Will E-cigarettes Cause Lung Health Problems?

Hi, my name is Eric Hamberger. I am an

assistant clinical professor of

pediatric pulmonology at UCLA, and I'm

going to talk about e-cigarettes and

lung health today. I have nothing to

disclose, I have no relationships to

disclose for this presentation. So,

e-cigarettes are a group of devices that

allow users to inhale an aerosol, usually

containing nicotine and flavoring, for

recreational use, and I wanted to

emphasize recreational use to

distinguish it from other aerosolized

things like nebulizers, inhalers, which

are prescribed by doctors. They go by a

lot of different names, e-cigarettes, e-cigs,

cigalikes, vapes, vape pens, tanks--some

people just refer to them by the brand

name itself, and they become very popular,

especially in the past decade. In 2014,

they surpassed traditional cigarette use

among adolescents and young adults. The

concept of noncombustible nicotine

delivery has actually been around for

quite a long time. The first patent can

be traced back to the 1920s. In 1927, a

man named Joseph Robinson filed a patent

for what was sort of a prototype of an

electronic cigarette, but it never--they

never used the word cigarette or tobacco.

I'm just going to read a short excerpt

from that patent: "It produces an

extremely simple vaporizer, which

extended use has demonstrated to be of

great effectiveness in the treatment of

afflictions for which its use is

intended." So it was really first intended

to be a medicinal tool. Again, nowhere in

the patent does it say the word

tobacco. In a way, it was described

something like a nebulizer, except it

uses a heated coil. The patent was

granted in 1931, but it was never

commercialized. In 1963, a man named

Herbert Gilbert also attempted to make a

smokeless nontobacco

cigarette, the goal being to replace

burning tobacco with a heated moist

flavored air. Again, that was never

commercialized. One notable product from

the late 1970s was something called the

the Favor. Their slogan was "Do yourself

a favor." It was a smokeless cigarette. It essentially

was just paper soaked in nicotine

containing liquid that the

user would inhale without lighting or

combusting anything, but they were very

expensive, they didn't deliver nicotine

very effectively, and as a result, they

were a massive commercial failure. But

the first modern e-cigarette was

mass-produced in 2003 by a Chinese

pharmacist named Hon Lik, who was the

former deputy director of the Institute

of Chinese Medicine, and the original

intent, as with these other products, was

a smoking cessation tool, and it's even a

statement stated as such in the patent.

It was the first recent innovation that

was mass-produced by a company called

Ruyan. It used something called a

piezoelectric ultrasound emitting

element, which is essentially a power

source that generated electricity. It

made its way to the US markets in 2005, a

lot of sort of copycat devices started

popping up globally, using both this

technology and, later, batteries, and at this

time, it was introduced to the US market.

A couple of years later, in 2007, we saw a

very rapid rise in sales in the United

States, so a company called Plume, which

was renamed to PAX Labs, was

founded by two Stanford grad students

in San Francisco. That company would

later become the company that produced

Joule, and in 2017, Joule actually spun

off into a separate company--again, I

mentioned that in 2015, e-cigarettes

surpassed traditional cigarette use

among youth for the first time, I'll talk

more about that a little bit later--by

2018, e-cigarettes had actually become

a multi-billion dollar industry, so it

was so profitable that tobacco companies

wanted in. So, Altria, the parent company

of Philip Morris, actually purchased a

35% stake in the popular brand Joule in

late 2018, and as you've probably heard,

in 2019, there have been hundreds of

cases of--really, thousands of cases of a

vaping-related illness that started

popping up around the United States--I'll

talk more about that as well a little

bit later. So, what exactly are these

devices? So, this is a modern e-cigarette.

They contain three basic elements.

There's a mouthpiece, so an interface

that's connected to a tank that contains

a heating coil, so that heat aerosolizes

what's called an e-liquid, and

then there's a power source with a

button, usually to--sometimes a button,

sometimes just the active inhaling

initializes the device. Inside the tank,

you have what's called an e-liquid, and

each e-liquid is comprised of really

three main ingredients. So, there's a

solvent--propylene glycol and/or

vegetable glycerin, usually a combination

of both--there is a usually nicotine

involved, although they don't have to

contain nicotine, and usually a flavoring

as well. Some of the flavors that are

currently available--this is from the

Surgeon General's report in 2016--we have

bubblegum, chocolate, cotton candy, grape,

gummy bear, and a lot of states have sort

of caught on to this, and jurisdictions--

Los Angeles, for example, has moved to ban

the sale of flavored e-cigarettes

because of the appeal to children. But

these are some examples of what a lot of

these cigarettes look like now. You'll

notice that they're very compact, they're

simple they share a lot of design

elements with popular tech products. The

product on the right is available from

Joule, sort of like a baby macbook or

iPhone or something. They have these

proprietary things called pods, so this

is the menthol pod, it's still available

through the Joule website. The amount of

nicotine in these pods is about 5% per

weight at maximum, which amounts to about

59 milligrams of nicotine. By comparison,

a cigarette contains about 6 to 12

milligrams, so a pod can contain as much

as 2/3 to one entire pack of

cigarettes, and a user can actually get

through a Joule pod anywhere from a

couple of days to a week, not much than

less than what you would expect for a

pack of cigarettes, but that number can

vary widely, of course, depending on the

user. So, one reason that a lot of people

use e-cigarettes is to help quit smoking,

and there have been sort of a handful of

large randomized control trials

examining the effectiveness of

e-cigarettes and smoking cessation. So,

this was published in 2013 in the


The Lancet. 657 people were randomized to

either nicotine e-cigarettes, nicotine

patches, or placebo e-cigarettes, so

e-cigarettes that don't contain

nicotine. They defined abstinence as not

using combustible cigarettes. What they

found was a rate of 7.3% of e-cigarette

users were abstinent from cigarettes

compared to 5.8% from nicotine

patches and about 4.1% who used

e-cigarettes which didn't contain

nicotine. So, from this study, they

concluded that e-cigarettes were

modestly effective at helping smokers,

similar to nicotine patches, but another

thing I liked about this study was just

simply giving someone something that

they thought contained nicotine--so, a

placebo--could also be effective at

helping people quit cigarettes even

though it's very minimal. Another study

that came out more recently--this is a

randomized control trial that came out

in early 2019 in the New England Journal

of Medicine--so this was nearly 900

participants, they were assigned to

either a combined smoking cessation

group, such as behavioral therapy and

nicotine patches, or an e-cigarette group,

and the primary outcome that they looked

at was, again, sustained abstinence from

from combustible cigarettes for one year.

They actually verified this by measuring

the level of carbon monoxide in the

blood to verify this. E-cigarettes do

work as a modality to quit cigarettes.

They do seem to work quite well if 1

in 5 cigarette users are switching to

e-cigarettes versus 1 in 10. It's hard

to argue that they don't work for their

intended purpose. They also saw a 10% to

20% reduction in cough and phlegm

production in these people

compared to nicotine replacement

therapy, but they did find an increase in

the amount of reported mouth irritation

that's been corroborated with others by

other studies, and they didn't see any

significant difference in the incidence

of wheezing or shortness of breath. But

again, I just want to point out this

disclaimer that this was a study done on

active smokers, so these are not never

smokers. So, how much nicotine does an

e-cigarette actually deliver? You can compare the amount of nicotine in a cigarrette or an ounce of liquid, but the more

important measure really is the

plasma-nicotine concentration. So, this is

a study that was published in 2017

comparing plasma and nicotine levels at

steady intervals, at 5, 10, 15, 20, etc.

minutes after the initial use, and I like

this study because it seemed

comprehensive, although it might be a

little bit outdated. It was done

before Joule was really popular--it was

still emerging--so that was not included

in this study. Also, the 11 people that

were studied were so-called experienced

vapers, so they were good at it, which may

or may not represent the general

population. But if we look at the data--so,

the amount of blood nicotine levels

from cigarettes in this study was

clearly the highest--that's this blue

line at the top, so at 5 minutes, it

peaked to a concentration of 18 nanograms

per mL. In close second was a

brand called Views, which is a popular

and later generations considered a

third-generation brand of e-cigarettes.

As we go down, we see that the level of

nicotine approaches about 2/3 to

about 1/2 of what you would find in a

traditional cigarette. But one

interesting finding was that although

they were--this was one so-called drag

from an e-cigarette--what they found was

that although they weren't achieving the

same levels they were taking more puffs

within the same period of time, or even though they were

getting less per puff, they were driven

to take more puffs to achieve a

greater nicotine buzz. The other

conclusion was the fact that later

generation of e-cigarettes delivered

nicotine more efficiently, suggesting

that e-cigarettes as a whole, as an

industry, are really just getting more

and more efficient at delivering

nicotine. A lot of it has to do with the

devices itself. So, before I get into e-cigarettes

and lung danger, I want to talk a

little bit more about nicotine and

general health detriments. These are

from the most recent Surgeon General's

Report. So, cigarettes contain

nicotine, and nicotine is very addictive,

we've known that for a very long time.

Nicotine exposure, especially during

adolescence, when the brain is developing,

they have long lasting consequences. It can have

behavioral or neurological long-term

consequences. We also know that there are

a lot of social and environmental

factors that influence tobacco use. So,

an example--if there's a family member, a

friend, who smokes, you have a greater

risk of smoking, yourself.

We know that nicotine is very dangerous

in pregnancy. It can result in preterm

delivery or stillbirth, it can affect

brain development for fetuses that are

exposed to nicotine in-utero, it can

result in a lot of behavioral disorders,

ADHD, it can result in--it's been linked

to type 2 diabetes, obesity, high blood

pressure. So, what about the lungs? That's

kind of a point of this talk. This was a

very compelling study that was published

in 2016, looking at the potential harm on lung

tissue from e-liquids containing

nicotine. I think this study embodies

some of the more compelling evidence of

the potential harms of nicotine in the

lungs. This was published by a New

York-based group in 2016. They looked

specifically at e-liquids on surface

cells of the airway, to both nicotine- and

non nicotine-containing liquids. They

looked at a variety of outcomes in both

humans and mice. So, the way that they did

this, mice were exposed to either a

control, something called phosphate

buffered saline--it's basically a saline

solution--or an e-liquid containing a

solvent that had either 0 or 18

milligrams per ml for 1 hour per day for

4 months straight, and that

concentration, 18 milligrams per mL, is

similar to what you would find in a

commercial e-liquid. So when

we're looking at these pictures,

these are the little air sacs at the ends of the lungs that

participate in gas exchange or

respiration. You'll notice that these air

spaces in the control group are

relatively small. Similarly, in the lung

tissue exposed to aerosol without

nicotine, you have these very small air

spaces with a lot of lung tissue, and

this is generally a good thing. When

you have smaller air spaces, there's a

lot of room for them

to expand, there's a lot of surface area

for oxygen to diffuse into the blood and

for carbon dioxide to diffuse out. The

tissue itself is very strong and robust.

It's elastic, it can easily expand and

snap back into place. Now, when you

compare that to the image on the right,

you'll notice these very large air sacs

with a lot less lung tissue. When there's

a lot less lung tissue, it means that

there's a lot less surface area for

these lungs to participate in gas

exchange, and in addition, the airways

themselves are weaker. So, this is a

similar finding under a microscope that

you would see in something like a 20

pack, your 30 pack, your adult smoker with

COPD or emphysema, where there are fewer

and larger air sacs for gas exchange.

They're also able to measure lung

function. This is a chart. This chart on

the left is essentially a measurement of

the force of exhalation. If you have

asthma, or if you have a child with

asthma, this is a form of a study called

spirometry, which we perform all the time

in our clinics, and it measures the

strength of flow of air during

inhalation and exhalation. In this

study, they were able to measure

something similar in mice called the FEF 50, or the forced expiratory force at

50%, and what they saw was a significant

reduction in this measurement in mice

exposed to nicotine. Again, this is a

finding similar to what you would see in

obstructive lung diseases, like asthma or

emphysema. Also, in these mice,

they measured the activity of various

enzymes involved in something called

apoptosis, or programmed cell death. So,

this is a protein called caspase, and

what they found is that they were able

to detect significantly higher activity

levels of these enzymes in cells that

were exposed to nicotine compared to

cells that weren't exposed to nicotine,

and the hypothesis is that this increase

in these substance is associated with

destruction of cells in the airway, which

is why we see some of these changes

under the microscope and this image on

the right. They also looked at the

effects of nicotine on human lung cells

by measuring the movement of an

important structure called the cilia. So, in

all of our airways we have these very

tiny microscopic finger-like projections

that serve to sweep out mucus and debris

and infections, and it's important that

these structures move in a very

coordinated and synergistic way to

function properly. What they

found was, when these structures

were exposed to aerosols containing

nicotine, the speed at which these

structures did their job, the so-called

beat frequency, was markedly reduced, in

some cases ceasing to function almost

entirely, making lungs susceptible to

more infections. And this, again, has been

corroborated by other studies, so I think

you see where I'm going for this. It sort

of dispels the notion that nicotine is

addictive and nothing more, you know, an

otherwise benign element in all this.

We're starting to learn more and more

that nicotine is a very real culprit in

lung damage associated with e-cigarette

use. What about the solvent? So, propylene

glycol and vegetable glycerin. This was just

an image that I got from Amazon of these

solvents. There have been studies that suggest

that in small doses, up to 28 days,

they're safe when they're ingested by

animals, but beyond that, they are

associated with toxic byproducts with

free radical productions, which can be

carcinogenic. A lot of this has to

do with the the so-called PG/VG ratio, so

that 70/30 propylene glycol to vegetable

glycerin is considered sort of the

safer ratio, so a lot of independent

vendors will sort of stick to that ratio.

As far as the flavorants, a lot of this

depends on the flavor.

Many of these flavor compounds are

derived, not surprisingly, from the flavor

source, so for example, cinnamon is

derived from cinnamon. I mentioned

cinnamon because it does--it's sort of

gotten a reputation as one of the

worst compounds. It does contain

several highly bioactive compounds.

Flavors, as you may have heard, are also

implicated to be the driving

factor for vaping initiation in youth,

and this has, again, been backed up by

numerous studies. Most flavorants

contain compounds that are in

general maybe safe to eat but not to

inhale, so some other toxic byproducts

that have been detected in e-cigarettes--

diethyl phthalate,

which has been detected in nearly half

of e-liquids. According to a study in 2015,

that's been associated with premature

puberty. It's also possibly

carcinogenic. This has gotten a lot of

press--diacetyl (DIE-uh-see-tuhl) or diacetyl (die-AH-si-teel), however

you choose to pronounce it, has been

used in various e-liquids and associated

with something called popcorn lung. The

technical term is bronchiolitis

obliterans. It's really irreversible

destruction of small airways, and the

only cure is a lung transplant. And then

finally, formaldehyde and acetaldehyde

are possible carcinogenic

byproducts. These are more likely to

form in devices that are higher voltage

or higher heat, and the reason this is

important, there are still some places where

custom flavors and independent vape

shops have the ability to basically

commercially extract any product

that they want directly from the source,

and I think we're seeing a lot

more of these so-called homebrew with

things like cannabis oil, things that

have that have been shown very recently

to have very catastrophic effects when

inhaled, and probably a large factor in

the recent outbreak of vaping-related

illnesses. There have been several

studies looking at immune function. I

already mentioned the effects of

nicotine on ciliary function, but there

have been a handful of studies

looking at the effects on local immune

function. So, one study showed that nasal

scrapings from humans--of e-cigarette

users--had large alterations in over 50

immune regulatory genes. Other studies

have shown an increase in molecules

associated with inflammation, so sort of

creating a pro-inflammatory

environment. It's also been shown to

increase the expression of

pro-inflammatory molecules, and in

general, many teens just don't know what

they're inhaling. A large portion don't

even know that they contain nicotine,

that they're just so called--they're just

flavored water--a lot of teens have

reported that, but I started this talk by

presenting evidence that e-cigarettes

are an effective smoking cessation tool

in adults. I put this in now because I

wanted to contrast this with evidence

that it actually has the opposite effect

in adolescents and young adults.

So, over the past few years have been a

slew of studies, one after the other

concluding that never smokers--so those

who had never even tried a cigarette--

during adolescence, if they tried

e-cigarettes, they were more likely to

initiate combustible cigarettes--so,

traditional cigarettes--later on, and the

likelihood of this happening

kind of depended on the location and the

actual study, but time and again, these

studies are coming to the same

conclusion, that vaping, that e-cigarette

use itself is a significant risk factor

for regular cigarette use. So, going back

to the Surgeon General's Report, the data

for e-cigarettes in this report go

back to 2011, and I'll show you more

recent data shortly, but the good news is

that in the last twenty years, there has

been a significant decline in just

combustible tobacco use. So, you can see

in 2011, 14% of middle school

students had ever used tobacco. That's

reduced pretty significantly, and that

trend continues to decrease and

eventually sort of plateau around 5% as of this year.

By contrast, you'll notice that

e-cigarette use--so, either e-cigarette only

use or combustible and e-cigarette use--

surpassed traditional cigarette

use somewhere between the data

collection of 2014 and 2015, and again,

similarly, that trend continues to 2019.

This is national data from the

Monitoring the Future database of 2017,

which is a survey of over 43,000

students in the United States that looks

at every manner of substance use from

8th graders through young adults. The

earliest data in the study on

e-cigarettes dates back to 2014. Some of

the important findings--so, vaping had a

higher 30-day prevalence than all

tobacco products among

eighth, tenth, and twelfth graders,

and the 30-day prevalence among

these among 12 graders is the highest. In

2017, 11% of 12th graders report

recent--so, within 30-day use--which is

pretty staggering. And one thing I want

to note with these arrows here is that

this cohort is the same as this cohort,

so you can see that the jump from

8th to 10th grade from 2015 to 2017 is

pretty staggering for ever use. You can

also notice that from 10th to

12th grade--so this cohort is the same as

this cohort--there is still an increase

from 10th to 12th grade for e-cigarette

use. And then this is the National Youth

Tobacco Survey from the CDC reported

last year. This is only getting worse.

Basically, e-cigarette use is still on

the rise with, as of last year, 3.5

million middle and high school students

engaging in active past 30-day cigarette

use, which is more than double what it

was a year before that at 1.5 million.

And you'll notice that past 30-day use

has increased from 11% to 21%, so

really, 1 in 5 are reporting past 30-day

use as of 2018. They cited nicotine

flavoring as the major reason for this.

So, after this report came out in

November of last year--so, one year ago--

the FDA proposed to address this by

revisiting the flavoring policies. The

proposal from the FDA's Center for

Tobacco Products called for a ban in

flavors in e-cigarettes except from

mint and menthol, which are

suggested to help adult smokers quit

using combustible cigarettes. They also

suggested age verification for online

sales. So, a lot of local ordinances are

taking this into their own hands before

this starts to take effect in

2022, especially in California, but on

November 6, 2019, the most

recent data from the National Youth

Tobacco Survey reported a jump from 21% to 27% of high school

students who use e-cigarettes and

10.5% of middle schoolers

who use e-cigarettes in the last 30 days.

About 1/3 of them use e-cigarettes

more than 20 days per month.

Compare that to combustible cigarette

use, which continues to decline

from 2011 through 2019.

You notice that it's about 5% to 6% of

high schoolers are using cigarettes

compared to 27.5% of high schoolers that

are using electronic cigarettes, and that

continues those trends continue to this day.

So finally, I wanted to talk about the

outbreak of vaping-related illnesses in

2019. It goes by a few different names.

The CDC has dubbed it E-cigarette or

Vaping-Associated Lung Injury. I think

it's pronounced EVALI.

That's how I'm gonna choose to pronounce

it. It's been referred to also as

Vaping-Associated Lung Injury (VALI),

Vaping-Related Pulmonary Illness,

basically any combination of those words,

but basically, it describes a sudden

respiratory illness that can take hours

to days. It might be life-threatening, and

it can mimic other causes of acute

respiratory failure, so, for example,

pneumonia. A vast majority of these

patients report respiratory symptoms, so

95% report things like

cough, shortness of breath, chest pain--but

a very large number of these patients

actually reported GI symptoms, and a lot

of the time these GI symptoms--things

like nausea, vomiting, diarrhea, abdominal

pain--can actually precede the

respiratory symptoms. Other signs and

symptoms are very nonspecific, so things

like body aches, fever, weight loss over

the course, diminished appetite, you know--

failure to respond to antibiotic therapy,

I think, is a key finding. Remember,

this is not an infection, so antibiotics

aren't going to fix this. But a lot of

these things are very nonspecific and

very difficult to detect, so I think a

strong index of suspicion should be had

by parents as well as providers if

someone comes in with acute respiratory

failure without a specific explanation

in an otherwise healthy person. So, as of

October 2019, there have been 1,299 cases.

Just recently, on November 5th,

the number of cases grew to over 2,000

cases of Vaping-Associated Lung Injury

in the United States. I mean, 49 states, the District of

Columbia, and the US Virgin Islands--I think

the one state was Alaska that hasn't

reported any vaping-related illnesses.

There have been--there were 21 reported

deaths a few weeks ago that has risen to

39 reported deaths, and the vast

majority of these cases have occurred

within the last 4 months. The median

age is 24, with 80% less than

the age of 35.

70% of these cases have been in

males, and the median age of death is 49

years old, with a very wide range of 17

to 75. So, even though the cases are more

prevalent in young adults, they tend to

be more resilient than older patients,

who are more susceptible, really, to

death from this vaping-related illness.

There has been at least one double lung

transplant in response to a patient who

was injured by vaping. That patient was a

minor, he was 17 years old and was, in my

opinion, extremely lucky to have even

been considered for a lung transplant,

since substance abuse and active

nicotine use is taken into strong

consideration when lungs are

allocated for donation. So, the CDC has

been actively investigating the cause of

this recent outbreak. They have reported

that 76% of patients reported

using THC--so, a byproduct of marijuana or

cannabis-containing products--but

13% still report not using

THC-containing products, but a very recent

report suggested that a derivative of

vitamin E acetate was found in

lung fluid in 100% of these cases, so

they looked at the lung fluid of 29

patients, and this vitamin E acetate

derivative was actually found in every

single one of these samples. So, why do

they--why do I bring this up? It's, you

know, it's very tempting to say that this

is sort of an isolated incident or this

was a bad batch or something. In this case, I

agree, I think it's very reasonable to

make that conclusion, but a few points I

want to make. One is that we don't really have any

idea how long this outbreak is going to

last. The numbers keep rising, every

report that comes out seems to indicate

that this product, this problem, is just

getting worse, and we really don't know

if it's gonna happen again. We don't know

if there are any other culprits in this,

and we still haven't detected anything

else. And so they say that this is

somehow proof that since commercial

vaping products are not the culprit in

this, they must be safe, that if it

doesn't cause lung injury, then then it

isn't harmful to your lungs, and the

truth is we still don't know about the

long-term effects of e-cigarettes, and

when you compare them to cigarettes, it

might be important for active adult

smokers, but that comparison kind of

loses its substance to

healthy lungs that are naive to the

effects of a foreign substance. One final

point I want to make just before--just be

careful when you're trying to seek

information, when using the internet, when

you look for information about vaping.

If it starts with something like, "Debunking the

myths about vaping," I would just stay

away. They're not really debunking

anything, they're really just trying to

preserve their industry, and just be

aware where you're getting the

information from. I think less is more, in

this case. A great starting point is the

CDC website. There's information about

vaping in general, the recent vaping

related illness outbreak, which is

updated weekly, the latest news and

resources, and you really can't go wrong

by starting there. Some other really

great resources--PAVE, so Parents Against

Vaping E-cigarette, is an advocacy

group. It's sort of geared more

toward parents, what to look for in

their children who are vaping. And then,

of course, drugfree.org is another

great resource. So, that's it. I will--at

this point, I'm going to open it up to

some questions from the audience.

Okay, so the first question I have is "Are e-cigarettes more dangerous

than traditional cigarettes?" So, I sort of

touched on this in my presentation. I

think, you know, the short answer is

we don't know.

I think, logically, anything combustible

is probably worse for you than

electronic cigarettes, but really, I think

the important point to take from this is

that when you're comparing traditional

cigarettes to electronic cigarettes, the

only people that that's actually

relevant to are active adult smokers. If

you saw my data earlier on the trends of

traditional cigarette use, if you're

looking at youth, if you're looking at

8th, 10th, 12th graders who are using

e-cigarettes, many of them--at least 94%

of them--probably wouldn't have

touched a cigarette to begin with, so you

shouldn't really be comparing cigarettes

to e-cigarettes in that population. You

should be comparing a cigarette to

nothing, and there's a lot of evidence

that suggests that e-cigarettes are

harmful in the short term and the long

term, but again, we don't know

the long-term effects of vaping.

"Is vitamin E acetate found in all vaping

liquids?" It is not. It is not a common

ingredient. From what I understand, it's

not included in commercial e-cigarettes.

I don't think the CDC has identified the

first source of this, whether it was

an intentional additive, whether it was a

bad batch of something, but no, it is not

a common ingredient in e-liquids,

although it seems to be more prevalent

in liquids that contain derivatives of

cannabis, so marijuana-containing

e-liquids. "Is vaping healthy as long as

there's no nicotine?" I think that's kind

of an interesting question. You know,

my stance as a pulmonologist is,

I would say, similar to the question of

cigarettes compared to e-cigarettes, you

know, you're not comparing one

thing to the other, you're comparing

something to not putting something into

your lungs. And I think, really, the only

thing that should go into your lungs is air, really,

oxygen, or if you have a medication

that's prescribed by a pulmonologist

or a primary care doctor, that those are

generally better for you than doing

something recreational that can be very

harmful to your lungs. "What about the

argument that everything's fine in

moderation? Does that apply here?" So I do

agree that everything is fine in

moderation. It really depends on how you

define moderation. In the case of

e-cigarettes, I would define moderation

as almost nothing. The reason for that is

we know that e-cigarettes--most

e-cigarettes contain nicotine, and once

you start using nicotine, it's very, very

difficult to quit, even with a small

amount of use, so I would say

"everything's fine in moderation" probably

doesn't apply to e-cigarettes. The other

argument I would make is that many of

these cases of e-cigarette use-related

lung injury are in patients who had

never even used an e-cigarette before, so

maybe not necessarily heavy users, so one

time can actually be catastrophic in

some cases, especially in these sort of

third-party homebrew applications of

electronic cigarettes. "How does one

combat smoking addiction and now

e-cigarette smoking addiction?" Again,

there are a lot of great resources on

the CDC. There are smoking cessation

programs that have been very helpful;

they've been demonstrated to be very

helpful. Nicotine replacement therapy

that's prescribed by a doctor, as long as

it's used correctly, can be very

effective. There are certain medications,

sort of off-label use medications that

can be very effective in nicotine

addiction and have been shown to be very

beneficial for active smokers and for

people who are addicted to nicotine. And

I think that's it. Were there anything else? Okay,

well, I hope you learned something today.

Please feel free to call the pulmonary

office at UCLA if you have any other