NEWS | November 20, 2019

Q&A on vaping-related lung injuries

UC Davis Children’s Hospital pediatric pulmonologist Rory Kamerman-Kretzmer discusses e-cigarettes and vaping


According to the U.S. Centers for Disease Control and Prevention (CDC), more than 2,000 cases of vaping-associated lung injury have been reported across the United States. UC Davis pediatric pulmonologist Rory Kamerman-Kretzmer shares his insights on e-cigarettes and why children and adults should steer clear.   

Rory Kamerman-Kretzmer Rory Kamerman-Kretzmer

Q: What makes e-cigarettes and vaping use so worrisome?

A: There are tens, if not hundreds, of different chemicals that are potentially contained in different forms of vaping liquid and so-called “juice.” Some of them are thought to cause cancer. It’s not regulated strictly enough. Vaping liquid that is advertised as “pure,” “nicotine-free” or “pure nicotine” does not mean it is absent of various chemicals that are dangerous.

It’s advertised or talked about as just water vapor, which isn’t an accurate characterization of a substance that contains a lot of different chemicals.

A lot of vaping pens or devices turn these chemicals into extremely fine particles. One of the things that we know is that fine particles make their way further into the lungs. Large particles are filtered out by the nose and the throat. Medium-sized particles hit your main airways, which is the trachea -- your main air tube -- or the large airways of the lungs. The finest particles make it all the way to the end portion of the lung, which is called the alveoli. That’s the part that is critical in moving oxygen and carbon dioxide into and out of the body and is arguably the most fragile part of the lung. We worry that the tiniest particles getting into that part of the lungs might be part of the reason why vaping is dangerous. But again, it would help to have more scientific data on all of this.

Q: Do we know what is causing these vaping-related injuries and deaths?

A: Our understanding of this is still limited. The CDC has asked all physicians who have seen these cases across the nation to report them so they can gather as much data as possible and get a better understanding of what is happening. What we have gathered so far is that a lot of the cases seem to involve vaping liquid that contains marijuana-related substances, including THC or synthetic forms of THC, which is one of the psychoactive substances in marijuana. We also think a lot of the lung injury-related cases involve vaping juices or vaping liquid that were unregulated or sold on the black market.

When you buy a pack of cigarettes over the counter, I don’t want to say that that is as regulated as I would prefer, but it is manufactured using a standardized process, according to the nicotine and cigarette industry. A lot of vaping liquids are either completely unregulated or sometimes are modified by the shop selling them or the person using them. Particularly liquids that are bought on the black market and shared between friends or family members. We don’t necessarily know what is in that liquid. According to data collected by the CDC, liquids bought on the black market, or were modified by people before they used them -- particularly with the addition of substances that are derivatives of marijuana -- are more associated with lung injury.

At least 10% of the cases, according to the CDC, had no association with marijuana whatsoever. The only active ingredient found was nicotine, so I don’t want to leave the impression that vaping pure nicotine is safe either.

Q: What are the signs or symptoms of vaping associated lung injury?

A: The symptoms are vague: decreased appetite, chills or night sweats. Maybe feeling a little out of breath or feeling like you can’t exercise as much as you could before. Maybe you’ve noticed that climbing a flight of stairs or walking a few blocks is harder than it used to be, even though you are still a relatively young, fit person. This can progress to more coughing and more shortness of breath.

If you are someone who vapes and notice respiratory symptoms, you should see a physician and be evaluated as soon as possible.

We see mood disorders, including increased anxiety and increased rates of depression related to nicotine use. Also, we see trouble with impulse control, acting out, attention-deficit, hyperactivity disorder (ADHD)-like symptoms. The brain continues to develop until 25 years of age, and we worry that nicotine use early on may permanently change the way the brain develops. I encourage parents to look out for those types of symptoms, particularly if there has been a recent change in their child’s or teenager’s behavior.

Of course, there are a variety of reasons kids may be experiencing anxiety, depression or acting out, so I’m not trying to imply that nicotine is the only cause. But it’s on the list of causes.

Q: What do these symptoms look like when vaping-associated lung illness gets worse?

A: We’re seeing profound inflammation of the lungs. If it’s airway disease, that inflammation prevents air from getting into the lungs effectively because an inflamed airway narrows as it swells. If it’s related to the fine tissue at the most distant portion of the lung called the alveoli, that profound inflammation and immune reaction can prevent the body from exchanging oxygen and carbon dioxide. In the worst cases, that means we have to put in a breathing tube and start a ventilator for that patient to try to get them over this massive wave of inflammation.

We also use anti-inflammatory medications like steroids, if we need to. In the worst cases, we have to use ECMO, which is a machine that exchanges oxygen and carbon dioxide. It’s related to heart-lung bypass and it’s a form of emergency life support that maintains the body’s functions while the heart and lungs are completely shutting down. This is a very serious thing when the most severe cases of vaping-associated injury happen.

Q: How prevalent is vaping among children?

A: We know that there are lots of kids who vape. As of 2018, one in five high schoolers had vaped in the past 30 days. For middle school, it was one in 20 kids who had vaped in the past 30 days. Our current numbers may be even higher. The other concern is, as of 2016, 70% of kids had been exposed to vaping-related advertisements. As you know, a lot of these products are advertised with flavors that naturally appeal to kids, in addition to adults. A lot of the flavors are fruit-based, candy-based, stuff that kids enjoy and all of those are risk factors for getting kids addicted to nicotine early on in life.

Nicotine is one of the most addictive substances that people use and that it is extremely difficult to quit. We’ve known this for years. I worry that getting addicted early in life is setting kids up for long-term health consequences.

My fear about vaping is that we’re going to have a second wave of nicotine addiction and nicotine-related disease over the coming decades.

Q: How should parents talk to their children about vaping?

A: Parents should be talking to their kids early about the risks of nicotine use in any form, including vaping, and keeping an open, honest conversation with their kids. For parents who may be smoking or vaping themselves, they can be talking about how they hope to quit at some point and how they would never want their son or daughter to abuse these substances themselves.

We want kids to feel that they can talk to their parents, their teachers and their physicians about the substances they are using in a nonjudgmental fashion so we can educate kids about the risks and help them discontinue use of these substances. Starting these conversations early in your child’s life so they know it’s a safe topic is going to help. We also know that kids who start vaping are a lot more likely to use traditional cigarettes in the future and potentially move on to more dangerous substances and drugs, so that’s why it’s really important to get ahead of this.

Additional resources

CDC information on e-cigarettes and lung injury

Do you vape? Stop!

UC Davis Children's Hospital is the Sacramento region's only nationally ranked, comprehensive hospital providing care for infants, children, adolescents and young adults with primary, subspecialty and critical care. It includes the Central Valley's only pediatric emergency department and level I pediatric trauma center, which offers the highest level of care for its critically ill patients, as well as a level I children’s surgery center. The 129-bed children's hospital includes the state-of-the-art 49-bed neonatal and 24-bed pediatric intensive care and pediatric cardiac intensive care units. For more information, visit