MarylandQuitter

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After vaping-related illness, teen now has lungs like 'a 70-year-old's' By Jacqueline Howard and Michael Nedelman, CNN Updated 5:06 PM ET, Fri September 13, 2019 https://www.cnn.com/2019/09/11/health/vaping-lung-illness-illinois-teen-profile/index.html (CNN)Adam Hergenreder's vaping habit almost killed him. Late last month, the 18-year-old student athlete in Gurnee, Illinois, was hospitalized after using e-cigarettes for more than a year and a half. Now his lungs are similar to those of a 70-year-old adult, doctors told him. "It was scary to think about that -- that little device did that to my lungs," Adam said, remembering the news from his doctors about his lung health. Adam is among the hundreds of e-cigarette users in the United States who have been sickened with mysterious vaping-related lung illnesses, many of them young people. Investigators haven't yet identified the cause of the illnesses. Amid calls for more regulation, the Trump administration now plans to remove flavored e-cigarettes -- except tobacco flavor -- from the marketplace. "Why is that important? We are seeing an absolute surge in high school and middle school kids using these flavored products," US Health and Human Services Secretary Alex Azar said in a video statement on Wednesday. "Mint, menthol, fruit flavor, alcohol flavor, bubble gum." The US Food and Drug Administration announced on Wednesday that more than a quarter of high school students this year have reported using e-cigarettes and the "overwhelming majority" reference using popular fruit and menthol or mint flavors, according to preliminary data from the National Youth Tobacco Survey. Adam, who vaped nicotine and THC products, said he isn't sure his lungs will ever be back at 100% -- and he worries whether he will ever be able to wrestle again. "I was a varsity wrestler before this and I might not ever be able to wrestle because that's a very physical sport and my lungs might not be able to hold that exertion. ... It's sad," Adam said. 'We must act swiftly' There are more than 450 possible cases of lung illness associated with using e-cigarettes across the United States, according to the US Centers for Disease Control and Prevention, which has called this an "outbreak." Health officials have also confirmed six deaths -- in California, Illinois, Indiana, Minnesota, Oregon and Kansas -- in connection to vaping-related lung illnesses. While the illnesses and deaths have occurred in both young people and older adults, experts have warned of a rise in vaping among youth. "We must act swiftly against flavored e-cigarette products that are especially attractive to children," Acting FDA Commissioner Dr. Ned Sharpless said in the announcement, adding that the FDA will take additional steps to address youth use of tobacco-flavored products still on the market, if young people begin to use them. "The tremendous progress we've made in reducing youth tobacco use in the US is jeopardized by this onslaught of e-cigarette use. Nobody wants to see children becoming addicted to nicotine, and we will continue to use the full scope of our regulatory authority thoughtfully and thoroughly to tackle this mounting public health crisis." Separate surveys also suggest that most teens think e-cigarettes are safe. Adam certainly thought vaping was safe when he started using e-cigarettes, he said. One of his favorite flavors was mango. "It didn't taste like a cigarette," he said. "It tasted good," and provided a little buzz due to the nicotine. The vaping began about a year and a half ago, he said, and he would pick up e-cigarette products, such as those of the Juul brand, from his neighborhood gas station. "They didn't card me," he said. "He would wake up in the morning and would puff on that Juul and then cough," said Adam's mother, Polly Hergenreder. "He would hit it several times throughout the day. My son was going through a pod and a half every other day, or a day and a half." Experts say that one Juul pod -- a cartridge of nicotine-rich liquid that users plug into the dominant e-cig brand -- delivers the same amount of nicotine to the body as a pack of cigarettes. "That's smoking a lot of cigarettes," Polly said. Eventually, Adam said that he went from vaping over-the-counter e-liquids to vaping THC or tetrahydrocannabinol, which is the main psychoactive component of marijuana. Adam would get the THC from "a friend" or dealer. Over time, Adam said that he developed shivers and couldn't control them. Then, the vomiting began. "I was just nonstop throwing up every day for three days," he said. "Finally I went to the pediatrician." At first, doctors did not connect Adam's symptoms to his vaping. He was given anti-nausea medication, but he said that his vomiting did not stop. After visiting various physicians, he finally saw someone who asked if he was "Juul-ing" and using THC. "I answered honestly," Adam said. "I said I was." The team overseeing Adam's care performed a CT scan of his stomach and noticed something unusual about the lower portion of his lungs. The doctors then took an X-ray of his lungs. "That's when they saw the full damage," Adam said. "If I had known what it was doing to my body, I would have never even touched it, but I didn't know," he said about vaping. "I wasn't educated." 'If we did not bring Adam in ... his lungs would have collapsed' Adam was admitted to the hospital in late August. "If his mom had not brought him to the hospital within the next two to three days, his breathing could have worsened to the point that he could have died if he didn't seek medical care," said Dr. Stephen Amesbury, a pulmonologist and critical care physician at Advocate Condell Medical Center in Illinois, who was one of the doctors who saw Adam. "It was severe lung disease, especially for a young person. He was short of breath, he was breathing heavily," Amesbury said. "It was very concerning that he would have significant lung damage and possibly some residual changes after he heals from this." Adam's mother Polly spent the following six days in the hospital with her son, who was connected to IVs and was provided oxygen through nasal tubes. "The doctors did tell us that if we did not bring Adam in when we brought him in, his lungs would have collapsed and he would have died," Polly said. Yet, she added, "you should always try to find the silver lining," and for her family, that is to use Adam's experience to educate others about the risks of vaping. Adam is now home from the hospital and "it's still difficult to even do normal activities, like going upstairs. I still get winded from that," he said. Even though he is still recovering -- including doing breathing treatments -- Adam has focused on sharing his story. Through his advocacy, he said that he has even convinced some of his friends to stop vaping. "I'm getting better each day," he said. "I don't want to see anybody in my situation. I don't want to see anybody in the hospital for as long as I was." Lawsuit filed On Friday, Adam filed a lawsuit against Juul Labs and the gas station that allegedly sold him Juul products when he was underage. The lawsuit alleges Juul "sought to fill the void left by big tobacco by creating a new-age electronic cigarette." By using social media, the lawsuit alleges, "JUUL was able to easily target and manipulate youth by using advertisements designed to fulfill powerful psychological needs like popularity, peer acceptance, and a positive self-image -- the same techniques used by big tobacco in decades past." In a statement, Antonio Romanucci, an attorney at Romanucci & Blandin, the firm that filed the lawsuit, said, "To put it mildly, Adam didn't stand a chance to avoid getting hooked on these toxic timebombs." In response to the lawsuit, Ted Kwong, a spokesperson for Juul Labs, said the company is committed to eliminating combustible cigarettes, and that its product is intended to be a "viable alternative" for adult smokers. "We have never marketed to youth and do not want any non-nicotine users to try our products. We have launched an aggressive action plan to combat underage use as it is antithetical to our mission," the statement said, including halting the sale of non-tobacco and non-menthol-based flavors in traditional retail stores, enhancing online age verification and shutting down its Facebook and Instagram accounts, among other steps. "It was our hope that others in the category would self-impose similar restrictions to address youth usage," the statement said. There really isn't enough vaping history to say what's going to happen' The federal investigation into the link between vaping and severe lung illnesses is ongoing and has not identified a cause, but all reported cases have indicated the use of e-cigarette products and some patients have reported using e-cigarettes containing cannabinoid products, such as THC. There are also separate investigations being conducted in separate states. New York health officials said last week that extremely high levels of the chemical vitamin E acetate were found in nearly all cannabis-containing vaping products that were analyzed as part of the investigation. At least one vape product containing this chemical has been linked to each person who fell ill and submitted a product for testing in the state. Laboratory tests conducted at the New York State Department of Health's Wadsworth Center in Albany showed "very high levels" of vitamin E acetate in the cannabis-containing samples, the state health department announced. Vitamin E acetate is now "a key focus" of the state's investigation into the illnesses, the New York Department of Health said. Some of the products that have been found to contain vitamin E acetate are candy-flavored vapes. Juul has maintained that its products are intended to convert adult smokers to what it described in the past as a less-harmful alternative. In other communications, the company says it cannot make claims its products are safer, in line with FDA regulations. Scientists point out that they are still learning about the long-term health effects of e-cigarettes. One study published in the Journal of the American College of Cardiology in May found that e-cigarette flavors can damage the cells that line your blood vessels and perhaps your heart health down the line. Another study, published in the journal Radiology in August, foud that vaping temporarily impacts blood vessel function in healthy people. Using MRI scans, it found, for example, changes in blood flow within the femoral artery in the leg after just one use. The researchers couldn't determine which chemical might be responsible for the changes they observed. There are many questions that remain to be answered, according to Amesbury. "We're very early in the stages of finding out what problems may come up from vaping," he said. "We're finding these acute, severe illnesses now, but there really isn't enough vaping history to say what's going to happen 10, 20, 30 years down the road." CNN's Michael Nedelman and Arman Azad contributed to this report.

A 7th person has died from vaping-related causes. The CDC is stepping up its probe of e-cigarette illnesses By Chuck Johnston and Hollie Silverman, CNN Updated 4:19 PM ET, Tue September 17, 2019 https://www.cnn.com/2019/09/17/health/seventh-vaping-related-death-california/index.html (CNN)A California man has become the seventh person to die from a vaping-related illness in the United States as the nation's leading health agency activates emergency operations to better investigate the outbreak of lung injuries associated with e-cigarettes. California will launch a $20 million ad campaign to warn against the dangers of vaping, Gov. Gavin Newsom announced Monday, the same day health officials said a 40-year-old had died over the weekend from complications related to using e-cigarettes. Vaping-related illness recently killed another person in California, plus one person each in Kansas, Illinois, Indiana, Minnesota and Oregon, officials have reported. In light of the outbreak of lung injuries, the US Centers for Disease Control has activated its Emergency Operations Center, the agency announced. Researchers are looking into 380 cases of lung illness associated with the use of e-cigarettes in 36 states and the US Virgin Islands, they have said. California weighs steeper vaping pod taxes. California, meantime, will focus on spreading the word about vaping risks while also boosting enforcement efforts on counterfeit products and weighing stricter package warning rules, Newsom said during a news conference. The state also will investigate tax policy regarding vaping pods. A pack of cigarettes carries a tax of $2.87, while a Juul pod, for example, gets only a $1.48 tax, the governor said. The intent of the investigation is to "substantially increase taxes to these products," said Newsom, who included the measures in an executive order he said is needed because of a lack of legislative efforts. As for flavored e-cigarettes, "they should be banned," Newsom said, adding he could not add that parameter to his order, though he didn't explain why. "Let's just dispense with any niceties," he said. "You don't have any bubblegum-flavored, mango-flavored tobacco products unless you're trying to target an audience that you were losing -- that's young people." The Trump administration is working to ban flavored e-cigarettes as health officials warn they're too appealing to teens. Tobacco companies claim flavored e-cigarettes help adults quit traditional cigarettes. 'Serious potential risk associated with vaping' The latest California victim had been sick for several weeks after he suffered a "severe pulmonary injury associated with vaping," Dr. Karen Haught, the Tulare County public health officer, said in a news release. "The Tulare County Public Health Branch would like to warn all residents that any use of ecigarettes poses a possible risk to the health of the lungs and can potentially cause severe lung injury that may even lead to death," Haught said. "Long-term effects of vaping on health are unknown. Anyone considering vaping should be aware of the serious potential risk associated with vaping," she said. County of Los Angeles Public Health staff earlier this month announced the death of a resident potentially related to the use of e-cigarettes. 'It is time to stop vaping' The first death identified as related to vaping was announced in August, when the Illinois Department of Public Health released a statement saying the person had been hospitalized with "severe respiratory illness" after recently vaping. Cases of vaping-related illness had been identified in 11 counties, the agency said. A person in Oregon who had recently vaped products containing cannabis purchased at a dispensary died in July, according to a statement released in early September by the Oregon Health Authority. The symptoms the patient suffered were similar to at least 200 cases in a national cluster that was mostly affecting teenagers and young adults, Oregon officials said. "We don't yet know the exact cause of these illnesses -- whether they're caused by contaminants, ingredients in the liquid or something else, such as the device itself," said Dr. Ann Thomas, public health physician at OHA's Public Health Division. Another death related to vaping was identified on September 6 by health officials in Indiana. The patient was older than 18 and died of a severe lung injury linked to a history of e-cigarette use. The same day, the Minnesota of Department of Health said a patient who was over 65 had died in August after a long and complicated hospitalization. The patient had a history of underlying lung disease and suffered a severe lung injury associated with vaping THC products, Minnesota state epidemiologist, Dr. Ruth Lynfield, said in a news release. Within a week, two more deaths were announced in Los Angeles County and Kansas. The Kansas patient was over 50 and had a history of underlying health issues with symptoms that quickly progressed, the Kansas Department of Health and Environment said. What type of products the patient had used wasn't known, a news release stated. "It is time to stop vaping," Kansas Department of Health and Environment Secretary Dr. Lee Norman said. "If you or a loved one is vaping, please stop. The recent deaths across our country, combined with hundreds of reported lung injury cases continue to intensify." CNN's Michael Nedelman, Jamie Gumbrecht, Cheri Mossburg

I see that. Thanks for letting me know. I'll contact the person I paid to write the script and have it fixed.

Juan, you know the drill.

Video explains why inhaling a drug like nicotine is the fastest way to deliver it to the brain and also how cigarette companies and now vaping manufacturers have manipulated their products to make them even easier to lead to addiction.

Video explains why inhaling a drug like nicotine is the fastest way to deliver it to the brain and also how cigarette companies and now vaping manufacturers have manipulated their products to make them even easier to lead to addiction.

CDC Launches Probe Into Surge Of Severe Lung Disease Cases Linked To Vaping The federal health agency reported 94 cases in 14 states and said the number is climbing. By Mary Papenfuss https://m.huffpost.com/us/entry/us_5d5b6ec4e4b0f667ed679101?utm_medium=facebook&utm_source=main_fb&ncid=fcbklnkushpmg00000063&utm_campaign=hp_fb_pages&guccounter=1 The federal Centers for Disease Control and Prevention is investigating the sudden emergence of severe lung disease linked to vaping in 14 states. Ninety-four possible cases of severe lung illness associated with vaping were reported from the end of June to Aug. 15, the CDC reported on Saturday. Thirty of those cases were in Wisconsin alone. Other states that appear to be especially affected are Illinois, California, New York, Indiana and New Jersey. A survey of state health departments by CNN found at least 120 possible cases, the network reported Monday. The largest number of cases, in Wisconsin, was first seen in teens and young adults, but the illness has now also appeared in older adults, according to a CDC statement. Patients experience shortness of breath, coughing, fatigue, chest pain and weight loss. Symptoms worsen over time, and some patients need ventilators to breathe and intensive care. Some have been hospitalized for several weeks. The illness could be linked to permanent lung damage. All patients reported vaping in the weeks or months before hospitalization, said the CDC. Investigators don’t yet know if only certain vaping brands are involved, or what specific ingredient had been consumed by those who were sickened. Products may include nicotine, THC, synthetic cannabinoids or some combination, the CDC reported. There is so far “no conclusive evidence that an infectious disease is causing the illnesses,” according to the health agency. “While some cases in each of the states are similar and appear to be linked to e-cigarette product use, more information is needed to determine what is causing the illnesses,” the CDC said in a brief statement. “This is the headline we’ve been trying to prevent,” Joseph Allen, an environmental health scientist at Harvard University, told Popular Science. Allen is a co-author of a study published earlier this year that found fungi and bacteria in some popular brands of e-cigarette liquid. Allen also warned that flavors in vapes that may be safely ingested through the digestive tract aren’t tested for safety when aerosolized and inhaled. “When you have millions of kids inhaling this cocktail of chemicals that were never tested for inhalation safety, this type of headline is predictable, and also avoidable,” Allen said. The CDC has sent notices and emails to physicians, hospitals and clinics providing background about the cases, and requests that they determine what vaping devices and brands people are using, what is being consumed — and to obtain samples if possible. The agency also asked whether people are sharing devices and ingredients. Earlier this month, the U.S. Food and Drug Administration said it had received more reports of e-cigarette users experiencing seizures and was investigating a possible link between vaping and neurological symptoms.

The cravings will pass and it's important not to dwell on them by doing just what you're doing. Taking a brisk walk and breathing dinne fresh air does wonders.

Yep, it's coming back. We're trying to figure out why the anonymous login isn't working.

NOPE

Electronic Cigarette Use and Myocardial Infarction Among Adults in the US Population Assessment of Tobacco and Health Dharma N. Bhatta and Stanton A. Glantz Originally published 18 Jun 2019https://doi.org/10.1161/JAHA.119.012317Journal of the American Heart Association. 2019;8 https://www.ahajournals.org/doi/10.1161/JAHA.119.012317?fbclid=IwAR34_ZKD7TnpD9J5vCKXIzTL7MTYUivnjxJSRs0k-ZHddM9L0WSNtXRS7kQ& Conclusions Some‐day and every‐day e‐cigarette use are associated with increased risk of having had a myocardial infarction, adjusted for combustible cigarette smoking. Effect of e‐cigarettes are similar as conventional cigarette and dual use of e‐cigarettes and conventional cigarettes at the same time is risker than using either product alone. What Are the Clinical Implications? E‐cigarettes should not be promoted or prescribed as a less risky alternative to combustible cigarettes and should not be recommended for smoking cessation among people with or at risk of myocardial infarction. Abstract Background E‐cigarettes are popular for smoking cessation and as an alternative to combustible cigarettes. We assess the association between e‐cigarette use and having had a myocardial infarction (MI) and whether reverse causality can explain the observed cross‐sectional association between e‐cigarette use and MI. Methods and Results Cross‐sectional analysis of the Population Assessment of Tobacco and Health Wave 1 for association between e‐cigarette use and having had and MI. Longitudinal analysis of Population Assessment of Tobacco and Health Waves 1 and 2 for reverse causality analysis. Logistic regression was performed to determine the associations between e‐cigarette initiation and MI, adjusting for cigarette smoking, demographic and clinical variables. Every‐day (adjusted odds ratio, 2.25, 95% CI: 1.23–4.11) and some‐day (1.99, 95% CI: 1.11–3.58) e‐cigarette use were independently associated with increased odds of having had an MI with a significant dose‐response (P<0.0005). Odds ratio for daily dual use of both products was 6.64 compared with a never cigarette smoker who never used e‐cigarettes. Having had a myocardial infarction at Wave 1 did not predict e‐cigarette use at Wave 2 (P>0.62), suggesting that reverse causality cannot explain the cross‐sectional association between e‐cigarette use and MI observed at Wave 1. Conclusions Some‐day and every‐day e‐cigarette use are associated with increased risk of having had a myocardial infarction, adjusted for combustible cigarette smoking. Effect of e‐cigarettes are similar as conventional cigarette and dual use of e‐cigarettes and conventional cigarettes at the same time is risker than using either product alone. Clinical Perspective What Is New? Both e‐cigarettes and combustible cigarettes are independently associated with increased risk of myocardial infarction. Dual use of e‐cigarettes and combustible cigarettes is riskier than using either product alone and switching from combustible cigarettes to e‐cigarettes is not associated with lower risk of myocardial infarction than continuing to smoke; complete cessation is the only way to reduce risk of myocardial infarction. These results are unlikely becauseof reverse causality, where smokers who had myocardial infarctions started using e‐cigarettes in an effort to quit smoking. What Are the Clinical Implications? E‐cigarettes should not be promoted or prescribed as a less risky alternative to combustible cigarettes and should not be recommended for smoking cessation among people with or at risk of myocardial infarction. Introduction Cardiovascular disease is the leading cause of death in the United States1 and tobacco smoking is a major modifiable risk factor for cardiovascular disease, including myocardial infarction.2 The risk of myocardial infarction is 2‐ to 5‐fold higher among young smokers compared with never smokers,2, 3 with a non‐linear dose‐response curve with even the low levels of exposure associated with smoking a single cigarette a day4 or breathing secondhand smoke conferring substantial risk.5 E‐cigarettes are promoted as a smoking cessation device and less dangerous way to self‐administer nicotine than conventional cigarettes6, 7 and people with cardiovascular disease are using e‐cigarettes as a smoking cessation aid.8 Like conventional cigarettes, e‐cigarettes deliver nicotine as an inhaled aerosol of nicotine and ultrafine particles.9 Fine particles increase cardiovascular risk.10 E‐cigarettes and combustible cigarettes have similar effects on endothelial function which increases the risk of cardiovascular disease.11, 12, 13, 14, 15 E‐cigarettes increase oxidative stress and the release of inflammatory mediators,11, 16 induce platelet activation, aggregation, and adhesion17 and alters cardiovascular function in mice.18, 19, 20 Acute exposure to electronic cigarettes with nicotine increases aortic stiffness21 and cardiac sympathetic tone (reflected in heart rate variability) in a way associated with increased cardiac risk.13 Nevertheless, the 2018 National Academies of Science, Engineering, and Medicine report Public Health Consequences of E‐Cigarettes22 observed that “there are no epidemiological studies evaluating clinical outcomes such as coronary heart disease …. This lack of data on e‐cigarettes and clinical and subclinical atherosclerotic outcomes represents a major research need.” Since then, 2 studies, 1 using data from the National Health Interview Survey23 and another using data from the Behavioral Risk Factors Surveillance Survey,24 found cross‐sectional associations between e‐cigarette use and having had a myocardial infarction among daily e‐cigarette users controlling for cigarette smoking and other risk factors. Nevertheless, this finding remains controversial, because of concerns about reverse causality based on the possibility that after having a myocardial infarction smokers switched to e‐cigarettes, which would induce a spurious association between e‐cigarette use and myocardial infarction.25, 26 We use the Population Assessment of Tobacco and Health27 (PATH) data set to test for the relationship between e‐cigarette use and myocardial infarction, controlling for cigarette use, demographic and clinical variables and use the longitudinal data from PATH to test the reverse causality hypothesis. Methods Study Population and Design We used PATH Waves 1 and 2 (Figure S1), a nationally representative population‐based longitudinal cohort study to collect data on uses of tobacco products, health outcomes, risk perception, and attitudes.27 The restricted use PATH data set is available at the University of Michigan National Addiction & HIV Data Archive Program.28 The Wave 1 data set contained 32 320 adults aged ≥18 years and 28 362 adults in Wave 2, of whom 26 447 completed a Wave 1 interview. Wave 1 data were collected from September 2013 to December 2014 and Wave 2 data were collected 1 year later (from October 2014 to October 2015). PATH uses a 4‐stage stratified probability sample technique. The weighted response rate at Wave 1 household screener was 54.0%; among screened households, overall weighted response rate at Wave 1 adult interview was 74.0%. The weighted retention rate for continuing adult at Wave 2 was 83.1%, and the weighted recruitment rate including youth aged <18 years at Wave 1 and ≥18 years (and so counted as adults at Wave 2) was 85.7%.28 Informed consent was obtained by PATH. The University of California San Francisco (UCSF) Committee on Human Research approved this study. Outcome Variables Wave 1: Participants who responded “Yes” to the question “Has a doctor, nurse, or other health professional ever told you that you had a heart attack (myocardial infarction)?” were considered as having had a myocardial infarction. Wave 2: Participants who responded “Yes” to the question “In the past 12 months, has a doctor, nurse, or other health professional told you that you had a heart attack (myocardial infarction)?” were considered as having had a myocardial infarction. Independent Variables Electronic cigarette use Respondents who reported that they have ever used e‐cigarettes, have used fairly regularly, and currently use every day were classified as “Every‐day users.” Respondents who reported that they have ever used e‐cigarettes, have used fairly regularly, and currently use some days were considered as “Some‐day users.” Respondents who reported that they have ever used e‐cigarettes and currently do not use them were considered “Former users.” Respondents who reported that they have never used e‐cigarettes, even once or twice were considered “Never users.” Current experimental e‐cigarette users (current e‐cigarette users but never used e‐cigarettes fairly regularly) were not included in the main analysis but were considered some‐day users in a sensitivity analysis. Cigarette smoking Respondents who reported that they smoked at least 100 cigarettes in their lifetime and currently smoke every day were classified as “Every‐day smokers.” Respondents who reported that they smoked at least 100 cigarettes in their lifetime and currently smoke some days were classified as “Some‐day smokers.” Respondents who ever smoked cigarettes and have not smoked in the past 12 months or currently do not smoke at all were classified as “Former smokers.” Respondents who reported that they have never smoked a cigarette, even 1 or 2 puffs were classified as “Never smokers.” Respondents who were current smokers but who had not smoked 100 cigarettes (experimental smokers) were excluded from the main analysis, but included in a sensitivity analysis as some‐day smokers. Demographic variables Demographic variables were assessed at Wave 1: age, body mass index (BMI), sex (men or women), race/ethnicity (white, black, Asian, and others), poverty level/income (below poverty: <100% of poverty line, at or above poverty: ≥100% of poverty line [poverty was calculated using this formula: [effective family income]/[poverty guideline]×100=family income as a percentage of the household size poverty guideline.]) and education. Clinical variables Wave 1: Respondents who answered “Yes” to the question “Has a doctor, nurse, or other health professional ever told you that you had a high blood pressure?” were considered as having “high blood pressure.” Respondents who answered “Yes” to the question “Has a doctor, nurse or other health professional ever told you that you had a high cholesterol?” were considered as having “high cholesterol.” Respondents who answered “Yes” to the question “Has a doctor, nurse, or other health professional ever told you that you had a diabetes, sugar diabetes, high blood sugar, or borderline diabetes?” were considered as having “diabetes mellitus.” Wave 2: Respondents who answered “Yes” to the question “In the past 12 months, has a doctor, nurse or other health professional told you that you had a high blood pressure?” were considered as having “high blood pressure.” Respondents who answered “Yes” to the question “In the past 12 months, has a doctor, nurse, or other health professional told you that you had a high cholesterol?” were considered as having “high cholesterol”. Respondents who answered “Yes” to the question “In the past 12 months, has a doctor, nurse, or other health professional told you that you had a diabetes, sugar diabetes, high blood sugar, or borderline diabetes?” were considered as having “diabetes mellitus.” Analysis We calculated weighted estimates of e‐cigarette and cigarette use and clinical and demographic variables at Wave 1 for the overall sample. We used Wave 1 sampling weights for analysis of Wave 1 and Wave 2 sampling weights for analysis of Wave 228 accounting for the complex survey design for all the outcomes.29 Multivariable logistic regressions were performed to examine the associations between e‐cigarette use (former, some day and every day) and myocardial infarction at Wave 1 controlling for cigarette smoking (former, some day and every day), age, BMI, sex, poverty level, race/ethnicity, education, and clinical variables. We tested for interaction between e‐cigarette use and cigarette smoking in a logistic regression by combining some‐day and every‐day users into “current e‐cigarette use” and “current smoking,” then ran the logistic regression with these variables, their interaction, and the demographic and clinical variables. The P value for the interaction was 0.671. Likewise, we analyzed interaction for “former e‐cigarette use” and “former smoking”, and P value for this model was 0.192. As a result, interaction terms were omitted from the remaining analysis. We tested for dose‐response by replacing the categorical use variables with continuous variables (0=never, 1=former, 2=some day, 3=every day) in logistic regressions including the demographic and clinical variables. We assessed the possibility of reverse causality accounting for the observed association between having had a myocardial infarction at Wave 1 being due to people who had a myocardial infarction preferentially trying to quit smoking with e‐cigarettes. Specifically, we used logistic regression to predict every day e‐cigarette use at Wave 2 as a function of having had a myocardial infarction at Wave 1 adjusting for age, BMI, sex, poverty level, and race/ethnicity among only every day, and only current (every day and some day) cigarette smoker at Wave 1 (excluding all e‐cigarette users) as well as in the entire longitudinal sample. We used “survey package” in R software for statistical analyses. Results Table 1 shows the descriptive statistics at Wave 1 baseline; 643 (2.4%) adults reported that they had a myocardial infarction. Table 2 shows the descriptive statistics stratified by myocardial infarction status at Wave 1 and first myocardial infarctions between Waves 1, 2, and 3 and Table S1 shows the descriptive statistics stratified by e‐cigarette use at Wave 1. Among the adults who had myocardial infarctions as of Wave 1, 10.2% reported that they were former e‐cigarette users, 1.6% were some‐day e‐cigarette users and 1.5% were every‐day e‐cigarette users, 58.8% adults reported that they were former cigarette smokers, 3.4% were some‐day cigarette smokers and 20.4% were every‐day cigarette smokers. The number of e‐cigarette users who had first myocardial infarctions between Waves 1 and 2 (only 6 some‐day and 2 every‐day e‐cigarette users) and Waves 2 and 3 (only 1 some‐day and 3 every‐day e‐cigarette users) was small, so, as required by PATH reporting rules, we combined some‐day and every‐day e‐cigarette users in Table 2 for the first myocardial infarction between Waves 1 and 2, and Waves 2 and 3. As expected, any cigarette smoking, age, BMI, sex, poverty level, education, and high blood pressure, high cholesterol, and diabetes mellitus were significantly associated with increased risk of myocardial infarction. There was a significant dose‐response for both e‐cigarette use (P<0.0005) and smoking (P=0.019) and myocardial infarction controlling for demographic and clinical variables (detailed results not shown). The longitudinal analysis did not reveal any statistically significant associations between e‐cigarette use at Wave 1 and having had a first myocardial infarction by Wave 2, perhaps because of the small numbers of first myocardial infarctions in e‐cigarette users between Waves 1 and 2 (Table S2). Daily cigarette smoking was also not significantly associated with having had a first myocardial infarction at Wave 2. The sensitivity analysis including current experimental e‐cigarette user with some‐day e‐cigarette user and current experimental cigarette smokers with some‐day cigarette smokers yielded similar results as the main analysis (Table S3). Reverse Causality There were 1990 respondents who started using e‐cigarettes between Waves 1 and 2 (Table 4). Having had a myocardial infarction at Wave 1 did not predict every‐day e‐cigarette use at Wave 2 among overall follow‐up sample (P=0.687), every‐day cigarette smokers at Wave 1 (P=0.675), or current cigarette smokers at Wave 1 (P=0.634), adjusting for demographic and clinical variables. Similar results were obtained for any e‐cigarette use (every day or some day) at Wave 2 (Table S4). Click here to see tables Discussion This study confirms earlier23, 24 findings that e‐cigarette use is an independent risk factor for having had a myocardial infarction controlling for cigarette smoking, demographic and clinical risk factors. The magnitudes of the effects in this study are similar to the updated analysis by Alzahrani and Glantz30 using the 2014, 2015, and 2016 from the National Health Interview Survey (some‐day e‐cigarette user [odds ratio: 1.99, 95% CI: 1.11–3.58 in this study versus 1.49: 1.08–2.09 in Alzahrani et al] and every‐day e‐cigarette user [2.25: 1.23–4.11 versus 2.14: 1.41–3.25]). Odds of myocardial infarction among former e‐cigarette users are not significantly elevated in either study. The increased odds of myocardial infarction are similarly and significantly associated with smoking in both studies, with higher estimates in the present study (former [1.48: 1.01–2.15 versus 1.70: 1.51–1.91], some day [2.38: 1.40–4.06 versus 2.36; 1.80–3.09] and every day [2.95: 1.91–4.56 versus 2.72: 2.29–3.24]). Vindhyal et al31 reported that e‐cigarette use is significantly associated with MI (odds ratio [OR] 1.56 [1.45–1.68]), stroke (OR 1.30 [1.20–1.40]), and circulatory problems (OR 1.44 [1.25–1.65]) using the 2014, 2016, and 2017 National Health Interview Survey. Ndunda and Muutu24 found that compared with non‐users, e‐cigarette users (without specifying frequency of use, but controlling for smoking and other risk factors) the odds of having had a myocardial infarction (OR 1.59 [1.53–1.66]) that was lower than in this study, although the CIs overlapped. They also found higher risks for angina or coronary heart disease (OR 1.4 [1.35–1.46]) and stroke (OR 1.71 [1.64–1.8]) using 2016 Behavioral Risk Factor Surveillance System. Both the present and earlier23, 24 results are based on cross‐sectional analysis, which raises the possibility of reverse causality,25, 26 specifically that after having had a myocardial infarction people might preferentially attempt to quit smoking using e‐cigarettes. In a cross‐sectional analysis of the National Health Interview Survey, Stokes et al8 reported that individuals with cardiovascular disease who recently quit smoking or recently attempt to quit were more likely to use e‐cigarettes than those who did not report a recent quit attempt, which may indicate that e‐cigarettes were being used for smoking cessation. We used the longitudinal data in PATH to test directly for reverse causality by testing whether having had a myocardial infarction at Wave 1 predicted e‐cigarette use at Wave 2 among people who were cigarette smokers at Wave 1 (Table 4). The results did not approach statistical significance (P>0.62 for all outcomes), strongly suggesting that reverse causality is not an issue. In addition, the presence of a statistically significant dose‐response is consistent with a causal effect. Our results on the lack of reverse causality are consistent with Gaalema et al32 who concluded based on longitudinal analysis of the first 2 waves of PATH, that having a myocardial infarction was not a significant predictor of initiating non‐combusted tobacco (mostly e‐cigarettes) use (P=0.20). Furthermore, they found, “cardiac status was significantly negatively associated with switching completely from combusted to non‐combusted products. While 9.2% of those with no change in health status switched (from combusted tobacco, mostly cigarettes) to non‐combusted use, none of those experiencing a new MI switched (P=0.0015).” Thus, any differential misclassification is in the direction opposite to what would be required for reverse causality to explain our results, which strengthens our conclusion that e‐cigarette use is associated with the risk of having had an MI. Our finding is also consistent with Alzahrani et al's26 cross‐sectional analysis of reverse causality using the National Health Interview Survey, which found a non‐significant association between MI and e‐cigarette use when controlling for covariates. Like Alzahrani et al,23, 30 we found that the increased odds of having had a myocardial infarction associated with e‐cigarette use were independent of the increased odds associated with smoking. This result means that dual use of e‐cigarettes and conventional cigarettes, the most common use pattern for e‐cigarette users, is more dangerous than use of either product alone (69% of current e‐cigarette users were also smoking cigarettes in our sample at Wave 1, which is similar to the 70% Stokes et al8 reported among people with cardiovascular disease in the National Health Interview Survey). For example, the total odds of having had a myocardial infarction among every‐day cigarette smokers who also use e‐cigarettes every day (dual users)—the most common use pattern (Table 1)—is (odds of myocardial infarction among every‐day smokers)×(odds of myocardial infarction among every‐day e‐cigarette user)=2.95×2.25=6.64 compared with a never cigarette smoker who has never used e‐cigarettes (which is similar from additional regression analysis estimating the effect directly, Adjusted Odds Ratio (AOR): 5.06, 95% CI: 1.99–12.83, Table S5). Odds of having had a myocardial infarction for individuals who switched from every‐day combustible cigarette smoking to every‐day e‐cigarette use would change by a factor of ([odds of myocardial infarction among former combustible cigarette smokers]×[odds of myocardial infarction among every‐day e‐cigarette user])/(odds of myocardial infarction among every‐day combustible cigarette smoker)=3.33/2.95=1.13, which is virtually no benefit in terms of myocardial infarction risk. More importantly, the total odds of having had a myocardial infarction for an individual who switched from every‐day combustible cigarette smoking to every‐day e‐cigarette use compared with quitting smoking would be ([odds of myocardial infarction among former smokers]×[odds of myocardial infarction among every‐day e‐cigarette user])/(odds of myocardial infarction among former cigarette smokers)=(1.48×2.25)/1.48=2.25. As discussed above, we cannot infer temporality from the cross‐sectional finding that e‐cigarette use is associated with having had an MI and it is possible that first MIs occurred before e‐cigarette use. PATH Wave 1 was conducted in 2013 to 2014, only a few years after e‐cigarettes started gaining popularity on the US market around 2007. To address this problem we used the PATH questions “How old were you when you were first told you had a heart attack (also called a myocardial infarction) or needed bypass surgery?” and the age when respondents started using e‐cigarettes and cigarettes (1) for the very first time, (2) fairly regularly, and (3) every day. We used current age and age of first MI to select only those people who had their first MIs at or after 2007 (Table S6). While the point estimates for the e‐cigarette effects (as well as other variables) remained about the same as for the entire sample, these estimates were no longer statistically significant because of a small number of MIs among e‐cigarette users after 2007. Note that this analysis does not capture reinfarctions occurring after 2007, whose risk could be increased by e‐cigarette use as it is for continued smoking conventional cigarettes.33, 34 One could argue that the cleanest study would have been one that only examined the association of sole e‐cigarette use with myocardial infarction. In contrast, most e‐cigarette users are dual users with cigarettes so it is important to study the effects of e‐cigarette use simultaneously with cigarette use. Our analysis quantified the additional risk of MI associated with e‐cigarette use in addition to cigarette smoking among dual users. Limiting the analysis to sole e‐cigarette users would not only be less clinically relevant, but would substantially reduce the sample size and the power of the analysis to detect an effect. Limitations While PATH is a longitudinal study, there were only 8 people who used e‐cigarettes and had first myocardial infarctions during this follow‐up, so there was not enough power to detect an effect. Confirming this problem, every‐day and former‐conventional cigarette smoking were not significant either. While longitudinal studies are more desirable than cross‐sectional studies, the reality is that it will be years before enough myocardial infarctions have occurred to do a meaningful analysis. In the meantime, millions of people are using e‐cigarettes and clinicians are being asked about them and this cross‐sectional analysis can be used to inform decision making about these products. Response for both e‐cigarette and combustible cigarette use were self‐reported, which could lead to recall bias. Participants with myocardial infarction might over‐report e‐cigarette and cigarette use, but previous work found that compared with biochemical monitoring with cotinine levels, self‐reporting in myocardial infarction survivors tended to understate the prevalence of smoking.35 Myocardial infarction was self‐reported which also could lead recall bias, but the questions “Has a doctor, nurse, or other health professional ever told you that you had a heart attack (myocardial infarction)?” and “In the past 12 months, has a doctor, nurse, or other health professional told you that you had a heart attack (myocardial infarction)?” have been found to have high agreement (81%–98%) with medical records.36, 37 Other possible risk factors including family history of myocardial infarction, angina, and heavy alcohol use are not available in the PATH data set. There is no information on the duration since smoking or e‐cigarette cessation. In the main analysis, it also is unknown whether the reported myocardial infarction occurred before or after the respondents’ initiated e‐cigarettes and cigarettes use. Conclusions As one would expect based on what is known about the biological effects of e‐cigarette use, in the cross‐sectional analysis some‐day and every‐day e‐cigarette use is associated with increased risk for having myocardial infarction, adjusted for combustible cigarette smoking, demographic and clinical variables. This result is unlikely because of reverse causality. Former, some‐day, and every‐day combustible cigarette smoking is also independently associated with myocardial infarction among adults in the United States. Dual use of the e‐cigarette and combustible cigarettes results in higher risk of myocardial infarction than using either product alone and switching from cigarettes to e‐cigarettes was not associated with any benefits in terms of reduced myocardial infarction risk. E‐cigarettes should not be promoted or prescribed as a less risky alternative to combustible cigarettes and should not be recommended for smoking cessation among people with or at risk of myocardial infarction. Sources of Funding This work was supported by grants R01DA043950 from the National Institute on Drug Abuse, P50CA180890 from the National Cancer Institute and the Food and Drug Administration Center for Tobacco Products, U54HL147127 from the National Heart, Lung, and Blood Institute and the Food and Drug Administration Center for Tobacco Products, and the University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center Global Cancer Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of National Institutes of Health or the Food and Drug Administration. The funding agencies played no role in study design, collection, analysis, and interpretation of data, writing the report, or the decision to submit for publication. Disclosures None. Footnotes *Correspondence to: Stanton A. Glantz, PhD, Center for Tobacco Control Research and Education, University of California, San Francisco, 530 Parnassus Ave, Suite 366, San Francisco, CA 94143‐1390. E‐mail: stanton.glantz@ucsf.edu

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Nope!

Congratulations!!!! I guess were busy!!

Two New Videos: Contrary to what you may have heard—vaping is not safe Sleep disruptions and adjustments after quitting smoking

Well, nihilism sure isn't a help in keeping your quit. Thoughts of joining other smokers are the same as other thoughts that enter our minds that we must push right back out. We can't control which thoughts pop into our heads but we do have a choice on acting upon them.

Set a goal of three days without smoking. Whenever you get the urge to smoke, quickly shift your focus onto something else because the crave will go away in a few minutes. I think your mind is your own worst enemy right now. How much of the educational material and videos have you read/watched on this site? Immerse yourself into this and learn about this drug addiction because once you do, you're armed with the knowledge never take another puff.

Nope

Good to see ya!!!!

Last night I upgraded to the latest version which is supposed to fix this issue (along with some other ones). We'll see...

I just checked the program and there's an error with the way the emails are being sent. I'll let Rixcz know so he can fix it. Sorry for the inconvenience.

Doreen, I'm so sorry, my friend. I can't imagine what you must be feeling. I'm here for you, whatever you need.