Q&A: Expanding knowledge, awareness of vaping-related lung injury

Since the CDC declared e-cigarette or vaping product use-associated lung injury, or EVALI, an epidemic in 2019, researchers have been working to understand its causes and harms and how to stymie the rise of this disease.

One such effort took place in 2021 though the form of a virtual workshop composed of pulmonologists, public health officials, epidemiologists and toxicologists. Together, 26 experts discussed the public health and regulatory response to EVALI, clinical care of EVALI, mechanisms contributing to EVALI and necessary actions that speak on the health effects of EVALI.

These discussions and recommendations have been published as a report in Annals of the American Thoracic Society.

Healio spoke with Meghan E. Rebuli, PhD, lead author of the report, assistant professor of pediatrics and member of the Center for Environmental Medicine, Asthma and Lung Biology at the University of North Carolina, to learn more about the rationale behind the workshop, challenges that need to be overcome to best address EVALI, and what efforts can be undertaken to prevent future EVALI outbreaks.

Healio: What were the reasons for convening this virtual workshop on EVALI?

Rebuli: The workshop was initially proposed in 2020, shortly after the peak of the EVALI epidemic in 2019. Researchers and clinicians were concerned by the epidemic — both by the seemingly quick onset and how many people were affected across the country — and wanted to set up a panel of experts to examine factors that contributed to the epidemic and identify ways we could improve research strategies and infrastructure to prevent such a large event in the future. The workshop proposal was approved in early 2021 by the American Thoracic Society and took place a few months after the approval.

Healio: What are some of the EVALI-related challenges that were addressed/discussed at the workshop?

Rebuli: The first major challenge we tackled as a group was how to conduct such a workshop in a virtual setting. Historically, major workshops such as this were conducted in-person to allow for dynamic discussion and interaction between workshop participants. So, we had to devise a way to work with everyone’s schedule across the country and make the workshop as interactive and informative as possible.

• how to study EVALI incidents now that the CDC is no longer collecting nationally representative data;
• increasing physician education around asking patients about e-cigarette use or second-hand exposure;
• the challenges around continually adapting research strategies to keep up with the quickly evolving e-cigarette market;
• the need for more regulation and manufacturing standards around e-cigarettes to facilitate safety testing and ensuring public health; and
• the continued need for investment in EVALI research as cases continue to be documented across the country, albeit not at the rates at the peak of the epidemic.

Healio: According to a press release from UNC Health Care, you discussed the chemical components of e-cigarettes and the role vitamin E plays in the development of EVALI. What were the key takeaways from this conversation?

Rebuli: First, we wanted to make it clear that although the majority of EVALI cases were associated with THC-based product that contained vitamin E acetate, there were some cases that were associated with only nicotine-based products. This leads us to believe that there may be other potential constituents in some e-cigarettes that contribute to the development of EVALI. This argument is strengthened by the fact that there are still EVALI cases being documented in hospital systems across the country and, as far as we know, vitamin E acetate has been removed from products on the market.

This then led us to discuss the potential for increased regulation of what compounds can be allowed in e-cigarettes and the development of manufacturing standards by the FDA, similar to what has been done with cigarettes. Further, there was discussion of the need for comprehensive safety testing of products before they become available on the market, which has historically not occurred with e-cigarettes, especially prior to the EVALI epidemic.

As most of the vitamin E acetate-containing products also contained THC, we discussed the need to better understand what inhaling THC-containing products does to the lungs. Currently, our biological understanding of the effects of THC are limited, as there are steep federal restrictions around its use in federally funded labs under the Controlled Substances Act. Declassification of marijuana as a Schedule I substance or a waiver of requirements around the use of Schedule I substances for research purposes would help scientists to more easily study its health effects.

Healio: What critical needs and areas of further work did you identify in the workshop as being necessary to prevent and address future EVALI outbreaks?

Rebuli: Critical needs to prevent future EVALI events include increased regulation of e-cigarettes, including manufacturing standards and curbed marketing to youth and young adults. Further work by researchers that is needed includes developing a national case registry and biorepository, continued safety and toxicity assessments as products on the market change, investment in research on the long-term health effects of EVALI and the identification of other potential harmful additive chemicals in e-cigarettes.

Healio: How can physicians, health care workers and the public help in combatting against EVALI?

Rebuli: Physicians and health care workers can help combat EVALI by seeking training in evaluating patient exposures and ensuring that they’re screening patients for e-cigarette use. They can also propose and participate in clinical studies with identified EVALI patients, ensuring consistent follow-up assessments with other researchers across the country to have a useful nationally representative dataset.

The public, as well as health care workers, can continue to seek and spread knowledge about the known health effects of e-cigarette use, especially among youth and young adults. Everyone can also advocate to government legislators and the NIH for dedicated resources, such as a national biorepository and case registry, as well as grant funding, to prevent future EVALI or EVALI-like outbreaks from new and emerging inhaled product use.

For more information:

Meghan E. Rebuli, PhD, can be reached at meradfor@email.unc.edu.

References:

Rebuli ME. Ann Am Thorac Soc. 2022;doi:10.1513/AnnalsATS.202209-796ST.

UNC researchers tackle the e-cigarette or vaping product use-associated lung injury (EVALI) epidemic. https://news.unchealthcare.org/2023/01/unc-researchers-tackle-the-e-cigarette-or-vaping-product-use-associated-lung-injury-evali-epidemic/. Published Jan. 3, 2023. Accessed Jan. 4, 2023.