EMERGENCY MEDICINE Volume 38, Issue 05 | March 7, 2021

Vaping
The Medical and Political State of Vaping present is shown to be less than with cigarettes (could possi-
bly change in 10 yr [limited studies on vaping to date]); many
Peter Croft, MD, Assistant Professor of Emergency Medi- patients and case reports in the last 6 mo; New England Journal
cine, Tufts University School of Medicine, Boston, MA of Medicine has had 4 different case report studies recently
Background: vaping was first started in China in 2003; invented about vaping-associated lung injury (VALI); occurring because
by a pharmacist whose father had passed away from adenocar- of children; nicotine from vaping is transmitted at high levels
cinoma of lung, the pharmacist was also a smoker and wanted when compared with cigarettes, leading to addiction; nicotine
to avoid that fate; he invented this product and patented it; in is more addictive than heroin; amount of nicotine transmitted
2006 it was first imported to US; currently is 4 billion dollar by vaping is hundreds of times higher compared with cigarettes
market in US and 15 billion dollars worldwide in daily vaper vs cigarette smoker
Rise in popularity of vaping products: they are sleek, compact, Prevalence of vaping: survey found 25% of 12th graders vaped
comfortable, discreet; accessorized mouth pieces are popu- within previous 90 days in the US, representing a 10% increase
lar; young individuals attracted to different colors and shapes; over 1 yr; the largest jump of any substance in one year since
marketing also contributes to vaping; criticism of this in the the beginning of this survey in the 1960s (includes 45,000 stu-
last several years; marketing of vaping emphasizes style and dents); represents the largest 1-yr jump to vaping from ciga-
attractiveness and has parallels with early cigarette advertis- rettes; in 2010 vaping took a huge turn upward; numbers of
ing; advertisement now on social media; recent study regarding all smokers (cigarettes and vaping) were not increasing for a
Twitter showed >2 million posts advocating vaping; >80% of period, but then began increasing back to 1997 totals; in high-
the post were created by bots; vaping comes in different fla- schoolers over 20-yr period alcohol use is slightly less,
vors (eg, berry, lemon, menthol, coffee); menthol and tobacco cigarette use is dropping, and illicit drug use has not changed
are the 2 flavors that have not been banned (based on recent significantly; youths tend to try things and are very susceptible
developments); menthol provides soothing effect and prevents to temptation; youths who are apt to try it are apt to experience
coughing (ie, prevents protective mechanism); menthol has the effects of nicotine; it is extremely difficult to get these indi-
higher addictive potential than other flavors because of lack viduals to quit subsequently
of protective cough that causes the user to stop vaping; mint is Vaping-associated lung injury: this has increased in recent
the most popular; vaping is easy, accessible, and chargeable; months; numbers are exponentially high in the latter part of
battery remains charged for 500 puffs (average daily vaper); that period; major impact according to Centers for Disease
cleaner than cigarettes, and ≈50% of the cost of cigarettes over Control and Prevention; diagnosis depends on several factors,
1 yr; Journal of Periodontology found that people who vape including history of vaping within 90 days, bilateral infiltrates,
have less periodontal inflammation than cigarette smokers, picture resembling acute respiratory distress syndrome, and
have less perceived oral symptoms, less phlegm production, no pulmonary infection; workup includes lavage; no viruses
and less coughing; vaping is allowed in a lot of areas where found; fungus with negative reports; this is the classic defini-
cigarettes are not tion of VALI
Effectiveness of vaping as an aid to smoking cessation: vaping Potential causes of VALI: the most important aspect of the vap-
does not help individuals quit smoking cigarettes; study — people ing device is the tank, where the liquid is stored; flavors in the
who smoke cigarettes every day and people who vape every tanks are the same that are added to processed foods; generally
day (both cohorts included hundreds of patients) and wanted regarded as safe by the Food and Drug Administration (FDA)
to quit smoking; followed for 2 yr; 6% of the daily cigarette when ingested; unclear what effects they have when inhaled in
smokers and 11% of daily vapers quit smoking (not statisti- large amounts; preliminary data show no major adverse events
cally significant); the people who were vaping were probably in long term regarding morbidity; the major substance is diace-
slightly more motivated to quit smoking; consensus statement tyl; this causes extreme pulmonary irritation and increased
from 2016 by Royal College of Physicians in Britain — stated asthmatic symptoms; increase in reactive airway process, but
the harm related to vaping is ≈5% of the harm related to does not lead to increased morbidity
tobacco smoking; stated vaping is safer than smoking ciga- Addictive potential of vaping: the amount of nicotine in vape
rettes; in 1962, Royal College of England similarly released a pods is higher than cigarettes by 30 to 40 times; murine study —
landmark consensus statement on adverse effects of smoking; assessing addictive nature of nicotine; involved 2 test tubes;
US followed 2 yr later one test tube exposed mouse to harmless smoke; mouse did
Adverse effects: cigarettes — have very high propensity to cause not want to get back into test tube; the other test tube exposed
platelet aggregation and clots, leading to strokes and myocar- another mouse to vape smoke; initially the mouse did not want
dial infarction (MI); vaping — has not been shown to cause to go into that tube the first day; the second day the same mouse
thrombotic adverse effects to date; carcinogenic potential at ran into the test tube to get the vape smoke and remained for

Educational Objectives Faculty Disclosure

The goal of this program is to improve diagnosis and man- In adherence to ACCME Standards for Commercial Support,
agement of vaping-associated lung injuries (VALI). After Audio Digest requires all faculty and members of the planning
hearing and assimilating this program, the clinician will be committee to disclose relevant financial relationships within
better able to: the past 12 mo that might create any personal conflicts of inter-
1. Explain the rise in popularity of vaping products. est. Any identified conflicts were resolved to ensure that this
educational activity promotes quality in health care and not a
2. List adverse effects of smoking vs vaping.
proprietary business or commercial interest. For this program,
3. Cite potential long-term morbidity associated with vaping. members of the faculty and the planning committee reported
4. Identify inflammatory markers associated with VALI. nothing to disclose.
5. Elaborate on possible prescription regulation of vaping
products.

EM-38-05
 Audio Digest Emergency Medicine 38:05
extended time; this shows the vast addictive potential of the and radiographic periodontal status and whole salivary cotinine, IL-1β
substances to which youths are exposed and IL-6 levels in cigarette- and waterpipe-smokers and E-cig users. Environ
Potential long-term morbidity associated with vaping: nico- Toxicol Pharmacol. 2018;61:38-43. doi:10.1016/j.etap.2018.05.016;
tine causes heart-rate variability; in those already prone to Wang W et al. Electronic cigarette use in China: Awareness, prevalence
and regulation [published correction appears in Tob Induc Dis. 2020
arrhythmias, risk increases with use of vaping; vapers do not Mar 12;18:15]. Tob Induc Dis. 2019;17:30. Published 2019 Apr 16.
experience as much platelet aggregation or as many ST-segment doi:10.18332/tid/105393; Zare S et al. A systematic review of consumer
elevation MIs and strokes; individuals experience more adverse preference for e-cigarette attributes: Flavor, nicotine strength, and type.
events related to arrhythmias when vaping than with cigarettes PLoS One. 2018;13(3):e0194145. Published 2018 Mar 15. doi:10.1371/
Chemicals in cigarette smoke vs vaping: 600 chemicals in journal.pone.0194145.
cigarettes, >7000 when burned; many are carcinogenic; major
chemicals include propylene glycol; when heated turns into Vaping-induced Lung Injury (VALI)
formaldehyde (seen in many household products); individuals
probably have enough formaldehyde in their house to equal William J. Banner Jr, MD, PhD, Medical Director,
5200 puffs of vaping Oklahoma Center for Poison and Drug Information, Okla-
Additives in tetrahydrocannabinol (THC) cartridges and homa City
VALI: THC cartridges are being sold in unregulated fashion Background: e-cigarette introduced in 1960-70s as substitute
on black market; additives are used to thicken liquid to make it for cigarettes; ultrasonic nebulizer first device, then a heated
look more authentic; vitamin E oil is consistently used; vitamin device to deliver nicotine; nicotine delivery conceived as a
E acetate is added to these cartridges to thicken the agent and substitute for smoking, considered harm reduction rather than
make it more smokable and more authentic; in study mentioned harm elimination; outweighed by problems created by vaping
above, 51 patients taken from the cohort and 99 individuals (eg, youths addicted to nicotine)
from outside the cohort and bronchoalveolar lavage was per- Popcorn lung: term associated with condition developing in fac-
formed; 94% of 51-patient group isolated vitamin E acetate, tory employees at plant where butter flavoring for microwave
and 0% in the other group; conclusion that this was the source popcorn was being added to product; included diacetyl initially
of infection in patients with bilateral infiltrates and no other when the product came out (has since been changed); employees
pulmonary source; after this was isolated cases have plum- got bronchiolitis obliterans, an adenoviral disease with destruc-
meted; different additives likely to be introduced in, eg, 6 mo tion of architecture of lungs; as employees developed disease
and may create new risks it was traced back to diacetyl; inflammatory reaction and then
Case example: 32-yr-old woman travelled through Georgia, North scarring to the point at which airways can no longer transmit air
Carolina, New Jersey, and New Hampshire and stopped in Diacetyl in vaping fluids: developed to improve solubility and
Maine; she stopped at vape shops on the way and picked up create liquid substance for vaping; media created message that
THC cartridges, none of which could be regulated or followed; vaping kills users (actual numbers were smaller than the per-
she presented to the hospital with cough, hypoxia, phlegm pro- ception); diacetyl was subsequently discontinued
duction, and no fever; initial x-ray showed bilateral infiltrates; Vaping as an industry: vaping has become a huge industry; ini-
urgent care sent her home with antibiotics and steroids and she tially this was not part of tobacco industry, but those in tobacco
did not improve; she was admitted to the hospital; day 4 of industry realized they were losing market share, and created
hospitalization she deteriorated and needed to be intubated; companies (eg, Juul) to develop products
she had no other medical problems; 2 wk after discharge lungs Initial cases of lung injury related to vaping: beginning months
cleared up bilaterally with no more infiltrates; she was given ago first deaths noted in almost every state; in speaker’s experi-
q6 hydrocortisone in the intensive care unit (ICU) for over a week; ence, no evidence to link vaping directly to disease, but there
data currently limited, but high-dose steroids appear to be an were suspicions in the intensive care unit and now ≈60 deaths
effective treatment for VALI caused by additives Possible causative agents: variety of substances; includes sub-
Flavor bans: all flavors except tobacco and menthol are cur- stances that should not be there, eg, tetrahydrocannabinol
rently banned for children; many vape shops sell many other (THC), involving use of vitamin E acetate and producing
flavors to customers aged >21 yr; flavor ban is mainly targeted disease in a fashion similar to diacetyl; synthetic cannabinoids
toward younger people to avoid attraction (eg, K2) used; adolescents and young adults often affected;
Political issues: lobbying involving vaping has increased over it became associated with nicotine and THC, but should ulti-
the last year; major executive at Altria, large tobacco com- mately be associated with solubilizing agents and what they
pany, recently moved to Juul and is now the CEO; tobacco and are using to make these products in unregulated environment;
vaping concerns becoming interconnected; American Hospi- most common agent is diacetyl; metal oxide fumes (“metal
tal Association investing 20 million dollars into research in fume fever”); sulfur mustard can produce similar effects; acids;
vaping in young people; every e-cigarette manufacturer must nitrogen oxide, chlorine gas, ammonia
defend their products to FDA, as per federal judge ruling; Presentation: many different presentations; typically profound
there will be upcoming announcements about regulating these hypoxia, a gradually worsening respiratory condition with
substances cough, increasing fever, chest pain, nausea, vomiting, and diar-
Suggested Readings rhea; historically vaping involves a new product, and almost
Beaglehole R et al. Nicotine without smoke: fighting the tobacco epidemic always questionably procured; initially there were reports of
with harm reduction. Lancet. 2019;394(10200):718-720. doi:10.1016/ commercially available products nationally that were causing
S0140-6736(19)31884-7; Blount BC et al. Vitamin E acetate in this, but this turned out to be a questionable strategy by makers
bronchoalveolar-lavage fluid associated with EVALI. N Engl J Med. to get their tainted materials into products; x-ray shows opaci-
2020;382(8):697-705. doi:10.1056/NEJMoa1916433; Cherian SV et al. ties; computed tomography shows ground glass dense lobar
E-cigarette or vaping product-associated lung injury: A Review. Am consolidations; similar presentations would historically have
J Med. 2020;133(6):657-663; D’Amario D et al. Electronic ciga- been attributed to a virus; the probability of missing a virus
rettes and cardiovascular risk: caution waiting for evidence. Eur has decreased with improved testing; some respond better with
Cardiol. 2019;14(3):151-158. Published 2019 Dec 18. doi:10.15420/ steroids; elevated white blood cell count is common; c-reactive
ecr.2019.16.2; Evans-Polce RJ et al. Reasons for Vaping among U.S.
12th graders. J Adolesc Health. 2018;62(4):457-462. doi:10.1016/j.jado- protein (CRP) level is elevated; it can mimic an infectious
health.2017.10.009; Fadus MC et al. The rise of e-cigarettes, pod mod process; bronchoalveolar lavage (BAL) show eosinophils and
devices, and JUUL among youth: Factors influencing use, health impli- lipid-laden macrophages very commonly; respiratory patho-
cations, and downstream effects. Drug Alcohol Depend. 2019;201:85- gen panels are negative; cultures are negative; eosinophilic-
93. doi:10.1016/j.drugalcdep.2019.04.011; Mokeem SA et al. Clinical predominant panels are very acute, severe, and have a ground
 Audio Digest Emergency Medicine 38:05
glass appearance; treatment with steroids appears the most Final considerations for VALI: it is multifactorial disease; it
effective therapy, but outcome data is currently lacking; pre- is probably a cluster of diseases with various severities and
sentations that more closely resemble pneumonia seem to various chemicals as the inciting agents; likely concentration
be more nonspecific with ground glass appearance; requires dependent, but that is not clear; variety of chemicals likely
longer to develop; the reason for differences are not currently put in to solubilize or stabilize the nicotine or THC; methods
known; lipoid pneumonia appearance is a more chronic effect; are available to add substances to supposedly sealed systems
milder; BAL shows lipid-laden macrophages; mixed presen- meant to be used with the original product in them; can make,
tations might be the result of exposure to multiple chemicals, eg, Juul into an unregulated device; prescription regulation for
but this is not clearly understood; it is not clear whether ste- products likely helpful for subset; political solutions and regu-
roids help with that; some patients develop more hemorrhagic lation are complicated by lobbying from different industries
presentations; clearly involves damage to the lungs; patchy and organizations
infiltrates; BAL shows more blood; causative agent for this Suggested Readings
syndrome is not currently known
Inflammatory markers: data on inflammatory markers in peo- Chaumont M et al. Fourth generation e-cigarette vaping induces tran-
ple vaping nicotine only; it does cause lung inflammation; lipid sient lung inflammation and gas exchange disturbances: results from
two randomized clinical trials. Am J Physiol Lung Cell Mol Physiol.
laden macrophages; lots of protein; aldehyde compounds; 2019;316(5):L705-L719. doi:10.1152/ajplung.00492.2018; Kreiss K.
airway hyperresponsiveness Flavoring-related bronchiolitis obliterans: Curr Opin Allergy Clin Immunol.
Vaping vs tobacco: even under normal circumstances vaping 2007;7(2):162-167. doi:10.1097/ACI.0b013e3280298235; Viswam D
is not healthful for lungs; vaping is in some ways worse than et al. Respiratory failure caused by lipoid pneumonia from vaping
tobacco use; they both predictively increase airway responsive- e-cigarettes. BMJ Case Rep. 2018;2018:bcr2018224350. Published 2018
ness; increase the need for bronchodilators Jul 6. doi:10.1136/bcr-2018-224350.

Acknowledgments
Dr. Croft was recorded at Vermont Emergency Medicine Update, held January 27-29, 2020 in Stowe, VT, and presented by the Larner
College of Medicine at The University of Vermont. For information about upcoming CME conferences presented by this sponsor,
please visit med.uvm.edu/cme/home. Dr. Banner was recorded at the 3rd Annual Toxicology Education Day: The Toxic Household,
held on February 21, 2020 in Oklahoma City, OK, and presented by the University of Oklahoma College of Medicine. For information
about upcoming CME conferences presented by this sponsor, please visit ouhsc.cloud-cme.com. Audio Digest thanks the speakers and
meeting presenters for their cooperation in the production of this program.

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 Audio Digest Emergency Medicine 38:05
Vaping
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To submit a test form by mail or fax, complete Pretest section before listening and Posttest section after listening.

1. Which of the following vaping flavors has(have) NOT been banned?

(A) Menthol (C) Tobacco
(B) Coffee (D) A and C ****

2. Which of the following flavors of vaping products has the highest addictive potential?
(A) Menthol **** (C) Lemon
(B) Mint (D) Coffee

3. According to the Journal of Periodontology, which of the following results is(are) less prevalent in individuals who vape
compared with smokers?
(A) Periodontal inflammation (C) Less phlegm production
(B) Greater perceived oral symptoms (D) A and C***

4. Which of the following statements about adverse effects associated with vaping vs smoking is(are) correct?
(A) Carcinogenic potential of vaping at present is shown to be less than with cigarettes
(B) Nicotine from vaping is transmitted at high levels when compared with cigarettes
(C) Amount of nicotine transmitted by vaping is ≈20 times higher compared with cigarettes in daily vaper vs cigarette smoker
(D) A and B***

5. Diagnosis of vaping-associated lung injury depends on which of the following factors?

(A) History of vaping within 90 days
(B) Picture that resembles acute respiratory distress syndrome
(C) Bilateral infiltrates
(D) All the above****

6. Which of the following statements about potential long-term morbidity associated with vaping is(are) true?
(A) In those already prone to arrhythmias, risk increases with use of vaping
(B) Vapers do not experience as much platelet aggregation as cigarette smokers
(C) Vapers do not experience as many ST-segment elevation myocardial infarctions as cigarette smokers
(D) All the above****

7. In a study on vaping, bronchoalveolar lavage was performed on a cohort of patients who vaped and this isolated _______
in 94% of patients.
(A) Vitamin E acetate **** (C) Chlorine gas
(B) Diacetyl (D) None of the above

8. Which of the following agents has been associated with “popcorn lung”?
(A) Chlorine gas (C) Diacetyl ****
(B) Ammonia (D) None of the above

9. Which of the following agents is most commonly used in vaping cartridges?

(A) Vitamin E acetate (C) Sulfur mustard
(B) Diacetyl *** (D) Chlorine gas

10. Data on inflammatory markers in individuals vaping nicotine only showed which of the following results?
(A) Lipid laden macrophages (C) Aldehyde compounds
(B) Lung inflammation (D) All the above***

Answers to Audio Digest Emergency Medicine Volume 38, Issue 04: 1-B, 2-A, 3-D, 4-C, 5-A, 6-B, 7-C, 8-C, 9-D, 10-B

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