Vaping Product Use Research Articles

Where There Is (No) Smoke, There Is Still Fire: a Review of Trends, Reasons for Use, Preferences and Harm Perceptions of Adolescent and Young Adult Electronic Cigarette Use.

Purpose of the reviewTo review the current prevalence, trends, perceptions, and effects of e-cigarette or vaping product use associated lung injury (EVALI) on e-cigarette use among US adolescents and young adults.Recent findingsCOVID-19 diagnosis was more likely among the current/ever dual cigarette and e-cigarettes users, as well as ever e-cigarette only users. Additionally, the EVALI outbreak may have influenced harm perceptions, as daily nicotine vaping declined significantly from 2019 to 2020, and more youth and young adults perceived vaping as harmful.SummaryThe prevalence of e-cigarette use, specifically flavored use, remains high among adolescents and young adults, which is concerning due to the short-term and unknown long-term effects of e-cigarettes and their association with future cigarette and other substance use.

Evidence against e-cigarettes for smoking cessation

Electronic cigarettes (e-cigarettes) have been touted as a safer alternative to cigarettes and even as a smoking cessation aid. The health risks associated with smoking are well known, and smoking cessation has been studied extensively with options including behavioral therapy and pharmacotherapy (nicotine replacement therapy [NRT], varenicline, and bupropion). Several studies analyzed the effects of e-cigarettes as a smoking cessation aid. When used for smoking cessation, those who successfully abstain from cigarette smoking have a higher rate of continuation on e-cigarettes than NRT or pharmacotherapy. Other risks of e-cigarettes are highlighted including e-cigarette or vaping product use–associated lung injury. There is no approved pharmacotherapy for e-cigarette cessation. Two of the analyzed studies demonstrated the use of varenicline as a potential pharmacotherapy for e-cigarette cessation. The proposed benefits of e-cigarettes as a smoking cessation aid should be weighed against their probable detrimental effects. E-cigarette use should be discouraged as a whole and notably, as a smoking cessation aid.

Toxicological assessment of e‐cigarette or vaping product use associated lung injury (EVALI) cartridges and constituents

Rationale Definitive causative agents of the outbreak associated with the use of e-cigarette, or vaping product use associated lung injury (EVALI) are unknown. Patients diagnosed with EVALI have used vape products containing tetrahydrocannabinol (THC) and vitamin E acetate (VEA). Hypothesis We hypothesized that inhalation of these EVALI vape cartridges and their constituents induce pulmonary toxicity, mediated by oxidative damage and inflammatory responses, leading to acute lung injury, and alters SARS-CoV-2 related proteins. Methods Vaping products were recovered from hospitalized patients at the University of Rochester Medical Center. Cartridge constituents were characterized by gas chromatography and mass spectrometry. Comparative toxicity of exposure to common vape cartridge components such as medium-chain triglyceride (MCT) oil, VEA, and patient-derived cartridge aerosols was assessed by in vitro and in vivo models. Lung epithelial cells (BEAS-2B) and monocytes (Mono-Mac-6). Cells were exposed to MCT, VEA, and cartridge aerosols and the elicited inflammatory response, barrier function, and lipid-laden index were determined. C57BL/6 mice were exposed to MCT, VEA, and vape cartridge aerosols for three days (1 hr/day). The immune response was determined by differential cell counts, cytokine milieu, and lipidomics analysis in bronchoalveolar lavage fluid (BALF). Lung surfactant protein (SP-A), SARS-CoV-2 proteins (ACE2 and TMPRSS2) were quantified in the lung homogenates. Results Constituents identified patient-derived vaping products included reactive hydrocarbons and various forms of cannabinoids. VEA and cartridge aerosols induced significantly increased IL-6 and IL-8 responses in lung epithelial cells and monocytes. MCT, VEA, and cartridge aerosols induced barrier dysfunction. Increased lipid-laden indices were observed in MM6 cells. In mice, acute exposure to cartridge aerosols caused a significant infiltration of leukocytes in BALF and increased IL-6, eotaxin, and G-CSF in the BALF. Lipidomics analysis showed significantly increased eicosanoid inflammatory mediators and leukotrienes. Reduced levels of SP-A levels were seen in lung homogenates. Exposure to cartridge aerosols showed the most significant effects and toxicity compared to MCT and VEA. SARS-CoV-2 related proteins were not affected. Conclusion Acute exposure to vape cartridges induces cytotoxicity, barrier dysfunction, and elicit an inflammatory response in lung cells and mice, which are potential predictive toxicological markers of EVALI. Toxicity of vape cartridges was independent of SARS-CoV-2 proteins. This study provides important identification of potential chemical constituents, toxicological responses, and potential biomarkers of EVALI.

Risk Factors and Medical Symptoms Associated With Electronic Vapor Product Use Among Adolescents and Young Adults

The use of electronic vapor products (EVPs) has increased dramatically in the past decade. The objectives of our study were to examine the frequency of EVP use; to identify demographic characteristics, risk-taking behaviors, and beliefs about vaping; and to determine symptoms associated with EVPs among adolescents. A questionnaire addressing these objectives was administered to a convenience sample of subjects aged 12 to 23 years. Among 494 completed questionnaires, 80% of responders were considered experimenters/nonusers (never tried or tried one time) and 20% were considered frequent users (at least once a month). We identified demographic features and risk-taking behaviors associated with EVP use. In the previous 6 months, frequent users were more likely to report headache, cough, sleep disturbances, dehydration, weakness, racing heart, chest pain, and tremors. Our findings provide evidence to support efforts to decrease EVP use through screening, education, and preventative strategies.

Bullying Victimization is Associated with a Significantly Greater Risk of Illicit Substance Use among US Female Adolescents: YRBS 2011 to 2017

Bullying victimization among adolescents is associated with increased illicit substance use. This research estimates whether the association between bullying victimization and substance use is significantly greater among female adolescents. Using R software and the national Youth Risk Behavior Survey (2011, 2013, 2014, and 2017), interactions were estimated to determine the association between self-reported school or electronic bullying victimization and previous 30-day alcohol use, binge drinking, marijuana use, cigarette smoking, and electronic vaping product use. Bullying victimization was significantly associated with each of the substance use variables, Effects were significantly greater in female students. Efforts should be put in place in schools and communities to reduce bullying, mitigate the harmful effects of this form of victimization, and reduce illicit substance use.

Cannabis Legalization and Adolescent Use of Electronic Vapor Products, Cannabis, and Cigarettes.

Cannabis legalization may have unintended consequences, such as effects on prevalence of adolescent use of other substances. We hypothesize that in states that have legalized recreational cannabis (RCL states), electronic vapor product use ("vaping"), cannabis, and cigarette use among adolescents is more prevalent than in states that have only legalized medical cannabis (MCL states) and states that have neither legalized recreational nor medical cannabis (NL states). Data are from the Center for Disease Control's 2017 Youth Risk Behavior Surveillance Survey (n = 107,665), a nationally representative survey of US high school students. We categorized student responses by cannabis legalization status of the state in which they lived at time of survey, then tested associations between cannabis legalization status and adolescent vaping, cannabis, and cigarette use, using logistic regressions. Students in RCL states were significantly more likely to report current vaping behaviors compared to NL students [odds ratios (OR's) 2.07-2.21]. Students in cannabis-legal states were significantly more likely to report ever or currently using cannabis compared to NL students (OR's 1.27-1.40). MCL students were significantly less likely to report current cigarette smoking (OR = 0.86) compared to NL students. Adolescents in cannabis-legal states were more likely to report vaping and cannabis use compared to adolescents in NL states. Public health officials, policymakers, and clinicians should consider the associations between cannabis legalization and adolescent vaping, cigarette, and cannabis use patterns.

Flavor additives facilitate oral self-administration of nicotine solution in mice.

Tobacco products are very addictive, partly because they contain nicotine which is reinforcing, but also because they include appealing aromas and tastes. Flavor additives are such sensory stimuli which enhance attractiveness, as well as use and abuse of tobacco and vaping products. Yet, the interaction between these flavor additives and nicotine remains poorly understood. We want to understand how flavors may reduce nicotine' aversive taste and how it may enhance its voluntary oral self-administration in mice. We first studied the effect of flavor additives on nicotine solution palatability in a free bottle choice paradigm. Second, we investigated the effect of vanilla flavoring on the different stages of nicotine (40μg/ml) oral self-administration in mice. We show that adding flavors increase nicotine palatability and facilitate acquisition and maintenance of oral self-administration when compared to nicotine-alone group. Mice adapt their operant behavior depending on changes in nicotine concentration. All mice reinstate nicotine seeking upon presentation of associated cues. Nevertheless, vanilla-flavored nicotine was not more reinforcing than vanilla-flavored water which was reinforcing enough to drive similar operant response rates. Flavor additives increase nicotine oral consumption and help maintaining operant behavior in mice. Moreover, flavors can be very attractive and can have high reinforcing value by themselves. Thus, it is crucial that the investigation on how taste signals play an important role in modulating oral nicotine intake in rodent models remains explored.

Student health behavior and academic performance.

ObjectiveTo explore the association between health behaviors and habits of university students and academic achievement.ParticipantsSix hundred fourteen undergraduate students at a state university in the United States.MethodsStudents were invited over a 2-year period to participate in an anonymous online survey that asked questions concerning a wide range of health behaviors and habits; participants were asked to report their current grade point average (GPA). Standard Least Squares Models were used to examine differences in self-reported GPA across the different health behaviors and habits, with individuals as replicates.ResultsThe study found positive associations between breakfast consumption, physical activity, and strength training and self-reported GPA, and negative associations between the hours of sleep per night, hours worked per week, fast food and energy drinks consumption, and use of marijuana, alcohol and electronic vaping products.ConclusionsWhile there is an association for some of the studied health behaviors and habits with self-reported GPA, the effect sizes for these health behaviors were low. The significant effect of vaping on GPA as well as the increased use reported in this study indicates that the topic should be explored further. Furthermore, students should be educated on the potential positive and negative effects of health behavior choices to help them make better choices.

Pharmacological Interventions for Vaping Cessation


 The use of electronic nicotine delivery systems and other vaping products is on the rise, and the health effects from these products remain uncertain.
 No evidence-based guidelines regarding the use of pharmacological vaping cessation interventions were identified.
 Some guidelines suggest that it may be reasonable to apply smoking cessation interventions and/or protocols for vaping cessation, but no guidance specific to the use of pharmacotherapy was identified.

A Problem To Be Solved: Vaping and EVALI in Coronavirus Days

Coronavirus disease 2019 (COVID-19) outbreak was declared as a global pandemic by the World Health Organization (WHO) on March 11, 2020. The disease has a high infectivity and the most common symptoms are related to respiratory system. Electronic cigarettes (e-cigarettes), considered by many as an alternative for cigarette smoking, rapidly gained popularity in recent years. Despite a legal age requirement of 18 years for purchasing e-cigarettes, use of vaping products has been increasing particularly among younger people. These products are known to cause a special type of disease called “e-cigarette, or vaping, product use-associated lung injury” (EVALI) which may be highly fatal. Diagnostic criteria for EVALI consists of a mixture of non-specific systemic symptoms (eg, fever, chills, and vomiting) and respiratory symptoms (eg, shortness of breath, cough, chest pain, dispnea, and hypoxia), along with detection of lung opacities and ground-glass opacities (GGOs) on imaging. Commonly, findings of EVALI reveal similarities with those of coronavirus disease 2019 (COVID-19). In the literature, there are numerous studies indicating e-cigarette users (vapers) have impaired immune response that might increase vulnerability to COVID-19 infection and death. However, studies claiming that smoking has protective effects against COVID-19 still exist in the literature. In this narrative review, we aimed to clarify confusions on effects of vaping on COVID-19 patients and prevent misdiagnoses of EVALI due to similarities of these diseases in many aspects.

Drug-related deaths associated with vaping product use in the United Kingdom.

Between March 2019 and February 2020 there was an outbreak of acute lung injury associated with vaping tetrahydrocannabinol (THC), contaminated with vitamin E acetate, in the United States. To date, there has been no comprehensive study of drug-related deaths associated with vaping products in the United Kingdom. We aimed to identify any trends in drug-related deaths associated with vaping product use in the United Kingdom. We retrospectively identified any deaths associated with the use of vaping products reported to the UK National Programme on Substance Abuse Deaths (NPSAD). This contains voluntarily reported information from UK Coroners on more than 42 000 deaths related to psychoactive drugs, other than nicotine or caffeine, which occurred between 1997 and 2020. Two drug-related deaths were reported which were associated with vaping products, one person having died in 2017 and one in 2018. Both decedents were men currently serving prison sentences in England and were aged 26 and 42years at the time of death. Both deaths were associated with recent use of Synthetic Cannabinoid Receptor Agonists (SCRAs), with no other substances found to be implicated in death. No details regarding the type of vaping products were available. In a UK sample (1997 to 2020) of 42 000 deaths related to psychoactive drugs other than nicotine or caffeine, only two deaths were associated with vaping products, and those involved use of synthetic cannabinoid receptor agonists.

‘95% less harmful’? Exploring reactions to quantitative modified risk claims for snus and e-cigarettes

ObjectivesStudies examining perceptions of ‘modified risk tobacco product’ (MRTP) messages for e-cigarettes and smokeless tobacco have indicated consumers want statistics and quantification of harm reduction. However, limited research exists on...

Clinical and Radiological Characteristics of E-cigarette or Vaping Product Use Associated Lung Injury

Clinical and Radiological Characteristics of E-cigarette or Vaping Product Use Associated Lung Injury

Adverse Effects Associated with the Use of Electronic Vaping Products on Adolescents and Young Adults

Adverse Effects Associated with the Use of Electronic Vaping Products on Adolescents and Young Adults

Does Tobacco Screening in Youth Primary Care Identify Youth Vaping?

PurposeThe purpose of this study was to evaluate the sensitivity of a tobacco use screening question, modified to include the word “e-cigarette,” in detecting past 12-month nicotine vaping and past 12-month tobacco product use inclusive of nicotine vaping, among adolescent primary care patients. MethodsWe conducted secondary analysis of data from a pilot trial of adolescent substance use screening and brief intervention in pediatric primary care. Participants were patients aged 12–18 years (N = 278) presenting for annual well-visits at five practices in Massachusetts in 2015–2017. Study measures consisted of a clinical brief screener item and tobacco/electronic cigarette items on a confidential, self-administered research questionnaire (criterion measure). ResultsThe clinical brief screener item identified 24 of 30 adolescents with past 12-month tobacco use (sensitivity 80%); 15 of 30 with past 12-month electronic cigarette use (sensitivity 50.0%), and 25 of 42 with tobacco and/or electronic cigarette use (sensitivity 59.5%). ConclusionsThese findings support the need to develop and test a screening measure that is sensitive for capturing electronic cigarette use.

E-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI) in an Active Duty Service Member.

E-cigarette or vaping product use-associated lung injury (EVALI) is a developing serious pulmonary disease associated with the increasing use of vaping products in both civilian and active duty populations. This case study describes an active duty trainee using unbranded vaping products who developed acute respiratory distress syndrome necessitating intubation and multiday intensive care unit hospitalization. Diffuse ground glass opacities in imaging, lipid-laden macrophages found on bronchoalveolar lavage, negative infectious disease workup, and recent vaping indicate EVALI. This case demonstrates more work needs to be done within the Armed Forces to reduce use of vaping products given the danger of EVALI.

The vaping product use associated lung injury: is this a new pulmonary disease entity?

In the summer of 2019, an epidemic of e-cigarette or vaping product use associated lung injury (EVALI) broke out in the United States of America. EVALI is a lung disease that can be severe and life-threatening. It should be emphasized that EVALI is not a clinical diagnosis, but surveillance case definition. Due to the profile of users of such devices, the pathology mainly affects young adults, although cases of EVALI have been reported in almost all age groups, from teenage children to seniors. The worst prognosis is in patients over 35 years of age, with accompanying diseases. A significant number of patients declared the use of products containing tetrahydrocannabinol (THC). The most likely factor responsible for the occurrence of EVALI is vitamin E acetate, which is sometimes added to liquids necessary for the use of electronic cigarette type devices, especially those liquids that contain THC. Nevertheless, it is possible that other substances used in liquids may also be a causative factor. Typical for EVALI are respiratory, gastrointestinal and systemic symptoms, while in imaging tests, a characteristic feature of EVALI isthe presence of opacities on the chest radiogram and ground-glass clouds on computed tomography scans. In the course of this disease, respiratory failure often occurs (58%). In the vast majority of cases oxygen substitution is necessary. Currently, the best treatment of EVALI is considered tobe the administration of systemic glucocorticosteroids. Over 90% of patients with EVALI required hospitalization, while the mortality rate was about 2.42%. Median age of thefatalities was 51 years. The aim of this review is to summarise the available information on EVALI and to consider possible causative factors and pathomechanism.

Electronic Vaping Product Use among Young Adults Who Receive Care at a Major Medical Institution

Background: National estimates of electronic vaping product (EVP) use exist, but little is known about young adult EVP users who interact with the healthcare setting. Methods: Cross-sectional survey of 18–25 year olds receiving care in our ambulatory medical practice. Population differences were evaluated with the chi square test reporting unadjusted odds ratios (ORs). Results: Response rate was 16.6% (n = 1,017/6,119). The prevalence of ever EVP use was 46.0% of whom 13.9% used every day. Each additional day of alcohol use (past 30 days) was associated with increased odds of being an EVP user (OR = 1.06, 95% CI 1.02–1.09), and cannabis use (past 30 days) was associated with a higher odds of being an EVP user compared to non-cannabis users (OR = 40.0, 95% CI 17.4 − 111.8). Observing a biological parent (OR = 2.89, 95% CI 1.98–4.24), step parent (OR = 2.03, 95% CI 1.02–4.19) and full sibling (OR = 2.31, 95% CI 1.78–3.00) using inhaled substances (past 30 days) was associated with increased odds of being an ever EVP user. Ever EVP users had lower odds than never users to report that EVPs with nicotine are “a little” or “a lot” more harmful than smoking “regular” tobacco cigarettes (OR = 0.53, 95% CI 0.37 − 0.76). Conclusion: Our survey is limited by a low response rate but confirms observed associations between EVP use and substance use and social influences. Our data also suggest that professionals should regularly screen for EVP use among young people, especially those with exposure to family members who used inhaled substances.

Abstract 13869: Inflammatory Changes in the Lungs of Rats Exposed to E-cigarettes Without Marijuana, Vitamin E Oil, or Nicotine

Background: Recently, the clinical entity of EVALI (E-cigarette or vaping product use associated lung injury) was described and has similarities to COVID -19 pneumonia. We determined in a quantitative manner the inflammatory changes in the lungs associated with EVALI in a rodent model that does not include use of marijuana, vitamin E oil, or nicotine, which had been implicated as a cause. Methods: Adult Sprague Dawley rats were exposed to either pure air (n=5) or electronic cigarette (eC) vapor (propylene glycol/vegetable glycerin, tobacco flavoring) using a device with a nickel-chromium alloy (NC) heating element at 70 Watts (n=6) for 2 hours. The e-liquid did not contain nicotine, marijuana, or Vitamin E oil. Rats were euthanized within a few days of exposure and H&E-stained lung sections were assessed. Inflammatory cells were counted from 10 random areas per section at 20х magnification. Results: Alveolar structure appeared normal in the air group (Figure, panel C); the eC group using the NC heating element showed alveolar inflammation (D). The numbers of inflammatory cells per high power field in the lung parenchyma were significantly greater in the rats exposed to eC using NC heating element (67.5 ± 44.5) compared to the air group (6.7 ± 0.3; P < 0.001, Kruskal-Wallis test). The predominant cell type was mononuclear and secondary were neutrophils. Other features included accumulation of fibrin and inflammatory cells in the lumen of the trachea (A); thickened alveolar walls; and red blood cell congestion (D). Inflammation of the nasal passages was also observed (B). Exposure of rats to e cigarettes using a stainless steel heating element did not result in EVALI, and the amount of inflammatory cells was closer to air exposed rats (7.2± 0.4). Conclusion: Vaping using a nichrome heating element at high power leads to respiratory tract pathology and a significant increase in the number of inflammatory cells in the alveoli. EVALI occurred without marijuana, vitamin E oil or nicotine.

Measuring Poly-tobacco Product Use with Ecological Momentary Assessment

Objectives: Poly-tobacco product use is common among tobacco users, but it is challenging to assess patterns of use in real-life contexts. The objective of this study is to determine whether intensive longitudinal methods are feasible for assessing concurrent use of multiple tobacco products. Methods: Overall, 28 participants completed a baseline questionnaire and 7 days of ecological momentary assessment data collection, including end-of-day, random, and real-time reporting. Results: When estimating use of cigarettes, vaping products, and other products individually, there were moderate correlations between baseline questionnaire estimates, end-of-day estimates, and random estimates (ρ= 0.379–0.640); however, daily totals of all products combined were poorly correlated (ρ = 0.198–0.461). Baseline questionnaire estimates were higher than random estimates for each product (median difference 1.5–7.0 products per day). End-of-day estimates were more consistent with the baseline questionnaire. There was low compliance with real-time product use reports. Conclusions: Random or daily reporting are feasible for poly-tobacco use assessment, but methods are needed to reconcile differences in estimates. Accurate measurement of poly-tobacco product use is needed to assess health impacts and inform policy.