In late August, early September of 2019, the media was blowing up with reports of illness and death related to the use of vapor devices. Frequently referred to as e-cigarettes, vapes, and electronic nicotine delivery systems, these devices consist of a heating unit and a liquid or wax pod that can deliver an aerosol mixture of nicotine, flavorings, marijuana, and other substances and chemicals. Over 450 potential cases of severe pulmonary disease had been identified as of September 6, 2019. A commonality in the group was a history of using e-cigarette devices or vaping. The Centers for Disease Control and Prevention (CDC) issued a warning once it determined that 33 states (Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Iowa, Illinois, Indiana, Kansan, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Montana, North Carolina, Nebraska, New Jersey, New Mexico, New York, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Vermont, Wisconsin, West Virginia) and the U.S. Virgin Islands were reporting possible cases of vaping-associated lung disease and the states of California, Illinois, Indiana, Minnesota, and Oregon were confirming they had related deaths.

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.h

One of the first cases to be highlighted by the media was a male adolescent. This brought more attention to the growing use of vapor devices by adolescents that seems to have reversed the decreasing trend for smoking. Using the 2018 National Survey on Drug Use and Health data for 12th graders' use of drugs, alcohol, and cigarettes, it was noted that about 37% reported vaping in 2018 as compared with 28% in 2017. Vaping of nicotine, flavored liquids, marijuana, and hash oil all demonstrated an increase. Dr. Nora D. Volkow, director of National Institutes of Health's (NIH) National Institute on Drug Abuse, attributes the reversal of the decline to the fact that teens may be attracted to the flavorings and the technology of vaping devices. Because it is important that teens be educated about the potential effects of vaping on their health, brain development, and risk of addiction, it is vital that everyone be educated about teens and vaping.

https://newsinhealth.nih.gov/2019/02/vaping-rises-among-teens

This February 2019, monthly newsletter from the NIH underscores the reason for concern. As a publication of the NIH, it speaks with authority, and the information is accurate, current, and objective. This document can be opened without additional cost or software. Numerous links are included for sharing through e-mail and social media accounts. Contact information for future newsletters and the sponsoring organization is included. This is a credible source for health information.

https://childmind.org/article/teen-vaping-what-you-need-to-know/

The Child Mind Institute, an independent, national nonprofit, describes itself as dedicated to children and families impacted by mental health and learning disorders. The Institute supports children through advocacy for delivery of care standards, advancement in science, and empowerment for parents, professionals, and policymakers. The article provides facts and food for thought. Although the site is dated 2019 and identifies the author and her credentials, the material is not cited, and the author's credentials are in journalism. The information on the site can be accessed for free and shared easily through multiple social media links. The site includes advertising and requests for donations.

https://e-cigarettes.surgeongeneral.gov/

In contrast, this site created by the partnering of the U.S. Department of Health and Human Services, the Office of the U.S. Surgeon General, and the U.S. CDC Office on Smoking and Health (OSH) features the contents of the 2016 U.S. Surgeon's General Report on e-cigarette use by youth and young adults with updates. The site is current to 2019. Links for facts, risks, taking action, and additional resources are easy to find and use. Each topic has links within links, and each page has a sharing link for e-mail and social media. No costs are involved in accessing the information that is offered in English and Spanish. This site is appropriate for all audiences.

https://www.fda.gov/tobacco-products/youth-and-tobacco/youth-tobacco-use-results

The U.S. Food and Drug Administration has an entire section of webpages for tobacco. As an authority, the accuracy and objectivity can be relied upon. This page covers the results of the 2018 National Youth Tobacco Survey in pictographs and offers a pdf link to download the full report. The page is current for May 2019, has no additional associated costs, and offers many links for resources and social media sharing. This site pairs well with the Surgeon General's site and is appropriate for all audiences.

https://www.cdc.gov/tobacco/data_statistics/surveys/nyts/index.htm

The CDC OSH's Smoking and Tobacco Use pages are a treasure trove of information. Data from all the national surveys on tobacco use are linked for download. Social media links are available. Everything is free, accurate, and objective and comes with the backing of the CDC. This site is more appropriate for a clinician or a researcher.

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Ri

The OSH Smoking and Tobacco Use pages also include more universally useable pages. Click on the Basic Information link on the left side for a page presented in bullet points and infographics. Additional resources are available through clickable pictures. Everything is free; no additional software is needed; links are included for sharing through e-mail and social media. The page was last reviewed in March 2019.

https://kidshealth.org/en/teens/e-cigarettes.html

The Nemours Foundation supports Kids Health. The website is divided into sections for kids, teens, parents, and educators. Within the teens section is a page entitled "Vaping: What You Need to Know." It was reviewed by a physician this past February 2019. The content can be listened to, viewed in Spanish, viewed with the font size adjusted, downloaded in a printer-friendly version, or shared through social media at no cost to access. The site is appropriate for all audiences,

https://www.drugabuse.gov/related-topics/trends-statistics/infographics/teens-e-

A somewhat dated infographic (2016) is available from the National Institute on Drug Abuse. The page was last reviewed in 2016, but some resources have been added toward the bottom of the page with more recent dates. Although the information may be accurate and objective, it is only current to 2016.

Chadi, N., Schroeder, R., Jensen, J. W., & Levy, S. (2019, August 12). Association between electronic cigarette use and marijuana use among adolescents and young adults: A systematic review and meta-analysis. JAMA Pediatrics, e192574. doi:10.1001/jamapediatrics.2019.2574

https://jamanetwork.com/journals/jamapediatrics/article-abstract/2748383

https://www.reuters.com/article/us-health-kids-smoking/teen-vaping-tied-to-marij

This is a systematic review and meta-analysis conducted to attempt to assess and quantify any association between the use of marijuana and vaporizing devices in youth aged 12-17 years and young adults aged 18-24 years. Those aged 12-17 years showed past or current use of marijuana 3.5 times higher than those using vapor devices. The researchers concluded that adolescents and young adults who used e-cigarettes and vapor devices were at risk for past, current, and future marijuana use. Addressing the rapid increases in e-cigarette use among youths may be a way of decreasing marijuana use in this population. The abstract is available at the JAMA Network site. The manuscript itself is only available through library or subscription access. For an overview of the meta-analysis results, see http://Reuter.com.

https://www.beaumont.org/health-wellness/blogs/dangers-of-vaping

This is a blog post from Beaumont Health, Michigan's largest healthcare system. The page contains factual information, embedded links for the National Youth Tobacco Survey, the American Lung Association, and an expert physician. This blog includes a list and infographic of six signs your child may be vaping (https://www.beaumont.org/images/default-source/default-album/vaping-infographic.). This is a wellness page dated 2019 available to the public. No cost is associated with accessing it.

Rubinstein, M. L., Delucchi, K., Benowitz, N. L., & Ramo, D. E. (2018, April). Adolescent exposure to volatile chemicals from e-cigarettes. Pediatrics, 141(4), doi:10.1542/peds.2017-3557 (originally published online March 5, 2018);

https://pediatrics.aappublications.org/content/141/4/e20173557

Saliva and urine specimens from adolescent e-cigarette users were taken and studied for the presence of volatile organic chemicals (VOCs). Those only using e-cigarettes had five times higher levels of VOC toxicants in their urine. They included metabolites of acrylonitrile, acrolein, propylene oxide, acrylamide, and crotonaldehyde. Dual users were three times higher than single use of e-cigarettes. Once the presence of harmful substances in the e-cigarette was established, a risk analysis of long-term harm from this exposure was conducted. As many of the VOCs identified are carcinogenic (propylene oxide, acrylamide, acrylonitrile, and crotonaldehyde) and the toxicants are present whether flavorings or nicotine were present, messaging to teens should include potential exposure to carcinogenic compounds. This research article from 2018 is readily available online for free access. It is a must read.

These are credible sources to educate yourself, peers, patients, and the general population. There is no mystery as to why people are getting ill and dying. Research and share the knowledge.