Pulmonology Advisor: How has the growing legalization of marijuana influenced the emerging vaping crisis?

Dr Tsai: We are now seeing more cases of patients who report vaping THC products, and this is in light of the recent outbreak of cases of individuals who have come in with severe respiratory illnesses from vaping.

Dr Neptune: Eleven states plus the District of Columbia have approved recreational marijuana, and 33 states plus the District of Columbia have approved medicinal marijuana.20 Despite this, there are no consensus polices or quality control targets. Each state has a different slate of policies and regulations governing the production and marketing of these products. This has resulted in an expanding armamentarium of cannabis-based products of different purity, composition, and consistency.

The recent evidence that a component of cannabis solutions might be implicated in several cases of vaping-related lung injury underscores the high risk of marijuana legalization without prudent nationwide oversight. In addition, because cannabis remains a Schedule I drug, rigorous observational and natural history studies are not being conducted or sufficiently supported by funding agencies.


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Pulmonology Advisor: How should clinicians advise patients regarding the risks of vaping and smoking? 

Dr Tsai: Clinicians should advise their patients that e-cigarettes with nicotine may potentially produce [fewer] toxic chemicals in the vapor, but that does not mean they are without long-term effects. Harmful toxins have been detected in the vapor, including formaldehyde, heavy metals, and diacetyl. At this time, vaping is still unregulated by the FDA, and the additives in the e-liquid can vary between products.

Dr Neptune: Given the lack of persuasive studies establishing e-cigarette efficacy that is comparable to current conventional therapies for tobacco dependence, and the recent concerns about serious respiratory toxicities, clinicians should discourage all patients from using these products.

Because smoking is the top preventable cause of premature death, we clinicians strenuously discourage youth and adults from smoking and should initiate smoking cessation therapy for all active smokers, regardless of whether they are ready to quit.

Pulmonology Advisor: What should be next steps in this area in terms of research, education, or otherwise?

Dr Tsai: More research is needed on vaping with THC products, as well as the long-term effects of e-cigarette use. Patients should be educated that vaping is not without harm and can still have potentially deadly effects.

Dr Neptune:

Research priorities should include:

  • Determine the toxicity of the most common components of e-cigarette solutions when delivered as a heated, inhaled vapor.
  • Continue long-term observational studies of e-cigarette users to identify the late consequences of use.
  • Develop new therapies that specifically address nicotine dependence in adolescents and teenagers.

Educational needs should include:

  • Devise creative uses of social media to warn young people about the risks of e-cigarette use.
  • Encourage the press to be discerning in their analyses of e-cigarette trials and clinical studies. There are many stakeholders that are not necessarily supportive of public health priorities.

The e-cigarette epidemic and recent lung injury crisis related to vaping reflect a failure of judicious federal regulation and fear of confronting powerful industries that do not serve public health interests. Everything that we are seeing was entirely predictable and preventable; that is the real tragedy.

References

1. Centers for Disease Control and Prevention. Smoking is down, but almost 38 million American adults still smoke. https://www.cdc.gov/media/releases/2018/p0118-smoking-rates-declining.html. January 18, 2018. Accessed September 25, 2019.

2. Centers for Disease Control and Prevention. Youth and tobacco use. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm. Accessed September 25, 2019.

3. Loukas A, Paddock EM, Li X, Harrell MB, Pasch KE, Perry CL. Electronic nicotine delivery systems marketing and initiation among youth and young adults. Pediatrics. 2019;144(3):e20183601.

4. American Heart Association. Leading health groups back Michigan Gov. Whitmer’s emergency action to address the youth e-cigarette epidemic. https://newsroom.heart.org/news/leading-health-groups-back-michigan-gov-whitmers-emergency-action-to-address-the-youth-e-cigarette-epidemic. September 4, 2019. Accessed September 25, 2019.

5. Amrock SM, Zakhar J, Zhou S, Weitzman M. Perception of e-cigarette harm and its correlation with use among U.S. adolescents. Nicotine Tob Res. 2015;17(3):330-336.

6. Bhatta DN, Glantz SA. Electronic cigarette use and myocardial infarction among adults in the US population assessment of tobacco and health. J Am Heart Assoc. 2019;8(12):e012317.

7. Clapp PW, Jaspers I. Electronic cigarettes: their constituents and potential links to asthma. Curr Allergy Asthma Rep. 2017;17(11):79.

8. Chapman DG, Casey DT, Ather JL, et al. The effect of flavored e-cigarettes on murine allergic airways disease. Sci Rep. 2019;9(1):13671.

9. Centers for Disease Control and Prevention. Severe pulmonary disease associated with using e-cigarette products. https://www.emergency.cdc.gov/han/HAN00421.asp August 30, 2019. Accessed September 25, 2019.

10. Centers for Disease Control and Prevention. Outbreak of lung injury associated with e-cigarette use, or vaping. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html. September 27, 2019. Accessed September 25, 2019.

11. CNN Health. First vaping deaths in Florida and Georgia bring nationwide total to 11. https://www.cnn.com/2019/09/25/health/georgia-vaping-death-bn/index.html. September 25, 2019. Accessed September 25, 2019.

12. Landry RL, Groom AL, Vu TT, et al. The role of flavors in vaping initiation and satisfaction among U.S. adults. Addict Behav. 2019;99:106077.

13. TIME. As the number of vaping-related deaths climbs, these states have implemented e-cigarette bans. https://time.com/5685936/state-vaping-bans/. September 25, 2019. Accessed September 25, 2019.

14. US Food and Drug Administration. Statement on federal and state collaboration to investigate respiratory illnesses reported after use of e-cigarette products. https://www.fda.gov/news-events/press-announcements/statement-federal-and-state-collaboration-investigate-respiratory-illnesses-reported-after-use-e. August 30, 2019. Accessed September 25, 2019.

15. Harris PA. AMA urges public to avoid e-cigarette use amid lung illness outbreak. https://www.ama-assn.org/press-center/ama-statements/ama-urges-public-avoid-e-cigarette-use-amid-lung-illness-outbreak. September 9, 2019. Accessed September 25, 2019.

16. Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med. 2019;380(7):629-637.

17. Walker N, Parag V, Verbiest M, Laking G, Laugesen M, Bullen C. Nicotine patches used in combination with e-cigarettes (with and without nicotine) for smoking cessation: a pragmatic, randomised trial [published online September 9, 2019]. Lancet Resp Med. doi:10.1016/S2213-2600(19)30269-3

18. Yuan M, Cross SJ, Loughlin SE, Leslie FM. Nicotine and the adolescent brain. J Physiol. 2015;593(16):3397-3412.

19. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems; Eaton DL, Kwan LY, Stratton K, editors. Public health consequences of e-cigarettes. Washington, DC: National Academies Press; 2018.

20. Business Insider. Illinois just became the first state to legalize marijuana sales through the legislature — here are all the states where marijuana is legal. https://www.businessinsider.com/legal-marijuana-states-2018-1. June 25, 2019. Accessed September 25, 2019.