Learning Objectives
At the conclusion of this activity, participants will be able to:
- Understand the health risks associated with e-cigarettes and vaping.
- Discuss how to communicate the risks and uncertainties associated with vaping use to patients.
- Describe the reporting recommendations for possible cases of vaping-associated pulmonary disease.
Vaping and electronic cigarettes have been a hot topic in the press lately. This is due in large part to a multistate outbreak of lung disease associated with e-cigarette product use, including a confirmed 26 deaths deaths in 21 states across the nation.1 The Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), state and local health departments and other clinical and public health partners are working together to investigate this outbreak.
Key Facts About E-Cigarette Use
E-cigarettes are nicotine delivery devices that have a battery, a heating element and a container for liquid. When the liquid is heated, users inhale the aerosol. The liquids are usually flavored and contain nicotine, so users experience a taste sensation as well as a hit of the same addictive stimulant found in cigarettes. The liquid can contain nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils and other substances and additives. Vaping is the word used to describe inhaling the aerosol produced by e-cigarettes or similar devices, such as vaporizers or vapor pens.
Nearly 11 million adults in the U.S. use electronic cigarettes, and only 15 percent of e-cigarette users are not former cigarette smokers.2 Some have celebrated the arrival of these smokeless nicotine tools as a safe alternative to cigarettes, cigars and other tobacco products. The devices do not emit the same cancer-causing tar and toxins that burning tobacco leaves produce. Additionally, a study published in The New England Journal of Medicine found vaping was more effective for helping tobacco users quit than nicotine replacement therapy, when both products were accompanied by behavioral support.3
On the other hand, many e-cigarettes are loaded with addictive nicotine, and even those without nicotine may contain toxic chemicals. The reality is that there is still much unknown about the health effects of vaping. A major issue is that no one knows exactly what goes into all of the flavorings. Vaping is still fairly new compared to smoking, and the science on its effects is far from conclusive. Experts say it could take 20 years to know the long-term health effects of vaping.4
There are some clear dangers to e-cigarettes, particularly when it comes to nicotine. Nicotine is addictive and is harmful, particularly to young, developing brains. Nicotine use can stunt an adolescent’s ability to learn and affect their behavior. Nicotine also worsens conditions such as depression and anxiety. For smokers, vaping can actually support their habit, not break it. Instead of transitioning from cigarettes to e-cigarettes, some smokers end up using both.4
Adolescents and Vaping
The 2018 National Youth Tobacco Survey found that e-cigarette use among high schoolers increased by 78 percent in one year.5 Recent data showed that more than a quarter of high school students had used e-cigarettes in the previous 30 days, compared to 21 percent in 2018. Two-thirds of adolescents who vape believe they are inhaling only the flavors—not nicotine or anything potentially dangerous.6
In response, the Trump administration announced a plan to ban flavored e-cigarettes to address youth vaping.6 After the FDA releases its final plan for banning the products, there will be a 30-day delay until the new policy goes into effect. At that point, all flavored e-cigarettes, other than tobacco flavor, would have to be removed from the market. Retailers would have to get rid of products with flavors such as cotton candy, bubble gum, crème brulee, fruit, menthol and mint. Companies can apply to the FDA to bring their flavored e-cigarettes back on the market, but the request will have to be approved by the regulator.
Influential public health advocates, including Mike Bloomberg, have come out in favor of banning flavors as a way to curb the youth vaping epidemic. Bans of sales of flavored vaping products are in place in New York and Michigan, and a temporary ban has been passed in Washington. Massachusetts recently announced a fourmonth ban on all sales of vaping products. Other states, including New Jersey, are also signaling interest in taking a tougher stance on e-cigarettes.7
On September 25, 2019, Juul announced that CEO Kevin Burns stepped down and will be replaced by K.C. Crosthwaite, who had been Chief Growth Officer at tobacco company Altria. Juul also states that it will suspend all TV, print and digital ads, will stop some of its lobbying efforts and will support and comply with any new federal policy related to vaping products.8
What Is Known About The Lung Injury Outbreak
According to the Centers for Disease Control and Prevention (CDC), there are 1,299 cases of lung injury reported from 49 states, the District of Columbia and one U.S. territory, as of October 8, 2019, and the number continues to climb. All these patients have a reported history of e-cigarette product use, and no consistent evidence of an infectious cause has been discovered.1 Therefore, the suspected cause is a chemical exposure.
“According to the CDC, there are 1,299 cases of lung injury reported”
The CDC and the U.S. Food and Drug Administration (FDA) have not found a specific cause of the illness. The latest findings from the investigation into lung injuries associated with e-cigarette use or vaping suggest products containing THC play a role in the outbreak.
Many of the samples tested by the states or by the FDA as part of their ongoing investigation have been identified as vaping products containing THC, the psychoactive component of the marijuana plant. Vitamin E became a key focus of New York state health officials’ investigation after cannabis-containing vaping cartridges submitted by those who had fallen ill tested positive for Vitamin E acetate. Vitamin E acetate is used to dilute cannabis oil and is a substance present in topical consumer products or dietary supplements, but data are limited about its effects after inhalation.
While the FDA does not have enough data presently to conclude that Vitamin E acetate is the cause of the lung injury in these cases, the agency believes it is prudent to avoid inhaling this substance. Because consumers cannot be sure whether any THC vaping products may contain Vitamin E acetate, consumers are urged to avoid buying vaping products on the street and to refrain from using THC oil or modifying/adding any substances to products purchased in stores.8
Diagnosing Lung Injuries Associated With Vaping
Patients with cases of e-cigarette or vaping-associated lung injury have reported experiencing a rapid onset of coughing, weight loss and significant breathing difficulties. Other symptoms may include fatigue, fever, nausea, vomiting, abdominal pain and diarrhea. Symptoms generally appear over the course of a few days but can take as long as a few weeks to arise. The majority of patients are hospitalized, and while many of their symptoms overlap, their diagnoses have included lipoid pneumonia, acute eosinophilic pneumonia and acute respiratory distress syndrome.9
Physicians need to be aware that there is an overlap between the early symptoms of vaping injury and common respiratory infections. Physicians should be asking patients about their vaping history as part of their standard protocol during routine visits. Gathering that information is especially important as doctors evaluate patients with respiratory symptoms from infectious causes. When evaluating patients for lung injury and illness, physicians should also be careful not to discriminate based on age and smoking status, as there are a large number of older Americans who vape (before and after quitting tobacco) and vapers who have never before smoked.
Physicians should consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms. Patients should be evaluated and treated for other possible causes of illness (e.g., infectious, rheumatologic, neoplastic) as clinically indicated. When there is any question of a vaping-related lung injury, a referral to a lung specialist should be made immediately.
As we enter flu season, some U.S. doctors have raised concerns that vaping injury cases will be missed in the rush of patients seeking treatment for seasonal flu and other respiratory ailments. Influenza can be deadly in people who have other underlying illnesses. The fact that a patient could present at a physician’s office with flu, a lung injury due to vaping, or both, makes diagnosis even more complicated for physicians. Other respiratory infections, including fungal infections, can also cause similar symptoms and could result in a delay of diagnosing a vaping injury.
It is particularly important this year that anyone, but especially people who have underlying pulmonary infections of any kind, receive the flu vaccination. The CDC recommends that all healthcare providers strongly consider respiratory infections as well as lung injury associated with the use of e-cigarettes or vaping products in all patients presenting with respiratory symptoms and a history of using these products.10
What Physicians Should Be Communicating To Patients About Vaping
Healthcare providers have a vital role to play in raising public awareness about the potential dangers of vaping. While the specific cause of these lung illnesses remains unknown, the CDC has released the following interim recommendations for healthcare providers, health departments and the public.11
Until more is known about the cause of these illnesses, physicians should be counseling patients to refrain from the use of all e-cigarette or vaping products. Adults who do not currently use tobacco products should be advised not to start using any cigarette products. Adults who used e-cigarettes containing nicotine to quit cigarette smoking should not be advised to return to smoking cigarettes. Physicians who examine patients who report e-cigarette or vaping product use within the last 90 days should ask them about any signs and symptoms of pulmonary illness.
In addition to these recommendations from the CDC, in a recent statement, American Medical Association President Dr. Patrice A. Harris wrote: “The AMA calls on physicians to make sure their patients are aware of the dangers of e-cigarettes, including toxins and carcinogens, and swiftly report any suspected cases of lung illness associated with e-cigarette use to their state or local health department.. . . We urge the U.S. Food and Drug Administration (FDA) to speed up the regulation of e-cigarettes and remove all unregulated products from the market. We also call on the FDA to immediately ban flavors, as well as marketing practices, that enhance the appeal of e-cigarette products to youth.”12
Reporting Recommendations For Clinicians
If an e-cigarette or vaping product is suspected as a possible cause for a patient’s pulmonary disease, the CDC recommends collecting data that is not usually part of the medical history, such as information about the vaping substances, devices and sources used. To identify other potential cases, it is advisable to determine if the e-cigarette products were shared with another person. Also, efforts should be made to determine if any remaining product, devices and liquids are available for testing. These types of records can be helpful in determining the cause or causes of these pulmonary illnesses, and may also be helpful in anticipation of future civil litigation for wrongful injury and death. As the investigation into the lung illness outbreak continues, the CDC encourages physicians to report possible cases of e-cigarette or vaping-associated pulmonary disease that occurred within the last 90 days to their local or state health department for further investigation.11
For More Information
At this time, the recommendations and guidance for diagnosing, treating and monitoring known or suspected vaping or e-cigarette related lung injury continues to evolve on a quick and regular basis. Physicians should keep current on the changing recommendations for the treatment of these patients, including the appropriate use of antibiotics and high-dose steroids, as well as aggressive diagnostic testing, such as lung biopsy and special staining. The CDC continues to publish updated information and resources for healthcare providers on its website. The investigation is ongoing, and the CDC will continue to work in collaboration with the FDA and state and local partners to investigate cases and to update guidance, as appropriate, as new data emerge from this complex outbreak.13
