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Review Article

The Good, the Bad, and the Ugly

Vaping in America

Grace, Kathleen RRT, RCP, MBA

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Journal of Pediatric Surgical Nursing: 4/6 2020 - Volume 9 - Issue 2 - p 52-56
doi: 10.1097/JPS.0000000000000249
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“If you save your breath I feel a man like you can manage it. And if you do not manage it, you’ll die. Only slowly, very slowly old friend.”—Tuco, from The Good, the Bad, and the Ugly. 1966.


In late September 2019, a 17-year-old presented to his primary care provider with symptoms of vomiting, cough, diarrhea, chills, and fever. Naturally, it was determined that he most likely had the flu. He was sent home with Tamiflu (an antiviral drug) and told to hydrate and rest.

His symptoms continued over the next 4 days, eventually experiencing chest pain. He presented to the emergency department with mild shortness of breath, dehydration, and a slight fever. A patient history was obtained, with no comorbidities, denying cigarette smoking and drug use. After further questioning, he revealed “a few times I vaped.” Antibiotics were initiated.


Up until very recently, terms such as vaping, e-cigarettes, vapes, JUUL, vape-pods, and vape-pens were not part of our everyday nomenclature and discussions. Chances are, 2 years ago, one would have questioned the odd terms. A vape device (vape-pod, vape-pens, e-cigs, JUUL) is a small gadget, about the size of a USB flash drive, that heats and evaporates a liquid substance and condenses it to an aerosol for the user to inhale. There is no smoke, but just a very fine mist of liquid droplets. The liquid can contain nicotine, tetrahydrocannabinol (THC), and cannabinoid (CBD) oils, along with other substances for flavorings and additives (Centers for Disease Control and Prevention [CDC], 2020; Lee, Allen, & Christiani, 2019).

The particle size of e-cigarette vapor appears to vary among the different researchers, with reports of 2.5–1 μm and reporting ultrafine particles of less than 0.1 μm (Belka, Lazai, & Jedelsky, 2017). This can be compared to the mean mass size of cigarette smoke of 0.3–0.5 μm (Anderson, Wilson, & Hiller, 1989; Cheng, 2014; Gardenhire, Burnett, Strickland, & Myers, 2017; Sahu, Tiwari, Bhangare, & Pandit, 2013). The reason these particle sizes are important is the relationship with our normal airways in air movement. In the tree of our airway system, inhaled particles of the 5- to 10-μm size impact upon the airway in the first six generations or the large bronchi. Diffusion of particles occurs in the last five to six generations of the tree at 1–5 μm or the lower airways and lung periphery (Gardenhire et al., 2017; Sosnowski & Odziomed, 2018). Both traditional cigarette smoke and e-cigarette vapor can reach the lower airways, but e-cigarettes have even finer particles, with the potential of reaching farther in the smaller airways (Lampos et al., 2019; Sosnowski, Odziomed, 2018).

Vaping devices were introduced to the U.S. market in 2007 (Richter, 2018). Nurses and healthcare providers must be concerned, as it is estimated (Preidt, 2019) by the CDC that, despite the warning about vaping dangers, one in four high school students and 1 in 10 middle school students continue to use e-cigarettes. The U.S. Food and Drug Administration (FDA) delayed any action regarding reviewing and regulating the electronic cigarette products, unlike current regulations already in place for nicotine patches or gum. The FDA was given authority to regulate all tobacco products in 2016 but chose to delay enforcement until 2022. After a lawsuit was filed, the FDA was ordered in April 2019 to speed up reviews of e-cigarettes already on the market (Weixel, 2019). By this time, it was already apparent that there was a spike in underage vaping and growing concerns of public health risks.

The global market for e-cigarettes was quite substantial by 2018, with a value of $14.05 billion, with an expected growth of more than 20% by 2022 (Business Research Company, 2019). The promoting factor by the e-cigarette industry was driven by the concerns around tobacco smoking, with the assumption that e-cigarettes provided a safer mechanism to deliver nicotine (Kanski, 2019). Companies, such as JUUL, started using social influence campaign strategies, causing the sharp increase in teen vaping. Popular flavored pods used in the devices were attractive with their mango, mint, cucumber, gummy bear, berry blend, chocolate, peach, cotton candy, strawberry, and grape flavors. According to survey released by National Youth Tobacco Survey, “more than 3.6 million middle and high school students used e-cigarettes, an increase of 1.5 million in one year” (Tobacco Free Kids, 2020). The stage was set, with youth and young adults addicted to nicotine, THC, and CBD vaping products.

The disastrous vaping outbreak began in June 2019, according to the CDC (CDC, 2020; Duffy et al., 2020; Ellington et al., 2020). It has been termed as electronic-cigarette vaping product use-associated lung injury (EVALI).


The CDC reports EVALI appears to be declining since its peak in September 2019 (CDC, 2020). Hopefully, between the CDC, the media reports, and professional society communication alerts (Balmes, 2019; CDC, 2020; Heart, 2020; Mayo Clinic, 2020; Office of Governor Gavin Newsome, 2019; Sisson, 2020; Tobacco Free Kids, 2020), the message is getting out: Refrain from the use of all e-cigarettes or vaping products.


From a review of the statistics as of early January 2020, the CDC reported 2,602 EVALI cases or deaths from all 50 U.S. states, the District of Columbia, Puerto Rico, and U.S. Virgin Islands (Figure 1). There were 57 confirmed deaths in 27 states and the District of Columbia. THC appears to be the most consistent element in the cases using e-cigarettes or vaping products. It also appears that these products are obtained mostly in-person from family and friends or online. Eighty percent of cases are younger than 34 years of age, with 38% younger than 21 years (Balmes, 2019). The January update by CDC recognized adolescents ages 13–17 years were more likely to obtain products from informal sources (family, friends, and online) than older individuals (Ellington et al., 2020).

Number of electronic-cigarette vaping product use-associated lung injury cases. From the Centers for Disease Control and Prevention website, used with permission.

Most EVALI cases were associated with THC-containing products acquired from informal sources; however, 16% reported obtaining from commercial sources (Ellington et al., 2020). Although a large number of EVALI cases are linked to use of THC, some patients presented with EVALI reported only using nicotine vaping/e-cigarette products (Balmes, 2019). The toxin vitamin E acetate has been identified in bronchoalveolar lavage (BAL) fluid samples of EVALI patients from a study published in the New England Journal of Medicine (Christiani, 2020), and it appears as though this is the underlying causative agent (Duffy et al., 2020; Triantafyllou et al., 2019). To complicate matters more, e-cigarettes have “at least six groups of potentially toxic compounds: nicotine, carbonyls, volatile organic compounds, particles, trace metal elements and bacterial endotoxins and fungal glucans” (Christiani, 2020).


THC-filled counterfeit brand cartridges are readily obtained online according to the CDC. A Wisconsin/Illinois public health official study reported that 66% of the patients interviewed used the counterfeit THC products (Balmes, 2019). The JUUL product is a closed-pod device and is primarily marketed as a nicotine delivery device. It has received considerable criticism for its marketing practices with flavored products (mint, strawberry, watermelon) attractive to teenagers and children. Products using a “tank” can be filled with a nicotine-type product, THC, or CBD oil. The pathophysiology identified behind most of the research centers around an additive oily product, which acts as a thickener to the liquid, resulting in an exogenous lipoid pneumonia, commonly called ELP (Chatham-Stephens et al., 2019; Christiani, 2019; Office of Governor Gavin Newsome, 2019).


Up until this recent outbreak of EVALI, ELP has been considered a rare form of pneumonia. Simply put, it is caused by a chronic foreign body reaction to the inhalation or aspiration of a fatty substance (Simmons, Rouf, & Whittle, 2007). In the past, if ELP was identified, it was due to aspiration or inhalation of petroleum jelly, mineral oil, or other ingestible oils. In the EVALI cases, evidence points to the vitamin E acetate found in the vaping products (Christiani, 2020; Duffy et al., 2020). The inhaled lipid remains in the alveoli or may be absorbed by the alveolar macrophages. Because the macrophages cannot metabolize the lipid, it is again released into the alveoli when the macrophages die (Russo, Chiumllo, Cassani, Maiocchi, & Gattinoni, 2006; Simmons et al., 2007). Patients present with interstitial fibrosis and chronic inflammation. Biopsies reveal normal alveolar walls and septae, but lipid-filled macrophages (Russo et al., 2006). CT scans of the chest are very typical of acute respiratory distress syndrome, with the ground glass appearance of the lung. BAL can also return with the lipid-filled macrophages. The specific diagnosis of ELP is difficult because the signs and symptoms are not specific (Simmons et al., 2007).


In late September 2019, an 18-year-old presented to his primary care provider with symptoms of vomiting, cough, diarrhea, chills, and fever. Naturally, it was determined that he most likely had the flu. He was sent home with Tamiflu (an antiviral drug) and told to hydrate and rest.

His symptoms continued over the next 4 days, eventually experiencing chest pain. He presented to the emergency department with mild shortness of breath, dehydration, and a slight fever. A patient history was obtained, with no comorbidities, denying cigarette smoking and drug use. After further questioning, he revealed “a few times I vaped.” Antibiotics were initiated.

Laboratory culture data did not reveal any infection. The chest radiograph upon admission to the emergency room was not remarkable. Within 6 hours, the patient became extremely short of breath, tachypneic, and continued to exhibit persistent nausea and vomiting. On 60% high-flow nasal cannula, his arterial blood gases revealed a PaO2 of 58 and a PCO2 of 60. He was intubated and placed on mechanical ventilation. A BAL was negative for cultures. The repeat chest radiograph showed bilateral, multifocal ground-glass opacifications. He showed evidence of a systemic inflammatory response.

The patient was admitted to the intensive care unit, and his respiratory status continued to deteriorate, was drug paralyzed, and placed in a medically induced coma for control of his respiratory status. A close friend notified the attending physician that the patient had been vaping quite regularly over the last several years and he obtained THC online.

EVALI is a diagnosis of exclusion as there is no marker or test for diagnosis. With this new information, the patient was taken off antibiotics and treated with steroids to reduce pulmonary inflammation. Within 5 days, the patent was successfully weaned from the ventilator and was released to home care a week later.

Three months after the incident, the patient’s pulmonary function is still not normal, with a reduced expiratory flow rate and vital capacity, consistent with moderate obstructive disease process. He continues to get short of breath with physical exertion.


For clinicians, the presentation of EVALI follows the similar initial pattern of general flu-like symptoms or a moderate pneumonia. This has caused a delay in diagnosis and confusion when symptoms are first presented. Furthermore, there is no diagnostic test to determine the EVALI disease process. Our role must be to obtain the most accurate patient history as possible. We have to ask the right question, which is not “do you use nicotine or tobacco products?” Potential patients most likely will answer “no.” Rephrase the question to “do you use vaping products?” or “do you use JUUL?” and follow it up with “how often?” Establish a comfort zone with the patient, ensuring an impartial viewpoint. Because there has been a stigma attached to vaping, encouraging the patient to answer truthfully can make a difference in getting a timely diagnosis and appropriate care.


In California, there is a directive to the Department of Public Health to provide a social media public awareness campaign to educate about the health risks of vaping nicotine and cannabis products. The California Department of Tax and Fee Administration is considering recommendations to reduce the availability of vaping devices to those under 21 years of age.

On the federal level, the FDA has embarked on an aggressive education campaign, mostly aimed toward youth and young adults. By June 2019, requirements for vaping products include labeling of products with ingredient listings and warning statements. The FDA is working on future regulations for marketing and development of vaping/e-cigarette products (Sharpless, 2020). In addition, warning letters have been issued to six companies, notifying them to remove a combined 71 products from the market.


This outbreak has challenged our clinicians, our governmental regulatory agencies, our families, and our communities. It has brought to light the extensiveness of the vaping/e-cigarette use, specifically with the youth and young adult population. The attractiveness of the flavored products and the ease of obtaining products online has enabled a greater population access. As Balmes (2019) described, “It is really no surprise to anyone with a background in inhalational toxicology that when chemically complex extracts are heated to the point of aerosolization and vaporization, toxic agents will be generated.” To complicate the situation further, the products were available on the market without careful testing and initial oversite by the FDA. Information campaigns were not developed and distributed, further creating the perfect storm of events. It will be up to us—the public, the governmental agencies, and the medical community—to increase public awareness and develop regulations around the product use.


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vaping; e-cigarette; electronic cigarette vaping product use-associated lung injury; EVALI; JUUL; exogenous lipoid pneumonia; ELP

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