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Andrus MR. E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Continues: An Opportunity for Pharmacist Intervention. Ann Pharmacother 2024; 58:549-554. [PMID: 37605427 DOI: 10.1177/10600280231193770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Abstract
Electronic cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) was first identified and reported in 2019, but media coverage and reporting of cases drastically decreased when the COVID-19 pandemic started in early 2020. The syndrome has continued to occur since that time and it is critical that pharmacists are aware of how EVALI presents, and when it should be considered as a potential diagnosis. Inpatient and outpatient pharmacists play a vital role in the treatment of EVALI, and should be knowledgeable of the utility of corticosteroids, even though data are extremely limited. Pharmacists should understand the importance of collecting detailed and accurate information about vaping from patient interviews. Pharmacists also play a leading role in cessation counseling and treatment, selecting medications that can be used to treat nicotine addiction from vaping, and assisting with transitions of care and follow-up.
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Affiliation(s)
- Miranda R Andrus
- Department of Pharmacy Practice, Harrison College of Pharmacy, Auburn University, Auburn, AL, USA
- Department of Family Medicine, Huntsville Regional Medical Campus, The University of Alabama at Birmingham, Huntsville, AL, USA
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2
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Adegbile OE, Adeniji OD, Amzat J, Kanmodi KK. E-cigarettes in Nigeria: A scoping review of evidence. Health Sci Rep 2024; 7:e2074. [PMID: 38660005 PMCID: PMC11040567 DOI: 10.1002/hsr2.2074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024] Open
Abstract
Background and Aims E-cigarettes will continue to be a public health issue in Nigeria. To curb the growing menace of the e-cigarette use in Nigeria through evidence-based approach, it is crucial to first map the empirical research landscape of e-cigarettes in Nigeria. No known study has mapped the existing empirical evidence and gaps concerning e-cigarettes in Nigeria; hence, this scoping review was conducted. Methods This scoping review adopted the research design by Arksey and O'Malley. Four databases (PubMed, SCOPUS, CINAHL Complete, and APA PsycINFO) were searched to retrieve literature on e-cigarettes in Nigeria. With the aid of Rayyan web application, all retrieved literature were deduplicated and screened based on the review's eligibility criteria. Only those peer-reviewed journal papers meeting the inclusion criteria were included in the review. Relevant data from the included papers were charted, collated, and summarized. Results A total of six papers were included in this review. The reviewed papers reported a lifetime prevalence of e-cigarette use (or vaping) ranging from 5.8% to 19.8%, with a current e-cigarette use prevalence of 11.8%, among different population groups in Nigeria. The major determinants of e-cigarette use, as reported in these articles, include being a youth, having a health condition, severe anxiety, tobacco use, peer influence, and current alcohol use. Dry mouth and oral lesions (gingival inflammation and oral ulcers) were also identified to be the medical conditions associated with e-cigarette use in Nigeria. Lastly, one of the included papers identified a lack of clear regulation on e-cigarettes in Nigeria. Conclusion There is an urgent need for more scientific investigations on the sociodemographic, economic, health, and regulatory landscape of e-cigarettes in Nigeria, as robust empirical evidence is needed for the effective planning, implementation, and evaluation of evidence-based policies and interventions on e-cigarettes control and regulation in Nigeria.
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Affiliation(s)
- Oluwatobi E. Adegbile
- Department of Biostatistics and EpidemiologyEast Tennessee State UniversityJohnson CityTennesseeUSA
- Campaign for Head and Neck Cancer Education (CHANCE) ProgrammeCephas Health Research Initiative IncIbadanNigeria
| | - Oluwatomilayo D. Adeniji
- Campaign for Head and Neck Cancer Education (CHANCE) ProgrammeCephas Health Research Initiative IncIbadanNigeria
- Department of Community and Behavioral HealthEast Tennessee State UniversityJohnson CityTennesseeUSA
| | - Jimoh Amzat
- Department of SociologyUsmanu Danfodiyo UniversitySokotoNigeria
- Department of SociologyUniversity of JohannesburgJohannesburgSouth Africa
| | - Kehinde K. Kanmodi
- Campaign for Head and Neck Cancer Education (CHANCE) ProgrammeCephas Health Research Initiative IncIbadanNigeria
- Faculty of DentistryUniversity of PuthisastraPhnom PenhCambodia
- School of DentistryUniversity of RwandaKigaliRwanda
- School of Health and Life SciencesTeesside UniversityMiddlesbroughUK
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3
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Yammine L, Tovar M, Yammine NA, Becker C, Weaver MF. E-cigarettes and Youth: The Known, the Unknown, and Implications for Stakeholders. J Addict Med 2024:01271255-990000000-00298. [PMID: 38498621 DOI: 10.1097/adm.0000000000001304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
ABSTRACT Despite the decline in the prevalence of e-cigarette use among youth during the coronavirus disease 2019 pandemic, more than 2.5 million of US high and middle schoolers are still using e-cigarettes. Furthermore, those who use e-cigarettes are starting at a younger age and are using them more intensely, reflecting, at least in part, a high addiction liability of modern e-cigarettes. Beyond addiction, accumulating evidence suggests that, in the short-term, e-cigarettes are associated with cardiovascular and pulmonary effects, whereas the long-term effects of e-cigarette use are yet to be established. The aim of this review is to synthesize current knowledge on e-cigarette use among youth, including established and potential risks and efforts to date to curb youth exposure to e-cigarettes. In addition, we provide recommendations for health care providers, researchers, and other stakeholders to address this significant public health issue.
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Affiliation(s)
- Luba Yammine
- From the Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, UTHealth McGovern Medical School, Houston, TX (LY, MFW); University of Texas Health Science Center at Houston, Houston, TX (MT, CB); and University of Texas Health Science Center at San Antonio, San Antonio, TX (NAY)
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4
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Mitchell MM, G Mitchell S, Brooks JH, Akinwolere OG, Dusek K, O'Grady KE, Schwartz RP, Gryczynski J. The Relationship between Vaping Cannabis and Frequency of Cannabis Use and Cannabis-Related Problems among Urban High School Students. Subst Use Misuse 2024; 59:329-335. [PMID: 38063201 DOI: 10.1080/10826084.2023.2269573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Background: Vaping, including vaping cannabis, is increasing among adolescents. In this longitudinal study, we examined the relationship between vaping cannabis and frequency of cannabis use and related problems over 6 months among adolescents. Material and Methods: Data were from 233 participants (46.8% male, 93.1% African American, mean age = 16.4 years) reporting cannabis use. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) assessed frequency of past 30-day cannabis use and cannabis-related problems at baseline, 3- and 6-months post-baseline. We used latent growth curve modeling to compare vaping to non-vaping adolescents on trends in cannabis use frequency and ASSIST cannabis scores. Results: Adolescents who vaped cannabis (11.7%) had higher past 30-day frequency (mean = 17.89 days, SD = 10.49) of cannabis use at baseline compared to adolescents who had not vaped (mean = 12.1 days, SD = 10.93), but reported a significantly sharper decline in frequency of cannabis use (b = -0.34, p = 0.017). A significantly steeper decrease existed in the mean cannabis ASSIST scores for the vaping group than for the non-vaping group (b = -0.34, p = 0.014). Mean ASSIST scores on the cannabis subscale between the two groups were significantly different at 6-month follow-up (Vape mean = 6.00, SD = 8.12 vs. Non-vape mean = 9.6, SD = 9.39; p < 0.021). Conclusions: In a sample of cannabis-using adolescents, adolescents with experience vaping cannabis, compared to adolescents without vaping experience, on average reported sharper decreases in frequency of cannabis use and cannabis-related problems such as health or social problems.
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Affiliation(s)
| | | | | | | | - Kristi Dusek
- Friends Research Institute, Baltimore, Maryland, USA
| | - Kevin E O'Grady
- Department of Psychology, University of Maryland, College Park, Maryland, USA
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5
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Martin A, Tempra C, Yu Y, Liekkinen J, Thakker R, Lee H, de Santos Moreno B, Vattulainen I, Rossios C, Javanainen M, Bernardino de la Serna J. Exposure to Aldehyde Cherry e-Liquid Flavoring and Its Vaping Byproduct Disrupt Pulmonary Surfactant Biophysical Function. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2024; 58:1495-1508. [PMID: 38186267 PMCID: PMC10809783 DOI: 10.1021/acs.est.3c07874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/16/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024]
Abstract
Over the past decade, there has been a significant rise in the use of vaping devices, particularly among adolescents, raising concerns for effects on respiratory health. Pressingly, many recent vaping-related lung injuries are unexplained by current knowledge, and the overall implications of vaping for respiratory health are poorly understood. This study investigates the effect of hydrophobic vaping liquid chemicals on the pulmonary surfactant biophysical function. We focus on the commonly used flavoring benzaldehyde and its vaping byproduct, benzaldehyde propylene glycol acetal. The study involves rigorous testing of the surfactant biophysical function in Langmuir trough and constrained sessile drop surfactometer experiments with both protein-free synthetic surfactant and hydrophobic protein-containing clinical surfactant models. The study reveals that exposure to these vaping chemicals significantly interferes with the synthetic and clinical surfactant biophysical function. Further atomistic simulations reveal preferential interactions with SP-B and SP-C surfactant proteins. Additionally, data show surfactant lipid-vaping chemical interactions and suggest significant transfer of vaping chemicals to the experimental subphase, indicating a toxicological mechanism for the alveolar epithelium. Our study, therefore, reveals novel mechanisms for the inhalational toxicity of vaping. This highlights the need to reassess the safety of vaping liquids for respiratory health, particularly the use of aldehyde chemicals as vaping flavorings.
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Affiliation(s)
- Alexia Martin
- National
Heart and Lung Institute, Imperial College
London, Sir Alexander Fleming Building, London SW7 2AZ, U.K.
| | - Carmelo Tempra
- Institute
of Organic Chemistry and Biochemistry, Czech Academy of Sciences, Prague 6 160 00, Czech Republic
| | - Yuefan Yu
- National
Heart and Lung Institute, Imperial College
London, Sir Alexander Fleming Building, London SW7 2AZ, U.K.
| | - Juho Liekkinen
- Department
of Physics, University of Helsinki, Helsinki 00560, Finland
| | - Roma Thakker
- National
Heart and Lung Institute, Imperial College
London, Sir Alexander Fleming Building, London SW7 2AZ, U.K.
| | - Hayoung Lee
- National
Heart and Lung Institute, Imperial College
London, Sir Alexander Fleming Building, London SW7 2AZ, U.K.
| | - Berta de Santos Moreno
- National
Heart and Lung Institute, Imperial College
London, Sir Alexander Fleming Building, London SW7 2AZ, U.K.
| | - Ilpo Vattulainen
- Department
of Physics, University of Helsinki, Helsinki 00560, Finland
| | - Christos Rossios
- National
Heart and Lung Institute, Imperial College
London, Sir Alexander Fleming Building, London SW7 2AZ, U.K.
| | - Matti Javanainen
- Institute
of Organic Chemistry and Biochemistry, Czech Academy of Sciences, Prague 6 160 00, Czech Republic
- Institute
of Biotechnology, University of Helsinki, Helsinki 00790, Finland
| | - Jorge Bernardino de la Serna
- National
Heart and Lung Institute, Imperial College
London, Sir Alexander Fleming Building, London SW7 2AZ, U.K.
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Arazi T, Mohammadi S, Movahedi A, Aryaee Far MR, Moeini V. Barriers to providing quality care for patients with substance use disorders from the perspective of baccalaureate nursing students: A descriptive qualitative study. NURSE EDUCATION TODAY 2023; 131:105961. [PMID: 37688943 DOI: 10.1016/j.nedt.2023.105961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND With Iran facing an epidemic in substance use disorders, nursing students are increasingly encountering people impacted by substance misuse. Providing care for this group brings with it many barriers and challenges. These serious barriers have not been a priority in Iranian nurse education. OBJECTIVES To describe barriers to providing quality care for people with substance use disorders from the perspective of nursing students. DESIGN A descriptive qualitative study, using content analysis was used to address the study aim. SETTING AND PARTICIPANTS Purposive sampling was used to recruit participants. Participants were 34 baccalaureate nursing students from different academic semesters studying at two medical sciences universities in Iran. METHODS Data were collected using semi-structured interviews from July 2022 to October 2022. Granheim & Lundman's method for qualitative content analysis was used to analyze data. RESULTS The barriers to providing quality care for people with substance use disorders were described through the major theme: "lack of communication skills and difficulty finding language for therapeutic communication with people with substance use disorders". Based on nursing student perspectives, a lack of communication and language for therapeutic communication was described through the three barriers of: 1. "possessing or witnessing prejudiced attitudes and stereotypes", 2 "negative role models", and 3. "Knowledge deficit in self or others". CONCLUSION The result of this study showed that nursing students interact with people with substance use disorders through prejudiced attitudes, negative stereotypes, and knowledge deficits. Academic education should include practical techniques to reduce negative stereotypes and moral distress among nursing students as well as strategies to manage tough ethical situations and decrease prejudiced attitudes. Nurses and clinical educators must be attentive to their power to influence nursing students and should model appropriate unbiased behavior and language.
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Affiliation(s)
- Tajmohammad Arazi
- Department of Nursing and Operating Room, Neyshabur University of Medical Sciences, Neyshabur, Iran
| | - Sepideh Mohammadi
- Department of Nursing, Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran.
| | - Ali Movahedi
- Department of Anesthesia Nursing, Neyshabur University of Medical Sciences, Neyshabur, Iran
| | | | - Vahid Moeini
- Department of Operating Room, Neyshabur University of Medical Sciences, Neyshabur, Iran
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7
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Barber AT, Liptzin DR, Gower WA, Hinds DM. Pediatric Pulmonology 2022 year in review: Rare and diffuse lung disease. Pediatr Pulmonol 2023; 58:2719-2724. [PMID: 37493100 DOI: 10.1002/ppul.26603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/25/2023] [Accepted: 07/06/2023] [Indexed: 07/27/2023]
Abstract
The field of rare and diffuse pediatric lung disease continues to evolve and expand rapidly as clinicians and researchers make advancements in the diagnosis and treatment of children's interstitial and diffuse lung disease, non-cystic fibrosis bronchiectasis, and primary ciliary dyskinesia. Papers published on these topics in Pediatric Pulmonology and other journals in 2022 describe newly recognized disorders, elucidate disease mechanisms and courses, explore potential biomarkers, and assess novel treatments. In this review, we will discuss these important advancements and place them in the context of existing literature.
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Affiliation(s)
- Andrew T Barber
- Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Deborah R Liptzin
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - William A Gower
- Division of Pediatric Pulmonology and Program for Rare and Interstitial Lung Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Daniel M Hinds
- Department of Pediatrics, University of Iowa School of Medicine, Iowa City, Iowa, USA
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8
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Mills A, Frazier J, Plants R, Burrage E, Coblentz T, Nassabeh S, Robinson M, Chantler PD, Olfert IM. Effects of electronic cigarette E-liquid and device wattage on vascular function. Toxicol Appl Pharmacol 2023; 474:116631. [PMID: 37468077 PMCID: PMC10534201 DOI: 10.1016/j.taap.2023.116631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023]
Abstract
Electronic cigarettes (e-cigs) are customizable tobacco products that allow users to select e-liquid composition, flavors, and (in some devices) adjust wattage or heat used to generate e-cig aerosol. This study compared vascular outcomes in a conducting vessel (thoracic aorta) and a resistance artery (middle cerebral artery, MCA) in C57Bl/6 mice exposed to e-cig aerosol generated from either pure vegetable glycerin (VG) or pure propylene glycol (PG) over 60-min (Study 1), and separately the effect of using 5- vs. 30-watt settings with an exposure of 100-min (Study 2). In Study 1, aortic endothelial-dependent-dilation (EDD) was only impaired with PG- exposure (p < 0.05) compared with air. In the MCA, EDD response was impaired by ∼50% in both VG and PG groups compared with air (p < 0.05). In Study 2, the aortic EDD responses were not different for either 5- or 30-watt exposed groups compared with air controls; however, in the MCA, both 5- and 30-watt groups were impaired by 32% and 55%, respectively, compared with air controls (p < 0.05). These pre-clinical data provide evidence that chronic exposure to aerosol produced by either VG or PG, and regardless of the wattage used, leads to vascular dysfunction at multiple levels within the arterial system. For all exposures, we observed greater impairment of arterial reactivity in a resistance artery (i.e. MCA) compared with the aorta. These data could suggest the smaller arteries may be more sensitive or first to be affected, or that different mechanism(s) for impairment may be involved depending on arterial hierarchy.
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Affiliation(s)
- Amber Mills
- Department of Physiology, Pharmacology and Toxicology, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America; Center for Inhalation Toxicology, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America
| | - James Frazier
- Division of Exercise Physiology, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America
| | - Rachel Plants
- Division of Exercise Physiology, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America
| | - Emily Burrage
- Department of Neuroscience, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America
| | - Tyler Coblentz
- Division of Exercise Physiology, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America
| | - Sydney Nassabeh
- Division of Exercise Physiology, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America
| | - Madison Robinson
- Division of Exercise Physiology, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America
| | - Paul D Chantler
- Division of Exercise Physiology, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America; Department of Neuroscience, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America
| | - I Mark Olfert
- Department of Physiology, Pharmacology and Toxicology, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America; Center for Inhalation Toxicology, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America; Division of Exercise Physiology, West Virginia University School of Medicine, Morgantown, WV 26506, United States of America.
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9
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Heinly A, Walley S. The nicotine and tobacco epidemic among adolescents: new products are addicting our youth. Curr Opin Pediatr 2023; 35:513-521. [PMID: 37335268 DOI: 10.1097/mop.0000000000001271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
PURPOSE OF REVIEW New nicotine and tobacco products such as electronic cigarettes and oral nicotine products have increased in use and threaten to addict a new generation of youth. This review summarizes current literature on nicotine and tobacco products used by youth, epidemiology, health effects, prevention and treatment of nicotine dependence, and current policies and regulations. RECENT FINDINGS Electronic cigarettes and oral nicotine products are popular among youth, attracting adolescents through exposure to deceptive marketing and fruit, candy and dessert flavors. Electronic cigarettes and oral nicotine product use can lead to nicotine addiction and is associated with respiratory, cardiovascular, and oral health problems, although long-term health effects are not fully known. The Food and Drug Administration (FDA) has authority to regulate nicotine and tobacco products; however, thousands of unregulated and unauthorized products remain on the market. SUMMARY Millions of adolescents continue to use nicotine and tobacco products, which puts them at risk for health problems, including nicotine addiction. Pediatric providers can provide prevention messages, screen youth for tobacco and nicotine use, and offer appropriate treatment options. Regulation of tobacco and nicotine products by the FDA is critical to reverse this public health epidemic of youth nicotine and tobacco use.
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Affiliation(s)
- Allison Heinly
- Hasbro Children's Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Susan Walley
- Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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10
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Saha P, Jain S, Mukherjee I, Panda SR, Zeki AA, Naidu V, Sharma P. The effects of dual IQOS and cigarette smoke exposure on airway epithelial cells: implications for lung health and respiratory disease pathogenesis. ERJ Open Res 2023; 9:00558-2022. [PMID: 37260462 PMCID: PMC10227640 DOI: 10.1183/23120541.00558-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/15/2023] [Indexed: 02/25/2023] Open
Abstract
Background Cigarette smoking remains a primary cause of chronic lung diseases. After a steady decline, smoking rates have recently increased especially with the introduction of newer electronic nicotine delivery devices, and it is also emerging that dual- or poly-product usage is on the rise. Additionally, with the introduction of IQOS (a heated tobacco product) globally, its impact on human health needs to be investigated. In this study we tested if dual exposure (cigarette smoke (CS)+IQOS) is detrimental to lung epithelial cells when compared with CS or IQOS exposure alone. Methods Human airway epithelial cells (BEAS-2B) were exposed to either CS, IQOS or their dual combination (CS+IQOS) at concentrations of 0.1%, 1.0%, 2.5% and 5.0%. Cytotoxicity, oxidative stress, mitochondrial homeostasis, mitophagy and effects on epithelial-mesenchymal transition (EMT) signalling were assessed. Results Both CS and IQOS alone significantly induced loss of cell viability in a concentration-dependent manner which was further enhanced by dual exposure compared with IQOS alone (p<0.01). Dual exposure significantly increased oxidative stress and perturbed mitochondrial homeostasis when compared with CS or IQOS alone (p<0.05). Additionally, dual exposure induced EMT signalling as shown by increased mesenchymal (α-smooth muscle actin and N-cadherin) and decreased epithelial (E-cadherin) markers when compared with CS or IQOS alone (p<0.05). Conclusion Collectively, our study demonstrates that dual CS+IQOS exposure enhances pathogenic signalling mediated by oxidative stress and mitochondrial dysfunction leading to EMT activation, which is an important regulator of small airway fibrosis in obstructive lung diseases.
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Affiliation(s)
- Pritam Saha
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research Guwahati, Guwahati, India
- These authors contributed equally
| | - Siddhi Jain
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research Guwahati, Guwahati, India
- These authors contributed equally
| | - Ipsita Mukherjee
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research Guwahati, Guwahati, India
- These authors contributed equally
| | - Samir R. Panda
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research Guwahati, Guwahati, India
| | - Amir A. Zeki
- UC Davis School of Medicine, UC Davis Lung Center and Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California – Davis, Sacramento, CA, USA
| | - V.G.M. Naidu
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research Guwahati, Guwahati, India
| | - Pawan Sharma
- Center for Translational Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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11
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Harry-Hernandez S, Thiboutot J, Wahidi MM, Giovacchini CX, De Cardenas J, Meldrum C, Los JG, Illei PB, Shojaee S, Eissenberg T, DiBardino D, Giannini H, Maldonado F, Roller L, Yarmus LB, Kapp CM. Bronchoalveolar Lavage (BAL) and Pathologic Assessment of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): The EVALI-BAL Study, A Multicenter Cohort. J Bronchology Interv Pulmonol 2023; 30:144-154. [PMID: 35993570 DOI: 10.1097/lbr.0000000000000890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/27/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND E-cigarette or vaping-use related acute lung injury (EVALI) is a spectrum of radiographic and histologic patterns consistent with acute to subacute lung injury. However, limited data exist characterizing bronchoalveolar lavage (BAL) findings. The goal of this study is to further define the pathologic findings from BAL and biopsy samples of subjects with EVALI across 7 institutions. METHODS A multicentered registry of patients admitted with EVALI who underwent flexible bronchoscopy with BAL+/-transbronchial biopsy from July 2019 to April 2021 was compiled for retrospective evaluation from 7 academic institutions throughout the United States. Radiographic and cytopathologic findings and frequencies were correlated with the substance vaped. RESULTS Data from 21 subjects (42.9% women) who were predominantly White (76.2%) with a median age of 25 years (range, 16 to 68) with EVALI were included in this study. Sixteen patients (76.2%) reported use of tetrahydrocannabinol; the remainder used nicotine. BAL was performed in 19 of the 21 subjects, and transbronchial lung biopsy was performed in 7 subjects. BAL findings revealed neutrophilic predominance (median, 59.5%, range, 3.1 to 98) in most cases. Ten BAL samples demonstrated pulmonary eosinophilia ranging from 0.2% to 49.1% with one subject suggesting a diagnosis of acute eosinophilic pneumonia associated with the use of e-cigarettes. Lipid-laden macrophages were noted in 10 of 15 reports (66.7%). Transbronchial biopsy most frequently demonstrated patterns of organizing pneumonia (57.1%). CONCLUSION EVALI-associated BAL findings typically demonstrate a spectrum of nonspecific inflammatory changes, including neutrophilia, lipid-laden macrophages, and in some cases eosinophilia.
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Affiliation(s)
| | - Jeffrey Thiboutot
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - Momen M Wahidi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC
| | - Coral X Giovacchini
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC
| | - Jose De Cardenas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Catherine Meldrum
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Jenna G Los
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - Peter B Illei
- Division of Cytopathology, Department of Pathology, Johns Hopkins University Baltimore, MD
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine
| | - Thomas Eissenberg
- Department of Psychology, Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, VA
| | - David DiBardino
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Heather Giannini
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lance Roller
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lonny B Yarmus
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - Christopher M Kapp
- Division of Pulmonary, Department of Medicine, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL
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12
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Baiden P, Cavazos-Rehg P, Szlyk HS, Onyeaka HK, Peoples JE, Kasson E, Muoghalu C. Association between Sexual Violence Victimization and Electronic Vaping Product Use among Adolescents: Findings from a Population-based Study. Subst Use Misuse 2023; 58:637-648. [PMID: 36803403 DOI: 10.1080/10826084.2023.2177963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Although studies have investigated the association between sexual violence (SV) victimization and substance use, few studies have examined the association between SV victimization and electronic vaping product (EVP) use among adolescents in the United States. The objective of this study was to examine the cross-sectional association between SV victimization and EVP use among adolescents. METHODS Data were pooled from the 2017 and 2019 Youth Risk Behavior Survey. An analytic sample of 28,135 adolescents (51.2% female) was analyzed using binary logistic regression. The outcome variable investigated was EVP use, and the main explanatory variable was SV victimization. RESULTS Of the 28,135 adolescents, the prevalence of past 30-day EVP use and SV victimization was 22.7% and 10.8%, respectively. Controlling for other factors, adolescents who experienced SV had 1.52 times higher odds of being EVP users when compared to their counterparts who did not experience SV (AOR = 1.52, p < .001, 95% CI = 1.27-1.82). Other factors associated with EVP use included cyberbullying victimization, symptoms of depression, and current use of cigarettes, alcohol, and marijuana. CONCLUSIONS Experiencing SV was associated with EVP use. Future studies that employ longitudinal designs may offer more insight into the mechanisms underlying the association between SV victimization and EVP use. In addition, school-based interventions that focus on sexual violence prevention and reducing substance use among adolescents are warranted.
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Affiliation(s)
- Philip Baiden
- School of Social Work, The University of Texas at Arlington, Arlington, Texas, USA
| | - Patricia Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hannah S Szlyk
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Henry K Onyeaka
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, McLean Hospital, Boston, Massachusetts, USA
| | - JaNiene E Peoples
- The Brown School at Washington University in St. Louis, Missouri, USA
| | - Erin Kasson
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
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13
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Mendelsohn CP, Wodak A, Hall W. Nicotine vaping was not the cause of e-cigarette, or vaping, product use-associated lung injury in the United States. Drug Alcohol Rev 2023; 42:258-261. [PMID: 36000177 DOI: 10.1111/dar.13533] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/28/2022] [Accepted: 08/09/2022] [Indexed: 02/03/2023]
Affiliation(s)
| | - Alex Wodak
- Emeritus Consultant, Alcohol and Drug Service, St Vincent's Hospital Sydney, Australia
| | - Wayne Hall
- Centre for Youth Substance Abuse Research, University of Queensland, Brisbane, Australia
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14
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Benowitz NL, Havel C, Jacob P, O'Shea DF, Wu D, Fowles J. Vaping THC-O Acetate: Potential for Another EVALI Epidemic. J Med Toxicol 2023; 19:37-39. [PMID: 36508081 PMCID: PMC9813278 DOI: 10.1007/s13181-022-00921-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Neal L Benowitz
- University of California, San Francisco, USA.
- Zuckerberg San Francisco General Hospital, San Francisco, USA.
| | - Christopher Havel
- University of California, San Francisco, USA
- Zuckerberg San Francisco General Hospital, San Francisco, USA
| | - Peyton Jacob
- University of California, San Francisco, USA
- Zuckerberg San Francisco General Hospital, San Francisco, USA
| | | | - Dan Wu
- Dept of Chemistry, RCSI, Dublin 2, Ireland
| | - Jefferson Fowles
- Environmental Health Investigations Branch, California Department of Public Health, Richmond, CA, USA
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15
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Rebuli ME, Rose JJ, Noël A, Croft DP, Benowitz NL, Cohen AH, Goniewicz ML, Larsen BT, Leigh N, McGraw MD, Melzer AC, Penn AL, Rahman I, Upson D, Crotty Alexander LE, Ewart G, Jaspers I, Jordt SE, Kligerman S, Loughlin CE, McConnell R, Neptune ER, Nguyen TB, Pinkerton KE, Witek TJ. The E-cigarette or Vaping Product Use-Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:1-17. [PMID: 36584985 PMCID: PMC9819258 DOI: 10.1513/annalsats.202209-796st] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
E-cigarette or vaping product use-associated lung injury (EVALI) is a severe pulmonary illness associated with the use of e-cigarettes or vaping products that was officially identified and named in 2019. This American Thoracic Society workshop was convened in 2021 to identify and prioritize research and regulatory needs to adequately respond to the EVALI outbreak and to prevent similar instances of disease associated with e-cigarette or vaping product use. An interdisciplinary group of 26 experts in adult and pediatric clinical care, public health, regulatory oversight, and toxicology were convened for the workshop. Four major topics were examined: 1) the public health and regulatory response to EVALI; 2) EVALI clinical care; 3) mechanisms contributing to EVALI; and 4) needed actions to address the health effects of EVALI. Oral presentations and group discussion were the primary modes used to identify top priorities for addressing EVALI. Initiatives including a national EVALI case registry and biorepository, integrated electronic medical record coding system, U.S. Food and Drug Administration regulation and enforcement of nicotine e-cigarette standards, regulatory authority over nontobacco-derived e-cigarettes, training in evaluating exogenous exposures, prospective clinical studies, standardized clinical follow-up assessments, ability to more readily study effects of cannabinoid e-cigarettes, and research to identify biomarkers of exposure and disease were identified as critical needs. These initiatives will require substantial federal investment as well as changes to regulatory policy. Overall, the workshop identified the need to address the root causes of EVALI to prevent future outbreaks. An integrated approach from multiple perspectives is required, including public health; clinical, basic, and translational research; regulators; and users of e-cigarettes. Improving the public health response to reduce the risk of another substantial disease-inducing event depends on coordinated actions to better understand the inhalational toxicity of these products, informing the public of the risks, and developing and enforcing regulatory standards for all e-cigarettes.
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16
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Baiden P, Spoor SP, Nicholas JK, Brown FA, LaBrenz CA, Spadola C. Association between use of electronic vaping products and insufficient sleep among adolescents: Findings from the 2017 and 2019 YRBS. Sleep Med 2023; 101:19-27. [PMID: 36334497 DOI: 10.1016/j.sleep.2022.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/13/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Although studies have investigated the association between cigarette smoking and sleep outcomes among adolescents in the United States, few studies have examined the association between electronic vaping products (EVPs) use and insufficient sleep among adolescents. The objective of this study was to investigate the cross-sectional association between the use of EVPs and insufficient sleep among adolescents. METHODS Data were pooled from the 2017 and 2019 Youth Risk Behavior Survey. An analytic sample of 28,135 adolescents (51.2% female) was analyzed using binary logistic regression. The dependent variable investigated was insufficient sleep, and the main independent variable was the use of EVPs. RESULTS Of the 28,135 adolescents, 22.6%, 19.2%, and 58.2% were current, former, and never users of EVPs, respectively. More than three in four adolescents (76.5%) did not obtain the recommended 8 h of sleep on an average school night. Controlling for demographic factors and other covariates, adolescents who currently used EVPs had 1.33 times higher odds of having insufficient sleep (AOR = 1.33, p < .001, 95% CI = 1.16-1.52), and adolescents who previously used EVPs had 1.29 times higher odds of having insufficient sleep (AOR = 1.29, p < .001, 95% CI = 1.15-1.44) when compared to adolescents who had never used EVPs. Adolescents were more likely to get insufficient sleep if they were older, non-Hispanic Black, had symptoms of depression, experienced suicidal ideation, engaged in excessive screen-time behaviors, or currently used alcohol. Physical activity had a protective effect on insufficient sleep. CONCLUSION This study found that EVPs use was associated with insufficient sleep among adolescents over and above demographic and other covariates. As EVP use increases among adolescents, it is important to consider the potential impact on multiple domains, including sleep. Future studies that employ longitudinal designs may offer additional insight into the mechanisms underlying the association between EVPs use and insufficient sleep.
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Affiliation(s)
- Philip Baiden
- The University of Texas at Arlington, School of Social Work, 211 S. Cooper St, Box 19129, Arlington, TX, 76019, USA.
| | - Samantha P Spoor
- University of Wyoming, Department of Psychology, 1000 E. University Ave, Laramie, WY, 82071, USA
| | - Julia K Nicholas
- University of Louisville, Department of Psychological and Brain Sciences, Room 307 Life Sciences Building, Louisville, KY, 40292, USA
| | - Fawn A Brown
- The University of Texas at Arlington, Department of Psychology, 501 Nedderman Dr, Box 19528, Arlington, TX, 76019, USA
| | - Catherine A LaBrenz
- The University of Texas at Arlington, School of Social Work, 211 S. Cooper St, Box 19129, Arlington, TX, 76019, USA
| | - Christine Spadola
- The University of Texas at Arlington, School of Social Work, 211 S. Cooper St, Box 19129, Arlington, TX, 76019, USA
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17
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Rose JJ, Rebuli ME, Noël A, Croft DP. Clearing Some of the Haze around E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI). Ann Am Thorac Soc 2022; 19:1805-1807. [PMID: 36318078 PMCID: PMC9667805 DOI: 10.1513/annalsats.202208-685ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Jason J Rose
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Meghan E Rebuli
- Center for Environmental Medicine, Asthma, and Lung Biology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alexandra Noël
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana; and
| | - Daniel P Croft
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, New York
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18
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Boakye E, El Shahawy O, Obisesan O, Dzaye O, Osei AD, Erhabor J, Uddin SMI, Blaha MJ. The inverse association of state cannabis vaping prevalence with the e-cigarette or vaping product-use associated lung injury. PLoS One 2022; 17:e0276187. [PMID: 36251673 PMCID: PMC9576092 DOI: 10.1371/journal.pone.0276187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 09/30/2022] [Indexed: 11/28/2022] Open
Abstract
The e-cigarette or vaping product-use-associated lung injury (EVALI) epidemic was primarily associated with the use of e-cigarettes containing tetrahydrocannabinol (THC)- the principal psychoactive substance in cannabis, and vitamin-E-acetate- an additive sometimes used in informally sourced THC-containing e-liquids. EVALI case burden varied across states, but it is unclear whether this was associated with state-level cannabis vaping prevalence. We, therefore, used linear regression models to assess the cross-sectional association between state-level cannabis vaping prevalence (obtained from the 2019 behavioral Risk Factor Surveillance System) and EVALI case burden (obtained from the Centers for Disease Control and Prevention) adjusted for state cannabis policies. Cannabis vaping prevalence ranged from 1.14%(95%CI, 0.61%-2.12%) in Wyoming to 3.11%(95%CI, 2.16%-4.44%) in New Hampshire. EVALI cases per million population ranged from 1.90(0.38-3.42) in Oklahoma to 59.10(19.70-96.53) in North Dakota. There was no significant positive association but an inverse association between state cannabis vaping prevalence and EVALI case burden (Coefficient, -18.6; 95%CI, -37.5-0.4; p-value, 0.05). Thus, state-level cannabis vaping prevalence was not positively associated with EVALI prevalence, suggesting that there may not be a simple direct link between state cannabis vaping prevalence and EVALI cases, but rather the relationship is likely more nuanced and possibly reflective of access to informal sources of THC-containing e-cigarettes.
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Affiliation(s)
- Ellen Boakye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, United States of America
- The American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX, United States of America
| | - Omar El Shahawy
- The American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX, United States of America
- Department of Population Health, New York University School of Medicine, New York, NY, United States of America
| | - Olufunmilayo Obisesan
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD, United States of America
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, United States of America
| | - Albert D. Osei
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD, United States of America
| | - John Erhabor
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, United States of America
- The American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX, United States of America
| | - S. M. Iftekhar Uddin
- Department of Medicine, Brookdale University Hospital Medical Center, Brooklyn, NY, United States of America
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, United States of America
- The American Heart Association Tobacco Regulation and Addiction Center, Dallas, TX, United States of America
- * E-mail:
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19
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Kreski NT, Cerdá M, Chen Q, Hasin DS, Martins SS, Mauro PM, Olfson M, Keyes KM. Adolescents' Use of Free Time and Associations with Substance Use from 1991 to 2019. Subst Use Misuse 2022; 57:1893-1903. [PMID: 36127772 PMCID: PMC9746067 DOI: 10.1080/10826084.2022.2115849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Understanding time trends in risk factors for substance use may contextualize and explain differing time trends in substance use. Methods: We examined data (N = 536,291; grades 8/10/12) from Monitoring the Future, years 1991-2019. Using Latent Profile Analyses, we identified six time use patterns: one for those working at a paid job and the other five defined by levels of socialization (low/high) and engagement in structured activities like sports (engaged/disengaged), with the high social/engaged group split further by levels of unsupervised social activities. We tested associations between time use profiles and past two-week binge drinking as well as past-month alcohol use, cigarette use, cannabis use, other substance use, and vaping. We examined trends and group differences overall and by decade (or for vaping outcomes, year). Results: Prevalence of most substance use outcomes decreased over time among all groups. Cannabis use increased, with the largest increase in the group engaged in paid employment. Vaping substantially increased, with the highest nicotine vaping increase in the high social/engaged group with less supervision and the highest cannabis vaping increase in the highly social but otherwise disengaged group. Substance use was lowest in the low social groups, highest in the high social and employed groups. Conclusions: While alcohol, cigarette, and other substance use have declined for all groups, use remained elevated given high levels of social time, especially with low engagement in structured activities or low supervision, or paid employment. Cannabis use and vaping are increasing across groups, suggesting the need for enhanced public health measures.
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Affiliation(s)
- Noah T Kreski
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Magdalena Cerdá
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Qixuan Chen
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Deborah S Hasin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
- Department of Psychiatry, New York State Psychiatric Institute, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York, USA
| | - Silvia S Martins
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Pia M Mauro
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Mark Olfson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
- Department of Psychiatry, New York State Psychiatric Institute, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York, USA
| | - Katherine M Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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20
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Wick KD, Fang X, Maishan M, Matsumoto S, Spottiswoode N, Sarma A, Simoneau C, Khakoo M, Langelier C, Calfee CS, Gotts JE, Matthay MA. Impact of e-cigarette aerosol on primary human alveolar epithelial type 2 cells. Am J Physiol Lung Cell Mol Physiol 2022; 323:L152-L164. [PMID: 35670478 PMCID: PMC9559034 DOI: 10.1152/ajplung.00503.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 05/03/2022] [Accepted: 06/01/2022] [Indexed: 11/22/2022] Open
Abstract
Electronic cigarettes (e-cigarettes) are designed to simulate combustible cigarette smoking and to aid in smoking cessation. Although the number of e-cigarette users has been increasing, the potential health impacts and biological effects of e-cigarettes are still not fully understood. Previous research has focused on the biological effects of e-cigarettes on lung cancer cell lines and distal airway epithelial cells; however, there have been few published studies on the effect of e-cigarettes on primary lung alveolar epithelial cells. The primary purpose of this study was to investigate the direct effect of e-cigarette aerosol on primary human lung alveolar epithelial type 2 (AT2) cells, both alone and in the presence of viral infection. The Melo-3 atomizer caused direct AT2 cell toxicity, whereas the more popular Juul pod's aerosol did not have a detectable cytotoxic effect on AT2 cells. Juul nicotine aerosol also did not increase short-term susceptibility to viral infection. However, 3 days of exposure upregulated genes central to the generation of reactive oxygen species, lipid peroxidation, and carcinogen metabolism and downregulated key innate immune system genes related to cytokine and chemokine signaling. These findings have implications for the potentially injurious impact of long-term use of popular low-power e-cigarette pods on the human alveolar epithelium. Gene expression data might be an important endpoint for evaluating the potential harmful effects of vaping devices that do not cause overt toxicity.
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Affiliation(s)
- Katherine D Wick
- Cardiovascular Research Institute, University of California, San Francisco, California
| | - Xiaohui Fang
- Cardiovascular Research Institute, University of California, San Francisco, California
| | - Mazharul Maishan
- Cardiovascular Research Institute, University of California, San Francisco, California
| | - Shotaro Matsumoto
- Cardiovascular Research Institute, University of California, San Francisco, California
| | - Natasha Spottiswoode
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, California
| | - Aartik Sarma
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California
| | - Camille Simoneau
- Gladstone Institutes, University of California, San Francisco, California
| | - Manisha Khakoo
- Cardiovascular Research Institute, University of California, San Francisco, California
| | - Chaz Langelier
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, California
- Chan Zuckerberg Biohub, San Francisco, California
| | - Carolyn S Calfee
- Cardiovascular Research Institute, University of California, San Francisco, California
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, California
| | - Jeffrey E Gotts
- Cardiovascular Research Institute, University of California, San Francisco, California
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco, California
- Department of Medicine, University of California, San Francisco, California
- Department of Anesthesia, University of California, San Francisco, California
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21
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Keyes KM, Kreski NT, Ankrum H, Cerdá M, Chen Q, Hasin DS, Martins SS, Olfson M, Miech R. Frequency of adolescent cannabis smoking and vaping in the United States: Trends, disparities and concurrent substance use, 2017-19. Addiction 2022; 117:2316-2324. [PMID: 35588004 PMCID: PMC10037679 DOI: 10.1111/add.15912] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/07/2022] [Indexed: 01/24/2023]
Abstract
AIM To quantify the trends in frequent and occasional cannabis vaping, demographic differences and concurrent nicotine and alcohol use. DESIGN Observational study. Survey-weighted multinomial logistic regression models assessed trends and disparities in past 30-day cannabis use. Trends were assessed overall and by sex, race/ethnicity, parental education and urbanicity. Multinomial logistic regression models also estimated associations of cannabis use (none, use without vaping, use with vaping) with past 2-week binge drinking and past 30-day nicotine/tobacco use. SETTING United States, 2017-19. PARTICIPANTS Participants in the national Monitoring the Future (n = 51 052) survey. MEASUREMENTS Past 30-day frequent cannabis use (six or more times/30 days) and past 30-day occasional use (one to five times/30 days), with and without vaping. FINDINGS Past 30-day frequent cannabis use with vaping and occasional use with vaping rose from 2017 to 2019. Past 30-day frequent and occasional cannabis use without vaping declined. Certain groups, such as Hispanic/Latino or lower socio-economic status adolescents, experienced particularly notable increases in frequent cannabis use with vaping (e.g. prevalence among Hispanic/Latino adolescents). Adolescents who reported smoking and vaping nicotine, and 10+ occasions of binge drinking, were 42.28 [95% confidence interval (CI) = 33.14-53.93] and 10.09 (95% CI = 4.51-22.53) times more likely to report past 30-day cannabis use with vaping, respectively, compared with no use. DISCUSSION Cannabis use without vaping appears to be declining among adolescents in the United States, while cannabis use with vaping is accelerating; frequent cannabis vaping is especially increasing, with consistent increases across almost all adolescent demographic groups. Cannabis use among US adolescents remains highly associated with other substance use.
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Affiliation(s)
- Katherine M. Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Noah T. Kreski
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Hadley Ankrum
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Magdalena Cerdá
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Qixuan Chen
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Deborah S. Hasin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Psychiatry, New York State Psychiatric Institute, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Silvia S. Martins
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Mark Olfson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- Department of Psychiatry, New York State Psychiatric Institute, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Richard Miech
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
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22
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Abstract
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.
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Affiliation(s)
- Judith Groner
- Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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23
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Vaping-Associated Lung Injury: A Review. Medicina (B Aires) 2022; 58:medicina58030412. [PMID: 35334588 PMCID: PMC8949983 DOI: 10.3390/medicina58030412] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/01/2022] [Accepted: 03/07/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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24
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Marrocco A, Singh D, Christiani DC, Demokritou P. E-cigarette vaping associated acute lung injury (EVALI): state of science and future research needs. Crit Rev Toxicol 2022; 52:188-220. [PMID: 35822508 PMCID: PMC9716650 DOI: 10.1080/10408444.2022.2082918] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/19/2022] [Accepted: 05/19/2022] [Indexed: 11/03/2022]
Abstract
"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.
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Affiliation(s)
- Antonella Marrocco
- Center for Nanotechnology and Nanotoxicology, T.H. Chan School of Public Health, Harvard University, 665 Huntington Ave., Boston, MA 02115, USA
| | - Dilpreet Singh
- Center for Nanotechnology and Nanotoxicology, T.H. Chan School of Public Health, Harvard University, 665 Huntington Ave., Boston, MA 02115, USA
| | - David C. Christiani
- Center for Nanotechnology and Nanotoxicology, T.H. Chan School of Public Health, Harvard University, 665 Huntington Ave., Boston, MA 02115, USA
| | - Philip Demokritou
- Center for Nanotechnology and Nanotoxicology, T.H. Chan School of Public Health, Harvard University, 665 Huntington Ave., Boston, MA 02115, USA
- Environmental Occupational Health Sciences Institute, School of Public Health, Rutgers University, 170 Piscataway, NJ 08854, USA
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Canchola A, Sabbir Ahmed C, Chen K, Chen JY, Lin YH. Formation of Redox-Active Duroquinone from Vaping of Vitamin E Acetate Contributes to Oxidative Lung Injury. Chem Res Toxicol 2022; 35:254-264. [PMID: 35077135 PMCID: PMC8860880 DOI: 10.1021/acs.chemrestox.1c00309] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In late 2019, the outbreak of e-cigarette or vaping-associated lung injuries (EVALIs) in the United States demonstrated to the public the potential health risks of vaping. While studies since the outbreak have identified vitamin E acetate (VEA), a diluent of tetrahydrocannabinol (THC) in vape cartridges, as a potential contributor to lung injuries, the molecular mechanisms through which VEA may cause damage are still unclear. Recent studies have found that the thermal degradation of e-liquids during vaping can result in the formation of products that are more toxic than the parent compounds. In this study, we assessed the role of duroquinone (DQ) in VEA vaping emissions that may act as a mechanism through which VEA vaping causes lung damage. VEA vaping emissions were collected and analyzed for their potential to generate reactive oxygen species (ROS) and induce oxidative stress-associated gene expression in human bronchial epithelial cells (BEAS-2B). Significant ROS generation by VEA vaping emissions was observed in both acellular and cellular systems. Furthermore, exposure to vaping emissions resulted in significant upregulation of NQO1 and HMOX-1 genes in BEAS-2B cells, indicating a strong potential for vaped VEA to cause oxidative damage and acute lung injury; the effects are more profound than exposure to equivalent concentrations of DQ alone. Our findings suggest that there may be synergistic interactions between thermal decomposition products of VEA, highlighting the multifaceted nature of vaping toxicity.
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Affiliation(s)
- Alexa Canchola
- Environmental Toxicology Graduate Program, University of California, Riverside, CA, USA
| | - C.M. Sabbir Ahmed
- Environmental Toxicology Graduate Program, University of California, Riverside, CA, USA
| | - Kunpeng Chen
- Department of Environmental Sciences, University of California, Riverside, CA, USA
| | - Jin Y. Chen
- Environmental Toxicology Graduate Program, University of California, Riverside, CA, USA
| | - Ying-Hsuan Lin
- Environmental Toxicology Graduate Program, University of California, Riverside, CA, USA,Department of Environmental Sciences, University of California, Riverside, CA, USA,Corresponding Author Ying-Hsuan Lin - Department of Environmental Sciences, University of California, Riverside, California 92521, United States; Environmental Toxicology Graduate Program, University of California, Riverside, California 92521, United States; Phone: +1-951-827-3785,
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26
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Shelton CM, Black H, Proctor J, Hagemann TM. A Comprehensive Review of Vaping Use in Pediatric Patients and Recent Changes in Regulatory Laws. J Pediatr Pharmacol Ther 2022; 27:109-119. [DOI: 10.5863/1551-6776-27.2.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/09/2021] [Indexed: 11/11/2022]
Abstract
The use of electronic cigarettes (e-cigarettes), also known as vapes, by adolescents and young adults has dramatically increased over the past several years. E-cigarettes continue to be the most used form of tobacco among youth. As a result of this concerning trend, policies at both the state and federal levels have been implemented to limit availability in this population. Additionally, the coronavirus disease 2019 (COVID-19) pandemic has had some positive and negative effects on the youth vaping epidemic with adolescent consumers reporting limited access to retail sites during the stay-at-home executive orders, but easier access with online purchasing because age verification was often not required. Complications resulting from vaping have been reported and include e-cigarette or vaping product use–associated lung injury (EVALI) and thrombotic events. Data suggest that the use of vaping devices can lead to both short- and long-term respiratory morbidity in the pediatric population. This review serves to provide a comprehensive examination of vaping use in pediatric patients and recent changes in regulatory laws to equip pharmacists with the knowledge to be aware of the different devices and products available, ask their pediatric patients regularly about use, and counsel and educate on the potential harmful effects.
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Affiliation(s)
- Chasity M. Shelton
- Department of Clinical Pharmacy and Translational Science (CMS, TMH), The University of Tennessee Health Science Center, Memphis, TN
| | - Haley Black
- College of Pharmacy (HB, JP), The University of Tennessee Health Science Center, Memphis, TN
| | - Johnathon Proctor
- College of Pharmacy (HB, JP), The University of Tennessee Health Science Center, Memphis, TN
| | - Tracy M. Hagemann
- Department of Clinical Pharmacy and Translational Science (CMS, TMH), The University of Tennessee Health Science Center, Memphis, TN
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Schaffer S, Strang A, Saul D, Krishnan V, Chidekel A. Adolescent E-cigarette or Vaping Use-Associated Lung Injury in the Delaware Valley: A Review of Hospital-Based Presentation, Management, and Outcomes. Cureus 2022; 14:e21988. [PMID: 35282521 PMCID: PMC8906560 DOI: 10.7759/cureus.21988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 11/15/2022] Open
Abstract
E-cigarette or vaping use-associated lung injury (EVALI) remains a major concern due to ongoing use of nicotine and/or cannabis-containing products and resulting acute lung injury. There are few published reports describing the clinical features, comorbidities, severity of disease, and outcomes of treatment in adolescents. This report describes the experience of a single tertiary care children’s hospital in the Delaware Valley and reviews data from all patients diagnosed with EVALI in the emergency department and inpatient setting from July 2019 to June 2021 at the Nemours Children’s Hospital in Wilmington, Delaware. Demographic, clinical, therapeutic, diagnostic features, and outcomes are presented. Abstinence and steroids improved outcomes in our population. Obtaining a vaping history, negative infectious testing, elevated inflammatory markers, and characteristic computed tomography findings were key to making the diagnosis of EVALI.
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Brosius C, Caron KT, Sosnoff CS, Blount BC, Wang L. Rapid Development and Validation of a Liquid Chromatography-Tandem Mass Spectrometry Method to Measure Cannabinoids in Bronchoalveolar-Lavage Fluid of Patients with e-Cigarette, or Vaping, Product Use-Associated Lung Injury. ACS OMEGA 2022; 7:443-452. [PMID: 35036713 PMCID: PMC8756437 DOI: 10.1021/acsomega.1c04815] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/16/2021] [Indexed: 06/14/2023]
Abstract
In 2019, the Centers for Disease Control and Prevention responded to an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). Bronchoalveolar-lavage (BAL) fluid from EVALI patients was available for analysis to investigate a range of potential toxicants that might be present at the presumed site of lung injury. Our laboratory developed and validated a novel method to measure cannabinoids and their metabolites in BAL fluid to aid in the investigation of the toxicants that might be the cause of EVALI. In this paper, we describe a sensitive liquid chromatography-tandem mass spectrometry method to measure the following six cannabinoids: Δ9-tetrahydrocannabinol (THC), THC metabolites 11-nor-9-carboxy-THC and 11-hydroxy-THC, cannabinol, cannabidiol (CBD), and CBD metabolite 7-nor-7-carboxycannabidiol. Cannabinoids were extracted from BAL fluid using solid-phase extraction. Accuracy, precision, stability, and limits of detection were determined from replicate analyses of spiked BAL pools. The lower limits of detection ranged from 0.019 to 0.153 ng/mL for a sample volume of 150 μL. Overall accuracy ranged from 71.0 to 100.8%. Within-run imprecision (measured by the coefficient of variation) was below 8%, and between-run imprecision was below 21% for all analytes and concentrations tested. The method was applied to samples from 59 EVALI case patients. We identified THC, CBD, or their metabolites in 76% of EVALI patient samples. These findings support previous evidence that THC-containing products played a major role in the EVALI outbreak and help to inform public health recommendations.
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Ismail ALS, Imaduddeen T, Ibrahim WH. Electronic Cigarette or Vaping Product Use-Associated Lung Injury in a Previously Healthy Young Male. Cureus 2021; 13:e18269. [PMID: 34722048 PMCID: PMC8545557 DOI: 10.7759/cureus.18269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2021] [Indexed: 11/05/2022] Open
Abstract
Vaping (i.e., the use of electronic cigarettes) has been gaining popularity among people for the past few years, perhaps due to the misconception that its use is less harmful than traditional cigarettes. Although the long-term effects of these products are still unknown, it has been shown that they can be implicated in acute lung injury in healthy people. In 2019, an epidemic of severe acute lung injury was reported in the United States, and it was linked to vaping or electronic cigarette use and was referred to as e-cigarette or vaping product use-associated lung injury (EVALI). Here, we present the first case of EVALI in the state of Qatar.
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Affiliation(s)
| | - Tahir Imaduddeen
- Internal Medicine Department, Hamad Medical Corporation, Doha, QAT
| | - Wanis H Ibrahim
- Internal Medicine Department, Hamad Medical Corporation, Doha, QAT
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Morean ME, Davis DR, Kong G, Bold KW, Camenga DR, Suttiratana S, Lee J, Rajeshkumar L, Krishnan-Sarin S. Demographic and substance use-related differences among high school adolescents who vape cannabis versus use other cannabis modalities. Drug Alcohol Depend 2021; 228:109104. [PMID: 34607191 PMCID: PMC8595758 DOI: 10.1016/j.drugalcdep.2021.109104] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/07/2021] [Accepted: 09/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Vaping is the second most common modality of using cannabis following smoking. We examined differences in demographics and substance use behaviors between adolescent cannabis vapers and those exclusively using other cannabis modalities. METHODS In 2019, 4875 students from six Connecticut high schools completed school-wide, online surveys. Past-month cannabis users (n = 931; 52.8% female, 16.38(1.27) years old, 44.9% non-Hispanic White) reported on cannabis modalities used (e.g., combustible, vaporizable, edible) and were classified as cannabis vapers or non-vapers. Cannabis vapers reported on device type used to vape cannabis: a cannabis-specific device or modified/hacked e-cigarette. Unadjusted and adjusted relationships were examined to identify demographic and substance-related differences between cannabis vapers and non-vapers. RESULTS 56.3% of past-month cannabis users reported vaping cannabis. Cannabis vapers reported using both cannabis-specific vaporizers (91.9%) and modifying/hacking e-cigarettes (23.7%). Cannabis vapers, relative to other cannabis users, were more likely to be male, White, initiate cannabis use at a younger age; endorse past-month use of all cannabis modalities, alcohol, and e-cigarettes; and report smoking and dabbing cannabis more frequently; consuming more drinks per drinking day; and using e-cigarettes at a younger age and more frequently. CONCLUSIONS Relative to other cannabis modalities, vaping was associated with increased use of several cannabis products and other substances. Adolescent past-month cannabis users reported modifying e-cigarettes to vape cannabis. Findings suggest that regulations should be implemented to prevent e-cigarettes from being modifiable for use with cannabis and highlight the importance of assessing different cannabis use modalities, as vaping was associated with distinct substance-related risks.
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Affiliation(s)
- Meghan E. Morean
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT, 06519, USA,Corresponding author:
| | - Danielle R. Davis
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT, 06519, USA
| | - Grace Kong
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT 06519, USA.
| | - Krysten W. Bold
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT, 06519, USA
| | - Deepa R. Camenga
- Yale School of Medicine, Dept. of Emergency Medicine, 464 Congress Avenue (Suite 260), New Haven, CT, 06519, USA
| | - Sakinah Suttiratana
- Yale School of Public Health, Dept. of Chronic Disease Epidemiology, 60 College Street, New Haven, CT 06520, USA.
| | - Juhan Lee
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT 06519, USA.
| | - Lavanya Rajeshkumar
- Yale School of Medicine, Dept. of Psychiatry, 34 Park Street, New Haven, CT 06519, USA.
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31
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Ciolino LA, Ranieri TL, Brueggemeyer JL, Taylor AM, Mohrhaus AS. EVALI Vaping Liquids Part 1: GC-MS Cannabinoids Profiles and Identification of Unnatural THC Isomers. Front Chem 2021; 9:746479. [PMID: 34631667 PMCID: PMC8499677 DOI: 10.3389/fchem.2021.746479] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
Tetrahydrocannabinol (THC)-containing products played a major role in the 2019 US nationwide outbreak of pulmonary lung illness associated with e-cigarettes or vaping liquids (EVALI). Due to the severity of the illness which resulted in 68 deaths, a comprehensive identification of the components in the vaping liquids was required. Our laboratory received over 1000 vaping liquid products for analysis including hundreds of vaping products from EVALI patients. In this work, we present the results for the GC-MS identification of the cannabinoids from a large subset of ca. 300 Cannabis-based vaping liquids, with emphasis on the identification of a series of unnatural THC isomers. GC-MS analysis was conducted using a validated, published method in which the cannabinoids were identified as the trimethylsilyl derivatives after separation on a commercial 35% silphenylene phase. Δ9- Tetrahydrocannabinol is the naturally occurring THC isomer found in the Cannabis plant, and was found in the majority of the vaping liquids. However, we also identified the presence of one or more additional THC isomers in many of the vaping liquids including Δ8-tetrahydrocannabinol, Δ6a,10a-tetrahydrocannabinol, Δ10-tetrahydrocannabinol, and exo-tetrahydrocannabinol. Significant or major amounts of unnatural THC isomers were found in over 10% of the THC vaping liquids, with lesser amounts found in another 60% of the vaping liquids. Exposure of the Cannabis source materials (such as marijuana concentrates or converted hemp materials) to chemical and thermal treatments during manufacturing, is proposed as the primary cause for the THC isomerizations.
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Affiliation(s)
- Laura A Ciolino
- Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, OH, United States
| | - Tracy L Ranieri
- Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, OH, United States
| | - Jana L Brueggemeyer
- Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, OH, United States
| | - Allison M Taylor
- Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, OH, United States
| | - Angela S Mohrhaus
- Forensic Chemistry Center, US Food and Drug Administration, Cincinnati, OH, United States
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32
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Shah M, Bryant MK, Mody GN, Maine RG, Williams JB, Upham TC. The Impact of Vaping on Primary Spontaneous Pneumothorax Outcomes. Am Surg 2021:31348211048849. [PMID: 34617455 DOI: 10.1177/00031348211048849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Cigarette smoking is associated with primary spontaneous pneumothorax (PSP). Electronic cigarettes (E-cigarettes) are touted as a healthier alternative to cigarettes; however, the impact E-cigarette use has on PSP management is not known. The goal of this study was to determine if E-cigarette use is associated with inferior outcomes after PSP, compared to never smokers and cigarette smokers. METHODS We conducted a retrospective cohort study of patients in a large tertiary care hospital system in an urban area who presented with PSP from September 2015 through February 2019. Primary spontaneous pneumothorax patients were identified from the institutional Society of Thoracic Surgeon (STS) database. Patients with pneumothoraces from traumatic, iatrogenic, and secondary etiologies were excluded. Baseline clinical and demographic data and outcomes including intervention(s) required, length of stay, and recurrence were evaluated. RESULTS Identified were 71 patients with PSP. Seventeen (24%) had unverifiable smoking history. Of the remaining, 7 (13%) currently vaped, 27(50%) currently smoked cigarettes, and 20(37%) were never smokers. Mean age was 33 years; 80% male. All vapers required tube thoracostomy vs 74% of current smokers and 75% of never smokers. Vaping was associated with increased odds of recurrence compared to never smokers (OR 2.00, 95% CI 0.35,11.44). Vapers had the shortest median time to recurrence after initial hospitalization (10 d[4,18] v 20 d[5,13] cigarette smokers v 27 d[13 275] never smokers, P < .001). CONCLUSION Vaping may complicate PSP outcomes. As vaping use increases, especially among adolescents, it is imperative that the manner of tobacco use is documented and considered when caring for patients, especially those with pulmonary problems.
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Affiliation(s)
- Mohsin Shah
- Department of Surgery, 2332University of North Carolina, Chapel Hill, NC, USA
| | - Mary K Bryant
- Department of Surgery, 2332University of North Carolina, Chapel Hill, NC, USA.,Department of General Surgery/Trauma, 10848WakeMed Health & Hospitals, Raleigh, NC, USA
| | - Gita N Mody
- Department of Surgery, 2332University of North Carolina, Chapel Hill, NC, USA
| | - Rebecca G Maine
- Department of Surgery, 312784University of Washington, Seattle, WA, USA
| | - Judson B Williams
- Department of General Surgery/Trauma, 10848WakeMed Health & Hospitals, Raleigh, NC, USA
| | - Trevor C Upham
- Department of General Surgery/Trauma, 10848WakeMed Health & Hospitals, Raleigh, NC, USA.,Department of Surgery, Duke University, Durham, NC, USA
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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). Addict Behav 2021; 121:106990. [PMID: 34087764 DOI: 10.1016/j.addbeh.2021.106990] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/09/2021] [Accepted: 05/12/2021] [Indexed: 01/20/2023]
Abstract
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.
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34
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Lee J, Kong G, Kassas B, Salloum RG. Predictors of vaping marijuana initiation among US adolescents: Results from the Population Assessment of Tobacco and Health (PATH) study Wave 3 (2015-2016) and Wave 4 (2016-2018). Drug Alcohol Depend 2021; 226:108905. [PMID: 34304122 DOI: 10.1016/j.drugalcdep.2021.108905] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/04/2021] [Accepted: 05/29/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Marijuana vaping among adolescents is a growing public health concern. Marijuana vaping exposes youth to greater levels of tetrahydrocannabinol (THC) and may be related to e-cigarette or vaping product use-associated lung injury (EVALI). This study examined the risk factors for initiating marijuana vaping among US adolescents. METHODS We analyzed Waves 3 (2015-2016) and 4 (2016-2018) of the Population Assessment of Tobacco and Health (PATH) Study. We estimate a multivariable logistic regression to model marijuana vaping initiation at Wave 4 among those who never vaped marijuana at Wave 3 (N = 7,821) as a function of key risk factors associated with youth substance use. RESULTS Marijuana vaping initiation is associated with current use of electronic nicotine delivery system (ENDS) (aOR = 2.16, 95 % CI = 1.20, 3.89), cigarettes (aOR = 2.65, 95 % CI = 1.10, 6.35), other marijuana products (aOR = 7.78, 95 % CI = 3.74, 6.15), and alcohol (aOR = 1.98, 95 % CI = 1.35, 2.91). Other factors contributing to marijuana vaping initiation include being 15-17 years old (aOR = 1.51, 95 % CI = 1.19, 1.90) and Hispanic (aOR = 1.37, 95 % CI = 1.08, 1.76), as well as having less than college-level parental education (aOR = 1.35, 95 % CI = 1.07, 1.70), vaping peers (aOR = 2.31; 95 % CI = 1.81, 2.96), and a high internalizing (aOR = 1.49, 95 % CI = 1.10, 2.02) and externalizing tendency (aOR = 1.66, 95 % CI = 1.14, 2.41). CONCLUSIONS Multi-level efforts are needed to target the varying risk factors leading to marijuana vaping initiation in adolescents. Knowledge of these risk factors can help policymakers and health program administrators to identify at-risk individuals and design interventions that can prevent marijuana vaping initiation at the individual, household, school, clinical and public health levels.
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Affiliation(s)
- Juhan Lee
- Department of Psychiatry, Yale School of Medicine, United States.
| | - Grace Kong
- Department of Psychiatry, Yale School of Medicine, United States.
| | - Bachir Kassas
- Department of Food and Resource Economics, Institute of Food and Agricultural Sciences, University of Florida, United States.
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, United States.
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Puetz A, Morel Espinosa M, Watson C, Blount BC, Valentín-Blasini L. Development, Validation, and Application of a Novel Method for the Analysis of Vitamin E Acetate and Other Tocopherols in Aerosol Emissions of E-Cigarettes, or Vaping Products Associated With Lung Injury. Front Chem 2021; 9:730954. [PMID: 34422773 PMCID: PMC8374938 DOI: 10.3389/fchem.2021.730954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/26/2021] [Indexed: 11/22/2022] Open
Abstract
E-cigarette, or vaping, product (EVP) use has increased dramatically in the United States over the last 4 years, particularly in youth and young adults. Little information is available on the chemical contents of these products. Typically, EVPs contain an active ingredient such as nicotine, CBD, or THC dissolved in a suitable solvent that facilitates aerosol generation. One EVP solvent, vitamin E acetate (VEA), has been measured in EVP liquids associated with lung injury. However, no validated analytical methods for measuring VEA in the aerosol from these devices was previously available. Therefore, we developed a high throughput isotope dilution LC-MS/MS method to simultaneously measure VEA and three other related tocopherols in aerosolized EVP samples. The assay was precise, with VEA repeatability ranging from 4.0 to 8.3% and intermediate precision ranging from 2.5 to 6.7%. Similar precision was obtained for the three other tocopherols measured. The LODs for the four analytes ranged from 8.85 × 10−6 to 2.28 × 10−5 μg analyte per mL of aerosol puff volume, and calibration curves were linear (R2 > 0.99). This method was used to analyze aerosol emissions of 147 EVPs associated with EVALI case patients. We detected VEA in 46% of the case-associated EVPs with a range of 1.87 × 10−4–74.1 µg per mL of aerosol puff volume and mean of 25.1 µg per mL of aerosol puff volume. Macro-levels of VEA (>0.1% w/w total aerosol particulate matter) were not detected in nicotine or cannabidiol (CBD) products; conversely 71% of the EVALI associated tetrahydrocannabinol (THC) products contained macro-levels of VEA. Trace levels of other tocopherol isoforms were detected at lower rates and concentrations (α-tocopherol: 41% detected, mean 0.095 µg analyte per mL of aerosol puff volume; γ-tocopherol: 5% detected, mean 0.0193 µg analyte per mL of aerosol puff volume; δ-tocopherol: not detected). Our results indicate that VEA can be efficiently transferred to aerosol by EVALI-associated EVPs vaped using a standardized protocol.
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Affiliation(s)
- Andrew Puetz
- Tobacco and Volatiles Branch, Division of Laboratory Sciences, National Center for Environmental Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Maria Morel Espinosa
- Tobacco and Volatiles Branch, Division of Laboratory Sciences, National Center for Environmental Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Clifford Watson
- Tobacco and Volatiles Branch, Division of Laboratory Sciences, National Center for Environmental Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Benjamin C Blount
- Tobacco and Volatiles Branch, Division of Laboratory Sciences, National Center for Environmental Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Liza Valentín-Blasini
- Tobacco and Volatiles Branch, Division of Laboratory Sciences, National Center for Environmental Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States
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Hswen Y, Yom-Tov E. Analysis of a Vaping-Associated Lung Injury Outbreak through Participatory Surveillance and Archival Internet Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18158203. [PMID: 34360495 PMCID: PMC8346109 DOI: 10.3390/ijerph18158203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 11/22/2022]
Abstract
The US Centers for Disease Control and Prevention alerted of a suspected outbreak of lung illness associated with using E-cigarette products in September 2019. At the time that the CDC published its alert little was known about the causes of the outbreak or who was at risk for it. Here we provide insights into the outbreak through analysis of passive reporting and participatory surveillance. We collected data about vaping habits and associated adverse reactions from four data sources pertaining to people in the USA: A participatory surveillance platform (YouVape), Reddit, Google Trends, and Bing. Data were analyzed to identify vaping behaviors and reported adverse events. These were correlated among sources and with prior reports. Data was obtained from 720 YouVape users, 4331 Reddit users, and over 1 million Bing users. Large geographic variation was observed across vaping products. Significant correlation was found among the data sources in reported adverse reactions. Models of participatory surveillance data found specific product and adverse reaction associations. Specifically, cannabidiol was found to be associated with fever, while tetrahydrocannabinol was found to be correlated with diarrhea. Our results demonstrate that utilization of different, complementary, online data sources provide a holistic view of vaping associated lung injury while augmenting traditional data sources.
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Affiliation(s)
- Yulin Hswen
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA 94158, USA;
- Bakar Computational Health Sciences Institute, University of California at San Francisco, San Francisco, CA 94143, USA
- Innovation Program, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Elad Yom-Tov
- Microsoft Research Israel, 3 Alan Turing Str., Herzeliya 4672415, Israel
- Faculty of Industrial Engineering and Management, Technion, Haifa 3200000, Israel
- Correspondence:
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Morel Espinosa M, Blount BC, Valentin-Blasini L. Liquid chromatography-tandem mass spectrometry method for measuring vitamin E acetate in bronchoalveolar lavage fluid. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1171:122607. [PMID: 33740693 DOI: 10.1016/j.jchromb.2021.122607] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/10/2021] [Accepted: 02/15/2021] [Indexed: 11/15/2022]
Abstract
We investigated the suitability of isotope-dilution liquid chromatography coupled with tandem mass spectrometry for identifying vitamin E acetate (VEA) in bronchoalveolar lavage (BAL) fluid. This new method demonstrates high accuracy, selectivity, and sensitivity, with mean recoveries higher than 90%, coefficients of variation ranging from 1.5% to 4.5%, and a limit of detection of 1.10 ng/mL. Calibration curves were linear (R2 > 0.99). The linear range and detection limit of the method were adequate for identifying VEA in 48 of 51 BAL fluid samples collected from people with lung injury resulting from e-cigarettes, or vaping, product use. We conclude that this method is an effective tool for studying VEA accumulation in lungs caused by using e-cigarettes, or vaping, products that contain VEA.
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Affiliation(s)
- Maria Morel Espinosa
- Division of Laboratory Sciences, National Center for Environmental Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
| | - Benjamin C Blount
- Division of Laboratory Sciences, National Center for Environmental Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
| | - Liza Valentin-Blasini
- Division of Laboratory Sciences, National Center for Environmental Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
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Hall W, Gartner C, Bonevski B. Lessons from the public health responses to the US outbreak of vaping-related lung injury. Addiction 2021; 116:985-993. [PMID: 32364274 DOI: 10.1111/add.15108] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/26/2020] [Accepted: 04/23/2020] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Wayne Hall
- The Centre for Youth Substance Abuse Research, University of Queensland, St Lucia, QLD, Australia
| | - Coral Gartner
- School of Public Health, University of Queensland, St Lucia, QLD, Australia
| | - Billie Bonevski
- School of Medicine and Public Health, University of Newcastle, Callahan, NSW, Australia
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Evans RE, Herbert S, Owen W, Rao D. Case of e-cigarette or vaping product use-associated lung injury (EVALI) in London, UK. BMJ Case Rep 2021; 14:14/4/e240700. [PMID: 33837028 PMCID: PMC8043006 DOI: 10.1136/bcr-2020-240700] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present a case of a 38-year-old man with no medical comorbidities who presented to the hospital with haemoptysis and shortness of breath on a background of vaping home-manufactured cannabis oil. He developed e-cigarette or vaping product use-associated lung injury (EVALI) visible on chest X-ray requiring oxygen, and corticosteroid treatment before making a recovery. Research reports that the contents vitamin E acetate and tetrahydrocannabinol are frequently found in substances acquired from informal sources which increase the likelihood of EVALI developing. Further research into their synergistic effect is ongoing. Although safer than smoking, vaping is not risk free and EVALI should be considered in patients presenting with respiratory disease.
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Affiliation(s)
- Ruth Elizabeth Evans
- Medicine, King's College Hospital NHS Foundation Trust, London, UK
- Medicine, Princess Royal University Hospital, Orpington, UK
| | - Sophie Herbert
- Medicine, King's College Hospital NHS Foundation Trust, London, UK
- Medicine, Princess Royal University Hospital, Orpington, UK
| | - William Owen
- Medicine, Princess Royal University Hospital, Orpington, UK
| | - Deepak Rao
- Medicine, Princess Royal University Hospital, Orpington, UK
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Toxicology of flavoring- and cannabis-containing e-liquids used in electronic delivery systems. Pharmacol Ther 2021; 224:107838. [PMID: 33746051 DOI: 10.1016/j.pharmthera.2021.107838] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/11/2021] [Indexed: 12/15/2022]
Abstract
Electronic cigarettes (e-cigarettes) were introduced in the United States in 2007 and by 2014 they were the most popular tobacco product amongst youth and had overtaken use of regular tobacco cigarettes. E-cigarettes are used to aerosolize a liquid (e-liquid) that the user inhales. Flavorings in e-liquids is a primary reason for youth to initiate use of e-cigarettes. Evidence is growing in the scientific literature that inhalation of some flavorings is not without risk of harm. In this review, 67 original articles (primarily cellular in vitro) on the toxicity of flavored e-liquids were identified in the PubMed and Scopus databases and evaluated critically. At least 65 individual flavoring ingredients in e-liquids or aerosols from e-cigarettes induced toxicity in the respiratory tract, cardiovascular and circulatory systems, skeletal system, and skin. Cinnamaldehyde was most frequently reported to be cytotoxic, followed by vanillin, menthol, ethyl maltol, ethyl vanillin, benzaldehyde and linalool. Additionally, modern e-cigarettes can be modified to aerosolize cannabis as dried plant material or a concentrated extract. The U.S. experienced an outbreak of lung injuries, termed e-cigarette, or vaping, product use-associated lung injury (EVALI) that began in 2019; among 2,022 hospitalized patients who had data on substance use (as of January 14, 2020), 82% reported using a delta-9-tetrahydrocannabinol (main psychoactive component in cannabis) containing e-cigarette, or vaping, product. Our literature search identified 33 articles related to EVALI. Vitamin E acetate, a diluent and thickening agent in cannabis-based products, was strongly linked to the EVALI outbreak in epidemiologic and laboratory studies; however, e-liquid chemistry is highly complex, and more than one mechanism of lung injury, ingredient, or thermal breakdown product may be responsible for toxicity. More research is needed, particularly with regard to e-cigarettes (generation, power settings, etc.), e-liquids (composition, bulk or vaped form), modeled systems (cell type, culture type, and dosimetry metrics), biological monitoring, secondhand exposures and contact with residues that contain nicotine and flavorings, and causative agents and mechanisms of EVALI toxicity.
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King BA, Jones CM, Baldwin GT, Briss PA. E-cigarette, or Vaping, Product Use-Associated Lung Injury: Looking Back, Moving Forward. Nicotine Tob Res 2021; 22:S96-S99. [PMID: 33320257 DOI: 10.1093/ntr/ntaa186] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/17/2020] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Brian A King
- Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Peter A Briss
- Centers for Disease Control and Prevention, Atlanta, GA
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Cecchini MJ, Mukhopadhyay S, Arrossi AV, Beasley MB, Butt YM, Jones KD, Pambuccian S, Mehrad M, Monaco SE, Saqi A, Smith ML, Tazelaar HD, Larsen BT. E-Cigarette or Vaping Product Use-Associated Lung Injury: A Review for Pathologists. Arch Pathol Lab Med 2021; 144:1490-1500. [PMID: 32401055 DOI: 10.5858/arpa.2020-0024-ra] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2010] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Matthew J Cecchini
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota (Cecchini)
| | - Sanjay Mukhopadhyay
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio (Mukhopadhyay, Arrossi)
| | - Andrea V Arrossi
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio (Mukhopadhyay, Arrossi)
| | - Mary B Beasley
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York (Beasley)
| | - Yasmeen M Butt
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona (Butt, Smith, Tazelaar, Larsen)
| | - Kirk D Jones
- Department of Pathology, University of California San Francisco, San Francisco (Jones)
| | - Stefan Pambuccian
- Department of Pathology, Loyola University Medical Center and Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois (Pambuccian)
| | - Mitra Mehrad
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee (Mehrad)
| | - Sara E Monaco
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania (Monaco)
| | - Anjali Saqi
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York (Saqi)
| | - Maxwell L Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona (Butt, Smith, Tazelaar, Larsen)
| | - Henry D Tazelaar
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona (Butt, Smith, Tazelaar, Larsen)
| | - Brandon T Larsen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona (Butt, Smith, Tazelaar, Larsen)
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Reagan-Steiner S, Gary J, Matkovic E, Ritter JM, Shieh WJ, Martines RB, Werner AK, Lynfield R, Holzbauer S, Bullock H, Denison AM, Bhatnagar J, Bollweg BC, Patel M, Evans ME, King BA, Rose DA, Baldwin GT, Jones CM, Krishnasamy V, Briss PA, Weissman DN, Meaney-Delman D, Zaki SR, Jatlaoui T, Koumans E, Kiernan E, Petersen E, Karwowski MP, Valentin-Blasini L, Blount BC, Cummings KJ, Ghinai I, Feder K, Wells EV, Turabelidze G, Byers P, Tanz LJ, Navarette KA, Ramadugu K, Dewart C, Miller J, Squires K, Marsden L, Fields CA. Pathological findings in suspected cases of e-cigarette, or vaping, product use-associated lung injury (EVALI): a case series. THE LANCET RESPIRATORY MEDICINE 2020; 8:1219-1232. [DOI: 10.1016/s2213-2600(20)30321-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/12/2022]
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Arons MM, Barnes SR, Cheng R, Whittle K, Elsholz C, Bui D, Gilley S, Maldonado A, LaCross N, Sage K, Lewis N, McCaffrey K, Green J, Duncan J, Dunn AC. 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. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 88:103026. [PMID: 33246266 DOI: 10.1016/j.drugpo.2020.103026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Melissa M Arons
- Epidemic Intelligence Service, Center for Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention; Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta Georgia
| | - Stephen R Barnes
- Utah Department of Health; National Foundation for the Centers for Disease Control and Prevention
| | | | | | - Christopher Elsholz
- State Bureau of Investigation, Major Crimes, Utah Department of Public Safety
| | - David Bui
- Epidemic Intelligence Service, Center for Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention; Division of Environmental Health Science and Practice, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta Georgia
| | - Stephen Gilley
- Intelligence Division, Organized Crime, Utah Department of Public Safety
| | | | | | | | - Nathaniel Lewis
- Epidemic Intelligence Service, Center for Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention; Utah Department of Health
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Wu TS, Chaffee BW. Parental Awareness of Youth Tobacco Use and the Role of Household Tobacco Rules in Use Prevention. Pediatrics 2020; 146:peds.2019-4034. [PMID: 33020248 PMCID: PMC7642113 DOI: 10.1542/peds.2019-4034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Noncigarette tobacco use is increasing. In this study, we reexamined (1) parental knowledge or suspicion of their children's tobacco use and (2) associations of household tobacco-free rules with youth initiation. METHODS Participants were youth (aged 12-17) in waves 1 to 4 (2013-2018) of the Population Assessment of Tobacco and Health Study. A pseudo cross-sectional time-series analysis (N = 23 170) was used to examine parent or guardian knowledge or suspicion of their child's tobacco use according to youth-reported use categories: cigarette only, electronic cigarette only, smokeless tobacco only, noncigarette combustible only, and poly use. A longitudinal analysis among wave 1 never users (n = 8994) was used to examine rules barring tobacco inside the home and whether parents talked with youth about not using tobacco as predictors of youth tobacco initiation after 1 to 3 years. Survey-weighted multivariable models were adjusted for tobacco use risk factors. RESULTS In all waves, parents or guardians much less often knew or suspected that their children used tobacco if youth only reported use of electronic cigarettes, noncigarette combustible products, or smokeless tobacco compared with cigarettes. Youth tobacco initiation was lower when youth and parents agreed that rules prohibited all tobacco use throughout the home (1-year adjusted odds ratio: 0.74; 95% confidence interval: 0.59-0.94) but not when parents talked with youth about tobacco (adjusted odds ratio: 1.08; 95% confidence interval: 0.94-1.23). CONCLUSIONS Many parents are unaware of their children's noncigarette tobacco use. Setting expectations for tobacco-free environments appears more effective at preventing youth tobacco initiation than parents advising children not to use tobacco.
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Affiliation(s)
- Tsu-Shuan Wu
- University of California, San Francisco, San Francisco, California
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Rice SJ, Hyland V, Behera M, Ramalingam SS, Bunn P, Belani CP. Guidance on the Clinical Management of Electronic Cigarette or Vaping-Associated Lung Injury. J Thorac Oncol 2020; 15:1727-1737. [PMID: 32866653 PMCID: PMC7455516 DOI: 10.1016/j.jtho.2020.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/07/2020] [Accepted: 08/12/2020] [Indexed: 02/06/2023]
Abstract
In the summer of 2019, there was a rise in clusters of adolescents and young adults in the United States reporting to emergency departments with acute respiratory distress related to use of e-cigarette (electronic cigarette) or vaping. The number of patients with e-cigarette or vaping-associated lung injury continued to rise through the summer before peaking in September 2019. Through the efforts of state and federal public health agencies, officials were able to define the condition, identify the relationship of the respiratory injury to tetrahydrocannabinol-containing products, and stem the rise in new cases. In this report, we present a comprehensive review of the clinical characteristics and features of patients with e-cigarette or vaping-associated lung injury and guidelines for patient care and management to inform and navigate clinicians who may encounter these patients in their clinical practice.
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Affiliation(s)
- Shawn J Rice
- Department of Medicine Penn State College of Medicine, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Victoria Hyland
- Department of Medicine Penn State College of Medicine, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Madhusmita Behera
- Department of Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Suresh S Ramalingam
- Department of Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Paul Bunn
- Department of Medicine, University of Colorado Cancer Center, Aurora, Colorado
| | - Chandra P Belani
- Department of Medicine Penn State College of Medicine, Penn State Cancer Institute, Hershey, Pennsylvania.
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Chang JT, Wang B, Rostron BL, Chen LH, Schroeder TJ, Mah JC, Chang CM, Ambrose BK. National Estimates of ENDS Liquid Nicotine Exposures, U.S., 2013-2017. Am J Prev Med 2020; 59:742-745. [PMID: 32826127 DOI: 10.1016/j.amepre.2020.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/08/2020] [Accepted: 05/11/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Increased use of ENDS in the U.S. is related to acute adverse events from liquid nicotine exposure. This paper provides national estimates of U.S. hospital emergency department visits for exposures from liquid nicotine exposure in individuals aged ≥5 years. METHODS In 2018-2019, data from the 2013-2017 National Electronic Injury Surveillance System All Injury Program were used to identify cases of liquid nicotine-related exposures in individuals aged ≥5 years. National estimates of exposures related to liquid nicotine exposure in ENDS for those aged ≥5 years by demographic characteristics, symptoms, diagnoses, and treatment dispositions were calculated. RESULTS From 2013 to 2017, an estimated 2,718 cases related to liquid nicotine among those aged ≥5 years were treated in U.S. hospital emergency departments. Most exposures occurred among those who were aged ≥25 years (51.7%), white (74.1%), and male (51.9%). Most case patients were treated and released from the hospitals, and 7.5% were admitted. Poisoning was the most common diagnosis of these exposures (82.7%). The most common symptoms were cardiovascular (29.7%). CONCLUSIONS This study provides national estimates of emergency department visits for injury and poisoning cases related to nicotine exposure from ENDS among individuals aged ≥5 years. Although long-term health outcome studies of liquid nicotine exposure are not available, these estimates provide some insight into the acute health effects. Findings from this study may inform education programs aimed at preventing exposures related to ENDS products.
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Affiliation(s)
- Joanne T Chang
- Center for Tobacco Products, U.S. Food and Drug Administration, Silver Spring, Maryland.
| | - Baoguang Wang
- Center for Tobacco Products, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Brian L Rostron
- Center for Tobacco Products, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Li Hui Chen
- Division of Hazard and Injury Data Systems, U.S. Consumer Product Safety Commission, Bethesda, Maryland
| | - Thomas J Schroeder
- Division of Hazard and Injury Data Systems, U.S. Consumer Product Safety Commission, Bethesda, Maryland
| | - Jean C Mah
- Division of Hazard and Injury Data Systems, U.S. Consumer Product Safety Commission, Bethesda, Maryland
| | - Cindy M Chang
- Center for Tobacco Products, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Bridget K Ambrose
- Center for Tobacco Products, U.S. Food and Drug Administration, Silver Spring, Maryland
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Stephen MJ, Chowdhury J, Tejada LA, Zanni R, Hadjiliadis D. Use of medical marijuana in cystic fibrosis patients. BMC Complement Med Ther 2020; 20:323. [PMID: 33109153 PMCID: PMC7590463 DOI: 10.1186/s12906-020-03116-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/14/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The usage and attitudes towards medical marijuana in Cystic Fibrosis (CF) patients is unknown. Through the use of a survey we aim to clarify rates and reasons for use. METHODS An anonymous survey was sent out to six centers in the Mid-Atlantic region of the United States. Use of and reason for medical marijuana was assessed, along with attitudes of the perceived utility of medical marijuana. RESULTS A total of 637 surveys were sent out, and 193 surveys were returned (30.3% return rate). Three did not give consent, and one was empty, for a total of 189 completed surveys. 31 subjects (16.5%) reported having used marijuana for medical purposes in their lifetime, with 29 (15.4%) of these in the past year. The most used forms were edible and vaporized. The most common indications for usage were pain and stress. 28 out of 31 found marijuana to be a great deal effective for their symptoms. 21 of the 31 rated marijuana very important or important to their health. There were two reported side effects, both mild. Of 156 subjects who responded to the question if they would be interested in medical marijuana if available, 72 (46.2%) replied yes. CONCLUSION The use of marijuana for medical reasons was 15.4% in the past year in this sample CF population, although more expressed interest if it was available through prescription. Side effects were rare. CF physicians are going to have to familiarize themselves with advantages and disadvantages of medical marijuana as there is a great deal of interest within the community, and legalization becomes more common.
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Affiliation(s)
- Michael J. Stephen
- Jefferson University, 834 Walnut St, Suite 650, Philadelphia, PA 19107 USA
| | - Jared Chowdhury
- Drexel University, 245 N 15th St, 6th Floor, Philadelphia, PA 19102 USA
| | - Luis Arzeno Tejada
- Morristown Medical Center, 435 South Street, Suite 310, Morristown, NJ 07960 USA
| | - Robert Zanni
- Robert Wood Johnson Barnabas Health, Unterberg Children’s Hospital at Monmouth Medical Center, 279 Third Ave Suite 604, Long Branch, New Jersey, 07740 USA
| | - Denis Hadjiliadis
- Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
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Pajak A, Bascoy S, Li JC, Benninghoff M, Deitchman A. E-cigarette or Vaping Product Use Associated Lung Injury Among Three Young Adults: A Retrospective Case Series From Delaware. Cureus 2020; 12:e11031. [PMID: 33224641 PMCID: PMC7673280 DOI: 10.7759/cureus.11031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: E-cigarette or vaping associated lung injury (EVALI) is a lung disease associated with an inflammatory response to the vaping fluid. Currently, diagnosis remains elusive without definitive biomarkers. Case presentation: Herein, we describe three cases of EVALI among 18- to 21-year-old patients ranging from mild to severe. All cases presented with a combination of respiratory, gastrointestinal, and constitutional symptoms. Oxygen support and level of medical care varied based on disease severity. Bilateral pulmonary opacities were observed on chest imaging in each case. Additionally, each case had markedly elevated inflammatory markers, specifically C-reactive protein (CRP). None of these patients improved with intravenous (IV) antibiotics and all required IV corticosteroid therapy to achieve clinical improvement. Conclusion: EVALI should be suspected among young, otherwise healthy patients who present with new-onset hypoxia, non-specific gastrointestinal symptoms, and endorse a history of vaping. Though considered a diagnosis of exclusion, diagnosing EVALI requires thorough history taking. Inflammatory studies, CRP, and erythrocyte sedimentation rate (ESR) should be considered adjunctive biomarkers to aid clinicians when the diagnosis remains unclear. Corticosteroids are the mainstay of treatment and patients should have close follow-up whether or not they require hospitalization.
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Affiliation(s)
| | - Soraya Bascoy
- Internal Medicine/Pediatrics Residency Program, ChristianaCare, Newark, USA
| | - Jonathan C Li
- Internal Medicine/Pediatrics Residency Program, ChristianaCare, Newark, USA.,Internal Medicine/Pediatrics Residency Program, University of Pittsburgh Medical Center, Pittsburgh, USA.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA
| | - Michael Benninghoff
- Department of Pulmonary & Critical Care Medicine, ChristianaCare, Newark, USA
| | - Andrew Deitchman
- Department of Pulmonary & Critical Care Medicine, ChristianaCare, Newark, USA
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