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Alejandro Comellas, MDDivision of Pulmonary and Critical Care Medicine

University of Iowa

Vaping and lung health

Disclosure

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• Dr. Meredith Frey has nothing to disclose for this presentation

• Dr. Alejandro Comellas reports:– Grant/research support from NIH and industry– Is a consultant for GSK and VIDA

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Learning Objectives

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Upon completion of this activity, participants should be able to:• Understand how vaping compares to combustible smoke • Review the different diagnostic tools that are used to determine

effects of vaping on lung health • Describe the effects of vaping on lung health in youth

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How popular is vaping?

E-cigarette use among adults

E-cigarette use among 11th

graders**More than doubled between 2016‐2018

E-cigarette use among 11th

graders*

Adult Tobacco Use in Iowa. 2018. Iowa Department of Public Health Youth Survey. 2018.

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Reasons for use

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Popularity and

acceptance among peers

Enjoyment of flavors

Smoking cessation

Ability to vape where smoking not

allowed

Perception of safety or

alternative to traditional cigarettes

Park E, et al. J Pediatr Nurse. 2019;48:82-91.Rhoades DA, et al. BMC Public Health. 2019;19(1):1211.

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Electronic Nicotine Delivery Systems (ENDS)

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3rd – 4th Gen2nd Gen

1st Gen

Harmful Additives

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• Nicotine• Humectants (propylene glycol,

vegetable glycerin)• Flavoring • Tobacco-specific nitrosamines

(TSNAs)• Cannabidiol (CBD)• Tetrahydrocannabinol (THC)• Diluents

• Nicotine • Tobacco-specific nitrosamines

(TSNAs)• Ethanol• Acetone• Benzene• Ammonia• Butane

Glasser A, et al. Am J Prev Med. 2017;52(2):e33-e66.

ENDS Traditional Cigarettes

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Nicotine Content in ENDS

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Measured nicotine content of 20 e-liquids

Products contained85-121% nicotine relative to labeling

Measured nicotine content of 91 e-liquids

Products labeled as “nicotine-free”

contained nicotine

Nicotine Delivery

1 0Yingst JM, et al. PLoS One. 2019;14(7):e0220300.Voos N, et al. Expert Opin Drug Deliv. 2019;13:1-11

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Nicotine Delivery

Yingst JM, et al. PLoS One. 2019;14(7):e0220300.Voos N, et al. Expert Opin Drug Deliv. 2019;13:1-11

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Nicotine Delivery

1 2Yingst JM, et al. PLoS One. 2019;14(7):e0220300.Voos N, et al. Expert Opin Drug Deliv. 2019;13:1-11

Nicotine exposure with traditional cigarettes versus e-cigarettes

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Device Tampering

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Alteration of e-liquid

Other substance use in e-

cigarettes

Kenne D, et al. Subst Abuse. 2017;11:117822187733736.Blount B, et al. N Engl J Med. 2020;382:697-705. .

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Pulmonary Function Tests

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Methacholine Challenge Test and Peak Flows

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PFTs and Obstructive Lung Diseases

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PFT COPD Asthma

Spirometry obstructive obstructive or normal

Lung Volumes air trapping/hyperinflation normal to air trapping and/or hyperinflation

DLCO reduced normal or increased

Computed Tomography Imaging

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Chest CT

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Normal Lung COPD lung

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Challenge of Vaping vs Combustible smoke

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• Vaping Aerosols are exceedingly different from conventional tobacco smoke

• ENDS evolve rapidly as they introduce new devices, flavors and chemicals

• If vaping follow in the footsteps of conventional tobacco smoking, it may take years to decades before profound physiological changes are evident

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Chronic Obstructive Pulmonary Disease (COPD) Natural History

2 3Fletcher C, et al. BMJ 1977; 1:1645-48

Health Effects of Vaping

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Health Effects of Vaping

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• Reactive airway disease• Cardiovascular effects • Psychological effects • Risk of infection • E-cigarette or vaping

product-use associated lung injury (EVALI)

Short-term Long-term

Animal model and vaping

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• Short Term– Increased flow resistance– Increased airway

reactivity

• Long Term– Emphysema– Higher airway resistance– Airway obstruction– Airway inflammation

Tsai M, et al. J Physiol. 2020 Sep 25. doi: 10.1113/JP279754. Online ahead of print

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COPD Natural History

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Twin with childhood asthma

COPD Natural History

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Vaping history as an adolescent?

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IDENTICAL TWIN SISTERS

E-cigarette or vaping use-associated lung injury (EVALI)

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• Vitamin E acetate (VEA) an additive in tetrahydrocannabinoids (THC) containing vaping products VEA induced lung injury in a mouse model

Blount BC, et al. NEJM. 2020; 382:697-705Bhat TA, et al. NEJM. 2020; 382:1175-1177

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Simah Herman, 18, shared the images of her holding up handwritten signs on Instagram, as

the Californian teen was on a ventilator after suffering from lung

failure

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Prevalence of Lung Injury and Death

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23 cases • 0 deaths

805 cases • 12 deaths

• Age range 17-60 years old • 18 linked to use of THC• 78% male

Centers for Disease Control. 2019.Iowa Department of Public Health. 2019.

Vaping and COVID-19

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• Higher incidence of COVID-19 among adolescent and young adult e-cigarette and dual users

• Considerations:

Exposure to nicotine and

harmful additives

Spread through touching hands to mouth, face

Sharing devices among youth

Gaiha MS, et al. J Adol Health. 2020.

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Unintended Consequences

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Burns and ExplosionsBurns and Explosions

• Thermal, chemical, or electrical • Most commonly affected areas:

• Thigh, groin

Unintentional IngestionUnintentional Ingestion

• Liquid nicotine exposures in pediatrics

Brownson E, et al. N Engl J Med. 2016;375:14.Govindarajan P, et al. Pediatrics. 2018;141(5):e20173361.

Patient Safety Counseling

3 6FDA. Center for Tobacco Products. 2020.

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Patient Safety Counseling

FDA Safety Reporting

FDA. Center for Tobacco Products. 2020.3 7

Pilot CTSA Grant

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• Team Science – Eric Hoffman– Peter Thorne– Stanley Kruger– Nagpal Prashant– Sajan Goud Lingala – Alejandro Comellas

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Cardiopulmonary effects of electronic cigarettes in young adults (survey)

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Table 1. Number of Returned Surveys per Participant.

Participant Control ENDS Combustible Smoking Only

Number of Participants 26 22 7

Number of Surveys 687 541 113

Average Completed Surveys per 30 days

26.4% 24.6% 16.1%

• The control group had only 4% who reported wheezing more than once a month, compared to 36% in the ENDS group.

• Cough reporting was more variable with cough 50% of the time during the month reported in 23% of controls and 55% in ENDS users.

Cardiopulmonary effects of electronic cigarettes in young adults (Future studies)

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Key Points

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• Vaping and combustible smoke both may have significant impact on lung health, but may variabilities in nicotine delivery and harmful additives

• CT scan and MRI are examples of diagnostic tools that can be used to determine effects of vaping on lung health

• Many short-term consequences associated with vaping have been identified, but long-term consequences are relatively unknown

alejandro-comellas@uiowa.edumeredith-frey@uiowa.edu

Questions?

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