Evidence-Based Strategies for Common Clinical Questions

The Implications of Vaping and Preparedness Post-Pandemic

Author: Allison Adam, MD | Pediatric Chief Resident

Column Editor: Kathleen Berg, MD | Co-Director, Office of Evidence-Based Practice | Pediatric Hospitalist, Division of Pediatric Hospital Medicine | Clinical Assistant Professor of Pediatrics, UMKC School of Medicine 

The term EVALI stands for “e-cigarette or vaping product use-associated lung injury,” and was coined by the Centers for Disease Control and Prevention (CDC) in response to severe lung illness that was first identified Summer 2019. The incidence of EVALI peaked in September 2019 with over 2,500 hospitalizations, including 52 deaths, reported throughout the U.S.¹ Vitamin E acetate was implicated in EVALI after being isolated in most, but not all, bronchoalveolar lavage samples obtained from study participants.¹ Since then, there has been a decline in cases which is considered multifactorial.² The public health response led to increased awareness around e-cigarette use and vaping. Vitamin E acetate was removed from some products, and law enforcement agencies acted against illicit products.²

These efforts were just prior to the outbreak of SARS-CoV-2 and subsequent closure of in-person schools and youth activities. A study in JAMA in December 2020 evaluated habits of e-cigarette users before and during the pandemic.³ It concluded there was a decline in use by youth and young adults, but not due to quitting or fear of lung injury, as was reported in adult e-cigarette users. Most youth and young adults that reported cessation during the pandemic reported reasons like parents being home more frequently and vape shops being closed. There is concern that once American teens and adolescents return to post-pandemic social activities we may see another rise in EVALI and other adverse effects of vaping. With this in mind, pediatricians should review the risks of e-cigarette use.

To refresh, symptoms of EVALI include shortness of breath, cough, chest pain, fever, nausea, vomiting, diarrhea and abdominal pain. It may cause primarily gastrointestinal symptoms with absence of respiratory symptoms. Two-thirds of cases are in males and over 80% are under 35 years of age. One-third of patients may progress to acute respiratory failure requiring mechanical ventilation. Diagnostic criteria include the use of an e-cigarette or similar product in the last 90 days, lung opacities on CXR or CT, absence of an alternative diagnosis and negative infectious work-up.⁴

In addition to EVALI, there are other health risks linked to e-cigarette use. The adolescent brain is profoundly vulnerable to the rewarding effects of nicotine. Studies have shown that e-cigarette use in youth increases their risk of using combustible (standard) cigarettes in the future.⁵ The long-term effects of e-cigarette use are still being investigated but studies have shown significant lung impairments, including increased oxidative stress and impaired pulmonary bacterial clearance.⁶ In addition to intrinsic risks associated with inhaling harmful compounds, there are also extrinsic risks. From 2015-2017 there were 2,065 explosion or burn injuries from e-cigarettes seen in U.S. emergency departments, nearly one-third requiring hospitalization.⁷ Additionally, e-cigarette solutions are sold in a variety of strengths. A mid-level strength is 36mg of nicotine per milliliter, or 540mg per tablespoon of “e-juice.” Lethal doses of nicotine have been reported between 0.8-13 mg/kg.⁸ The accidental ingestion of a teaspoon of liquid nicotine could be fatal to a 10kg child. From 2012-2017, prior to the peak of e-cigarette use, there were more than 8,200 liquid nicotine exposures in U.S. children.⁹

The American Academy of Pediatrics (AAP) and U.S. Preventive Services Task Force recommend pediatricians screen, educate and counsel youth regarding the use of e-cigarettes.^10,11 The ease of accessibility of nicotine delivery devices and youth-directed marketing strategies make it paramount that pediatricians communicate the health risks to patients and families. To do so, we must be familiar with the vernacular of such devices. The CDC offers a visual dictionary of e-cigarette, vaping and dabbing products. It can be found at: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/ecigarette-or-vaping-products-visual-dictionary-508.pdf.

E-cigarette use is often not considered smoking by the user, so asking patients, “Do you smoke?” leads to missed opportunities for education and intervention. Rather, we should ask, “In the past year have you used any tobacco products, like cigarettes, e-cigarettes, vaping devices, mods or pod systems?” The AAP recommends that pediatricians have resources readily available, even without the need for disclosure (e.g., visible posters, brochures or social media content.)¹⁰ The AAP offers a free online e-cigarette curriculum for providers with topics such as screening, counseling, cessation support, coding and billing, and advocacy. This valuable, evidence-based resource can be found at https://services.aap.org/en/learning/e-cigarette-curriculum/.

References:

1. Blount BC, Karwowski MP, Shields PG, et al.; Lung Injury Response Laboratory Working Group. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. N Engl J Med. 2020 Feb 20;382(8):697-705. doi: 10.1056/NEJMoa1916433.
2. Centers for Disease Control and Prevention [CDC] (2020). Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-information. Last accessed June 16, 2021.
3. Gaiha SM, Lempert LK, Halpern-Felsher B.  Underage youth and young adult e-cigarette use and access before and during the coronavirus disease 2019 pandemic. JAMA Netw Open. 2020 Dec 1;3(12):e2027572. doi:10.1001/jamanetworkopen.2020.27572.
4. Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin - Final Report. N Engl J Med. 2020 Mar 5;382:903. doi: 10.1056/NEJMoa1911614.  
5. Soneji S, Barrington-Trimis JL, Wills TA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: A systematic review and meta-analysis. JAMA Pediatr. 2017 Aug 1;171(8):788–797. doi: 10.1001/jamapediatrics.2017.1488.
6. Sussan TE, Gajghate S, Thimmulappa RK, et al. Exposure to electronic cigarettes impairs pulmonary antibacterial and anti-viral defenses in a mouse model. PLoS One. 2015 Feb 4;10(2):e0116861. doi: 10.1371/journal.pone.0116861.
7. Rossheim ME, Livingston MD, Soule EK, Zeraye HA, Thombs DL. Electronic cigarette explosion and burn injuries, U.S. emergency departments 2015–2017. Tob Control. 2019 Jul;28:472-474. doi: 10.1136/tobaccocontrol-2018-054518.
8. Benowitz N. Poisoning and Drug Overdose. 5th edition. McGraw-Hill Medical. 2007.
9. Govindarajan P, Spiller HA, Casavant MJ, Chounthirath T, Smith GA. E-Cigarette and liquid nicotine exposures among young children. Pediatrics. 2018 May;141(5):e20173361. doi: 10.1542/peds.2017-3361.
10. Jenssen BP, Walley SC; Section on Tobacco Control. E-cigarettes and similar devices. Pediatrics. 2019 Feb;143(2):e20183652. doi: 10.1542/peds.2018-3652.
11. U.S. Preventive Services Task Force. Draft Recommendation Statement: Prevention and Cessation of Tobacco Use in Children and Adolescents: Primary Care Interventions. April 28, 2020. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-and-nicotine-use-prevention-in-children-and-adolescents-primary-care-interventions.