Letters to the Editor

Electronic Cigarettes: More Questions Than Answers


Am Fam Physician. 2019 Nov 15;100(10):600-601.

Original Article: Electronic Cigarettes: Common Questions and Answers

Issue Date: August 15, 2019

See additional reader comments at: https://www.aafp.org/afp/2019/0815/p227.html

To the Editor: Because we provide care to thousands of adults and youth with nicotine dependence annually, we appreciate the excellent overview article on electronic cigarettes (e-cigarettes). The article contains excellent references for helpful terms when screening for and talking about e-cigarette use. Although there are likely benefits of e-cigarettes in assisting patients with quitting regular cigarettes, it is increasingly certain that vaping can be harmful.

Millions of e-cigarette users face potential exposure to toxins. For instance, as of October 15, 2019, there were 1,479 cases of severe pulmonary disease associated with vaping reported in adolescents and young adults in 49 states (all except Alaska), the District of Columbia, and one U.S. territory (USVI), and 33 deaths.1 In response to these cases, Michigan has enacted policy to prohibit the sale of flavored e-cigarette products and Massachusetts banned all e-cigarettes for a four-month period. Symptoms have included dyspnea, fatigue, chest pain, cough, and weight loss that worsened days or weeks before hospitalization. Imaging studies demonstrated bilateral opacities on chest radiography and diffuse ground-glass opacities on computed tomography. Recent case studies have highlighted eosinophilic pneumonia in e-cigarette users,2,3 and an observational study found increased rates of bronchitis in adolescent e-cigarette users.4 These cases have involved traditional e-cigarette use and vaping of multiple substances, including nicotine, tetrahydrocannabinol (THC), synthetic cannabinoids, and combinations of these substances.5

Clinicians need to ask patients about their use of traditional e-cigarettes, but also about their use of emerging vaping products, devices, liquids, refill pods, and cartridges. Clinicians should also report cases of significant respiratory illness of uncertain etiology in patients with a history of vaping to state and local health departments.

Although e-cigarettes are marketed as a healthier alternative to cigarettes, far more longitudinal research is needed to examine e-cigarettes and their ingredients, including high nicotine content and flavoring; exposure to metals; combination use with other substances; and chronic use influence pulmonary toxicity.6 In the meantime, clinicians should discuss adverse pulmonary toxicity with both traditional cigarette users and e-cigarette users.

Author disclosure: Dr. Goldstein disclosed that in 2018 he was paid by Pfizer to attend a one-day meeting on tobacco cessation treatments. Drs. Baca-Atlas and Mounsey have no relevant financial affiliations.


show all references

1. Centers for Disease Control and Prevention. Outbreak of lung injury associated with e-cigarette use, or vaping. October 17, 2019. Accessed October 21, 2019. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-outbreak-information...

2. Arter Z, Wiggins A, Hudspath C, et al. Acute eosinophilic pneumonia following electronic cigarette use. Respir Med Case Rep. 2019;27:100825. Accessed August 17, 2019. https://linkinghub.elsevier.com/retrieve/pii/S2213-0071(19)30026-7.

3. Thota D, Latham E. Case report of electronic cigarettes possibly associated with eosinophilic pneumonitis in a previously healthy active-duty sailor. J Emerg Med. 2014;47(1):15–17.

4. McConnell R, Barrington-Trimis JL, Wang K, et al. Electronic cigarette use and respiratory symptoms in adolescents. Am J Respir Crit Care Med. 2017;195(8):1043–1049.

5. Kowitt SD, Osman A, Meernik C, et al. Vaping cannabis among adolescents: prevalence and associations with tobacco use from a cross-sectional study in the USA. BMJ Open. 2019;13;9(6):e028535.

6. Chun LF, Moazed F, Calfee CS, et al. Pulmonary toxicity of e-cigarettes. Am J Physiol Lung Cell Mol Physiol. 2017;313(2):L193–L206.

Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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