Abstract
Observational studies investigating the health consequences of vaping among youth and young adults are limited. This study aimed to describe and examine the risk for health symptoms by vape user category (never users, marijuana only, nicotine only, and dual users). Health symptoms included adverse respiratory, gastrointestinal, and constitutional problems. This cross-sectional study analyzed data from Fall 2020, Wave 12 (n = 2389) of the Texas Adolescent Tobacco and Marketing Surveillance System. Chi-square, one-way analysis of variance (ANOVA), and multivariable logistic regression analyses examined the associations between past 30-day vape user category and 15 health symptoms (e.g., coughing, nausea, vomiting, fever). For total symptoms, dual vapers reported the highest mean (2.76[standard deviation = 3.17]), followed by nicotine-only vapers (2.47 [2.89]), marijuana-only vapers (1.94[2.60]), and never users (1.56[2.31]), p < .001. Dual vapers and nicotine-only vapers had significantly higher odds of experiencing respiratory symptoms as compared with never users (adjusted odds ratios [AORs] = 2.35, 95% confidence interval [CI]: 1.30, 4.25; AOR = 1.86, 95% CI: 1.22, 2.81, respectively). Marijuana-only (AOR = 2.41, 95% CI: 1.53, 3.79), nicotine-only (AOR = 2.03, 95% CI: 1.38, 2.99), and dual vapers (AOR = 2.03, 95% CI: 1.15, 3.57) had significantly higher odds of gastrointestinal symptoms compared with never users. Dual vapers had significantly higher odds of experiencing constitutional symptoms as compared to never users (AOR = 1.92, 95% CI: 1.10, 3.34). This study uniquely highlights the risk for gastrointestinal symptoms from vaping. Future research and clinical practice should monitor the occurrence of these symptoms and explore potential mechanisms, such as specific flavorings or chemicals, for the link between vaping and health symptoms.
Keywords: Marijuana, Nicotine, Vaping, E-cigarettes, Young adults, Health risks
1. Introduction
The emergence of e-cigarette, or vaping, product use-associated lung injury (EVALI) amplified concerns over the health consequences of vaping. Symptoms of EVALI included respiratory (e.g. shortness of breath, chest pain, coughing), gastrointestinal (e.g. nausea, vomiting, diarrhea, abdominal pain), and constitutional (e.g. fever, chills, malaise) issues (Kalininskiy et al., 2019). Vitamin E acetate, an additive in tainted tetrahydrocannabinol (THC)-vaping products was implicated in the development of EVALI (Blount et al., 2020). While reporting of cases of EVALI has declined steadily since September 2019, concerns remain that vaping may lead to health consequences beyond EVALI (Douglass et al., 2020).
Observational studies investigating the health consequences of vaping among youth and young adults are limited (Boyd et al., 2021; Chaffee et al., 2021; Braymiller et al., 2020; McConnell et al., 2017; King et al., 2020). In one of the few studies to explore self-reported respiratory symptoms of vaping, researchers found that marijuana vaping was associated with increased odds of bronchitic symptoms across all levels of use (lifetime, past 6 months, 1–2 days in the past 30 days, and ≥3 days in the past 30 days; adjusted odds ratios [AORs] ranged from 1.63–2.79) after controlling for sociodemographic characteristics, nicotine vaping, and combustible marijuana/cigarette use (Braymiller et al., 2020). Nicotine vaping was not associated with any of the respiratory symptoms after controlling for all covariates (Braymiller et al., 2020). In another examination of respiratory symptoms among youth and young adult e-cigarette (i.e. nicotine vaping) users across 4 study populations, researchers found that e-cigarette use on 6 or more days in the past 30 days was consistently associated with increased odds of bronchitis (summary odds ratio = 1.56, 95% confidence interval “CI”: 1.37, 1.77) (Chaffee et al., 2021).
The focus on the respiratory consequences of vaping is warranted given the biologic plausibility that inhaling nicotine or marijuana, flavorings, and other chemicals may have adverse outcomes on respiratory health (Chaffee et al., 2021). Notably, gastrointestinal and constitutional symptoms have been investigated less. Among patients with EVALI, pediatric patients were more likely than adults to report gastrointestinal and constitutional symptoms (Adkins et al., 2020). Furthermore, there are reports of “greening out” from marijuana vaping that result in nausea and headache (Wagoner et al., 2016); “nic sick” refers to similar symptoms resulting from using vaping devices with high nicotine concentrations (Kong et al., 2021). In a qualitative study of current and former nicotine vapers, reasons for disliking vaping were health effects including vomiting, coughing, and shortness of breath, among other reasons (Kong et al., 2021). Biologic models support the negative impact of e-liquid on gastrointestinal health; in both mouse and human models, chronic exposure to non-nicotine e-cigarette aerosol led to increased gut inflammation (Sharma et al., 2021).
No study has yet examined the prevalence of a wide range of potential health symptoms across vape product type (nicotine and/or marijuana). Thus, the aims of this study were to 1) describe health symptoms by vape user category (marijuana-only, nicotine-only, and dual users as compared to never users), and 2) examine the risk for respiratory, gastrointestinal, and constitutional symptoms by vape user category.
2. Methods
This study utilizes data from Wave 12 (Fall 2020) of the Texas Adolescent Tobacco and Marketing Surveillance System (TATAMS). TATAMS is a longitudinal study that assesses vaping, tobacco and other substance use behaviors, and factors associated with vaping and tobacco use among a cohort of adolescents and young adults in Texas. TATAMS was approved by the University of Texas School of Public Health Committee for the Protection of Human Subjects (HSC-SPH-13–0377). The sampling methods for the cohort have been previously published (Pérez et al., 2017). At Wave 12 (n = 2389), participants ranged in age from 17 to 24 (mean age = 20, standard deviation = 1.6); 59% were female; 31.1% were non-Hispanic white, 14.7% were African American, 38.1% were Hispanic, and 16.5% reported another race.
2.1. Measures
2.1.1. Health symptoms in the past 90 days and vaping-related diagnoses
The 15 health symptoms comprised 3 different categories: respiratory (coughing, shortness of breath, chest pain, and wheezing), gastrointestinal (nausea, vomiting, diarrhea, and abdominal pain), and constitutional (headache, change in appetite, dehydration, fatigue, fever, weight loss, and weight gain). These items and the time period (past 90 days) were chosen based on the literature examining common symptoms of EVALI, adverse health symptoms associated with vaping, as well as clinical guidance for EVALI diagnoses (Kalininskiy et al., 2019; Adkins et al., 2020; Blagev et al., 2019). For the logistic regression analyses, individual symptoms were collapsed into the 3 categories (i.e., respiratory, gastrointestinal, and constitutional). The variables were dichotomized to 0 for no reported symptoms and 1 for 1 or more symptoms. Participants were also asked if they had ever been diagnosed with a vaping-related illness, response options included, “Yes, e-cigarette, or vaping, associated lung injury (EVALI);” “Yes, other health issue,” and “No.”
2.1.2. Vape user categories
Responses to 2 questions were analyzed: “During the past 30 days, on how many days did you smoke marijuana (liquid or wax-based THC) from an electronic cigarette?” and “During the past 30 days, on how many days did you use an electronic cigarette?” Participants who indicated 1 or more days of marijuana vaping but not nicotine vaping were classified as “marijuana-only vapers;” participants who indicated 1 or more days of nicotine vaping but not marijuana vaping were classified as “nicotine-only vapers;” and participants who used both products were classified as dual vapers. The referent category included individuals who reported that they had never used e-cigarettes with nicotine or marijuana.
2.1.3. Demographics and clinical variables
Covariates included variables such as gender, age, race/ethnicity, current (past 30-day) combustible tobacco and marijuana use, history of asthma and bronchitis, as well as prior COVID-19 diagnosis (Centers for Disease Control and Prevention (CDC), 2017; Case et al., 2020).
2.2. Analyses
Chi-Square analyses and analysis of variance tests (ANOVAs) were conducted for bivariate statistics. The Bonferroni correction was used to adjust for multiple comparisons. Multivariable logistic regression analyses were conducted to examine the associations between vape user categories and health symptoms by symptom category after controlling for covariates. All analyses were conducted using Stata 17.0 (College Station, TX).
3. Results
For most of the health symptoms, dual vapers reported the highest prevalence, followed by nicotine-only vapers, marijuana-only vapers, and then never users (Table 1). For dual vapers as compared to never users, they reported a significantly higher prevalence of cough (27.7% vs. 9.4%), chest pain (18.1% vs. 6.0%), vomiting (13.3% vs. 3.9%), diarrhea (22.9% vs. 11.5%) and change in appetite (31.3% vs. 13.8%). For marijuana-only vapers as compared to never users, they reported a significantly higher prevalence of vomiting (13.1% vs. 3.9%) and diarrhea (19.4% vs. 11.5%). For nicotine-only vapers as compared to never users, they reported a significantly higher prevalence of cough (21.0% vs. 9.4%), shortness of breath (11.3% vs. 5.9%), nausea (23.1% vs. 11.4%), vomiting (8.6% vs. 3.9%), diarrhea (22.0% vs. 11.5%), and change in appetite (23.7% vs. 13.8%). Additionally, 10 current vapers reported being diagnosed with a vaping-related health issue: 8 with EVALI, and 2 with some other issue. A significantly higher proportion of marijuana-only vapers (4.3%) reported an EVALI diagnosis as compared to nicotine-only vapers (0%).
Table 1.
Descriptive statistics and unadjusted frequencies of past 90-day health symptoms by past 30-day vape user category; TATAMS wave 12.
| PAST 30-DAY VAPE USER CATEGORY | |||||
|---|---|---|---|---|---|
| Never users (n = 962) | Marijuana-only (n = 163) | Nicotine-only (n = 187) | Dual (n = 85) | P-value | |
| Age m (sd) | 19.51 (1.59)a | 20.25 (1.52)b | 20.39 (1.42)b | 20.15 (1.44)b | <0.001 |
| Race/ethnicity n (%) | |||||
| White, non-Hispanic | 281 (29.2)a | 38 (23.3)a | 95 (50.8)b | 51 (44.7)b | <0.001 |
| African American | 154 (16.0)a | 30 (18.4)a | 6 (3.2)b | 3 (3.5)b | <0.001 |
| Hispanic | 350 (36.4)a,b | 76 (46.6)a | 64 (34.2)a,b | 24 (28.2)b | 0.02 |
| Other | 177 (18.4) | 19 (11.7) | 22 (11.8) | 20 (23.5) | 0.01 |
| Gender n (%) | |||||
| Female | 566 (58.8) | 101 (62.0) | 101 (54.0) | 43 (50.6) | 0.22 |
| Male | 396 (41.2) | 62 (38.0) | 86 (46.0) | 42 (49.4) | |
| Days marijuana vaped in the past 30 days; m (sd) | – | 8.5 (9.4) | – | 10.2 (11.3) | 0.21 |
| Days nicotine vaped in the past 30 days; m (sd) | – | – | 15.7 (11.9) | 16.13 (11.8) | 0.77 |
| Other substance use n (%) | |||||
| Current combustible tobaccoΨ | 7 (0.7)a | 30 (18.5)b | 50 (26.7)b | 26 (30.6)b | <0.001 |
| Current combustible marijuanaφ | 7 (0.7)a | 100 (61.4)b | 42 (22.7)c | 51 (60.0)b | <0.001 |
| Previous health conditionsч | |||||
| Asthma n (%) | 116 (12.1) | 24 (14.8) | 30 (16.0) | 15 (17.9) | 0.23 |
| Bronchitis n (%) | 22 (2.3)a | 4 (2.5)a,b | 7 (3.7)a,b | 9 (10.8)b | <0.001 |
| Covid diagnosis n (%) | 54 (5.6)a | 14 (8.6)a,b | 25 (13.4)b | 9 (10.7)a,b | 0.001 |
| Past 90-day health symptoms Respiratory n (%) | |||||
| Cough | 90 (9.4)a | 22 (13.8)a,b | 39 (21.0)b | 23 (27.7)b | <0.001 |
| Shortness of breath | 56 (5.9)a | 12 (7.5)a,b | 21 (11.3)b | 10 (12.1)a,b | 0.02 |
| Chest pain | 57 (6.0)a | 9 (5.6)a,b | 21 (11.3)a,b,c | 15 (18.1)c | <0.001 |
| Wheeze | 14 (1.5) | 2 (1.3) | 3 (1.6) | 1 (1.2) | 0.99 |
| Mean symptoms†; m(sd) | 0.23 (0.60)a | 0.28 (0.70)a,b | 0.45 (0.80)b,c | 0.59 (0.94)c | <0.001 |
| Gastrointestinal n (%) | |||||
| Nausea | 109 (11.4)a | 28 (17.5)a,b | 43 (23.1)b | 16 (19.3)a,b | <0.001 |
| Vomiting | 37 (3.9)a | 21 (13.1)b | 16 (8.6)b | 11 (13.3)b | <0.001 |
| Diarrhea | 110 (11.5)a | 31 (19.4)b | 41 (22.0)b | 19 (22.9)b | <0.001 |
| Abdominal pain | 45 (4.7) | 9 (5.6) | 15 (8.1) | 9 (10.8) | 0.05 |
| Mean symptoms‡; m(sd) | 0.31 (0.72)a | 0.56 (0.95)b | 0.62 (0.99)b | 0.66 (1.10)b | <0.001 |
| Constitutional n (%) Headache | 317 (33.1) | 44 (27.5) | 70 (37.6) | 31 (37.4) | 0.20 |
| Change in appetite | 132 (13.8)a | 29 (18.1)a,b | 44 (23.7)b | 26 (31.3)b | <0.001 |
| Dehydration | 107 (11.2) | 16 (10.0) | 33 (17.7) | 11 (13.3) | 0.07 |
| Fatigue | 165 (17.2) | 28 (17.5) | 47 (25.3) | 24 (28.9) | 0.007 |
| Fever | 32 (3.3) | 7 (4.4) | 6 (3.2) | 3 (3.6) | 0.92 |
| Weight loss | 86 (9.0) | 22 (13.8) | 28 (15.1) | 15 (18.1) | 0.005 |
| Weight gain | 131 (13.7) | 29 (18.1) | 28 (15.1) | 16 (19.3) | 0.30 |
| Mean Symptomsɫ; m (sd) | 1.01 (1.40)a | 1.09 (1.43)a,b | 1.38 (1.62)b | 1.52 (1.60)b | <0.001 |
| Total Symptomsϕ; m(sd) | 1.56 (2.31)a | 1.94 (2.60)a,b | 2.47 (2.89)b | 2.77 (3.17)b | <0.001 |
| Vaping-related health issue¥ n (%) | |||||
| EVALI | – | 7 (4.3)a | 0 (0.0)b | 1 (1.2)a,b | 0.010 |
| Other health issue | – | 2 (1.2) | 0 (0.0) | 0 (0.0) | .19 |
Cells that do not share a superscript are significantly different, p < .05. m = mean, sd = standard deviation.
Current combustible tobacco use included use of cigarettes, cigar products, and hookah in the past 30 days (0 for no past 30-day use; 1 for any past 30-day use).
Current combustible marijuana use included use of marijuana in cigarettes, cigar products, or hookah in the past 30 days (0 for no past 30-day use; 1 for any past 30-day use)
Previous health conditions include ever diagnosis of asthma, bronchitis, and COVID-19.
Mean respiratory symptoms range from 0 to 4;
mean gastrointestinal symptoms range from 0 to 4;
Mean constitutional symptoms range from 0 to 7.
Total symptoms included mean number of symptoms for all 15 symptoms (range: 0 to 15).
Ever diagnosed with vaping related health issue; comparison only between current vape users.
In the multivariable analyses (see Table 2), with presence of any respiratory symptom as the dependent variable, nicotine-only vapers and dual vapers had significantly higher odds of these problems than never users (AOR = 1.86, 95% CI: 1.23, 2.81 and AOR = 2.35, 95% CI: 1.30, 4.25, respectively). For gastrointestinal symptoms, marijuana-only (AOR = 2.41, 95% CI: 1.53, 3.79), nicotine-only (AOR = 2.03, 95% CI: 1.38, 2.99), and dual vapers (AOR = 2.03, 95% CI: 1.15, 3.57) had significantly higher odds of these problems as compared with never users. For constitutional symptoms, dual vapers had significantly higher odds of these problems than never users (AOR = 1.92, 95% CI: 1.10, 3.34). Analyses were also conducted with vape user categories that excluded combustible tobacco and marijuana use. The results were generally consistent with the presented findings. However, the associations between dual use and GI and constitutional symptoms were non-significant, likely due to the small sample size of the dual use category (n = 27). Given the detrimental impact of excluding combustible users on sample size, combustible users were included in the final analyses.
Table 2.
Multivariable logistic regression analyses examining the associations between past 30-day vape user Categories and past 90-day health symptoms; TATAMS wave 12.
| Respiratory (n = 1383) | Gastrointestinal (n = 1383) | Constitutional (n = 1383) | |
|---|---|---|---|
| AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | |
| Past 30-day Vape user category | |||
| Never users | Referent | Referent | Referent |
| Marijuana-only | 1.22 (0.72, 2.07) | 2.41 (1.53, 3.79) | 1.37 (0.89, 2.11) |
| Nicotine-only | 1.86 (1.23, 2.81) | 2.03 (1.38, 2.99) | 1.44 (0.99, 2.09) |
| Dual | 2.35 (1.30, 4.25) | 2.03 (1.15, 3.57) | 1.92 (1.10, 3.34) |
| Demographic characteristics | |||
| Male gender | 1.15 (0.86, 1.53) | 0.66 (0.51, 0.86) | 0.58 (0.46, 0.73) |
| Age | 1.09 (0.99, 1.19) | 1.00 (0.92, 1.09) | 1.07 (1.00, 1.15) |
| Race/ethnicity | |||
| White, non-Hispanic | Referent | Referent | Referent |
| African American | 0.30 (0.17, 0.53) | 0.36 (0.23, 0.58) | 0.35 (0.25, 0.51) |
| Hispanic | 0.63 (0.46, 0.88) | 0.61 (0.46, 0.83) | 0.57 (0.43, 0.74) |
| Other | 0.69 (0.46, 1.03) | 0.64 (0.44, 0.93) | 0.58 (0.41, 0.80) |
| Other substance use | |||
| Current combustible tobacco use | 0.87 (0.51, 1.47)) | 1.02 (0.63, 1.65) | 0.76 (0.48, 1.19) |
| Current combustible marijuana use | 0.87 (0.53, 1.42) | 0.74 (0.47, 1.15) | 0.73 (0.48, 1.11) |
| Previous health conditions | |||
| Asthma | 2.46 (1.72, 3.53) | 1.37 (0.96, 1.95) | 1.50 (1.08, 2.08) |
| Bronchitis | 2.92 (1.49, 5.73) | 1.81 (0.93, 3.51) | 2.70 (1.24, 5.86) |
| COVID diagnosis | 2.46 (1.56, 3.88) | 1.39 (0.89, 2.19) | 1.23 (0.80, 1.90) |
AOR = adjusted odds ratio; CI = confidence interval. Bolded equals p < .05 for the comparison.
Current combustible tobacco use included use of cigarettes, cigar products, and hookah in the past 30 days (0 for no past 30-day use; 1 for any past 30-day use).
Current combustible marijuana use included use of marijuana in cigarettes, cigar products, or hookah in the past 30 days (0 for no past 30-day use; 1 for any past 30-day use)
Previous health conditions include ever diagnosis of asthma, bronchitis, and COVID-19.
4. Discussion
Previous research has documented the adverse respiratory effects associated with vaping; however, less research has investigated other EVALI-related (Chaffee et al., 2021; Braymiller et al., 2020; McConnell et al., 2017; King et al., 2020; Adkins et al., 2020). Results from the current study report on the prevalence of physical health symptoms among adolescent and young adult vapers. Results from the multivariable logistic regression analyses indicate that dual vapers of nicotine and marijuana, as well as nicotine-only vapers, had higher odds of respiratory symptoms as compared with never users. In addition, there were consistent associations between vaping and gastrointestinal issues; all 3 vaping categories were associated with significantly higher odds of gastrointestinal symptoms as compared with never users.
Our results describe the patterns of adverse health symptoms experienced by marijuana and nicotine vapers; for most symptoms, dual vapers reported the highest prevalence, followed by nicotine-only and marijuana-only vapers. To date, the majority of this literature has focused on respiratory effects of vaping. Braymiller et al. found that after controlling for covariates, nicotine vaping was not associated with higher odds of any of the respiratory symptoms (McConnell et al., 2017). Conversely, marijuana vaping was associated with bronchitic symptoms across all levels of use. In the present study, marijuana vaping was not associated with respiratory symptoms after controlling for covariates. Notably, our categories of vaping use were mutually exclusive, whereas the Braymiller et al. study did not compare odds of symptoms across vaping categories. Another explanation is that our study asked items specific to vaping marijuana with an electronic cigarette, whereas the aforementioned study also included dabbing (heating butane oil) in their assessment of marijuana vaping behaviors. The use of butane hash oil has been implicated in the development of respiratory issues, including pneumonia (Stephens et al., 2020). Thus, including dabbing in their assessment may explain the heightened association between marijuana vaping and respiratory symptoms.
Our results indicate that gastrointestinal symptoms are prevalent among both nicotine and marijuana vapers, particularly nausea and diarrhea. “Nic sickness” occurs as a result of exposure to high levels of nicotine and is marked by symptoms such as nausea, vomiting, and headache (American Lung Association, 2019). Ultimately, the high concentration of nicotine in commonly used e-cigarettes, like JUUL (Jackler and Ramamurthi, 2019), may be responsible for the gastrointestinal symptoms that nicotine vapers experience. Similarly, in examining reasons for gastrointestinal symptoms among young people with EVALI, research suggested that the habits of young vapers, including accidentally swallowing e-liquid during a vape session, may contribute to such symptoms (Adkins et al., 2020). Notably, our results differ from the Sharma et al. study, which found that non-nicotine e-cigarette aerosol, but not nicotine aerosol, was associated with gut inflammation (Sharma et al., 2021). Explanations for the null findings between nicotine e-cigarette aerosol and gut inflammation may include that researchers only measured inhaled aerosol (versus swallowing e-liquid) and the nicotine concentration tested was low (6 mg/mL, for reference, JUUL contains 59 mg/mL) (Sharma et al., 2021; Jackler and Ramamurthi, 2019).
The relationship between marijuana use and gastrointestinal symptoms has come into focus due to the discovery of cannabis hyperemesis syndrome (CHS) (Wang et al., 2021). In a recent study, researchers report on CHS, which is characterized by symptoms of nausea, vomiting, and abdominal pain (Wang et al., 2021). That study, found a positive association between the number of county recreational marijuana dispensaries and vomiting-related emergency department visits (incidence rate ratio = 1.03; 95% CI: 1.01, 1.05). Researchers suggest that the high THC content found in current marijuana products may be to blame for CHS (Wang et al., 2021). Our findings that all vaping categories had significantly higher odds of gastrointestinal symptoms as compared with never users, highlight the need for monitoring the prevalence of these symptoms among vapers, and further exploring the biological mechanisms that underly these associations.
A limitation of our study is that we asked about health symptoms concurrently with vaping; therefore, we cannot conclusively state that vaping was the cause of the described symptoms. Additional limitations include that the overall prevalence of symptoms was low, and the symptoms were not asked in the context of vaping, therefore, the symptoms may be unrelated to nicotine or marijuana vaping. However, the consistent differences between never users and vapers suggest these relationships do exist. Importantly, our study involved an ethnically diverse sample of adolescents and young adults, and assessed a wide range of EVALI-type symptoms, which have not been investigated utilizing a large cohort of young people.
In addition to documenting the increased risk of respiratory symptoms among dual and nicotine-only vapers, this study highlights the risk for gastrointestinal symptoms across all user categories (dual users, nicotine-only, and marijuana-only). Future research and clinical practice should continue to monitor the occurrence of these symptoms, as well as explore potential mechanisms, such as specific flavorings or chemicals, for the link between vaping and health symptoms.
Funding credits and disclosures of potential and real conflicts of interest
Research reported in this publication was supported by grant number [R01CA239097] from the National Cancer Institute. Drs. Harrell and Clendennen are consultants for the state of Minnesota in litigation involving the vaping industry. Other authors have no conflicts of interest to disclose.
Research reported in this publication was supported by grant number [R01CA239097] from the National Cancer Institute.
Footnotes
CRediT authorship contribution statement
Kathleen R. Case: Conceptualization, Methodology, Formal analysis, Writing – original draft, Writing – review & editing. Stephanie L. Clendennen: Methodology, Project administration, Investigation, Writing – review & editing, Data curation. Joel Tsevat: Writing – review & editing, Supervision. Melissa B. Harrell: Conceptualization, Validation, Resources, Writing – original draft, Writing – review & editing, Supervision, Funding acquisition.
References
- Adkins SH, Anderson KN, Goodman AB, et al. , 2020. 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. 174 (7), e200756. 10.1001/jamapediatrics.2020.0756. [DOI] [PMC free article] [PubMed] [Google Scholar]
- American Lung Association, 2019. What it Means to Be Nic-Sick. https://www.lung.org/blog/nic-sick. Published October 1. Accessed January 20, 2022.
- Blagev DP, Harris D, Dunn AC, Guidry DW, Grissom CK, Lanspa MJ, 2019. Clinical presentation, treatment, and short-term outcomes of lung injury associated with e-cigarettes or vaping: a prospective observational cohort study. Lancet 394 (10214), 2073–2083. 10.1016/S0140-6736(19)32679-0. [DOI] [PubMed] [Google Scholar]
- Blount BC, Karwowski MP, Shields PG, et al. , 2020. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. N. Engl. J. Med 382 (8), 697–705. 10.1056/NEJMoa1916433. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Boyd CJ, McCabe SE, Evans-Polce RJ, Veliz PT, 2021. Cannabis, vaping, and respiratory symptoms in a probability sample of U.S. youth. J. Adolesc. Health 69 (1), 149–152. 10.1016/j.jadohealth.2021.01.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Braymiller JL, Barrington-Trimis JL, Leventhal AM, et al. , 2020. Assessment of nicotine and cannabis vaping and respiratory symptoms in young adults. JAMA Netw. Open 3 (12), e2030189. 10.1001/jamanetworkopen.2020.30189. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Case KR, Obinwa UC, Clendennen SL, Perry CL, Harrell MB, 2020. Predictors of JUUL, other electronic nicotine delivery systems, and combustible tobacco initiation among Texas youth. Prev. Med 138, 106097 10.1016/j.ypmed.2020.106097. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Centers for Disease Control and Prevention (CDC), 2017. Behavioral Risk Factor Surveillance System survey questionnaire. https://www.cdc.gov/brfss/questionnaires/pdf ques/2017_BRFSS_Pub_Ques_508_tagged.pdf. Accessed September 23, 2021.
- Chaffee BW, Barrington-Trimis J, Liu F, et al. , 2021. E-cigarette use and adverse respiratory symptoms among adolescents and young adults in the United States. Prev. Med 153, 106766 10.1016/j.ypmed.2021.106766. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Douglass B, Solecki S, Fay-Hillier T, 2020. The harmful consequences of vaping: a public health threat. J. Addict. Nurs 31 (2), 79–84. 10.1097/JAN.0000000000000332. [DOI] [PubMed] [Google Scholar]
- Jackler RK, Ramamurthi D, 2019. Nicotine arms race: JUUL and the high-nicotine product market. Tob. Control 28, 623–628. 10.1136/tobaccocontrol-2018-054796. [DOI] [PubMed] [Google Scholar]
- Kalininskiy A, Bach CT, Nacca NE, et al. , 2019. E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. Lancet Respir. Med 7 (12), 1017–1026. [DOI] [PMC free article] [PubMed] [Google Scholar]
- King JL, Reboussin BA, Merten JW, Wiseman KD, Wagoner KG, Sutfin EL, 2020. Negative health symptoms reported by youth e-cigarette users: results from a national survey of US youth. Addict. Behav 104, 106315 10.1016/j.addbeh.2020.106315. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kong G, Bold KW, Cavallo DA, Davis DR, Jackson A, Krishnan-Sarin S, 2021. Informing the development of adolescent e-cigarette cessation interventions: a qualitative study. Addict. Behav 114, 106720 10.1016/j.addbeh.2020.106720. [DOI] [PMC free article] [PubMed] [Google Scholar]
- McConnell R, Barrington-Trimis JL, Wang K, et al. , 2017. Electronic cigarette use and respiratory symptoms in adolescents. Am. J. Respir. Crit. Care Med 195 (8), 1043–1049. 10.1164/rccm.201604-0804OC. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pérez A, Harrell MB, Malkani RI, et al. , 2017. Texas adolescent tobacco and marketing surveillance system’s design. Tob. Regul. Sci 3 (2), 151–167. 10.18001/TRS.3.2.3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Sharma A, Lee J, Fonseca A, et al. , 2021. E-cigarettes compromise the gut barrier and trigger inflammation. iScience. 24 10.1016/j.isci.2021.102035. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Stephens D, Patel JK, Angelo D, Frunzi J, 2020. Cannabis butane hash oil dabbing induced lung injury mimicking atypical pneumonia. Cureus. 12 (2), e7033 10.7759/cureus.7033. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Wagoner KG, Cornacchione J, Wiseman KD, Teal R, Moracco KE, Sutfin EL, 2016. E-cigarettes, hookah pens and vapes: adolescent and young adult perceptions of electronic nicotine delivery systems. Nicotine Tob. Res 18 (10), 2006–2012. 10.1093/ntr/ntw095. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Wang GS, Buttorff C, Wilks A, Schwam D, Tung G, Pacula RL, 2021. Changes in emergency department encounters for vomiting after cannabis legalization in Colorado. JAMA Netw. Open 4 (9), e2125063. 10.1001/jamanetworkopen.2021.25063. [DOI] [PMC free article] [PubMed] [Google Scholar]