Public Health in the Emergency Department Series #1

Author: Olivia Villegas, Ines Corcuerra / Editor: Nikki Abela / Codes: MHC1, RP5, RP8, SLO11, SLO3 / Published: 22/08/2023

“I don’t smoke Doctor, I only vape”

The Case

A 28-year-old female was brought to the Emergency Department (ED) after she was found unresponsive by her friend. Her friend had been with her a few hours earlier when she had been well. In ED she has a low GCS and was found to be hypoxic possible (?aspiration) and hypoglycaemic.

Her past medical history included Type 1 diabetes and she was an ex-smoker, “she only vapes now doctor”. There wasn’t anything to suggest she had taken an overdose.

She arrived to the department in extremis, and ended up being intubated and ventilated. The team struggled to get her oxygen saturations above 40% (despite trying to prone her). A CXR showed diffuse pneumonitis, that couldn’t be explained by aspiration alone. Her COVID swab was negative. She was placed on ECMO and was eventually diagnosed with a Vaping- Induced Pneumonitis.

Background

E-Cigarettes (a.k.a nicotine-replacement products or vapes) have increased in popularity in the last decade and their use has risen since 2020, particularly among young adults. They come in various different forms: rechargeable, disposable, some with pre-filled cartridges and some with an easily refillable reservoir. In e-cigarettes, tobacco combustion is replaced by e-liquid heating, and users inhale vapor created by heating a solution containing psychoactive substances, most frequently nicotine or tetrahydrocannabinol (THC) as well as other flavourings¹.

Tobacco smoking is the leading cause of preventative illness and premature death in England² and kills half of its users³. The evidence that e-cigarettes are safer than smoking and better than other forms of nicotine-replacement therapy (NRT) is strong^4,5 and offer smokers the best chance of quitting. As such, the swap to e-cigarettes was encouraged as part of a recent Government initiative which set out an ambition for England to become ‘smokefree’ by 2030⁴. 

However, this has posed concerns about the uptake of e-cigarettes amongst youths and those who have never smoked⁶. A number of recent investigations have put the negative health impact or e-cigarette use into the spotlight, finding dangerous levels of lead, nickel and chromium in e-cigarettes and urging that disposable vapes be banned to protect our children. Additionally, local councils have called for a complete ban of disposable e-cigarettes by 2024 due to the environmental hazard of single-use plastic waste, fire risks and appeal to young children. This has contributed to an ongoing discourse between medical professionals and the multi-billion-pound e-cigarette industry that target themselves as a smoking cessation intervention, but seemingly market themselves towards millions of non-smokers and children as a ‘safe option’. This blog will continue to outline the literature examining the health impacts of e-cigarettes and explore how as ED clinicians we should be considering e-cigarette use.

So what does the literature tell us about the health impacts of vaping?

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Respiratory disease

There is evidence that e-cigarette users have increased respiratory symptoms compared to never-smokers. Some studies have highlighted cases of vaping-induced pneumonitis, or e-cigarette or vaping – use associated lung injury (EVALI)^9,10, as well as a higher likelihood of developing asthma¹¹, however there is currently no concrete evidence that e-cigarettes cause respiratory disease¹². Although lung function has been shown to be unaffected in a study over 3.5 years¹³ there is concern for early changes to airway resistance and conductance¹⁴.

E-cigarettes as a gateway to smoking/ drug use

E-cigarette use has been shown to be a predictor for future smoking amongst youths^12,15. Studies have also shown an association between vaping and cannabis use, as vapes are now utilised as a new method of cannabis ingestion compared to typical methods such as edible forms, oils, combustible smoking or cannabis and resins¹⁶. This ‘gateway theory’ suggests that those who use e-cigarettes recreationally are more at risk of taking more harmful drugs or smoking tobacco.

Cardiovascular disease

Exposure to nicotine from e-cigarettes likely elevates the cardiovascular disease risk in people with preexisting cardiovascular disease, but the cardiovascular risks in people without cardiovascular disease is uncertain. There is insufficient evidence that e-cigarettes cause long term cardiovascular conditions, but moderate evidence of changes to blood pressure and heart rate after using e-cigarettes¹².

Exposure to toxins

E-cigarette users are more exposed to toxins than non-smokers, with toxicity thought to be due to oxidative stress as well as mucous hypersecretion, inflammation and airway hypersensitivity. High levels of nicotine, lead and nickel can have damaging effects on young adult brain development. Furthermore, there is substantial evidence that some chemicals present in e-cigarette aerosols (e.g., formaldehyde, acrolein) can cause DNA damage and mutagenesis, but no available evidence to suggest a concrete association between e-cigarettes and cancer¹². Studies have also suggested that flavourings may lead to cytokine production and toxicity¹⁷.

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What does this mean for us in the Emergency Department? The Take Home

Delivering public health messages in the ED is often difficult given the level of high acuity, critically unwell patients we see. As ED clinicians our role should aim to educate and raise awareness of these issues when the opportunity presents itself.  It is clear that e-cigarettes are safer than smoking tobacco, and we should be encouraging smokers to make the swap as a smoking cessation aid where possible. But using e-cigarettes is not risk-free. The key thing to consider here is the relative risk of e-cigarettes vs smoking and the absolute risk of e-cigarettes compared to nothing. However, with e-cigarettes becoming more popular for recreational use among non-smokers and youths, there are virtually no long-term studies to evidence the true harms. 

The public health approach to e-cigarettes can be demonstrated through our delivery of brief interventions during our consultations; a public health method that has been tried and tested in different contexts. We should be mindful of the cohort of non-smokers or youths that admit to using e-cigarettes and use our consultations as an opportunity to inform patients of the potential unknown risks. Prevention is better than cure.

The bottom line should be: if you don’t smoke, don’t vape.

Future work

Increasing knowledge on the safety of e-cigarettes will inform policy and e-cigarette regulations as well as guidance to clinicians on smoking harm reductions. This means longitudinal studies assessing the impact of e-cigarette use on measurable health outcomes such as lung function, cardiovascular disease and other health outcomes. It is important to assess how far e-cigarettes appear to be promoting or detracting from reduction in prevalence of cigarette smoking. 

The COSTED (Cessation of smoking trial in the emergency department) Trial is a UK multi-centre randomised control trial examining whether a smoking cessation intervention in the ED can help daily smokers quit, is due to be published in the next few weeks²⁰. Additionally, a Cochrane review on smoking in the ED is due to be published later this year. Further work is also being conducted assessing the suitability of urgent care centres, including the ED, as a setting for health promotion interventions²¹.

The main take homes

• The evidence that e-cigarette use is safer than smoking cigarettes is very strong.
• The numbers of non-smokers and youths smoking e-cigarettes recreationally is rising
• E-cigarette use is not risk-free, with no studies assessing the long-term impact
• Non-smokers should be strongly discouraged from starting e-cigarette smoking
• Increasing small studies highlighting the health hazards of e-cigarettes, particularly on brain development amongst youths
• E-cigarette use among non-smokers and youths may act as a gateway to smoking and to more harmful drugs 
• The ED can be an opportunity for brief intervention to discuss the options for both smokers and non-smokers
• The ED can also be an important resource for data collection
• Our current research is limited due to the novelty of e-cigarettes. Future research should assess the longitudinal health risks from e-cigarette use

References

1. Advancing our health: prevention in the 2020s – consultation document. Department of Health and Care. Gov.UK 2019.
2. Health matters: stopping smoking – what works? Guidance. Public Health England. Gov.UK 2019.
3. Tobacco. World Health Organisation (WHO), 2023.
4. Nicotine vaping in England: 2022 evidence update main findings. Office of Health Improvement and Disparities. Gov. UK, 2022.
5. Hartmann-Boyce J, Lindson N, Butler AR, et al. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews 2022, Issue 11. Art. No.: CD010216. DOI: 10.1002/14651858.CD010216.pub7. [Accessed 13 July 2023].
6. Alotaybi M, Alzahrani SS, Algethmi AM, et al. E-cigarettes and Vaping: A Smoking Cessation Method or Another Smoking Innovation? Cureus. 2022 Dec 12;14(12):e32435.
7. Action on Smoking and Health (ASH). Use of e-cigarettes (vapes) among adults in Great Britain. August 2022.
8. Buss V, Kock L, et al. Trends in electronic cigarette use in England. Smoking in England, 2023.
9. Li D, Sundar IK, McIntosh S, et al. Association of smoking and electronic cigarette use with wheezing and related respiratory symptoms in adults: cross-sectional results from the Population Assessment of Tobacco and Health (PATH) study, wave 2Tobacco Control 2020;29:140-147.
10. The Lancet Respiratory Medicine. The EVALI outbreak and vaping in the COVID-19 era. Lancet Respir Med. 2020 Sep;8(9):831. doi: 10.1016/S2213-2600(20)30360-X. Epub 2020 Aug 14.
11. Rebecca J. Schweitzer, Thomas A. Wills, Elizabeth Tam, Ian Pagano, Kelvin Choi, E-cigarette use and asthma in a multiethnic sample of adolescents, Preventive Medicine, Volume 105, 2017,
12. NASEM, 2018 https://www.ncbi.nlm.nih.gov/books/NBK507174/#sec_000158
13. Polosa R, Cibella F, Caponnetto P, et al. Health impact of e-cigarettes: a prospective 3.5-year study of regular daily users who have never smoked. Sci Rep. 2017;7(1):13825
14. Honeycutt, L., Huerne, K., Miller, A. et al. A systematic review of the effects of e-cigarette use on lung function. npj Prim. Care Respir. Med. 32, 45 (2022). https://doi.org/10.1038/s41533-022-00311-w
15. Miech R, Patrick ME, O’Malley PM, et al E-cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students Tobacco Control 2017;26:e106-e111.
16. Sun R, Mendez D, Warner KE. Use of Electronic Cigarettes Among Cannabis-Naive Adolescents and Its Association With Future Cannabis Use. JAMA Netw Open. 2022;5(7):e2223277. doi:10.1001/jamanetworkopen.2022.23277
17. Bozier, Jack & Chivers, Emily & Chapman, David & Larcombe, Alexander & Bastian, Nicole & Masso-Silva, Jorge & Byun, Min & McDonald, Christine & Crotty, Laura & Ween, Miranda. (2020). The Evolving Landscape of Electronic Cigarettes: A Systematic Review of Recent Evidence. Chest. 157. 10.1016/j.chest.2019.12.042.
18. House of commons (2022) https://researchbriefings.files.parliament.uk/documents/CDP-2022-0216/CDP-2022-0216.pdf
19. Pourchez 2022 https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(22)00187-4/fulltext
20. Notley https://bmjopen.bmj.com/content/13/1/e064585
21. Adams, E.J., Morris, L., Marshall, G. et al. Effectiveness and implementation of interventions for health promotion in urgent and emergency care settings: an umbrella review. BMC Emerg Med 23, 41 (2023). https://doi.org/10.1186/s12873-023-00798-7