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EVALI: Adolescents More Likely to Obtain Vaping Products Through Informal Sources

MedicalResearch.com Interview with:
Susan Hocevar Adkins, MD
Lead Author, Senior Medical Officer, and Commander
United States Public Health Service

MedicalResearch.com: What is the background for this study?

Response: Since August 2019, the Centers for Disease Control and Prevention (CDC), the US Food and Drug Administration (FDA), and state, local, and territorial health departments have been investigating a national outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). Although clinical presentation and outcomes of EVALI patients generally have been reported, data on adolescent patients are more limited.

This article fills this gap by using data from national EVALI surveillance at CDC to examine demographic, substance use, and clinical characteristics of adolescent EVALI patients relative to young adult and adult EVALI patients.

MedicalResearch.com: What are the main findings?

Response: A total of 2155 patients were included in this cross-sectional study. Based on national surveillance data, adolescents were more likely to report obtaining nicotine-containing and THC (tetrahydrocannabinol)-containing e-cigarette or vaping products through informal sources than young adults or adults with EVALI. A history of attention-deficit/hyperactivity disorder and asthma were more common among adolescents. Gastrointestinal and constitutional symptoms of e-cigarette, or vaping, product use-associated lung injury were also more common in adolescents than adults.

MedicalResearch.com: What should readers take away from your report?

Response: Adolescents are a vulnerable population with unique needs. Compared with adults, our data suggest that adolescents with EVALI more frequently have a history of asthma and ADHD, and report nonspecific symptoms associated with EVALI, including gastrointestinal and constitutional symptoms. Therefore, clinician awareness that adolescents commonly report nonspecific gastrointestinal and constitutional symptoms may hasten timely recognition of EVALI.

Additionally, health care professionals should inform adolescents about the risks of using e-cigarette, or vaping, products, especially those containing tetrahydrocannabinol obtained from informal sources. Clinicians can also work with adolescents to provide education and access to services.

Teaching should:
(1) Emphasize the association between THC-containing e-cigarette, or vaping, product use and EVALI;
(2) Reinforce that there may be other harmful chemicals in these products besides vitamin E acetate, which is strongly associated with EVALI; and
(3) Counsel adolescents that any e-cigarette, or vaping, product use is unsafe.

The findings also support the critical need to make tobacco use cessation, substance use screening, and mental health services easily accessible to all youth.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: Continued efforts are warranted to monitor the extent of e-cigarette, or vaping, product use among adolescents, and to evaluate interventions to prevent and reduce the use of these products among youth – irrespective of whether the products contain nicotine or THC. Further work with clinicians to increase appropriate and effective confidential history taking is also imperative to identify at-risk youth; strategies to increase these practices could be explored. Finally, further research around the higher occurrence of gastrointestinal and constitutional complaints as the presenting symptoms in adolescents is important to help inform the pathophysiology of this disease and to aid clinicians in recognizing this illness.

MedicalResearch.com: Is there anything else you would like to add? Any disclosures?

Response: The 2019 EVALI outbreak occurred in the context of an epidemic of e-cigarette, or vaping, product use among US adolescents. These are two distinct public health issues, but both are critically important to address. Adolescent and young adult nicotine and THC use can alter neurodevelopment in the long term and may lead to increased risk of substance use disorder and cognitive difficulties. Both of these issues represent opportunities for public health and clinical communities to prevent and reduce the use of e-cigarette, or vaping, products among adolescent and young adult populations.

Regardless of whether nicotine, THC, or any other substance is used in an e-cigarette, or vaping product, these products are not safe for youth or young adults because of known negative health effects.


Adkins SH, Anderson KN, Goodman AB, et al. Demographics, Substance Use Behaviors, and Clinical Characteristics of Adolescents With e-Cigarette, or Vaping, Product Use–Associated Lung Injury (EVALI) in the United States in 2019. JAMA Pediatr. Published online May 18, 2020. doi:10.1001/jamapediatrics.2020.0756

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Last Updated on May 18, 2020 by Marie Benz MD FAAD