoking is a major cause of pulmonary disease due to pulmonary/lung inflammation. However, due to a highly dynamic market place and an abundance of diverse products, less is known about the effects of e-cigarette (E-cig) use on the lung. In addition, varieties of E-cig liquids (e-liquids), which deliver nicotine and numerous flavor chemicals into the lungs, now number in the 1000s. Thus, a critical need exists for safety evaluations of these E-cig products. Herein, we employed a "2-stage in vivo screening platform" (zebrafish to mouse) to assess the safety profiles of e-liquids. Using the zebrafish, we collected embryo survival data after e-liquid exposure as well as neutrophil migration data, a key hallmark for a pro-inflammatory response. Our data indicate that certain e-liquids induce an inflammatory response in our zebrafish model and that e-liquid exposure alone results in pro-inflammatory lung responses in our C57BL/6J model, data collected from lung staining and ELISA analysis, respectively, in the mouse. Thus, our platform can be used as an initial assessment to ascertain the safety profiles of e-liquid using acute inflammatory responses (zebrafish, Stage 1) as our initial metric followed by chronic studies (C57BL/6J, Stage 2).

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.

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.

Electronic cigarettes, vaping-related lung injury and lung cancer: where do we stand?

Electronic cigarettes have been considered a promising alternative to nicotine replacement products to help heavy tobacco smokers quit smoking. They work thanks to a heating coil causing evaporation of the liquid rapidly followed by cooling, thus creating an aerosol, a completely different mechanism from the combustion of tobacco in traditional cigarettes. The term 'vaping' indicates the use of electronic cigarettes or other devices to inhale heated, aerosolized nicotine, or other substances like cannabidiol, tetrahydrocannabinol, or butane hash oils together with solvents, mainly propylene glycol and vegetable glycerine or their combination. A very fast increase of vaping among adolescents has been observed since electronic cigarettes and other vaping devices first appeared. Although electronic cigarettes have been advocated as a short-term cessation aid for tobacco smokers or as a long-term alternative, there is the concrete risk that they can be perceived by young nonsmokers as a less dangerous alternative to tobacco smoking, thus stimulating nonsmokers to start smoking rather than helping heavy tobacco smokers to quit smoking. Moreover, several cases of exogenous lipoid pneumonia and diffuse alveolar hemorrhage with proven alveolar injury, as well as vaping-associated bronchiolitis obliterans, have been recently reported among electronic cigarette smokers, with severe clinical impact, thus posing the risk of the life-threatening toxic potential of vaping. At the moment, no definitive assessment can be made about the efficacy of electronic cigarettes as a smoking cessation aid, and further studies are required about vaping-related life-threatening acute lung injury.

The vaping product use associated lung injury: is this a new pulmonary disease entity?

In the summer of 2019, an epidemic of e-cigarette or vaping product use associated lung injury (EVALI) broke out in the United States of America. EVALI is a lung disease that can be severe and life-threatening. It should be emphasized that EVALI is not a clinical diagnosis, but surveillance case definition. Due to the profile of users of such devices, the pathology mainly affects young adults, although cases of EVALI have been reported in almost all age groups, from teenage children to seniors. The worst prognosis is in patients over 35 years of age, with accompanying diseases. A significant number of patients declared the use of products containing tetrahydrocannabinol (THC). The most likely factor responsible for the occurrence of EVALI is vitamin E acetate, which is sometimes added to liquids necessary for the use of electronic cigarette type devices, especially those liquids that contain THC. Nevertheless, it is possible that other substances used in liquids may also be a causative factor. Typical for EVALI are respiratory, gastrointestinal and systemic symptoms, while in imaging tests, a characteristic feature of EVALI is the presence of opacities on the chest radiogram and ground-glass clouds on computed tomography scans. In the course of this disease, respiratory failure often occurs (58%). In the vast majority of cases oxygen substitution is necessary. Currently, the best treatment of EVALI is considered to be the administration of systemic glucocorticosteroids. Over 90% of patients with EVALI required hospitalization, while the mortality rate was about 2.42%. Median age of the fatalities was 51 years. The aim of this review is to summarise the available information on EVALI and to consider possible causative factors and pathomechanism.

Toxicity of electronic cigarettes: A general review of the origins, health hazards, and toxicity mechanisms

Electronic cigarettes (E-cigarette) are an alternative for traditional cigarette smokers to quit smoking. Based on the current understanding, electronic cigarettes have rapidly become popular among existing smokers and former non-smokers. However, increasing research at different levels reveals that e-cigarettes are unsafe. This review provides an overview of the toxicology of e-cigarettes based on existing in vivo and in vitro studies and compares their toxicity with that of traditional cigarettes. Moreover, we describe the associated toxicity components in e-cigarettes, as well as the potential mechanism by which e-cigarettes exert toxic effects. As is known to all, the nicotine in traditional cigarettes and e-cigarettes has certain toxicity. Besides, a few studies have shown that propylene glycol and vegetable glycerin mixture and flavoring agents in e-cigarettes also are the key components causing adverse effects in animals or cells. There is insufficient scientific evidence on the toxicity of e-cigarettes due to the lack of standardized research methods, prompting the need to conduct a comprehensive toxicity assessment of e-cigarette toxicity to elucidate the safety issues of e-cigarettes. Eventually, a basis for decision-making on whether people use e-cigarettes will be obtained.

Lessons from the public health responses to the US outbreak of vaping-related lung injury

AIM

To describe an outbreak of lung injuries in 2019 among people who vaped in the United States (type of injuries, people afflicted, substances vaped and cause of the injuries) and to analyse critically the regulatory responses of public health authorities and the media reporting of the outbreak.

METHODS

Case studies of the reporting of the e-cigarette or vaping product use associated lung injury (EVALI) outbreak. We examined data on the number of cases of lung injury provided by the US Centers for Disease Control (CDC), public advice on the causes of the outbreak provided by the CDC and the Food and Drug Administration (FDA), major media reports of the outbreak and proposed regulatory responses by governments in the United States, Australia and the United Kingdom.

RESULTS

The CDC initially suggested that the cause of the outbreak was nicotine vaping because the outbreak followed a large increase in nicotine vaping among US adolescents. Case-control studies revealed that the majority of cases had vaped illicit cannabis oils that were contaminated by vitamin E acetate. The CDC's public advice and the media were slow to report the evidence on the role of cannabis vaping. Popular government regulatory proposals-bans on sales of nicotine flavours and vaporizers-were based on the assumption that nicotine vaping was the cause of the outbreak.

CONCLUSIONS

Media reporting in the United States, Australia and the United Kingdom of the US Centers for Disease Control's analysis of the causes of the e-cigarette or vaping product use associated lung injury outbreak contributed to regulatory over-reactions to nicotine vaping by the public health community.

Electronic Cigarettes: Past, Present, and Future: What Clinicians Need to Know

Electronic cigarettes (EC) are battery-operated devices that heat and aerosolize a liquid solution that typically contains nicotine. ECs have become commonly used among youth and may pose substantial risks of future addiction and health problems in this population. However, ECs are far less toxic per puff compared with combustible cigarettes, and as a result, might present an important harm reduction opportunity for cigarette smokers who cannot stop smoking by traditional means. The long-term health effects of ECs on individuals and the net effect on public health will remain unknown for many years.

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.

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.

The influence of terpenes on the release of volatile organic compounds and active ingredients to cannabis vaping aerosols

Cannabinoid and VOC emissions from vaping cannabis concentrates vary depending on terpene content, power level and consumption method.

Assessment of Nicotine and Cannabis Vaping and Respiratory Symptoms in Young Adults

IMPORTANCE

Rates of e-cigarette use (ie, nicotine vaping) and cannabis vaping continue to increase among youth and young adults. However, the association of nicotine and cannabis vaping with independent respiratory health outcomes has not been well studied.

OBJECTIVE

To investigate associations of nicotine and cannabis vaping with bronchitic symptoms, wheeze, and shortness of breath.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional survey data on self-reported lifetime, 6-month, and 30-day vaping from 2553 young adults recruited from high schools in Southern California were collected from June 2018 to October 2019. Of these participants, 94% provided data for shortness of breath and wheeze, and 86% provided data for chronic bronchitis.

MAIN OUTCOMES AND MEASURES

Self-reported nicotine and cannabis vaping were measured on a Likert-type scale using the following responses: (1) never used, (2) lifetime but no past 6-month use, (3) past 6-month use but no use in the past 30 days, (4) use on 1 or 2 of the past 30 days, and (5) use on 3 or more of the past 30 days. Three respiratory health outcomes were assessed separately on the basis of self-reported symptoms: bronchitic symptoms in the previous 12 months (ie, daily cough for 3 months in a row, congestion or phlegm other than with a cold, and/or bronchitis), wheeze in the previous 12 months, and shortness of breath when hurrying on level ground or walking up a slight hill.

RESULTS

Of 2553 participants in the analytic sample (mean [SD] age, 19.3 [0.79] years; 1477 [57.9%] female individuals), 1095 of 2553 young adults (42.9%) reported vaping nicotine and 939 of 2553 (38.4%) reported vaping cannabis. Compared with those who never vaped cannabis, individuals who vaped cannabis in their lifetime but not in the past 60 months (204 of 2553 [8.4%]; adjusted odds ratio [aOR], 1.83 [95% CI, 1.08-3.10]), in the past 6 months but not in the last 30 days (490 of 2443 [20.1%]; aOR, 1.58 [95% CI, 1.02-2.46]), 1-2 days in the past 30 days (90 of 2443 [3.7%]; aOR, 2.83 [95% CI, 1.46-5.50]), and 3 or more days in the past 30 days (155 of 2443 [6.3%]; aOR, 2.14 [95% CI, 1.16-3.92]) had significantly higher odds of chronic bronchitic symptoms after adjusting for nicotine vaping, cigarette smoking, cannabis smoking, and sociodemographic characteristics. Cannabis vaping 3 or more times in the last 30 days was also associated with increased odds of wheeze (aOR, 2.27 [95% CI, 1.17-4.37]). Associations of cannabis vaping with shortness of breath and nicotine vaping with any respiratory health outcome were not statistically significant in fully adjusted models.

CONCLUSIONS AND RELEVANCE

Findings of this cross-sectional study suggest that cannabis vaping is associated with increased risk of bronchitic symptoms and wheeze in young adults. Further research is needed to understand the temporality of the association and the mechanisms underlying the difference between nicotine and cannabis vaping in the risk of bronchitic symptoms and wheeze.

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.

Clinical, Bronchoscopic, and Imaging Findings of e-Cigarette, or Vaping, Product Use-Associated Lung Injury Among Patients Treated at an Academic Medical Center

IMPORTANCE

e-Cigarette, or vaping, product use-associated lung injury (EVALI) has caused more than 2800 illnesses and 68 deaths in the United States. Better characterization of this novel illness is needed to inform diagnosis and management.

OBJECTIVE

To describe the clinical features, bronchoscopic findings, imaging patterns, and outcomes of EVALI.

DESIGN, SETTING, AND PARTICIPANTS

This case series of 31 adult patients diagnosed with EVALI between June 24 and December 10, 2019, took place at an academic medical center in Salt Lake City, Utah.

EXPOSURES

e-Cigarette use, also known as vaping.

MAIN OUTCOMES AND MEASURES

Symptoms, laboratory findings, bronchoscopic results, imaging patterns, and clinical outcomes.

RESULTS

Data from 31 patients (median [interquartile range] age, 24 [21-31] years) were included in the study. Patients were primarily men (24 [77%]) and White individuals (27 [87%]) who used e-cigarette products containing tetrahydrocannabinol (THC) (29 [94%]). Patients presented with respiratory (30 [97%]), constitutional (28 [90%]), and gastrointestinal (28 [90%]) symptoms. Serum inflammatory markers were elevated in all patients. Bronchoscopy was performed in 23 of 28 inpatients (82%) and bronchoalveolar lavage (BAL) revealed the presence of lipid-laden macrophages (LLMs) in 22 of 24 cases (91%). BAL samples tested positive for Pneumocystis jirovecii (3 patients [13%]), rhinovirus (2 patients [8%]), human metapneumovirus and Aspergillus (1 patient each [4%]); all except human metapneumovirus were determined to be false-positives or clinically inconsequential. The exclusive or dominant computed tomography (CT) pattern was organizing pneumonia in 23 of 26 cases (89%). Patients received antibiotics (26 [84%]) and corticosteroids (24 [77%]), and all survived; 20 patients (65%) seen in follow-up showed marked improvement, but residual symptoms (13 [65%]), radiographic opacities (8 [40%]), and abnormal pulmonary function tests (8 of 18 [44%]) were common.

CONCLUSIONS AND RELEVANCE

In this case series, patients with EVALI characteristically presented with a flu-like illness with elevated inflammatory markers, LLMs on BAL samples, and an organizing pneumonia pattern on CT imaging. Bronchoscopic testing for infection had a high incidence of false-positive results. Patients had substantial residual abnormal results at early follow-up. These data suggest a limited role for bronchoscopy in typical presentations of EVALI without risk factors for alternative diagnoses and the need for careful longitudinal follow-up.

Electronic cigarettes and e-cigarette/vaping product use associated lung injury (EVALI)

Electronic cigarettes (e-cigarettes) are noncombustible tobacco products that have been promoted as safer alternatives to conventional cigarettes and beneficial tools for smoking cessation. However, e-cigarettes have been shown to produce aerosols with high concentrations of propylene glycol, glycerol, volatile organic compounds, and free radicals, which can lead to lung damage. Furthermore, e-cigarettes can deliver nicotine at concentrations higher than traditional combustibles, making them highly addictive. As delivery devices became smaller, less expensive, and refillable, the use of e-cigarettes dramatically increased, especially among adolescents and young adults in the United States. This rise in popularity of noncombustible products led to an outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) in the fall of 2019. In this article, we review the history of e-cigarettes and its prevalence among American youth, the EVALI outbreak and clinical presentation of EVALI patients, and recent legislative efforts to regulate e-cigarette use.

All up in smoke: vaping-associated lung injury

The electronic cigarette (EC), was initially introduced as a safe alternative to conventional cigarette smoking While initially seemingly innocuous, over 2800 E-cigarette, or Vaping, product use-associated lung injury (EVALI) cases have been reported in the USA, with a spectrum of clinical severity ranging from mild dyspnea to overt respiratory failure In this report we highlight three EVALI cases whom presented with dyspnea and a variety of non-specific symptoms. Diagnostic imaging demonstrated bilateral reticular infiltrates and ground-glass opacities with lymphadenopathy. Clinically, patients failed to respond to empiric antibiotics but improved after initiating steroids. Consistent with prior case series, our patients reported exposure to EC liquids containing tetrahydrocannabinol (THC)/cannabidiols (CBD) additives, suggesting Vitamin E acetate as the potentially harmful constituent. In this case series and review, we not only summarize prior clinical studies that have evaluated the effects of vaping on cardiopulmonary function as well as case reports on EVALI, but also discuss the pathophysiology of vaping and EVALI. It remains unclear not only why some individuals develop EVALI, but why the clinical and pathological presentations vary. EVALI remains a significant public health concern and clinicians must maintain a high index of suspicion for this novel phenomenon.

Public Support for E-Cigarette-related Policies among a Nationally Representative Sample of US Adults

Background:

The wide availability of flavored e-cigarettes and broad use of e-cigarettes in public places may contribute to the rapidly increasing rates of use among youth and young adults in the U.S. However, policies at the federal, state and local levels can address these factors.

Objective:

Assess public support for 5 e-cigarette-related policies and evaluate response patterns by demographics, tobacco use, e-cigarette harm perceptions, geographic region, and strength of state-level clean indoor air policies.

Methods:

Data were collected Oct-Dec 2018 from a nationally representative online panel of U.S. adults (n = 3211). We measured support for 5 policies: (1) a ban on the sale flavored e-cigarettes; (2) requiring tobacco products, like e-cigarettes, be kept out of view in stores where adolescents shop; and prohibiting e-cigarette use in (3) all public places; (4) restaurants; and (5) bars. Weighted, adjusted logistic regressions modeled variation in policy support.

Results:

A majority of respondents (63.3%) supported a flavor ban, with no differences in support by smoking status. Most respondents supported keeping tobacco products out of view (78.0%) and prohibiting e-cigarette use in indoor public places (82.9%), restaurants (86.5%), and bars (76.1%). In the adjusted models, current e-cigarette users had significantly lower odds of policy support compared to never users. We observed no differences in support by geographic region or strength of state-level clean indoor air policies.

Conclusion:

Results suggest high levels of public support to regulate e-cigarette flavors, marketing, and use in public places. Targeted messaging may be needed to increase support among current e-cigarette users.

Are In Silico Approaches Applicable As a First Step for the Prediction of e-Liquid Toxicity in e-Cigarettes?

Recent studies have raised concerns about e-cigarette liquid inhalation toxicity by reporting the presence of chemicals with European Union CLP toxicity classification. In this scenario, the regulatory context is still developing and is not yet up to date with vaping current reality. Due to the paucity of toxicological studies, robust data regarding which components in e-liquids exhibit potential toxicities, are still inconsistent. In this study we applied computational methods for estimating the toxicity of poorly studied chemicals as a useful tool for predicting the acute toxicity of chemicals contained in e-liquids. The purpose of this study was 3-fold: (a) to provide a lower tier assessment of the potential health concerns associated with e-liquid ingredients, (b) to prioritize e-liquid ingredients by calculating the e-tox index, and (c) to estimate acute toxicity of e-liquid mixtures. QSAR models were generated using QSARINS software to fill the acute toxicity data gap of 264 e-liquid ingredients. As a second step, the potential acute toxicity of e-liquids mixtures was evaluated. Our preliminary data suggest that a computational approach may serve as a roadmap to enable regulatory bodies to better regulate e-liquid composition and to contribute to consumer health protection.

Bronchoalveolar lavage as a diagnostic procedure: a review of known cellular and molecular findings in various lung diseases

Bronchoalveolar lavage (BAL) is a commonly used procedure in the evaluation of lung disease as it allows for sampling of the lower respiratory tract. In many circumstances, BAL differential cell counts have been reported to be typical of specific lung disorders. In addition, more specific diagnostic tests including molecular assays such as polymerase chain reaction (PCR) or enzyme-linked immunosorbent assay, special cytopathologic stains, or particular microscopic findings have been described as part of BAL fluid analysis. This review focuses on common cellular and molecular findings of BAL in a wide range of lung diseases. Since the performance of the first lung irrigation in 1927, BAL has become a common and important diagnostic tool. While some pulmonary disorders have a highly characteristic signature of BAL findings, BAL results alone often lack specificity and require interpretation along with other clinical and radiographic details. Development of new diagnostic assays is certain to reinforce the utility of BAL in the future. Our review of the BAL literature is intended to serve as a resource to assist clinicians in the care of patients with lung disorders.

Electronic-Cigarette Vehicles and Flavoring Affect Lung Function and Immune Responses in a Murine Model

The use of electronic nicotine delivery systems (ENDS), also known as electronic-cigarettes (e-cigs), has raised serious public health concerns, especially in light of the 2019 outbreak of e-cig or vaping product use-associated acute lung injury (EVALI). While these cases have mostly been linked to ENDS that contain vitamin E acetate, there is limited research that has focused on the chronic pulmonary effects of the delivery vehicles (i.e., without nicotine and flavoring). Thus, we investigated lung function and immune responses in a mouse model following exposure to the nearly ubiquitous e-cig delivery vehicles, vegetable glycerin (VG) and propylene glycol (PG), used with a specific 70%/30% ratio, with or without vanilla flavoring. We hypothesized that mice exposed sub-acutely to these e-cig aerosols would exhibit lung inflammation and altered lung function. Adult female C57BL/6 mice (n = 11–12 per group) were exposed to filtered air, 70%/30% VG/PG, or 70%/30% VG/PG with a French vanilla flavoring for 2 h a day for 6 weeks. Prior to sacrifice, lung function was assessed. At sacrifice, broncho-alveolar lavage fluid and lung tissue were collected for lipid mediator analysis, flow cytometry, histopathology, and gene expression analyses. Exposures to VG/PG + vanilla e-cig aerosol increased lung tidal and minute volumes and tissue damping. Immunophenotyping of lung immune cells revealed an increased number of dendritic cells, CD4+ T cells, and CD19+ B cells in the VG/PG-exposed group compared to air, irrespective of the presence of vanilla flavoring. Quantification of bioactive lung lipids demonstrated a >3-fold increase of 2-arachidonoylglycerol (2-AG), an anti-inflammatory mediator, and a 2-fold increase of 12-hydroxyeicosatetraenoic acid (12-HETE), another inflammatory mediator, following VG/PG exposure, with or without vanilla flavoring. This suggests that e-cig aerosol vehicles may affect immunoregulatory molecules. We also found that the two e-cig aerosols dysregulated the expression of lung genes. Ingenuity Pathway Analysis revealed that the gene networks that are dysregulated by the VG/PG e-cig aerosol are associated with metabolism of cellular proteins and lipids. Overall, our findings demonstrate that VG and PG, the main constituents of e-liquid formulations, when aerosolized through an e-cig device, are not harmless to the lungs, since they disrupt immune homeostasis.

Chemical and Toxicological Characterization of Vaping Emission Products from Commonly Used Vape Juice Diluents

Recent reports have linked severe lung injuries and deaths to the use of e-cigarettes and vaping products. Nevertheless, the causal relationship between exposure to vaping emissions and the observed health outcomes remains to be elucidated. Through chemical and toxicological characterization of vaping emission products, this study demonstrates that during vaping processes, changes in chemical composition of several commonly used vape juice diluents (also known as cutting agents) lead to the formation of toxic byproducts, including quinones, carbonyls, esters, and alkyl alcohols. The resulting vaping emission condensates cause inhibited cell proliferation and enhanced cytotoxicity in human airway epithelial cells. Notably, substantial formation of the duroquinone and durohydroquinone redox couple was observed in the vaping emissions from vitamin E acetate, which may be linked to acute oxidative stress and lung injuries reported by previous studies. These findings provide an improved molecular understanding and highlight the significant role of toxic byproducts in vaping-associated health effects.

Clinical Features of E-cigarette, or Vaping, Product Use-Associated Lung Injury in Teenagers

BACKGROUND

In the United States in 2019, there was an outbreak of electronic cigarette, or vaping, product use-associated lung injury (EVALI). The manifestations of EVALI in adolescents are not well characterized. We describe the diagnosis, evaluation, and management of EVALI in adolescents hospitalized at a tertiary care, university-affiliated children's hospital.

METHODS

A multidisciplinary committee developed an EVALI algorithm on the basis of guidelines from the Centers for Disease Control and Prevention. A retrospective chart review was conducted on patients diagnosed with EVALI. Descriptive analyses included sociodemographic characteristics, clinical presentation, laboratory and imaging results, pulmonary function testing, oxygen requirements, and clinic follow-up.

RESULTS

Thirteen hospitalized adolescents were diagnosed with confirmed or probable EVALI. The majority were female (54%) with a mean age of 15.9 years. Sixty-nine percent of patients presented with respiratory symptoms, whereas gastrointestinal symptoms were prominent in 85% of patients. Vaping Δ-9-tetrahydrocannabinol was reported in 92% of patients, and vaping nicotine was reported in 62% of patients. All had bilateral ground-glass opacities on the chest computed tomography (CT) scan. Treatment with glucocorticoids led to clinical improvement in 11 of 12 patients. Treatment with glucocorticoids led to improvement in both forced expiratory volume in 1 second and forced vital capacity (P < .05). Four patients required home oxygen on the basis of 6-minute walk test results.

CONCLUSIONS

Diagnosis of EVALI should be suspected on the basis of vaping history and clinical presentation. Glucocorticoid treatment led to an improvement in symptoms and lung function. The 6-minute walk test may help determine oxygen needs at discharge.

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.

Review of Health Consequences of Electronic Cigarettes and the Outbreak of Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury

Electronic cigarettes (e-cigarettes) are battery-operated devices to insufflate nicotine or other psychoactive e-liquid aerosols. Despite initial claims of e-cigarettes as a nicotine-cessation device, aggressive marketing of e-cigarettes has led to an explosion in adolescents' and young adults' use over the last few years. Coupled with a lack of adequate investigation and regulation of e-cigarettes, the USA is facing an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) starting in mid-2019. While little long-term health hazard data are available, the components and constituents of e-cigarettes may adversely impact health. Propylene glycol and glycerin are humectants (water-retaining excipients) that generate pulmonary irritants and carcinogenic carbonyl compounds (e.g., formaldehyde, acetaldehyde, and acrolein) when heated in e-cigarettes. Metals contained in heating coils and cartridge casings may leach metals such as aluminum, chromium, iron, lead, manganese, nickel, and tin. Flavoring agents are considered safe for ingestion but lack safety data for inhalational exposures. Diacetyl, a common buttery flavoring agent, has known pulmonary toxicity with inhalational exposures leading to bronchiolitis obliterans. In 2019, clusters of lung injury associated with e-cigarette use were identified in Wisconsin and Illinois. Patients with EVALI present with a constellation of respiratory, gastrointestinal, and constitutional symptoms. Radiographically, patients have bilateral ground glass opacifications. As of February 18, 2020, the Centers for Disease Control has identified 2807 hospitalized patients diagnosed with either "confirmed" or "probable" EVALI in the US. Currently, vitamin E acetate (VEA) used as a diluent in tetrahydrocannabinol vape cartridges is implicated in EVALI. VEA cuts tetrahydrocannabinol oil without changing the appearance or viscosity. When inhaled, pulmonary tissue lacks the mechanism to metabolize and absorb VEA, which may lead to its accumulation. While most EVALI patients were hospitalized, treatment remains largely supportive, and use of corticosteroids has been associated with clinical improvement. The outbreak of EVALI highlights the need for regulation of e-cigarette devices and e-liquids. Clinicians need to be aware of the health hazards of e-cigarettes and be vigilant in asking about vaping.

Review of Cases of E-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI) and Brief Review of the Literature

Since the appearance of the E-Cigarette in the early 2000s, its industry, popularity, and prevalence have risen dramatically. In the past, E-Cigarette use with the vaping of nicotine or cannabis products had been associated with a few reported cases of lung injury. However, in 2019, thousands of cases of E-Cigarette or vaping product use-associated lung injury (EVALI) were reported in the United States. Evidence linked this outbreak with vaping of tetrahydrocannabinol (THC). We report two confirmed cases of EVALI and their associated clinical, radiologic, and pathologic features. This report supports the growing body of information regarding EVALI. It also discusses various substances, particularly vitamin E acetate, which has been suggested as a causative agent.

New Insights From MRI and Cell Biology Into the Acute Vascular-Metabolic Implications of Electronic Cigarette Vaping

The popularity of electronic cigarettes (e-cigs) has grown at a startling rate since their introduction to the United States market in 2007, with sales expected to outpace tobacco products within a decade. Spurring this trend has been the notion that e-cigs are a safer alternative to tobacco-based cigarettes. However, the long-term health impacts of e-cigs are not yet known. Quantitative magnetic resonance imaging (MRI) approaches, developed in the authors’ laboratory, provide conclusive evidence of acute deleterious effects of e-cig aerosol inhalation in the absence of nicotine in tobacco-naïve subjects. Among the pathophysiologic effects observed are transient impairment of endothelial function, vascular reactivity, and oxygen metabolism. The culprits of this response are currently not fully understood but are likely due to an immune reaction caused by the aerosol containing thermal breakdown products of the e-liquid, including radicals and organic aldehydes, with particle concentrations similar to those emitted by conventional cigarettes. The acute effects observed following a single vaping episode persist for 1–3 h before subsiding to baseline and are paralleled by build-up of biological markers. Sparse data exist on long-term effects of vaping, and it is likely that repeated regular exposure to e-cig aerosol during vaping will lead to chronic conditions since there would be no return to baseline conditions as in the case of an isolated vaping episode. This brief review aims to highlight the potential of pairing MRI, with its extraordinary sensitivity to structure, physiology and metabolism at the holistic level, with biologic investigations targeting serum and cellular markers of inflammation and oxidative stress. Such a multi-modal framework should allow interpretation of the impact of e-cigarette vaping on vascular health at the organ level in the context of the underlying biological alterations. Applications of this approach to the study of other lifestyle-initiated pathologies including hypertension, hypercholesterolemia, and metabolic syndrome are indicated.

Modifications to Electronic Nicotine Delivery Systems: Content Analysis of YouTube Videos

BACKGROUND

As user modification can alter the addictiveness and toxicity of electronic nicotine delivery systems (ENDS), more research is needed to understand the types, motivations, risks, and information sources that lead to these product alterations. YouTube has been identified as a major platform where ENDS users obtain and share information about ENDS products and modifications. However, a comprehensive study of ENDS modification videos on YouTube is lacking.

OBJECTIVE

This study aimed to analyze the content of YouTube videos depicting modifications of ENDS.

METHODS

YouTube was searched in March 2019 to identify videos depicting ENDS modifications. Search terms were derived from interviews with ENDS users and current literature. We used 28 search phrases that combined the words vape and vaping with modification-related key terms (eg, custom build, modification, and dripping). The final sample included 168 videos.

RESULTS

Videos were 1 to 108 min long (median 9.55). Presenters were largely male (117/168, 69.6%), white (94/168, 56.0%), and older than 25 years (94/168, 56.0%). Most videos gave how to instructions (148/168, 88.1%), but few offered warnings (30/168, 17.9%) or mentioned commercial alternatives to modifications they presented (16/168, 9.5%). The ENDS devices most often featured were drippers (63/168, 37.5%) and refillable tanks (37/168, 22.0%). The most often modified ENDS components were coils (82/168, 48.8%) and e-liquids (34/168, 20.2%), which included adding other substances, such as cannabis, to the e-liquids (6/168, 3.6%). Most videos portrayed ENDS modifications positively (106/168, 63.1% positive; 60/168, 35.7% neutral; and 2/168, 1.2% negative) and were either neutral or positive in their overall portrayal of ENDS devices (78/168, 46.4% positive; 89/168, 53.0% neutral; and 1/168, 0.6% negative).

CONCLUSIONS

This study identified several concerning trends in popular YouTube videos on ENDS modifications, including lack of warnings, the addition of marijuana derivatives to e-liquids, and the positive portrayal of ENDS devices and modifications. By identifying the types of modifications (coil and e-liquid being the most prevalent), this study sets an agenda for research on the effects of modifications.

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.

Smoking-associated interstitial lung disease: update and review

INTRODUCTION

Smoking-associated interstitial lung disease manifests as several heterogeneous disorders involving the airways, pleura, and lung parenchyma with various radiological patterns. The clinical history, radiologic, and pathologic findings are important to distinguish these more uncommon diseases. A multidisciplinary approach is recommended for diagnosis and to manage these conditions appropriately.

AREAS COVERED

This review provides an overview of the epidemiology, risk factors, pathogenesis, clinical features, diagnosis, and treatment of acute eosinophilic pneumonia, e-cigarettes, or vaping associated lung injury, respiratory bronchiolitis interstitial lung disease, desquamative interstitial pneumonitis, pulmonary Langerhans cell histiocytosis, idiopathic pulmonary fibrosis, and combined pulmonary fibrosis emphysema.

EXPERT OPINION

Cigarette smoking is associated with a variety of pathologic conditions that affect the airways and lungs. E-cigarette use and vaping present new challenges to the clinician. Consensus between the clinical, radiographic, and pathologic findings is important in identifying and differentiating between the various entities to properly diagnose smoking-related interstitial lung diseases discussed in this review.

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.

[E-cigarette use among cannabis users and multi-users of psychoactive products: A cohort study]

INTRODUCTION

There is no evidence in the literature relating to the evolution of e-cigarette use among cannabis users and multi-users (of alcohol, tobacco or cannabis).

OBJECTIVE

To describe the evolution over 12 months of e-cigarette use in cannabis users and multi-users.

METHODS

A prospective observational cohort study in general practice, between 2015 and 2016.

RESULTS

A total of 4.8% of monitored cannabis users remained or became current users of e-cigarettes by the end of the monitoring period versus 4.5% among non-users of cannabis, with no statistically significant difference. A total of 5.1% of monitored multi-users remained or became current users of e-cigarettes by the end of the monitoring period versus 2.4% among the non-multi-users, with no statistically significant difference. Cannabis users and multi-users reported more e-cigarette experimentation through curiosity and following someone's suggestion, compared to non-cannabis users or non multi-users. No statistically significant association was found between cannabis or multi-drug use and staying or becoming a current e-cigarette user over 12 months.

CONCLUSION

Cannabis users and multi-users would tend to experiment with e-cigarettes more than other patients but this use would not be sustained.

E-cigarette or vaping product use-associated lung injury

E-cigarette or vaping product use-associated lung injury is a recently recognised, acute pulmonary syndrome which has been reported (particularly from June to October 2019) throughout the USA, but not in Europe (although one probable case, in the UK, has been reported; Medicines and Healthcare products Regulatory Agency, 2020). It presents acutely, most often in young men, as severe pulmonary consolidation, usually with respiratory failure. The mortality is around 2%. The cause(s) are unknown, but it is associated with vaping, particularly using unlicensed cannabis-containing products with tetrahydrocannabinol. Vitamin E acetate, often present in tetrahydrocannabinol-containing vape products as a solvent, has been implicated, as it has been identified in the bronchoalveolar lavage fluid of patients with e-cigarette or vaping product use-associated lung injury. This article reviews the recent literature, including clinical features, presentation and investigations, and possible mechanisms, in the context of vaping practices in the USA and the UK.

Neurotoxicity of e-cigarettes

It appears that electronic cigarettes (EC) are a less harmful alternative to conventional cigarette (CC) smoking, as they generate substantially lower levels of harmful carcinogens and other toxic compounds. Thus, switching from CC to EC may be beneficial for smokers. However, recent accounts of EC- or vaping-associated lung injury (EVALI) has raised concerns regarding their adverse health effects. Additionally, the increasing popularity of EC among vulnerable populations, such as adolescents and pregnant women, calls for further EC safety evaluation. In this state-of-the-art review, we provide an update on recent findings regarding the neurological effects induced by EC exposure. Moreover, we discuss possible neurotoxic effects of nicotine and numerous other chemicals which are inherent both to e-liquids and EC aerosols. We conclude that in recognizing pertinent issues associated with EC usage, both government and scientific researchers must address this public health issue with utmost urgency.

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.

The Dangers of Vaping

As our nation turns away from smoking tobacco and toward legalization of marijuana, vaporization of both plants has increased in popularity. There are medical and cultural implications of this new trend which are just recently being reported and investigated. The purpose of this article is to review the scientific and sociological literature as it pertains to the vaporization of both marijuana and tobacco products and the potential medical and cultural implications of this new phenomenon.

Diagnosis of EVALI: General Approach and the Role of Bronchoscopy

A 23-year-old man arrives at the ED with a 3-week history of dyspnea, dry cough, fevers, and night sweats. Two weeks previously, he was evaluated in an outpatient clinic and given a course of azithromycin for presumed infectious pneumonia. His symptoms did not improve, and he was seen 1 week later in an urgent care center and given a prescription for doxycycline, which he has been taking without improvement. He states that he feels miserable, has severe nausea and vomiting, and has not eaten in several days. His only medical history is childhood asthma. He reports no surgeries and takes no medications. He has no risk factors for HIV, does not smoke combustible cigarettes or use IV drugs, and has not recently traveled. Examination shows a room air saturation of 89%, a temperature of 38.3°C, and a respiratory rate of 22 breaths/min. Results of his examination are normal, and there are no rales or wheezing heard in the lungs. Chest radiograph shows bilateral, consolidative opacities. WBC count is 14,000, with left shift. Results of biochemistries are normal. Erythrocyte sedimentation rate is 104, and procalcitonin is 0.08. Urine toxicology screen is positive for tetrahydrocannabinol (THC). Asked specifically about vaping and e-cigarette use, he reports that he recently began using THC "carts" that his friend gets from an unknown supplier. What is the diagnosis and what additional steps are necessary to confirm it? Is bronchoscopy indicated?

Analysis of Cannabinoid-Containing Fluids in Illicit Vaping Cartridges Recovered from Pulmonary Injury Patients: Identification of Vitamin E Acetate as a Major Diluent

Beginning in June of 2019, there was a marked increase in reported cases of serious pulmonary injury associated with vaping. The condition, referred to as e-cigarette or vaping product use-associated lung injury (EVALI), does not appear to involve an infectious agent; rather, a chemical adulterant or contaminant in vaping fluids is suspected. In August of 2019, the Wadsworth Center began receiving vaporizer cartridges recovered from patients with EVALI for analysis. Having no a priori information of what might be in the cartridges, we employed untargeted analyses using gas chromatography-mass spectrometry and high-resolution mass spectrometry to identify components of concern. Additionally, we employed targeted analyses used for New York medical marijuana products. Here, we report on the analyses of 38 samples from the first 10 New York cases of EVALI for which we obtained cartridges. The illicit fluids had relatively low cannabinoid content, sometimes with unusual Δ9-/Δ8-tetrahydrocannabinol ratios, sometimes containing pesticides and many containing diluents. A notable diluent was α-tocopheryl acetate (vitamin E acetate; VEA), which was found in 64% of the cannabinoid-containing fluids. To investigate potential sources of the VEA, we analyzed six commercial cannabis-oil diluents/thickeners. Three were found to be >95% VEA, two were found to be primarily squalane, and one was primarily α-bisabolol. The cause(s) of EVALI is unknown. VEA and squalane are components of some personal care products; however, there is growing concern that vaping large amounts of these compounds is not safe.

Acute lung injury secondary to e-cigarettes or vaping

As of October 2019, 1299 cases of "e-cigarette, or vaping, product use associated lung injury" (EVALI) have been reported in the USA, with 26 deaths. Multiple patterns of lung injury have been reported, including lipoid pneumonia, organizing pneumonia, and acute eosinophilic pneumonia, with radiographic findings including diffuse pulmonary infiltrates. We report a case of lipoid pneumonia secondary to EVALI. Physicians should be alert to recognizing these patterns of lung injury, as well as emphasizing to patients the importance of e-cigarette cessation.

Clinical presentation, treatment, and short-term outcomes of lung injury associated with e-cigarettes or vaping: a prospective observational cohort study

BACKGROUND

An ongoing outbreak of lung injury associated with e-cigarettes or vaping (also known as E-VALI or VALI) started in March, 2019, in the USA. The cause, diagnosis, treatment, and course of this disease remains unknown.

METHODS

In this multicentre, prospective, observational, cohort study, we collected data on all patients with lung injury associated with e-cigarettes or vaping seen in Intermountain Healthcare, an integrated health system based in Utah, USA, between June 27 and Oct 4, 2019. Telecritical care, based in Salt Lake City, UT, USA, was used as the central repository for case validation, public reporting, and system-wide dissemination of expertise, which included a proposed diagnosis and treatment guideline for lung injury associated with e-cigarettes or vaping. We extracted data on patient presentation, treatment, and short-term follow-up (2 weeks after discharge) from chart review and interviews with patients undertaken by the Utah Department of Health (Salt Lake City, UT, USA).

FINDINGS

60 patients presented with lung injury associated with e-cigarettes or vaping at 13 hospitals or outpatient clinics in the integrated health system. 33 (55%) of 60 were admitted to an intensive care unit (ICU). 53 (88%) of 60 patients presented with constitutional symptoms, 59 (98%) with respiratory symptoms, and 54 (90%) with gastrointestinal symptoms. 54 (90%) of 60 were given antibiotics and 57 (95%) were given steroids. Six (10%) of 60 patients were readmitted to an ICU or hospital within 2 weeks, three (50%) of whom had relapsed with vaping or e-cigarette use. Of 26 patients who were followed up within 2 weeks, despite clinical and radiographic improvement in all, many had residual abnormalities on chest radiographs (ten [67%] of 15) and pulmonary function tests (six [67%] of nine). Two patients died and lung injury associated with e-cigarettes or vaping was thought to be a contributing factor, but not the cause of death, for both.

INTERPRETATION

Lung injury associated with e-cigarettes or vaping is an emerging illness associated with severe lung injury and constitutional and gastrointestinal symptoms. Increased awareness has led to identification of a broad spectrum of severity of illness in patients who were treated with antibiotics and steroids. Despite improvement, at short-term follow-up many patients had residual abnormalities. Lung injury associated with e-cigarettes or vaping remains a clinical diagnosis with symptoms that overlap infectious and other lung diseases. Maintaining a high index of suspicion for this disease is important as work continues in understanding the cause or causes, optimal therapy, and long-term outcomes of these patients.

FUNDING

Intermountain Healthcare.

Life-threatening bronchiolitis related to electronic cigarette use in a Canadian youth

BACKGROUND

Although electronic cigarettes (e-cigarettes) were initially marketed as a potential smoking-cessation aid and a safer alternative to smoking, the long-term health effect of e-cigarette use ("vaping") is unknown. Vaping e-liquids expose the user to several potentially harmful chemicals, including diacetyl, a flavouring compound known to cause bronchiolitis obliterans with inhalational exposure ("popcorn worker's lung").

CASE DESCRIPTION

We report the case of a 17-year-old male who presented with intractable cough, progressive dyspnea and malaise after vaping flavoured e-liquids and tetrahydrocannabinol intensively. Initial physical examination showed fever, tachycardia, hypoxemia, and bibasilar inspiratory crackles on lung auscultation. Computed tomography of the chest showed diffuse centrilobular "tree-inbud" nodularity, consistent with acute bronchiolitis. Multiple cultures, including from 2 bronchoalveolar lavage samples, and biopsy stains, were negative for infection. He required intubation, invasive mechanical ventilation and venovenous extracorporeal membrane oxygenation (ECMO) for refractory hypercapnia. The patient's condition improved with high-dose corticosteroids. He was weaned off ECMO and mechanical ventilation, and discharged home after 47 days in hospital. Several months after hospital discharge, his exercise tolerance remained limited and pulmonary function tests showed persistent, fixed airflow obstruction with gas trapping. The patient's clinical picture was suggestive of possible bronchiolitis obliterans, thought to be secondary to inhalation of flavouring agents in the e-liquids, although the exact mechanism of injury and causative agent are unknown.

INTERPRETATION

This case of severe acute bronchiolitis, causing near-fatal hypercapnic respiratory failure and chronic airflow obstruction in a previously healthy Canadian youth, may represent vaping-associated bronchiolitis obliterans. This novel pattern of pulmonary disease associated with vaping appears distinct from the type of alveolar injury predominantly reported in the recent outbreak of cases of vaping-associated pulmonary illness in the United States, underscoring the need for further research into all potentially toxic components of e-liquids and tighter regulation of e-cigarettes.