Electronic Cigarettes, Young People, Mysterious Lung Disease, and Cannabis

Since e-cigarettes entered the US market in 2007, a distinct inhaled-product category emerged. First-generation devices resembled cigarettes and delivered nicotine. New devices differ, are rechargeable, and deliver various substances including nicotine and tetrahydrocannabinol, cannabis's psychoactive THC. In the short period since 2007, sales of nicotine- and THC-containing devices rose substantially worldwide and in the USA.

Cannabis use consequently increased nationwide. Growing product numbers and market expansion raised health concerns, chiefly because e-cigarettes marketed as healthier alternatives became particularly popular among young people.

E-Cigarettes Led to New Addictions

Statistics show new addictions: total youth tobacco use rose rapidly, with e-cigarettes preferred. Despite government regulations and restrictions, an expanding illicit market enabled many sales outside oversight.

The USA therefore needed to examine both the youth vaping epidemic and recently prominent e-cigarette-associated lung diseases. The Wisconsin branch of the US Centers for Disease Control and Prevention (CDC) began intensive investigation of reported vaping-associated mysterious lung injury (EVALI: E-cigarette or VAping product use–associated Lung Injury). EVALI describes an inflammatory respiratory syndrome involving multiple organs. By 7 January 2020, CDC received reports from 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands totaling 2602 cases, with 57 deaths confirmed. All patients reported vaping, most importantly THC products. Average age was 24; % 62 were aged 18 to 34 and % 16 below 18. Most acquired products informally through friends or online. In addition, 51 patients underwent bronchoalveolar lavage (BAL); samples contained THC in most and vitamin E acetate in all. Vitamin E acetate may be used as a thickener-hardener in THC vaping products.

- Additional information:

BAL, bronchoalveolar lavage: An invasive diagnostic method for lung diseases, using a flexible instrument positioned in a bronchus to introduce and retrieve fluid. 

History's Youngest Epidemic: E-Cigarettes

The youth vaping epidemic is recent. Between 2011-2015, US middle and high school use showed a % 900 increase . Campaigns in 2016 slightly reduced use, but it surged again in 2017-2018. By 2019, over 5,2 million young Americans (% 27,5 of high school and % 10,5 of middle school students) reported vaping. Adult use was % 8,1 (8,1 million). Among adults aged 18-24 it was % 7,6 (2,1 million). Youth popularity reflected flavors, colors, smells, and easily concealed small USB-like designs.

New-generation Pod Moddevices invite greater addiction through high nicotine levels. Their nicotine saltsare equivalent to 20 cigarettes. Popular brands such as JUUL promote increasing dependence. Because nicotine may harm brain development and is highly addictive, youth use is concerning.

THC vaping likely creates conditions fueling EVALI. Its high incidence among those aged 18-34 corresponds to the US age group with highest marijuana use. Vaping has made youth access easy and widespread.

Conclusion

Youth vaping is unsafe regardless of nicotine or THC content. Both cannabis and nicotine may harm young-adult brain development. Earlier initiation increases later tobacco and cannabis use disorder risk. EVALI further increases risks. The focus and scope of responses should be scientific and address underlying drivers.

This article, published on 17 January 2020 in NEJM , received additional comments in the NEJM bulletin of 23 January 2020 regarding bronchial imaging and BAL. These procedures can cause severe airway resistance and problems during or afterward in EVALI patients. Routine BAL is therefore not recommended. Excluding infection-related causes is also crucial. Recent CDC guidance recommends imaging and BAL in consultation with pulmonologists.

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