Public health experts are formulating recommendations to help prevent lung injury associated with vaping product use



Nearly four years ago, federal health officials reported a frightening new epidemic linked to e-cigarette use that caused a life-threatening and potentially irreversible lung condition. The condition — called e-cigarette or vaping product use-related lung injury (EVALI) — has been linked primarily to the inclusion of vitamin E acetate (VEA) in e-liquids used in vape cartridges. It is mainly found in unregulated marijuana vape products.

Jason Rose, MD, MBA, assistant professor of medicine and associate dean for Innovation and Physician Science Development at the University of Maryland School of Medicine (UMSOM), co-led a workshop through the American Thoracic Society that brought together public health experts from around the world. country to discuss the findings of the investigation and research on EVALI and formulate recommendations to help prevent future epidemics. Their analysis is published in a new report in the January 2023 issue of Annals of the American Thoracic Society.

We are trying to raise awareness of this as a growing public health concern. We have identified and addressed the problem of VEA, but there are likely new substances and contaminants present in e-liquid formulations that could cause lung injuries in the future. “


Jason Rose, MD, MBA, assistant professor of medicine and associate dean for Innovation and Advancement of Physician Sciences at the University of Maryland School of Medicine

There has been an increase in the use of e-cigarettes over the years as some adults use these nicotine products to help them quit smoking. However, what has been worrying is the increase in vaping among teens and young adults who use these products for recreational purposes. In a 2019 federally funded survey, 22 percent of college students said they vaped nicotine in the past month, more than double the percentage of those who reported vaping in the 2017 survey. The percentage of college students who said they smoked increased Marijuana use in the past 30 days increased from 5 percent in 2017 to 14 percent in 2019, according to the National Institute on Drug Abuse. Similar rates and a similar increase in the rate of young people who did not attend college were also seen.

The 2019 EVALI epidemic caused 2,807 hospitalizations and 68 deaths in the United States before VEA was identified and removed from e-cigarette products, according to the new analysis. The symptoms of EVALI are similar to an acute respiratory illness with symptoms such as coughing, shortness of breath, chest pain, and in some cases coughing up blood. Gastrointestinal symptoms, fever, fatigue, and rapid weight loss have also been associated with EVALI.

At its core, EVALI is a serious disease that primarily affects the lungs and results in a high number of hospitalizations and deaths in a relatively young and otherwise healthy population across the United States. This epidemic is largely caused by the unregulated and rapidly evolving nature of the e-cigarette industry, and it certainly highlights the need for continued action by both researchers and government agencies.”


Megan Riboli, MD, study co-leader, assistant professor, department of pediatrics, University of North Carolina School of Medicine

Early in the pandemic, the Centers for Disease Control and Prevention (CDC) took samples from e-cigarettes to determine what EVALI patients breathed into their respiratory systems. Tetrahydrocannabinol (THC) – the psychoactive ingredient in marijuana – and vitamin E acetate were found in the majority of samples; This led the CDC to conclude that vitamin E acetate was likely responsible for causing EVALI. However, vitamin E acetate was not found in all e-cigarette products linked to EVALI cases, which raises the question of whether other ingredients may also have triggered the lung condition, according to Dr. Rose.

The workshop committee issued several public health recommendations to prevent such outbreaks in the future. First and foremost, the panel stressed the need for scientists to fully understand the mechanisms of EVALI. More study is needed, for example, to assess the role that different compounds in vaping products play in the development of lung diseases. This step will require further research and testing of e-liquid formulations to determine their toxicity (based on dose and inhalation delivery) with the goal of classifying ingredients to establish safety standards. The workshop committee advised less restrictive regulations on the study of marijuana — which is currently a controlled substance by the federal government — to allow for more robust studies of THC in vaping products.

Health care providers need to be better acquainted with the signs and symptoms of EVALI to quickly recognize the condition and identify new outbreaks. Equally important, though, is the need to inform consumers through public health messages of the potential risks of highly unregulated e-cigarette products that carry unknown health risks.”


Mark T. Gladwin, MD, Dean of UMSOM, Vice President for Medical Affairs, University of Maryland, Baltimore, and John Z. and Ikeko Powers Distinguished Professor



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