Smoking or Vaping, There’s No Escaping – UPDATED

Traditional smoking of cigarettes has become less appealing to the public over time, and there is still a significant segment of society that partakes in this activity. Some willingly view this activity as an outlet for stress relief, while others have acknowledged their addiction and are open to quitting their habit with an implemented program. As the dangers of smoking have become more exposed over time, a variety of quitting mechanisms have arisen from gum, to skin patches, to other forms of pharmaceutical interventions. Unfortunately, with the use of these options, there has only been a 10% success rate in quitting smoking.

In 2003 the first commercially available E-cig was created by Hon Lik in China, and in 2006 the E-cig was introduced to the U.S. market. Today, the most influential player in the E-cig market is Juul, a startup which after launching in 2015 captured 70% of the E-cig market within 3 years. The intention was to provide a “healthy cigarette” and as opposed to attaching itself to the stigma of smoking, E-cig usage was popularly dubbed “vaping”. 

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Instead of burning the nicotine-containing substance or other alternative, that main ingredient is suspended in a complex liquid which is heated to an aerosol for inhalation. Much contention has arisen over the effect heating may have on the ingredients, and whether enough reproducible research has been conducted on the health impacts of vaping. Over the course of marketing the product, a perception developed that this product could be used as a bridge to lead smokers to a non-smoking lifestyle, if desired. Unfortunately, controversy has struck, as a mysterious lung disorder initially described as “vaping associated pulmonary illness” (VAPI), and now reclassified as “E-cigarette, or vaping, product use associated lung injury” (EVALI) began impacting hundreds of vaping clients requiring them to be hospitalized, with over 3 dozen individuals dying from the symptoms, as of this post. Below is a list of states with some of the most EVALI-related cases, including some statistics from the current EVALI epidemic, as it has evolved over time:

CALIFORNIA

• In our previous issue, according to the CDC, as of September 24, 2019, there had been 805 confirmed and suspected vaping-related cases in the U.S. and U.S. territories. By November 13*, they saw that number jump to 2,172 cases. Pertaining to deaths related to vaping, as of October 2, there had been 17 deaths reported. As of this publication, that number has more than doubled to 42, with 4 of those deaths occurring in California. This state is among the top 3 states reporting vaping-related cases.

• Regarding what is physiologically leading to this outcome, research has shone the spotlight on what appears to be an infiltration of certain immune cell types that typically don’t represent the quiescent lung environment, seemingly caused by vaping. 

ILLINOIS

• In addition to having one of the highest number of reported cases amongst reporting states for lung illness related to vaping, Illinois has 4 vaping-related deaths reported to the CDC. To determine if these cases are legitimately related to vaping, teams including state investigators, clinicians, and public health officials are organized to align their findings with a validated case definition. If possible, interviews are also conducted with the patient to establish confirmation of the case.

• Based on the cases investigated so far, all patients were reported to have been vaping leading up to their hospitalization status. Additionally, most patients used THC-containing products or a combination of nicotine-containing and THC-containing products; one subset of patients only used nicotine-containing vaping products. No consistent evidence of infection has been associated with these cases.

• CDC officials have recently revealed that vitamin E acetate may be an ingredient included in THC-containing E-cigs and vaping products, to serve as a thickening agent. Although vitamin E is safe to use as a cosmetic or dietary supplement, previous research suggests vitamin E acetate may interfere with normal lung function, when inhaled.

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INDIANA

• Indiana, a state with a high number of EVALI cases, shares the highest number of reported EVALI-related deaths which have risen to 4, as of this posting. Texas rounds out the top 3 reporting states for vaping-related cases, although it reported it’s first and only related-death in early October.

• As of the latest statistics, 79% of total patients were under the age of 35 years old; 65% of patients were between the ages of 18 and 34. Roughly 70% of EVALI cases involved male patients, as of October 15, 2019. Alarmingly, 14% of patients were under 18 years old, as this product is prohibited for sale to minors. This implies that further enforcement of the law is needed.

• The first reported double lung transplant surgery related to vaping was successfully conducted on a 17-year old boy from Michigan. Health officials declined to provide information on what the teen had vaped or how long he had been vaping. Regardless, the extent to which this vaping crisis has evolved and reared its ugly head continues to baffle and concern health care officials nationwide.

MINNESOTA

• Minnesota is a moderately high reporting state as it pertains to lung illness cases; this includes 3 EVALI-related deaths being reported from this state, as of this posting.

• Investigators are diligently working to uncover what may be the primary culprit in manifesting this mysterious lung illness, as this is still unknown. However, contrary to some E-cigarettes being marketed to contain zero percent nicotine, they have been found to contain the substance. The aerosolized liquids used in these vaping vectors typically contain:

• Nicotine
• Ultra-fine particles
• Flavorings (such as diacetyl, which has been linked to serious lung disease)
• Volatile organic compounds
• Cancer-causing chemicals
• Heavy metals such as nickel, tin, and lead

Although many countries have long banned the import of E-cigarette products, more bans are now cascading down from the U.S. federal government and sweeping across the country. There is simply too much controversy around not only the marketing practices of E-cig manufacturers, but also the safety of the vape fillers themselves when heated and inhaled.

A similar dark cloud of uncertainty hovers over the hookah community, too, as similar arguments have been made regarding the safety of the activity. It is best advised to avoid E-cig use until more substantiated reviews and studies are conducted, regarding the concerns therein. And of course, it is best to avoid the habit of smoking altogether. Check back for the latest news and updates on the U.S. vaping outbreak, as we revise our coverage on a regular basis.

*This content has been updated, as of November 14, 2019, to provide you with the most current coverage of the EVALI outbreak in the U.S.

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