Study findings suggest a strong preference for flavored products among youth who use e-cigarettes, 70% of whom identified flavors as a key reason for using such products, and other results indicate greater satisfaction and perceived addiction among users of flavored vs nonflavored e-cigarettes.4,12 Advertising of vaping products also appears to have been highly effective in attracting young users. For example, a recent longitudinal study3 found higher odds of subsequent e-cigarette initiation up to 2.5 years after exposure to e-cigarette marketing in retail stores among school-aged youth (adjusted odds ratio [aOR], 1.99; 95% CI, 1.25-3.17) and young adults (aOR, 1.30; 95% CI, 1.05-1.61), as well as on television among young adults (aOR, 1.29; 95% CI, 1.03-1.63).
“In the absence of strong federal regulation, parents have been blindsided by the e-cigarette epidemic and children have been lured by the tobacco industry’s savvy online marketing campaigns promoting flavors — more than 15,000 on the market, from mango and mint to cotton candy and gummy bear — that hook them onto a highly addictive product,” as charged in the statement by the American Heart Association, et al.4 “The youth e-cigarette epidemic is nothing short of a public health emergency that must be urgently confronted.”
US Health and Government Agencies Tackling the Vaping Crisis
In response to the unfolding crisis, New York and Michigan have banned the sale of flavored vaping products, and Massachusetts has placed a 4-month ban on the sale of all vaping products until more is known about the associated risks.13 Several other states have enacted or are considering adopting similar restrictions.
The FDA and CDC are working together to investigate the issue and to keep healthcare professionals and the public informed.14 In the meantime, the American Medical Association has issued a statement advising that people refrain from the use of any e-cigarette products while health officials seek to elucidate associated risks.15 The CDC has published detailed recommendations for clinicians on this topic, citing the need to report “cases of severe pulmonary disease of unclear etiology and a history of e-cigarette product use within the past 90 days to your state or local health department.”9
All patients reporting e-cigarette use within the previous 90 days should be asked about signs and symptoms of pulmonary illness. “If e-cigarette product use is suspected as a possible etiology of a patient’s severe pulmonary disease,” clinicians should obtain a detailed history and ask if the patient has any remaining product that could be used for testing in coordination with local or state health departments. The CDC advisory also contains further recommendations for screening and treatment.9
For clinician perspectives and further guidance, Pulmonology Advisor interviewed Joanna Tsai, MD, a pulmonary care physician at the The Ohio State University Wexner Medical Center in Columbus, who is currently investigating the potential effects of vaping on the innate immunity of the lung; and Enid Rose Neptune, MD, associate professor of medicine in the division of pulmonary and critical care medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland.
Pulmonology Advisor: For both nicotine and cannabis, is vaping now considered more problematic, or less so, than combustible smoking? And what is the current view of e-cigarettes as a means of quitting combustibles” Are they worth it?
Dr Tsai: I would not necessarily say vaping is more (or less) problematic compared with combustible smoking, just different. We have decades of research to support that combustible smoking is bad for your health, including findings that link it to cancer, cardiovascular issues, and strokes, but vaping is still considered a relatively new phenomenon that research is just trying to keep up with and is only in its early stages. Specifically for e-cigarettes with nicotine, there are [fewer] toxic chemicals in the vapor compared with traditional smoke, but that does not preclude the possibility of long-term health effects related to their use. Right now, there is very little research on vaping cannabis.
Dr Neptune: The either/or comparison is not helpful because the vast majority of persons using e-cigarettes containing nicotine or cannabis are not trying to stop or reduce the use of combustible cigarettes. The more helpful question is whether vaping these solutions is safe, and the answer is clearly no, as of September 2019. It is also clear that the e-cigarettes vs combustible cigarette comparison serves the interest of e-cigarette manufacturers because they do not have to defend the isolated toxicities and harms of e-cigarette use that [affect] the public at large.
When one considers the rapidly expanding use of e-cigarettes among youth and the lack of aggressive regulation of these devices and solutions by the FDA and current administration, the public health alarm is considerable.
Two randomized trials addressing e-cigarettes for smoking cessation have been published: one comparing e-cigarettes with nicotine replacement therapy and the other comparing nicotine replacement therapy with or without e-cigarettes with or without nicotine (3-prong study).16,17 Both had serious methodological issues that compromise interpretation, including the inability to stop using e-cigarettes at study conclusion and extremely high attrition rates. In addition, there have been no studies comparing e-cigarettes with varenicline, the best controller medication for tobacco dependence. We need better trials that focus on well-defined groups of active smokers. These could possibly identify subgroups of smokers for which e-cigarettes have specific efficacy.
Pulmonology Advisor: What is the potential effect of vaping on children and adolescents?
Dr Tsai: Vaping is definitely very concerning in children and adolescents. We are seeing individuals who were usually never smokers picking up a habit that can lead to addiction and potentially transition to traditional smoking. Also, nicotine is known to harm brain development, which can continue into one’s 20s.18 Researchers also do not know the long-term effects of vaping use yet.
Dr Neptune: The main concerns regarding youth e-cigarette use are the adverse [effect] of early and chronic nicotine exposure on neurologic development and the heightened risk of initiating combustible cigarettes. In 2018, The National Academy of Sciences published an extensive evidence-based report on e-cigarettes and strenuously concluded that the use of these devices increased the likelihood of combustible cigarette use among youth.19 Of note, the reduction in youth tobacco use reflecting decades of assertive tobacco control policies has been fully erased by the increase in e-cigarette use.