E-Cigarettes and Vaping-Related Disease

• • Original Article Role of Vitamin E Acetate in EVALI B.C. Blount and Others

    In a study involving 51 patients with EVALI (electronic-cigarette, or vaping, product use–associated lung injury) in 16 states across the United States, vitamin E acetate was detected in samples of bronchoalveolar-lavage fluid from 94% of the patients but not in samples from a healthy comparator group.

    Dec 20
  • Correspondence More on the Pathology of Vaping-Associated Lung Injury

    This description of untreated vaping-associated lung injury examined at autopsy provides a look at the pathology of the process independent of medical intervention.

    Nov 20
• • Special Report Vaping Syndromic Surveillance K.P. Hartnett and Others

    Recent increases in e-cigarette, or vaping, product use–associated acute lung injury (EVALI) have been identified. Using the National Syndromic Surveillance Program, which includes about 70% of U.S. EDs, researchers found a gradual increase in ED visits associated with shortness of breath and e-cigarette use from January 2017 through early June 2019. A sharp increase was identified in June, peaking in September. A decrease has been observed in the past 2 months.

    Dec 20

• Characteristics of EVALI Patients Who Were Rehospitalized or Died after Discharge

  A report and clinical guidance in the Center for Disease Control’s (CDC) Morbidity and Mortality Weekly Reports (MMWR) published on Friday, December 20, emphasize the risk of death or recurrent hospitalization due to e-cigarette, or vaping, product use–associated lung injury (EVALI).

  Among the 1139 patients with EVALI discharged on or before October 31, 2019, 31 (2.7%) were rehospitalized a median of 4 days after discharge and with half of the events occurring between 2 and 20 days after discharge. Seven patients, five of whom were women, died outside the hospital. All patients who died had been in an intensive care unit (ICU) during hospitalization. The deaths occurred a median of 3 days after discharge. The median age of patients who died after discharge was 54 years, as compared with 23 years among patients with no rehospitalizations. Patients with EVALI who required rehospitalization or who died after discharge were more likely to have cardiac disease, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), diabetes mellitus, and multiple chronic comorbidities.

  The clinical guidance urges health care professionals to work with appropriate staff to ensure that all patients discharged after treatment for EVALI are reevaluated at 48 hours, especially those who have been in an ICU, have social support networks in place to monitor their health, to ensure that post-discharge medications, such as glucocorticoids on taper and medications for known comorbid conditions, are taken appropriately, and that they do not resume use of vaping or combustible tobacco.

  See the MMWR reports for full details:

  Characteristics of Patients Experiencing Rehospitalization or Death After Hospital Discharge in a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — United States, 2019

  Update: Interim Guidance for Health Care Professionals Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury and for Reducing the Risk for Rehospitalization and Death Following Hospital Discharge — United States, December 2019

Additional Articles on E-Cigarettes and Vaping-Related Disease

• Correspondence Nov 20, 2019 Pulmonary Illness Related to E-Cigarette Use
  

  In these letters, Diaz et al. highlight the potential for severe airway reactivity and perioperative challenges when performing bronchoscopy and BAL in patients with e-cigarette, or vaping, product use–associated lung injury, and Russell and Cevik stress the importance of ruling out infectious causes in these patients. Layden et al. respond.

• Correspondence Oct 31, 2019 Real-Time Surveillance of Vaping-Induced Pulmonary Disease
  Y. Hswen and J.S. Brownstein N Engl J Med 2019; 381:1778-1780

  This report documents the ongoing surge in cases of severe pulmonary disease associated with e-cigarettes, collecting online information from news aggregators, eyewitness reports, and official alerts.

• Correspondence Oct 31, 2019 Pathology of Vaping-Associated Lung Injury
  Y.M. Butt and Others N Engl J Med 2019; 381:1780-1781

  This letter describes findings in 17 patients with a history of vaping who had lung biopsies after presenting with symptoms and bilateral pulmonary opacities that led to a clinical diagnosis of vaping-associated lung injury. The lung histopathology is described, along with some preliminary insights into the pathogenesis of acute lung injury.

• Correspondence Oct 10, 2019 Imaging of Vaping-Associated Lung Disease
  T.S. Henry, J.P. Kanne, and S.J. Kligerman N Engl J Med 2019; 381:1486-1487

  A sampling of imaging findings in patients with lung disease associated with electronic cigarette use is provided.

  Editorial Vaping-Induced Lung Injury
  Original Article Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report

• Correspondence Oct 10, 2019 Vaping Trends among Adolescents, 2017–2019
  R. Miech and Others N Engl J Med 2019; 381:1490-1491

  Vaping by adolescents is a concern because of the risks of nicotine addiction and because of reports of an association between vaping and acute lung injury. This nationally representative survey finds sharp increases in the frequency of vaping among 8th-, 10th-, and 12th-grade students.

  Original Article Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report

• Correspondence Oct 10, 2019 Pulmonary Lipid-Laden Macrophages and Vaping
  S.D. Maddock and Others N Engl J Med 2019; 381:1488-1489

  The use of electronic cigarettes has been associated with pulmonary injury, one feature of which has been lipid-laden macrophages in pulmonary-lavage fluid. Six cases in Utah are reported.

  Editorial Vaping-Induced Lung Injury
  Original Article Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report

• Editorial Sep 06, 2019 Vaping-Induced Lung Injury
  D.C. Christiani

  Until the investigation into the cause of this epidemic of vaping-induced respiratory injury is complete, no conclusions can be drawn as to which compound or compounds are the causes of injury. In light of these cases, however, efforts should be made to increase public awareness of the harmful effect of vaping, and physicians should discourage their patients from vaping.

  Original Article Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report
  Correspondence Pulmonary Lipid-Laden Macrophages and Vaping
  Correspondence Imaging of Vaping-Associated Lung Disease

• Original Article Sep 06, 2019 Vaping-Induced Lung Injury
  J.E. Layden and Others

  Vaping use has rapidly increased. In this report from the Wisconsin and Illinois departments of public health, a severe respiratory illness in otherwise healthy young people is described. Of the 53 case patients identified to date in this ongoing investigation, 94% were hospitalized, 32% were intubated, and 1 person has died.

  Editorial Vaping-Induced Lung Injury
  Correspondence Imaging of Vaping-Associated Lung Disease
  Correspondence Pulmonary Lipid-Laden Macrophages and Vaping
  Correspondence Trends in Adolescent Vaping, 2017–2019

• Images in Clinical Medicine Jun 20, 2019 Injury from E-Cigarette Explosion
  M.G. Katz and K.W. Russell N Engl J Med 2019; 380:2460

  A 17-year-old boy presented to the ED with pain and swelling in his jaw 2 hours after an e-cigarette exploded during use. He had extensive lacerations in his mouth, multiple disrupted lower incisors, and bony incongruity of his left mandible.

• Original Article Feb 14, 2019 E-Cigarettes vs. Nicotine-Replacement Therapy
  P. Hajek and Others N Engl J Med 2019; 380:629-637

  In a randomized trial involving 886 smokers, e-cigarettes were more effective than nicotine-replacement therapy with respect to the 1-year abstinence rate (18% vs. 10%). Throat or mouth irritation was more common in the e-cigarette group, and nausea was more common in the nicotine-replacement group.

  Editorial The Dangerous Flavors of E-CigarettesEditorial E-Cigarettes to Assist with Smoking CessationCorrespondence E-Cigarettes versus Nicotine-Replacement Therapy for Smoking Cessation

• Correspondence Feb 14, 2019 Youth Vaping in Colorado
  T.S. Ghosh and Others N Engl J Med 2019; 380:689-690

  In a 2017 survey of Colorado high-school students, 27% reported current use of electronic cigarettes (vaping). These students were also more likely to report risky behaviors (including binge drinking and the use of opioid pain medications without a prescription) than nonusers.

• Correspondence Jan 10, 2019 Adolescent Vaping and Nicotine Use in 2017–2018
  R. Miech and Others N Engl J Med 2019; 380:192-193

  A national survey revealed a large increase in nicotine vaping among high school students; more than 20% of 12th-graders reported that they vaped nicotine in 2018. The increase in adolescent nicotine use from 2017 to 2018 was explained by an increase in vaping; the use of other nicotine products declined.

• Perspective Sep 20, 2018 Adolescents’ Use of “Pod Mod” E-Cigarettes
  J.L. Barrington-Trimis and A.M. Leventhal N Engl J Med 2018; 379:1099-1102

  Use of a new e-cigarette product class called “pod mods” is rampant among young people. There is reason to be concerned that adolescents’ use of these products could bring a host of adverse health consequences to the current generation of adolescents and young adults.

• Special Article Jun 14, 2018 Approaches to Smoking Cessation
  S.D. Halpern and Others N Engl J Med 2018; 378:2302-2310

  In a pragmatic trial involving smokers, financial incentives were more effective than free cessation aids; free cessation aids or e-cigarettes were no more effective than usual care. Cessation rates among smokers assigned to financial incentives were less than 3%.

  Correspondence E-Cigarettes, Incentives, and Drugs for Smoking Cessation

• Perspective Jan 18, 2018 E-Cigarettes and the Harm-Reduction Continuum
  A.L. Fairchild and Others N Engl J Med 2018; 378:216-219

  In recent years, there has been a trend of acknowledging the importance of a harm-reduction approach in policy discussions about e-cigarettes. But some proposed strategies might well limit, if not entirely undermine, the population benefits associated with e-cigarettes.

• Review Article Oct 06, 2016 The Health Effects of Electronic Cigarettes
  C. Dinakar and G.T. O’Connor N Engl J Med 2016; 375:1372-1381

  The use of electronic cigarettes is growing, and some hope that they will replace what is felt to be the more dangerous nicotine-delivery system — cigarettes. However, data on the long-term safety of e-cigarettes are still being gathered.

  Correspondence The Health Effects of Electronic Cigarettes

• Correspondence Oct 06, 2016 Explosion Injuries from E-Cigarettes
  E.G. Brownson and Others N Engl J Med 2016; 375:1400-1402

  This report from a single center describes 15 patients with injuries caused by explosions of e-cigarettes that occurred over a period of less than a year. Patients had a combination of flame burns, chemical burns, and blast injuries.

• Perspective Jul 21, 2011 E-Cigarette or Drug-Delivery Device? Regulating Novel Nicotine Products
  N.K. Cobb and D.B. Abrams N Engl J Med 2011; 365:193-195

  The FDA intends to regulate e-cigarettes as tobacco products, since the courts blocked it from treating them as drug-delivery devices. Until the FDA asserts its new authority over tobacco, concentrated nicotine products may be sold to consumers, raising safety concerns.