The Vaping Crisis: Counseling Patients

As the vaping crisis continues, pharmacists are being called upon in growing numbers to help counsel patients about recent deaths and how individuals can protect themselves. Research into the pathology of vaping-associated lung injury is in its infancy. However, a study published in The New England Journal of Medicine has found that lung injuries from vaping are most likely caused by direct toxicity or tissue damage from noxious chemical fumes.

Researchers at the Mayo Clinic reviewed lung biopsies from 17 patients, all of whom had vaped and were suspected to have vaping-associated lung injury. The study found no evidence of tissue injury caused by accumulation of lipids, which had been suspected as a possible cause. In recent months, CDC has received almost 2,000 lung injury reports associated with vaping and dozens of deaths. 

Thomas Ferkol, MD, pediatric pulmonologist at Washington University School of Medicine in St. Louis, Missouri, has thoroughly investigated the threat of electronic cigarettes in children and adolescents and helped develop a position statement. “We are not certain what anyone is inhaling when they use electronic cigarettes. Their vapors can contain ultrafine particulates, volatile organic compounds, and heavy metals, such as nickel, tin, and lead. Other reports have shown that these products can be contaminated with bacterial and fungal toxins,” Ferkol says. 

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He says electronic cigarettes were designed to deliver nicotine, and the nicotine content in vapors can be as high and often higher than combustible cigarettes. Other chemicals he says are common in these products are propylene glycol and glycerin-solvents for nicotine and flavorings. 

“A growing literature has shown that e-cigarette exposure causes acute inflammation, injury, oxidative stress, and other toxicities in the lung,” says Ferkol.

Vaping among American middle school and high school students is also on the rise. Ferkol cites preliminary data reported by the National Youth Tobacco Survey which shows continued increase among high school students: 30-day nicotine vaping rates are at 28% this year, compared to 21% last year and 12% in 2017. “The warning signs for chronic [e-cigarette] use are the same as those seen in nicotine addiction. In addition, bronchitic symptoms have been associated with e-cigarette use in adolescents, manifested as a persistent, daily productive or ‘wet’ cough for several weeks,” says Ferkol.

Changing Laws 

Recent deaths and illnesses linked to vaping prompted New York in September to become the first state to ban flavored e-cigarettes; since then other states have imposed temporary bans on the sale of e-cigarettes or the flavored 

liquids used in them until more is known. The CDC recommends that e-cigarettes should not be used by children, young adults, pregnant women, or adults who don’t already use tobacco products. 

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Many young and pregnant women are using e-cigarettes as a safer alternative to smoking, but little is known about the effects on fertility and pregnancy outcomes. In a mouse model, researchers at the University of North Carolina at Chapel Hill found that e-cigarette usage prior to conception significantly delayed implantation of a fertilized embryo to the uterus. They also discovered that e-cigarette usage throughout pregnancy changed the long-term health and metabolism of female offspring. 

Sean Callahan, MD, assistant professor in pulmonary and critical care medicine, University of Utah, says pharmacists have to be concise and direct when counseling individuals. He said the message needs to be clear that the potential lung damage and other sequalae is still unknown.