Research In Action

Youth vaping is a serious public health issue. CHOP has been a leader in considering policy to protect adolescents from the harms of e-cigarettes. Misperceived as a “safe” alternative to combustible tobacco (e.g. cigarettes), vaping poses significant risks to cardiovascular, respiratory, gastrointestinal, neurologic, psychiatric, developmental, immune and reproductive health, and can cause life-threatening complications.

Consider this case from the Children’s Hospital of Philadelphia:

A teenager had several days of cough, diarrhea, and loss of appetite. He became short of breath, and his blood was found to be critically low in oxygen. An x-ray showed that his lungs were inflamed, and now gasping for breath he was supported with a ventilator machine and hospitalized in the Intensive Care Unit. Tests were negative for pneumonia from COVID-19 and the flu, and it was discovered that he had been vaping THC for several months. He was diagnosed with E-cigarette or Vaping-Associated Lung Injury (EVALI). His treatment included a dedicated collaborative team including specialists from Emergency Medicine, Critical Care Medicine, Respiratory Therapy, Pulmonary Medicine, Infectious Diseases, General Pediatrics, and Adolescent Medicine.

What is EVALI?

Electronic Nicotine Delivery Systems (ENDS), including “vapes” and “e-cigarettes”, entered the U.S. market in 2006 as an alternative to traditional combustible tobacco. In 2019, amid peak ENDS use among youth, and coinciding with the COVID-19 pandemic, a sudden epidemic of a distinct life-threatening respiratory illness arose, now recognized as EVALI. The production of e-cigarette cartridges has included an unregulated, wild frontier. Most EVALI cases were thought to be caused by e-cigarette cartridges contaminated with a chemical known as vitamin E acetate, which when vaporized is exceptionally toxic to the lungs. Typically, the cartridges were obtained from informal or illicit sources, usually containing THC. Adolescents were observed to be particularly susceptible to EVALI due to higher use of THC products and acquisition of cartridges from illegitimate sources.

Symptoms and signs of EVALI include:

• Fever, chills, fatigue, weight loss
• Shortness of breath, fast breathing, low blood oxygen, cough, coughing blood
• Fast heart rate, chest pain
• Nausea, vomiting, diarrhea, abdominal pain
• Headache, confusion
• Laboratory findings include elevated inflammatory markers and signs of liver inflammation; lung fluid may contain neutrophil cells and lipid-laden macrophages.

EVALI can be diagnosed if the symptoms and signs appear in the setting of documented ENDS use, there are typical findings on chest x-rays or CT scans, and there is no other more likely diagnosis.

EVALI frequently causes severe illness and can be fatal. Since the identification of the dire toxicity of vitamin E acetate, and the ensuing public health response, the incidence of EVALI has declined. However, EVALI continues to pose a threat to youths, with recent cases still being treated at CHOP.

The Rise of Youth Vaping

The good news is that traditional tobacco product use among teens has declined over the past decade. The bad news is that vaping increased sharply with more than 1 in 4 teens using e-cigarettes in 2019. Approximately 8% of high school and 4% of middle school students report current use, a quarter of whom use daily.

What Can Clinicians Do to Address the Specter of EVALI?

ENDS cessation is the best strategy to prevent EVALI. If continuing to use e-cigarettes, clinicians can share these tips to reduce the risk of EVALI with their patients:

• Individuals should only use ENDS devices and cartridges from regulated, commercial manufacturers. Teens should avoid refilled, adulterated, or altered products.
• Be especially wary of THC-containing vape cartridges – these are often illicitly made, unregulated, and may contain vitamin E acetate or other harmful chemicals.

What Can Policymakers Do to Address the Specter of EVALI?

A recent literature review outlines key recommendations to help guide researchers, advocates and policymakers in developing and implementing interventions that address youth ENDS use.

In 2016, the FDA gained regulatory control over nicotine-containing ENDS. Since then, several interventions have likely contributed to the decline in youth ENDS use and EVALI, including:

• Comprehensive regulations for ENDS manufacturers and retailers
• Raising the minimum purchase age for ENDS from 18 to 21 years old
• Requiring photo ID verification for buyers under the age of 30 years old.
• Banning the sale of pre-filled flavored cartridges (except menthol)
• Providing recommendations on EVALI risk reduction
• State-based regulations including:
  • Requiring ENDS sale licensure and limiting license availability
  • Expanding Medicaid coverage for tobacco cessation treatment
  • Extending smoke-free indoor air laws to include ENDS
  • Increasing excise taxes on ENDS products
  • Expanding educational campaigns on ENDS at various levels

Further intervention opportunities include:

• Expanding bans on flavored cartridges (e.g. Menthol, refillable tanks, disposable ENDS)
• Extending state level interventions (e.g. Licensure, Medicaid coverage, air laws, excise tax)
• Reducing nicotine content in cartridges (proposed by the FDA for combustible products)
• Creating limits on ENDS product advertisement, promotion and sponsorship

Youth vaping remains a significant public health threat, with serious and potentially fatal consequences. Continued efforts from clinicians, policymakers, and public health leaders are critical to educate adolescents, regulate e-cigarette products, and reduce youth exposure to these harmful substances.