Life-threatening bronchiolitis related to electronic cigarette use in a Canadian youth

Vaping-associated constrictive bronchiolitis

A woman in her 40s who vaped reported rapid onset of shortness of breath and cough. Pulmonary function testing showed severe obstruction and no substantial response to an inhaled bronchodilator, and chest computed tomography revealed extensive air trapping. A lung cryobiopsy was done after a comprehensive and unrevealing evaluation, which showed characteristics of airway inflammation and prominent bronchial-associated lymphoid tissue. With this knowledge and her vaping history, we diagnosed vaping-associated constrictive bronchiolitis. This phenomenon has not been well described. Clinicians should know to consider vaping when a patient with a vaping history presents with severe airway obstruction.

Targeted Education for School Staff on Electronic Nicotine Delivery Systems: A Nurse Led Intervention

There is a public health epidemic in adolescents' use of Electronic Nicotine Delivery Systems (ENDSs), also known as electronic cigarettes, vaping products, or JUULs. However, little is known about the level of knowledge school staff have about ENDS. The purpose of this study is to examine outcomes of a nurse-led educational intervention designed to increase school staff knowledge about ENDS. A descriptive, nonrandomly selected pre-test/post-test design was used with 125 Wisconsin school staff. Results revealed further educational needs of school staff in content areas including advertising to youth and flavoring of ENDS. Following the educational intervention, post-test results showed a significant overall improvement in participant knowledge scores. Recommendations include implementing nurse-led education about ENDS to a more diverse population of school staff. Providing nurse-led ENDS education to school staff offers an upstream, proactive approach for school nurses to help address this public health epidemic.

Review of quantitative and functional lung imaging evidence of vaping-related lung injury

Introduction

The pulmonary effects of e-cigarette use (or vaping) became a healthcare concern in 2019, following the rapid increase of e-cigarette-related or vaping-associated lung injury (EVALI) in young people, which resulted in the critical care admission of thousands of teenagers and young adults. Pulmonary functional imaging is well-positioned to provide information about the acute and chronic effects of vaping. We generated a systematic review to retrieve relevant imaging studies that describe the acute and chronic imaging findings that underly vaping-related lung structure-function abnormalities.

Methods

A systematic review was undertaken on June 13th, 2023 using PubMed to search for published manuscripts using the following criteria: [("Vaping" OR "e-cigarette" OR "EVALI") AND ("MRI" OR "CT" OR "Imaging")]. We included only studies involving human participants, vaping/e-cigarette use, and MRI, CT and/or PET.

Results

The search identified 445 manuscripts, of which 110 (668 unique participants) specifically mentioned MRI, PET or CT imaging in cases or retrospective case series of patients who vaped. This included 105 manuscripts specific to CT (626 participants), three manuscripts which mainly used MRI (23 participants), and two manuscripts which described PET findings (20 participants). Most studies were conducted in North America (n = 90), with the remaining studies conducted in Europe (n = 15), Asia (n = 4) and South America (n = 1). The vast majority of publications described case studies (n = 93) and a few described larger retrospective or prospective studies (n = 17). In e-cigarette users and patients with EVALI, key CT findings included ground-glass opacities, consolidations and subpleural sparing, MRI revealed abnormal ventilation, perfusion and ventilation/perfusion matching, while PET showed evidence of pulmonary inflammation.

Discussion and conclusion

Pulmonary structural and functional imaging abnormalities were common in patients with EVALI and in e-cigarette users with or without respiratory symptoms, which suggests that functional MRI may be helpful in the investigation of the pulmonary health effects associated with e-cigarette use.

Thermal reaction products and formation pathways of two monoterpenes under in situ thermal desorption conditions that mimic vaping coil temperatures

Vaping has become more popular and different brands and types of vaping devices have rapidly emerged. However, little is known about the potential health risks of human inhalation exposures to the volatile chemicals in the vapour, which includes both directly vaporised components of vaping liquid and their reaction products formed during vaping processes. This study investigated reaction products of two monoterpenes (α-pinene and terpinolene) that are used as flavouring agents in vaping liquids with a focus on the identification of reaction products and their formation pathways. The thermal desorption was conducted under an in situ condition that is in the range of heating coil temperature in vaping by thermally desorbing the chemicals at a temperature range of 100-300 °C. Additional clean air was introduced during the thermal desorption. 36 and 29 reaction products were identified from α-pinene and terpinolene, respectively, at a relative concentration of 0.01% and greater in the desorbed mixture. 3-Carene was the dominant reaction product of α-pinene, while reaction products of terpinolene was dominated by p-isopropenyltoluene. Several reaction pathways including ring opening, allylic oxidation, cyclo-etherification, Wagner-Meerwein rearrangement, epoxidation, cleavage and removal of partial structure, and dehydration were involved in the formation of various reaction products. These pathways and resulting relative concentrations of residual parent compound and reaction products were influenced by both temperature and amount of air present during thermal desorption. The study results demonstrate possible existence of reaction products from thermally labile chemicals like monoterpenes in vaping aerosols and can help inform policies regulating vaping devices and products to protect public health.

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.

Place of therapeutic cannabis in France and safety data: A literature review

OBJECTIVES

To date, very few cannabis-based specialities are authorised on the French market despite a growing demand from patients and health professionals. The objective of this study is to review the tolerance profile and the French legislative status of the two main cannabinoids used for therapeutic purposes: tetrahydrocannabiol (THC) associated with psychoactive effects and non-psychoactive cannabidiol (CBD).

METHODS

This review is based on relevant articles retrieved by a search in Google Scholar and PubMed databases and on an assessment of the legal texts and summaries of product characteristics available in France.

RESULTS

Evidence for the tolerability of CBD during chronic use is reassuring, but a significant risk of drug interactions exists. THC use appears to be associated with a higher proportion of serious adverse effects, including neuropsychological and cardiovascular effects. Inhaled cannabis appears to be associated with greater toxicity than the oral route. These data are presented together with the pharmacokinetic and pharmacodynamic data of THC and CBD.

CONCLUSION

The literature reports several frequent but rarely serious adverse effects of CBD during chronic use as well as a significant risk of drug interactions. THC use seems to be associated with a higher proportion of serious adverse effects compared to CBD, particularly at the neuropsychological and cardiovascular levels. Health professionals should be up to date on the particularities of therapeutic cannabis in terms of efficacy, safety and drug interactions.

E-cigarette or vaping-associated lung injury (EVALI): a review of international case reports from outside the United States of America

INTRODUCTION

E-cigarette or vaping-associated lung injury has been reported extensively throughout the United States without a corresponding number of international cases. Cannabinoid-based products have been implicated in the majority of cases.

OBJECTIVES

To collate published reports of E-cigarette or vaping-associated lung injury outside the United States and to identify the reasons behind the discrepancy in reported cases between the United States and the international community.

METHODS

PubMed and Healthcare Databases Advanced Search were used to identify published case reports of E-cigarette or vaping-associated lung injury prior to February 2021 using the search terms "e-cigarette", "e-cigarettes", "vaping", "vape" and, "lung injury", "pulmonary", "respiratory". Cases occurring in the United States were excluded. Non-United States case reports were excluded if they did not meet the Centers for Disease Control and Prevention "probable case" criteria. This requires use of a vaping device within 90 days of symptom onset, the presence of pulmonary infiltrates on plain film chest radiography or ground glass opacities on computerised tomography, clinical suspicion that infection was not the underlying cause of lung injury, and the absence of other plausible medical processes to account for the presentation. Patient demographics, nature of exposure, symptomatology and outcome were compared to 125 cases from three regional United States based case series, which were chosen on the basis of having complete data for these comparative factors.

RESULTS

Seventeen international cases from 13 countries were identified for analysis. There was a male predominance in both non-United States and United States cohorts (76% vs 58-83%), with a marginally higher median patient age in non-United States cases (31 vs 27, 19, 27 years). Reported use of nicotine/flavoured e-liquids was more common in non-United States cases (100% vs 58-67%), and use of cannabinoid-based products was less common (24% vs 78-92%). The most common symptoms across all cohorts were shortness of breath (76% vs 85-91%), cough (59% vs 78-83%) and fever (47% vs 78-83%). The majority of patients were hypoxic (76% vs 69-86%) and required hospital admission (88% vs 90-94%). Fewer of the non-United States patients required intensive care admission (24% vs 55-67%) though their median length of stay was longer (15 days vs 5, 6, 7 days).

DISCUSSION

Uniformity amongst non-United States cases in regards to nicotine based and/or flavoured e-liquid exposure may underestimate the role of these substances in e-cigarette or vaping-associated lung injury. This is consistent with prior United States based research demonstrating increased presentations to emergency departments prior to the recognised "outbreak" of e-cigarette or vaping-associated lung injury at a time of increased nicotine based e-liquid uptake. A longer length of hospital stay, lower rate of intensive care admission and a higher rate of bronchoscopy in the non-United States cohort could be indicative of clinician inexperience internationally. It is unclear why the non-United States cases also had a lower incidence of gastrointestinal symptoms however this may also be explained by poorer diagnostic awareness.

CONCLUSIONS

E-cigarette or vaping-associated lung injury is not limited to cannabinoid-based products. Apparent similarities in patient demographics, clinical features, and clinical course between non-United States and United States cases raise concern for underreporting of E-cigarette or vaping- associated lung injury internationally.

E-cigarette aerosol exposure of pulmonary surfactant impairs its surface tension reducing function

Introduction

E-cigarette (EC) and vaping use continue to remain popular amongst teenage and young adult populations, despite several reports of vaping associated lung injury. One of the first compounds that EC aerosols comes into contact within the lungs during a deep inhalation is pulmonary surfactant. Impairment of surfactant’s critical surface tension reducing activity can contribute to lung dysfunction. Currently, information on how EC aerosols impacts pulmonary surfactant remains limited. We hypothesized that exposure to EC aerosol impairs the surface tension reducing ability of surfactant.

Methods

Bovine Lipid Extract Surfactant (BLES) was used as a model surfactant in a direct exposure syringe system. BLES (2ml) was placed in a syringe (30ml) attached to an EC. The generated aerosol was drawn into the syringe and then expelled, repeated 30 times. Biophysical analysis after exposure was completed using a constrained drop surfactometer (CDS).

Results

Minimum surface tensions increased significantly after exposure to the EC aerosol across 20 compression/expansion cycles. Mixing of non-aerosolized e-liquid did not result in significant changes. Variation in device used, addition of nicotine, or temperature of the aerosol had no additional effect. Two e-liquid flavours, menthol and red wedding, had further detrimental effects, resulting in significantly higher surface tension than the vehicle exposed BLES. Menthol exposed BLES has the highest minimum surface tensions across all 20 compression/expansion cycles. Alteration of surfactant properties through interaction with the produced aerosol was observed with a basic e-liquid vehicle, however additional compounds produced by added flavourings appeared to be able to increase inhibition.

Conclusion

EC aerosols alter surfactant function through increases in minimum surface tension. This impairment may contribute to lung dysfunction and susceptibility to further injury.

Electronic Cigarettes: A Pro-Con Review of the Current Literature

Electronic cigarettes (e-cigarettes, e-cigs, or electronic nicotine delivery systems) are battery-operated devices typically containing glycerol and/or propylene glycol-based solutions with varying nicotine content, known as e-liquids. Although e-cigarettes were originally developed as a potentially less harmful alternative to traditional combustible tobacco cigarette smokers, several factors have driven their popularity among smokers and nonsmokers alike, including their sleek product designs, innumerable appealing flavors, lack of combustible smoke and odor, and high potential nicotine concentrations. Furthermore, many advocates have promoted the idea that e-cigarettes are safe to use, or at least safer than conventional tobacco, despite limited longitudinal data to support these claims. Here, we examine what is known about the impacts of e-cigarette use on traditional cigarette smoking cessation, lung health, and youth and young adult tobacco product exposure. Upon review of the currently available literature, the negative effects of e-cigarette use seem to outweigh any potential benefit, because the available evidence does not confirm the use of e-cigarettes as an effective strategy for supporting traditional combustible tobacco cigarette smoking cessation, particularly given the emerging adverse effects on lung health and the potential future public health effects of e-cigarette adoption among a burgeoning new generation of tobacco product users.

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.

Secondhand nicotine vaping at home and respiratory symptoms in young adults

RATIONALE

Despite high prevalence of e-cigarette use (vaping), little is currently known regarding the health effects of secondhand nicotine vape exposure.

OBJECTIVE

To investigate whether exposure to secondhand nicotine vape exposure is associated with adverse respiratory health symptoms among young adults.

METHOD

We investigated the effect of secondhand nicotine vape exposure on annually reported wheeze, bronchitic symptoms and shortness of breath in the prospective Southern California Children Health Study cohort. Data were collected from study participants (n=2097) with repeated annual surveys from 2014 (average age: 17.3 years) to 2019 (average age: 21.9). We used mixed effect logistic regression to evaluate the association between secondhand nicotine vape and respiratory symptoms after controlling for relevant confounders.

RESULTS

Prevalence of secondhand nicotine vape increased from 11.7% to 15.6% during the study period in this population. Prevalence of wheeze, bronchitic symptoms and shortness of breath ranged from 12.3% to 14.9%, 19.4% to 26.0% and 16.5% to 18.1%, respectively, during the study period. Associations of secondhand nicotine vape exposure with bronchitic symptoms (OR 1.40, 95% CI 1.06 to 1.84) and shortness of breath (OR 1.53, 95% CI 1.06 to 2.21) were observed after controlling for vaping, active and passive exposure to tobacco or cannabis, and demographic characteristics (age, gender, race/ethnicity and parental education). Stronger associations were observed when analysis was restricted to participants who were neither smokers nor vapers. There were no associations with wheezing after adjustment for confounders.

CONCLUSION

Secondhand nicotine vape exposure was associated with increased risk of bronchitic symptoms and shortness of breath among young adults.

Acute injury or illness related to the inhalation of vaping aerosols among children and adolescents across Canada: A cross-sectional survey of Canadian paediatricians

Background

Vaping prevalence rates have increased among Canadian youth. Evidence suggests that vaping poses significant health risks to children and adolescents.

Objectives

The objectives of the study were to investigate epidemiological characteristics of acute injury/illness cases due to the inhalation of vaping aerosols among children and adolescents across Canada and to explore factors contributing to severe cases.

Methods

Data from the 2019 Canadian Paediatric Surveillance Program cross-sectional survey on vaping-related injury/illness were used. Analyses focused on injury/illness cases (n=71) among children and adolescents aged 0 to 17 years who presented to participating paediatricians for a harm related to the inhalation of vaping aerosols. We conducted descriptive analyses and performed logistic regression to explore associations between severe presentations requiring hospitalization or intensive care unit (ICU) admission and selected case characteristics.

Results

Of the 71 reported injury/illness cases related to inhalation of vaping aerosols, 56% of patients were male, and 68% were aged 15 to 17 years. Nicotine vaping was reported in 42% of cases, and cannabis vaping in 24%. Fifty-four per cent presented with respiratory distress, 18% with symptoms of nicotine toxicity, and 41% required hospitalization and/or admission to the ICU. Cases presenting with respiratory distress were more likely to be hospitalized/admitted to the ICU (odds ratio [OR]=5.37, 95% confidence interval [CI]:1.76 to 16.39).

Conclusions

The inhalation of vaping aerosols among children and adolescents may contribute to acute injury/illness. Clear associations between study variables and severe cases could not be established due to a small sample size. Additional research is needed to determine predictors and preventable risk factors of severe vaping-related injuries.

Harm reduction in tobacco control: where do we draw the line?

With substance abuse, harm reduction refers to reducing or replacing use of a harmful product with a less risky agent. But many advertised "non-pharmaceutical" harm reduction alternatives for tobacco smoking are problematic. Studies have revealed inconclusive results using agents including chewing tobacco and e-cigarettes to quit smoking and have demonstrated continued use of these agents. Many smoking harm reduction agents pose other health risks not found in traditional tobacco smoking. Given these limitations, efforts should focus on promoting nicotine replacement therapy, and other pharmacologic agents with a better chance of producing sustained smoking cessation. To address the harmful nature of many tobacco replacement products, public health should focus on regulating these alternatives with the same stringency as tobacco, and social marketing efforts should target evidence-based and safer pharmaceutical grade or behavioural alternatives.

E-cigarette vaping associated acute lung injury (EVALI): state of science and future research needs

"E-Cigarette (e-cig) Vaping-Associated Acute Lung Injury" (EVALI) has been linked to vitamin-E-acetate (VEA) and Δ-9-tetrahydrocannabinol (THC), due to their presence in patients' e-cigs and biological samples. Lacking standardized methodologies for patients' data collection and comprehensive physicochemical/toxicological studies using real-world-vapor exposures, very little data are available, thus the underlying pathophysiological mechanism of EVALI is still unknown. This review aims to provide a comprehensive and critical appraisal of existing literature on clinical/epidemiological features and physicochemical-toxicological characterization of vaping emissions associated with EVALI. The literature review of 161 medical case reports revealed that the predominant demographic pattern was healthy white male, adolescent, or young adult, vaping illicit/informal THC-containing e-cigs. The main histopathologic pattern consisted of diffuse alveolar damage with bilateral ground-glass-opacities at chest radiograph/CT, and increased number of macrophages or neutrophils and foamy-macrophages in the bronchoalveolar lavage. The chemical analysis of THC/VEA e-cig vapors showed a chemical difference between THC/VEA and the single THC or VEA. The chemical characterization of vapors from counterfeit THC-based e-cigs or in-house-prepared e-liquids using either cannabidiol (CBD), VEA, or medium-chain triglycerides (MCT), identified many toxicants, such as carbonyls, volatile organic compounds, terpenes, silicon compounds, hydrocarbons, heavy metals, pesticides and various industrial/manufacturing/automotive-related chemicals. There is very scarce published toxicological data on emissions from THC/VEA e-liquids. However, CBD, MCT, and VEA emissions exert varying degrees of cytotoxicity, inflammation, and lung damage, depending on puffing topography and cell line. Major knowledge gaps were identified, including the need for more systematic-standardized epidemiological surveys, comprehensive physicochemical characterization of real-world e-cig emissions, and mechanistic studies linking emission properties to specific toxicological outcomes.

Chemical Emissions From Heated Vitamin E Acetate—Insights to Respiratory Risks From Electronic Cigarette Liquid Oil Diluents Used in the Aerosolization of Δ9-THC-Containing Products

As of February 18, 2020, the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak caused the hospitalization of a total of 2,807 patients and claimed 68 lives in the United States. Though investigations have reported a strong association with vitamin E acetate (VEA), evidence from reported EVALI cases is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products. This study characterized chemicals evolved when diluent oils were heated to temperatures that mimic e-cigarette, or vaping, products (EVPs) to investigate production of potentially toxic chemicals that might have caused lung injury. VEA, vitamin E, coconut, and medium chain triglyceride (MCT) oil were each diluted with ethanol and then tested for constituents and impurities using a gas chromatograph mass spectrometer (GC/MS). Undiluted oils were heated at 25°C (control), 150°C, and 250°C in an inert chamber to mimic a range of temperatures indicative of aerosolization from EVPs. Volatilized chemicals were collected using thermal desorption tubes, analyzed using a GC/MS, and identified. Presence of identified chemicals was confirmed using retention time and ion spectra matching with analytic standards. Direct analysis of oils, as received, revealed that VEA and vitamin E were the main constituents of their oils, and coconut and MCT oils were nearly identical having two main constituents: glycerol tricaprylate and 2-(decanoyloxy) propane-1,3-diyl dioctanoate. More chemicals were measured and with greater intensities when diluent oils were heated at 250°C compared to 150°C and 25°C. Vitamin E and coconut/MCT oils produced different chemical emissions. The presence of some identified chemicals is of potential health consequence because many are known respiratory irritants and acute respiratory toxins. Exposure to a mixture of hazardous chemicals may be relevant to the development or exacerbation of EVALI, especially when in concert with physical damage caused by lung deposition of aerosols produced by aerosolizing diluent oils.

Human Bronchial Epithelial Cell Culture Models for Cigarette Smoke and Vaping Studies

Despite the continuing public health efforts to stop or reduce smoking, cigarette smoke use remains popular in the youth and adult population. A recent surge in the use of electronic cigarette and vaping products has created another major health challenge in public health. There is an urgent need to use physiologically relevant models to study the health effect of smoking or vaping in human subjects. Airway diseases such as bronchitis (Landman et al., CMAJ 191:E1321-E1331, 2019; Goniewicz, et al. Harm Reduct J 17:91, 2020; Xie et al., JAMA Netw Open 3:e2020816, 2020) have been described in people who smoke, vape, or both. Here, we will describe methods to collect, expand, and culture human airway epithelial cells from endobronchial brushings and expose these cells cultured at the air-liquid interface to cigarette smoke or electronic cigarette vapor.

Vaping-associated lung illness (VALI) in Canada: a descriptive analysis of VALI cases reported from September 2019 to December 2020

INTRODUCTION

The aim of this study was to explore demographic and clinical characteristics of vaping-associated lung illness (VALI) cases reported in Canada from September 2019 to December 2020; compare the epidemiology of VALI cases in Canada to e-cigarette or vaping product use-associated lung injury (EVALI) cases in the US; and examine possible explanations for differences between the two countries.

METHODS

A federal/provincial/territorial task group developed a national outbreak definition, minimum dataset and case report form for identification and surveillance of VALI cases in Canada. Descriptive analysis explored the characteristics and epidemiology of reported VALI cases.

RESULTS

Of the 20 VALI cases reported, none resulted in a death. Of all cases, 5 (25%) involved youth aged 15 to 19 years, 10 (50%) adults aged 20 to 49 years and 5 (25%) aged 50 years and older. Sixty percent of patients were men. Half (50%) required breathing assistance. Three-quarters (75%) reported using nicotine-containing vaping products, and 40% reported use of cannabis-containing vaping products; of those who reported frequency of vaping, most (71%) reported vaping daily. VALI cases were reported at a lower prevalence (0.9 per million) than EVALI (8.5 per million). Demographics and vaping behaviour also differed.

CONCLUSION

VALI cases were reported in Canada between September 2019 and December 2020; however, there was a much lower prevalence and they may have been caused by different factors from the EVALI outbreak in the US. The factors influencing VALI in Canada are complex and multifactorial. Research is needed to understand the short- and long-term health effects of nicotine and cannabis vaping.

Cannabis Vaping Among Youth and Young Adults: a Scoping Review

Purpose of Review

The purpose of this review was to describe the state-of-the-literature on research specific to cannabis vaping among youth and young adults.

Recent Findings

Out of 1801 records identified, a total of 202 articles met eligibility criteria for inclusion in this review. Most of this literature (46.0% of studies) was specific to the health effects of cannabis vaping, particularly EVALI (e-cigarette and vaping associated lung injury). Other research areas identified in the review included the etiology (24.3%) and epidemiology (24.8%) of cannabis vaping, in addition to articles on regulation (8.4%) and marketing (5.5%) of the same.

Summary

Cannabis vaping is increasingly common among youth and young adults and more prevalent is settings where recreational use for adults has been legalized. The literature documents a number of negative health effects of cannabis vaping for young people, along with risk factors and reasons for the same.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40429-022-00413-y.

Reporting of pneumothorax in association with vaping devices and electronic cigarettes

Vaping may lead to spontaneous pneumothorax, but there are few published reports on this phenomenon. We present a case of vaping-related pneumothorax and make recommendations for structured reporting of this emerging cause for pneumothorax. A normal-weight 34-year-old male presented to our emergency department with dyspnoea and back pain increasing over 24 hours. Chest X-ray showed a large right-sided pneumothorax. Three years ago, he had quit smoking cigarettes and switched to vaping. CT scan revealed bullae, and the patient received apical lung resection. Histology revealed mild alveolitis. Vaping is an emerging cause of lung injury. This report demonstrates a potential association between vaping and pneumothorax. However, structured reporting and future research are needed to establish a definitive (or causal) relationship between vaping and pneumothorax.

E-cigarette use and adverse respiratory symptoms among adolescents and Young adults in the United States

E-cigarette use among adolescents and young adults has been associated with adverse respiratory symptoms, including symptoms of asthma and bronchitis. This investigation examined whether such associations differ by primary type of e-cigarette device used. This cross-sectional study included data from four study populations in California and Connecticut, United States, ages 13-21 years (N = 10,483), who self-reported their tobacco use behaviors and health status from 2018 to 2020. Adverse respiratory symptoms were grouped as bronchitis, asthma exacerbation, and shortness of breath. Associations with e-cigarette use were examined by frequency of e-cigarette use (regardless of device type) and most-frequently use device type in the past 30 days (pod, pen/tank, disposable, or mod). Multivariable modeling accounted for demographic variables and use of other tobacco and cannabis. Results were pooled at the study level via random-effects meta-analysis. Across the four studies, e-cigarette use >5 days/month versus never use was associated with bronchitic symptoms (summary odds ratio, sOR: 1.56; 95% confidence interval, CI: 1.37, 1.77) and shortness of breath (sOR: 1.68; 95% CI: 1.35, 2.08) but not statistically significantly with asthma exacerbations (sOR: 1.36; 95% CI; 0.95, 1.95). Among past 30-day e-cigarette users, associations with respiratory symptoms did not differ by device type. In these populations, e-cigarette use was positively associated with symptoms of bronchitis and shortness of breath, but adjusted odds of symptoms did not differ meaningfully by device type. These findings suggest that risk of these respiratory outcomes is elevated among more frequent e-cigarette users regardless of device type used.

Extracorporeal Membrane Oxygenation for Acute Toxic Inhalations: Case Reports and Literature Review

Previous studies have shown that poisoning is a major threat to human health. Inhalation of acute toxic gas has been linked to serious health consequences. Among the antidotes for poisoning currently used, supportive care is the most common intervention in clinical practice. Severe acute respiratory distress syndrome (ARDS) and/or refractory cardiogenic shock or cardiac arrest caused by toxins are associated with high mortality and are difficult to treat. Extracorporeal membrane oxygenation (ECMO) is an aggressive supportive measure used to manage severely poisoned patients. This study presents two cases of acute toxic gases inhalation, severe ARDS and circulatory instability induced by bromine inhalation, and ARDS induced by nitric acid inhalation which were successfully treated with ECMO. The ECMO techniques used in the animal models and in human cases to treat severe poisoning are described as well as the indications, contraindications, complications, and weaning of ECMO.

Association between electronic cigarette use in children and adolescents and coughing a systematic review

BACKGROUND

The use of electronic cigarettes (e-cigarettes) among adolescents is increasing worldwide. E-cigarettes are marketed as a safe alternative to other tobacco products. The aim of this systematic review is to evaluate whether e-cigarette use in children and adolescents is associated with coughing.

METHOD

Studies were identified through systematic searches of Excerpta Medica Database, Medline, Cumulative Index to Nursing and Allied Health Literature, British Nursing Index, OVID Emcare, Health Management Information Consortium, PsycINFO, and Allied and Complementary Medicine. The Grey Literature was also searched. Selected studies either contained only children and adolescents as study participants or if adults were included, the data for adolescents and children must be presented separately.

RESULTS

Seven studies were selected from 104. Three studies compared e-cigarette users with nonusers; two studies found a significant association between coughing and e-cigarette use in adolescence. Two studies investigated whether adolescents attributed their symptoms to their e-cigarette use. One study reported that coughing was the most likely negative symptom reported by adolescents on initiation of e-cigarette use; the other study found that adolescents, on initiation of e-cigarette use, reported coughing. Two studies looked at the cases of children and adolescents who had presented to the hospital after e-cigarette use and found coughing was a common presenting symptom.

CONCLUSION

This systematic review shows that adolescent use of e-cigarettes is associated with increased coughing and e-cigarette users are more likely to report coughing compared to non-users.

Extracorporeal Life Support for Respiratory Failure in Patients With Electronic Cigarette or Vaping Product Use-Associated Lung Injury

OBJECTIVES

Electronic cigarette or vaping product use-associated lung injury is a clinical entity that can lead to respiratory failure and death. Despite the severity of electronic cigarette or vaping product use-associated lung injury, the role of extracorporeal life support in its management remains unclear. Our objective was to describe the clinical characteristics and outcomes of patients with electronic cigarette or vaping product use-associated lung injury who received extracorporeal life support.

DESIGN

We performed a retrospective review of records of electronic cigarette or vaping product use-associated lung injury patients who received extracorporeal life support. Standardized data were collected via direct contact with extracorporeal life support centers. Data regarding presentation, ventilatory management, extracorporeal life support details, and outcome were analyzed.

SETTING

This was a multi-institutional, international case series with patients from 10 different institutions in three different countries.

PATIENTS

Patients who met criteria for confirmed electronic cigarette or vaping product use-associated lung injury (based on previously reported diagnostic criteria) and were placed on extracorporeal life support were included. Patients were identified via literature review and by direct contact with extracorporeal life support centers.

MEASUREMENTS AND MAIN RESULTS

Data were collected for 14 patients ranging from 16 to 45 years old. All had confirmed vape use within 3 months of presentation. Nicotine was the most commonly used vaping product. All patients had respiratory symptoms and radiographic evidence of bilateral pulmonary opacities. IV antibiotics and corticosteroids were universally initiated. Patients were intubated for 1.9 days (range, 0-6) prior to extracorporeal life support initiation. Poor oxygenation and ventilation were the most common indications for extracorporeal life support. Five patients showed evidence of ventricular dysfunction on echocardiography. Thirteen patients (93%) were placed on venovenous extracorporeal life support, and one patient required multiple rounds of extracorporeal life support. Total extracorporeal life support duration ranged from 2 to 37 days. Thirteen patients survived to hospital discharge; one patient died of septic shock.

CONCLUSIONS

Electronic cigarette or vaping product use-associated lung injury can cause refractory respiratory failure and hypoxemia. These data suggest that venovenous extracorporeal life support can be an effective treatment option for profound, refractory respiratory failure secondary to electronic cigarette or vaping product use-associated lung injury.

Inhalants

Toxic inhalants include various xenobiotics. Irritants cause upper and lower respiratory tract injuries. Highly water-soluble agents injure the upper respiratory tract, while low water-soluble inhalants injure the lower track. Asphyxiants are divided into simple asphyxiants and chemical asphyxiants. Simple asphyxiants displace oxygen, causing hypoxia, while chemical asphyxiants also impair the body's ability to use oxygen. Cyanide is a classic chemical asphyxiant. Treatment includes hydroxocobalamin. Electronic cigarette or vaping use-associated lung injury (EVALI) is a relatively new illness. Patients present with respiratory symptoms and gastrointestinal distress. EVALI appears to be associated with vaping cannabinoids. Treatment is supportive and may include steroids.

Electronic cigarettes, vaping-related lung injury and lung cancer: where do we stand?

Electronic cigarettes have been considered a promising alternative to nicotine replacement products to help heavy tobacco smokers quit smoking. They work thanks to a heating coil causing evaporation of the liquid rapidly followed by cooling, thus creating an aerosol, a completely different mechanism from the combustion of tobacco in traditional cigarettes. The term 'vaping' indicates the use of electronic cigarettes or other devices to inhale heated, aerosolized nicotine, or other substances like cannabidiol, tetrahydrocannabinol, or butane hash oils together with solvents, mainly propylene glycol and vegetable glycerine or their combination. A very fast increase of vaping among adolescents has been observed since electronic cigarettes and other vaping devices first appeared. Although electronic cigarettes have been advocated as a short-term cessation aid for tobacco smokers or as a long-term alternative, there is the concrete risk that they can be perceived by young nonsmokers as a less dangerous alternative to tobacco smoking, thus stimulating nonsmokers to start smoking rather than helping heavy tobacco smokers to quit smoking. Moreover, several cases of exogenous lipoid pneumonia and diffuse alveolar hemorrhage with proven alveolar injury, as well as vaping-associated bronchiolitis obliterans, have been recently reported among electronic cigarette smokers, with severe clinical impact, thus posing the risk of the life-threatening toxic potential of vaping. At the moment, no definitive assessment can be made about the efficacy of electronic cigarettes as a smoking cessation aid, and further studies are required about vaping-related life-threatening acute lung injury.

Alveolar hemorrhage due to marijuana smoking using water pipe made with plastic bottle: case report and narrative review of the literature

INTRODUCTION

We described a case of alveolar hemorrhage (AH) after marijuana smoking using a water pipe made with plastic bottle (bong) before making a narrative review of the literature.

CASE REPORT

A 19-year-old male was admitted for hemoptysis and dyspnea evolving since the previous day. He smoked marijuana ten times a day using bongs. Computed tomography scan of the chest (chest CT-scan) evidenced ground glass opacities involving upper lobes with crazy-paving pattern. Bronchoalveolar lavage (BAL) yielded fluid becoming progressively bloody suggestive of AH. Screening of drug metabolites ruled out the presence of cocaine degradation products. Treatment with prednisone was prescribed and oxygen requirements decreased rapidly. The patient accepted to stop bongs, but kept on smoking marijuana using joints. He was asymptomatic 2 months later; all ground glass opacities had vanished.

REVIEW OF THE LITERATURE

Four cases described exactly the same circumstances as ours. All were young male patients containing ground glass opacities with diffuse or bilateral pattern in their chest CT-scan. The explanation suggested by the authors of these cases was the potential concomitant inhalation of acid anhydrides derived from use of heated plastic bottle. No acid anhydrides were experimentally evidenced after thermodesorption of heated polyethylene terephthalate (PET) (in which a majority of plastic bottles are made) we performed, but other compounds were. E-cigarette, or vaping, product use-associated lung injuries cases share some chest CT-scan patterns with those of AH following bong use and we tried to draw a parallel between these two latter before discussing a physiopathological hypothesis.

The vaping product use associated lung injury: is this a new pulmonary disease entity?

In the summer of 2019, an epidemic of e-cigarette or vaping product use associated lung injury (EVALI) broke out in the United States of America. EVALI is a lung disease that can be severe and life-threatening. It should be emphasized that EVALI is not a clinical diagnosis, but surveillance case definition. Due to the profile of users of such devices, the pathology mainly affects young adults, although cases of EVALI have been reported in almost all age groups, from teenage children to seniors. The worst prognosis is in patients over 35 years of age, with accompanying diseases. A significant number of patients declared the use of products containing tetrahydrocannabinol (THC). The most likely factor responsible for the occurrence of EVALI is vitamin E acetate, which is sometimes added to liquids necessary for the use of electronic cigarette type devices, especially those liquids that contain THC. Nevertheless, it is possible that other substances used in liquids may also be a causative factor. Typical for EVALI are respiratory, gastrointestinal and systemic symptoms, while in imaging tests, a characteristic feature of EVALI is the presence of opacities on the chest radiogram and ground-glass clouds on computed tomography scans. In the course of this disease, respiratory failure often occurs (58%). In the vast majority of cases oxygen substitution is necessary. Currently, the best treatment of EVALI is considered to be the administration of systemic glucocorticosteroids. Over 90% of patients with EVALI required hospitalization, while the mortality rate was about 2.42%. Median age of the fatalities was 51 years. The aim of this review is to summarise the available information on EVALI and to consider possible causative factors and pathomechanism.

Radiological findings of e-cigarette or vaping product use associated lung injury: A systematic review

INTRODUCTION

Chest radiology provides an opportunity to better understand the diagnostic characteristics of e-cigarette or vaping product use associated lung injury (EVALI). This systematic review aimed to summarize the radiological findings associated with EVALI reported in the literature.

METHODS

This systematic review was conducted in accordance with PRISMA guidelines. Electronic searches of MEDLINE®, CINAHL, Embase® and CENTRAL were conducted in February 2020. Included were all English-language studies reporting radiological findings of EVALI. Data was synthesized using descriptive statistics.

RESULTS

Thirty studies comprising 184 participants were included. Mean patient age was 24.5 years old. The majority (n = 141, 76.6%) of included patients were male. The most common radiological features reported on chest x-ray were bilateral infiltrates (n = 64, 41.3%) and ground glass opacities (n = 17, 11.0%), and on chest CT were bilateral infiltrates (n = 62, 36.9%), bilateral ground glass opacities (n = 56, 33.3%), subpleural sparing (n = 29, 17.3%), pleural effusions (n = 14, 8.3%), and centrilobular nodularity (n = 13, 7.7%). Of patients with follow-up data reported (n = 81), only 28.4% (n = 23) had complete resolution of symptoms or radiological findings.

CONCLUSION

Chest radiology is the cornerstone of diagnosis and monitoring of EVALI. A wide variety of radiological findings highlight the need for standardisation of terminology in the radiological descriptions of EVALI. Common findings included bilateral infiltrates and ground glass opacities. Higher quality evidence is warranted to help develop evidenced-based guidelines for the diagnosis and management of EVALI.

Ambulatory Anesthesia for a Case of Idiopathic Bronchiolitis Obliterans

Bronchiolitis obliterans is rarely described in the nonlung transplant anesthesia literature. This case report describes a 27-year-old female patient with idiopathic bronchiolitis obliterans and dental anxiety who safely received intravenous deep sedation using diphenhydramine, dexmedetomidine, and ketamine in an ambulatory community dental clinic. This report outlines the anesthetic plan developed following a thorough preoperative assessment and review of the key anesthetic considerations of idiopathic bronchiolitis obliterans (eg, potential respiratory complications and appropriateness for the ambulatory dental environment) and discusses the careful anesthetic management of this patient using deep sedation to facilitate comprehensive restorative dentistry.

Smoking cessation or initiation: The paradox of vaping

In recent years, there has been a rapid expansion of the vaping market which has led many to question whether vaping can assist people in smoking cessation, or if it in fact paves the way for new smokers. While there has not been conclusive evidence regarding vaping as a smoking cessation tool, there is striking evidence that vaping is linked to new smoking addictions, especially in teenagers and young adults. Despite the prevalent belief that tobacco is more harmful to the body, early research on vaping has already shown very detrimental effects, and the comprehensive effects may become much clearer in the years to come. To curtail the rapidly increasing number of teenagers and young adults vaping, strict action must be taken. Legalization with tight control of vaping products would focus the efforts on those attempting to quit, while helping to prevent acquisition by teenagers and young adults that are not of legal age. In the years to come, vaping controls should be carefully considered to ensure that the purported benefits of helping those overcome a smoking addiction are not outweighed by the unintended consequences of creating a teenage demographic addicted to vaping.

Carrier Solvents of Electronic Nicotine Delivery Systems Alter Pulmonary Surfactant

In late 2019, hundreds of users of electronic products that aerosolize a liquid for inhalation were hospitalized with a variety of respiratory and gastrointestinal symptoms. While some investigations have attributed the disease to the presence of vitamin E acetate in liquids that also contained tetrahydrocannabinol, some evidence suggests that chronic inhalation of two common solvents used in electronic nicotine delivery systems (ENDS), propylene glycol (PG) and vegetable glycerin (VG), can interfere with the lipid components of pulmonary surfactant and cause or exacerbate pulmonary injury. The interaction between PG, VG, and lung surfactant is not yet understood. This study presents an examination of the molecular interactions of PG and VG with lung surfactant mimicked by 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC). The interaction of DPPC and PG-VG is studied by attenuated total reflectance fourier transform infrared spectroscopy. The results showed that PG and VG altered the molecular alignment of the DPPC surfactant. The orientation of the surfactant at the surface of the lung affects the surface tension at the air–water interface, thereby influencing breathing. These findings suggest that chronic aerosolization of the primary solvents in ENDS might alter the function of pulmonary surfactant.

A 20-Year-Old Man with e-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI) and Thrombotic Coagulopathy

BACKGROUND In 2019, the US Centers for Disease Control and Prevention (CDC) described the criteria for the diagnosis of e-cigarette or vaping product use-associated lung injury (EVALI), which may be caused by contamination of delta-9-tetrahydrocannabinoid (THC) e-liquids with vitamin E acetate. This report describes a case of a 20-year-old man with a history of recreational drug use that included vaping, who presented with EVALI and a coagulopathy associated with thrombotic events. CASE REPORT We present a 20-year-old patient who worked at a cannabidiol (CBD) manufacturing facility with a history of e-cigarette use and polysubstance abuse in remission who presented with respiratory and gastrointestinal symptoms accompanied by 50-pound weight loss over 6 months. The patient had been vaping with nicotine and THC-containing e-cigarettes multiple times per day for 1.5 years. He met the CDC surveillance criteria for EVALI, consisting of respiratory symptoms and infiltrates on imaging within 90 days of vaping, and was found to have eosinophilic pneumonia secondary to THC-containing e-cigarette use. Additionally, thrombi were detected in the pulmonary arteries, right saphenous vein, and right ventricle. A segmental infarct was noted in the inferior pole of the left kidney. CONCLUSIONS We present the second case report potentially linking e-cigarette use with clinically significant thrombogenesis, the first with both arterial and venous thromboses. This report demonstrates the importance of taking a history of e-cigarette use in patients presenting with lung injury. Although EVALI and the diagnostic criteria have only recently been described, systemic effects, including coagulopathy, are now being reported.

Unfriendly Fire: How the Tobacco Industry is Destroying the Future of Our Children

Tobacco has long been known to be one of the greatest causes of morbidity and mortality in the adults, but the effects on the foetus and young children, which are lifelong, have been less well appreciated. Developing from this are electronic nicotine delivery systems or vapes, promulgated as being less harmful than tobacco. Nicotine itself is toxic to the foetus, with permanent effects on lung structure and function. Most vapes contain nicotine, but they also contain many other compounds which are inhaled and for which there are no toxicity studies. They also contain known toxic substances, whose use is banned by European Union legislation. Accelerating numbers of young people are vaping, and this does not reflect an exchange of vapes for cigarettes. The acute toxicity of e-cigarettes is greater than that of tobacco, and includes acute lung injury, pulmonary haemorrhage and eosinophilic and lipoid pneumonia. Given the worse acute toxicity, it should be impossible to be complacent about medium and long term effects of vaping. Laboratory studies have demonstrated changes in lung proteomics and the innate immune system with vaping, some but not all of which overlap with tobacco. It would be wrong to consider vapes as a weaker form of tobacco, they have their own toxicity. Children and young people are being targeted by the vaping industry (which is largely the same as the tobacco industry), including on-line, and unless an efficient legislative program is put in place, a whole new generation of nicotine addicts will result.

E-cigarette use and respiratory disorders: an integrative review of converging evidence from epidemiological and laboratory studies

Background

Use of electronic cigarettes (e-cigarettes) is prevalent among adolescents and young adults, but there has been limited knowledge about health consequences in human populations. We conduct a systematic review and meta-analysis of results on respiratory disorders from studies of general-population samples and consider the mapping of these results to findings about biological processes linked to e-cigarettes in controlled laboratory studies.

Method

We conducted a literature search and meta-analysis of epidemiological studies on the association of e-cigarette use with asthma and with COPD. We discuss findings from laboratory studies about effects of e-cigarettes on four biological processes: cytotoxicity, oxidative stress/inflammation, susceptibility to infection and genetic expression.

Results

Epidemiological studies, both cross-sectional and longitudinal, show a significant association of e-cigarette use with asthma and COPD, controlling for cigarette smoking and other covariates. For asthma (n=15 studies), the pooled adjusted odds ratio (aOR) was 1.39 (95% CI 1.28–1.51); for COPD (n=9 studies) the aOR was 1.49 (95% CI 1.36–1.65). Laboratory studies consistently show an effect of e-cigarettes on biological processes related to respiratory harm and susceptibility to illness, with e-cigarette conditions differing significantly from clean-air controls, although sometimes less than for cigarettes.

Conclusions

The evidence from epidemiological studies meets established criteria for consistency, strength of effect, temporality, and in some cases a dose–response gradient. Biological plausibility is indicated by evidence from multiple laboratory studies. We conclude that e-cigarette use has consequences for asthma and COPD, which is of concern for respirology and public health.

Epidemiological studies show a relationship of e-cigarette use with asthma and COPD, and laboratory studies show their adverse effects on four biological processes. It can be concluded that e-cigarette use is of significant concern for public health.https://bit.ly/3drH4pj

Diagnosis and Acute Management of E-Cigarette or Vaping Product Use-Associated Lung Injury in the Pediatric Population: A Systematic Review

OBJECTIVE

To assess quantitative data on the presentation, investigative findings, patterns of lung injury, and interventions of pediatric cases of e-cigarette or vaping-associated lung injury (EVALI) in the acute care setting.

STUDY DESIGN

A literature search using keywords was performed on April 17, 2020, in accordance with PRISMA guidelines. Three thousand five hundred fifty-eight articles were retrieved from MEDLINE via PubMed, Embase via OVID, CINAHL via EBSCO, Web of Science, and the Cochrane Library. Studies were evaluated for inclusion based on predetermined inclusion and exclusion criteria by 2 independent reviewers.

RESULTS

The search yielded a total of 3558 individual results, 145 of which were evaluated by full text review, resulting in 23 articles included in this systematic review. Two of these articles were identified by manual search of article references. A total of 61 cases of EVALI were described, and 10 major patterns of lung injury were identified for which presenting symptoms, diagnostic and laboratory investigations, interventions, and outcomes were synthesized.

CONCLUSIONS

Cases of EVALI in the pediatric population have been reported in patients as young as 13 years and often present with respiratory, constitutional, abdominal, and cardiovascular signs and symptoms. Diagnostic findings vary based on the underlying lung injury pattern. However, typical patterns of common findings were identified, including the presence of ground-glass opacities on computed tomography scan and leukocytosis. Mainstays of treatment include the use of corticosteroids, antibiotics, and ventilatory support, including extracorporeal membrane oxygenation. Outcomes range from complete or near complete recovery of lung function to death.

E-cigarette use and respiratory disorders: an integrative review of converging evidence from epidemiological and laboratory studies

BACKGROUND

Use of electronic cigarettes (e-cigarettes) is prevalent among adolescents and young adults, but there has been limited knowledge about health consequences in human populations. We conduct a systematic review and meta-analysis of results on respiratory disorders from studies of general-population samples and consider the mapping of these results to findings about biological processes linked to e-cigarettes in controlled laboratory studies.

METHOD

We conducted a literature search and meta-analysis of epidemiological studies on the association of e-cigarette use with asthma and with COPD. We discuss findings from laboratory studies about effects of e-cigarettes on four biological processes: cytotoxicity, oxidative stress/inflammation, susceptibility to infection and genetic expression.

RESULTS

Epidemiological studies, both cross-sectional and longitudinal, show a significant association of e-cigarette use with asthma and COPD, controlling for cigarette smoking and other covariates. For asthma (n=15 studies), the pooled adjusted odds ratio (aOR) was 1.39 (95% CI 1.28-1.51); for COPD (n=9 studies) the aOR was 1.49 (95% CI 1.36-1.65). Laboratory studies consistently show an effect of e-cigarettes on biological processes related to respiratory harm and susceptibility to illness, with e-cigarette conditions differing significantly from clean-air controls, although sometimes less than for cigarettes.

CONCLUSIONS

The evidence from epidemiological studies meets established criteria for consistency, strength of effect, temporality, and in some cases a dose-response gradient. Biological plausibility is indicated by evidence from multiple laboratory studies. We conclude that e-cigarette use has consequences for asthma and COPD, which is of concern for respirology and public health.

An update on controversies in e-cigarettes

E-cigarettes are electronic nicotine delivery systems (ENDS) which mimic tobacco smoking without the combustion of tobacco. These devices have been misleadingly marketed as "less harmful" alternatives to conventional smoking tobacco products. The e-liquid in e-cigarettes include nicotine, a humectant and other additives including flavourings, colourants, or adulterants such as bacterial and fungal products. In this review, we discuss the contrasting views of the tobacco lobby and most professional societies. We describe the epidemiology of the use of these devices, with a widespread and significant rise in youth e-cigarette use seen in both the USA and Europe. We also describe what is known about the toxicity and mechanisms of EVALI (e-cigarette or vaping associated lung injury). This characterised by respiratory failure with an intense inflammatory response. The presentations are diverse and clinicians should consider vaping as a possible cause of any unusual respiratory illness in patients who have a history of vaping or other use of e-cigarette-related products. Second hand exposure to e-cigarettes is also harmful through respiration and transdermal absorption. E-cigarettes have a worse acute toxicity than tobacco and their long-term toxicity is unknown, and we advocate for the immediate, most vigorous anti-vaping legislation possible.

Guidance on the Clinical Management of Electronic Cigarette or Vaping-Associated Lung Injury

In the summer of 2019, there was a rise in clusters of adolescents and young adults in the United States reporting to emergency departments with acute respiratory distress related to use of e-cigarette (electronic cigarette) or vaping. The number of patients with e-cigarette or vaping-associated lung injury continued to rise through the summer before peaking in September 2019. Through the efforts of state and federal public health agencies, officials were able to define the condition, identify the relationship of the respiratory injury to tetrahydrocannabinol-containing products, and stem the rise in new cases. In this report, we present a comprehensive review of the clinical characteristics and features of patients with e-cigarette or vaping-associated lung injury and guidelines for patient care and management to inform and navigate clinicians who may encounter these patients in their clinical practice.

Vaping and e-cigarette use. Mysterious lung manifestations and an epidemic

Electronic (e)-cigarette use and the practice of vaping has rapidly expanded both in adult smokers and previously nicotine naïve youths. Research has focused on harm reduction in adults using e-cigarettes to stop or reduce traditional cigarette use, but the short and long-term safety of these products has not been established. Vaping has more recently been associated with a growing list of pulmonary complications with the most urgent being the e-cigarette or vaping product use-associated lung injury (EVALI) epidemic. This review details the inhalant toxicology of vaping products, the described lung diseases associated with vaping with a focus on EVALI, and the predicted long-term consequences of e-cigarette use, including increased asthma severity.