Hospitalizations and Deaths Associated with EVALI

Associations between vaping during pregnancy and perinatal outcomes: A systematic review and meta-analysis

Despite numerous studies linking prenatal vaping to adverse perinatal outcomes, a systematic assessment for critical comparison remains absent. To investigate these associations, we conducted a systematic search of studies assessing perinatal outcomes in mothers and/or neonates exposed to vaping during pregnancy compared to those in women without prenatal vaping exposure through MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Library, PROSPERO, and Google Scholar until July 5, 2024. We performed inverse-variance random-effects meta-analyses for maternal and neonatal outcomes of 23 studies with a total of 924,376 participants with 7552 reporting vaping-only use during pregnancy. Prenatal vaping was associated with 53 % higher odds of an adverse maternal outcome (OR: 1.53; 95 % CI: 1.27-1.85; I2 = 80 %), particularly with decreased breastfeeding (OR: 0.53; 95 % CI: 0.38-0.72; I2 = 45 %) and reduced prevalence of adequate prenatal care (OR: 0.69; 95 % CI: 0.56-0.86; I2 = 82 %). Prenatal vaping was also associated with a similarly 53 % higher odds of an adverse neonatal outcome (OR: 1.53; 95 % CI: 1.34-1.76; I2 = 45 %), such as low birth weight (OR: 1.56; 95 % CI: 1.28-1.93; I2: 15 %), preterm birth (OR: 1.49; 955 CI: 1.27-1.76; I2: 0 %), and small for gestational age (OR: 1.48; 955 CI: 1.16-1.89; I2: 70 %). This is the first comprehensive systematic review and meta-analysis demonstrating vaping during pregnancy as a risk factor for increased odds of both maternal and neonatal outcomes and underscores the urgency to address awareness and regulations of vaping and its potential harms to both humans and the environment. REGISTRATION: PROSPERO CRD42023446266.

Association between e-cigarette exposure and ventilation homogeneity in young adults: a cross-sectional study

BACKGROUND

The number of young people who use e-cigarettes is rising. It remains unclear whether e-cigarette use impairs lung function. We aimed to compare ventilation distribution between young adults exposed to e-cigarettes and an unexposed group.

METHODS

Study participants included otherwise healthy young adults (18-24 years) who self-reported e-cigarette use and unexposed participants who had no history of e-cigarette, tobacco or cannabis exposure. Exposure to e-cigarettes was defined using three measures: 1) ever-exposed, 2) daily use and 3) puff frequency, which includes none (unexposed), minimal (<2 puffs·h-1), moderate (3-4 puffs·h-1) and heavy (≥5 puffs·h-1). Ventilation distribution was measured using the multiple-breath washout test and reported as lung clearance index (LCI).

RESULTS

A total of 93 participants were recruited; 38 unexposed and 41 exposed participants had LCI measures. The exposed group consisted predominately of participants who used flavoured e-liquids (94.5%) that contained nicotine (93.5%). The magnitude and direction of the difference in LCI across the exposure definitions was similar. Compared with the unexposed group, in the unadjusted models LCI was higher in those with any e-cigarette use (mean difference 0.15, 95% CI -0.004-0.31), daily users (mean difference 0.10, 95% CI -0.08-0.28) and heavy users (mean difference 0.22, 95% CI 0.03-0.41).

CONCLUSION

This preliminary work suggests that LCI may be a useful biomarker to measure the effects of e-cigarette use on ventilation distribution and to track early functional impairment of the small airways.

Composition of e-cigarette aerosols: A review and risk assessment of selected compounds

The potential harms and benefits of e-cigarettes, or electronic nicotine delivery systems (ENDS), have received significant attention from public health and regulatory communities. Such products may provide a reduced risk means of nicotine delivery for combustible cigarette smokers while being inappropriately appealing to nicotine naive youth. Numerous authors have examined the chemical complexity of aerosols from various open- and closed-system ENDS. This body of literature is reviewed here, with the risks of ENDS aerosol exposure among users evaluated with a margin of exposure (MoE) approach for two non-carcinogens (methylglyoxal, butyraldehyde) and a cancer risk analysis for the carcinogen N-nitrosonornicotine (NNN). We identified 96 relevant papers, including 17, 13, and 5 reporting data for methylglyoxal, butyraldehyde, and NNN, respectively. Using low-end (minimum aerosol concentration, low ENDS use) and high-end (maximum aerosol concentration, high ENDS use) assumptions, estimated doses for methylglyoxal (1.78 × 10-3-135 μg/kg-bw/day) and butyraldehyde (1.9 × 10-4-66.54 μg/kg-bw/day) corresponded to MoEs of 227-17,200,000 and 271-280,000,000, respectively, using identified points of departure (PoDs). Doses of 9.90 × 10-6-1.99 × 10-4 μg/kg-bw/day NNN corresponded to 1.4-28 surplus cancers per 100,000 ENDS users, relative to a NNN-attributable surplus of 7440 per 100,000 cigarette smokers. It was concluded that methylglyoxal and butyraldehyde in ENDS aerosols, while not innocuous, did not present a significant risk of irritant effects among ENDS users. The carcinogenic risks of NNN in ENDS aerosols were reduced, but not eliminated, relative to concentrations reported in combustible cigarette smoke.

What Do We Know About the Harms of Electronic Cigarettes?

Electronic cigarettes are commonly misperceived as safe, hence the importance of health care providers understanding the harms of these devices. To date, there is substantial evidence of impaired immune defenses leading to increased risk for severe infections. Electronic cigarette users have increased respiratory symptoms, including bronchitis, cough, and wheeze. There is evidence of emphysema from electronic cigarette use in both laboratory mouse studies and population health surveys. There is evidence of increased cardiovascular disease from electronic cigarettes in both laboratory mouse models and population health surveys. There have been many cases of acute severe lung disease leading to hospitalization and death in electronic cigarette users; although most cases reported were associated with vitamin E acetate in tetrahydrocannabinol-containing products, some cases report exclusive use of nicotine-containing electronic cigarettes. Recently, constrictive bronchiolitis has been found in lung biopsies of electronic cigarette users with dyspnea. There are multiple carcinogenic chemicals in electronic cigarette emissions. Mouse models demonstrate increased rates of lung cancer and carcinogenic chemicals accumulate in the urine of human users. Neurotoxicity has been demonstrated in laboratory mouse models. There is concern about nicotine exposure adversely impacting brain development and serving as a gateway drug for other harmful drug use. Dual use of electronic and combustible cigarettes appears to be more harmful than the use of combustible cigarettes alone. Conclusion: Electronic cigarettes have substantial harms and are not a safe alternative to combustible tobacco use. It is important for health care providers to know these harms and counsel their patients.

Vaping cessation interventions: a systematic review and meta-analysis

OBJECTIVE

Electronic nicotine delivery systems (ENDS), such as e-cigarettes, have surged in popularity. While long-term risks remain unclear, known dangers include nicotine addiction, E-cigarette or Vaping Use-Associated Lung Injury and potential extrapulmonary effects on the heart, immune system and neurodevelopment. Addressing ENDS addiction may require strategies akin to smoking cessation. However, evidence is lacking; there are no currently approved vaping-cessation aids. The objective of this review is to summarise the available literature addressing interventions for vaping cessation.

DATA SOURCES AND STUDY SELECTION

A librarian-assisted search was conducted in MEDLINE, Embase and Scopus, as well as preprints in Europe PMC, Open Science Framework, and the grey literature searches until January 2024. Six included studies used self-report methods to determine the abstinence rate, while one study used cotinine-level-verified self-reported abstinence. We included randomised controlled trials (RCTs) that examine 'rates of vaping cessation' outcomes. An intention-to-treat approach was used for data extraction, and random-effects meta-analyses models were applied.

DATA SYNTHESIS

Seven RCTs were included, which studied pharmacological therapy, digital interventions and/or educational content. The primary meta-analyses demonstrated a statistically significant increase in the odds of achieving 7-day point prevalence abstinence (PPA) (OR 1.52, 95% CI 1.15 to 2.01, number of participants=3244, moderate-certainty) and continuous abstinence (OR 2.71, 95% CI 1.31 to 5.61, number of participants=164, low-certainty) following intervention. A non-significant increase in odds was noted at 30-day PPA (OR 1.32, 95% CI 0.72 to 2.42, number of participants=1994, very low certainty).

CONCLUSIONS

Vaping cessation interventions increase 7-day PPA rates at 1-12 months follow-up and this was consistent across prespecified subgroup analyses of the intervention type, outcome and duration of follow-up. More high-quality studies with reproducible findings are needed to enhance the certainty of the evidence and guide clinical interventions.

PROSPERO REGISTRATION NUMBER

CRD42022383670.

Adolescents' perceptions, experiences, and reactions to "fake" vaping devices

Use of electronic cigarette (vaping) devices, whether to inhale nicotine, cannabis, or other substances, may pose health risks to adolescents. Those risks could be heightened when a vaping device is "fake," a term we use to include inauthentic, knockoff, counterfeit, and/or adulterated devices, an issue exemplified by the Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) outbreak of 2019-2020.

METHODS

Investigators completed in-depth, semi-structured interviews in 2020-2021 with 47 California adolescents (ages 13-17) who used nicotine products. Investigators used thematic analysis to examine participants' perceptions and reactions to fake vaping products, including devices to inhale nicotine or cannabis.

RESULTS

Participants were familiar with fake vaping devices, which they considered to be low-quality and potentially dangerous, learning about them from peers, their own experience, seeing other young people affected by them, social media, and occasionally from classes in school. Some had heard about health emergencies after using a fake product, but few were specifically familiar with EVALI. Some adolescents were confident that they could detect fake products, although others perceived encountering and using fake devices to be unavoidable. Participants believed that profit motives drove the existence of fake products, especially from informal sellers, and assumed that large companies and government agencies were actively protecting consumers.

CONCLUSIONS

Adolescents are aware of and may encounter fake vaping devices, potentially exposing them to elevated health risks. Effective public messaging and stronger actions to curb the fake product supply would better protect this population.

Exploring the Practice of Dual Vaping: Health Risks and Behavioral Patterns in Nicotine and Cannabis E-Cigarette Users

BACKGROUND

E-cigarettes, initially designed for nicotine consumption, are now increasingly being used to smoke cannabis, resulting in a growing trend known as "dual vaping". This term describes individuals, referred to as "dual users", who use e-cigarettes for both substances. This study aims to review and analyze existing research on dual vaping, with a focus on the associated health risks and behavioral patterns.

METHODS

A narrative review of the literature was conducted using PubMed. Studies focusing on individuals who use electronic cigarettes for vaping tobacco and cannabis, either chronically or episodically, were examined. Relevant articles were identified and thematically synthesized to provide a comprehensive overview of the topic.

RESULTS

Dual vaping was found to be prevalent among younger men, White and Hispanic populations, and individuals with higher economic status and educational level. The use of one substance was shown to predispose individuals to the use of the other, often leading to concurrent use of both substances. Peer influence and positive expectations regarding e-cigarettes were identified as significant predictors of dual use. Dual vapers exhibited a higher susceptibility to respiratory and systemic symptoms compared to those who exclusively vaped nicotine or cannabis. Moreover, a notable prevalence of psychiatric disorders, such as substance use disorders, anxiety, and depression, was observed in this group. Fruit-flavored e-cigarettes were the most preferred option among dual vapers when using both nicotine and cannabis.

CONCLUSIONS

Current evidence is insufficient to fully elucidate the long-term impacts of dual vaping on physical and mental health, particularly when compared to individuals who have never vaped. Further studies are needed to gain a more comprehensive understanding of this behavior.

A Review of Cardiovascular Effects of Marijuana Use

OBJECTIVE

Cannabinoids exert their effects on body tissues via cannabinoid 1 (CB 1 ) and cannabinoid 2 (CB 2 ) receptors. Receptors are present in brain, myocardium, vascular endothelium, platelets, and adipose tissues. Under normal physiologic conditions, endocannabinoid effects are minimal. The use of exogenous cannabis leads to endothelial dysfunction and increases vascular thrombosis via CB 1 receptor stimulation. On the other hand, CB 2 receptors may have a beneficial anti-inflammatory response.

REVIEW METHODS

We reviewed reports of the effects of cannabis on the cardiovascular system utilizing PUBMED from the last 20 years with emphasis on the most recent reports.

SUMMARY

Despite a plethora of reviews and some retrospective studies, there is a need for more definitive data regarding the effect of cannabis use on cardiovascular events (CVE). Marijuana does not appear to accelerate atherosclerosis. There is a suggestion that it may induce myocardial infarction in a small percentage of users, especially in male users, particularly during recent use. It has a possibility of increasing cerebrovascular events when combined with other risk factors such as tobacco use. There is an association between cannabis use and increased evidence of peripheral vascular disease. To have a definitive answer to the question of whether cannabis contributes to CVE, there is an urgent need for prospective controlled studies with patients presenting to academically oriented medical facilities with CVE following cannabis use for either medicinal or recreational use.

Environmental Risk Factors for Acute Respiratory Distress Syndrome

Several environmental exposures increase susceptibility to the acute respiratory distress syndrome (ARDS). Specifically, chronic exposure to ambient air pollution, cigarette smoke, and alcohol "prime" the lung via epithelial injury, endothelial dysfunction, and immunomodulatory mechanisms, increasing the risk and severity of ARDS following an array of acute insults. Future research of these pathways may reveal therapeutic targets. Relevant emerging threats, such as electronic cigarettes and vaping, wildfire smoke, and the environmental hazards associated with climate change, may also be associated with ARDS. Building upon existing public policy interventions can prevent substantial morbidity and mortality from ARDS.

When Vaping Isn't Actually Safer: A Death From Toxic Alcohol Contaminated Vape Juice

ABSTRACT

Vape juice is a diluent for e-cigarette active ingredients, nicotine or tetrahydrocannabinol (THC). Lack of strict regulation in vape juice production is a concern as ingredients and their concentrations may vary widely from the labeling.A 43-year-old woman was transported via ambulance to the hospital after ingesting homemade vape juice, presenting unresponsive with decerebrate posturing. She reportedly made a tincture combining a vape juice purchased online (containing "ethylene glycol") and THC for "endometriosis-related pain relief." Laboratory evaluation revealed anion gap metabolic acidosis, elevated serum lactate, and high serum osmolality. Urine fluoresced under Wood's lamp, and fomepizole was administered as an ethylene glycol antidote, but she expired the following afternoon. Clinical serum toxicology results returned after death revealed 235 mg/dL of methanol, and no ethylene glycol.Autopsy findings included ischemic changes of the gastrointestinal tract and cerebral edema with herniation. Postmortem toxicology performed on hospital admission blood revealed methanol (220 mg/dL), propylene glycol (59 mg/dL), Δ-9 THC and metabolites, and medications administered during hospitalization. The medical examiner determined the cause of death to be methanol and propylene glycol toxicity.To our knowledge, this is the first report of accidental death from ingestion of vape juice contaminated with toxic alcohol.

Cannabis Vaping Among US Adults With Disabilities: Findings From the 2022 Behavioral Risk Factor Surveillance System

OBJECTIVES

Studies have demonstrated that people with disabilities are more likely to use cannabis than people without disabilities. However, less is known about novel forms of use, such as cannabis vaping, in this population. We examined the correlates of cannabis vaping among people with disabilities and the association between cannabis vaping and the frequency of cannabis use in any form.

METHODS

We used data from the 2022 Behavioral Risk Factor Surveillance System to examine the association between disabilities and past-month cannabis vaping, as well as the number of days that cannabis was used in the past month, among US adults. We used weighted multivariable logistic and modified Poisson regression models with incidence rate ratios to examine the associations.

RESULTS

The prevalence of cannabis vaping was higher among adults with any disability (4.6%) than among adults without disabilities (2.8%); adults with only cognitive disabilities had the highest prevalence (8.2%). Daily nicotine vaping (adjusted odds ratio [AOR] = 6.04; 95% CI, 4.14-8.80), former cigarette smoking status (AOR = 1.67; 95% CI, 1.25-2.25), and being aged 18-24 years (vs ≥65 y) (AOR = 11.07; 95% CI, 7.05-17.38) were associated with higher odds of cannabis vaping among adults with any disability. Disability status modified the relationship between cigarette smoking and cannabis vaping (P < .001). Additionally, among adults with disabilities, the rate of cannabis-use days was higher among adults who vaped cannabis (adjusted incidence rate ratio = 1.28; 95% CI, 1.19-1.36) than among adults who did not vape cannabis.

CONCLUSIONS

Among adults with disabilities, nicotine consumption by vaping was associated with cannabis vaping. Our findings highlight the need for interventions that reduce the risk of polysubstance use (ie, nicotine and cannabis) in this population.

Assessing vitamin E acetate as a proxy for E-cigarette additives in a realistic pulmonary surfactant model

Additives in vaping products, such as flavors, preservatives, or thickening agents, are commonly used to enhance user experience. Among these, Vitamin E acetate (VEA) was initially thought to be harmless but has been implicated as the primary cause of e-cigarette or vaping product use-associated lung injury, a serious lung disease. In our study, VEA serves as a proxy for other e-cigarette additives. To explore its harmful effects, we developed an exposure system to subject a pulmonary surfactant (PSurf) model to VEA-rich vapor. Through detailed analysis and atomic-level simulations, we found that VEA tends to cluster into aggregates on the PSurf surface, inducing deformations and weakening its essential elastic properties, critical for respiratory cycle function. Apart from VEA, our experiments also indicate that propylene glycol and vegetable glycerin, widely used in e-liquid mixtures, or their thermal decomposition products, alter surfactant properties. This research provides molecular-level insights into the detrimental impacts of vaping product additives on lung health.

Alveolar macrophage function is impaired following inhalation of berry e-cigarette vapor

In the lower respiratory tract, the alveolar spaces are divided from the bloodstream and the external environment by only a few microns of interstitial tissue. Alveolar macrophages (AMs) defend this delicate mucosal surface from invading infections by regularly patrolling the site. AMs have three behavior modalities to achieve this goal: extending cell protrusions to probe and sample surrounding areas, squeezing the whole cell body between alveoli, and patrolling by moving the cell body around each alveolus. In this study, we found Rho GTPase, cell division control protein 42 (CDC42) expression significantly decreased after berry-flavored e-cigarette (e-cig) exposure. This shifted AM behavior from squeezing to probing. Changes in AM behavior led to a reduction in the clearance of inhaled bacteria, Pseudomonas aeruginosa. These findings shed light on pathways involved in AM migration and highlight the harmful impact of e-cig vaping on AM function.

Smoking cessation program preferences of individuals with chronic obstructive pulmonary disease: a qualitative study

AIM

To explore the views of tobacco-smoking chronic obstructive pulmonary disease (COPD) and asthma-COPD overlap (ACO) patients on telehealth-based cessation programs and the role of e-cigarettes as an aid to quit smoking.

BACKGROUND

Tobacco smoking accelerates the progression of COPD. Traditional smoking cessation programs often do not entirely address the unique needs of COPD patients, leading to suboptimal effectiveness for this population. This research is aimed at describing the attitudes and preferences of COPD and ACO patients toward innovative, telehealth-based smoking cessation strategies and the potential application of e-cigarettes as a quitting aid.

METHODS

A qualitative exploratory approach was adopted in this study, employing both focus groups and individual interviews with English-speaking adults with diagnosed COPD or ACO. Participants included both current smokers (≥ 5 cigarettes/day) and recent ex-smokers (who quit < 12 months ago). Data were systematically coded with iterative reliability checks and subjected to thematic analysis to extract key themes.

FINDINGS

A total of 24 individuals participated in this study. The emergent themes were the perceived structure and elements of a successful smoking cessation program, the possible integration of telehealth with digital technologies, and the strategic use of e-cigarettes for smoking reduction or cessation. The participants stressed the importance of both social and professional support in facilitating smoking cessation, expressing a high value for insights provided by ex-smokers serving as mentors. A preference was observed for group settings; however, the need for individualized plans was also highlighted, considering the diverse motivations individuals had to quit smoking. The participants perceived online program delivery as potentially beneficial as it could provide immediate access to support during cravings or withdrawals and was accessible to remote users. Opinions on e-cigarettes were mixed; some participants saw them as a less harmful alternative to conventional smoking, while others were skeptical of their efficacy and safety and called for further research.

Perceiving the functions of vitamin E through neutron and X-ray scattering

Take your vitamins, or don't? Vitamin E is one of the few lipophilic vitamins in the human diet and is considered an essential nutrient. Over the years it has proven to be a powerful antioxidant and is commercially used as such, but this association is far from linear in physiology. It is increasingly more likely that vitamin E has multiple legitimate biological roles. Here, we review past and current work using neutron and X-ray scattering to elucidate the influence of vitamin E on key features of model membranes that can translate to the biological function(s) of vitamin E. Although progress is being made, the hundred year-old mystery remains unsolved.

Trends in varenicline use for tobacco cessation, and their implications

BACKGROUND

Tobacco use remains a leading cause of death in the U.S. Varenicline is a preferred medication for tobacco cessation, and a prior report in the literature showed its use fell dramatically after the voluntary recall of Chantix (brand) varenicline (name) in July 2021.

OBJECTIVES

Working with data on prescriptions for varenicline and nicotine-replacement therapy (NRT), we studied use from 2018 to 2023 to determine if varenicline use had recovered or if there had been a compensatory increase in NRT use.

METHODS

Data are yearly from state employees and their dependents who were ≥18 years of age and were health-insurance beneficiaries of the Washington Public Employees Benefits Board from July 2018 through June 2023. Data include numbers of tobacco users and numbers of prescriptions filled.

RESULTS

The 5-year prevalence of tobacco use among 224,816 beneficiaries was 4.6%. The percentage of tobacco users who filled a prescription for varenicline fell from highs of 9.5% and 9.6% in the 2018-2019 and 2019-2020 years to lows of 5.3% and 6.4% in the 2021-2022 and 2022-2023 years. For nicotine replacement therapy, prescriptions rose modestly over the 5 years, from 4.5% in 2018-2019% to 6.0% in 2022-2023.

DISCUSSION

Varenicline use dropped after the voluntary recall of Chantix by Pfizer in mid-2021 and has not returned to prerecall levels.

CONCLUSION

Pharmacists and other clinicians should address this drop, in addition to addressing longer-term challenges to increasing varenicline use; these include the requirement for a prescription and the black-box warning by the Food and Drug Administration, rescinded in 2016.

Understanding the Cardiovascular Fallout of E-cigarettes: A Comprehensive Review of the Literature

E-cigarettes (ECs) deliver chemicals, including nicotine. They can cause respiratory distress, addiction, cardiovascular effects, and death. More research is needed, especially regarding their impact on the cardiovascular system (CVS) and during pregnancy. Our article aims to fill this gap by summarizing studies elaborating upon the current impact of ECs and the components thereof on the CVS. Acute respiratory distress outbreaks, nicotine addiction, CVS effects, and deaths have been occasionally reported within this cohort, although these events are not uncommon with neighboring age groups. Randomized control trials implying ECs have some contribution toward quitting smoking have been studied. To regulate EC distribution, the Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) have created key checkpoints. Additionally, taxation, pricing, age restriction, and media campaigns could be modulated to significantly reduce illicit sales. Education to the users, distributors, and regulators about this product can also play an aiding role in promoting responsible EC use. Another strategy about licensing could be employed, which could incentivize genuine resellers. The effects on CVS and child-bearing by ECs are grim, which calls for strict regulation, awareness, and avoidance by the teetotaler public. They may help individuals stop smoking but not without harming themselves. Strict regulations are necessary to prevent non-judicious use of these devices.

Heated Tobacco Products Have Detrimental Effects on Rotator Cuff Healing, Similar to Conventional Cigarettes

BACKGROUND

Cigarette smoking impairs rotator cuff healing, but no study, to our knowledge, has focused on the association between heated tobacco products and rotator cuff tears.

METHODS

This study retrospectively investigated 1,133 patients who underwent arthroscopic repair of symptomatic rotator cuff tears between March 2011 and April 2021. Patients were grouped on the basis of their smoking patterns as nonsmokers, cigarette smokers, and heated tobacco smokers. Propensity score matching was used to reduce selection bias, and 45 subjects were selected from each group via 1:1:1 matching. Functional scores and active range of motion were compared among the 3 groups preoperatively and at a 2-year follow-up. Postoperative magnetic resonance imaging was performed 6 months after the surgical procedure to assess structural integrity.

RESULTS

Except for sex, similar baseline characteristics were achieved after propensity score matching. There were no differences in the clinical scores or range of motion between the matched groups either preoperatively or at the 2-year follow-up. However, the retear rate for the matched nonsmoker group was significantly lower (8.9%) than those for the matched cigarette smoker group (31.1%) and the heated tobacco smoker group (28.9%) (p = 0.022). Multivariable logistic regression analysis revealed that the retear rates were 3.403 times higher for the cigarette smoker group and 3.397 times higher for the heated tobacco smoker group than that for the nonsmoker group.

CONCLUSIONS

Heated tobacco users, like conventional cigarette smokers, have worse clinical outcomes with respect to rotator cuff healing than nonsmokers. Regardless of the type of cigarette, abstinence from smoking is necessary for patients undergoing rotator cuff repair surgery.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Documento de consenso sobre tabaquismo y riesgo vascular

Consensus statement on smoking and vascular risk About 22% of the Spanish population are daily smokers. Men are more likely to smoke than women. In Spain, women between 15-25 years of age smoke as much or more than men. Every smoker should be assessed for: physical dependence on nicotine (Fagerström test), social and psychological dependence (Glover Nilsson test), level of motivation to quit (Richmond test), probability of therapy success (Henri-Mondor and Michael-Fiore tests), and stage of behavioral change development (Prochaska and DiClementi). Advice on smoking cessation is highly cost-effective and should always be provided. Smoking is an enhancer of cardiovascular risk because it acts as a pathogen agent in the development of arteriosclerosis and is associated with ischemic heart disease, stroke, and peripheral artery disease. Smoking increases the risk of chronic lung diseases (COPD) and is related to cancers of the lung, female genitalia, larynx, oropharynx, bladder, mouth, esophagus, liver and biliary tract, and stomach, among others. Combined oral contraceptives should be avoided in women smokers older than 35 years of age due to the risk of thromboembolism. In smoking cessation, the involvement of physicians, nurses, psychologists, etc. is important, and their multidisciplinary collaboration is needed. Effective pharmacological treatments for smoking cessation are available. Combined treatments are recommended when smoker's dependence is high. For individuals who are unable to quit smoking, a strategy based on tobacco damage management with a total switch to smokeless products could be a less dangerous alternative for their health than continuing to smoke.

Exposure to Aldehyde Cherry e-Liquid Flavoring and Its Vaping Byproduct Disrupt Pulmonary Surfactant Biophysical Function

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.

E-cigarette use-associated lung injury (EVALI)

The prevalence of vaping has overtaken conventional cigarettes as the most frequent form of nicotine consumption among 15-24-year olds. There are currently a large number of both legitimate and illegitimate products and suppliers offering more than 8000 different flavors of vape on the market, whose additives are not tested, studied or regulated and whose safety and toxicity profile remains unknown. In vitro studies have demonstrated a dose-dependent decrease in the viability of normal human bronchial epithelial cells after exposure to vapor from electronic vape devices.Short- and medium-term studies to date indicate that vapor-induced pulmonary lesions are the most serious and commonly reported side effect; such lesions include bilateral ground glass opacities in lung bases with subpleural preservation, bilateral infiltrates, pleural effusion, pneumomediastinum and nodular opacities. Cases of EVALI have been described in patients with daily exposure, as well as in users who reported having been exposed to these substances at least once a month. The most frequently inhaled substances are THC, flavored liquids of unknown content, and nicotine.The clinical manifestations of dyspnea and cough are the most frequent respiratory symptomatology, in addition to constitutional manifestations such as fever and chills, and gastrointestinal manifestations such as vomiting, nausea, abdominal pain and diarrhea. To these can be added the presence of tachypnea, tachycardia, elevated blood pressure, hypoxia, leukocytosis with neutrophilia and elevated ESR.

E-cigarette use and respiratory symptoms in adults: A systematic review and meta-analysis

INTRODUCTION

Electronic cigarette (e-cigarette) use is gaining popularity among adults. Monitoring e-cigarette-induced respiratory symptoms is crucial for both clinical and regulatory purposes. We systematically reviewed the current literature to understand the prevalence of respiratory symptoms among exclusive e-cigarette users, dual users, and former smokers.

METHODS

Databases searched included PubMed, CINAHL, Cochrane Library, Embase, and Scopus. We included all English-language, empirical quantitative articles that explored the prevalence of e-cigarette-related respiratory symptoms. Random-effects models were utilized in conducting the meta-analyses. The quality of identified studies was evaluated using the NIH Study Quality Assessment Tools. This study is registered with PROSPERO(#CRD42020165973).

RESULTS

The literature search identified 1240 references. After removing duplicates and screening for eligibility, 168 studies were included in the final review. The majority of included studies reported a wide range of adverse respiratory symptoms. The respiratory symptoms were prevalent among the exclusive e-cigarette users, dual users, and those who switched from combustible cigarettes to e-cigarettes. Further, out of the RCT studies, 5 were rated as good quality, while 3 were rated as fair. Among the observational studies, 24 were rated as good quality, and 9 were rated as fair. The two experimental studies were both rated as fair quality.

CONCLUSIONS

Continued monitoring of respiratory symptoms among e-cigarette users is warranted. Due to the heterogeneity and inconsistencies among studies, which limit result interpretation and highlight the need for studies assessing causal inference, further research using robust study designs is essential. This will provide clinicians with comprehensive knowledge about the potential respiratory risks of e-cigarette use.

A Review of the Effects of Adolescent Cannabis Use on Physical Health

The current review highlights the available research related to cannabis and indicators of physical health in a variety of domains. Various studies have found associations between cannabis use with pulmonary, cardiovascular, gastrointestinal, and endocrine function as well as body mass index and sleep. At this time, more research is needed to understand the influence of cannabis use on physical health, particularly among adolescent samples.

Vaping industry participation standards in health organizations: an exploratory policy content analysis

The vaping industry has been found to employ similar tactics to tobacco industry actors to seek credibility and distort the scientific evidence base around the health harms of nicotine vaping products. As vaping industry interests undermine vaping control efforts, safeguards are necessary to protect against this influence. We aimed to examine health organizations' policies on vaping industry participation in their activities in Australia. A descriptive approach integrating policy analysis and key informant surveys was used to obtain vaping industry participation information from health research stakeholders. Descriptive statistics on organization type, policy document type, policy document industry focus (tobacco or vaping) and respondent role and responsibility were collected. We used framework analysis to identify themes describing organizational allowances, constraints, and rationale for vaping industry research participation. Relevant health organizations were identified within Australia for policy searching (n = 156), which identified 47 unique policy documents. After contacting 267 key stakeholders from eligible organizations, 31 survey responses were analysed. Research organizations and universities were highly represented in both the policy and survey data. Most health research stakeholders recognized that vaping industry interests counteract public health priorities and opposed vaping industry participation. However, many organizations lacked clear, vaping industry-specific participation policies. To protect the integrity of the emerging evidence base around vaping harms which inform vaping policy, health organizations require strong, comprehensive policies to resist vaping industry participation in research.

E-cigarette and Vaping-Induced Lung Injury (EVALI) Long Taken for Miliary Tuberculosis: A Rare Cause of Interstitial Lung Disease

Electronic cigarettes, a recent and burgeoning product, are gaining traction among the general population. However, despite their growing popularity, there is a lack of comprehensive research on their potential health risks. A prominent concern is EVALI (electronic cigarette or vaping product use-associated lung injury), a newly recognized condition currently under intense investigation. Here, we report the case of a 24-year-old male with a history of chronic smoking e-cigarettes and vaping products heavily over the past year. He sought urgent care at the emergency room due to symptoms that had been present for seven days before seeking medical attention. These symptoms included a sudden onset of difficulty breathing at rest, an intermittent dry cough producing a small amount of greenish sputum, and occasional episodes of mild hemoptysis. Chest radiograph showed bilateral diffuse infiltrates including almost innumerable tiny interstitial nodules. Multiple lobes of the lungs were affected by consolidations and patches of ground-glass opacities in the chest high-resolution computed tomography (HRCT) image. Throughout the following week, the patient's health showed gradual improvement with the aid of supportive measures and corticosteroid treatment. As part of the recovery plan, the patient was released with a gradually reducing regimen of oral corticosteroids and was scheduled for regular outpatient monitoring. The progression of the recovery was notable through enhancements in clinical symptoms, biological markers, and radiological findings.

Carcinogenic and non-carcinogenic health risk assessment of organic compounds and heavy metals in electronic cigarettes

E-cigarettes are now very popular in the world. Compared to traditional cigarettes, e-cigarettes are often considered safer and healthier. However, their safety remains controversial and requires further research and regulation. In this study, we aimed to understand the possible hazards to humans of four compounds (formaldehyde, acetaldehyde, acrolein, and acetone) and seven heavy metals (arsenic, cadmium, manganese, lead, copper, nickel, and chromium) contained in e-cigarette liquids and aerosols and perform a health risk assessment. We searched PubMed, CNKI, and other databases for relevant literature to obtain data on organic compounds and heavy metals in e-cigarette liquids and aerosols, and conducted acute, chronic, and carcinogenic risk assessments of various chemicals by different exposure routes. This study showed that exposure to four organic compounds and seven heavy metals in e-cigarette aerosols and e-liquids can cause varying levels of health risks in humans through different routes, with the inhalation route posing a higher overall risk than dermal exposure and oral intake. Various chemicals at high exposure doses can produce health risks beyond the acceptable range. E-cigarette designers must improve their products by changing the composition of the e-liquid and controlling the power of the device to reduce the health effects on humans.

Cardiopulmonary Impact of Electronic Cigarettes and Vaping Products: A Scientific Statement From the American Heart Association

Vaping and electronic cigarette (e-cigarette) use have grown exponentially in the past decade, particularly among youth and young adults. Cigarette smoking is a risk factor for both cardiovascular and pulmonary disease. Because of their more limited ingredients and the absence of combustion, e-cigarettes and vaping products are often touted as safer alternative and potential tobacco-cessation products. The outbreak of e-cigarette or vaping product use-associated lung injury in the United States in 2019, which led to >2800 hospitalizations, highlighted the risks of e-cigarettes and vaping products. Currently, all e-cigarettes are regulated as tobacco products and thus do not undergo the premarket animal and human safety studies required of a drug product or medical device. Because youth prevalence of e-cigarette and vaping product use was as high as 27.5% in high school students in 2019 in the United States, it is critical to assess the short-term and long-term health effects of these products, as well as the development of interventional and public health efforts to reduce youth use. The objectives of this scientific statement are (1) to describe and discuss e-cigarettes and vaping products use patterns among youth and adults; (2) to identify harmful and potentially harmful constituents in vaping aerosols; (3) to critically assess the molecular, animal, and clinical evidence on the acute and chronic cardiovascular and pulmonary risks of e-cigarette and vaping products use; (4) to describe the current evidence of e-cigarettes and vaping products as potential tobacco-cessation products; and (5) to summarize current public health and regulatory efforts of e-cigarettes and vaping products. It is timely, therefore, to review the short-term and especially the long-term implications of e-cigarettes and vaping products on cardiopulmonary health. Early molecular and clinical evidence suggests various acute physiological effects from electronic nicotine delivery systems, particularly those containing nicotine. Additional clinical and animal-exposure model research is critically needed as the use of these products continues to grow.

The Substitution of Fifty Percent of Combustible Tobacco Smoke Exposure With Either Electronic Cigarettes or Heated tobacco Products Did Not Attenuate Acute Lung Injury in an Animal Model

BACKGROUND

To reduce the harmful health effects of combustible cigarette smoke (CS), some (CS) users attempt to substitute CS with electronic cigarettes (ECIG) and/or heated tobacco products (HTP). In this animal study, we evaluated the acute effects of substituting CS consumption with ECIG or HTP thus mimicking the dual users' approach, on the lungs of a mouse model.

METHODS

C57BL/6 mice were divided into Control, ECIG, HTP, CS, ECIG + CS, HTP + CS, and HTP + ECIG groups. Animals were exposed for 3 hours in AM and PM sessions to either air, CS, ECIG, or HTP for seven days. Lung injury was assessed by: wet to dry (W/D) ratio, albumin concentration in bronchoalveolar lavage fluid, expression of IL-1β, IL-6, and TNF-α, histopathology examination, reactive oxygen species (ROS) production, and assessment of cellular apoptosis.

RESULTS

W/D ratio was significantly increased in mice exposed to CS only. Albumin leak and expression of IL-1β, IL-6, and TNF-a were elevated in CS, ECIG + CS, and HTP + CS. Histological examination revealed significant inflammatory cells infiltration, as well as collagen deposit in CS, ECIG + CS, HTP + CS. ROS production was significantly increased in CS, ECIG + CS, HTP + CS. Finally, cell death was also significantly increased in CS, ECIG + CS, and HTP + CS.

CONCLUSION

In this animal model, substituting 50% of daily CS exposure by either ECIG or HTP exposure did not result in significant attenuation of acute lung injury.

Delta-8 tetrahydrocannabinol: a scoping review and commentary

BACKGROUND AND AIMS

Delta-8 tetrahydrocannabinol (THC) is a psychoactive substance from the Cannabis plant that has been rising in popularity in the United States since the 2018 US Farm Bill implicitly legalized it. This study reviewed research from peer-reviewed and non-peer-reviewed (e.g. anecdotal and news) reports related to delta-8 THC to summarize current knowledge and implications for public health and safety.

METHODS

A scoping review was conducted using PubMed, Scopus, Google Scholar and Google as search engines, leading to the identification of 103 documents that were summarized. The themes that emerged were (1) legality, (2) use (popularity, motives, psychoactivity/potency, benefits/consequences), (3) synthesis (byproducts, laboratory testing) and (4) retail (availability, price, packaging, youth-oriented marketing). A second author independently coded 20% of the documents, which verified the categorization of articles by these emergent themes.

RESULTS

Most research used animal/cell models or focused upon ways to identify the chemical structure of delta-8 THC in various products. Findings suggest that people often use delta-8 THC as a substitute for other substances. Anecdotally, delta-8 THC is a less potent psychoactive than delta-9 THC; however, several negative consequences have been reported. There is no federal age restriction for purchase/possession of delta-8 THC products. Delta-8 THC is readily accessible on-line, is typically less expensive than delta-9 THC and is often marketed in ways that would seemingly appeal to children. There are no regulations on synthesis, resulting in products being contaminated and/or yielding inconsistent effects. There have been thousands of calls to US poison control centers due to accidental delta-8 THC exposure among minors.

CONCLUSIONS

Most research on delta-8 THC is largely anecdotal, not peer-reviewed and does not involve human subjects. Future research should examine delta-8 THC use using nationally representative samples to more clearly understand the prevalence and consequences of use. Laws are needed to mitigate the risks of using delta-8 THC, particularly quality control of synthesis and minimum purchase age.

The association between dual use of electronic nicotine products and illicit drugs with adverse cardiovascular and respiratory outcomes in a longitudinal analysis using the Population Assessment of Tobacco and Health (PATH) survey

Background

Drug use and electronic nicotine delivery systems (ENDS) are independently associated with increased risk of cardiovascular and respiratory outcomes. Literature on the association between the dual use of these key substances and potential health outcomes is limited.

Methods

We examined the association between dual use of ENDs and drugs (including heroin, methamphetamine, cocaine, painkillers, and misused stimulant medications) with adverse cardiovascular and respiratory outcomes in a longitudinal analysis using waves 1-5 from the Population Assessment of Tobacco and Health survey (2014-2018). Multivariable logistic regression with Generalized Estimating Equations was utilized.

Results

About 0.9% (n = 368) of respondents at wave 2 used both ENDS and drugs, 5.1% (n = 1,985) exclusively used ENDS, and 5.9% (n = 1,318) used drugs. Compared with people who do not use drugs, both those who used only ENDS (Adjusted Odds Ratio (AOR) 1.11 [95% CI 0.99-1.23], P = 0.07758) and those who used only drugs (AOR 1.36 [95% CI 1.15-1.60], P = 0.00027) were more likely to experience adverse respiratory conditions. Individuals who used drugs and ENDS compared to people who did not use drugs or ENDS had the largest odds of respiratory problems among all drug use category comparisons (AOR 1.52 [95% CI 1.20-1.93], P = 0.00054). Individuals who only used drugs had elevated odds of cardiovascular ailments compared to people who did not use drugs or ENDS (AOR 1.24 [95% CI 1.08-1.42], P = 0.00214) and compared to people who only used ENDS (AOR 1.22 [95% CI 1.04-1.42], P = 0.0117).

Conclusions

Inhaling electronic nicotine delivery systems and other substances may negatively affect the users' respiratory health.

Longitudinal transitions in e-cigarette and cigarette use among US adults: prospective cohort study

Background

To support tobacco control efforts, this study sought to characterize longitudinal transitions in use of electronic nicotine delivery systems (ENDS) and cigarettes.

Methods

Participants were nationally representative samples of 53,729 US adults from Waves 3-5 (2015-2019) of the Population Assessment of Tobacco and Health Study. We examined behavioral transitions (initiation, relapse, progression, and cessation) in ENDS and cigarette use across waves. Weighted generalized estimating equation models adjusted for sociodemographic variables.

Findings

Of never ENDS users at baseline, an estimated 1.7% reported initiating ENDS use by follow-up. Of former ENDS users, an estimated 12.1% relapsed into ENDS use. Of periodic ENDS users at baseline, 13% progressed to established ENDS use. Of baseline current ENDS users, 46.3% discontinued ENDS use. The corresponding transitions for cigarette smoking were 1.6% (initiation), 4.8% (relapse), 21.1% (progression), and 14% (discontinuation). Adults aged 18-24 (vs. older age), Hispanics (vs. non-Hispanic white), and past 12-month cannabis users were more likely to initiate ENDS or cigarettes (all p < 0.05). Having any internalizing mental health symptoms increased the odds of ENDS initiation, while externalizing symptoms increased the odds of cigarette initiation. Those who perceived nicotine as very harmful (vs. none/low harm) were more likely to discontinue ENDS. Current cigarette users (vs. non-users) at baseline were more likely to initiate, relapse, or discontinue ENDS (all p < 0.05) and vice versa.

Interpretation

We observed high changeability in ENDS and cigarette use among US adults over time. In absolute terms, ENDS use grew, while smoking fell. Tobacco control programs should focus on priority populations, including young adults and people with internalizing and externalizing mental health symptoms.

Funding

National Institutes of Health, R01-CA246606-01A1, R01-DA048390.

The Dark Side of Cannabidiol: The Unanticipated Social and Clinical Implications of Synthetic Δ8-THC

Introduction: The explosive growth of the cannabis industry in the United States over the past decade has spurred a multitude of products derived from phytocannabinoids produced by Cannabis sativa L. Decades of cannabis prohibition coupled with the more recent 2018 Farm Bill have lead to several unanticipated consequences and the widespread availability of synthetic cannabinoids derived from hemp CBD, including Δ8-THC, Δ10-THC and HHC. Methods: Herein, we review the available literature of the complexity of the chemistry of its current manufacture, namely, the acid-catalyzed ring closure of cannabidiol (ACRCC), the myriad of issues involving the unsolved technical problems with quality control of ACRCC-Δ8-THC and the multitude of isomerized byproducts, and the lack of consistent regulation regarding consumer safety and labeling. Results: We provide what we believe is the first comprehensive listing of all the documented ACRCC-Δ8-THC byproducts. Perhaps, most importantly, we highlight the growing concern that, other than Δ8-THC itself, the compounds in ACRCC-Δ8-THC product mixtures have not been subjected to any human toxicological evaluation. This is especially troubling as ACRCC-Δ8-THC products relate to vaping, and their contribution to a growing and lethal epidemic of electronic cigarette, or vaping, product use-associated lung injury (EVALI). Conclusions: Quality control is totally inadequate in the newly emerging Δ8-THC industry. American consumers are ingesting products that are mislabeled with many compounds that have never received any toxicological testing. EVALI cases continue to be reported with a fatality rate approaching 2% (in California).

Bronchoalveolar Lavage (BAL) and Pathologic Assessment of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): The EVALI-BAL Study, A Multicenter Cohort

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.

Trends in E-cigarette Use in Callers to the Wisconsin Tobacco Quit Line

INTRODUCTION

E-cigarette use has been increasing for years with a limited understanding of how to help users quit. Quit lines are a potential resource for e-cigarette cessation. Our objective was to characterize e-cigarette users who call state quit lines and to examine trends in e-cigarette use by callers.

METHODS

This retrospective study examined data from adult callers to the Wisconsin Tobacco Quit Line from July 2016 through November 2020, including demographics, tobacco product use, motivations for use, and intentions to quit. Descriptive analyses were performed by age group with pairwise comparisons.

RESULTS

A total of 26,705 encounters were handled by the Wisconsin Tobacco Quit Line during the study period. E-cigarettes were used by 11% of callers. Young adults aged 18-24 had the highest rates of use at 30%, and their use rose significantly from 19.6% in 2016 to 39.6% in 2020. E-cigarette use among young adult callers peaked at 49.7% in 2019, coinciding with an outbreak of e-cigarette-related lung injury. Only 53.5% of young adult callers used e-cigarettes to "cut down on other tobacco," compared to 76.3% of adult callers aged 45-64 (P <0.05). Of all callers using e-cigarettes, 80% were interested in quitting.

CONCLUSIONS

E-cigarette use among callers to the Wisconsin Tobacco Quit Line has increased, driven largely by young adults. Most e-cigarette users who call the quit line want to quit. Thus, quit lines can serve an important role in e-cigarette cessation. A better understanding of strategies to help e-cigarette users quit is needed, particularly in young adult callers.

Clinical manifestations of EVALI in adolescents before and during the COVID-19 pandemic

INTRODUCTION

E-cigarette, or vaping, product use-associated lung injury (EVALI) results from inhaling the aerosol of e-cigarettes and has similar clinical features to coronavirus disease 2019 (COVID-19). EVALI case counts since the declaration of the COVID-19 pandemic is unknown.

METHODS

A retrospective electronic health record chart review of adolescents hospitalized at one institution with EVALI was conducted. Clinical characteristics and hospital course of patients hospitalized during the pandemic were compared to those prepandemic.

RESULTS

The clinical presentation of adolescents hospitalized prior-to (n = 19) and during the COVID-19 pandemic (n = 22) were similar with respect to constitutional, respiratory, and gastrointestinal symptoms. All patients hospitalized during the pandemic were tested for COVID-19 at least once. Only one patient had a positive SARS-CoV-2 RT-PCR test result. Thirty-one out of 39 patients treated with corticosteroids had clinical improvement within 24 h (79%). Patients hospitalized during the pandemic had a shorter median length of stay (5 vs. 7 days, p < 0.01), and were less often discharged with home oxygen (1 vs. 6 patients, p = 0.04). Pulmonary function tests improved pre- to postcorticosteroid treatment and postcorticosteroid to follow-up.

CONCLUSIONS

Eliciting a history of vaping in adolescents presenting with constitutional, respiratory, and gastrointestinal symptoms is important to identify EVALI cases, which have continued throughout the COVID-19 pandemic. A shorter length of stay with less need for mechanical ventilation and home oxygen in adolescents hospitalized during the pandemic may reflect increased familiarity with EVALI characteristics. Corticosteroids led to clinical and pulmonary function improvement.

A Novel Puff Recording Electronic Nicotine Delivery System for Assessing Naturalistic Puff Topography and Nicotine Consumption During Ad Libitum Use: Ancillary Study

BACKGROUND

Assessing the naturalistic puff topography and associated nicotine consumption during e-cigarette use is important as such information will not only unveil how these products are being consumed in real-world conditions, but also enable investigators and regulatory bodies to conduct quantitative, accurate, and realistic harmful exposure and nicotine abuse liability risk assessments based on actual e-cigarette use. Conventional approaches cannot accurately, conveniently, and noninvasively determine e-cigarette puff topography in a natural use environment. Thus, novel technology-enabled systems that do not primarily rely on self-report mechanisms or intrusive measurements to monitor e-cigarette product use behaviors are highly desired.

OBJECTIVE

This study aimed to explore and demonstrate the feasibility of a novel puff recording electronic nicotine delivery system (PR-ENDS) device for measuring naturalistic puff topography and estimating nicotine consumption during the ad libitum use of products among smokers and vapers.

METHODS

An ancillary data analysis based on a completed parent study was conducted. The parent study was a 1-way randomized controlled open-label puff topography and nicotine pharmacokinetic assessment carried out in 24 healthy adults (12 smokers and 12 vapers). Participants were assigned a randomized product use sequence of a PR-ENDS device within 5 site visits for both controlled and ad libitum product use sessions. Blood samples were obtained for plasma nicotine analysis, and questionnaires were administered at various time points. During the ad libitum use session, puff topography was measured using a Clinical Research Support System (CReSS) device as a benchmark, as well as the PR-ENDS device with a built-in puff recording feature.

RESULTS

There were no significant differences in representative puff topography parameters (number of puffs, total puff duration, and average puff duration) between the PR-ENDS and CReSS devices at the populational level across different device powers, e-liquid nicotine strengths, and flavors. The nicotine consumption estimated by the PR-ENDS device suggested that this device can be employed as a convenient monitoring tool for estimating nicotine use without measuring e-liquid weight loss between puffs. The linear relationship between nicotine consumption estimated by the PR-ENDS device and the pharmacokinetic parameter AUC_{ad lib} (plasma concentration-time curve for 1-hour ad libitum use) substantiated the potential of using this device as a pragmatic, noninvasive, and convenient means for estimating nicotine intake in the human body without blood collection.

CONCLUSIONS

The novel PR-ENDS device was feasible for assessing naturalistic puff topography and estimating nicotine consumption and intake in the human body during ad libitum use. Several key factors can influence users' puff topography, including device power levels, e-liquid nicotine strengths, and flavors. The study results pave the way for further research in the real-time measurement of naturalistic puff topography and puffing behaviors in the real world.

Demographic, Clinical, and Behavioral Factors Associated With Electronic Nicotine Delivery Systems Use in a Large Cohort in the United States

Introduction

Our primary purpose is to understand comorbidities and health outcomes associated with electronic nicotine delivery systems (ENDS) use.

Methods

Study participants were Kaiser Permanente (KP) members from eight US regions who joined the Kaiser Permanente Research Bank (KPRB) from September 2015 through December 2019 and completed a questionnaire assessing demographic and behavioral factors, including ENDS and traditional cigarette use. Medical history and health outcomes were obtained from electronic health records. We used multinomial logistic regression to estimate odd ratios (ORs) and 95% confidence intervals (CIs) of current and former ENDS use according to member characteristics, behavioral factors, and clinical history. We used Cox regression to estimate hazard ratios (HRs) and 95% CIs comparing risk of health outcomes according to ENDS use.

Results

Of 119 593 participants, 1594 (1%) reported current ENDS use and 5603 (5%) reported past ENDS use. ENDS users were more likely to be younger, male, gay or lesbian, and American Indian / Alaskan Native or Asian. After adjustment for confounding, current ENDS use was associated with current traditional cigarette use (OR = 39.55; CI:33.44-46.77), current marijuana use (OR = 6.72; CI:5.61-8.05), history of lung cancer (OR = 2.64; CI:1.42-4.92), non-stroke cerebral vascular disease (OR = 1.55; CI:1.21-1.99), and chronic obstructive pulmonary disease (OR = 2.16; CI:1.77-2.63). Current ENDS use was also associated with increased risk of emergency room (ER) visits (HR = 1.17; CI: 1.05-1.30) and death (HR = 1.84; CI:1.02-3.32).

Conclusions

Concurrent traditional cigarette use, marijuana use, and comorbidities were prevalent among those who used ENDS, and current ENDS use was associated with an increased risk of ER visits and death. Additional research focused on health risks associated with concurrent ENDS and traditional cigarette use in those with underlying comorbidities is needed.

The E-cigarette or Vaping Product Use-Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report

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.

The main e-cigarette component vegetable glycerin enhances neutrophil migration and fibrosis in endotoxin-induced lung injury via p38 MAPK activation

We investigated the effects of vegetable glycerin (VG), a main e-cigarette constituent, on endotoxin-induced acute lung injury (ALI). Mice received intratracheal administration of 30% VG in phosphate buffered saline (PBS) vehicle or only PBS (control) for 4 days. On Day 5, mice received an intratracheal instillation of lipopolysaccharide (LPS) (LPS group and VG + LPS group) or PBS (VG group and control group). Lung histopathology, expression of chemokine receptors, and regulatory signaling were analyzed 24 h after the Day 5 treatment. VG significantly increased ALI-associated histopathological and fibrotic changes in both the VG group and LPS-induced ALI mice (VG + LPS group). Immunohistochemistry (IHC) and western blot analyses revealed that VG administration resulted in upregulation of neutrophil markers [lymphocyte antigen 6 complex locus G6D (Ly6G) and myeloperoxidase (MPO)] as well as upregulation of the expression of transforming growth factor-β (TGF-β), a central mediator of fibrogenesis, in the lungs of both VG and VG + LPS groups. VG enhanced the expression of adhesion molecules [very late antigen 4 (VLA-4) and vascular cell adhesion molecule 1 (VCAM-1)] and increased activation of p38 mitogen-activated protein kinase (p38 MAPK) to prompt neutrophil recruitment in the lungs of mice with ALI. Intraperitoneal administration of a p38 inhibitor attenuated these histopathological changes significantly as well as VG-induced upregulation in expression of Ly6G, MPO, VLA-4, VCAM-1, TGF-β, and collagen-1 in mice with ALI. In conclusion, VG enhances neutrophil chemotaxis and fibrosis and it amplifies the inflammatory response associated with LPS-induced ALI in the lungs via enhancement of p38 MAPK activity.

A Review of the Effects of Adolescent Cannabis Use on Physical Health

The current review highlights the available research related to cannabis and indicators of physical health in a variety of domains. Various studies have found associations between cannabis use with pulmonary, cardiovascular, gastrointestinal, and endocrine function as well as body mass index and sleep. At this time, more research is needed to understand the influence of cannabis use on physical health, particularly among adolescent samples.

Vaping Associated Acute Eosinophilic Pneumonia: A Clinical and Radiologic Mimicker of COVID-19

Acute eosinophilic pneumonia (AEP) is a rare cause of respiratory failure. It is primarily a disease of smokers, either a new smoker or an existing one with a recent increase in cigarette consumption. Other risk factors include toxic gas exposure, inhalational illicit drugs, and smoking marijuana. AEP has also been reported in patients with e-cigarette or vaping associated lung injury (EVALI). We present the case of a 20-year-old male who presented to the hospital with acute respiratory failure. The patient has been vaping heavily for the past three months and started smoking three days before presenting to the emergency department. He was hypertensive, tachycardic, tachypneic, and required high-flow nasal cannula to maintain SpO2 > 92%. His condition deteriorated in the first 24 hours following hospitalization requiring noninvasive positive pressure ventilation. Bronchoalveolar lavage revealed an eosinophil count of 36%. Bronchoalveolar lavage (BAL) cytology revealed lipid-laden macrophages. He was diagnosed with AEP due to EVALI, and the patient was treated with high dose corticosteroid with subsequent improvement. Before the bronchoscopic evaluation, the clinical and radiologic findings were consistent with COVID-19, and the patient was tested twice for SARS-CoV-2 PCR. In the appropriate clinical setting, AEP should be considered in the differential diagnoses of community-acquired pneumonia, acute respiratory distress syndrome (ARDS), and COVID-19, especially in this pandemic era.

Evidence from an fMRI study that dessert-flavored e-cigarettes engage taste-related, but not smoking-related, brain circuitry for female daily smokers

Regulations limiting the sale of flavored e-cigarette products are controversial for their potential to interfere with e-cigarette use as a cessation aid in addition to curbing youth use. Limited research suggests that flavor might enhance the addictive potential of e-cigarettes; however, the acute effects of flavored aerosols on brain function among humans have not been assessed. The present study aimed to isolate and compare the neural substrates of flavored and unflavored e-cigarette aerosols on brain function among nine female daily smokers. Participants inhaled aerosolized e-liquid with 36 mg/mL of nicotine with and without a strawberry-vanilla flavor while undergoing functional magnetic resonance imaging. We used general linear modeling to compare whole-brain mean neural activation and seed-to-voxel task-based functional connectivity between the flavored and unflavored inhalation runs. Contrary to our hypothesis, the flavored aerosol was associated with weaker activation than the unflavored aerosol in the brain stem and bilateral parietal-temporal-occipital region of the cortex. Instead, the flavor engaged taste-related brain regions while suppressing activation of the neural circuits typically engaged during smoking and nicotine administration. Alternatively, functional connectivity between subcortical dopaminergic brain seeds and cortical brain regions involved in motivation and reward salience were stronger during the flavored compared to unflavored aerosol run. The findings suggest that fruity and dessert-flavored e-cigarettes may dampen the reward experience of aerosol inhalation for smokers who initiate e-cigarette use by inhibiting activation of dopaminergic brain circuits. These preliminary findings may have implications for understanding how regulations on flavored e-cigarettes might impact their use as cessation aids. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

[Inhaled marijuana and the lung, a toxic cocktail?]

Unlike the well-documented effects of tobacco smoke on the lung, the effects of cannabis smoke remain controversial, the main bias consisting in co-consumption of tobacco. That said, the composition of joint smoke is close to that of cigarettes, containing many compounds that are carcinogenic and/or alter the respiratory epithelium. Confirmed respiratory effects in chronic cannabis smokers include aggravated chronic bronchitis symptoms, a cumulative effect with tobacco on COPD and emphysema occurrence, an increased risk of bullous emphysema, and pneumothorax with heightened risk of recurrence after pleural symphysis. Recent prospective studies have shown a negative impact on lung function, with not only damage to the airways, but also DLCO alteration and an accelerated drop in FEV1. Finally, cannabis smoking is very common among young patients with lung cancer. Its consumption could lead to a different lung cancer profile, potentially more undifferentiated and less accessible to targeted therapy. Questioning about cannabis consumption must be systematic and targeted medical care should be offered.

Impact of vaping on respiratory health

Widespread uptake of vaping has signaled a sea change in the future of nicotine consumption. Vaping has grown in popularity over the past decade, in part propelled by innovations in vape pen design and nicotine flavoring. Teens and young adults have seen the biggest uptake in use of vape pens, which have superseded conventional cigarettes as the preferred modality of nicotine consumption. Relatively little is known, however, about the potential effects of chronic vaping on the respiratory system. Further, the role of vaping as a tool of smoking cessation and tobacco harm reduction remains controversial. The 2019 E-cigarette or Vaping Use-Associated Lung Injury (EVALI) outbreak highlighted the potential harms of vaping, and the consequences of long term use remain unknown. Here, we review the growing body of literature investigating the impacts of vaping on respiratory health. We review the clinical manifestations of vaping related lung injury, including the EVALI outbreak, as well as the effects of chronic vaping on respiratory health and covid-19 outcomes. We conclude that vaping is not without risk, and that further investigation is required to establish clear public policy guidance and regulation.

Do Not Miss Acute Diffuse Panbronchiolitis for Tree-in-Bud: Case Series of a Rare Lung Disease

Acute bronchiolitis is a common disease of infants affecting the small airways. Rarely, acute bronchiolitis may occur in adolescents and adults. Here, we present four unrelated adolescent patients with severe clinical presentation and unique CT imaging with extensive tree-in-bud pattern, representing a rare clinical phenotype of acute diffuse panbronchiolitis. This characteristic disease pattern caused by inhalation injury from waterpipes, smoked tobacco, and cannabinoids must be differentiated from e-cigarette or vaping product-use-associated lung injury (EVALI). Visual diagnosis of CT and an early diagnostic procedure for detection and differentiation of inhaled hazards, including sample storage for future identification of novel noxious agents, are warranted.