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New Evidence About Severe Pulmonary Disease Linked to Electronic Nicotine Delivery Systems (ENDS)

Electronic Nicotine Delivery systems (ENDS) are the newest emerging technology in the epidemic of novel tobacco products that has been spilling out of start-up companies for the last 13 years. Their storefront and online marketing techniques appeal to adult smokers by a promise of being “safer,” parading the recycled hype of the “low-tar, light cigarettes” of the 1960-70s. Of particular concern is targeted marketing to children and youth, who (unlike the 60s-70s) are now easily accesible via the internet. So physicians wonder, “How should I respond when my patients seek advice about using these electronic devices?”

Recent evidence indicates ENDS are not effective in promoting abstinence from combustible tobacco, based on the same FDA criteria for other nicotine replacement products. The obvious reason that ENDS do not enhance quitting rates from traditional combustible tobacco is because they also perpetuate the inhaled delivery of nicotine directly to the alveoli with rapid transmission to the blood stream and stimulate activation of the mesolimbic dopamine-reward pathway. We have incontrovertible evidence that 90 percent of ENDS users continue to smoke combustible tobacco during the day, resulting in dual-use.  Only 10% of smokers can completely switch from smoking to ENDS for any length of time. 

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ENDS are more expensive than combustible tobacco and less satisfying to an experienced smoker, but have they have health risks that are only now being exposed. “Harm reduction” is the mantra of those promoting the product, but it has not been shown to be “harmless.” Carbon monoxide levels and other toxic chemicals are definitely lower than combustible tobacco products, but ENDS are not “safe” on the level of food or medications approved by the FDA to control nicotine withdrawal and help people stop smoking. ENDS devices are poorly designed with inadequate manufacturing quality controls required, e.g., batteries burning/exploding, etc.

By anyone’s standards, ENDS are clearly not declared "safe" for use by children, youth or pregnant women.  The Poison Control Centers report an increase in toxicity and poisoning from toddlers and children accidentally swallowing the vaping liquids. 

Of recent concern is the trends that rates of grade school and middle school children adoption of ENDS are doubling every year. The ENDS use rate is 3 to 4 times higher in young teens and young adults (in their 20s 11.3%) than the rate in US adults (3.2%). Children and youth/college students are the most vulnerable population target because of the appeal of novelty of flavors and the playful, "visual white mist" when exhaling. Once a non-smoking child or teen begins to experiment with ENDS, they are more likely to advance to using combustible tobacco within a couple of years when compared with those who do not experiment with ENDS. ENDS are simply a recruitment strategy for youth by the tobacco industry to sustain their profits and build their clientele for the future. This means another upward trend of the tobacco epidemic is looming in the next decade.

The youth appeal is fueled by the flavor marketing, which logically makes you ask “Why would anyone inhale flavored liquids?  Can you taste grape flavor in your bronchi and alveola?” What are the consequence of these chemicals aerosolized into the tracheobronchial tree? The combination of the following ingredients is the industry standard for eCigarette liquids: flavor, tobacco extract (containing nicotine), vegetable glycerin, propylene glycol and water. Anything else can be added in “homemade” concoctions that add CBD oils, marijuana, or illicit substances (e.g., heroin, cocaine, methamphetamine, PCP) which are the basis of the current CDC investigation of the cases of severe pulmonary disease reported in the recent 2-3 years with only ENDS use at the common causative indicator.

And that may be exactly the source of the current concerns for severe pulmonary diseases traced back to ENDS, with 215 reported cases undergoing investigation by the CDC. The Xray pulmonary appearance is like “Acute Respiratory Disease Syndrome” with diffuse, patchy ground glass appearance. Treatment is similar to ARDS. The CDC is issuing a warning, but believes the purity and quality of the eCig liquid may have contaminants especially linked to CBD oils and marijuana combinations from homemade products or custom “Vape Salons.” This may be the evidence needed for stricter FDA controls on ENDS manufacturing.

The CDC has also issued a Clinical Outreach and Communication Activity Clinical Action guidelines for physicians to gather essential information and report similar cases. You can measure serum nicotine, cotinine and 3OH-cotinine to evaluate the effect of metabolism/toxicity of ENDS users. 

The additional concerns of ENDS in the next generation of youth is the ease of delivery of illicit drugs and marijuana in the devices far beyond the acceleration of tobacco use. You will never know what you are being exposed to when you walk near those “plumes of white mist” being exhaled. Check out YouTube for videos explaining how to extract any drug into liquid form to be used in ENDS. There are now international competitions for the most creative “visual effects and tricks or illusions” created from the exhaled mist, search on “vaping tricks.”

Clinical judgment is required for those who may be encouraged to use ENDS, including those with diseases that would be adversely affected by low oxygenation from carbon monoxide inhaled from combustible tobacco and those in palliative care with limited days or weeks to live who do not wish to stop tobacco use. If they use ENDS instead of combustible tobacco, they clearly will have better oxygenation due to lower carbon monoxide produced by ENDS heating coils, less particulate matter inhaled via mist, lower risk for burns/fire and second-hand smoke. You have to use your judgment in each case, by applying harm-reduction strategies and first offering safe and effective FDA approved medications to achieve abstinence. The evidence is not all in, however the verdict is clear: “Anything promoted by the tobacco industry is suspect for doing more harm than good.”


CAP Risk Management wishes to thank the author for providing this article to assist our members with this very difficult societal health issue. 

Authored by:

Linda Hyder Ferry, MD, MPH

Associate Professor, Loma Linda University

School of Medicine, Preventive Medicine Department and School of Public Health

Chief, Preventive Medicine Section

Medical Director, Tobacco Dependence Treatment Program

Project Director, VA Virtual Medical Center “Cardiovascular Disease Risk Management”

Jerry L. Pettis VAMC

Loma Linda, California  92357