Public Health

Michigan outlaws flavored e-cigs as vaping illnesses spread

What’s the news: Bubble gum, “fruit loops,” mint, menthol and other e-cigarette flavors have been banned—at least in the state of Michigan, per an order by Gov. Gretchen Whitmer. That order comes on the heels of a health advisory from the Centers for Disease Control and Prevention regarding an outbreak of more than 200 potential cases of severe pulmonary disease associated with using e-cigarette products.

Why it matters for patients and physicians: “My No. 1 priority is keeping our kids safe and protecting the health of the people of Michigan,” Gov. Whitmer said regarding her first-in-the-nation decision to ban e-cig flavors statewide.

AMA President Patrice A. Harris, MD, MA, commended Whitmer’s crackdown on flavors and marketing practices “that enhance the appeal of e-cigarette products to youth.” The AMA recognizes that the use of products containing nicotine in any form among youth, including e-cigarettes, is unsafe and can cause addiction, and has policy opposing the addition of flavors to tobacco products.

The AMA House of Delegates has declared the skyrocketing use of e-cigarettes to be an “urgent public health epidemic” and urged the Food and Drug Administration (FDA) to take action to address it.

The outbreak of severe pulmonary disease linked to vaping—including one patient death in Illinois—adds to the concerns. According to the CDC advisory, people are using “street” sources of e-cigarette pods or cartridges that contain illicit substances. Patients sickened have experienced respiratory symptoms, some have also experienced gastrointestinal symptoms or nonspecific constitutional symptoms such as fatigue or weight loss.

“Fever, tachycardia, and elevated white blood cell count have been reported in the absence of an identifiable infectious disease,” the CDC advisory says. “Many patients have sought initial care in ambulatory settings, some with several visits, before hospital admission.

What’s next: Here are the CDC advisory’s recommendations for physicians and other clinicians amid this vaping-related outbreak.

  • Report cases of severe pulmonary disease of unclear etiology and a history of e-cigarette product use within the past 90 days to your state or local health department. Reporting of cases may help CDC and state health departments determine the cause or causes of these pulmonary illnesses.
  • Ask all patients who report e-cigarette product use within the last 90 days about signs and symptoms of pulmonary illness.
  • If e-cigarette product use is suspected as a possible etiology of a patient’s severe pulmonary disease, obtain detailed history regarding: substances used; the source of the substances used; the devices used; where the products were purchased; the method of substance use; and other potential cases the patient may know of due to sharing e-cig products.
  • Determine if any remaining product, including devices and liquids, are available for testing. Testing can be coordinated with the local or state health departments.
  • Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms and of e-cigarette product use. Evaluate and treat for other possible causes of illness (e.g., infectious, rheumatologic, neoplastic) as clinically indicated. Consider consultation with specialists (pulmonary, infectious disease, critical care, medical toxicology) as appropriate.
  • Clinical improvement of patients with severe pulmonary disease associated with e-cigarette use has been reported with the use of corticosteroids. The decision to use corticosteroids should be made on a case-by-case basis based on risks and benefits and the likelihood of other etiologies.
  • Lipoid pneumonia associated with inhalation of lipids in aerosols generated by e-cigarettes has been reported based on the detection of lipid-laden alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining (e.g., oil red O). The decision about whether to perform a BAL should be based on individual clinical circumstances.
  • Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining may be considered during pathologic examination, and is best performed on fresh tissue. Routine pathology tissue processing (including formalin-fixation and paraffin-embedding) can remove lipids. Conducting routine tissue processing and histopathologic evaluation is still important. Consider consultation with specialists in pulmonary medicine and pathology to help inform any evaluation plan.
  • Patients who have received treatment for severe pulmonary disease related to e-cigarette product use should undergo follow-up evaluation as clinically indicated to monitor pulmonary function.

Meanwhile, here is good advice for your patients, per the CDC. They should consider refraining from using e-cigarette products while the CDC investigation is ongoing. And regardless of the investigation, no one should buy such products off the street or modify e-cigarette products, or add substances to them not intended by the manufacturer.

Also, e-cigarette products shouldn’t be used by children, young adults, pregnant women or people who don’t already use tobacco products. Adult smokers looking to quit should use evidence-based treatments such as counseling and FDA-approved medications.