PUBLIC HEALTH
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85% (289/339) of patients.
While this sudden outbreak is concerning and tragic, it certainly
should not come as a surprise. E-cigarettes are largely unregulated
products. No government entity oversees what goes into them and
no authority tests them for safety.
All cases in the outbreak have been linked to the use of electronic
cigarettes or other vaping products. Most patients have reported a
history of using products containing THC, tetrahydrocannabinol,
the principal psychoactive constituent of cannabis.
Last month, the CDC announced a possible cause of the lung in-
jury may be vitamin E acetate, a common additive in many cosmetic
and food products. Although vitamin E acetate is considered safe
when applied to the skin or consumed, new evidence indicates that
it may be dangerous when inhaled. CDC laboratory test results of
bronchoalveolar lavage (BAL) samples from 29 patients submitted
to CDC from 10 states identified vitamin E acetate in all BAL fluid
samples. THC was identified in 82% of the samples and nicotine
was identified in 62% of the samples.
As of this article going to print, investigators have not conclu-
sively narrowed down the cause of this very serious lung injury
to any specific group of vaping products, and the CDC continues
to recommend that people should refrain from vaping while the
investigation is under way.
ADVICE TO JEFFERSON COUNTY RESIDENTS
Given what we presently know about the outbreak, here is what we
are advising Jefferson County residents:
1. Vaping is not safe. It’s causing deaths across the country, and
right now, there is no way to know if products purchased in
retail outlets are safer than products bought on the street.
2. Adults who are using e-cigarettes containing nicotine to quit
cigarette smoking, should not return to smoking cigarettes. If
you have patients who are using e-cigarettes to quit smoking,
please refer them to cessation classes. The Department of Public
Health and Wellness offers free smoking and vaping cessation
classes with FDA approved nicotine replacement products such
as patches and gum. Call us at 574-STOP (574-7867).
3. Parents, teachers and mentors, and health care providers should
discuss this outbreak with children. Let them know about the
life-threatening consequences of vaping and e-cigarette use. If
they are vaping, treat it as a serious medical issue. Help them
stop vaping.
We are further advising people who have recently used an e-cigarette
or vaping product and have symptoms like those reported in this out-
break, to see a physician. Those who persist in using e-cigarettes and
other vaping devices should not buy these products “off the street,”
and should not modify or add any substances to these products.
YOUNG PEOPLE DISPROPORTIONATELY AFFECTED
Perhaps the most concerning thing about the outbreak is that it is
disproportionately affecting our young people. Approximately 80%
of patients are under 35 years old, 16% are under 18 and 21% are
between the ages of 18 and 20. This makes sense since it is mostly
younger people who use e-cigarettes and vaping products.
A cross-sectional survey conducted this year, that included more
than 19,000 participants published in the November issue of the
Journal of the American Medical Association (JAMA), found that
nearly one-third (27.5%) of high school students and 10.5% of
middle school students use e-cigarettes.
POLICY INITIATIVES
In 2017 Louisville Metro Government, with help and support from
the Greater Louisville Medical Society, included e-cigarettes and
other vaping and hookah products under its Smoke Free Ordinance.
Now one of the strongest such ordinances in the Unites States, the
ordinance prohibits conventional tobacco products, e-cigarettes
and other vaping and hookah products in indoor public places and
worksites. We encourage everyone to call 311 to report a violation.
However, we need to do more.
If the Trump administration does not follow through on the
commitment it made in September to ban flavored e-cigarettes and
vaping products, and to raise the legal age for purchasing tobacco
products, including vaping products to 21, Kentucky should do so.
Right now, e-cigarettes are the only tobacco product sold in
Kentucky that is not subject to a state excise tax, yet they’re the most
popular tobacco product for youth. Only eight percent of Kentucky
adults use e-cigs, but 27.5% of Kentucky high school seniors use
them. We support the Foundation for a Healthy Kentucky’s cam-
paign to put an excise tax on e-cigarettes that is at least equivalent
to the tax on conventional cigarettes. Making these products more
expensive will curb their use among young people, as we have shown
reduced cigarette use by young people in Kentucky when the tax
was last raised on cigarettes.
We also need increased funding for prevention and cessation.
This year, Kentucky took in $354 million in tobacco taxes and an-
other $117 million in tobacco master settlement funds (total $471
million). Yet the state public health department was given only
$3.7 million to prevent youth tobacco use and help smokers quit.
CLINICAL EVALUATION
EVALI is a diagnosis of exclusion because, at present, no specific
test or marker exists for its diagnosis. Health care providers should
consider multiple etiologies, including the possibility of EVALI and
concomitant infection.
History
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Ask about respiratory (e.g., cough, chest pain and shortness of
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DECEMBER 2019
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