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Severe E-Cigarette, or Vaping, Product Use Associated Lung Injury Requiring Venovenous Extracorporeal Membrane Oxygenation

https://journals.lww.com/pccmjournal/Citation/2020/04000/Severe_E_Cigarette,_or_Vaping,_Product_Use.11.aspx

Abstract

Objectives:

To report a severe case of e-cigarette or vaping product use-associated lung injury with complex course requiring venovenous extracorporeal membrane oxygenation.

Design:

Case report.

Setting:

PICU in an academic medical center.

Patients:

A 16-year-old girl presenting with gastrointestinal and respiratory symptoms was admitted to our PICU after having progressive respiratory failure and bilateral pulmonary ground-glass opacities on chest CT.

Interventions:

Venovenous extracorporeal membrane oxygenation

Measurements and Main Results:

After extensive infectious workup was unrevealing, she reported a history of vaping e-cigarette containing either nicotine or delta-9-tetrahydrocannabinol oil prior to symptom onset. She was given a presumptive diagnosis of e-cigarette or vaping product use-associated lung injury. The PICU team in consultation with pulmonology and medical toxicology started high-dose IV methylprednisolone 1 mg/kg bid. Despite initial improvements, she continued to require positive pressure ventilation and developed pneumomediastinum with progression to tension pneumothoraces and a persistent air leak. Unable to maintain her oxygenation, she was placed on venovenous extracorporeal membrane oxygenation for a prolonged course and had a tracheostomy placement. The clinical course, severity, and range of interventions in affected patients around the country have varied widely. Respiratory symptoms have been the most severe, but the constellation of symptoms in e-cigarette or vaping product use-associated lung injury include constitutional symptoms (fevers, weight-loss) and gastrointestinal symptoms (nausea, vomiting, diarrhea). In many cases, steroid use led to rapid clinical improvements. However, other cases with severe illness, like our patient, necessitated high-dose IV steroids, intubation, and venovenous extracorporeal membrane oxygenation. The underlying etiology and pathophysiology of e-cigarette or vaping product use-associated lung injury remains unknown. The Centers for Disease Control and Prevention in conjunction with state/local health departments and the Food and Drug Administration is actively investigating the outbreak.

Conclusions:

Clinicians need to be aware of the current outbreak of e-cigarette or vaping product use-associated lung injury and ask about vaping in patients presenting with gastrointestinal and respiratory symptoms. Treatment options are anecdotal and necessitate a multidisciplinary approach.

Third of NZ students have tried vaping, despite most being non-smokers

http://www.voxy.co.nz/health/5/361613

New research shows that more than a third of New Zealand high school students have tried vaping even though nearly two-thirds of those doing so have never smoked cigarettes.

Vapes, or electronic cigarettes, are not recommended for non-smokers, as the long-term effects are not known, and vapes containing nicotine are likely to be addictive.

“Vaping is not as harmful as smoking, but it is not harmless. Taking up vaping is not a good idea for people who are not otherwise smokers, particularly young people,” says study co-author Dr Terry Fleming from Te Herenga Waka-Victoria University of Wellington’s School of Health.

The study is the first in New Zealand to look at vaping in high school students of all ages. It found 65 percent of teenagers who had tried vaping reported they had never smoked cigarettes, as well as 48 percent of those who said they vaped regularly. Overall, 38 percent of teenagers reported they had tried vaping, 10 percent said they vaped regularly, and 6 percent vaped weekly or more often.

The research also shows vaping is relatively common for students in all school deciles, whereas smoking is now rare in higher decile schools.

“Vaping seems to appeal to a wider range of young people than smoking and unlike smoking it is more common in boys than girls,” says Dr Fleming.

Recently published data from another New Zealand study shows the long-term decline in smoking among Year 10 students that began in 2000 stalled from about 2015 and may even be reversing, particularly in MÄori and low decile schools.

“When you put these findings together, it calls into question the idea that vaping is displacing smoking. The alternative possibility, that vaping is fuelling smoking, must be taken seriously by communities and policymakers,” says study co-author Associate Professor Terryann Clark from the University of Auckland.

Researchers say measures to protect youth, particularly MÄori and disadvantaged youth, from both vaping and smoking harm are needed, such as limits on where vapes and tobacco can be sold and a ban on vaping advertising and sponsorship, including online and social media promotion.

The research is timely, as the Government is currently consulting on new vaping regulations announced earlier in the month.

“New Zealand has fewer restrictions on promoting vaping and on vape flavours than many other countries. Supporting smokers to step down to vaping and non-smokers to stay that way are both important-this is possible with good policy and leadership,” says Dr Fleming.

The research is part of the Youth19 survey, which aims to collect data on a range of issues affecting New Zealand youth. Further results from the survey will be available over the coming year. This survey is a collaboration between Te Herenga Waka-Victoria University of Wellington, the University of Auckland, the University of Otago, and AUT.

Regulating Vaping — Policies, Possibilities, and Perils

https://www.nejm.org/doi/full/10.1056/NEJMp1917065

Smoking rates peaked in the United States in the mid 1960s and have since declined to historically low levels. In contrast, use of e-cigarettes has recently soared, particularly among young people. In 2019, more than 27% of high school students reported using e-cigarettes during the past month, as compared with about 6% who reported using combustible cigarettes.1 Use of Juul products accounts for much of the doubling of vaping rates between 2017 and 2019, and these products represent 75% of the multibillion-dollar e-cigarette market. The growth in vaping among young people has alarmed policymakers and many others.

Federal and state governments have implemented numerous policies to combat the growth of vaping. To promote the health of the population, however, policies should protect young people without diminishing the ability of e-cigarettes to help adult smokers transition away from more harmful combustible cigarettes or to serve as a cessation aid for people attempting to quit smoking. This tension presents a quandary for policymakers, since vaping policies often promote one goal at the expense of the other. Furthermore, the facts that certain state and federal policies complement, substitute for, or undermine each other and that some federal policies supersede state policies add another layer of complexity to policymaking in this arena.

Because e-cigarettes vaporize liquid instead of burning tobacco, they are generally thought to be less harmful than combustible cigarettes.2 However, the long-term health effects of inhaling liquid flavoring chemicals and nicotine are unknown.

Juul is a cartridge (“pod”) type of e-cigarette — it is a reusable, rechargeable device that holds a liquid-containing pod, rather than a refillable open-tank system or a disposable device. Juul pods contain higher levels of nicotine than many other e-cigarette products, which makes them a better substitute for combustible cigarettes for smokers. However, high nicotine levels increase the risk of addiction among young people and can harm their cognitive development. Vaping e-cigarettes adulterated with tetrahydrocannabinol (THC) and vitamin E acetate recently caused an outbreak of acute lung disease and deaths.3 Although these harms are seemingly linked to the addition of THC and to the use of e-cigarettes obtained from informal sources rather than to e-cigarettes in general, these complications heighten concerns about e-cigarettes.

Capture5

State and federal policymakers are focusing on two key policies for preventing vaping among young people: minimum sales age laws that restrict the sale of e-cigarettes to adolescents and bans on flavored e-cigarettes. Some states have also implemented e-cigarette taxes (see table).

In December 2019, Congress passed so-called Tobacco 21 legislation, which immediately sets a federal minimum age of 21 for purchasing tobacco products, including e-cigarettes. Twenty-four states and the District of Columbia had enacted policies that set the minimum age for purchasing e-cigarettes at either 19 or 21; in other states, the minimum age was 18.

Because most tobacco use begins before 19 years of age, the new federal law has the potential to dramatically reduce current tobacco use among young people and prevent some people from ever using tobacco. However, enforcing bans on sales to minors is difficult in retail locations and even more so online, and young people often obtain e-cigarettes from family members and friends. To reduce access to e-cigarettes among young people, federal and state governments could increase funding for enforcement efforts and collaborate to find better ways to prevent sales to young people in stores and online.

Another important policy is banning flavored e-cigarettes. Because flavors are more attractive to young people than to adults, a flavor ban could reduce the appeal of e-cigarettes for young people without diminishing their role in harm reduction for adult smokers. Nine states have passed flavor bans, but most have been short-term emergency bans or have been blocked by legal challenges.

In December 2019, the Food and Drug Administration (FDA) announced that it will use its market-review authority to essentially ban all flavors except tobacco and menthol in cartridge (pod-based) e-cigarettes. These changes became effective in February 2020. Disposable e-cigarettes and e-liquids for open-tank–system e-cigarettes typically sold in vape shops are not covered by the policy. The effect of the ban may be limited because of these important exemptions.

Banning all flavors in all tobacco products with few or no exemptions could be more effective than the current narrow ban for several reasons.4,5 First, menthol cigarettes, which remain on the market, have been shown to be appealing to young people. Second, although young people prefer fruit- and candy-flavored pods to menthol-flavored pods, the latter might become more attractive if they are the only flavored pods available. Third, under the current ban, young people may switch to e-cigarettes that are still permitted to contain flavoring. Indeed, adolescents have recently been favoring new flavored, disposable e-cigarettes that resemble Juul devices but have higher nicotine concentrations and cost less.

Another concern is that it is unclear how committed the FDA is to enforcing the flavor ban for cartridge e-cigarettes. The agency has largely declined to act on its authority to regulate e-cigarettes and to fulfill an obligation established by Congress to force products that do not protect public health, such as Juul devices, off the market. State bans on flavored e-cigarettes may therefore still be important.

A final policy is taxation of e-cigarettes. Twenty-one states and the District of Columbia tax both e-cigarettes and combustible cigarettes; the federal government taxes only combustibles.

The effects of such taxes on public health are complicated for several reasons. Levying taxes on e-cigarettes raises their price, thereby deterring some people from vaping. However, such taxes will also drive some vapers toward smoking, since taxes tend to increase the price of e-cigarettes relative to the price of combustibles.4,5 Consequently, the tax rate on e-cigarettes should be set so that it is cheaper to vape than to smoke. Determining optimal tax rates is complicated by the multiple types of e-cigarettes available, the fact that devices and pods are often bought separately, and the ability of companies — not the government — to set prices. Furthermore, too high a tax on e-cigarettes will encourage vaping of lower-priced or black-market e-cigarettes, thus undermining the benefits of the tax.

Given these considerations and the lack of evidence regarding how people respond to taxes on e-cigarettes, it may be preferable to rely on greater enforcement of Tobacco 21 policies and flavor bans to prevent vaping among young people. The appeal of tax revenue, however, may be too strong for governments to resist.

But at what level of government — state or federal — should e-cigarette policies be implemented? There are several advantages to states taking the lead. States may be more nimble regulators than the federal government, each state can regulate to meet its own needs, and state policies can serve as experiments and generate useful evidence. State laws can fill voids when federal regulations are absent or ineffective. States can also provide an impetus for federal action by demonstrating nationwide political will, as they did by passing Tobacco 21 laws. However, differing state policies risk leaving young people in some states unprotected and promoting the flow of e-cigarettes across state lines.

On the other hand, implementing regulations at the federal level has potential advantages over relying on state-based regulation of e-cigarettes because of the broad reach of national policies and their capacity to reduce trafficking across state borders. Nevertheless, as compared with states, the federal government has been slow to implement certain regulations.

Soaring rates of vaping among young people and associated problems have resulted in great urgency and important challenges for policymakers. Despite the urgency, policies should be evidence-based and thoughtfully designed. They require effective, collaborative, and well-funded enforcement by federal and state governments. Policymakers should aim to reduce vaping among young people while maintaining avenues to help smokers quit. Finally, policies should be forward-thinking, since the e-cigarette market is rapidly changing and e-cigarette companies can be more agile than regulators.

Doctors monitor vaping as possible connection to young COVID-19 patients

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Young People Have No Idea How Much Nicotine They Vape: Study

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Are non-smoking young adults who use e-cigarettes more likely to smoke in the future?

https://www.eurekalert.org/pub_releases/2020-03/uob-any030920.php

Young people who have tried e-cigarettes but have never smoked before are nearly five times more likely to go on to try smoking, a new study has found. However, the findings do not provide clear support for the claim that e-cigarettes cause young people to start smoking (the so-called possible “gateway effect”).

Researchers from the University of Bristol’s Tobacco and Alcohol Research Group (TARG), with support from Bristol’s MRC Integrative Epidemiology Unit (IEU) and the NIHR Bristol Biomedical Research Centre (BRC), combined the results of 17 studies to investigate whether e-cigarette use compared to non-use in young non-smokers is associated with subsequent cigarette smoking.

The research, funded by the MRC IEU and NIHR BRC, is published today [11 March 2020] in Tobacco Control.

Existing evidence suggests that e-cigarette use is less harmful than smoking and is an effective aid to stop smoking, but there are concerns that e-cigarettes may be a route into smoking cigarettes, especially among young people. If this is correct, rather than smoking rates falling, smoking rates might remain stable or increase due to a new generation of smokers where e-cigarettes have instigated smoking.

In this study, the researchers combined evidence from 17 studies that had investigated e-cigarette use and subsequent smoking, where an odds ratio could be calculated, to explore whether e-cigarette use, compared to non-use, in young non-smokers is associated with subsequent cigarette use.

Jasmine Khouja, a PhD student in TARG based in the School of Psychological Science, said: “Policymakers have used the findings of studies, including the studies we reviewed in this research, to support the heavy regulation of e-cigarettes, including restrictions on flavours and even total bans, but the evidence that e-cigarette use might cause young people to take up smoking is not as strong as it might appear.”

The study found that young people who had never smoked before but had used e-cigarettes were four-and-a half times more likely to go on to use e-cigarettes. However, the research team also identified a number of issues with the studies included in this analysis, which makes them cautious to conclude that e-cigarette use is causing young people to start smoking.

Whilst the association between e-cigarette use among non-smokers and subsequent smoking appears strong, the available evidence is limited by the reliance on self-report measures of smoking history without biochemical verification. None of the studies included negative controls which would provide stronger evidence for whether the association may be causal. Much of the evidence also failed to consider the nicotine content of e-liquids used by non-smokers meaning it is difficult to make conclusions about whether nicotine is the mechanism driving this association.

The researchers recommend future studies should address the issues which have been highlighted by using more advanced tests to confirm whether or not young people are smokers or e-cigarette users, using different statistical analyses, and considering whether the e-cigarettes contain nicotine or not.

A previous meta-analysis study carried out in 2016 combined the results of nine studies, which explored whether e-cigarette use among non-smoking adolescents and young adults was linked to later smoking. The study found that young people who had used an e-cigarette were nearly four times more likely to go on to try smoking than those who hadn’t.

###

Paper

‘Is e-cigarette use in non-smoking young adults associated with later smoking? A systematic review and meta-analysis’ by Jasmine N Khouja, Steph F Suddell, Sarah Peters, Amy E Taylor, Marcus R Munafò in Tobacco Control

Young vapers are almost five times more likely to try real cigarettes

The study suggests that e-cigarettes could contribute to a new generation of real smokers

https://inews.co.uk/news/health/young-vapers-e-cigarettes-more-likely-cigarettes-explained-2446147

Younger people who have tried e-cigarettes but had never previously smoked are nearly five times more likely to try tobacco cigarettes, suggesting vaping may play a role in instigating smoking.

Researchers from the University of Bristol’s Tobacco and Alcohol Research Group (TARG) worked with the city’s Medical Research Council’s Integrative Epidemiology Unit and the National Institute for Health Research’s Bristol Biomedical Research Centre to combine 17 studies into whether e-cigarette smoking was associated with subsequent cigarette smoking.

While existing studies suggest that smoking e-cigarettes, also known as vaping, is less harmful than smoking cigarettes and can be an effective quitting tool, concerns have circulated over whether they can present a ‘gateway’ into smoking.

This latest study found that young people who had never previous smoked but had tried vaping were four-and-a-half times more likely to go on to smoke.

Lack of hard evidence

However, the researchers are reluctant to conclude that vaping is causing young people to start smoking, as the results rely on the participants’ self-reported smoking history.

Without biochemical verification, they would be unable to reliably check whether a participant had never previously smoked a cigarette.

“Policymakers have used the findings of studies, including the studies we reviewed in this research, to support the heavy regulation of e-cigarettes, including restrictions on flavours and even total bans, but the evidence that e-cigarette use might cause young people to take up smoking is not as strong as it might appear,” said Jasmine Khouja, a PhD student in TARG based in the School of Psychological Science.

None of the studies were able to provide stronger evidence whether the association of early vaping with later smoking was casual, and much of their evidence also failed to consider the nicotine content of e-liquids.

This makes it difficult to conclude whether nicotine was the mechanism driving the association, the report, published in journal Tobacco Control, claimed.

Derailing efforts to quit

A separate study from the Ohio State University College of Public Health in December warned that knee-jerk reaction bans on e-cigarettes could derail the efforts of millions of people trying to stop smoking traditional nicotine cigarettes.

The US Centres for Disease Control and Prevention (CDC) had reported 48 deaths and 2,291 cases of serious lung injury linked to smoking e-cigarettes, also known as vaping, as of 3 December, prompting the American Medical Association to call for a blanket ban.

Amy Fairchild, dean of The Ohio State University College of Public Health, said that while the alarm was justifiable, the response needed to acknowledge the “powerful evidence” supporting the availability of legal nicotine products.

Is e-cigarette use in non-smoking young adults associated with later smoking?

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Juul and the upsurge of e-cigarette use among college undergraduates

Abstract

Objective: Examine trends in e-cigarette use, and Juul use specifically, among U.S. college students.

https://www.tandfonline.com/doi/full/10.1080/07448481.2020.1726355

Participants: In 2016, we established a cohort of 529 incoming first-year students to a large Midwestern University. In 2018, these students (now third-years) were re-contacted, and a new sample of 611 incoming first-year students was enrolled.

Methods: First-year students in 2016 completed a survey assessing their e-cigarette use; in 2018, first- and second-year students reported on e-cigarette use, and use of Juul specifically.

Results: From 2016 to 2018, past 30-day e-cigarette use rose from 5.9% to 27.7%. In 2018, for Juul alone, ever use was above 35% and past 30-day use was above 20% for both cohorts. Juul use did not differ by gender, but was associated with higher socioeconomic status (SES) and being White.

Conclusions: Findings present disturbing possibilities for long-term nicotine addiction among the next generation, and underscore the need for a rapid public health response.