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Scientific Letter
DOI: 10.1016/j.anpede.2019.10.011
Open Access
Available online 4 October 2020
Vaping: The new problems of a new epidemic and the importance of paediatricians in their prevention
Vaping: los nuevos problemas de una nueva epidemia y la importancia de los pediatras en su prevención
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Laura Moreno-Galarraga
Unidad de Neumología Infantil, Servicio de Pediatría, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
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Dear Editor:

In 2014, the Oxford English Dictionary named “vape” word of the year, a verb meaning “to inhale and exhale the vapour produced by an electronic cigarette or similar device. In Spain, the first devices used for vaping, known as e-cigarettes, entered the market in 2007, and their use has grown considerably since.1

Vaping originally emerged as a strategy to quit smoking, a tool for everyday smokers to overcome nicotine dependence, but turned out to be a double-edged sword. The data regarding the efficacy of e-cigarettes as an aid to quit smoking are contradictory, while their use is expanding among nonsmokers, especially in the young population, and not only to deliver nicotine but also other substances, such as cannabinoids, tetrahydrocannabinol, marihuana or a variety of oils.2 Multiple studies have warned that vaping has had the opposite effect in youth, with its use associated with progression to conventional smoking.1,2 In the United States, vaping has become a public health problem in the adolescent population, as use of e-cigarettes has become widespread and 1 out of every 11 middle school students reports consuming them.2 Vaping in the young population is also growing in Spain, where 1 out of every 4 users of e-cigarettes does not have a previous history of tobacco use.1

At present, a variety of battery-operated devices are available to inhale aerosolised substances. Although social acceptance of these devices is greater, the legislation on their use is underdeveloped, and they have been marketed as a preferable alternative to conventional smoking. However, significant conflicts of interest have been reported in studies on the subject,3 and the development of cases of severe pulmonary disease associated with their use has caused widespread concern in recent months.4–6

Research on the effects of vaping is currently insufficient. Side effects have not been associated solely to classic vaping products (nicotine and cannabinoids), but oils and chemicals used in the different flavours may also be harmful to health.4,5 The potential of inhaling chemicals with unknown effects is high, and it is difficult to determine the amounts that are being inhaled (which depend on the product consumed, its concentration and the device used for delivery) or the source of the product. Recently, evidence has emerged warning of potential, hereto unknown side of vaping. The Centers for Disease Control and Prevention (CDC) and the health authorities of the United States are collaborating to investigate the growing number of cases of severe lung disease associated with e-cigarette use, urging doctors to actively collect data on this potential association.4 There have been reports in previously healthy youth of cases of acute lung disease presenting with cough and chest pain with quick progression to dyspnoea and severe respiratory failure, sudden onset sometimes associated with fever, gastrointestinal manifestations (such as vomiting or diarrhoea) and systemic manifestations. According to different publications of the CDC, the first case of severe pulmonary disease associated with vaping was diagnosed in July 2019, in August 110 cases had been reported in 15 states, and in September the case count had already risen to 500.4 The definition of the CDC of a confirmed case of pulmonary disease associated with vaping is a patient reported use of an e-cigarette (vaping) or dabbing in the 90 days before onset with evidence of pulmonary infiltration on chest plain radiograph and in the absence of an alternative plausible cause,5 and, along with the Food and Drug Administration (FDA) of the United States, it has been investigating its relationship with cases of convulsive seizures since its initial statement warning of this potential side effect.6

In conclusion, e-cigarette use is increasing among our youth and vaping is associated with an increased risk of starting to smoke conventional cigarettes, their long-term effects have not been investigated adequately, and at present both the CDC and the FDA are researching potential severe adverse effects.

As paediatricians in Spain, whether in primary care or at the hospital level, we must be prepared to face this new epidemic. Recommendations against tobacco given in primary care must now be accompanied by recommendations against vaping, and we must also warn of the risks involved in passive exposure to vaping products. Educational materials must be developed to provide to our patients and their families. We must directly ask adolescents about their use of e-cigarettes and warn parents about them, as use is difficult to detect due to their near non-existent smell. Furthermore, in case of acute respiratory diseases or convulsive seizures of unclear aetiology in adolescents, we must rule out a potential association with vaping, and start a national register of potential cases.

In light of all of the above, I consider that working groups should be created in the Asociación Española de Pediatría to detect and study potential side effects of vaping, and urgent strategies developed to prevent e-cigarette use in our patients.

Funding

This study was made possible by the aid received from the Asociación Española de Pediatría (Spanish Association of Pediatrics, AEP): 2018 InvestAEP research grant.

References
[1]
C. Lidón-Moyano, J.M. Martínez-Sánchez, M. Fu, M. Ballbè, J.C. Martín-Sánchez, E. Fernández.
Prevalence and user profile of electronic cigarettes in Spain (2014) [Article in Spanish].
Gac Sanit, 30 (2016), pp. 432-437
[2]
K.W. Bold, G. Kong, D.R. Camenga, P. Simon, D.A. Cavallo, M.E. Morean, et al.
Trajectories of e-cigarette and conventional cigarette use among youth.
Pediatrics, 141 (2018),
[3]
C. Martínez, M. Fu, I. Galán, M. Pérez-Rios, J.M. Martínez-Sánchez, M.J. López, et al.
Conflicts of interest in research on electronic cigarettes.
Tob Induc Dis, 16 (2018), pp. 28
[4]
CDC, FDA States continue to investigate severe pulmonary disease among people who uses e-cigarettes. Available at: https://www.cdc.gov/media/releases/2019/s0821-cdc-fda-states-e-cigarettes.html [accessed August 2019].
[5]
J.E. Layden, I. Ghinai, I. Pray, A. Kimball, M. Layer, M. Tenforde, et al.
Pulmonary illness related to e-cigarette use in Illinois and Wisconsin – preliminary report.
[6]
Statement from FDA Commissioner Scott Gottlieb, M.D., and Principal Deputy Commissioner Amy Abernethy, M.D., Ph.D., on FDA's ongoing scientific investigation of potential safety issue related to seizures reported following e-cigarette use, particularly in youth and young adults. Available at: https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-and-principal-deputy-commissioner-amy-abernethy-md-phd [accessed August 2019].

Please cite this article as: Moreno-Galarraga L. Vaping: los nuevos problemas de una nueva epidemia y la importancia de los pediatras en su prevención. An Pediatr (Barc). 2020. https://doi.org/10.1016/j.anpedi.2019.10.008

Copyright © 2019. Asociación Española de Pediatría
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