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Taking a Science-driven Approach to Address the Vaping Threat

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For 50 years, the NHLBI has led the nation in groundbreaking discovery science that has improved lung health. It’s a legacy of excellence that includes, among other public health achievements, funding for studies that linked smoking with chronic respiratory diseases, cardiovascular disease, and cancer. These findings led to changes in public health practice and policies that paved the way for a steep decline in smoking rates.

Today, we face a new and evolving public health threat that reminds us why research matters. Since this spring, the Centers for Disease Control and Prevention (CDC) has reported more than 2,000 confirmed or probable cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) across the country.  More than half of the cases are patients 24 years or younger. Sadly, this epidemic has claimed more than 40 lives, and the number of cases continues to rise.

In response, the CDC is coordinating with its federal partners, including NIH and the U.S. Food and Drug Administration (FDA), as well as with state health departments, to confront this public health threat head-on. The NHLBI is an active partner in this urgent response. We are engaged in a trans-NIH effort to formulate and implement a coordinated response to support researchers who can tackle the issue from different, but complementary, angles.

Together with several NIH Institutes, NHLBI has issued a Notice of Special Interest (NOSI) that will enable currently funded investigators to quickly leverage existing research projects to collect data or test hypotheses regarding the effect of vaping on lung health. This notice is intended as a call-to-action to rally the best ideas and approaches toward understanding the causes, disease mechanisms, and long-term prognosis of individuals with EVALI and related health effects associated with vaping.  In addition, the NHLBI funded two population-based studies just this year—the American Lung Association Lung Health Cohort and the Risk Underlying Rural Areas Longitudinal Cohort Study. These multisite, epidemiological studies are expected to help researchers better understand the chronic, long-term effects of e-cigarette, vaping, and nicotine products on heart and lung health among adults.

There is much to learn about the effects of e-cigarettes on health, but we already have scientific evidence that nicotine and flavorings found in these products are associated with effects on the cardiovascular system and lungs. A 2002 study by the National Institute for Occupational Safety and Health (NIOSH) for example, found that diacetyl – a flavoring inhaled by workers at microwave popcorn plants – caused severe obstructive lung disease, or “popcorn lung.”  Diacetyl is commonly used in e-cigarettes as well as many other flavorings whose safety in inhaled form is unknown.   

Even before alarming reports of EVALI emerged this year, the NHLBI had already begun to invest in research to better understand the health repercussions of chronic exposure from electronic nicotine delivery systems (ENDS), such as e-cigarettes, vapes, e-hookahs and other vaping devices. Those efforts are beginning to bear fruit. For example, a recently published NHLBI-supported study suggests that just one vaping session -- even without nicotine -- can produce a negative response in the blood vessels of healthy nonsmokers.  Additionally, several other investigations have shown that e-cigarettes are associated with endothelial dysfunction and oxidative stress in the vasculature and the lungs, even in the absence of nicotine.  There is also some clinical evidence that daily vaping may prime the lungs for chronic lung disease. Another study from Sweden suggests that e-cigarette aerosols with nicotine can adversely impact vascular and pulmonary function.  While only time will reveal lasting adverse effects among e-cigarette users, we already know from NIH-funded mouse studies that chronic e-cigarette exposure can adversely change the physiology of lung epithelial cells, compromise immune defenses again lung infection, and increase arterial stiffness, which can contribute to cardiovascular disease.

The NHLBI also continues to administer a substantial portfolio of research grants on the cardiovascular and pulmonary consequences of vaping through the FDA’s Tobacco Regulatory Science Program. By leveraging our existing research platforms, we can rapidly expand our effort to address the ongoing public health threat we are facing today and make inroads into answering questions about both the acute and chronic health effects of vaping. For example, as vaping among young people continues to grow, we need to know more about how exposure early in life to nicotine and other vaping components affects the heart and the lungs, which are still developing in adolescence.  Also, we need to better understand the roles that device features, delivery mechanisms, flavorings, aerosols or additives play in both vaping-related lung injury and illnesses and cardiac functioning, as well as the pathobiology of EVALI.

For decades, the NHLBI has advanced discovery science that has transformed health outcomes by tackling some of the most pressing public health issues. We are applying this same commitment and scientific rigor to the public health threat posed by vaping through a multi-pronged, multi-partner approach to research on the short- and long-term health effects of vaping on heart and lung health.

With the help of physicians, patients, our federal and state partners, and the NHLBI community, we can answer critical questions and, hopefully, save lives.

For More Information

To learn more about e-cigarettes and the EVALI outbreak, refer to the CDC’s electronic cigarettes web page.  You may find additional and detailed information on the NIH NOSI: “Availability of Administrative and Revision Supplements to Expand Vaping Research and Understand EVALI” here

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November 12, 2019