No smoke without fire? Vaping, EVALI and respiratory health

Asking a patient about their smoking habits is second nature. But when it comes to asking my patients about vaping, let’s just say I’m much less consistent. Given the growing body of evidence and public interest in this area, I suspect this is one habit I will have to get into…

A BMJ review has recently tried to address some of the questions about the long term safety of vaping, as well as providing helpful tips on collecting and recording a vaping history. 

First up, it makes the important point - e-cigarettes are generally considered to be less dangerous than traditional cigarettes. Public Health England suggests they are perhaps 95% less harmful overall. They can also be a useful tool to help smokers quit - a recent Cochrane review concluded that e-cigarettes can increase quit rates compared with nicotine replacement therapy and placebo. 

However, vaping has grown in popularity dramatically over the past decade with teens and young adults seeing the biggest increases in usage. The uptake amongst never smokers is a real worry. That’s before the cost or environmental impact is considered, especially with the increasingly popularity of single-use, disposable vapes.

The image of e-cigarettes as a ‘safe’ alternative was also rocked in 2019 by reports from America of sudden, severe lung problems, including deaths, linked to vaping in young, healthy individuals. Now known as EVALI (E-cigarette or Vaping use Associated Lung Injury) the condition is characterised by new respiratory symptoms, often in combination with constitutional and gastrointestinal symptoms. No definitive treatment has been identified. Thankfully there’s been no similar large scale outbreak in the UK, where we have higher and more consistent safety regulations but an MHRA alert in 2020 reminded us to be vigilant.

In terms of longer terms risks, it’s very much a ‘watch this space’ situation. Teens who regularly vape report increased respiratory symptoms and studies in adults show increased prevalence of asthma and COPD, as well as higher risks of stroke and MI in users. It’s crucial to remember the consequences of long term e-cigarette use remain unknown and the true impacts will likely only become apparent over the coming decades.

We also know that nicotine, which is present in the vast majority of e-cigarettes, is highly addictive and can affect the developing brain. Selling e-cigarettes or vapes to children is illegal in the UK but that doesn’t appear to be deterring the high numbers of children being enticed to e-cigarettes with bright packaging, exotic flavours and enticing names. 

So what can we do? 

As vaping becomes more common, we need to start asking about it more, particularly in young people who are the most likely users. Taking a vaping history is actually pretty similar to asking about smoking, so, we’ve got this guys!  Familiarity with vaping terms, a non-judgmental approach and talking to young people without their parents present will all help. The BMJ review provides a helpful practical guide to collecting a vaping history, but simply recording whether a patient is vaping or not, just as we would with cigarettes, is still valuable. 

If we find it confusing, our patients probably do too. There’s useful information out there from the NHS, Better Health and FRANK that you can helpfully signpost to.

As per the 2020 MHRA alert, use the Yellow Card Scheme website to report any suspected side effects or safety concerns with e-cigarettes and e-liquids used for vaping. 

What a drag

I, like many of us, love certainty. With vaping, for now, that’s a luxury we don’t have. It certainly remains the lesser of two evils for current smokers, but important questions about safety remain. So whilst we wait for those answers, maybe opening up the conversation is the best we can do, particularly with those young never smokers. It took many years to recognise the damage cigarettes can cause, and it’s crucial we don’t repeat the same mistakes with vaping.