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Original Investigation
May 18, 2020

Demographics, Substance Use Behaviors, and Clinical Characteristics of Adolescents With e-Cigarette, or Vaping, Product Use–Associated Lung Injury (EVALI) in the United States in 2019

Author Affiliations
  • 1National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 2National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 3National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Decatur, Georgia
  • 4Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 5National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 6National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 7Agency for Toxic Substances and Disease Registry, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 8National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
JAMA Pediatr. Published online May 18, 2020. doi:10.1001/jamapediatrics.2020.0756
Key Points

Question  Do adolescents with e-cigarette, or vaping, product use–associated lung injury (EVALI) differ from adults with EVALI?

Findings  A total of 2155 patients were included in this cross-sectional study. Based on national surveillance data, adolescents with EVALI are more likely than adults with EVALI to report the use of informally sourced e-cigarette or vaping products that contain tetrahydrocannabinol and to have attention-deficit/hyperactivity disorder, asthma, and gastrointestinal and constitutional symptoms.

Meaning  Public health and clinical efforts could include messaging to adolescents about the risks of tetrahydrocannabinol-containing e-cigarette or vaping products, especially those obtained from informal sources, and their association with EVALI.


Importance  To date, limited information is available on the characteristics of adolescents with e-cigarette, or vaping, product use–associated lung injury (EVALI).

Objective  To inform public health and clinical practice by describing differences in demographics, substance use behaviors, and clinical characteristics of EVALI among adolescents compared with adults.

Design, Setting, and Participants  Surveillance data reported to the Centers for Disease Control and Prevention during the 2019 EVALI outbreak were used to calculate adjusted prevalence ratios (aPRs) with 95% CIs and to test differences between 360 hospitalized or deceased adolescents vs 859 young adults and 936 adults with EVALI (N = 2155).

Main Outcomes and Measures  Demographics, substance use behaviors, and clinical characteristics.

Results  Included in this cross-sectional study were 360 hospitalized or deceased adolescents (age range, 13-17 years; 67.9% male) vs 859 young adults (age range, 18-24 years; 72.4% male) and 936 adults (age range, 25-49 years; 65.6% male) with EVALI. Adolescents diagnosed as having EVALI reported using any nicotine-containing (62.4%), any tetrahydrocannabinol (THC)-containing (81.7%), and both (50.8%) types of e-cigarette or vaping products. Informal sources for obtaining nicotine-containing and THC-containing e-cigarette or vaping products were more commonly reported by adolescents (50.5% for nicotine and 96.5% for THC) than young adults (19.8% for nicotine [aPR, 2.49; 95% CI, 1.78-3.46] and 86.9% for THC [aPR, 1.11; 95% CI, 1.05-1.18]) or adults (24.3% for nicotine [aPR, 2.06; 95% CI, 1.49-2.84] and 75.1% for THC [aPR, 1.29; 95% CI, 1.19-1.40]). Mental, emotional, or behavioral disorders were commonly reported; a history of attention-deficit/hyperactivity disorder was almost 4 times more likely among adolescents (18.1%) than adults (4.9%) (aPR, 3.74; 95% CI, 1.92-7.26). A history of asthma was more likely to be reported among adolescents (43.6%) than adults (28.3%) (aPR, 1.53; 95% CI, 1.14-2.05). Gastrointestinal and constitutional symptoms were more common in adolescents (90.9% and 97.3%, respectively) than adults (75.3% and 94.5%, respectively) (aPR, 1.20; 95% CI, 1.13-1.28 and aPR, 1.03; 95% CI, 1.00-1.06, respectively). Because of missing data, percentages may not be able to be calculated from data provided.

Conclusions and Relevance  Public health and clinical professionals should continue to provide information to adolescents about the association between EVALI and THC-containing e-cigarette or vaping product use, especially those products obtained through informal sources, and that the use of any e-cigarette or vaping product is unsafe. Compared with adults, it appears that adolescents with EVALI more frequently have a history of asthma and mental, emotional, or behavioral disorders, such as attention-deficit/hyperactivity disorder, and report nonspecific problems, including gastrointestinal and constitutional symptoms; therefore, obtaining a confidential substance use history that includes e-cigarette or vaping product use is recommended.

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    1 Comment for this article
    Adolescents' Vaping Epidemic During the Covid 19 Pandemic
    Aki Nilanga Bandara, BSc | Instructor, Faculty of Land and Food System, UBC
    We wholeheartedly agree with the authors that we need to redouble our efforts to prevent adolescents' and young adults’ e cigarette epidemic (1). JUUL appears to be associated with the youth e-cigarette epidemic, attracting new users and facilitating frequent use with their highly addictive nicotine content and appealing flavors (2).

    Investing our resources to enhance tobacco cessation during the Covid 19 pandemic is vital. Like the previous outbreaks of MERS and SARS, COVID-19 attacks the lungs and other parts of the respiratory system. A recent state of art review concluded that the e-cigarette use is significantly and independently associated
    with an increased risk of respiratory illness (3).

    It is very critical and important that health care investments be made to prevent and control Covid 19. New research shows that smoking spurs the lungs to make more ACE2, the protein that the coronavirus uses to enter human cells. This finding may explain why smokers appear to be particularly vulnerable to severe infections. The analysis also indicates that the change is reversible, suggesting that quitting smoking might reduce the risk of a severe coronavirus infection (4). This report further provides welcome evidence to priorities smoking cessation within vulnerable communities.

    The frequency of patient inquiries on e-cigarette is increasing, (5) but most clinicians feel they lack sufficient knowledge to counsel and express interest in learning more (6). Physicians infrequently screen or counsel their adolescent patients about e-cigarette use, even though e-cigarettes often come up during visits. Additional efforts by physicians could help prevent future use by adolescents (7). We suggest a patient-centered strategy to incorporate vaping into routine substance counseling. Health care providers caring for adolescents and young adults should be aware of surging e-cigarette use in this population and, in a preventive health role, should include e-cigarette in substance use counseling (8).

    Nicotine addiction is a pediatric disease (9) and nicotine exposure to the developing adolescent brain has been shown to have long-term cognitive and behavioral impairments (10).Juul uses nicotine salts in its vaping devices to deliver “dramatically higher levels” of nicotine to the brain with less irritation and “Adolescents simply do not stand a chance”(11). The Surgeon General estimates that 5.6 million of today’s youth will die prematurely from a smoking related illness (12).

    Protecting our vulnerable children from nicotine dependence is of paramount importance to clinicians and the health care community. We need to bring every possible advocacy effort to create an environment in which our children could grow without compromising their overall health and wellbeing. Primary care physicians, the pediatricians and other practitioners have the unique power and responsibility to advocate for their patients' health by screening for, offering education on, and promoting cessation of e-cigarette use (13, 14). Pediatricians feel poorly informed about e-cigarettes and are concerned about their potential health effects. While clinical discussions about e-cigarettes are rare, recent increases in their use leaves many clinicians wanting guidance about what to say to patients and families. One-step toward educating the adolescents is to ensure pediatricians and primary care physician have an accurate knowledge of the current best practices for e cigarettes and prevention (14).

    (1). Adkins SH, Anderson KN, Goodman AB, et al. Demographics, Substance Use Behaviors, and Clinical Characteristics of Adolescents With e-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) in the United States in 2019 [published online ahead of print, 2020 May 18]. JAMA Pediatr. 2020;e200756.
    (2). Vallone DM, Cuccia AF, Briggs J, Xiao H, Schillo BA, Hair EC.Electronic cigarette and JUULuse among adolescents and young adults. JAMA Pediatr. 2020 Jan 21. doi: 10.1001/jamapediatrics.2019.5436
    (3). Gotts JE, Jordt SE, McConnell R, Tarran R. What are the respiratory effects of e-cigarettes? BMJ. 2019 Sep 30;366:l5275. doi: 10.1136/bmj.l5275
    (4). Smith, J. C., et al., (2020). Cigarette smoke exposure and inflammatory signaling increase the expression of the SARS-CoV-2 receptor ACE2 in the respiratory tract. Developmental Cell- http://dx.doi.org/10.1016/j.devcel.2020.05.012   
    (5). Steinberg MB, Giovenco DP, Delnevo CD. Patient–physician communication regarding electronic cigarettes. Prev Med Rep. 2015; 2:96-98
    (6). England LJ, Anderson BL, Tong VT, et al. Screening practices and attitudes of obstetricians-gynecologists toward new and emerging tobacco products. Am J Obstet Gynecol. 2014; 211:695.e691-697 (7). Pepper JK, Gilkey MB, Brewer NT. Physician counselling of adolescents regarding e-cigarette use. J Adolesc Health. 2015 Dec;57(6):580-6. doi: 10.1016/j.jadohealth.2015.06.017. 
    (8). Hildick-Smith GJ, Pesko MF, Shearer L, Hughes JM, Chang J, Loughlin GM, Ipp LS. . A Practitioner's Guide to Electronic Cigarettes in the Adolescent Population. J Adolesc Health. 2015 Dec;57(6):574-9. doi: 10.1016/j.jadohealth.2015.07.020
    (9). Kessler DA, Natanblut SL, Wilkenfeld JP, Lorraine CC, LindanMayl S, Bernstein IBG, Thompson L. Nicotine addiction: a pediatric disease. J Pediatr. 1997;130:518–524.
    (10). Surgeon General’s report (2016) US Department of Health and Human Services. E-cigarette use among youth and young adults: A report of the Surgeon General-http://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_non-508.pdf.
    (11). The American Academy of Pediatrics- Congressional testimony 2019-https://www.cnbc.com/2019/10/15/pediatrician-to-congress-adolescents-dont-stand-a-chance-against-juul.html
    (12). National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention (US); 2014
    (13). Hildick-Smith GJ, Pesko MF, Shearer L, Hughes JM, Chang J, Loughlin GM, Ipp LS. A practitioner’s guide to electronic cigarettes in the adolescent population. J Adolesc Health. 2015 Dec; 57(6):574-9. doi: 10.1016/j.jadohealth.2015.07.020
    (14). Gorzkowski JA, Whitmore RM, Kaseeska KR, Brishke JK, Klein JD. Pediatrician Knowledge, Attitudes, and Practice Related to Electronic Cigarettes. J Adolesc Health. 2016;59(1):81‐86. doi:10.1016/j.jadohealth.2016.03.036

    Aki Nilanga Bandara- nilangabandara527@gmail.com   
     Dr. Vahid Mehrnoush- mv1361@yahoo.com

    CONFLICT OF INTEREST: Founding Director, Global Coalition for Adolescents’ Unique Tobacco Addictions Related Issues​ https://gcfautari.weebly.com/about.html