Dr. Bob Underwood (Host): Welcome to Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. I'm your host, Dr. Bob Underwood. And today, we are discussing research on the psychosocial factors behind e-cigarette or vaping-associated lung injury, also known as EVALI.

And we are joined by pediatric pulmonologist at Children's Health and Associate Professor at UT Southwestern, Dr. Devika Rao. Dr. Rao, thank you for joining us today and sharing with us on this really interesting but important topic.

Dr Devika Rao: Thank you for having me.

Host: So, we often hear about vaping, but what exactly is EVALI, and why did this condition prompt a deeper look into the experiences of hospitalized adolescents?

Dr Devika Rao: So, EVALI is a relatively new diagnosis. It's a clinical diagnosis, a disease that was first formally recognized in 2019 when there was an outbreak of severe lung injury in both adolescents and adults, mostly young adults, who presented with severe lung disease as a consequence of vaping. And basically, the aerosol that one inhales when using an e-cigarette contains a lot of toxic substances like heavy metals and other substances like organic substances that lead to cell inflammation and even lung cell death. And that causes a lot of symptoms in users, including coughing, shortness of breath, chest tightness. It can even lead to the user having low oxygen levels and having sort of a pneumonia-like picture to the point where they need immediate medical attention, like oxygen and even needing IV steroids to improve.

Host: Wow. So, your research also found that 93% of adolescents hospitalized with EVALI had significant psychosocial stressors. What are some of the most common challenges identified, and what were some of the things that were surprising?

Dr Devika Rao: So when I was seeing these kids who were hospitalized with this lung injury, I was really struck by their stories. They had a lot of stress in their lives, whether it was related to family dynamics, difficulties with a parent even using other substances like alcohol, smoking marijuana. And these kids also had a lot of other mental health issues like anxiety, ADHD, depression. A lot of them require medication for these issues. Some of them had not really been diagnosed or had not been in touch with a counselor, but reported having anxiety and depression.

So, I was really struck by the stories and what these kids were going through, and it kind of made me think that there's a lot behind this diagnosis. We have the medical treatment of this terrible disease. But we also have what's going on at home. What's happening in the year or even years before this patient is presenting to me. And so, that led me to look at this kind of in a more scientific way. And what we found was, like you had mentioned almost 100% of these patients had psychosocial stressors, the most common being stress at home.

For example, I even had one patient who had a restraining order filed against them by a parent. I had a patient who had already been in alcohol rehab for alcohol use. And many, many of the patients that I saw and treated had mental health comorbidities like depression and anxiety.

Host: Yeah. So, many of the adolescents, as you said, they had experienced these kinds of things like trauma, mood concerns, chronic stress before they developed EVALI. So, how do these factors perhaps influence these behaviors and overall health?

Dr Devika Rao: So, it's hard to know what came first. Was it the anxiety or depression that led the adolescent to start e-cigarette use as a coping mechanism? Or was it the e-cigarette use that led to a change in brain chemistry that then made them more susceptible to having a mental health problem?

It's really unclear. I think that there's probably both going on. Perhaps some patients fit into the first category where the mental health issue comes first, and some patients fit into the second category where the e-cigarette use makes the ADHD or the anxiety worse. And then, some patients probably fit into a little bit of both.

Host: Right. So for some teens, vaping may actually be a way to cope with this kind of stress or difficult emotions. So with that in mind, how can nicotine and THC use actually affect the developing brain of these pediatric patients?

Dr Devika Rao: Yeah. So, the developing brain, particularly in adolescence and even into young adulthood, like 18, 19, 20, is extremely susceptible to addiction. So even one dose of an e-cigarette can prime the brain and enhance the susceptibility to addiction. And so, I think that's the most important thing for parents and any caregivers to know of kids, as well as clinicians who see kids, adolescents, young adults in their clinical practice, to know that this particular group is much more susceptible to addiction.

And because of that, that can kind of set them up for a lifetime of addiction to nicotine and THC. Most smokers actually start using cigarettes before the age of 18, and I think we're finding the same is true for e-cigarettes. We don't have quite as much data on e-cigarettes as we do cigarettes, but we suspect that the trajectory will be similar.

Host: Yeah. Yeah, absolutely. So onto that, so you kind of mentioned if you find out that this is going on. So if a pediatrician or a parent learns that a teen is vaping, what should the next step, beyond simply telling them to quit, what should that next step be? Are there any tools or practical advice that can help in this kind of situation?

Dr Devika Rao: Yes. So, I would say to take a step back first, the best method is going to be prevention. So, I encourage parents to speak to their kids about what they know about e-cigarettes and vaping, even starting as early as age 10 or 11. I was visiting my son's elementary school a few years ago, and I was in a fifth-grade class, and I asked the kids, "Who here knows what vaping is?"

And all of the hands shot up. So, kids know what this is. They've seen it in their peers. They've seen it in perhaps an older sibling, a cousin or an aunt and uncle, or they see their parents trying to quit smoking and using e-cigarettes to try and do that. And they get the impression that actually this is, like, safer than cigarettes. And so, they're going to have a mindset that this might be okay. And then, they're also enticed by the flavorings. The flavorings are very enticing to kids, like fruit punch and mango and mint and all of these types of flavors. So, that's why prevention is the most important.

If you do happen to find that your child or a niece or nephew is using these products, it can be a really difficult thing. But I just encourage caregivers to take a step back and remain calm and to seek the help of a medical professional like a pediatrician, a family practice physician, because basically a clinician can help a family tease out how often they're using these devices, if there's any health effects going on, and then kind of moving on to how to treat the use of these products with, like, cessation techniques such as counseling.

There's even medications available. If the youth is using nicotine-containing vapes, nicotine replacement therapy can be helpful in the form of patches and lozenges. So, there's several different methods. I recently led a clinical practice guideline with the American Thoracic Society looking at the evidence behind cessation techniques for e-cigarette use, particularly nicotine-containing products. And we put out recommendations, and these are available for clinicians to refer to.

Host: Well, that's awesome. That is awesome. And I think you really hit on something is that illusion of safety. I don't know how many discussions as a physician I have had with people who are under the impression that this is a safer alternative when we have learned that it's definitely not.

Dr Devika Rao: Exactly. There's definitely the illusion of safety. The products are marketed to look like food products, like cookies and candy and things like that. And I mentioned the flavorings before. It's a very important aspect of these products that makes them extremely attractive. In fact, curiosity about flavorings is one of the top three reasons why adolescents start to use these products. And then, if the adolescent brain is primed for addiction, it can be very, very difficult. If the adolescent is using this product continuously or uses it more and more frequently, it can be very difficult to help them quit these products.

These products are extremely potent. They contain even synthetic nicotine that's much more potent than previous generations of nicotine. And with the latest types of vaping devices, kids get a huge hit with each puff. And now, they even have devices that have, like, tens of thousands of puff per device. And so, it's very, very easy to ramp up the use even after the first use. And especially if that adolescent is going through something in their life and they're using this device to cope, it can set that individual up for a lifetime of problems

Host: Yeah. And that leads us to the next question, with treating EVALI, it requires more than just addressing lung injury alone. So, how does Children's Health bring together pulmonology, psychiatry, social work, and child life to really support these patients?

Dr Devika Rao: So when we started seeing these patients back in 2019, we formed a multidisciplinary group in order to standardize the care of these patients. And so, what we decided is that having multiple disciplines on board, including pulmonology, including toxicology, psychology, social work, is really the best way to provide holistic care for these patients, as we found these patients have a lot of psych needs, a lot of social work needs, a lot of barriers to care.

They came from areas in Dallas characterized as a lower socioeconomic status. So, the EVALI diagnosis for me is like the tip of the iceberg. It's reflective of other issues going on in the child. And it's also the tip of the iceberg in terms of e-cigarette use. Not all patients who use e-cigarettes, not all kids who use these dangerous products are going to develop EVALI.

So, the most important thing is to screen, not only to talk to your child and talk to your patients about prevention, but also for these individuals who are seeing kids in their clinical practice to screen for e-cigarette use. You cannot make a difference in your patient's life if you don't know that they're using these products.

And as pediatricians, you know, I graduated from medical school 20 years ago. I didn't receive education on e-cigarette products and vaping. But now, we're starting to see the new generation in medical school. I mentor medical students, and they tell me when they were in high school that these products were extremely common. And so, we have a new generation of trainees coming into the workforce that have experience with these products. And it's important for those of us in academia to provide education for trainees on e-cigarette use in adolescents.

Host: Yeah, absolutely. And I think that this kind of got onto this very next piece. And as we close, what is the one thing you want pediatricians and caregivers to understand about the connection between vaping, mental health, and adolescent well-being?

Dr Devika Rao: I would say that it's almost impossible to tease out the difference between mental health and e-cigarette use. Behind the e-cigarette use is a story. And as pediatricians, as family practitioners, we love seeing our patients and we get to know them over the course of a lifetime. And so, let's be open to hearing their stories and making a difference so that at least they can feel supported by our encouragement and our dedication to their wellbeing.

Host: That's awesome. Dr. Rao, thank you so much for being with us today. This is really, really informative.

Dr Devika Rao: Thank you so much for having me.

Host: Absolutely. And thank you to our audience for listening to Pediatric Insights: Advances and Innovations with Children's Health, where we explore the latest in pediatric care and research. You can find more information at childrens.com. And if you found this podcast helpful, please rate and review or share the episode, and please follow Children's Health on your social channels.