E-cigarette, or Vaping, Product Use-Associated Lung Injury Among Clusters of Patients Reporting Shared Product Use - Wisconsin, 2019

Multi-omic assessment shows dysregulation of pulmonary and systemic immunity to e-cigarette exposure

Electronic cigarette (Ecig) use has become more common, gaining increasing acceptance as a safer alternative to tobacco smoking. However, the 2019 outbreak of Ecig and Vaping-Associated Lung Injury (EVALI) alerted the community to the potential for incorporation of deleterious ingredients such as vitamin E acetate into products without adequate safety testing. Understanding Ecig induced molecular changes in the lung and systemically can provide a path to safety assessment and protect consumers from unsafe formulations. While vitamin E acetate has been largely removed from commercial and illicit products, many Ecig products contain additives that remain largely uncharacterized. In this study, we determined the lung-specific effects as well as systemic immune effects in response to exposure to a common Ecig base, propylene glycol and vegetable glycerin (PGVG), with and without a 1% addition of phytol, a diterpene alcohol that has been found in commercial products. We exposed animals to PGVG with and without phytol and assessed metabolite, lipid, and transcriptional markers in the lung. We found both lung-specific as well as systemic effects in immune parameters, metabolites, and lipids. Phytol drove modest changes in lung function and increased splenic CD4 T cell populations. We also conducted multi-omic data integration to better understand early complex pulmonary responses, highlighting a central enhancement of acetylcholine responses and downregulation of palmitic acid connected with conventional flow cytometric assessments of lung, systemic inflammation, and pulmonary function. Our results demonstrate that Ecig exposure not only leads to changes in pulmonary function but also affects systemic immune and metabolic parameters.

Illegal Experimental Tobacco Marketplace II: effects of vaping product bans - findings from the 2020 International Tobacco Control Project

SIGNIFICANCE

Restrictive e-cigarette policies may increase purchases from illegal sources. The Illegal Experimental Tobacco Marketplace (IETM) allows examination of how restrictions impact illegal purchases. We investigated (1) the effect of a vaping ban, total flavour vaping ban and partial flavour vaping ban on the probability of purchasing illegal vaping products among different regulatory environments (USA, Canada and England) and tobacco user types (cigarette smokers, dual users and e-cigarette users); and (2) the relation between ban endorsement and illegal purchases.

METHODS

Participants (N=459) from the International Tobacco Control Survey rated their support of bans and chose to purchase from a hypothetical legal experimental tobacco marketplace or IETM under control and the three ban conditions.

RESULTS

In total, 25% of cigarette smokers, 67% of dual users and 79% of e-cigarette users made IETM purchases. Cross-country comparisons depicted dual users from Canada (OR: 19.8), and e-cigarette users from the USA (OR: 12.9) exhibited higher illegal purchases odds than the same user type in England. Within-country comparisons showed e-cigarette and dual users are more likely to purchase from the IETM than cigarette smokers in the most restrictive condition, with the largest effects in e-cigarette users (England-OR: 1722.6, USA-OR: 22725.3, Canada-OR: 6125.0). Increased opposition towards partial or total flavour ban was associated with increased IETM purchasing in the corresponding condition.

CONCLUSIONS

Vaping restrictions may shift users' preference to the illegal marketplace in a regulatory environment. Evidence of the IETM generalisability in a geographically dispersed sample enhances its utility in tobacco regulatory science.

Illicit trade in tobacco products: recent trends and coming challenges

BACKGROUND

Illicit trade in tobacco products is a menace to the goal of eliminating tobacco consumption. Although tax policy is very effective in reducing consumption, illicit trade can reduce (though not eliminate) its effectiveness.

METHODS

This article discusses the recent evolution of illicit trade and the context in which it occurred; the new methods that have been developed to measure it and, finally, the challenges in the next phase in the control of illicit trade.

RESULTS

There has been a remarkable stability in the penetration of cigarette illicit trade in the past decade. Such a stability, however, occurred in a world of shrinking tobacco consumption, implying a decreasing absolute illicit trade. Most countries have progressed in increasing tobacco taxes and changing tax structures. Prices of illicit cigarettes follow legal cigarette prices. Concomitantly, many new studies, independent from the tobacco industry, have been conducted allowing for better understanding of the illicit trade and providing inputs to its solution. The entry into force of the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products provides both a global and a national policy framework to further curb illicit trade. Instruments such as track-and-trace systems must be promoted and adopted to maximise reductions in illicit trade.

CONCLUSIONS

Global efforts to curb the illicit trade in tobacco products are gaining momentum and progress has been made in many parts of the world. The next decade can witness a decisive decrease in tobacco consumption, both licit and illicit, if countries further engage in international collaboration.

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.

Association between electronic nicotine delivery systems (ENDS) device and E-liquid alterations and flavor use with clinical and EVALI-like symptoms

Studies reporting clinical symptoms related to electronic nicotine delivery systems (ENDS) usage, especially types of devices and e-liquids, are sparse. The sample included 1,432 current ENDS users, ages 18-64, from a nationwide online survey conducted in 2016. ENDS use included device types, nicotine content, flavors, and e-liquid used. Outcomes included any e-cigarette, or vaping, product use-associated lung injury (EVALI)-like symptoms (e.g., cough, shortness of breath, nausea) as well as any clinical symptoms. Of the sample, 50% were female, 23% non-Hispanic (NH) White, 23% NH Black, 54% Hispanic, 18% aged 18-24, 17% LGBTQ, 41% with <$50 K income, 55% 1 + any symptoms, and 33% 1 + any EVALI-like symptoms. Cough and nausea were most prevalent among EVALI-like symptoms (27% and 7.3%, respectively). The proportion having any EVALI-like symptoms was higher in the following groups: younger, Hispanic, current smokers, and current other product users. With multiple adjustments, participants who used refillable devices, varied nicotine content, used flavored products, or made their own e-liquids were more likely to have clinical symptoms than their counterparts. For example, the odds (95% CI) of having 1 + EVALI-like symptoms in participants who used refillable devices with e-liquid pour or e-liquid cartridge replacement were 1.70 (1.13, 2.56) and 1.95 (1.27, 2.99), respectively, compared to the non-refillable group. Use of products (devices and e-liquids) that can be altered and flavored products are associated with higher odds of having clinical symptoms, including EVALI-like symptoms.

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.

Vitamin E Acetate Determination in Vaping Liquids and Non-targeted Analysis of Vaping Emissions of Diluents of Concern, Vitamin E Acetate and Medium-Chain Triglycerides Oil

During the summer of 2019, cases of lung injury associated with vaping emerged in North America, including among individuals who reported exclusive use of nicotine vaping liquids. Once vitamin E acetate was identified as a potential causative agent a quantitative method based on a simple sample dilution, separation by gas chromatography and analysis by triple quadrupole mass spectrometry (GC MSMS) was developed. Method detection limit (MDL) and limit of quantification (LOQ) were determined at 0.159 µg/mL and 0.505 µg/mL, respectively. The analysis was performed on a subset of 203 commercially sourced nicotine containing vaping liquids of various flavour profile and nicotine range (nicotine free-59 mg/mL) from an internal inventory. The target analyte, Vitamin E Acetate, was not detected in any samples analyzed, as expected, given the reported detection in literature and high association of the chemical with cannabis and not nicotine containing vaping products.

Cannabis Vaping: Existing and Emerging Modalities, Chemistry, and Pulmonary Toxicology

The outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) has been cause for concern to the medical community, particularly given that this novel illness has coincided with the COVID-19 pandemic, another cause of severe pulmonary illness. Though cannabis e-cigarettes tainted with vitamin E acetate were primarily associated with EVALI, acute lung injuries stemming from cannabis inhalation were reported in the literature prior to 2019, and it has been suggested that cannabis components or additives other than vitamin E acetate may be responsible. Despite these concerning issues, novel cannabis vaporizer ingredients continue to arise, such as Δ⁸-tetrahydrocannabinol, Δ¹⁰-tetrahydrocannabinol, hexahydrocannabinol, and cannabichromene. In order to address cannabis e-cigarette safety and vaping in an effective manner, we provide a comprehensive knowledge of the latest products, delivery modes, and ingredients. This perspective highlights the types of cannabis vaping modalities common to the United States cannabis market, with special attention to cartridge-type cannabis e-cigarette toxicology and their involvement in the EVALI outbreak, in particular, acute lung injurious responses. Novel ingredient chemistry, origins, and legal statuses are reviewed, as well as the toxicology of known cannabis e-cigarette aerosol components.

Using a mixed methods approach to identify public perception of vaping risks and overall health outcomes on Twitter during the 2019 EVALI outbreak

INTRODUCTION

Vaping product use (i.e., e-cigarettes) has been rising since 2000 in the United States. Negative health outcomes associated with vaping products have created public uncertainty and debates on social media platforms. This study explores the feasibility of using social media as a surveillance tool to identify relevant posts and at-risk vaping users.

METHODS

Using an interdisciplinary method that leverages natural language processing and manual content analysis, we extracted and analyzed 794,620 vaping-related tweets on Twitter. After observing significant increases in vaping-related tweets in July, August, and September 2019, additional human coding was completed on a subset of these tweets to better understand primary themes of vaping-related discussions on Twitter during this time frame.

RESULTS

We found significant increases in tweets related to negative health outcomes such as acute lung injury and respiratory issues during the outbreak of e-cigarette/vaping associated lung injury (EVALI) in the fall of 2019. Positive sentiment toward vaping remained high, even across the peak of this outbreak in July, August, and September. Tweets mentioning the public perceptions of youth risk were concerning, as were increases in marketing and marijuana-related tweets during this time.

DISCUSSION

The preliminary results of this study suggest the feasibility of using Twitter as a means of surveillance for public health crises, and themes found in this research could aid in specifying those groups or populations at risk on Twitter. As such, we plan to build automatic detection algorithms to identify these unique vaping users to connect them with a digital intervention in the future.

Analysis of a Vaping-Associated Lung Injury Outbreak through Participatory Surveillance and Archival Internet Data

The US Centers for Disease Control and Prevention alerted of a suspected outbreak of lung illness associated with using E-cigarette products in September 2019. At the time that the CDC published its alert little was known about the causes of the outbreak or who was at risk for it. Here we provide insights into the outbreak through analysis of passive reporting and participatory surveillance. We collected data about vaping habits and associated adverse reactions from four data sources pertaining to people in the USA: A participatory surveillance platform (YouVape), Reddit, Google Trends, and Bing. Data were analyzed to identify vaping behaviors and reported adverse events. These were correlated among sources and with prior reports. Data was obtained from 720 YouVape users, 4331 Reddit users, and over 1 million Bing users. Large geographic variation was observed across vaping products. Significant correlation was found among the data sources in reported adverse reactions. Models of participatory surveillance data found specific product and adverse reaction associations. Specifically, cannabidiol was found to be associated with fever, while tetrahydrocannabinol was found to be correlated with diarrhea. Our results demonstrate that utilization of different, complementary, online data sources provide a holistic view of vaping associated lung injury while augmenting traditional data sources.

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.

Content Analysis of U.S. Newspaper Coverage of Causes and Solutions to Vaping-Associated Lung Injury

In 2019, an outbreak of vaping-associated lung injury (also known as "EVALI") spread throughout the U.S., linked to use of illicit THC cartridges. This paper examines U.S. newspaper coverage on the causes and solutions to EVALI. Methods: A content analysis of 417 articles from April to December 2019 from two national newspapers, one regional newspaper, and the Associated Press was conducted. Articles were coded for information about EVALI causes, mentions of the brand Dank Vapes, calls for individuals take a specific action to prevent harm, and mentions of policy actions to address vaping. Mentions of increasing youth vaping and JUUL were also coded. Results: Most articles (77%) provided an update on the number of EVALI cases and/or deaths. Fewer described EVALI symptoms (20%) or mentioned vaping cessation resources available to the public (2%). Almost half of articles also mentioned youth vaping as a concern (49%). Dank Vapes was mentioned rarely (4%) compared to JUUL (39%). After CDC recommendations changed to no longer recommend avoiding all vaping products, news articles became significantly less likely to mention nicotine products as a cause of EVALI or suggest that individuals cease all vaping. While policy was generally not articulated as a solution to EVALI, banning or limiting flavored nicotine vaping products were the most common policy actions mentioned. Conclusions/Importance: The discussions of causes of and solutions to EVALI were often intertwined with coverage of youth vaping, potentially failing to convey a clear sense of how the public should respond to the EVALI outbreak.

Exclusive E-Cigarette Users Report Lower Levels of Respiratory Symptoms Relative to Dual E-Cigarette and Cigarette Users

INTRODUCTION

Exclusive e-cigarette use has been shown to be associated with reduced levels of respiratory symptoms relative to smoking combustible cigarettes; this association has been less frequently studied in smokers using advanced-generation e-cigarette devices. Advanced-generation devices generate denser vapor than either early generation or pod-style devices, and engender longer inhalations; these vaping topography patterns may contribute to respiratory symptoms.

METHODS

In a single-session, cross-sectional study of exclusive e-cigarette users (N = 59) and dual users of e-cigarettes and cigarettes (N = 54), participants completed questionnaires, including the American Thoracic Society Questionnaire (ATSQ) and were videotaped vaping their own device in the lab for 1 hour. Using a hierarchical regression method, we examined whether topography variables, level of nicotine concentration used in their e-cigarette device in the past month, e-cigarette dependence, amount of e-cigarette use in the past month, and smoking status (any smoking in the last month vs. none) predicted ATSQ score severity.

RESULTS

There was a significant mean difference in ATSQ score across smoking status, with greater ATSQ scores for vapers who also smoked cigarettes (19.0, SD = 6.7) than for exclusive vapers (13.4, SD = 5.3). In the final model, of the predictors of interest, only cigarette smoking status predicted significantly greater ATSQ scores (overall F = 2.51, p = .006; R2 = .26; smoking status β = 0.39, p < .0001).

CONCLUSIONS

Findings suggest that differences in respiratory symptoms between dual and exclusive e-cigarette users appear to be attributable to combustible cigarette smoking, rather than more intense or frequent e-cigarette use across groups.

IMPLICATIONS

In this comparison of exclusive advanced-generation vape device users (N = 59) versus dual users of these devices and combustible cigarettes (N = 54), we set out to determine the extent to which smoking status and e-cigarette use variables predicted self-reported respiratory symptom severity. We found that dual users showed greater respiratory symptom severity (ATSQ scores) than exclusive vapers. Despite examining vaping topography and other variables, smoking status and race were the only significant predictor of respiratory symptoms. We conclude that combustible cigarette use, not individual vaping topography, likely accounts for differences in respiratory symptoms between dual users and exclusive vapers.

Factors Associated with E-Cigarette Use in U.S. Young Adult Never Smokers of Conventional Cigarettes: A Machine Learning Approach

E-cigarette use is increasing among young adult never smokers of conventional cigarettes, but the awareness of the factors associated with e-cigarette use in this population is limited. The goal of this work was to use machine learning (ML) algorithms to determine the factors associated with current e-cigarette use among US young adult never cigarette smokers. Young adult (18-34 years) never cigarette smokers from the 2016 and 2017 Behavioral Risk Factor Surveillance System (BRFSS) who reported current or never e-cigarette use were used for the analysis (n = 79,539). Variables associated with current e-cigarette use were selected by two ML algorithms (Boruta and Least absolute shrinkage and selection operator (LASSO)). Odds ratios were calculated to determine the association between e-cigarette use and the variables selected by the ML algorithms, after adjusting for age, gender and race/ethnicity and incorporating the BRFSS complex design. The prevalence of e-cigarette use varied across states. Factors previously reported in the literature, such as age, race/ethnicity, alcohol use, depression, as well as novel factors associated with e-cigarette use, such as disabilities, obesity, history of diabetes and history of arthritis were identified. These results can be used to generate further hypotheses for research, increase public awareness and help provide targeted e-cigarette education.

A review of toxic effects of electronic cigarettes/vaping in adolescents and young adults

In this review, we examine the known and suspected toxicity of electronic cigarettes (e-cigarettes) in adolescents and young adults, to improve awareness of risks and identification of complications of their use. The use of e-cigarettes, or "vaping," is exploding among the pediatric population. E-cigarettes heat a solution containing a psychoactive compound, most commonly nicotine or tetrahydrocannabinol (THC), along with flavorings and other additives to a vapor, which users inhale. Since their introduction in the early 2000s, e-cigarette use is now prolific among youth, per the Monitoring the Future survey, with over 40% of high school seniors reporting use within the past year. Adolescents are vulnerable to the risks of e-cigarettes, as they are targeted as new consumers with advertisements and flavoring compounds, and are not utilizing them as a means to smoking cessation. The pulmonary risks of vaping are rapidly emerging, with the most immediately alarming being the condition electronic-cigarette/vaping associated lung injury (EVALI). Additionally, there have been more recent studies showing extrapulmonary effects including cardiovascular, immunologic and neuro-developmental effects. Many of these effects are likely dose-dependent. Public health efforts are urgently needed to decrease or eliminate new e-cigarette initiation, and support should be established to assist current e-cigarette users with cessation. We strongly advocate for the elimination of e-cigarette flavorings and advertising directed at adolescents, and call for physicians to be cognizant of this expanding epidemic.

Free-Base Nicotine Fraction αfb in Non-Aqueous versus Aqueous Solutions: Electronic Cigarette Fluids Without versus With Dilution with Water

An important design aspect of electronic cigarettes ("e-cigarettes") is the nature of the acid/base chemistry in the e-liquid phase. E-liquids having formulations similar to those of early products are mixes of propylene glycol/glycerol (PG/GL) plus free-base (fb) nicotine and (usually) flavor chemicals that are either rather weak or non-acid/base actors in PG/GL. The fraction of nicotine in the fb form is denoted (α_fb)_e-liquid, with a possible range of 0 < (α_fb)_e-liquid < 1. For e-liquids of an early design, (α_fb)_e-liquid ≈ 1. Because e-cigarette aerosols high in fb nicotine are harsh upon inhalation, many commercial e-liquids now also contain variable levels of an acid additive (e.g., benzoic acid, levulinic acid, etc.) to protonate the nicotine and form dissolved "nicotine salts": (α_fb)_e-liquid values significantly less than 1 are now common. A framework is developed for predicting α_fb values in a given medium based on the following: (1) acid/nicotine ratios and (2) overall acid + nicotine protonation constant (K_oa) values. This framework is required for understanding (1) e-liquid design in regard to how acid additives affect (α_fb)_e-liquid values, and (2) why (α_fb)_e-liquid values cannot, in general, be measured by any method that involves significant dilution with water.