In this month’s issue of Pediatrics, Rao et al1 report a retrospective study of 13 adolescents in Dallas, Texas, who were hospitalized and treated for electronic cigarette, or vaping, product use–associated lung injury (EVALI). The first EVALI cases were reported to the Centers for Disease Control and Prevention on August 1, 2019, although subsequent retrospective analysis of emergency department data has revealed that visits for EVALI had started by June 20192 and peaked in September 2019.3 The group of patients described by Rao et al1 are younger than the national average (15.9 vs 24 years nationally), with a higher percentage of girls (54% vs 34%) and more people of Hispanic ethnicity (46% vs 15%).3 Similar to national reports, the majority of patients (92%) reported vaping tetrahydrocannabinol-containing products, and more than half (62%) reported vaping nicotine-containing products.
Consistent with previous reports of EVALI, clinical severity varied greatly between cases, including one patient experiencing a near-fatal clinical course involving extracorporeal membrane oxygenation and long-term mechanical ventilation. Interestingly, 85% of patients had gastrointestinal symptoms (commonly nausea and vomiting), and 4 presented with predominantly gastrointestinal symptoms. The authors report rapid clinical improvement attributed to the use of steroids in 11 of 12 patients who received them, and steroid doses and regimens varied. The 5 patients who had pulmonary function tests before and after steroids showed substantial improvement in all parameters tested. The improvement in clinical and pulmonary function test outcomes related to steroid administration adds to our understanding of the clinical course of EVALI.
The authors highlight 2 additional vital aspects of care for adolescents with EVALI: (1) assessing and addressing psychosocial risk factors and (2) facilitating cessation. Approximately half of patients reported stressors in at least 3 of 5 psychosocial risk domains (home environment, academic difficulty, behavior problems, mental health, and substance use). Although there is a lack of evidence to inform best practices for adolescent nicotine or tetrahydrocannabinol cessation and even less is understood about cessation for users who consume these substances through vaping, cessation remains a vital aspect of EVALI treatment. Providers caring for adolescents who use electronic cigarettes (e-cigarettes) or vaping devices (whether or not they have experienced EVALI) should encourage and support efforts toward cessation. Because many of those affected by EVALI were using black market or bootleg products, providers should counsel and strongly discourage consumption. Assessing psychosocial risk factors and referring to psychology or psychiatry experts, including addiction specialists, when needed, are good practices. In addition, research on adolescent nicotine cessation should be a priority for drug makers and research funders. This research could not only help prevent future cases of EVALI but also reduce other negative health outcomes, including pulmonary damage and lifelong nicotine addiction.
Although EVALI incidence has decreased nationally, cases continue to occur,3 and teenage vaping continues at epidemic and rising levels nationwide.4 The Centers for Disease Control and Prevention annual National Youth Tobacco Survey revealed that 27.5% of high school students reported use of an e-cigarette in the past 30 days in 2019, compared with 20.8% in 2018, and 10.5% of middle school students reported use of e-cigarettes in the past 30 days, compared with 0.6% in 2011.4 The survey also revealed that there are several gaps in e-cigarette policy and regulation.
Although progress has been made, e-cigarette use among adolescents remains an urgent pediatric advocacy priority. Increasing the tobacco purchasing age, banning or limiting flavored tobacco products, extending existing tobacco marketing restrictions to e-cigarettes, and increasing US Food and Drug Administration (FDA) oversight of e-cigarette products are strategies that will benefit adolescents.5 In December 2019, a bill was signed into law that raises the national tobacco purchasing age to 21. In 2019, amid increasing recognition of the epidemic of adolescent vaping and growing national concerns about EVALI, the Trump Administration issued rules to prohibit several types of flavorings (but not tobacco or menthol flavors) from refillable pod-based e-cigarettes. Unfortunately, this policy does not go far enough because it exempts both tank-based systems and disposable e-cigarettes, the latter of which are becoming increasingly popular among youth. Broader regulation is needed, and in February 2020, the US House of Representatives voted to ban the sale of all flavored cigarettes and e-cigarette liquids without exceptions and to prohibit online sales of e-cigarettes. In response to a lack of FDA regulation of e-cigarettes, a group of 6 health organizations, led by the American Academy of Pediatrics, filed suit against the FDA in a US district court in 2018. In July 2019, a judge ruled in the group’s favor, stating that the FDA had exceeded its authority in allowing e-cigarettes to stay on the market until 2022 before companies applied for regulatory approval. On the basis of this decision, e-cigarette makers must submit a formal application and undergo review by the FDA by May 2020 to continue selling their products. Because of the COVID-19 pandemic, the court has stated that it will modify this deadline to September 9, 2020. The case is currently on appeal.
One upside of the EVALI crisis of 2019 is that it drew national attention to the high rates of youth e-cigarette use and furthered the conversation about the youth vaping epidemic. More work remains for policy makers and advocates. Through prevention, cessation, and advocacy efforts, curbing the epidemic of youth e-cigarette use must remain a priority.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: Dr Sadreameli received support from the National Institutes of Health (K23HL138227). Funded by the National Institutes of Health (NIH).
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-4104.
- e-cigarette
electronic cigarette
- EVALI
electronic cigarette, or vaping, product use–associated lung injury
- FDA
US Food and Drug Administration
References
Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Comments
RE: Covid19 and vaping
Like the previous viral outbreaks MERS and SARS, COVID-19 attacks the lungs and other parts of the respiratory system. According to a recent state of art review concluded that the e-cigarette use is significantly and independently associated with an increased risk of respiratory illness (1). Systematic review and a meta-analysis published recently confirm that the current smokers are at a higher risk of dying from COVID-19 than non-smokers. Further the study results showed that 22% (31/139) of current smokers and 46% (13/28) of ex-smokers had severe complications. The calculated RR showed that current smokers were 1.45 times more likely [95% CI: 1.03–2.04] to have severe complications compared to former and never smokers. Current smokers also had a higher mortality rate of 38.5% (2).
To date, more than 4 700 000 severe Covid 19 related cases and more than 316 000 death were reported globally. In US alone the death rate has surpassed 90 000. No vaccine or promising pharmacological therapy is currently available to treat patients infected with coronavirus disease (COVID-19) effectively and efficiently.
People with decreased lung function caused by smoking or vaping are more likely to develop serious complications caused by infections (3). This accumulating evidence have resulted in a recommendation from reputed legal and medical organizations that the public avoid the use of tobacco, marijuana and e-cigarette products in the midst of this critical and uncertain time. American Academy of Family Physicians recently developed guidance stating that “people who smoke or use vapes or e-cigarettes have a significantly higher risk of contracting respiratory infections like corona virus” (3).
In the past 5 years, the use of nicotine delivered through e-cigarettes has significantly increased among adolescents and young adults and this dangerous trend would reverse 5 decades of progress in the fight against nicotine addiction. Meanwhile, Canadian Pediatric Society (CPS) encourages pediatricians and other health care professionals who work with adolescents, youth and families to communicate the message that smoking and vaping may increase their risk of acquiring the COVID-19 infection (4).
Adolescents and youth tobacco cessation efforts during this pandemic are a public health priority. It is necessary to develop targeted interventions to minimize the adverse public health impact of e-cigarettes in the adolescent population. We need to reinforce and deploy effective e cigarette cessation efforts in this high risk vulnerable population and this should be a important part of Covid 19 pandemic prevention measures. We need to bring every possible advocacy effort to create an environment in which our children could grow without compromising their health and wellbeing.
American Academy of Pediatrics (AAP) and US Preventive Services Task Force (UPSTF) have guidelines on best practices for preventing and treating adolescents tobacco use and evidence show that the primary care-based interventions for children and adolescents can be effective for preventing and treating adolescent tobacco use (5).
REFRENCES:
(1). Gotts JE, Jordt SE, McConnell R, Tarran R. What are the respiratory effects of e-cigarettes? BMJ. 2019 Sep 30;366:l5275. doi: 10.1136/bmj.l5275
(2). Alqahtani JS, Oyelade T, Aldhahir AM, Alghamdi SM, Almehmadi M, Alqahtani AS, Quaderi S, Mandal S, Hurst JR. Prevalence, Severity and Mortality associated with COPD and Smoking in patients with COVID-19: A Rapid Systematic Review and Meta-Analysis. PLoS One. 2020 May 11;15(5):e0233147. doi: 10.1371/journal.pone.0233147.
(3). NYSAFP clinical guidance to prevent tobacco and vaping use during Covid 19 pandemic-http://www.nysafp.org/News/What-s-New/COVID-19-Resources
(4). Chadi N, Bélanger R. Canadian Pediatric Society- COVID-19 information and resources for pediatricians. COVID-19 and substance use: Critical messages for youth and families: Dr. Nicholas Chadi and Dr. Richard Bélanger, adolescent medicine specialists, discuss vaping, smoking, and cannabis use- https://www.cps.ca/en/blog-blogue/covid-youth-and-substance-use-critical...
(5). US Preventive Services Task Force, Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Curry SJ, Donahue K, Doubeni CA, Epling JW Jr, Kubik M, Ogedegbe G, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB. Primary Care Interventions for Prevention and Cessation of Tobacco Use in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. 2020 Apr 28;323(16):1590-1598. doi: 10.1001/jama.2020.4679.
Aki NilangaBandara- nilangabandara527@gmail.com
Founding Chair-Global coalition to empower adolescent and youth on harmful therapeutic interventions to prevent combustible tobacco use.
Instructor, Faculty of Land and Food System, University of British Columbia, British Columbia, Canada, 2357 Main Mall, Vancouver, BC V6T 1Z4 Canada.
MeharaSeneviratne- meharaseneviratne@yahoo.com
Coordinator-Global coalition to empower adolescent and youth on harmful therapeutic interventions to prevent combustible tobacco use.
Dr. Vahid Mehrnoush- mv1361@yahoo.com
Senior Advisor-Global coalition to empower adolescent and youth on harmful therapeutic interventions to prevent combustible tobacco use.
Postdoctoral research fellow, Section of Trauma, Acute Care, and Global Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC
RE: Covid19 and vaping
In the past 5 years, the use of nicotine delivered through e-cigarettes has significantly increased among adolescents and young adults and this dangerous trend would reverse 7 decades of progress in the fight against nicotine addiction (1). Nicotine addiction is a pediatric disease (2) and nicotine exposure to the developing adolescent brain has been shown to have long-term cognitive and behavioral impairments (3).Juul uses nicotine salts in its vaping devices to deliver “dramatically higher levels” of nicotine to the brain with less irritation and “Adolescents simply do not stand a chance”(4). JUUL appears to be associated with the youth e-cigarette epidemic, attracting new users and facilitating frequent use with their highly addictive nicotine content and appealing flavors (5). The Surgeon General estimates that 5.6 million of today’s youth will die prematurely from a smoking related illness (6).
Like the previous viral outbreaks MERS, SARS, COVID-19 attacks the lungs and other parts of the respiratory system. According to 3 recent studies, including one state of art review concluded that the e-cigarette use is significantly and independently associated with an increased risk of respiratory illness (7, 8, 9). Systematic review and a meta-analysis published recently in the Journal PLOS ONE (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0233147) confirms that the current smokers are at a higher risk of dying from COVID-19 than non-smokers. Further the study results showed that 22% (31/139) of current smokers and 46% (13/28) of ex-smokers had severe complications. The calculated RR showed that current smokers were 1.45 times more likely [95% CI: 1.03–2.04] to have severe complications compared to former and never smokers. Current smokers also had a higher mortality rate of 38.5%.
To date, more than 4 700 000 severe Covid 19 related cases and more than 316 000 death were reported globally. People with decreased lung function caused by smoking or vaping are more likely to develop serious complications caused by infections. (10). These accumulating evidence have resulted in a recommendation from reputed legal and medical organizations that the public avoid the use of tobacco, marijuana and e-cigarette products in the midst of this uncertain time. American Academy of Family Physicians recently developed guidance stating that “people who smoke or use vapes or e-cigarettes have a significantly higher risk of contracting respiratory infections like corona virus” (10).
Office of Attorney General Massachusetts and MassGeneral hospital for Children joint statement extended a similar clinical guidance and advice to young people (11). Meanwhile, Canadian Pediatric Society (CPS) encourages pediatricians and other health care professionals who work with adolescents, youth and families to communicate the message that smoking and vaping may increase their risk of acquiring the COVID-19 infection (12). We need to bring every possible advocacy effort to create an environment in which our children could grow without compromising their overall health and wellbeing and curbing the epidemic of youth e-cigarette use must remain a priority (13)
American Academy of Pediatrics (AAP) and US Preventive Services Task Force (UPSTF) have guidelines on best practices for preventing and treating adolescents tobacco use and evidence show that the primary care-based interventions for children and adolescents can be effective for preventing and treating adolescent tobacco use (14, 15). .
REFRENCES:
(1). Chadi N, Hadland SE, Harris SK. Understanding the implications of the "vaping epidemic" among adolescents and young adults: A call for action.Subst Abus. 2019;40(1):7-10. doi: 10.1080/08897077.2019.1580241.
(2). Kessler DA, Natanblut SL, Wilkenfeld JP, Lorraine CC, LindanMayl S, Bernstein IBG, Thompson L. Nicotine addiction: a pediatric disease. J Pediatr. 1997;130:518–524.
(3). Surgeon General’s report (2016) US Department of Health and Human Services. E-cigarette use among youth and young adults: A report of the Surgeon General-http://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_no....
(4). The American Academy of Pediatrics- Congressional testimony 2019-https://www.cnbc.com/2019/10/15/pediatrician-to-congress-adolescents-don...
(5). Vallone DM, Cuccia AF, Briggs J, Xiao H, Schillo BA, Hair EC.Electronic cigarette and JUULuse among adolescents and young adults. JAMA Pediatr. 2020 Jan 21. doi: 10.1001/jamapediatrics.2019.5436
(6). National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention (US); 2014
(7). Bhatta DN, Glantz SA. Association of E-Cigarette Use With Respiratory Disease Among Adults: A Longitudinal Analysis. Am J Prev Med. 2019 Dec 11. pii: S0749-3797(19)30391-5. doi: 10.1016/j.amepre.2019.07.028.
(8). Gotts JE, Jordt SE, McConnell R, Tarran R. What are the respiratory effects of e-cigarettes? BMJ. 2019 Sep 30;366:l5275. doi: 10.1136/bmj.l5275
(9). Gilpin DF, McGown KA, Gallagher K, Bengoechea J, Dumigan A, Einarsson G, Elborn JS, Tunney MM. Electronic cigarette vapour increases virulence and inflammatory potential of respiratory pathogens. Respir Res. 2019;20(1):267. doi: 10.1186/s12931-019-1206-8. PMID: 31847850
(10). NYSAFP clinical guidance to prevent tobacco and vaping use during Covid 19 pandemic-http://www.nysafp.org/News/What-s-New/COVID-19-Resources
(11). Health advisories on smoking and vaping and COVID-19- Office of Attorney General Massachusetts and MassGeneral hospital for Children joint statement-https://www.mass.gov/doc/covid-vaping-advisory/download
(12). Chadi N, Bélanger R. Canadian Pediatric Society- COVID-19 information and resources for pediatricians. COVID-19 and substance use: Critical messages for youth and families: Dr. Nicholas Chadi and Dr. Richard Bélanger, adolescent medicine specialists, discuss vaping, smoking, and cannabis use- https://www.cps.ca/en/blog-blogue/covid-youth-and-substance-use-critical...
(13). Sadreameli SC, Mogayzel PJ Jr. Curbing Youth E-cigarette Use Must Remain a Priority. Pediatrics. 2020 May 11. pii: e20200902. doi: 10.1542/peds.2020-0902
(14). Hagan JF, Shaw JS, Duncan PM, editors. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3. Elk Grove Village, IL: American Academy of Pediatrics; 2008.
(15). US Preventive Services Task Force, Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, Curry SJ, Donahue K, Doubeni CA, Epling JW Jr, Kubik M, Ogedegbe G, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB. Primary Care Interventions for Prevention and Cessation of Tobacco Use in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. 2020 Apr 28;323(16):1590-1598. doi: 10.1001/jama.2020.4679.
Aki NilangaBandara
Founding Chair-Global coalition to empower adolescent and youth on harmful therapeutic interventions to prevent combustible tobacco use.
Instructor, Faculty of Land and Food System, University of British Columbia, British Columbia, Canada, 2357 Main Mall, Vancouver, BC V6T 1Z4 Canada.
MeharaSeneviratne
Coordinator-Global coalition to empower adolescent and youth on harmful therapeutic interventions to prevent combustible tobacco use.
Dr. Vahid Mehrnoush
Senior Advisor-Global coalition to empower adolescent and youth on harmful therapeutic interventions to prevent combustible tobacco use.
Postdoctoral research fellow, Section of Trauma, Acute Care, and Global Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC