Last month, a patient arrived in our ER after having tried a friend’s vape. They’d used it several times before, but this time they became lightheaded, unsteady, and entered an extended convulsive episode. It was the patient’s first seizure ever, which was also accompanied by severe muscle and kidney damage.
There’s nationwide concern over vaping-related lung injuries and the teen vaping epidemic. In recent months, e-cigarette company JUUL announced it would stop selling its flavored e-cigarette pods, and there’s an expected announcement coming from the FDA about a federal ban of flavored vapes. The injuries and the resounding lack of public information on the potential health effects of e-cigarettes have led to a number of lawsuits accusing vape company JUUL of wrongful deaths and endangering young people. While most of the attention has gone to“e-cigarette or vaping product use-associated lung injuries,” or EVALIs, a recent case at our institution, the Perelman School of Medicine at the Hospital of the University of Pennsylvania, and other hospitals across the nation, highlights another potential effect of vaping: seizures.
The above story is one of nearly 150 cases of vaping-related seizures reported to the Food and Drug Administration (FDA) as of July. With almost 1,500 reported injuries and at least 30 deaths associated with e-cigarette injuries, there is strong evidence of a causal relationship between the use of vapes and lung damage. But the public has heard less about the other health impacts associated with vaping, including seizures like the one seen in our patient. Reports describe seizures that happened while driving, while showering, or in one case, that left a victim passed out in sub-zero temperatures for hours. Some case descriptions are limited to tremors or fainting, while others describe extended convulsions like the one our patient experienced. While not formally reported, similar cases have been described online.
At this point, leading theories as to the cause of these seizures center on the addictive drug in vapes: nicotine, the same addictive chemical in tobacco. For years, nicotine has been known to cause seizures in high doses, including in tobacco workers and toddlers who consume e-cigarette fluid accidentally. It’s possible that the cases reported to the FDA may similarly be caused by nicotine overdose, especially given that vape pods contain the same amount of nicotine as an entire pack of cigarettes. However, with so few cases of these e-cigarette-associated seizures, it’s difficult to confidently assess how much vaping contributes to the reported seizures. Even with the growing number of cases of EVALI, the underlying cause of these illnesses remains unknown. Despite this lack of information about the safety of e-cigarettes, Americans continue to increasingly use these devices—now more than traditional cigarettes among young adults, according to the surgeon general—and new health effects are only recently being identified.
While e-cigarettes have been found to help some smokers quit traditional cigarettes, they can also be a gateway for non-smokers to take up the habit. This is particularly the case among grade-schoolers and young adults, where the overall use of e-cigarettes has steadily increased in step with a simultaneous increase in e-cigarette marketing efforts. What’s more, these kids don’t even understand what they are consuming. In a 2018 survey of more than 1,000 e-cigarette users between 15 and 24, a majority of respondents were not aware that the product contains nicotine. Altogether, these findings suggest that the success of e-cigarettes can be attributed to a combination of a lack of regulation, support from big tobacco corporations, and an unawareness of the contents of e-cigarettes, especially among those most vulnerable to becoming addicted to nicotine: adolescents and young adults.
The mysterious injuries associated with vapes are only the most recent in a long history of unexpected and, at times, fatal consequences of poorly regulated or understudied products. Perhaps the largest example of a harmful product promoted by successful marketing would be cigarettes, whose history is eerily similar to today’s vape industry. Tobacco companies enjoyed progressive growth of their consumer base for nearly 60 years, starting in the 1880s with the creation of the electric cigarette roller. It wasn’t until the middle of the 20th century that researchers began to identify a relationship between tobacco smoking and lung disease.
Not unlike what we’re seeing with e-cigarettes today, tobacco companies fought hard to undermine claims of the harms of cigarettes. In the decades since these harms were first identified, the tobacco industry has continued to spend billions of dollars on targeted advertising towards women, people of color, and youth to contest the proven negative health effects of smoking, including coronary artery disease and stroke in addition to various types of cancer. Representing an opportunity to expand their consumer base with relatively limited regulation, e-cigarettes may just be the latest installment in big tobacco’s efforts to increase the consumption of nicotine products.
The way things look, the vaping companies seem doomed to repeat similarly harmful actions of the traditional cigarette companies. In general, consumers should consult their doctors before trying a new product that goes in or on their body, and doctors should continue to be vocal when their patients are using a new product that lacks sufficient evidence to be considered safe.
Importantly, as seen with traditional cigarettes, it may take decades before the health effects of these products become clear, and consumers should be hesitant to adopt new practices or products before a strong evidence base has been provided to support safety claims. Because so much remains unknown about vaping, including any related injuries and the potential for long-term damage, it might be safer to just avoid using vapes until they are better understood. To help researchers identify any previously unknown side effects of a new product, we should all report any suspected adverse reactions to the FDA. With a larger number of thorough reports, it is easier and more reliable to determine whether a side effect—like a seizure—is caused by products like e-cigarettes or components of these products, like individual batches of vape pods. This information can help medical professionals treat these conditions and prevent them from occurring altogether.
Ramie Fathy is a medical student in the Perelman School of Medicine at the University of Pennsylvania. Nilan Schnure is a senior resident in Internal Medicine at the Perelman School of Medicine at the University of Pennsylvania. The opinions expressed in this article do not represent those of the University of Pennsylvania Health System or the Perelman School of Medicine.