vaping

Introduction: The association between e-cigarette use and chronic bronchitis, emphysema, and
chronic obstructive pulmonary disease has not been studied thoroughly, particularly in populations
defined by concomitant combustible smoking status.

Methods: Using pooled 2016 and 2017 data from the Behavioral Risk Factor Surveillance System,
investigators studied 705,159 participants with complete self-reported information on e-cigarette use,
combustible cigarette use, key covariates, and chronic bronchitis, emphysema, or chronic obstructive
pulmonary disease. Current e-cigarette use was the main exposure, with current use further classified
as daily or occasional use. The main outcome was defined as reported ever having a diagnosis of

chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. For all the analyses, multi-
variable adjusted logistic regression was used, with the study population stratified by combustible ciga-
rette use status (never, former, or current). All the analyses were conducted in 2019.

Results: Of 705,159 participants, 25,175 (3.6%) were current e-cigarette users, 64,792 (9.2%) current
combustible cigarette smokers, 207,905 (29.5%) former combustible cigarette smokers, 432,462

(61.3%) never combustible cigarette smokers, and 14,036 (2.0%) dual users of e-cigarettes and combus-
tible cigarettes. A total of 53,702 (7.6%) participants self-reported chronic bronchitis, emphysema, or

chronic obstructive pulmonary disease. Among never combustible cigarette smokers, current e-ciga-
rette use was associated with 75% higher odds of chronic bronchitis, emphysema, or chronic obstruc-
tive pulmonary disease compared with never e-cigarette users (OR=1.75, 95% CI=1.25, 2.45), with

daily users of e-cigarettes having the highest odds (OR=2.64, 95% CI=1.43, 4.89). Similar associations
between e-cigarette use and chronic bronchitis, emphysema, or chronic obstructive pulmonary disease
were noted among both former and current combustible cigarette smokers.
Conclusions: The results suggest possible e-cigarette−related pulmonary toxicity across all thecategories of combustible cigarette smoking status, including those who had never smoked combus-
tible cigarettes.

What is already known about this topic?

CDC and partners are investigating the ongoing outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI) in the United States, the District of Columbia, and one U.S. territory.

What is added by this report?

As of October 22, 2019, a total of 1,604 cases of EVALI, including 34 deaths, were reported to CDC. Based on data collected as of October 15, 2019, use of tetrahydrocannabinol (THC)-containing products in the 3 months preceding symptom onset was reported by 86% of patients. The median age of EVALI patients who survived was 23 years, and the median age of EVALI patients who died was 45 years.

What are the implications for public health practice?

Most EVALI patients report using THC-containing products before symptom onset. CDC recommends that persons should not use e-cigarette, or vaping, products containing THC. Because the specific compound or ingredient causing EVALI is not known, persons should consider refraining from use of all e-cigarette, or vaping, products.

Abbreviation: THC = tetrahydrocannabinol.
* Reported as of October 15, 2019.
^† Percentages might not add up to 100% because of rounding.
^§ Data for the 13–17 and 18–24 age groups were combined to protect patient identity.
^¶ Whites; blacks or African Americans; American Indians or Alaska Natives; Asians, Native Hawaiians and other Pacific Islanders; and Others were non-Hispanic. Hispanic persons could be of any race.
** Data for persons in the following race/ethnicity groups were combined to protect patient identity: black or African American; American Indian or Alaska Native, Asian, Native Hawaiian, or other Pacific Islander, and Other.
^†† In the 3 months preceding symptom onset; categories not mutually exclusive.
^§§ Data on both THC- and nicotine-containing product use required to be included.

BACKGROUND:

E-cigarettes are battery-operated devices that heat a liquid and deliver an aerosolized product to the user. Pulmonary illnesses related to e-cigarette use have been reported, but no large series has been described. In July 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health received reports of pulmonary disease associated with the use of e-cigarettes (also called vaping) and launched a coordinated public health investigation.

METHODS:

We defined case patients as persons who reported use of e-cigarette devices and related products in the 90 days before symptom onset and had pulmonary infiltrates on imaging and whose illnesses were not attributed to other causes. Medical record abstraction and case patient interviews were conducted with the use of standardized tools.

RESULTS:

There were 53 case patients, 83% of whom were male; the median age of the patients was 19 years. The majority of patients presented with respiratory symptoms (98%), gastrointestinal symptoms (81%), and constitutional symptoms (100%). All case patients had bilateral infiltrates on chest imaging (which was part of the case definition). A total of 94% of the patients were hospitalized, 32% underwent intubation and mechanical ventilation, and one death was reported. A total of 84% of the patients reported having used tetrahydrocannabinol products in e-cigarette devices, although a wide variety of products and devices was reported. Syndromic surveillance data from Illinois showed that the mean monthly rate of visits related to severe respiratory illness in June through August of 2019 was twice the rate that was observed in the same months in 2018.

CONCLUSIONS:

Case patients presented with similar clinical characteristics. Although the features of e-cigarette use that were responsible for injury have not been identified, this cluster of illnesses represents an emerging clinical syndrome or syndromes. Additional work is needed to characterize the pathophysiology and to identify the definitive causes.