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

Discussion

Since the introduction of e-cigarettes into the United States in 2007, use of these devices has increased rapidly, particularly among youths.[6] Although initially created for use with nicotine-containing products, e-cigarettes are also used to aerosolize THC.[7] In this survey of Illinois residents who used e-cigarette, or vaping, products and did not have EVALI, use of THC-containing products was less prevalent (21%) than was use of nicotine-containing products (94%); however, a higher proportion of survey respondents aged <35 years reported using THC-containing products, consistent with the observed age distribution of EVALI patients in this outbreak both in Illinois and nationally.[1,2] Two thirds of survey respondents were men, reflecting the sex distribution of outbreak-associated EVALI patients, in Illinois and nationally.[1,2] Among persons aged 18–34 years, the prevalence of frequent daily use of both nicotine-containing and THC-containing e-cigarette, or vaping, products was higher among men than among women. These findings suggest that e-cigarette, or vaping, product use behaviors among younger adults, especially men, might place them at higher risk for developing EVALI associated with this outbreak.

A much higher proportion of adult EVALI patients reported use of THC-containing e-cigarette, or vaping, products (85%) than did adults who use e-cigarette, or vaping, products and have not developed lung injury (21%). When e-cigarette, or vaping, product use among EVALI patients aged 18–44 years was compared with that of a subset of survey respondents aged 18–44 years who reported use of THC-containing products, a number of significant differences were found. Specifically, patients with EVALI had higher odds of reporting exclusive use of THC-containing products, as well as reporting frequent use of these products, obtaining them through informal sources, and using a counterfeit THC-containing product marketed as Dank Vapes. Because the comparative analysis was restricted to survey respondents who reported using THC-containing e-cigarette, or vaping products, the calculated ORs comparing THC-containing product use behaviors between EVALI patients and survey respondents are likely conservative.

The findings in this report are subject to at least six limitations. First, the survey was restricted to persons aged ≥18 years and findings might not be representative of younger persons; 15% of EVALI patients in Illinois during July–October 2019 were aged <18 years. Second, survey respondents were self-selected and might not be representative of the overall population of persons who use e-cigarette, or vaping, products in Illinois. To address this potential for bias, the comparative analysis was restricted to survey respondents in the same age group, geographic areas of residence, and with similar types of product use as those of EVALI patients and was adjusted for higher survey response rates among whites and older adults. Third, only 58% of Illinois EVALI patients aged 18–44 years have been interviewed; this nonresponse rate might introduce selection bias, although the characteristics of interviewed patients were similar to those of all reported EVALI patients. Fourth, EVALI patients who reported exclusive use of nicotine-containing products were also included in the comparative analysis with the subset of survey respondents who reported use of THC-containing products. Including these EVALI patients might have introduced bias, however, the prevalence of using nicotine-containing products was similar among the two groups. In addition, because analysis of product use behaviors was limited to only those persons who reported using a specific product (e.g., THC product use behaviors were only compared among EVALI patients and survey respondents who reported using THC-containing products) the inclusion of these EVALI patients did not affect the analysis of THC-containing product use behaviors. Fifth, although a similar survey instrument was used with EVALI patients and online survey respondents, most EVALI patients were interviewed by public health staff members via telephone. Differences in data collection methodology might have affected reporting of product use behaviors by EVALI patients compared with that of anonymous online survey respondents. Finally, these data were only collected from Illinois residents. Illinois has a comprehensive medical marijuana program in place but has not yet implemented sales of marijuana for recreational use; the legal purchase of tobacco products is restricted to persons aged ≥21 years. E-cigarette, or vaping, product use behaviors likely vary by jurisdictional policies that control access to these products; this might limit the generalizability of the results in this report.

This is the first report to analyze e-cigarette, or vaping, product use behaviors associated with increased risk of EVALI during this outbreak. The use of an anonymous public survey facilitated the rapid collection of data to inform the ongoing investigation. Differences were observed in e-cigarette, or vaping, product use behaviors between adults who use THC-containing e-cigarette, or vaping, products and patients with EVALI. The findings in this report reinforce current recommendations that persons should not use e-cigarette, or vaping, products that contain THC, or any e-cigarette, or vaping, products obtained from informal sources such as off the street, from a dealer, or from a friend. 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]

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