The study investigates severe lung injuries among e-cigarette users in rural Appalachians

Just as the ingredients of e-cigarettes can vary from region to region, the health effects of vaping can also have regional characteristics. New research from the University of West Virginia suggests that e-cigarette users in villages are older – and often sicker – than their urban counterparts.

Researchers from the WVU School of Medicine are investigating severe lung injuries that have occurred among e-cigarette users in rural Appalachians. In a recent study, Sunil Sharma – head of the Department of Pulmonary / Critical Care and Sleep Medicine at the School of Medicine – and his colleagues present a case study of patients with EVALI (electronic cigarettes and vaping-related lung injuries) admitted to WVU Hospital from August 2019 to March 2020

Study published in Hospital practice, suggests that EVALI in rural Appalachia leads to severe respiratory failure.

It is our first rural study. One of the real lessons we have learned is that we cannot take data from urban centers and apply them to rural areas. We could be different and we doctors need to behave the way science shows in our areas. “

Sunil Sharma, Head of Pulmonary / Critical Care and Sleep Medicine, WVU School of Medicine

Sharma and his team recorded demographics, baseline characteristics, health status, and vaping behavior for 17 patients admitted to WVU hospitals with EVALI. They also analyzed lung samples for signs of inflammation and analyzed e-liquid materials voluntarily guided by patients using mass spectrometry to determine chemical composition.

Compared to other EVALI studies conducted in urban centers, patients in the rural study were older, had a higher amount of illegal drugs, and were much sicker. The mean age of the patients in this study was 33, compared with 23 in the large national study.

Thirteen patients have smoked cigarettes in the past, while four have never smoked. Urine testing found that nine patients also consumed THC, and another nine tested positive for other illegal drugs. Seven patients who consumed THC needed critical care, and four of the 17 had a secondary lung infection. Ten patients required mechanical or noninvasive ventilation, while two required treatment with an extracorporeal membrane oxygenation apparatus, which pumps someone’s blood out of their body, oxygenates it, and returns it to the body.

Sharma’s e-liquid analysis identified, in addition to nicotine, toxic volatile organic compounds – such as formaldehyde, acetaldehyde, acetone, propylene glycol and cyclohexane. Higher levels of these VOCs were found in e-fluids provided by the three most seriously ill patients.

“We were the first to show that there is a large correlation between volatile organic compounds, especially in patients who were really sick,” Sharma said. “Inhaling all of these volatile organic compounds into your lungs at high temperatures, creating these really toxic gaseous compounds, can cause chemical burns in your lungs.”

Sharma suspects that particularly high VOC levels may be due to the production of some e-liquids in local “garage labs”. Garage laboratories are not regulated and laboratories probably use chemicals that are readily available to them.

“Volatile organic compounds are very common,” he said. “They’re very easy to get, and they’re cheap. And we’ve found that each of the e-liquids has a regional flavor, depending on what their garage labs have access to, what they consider cheaper, and how they’re made.”

Despite a strong correlation between lung injury and high VOC levels, Sharma said many other factors determine how much e-cigarettes damage the lungs. These factors include the type of device or technique used for vaping, the ratio of propylene glycol to plant glycol used as the e-liquid base, which flavors are added, the age of the patient, and whether he uses other medications.

“Depending on it, you could have mild chest pain and a feeling of discomfort, which could go away when you stop smoking, or you could get a lung injury so severe that intubation, mechanical ventilation, and sometimes even ECMO are needed,” he said. .

Sharma believes that the age difference between urban and rural e-cigarette users stems from the relatively older population of rural areas. He also believes that older adults can engage in vaping as a way to quit smoking and may not know how dangerous it is, because most of the warnings of regulatory agencies are aimed at teenagers.

Ad campaigns, such as the Food and Drug Administration’s “Real Cost,” have warned teens and young adults about the “real costs” of e-cigarettes and vaping since 2014. The FDA has also banned ads for targeted e-cigarette products for minors and banned tempting flavors. e-liquids of fruit and mint.

The results of the Sharma study show that it may be time to target older messages about the dangers of vaping to older populations in rural areas.

“All efforts are focused on high school students and young people, but perhaps we should run awareness-raising campaigns for older people in rural areas,” he said.

E-cigarettes are generally considered to be healthier or less dangerous than traditional cigarettes. The results of subsequent interviews highlight how inaccurate this is, especially for older people. Six to 12 weeks after discharge, 12 patients were found to have completely stopped vaping or smoking, but four patients still had persistent coughs, breathing and wheezing problems, and two needed home oxygen therapy.

“The older you get, the more dangerous vaping is for you and you’ll end up in a very bad situation, probably in a JIL,” Sharma said.

Three patients reportedly continued vaping after discharge and had a persistent cough and breathing problems.

“They’re all tied,” Sharma said. “You have garage labs that produce all kinds of chemicals – which are adulterous and not approved by the regulatory agency – and the people who buy them are a much older population. And I think these two conspired so we could see a very, very sick population in the west Virginia. “


Journal reference:

Sangani, R., and others. (2021) Electronic cigarettes and vaping-related lung injury (EVALI): Rural Appalachian Experience. Hospital practice.