New findings and recommendations to combat the EVALI epidemic

According to the Centers for Disease Control and Prevention (CDC), roughly 1 in every 20 Americans use electronic cigarettes or vapes – with many being middle and high school students. There has been an uptick in e-cigarette use over the years, as some adults have turned to the products to quit smoking and many adolescents are attracted to fun flavors and advertisements.

Although doctors and researchers sympathize with smokers wanting to quit smoking, scientists are discovering that vaping might not be a healthier alternative to smoking, especially in adolescents. E-cigarette products have recently been linked to a new, serious lung condition known as E-cigarette or Vaping Product Use-associated Lung Injury, or EVALI, which primarily affects youth and young adults. In 2019, the illness was declared an epidemic by the CDC.

At its core, EVALI is a serious disease that primarily affects the lungs and results in a substantial number of hospitalizations and deaths in a relatively young and otherwise healthy population across the United States. This epidemic is largely caused by the unregulated and quickly evolving nature of the e-cigarette industry and certainly highlights the need for continued action by both researchers and government agencies."

Meghan Rebuli, PhD, Assistant Professor, Department of Pediatrics, UNC School of Medicine

In 2021, Rebuli co-led a virtual workshop which brought together pulmonologists, public health officials, epidemiologists, and toxicologists from across the country to discuss their latest research findings and recommendations in the wake of the epidemic. A new report, with Rebuli as its lead author, was published in the Annals of the American Thoracic Society in December.

Navigating the EVALI diagnosis

EVALI presents as an acute respiratory illness with nonspecific symptoms such as cough, shortness of breath, chest pain, and even coughing up blood. Patients with EVALI may also have gastrointestinal symptoms, fever, fatigue, or rapid weight loss.

"Symptoms tend to develop over days or weeks, right around the time patients begin to use some of these e-cigarette-based products," said Rebuli, who is also a faculty member in the Center for Environmental Medicine, Asthma, and Lung Biology.

Unfortunately, EVALI can be challenging for doctors to diagnose since its symptoms mimic those of other respiratory conditions like COVID-19. To diagnose a confirmed case, physicians are urged to employ a multifaceted approach. There must be documented e-cigarette use before the symptoms occur, evidence of infiltrate within the lungs through an X-Ray or CT scan, and an absence of other pulmonary infections or diseases.

One of the easiest ways to confirm a case of EVALI is through patient observation. Rebuli and colleagues around the world have identified a language barrier between physicians and patients who are using e-cigarettes. With so many brands in circulation and the rapidly evolving product market, it can be difficult for physicians and users to identify what brand and/or pods that they have been using. Pictorial questionnaires can help physicians accurately identify the product used and facilitate the conversation around e-cigarette use.

A fight for public safety

At the heart of the workshop was a discussion about the chemical components of e-cigarettes. Early in the epidemic, the CDC took e-cigarette samples to identify what EVALI patients were breathing into their respiratory systems. Tetrahydrocannabinol – the psychoactive ingredient in marijuana – and vitamin E acetate were found in the majority of samples.

If you have a keen eye for ingredient labels, you may have heard of Vitamin E. The vitamin can be taken as a supplement and is present in both healthy foods and cosmetics. Although it is safe for skin application and ingestion, studies suggest that inhaling vitamin E acetate can be harmful for the lungs. With this information in hand, the CDC has stated that vitamin E acetate was likely responsible for causing EVALI. However, Vitamin E acetate wasn't found in all of the EVALI-associated products.

"So, it is still quite possible that there are other components in E-cigarettes that can cause EVALI," said Rebuli. "We just have not identified many of those yet."

The chemical components of e-cigarettes are just one example of the many mysteries that scientists have yet to uncover as they work to get buy-in from governmental entities. But, what is most important to the researchers is to protect the public from harmful chemicals, even if that means promoting the fact that they do not know much about the long-term effects of these products.

"I think, as scientists, a lot of us are passionate about seeing our research protect the public," said Rebuli. "We need to have good scientific evidence before we start promoting product use. If there is not safety data available, we need to make sure that we are protecting the public until that safety data is established."

Moving the needle

In addition to physician and healthcare worker education, robust pushes for public health messaging and further regulation will be key to combating and preventing further cases of EVALI in the future, Rebuli and colleagues agree. Researchers, physicians, and governmental entities should work together to communicate with the public about the risks of e-cigarette use through the media and national level advocacy.

The e-cigarette industry is rapidly evolving, which means researchers are always playing catchup. Every time a new product comes out, researchers need to hop in the lab to learn about its health ramifications. Rebuli says investment and research in EVALI, as well as tighter regulation from the Federal Drug Administration, is needed to help move the needle.

"I think continuing to push for regulation on e-cigarettes is really important, especially in light of the fact so many youth use these products," said Rebuli. "And as part of that I think it's important to develop manufacturing standards so that e-cigarettes are more consistent, less variable, and easier to study, which would move research and public health initiatives further faster."