Last fall, a teenager entered Dell Children’s Medical Center in Austin complaining of some alarming symptoms: high fever, night sweats, weight loss, chills, general body pain and achiness, says James Tomkinson, MD, a pediatric resident at Dell who helped treat the patient.
Those symptoms matched a recent ailment that first appeared in the news in August 2019: EVALI, or “e-cigarette or vaping product use associated lung injury.” But the patient’s symptoms – as well as a CT scan that showed fibrous nodules in his lungs – could easily fit more established illnesses, including tuberculosis and cancer. On top of that, the teenager denied ever having vaped, Dr. Tomkinson says.
“Right now, if they’re denying that they’re [vaping] – which is not uncommon – we don’t have a pattern of lab results or findings of imaging that can clearly say, ‘Oh, yeah, we think this is vaping.’” Dr. Tomkinson said. “You’re stuck with doing a large, invasive workup to rule out all those other dangerous things first.”
That’s exactly what happened until, after two days of tests and denials, the patient admitted using vaping products that contained tetrahydrocannabinol (or THC), the psychoactive component in marijuana. (See “How E-cigarettes Cause EVALI,” page 20).
After treatment with steroids, the patient improved quickly and was sent home. But EVALI is so new that nobody knows what long-term damage EVALI patients may face, says Maria Monge, MD, director of adolescent medicine at Dell Children’s Medical Center.
“We’re really behind on the science compared to where the symptoms and the illness are,” she says.
Statistically, it appears a vaping-related health crisis is at hand. (See “EVALI By the Numbers,” page 19.)
Even before the news of EVALI and the growth of vaping use among teens, there were plenty of reasons for physicians to be concerned, says Dr. Monge, who also chairs the Texas Medical Association’s Committee on Child and Adolescent Health.
“Last year, probably in the spring, we started to see more and more kids who are having physical symptoms,” she said. “[It’s] not like EVALI and the lung-related stuff. We’re seeing increased anxiety, insomnia, difficulty [getting by] without vaping multiple times a day – like getting up in the middle of the night to vape. This is much more so than has ever happened with cigarettes.”
The rise in EVALI deaths and hospitalizations has changed the conversation about vaping, says Valerie Smith, MD, a pediatrician in Tyler who sits on TMA’s Council on Science and Public Health and chairs the Subcommittee on Behavioral Health. It gives physicians an opportunity to champion tighter rules and higher taxes on an untested, unhealthy product that remains lightly regulated in both the U.S. and Texas.
It’s also an opportunity to reset the conversation with teenage patients, widely seen as the main targets of vaping companies, she says.
“One of the great challenges of adolescent medicine is that we have to encourage patients to make choices for their long-term health and not just the short term,” she said. “Those stories [about EVALI deaths and illness] really do have some impact among teenagers. It’s not just that the thing might kill you in 30 years, but that this thing might just kill you tomorrow.”
Picking up steam
The first e-cigarettes appeared in the U.S. in 2006, as combustible tobacco products and chewing tobacco – the traditional nicotine delivery systems of choice – were in the midst of a long retreat from American life.
Over the past two decades, courts have ruled against tobacco companies, anti-tobacco advertising has increased, and more workplace smoking bans as well as long-sought regulation of tobacco products by the U.S. Food and Drug Administration (FDA) have taken effect. Most importantly, young people have turned away from smoking. Cigarette use among Texas high school students dropped from 30.9% in 2001 to 8.7% in 2017, closely following national trends, according to the Texas Department of State Health Services (DSHS).
But physicians say the rise in popularity of vaping threatens that progress. Not only are more high school students vaping, they’re doing it more than before. CDC stated in September 2019 that 27.5% of U.S. teens reported using an e-cigarette in the previous 30 days, up from 20.8% in 2018 and 12% in 2017.
“The skyrocketing growth of young people’s e-cigarette use over the past year threatens to erase progress made in reducing youth tobacco use,” CDC Director Robert Redfield, MD, said in a statement in February 2019. “It’s putting a new generation at risk for nicotine addiction.”
The vaping industry has touted e-cigarettes as a way to wean smokers off traditional cigarettes. But there’s no evidence that approach works, Dr. Monge says. In her experience, young people are simply vaping where they think they can’t smoke, and smoking the rest of the time, she says.
“It has become much more socially acceptable to have a vape pen [at schools],” she said.
Vaping also is so widely billed as being harmless that many young people don’t even realize that they are inhaling a poisonous substance, says Lindy McGee, MD, an assistant professor of pediatrics at Baylor College of Medicine in Houston. Vaping appeals to them because it comes in candy-like favors.
“I’ve heard that before [from young patients] – ‘I’m just vaping flavors, there is no nicotine in it,’” she said.
The vape flavoring diacetyl – a compound used to give a butter-like flavor to foods like popcorn – has been shown to cause “popcorn lung,” a dangerous scarring of the lungs, and nicotine use among young people has been shown to impair brain growth (tma.tips/2016SurgeonGeneralReport).
But because vaping is so new, there’s no long-term data about whether it causes chronic ailments such as lung cancer, Dr. Monge says. There also is no science to explain the full long-term impact on vapers when they regularly receive such high doses of a powerful stimulant, though some of the short-term effects are obvious, she says.
“They’re coming in with heart rates in the abnormal range,” she said. “They’ve got heart rates of 100 to 120 just sitting in front of me. I don’t think it can be underestimated the systemic effects of these high levels of nicotine.”
There also is no science explaining how to get e-cigarette users to stop vaping. For instance, it’s unclear if smoking cessation drugs like Chantix and Wellbutrin work for people who are used to the high levels of nicotine vapers become accustomed to, she says.
“We’re kind of flying blind on that,” Dr. Monge said. “We have so many young adults who vape [at our clinics] – it’s just staggering,” she said. “And we have not been successful in [helping] many – if any – of them to cut back.”
Vaping also can have a huge social cost for the young people who take it up, Dr. Smith says.
“Nicotine is such an addictive substance it becomes the driver for everything they’re doing,” she said. “It becomes the driver for how they spend their time, who their friends are, and their other relationships. It can be very isolating once they become addicted.”
Kicking the habit
Physicians who want to tackle this problem need to screen patients specifically for vaping if they aren’t doing that already, Dr. Smith says.
“One of the most important places to start is to begin asking [patients about vaping],” she said. “We’re trained to ask about tobacco use or cigarette use, but that is not the language teenagers speak. They often don’t even equate vaping with tobacco…. [Physicians should] be asking those things to get a handle on who’s using and who’s not.”
Adding vaping to electronic medical records also is important, says Dr. McGee.
“I’m working on a project right now with Baylor College of Medicine to increase physician communication on vaping,” she said. “One of the things we did was get it added to the electronic medical record so that during the well-child check with adolescents the language is there, and the way to track it is there.”
And prevention efforts that work for smoking are worth trying on vaping, Dr. McGee adds.
“There’s a lot of research on smoking that says physicians counseling against smoking – especially to patients who haven’t started yet – is very effective in keeping them from smoking,” she said. “Even if they are using tobacco products, brief counseling from a physician can help them decide to quit. We may not feel like we’re doing much sometimes, that we’re just saying, ‘Good job,’ but it has been shown to help.”
One of the most effective ways to counsel young people is to praise them for being smart enough to ignore tobacco industry ads.
“If you ask a patient, and they say haven’t started smoking [or vaping], say, ‘That is an excellent decision. I know the tobacco industry is pouring millions into advertising to get kids your age to start smoking. You’re so smart to see past all that,’” Dr. McGee said. “You want them to rebel against the tobacco industry instead of rebelling against you.”
Regulatory efforts
Vaping is subject to the “Tobacco 21” law, or Senate Bill 21, passed by the 2019 Texas Legislature with backing from the TMA. It forbids the sale of tobacco or vaping products to anyone under 21 (except for military personnel). And in late December, Congress passed a similar federal law, with no exception for the military.
However, there are few other state and federal regulations on vaping. In November, the American Medical Association House of Delegates urged the federal government and the states to ban all e-cigarettes and vaping products except those FDA-approved items prescribed by physicians to help their patients stop smoking.
At the federal level, FDA has the authority to clamp down on vaping, but most efforts to do that have been delayed or weakened by the courts and by both Democratic and Republican administrations over the past decade.
News of the EVALI outbreak prompted renewed calls for a ban on flavored e-cigarettes. In September, President Donald Trump announced his support for a ban on flavors. In January, FDA announced a partial ban on most flavored e-cigarettes and vaping products that is expected to take effect by the end of January. The ban does not apply to menthol and tobacco-flavored products, and vape shops still will be allowed to sell flavors from tank-based systems.
“By prioritizing enforcement against the products that are most widely used by children, our action today seeks to strike the right public health balance by maintaining e-cigarettes as a potential off-ramp for adults using combustible tobacco while ensuring these products don’t provide an on-ramp to nicotine addiction for our youth,” HHS Secretary Alex Azar said in a statement. “We will not stand idly by as this crisis among America’s youth grows and evolves, and we will continue monitoring the situation and take further actions as necessary.”
In October, Juul – the largest e-cigarette company – suspended the sale of most of its flavors. On Nov. 7, 2019, Juul, which is partly owned by cigarette-maker Altria, said on its website that it sells only tobacco and menthol flavors in the U.S. and will not sell any others unless they are authorized by the FDA.
Some cities, like San Francisco, have moved to ban the sale and distribution of e-cigarettes, while others have moved to regulate the devices more tightly. Meanwhile, some large retailers, like Kroger and Wal-Mart, have said they would stop selling e-cigarettes.
In November 2019, state Lt. Gov. Dan Patrick charged a Texas Senate committee with examining the public health concerns stemming from the rise in e-cigarette use, especially among minors. The committee, which met on Dec. 3, 2019, heard testimony from Dr. McGee, who spoke on behalf of TMA as well as the Texas Pediatric Society and other health organizations.
She called for several strong measures to regulate vaping, including:
• Increased taxes on conventional cigarettes of at least $1 per pack and an excise tax on e-cigarettes that achieves parity with combustible cigarettes. That includes using a significant portion of tax revenue for additional evidence-based tobacco cessation programming at DSHS and retail enforcement activities. Raising the price of tobacco products is a proven way to discourage young people from buying them, Dr. McGee says.
• Banning all characterizing flavors in tobacco products and e-cigarettes.
• Requiring all e-cigarette retailers to obtain a permit to sell e-cigarette products, similar to the current tobacco retailer permit.
“While we had been lauding ourselves for the decreasing rates of smoking in teens over the past 20 years, the tobacco industry had been actively recruiting a new generation of nicotine addicts right under our noses,” Dr. McGee told the committee.
Tex Med. 2020;116(2):16-21
February 2020 Texas Medicine Contents
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