While there is still lacking research, the adverse effects of using e-cigarettes include more than just the risks of nicotine. Some of the additional risks include re-normalizing smoking behavior in youths, causing injury from device malfunction, and unknowingly inhaling potentially toxic chemicals.
The E‐cigarette or vaping product use‐associated lung injury (EVALI) health crisis in the Fall 2019 was likely due to an additive (Vitamin E acetate) in e-cigarettes involving THC.
Healthcare providers should recommend that patients who use e-cigs avoid THC containing products due to the potential association with EVALI.
The USPSTF does not recommend the use of e-cigarettes as a smoking cessation tool due to a lack of evidence.
Known in colloquial terms as “ vapes”, “vape pens”, or “e-cigs”, electronic cigarettes refer to electronic, handheld devices that heat a liquid, usually containing nicotine, to produce an aerosol which the user may inhale (Rigotti & Kalkhoran, 2020). These electronic nicotine delivery devices were first commercialized by a Chinese inventor in 2003 and did not find their way to the US market until 2006, where they have made quite an impact in the last 14 years (Historical Timeline of Electronic Cigarette, 2019).
Potential Adverse Effects of E-cigs
Nicotine, most often vaporized in e-cigs, is a highly addictive substance and has multiple known health risks to people of all ages (CDC, September 2020). Using nicotine can be toxic to developing fetuses, interfere with brain development in adolescents, and may contribute to acute coronary events in adults (CDC, September 2020 ; Giardina, 2020). The health risks attributed to e-cigarettes were considered to be mostly those of the inhaled nicotine, but, while still applicable, there are other additional potential adverse effects to consider. The physical use of the device can cause potential burns/injuries from malfunctioning or exploding (Uptodate, 2020). The CDC found that in 2020, 3.6 million U.S. middle and high school students used e-cigarettes in the past 30 days (CDC, September 2020). Youths are especially at risk for nicotine dependence given their developing brains.
Other concerns are not so apparent though. Some speculate there may be a “gateway effect”, where e-cigarettes could lead to smoking conventional cigarettes (Rigotti & Kalkhoran, 2020). The popularity of vaping products among the youths may be renormalizing smoking behavior and reverse the negative associations attributed to conventional smoking (Rigotti & Kalkhoran, 2020). What’s more,vaping products do not deliver a uniform amount of nicotine with each inhalation which creates more unknown potential health risks. The level of nicotine inhaled is dependent on individual puffing intensity, device characteristics, and nicotine concentration of the liquid, so blood nicotine levels can vary greatly (Rigotti & Kalkhoran, 2020). To add to this variability, many manufactured e-cigarettes contain a number of chemical substances that can be potentially toxic (CDC, September 2020). This danger was made apparent in the fall of 2019 when there was a sharp, sudden rise of emergency department visits related to e-cigarette or vaping products (CDC, 2020).
EVALI
E‐cigarette or vaping product use‐associated lung injury (EVALI) is a serious respiratory condition that, as of February 2020, has claimed a total of 68 lives across the U.S. and is responsible for 2,807 hospitalizations in all US territories (CDC, February 2020).
Presentation consists most often of respiratory symptoms, including shortness of breath and cough, and can be accompanied by common GI symptoms, like nausea, vomiting, and diarrhea (Hollingsworth, 2020). There will also be a positive history of vaping in the last 90 days, lung opacities on chest imaging, and negative testing for other common causes (Hollingsworth, 2020). Progression to respiratory distress/failure is common, and about 95% of patients of EVALI cases needed hospitalization (Hollingsworth, 2020).
Since September 2019, the incidence of EVALI is steadily declining but should still be considered if consistent symptoms are noted upon exam.
Vitamin E Acetate – The Cause?
The declining rate is likely in part due to the investigations headed by the FDA and CDC. They have both found laboratory data suggesting an additive in tetrahydrocannabinol (THC)-containing e-cigarette products is correlated to the development of this respiratory illness (CDC, February 2020; U.S Food and Drug Association, 2020). In a recent study, Vitamin E acetate was speculated to be this specific additive as it was found in the lungs of 48 out of the 51 EVALI cases (Blount et al., 2020). It was also found in 81% of the e-cigarette samples that were confirmed to be connected with specific CDC cases, further supporting its involvement (Blount et al., 2020; U.S Food and Drug Association, 2020).
Recommendations for Healthcare Providers
Overall, no confirmed causation or specific correlation has been identified but the CDC still recommends avoidance of using Vitamin E acetate as an additive (February 2020). Based on the current studies, the CDC recommends avoiding use of THC-containing electronic cigarette products as well (February 2020).
Healthcare providers should urge patients to refrain from smoking altogether, but should especially stress avoidance of “dual use”- using both e-cigs and cigarettes/other tobacco products together (CDC, February 2020). A Cochrane Review did provide some evidence that showed e-cigarettes with nicotine can play a positive role in long term smoking cessation (Hartmann-Boyce et al., 2020). However, the limited sample size of the studies and small number of trials limit the evidence. Ultimately, the US Preventive Services Task Force deemed the evidence to be insufficient, and more information is needed prior to recommending e-cigarettes for smoking cessation (Rigotti & KalKhoran, 2020).
Blount, B. C., Karwowski, M. P., Shields, P. G., Morel-Espinosa, M., Valentin-Blasini, L., Gardner, M., . . . Pirkle, J. L. (2020). Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI. New England Journal of Medicine,382(8), 697-705. doi:10.1056/nejmoa1916433
The Vaping Crisis – Updates in EVALI
Takeaways
Known in colloquial terms as “ vapes”, “vape pens”, or “e-cigs”, electronic cigarettes refer to electronic, handheld devices that heat a liquid, usually containing nicotine, to produce an aerosol which the user may inhale (Rigotti & Kalkhoran, 2020). These electronic nicotine delivery devices were first commercialized by a Chinese inventor in 2003 and did not find their way to the US market until 2006, where they have made quite an impact in the last 14 years (Historical Timeline of Electronic Cigarette, 2019).
Potential Adverse Effects of E-cigs
Nicotine, most often vaporized in e-cigs, is a highly addictive substance and has multiple known health risks to people of all ages (CDC, September 2020). Using nicotine can be toxic to developing fetuses, interfere with brain development in adolescents, and may contribute to acute coronary events in adults (CDC, September 2020 ; Giardina, 2020). The health risks attributed to e-cigarettes were considered to be mostly those of the inhaled nicotine, but, while still applicable, there are other additional potential adverse effects to consider. The physical use of the device can cause potential burns/injuries from malfunctioning or exploding (Uptodate, 2020). The CDC found that in 2020, 3.6 million U.S. middle and high school students used e-cigarettes in the past 30 days (CDC, September 2020). Youths are especially at risk for nicotine dependence given their developing brains.
Other concerns are not so apparent though. Some speculate there may be a “gateway effect”, where e-cigarettes could lead to smoking conventional cigarettes (Rigotti & Kalkhoran, 2020). The popularity of vaping products among the youths may be renormalizing smoking behavior and reverse the negative associations attributed to conventional smoking (Rigotti & Kalkhoran, 2020). What’s more,vaping products do not deliver a uniform amount of nicotine with each inhalation which creates more unknown potential health risks. The level of nicotine inhaled is dependent on individual puffing intensity, device characteristics, and nicotine concentration of the liquid, so blood nicotine levels can vary greatly (Rigotti & Kalkhoran, 2020). To add to this variability, many manufactured e-cigarettes contain a number of chemical substances that can be potentially toxic (CDC, September 2020). This danger was made apparent in the fall of 2019 when there was a sharp, sudden rise of emergency department visits related to e-cigarette or vaping products (CDC, 2020).
EVALI
E‐cigarette or vaping product use‐associated lung injury (EVALI) is a serious respiratory condition that, as of February 2020, has claimed a total of 68 lives across the U.S. and is responsible for 2,807 hospitalizations in all US territories (CDC, February 2020).
Presentation consists most often of respiratory symptoms, including shortness of breath and cough, and can be accompanied by common GI symptoms, like nausea, vomiting, and diarrhea (Hollingsworth, 2020). There will also be a positive history of vaping in the last 90 days, lung opacities on chest imaging, and negative testing for other common causes (Hollingsworth, 2020). Progression to respiratory distress/failure is common, and about 95% of patients of EVALI cases needed hospitalization (Hollingsworth, 2020).
Since September 2019, the incidence of EVALI is steadily declining but should still be considered if consistent symptoms are noted upon exam.
Vitamin E Acetate – The Cause?
The declining rate is likely in part due to the investigations headed by the FDA and CDC. They have both found laboratory data suggesting an additive in tetrahydrocannabinol (THC)-containing e-cigarette products is correlated to the development of this respiratory illness (CDC, February 2020; U.S Food and Drug Association, 2020). In a recent study, Vitamin E acetate was speculated to be this specific additive as it was found in the lungs of 48 out of the 51 EVALI cases (Blount et al., 2020). It was also found in 81% of the e-cigarette samples that were confirmed to be connected with specific CDC cases, further supporting its involvement (Blount et al., 2020; U.S Food and Drug Association, 2020).
Recommendations for Healthcare Providers
Overall, no confirmed causation or specific correlation has been identified but the CDC still recommends avoidance of using Vitamin E acetate as an additive (February 2020). Based on the current studies, the CDC recommends avoiding use of THC-containing electronic cigarette products as well (February 2020).
Healthcare providers should urge patients to refrain from smoking altogether, but should especially stress avoidance of “dual use”- using both e-cigs and cigarettes/other tobacco products together (CDC, February 2020). A Cochrane Review did provide some evidence that showed e-cigarettes with nicotine can play a positive role in long term smoking cessation (Hartmann-Boyce et al., 2020). However, the limited sample size of the studies and small number of trials limit the evidence. Ultimately, the US Preventive Services Task Force deemed the evidence to be insufficient, and more information is needed prior to recommending e-cigarettes for smoking cessation (Rigotti & KalKhoran, 2020).
Want to Learn More?
For Healthcare Providers | Electronic Cigarettes | Smoking & Tobacco Use
Quick Facts on the Risks of E-cigarettes for Young People
Vaporizers, E-Cigarettes, and other Electronic Nicotine Delivery Systems (ENDS)
References
Blount, B. C., Karwowski, M. P., Shields, P. G., Morel-Espinosa, M., Valentin-Blasini, L., Gardner, M., . . . Pirkle, J. L. (2020). Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI. New England Journal of Medicine, 382(8), 697-705. doi:10.1056/nejmoa1916433
CDC. (2020, September 09). About Electronic Cigarettes (E-Cigarettes). Retrieved October 25, 2020, from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html
CDC. (2020, February 25). Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Retrieved October 25, 2020, from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
Giardina, E. (2020, May 06). Cardiovascular effects of nicotine. Retrieved October 26, 2020, from https://www.uptodate.com/contents/cardiovascular-effects-of-nicotine?sectionName=SMOKING+AND+CARDIOVASCULAR+RISK
Hartmann-Boyce, J., Mcrobbie, H., Lindson, N., Bullen, C., Begh, R., Theodoulou, A., . . . Hajek, P. (2020). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd010216.pub4
Historical Timeline of Electronic Cigarettes. (2019, November 18). Retrieved October 28, 2020, from http://www.casaa.org/historical-timeline-of-electronic-cigarettes/
Hollingsworth, H. (2020, August 31). E-cigarette or vaping product use associated lung injury (EVALI). Retrieved October 25, 2020, from https://www.uptodate.com/contents/e-cigarette-or-vaping-product-use-associated-lung-injury-evali?search=vaping
Rigotti, N., & KalKhoran, S. (2020, October 6). Vaping and e-cigarettes. Retrieved October 24, 2020, from https://www.uptodate.com/contents/vaping-and-e-cigarettes?search=vaping
U.S Food and Drug Association. (2020, April 13). Respiratory Illnesses Associated with Use of Vaping Products. Retrieved October 28, 2020, from https://www.fda.gov/news-events/public-health-focus/lung-injuries-associated-use-vaping-products
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