Patient Perception of Vaping in the Midst of the Electronic Cigarette and Vaping Product Associated Lung Injury (EVALI) Epidemic

Abstract

Purpose of Study

EVALI has reached epidemic proportions. With the increasing prevalence, new information has come to light regarding the safety of electronic cigarettes. We investigate the impact of the recent EVALI epidemic on patient perception surrounding vaping.

Methods

An anonymous survey was developed to evaluate patient perception regarding vaping. The survey was administered to adult patients at various clinics at University of Missouri. A total of 287 survey responses were analyzed.

Results

In all, 81.5% of respondents reported that e-cigarettes are unsafe, 73.2% did not feel that the absence of THC oils or vitamin E acetate made e-cigarettes safer, and 55.1% felt that e-cigarettes are less safe than traditional cigarettes. A majority (76%) felt that e-cigarettes/vaping products should be more regulated and pose a public health concern. Most surprising, 67.6% of participants answered that they knew somebody who was negatively affected by EVALI.

Conclusion

The survey responses suggest that the current EVALI epidemic is changing the public’s perception and the narrative surrounding safety of e-cigarettes and vaping products.

Introduction

Electronic cigarettes (e-cigarettes) were introduced into the marketplace in 2003.¹ Since then the e-cigarette has undergone many iterations, evolving into hundreds of brands, designs, and flavors.^1,2 It is now well established that e-cigarette use (vaping) can cause a myriad of lung injury patterns, including but not limited to acute eosinophilic pneumonia, diffuse alveolar hemorrhage, organizing pneumonia, hypersensitivity pneumonitis, and lipoid pneumonia.^3–5 Collectively these patterns of lung injury are referred to as electronic cigarette or vaping product associated lung injury (EVALI).³ As of January 2020, there have been over 2,600 reported cases of EVALI requiring hospitalization.⁶

Despite the reported health risks and widespread media coverage regarding EVALI, e-cigarette popularity and use have increased significantly in the past five years amongst people of all ages. Most concerning is the incidence of e-cigarette use among the youth, which has more than doubled from 2017 to 2019.^7,8 Several factors have contributed to the widespread use and adoption of e-cigarettes by the youth. These include the introduction of newer, sleeker, easily hidden vaping devices, unrestricted marketing techniques, and creation of flavors that are targeted to be appealing to a younger demographic.^9,10

In our review of the current literature, there has been no assessment of public perceptions surrounding e-cigarette use since the emergence of the EVALI epidemic. We set out to investigate various patient populations’ understanding and perception surrounding vaping. A survey was developed to elucidate the reason vaping continues to remain popular despite the emergence of significant health risks over the past six months. Hypothesizing that perception regarding the safety of e-cigarettes, the necessity for e-cigarette regulation, and their role in smoking cessation would vary significantly based on age and prior e-cigarette use.

Materials and Methods

An anonymous survey was developed to evaluate perception regarding e-cigarettes and vaping among various patient populations. The aim of our study was to develop a concise survey tool that could provide demographic data, unbiased insight into opinions surrounding e-cigarettes, and perception surrounding the use of e-cigarettes as a smoking cessation tool.

The survey tool was comprised of 15 multiple choice questions. The first five questions captured demographic data (age group, gender, education, familiarity with vaping products, and history of vaping product use). The subsequent six questions used a Likert scale to evaluate the participant’s perception surrounding the safety and need for regulation of e-cigarette/vaping products. The survey tool concluded with a final four set of yes/no questions which assessed experience with vaping and opinions regarding the role of e-cigarettes as a smoking cessation tool.

Approval was obtained from the University of Missouri Institutional Review Board (IRB); the survey tool was created using Qualtrics^TM, and underwent validation using Collingridge’s survey validation method. This included establishment of face validation with the use of a combination of eight board certified Internal Medicine physicians and board certified Pulmonary and Critical Care Medicine physicians. After undergoing face validation, the survey tool was pilot tested with 30 participants (10% of the anticipated sample population) at the internal medicine clinic site. The collected pilot data was reviewed to assess proper understanding of the survey questions by the pilot test group. Pilot data was not used in the final analysis.

After validation, the survey was administered to adults (age > 18 years). Prior to survey administration, study participants were notified that the survey was completely anonymous, voluntary, and no incentive would be provided for participation. Administration of the survey occurred over the course of two weeks between 1/27/2020 and 2/7/2020. During this time, the survey was administered by the study group for three one-half days at each clinic location. Three separate clinic locations (general internal medicine clinic, medicine specialty clinic, and student health clinic) were chosen for the purposes of achieving a broad range of study participants. Subjects were given the option of taking the survey on their mobile device via use of a QR code or by filling out a printed (pen and paper) version of the same survey questions. At the conclusion of data collection, statistical analysis was performed using Fisher’s exact test.

Results

A total of 308 participants were asked to complete the survey, of which 296 completed the survey. Nine surveys were excluded from the analysis as they were incomplete. A total of 287 completed surveys were used for the final analysis. The basic demographic data of the study participants is outlined in Table 1. Those surveyed were asked to quantify their familiarity with e-cigarettes and whether they had used e-cigarettes/vaping products. Among respondents, 26.5% (76/287) reported being very familiar, 53.7% (154/287) somewhat familiar, and 19.9% (57/287) unfamiliar with vaping products. In regard to prior e-cigarettes/vaping product use, 4.5% (13/287) endorsed daily use, 30% (89/287) endorsed prior use, and 64.5% (185/287) reported no prior use.

Table 1.

Patient Demographics

Patient Demographics (n=287)
Q1: What age group do you fall in?	18–35	35–50	>50
	n=147	n=39	n=101
	51.2%	13.6%	35.2%
Q2: What gender do you identify as?	Male	Female	Other
	n=102	n=184	n=1
	35.6%	64.1%	0.3%
Q3: What is your highest level of education?	High school/GED	Undergraduate	Graduate
	n=141	n=81	n=65
	49.1%	28.2%	22.6%
Q4: How familiar are you with electronic cigarettes/vaping products?	Very familiar	Somewhat	Unfamiliar
	n=76	n=154	n=57
	26.5%	53.7%	19.9%
Q5: Have you used electronic cigarettes/vaping products?	Use daily	Used previously	Never used
	n=13	n=89	n=185
	4.5%	30.0%	64.5%

Additionally, a Likert scale was used to gauge public perception of e-cigarette/vaping products. A majority, 81.5% (234/287) of respondents disagreed with the statement that e-cigarettes/vaping products are safe. Furthermore, 73.2% (210/287) did not feel that the absence of tetrahydrocannabinol (THC) oils or vitamin E acetate made e-cigarettes safer. This closely resembled the group’s opinion on the safety of post-purchase modifications (modding) of e-cigarettes with 85.4% (245/287) considering this to be an unsafe practice. The remaining three Likert scale-based questions were designed to assess the safety of e-cigarettes compared to traditional cigarettes and participants views on the necessity for further regulation of e-cigarettes. Here, 55.1% (158/287) felt that e-cigarettes were less safe when compared to traditional cigarettes. Whereas, 25.1% (72/287) felt that e-cigarettes were safer than traditional cigarettes, and 19.9% (57/287) were neutral on the issue. Although, the majority (76%) still felt that e-cigarettes/vaping products pose a public health concern and should be more regulated (Figure 1).

Figure 1.

Likert Scale Answers. Responses from participants to each Likert scale question.

The final set of questions in the survey study were a series of yes/no questions to evaluate provider screening of e-cigarette use in the ambulatory setting, to assess perception related to the use of e-cigarettes to assist with smoking cessation, and to quantify the scope of the EVALI epidemic in the mid-Missouri region. Surprisingly, 56.8% (163/287) of respondents reported no screening by their providers regarding e-cigarette use. Furthermore, in regard to the role of e-cigarettes as a smoking cessation tool, only 10.1% (29/287) reported use of e-cigarettes to quit smoking, while 76.7% (220/287) recommended against the use of e-cigarettes as a smoking cessation aid. The scope of the EVALI epidemic was highlighted by the final question of the survey. Of the 287 participants, 194 (67.6%) answered that they knew somebody who was negatively affected by EVALI (Figure 2. Patient Perceptions).

Figure 2.

Patient Perceptions of Electronic Cigarettes/Vaping Products and responses from participants to each Yes/No question.

Discussion

To understand the mounting popularity of vaping, one needs to look no further than our youth. Since 2014, e-cigarettes have replaced traditional cigarettes and tobacco chew as the most commonly used forms of nicotine.¹¹ Even more concerning is that the prevalence of vaping among youth has more than doubled between 2017–2019.⁷ There have been many proposed reasons behind this, many of which revolve around the targeted marketing of youth, the wide variety of flavors, and the ability to customize the device.⁹ There also appears to be a discrepancy in respect to age and the safety of vaping. Analysis of our survey responses illustrated that those between the ages of 18–35 tend to view e-cigarettes as safer than traditional cigarettes when compared to the responses of those over the age of 50 (p<0.001). Furthermore, those over the age of 50 were more inclined to feel that e-cigarettes should be more tightly regulated versus their younger counterparts (p<0.001). This data indicates that age plays a significant role in regard to perception of vaping, which we suspect is one of the driving factors of the vaping epidemic.

The increasing popularity in the use of e-cigarettes among youth, and the general population, is alarming as it represents a major set-back in the decades long fight to curtail the use of tobacco products among Americans. It appears that e-cigarettes have captured popularity by propagating the unsubstantiated notion of a safer alternative to traditional cigarette products.^12,13 In the United States, electronic cigarettes were first introduced to the public as a safer alternative to traditional cigarettes in 2008.⁹ However, studies evaluating e-cigarettes as a smoking cessation tool compared to FDA approved medications have been inconclusive at best.^14–17 Furthermore, the combination of nicotine replacement therapy with pharmacologic smoking cessation aids (varenicline or bupropion) may be superior to e-cigarettes in continued smoking abstinence.¹⁸ Particularly as, many of those that used e-cigarettes as a smoking cessation tool subsequently maintain dependence on vaping products for more than a year after smoking cessation.^18,19 The findings of these studies call to question if e-cigarettes truly play any role in smoking cessation. In fact, only 10.1% (29/287) of respondents in our survey reported using e-cigarettes as a smoking cessation tool and 76.7% (220/287) recommended against the use of e-cigarettes as a smoking cessation aid.

Since the initial reports were published regarding EVALI, it was clear that THC containing e-cigarette products played a role in the propagation of EVALI. In an epidemiologic study of the initial 53 patients affected by EVALI, 80% were noted to have used THC oils when vaping.^3,20 THC oils and vitamin E acetate were not the only compounds implicated in EVALI, in fact 14% of the reported cases of EVALI were the result of e-cigarettes containing only nicotine.⁶ These findings suggest that additional factors, unique to e-cigarettes, may also play a role in EVALI. One such factor is that the heat produced by e-cigarette vapor may results in direct thermal injury to the airways.²¹ Additionally, e-cigarette cartridges contain propylene glycol and vegetable glycerin, both of which have been implicated in causing epithelial compromise and aberrant airway remodeling.^13,21–23 Within our survey participants, 67.6% (194/287) indicated that they know someone who has been negatively affected by EVALI. This unique subset felt strongly that e-cigarettes are not safe (p=0.012), pose a public health concern (p=0.085), and should be more closely regulated (p=0.023). Whereas, those who did not know someone affected by EVALI remained neutral. These findings echo the conclusions found in the literature, which note lower rates of EVALI in nations (United Kingdom) where e-cigarettes and vaping products are more strictly regulated.²²

Survey responses were analyzed to assess if there were any significant differences in opinions regarding the role of THC oils and vitamin E acetate in the safety of e-cigarettes. It revealed significant differences in opinions regarding overall safety of e-cigarettes (p<0.001), the role of THC oils and vitamin E acetate on e-cigarette safety (p=0.001), and the safety of e-cigarettes compared to traditional cigarettes (p<0.001) between those who endorsed prior e-cigarette use versus those who had never used e-cigarettes. As a group, prior e-cigarettes users viewed e-cigarettes and THC oils or vitamin E acetate containing e-cigarettes as safer than traditional cigarettes. These results demonstrate that perceptions of e-cigarettes vary widely between prior users and those who have never used e-cigarettes. In fact, 75% of current and prior e-cigarette users responded that e-cigarettes are safe and 66.7% responded that they were safer than traditional cigarettes. These findings are in line with prior surveys of e-cigarette users that show >90% of respondents reporting e-cigarettes as safer than traditional cigarettes.²⁴ The results suggest that novel information regarding the role of THC oils, vitamin E acetate, and e-cigarette specific factors in EVALI are not significantly changing the perceptions surrounding e-cigarettes safety in current and prior users. Although the overall perception among survey respondents has clearly been impacted by the EVALI epidemic.

Despite our best efforts to distribute the survey to a large number of participants, we only received 287 complete responses. Additionally, our survey only evaluated participants at a single academic teaching hospital within the United States. This may limit the external validity of our findings outside of the mid-Missouri region. Although, the authors attempted to design the survey questions to succinctly assess perceptions surrounding EVALI and e-cigarettes more questions would have been helpful in providing additional insight. However, we feel that additional questions would have adversely impacted response rates by increasing complexity and time needed to complete the survey. Lastly, we cannot say with certainty that perceptions surrounding EVALI, e-cigarettes, and vaping products are directly the result of new information brought to light in the literature. This may be an area that warrants further evaluation in the future.

Conclusion

The responses clearly indicate a shift in opinion regarding the safety of e-cigarettes and vaping related products among patients. Although the younger respondents and e-cigarette users continue to view these products as safe, the overall consensus among respondents remains that they are unsafe, require additional regulation, and should not be recommended as a smoking cessation aid. It appears that increased media attention and public education have been contributing to a change in perception. Although our results show that knowing someone or being personally affected by EVALI has the most significant impact on perceptions.

While the long-term effect of EVALI is yet to be fully understood, it is clear that this national epidemic has led to a fundamental paradigm shift regarding the safety of electronic cigarettes. A plethora of international experts and national societies have provided input regarding proposed mechanisms of EVALI, calls for nationwide action to limit the sales and marketing of e-cigarettes, and to define the part e-cigarettes play in smoking cessation. It is the combination of widespread media coverage, multiple public service announcements, and the availability of new information regarding the significant health risks surrounding e-cigarettes which has molded public perception of vaping as a generally unsafe practice and to be in dire need for further regulation.

Epilogue

Patient understanding surrounding the dangers of vaping has become even more important during the COVID-19 pandemic caused by the novel coronavirus (SARS-CoV-2). Analysis of patients who have been infected by SARS-CoV-2 in China showed a case fatality rate of 6.3% in those with chronic respiratory illnesses compared to 2.3% amongst the overall infected group.²⁵ Moreover, prior studies have shown chronic smokers and those with substance abuse disorders have a worsened prognosis when infected with other strains of coronaviruses, specifically SARS-CoV-1 and Middle Eastern Respiratory Syndrome (MERS).²⁶ One proposed mechanism for the worsened outcomes in chronic smokers with SARS-CoV-1 and SARS-CoV-2 is that both of these coronavirus strains utilize angiotensin-converting enzyme 2 (ACE-2) receptors to gain cellular entry.^27,28 ACE-2 utilizing coronaviruses may have higher infectivity in chronic smokers as ACE-2 receptors are upregulated in the lungs in response to smoking.²⁹ It is plausible that a similar upregulation of ACE-2 receptors is seen among users of vaping products; a topic that would certainly merit more robust formal studies to establish a causal relationship.

While the role of vaping in regard to infectivity and outcomes with SARS-CoV-2 has not been specifically studied, some postulate that the aerosols generated by vaping nicotine, THC, or flavorings downregulate the lungs’ immune response to infections making vaping use a potential risk factor for SARS-CoV-2 infection.^26,30,31 Furthermore, though it has not yet been established, we need to consider the possibility that vaping by patients already infected with SARS-CoV-2 could lead to aerosolization of the virus and act as a vector for transmission. While additional clinical trials will need to be conducted in order to assess the role of vaping in SARS-CoV-2, it is reassuring that public perception towards vaping is changing. Although we have made significant progress over the past year, the need for continued patient education regarding the health hazards of vaping and further regulation of vaping related products remains of outmost importance in light of the current COVID-19 pandemic.