Study investigates severe lung injuries among e-cigarette users in rural Appalachia

Just as e-cigarette ingredients can vary from one region to another, the health effects of vaping can have regional characteristics as well. A new study out of West Virginia University suggests that rural e-cigarette users are older--and often get sicker--than their urban counterparts.

Researchers with the WVU School of Medicine are investigating severe lung injuries occurring among e-cigarette users in rural Appalachia. In a recent study, Sunil Sharma--section chief of pulmonary/critical care and sleep medicine at the School of Medicine--and his colleagues present a case study of patients with EVALI (electronic cigarettes and vaping-associated lung injury) admitted to WVU hospitals from August 2019 to March 2020.

The study, published in Hospital Practice, suggests that EVALI in rural Appalachia results in severe respiratory failure.

Ours is the first rural study. One of the real lessons we learned is we can't take data from urban centers and apply them to rural. We could be different, and we physicians need to treat the way that the science is showing in our areas."

Sunil Sharma, section chief of pulmonary/critical care and sleep medicine, WVU School of Medicine

Sharma and his team recorded demographics, baseline characteristics, health conditions and vaping behavior for 17 patients admitted to WVU hospitals with EVALI. They also evaluated lung specimens for signs of inflammation and analyzed patient-volunteered e-liquid materials using mass spectrometry to determine chemical composition.

Compared to other EVALI studies performed in urban centers, patients in the rural study were older, had a higher amount of illicit drug use and were much sicker. The median age of patients in this study was 33, compared to 23 in a large national study.

Thirteen patients had a history of cigarette smoking, while four were never smokers. Urine testing determined that nine patients were also consuming THC and another nine were positive for other illicit drugs. Seven of the patients consuming THC required critical care, and four of the 17 had secondary infection of the lungs. Ten patients required mechanical or noninvasive ventilation while two required treatment with an extracorporeal membrane oxygenation machine, which pumps someone's blood outside of their body, oxygenates it and returns it to the body.

Sharma's analysis of e-liquids identified toxic volatile organic compounds--such as formaldehyde, acetaldehyde, acetone, propylene glycol and cyclohexane--in addition to nicotine. Higher levels of these VOCs were found in the e-liquids provided by the three most severely ill patients.

"We were the first ones to show that there was high correlation of volatile organic compounds, specifically in patients who were really sick," Sharma said. "Inhaling all these volatile organic compounds into your lungs at high temperatures, producing these really toxic gaseous compounds, can cause chemical burns in your lungs."

Sharma suspects the particularly high levels of VOCs may be due to the production of some e-liquids in local "garage labs." Garage labs are unregulated, and the labs likely use chemicals easily available to them.

"Volatile organic compounds are very common," he said. "They are very easily acquired, and they are cheap. And we found that there's a regional flavor to each one of the e-liquids, depending on what their garage labs have access to, what they think is cheaper and how it's made."

Despite the strong correlation between lung injury and high VOC levels, Sharma said many other factors determine how much e-cigarettes harm the lungs. These factors include the type of device or technique used to vape, the ratio of propylene glycol and vegetable glycol used as the e-liquid base, what flavors were added, the age of the patient and if the patient uses other drugs.

"Depending on these, you could have a mild chest pain and feeling of discomfort, which might go away once you stopped smoking, or you could get a lung injury so severe that it requires intubation, mechanical ventilation and sometimes even ECMO," he said.

Sharma believes that the age gap between urban and rural e-cigarette users stems from rural areas' relatively older populations. He also believes that older adults may become engaged in vaping as a way to quit smoking and may not know how dangerous it is, as most warnings from regulatory agencies have targeted teens.

Ad campaigns, such as the Food and Drug Administration's "The Real Cost," have been warning teens and young adults of the "real cost" of e-cigarettes and vaping since 2014. The FDA has also banned advertisements for e-cigarette products targeted at minors and banned enticing fruit and mint e-liquid flavors.

The results of Sharma's study indicate that it may be time to target messages about the dangers of vaping to older populations in rural areas.

"All the effort has been directed toward high schoolers and young people, but maybe in rural areas, we should be having awareness campaigns for older populations," he said.

E-cigarettes are commonly thought to be healthier or less dangerous than traditional cigarettes. Results of the study's follow-up interviews emphasize just how untrue this is, especially for older people. Six to 12 weeks after discharge, it was found that 12 patients completely stopped vaping or smoking, but four patients still experienced persistent cough, trouble breathing and wheezing, and two needed home oxygen therapy.

"The older you are, the more dangerous vaping is for you, and you're going to end up in a very bad situation, probably in an ICU," Sharma said.

Three patients reportedly continued vaping after discharge and had persistent cough and trouble breathing.

"All of these are tied," Sharma said. "You have garage labs that are producing all kinds of chemicals--which are adulterants and not authorized by a regulatory agency--and the people who are buying them are a much older population. And I think these two conspired in order for us to see a very, very sick population in West Virginia."