Is Vaping a New Epidemic?

Mary Gao for Health Empowerment Coalition

Vaping is the inhaling of vapor created by heating a liquid or wax that can contain substances like nicotine, cannabinoids, and other additives.¹ Over the years, the activity has grown increasingly popular among young adults, especially through the usage of electronic cigarettes (e-cigarettes). However, negative health consequences have arisen from the increasing popularity. According to the Center for Disease Control (CDC), an estimated 2 million middle and high school students in the United States use e-cigarettes, with almost 85% using flavored e-cigarettes.² As of February 2020, over 2800 patients in the United States were admitted to hospitals for vaping-induced lung injuries, and 68 deaths were reported.³

Vaping-induced lung injury is now officially termed e-cigarette or vaping product use associated lung injury (EVALI). EVALI is an inflammatory response in the lungs triggered by the inhalation of certain substances, and it categorizes a broad range of diagnoses. It can appear as pneumonia, damage to the alveoli, which are air-filled sacs in the lungs, or fibrinous pneumonitis, an inflammatory reaction in the lungs. The symptoms of EVALI are often like those of other respiratory illnesses, making it difficult to diagnose. Patients with EVALI can display a wide variety of symptoms, such as coughing, chest pain, shortness of breath, nausea, fever, or chills.³ Due to its pathology being poorly understood, there is not yet a test for diagnosing EVALI.³ As these symptoms can overlap with many other illnesses,⁴ EVALI is determined using a “diagnosis of exclusion,” in which a doctor will conduct a variety of tests to rule out other potential diseases before diagnosing a patient. To diagnose a patient, a detailed history must be taken during the patient interview, including the type of vaping device used, frequency of vaping, and where the product was obtained.⁵ The physical examination focuses on vital signs, like heart rate and blood pressure, oxygen levels, and a detailed chest examination. Due to the unspecified nature of EVALI, diagnoses can sometimes be mistaken, leading to people being diagnosed with EVALI even with a mild respiratory disease. Therefore, the CDC has altered its guidelines for the inclusion criteria of the EVALI registry, now only including patients who require hospitalization and those leading to death by EVALI.¹²

To rule out other possible causes of lung injury, other diagnostic exams will also be performed, such as a full respiratory viral panel to test for the flu or SARS-COV2, or a urine antigen test for certain strains of bacteria like Streptococcus pneumoniae, which causes strep throat. Chest CTs will typically scan for lung injury in the alveoli and pneumonia-like patterns of inflammation.⁶ Laboratory tests also include a complete blood count and urine toxicology with the consent of the patient to test for the presence of THC, the main psychoactive component of cannabis. When the findings are considered abnormal, bronchoscopy, a procedure to visualize the passages in the lungs, is performed to exclude alternative diagnoses.

Most patients with EVALI report usage of products containing THC and/or Vitamin E acetate, a synthetic form of Vitamin E. One study compared the amount of bronchoalveolar lavage fluid (BAL) in patients with confirmed or probable EVALI with healthy patients and confirmed that THC was found in the BAL of 94% of patients with EVALI.⁷ Similarly, another study showed that Vitamin E acetate was also detected in BAL of 94% of tested patients, compared to 0% detected in the healthy individual control group.⁷ Studies also show that approximately 71% of patients with EVALI reported using nicotine-containing vaping products with or without THC.⁸ However, nicotine was also discovered in the BAL of individuals who vape and show no signs of EVALI. Therefore, it is not quite certain how much of a role nicotine itself plays in EVALI. Other potential suspected causes for EVALI include CBD (an oil derived from marijuana) or other plant oils, but none have been consistently found in EVALI patients.⁷

Treatment for EVALI depends on the severity of the case but is mainly based on supportive care. Severe cases require hospital admission, while the less severe can be managed on an outpatient basis.³ Hospital admission is typically measured by the general markers of respiratory distress or decreased oxygen saturation (less than 95%). It is also important to rule out any possibility of infectious or contagious diseases by monitoring signs of respiratory pathogens. Prior to discharge, clinicians are recommended to check that the patient has stable oxygen levels and tolerance to exercise.³ Most patients with EVALI tend to improve on high doses of corticosteroids, steroid hormones used to treat inflammation, but this method of treatment should be withheld for patients with infectious diseases.¹² Antibiotics are also administered at times, due to EVALI sometimes being associated with bacterial or viral pneumonia.¹² In older patients, the risk of respiratory failure is higher, occasionally leading to intubation and mechanical ventilation.

EVALI first became prominent in 2019, reaching its peak around February 2020. Although EVALI diagnoses became more recognized, the number of reported cases began to decrease with law enforcement attempts to prohibit the selling of flavored and THC/Vitamin E acetate-containing vaping devices.¹⁰ Additionally, due to the COVID-19 pandemic, e-cigarette use has decreased among youth and young adults.⁹ One study showed that e-cigarette usage during the pandemic was significantly lower among youths aged 15-17 years and young adults aged 18-20 years.⁹ It is highly suspected that reduced access to environments prompting purchase of e-cigarettes was associated with the decline. The emergence of the COVID-19 pandemic has certainly coincided with a decrease in EVALI cases, but vaping rates are still considered high among youths. In 2021, there may be a resurgence of vaping and EVALI cases as the pandemic subsides.

At the present time, the CDC recommends that people who have been treated for EVALI refrain from using e-cigarettes and vaping, especially products that contain THC. Vaping products should especially not be used by young adults, youths, or women who are pregnant. Additionally, people who are not using tobacco products should not start using e-cigarette or vaping products.¹¹ Further research should be done investigating how vaping affects health at different ages, and reforms should be put into place to prevent minors from acquiring this habit.

References:

1. Hollingsworth, H. (2021). E-cigarette or vaping product use associated lung injury (EVALI). Wolters Klewer.

2. Centers for Disease Control and Prevention (2021). Youth e-cigarette use remains serious public health concern amid Covid-19 Pandemic. Centers for Disease Control and Prevention. Retrieved November 21, 2021 from https://www.cdc.gov/media/releases/2021/p0930-e-cigarette.html

3. Zulfiqar, H. and Rahman O. (2021). Vaping Associated Pulmonary Injury. StatPearls Publishing.

4. Yale Medicine (2021). E-cigarette, or Vaping Product, Use Associated Lung Injury (EVALI). Yale Medicine. Retrieved November 21, 2021 from https://www.yalemedicine.org/conditions/evali

5. Jatlaoui T.C. et al. (2019). Update: Interim Guidance for Health Care Providers for Managing Patients with Suspected E-cigarette, or Vaping, Product Use-Associated Lung Injury – United States, November 2019. Morbidity and Morality Weekly Report, 68(46), 1081-1086. DOI: 10.15585/mmwr.mm6841e3

6. Kligerman S. et al. (2020). Radiologic, Pathologic, Clinical, and Physiologic Findings of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): Evolving Knowledge and Remaining Questions. Journal of Radiology, 294(3). https://doi.org/10.1148/radiol.2020192585

7. Blount, B.C. et al. (2020). Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI. New England Journal of Medicine, 382(8), 697-705. DOI: 10.1056/NEJMoa1916433

8. Layden J.E. et al. (2020). Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Final Report. New England Journal of Medicine, 382(10), 903-916. DOI: 10.1056/NEJMoa1911614

9. Kreslake J.M. et al. (2021). E-Cigarette Use Among Youths and Young Adults During the COVID-19 Pandemic: United States, 2020. American Journal of Public Health, 111(6), 1132-1140. DOI: 10.2105/AJPH.2021.306210

10. Callahan S.J. et al. (2021). Is COVID-19 masking the ongoing youth vaping crisis? Expert Review of Respiratory Medicine, 15(9), 1089-1091. DOI: 10.1080/17476348.2021.1929927

11. Siegel D.A. et al. (2019). Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury - United States, October 2019. Morbidity and Mortality Weekly Report, 68(41), 919-927. DOI: 10.15585/mmwr.mm6841e3

12. Hage R. and Schuurmans M.M. (2020). Suggested management of e-cigarette or vaping product use associated lung injury (EVALI). Journal of Thoracic Disease, 12(7), 3460-3468. doi: 10.21037/jtd.2020.03.101

Author: Mary Gao

Edited by: Athena Wang, Maggie Sell, and Emily Lin

The Health Empowerment Coalition is a student-led organization that aims to empower individuals across the United States to improve their health literacy and take charge of their health. The views expressed in this article are the authors’ own and do not reflect the official opinions of the institutions at which they work and study. Additionally, the content in this article is not intended to provide medical advice.