Vaping has been a focus in recent headlines and the story continues to unfold. As of August 27, 2019, 215 people in 25 states were hospitalized for severe lung disease possibly linked to vaping nicotine or tetrahydrocannabinol (THC)-containing products (Centers for Disease Control and Prevention [CDC], 2019a). Patient complaints included cough, shortness of breath, fatigue, fever, chest pain, weight loss, nausea and diarrhea. A few patients required intensive care treatment and mechanical ventilation. While some chest radiographs showed bilateral opacities, infectious causes were ruled out (CDC, 2019b). Several state departments are urging people to stop using vaping devices also known as electronic cigarettes (e-cigarettes) immediately.

Is vaping a public health crisis?

Prevalence:

• According to the Food and Drug Administration (FDA, 2019a), among middle and high school students, 3.62 million used e-cigarettes in 2018.
  • Current e-cigarette use (use on at least one day in the past 30 days) increased 78% among high school students, from 11.7% users to 20.8%, (3.05 million users) between 2017 and 2018.
  • E-cigarette use among middle school students increased 48%, from 3.3% to 4.9% (570,000 users) between 2017 and 2018.

These statistics are alarming. Let’s take a closer look at this dangerous trend.

Electronic nicotine delivery systems (ENDS)

Electronic nicotine delivery systems (ENDS) were introduced into the U.S. market in 2006 (Rigotti & Kalkhoran, 2019), and were initially promoted as a safer alternative to smoking and as means to assist in smoking cessation, however studies have not substantiated this claim. Since that time, these devices have become the most commonly used tobacco product in the United States (Simerson, 2018). ENDS are also known as electronic cigarettes, e-cigarettes, e-cigs, electronic cigars, vapes, vaporizers, vape pens/sticks, hookah pens, e-hookas, tank systems, and mods (CDC, 2019c). The products are non-combustible, battery-operated, and consist of a reservoir, heating mechanism, and mouthpiece. Liquids, (“e-juice”, “e-liquid”, “vape juice”, or “vape liquid”) containing nicotine and other chemicals such as propylene glycol, glycerol, and flavorings, are heated until they become an aerosol mist or vapor which is then inhaled by the user. While ENDS typically contain less nicotine than traditional cigarettes and do not expose the user to tar and carbon monoxide, the added chemicals and flavorings may be toxic (Rigotti & Kalkhoran, 2019).

ENDS were not regulated by the FDA until 2016 when the regulatory authority was extended to include the manufacture, import, packaging, labeling, advertising, promotion, sale, and distribution of ENDS (FDA, 2019b). However, despite new regulations, great variation in nicotine content and other chemicals exists among the numerous products on the market.

Key Points

Here is a summary of key points all nurses should know regarding ENDS:

• Nicotine (Rigotti & Kalkhoran, 2019):
  • Content of e-cigarettes varies from zero to 36 mg/mL.
  • Typical concentrations are 6 mg/mL, 12 mg/mL, 18 mg/mL or 24 mg/mL.
  • Actual levels in products are not consistent with package labeling (i.e. nicotine-free products have been found to contain nicotine).
  • Heating e-liquid to high temperatures increases nicotine release and its effects.
  • Longer puffs and more intense use may result in higher blood nicotine levels.
  • Nicotine is addictive and is harmful to the developing adolescent brain.
• Other chemicals:
  • Include propylene glycol, glycerol, or ethylene glycol (Rigotti & Kalkhoran, 2019).
  • At high temperatures, these chemicals may convert to toxic aldehydes such as formaldehyde, acetone, and acetaldehyde which are known to cause lung disease, inflammation and upper airway irritation (Simerson, 2018).
• Flavorings:
  • Over 7000 flavors are available, many of which are marketed to appeal to youths, such as candy, fruit, soda, and alcohol (Rigotti & Kalkhoran, 2019).
  • Some contain chemicals such as diacetyl which can cause bronchiolitis obliterans, an inflammatory obstruction of the bronchioles (O’Malley, 2017; Simerson, 2018).
• Metals and other compounds:
  • Heavy metals and carcinogens such as mercury, nickel, chromium, cadmium, tin, arsenic and lead have been found in some e-liquids (O’Malley, 2017).
  • Compounds include tobacco-specific nitrosamines, carbonyl and phenolic compounds (Rigotti & Kalkhoran, 2019).
• Cannabis (CDC, 2019a):
  • E-cigarettes may be used to vape illicit substances:
    • Pods or cartridges designed as single-use are being refilled with illicit substances.
    • “Dripping”: e-liquids such as THC and cannabinoid compounds are dropped directly onto the hot coils of the device resulting in highly concentrated forms.
    • “Dabbing” involves superheating substances such as “budder” (cannabis extract) or butane hash oil (BHO) that contain high concentrations (70% or greater) of THC and other cannabidiols (CBD).

Additional Hidden Dangers

• Devices are designed to look like cigarettes, cigars, pipes or ordinary items such as pens and USB memory sticks.
• E-cigarettes may remove the stigma of smoking, “normalize” the habit, and act as a bridge to traditional tobacco products (Rigotti & Kalkhoran, 2019).
• If accidentally ingested by a child, e-liquids can cause nicotine toxicity (Simerson, 2018).
  • Mild toxicity symptoms include tremor, nausea, tachycardia, and hypertension.
  • Severe toxicity symptoms include increased salivation, vomiting, diaphoresis, hypotension, bradycardia, lethargy, and respiratory failure.
  • Fatal dose in children is 1 mg/kg or 10 mg (Rigotti & Kalkhoran, 2019).
  • E-liquids can contain 20 mg/mL or more of nicotine.
• Burn injuries have occurred from overheated devices and battery explosions.
• Similar to traditional cigarettes, second hand smoke from vaping products may be noxious.
• E-cigarettes are harmful to pregnant women and the unborn child.

Evaluating the Patient with Respiratory Complaints

When assessing patients with respiratory complaints, incorporate the following recommendations (CDC, 2019a):

• Ask all patients about potential drug (legal and illicit) use as part of the general history.
• Ask the patient if he/she used e-cigarette products (devices, liquids, refill pods and/or cartridges) for vaping within the last 90 days
• If e-cigarette use is a potential cause of the patient’s respiratory complaints, obtain more specific information:
  • Substances used: nicotine, cannabinoids (i.e. marijuana, THC, THC concentrates, CBD, CBD oil, synthetic cannabinoids, hash oil), flavors or other substances.
  • Source: commercially available liquids (i.e. bottles, cartridges, pods), homemade liquids, re-use of old cartridges or pods with homemade or commercially purchased liquids.
  • Devices used: manufacturer, brand name, product name, model, serial number (product, device, e-liquid), was device or product altered by the user.
  • Where was the product purchased?
  • Method used: vaping, dabbing, dripping.
  • Were e-cigarettes shared with others?
• Report cases of significant respiratory illness of unknown etiology and a history of vaping within the past 90 days to the state and/or local health department.
• Evaluate all possible causes of respiratory illness such as infectious, rheumatologic and neoplastic etiologies and treat as clinically indicated.
• Consult specialists as appropriate (pulmonary, infectious disease, critical care, medical toxicology).
• Some patients have benefited from corticosteroids, bronchoalveolar lavage and lung biopsy.

Supporting Patients in Smoking Cessation Efforts

• ENDS should not be recommended as a first-line strategy to quit smoking traditional cigarettes (Rigotti & Kalkhoran, 2019) as they are not approved by the FDA for smoking cessation and have not been associated with long-term success.
• Nicotine replacement strategies should include those methods that have been proven safe and effective by the FDA:
  • Patches
  • Gum
  • Inhalers
  • Sustained-release  bupropion hydrochloride
  • Varenicline
  • Clonidine
  • Nortriptyline
  • Counseling
  • Support groups
• If a patient is not willing to use FDA-approved nicotine replacement strategies and insists on utilizing e-cigarettes, the clinician should inform the smoker of the safety and efficacy issues related to ENDS use and continue to support their efforts to quit smoking (Rigotti & Kalkhoran, 2019).

CDC Recommendations for the Public (CDC, 2019a):

• If you are concerned about the health risks of vaping, stop using e-cigarette products.
• Do not buy e-cigarette products “off the street” (THC or other cannabinoids) and do not alter e-cigarettes products or add any substances that were not designed to be used with these devices.
• E-cigarettes should not be used by youths, young adults, pregnant women or adults who do not currently use tobacco products.
• If you currently use e-cigarette products and have symptoms such as cough, shortness of breath, or chest pain, seek medical attention immediately.
• Adult smokers who are trying to quit should use evidence-based treatments, including counseling and FDA-approved medications.
• If you are concerned about harmful effects from e-cigarettes, call your local poison control center at: 1-800-222-1222.
• If you experience any unexpected health or product issues related to e-cigarettes, notify the FDA via the online Safety Reporting Portal: https://www.safetyreporting.hhs.gov.

As part of the on-going investigation, the CDC is collecting product samples to test at the U.S. FDA Forensic Chemistry Center. If you encounter a potential case of vaping-related respiratory illness, request a product sample from your patient and submit it to your local or state health department. Vaping is an evolving public health issue. We, at NursingCenter, will continue to provide updates as new information is uncovered by the CDC and FDA investigations.
 

References
Centers for Disease Control and Prevention (2019a). Severe pulmonary disease associated with using e-cigarettes products. Health Advisory. Retrieved from https://emergency.cdc.gov/han/han00421.asp

Centers for Disease Control and Prevention (2019b). CDC, FDA, State continue to investigate severe pulmonary disease among people who use e-cigarettes. Retrieved from https://www.cdc.gov/media/releases/2019/s0821-cdc-fda-states-e-cigarettes.html

Centers for Disease Control and Prevention (2019c). Quick facts on the risks of e-cigarettes for kids, teens, and young adults. Retrieved from  https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html

Food and Drug Administration (2019a). 2018 NYTS Data: A startling rise in youth e-cigarette use. Retrieved from https://www.fda.gov/tobacco-products/youth-and-tobacco/2018-nyts-data-startling-rise-youth-e-cigarette-use

Food and Drug Administration (2019b). Vaporizers, e-cigarettes, and other electronic nicotine delivery systems (ENDS). Retrieved from https://www.fda.gov/tobacco-products/products-ingredients-components/vaporizers-e-cigarettes-and-other-electronic-nicotine-delivery-systems-ends

O’Malley, P.A. (2017). Safety and efficacy of electronic cigarettes – update for the clinical nurse specialist. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 31(1): 17-19.

Rigotti, N.A. & Kalkhoran, S. (2019). Vaping and e-cigarettes. UpToDate. Retrieved from https://www.uptodate.com/contents/vaping-and-e-cigarettes?search=e-cigarettes&source=search_result&selectedTitle=1~50&usage_type=default&display_rank=1

Simerson, D. (2018). What the advanced practice nurse in the emergency department needs to know about the health risks and hazards of electronic cigarette use by youth. Advanced Emergency Nursing Journal, 40(1): 36 – 44.