The Connecticut Department of Public Health (DPH) is investigating reports of lung injury associated with the use of e-cigarette or vaping products.
In August, 2019 reports began to come in about lung injuries that were occurring in otherwise healthy patients who all reported the use of vaping products. The outbreak spread to all 50 United States, the District of Columbia, and two U.S. territories. Symptoms include shortness of breath, cough, fever, fatigue, body aches, vomiting and/or diarrhea.
As of January 21, 2020 a total of 51 patients have been hospitalized in Connecticut with these lung injuries; and one person has died. DPH continues to work with the U.S. Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and other states to determine all of the causes of these lung injuries.
Information on the CT patients hospitalized with vaping-associated lung injury is as follows:
| Age Group | Case Count |
| Less than 18 years old | 8 |
| 18 to 24 years | 15 |
| 25 to 34 years | 13 |
| Over 35 years old | 15 |
| Total | 51 |
| Gender | Case Count |
| Female | 18 |
| Male | 33 |
| Total | 51 |
Note: The 51st Connecticut patient was hospitalized in December 2018
| County | Case Count |
| Fairfield | 19 |
| New Haven | 13 |
| Hartford | 8 |
| New London | 5 |
| Tolland | 3 |
| Litchfield | 2 |
| Windham | 1 |
| Middlesex | 0 |
| Grand Total | 51 |
More information on this outbreak, including recommendations for the public and healthcare providers, is available on the CDC's website.
Updated information on injured patients are included in these two articles published in January 2020:
- Update: Characteristics of a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — United States, August 2019–January 2020
- Characteristics of Persons Who Report Using Only Nicotine-Containing Products Among Interviewed Patients with E-cigarette, or Vaping, Product Use Associated Lung Injury — Illinois, August–December 2019
More information for health care providers, parents, schools and colleges is provided below the following general introduction section.
Introduction to Vaping
Although the use of conventional tobacco products, which include cigarettes, cigars, and pipes has decreased; a new breed of items, designed to imitate the action and sensation of smoking have become increasingly popular, especially with adolescents. These newcomers belong to a group of devices referred to as electronic nicotine delivery systems (ENDS) and vapor products. ENDs are continuing to evolve and include a wide range of products including electronic or e-cigarettes, e-pipes, e-hookah and e-cigars. These items can differ in their design and the way in which they work, and come in a wide variety of designs. ENDS will be used to describe this category of devices.
ENDS are handheld electronic devices that simulate the experience of smoking a regular (combustible) cigarette. They produce an aerosol by heating a liquid that usually contains nicotine - the addictive drug in regular (combustible) cigarettes, cigars, and other tobacco products - flavorings, and other chemicals that help to make the aerosol. Users inhale this aerosol into their lungs. Bystanders can also breathe in this aerosol when the user exhales into the air, called secondhand aerosol. The process for using these products is often referred to as “vaping”.
Where did e-cigarettes originate?
ENDS originated in China in 2003 and came to the U.S. market in 2007. In 2009, the Food and Drug Administration (FDA) attempted to oversee them as a cessation device since the original inventor anticipated they would provide a safer alternative for smoking. However, ENDS manufacturers filed a lawsuit against the FDA and a subsequent order from the U.S. District Court of Appeals confirmed that they were to be regulated as a tobacco product. FDA deemed authority over ENDS in 2016, although the implementation date will not occur until May of 2020.
Adult use of ENDS continues to increase, however the appeal of these devices has become particularly high among youth and young adults. Their popularity rose to new heights when a new product called JUUL (pronounced “jewel”) burst on the scene in 2015. The rate of use among adolescents has risen so quickly, the Surgeon General labeled vaping among youth an ‘epidemic’ in the fall of 2018.
What do ENDS look like?
ENDS come in many different sizes, types and colors. Some e-cigarettes are made to look like regular cigarettes, cigars, or pipes, others resemble pens, small electronic devices such as USB sticks, and other everyday items. Many of them are compact and allow for discreet carrying and use, and schools have been having trouble with students using them in school bathrooms and even classrooms.
ENDS come in a variety of devices and include disposable, refillable, and pod-based systems.
Most e-cigarettes consist of four different components, including a cartridge or reservoir, which holds a liquid solution that can contain varying amounts of nicotine, flavorings, and other chemicals; a heating element; a power source (usually a battery); and the mouthpiece from which the user inhales.
Graphic courtesy of Wikimedia.com
The liquid solution (e-juice or e-liquid) typically contains nicotine, propylene glycol, glycerin or some other solvent, and other additives such as flavorings. These flavorings include fruit and candy flavors that are not permitted in combustible cigarettes. Over 15,000 flavors are currently available. Ingredient amounts in e-juice can vary since there are no adopted manufacturing standards in place yet.
Photo courtesy of Vapor360.com
Pod-based systems have a pre-filled cartridge (or pod); Juul says their pods provide up to 200 puffs. Pods come in a variety of flavors and many have a high level of nicotine.
Photos courtesy of Juul Labs
ENDS can also be used to vape other substances, and even the pre-filled pods can be opened and filled with other liquids.
Youth Use
Data from the 2017 Connecticut Youth Tobacco Survey highlighted that Connecticut high school youth are using vaping products at an increasing rate.
The youth rate has been increasing so rapidly that in December 2018 the U.S. Surgeon General released an advisory labelling the youth vaping problem an epidemic that included an action plan.
Resources
Vaping and ENDS Fact Sheet, December 2018
Health Care Providers
Besides the youth ENDS use epidemic identified by the Surgeon General in late 2018, during the summer of 2019 a lung injury outbreak was identified and information was distributed through both the Centers for Disease Control and Prevention - Clinician Outreach and Communication Activity (COCA) and the Connecticut Department of Public Health (DPH) Health Alert Networks. Symptoms mimic that of many other causes, so asking patients about their vaping history can be important.
DPH Commissioner Coleman-Mitchell mandated that the disease become reportable in September 2019 on an emergency basis, and beginning on January 1, E-Cigarette or Vaping Product use Associated Lung Injuries (EVALI) will be added to the established reportable disease framework .
Guidance to health care providers was updated on November 19, 2019 and only hospitalized patients will be counted in the state and national totals.
On December 20, 2019, CDC issued new clinical guidelines for health care providers, particularly concerning discharge planning and follow up.
A MedScape Case Study is in the process of being developed and the link will be available when it is complete.
Morbidity and Mortality Weekly Report (MMWR)
Update: Demographic, Product, and Substance-Use Characteristics of Hospitalized Patients in a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injuries — United States, December 2019
Characteristics of E-cigarette, or Vaping, Products Used by Patients with Associated Lung Injury and Products Seized by Law Enforcement — Minnesota, 2018 and 2019
[Weekly / November 27, 2019 / 68(47);1096-1100]
Update: Interim Guidance for Health Care Providers for Managing Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury — United States, November 2019
Risk Factors for E-Cigarette, or Vaping, Product Use–Associated Lung Injury (EVALI) Among Adults Who Use E-Cigarette, or Vaping, Products — Illinois, July–October 2019
Evaluation of Bronchoalveolar Lavage Fluid from Patients in an Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — 10 States, August–October 2019
[Weekly / November 15, 2019 / 68(45);1040-1041]
National Academy of Sciences, Engineering, Medicine: Public Health Consequences of E-Cigarettes
American Academy of Pediatrics Policy E-Cigarettes and Similar Devices
CDC Health Advisory 8/30/2019: Severe Pulmonary Disease Associated with Using E-Cigarette Products
Cessation Resources
Surgeon General Consumer Guide on Cessation
American Academy of Pediatrics Guidance on Tobacco Use Cessation for Adolescents
Cochrane Review-Tobacco Cessation Interventions for Young People
What Happens When I Contact the Connecticut Quitline?
Parents
There are a wide variety of devices, liquids, flavors, and nicotine levels available on the market, and there has been little manufacturing oversight; the Food and Drug Administration deemed authority over ENDS products in 2016 although the implementation dates begin May 2020.
Besides the different devices, there is a whole market of concealment products that are also available for sale.
Although we don’t fully understand the long term health effects from vaping because they haven’t been on the market for very long yet (a decade), studies are showing that adolescents who vape are more likely to move on to combustible cigarettes. We also know that youth can become addicted to nicotine much more quickly, and that makes them more likely to move on to other substances as well. ENDS that have been tested have produced aerosol with the following characteristics.
Graphic courtesy of the Centers for Disease Control and Prevention
Also, on the 2017 Youth Tobacco Survey that was administered in Connecticut high schools, over half of the teens who reported vaping said that they had used their vapes for other products, including THC oil or wax (THC is the psychoactive ingredient found in cannabis, or marijuana). <\p>
This is especially concerning since the majority of patients from the lung injury investigation report the use of THC products, and many are expected to have long term health complications.<\p>
Surgeon General’s Advisory on E-Cigarette Use Among Youth
Handbook to assist someone with Quitting their tobacco use
New Laws
Cessation Resources for Teens
In addition, parents who want to help their teen quit their tobacco use may text “QUIT” to 202-899-7550 for information on quitting assistance.
Schools
With the marked increase in teen vaping, schools throughout Connecticut have had to revise their policies and procedures for teen tobacco and substance use during the school day. Teachers have reported students vaping during class, students do not want to visit the restrooms because there is so much aerosol present, and parents find it difficult to recognize the wide variety of vaping devices that are easily hidden.
Effective with Public Act 19-13, beginning 10/1/2019 the age for the sale of tobacco products was increased from 18 to 21 years old. In addition, all school properties must be smoke and vape free 24/7/365. These changes offer more potential for schools to be able to eliminate tobacco and other substance use during school hours.
State Department of Education Memo with Resource List
(Student Use of Tobacco and Tobacco Alternatives)
State Department of Education Memo with Resources Listing
(Dangers of E-cigarettes and Subsequent Changes to Connecticut Tobacco Statutes)
Adolescents, Nicotine Addiction, and Cessation Services (coming soon)
CDC Information for Schools
Public Health Law Center
American Lung Association
Journal of the American Medical Association Article
2017 CT Youth Tobacco Survey Summary
Scholastic Resources
Colleges and Universities
With the marked increase in teen vaping after cigarette use had decreased to a few percentage points, colleges have also seen an increase in youth vaping and other tobacco use on campus. DPH has been working with colleges to adopt smoke and vape free policies since 2015. This encourages the voluntary adoption of tobacco free policies at institutions of higher education, and some funding has been available from time to time in order to encourage schools to move forward.
Technical assistance is available for any college or university in Connecticut that wants to adopt a tobacco free campus policy. This includes training for tobacco treatment specialists to ensure that wellness/health center staff have the knowledge and skills needed to successfully provide tobacco use cessation coaching to students and staff. Any school interested may contact DPHTobacco@ct.gov
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Cessation Program Directory
College Vaping Poster
Tobacco and Marijuana Use Among US College and Noncollege Young Adults 2002-2016