Risk Factors for E-Cigarette, or Vaping, Product Use–Associated Lung Injury (EVALI) Among Adults Who Use E-Cigarette, or Vaping, Products

Illinois, July-October 2019

Livia Navon, MS; Christopher M. Jones, PharmD, DrPH; Isaac Ghinai, MBBS; Brian A. King, PhD; Peter A. Briss, MD; Karen A. Hacker, MD; Jennifer E. Layden, MD, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(45):1034-1039. 

In This Article

Abstract and Introduction

Introduction

The United States is experiencing an unprecedented outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI).[1] All EVALI patients have used e-cigarette, or vaping, products, and most (≥85%) have reported using products containing tetrahydrocannabinol (THC),[2,3] the principal psychoactive component of cannabis. To examine whether e-cigarette, or vaping, product use behaviors differed between adult EVALI patients and adults who use these products but have not developed lung injury, the Illinois Department of Public Health (IDPH) conducted an online public survey during September–October 2019 targeting e-cigarette, or vaping, product users in Illinois. Among 4,631 survey respondents, 94% reported using any nicotine-containing e-cigarette, or vaping, products in the past 3 months; 21% used any THC-containing products; and 11% used both THC-containing products and nicotine-containing products. Prevalence of THC-containing product use was highest among survey respondents aged 18–24 years (36%) and decreased with increasing age. E-cigarette, or vaping, product use behaviors of 66 EVALI patients aged 18–44 years who were interviewed as part of the ongoing outbreak investigation were compared with a subset of 519 survey respondents aged 18–44 years who reported use of THC-containing e-cigarette, or vaping, products. Compared with these survey respondents, EVALI patients had higher odds of reporting exclusive use of THC-containing products (adjusted odds ratio [aOR] = 2.0, 95% confidence interval [CI] = 1.1–3.6); frequent use (more than five times per day) of these products (aOR = 3.1, 95% CI = 1.6–6.0), and obtaining these products from informal sources, such as a dealer, off the street, or from a friend (aOR = 9.2, 95% CI = 2.2–39.4). The odds of using Dank Vapes, a class of largely counterfeit THC-containing products, was also higher among EVALI patients (aOR = 8.5, 95% CI = 3.8–19.0). These findings reinforce current recommendations not to use e-cigarette, or vaping, products that contain THC and not to use any e-cigarette, or vaping, products obtained from informal sources. In addition, because the specific compound or ingredient causing lung injury is not yet known, CDC continues to recommend that persons consider refraining from use of all e-cigarette, or vaping, products while the outbreak investigation continues.[1]

IDPH developed an online public survey targeting Illinois adults who use e-cigarette, or vaping, products based on the structured questionnaire developed by IDPH and administered to EVALI patients as part of the ongoing outbreak investigation. The public survey included questions about the types of e-cigarette, or vaping, products survey respondents used in the past 3 months, where these products were obtained, combustible cigarette and marijuana use, and any reported illness associated with e-cigarette, or vaping, product use. The public survey link was posted on the IDPH website during September 17–October 8, 2019 and was publicized through the media, posted on IDPH social media accounts, and promoted by local health departments.[4] Because of an IDPH Institutional Review Board determination, the survey was restricted to persons aged ≥18 years.

To compare survey respondents with EVALI patients, a subset of respondents with similar characteristics to those of EVALI patients was selected. Data were available for 137 EVALI patients reported to IDPH; 15% (20 of 137) were aged <18 years; of adult EVALI patients, 97% (113 of 117) were aged 18–44 years (Supplementary Figure, https://stacks.cdc.gov/view/cdc/82320).* Among EVALI patients aged 18–44 years, 66 of 113 (58%) had the structured patient questionnaire administered either via telephone, by a public health staff member (53 of 66, 80%); during an in-person interview, usually by a health care provider (nine of 66, 14%); or online (four of 66; 6%).[3] Among these 66 EVALI patients, 85% reported use of THC-containing e-cigarette, or vaping, products. Based on these characteristics of EVALI patients (i.e. primarily adults aged <44 years with high THC-containing product use prevalence), survey respondents for the comparative analysis were limited to those aged 18–44 years who reported use of THC-containing e-cigarette, or vaping, products. Survey respondents were further restricted to those who resided in one of the 28 Illinois counties with any reported EVALI cases and who did not report seeking health care for illness compatible with EVALI. All interviewed EVALI adult patients aged 18–44 years were included in the comparative analysis.

Survey results were summarized with descriptive statistics. P-values were assessed using Pearson's chi-square test; for cells with small numbers, Fisher's exact test was used. To compare EVALI patients with the subset of survey respondents that reported using THC-containing products, aORs were calculated using multivariable logistic regression models that controlled for race/ethnicity and age group. P-values <0.05 were considered statistically significant. Analyses were conducted using SAS (version 9.4; SAS Institute).

Among 7,704 survey respondents, 4,631 (60%) met the study inclusion criteria (i.e., Illinois residents aged ≥18 years who completed demographic questions, reported use of e-cigarette, or vaping, products in the past 3 months, and did not have EVALI) (Supplementary Figure, https://stacks.cdc.gov/view/cdc/82320). The median age of included respondents was 38 years (range = 18–83 years), 3,035 (66%) were men, and 3,932 (89%) identified as non-Hispanic white (white) (Table 1). Overall, 3,641 (94%) respondents reported using any nicotine-containing e-cigarette, or vaping, products in the preceding 3 months, including 3,222 (84%) who reported exclusive use of nicotine-containing products. Use of any THC-containing e-cigarette, or vaping, products was reported by 930 (21%) of survey respondents, including 212 (5%) who used such products exclusively. Use of both nicotine-containing and THC-containing products was reported by 418 (11%) survey respondents. Prevalence of THC-containing product use decreased with increasing age: 36% and 13% of respondents aged 18–24 years and ≥45 years, respectively, reported using THC-containing products. Use of nicotine-containing products was consistent across age groups (93%–96%). Among survey respondents, use of combustible marijuana (24%) was higher than that of combustible tobacco (7%).

Approximately 82% of male survey respondents aged 18–34 years reported frequent (more than five times per day) use of nicotine-containing e-cigarette, or vaping, products, compared with 76% of women of the same age (Table 2). Among adults aged 18–34 years, the prevalence of frequent use of THC-containing e-cigarette, or vaping, products was twice as high among men (25%) as among women (13%). Among survey respondents who reported any use of THC-containing products, exclusive use was reported by a higher proportion of women than of men both among those aged 18–34 years (26% versus 17%) and among those aged ≥35 years (31% versus 22%). A similar proportion of male and female survey respondents aged 18–34 years obtained THC-containing products from informal sources (a dealer, friends, or on the street) (72% and 68%, respectively); however, among adults aged ≥35 years, men were more likely to report informal sources of THC-containing products (56%) than were women (39%).

Among the 4,631 survey respondents, 519 (11%) met the additional age, THC-use, and county of residence criteria for the comparative analysis with the 66 interviewed EVALI patients aged 18–44 years. Significant demographic differences between EVALI patients and this subset of survey respondents were identified (Table 3). Compared with the subset of survey respondents, EVALI patients had higher odds of being aged <30 years (odds ratio [OR] = 6.0, 95% CI = 3.1–11.5) and of identifying as a racial/ethnic group other than white (OR = 2.9, 95% CI = 1.7–5.2). Among EVALI patients who used THC-containing e-cigarette, or vaping, products, the odds for frequent use of these products were significantly higher compared with the subset of THC-using survey respondents (aOR = 3.1, 95% CI = 1.6–6.0). In addition, the odds were significantly higher among EVALI patients for exclusive use of THC-containing e-cigarette, or vaping, products (aOR = 2.0, 95% CI = 1.1–3.6) and obtaining THC-containing products through informal sources versus from a licensed dispensary or store§ (aOR = 9.2, 95% CI = 2.2–39.4). Compared with the subset of survey respondents, EVALI patients also had higher odds of reporting use of Dank Vapes (aOR = 8.5, 95% CI = 3.8–19.0), a class of largely counterfeit THC-containing products of unknown provenance that are marketed under a common name and distributed through informal sources.[5]

*EVALI cases were reported to the Illinois Department of Public Health during July 31–October 15, 2019, from 28 counties. These counties accounted for an estimated 83% of the Illinois population in 2018.
Thirty-two survey respondents were aged <18 years; 1,800 resided in states other than Illinois or did not confirm Illinois residency, and age or gender information was missing for 1,120 respondents. Respondents who reported no e-cigarette, or vaping, product use in the past 3 months (n = 106) or who visited an emergency department and/or were hospitalized for vaping-related symptoms (n = 15) were excluded.
§No EVALI patients in Illinois have reported purchasing THC-containing e-cigarette, or vaping, products online. Among public survey respondents who reported using THC-containing e-cigarette, or vaping, products, five of 519 (1%) reported online purchase of dry marijuana herb, butane hash oil, or THC-containing prefilled cartridges. Online sites likely represent a mix of illicit and licit sources; therefore, respondents who purchased THC-containing products online were not included in the comparison of informal to formal place of e-cigarette, or vaping, product purchase.

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