What is an E-cigarette
Electronic cigarettes (e-cigarettes) first entered the United States market in 2006 and were originally marketed as a tool for traditional cigarette users to use as a harm-reduction product and aid in smoking cessation. Since that time, they have gained popularity in a wide variety of users, including adolescents and individuals who had never smoked cigarettes. E-cigarettes are electronic devices that consist of a power source, heating element and reservoir for the e-liquid. The e-liquid in typically made of 3 components which include a solvent in the form of glycerin or propylene glycol, flavoring and nicotine. In an e-cigarette, this liquid is heated and an aerosol is produced which is inhaled and exhaled or “vaped”. E-cigarettes come in a variety of shapes and sizes and range from looking like regular cigarettes, pipes to USB flash drives and pens.
Unfortunately the safety of e-cigarettes when it comes to long-term health effects is largely unknown. While the solvents and flavors used in e-cigarettes are generally safe for oral consumption, the safety of these once aerosolized in unknown. Chemicals found in aerosols of e-cigarettes are known toxins or carcinogens and include formaldehyde, acetaldehyde, acetone, acrolein, benzene, toluene, and metals including nickel, copper, zinc, tin, lead, chromium, manganese, arsenic. In vitro and animal studies have found evidence of cell damage, cell death, inflammation and impaired ability to fight bacterial and viral infections. It is known that nicotine is a toxic substance which raises blood pressure, increases heart rate and risk for cardiovascular disease.
E-cigarette use and adolescents
There has been a steady increase in e-cigarette use in middle and high school adolescents over the past decade. Based on the 2020 National Youth Tobacco Survey, 19.6% of high school students and 4.7% of middle school students reported current use of e-cigarettes. Nicotine does have effects on the adolescent brain and can alter attention, learning, mood, impulse control and future addiction tendencies. JUUL is a popular brand of e-cigarette in this age group and contains a high level of nicotine. A single JUUL pod contains as much nicotine as 20 cigarettes as it uses nicotine salts which allows high levels of nicotine to be inhaled with less irritation. Many adolescents who use e-cigarettes report respiratory symptoms including cough and phlegm production and have an increased prevalence of asthma and chronic bronchitis. It is unknown whether this is due to chronic airway inflammation or increased susceptibility to infection. Some to the chemicals and flavors in e-cigarettes are known to be associated with respiratory disease and irritation.
Asthma and e-cigarettes
The safety of use of e-cigarettes is asthma patient’s remains unclear. There is some data from a large federal government telephone survey of adults. This data was analyzed and results were published in the BMC Pulmonary Medicine. It was found that approximately 11% of e-cigarette uses reported having asthma as compared with 8% in those who had never used. People who were current e-cigarette users were 39% more likely to self-report having asthma when compared to non-users. Individuals who used e-cigarettes some days were 31% more likely and daily users 73% more likely to report asthma when compared to non-users. The same data was analyzed and published in the American Journal of Preventative Medicine and similar numbers were found for chronic bronchitis, emphysema and COPD. The data appears to be even worse for individual who smoke traditional cigarettes and use e-cigarettes in combination.
EVALI (e-cigarette or vaping product use associated lung injury)
A serious complication of e-cigarette use is EVALI (e-cigarette or vaping product use associated lung injury). There were over 2,000 suspected cases of this severe lung disease reported by the CDC in 2019. The majority of patients had respiratory, gastrointestinal and constitutional symptoms which quickly progressed to severe acute lung injury. Asthma was reported as an underlying condition in 30% of these patients. In the majority of cases, modifications had been made to the e-liquid by the user or manufacture or both. Cannabidol, tetrahydrocannabinol (THC), medium-chain triglycerides and vitamin E acetate were often found in these cases.
We understand that this is an incredibly difficult time for parents as they prepare to make decisions about sending their children back to school. We have received a great deal of questions about this topic, and we empathize that many of our families are weighing the pros and cons of each scenario. While we cannot make this decision for you, we hope to provide some reliable information on masks for those who plan to return to in-person teaching this year.
The AAP recommends that children 2 years and older wear masks in public places. Due to the nature of our specialty, we have a number of patients with breathing related concerns such as asthma. We will not be providing letters stating that our patients are exempt from any policy requiring masks. We believe that masks help protect our patients and those around them from contracting and spreading illness. Oxygen and carbon dioxide levels are not affected by wearing a mask, even for extended periods of time. If you have concerns about your child or yourself wearing a mask, we encourage you to make an appointment so we can help address these concerns. We would be happy to measure oxygen levels during these appointments.
There are a wide variety of masks available, and many local stores are now carrying them. In general, we recommend trying different types of masks and using one that works best for you/your child. A mask with a good fit to your face that leaves minimal to no “gaping” is ideal. You may consider a trial of different types of straps/ties to help with the fit/comfort. There are also “ear savers” available that help keep pressure off the backs of the ears if you prefer the ear-loop style masks. Some masks are designed to be washed and re-used, and others are disposable. We recommend keeping backups in the car, back pack, purse, etc in case your original mask is soiled, lost, or forgotten.
While we encourage finding masks that fit your individual preferences, we wanted to make our readers aware of two big points. First, valved masks generally do a good job of protecting the person wearing them, but allow respiratory droplets from the wearer to escape the valve, which could put others at risk. If you have a valved mask we recommend covering the valve with tape, a Band-Aid, etc. Second, research has emerged recently on the efficacy of different masks, and bandana style masks and fleece masks were found to be clearly inferior compared to other types of masks. Briefly, in this study participants wore different types of masks and the “relative droplet count” (or respiratory droplets that escaped the mask while they were speaking) was recorded. Bandana masks were minimally effective and only cut the relative droplet count in half on average. Fleece masks appeared to actually increase the relative droplet count, and the authors hypothesize that this is from larger droplets dispersing into smaller droplets as they pass through the fabric.
As we approach fall and winter don’t forget the basics of washing your hands, avoiding touching your face, and staying home if you are showing any symptoms of illness. We plan to continue to offer telemedicine visits to our patients for convenience and safety. If you have additional questions please call to schedule an appointment for the near future.