Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine : Anesthesia & Analgesia

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Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine

Rusy, Deborah A. MD, MBA, FASA*; Honkanen, Anita MD; Landrigan-Ossar, Mary F. MD, PhD, FASA, FAAP; Chatterjee, Debnath MD, FAAP, FASA§; Schwartz, Lawrence I. MD; Lalwani, Kirk MBBS, FRCA, MCR; Dollar, Jennifer R. MD#; Clark, Randall MD, FASA; Diaz, Christina D. MD, FASA, FAAP**; Deutsch, Nina MD††; Warner, David O. MD‡‡; Soriano, Sulpicio G. MD

Author Information
Anesthesia & Analgesia 133(3):p 562-568, September 2021. | DOI: 10.1213/ANE.0000000000005519
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See Article, p 561

Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population.1,2 Vaping is a term referring to the inhalation of aerosols produced by a variety of devices that heat a liquid generally containing nicotine, flavoring, and various other chemicals. Other names for vaping devices, or electronic nicotine delivery systems (ENDS), include mods, vapes, subohms, vape pens, e-hookahs, tank systems, and e-cigarettes. Over 460 brands of vaping devices were described in an article published in 2014.3 They are marketed with the trendy names, such as GeekVape Aegis (Shenzhen, China), Baton V2 (Baton Vapor, Seattle, WA), Suorin Shine (Suorin USA, Brea, CA), Mango Ice (Vaporlax, Shenzhen, China), and Strawberry Ice (Tripl3, Ft. Mill, SC), and contain flavor additives targeting the appetites of children and teens.

These devices function through 4 key components, such as a container for the liquid solution, a heating element to vaporize the liquid, a power source, and a mouthpiece to channel the vapor to the user. They are often not only made to resemble a variety of traditional nicotine-producing products, such as cigarettes, cigars, and pipes, but also disguised in many everyday object designs, such as pens or memory sticks, enabling surreptitious use.

Vaping products may have significantly higher nicotine levels when compared to traditional cigarettes, and no consensus exists on how the strength of nicotine is reported on these products. Vaping liquid nicotine strength is often characterized as low (6–12 mg/mL), medium (18 mg/mL), and high (24 mg/mL). Products exceeding 24 mg/mL are also commercially available.4 In comparison, the average cigarette has 10–12 mg of nicotine.

Since 2014, e-cigarettes have become the most commonly used tobacco-based products among youth in the United States. E-cigarette use among the US middle and high school students increased by 900% during 2011–2015.5 Following a decline in use between 2015 and 2017, e-cigarette use again increased by 78% between 2017 and 2018.6 In 2019, an estimated 27.5% of high school students and 10.5% of middle school students reported using e-cigarettes within the past 30 days. Among those e-cigarette users, an estimated 34% of high school students and 18% of middle school students reported frequent use (20 or more days in the past 30 days), and 21% of high school students and 8.8% of middle school students reported daily use.7 JUUL (San Francisco, CA) was the most popular brand among the youth e-cigarette users. Seventy-eight percent of young users have seen a television advertisement for e-cigarettes.8 Furthermore, the use of flavored products, such as fruit, candy, and mint, has been successful in marketing to children and adolescents. Notably, 72% of high school students who vape and 59% of middle school students used flavored products.5 Children and adolescents are 3–4 times more likely to use these flavored substances than adults.9 Marijuana products are also becoming increasingly popular among students who vape. From 2017 to 2018, the reported prevalence of marijuana use in e-cigarettes among all students increased by 3.6%.10 Furthermore, youth who use e-cigarettes are more likely to use traditional cigarettes or other tobacco products. In a recent meta-analysis, adolescents and young adults who have used e-cigarettes are 3.6 times more likely to report subsequent cigarette smoking compared with those who have not.11

The addictive nature of e-cigarettes is at least equivalent to the addictive nature of conventional cigarettes, if not more.5 Multiple studies continue to confirm the increased risk of long-term nicotine use, including conventional cigarettes, in youth who use e-cigarettes. Nicotine is a central nervous system stimulant that activates the release of multiple neurotransmitters throughout the brain with subsequent positive mood–modulating effects.12 Adding to the risk of addiction, at least 1 study has determined that e-cigarettes are less irritating during use compared to the Food and Drug Administration (FDA)–approved nicotine inhalers for smoking cessation.13 The availability of enticing flavors for e-cigarettes in addition to less noticeable irritation with possibly higher inhaled nicotine levels makes these products much more attractive to youth and young adults leading to an increased risk of long-term nicotine addiction.


E-cigarette, or vaping, product use–associated lung injury (EVALI) is a newly identified lung disease caused by vaping. Initial clinical presentation of EVALI can be varied, but most commonly includes the respiratory and gastrointestinal tracts as well as constitutional symptoms. Respiratory symptoms frequently include hypoxia, tachypnea, shortness of breath, pleuritic chest pain, chest pain, occasionally hemoptysis, and cough. Many patients present with concurrent nausea and vomiting, abdominal pain, diarrhea, anorexia, and weight loss. Occasionally, patients present with gastrointestinal symptoms before noting any respiratory symptoms. Constitutional symptoms include fever, malaise, and fatigue.14–18 Patients may also present with headache, and 1 episode of seizures has been reported.15 The majority of patients present with respiratory symptoms, and respiratory failure can progress quickly and may even develop into acute respiratory distress syndrome (ARDS).19 Radiologic imaging generally demonstrates bilateral diffuse lung opacities on chest radiograph. Computerized tomography (CT) scan shows lower lobe predominant ground glass and consolidative opacities, often with subpleural space or lobular sparing. Pleural effusion is not common.20,21

As part of the diagnostic workup, some patients may undergo flexible bronchoscopy with bronchoalveolar lavage (BAL). BAL specimens have demonstrated the presence of neutrophils and lipid-laden macrophages.22 Bronchoscopy has demonstrated mucosal hypervascularity and erythema, edema, hemorrhage, and lesions in the airway.17 Flexible bronchoscopy with BAL and the associated anesthesia has led to the prolonged intubation and the progression of respiratory distress in patients and was noted to trigger an increased airway reactivity during the procedure.19 Some patients have also undergone either an open lung biopsy or a transtracheal lung biopsy as part of their diagnostic workup.23 While the mechanism of injury is not well defined, EVALI is considered a diagnosis of exclusion and infectious, oncologic, and rheumatologic etiologies need to be considered and ruled out.24

The treatment consisted of supportive therapy including supplemental oxygen, noninvasive ventilation, mechanical ventilation, and rarely extracorporeal membrane oxygenation (ECMO).14,19,22 Empiric antibiotics are typically administered during the diagnostic workup.14 EVALI is treated with vaping cessation and, when necessary, the initiation of a course of glucosteroids.14,17,23,25,26 The length and dose of steroid treatment are yet to be determined, as some patients have required a second course or hospital readmission.17,18

While most patients recover, a significant portion of patients identified with EVALI require hospitalization and treatment, and some patients have died as a result of the disease.27 Furthermore, EVALI patients who are older or with preexisting conditions are at a greater risk of death. Although there is a resolution of symptoms and CT scan findings in the patients who were followed up after discharge,26 2 other articles described persistent increased airway reactivity and impaired diffusion capacity on pulmonary function tests at 2- to 6-week follow-up.17,18 The Center for Disease Control published a comprehensive report of pulmonary histopathology from lung tissue from 23 individuals with a history of e-cigarette use.28 Acute to subacute lung injuries ranging from pneumonia to diffuse alveolar damage were noted in these specimens.


Risk factors for EVALI are still undetermined. In a recent report on EVALI in Illinois and Wisconsin, the median age of patients was 21 years (range, 15–53), with 26% <18 years. The majority of patients had no underlying chronic lung disease, with the exception of asthma in 22%.14 Similarly, in a case series from Utah, nearly a quarter of patients who presented with EVALI had a history of asthma, bringing into question whether this is an association or whether those with asthma are predisposed to this form of lung injury.18

The more frequent use of vaping products is associated with EVALI as well, with 87% of patients reporting e-cigarette use 90 days prior in 1 study.28 In a survey conducted by the Illinois Department of Health, EVALI patients reported a higher incidence of frequent use (more than 5 times per day) compared to those who vaped and were not affected by EVALI.29

Pathologically, EVALI can present in many forms though the exact causative agents remain unknown. Identification of these agents is complicated by the fact that numerous compounds are often present in vaping mixtures, many of which are bought from the black market. In a recent evaluation of EVALI patients, most of the used products were obtained illicitly or informally (from friends and family members).30 Many patients are also not forthcoming with known information due to concerns that some of these agents are illegal in many states, further confusing the picture.

Tetrahydrocannabinol (THC)-containing products have most commonly been associated with EVALI nationwide, with 89% of affected patients having an exposure to THC in 1 cohort.28 Vitamin E acetate is also contained in THC-containing e-cigarette products. Its presence in the BAL samples of 94% of affected patients and complete lack of presence in control patients are highly suggestive of its association with interstitial lung injuries.31 However, nicotine alone has been associated with acute interstitial lung disease, including acute eosinophilic pneumonia, respiratory bronchiolitis-associated interstitial lung disease, and hypersensitivity pneumonitis.28,32

Propylene glycol, another agent commonly found in vaping products, activates irritant receptors, which have been shown to promote asthmatic inflammation and airway hyperreactivity. An in vitro study found that varying concentrations of some flavors, most notably vanillin and cinnamaldehyde, correlate with cytotoxicity and ciliary dysfunction.33 Interactions of these flavors with propylene glycol may form acetal compounds that have respiratory effects.34 Diacetyl, a compound previously used in the flavoring of popcorn, is also found in many e-cigarette flavors. It is known to cause bronchiolitis obliterans when inhaled, and this clinical presentation has been seen in some cases of EVALI.35 Other potentially toxic compounds linked to vaping and potentially EVALI include benzene, toluene, and trace metals.36 Ultimately, the cause of EVALI may be multifactorial. As vaping involves heating an e-liquid with the aforementioned solvents, there may be a production of new toxins that cause further inhalational burn injury.18,28

Fortunately, the number of EVALI cases has been rapidly declined because of its peak in the United States in September 2019.37 Contributing factors to this decline may include increased public awareness of the risk associated with THC-containing e-cigarette or vaping product use as a result of the rapid public health response, removal of vitamin E acetate from some products, and law enforcement actions related to the illicit products. Nonetheless, EVALI serves as a cautionary tale of the potential dangers of inhaling vapors and that both the short- and long-term effects of these vapors remain largely unknown.


A cross-sectional study of 705,159 respondents from the 2016 and 2017 Behavioral Risk Factor Surveillance System pooled data reported that among e-cigarette users who were never combustible cigarette smokers, there was an associated 75% higher odds of chronic bronchitis, emphysema, or chronic obstructive pulmonary disease compared with never e-cigarette users.38

Another large cohort study of 21,618 US adults demonstrated that e-cigarette use was associated with significantly increased risk of major respiratory diseases, independent of cigarette smoking, and other tobacco product use.39 Among current e-cigarette respondents with good self-reported health, the incidence rate ratio (IRR) was 1.33 (95% confidence interval [CI], 1.06-1.67) for chronic bronchitis, 1.69 (95% CI, 1.15-2.49) for emphysema, 1.57 (95% CI, 1.15-2.13) for chronic obstructive lung disease (COPD), and 1.31 (95% CI, 1.01-1.71) for asthma. The limitations of this study included a reliance on self-reported data. They concluded that despite existing evidence, the long-term effects of e-cigarette use on clinical respiratory end points remain unclear. As COPD is typically a disease that is evident after years of smoking, future studies, such as serial pulmonary function tests, may be needed to understand the full risk of e-cigarette–attributable lung disease, such as COPD.


Coronavirus disease 2019 (COVID-19) has not only wreaked havoc on global health but has also had an impact on the vaping community. A case series of adolescents who had symptoms consistent with COVID-19 but negative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA test and respiratory viral panels revealed significant e-cigarette use by these individuals.40 A recent survey of individuals aged 13–24 years who vaped alone, or with smoking, were at 5 or 7 times increased risk, respectively, of a COVID-19 diagnosis compared with naive cohorts.41 This alarming finding underscores the need for vaping and smoking education, cessation, and adjustments in risk stratification in these doubly vulnerable individuals.42 During the COVID-19 pandemic, the reported use of e-cigarettes by youth changed due to diminished access to vape shops.43


Studies have shown that cigarette smoking has been implicated as a risk factor for postoperative complications in many different surgical subspecialties. Patients who smoke and undergo surgery have longer hospital stays, a higher risk of readmission, a higher rate of being admitted to an intensive care unit, and an increased risk of in-hospital mortality in comparison to nonsmoking patients.44–47 Longer periods of smoking cessation appear to be more effective in reducing the incidence/risk of postoperative complications. A systematic review of 25 studies on the optimal timing of smoking cessation concluded that at least 4 weeks of abstinence from smoking reduced respiratory complications, and abstinence of at least 3–4 weeks reduced wound healing complications.48 A retrospective review of ambulatory surgeries demonstrated that smokers may be at a greater risk of postoperative complications, such as delayed wound healing, pulmonary complications, and mortality than nonsmokers.49

Smoking and vaping appear to be equally detrimental to wound healing and to be associated with a statistically significant increase in flap necrosis compared with the unexposed group. The results suggest that vaping should not be seen as a better alternative to cigarette smoking in the context of wound healing.50

E-cigarettes may have just as much of a detrimental effect on tissue oxygenation as traditional cigarettes. Thermal imaging has demonstrated that the use of ENDS reduced cutaneous blood flow in the peripheral circulation in humans.51 Despite the normal pulmonary function tests, asymptomatic patients with a daily use of e-cigarettes for at least 1 year had a significant ventilation–perfusion mismatching that worsen immediately after vaping.52 Studies suggest that subclinical alterations in the lung function in asymptomatic patients who routinely use e-cigarettes are usually not detected by routine spirometry.53 It is, therefore, not practical to perform preoperative pulmonary function tests in asymptomatic vapers.


There is a clear evidence that demonstrates the benefits of preoperative and long-term postoperative smoking cessation. Smoking cessation discussions should be introduced early by patient’s primary care provider; however, it is also imperative that this topic is discussed in both the surgical and anesthesia preoperative screening clinics.54–56 We recommend that screening regarding vaping use is done on all adolescents undergoing preoperative evaluations. A clear distinction between e-cigarette and cigarette use should be made during the preoperative interview. Nonthreatening and nonjudgmental queries into inhalant use that include nicotine and cannabis either through smoking or ENDS should routinely be obtained in this vulnerable patient group.

If suspected that a patient may have EVALI, preoperative workup should include a thorough history enquiring about smoking history including e-cigarette and vaping use, respiratory symptoms (eg, cough, chest pain, and shortness of breath), gastrointestinal symptoms (eg, abdominal pain, nausea, vomiting, and diarrhea), fever, chills, and weight loss. Physical examination should include vital signs and pulse oximetry, as these patients may present with tachycardia, tachypnea, and O2 saturation <95% at rest on room air. If respiratory symptoms are present, consider chest X-ray or chest CT scan.25 Consider consultation with a pulmonologist in patients with significant findings. The decision to perform bronchoscopy and BAL to rule out other diagnoses such as pulmonary infection should be made on an individual patient basis. A recent case series reported a significant intraoperative reactive airway disease and hypoxia and postoperative mechanical ventilation for respiratory failure in adolescents with EVALI.57 As noted earlier, the most severe cases may require the administration of steroids.17

For patients using e-cigarettes, or vaping products, consider referral to tobacco cessation strategy therapies. The Society for Perioperative Assessment and Quality Improvement recently published a consensus statement that promotes perioperative smoking cessation as a modifiable risk factor for improving overall patient outcomes.56 Although this document stated that “There is insufficient evidence to determine the safety and efficacy of e-cigarettes for perioperative smoking cessation,” EVALI clearly places these patients at an increased risk of perioperative pulmonary morbidity. Therefore, clinicians should identify “at-risk” individuals during preanesthetic evaluations and determine the substance that they vape because chronic bronchitis is more prevalent with cannabis when compared to nicotine.58 Given the relatively recent introduction of e-cigarettes, and the lack of published reports of the intraoperative course of e-cigarette users, no current evidence is available to guide the intraoperative management of these patients. As the long-term impact on adolescent health is unknown, there is a paucity of postoperative outcomes in this vulnerable population to propose evidence-based recommendations for the management of these patients.

There is, to date, no evidence to justify extended postoperative monitoring for the patients with a history of vaping. Patients who use tobacco vaping products may be at risk for nicotine withdrawal in the perioperative period. Caregivers should be aware of the potential physical (headaches, sweating, restlessness, tremors, and digestive issues) and psychological (irritability, anxiety, and mood swings) symptoms and how to manage them.

The current epidemic of youth e-cigarette use and EVALI demand immediate and swift action by regulatory bodies at the state and national level to protect public health.59 Vaping products are inherently unsafe whether they contain THC or not. Both nicotine and marijuana affect brain development in young adulthood and serve to increase the likelihood of tobacco and cannabis use disorders later in life. Strategies to address these epidemics include adding vaping products to tobacco control strategies, additional restrictions on flavors, as well as youth and provider education and long-term surveillance of the health outcomes of EVALI. Given the addictive nature and potential detrimental health consequences of nicotine, THC, and e-cigarettes, it is the recommendation of these health organizations to prevent the habit of vaping and to advocate cessation of use to our patients. A recent web-based review of current e-cigarette prevention and cessation programs noted the lack of evidence-based tools, resources, and evaluations available to assess and inform adolescents about e-cigarette risks and cessation.60 We encourage continued research on the longitudinal effects of e-cigarette use on symptomatology, especially the early subclinical effects of vaping, and further postoperative outcome studies of patients who use vaping products. We also recommend limiting access of vaping products and nicotine-containing products to our youth. We encourage continued education of the public and health care providers of the risks associated with vaping and encourage regular screening of patients with regard to smoking and vaping use. Finally, we recommend that advertising of the e-cigarette products no longer be directed toward children and adolescents.


Name: Deborah A. Rusy, MD, MBA, FASA.

Contribution: This author helped research, write, and submit the manuscript.

Name: Anita Honkanen, MD.

Contribution: This author helped research and write the manuscript.

Name: Mary F. Landrigan-Ossar, MD, PhD, FASA, FAAP.

Contribution: This author helped research and write the manuscript.

Name: Debnath Chatterjee, MD, FAAP, FASA.

Contribution: This author helped research and write the manuscript.

Name: Lawrence I. Schwartz, MD.

Contribution: This author helped research and write the manuscript.

Name: Kirk Lalwani, MBBS, FRCA, MCR.

Contribution: This author helped research and write the manuscript.

Name: Jennifer R. Dollar, MD.

Contribution: This author helped research and write the manuscript.

Name: Randall Clark, MD, FASA.

Contribution: This author helped research and write the manuscript.

Name: Christina D. Diaz, MD, FASA, FAAP.

Contribution: This author helped research and write the manuscript.

Name: Nina Deutsch, MD.

Contribution: This author helped research and write the manuscript.

Name: David O. Warner, MD.

Contribution: This author helped research and write the manuscript.

Name: Sulpicio G. Soriano, MD.

Contribution: This author helped research, write, and submit the manuscript.

This manuscript was handled by: James A. DiNardo, MD, FAAP.


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