The Centers for Disease Control recently linked a current lung disease outbreak to electronic cigarettes (e-cigarettes) and vape devices. These devices have rapidly become the most common tobacco products used by teens, driven in large part by marketing and advertising by e-cigarette companies that market the products’ convenience of use and flavor variety. Now, however, the use of these unregulated products is landing many kids in the emergency rooms of hospitals across the country with serious lung illnesses.
Dr. Ferkol joins the show to discuss the current outbreak, when a child should be seen for treatment, as well as recommendations for pediatricians and pediatric health care providers to combat tobacco use in all forms.
Selected Podcast
Spike In Lung Disease Cases Shines Light On The Dangers Of Vaping
Featured Speaker:
Learn more about Thomas Ferkol, MD
Thomas Ferkol, MD
Thomas Ferkol, MD has 34 years of experience. his specialties include Pediatric Pulmonology. Dr. Ferkol Jr is affiliated with Saint Louis Children's Hospital.Learn more about Thomas Ferkol, MD
Transcription:
Melanie Cole, MS (Host): If you’ve been paying attention, you’ve seen so much information in the media lately about the dangers of vaping related illnesses in our children. Here to tell us about that today is Dr. Thomas Ferkol. He's a Washington University pediatric pulmonologist at St. Louis Children’s Hospital. Dr. Ferkol, as I said in my intro, vaping. Boy we’re hearing sure a lot about it, but not everybody knows exactly what it is. Tell us exactly what is vaping, and do we know what's even in these e-liquids.
Thomas Ferkol MD (Guest): Ah, that’s a great question. So electronic cigarettes—and they're also known as electronic nicotine delivery systems—are designed to deliver aerosols of nicotine and other chemicals to the lungs. Though these devices do not necessarily have to look like a cigarette, nor do they necessarily have to deliver nicotine. They come in various shapes and sizes. They have many names including vapes, vape pens, mods, and more recently Juuls. Now what is in these liquids is a bit of a challenge. The only ingredient that we know that is in nearly all commercially available electronic cigarette products is nicotine. I mean as I mentioned electronic cigarettes were designed to deliver nicotine. The nicotine content in these vapors can be as high and often higher than combustible cigarettes. Past studies have shown that 99% of all electronic cigarettes sold in American convenient stores, drug stores, mass merchandizers contain nicotine.
Now, these e-liquids also have other chemicals such as propylene glycol and glycerin which serve as nicotine and flavorings. Other than that it’s a complete mix. If you’re asking about these illicit e-liquids that people are particular interesting in with the recent surge of these severe illnesses, it’s anyone’s guess what's in them.
Host: So as you're talking about the recent surge, do we know anything about what’s causing the sudden spike in lung illnesses and deaths related to vape and e-cigarette products. What does vaping do to a children’s lungs and what do we know now about what’s going on.
Dr. Ferkol: Well, the thing is is that we don’t know precisely. I mean there is mounting evidence that has linked to some of the legal THC containing products, which is the active psychotropic agent in marijuana. We just really do not know. In fact, even now, we’re not certain what we only is inhaling when they use an electronic cigarette whether they're using a product that they got from a friend or whether they're using a product as a store. These vapors, we know, contain ultrafine particulates, organic compounds, and heavy metal such as nickel and tin. There are other reports that have shown these products are contaminated with bacteria and fungal toxins. It’s also quite possible that the respiratory complications we are seeing are related to existing or newer chemicals or flavorings, which we know are toxic.
I mean that’s the great problem. To date the U.S. Food and Drug Administration has not required manufacturer’s to describe the manufacturing product, their standards, quality control, or even list the ingredients in their products. So that’s why an awful lot of these illnesses are still fairly mysterious. We have not been able to specifically link all cases to a single product or to anything that may be within them.
Now, what does vaping do to the child’s lungs? What's another issue because we’re only just beginning to learn the damaging effects of these products. There are have been some who’ve argued that electronic cigarettes are safer than combustible cigarettes, but it would be a terrible mistake to conclude that they are safe. There is growing literature that electronic cigarette exposure leads to acute information injury and other toxicity’s in the lungs. The thing that keeps me up at night—and perhaps the most worrisome aspect of these products—is that we do not know what the long term consequences of a long term cigarette are. We do know that it’s created a new generation of nicotine addicts. Vaping in American middle and high school students are on the rise. Preliminary data that was just reported by the national use tobacco survey showed a continued increase among high school students who regularly vape. It was just reported that 28%--more than one in four—high school students use electronic cigarettes regularly. When you compare that to last year where it was 21% and the year before that that it was 12%, you can see the scope of the problem.
Host: Wow, we certainly can. It’s pretty scary for both parents and providers I imagine. So tell us a little bit. How many kids have been seen at St. Louis Children’s Hospital with complications that you might link to vaping, and what symptoms did they present? How are they treated?
Dr. Ferkol: Well, we’ve seen a few who we’re fairly confident had an acute vaping associated respiratory illness, which I think is the current term for what they're experiencing. Some of them were quite ill. Most of the patients presented with a variety of respiratory gastrointestinal and constitutional symptoms like fever. What's interesting is is that since the initial reports we have seen adolescents in our emergency department and subspecialty clinics who also likely have some vaping associated illness, but they did not require a hospital admission. So what we’re seeing here with regard to these young men and young women who are being hospitalized as a result of vaping, I think we’re just looking at the tip of the iceberg. There may be some individuals who are having significant problems related to vaping that are symptomatic but not so symptomatic that they require hospitalization.
In fact, this phenomenon has—I mean not these acute illnesses, but there has been a phenomenon called vaping bronchitis where patients who use electronic cigarettes have a persistent daily wet cough for several weeks. So I think this phenomenon has been going on well before this current surge. It’s just that either we didn’t recognize it, or we didn’t put two and two together that vaping was at least contributing to the symptoms.
Host: So interesting. So what would you like pediatricians to know about speaking with the parents and with these teens—whether it’s in private or with the parent present—about the dangers of vaping and how to discuss the outbreak with the patients and their families. Because I think that that is one of the things parents, they want the help from the pediatricians. What do you want those pediatricians to know about how to start that discussions and get the child involved?
Dr. Ferkol: Well, I think most important is that pediatricians in the community need to recognize that electronic cigarette use is far more common than they realize in the patients they treat. I just gave you the numbers that support that. So what can they do? What can a parent do? Well, needless to say the best treatment is to never start. Quitting, on the other hand, poses a bit of a dilemma for younger electronic users. I mean we can try approaches that have some success in individuals who use combustible cigarettes, like behavioral counseling and behavioral therapy. But as you can imagine their effectiveness in the context of vaping has not been studied. They certainly have not been studied in teenagers.
Then the other sort of approaches like prescription based smoking cessation medications like bupropion, they’ve not been approved in use for individuals under 18 years of age. So I think the first thing that our colleagues need to do is to ask. To ask them whether they are using electronic cigarettes or not. If they don’t, strongly council them not to begin. If they're using it infrequently, you may have the opportunity to have them stop without any further interventions. Then you can try. If the individuals, if these kids are not able to stop because they are indeed nicotine addicts then you have these other options that we outlined.
Host: Wow. It’s such a good topic and so important. Right now as we wrap up, what is the best information that you can provide about what we’re seeing now with vaping related illnesses and our teens and the FDA and what we’re seeing going on with it being banned in places and the advertising and Juul changing their advertising. Kind of wrap it all up for us Dr. Ferkol.
Dr. Ferkol: Well, I think the key take home message is electronic cigarettes have become a bit of a monster in the United States, especially among youths. We’re seeing a lot of it now. We’re seeing a lot of it now. We’re going to see even more of it now in the future, I'm afraid. Unfortunately because of gaps in the regulatory system when electronic cigarettes were introduced, the Food and Drug Administration was not involved in controlling or even understanding what are in these products. Three years ago, the deeming role gave the US FDA full authority over electronic cigarettes. It’s just that they kicked the can down the road, and they hadn’t done anything. Or they delayed it until 2021/2022. That has to stop. They have to be very much engaged. They have to provide clear guidance because right now you're absolutely right. We’re seeing different communities. We’re seeing different states enacting various laws and rules regarding electronic cigarettes. There's not a consistent policy across the country at this point. Like I said, that needs to change.
The other aspect of this, as you had mentioned, the idea of banning or prohibiting flavors in these products I cannot stress how important that is. When you look at children and adolescents who use electronic cigarettes, one of the primary reasons they're using these products is because of the flavorings. I had one young man describe it like he was inhaling candy. They were lures for our patients to begin to use these products and, unfortunately, become addicted to them. Which gets to the second aspect of this. The amount of nicotine that are in these products has gradually increased over the past several years. You’ll find in the literature they refer to this as the nicotine wars. So we’ve now created a product that is very attractive to kids because of the way they taste and a product that is difficult to give up because of the high concentrations of nicotine that they receive.
Host: Wow. What great information Dr. Ferkol. So scary, not only for pediatricians but for parents. Thank you for coming on and educating us about the dangers of vaping and really how pediatricians can get involved with the families and the parents to explain those dangers to their patients. That wraps up this episode of Radio Rounds with St. Louis Children’s Hospital. To consult with a specialist or to learn more about services and resources available at St. Louis Children’s Hospital, please call the Children’s direct physician access line at 1-800-678-HELP. Or you can head on over to our website at stlouischildrens.org for more information and to get connected with one of our providers. If you as a provider or parent found this podcast as informative as I did, please share with other providers. Share with other parents, share with people that you know because this is an issue that’s effecting all of our children right now. It’s pretty scary. So please share on your social media and be sure to check out all the other interesting podcasts in the St. Louis Children’s Hospital library. Until next time, this is Melanie Cole.
Melanie Cole, MS (Host): If you’ve been paying attention, you’ve seen so much information in the media lately about the dangers of vaping related illnesses in our children. Here to tell us about that today is Dr. Thomas Ferkol. He's a Washington University pediatric pulmonologist at St. Louis Children’s Hospital. Dr. Ferkol, as I said in my intro, vaping. Boy we’re hearing sure a lot about it, but not everybody knows exactly what it is. Tell us exactly what is vaping, and do we know what's even in these e-liquids.
Thomas Ferkol MD (Guest): Ah, that’s a great question. So electronic cigarettes—and they're also known as electronic nicotine delivery systems—are designed to deliver aerosols of nicotine and other chemicals to the lungs. Though these devices do not necessarily have to look like a cigarette, nor do they necessarily have to deliver nicotine. They come in various shapes and sizes. They have many names including vapes, vape pens, mods, and more recently Juuls. Now what is in these liquids is a bit of a challenge. The only ingredient that we know that is in nearly all commercially available electronic cigarette products is nicotine. I mean as I mentioned electronic cigarettes were designed to deliver nicotine. The nicotine content in these vapors can be as high and often higher than combustible cigarettes. Past studies have shown that 99% of all electronic cigarettes sold in American convenient stores, drug stores, mass merchandizers contain nicotine.
Now, these e-liquids also have other chemicals such as propylene glycol and glycerin which serve as nicotine and flavorings. Other than that it’s a complete mix. If you’re asking about these illicit e-liquids that people are particular interesting in with the recent surge of these severe illnesses, it’s anyone’s guess what's in them.
Host: So as you're talking about the recent surge, do we know anything about what’s causing the sudden spike in lung illnesses and deaths related to vape and e-cigarette products. What does vaping do to a children’s lungs and what do we know now about what’s going on.
Dr. Ferkol: Well, the thing is is that we don’t know precisely. I mean there is mounting evidence that has linked to some of the legal THC containing products, which is the active psychotropic agent in marijuana. We just really do not know. In fact, even now, we’re not certain what we only is inhaling when they use an electronic cigarette whether they're using a product that they got from a friend or whether they're using a product as a store. These vapors, we know, contain ultrafine particulates, organic compounds, and heavy metal such as nickel and tin. There are other reports that have shown these products are contaminated with bacteria and fungal toxins. It’s also quite possible that the respiratory complications we are seeing are related to existing or newer chemicals or flavorings, which we know are toxic.
I mean that’s the great problem. To date the U.S. Food and Drug Administration has not required manufacturer’s to describe the manufacturing product, their standards, quality control, or even list the ingredients in their products. So that’s why an awful lot of these illnesses are still fairly mysterious. We have not been able to specifically link all cases to a single product or to anything that may be within them.
Now, what does vaping do to the child’s lungs? What's another issue because we’re only just beginning to learn the damaging effects of these products. There are have been some who’ve argued that electronic cigarettes are safer than combustible cigarettes, but it would be a terrible mistake to conclude that they are safe. There is growing literature that electronic cigarette exposure leads to acute information injury and other toxicity’s in the lungs. The thing that keeps me up at night—and perhaps the most worrisome aspect of these products—is that we do not know what the long term consequences of a long term cigarette are. We do know that it’s created a new generation of nicotine addicts. Vaping in American middle and high school students are on the rise. Preliminary data that was just reported by the national use tobacco survey showed a continued increase among high school students who regularly vape. It was just reported that 28%--more than one in four—high school students use electronic cigarettes regularly. When you compare that to last year where it was 21% and the year before that that it was 12%, you can see the scope of the problem.
Host: Wow, we certainly can. It’s pretty scary for both parents and providers I imagine. So tell us a little bit. How many kids have been seen at St. Louis Children’s Hospital with complications that you might link to vaping, and what symptoms did they present? How are they treated?
Dr. Ferkol: Well, we’ve seen a few who we’re fairly confident had an acute vaping associated respiratory illness, which I think is the current term for what they're experiencing. Some of them were quite ill. Most of the patients presented with a variety of respiratory gastrointestinal and constitutional symptoms like fever. What's interesting is is that since the initial reports we have seen adolescents in our emergency department and subspecialty clinics who also likely have some vaping associated illness, but they did not require a hospital admission. So what we’re seeing here with regard to these young men and young women who are being hospitalized as a result of vaping, I think we’re just looking at the tip of the iceberg. There may be some individuals who are having significant problems related to vaping that are symptomatic but not so symptomatic that they require hospitalization.
In fact, this phenomenon has—I mean not these acute illnesses, but there has been a phenomenon called vaping bronchitis where patients who use electronic cigarettes have a persistent daily wet cough for several weeks. So I think this phenomenon has been going on well before this current surge. It’s just that either we didn’t recognize it, or we didn’t put two and two together that vaping was at least contributing to the symptoms.
Host: So interesting. So what would you like pediatricians to know about speaking with the parents and with these teens—whether it’s in private or with the parent present—about the dangers of vaping and how to discuss the outbreak with the patients and their families. Because I think that that is one of the things parents, they want the help from the pediatricians. What do you want those pediatricians to know about how to start that discussions and get the child involved?
Dr. Ferkol: Well, I think most important is that pediatricians in the community need to recognize that electronic cigarette use is far more common than they realize in the patients they treat. I just gave you the numbers that support that. So what can they do? What can a parent do? Well, needless to say the best treatment is to never start. Quitting, on the other hand, poses a bit of a dilemma for younger electronic users. I mean we can try approaches that have some success in individuals who use combustible cigarettes, like behavioral counseling and behavioral therapy. But as you can imagine their effectiveness in the context of vaping has not been studied. They certainly have not been studied in teenagers.
Then the other sort of approaches like prescription based smoking cessation medications like bupropion, they’ve not been approved in use for individuals under 18 years of age. So I think the first thing that our colleagues need to do is to ask. To ask them whether they are using electronic cigarettes or not. If they don’t, strongly council them not to begin. If they're using it infrequently, you may have the opportunity to have them stop without any further interventions. Then you can try. If the individuals, if these kids are not able to stop because they are indeed nicotine addicts then you have these other options that we outlined.
Host: Wow. It’s such a good topic and so important. Right now as we wrap up, what is the best information that you can provide about what we’re seeing now with vaping related illnesses and our teens and the FDA and what we’re seeing going on with it being banned in places and the advertising and Juul changing their advertising. Kind of wrap it all up for us Dr. Ferkol.
Dr. Ferkol: Well, I think the key take home message is electronic cigarettes have become a bit of a monster in the United States, especially among youths. We’re seeing a lot of it now. We’re seeing a lot of it now. We’re going to see even more of it now in the future, I'm afraid. Unfortunately because of gaps in the regulatory system when electronic cigarettes were introduced, the Food and Drug Administration was not involved in controlling or even understanding what are in these products. Three years ago, the deeming role gave the US FDA full authority over electronic cigarettes. It’s just that they kicked the can down the road, and they hadn’t done anything. Or they delayed it until 2021/2022. That has to stop. They have to be very much engaged. They have to provide clear guidance because right now you're absolutely right. We’re seeing different communities. We’re seeing different states enacting various laws and rules regarding electronic cigarettes. There's not a consistent policy across the country at this point. Like I said, that needs to change.
The other aspect of this, as you had mentioned, the idea of banning or prohibiting flavors in these products I cannot stress how important that is. When you look at children and adolescents who use electronic cigarettes, one of the primary reasons they're using these products is because of the flavorings. I had one young man describe it like he was inhaling candy. They were lures for our patients to begin to use these products and, unfortunately, become addicted to them. Which gets to the second aspect of this. The amount of nicotine that are in these products has gradually increased over the past several years. You’ll find in the literature they refer to this as the nicotine wars. So we’ve now created a product that is very attractive to kids because of the way they taste and a product that is difficult to give up because of the high concentrations of nicotine that they receive.
Host: Wow. What great information Dr. Ferkol. So scary, not only for pediatricians but for parents. Thank you for coming on and educating us about the dangers of vaping and really how pediatricians can get involved with the families and the parents to explain those dangers to their patients. That wraps up this episode of Radio Rounds with St. Louis Children’s Hospital. To consult with a specialist or to learn more about services and resources available at St. Louis Children’s Hospital, please call the Children’s direct physician access line at 1-800-678-HELP. Or you can head on over to our website at stlouischildrens.org for more information and to get connected with one of our providers. If you as a provider or parent found this podcast as informative as I did, please share with other providers. Share with other parents, share with people that you know because this is an issue that’s effecting all of our children right now. It’s pretty scary. So please share on your social media and be sure to check out all the other interesting podcasts in the St. Louis Children’s Hospital library. Until next time, this is Melanie Cole.