Vaping and E-Cigarette Use in Children and Adolescents

Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine

Deborah A. Rusy, MD, MBA, FASA; Anita Honkanen, MD; Mary F. Landrigan-Ossar, MD, PhD, FASA, FAAP; Debnath Chatterjee, MD, FAAP, FASA; Lawrence I. Schwartz, MD; Kirk Lalwani, MBBS, FRCA, MCR; Jennifer R. Dollar, MD; Randall Clark, MD, FASA; Christina D. Diaz, MD, FASA, FAAP; Nina Deutsch, MD; David O. Warner, MD; Sulpicio G. Soriano, MD


Anesth Analg. 2021;133(3):562-568. 

In This Article

Implications for Perioperative Management

There is a clear evidence that demonstrates the benefits of preoperative and long-term postoperative smoking cessation. Smoking cessation discussions should be introduced early by patient's primary care provider; however, it is also imperative that this topic is discussed in both the surgical and anesthesia preoperative screening clinics.[54–56] We recommend that screening regarding vaping use is done on all adolescents undergoing preoperative evaluations. A clear distinction between e-cigarette and cigarette use should be made during the preoperative interview. Nonthreatening and nonjudgmental queries into inhalant use that include nicotine and cannabis either through smoking or ENDS should routinely be obtained in this vulnerable patient group.

If suspected that a patient may have EVALI, preoperative workup should include a thorough history enquiring about smoking history including e-cigarette and vaping use, respiratory symptoms (eg, cough, chest pain, and shortness of breath), gastrointestinal symptoms (eg, abdominal pain, nausea, vomiting, and diarrhea), fever, chills, and weight loss. Physical examination should include vital signs and pulse oximetry, as these patients may present with tachycardia, tachypnea, and O2 saturation <95% at rest on room air. If respiratory symptoms are present, consider chest X-ray or chest CT scan.[25] Consider consultation with a pulmonologist in patients with significant findings. The decision to perform bronchoscopy and BAL to rule out other diagnoses such as pulmonary infection should be made on an individual patient basis. A recent case series reported a significant intraoperative reactive airway disease and hypoxia and postoperative mechanical ventilation for respiratory failure in adolescents with EVALI.[57] As noted earlier, the most severe cases may require the administration of steroids.[17]

For patients using e-cigarettes, or vaping products, consider referral to tobacco cessation strategy therapies. The Society for Perioperative Assessment and Quality Improvement recently published a consensus statement that promotes perioperative smoking cessation as a modifiable risk factor for improving overall patient outcomes.[56] Although this document stated that "There is insufficient evidence to determine the safety and efficacy of e-cigarettes for perioperative smoking cessation," EVALI clearly places these patients at an increased risk of perioperative pulmonary morbidity. Therefore, clinicians should identify "at-risk" individuals during preanesthetic evaluations and determine the substance that they vape because chronic bronchitis is more prevalent with cannabis when compared to nicotine.[58] Given the relatively recent introduction of e-cigarettes, and the lack of published reports of the intraoperative course of e-cigarette users, no current evidence is available to guide the intraoperative management of these patients. As the long-term impact on adolescent health is unknown, there is a paucity of postoperative outcomes in this vulnerable population to propose evidence-based recommendations for the management of these patients.

There is, to date, no evidence to justify extended postoperative monitoring for the patients with a history of vaping. Patients who use tobacco vaping products may be at risk for nicotine withdrawal in the perioperative period. Caregivers should be aware of the potential physical (headaches, sweating, restlessness, tremors, and digestive issues) and psychological (irritability, anxiety, and mood swings) symptoms and how to manage them.

The current epidemic of youth e-cigarette use and EVALI demand immediate and swift action by regulatory bodies at the state and national level to protect public health.[59] Vaping products are inherently unsafe whether they contain THC or not. Both nicotine and marijuana affect brain development in young adulthood and serve to increase the likelihood of tobacco and cannabis use disorders later in life. Strategies to address these epidemics include adding vaping products to tobacco control strategies, additional restrictions on flavors, as well as youth and provider education and long-term surveillance of the health outcomes of EVALI. Given the addictive nature and potential detrimental health consequences of nicotine, THC, and e-cigarettes, it is the recommendation of these health organizations to prevent the habit of vaping and to advocate cessation of use to our patients. A recent web-based review of current e-cigarette prevention and cessation programs noted the lack of evidence-based tools, resources, and evaluations available to assess and inform adolescents about e-cigarette risks and cessation.[60] We encourage continued research on the longitudinal effects of e-cigarette use on symptomatology, especially the early subclinical effects of vaping, and further postoperative outcome studies of patients who use vaping products. We also recommend limiting access of vaping products and nicotine-containing products to our youth. We encourage continued education of the public and health care providers of the risks associated with vaping and encourage regular screening of patients with regard to smoking and vaping use. Finally, we recommend that advertising of the e-cigarette products no longer be directed toward children and adolescents.