Soaring rates of vaping among young people and associated problems have resulted in great urgency and important challenges for policymakers. Despite the urgency, policies should be evidence-based and thoughtfully designed. They require effective, collaborative, and well-funded enforcement by federal and state governments. Policymakers should aim to reduce vaping among young people while maintaining avenues to help smokers quit. Finally, policies should be forward-thinking, since the e-cigarette market is rapidly changing and e-cigarette companies can be more agile than regulators.
Published March 25, 2020, at NEJM.org. DOI: 10.1056/NEJMp1917065
Abstract – Background: E-cigarettes are battery-operated devices that heat a liquid and deliver an aerosolized product to the user. Pulmonary illnesses related to e-cigarette use have been reported, but no large series has been described. In July 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health received reports of lung injury associated with the use of e-cigarettes (also called vaping) and launched a coordinated public health investigation.
Methods: We defined case patients as persons who reported use of e-cigarette devices and related products in the 90 days before symptom onset and had pulmonary infiltrates on imaging and whose illnesses were not attributed to other causes. Medical record abstraction and case patient interviews were conducted with the use of standardized tools.
Results: There were 98 case patients, 79% of whom were male; the median age of the patients was 21 years. The majority of patients presented with respiratory symptoms (97%), gastrointestinal symptoms (77%), and constitutional symptoms (100%). All case patients had bilateral infiltrates on chest imaging. A total of 95% of the patients were hospitalized, 26% underwent intubation and mechanical ventilation, and two deaths were reported. A total of 89% of the patients reported having used tetrahydrocannabinol products in e-cigarette devices, although a wide variety of products and devices was reported. Syndromic surveillance data from Illinois showed that the mean monthly rate of visits related to severe respiratory illness in June through August of 2019 was twice the rate that was observed in the same months in 2018.
Conclusions: Case patients presented with similar clinical characteristics. Although the definitive substance or substances contributing to injury have not been determined, this initial cluster of illnesses represents an emerging clinical syndrome or syndromes. Additional work is needed to characterize the pathophysiology and to identify the definitive causes.
Electronic cigarettes, or e-cigarettes, include a diverse group of battery-powered devices that allow users to inhale aerosolized substances.1 E-cigarette aerosol generally contains fewer toxic chemicals than conventional cigarette smoke.2 However, e-cigarette aerosol is not harmless; it can expose users to substances known to have adverse health effects, including ultra-fine particles, heavy metals, volatile organic compounds, and other harmful ingredients.2,3 E-cigarettes are commonly used to inhale nicotine but can also be used to deliver substances such as tetrahydrocannabinol (THC), cannabidiol (CBD), and butane hash oils (also known as dabs).4 E-cigarettes entered the U.S. marketplace around 2007 and since 2014 have been the most commonly used tobacco product among youths in the United States.1 During the 2017–2018 period, the prevalence of current use of e-cigarettes (also called vaping) increased from 11.7% to 20.8% among U.S. high school students.5 In contrast, 3.2% of U.S. adults reported current e-cigarette use in 2018.6
Published case reports have detailed a range of severe pulmonary illnesses among persons who have reported use of nicotine or cannabis extracts in e-cigarettes.7-13 No previous case series, however, has described large clusters of temporally related pulmonary illnesses linked to the use of e-cigarette products (e.g., devices, liquids, refillable pods, and cartridges).
From August 2019 to date, over 2,700 patients have been reported with e-cigarette, or vaping, associated lung injury (EVALI) in all the states of the US.
Study - Severe Lung Injury Associated With Use of e-Cigarette, or Vaping, Products—California, 2019. Image Credit: Shannon Laura / Shutterstock
The study results
The investigators found that among 160 patients with EVALI of whom approximately 60% were male, with a median age of 27 years, about half received intensive care, and a little less than a third had to be put on mechanical ventilation. Four of them died in hospital.
Of the 160 patients, 86 were subject to interview. Among this group, 83% said they vaped products containing tetrahydrocannabinol (THC), which is the psychoactive component of cannabis. 43% had vaped products containing cannabidiol (CBD), another principal constituent of the same plant. 47% had vaped products containing nicotine.
The authors emphasize, “These findings underscore the importance for all clinicians, including outpatient health care providers, to consider EVALI in patients with a history of vaping who present with typical findings of infection, as well as monitor their clinical course and respiratory status closely for decompensation, in accordance with CDC guidance.”...depression, and anxiety are the most common illnesses found in patients with EVALI in California, which could indicate that such patients vape at higher rates or that such patients are at higher risk of EVALI.
Again, vitamin E or vitamin E acetate proved to be present in most products containing THC.
The study concludes, “The California Department of Public Health recommends that individuals refrain from using any vaping or e-cigarette products, particularly THC-containing products from informal sources, while this investigation is ongoing.”
Journal reference: Heinzerling A, Armatas C, Karmarkar E, et al. Severe Lung Injury Associated With Use of e-Cigarette, or Vaping, Products—California, 2019. JAMA Intern Med. Published online March 06, 2020. doi:10.1001/jamainternmed.2020.0664
“Compared to many, my childhood was a cakewalk. Because your childhood beat you around and left you in pain doesn’t mean that you’ll continue the cycle. Let your hurt be the source of your greatest compassion, the deepest love and understanding. You can do anything.
Walk through it, don’t numb or hide.
It’s been twenty-eight years since I stopped drugs and dedicated myself to a spiritual path, but those hard drugs I did, the heroin, cocaine, and meth, they hurt me bad, it took a long time to really recovery from ‘em. I hope for you that you don’t waste your energy there.
Even the Weed. Man, I was way too damn young for that Shit, it made growing up a more difficult challenge that it needed to be. For years and years, I made the mistake of trying to run away, before I learned to surrender, accept my pain as a blessing, trust in the love, and let it change me.”
Acid for the Children, ‘Flea’ – Bassist and co-founder Red Hot Chilli Peppers