Banning tobacco sales to under 21s reduces smoking, study findsBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4956 (Published 31 July 2019) Cite this as: BMJ 2019;366:l4956
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The recent outbreak of vaping associated lung injury (EVALI) has posed a lot of clinical burden and questions to ponder for health policy makers. As of December 10, 2019, a total of 2,409 EVALI patients have been hospitalized, including 52 (2%) deaths.(1,2) Considering that a total of 1,479 patients presented in October, this represents a shocking 62·8% increment in the number of hospitalizations.(1) This alarming increment in the number of cases warranted undertaking a stronger health policy and further improve clinical care recommendations. On December 20th, 2019, the US Centers for Disease Control and Prevention (CDC) released updated recommendations regarding discharge and follow up of patients. Furthermore, late Friday (Dec 20,2019), the United States congress voted to raise the minimum age to buy tobacco and e-cigarettes from 18 to 21.(3) These recommendations, in my opinion are a major leap towards addressing the many adverse concerns highlighted .
Recent analysis conducted by the CDC revealed that 2·7% of discharged EVALI patients were re-hospitalized.(1) The number of deaths reported in EVALI patients post-discharge was 13·5%.(1,2) An estimated 70·6% of patients who were re-hospitalized and 83.3% who died also had one or more chronic conditions.(2) This suggests that risk factors such as cardiac disease, chronic pulmonary disease and diabetes factor for the high rate of mortality.(2) These adverse clinical outcomes suggest the need for clinical stability and importance of follow up care. Therefore, a criteria/checklist to determine the readiness for hospital discharge of patients using e-cigarettes has been developed. The new discharge criteria requires that the patient be clinically stable for 24-48 hours prior to discharge.(1) This can be achieved by the assessment of vital signs, exercise tolerance, resolution of symptoms and lab tests.(1) Previous guidance recommended initial outpatient follow up within 1-2 weeks of discharge.(1) However, this has been amended to ensure that the initial follow up takes place within 48 hours of anticipated discharge.(1) This is a positive change because early outpatient follow up allows improving management of other associated pulmonary conditions.(1) Furthermore, specialized pulmonary follow up should take place within 2-4 weeks of discharge.(1) This allows for the tapering of corticosteroids to better assess lung function.(1) Due to the prevalence of mental health conditions in patients with EVALI, doctors are recommended to screen the patient for anxiety, depression and other conditions.(1,2) The criteria also outline the importance of patient education. Patients are now required to attend discharge medication counselling with the inpatient pharmacist.(1) Finally, physicians are also recommended to offer and optimize cessation support with the help of World Health Organization’s Alcohol, Smoking, and Substance Involvement Screening Test for adults or the CRAFFT-N screening tools.(1)
The decision to raise the minimum age to buy tobacco products is indeed a major public health achievement for the White House. This will ensure a 12% decrease in smoking prevalence.(4) As per the national tobacco youth survey (2019), 27.5% of high school students reported using e-cigarettes in the past month.(3) Given the current trend, without any reform it is projected that 5.6 million school aged youths will die prematurely.(4) The current reform will ensure a decrease in tobacco initiation among adolescents.(4) It is also projected to reduce rates of preterm birth, low birth weight and sudden infant death syndrome. (4) However, this can only come to fruition if it is implemented and enforced nationally.
1. Update: Interim Guidance for Health Care Professionals Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury and for Reducing the Risk for Rehospitalization and Death Following Hospital Discharge — United States, December 2019. Centers for disease control and prevention. 2019 [cited 23 December 2019]. Available from: https://www.cdc.gov/mmwr/volumes/68/wr/mm685152e2.htm
2. Characteristics of Patients Experiencing Rehospitalization or Death After Hospital Discharge in a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury . Centers for disease control and prevention. 2019 [cited 23 December 2019]. Available from: https://www.cdc.gov/mmwr/volumes/68/wr/mm685152e1.htm?s_cid=mm685152e1_w
3. Sullum J. As the FDA Prepares to Ban E-Cigarette Flavors, the Government's Own Data Contradict Wild Claims About Adolescent Nicotine Addiction [Internet]. Reason. 2019 [cited 21 December 2019]. Available from: https://reason.com/2019/11/06/as-the-fda-prepares-to-ban-flavored-e-ciga...
4. Tobacco 21 - Model Policy . Tobacco 21. 2019 [cited 22 December 2019]. Available from: https://tobacco21.org/tobacco-21-model-policy/
Competing interests: No competing interests
I agree with the recent nationalisation of the tobacco 21 law in the USA, which came into effect in December 2019 stating that persons must be aged 21 to buy tobacco products.(1) This came after an increasing number of US States adopted the law.(2) Yet the sale of e-cigarettes remains at 18 years of age. The Centres for Disease Control and Prevention has reported thousands of e-cigarette related injuries, particularly in younger age groups, many of which are unknown due to the lack of research and long term effects of vaping.(3)
Initially vaping was seen as an alternative to cigarette smoking due to the lack of harmful chemicals and thus reduction in associated health conditions, yet still providing nicotine. However e-cigarette use has increased in younger groups who previously haven’t smoked, due to the glamorisation of vaping, slick design, and range of non-nicotine-containing flavours. Compiled with a perceived health benefit and lack of stigma in comparison to regular cigarettes. From 2017 to 2019 vaping in youth populations has increased, from 8% to 20% in 15-16 year olds, 11% to 25% in 18 year olds, and 6% to 16% in those at college (18+ years).(4) In comparison, only 5% of 18 year olds regularly smoke tobacco cigarettes.(5)
The rise in vaping popularity has seen a new term; EVALI (e-cigarette, or vaping, product use-associated lung injury) grouping the respiratory (cough, chest pain, and shortness of breath) and gastrointestinal (abdominal pain, nausea, vomiting, and diarrhoea) symptoms associated with the presence of e-cigarette products (such as vitamin E acetate) in the lungs.(6) It will be interesting to see what effect the tobacco 21 law will have regarding e-cigarette legislation, and whether similar regulations will be implemented in the UK.
1. American Lung Association. 2019; Tobacco 21 Laws: Raising the Minimum Sales Age for All Tobacco Products to 21 | American Lung Association. Available from: https://www.lung.org/our-initiatives/tobacco/cessation-and-prevention/to...
2. Friedman AS, Wu RJ. 2019 Jul 26; Do Local Tobacco-21 Laws Reduce Smoking Among 18 to 20 Year-Olds? Nicotine Tob Res [Internet]. Available from: https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntz123/5538951
3. Hartnett KP, Kite-Powell A, Patel MT, Haag BL, Sheppard MJ, Dias TP, et al. 2019 Dec 20; Syndromic Surveillance for E-Cigarette, or Vaping, Product Use–Associated Lung Injury. N Engl J Med [Internet]. :NEJMsr1915313. Available from: http://www.nejm.org/doi/10.1056/NEJMsr1915313
4. Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME. 2019 Oct 10; Trends in Adolescent Vaping, 2017–2019. N Engl J Med [Internet]. 381(15):1490–1. Available from: http://www.nejm.org/doi/10.1056/NEJMc1910739
5. Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick ME. 2019. Monitoring the Future national survey results on drug use 1975-2018: Overview, key findings on adolescent drug use.
6. Blount BC, Karwowski MP, Shields PG, Morel-Espinosa M, Valentin-Blasini L, Gardner M, et al. 2019 Dec 20; Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI. N Engl J Med [Internet]. :NEJMoa1916433. Available from: http://www.nejm.org/doi/10.1056/NEJMoa1916433
Competing interests: No competing interests