Vaping-Related Illnesses, Deaths Continue to Climb

An 18-year-old student was rushed to the emergency room in Illinois last month after he began vomiting and shivering continuously. An X-ray revealed bilateral infiltrates on his lungs, and physicians told him his lungs looked like those of a 70-year-old man. It is unclear if his lungs will fully heal.

The culprit? The e-cigarettes the student-athlete began using a year and a half ago “to fit in, because everyone else was doing it,” he said during a televised interview. The teen eventually began vaping THC, the psychoactive compound in marijuana.

As of press time, officials had identified more than 1,080 cases of severe vaping-related lung injury across 48 states and the U.S. Virgin Islands, including 18 deaths. Many of the victims have reported a history of vaping THC products bought on the black market. The Centers for Disease Control and Prevention (CDC) reported that about 70% are male, and about 80% are under 35 years old; 16% are under age 18.

The CDC said the agency believes a chemical exposure is likely associated with the illnesses. The Food and Drug Administration (FDA) said in a statement that the agency is working with state and federal partners on potential leads, including the presence of vitamin E acetate in some product samples, which can be hazardous when inhaled.

“At this time, no one device, product, or substance has been linked to all cases,” said Ileana Arias, Ph.D., the CDC’s senior scientific advisor and acting deputy director for noninfectious diseases, during a briefing in September. The FDA is urging consumers to stop buying vaporizers, cartridges, and liquids on the street or modifying vaping products.

A study of more than 50 patients with severe respiratory syndrome related to e-cigarette use in Illinois and Wisconsin found that all patients had bilateral infiltrates in their lungs and nearly all (94%) were hospitalized, according to a study posted September 6 in the New England Journal of Medicine (NEJM) last month. One-third needed intubation and mechanical ventilation, and one patient died.

Trump Administration Responds

To tackle the epidemic of youth use of e-cigarettes, President Donald Trump announced last month that the FDA would restrict the sale of flavored e-cigarette products—except those that taste like tobacco. “Moreover, if we see a migration to tobacco-flavored products by kids, we will take additional steps to address youth use of these products,” said Acting FDA Commissioner Ned Sharpless, M.D., in a press statement.

While the federal government starts its process to bar candy- and fruit-flavored e-cigarettes, several states have stepped in: So far, Michigan, New York, Rhode Island, and Washington have banned flavored e-cigarettes, and Massachusetts banned all vaping products. Other states are considering similar bans.

Across the country, it seems that far more high schoolers are using e-cigarettes than adults and that flavors are playing a big role. One study in 2017 estimated that less than 4% of adults used e-cigarettes. According to the 2019 National Youth Tobacco Survey, 27.5% of high school students used e-cigarettes in 2019—up from 11.79% in 2017. Most youth surveyed said they vaped flavored e-cigarettes, such as fruit, menthol/mint, and candy flavors.

The FDA issued a harsh warning letter and a separate letter requesting more information from Juul Labs Inc. in September, writing that its “Make the Switch” marketing campaign may give the impression that its e-cigarettes are lower risk than traditional tobacco products, which is unproven. The FDA also wrote that it is troubled by Juul’s use of nicotine salt e-liquids and the concentration of nicotine in its products, which could increase the addictiveness of the products.

At congressional hearings held in July, Juul faced questions about its marketing and outreach activities targeting schools, youth leagues, faith-based youth groups, employers, Native American tribes, and health insurers. Lawmakers questioned Juul officials for offering some schools and youth groups as much as $134,000 to use the company’s “health education” programming. The company said it ended those programs in the fall of 2018.

Juul has since announced it would suspend all its product advertising in the United States and will not be lobbying against the proposed federal flavor ban.

Psychiatrists Weigh In on Vaping

Psychiatrists should be incorporating routine assessment of tobacco use, including use of e-cigarettes as well as cessation assistance into their regular practice, experts say.

“Psychiatrists are often the primary care provider for people with serious mental illness, and these individuals are going to need some guidance and help regarding vaping and their use of e-cigarettes,” said Douglas Ziedonis, M.D., M.P.H., an addiction psychiatrist and associate vice chancellor of health sciences at the University of California, San Diego, and a professor of psychiatry at UC San Diego Health.

As for the latest vaping headlines, “We should inform patients that these are concerning findings about e-cigarettes and that there is other evidence suggesting that vaping may cause cell damage. More research is needed.”

Ziedonis said that there has been some ambivalence in the medical field about e-cigarettes, and some physicians have been more lenient because of the lack of data. “But there has always been a concern that we do not fully know the impact of all the components of vaping and e-cigarettes on human health.”

Ziedonis said informing adolescent patients about the e-cigarette industry’s aggressive marketing campaigns that specifically target young people may be an effective means of reaching them and convincing them not to start or to quit. That was one of the lessons learned from an anti-tobacco program aimed at helping teens quit traditional cigarettes that operated in New Jersey for a decade called Reaching Everyone by Exposing Lies.

What about patients who want to try e-cigarettes to help them quit smoking? “When patients come in to my office and want to quit smoking and use e-cigarettes to do that, I first express that I am very excited for them and help solidify their motivation to quit smoking,” said Smita Das, M.D., Ph.D., M.P.H., a clinical assistant professor at Stanford University School of Medicine. She then explores whether the patient has ever used one of the seven FDA-approved, evidence-based treatments for quitting, such as nicotine replacement therapy, bupropion, or varenicline and the patient’s experience with these options.

Das said quit attempts are foiled often by incorrect use of nicotine replacement therapy products, so she helps patients troubleshoot these common issues. Das said she never recommends e-cigarettes as a potential method to help patients quit smoking, but for patients who are set on them, she goes over the risks, as well as the lack of evidence surrounding vaping as a smoking cessation method.

Although data on e-cigarettes are sparse, a study published earlier this year in NEJM suggests smokers who use e-cigarettes may have greater success quitting than those who use nicotine replacement therapy. For this randomized, controlled trial, both groups had expert guidance and behavioral support. Still 18% of those who used only e-cigarettes were abstinent from cigarettes at one year, compared with 8% of those who used only nicotine replacement therapy. However, researchers noted a high rate of ongoing e-cigarette use among participants, so they weren’t able to ditch tobacco products altogether.

“People should be thoughtful and really consider a wider range of FDA-approved medications and psychosocial treatment options if their goal is to quit tobacco products,” Ziedonis said. There are also many community resources, including quit lines, apps, and text programs available for patients who want to quit. ■