The Case

A 49-year-old woman was admitted for an exacerbation of chronic obstructive pulmonary disease (COPD) without any signs of infection. Her baseline oxygen requirement at home was 2 liters via nasal cannula, and she used a continuous positive airway pressure (CPAP) machine at night; however, her machine stopped working prior to the hospitalization. Throughout her hospital stay, the patient continued to require 5 liters of oxygen by nasal cannula.

When asked about her smoking history, the patient reported receiving smoking cessation education in the past and that she no longer smoked regular cigarettes, but she did continue to vape with an electronic cigarette (e-cigarette). Having not been told to avoid vaping in the hospital, the patient asked her friend to bring her e-cigarette so she could use it during her hospitalization.

The patient took a puff on the e-cigarette while she was receiving oxygen through her nasal cannula and sparked an explosion. The patient ripped off the nasal cannula, which had melted, and sustained first- and second-degree burns to her face and hand. This resulted in a prolonged hospitalization for burn care and extensive pain management. In addition, the facial burns made it difficult for her to use CPAP as she had been doing at home.

The exact type of e-cigarette the patient used was not known. It did contain a heating element to vaporize the e-liquid, but it is unclear which piece of the device triggered the explosion. Regardless, the vendor who sold the e-cigarette to the patient stated it was safe to use while on oxygen.

The Commentary

by Neal L. Benowitz, MD

This case, of a woman who sustained burn injuries from using an electronic cigarette (e-cigarette) in the hospital, represents an unusual safety hazard of e-cigarettes. There is considerable debate about the impact of e-cigarettes on public health, but many smokers are using them to reduce or substitute cigarette smoking. In 2017, 6.9 million (2.8%) Americans aged 18 or older used e-cigarettes regularly or occasionally.(1) This discussion will explore the benefits and potential harms of e-cigarette use and how to address e-cigarette use in a hospitalized patient.

Electronic cigarettes are devices that employ a battery to heat a coil, which heats a liquid (usually containing nicotine) to generate an aerosol that is inhaled by the user (vaper).(2) There are many types of e-cigarette devices, which can look like cigarettes, pens, pipes, USB drives, or other shapes. Their features also vary. Some devices have relatively low voltage batteries and temperature-controlled heating; others have variable and higher voltage batteries that can produce high temperatures. Some e-cigarettes are disposable; many are rechargeable. And some are made by large companies with good quality control, others by small companies with marginal quality control.

The public health appeal of e-cigarettes comes from the fact that the great majority of harms from cigarette smoking derive from products of tobacco combustion. Nicotine is not necessarily safe, but alone it is less harmful than cigarette smoking. Nicotine replacement therapy (NRT) is commonly used to aid cessation and may be used long term if necessary. However, it has been long recognized that inhaling nicotine provides high levels of nicotine to the brain that promote nicotine-related satisfaction and addiction; existing NRT options do not provide such delivery. The idea of finding a noncombustible delivery system for nicotine as a substitute for smoking has been discussed in scientific circles for more than 30 years. When e-cigarettes were introduced about 10 years ago, it was hoped that the device would provide the same nicotine satisfaction as a cigarette and thus be able to compete with cigarettes so smokers would quit smoking.

The controversy surrounding e-cigarettes is the question of whether their benefits outweigh their risks. The potential benefits are to reduce harm from cigarette smoking by aiding quitting or replacing smoking with a less harmful nicotine delivery system.(3,4) The potential risks include unknown long-term adverse effects of e-cigarette use on health (including exploding batteries), reduction in tobacco cessation by providing a form of nicotine that can be used in places where smoking cigarettes is prohibited, and creating nicotine addiction among users who had never smoked, possibly serving as a gateway to cigarette smoking among adolescents and young adults.(5)

The public health positions on this debate vary considerably by country. For example, the United States public health community has generally discouraged e-cigarette use, while the United Kingdom (UK) has embraced tobacco harm reduction using e-cigarettes as part of their national tobacco control program.(6) A 2018 Public Health England report estimated that 22,000 to 57,000 long-term cigarette quitters each year have done so in the setting of e-cigarette use, far more than have quit using NRT or other forms of pharmacotherapy.(6) Regardless of location, however, no health care provider wants a smoker who has quit smoking to relapse. All of this leads to the question of what to do with hospitalized former smokers who want to use e-cigarettes in order to not start smoking cigarettes again.

This case involves a woman with severe COPD, receiving home oxygen, who is hospitalized with respiratory failure. Most COPD is caused by smoking and most smokers with COPD are highly nicotine dependent. This patient had quit smoking using e-cigarettes, and it is important to do whatever can be done to support her smoking cessation and prevent relapse. While there are some concerns about adverse respiratory effects of inhaled e-cigarette vapor (7), studies have reported that people with asthma and COPD who switch from cigarettes to e-cigarettes enjoy improved pulmonary function and quality of life.(8,9) Understandably, this highly addicted former smoker wanted to use her e-cigarette in the hospital. Unfortunately, the result was an explosion ignited by the e-cigarette in the presence of medical oxygen, resulting in severe burns. It is not known what type of e-cigarette was used by this patient, but the type of product is relevant to the potential risk of igniting a fire. There are many types of devices and batteries, and quality of batteries can vary. Numerous reports have emerged of fires and explosions caused by e-cigarettes, some resulting in severe injuries.(10) Most of these explosions are due to defective batteries or the process of recharging lithium ion batteries.

However, the use of any ignition source in the presence of oxygen is potentially hazardous. This issue was addressed specifically by the British Compressed Gases Association, which stated, "Electronic cigarettes are … a potential ignition source and, in the context of oxygen-rich environments, have the same fire risks as traditional cigarettes."(11) This opinion was supported by the Electronic Cigarettes Industry Trade Association, which agreed that in the context of oxygen use, "it would be appropriate to describe electronic cigarette use as similarly hazardous to smoking."(11) Furthermore they suggest that if a patient needs oxygen, a nonheated source of nicotine such as NRT be considered. In light of these statements, banning e-cigarette use in presence of medical oxygen should be the policy in every hospital.

A broader issue is what the policy should be about the use of e-cigarettes in hospitals as well as in other facilities, such as assisted living and nursing facilities. In many states and cities in the US, the use of e-cigarettes is prohibited wherever smoking tobacco is not allowed, which would include hospitals and health care facilities. One research group surveyed 75 hospitals in North Carolina and found that 80% had an e-cigarette policy in place, and most incorporated their e-cigarette policies into existing tobacco-free policies.(12) The rationale for incorporating e-cigarettes into existing smoke-free laws and policies comes from enforcement challenges due to difficulty distinguishing e-cigarette use from smoking (mostly a problem with cigarette-like disposable devices), avoiding renormalization of smoking-type behaviors, and concern about harm from secondhand emissions. With respect to the latter, secondhand emission from e-cigarettes are far lower than those from cigarettes.(13) Most of the secondhand smoke from cigarettes comes while the cigarette is smoldering, and e-cigarettes do not smolder. The amount of secondhand emissions from e-cigarettes depends on the vaping behavior of the individual. While nicotine levels in homes of vapers is generally low, substantial environmental contamination with nicotine and particles has been documented in some public places where much vaping is occurring, such as at vaping conventions.(14) Given the relatively low emissions, it is likely that harm from secondhand exposure to e-cigarette emissions is low, but no research on such health effects is available at this time.

The approach toward e-cigarette use in hospital in the UK has been quite different. National Health Service hospitals must be cigarette smoke-free, but these policies do not include e-cigarettes. Public Health England recommendations include the use of e-cigarettes to support tobacco control policies.(6) Individual hospitals may develop their own policies. Some hospitals allow e-cigarette use in individual patient rooms, but not in common rooms. Others do not permit use in hospital buildings, but do permit use on hospital grounds. In hospitals that permit inpatient use, patients are not permitted to recharge e-cigarettes due to fire concerns; recharging must be done by nursing staff or done at home by families. Some policies may even allow only non-rechargeable devices and/or prohibit users from refilling devices with e-cigarette liquids, requiring use of prefilled devices. Disposal of non-rechargeable devices must also be managed by providing specified bins for collection of batteries. The extra work required to allow e-cigarette use in hospital is considerable, but it is thought to be warranted by the overarching commitment to tobacco harm reduction. An example of a guidance for e-cigarette use in hospital is that from Homerton University Hospital, London.(15)

Another potential issue with e-cigarette use in medical facilities is safety among people with impaired cognitive function, such as in assisted living or nursing facilities. If a smoke-free policy does not cover e-cigarette use, the individual facility must decide how to ensure safety of e-cigarette use. Impaired cognitive function could lead to misuse of devices and chargers, increasing the risks of fires as well as problems with spills or inappropriate exposure to e-cigarette liquid solutions containing nicotine (such as mistaking refill bottle for eye drops, etc.). Due to the difficulty of developing criteria for use by individual clients who are competent, facilities with significant numbers of cognitively impaired residents might want to consider encouraging all e-cigarette users to switch to NRT—perhaps nicotine inhalers, which provide a similar hand-to-mouth experience as e-cigarette use.

In summary, this case describes a serious injury due to use of an e-cigarette, a known ignition source, in the presence of medical oxygen. Electronic cigarette use should be uniformly prohibited in such environments. The use of e-cigarettes in hospitals is controversial, with different policies in different countries, and in different hospitals within countries. In the United States, most hospitals have prohibited e-cigarette use among inpatients. If that is the policy, then providing effective NRT is important to keep patients comfortable and reduce the risk of relapse to smoking after discharge. In hospitals that do permit e-cigarette use, specific safety measures need to be in place to address proper recharging of batteries, handling of refill liquids, and disposal of non-rechargeable batteries. Particular attention must be paid to patients with impaired cognitive function, in whom accidents involving e-cigarettes are more likely to occur.

Take-Home Points

• While considerable public health debate surrounds the benefits and risks of electronic cigarette (e-cigarette) use, many former smokers have switched to e-cigarettes in order to stop cigarette smoking. Keeping those former smokers from relapsing to smoking is a priority of good medical care.
• Electronic cigarette devices are quite variable with respect to appearance, delivery of nicotine and other toxicants, and risk of explosion or fire.
• The use of e-cigarettes in the presence of medical oxygen is potentially hazardous and should be banned in every hospital.
• Most hospitals in the United States include e-cigarettes in smoke-free policies that were developed for cigarette smoking. However, that is not the policy in all countries. Some hospitals in the United Kingdom permit e-cigarette use, under careful supervision.
• Where smoke-free policies include banning the use of e-cigarettes, all cigarette smokers and e-cigarette users should be offered effective nicotine medication to prevent nicotine withdrawal symptoms while in hospital.

Neal L. Benowitz, MD
Professor
Departments of Medicine and Biopharmaceutical Sciences
Division of Clinical Pharmacology and Experimental Therapeutics
University of California, San Francisco
Zuckerberg San Francisco General Hospital
San Francisco, CA

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