E-cigarettes warning after link with pulmonary illness in US

A new statement on e-cigarettes has been issued by the Australian Government Department of Health.

The Australian Government Department of Health has issued a new statement on vaping pending the results of investigations into six deaths and hundreds of cases of pulmonary illness, which emerged recently across 36 American states. The deaths and illness are associated with vaping e-cigarettes containing both nicotine products and tetrahydrocannabinol (THC), or cannabidiol (CBD) products.¹  

Yesterday, the state of New York became the first in the United States to ban the sale of flavored electronic cigarettes and nicotine e-liquids, following a vote on emergency regulations.

‘New York is not waiting for the federal [US] government to act, and by banning flavored e-cigarettes we are safeguarding the public health and helping prevent countless young people from forming costly, unhealthy and potentially deadly life-long habits,’  the governor of New York, Andrew M. Cuomo, announced.² 

New York state retailers have until October 7 to clear their shelves or face fines of US$2,000 per violation [each unit of flavored e-liquid or product containing e-liquid that is possessed, manufactured, sold or offered for sale].² 

In Australia, the statement from the Chief Medical Officer and State and Territory Chief Health Officers, includes advice for anyone who uses e-cigarettes with ‘unexplained respiratory symptoms’ such as cough, shortness or breath or chest pain, to seek medical advice.

‘There is growing evidence implicating e-cigarettes in a range of harms to individual and population health,’ the statement said. ‘E-cigarettes are relatively new products and the long-term safety and health effects associated with their use and exposure to second-hand vapour are unknown.’

The Department of Health recommends health professionals ask patients about e-cigarette use in the same context as encouraging smoking cessation. 

Its statement follows a second warning, issued last week by the US Centres for Disease Control (CDC), to anyone who has recently used an e-cigarette or vaping product and who has concerning symptoms, to see a healthcare professional.³ 

Symptoms include shortness of breath, chest pain, cough and coughing up blood in addition to gastrointestinal symptoms. In those that became ill, symptoms lasted for a median of six days before medical attention was sought.

‘All Australian governments are united in maintaining a precautionary approach to the marketing and use of e-cigarettes,’ said the statement.¹

‘Clinicians should ask individuals presenting with respiratory symptoms of unclear cause whether they use e-cigarettes … and should reiterate that no e-cigarette product has been evaluated for safety.’ 

Warnings about the sudden outbreak of cases in people who reported vaping in the past 90 days were repeated earlier this month in an editorial in the New England Journal of Medicine (NEJM)4 and a statement from the American Medical Association.⁵ 

The British Medical Journal also reiterated the initial CDC warning in its health advisory of 30 August⁶ with the additional caveat to use ‘UK regulated e-liquids and never risk vaping homemade or illicit e-liquids or adding substances, any of which could be harmful’.⁷

Vaping products found in many of the 380 confirmed or probable cases of pulmonary illness and death to date – devices, liquids, refill pods, and cartridges – contained Vitamin E acetate. This is a derivative of vitamin E, which is currently under investigation as a possible culprit.

‘No consistent e-cigarette or vaping product, substance, or additive has been identified in all cases, nor has any one product or substance been conclusively linked to lung disease in patients,’ the CDC reported on 12 September in its latest statement on the vaping outbreak.³

According to the CDC, ‘lung illnesses are likely associated with a chemical exposure’³ rather than infection.

However, some who became ill reported only nicotine-based vaping. In the state of New York, for instance, at least one vitamin E acetate-containing vape product has been linked to each patient who submitted a product for testing. Vitamin E acetate was not seen in the nicotine-based products that were tested, according to a statement from the New York Health Department.⁸

Who is at risk?

Anyone using e-cigarette products or who is exposed to e-cigarette emissions and/or e-liquids is potentially at risk, according to the Department of Health in Australia. 

‘This includes but is not limited to young people, pregnant women and their unborn children.’¹  

The Director of Quit Victoria, Dr Sarah White, told Australian Pharmacist that despite the ban on e-cigarettes containing nicotine, there is no regulation in Australia about the liquid used in e-cigarettes and there are no consumer safety standards about the liquids.

As the Department of Health points out: ‘Liquids used in e-cigarettes (e-liquids), even when labelled ‘nicotine free’, can contain harmful and widely varying substances such as nicotine, heavy metals, volatile organic compounds and cancer-causing chemicals.’¹ 

Because regulatory health departments cannot confirm what liquid is used in e-cigarettes, the health risks are uncertain, Dr White said.

E-cigarette fluid becomes more toxic during inhalation.⁹ Dr White said this is because soluble compounds break down into toxic by-products when heated, and are released into the lungs when inhaled. 

State and Territory Governments have varied positions on the safety of e-cigarettes. The Australian Capital Territory and New South Wales Departments of Health carry specific warnings on their websites on the use of e-cigarettes, stating they are likely not harm-free and their use may increase the risk of various diseases.^10,11  The Tasmanian Government advises people against e-cigarette use.¹²

‘At a population level, there continues to be insufficient evidence to promote the use of e-cigarettes for smoking cessation,’ according to the Department of Health statement.¹ 

Nor has the TGA approved e-cigarettes as an aid to help smokers quit. All smoking cessation products lawfully available for sale in Australia have been evaluated for safety and efficacy, and have been registered with the TGA. They are available for therapeutic use with a prescription, and also without one from online vendors.¹

Harm minimisation

Dr White said pharmacists should advise patients seeking treatment to use traditional nicotine replacement therapies (NTRs), such as a patch or chewing gum, as they are safe and not-addictive and should be used in conjunction with behavioural therapy, such as those offered by Quitline. 

She strongly advises against smokers looking for NRTs to switch from using traditional cigarettes to e-cigarettes.

‘The short-term effects [of e-cigarettes] are shown to cause harmful cardio-vascular and respiratory issues,’ Dr White said. ‘E-cigarettes are a last-resort option only when all other options have been exhausted. However, if prescribed they should also be used with behavioural therapy.’

Note: The Department of Health has urged Australian health professionals and consumers to report adverse events following e-cigarette exposures to the Poisons Information Centre on 13 11 26.

References

1. Australian Government. Department of Health. E-cigarettes linked to severe lung illness. 13 Sep 2019. At: www.health.gov.au/news/e-cigarettes-linked-to-severe-lung-illness
2. Governor Andrew M. Cuomo. Governor Cuomo Announces New York State Implements First-in-the-Nation Ban on E-Cigarettes. At: www.governor.ny.gov/news/governor-cuomo-announces-new-york-state-implements-first-nation-ban-flavored-e-cigarettes
3. Centres for Disease Control and Prevention. Outbreak of lung illness associated with using e-cigarette products: investigation notice. 12 Sep 2019. At: www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
4. Christiani DC. Vaping-induced lung injury. NEMJ 2019. Epub 2019 Sep 6.
5. Harris PA. AMA urges public to avoid e-cigarette use amid lung illness outbreak. AMA statements 2019.
6. Centres for Disease Control and Prevention. Severe Pulmonary Disease Associated with Using E-Cigarette Products. 30 August 2019. At: https://emergency.cdc.gov/han/han00421.asp
7. Tanne JH. Don’t vape, CDC says, as US lung disease epidemic grows. BMJ 2019. Epub 2019 Sep 9.
8. New York State Department of Health. Pulmonary Illness Associated with Black Market Vaping Products. 5 Sep 2019. At: www.health.ny.gov/press/releases/2019/2019-09-05_vaping.htm
9. Researchers find that e-cigarette fluid becomes more toxic during vaping. Pharmaceutical Journal 2018. At: www.pharmaceutical-journal.com/news-and-analysis/research-briefing/researchers-find-that-e-cigarette-fluid-becomes-more-toxic-during-vaping/20205527.article?firstPass=false
10. ACT Government. Health. Electronic Cigarettes. 2 July 2019. At: www.health.act.gov.au/about-our-health-system/population-health/smoke-free-environments/electronic-cigarettes. 
11. NSW Government. Health. Electronic cigarettes – Tobacco and Smoking. 12 July 2019. At:  www.health.nsw.gov.au/tobacco/Pages/e-cigarettes.aspx. 
12. Tasmanian Government. Department of Health and Human Services. Electronic Cigarettes Fact Sheet – Public Health. At: www.dhhs.tas.gov.au/publichealth/tobacco_control/electronic-cigarettes/fact_sheet-_electronic_cigarettes2.