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Not Just “Harmless Water Vapor” :

October 15, 2019

Vaping and e-cigarettes have catapulted to the top of the fold in the last several months as we have seen a sudden outbreak of cases termed “Vaping Induced Lung Injury” or VILI.

Vaping and e-cigarettes have catapulted to the top of the fold in the last several months as we have seen a sudden outbreak of cases termed “Vaping Induced Lung Injury” or VILI. While many of us in the pediatric tobacco control community have been worried about the impact of these products on the long-term health of teens and young adults, these new cases represent a significant risk of acute lung injury, hospitalization, and even death. The CDC is currently investigating the cause. While tetrahydrocannabinol (THC) containing cartridges have been implicated in the majority of the cases, a significant number were associated with nicotine-only use. 

It is important to understand what these products are.  E-cigarettes, and their like (ehookah, vape pens, etc), use a battery to heat up a liquid, usually containing a propylene glycol or vegetable glycerin, flavors, and nicotine.  THC-containing products usually use hash oil, but can also aerosolize marijuana leaf, as in this disturbing product, which is fortunately no longer on the market.  While they have been marketed as producing a “harmless water vapor”, do not be fooled.  The heating of the compounds in the liquid creates particulates, volatile organic compounds, and tobacco-specific nitrosamines, among other toxic chemicals, all of which can provoke inflammatory reactions in the lungs and circulation.  While early generation e-cigarettes were designed to mimic combusted tobacco, recent versions have built on technology and look like flash drives or other “cool tools”.  In addition, while flavors in cigarettes have long been restricted to menthol and tobacco, e-cigarettes have not been regulated, and thus have adopted child-friendly versions like Cherry Crush, Mango, Cotton Candy, and Juice Roll Upz Strawberry.  These products have been marketed heavily using teen-age appearing “influencers” on social media; all of these marketing tactics, taken straight from the tobacco company playbooks from the 1950s, have resulted in a huge increase in the percent of teens who are current users (27% in the last National Youth Tobacco Survey).

Juul is an e-cigarette company that has had a lot of attention, primarily because it first used nicotine salts as a method for increasing the nicotine delivery to the lungs. This strongly increases the risk of addiction, and while they claimed that they were only a product for adults looking to quit combusted tobacco, their marketing of flavors and using social media lead many teens to try e-cigarettes, even without having used combusted tobacco.  In fact, multiple studies have found that teens that try e-cigarettes are more likely to go on to use combusted tobacco. Juul and other companies are suddenly trying very hard not to appeal to teens, but the damage appears to be done.

What can pediatricians and other health care providers do?  First, ask teens specifically about use and counsel all teens and young adults to NEVER use e-cigarettes or any other vaping product.  You may need to use a few terms, like ehookah, vape pens, vape cartridges, or Juuling, to get across what you mean!  For teens who have already started and are addicted, we don’t have a lot of evidence to go on, but certainly offer nicotine replacement therapy (patch, gum, or lozenge works best!); counseling may also be helpful.  It can’t hurt to recommend exercise, a healthy diet, and stress reduction.  If you have a patient with nausea and vomiting, and/or respiratory symptoms, get a detailed vaping history, and keep VILI on your differential diagnosis.  And remember, please let your local health department know, as they are still tracking cases.  The AAP’s Richmond Center of Excellence website is an excellent source of up-to-date information on tobacco and electronic cigarettes, and the AAP’s Section on Tobacco Control connects pediatricians across the country interested in protecting children from tobacco.  The Section on Tobacco Control has recently updated the AAP Policy Statement on E-Cigarettes and Similar Devices.

Finally, since the aerosol that emits from the product contains harmful chemicals and nicotine, it is very important to counsel parents that it is not safe to use around their younger children.  They will inhale the particulates, the chemicals, and the nicotine; all of which can be problematic exposures.

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