E-cigarette Use, or Vaping, Practices and Characteristics Among Persons With Associated Lung Injury

Utah, April-October 2019

Nathaniel Lewis, PhD; Keegan McCaffrey; Kylie Sage, MS; Chia-Jung Cheng, PhD; Jordan Green, MPH; Leah Goldstein; Hillary Campbell; Deanna Ferrell, MPH; Nathan Malan, MPH; Nathan LaCross, PhD; Alejandra Maldonado, PhD; Amy Board, PhD; Arianna Hanchey, MPH; Dixie Harris, MD; Sean Callahan, MD; Scott Aberegg, MD; Ilene Risk, MPH; Sarah Willardson, MPH; Amy Carter; Allyn Nakashima, MD; Janae Duncan, MPA; Cindy Burnett, MPH; Robyn Atkinson-Dunn, PhD; Angela Dunn, MD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(42):953-956. 

In This Article

Abstract and Introduction

Introduction

In August 2019, the Utah Department of Health (UDOH) received reports from health care providers of several cases of lung injury in persons who reported use of electronic cigarette (e-cigarette), or vaping, products.[1,2] To describe the characteristics of medical care, potentially related conditions, and exposures among 83 patients in Utah, detailed medical abstractions were completed for 79 (95%) patients. Among patients receiving chart abstractions, 70 (89%) were hospitalized, 39 (49%) required breathing assistance, and many reported preexisting respiratory and mental health conditions. Interviews were conducted by telephone or in person with 53 (64%) patients or their proxies, and product samples from eight (15%) of the interviewed patients or proxies were tested. Among 53 interviewed patients, all of whom reported using e-cigarette, or vaping, products within 3 months of acute lung injury, 49 (92%) reported using any products containing tetrohydrocannabinol (THC), the principal psychoactive component of cannabis; 35 (66%) reported using any nicotine-containing products, and 32 (60%) reported using both. As reported in Wisconsin and Illinois,[1] most THC-containing products were acquired from informal sources such as friends or illicit in-person and online dealers. THC-containing products were most commonly used one to five times per day, whereas nicotine-containing products were most commonly used >25 times per day. Product sample testing at the Utah Public Health Laboratory (UPHL) showed evidence of vitamin E acetate in 17 of 20 (89%) THC-containing cartridges, which were provided by six of 53 interviewed patients. The cause or causes of this outbreak is currently unknown;[2] however, the predominant use among patients of e-cigarette, or vaping, products with prefilled THC-containing cartridges suggests that the substances in these products or the way in which they are heated and aerosolized play an important role in the outbreak. At present, persons should not use e-cigarette, or vaping, products that contain THC. In addition, because the specific cause or causes of lung injury are not yet known and while the investigation continues, persons should consider refraining from use of all e-cigarette, or vaping, products.

During August–October 2019, possible cases of e-cigarette, or vaping, product use–associated lung injury (EVALI) in Utah were investigated to determine symptoms, medical care history, and exposures related to the injury. Cases were classified as confirmed or probable according to established case definitions.[3] Medical record abstraction was completed using a detailed form provided by CDC in September 2019. Interviews were conducted with patients, or a proxy (a spouse or parent), using an adaptation of a questionnaire developed in Illinois and Wisconsin in consultation with CDC during investigation of cases in those states.[1] Medical record abstractions were conducted by UDOH staff members. Interviews were conducted by UDOH staff members or local health department staff members in-person or by telephone to assess product acquisition and use behaviors.

UDOH and Utah local health departments collected e-cigarette, or vaping, products from patients for testing using gas chromatography–mass spectrometry at UPHL to identify peaks for known chemical substances (including nicotine and THC) through nontargeted testing followed by partial verification of results with targeted tests for analytes that have known chemical standards (nicotine and vitamin E acetate, along with 16 others*) or known m/z values (i.e., mass) and relative retention times (myclobutanil and thiodiglycol).[4]

During August 6–October 15, 2019, 83 confirmed and probable cases of EVALI were reported, primarily by clinicians and Utah Poison Control Center, to UDOH. The overall prevalence was 26 per 1,000,000 population. Most (86%) of the patients lived in Salt Lake County and surrounding urban counties (Davis, Morgan, Weber, and Utah); 14% lived in outlying counties. Abstraction of medical records was completed for 79 (95%) patients, and 53 (64%) interviews were completed.

Among the 83 patients, 69 (83%) were male, and the median age was 26 years (range = 14–66 years) (Table 1). Among the 79 patients for whom medical record data were available, 70 (89%) were hospitalized during June 5–September 23 (median duration = 4 days; range = 1–17 days), including 35 (44%) who required intensive care unit (ICU) admission; nine (11%) were not hospitalized. Many patients required respiratory support; continuous or bilevel positive airway pressure was required by 30 (38%), and endotracheal intubation and mechanical ventilation was required by nine (11%). Fifty-nine (75%) patients were treated with steroids. Twenty (25%) patients received a diagnosis of acute respiratory distress syndrome. Patients reported having histories of asthma, 16 (20%); anxiety, 27 (34%); depression, 18 (23%); hypertension, four (5%); and heart failure, one (1%). Approximately half of the patients had at least one of these preexisiting conditions. Patients also reported smoking combustible marijuana (43%), tobacco (54%), or both (24%).

Among the 53 patients interviewed, 49 (92%) reported use of THC-containing e-cigarette, or vaping, products during the 3 months preceding illness (Table 2); 35 (66%) reported using nicotine-containing products; and 32 (60%) reported using both THC- and nicotine-containing products. Seventeen (32%) patients reported exclusive use of THC-containing products, whereas three (6%) reported exclusive use of nicotine-containing products. Use of three brands of prefilled THC-containing cartridges was reported frequently by patients; these included Dank Vapes (21, 40%), Rove (19, 36%), and Golden Gorilla (11, 21%). Seventeen (32%) patients reported using more than one of these brands.

Patients reported a total of 131 e-cigarette, or vaping, products used during the 3 months before illness and for which the method of acquisition was known; 84 of these were THC-containing products, and 47 were nicotine-containing products (Table 3). Most THC-containing products were acquired through informal sources, including friends (44%), in-person dealers (25%), and online dealers (24%). Five products were purchased at an out-of-state dispensary and one at an in-state vape shop selling these products illicitly. Among 84 THC-containing products used, frequency of use was reported for 70 of 84 (83%). Approximately two thirds (65%) of the THC-containing products were used ≤5 times per day. Among 47 nicotine-containing products used, frequency of use was reported for 29 of 47 (62%). The majority of the nicotine-containing products were used >25 times per day (55%) and were acquired primarily through in-state vape shops (49%) or convenience stores and gas stations (18%).

To date, UDOH and Utah local health departments have collected 72 products from eight (15%) of 53 patients interviewed. Products tested at UPHL comprised 19 prefilled THC-containing cartridges from six patients and 20 nicotine-containing vaping liquids (19 bottled e-liquids and one from an atomizer) from six patients; six patients provided both THC- and nicotine-containing samples, and two provided only nicotine-containing samples). Among the 19 THC-containing cartridges, THC was detected in 19 of 19 (100%), nicotine was detected in one (5%), and evidence of vitamin E acetate was detected in 17 (89%). Samples of nicotine-containing e-liquid, in contrast, only showed evidence of nicotine and no evidence of THC or vitamin E acetate. No other analytes were found.

*The other 16 analytes are diazion, phorate, terbuphos, tetramine, paraoxon parathion, pentazocine, scopolamine, codeine, strychnine, aldrin, endrin, dichlorodiphenyltrichloroethane (DDT), fentanyl, dichlorodiphenyldichloroethylene (DDE), arecoline, pilocarpine, and morphine.

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