Current status of tobacco use, cessation and control policy in Korea.

Background: Tobacco use is a leading cause of countless deaths and disabilities worldwide. An estimated 11 million Korean adults were still using tobacco in 2020, according to the Korea National Health and Nutrition Examination Survey. This review aims to explain the current trends in tobacco use, sales, cessation, and control policies in South Korea. Current Concepts: Heated tobacco products (HTPs), a hybrid between conventional and electronic cigarettes, were first launched in South Korea in June 2017. Advertisements stating that HTPs are odorless, tar-free, and less harmful to health have caused sales of HTPs to grow quickly over the past 5 years, such that they account for about 15% of the total tobacco market. According to national smoking rate statistics and tobacco sales trends, declines in current smoking rates have slowed and even risen in some groups, and declines in total tobacco sales have slowed but also risen again during the coronavirus 19 pandemic. In addition, the number of visitors to smoking cessation clinics decreased just after the advent of HTPs and social distancing policies triggered by the coronavirus. Nicotine replacement therapy can serve as a drug therapy for smoking cessation, or bupropion and varenicline can be prescribed. Korea's representative tobacco control policies include the tax increase policy, non-smoking area policy, cigarette pack warning picture policy, and support policy for visiting smoking cessation clinics. Discussion and Conclusion(s): There is a pressing need to reflect tobacco control policies in line with changes in tobacco user behaviors and tobacco company marketing strategies.Copyright © Korean Medical Association.

Lung injury associated with an e-cigarette (vaping) use during the COVID-19 pandemic

In recent years, the excessive use of electronic cigarettes (e-cigarettes), and vaping, as a re-placement for traditional tobacco cigarettes, have highlighted potential health risks for users. One such risk is the development of "electronic cigarette (vaping) product use-associated lung injury" (EVALI). This type of lung injury has an unclear cause that may be related to the various components found in e-cigarette fluids. The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection (coronavirus disease . 2019 or COVID-19) may worsen EVALI symptoms in individuals with both conditions. This could be due to the increased oxidative stress and inflammation caused by e-cigarette use, as re-search shows increased levels of reactive oxygen species (ROS) and decreased glutathione. In this paper, we present two critical cases of COVID-19 patients with a history of chronic e-cigarette smoking and describe their clinical progression during hospitalization. The findings suggest that their prolonged use of e-cigarettes may have sig-nificantly impacted the severity of the disease.Copyright © 2023, The Indonesian Foundation of Critical Care Medicine. All rights reserved.

Oral epithelium response of electronic cigarette users to electronic cigarette.

BACKGROUND: Electronic cigarettes are increasing in popularity, but there is only little information on their biologic effects on the oral epithelium, the initial site exposed to electronic cigarette smoke. METHODS: We assessed the oral epithelium response to electronic cigarettes by comparing the histology and RNA transcriptome (mRNA and miRNA) of healthy electronic cigarette vapers to nonsmokers. mRNA was assessed based on: (1) genome-wide; (2) genes previously identified as dysregulated in the oral epithelium of electronic cigarette vapers versus nonsmokers; (3) immune and inflammatory-related genes previously identified as dysregulated in the nasal epithelium of electronic cigarette vapers compared to nonsmokers; (4) genes previously identified as dysregulated in the small airway epithelium of nonsmokers following an acute exposure to electronic cigarette; and (5) genes related to the initial steps of COVID-19 infection. In addition, miRNA was assessed genome-wide. Comparisons were performed using analysis of variance, and Benajmini-Hochberg corrected p < 0.05 was considered significant. RESULTS: The histology of the epithelium, lamina propria and basal layer in electronic cigarette vapers appeared normal. Assessment of mRNA and miRNA, based on all gene lists, did not identify any genes significantly modified in the oral epithelium of electronic cigarette vapers in response to electronic cigarette use. CONCLUSION: An average history of 2 years of vaping results in no detectable histologic or transcriptome abnormalities in the buccal mucosa.

Tobacco smoking and severity of COVID-19: Experience from ICU department in a referral hospital during the third pandemic wave

Aim: To investigate the association between tobacco smoking habits and severity and mortality of COVID-19 disease among ICU hospitalized patients. Material: Baseline sociodemographic, co-morbidities and clinical characteristics of 222 adult (70 women) COVID-19 hospitalized patients, aged 69+/-8yrs, mean ICU length of stay 35+/-12 days, were retrospectively collected and analyzed from 01/08/2020-01/08/2021. Also, information about caregivers' tobacco smoking behaviors were obtained. Result(s): 57 patients were current smokers (35+/-4 pack/yrs) and 61 ex-smokers(28+/-9pack/yrs). E-cigarette users were 18 patients (2 ex-smokers), dual users 22 (all current smokers). 37 continued to smoke up to hospital admission. Arterial hypertension (47/35) diabetes (44/24), betamuI>30 (22/34), coronary disease (40/22) and COPD (41/28) noted as main comorbidities in current smokers and ex-smokers. CT findings of pulmonary emphysema were detected in 31% of current and ex-smokers. 51% (113) of total patients died, aged 71+/-4 yrs, and ICU length of stay 40+/-15 days. Current smokers and ex-smokers were hospitalized in ICU for a longer period 29+/-7 days (p=0.001). APACHE II (48+/-8) and SOFA score (11+/-3) were higher in current smokers and ex-smokers (p=0.003). 53% of ICU patients had a family member that smoked, and 35% of them were willing to undergo a Tobacco Prevention and Cessation Program. 90% of current smokers after ICU discharge quitted smoking. Conclusion(s): Tobacco smoking is a serious comorbidity in ICU patients hospitalized for covid 19 disease, with both current smokers and ex-smokers reveal more severe rates of mortality and morbidity.

Human induced pluripotent stem cell-derived alveolar type 2 cells mature at air-liquid interface and respond to airborne stimuli

Human alveolar type II cells (AT2s) are progenitors of the alveolar epithelium and are among the pulmonary cells that are directly exposed to inhaled stimuli. Primary human AT2s can be cultured in three-dimensional alveolospheres, but are difficult to culture in the physiologically relevant air-liquid interface (ALI) format. Human induced pluripotent stem cells (iPSCs) can be directed to differentiate to iPSC-derived AT2s (iAT2s) in alveolospheres, where they transcriptomically resemble fetal lung. Here we report the successful adaptation of iAT2s to ALI culture, which promotes their maturation and permits exposure to inhaled stimuli. We transcriptomically profile iAT2s cultured at ALI and find that they mature as they downregulate cell cycle-associated transcripts. We then evaluate the extent of iAT2 maturation at ALI within the developmental context by comparison to primary AT2s. We find that iAT2s at ALI are more similar to primary AT2s than iAT2s cultured as spheres, and that differences are driven by primary AT2s' response to immune stimuli. We then test the capacity of iAT2s to respond to immune stimuli by infecting with SARSCoV-2. We find that iAT2s mount an epithelial-intrinsic interferon and inflammatory response to SARS-CoV-2 infection, and can serve as a platform for testing antiviral therapeutics. Finally, we demonstrate that iAT2s at ALI respond to cigarette smoke and electronic cigarette vapor, enabling the direct comparison of these common inhaled stimuli. Overall, we describe a novel disease modeling platform that will enable exploration of gene-environment interactions unique to inhaled exposures of the alveolar epithelium.

E-cigarette use and lung function: preliminary results from the VapeScan Study

Aims: VapeScan aims to study associations between e-cigarette (e-cig) use and lung structure and function in diverse young adults from New York City. Since the Study started during the pandemic, we performed preliminary analyses to test if recent COVID infection is a confounder of associations between e-cig use and lung function. Method(s): We are enrolling adults ages 18-50 years using e-cigs only, e-cigs and cigarettes, and dual non-users. Pre-bronchodilator spirometry and questionnaires are done at baseline. Lung function was regressed on e-cig use adjusted for age, sex, race, BMI, height, asthma, and COVID history. Result(s): 57 participants completed spirometry between October 2021 and May 2022, including 14 (25%) e-cig users, 13 (23%) dual e-cig/cigarette users, and 30 (53%) dual non-users. Average age was 26 years (range:18-49), 38 (67%) were women, 25 (44%) were non-Hispanic White, 6 (11%) were Black, 16 (28%) were Asian, 19 (33%) were Hispanic, 10 (18%) had asthma, 15 (26%) had prior COVID. After adjustment, e-cig use was associated with 8% lower FEV1-predicted (95%CI:17%,-2%,p=.1) and 0.05 lower FEV1/FVC (95%CI:0.11,-0.001,p=.06). COVID history was not associated with outcomes (p>.27) and effect estimates did not change after adjustment (Figure). Conclusion(s): In data collected during the Omicron Wave of the COVID-19 pandemic, e-cig use showed a trend towards association with lower FEV1% and FEV1/FVC independent of COVID history.

Vaping Behavior in Young Adults During the COVID-19 Pandemic.

BACKGROUND: Electronic nicotine delivery systems (ENDS) continue to be popular among young adults. These devices are often advertised as a healthy alternative to quitting tobacco cigarettes. However, young adults represent a population who view it as a novel behavior that provides a sense of popularity, social acceptance, and desired physiologic properties. The objective of this study was to examine characteristics of vaping behavior among college students and explore possible associations between groups of vaping behavior (stopped, initiated, increased, decreased, stayed the same). METHODS: In a multi-center cross-sectional study, 656 students from University of Tampa in the United States and University of Applied Sciences in Germany (IST) were recruited to answer a 31-item online questionnaire. A chi-square test was used to evaluate associations between the groups. RESULTS: Prevalence rates indicated approximately 31% of all students were currently using ENDS. Even though more negative than positive experiences with ENDS were reported, most students stated their vaping increased during COVID-19 lockdowns. Addiction and stress relief emerged to be predictors (P < .001) of an increase in vaping, whereas social motives were not statistically significant. Living situation (P = .63) and depression (P = .10) were not significantly associated with vaping behavior. CONCLUSIONS: ENDS products continue to yield very high levels of nicotine creating addiction in young adults. Addiction counseling and evidenced-based practices should be employed at every level (individual, community, and school). Additionally, mental health counseling for students in pandemic and high-stress environments may help to combat stress in a more proactive manner than self-medicating.

Impact of the COVID-19 pandemic on alcohol use and smoking habits

Background: It is very important to monitor changes in substance use during the pandemic period, as individuals dealing with substance use may be at greater risk for COVID-19, and stress factors and changes resulting from the pandemic may cause alterations in substance use models. Method(s): In this review, the existing literature on how COVID-19 affected people's alcohol consumption, smoking, and vaping use in different societies was evaluated. Articles that are relevant to the subject were searched using PubMed, ScienceDirect and Google Scholar and reviewed. Result(s): It was observed that due to COVID-19, there may be no alterations in these substance use types or it may result in a decrease of consumption of substances or a quit attempt due to health concerns about COVID-19 or it may cause an increase in the alcohol, or cigarette consumption. Conclusion(s): With this review we hope to present detailed information on the impact of the pandemic on alcohol consumption, and cigarette or e-cigarette use from various studies conducted in different societies all around the world and highlight the importance and necessity of new studies on this subject. Copyright © 2023 Taylor & Francis Group, LLC.

Electronic Cigarette Users' Perspective on the COVID-19 Pandemic: Observational Study Using Twitter Data.

BACKGROUND: Previous studies have shown that electronic cigarette (e-cigarette) users might be more vulnerable to COVID-19 infection and could develop more severe symptoms if they contract the disease owing to their impaired immune responses to viral infections. Social media platforms such as Twitter have been widely used by individuals worldwide to express their responses to the current COVID-19 pandemic. OBJECTIVE: In this study, we aimed to examine the longitudinal changes in the attitudes of Twitter users who used e-cigarettes toward the COVID-19 pandemic, as well as compare differences in attitudes between e-cigarette users and nonusers based on Twitter data. METHODS: The study dataset containing COVID-19-related Twitter posts (tweets) posted between March 5 and April 3, 2020, was collected using a Twitter streaming application programming interface with COVID-19-related keywords. Twitter users were classified into two groups: Ecig group, including users who did not have commercial accounts but posted e-cigarette-related tweets between May 2019 and August 2019, and non-Ecig group, including users who did not post any e-cigarette-related tweets. Sentiment analysis was performed to compare sentiment scores towards the COVID-19 pandemic between both groups and determine whether the sentiment expressed was positive, negative, or neutral. Topic modeling was performed to compare the main topics discussed between the groups. RESULTS: The US COVID-19 dataset consisted of 4,500,248 COVID-19-related tweets collected from 187,399 unique Twitter users in the Ecig group and 11,479,773 COVID-19-related tweets collected from 2,511,659 unique Twitter users in the non-Ecig group. Sentiment analysis showed that Ecig group users had more negative sentiment scores than non-Ecig group users. Results from topic modeling indicated that Ecig group users had more concerns about deaths due to COVID-19, whereas non-Ecig group users cared more about the government's responses to the COVID-19 pandemic. CONCLUSIONS: Our findings show that Twitter users who tweeted about e-cigarettes had more concerns about the COVID-19 pandemic. These findings can inform public health practitioners to use social media platforms such as Twitter for timely monitoring of public responses to the COVID-19 pandemic and educating and encouraging current e-cigarette users to quit vaping to minimize the risks associated with COVID-19.

A COVID-19 MIMICRY MYSTERY

SESSION TITLE: Signs and Symptoms of Chest Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Vaping products have been rapidly gaining popularity, with studies showing increasing use, even among school-going children and adolescents. E-cigarette or Vaping Associated Lung Injury (EVALI) is defined as respiratory failure within 90 days of e-cigarette use with pulmonary infiltrates on imaging, in the absence of infectious or alternative causes of respiratory failure.[1] Vitamin E acetate, a thickening agent in THC containing e-cigarettes, is thought to be the main causative agent of EVALI and has been found in the bronchoalveolar lavage samples in almost all cases of EVALI.[2] However, diagnosing EVALI in this era of COVID -19 is a challenge due to striking similarities in clinical symptoms and imaging findings. CASE PRESENTATION: A 32-year-old male with anxiety and polysubstance abuse, presented with headache, cough, low-grade fevers and chills of 1 week. In the ED, he was febrile to 102 F and hypoxic to 89% on room air and was started on 3 liters of oxygen. Labs showed leukocytosis and elevated inflammatory markers. Urine toxicology was positive for THC. Chest X-ray showed bilateral interstitial opacities. CT angio of the chest showed bilateral ground glass opacities. Despite 2 negative PCR tests, suspicion for COVID was high and the patient was initially started on dexamethasone and other supplements, along with antibiotic coverage for a possible bacterial etiology. Despite this, respiratory symptoms and hypoxia continued to worsen. Infectious work up including blood, sputum cultures with AFB staining, urine streptococcus and legionella tested negative. The patient however now revealed the regular use of THC containing vape and procuring the THC oil from a new street vendor. This prompted us to suspect vaping induced chemical pneumonitis. He was restarted on steroid therapy with methylprednisolone and within 1 week, had symptomatic improvement and resolution of hypoxia. The patient was eventually discharged on prednisone taper over 7-10 days. DISCUSSION: Our patient was initially treated for COVID pneumonia despite repeated negative PCR tests, as findings were suggestive of SARS-COV-2 infection. Fortunately, the patient eventually revealed about regular use of THC-oil vapes, making us consider a diagnosis of vaping induced chemical pneumonitis. The mainstay of treatment is steroid therapy and cessation of e-cigarette use. The severity of the pandemic has led to a low threshold for suspecting COVID, causing increased anchoring and availability bias, and potentially under-diagnosing conditions like EVALI which resemble COVID infection.[3] CONCLUSIONS: While it is important to have a low threshold for suspecting COVID-19, considering other mimics of COVID is prudent for providing treatment in an appropriate and timely manner. Detailed inquiry of e-cigarette use, particularly THC-oil containing vapes, duration of use and source of procurement, goes a long way in diagnosing of EVALI. Reference #1: EVALI and the Pulmonary Toxicity of Electronic Cigarettes: A Review Lydia Winnicka, MD and Mangalore Amith Shenoy, MD PMCID: PMC7351931 PMID: 32246394 Reference #2: Clinical presentation, treatment, and short-term outcomes of lung injury associated with e-cigarettes or vaping: a prospective observational cohort study Denitza P Blagev 1, Dixie Harris 2, Angela C Dunn 3, David W Guidry 2, Colin K Grissom 4, Michael J Lanspa 5 PMID: 31711629 DOI: 10.1016/S0140-6736(19)32679-0 Reference #3: EVALI: A Mimicker of COVID-19 Mitchell M. Pitlick, MD,a Daenielle K. Lang, MD,a Anne M. Meehan, MBBCh, PhD,b and Christopher P. McCoy, MDb, PMCID: PMC8006188 PMID: 33817560 DISCLOSURES: No relevant relationships by Kaushik Darbha No relevant relationships by Rashmikant Doshi No relevant relationships by Ishan Sahu No relevant relationships by sara samad

E-CIGARETTE OR VAPING USE-ASSOCIATED LUNG INJURY (EVALI): EFFECTS OF VAPING OR COVID-19?

SESSION TITLE: Critical Care in Chest Infections Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: EVALI is an acute lung injury that occurs due to the use of e-cigarettes or vaporizer products that usually contain THC or nicotine. There was an outbreak of EVALI in 2019. This is a diagnosis of exclusion with foamy macrophages with pneumocyte vacuolization being the best diagnostic clues. (1) Vitamin E acetate laced products seem to be the causing factor. CASE PRESENTATION: A 34-year-old female presented to the emergency department due to increasing shortness of breath, fever, pleuritic chest pain, cough, and headaches for the last 9 days. Two days prior she presented to urgent care where she was given an albuterol inhaler and azithromycin. At arrival, the patient was found to have tachycardia with a rate of 120-130, afebrile, SpO2 at 96% on room air, BP at 100/59. Her initial workup was grossly normal except for an elevated WBC and elevated D-Dimer. Chest X-ray revealed opacities in the lower lungs consistent with pneumonia. CTA of the chest revealed patchy pulmonary opacities consistent with COVID pneumonia. She took three separate SARS-CoV-2 PCR tests which all came back negative. The patient underwent a large workup which included infectious disease, pulmonology, and cardiology consults. She was treated with broad-spectrum antibiotics for the presumed diagnosis of pneumonia but her condition quickly deteriorated, eventually requiring 6L of O2 via nasal cannula. Screening for a large array of bacteria, fungus, and viruses all resulted negative. Upon further discussion with the patient, she admitted to smoking a THC vaporizer every night for the last seven months and that she had recently purchased a new fluid for her THC vaporizer through the internet. Bronchoscopy was also acquired but did not show any specific findings, including being negative for eosinophils. Discontinuation of antibiotics and initiation of IV steroids treatment provided rapid improvement of the patient's condition. Based on her history of THC vaping, the clinical presentation of fever, hypoxia, her chest x-ray, and chest CT showing extensive lung infiltrates, infections were ruled out and the most likely diagnosis of EVALI was made which responded well to steroids. DISCUSSION: COVID and EVALI initially can present similarly as respiratory problems, fever, and the need for oxygen. It is important to gather history on the patient as a vaping history is needed to suspect EVALI as imaging can show a wide range from ground-glass opacities to acute hypersensitivity pneumonitis. (2) CONCLUSIONS: There are some distinguishing features of EVALI from COVID one being in EVALI there is a large increase in the white count and lastly the response to steroids is the key (2). Steroids are the primary care for someone with EVALI with most patients recovering in 1-3 days with the use of steroids. (2) Reference #1: Bierwirth, A., Orellana, G., Milazzo, E. and Hamdan, A., 2020. TETRAHYDROCANNABINOL VAPING-ASSOCIATED LUNG INJURY (EVALI): A US EPIDEMIC?. Chestnet Journal. Reference #2: MacMurdo, M., Lin, C., Saeedan, M., Doxtader, E., Mukhopadhyay, S., Arrossi, V., Reynolds, J., Ghosh, S. and Choi, H., 2020. e-Cigarette or Vaping Product Use-Associated Lung Injury. Chestnet Journal. DISCLOSURES: No relevant relationships by Narden Gorgy No relevant relationships by Matheus Moreira Sanches Peraci No relevant relationships by George Walbridge No relevant relationships by John Zakhary

A Comparison of Virtual versusIn-person Curriculum on Student Knowledge and Perceptions of E-cigarettes

Background: E-cigarettes are the most commonly used tobacco product by U.S. adolescents. Prior research shows that school-based e-cigarette prevention education was associated with reduced actual and intended use of e-cigarettes. During the COVID-19 pandemic, such e-cigarette education was delivered through virtual teaching in addition to in-person classes. The purpose of this study is to assess the effectiveness of e-cigarette prevention curriculum delivered virtually compared to in-person sessions in improving e-cigarette-related knowledge and reducing adolescents' intent to try e-cigarettes. Methods: A 30- minute educational presentation on e-cigarettes based on the Stanford Tobacco Prevention Toolkit was delivered to middle and high school students in Alabama from November 2020-May 2021. Study participants were divided into two groups based on the mode of receiving the presentation: 1) by an in-person educator (“in-person group”) and 2) by an off-site educator presenting through a recorded video or a video chatting platform (“virtual group”). The presentation covered e-cigarette contents, health effects, nicotine addiction and marketing. Using a quasi-experimental pre- and post-intervention group study we assessed students' e-cigarette-related knowledge and perceptions on 15 questions, and intent to try e-cigarettes. Descriptive statistics were summarized for the total sample, in-person group and virtual group. Within-subject and within-group analyses were conducted for all perceptions and intent to try Amelia Warnock, MPH;Shelby Kile, MPH;Shivani Mathur Gaiha, PhD;Clementino Vong Do Rosario, n/a;Kennon Brake, n/a;tobacco products using McNemar's chi-squared exact tests of paired proportions. Between-group analyses were conducted using multi-level mixed-effects regression models to assess treatment effects by group and time on perceptions, addictiveness and intent to try e-cigarettes after adjusting for school-level clustering effects. Independent variables included grade (high school vs middle school) and race/ethnicity. Results: Study participants were drawn from 10 schools and included 1031 total participants. 745 participants were in the virtual group (72.3%) and 286 participants were in the in-person group (27.74%). See participant characteristics in Table 1. Within-subject and within-group analyses showed positive significant changes after education in 8 out of 15 e-cigarette-related perceptions (for both groups), increase in perceived addictiveness among the virtual group and reduced intent to try e-cigarettes, particularly among the in-person group. Within-subject changes were more pronounced among high school participants. Time x group interaction effects show the in-person presentation was more effective compared to the virtual group at improving knowledge of e-cigarette nicotine content and delivery through aerosol and health effects (see Table 2). There was no significant difference in the treatment effect by study group on perceived addictiveness and intent to try e-cigarette products. Conclusion: In our study, a one session in-person educational presentation was not more effective than virtual on student knowledge, perceived addictiveness and intended behavior. There were select aspects of knowledge that improved among students receiving in-person education. (Table Presented).

E-cigarette or Vaping Product Use Associated Lung Injury (EVALI) in Teenager After Reported COVID-19 Infection

Introduction: E-cigarette or vaping product use associated lung injury (EVALI) is a relatively new pulmonary syndrome linked to e-cigarette consumption. As of February 18th, 2020, a total of 2,807 hospitalized EVALI cases have been reported to the CDC. Among hospitalized EVALI cases, 15% (421 patients) were under the age of 18. Case Description: Patient is a 17-year-old previously healthy male who presented to the ED for a 3-day history of fever, progressively worsening nausea and vomiting, anorexia, dry cough, and night sweats. PMH was significant for COVID-19 infection in April 2021 and he was fully vaccinated for COVID-19 as of May 2021. Patient also noted 10 lbs. unintentional weight loss in the last month. Patient denied substance use or sexual activity. Family history was unremarkable. In the ED the patient was febrile and mildly tachycardic. Physical exam was grossly unremarkable including a normal lung exam. Relevant labs revealed a leukocytosis, hyponatremia, elevated ESR and CRP. SARS-COVID-2 PCR negative, SARS-COVID-2 IgG S1/S2 Spike protein positive, nucleocapsid negative. CXR, ECG, and RUQ U/S were unremarkable. Patient was subsequently admitted to the inpatient pediatric service for further management. During hospitalization the patient reported increased shortness of breath and pleuritic chest pain with SaO2 down to 86% on room air requiring supplemental oxygen. New social history obtained without family present revealed heavy vaping of nicotine and THC 'most days' for the past 3 years. Pediatric pulmonology was consulted and diagnosed the patient with EVALI and started him on methylprednisolone and a 5-day course of azithromycin for its anti-inflammatory effects. The patient was subsequently able to be weaned off oxygen and was discharged home on an oral prednisone taper and azithromycin after 6 days in the hospital. CXR 2 weeks after discharge was normal with complete resolution. Discussion: EVALI is mainly a diagnosis of exclusion and can mimic other infectious and rheumatologic conditions, therefore clinicians must maintain a high index of suspicion in order to make the diagnosis. Clinical manifestations of EVALI can include respiratory, gastrointestinal, and constitutional symptoms. The most frequently reported symptoms include shortness of breath, fever, cough, vomiting, diarrhea, dizziness, headache, tachycardia, and chest pain. Laboratory studies often show an elevated CRP and procalcitonin, leukocytosis, and a transaminitis. Radiographic features can include diffuse, bilateral, ground-glass infiltrates with basilar predominance and sub-pleural sparing. Conclusion: This case demonstrates the importance of obtaining a social history in a confidential environment in any adolescent case. When this was done on hospital day two, we learned of an extensive vaping history which helped us diagnose the patient with EVALI. In addition to drug use, clinicians should specifically ask about the use of e-cigarettes and vaping products since not all adolescents will divulge these details unless directly asked.

Substance Use Behaviors Among LGBTQ Youth of Color: Applying a Novel Method in Two Large Samples to Identify Intersecting Social Positions Bearing the Greatest Burden

Purpose: The global COVID pandemic, social uprisings, and a wave of discriminatory policy proposals have highlighted the ways in which structural oppression contributes to health disparities facing youth of color and those identifying as LGBTQ. Young people living at the intersection of multiple types of oppression face the greatest burden, yet also have unique strengths and supports. Existing research has demonstrated persistent substance use disparities across sexual orientation, gender identity, and racial/ethnic groups – as individual categories. However, very little research has examined substance use among those with multiple stigmatized identities. Capitalizing on two very large datasets and a novel analytic technique, this study seeks to identify groups with the highest prevalence of past 30-day alcohol, e-cigarette, and marijuana use. This first step in a larger project will determine key intersecting identities for qualitative interviews regarding interpersonal and community supports that can reduce health disparities. Methods: Data come from the 2019 Minnesota Student Survey and the 2017-2019 California Healthy Kids Survey, two surveillance programs with a combined sample of 892,664 students in grades 6-12. Data were harmonized across sources to create compatible variables including race/ethnicity (non-Hispanic Native American, Asian/Pacific Islander, Black/African/African American, White, Multiracial;Latina/x/o), sexual orientation (straight, gay/lesbian, bisexual, questioning, something else [e.g. pansexual, queer]), gender identity (cisgender, transgender/gender diverse [TGD], questioning), sex assigned at birth (male, female), state, and past 30-day substance use (yes/no for alcohol, e-cigarettes, marijuana). Exhaustive Chi-square Automatic Interaction Detection (CHAID) analysis, a decision tree approach, was used to examine all interactions among social positions with the goal of identifying distinct groups with significantly different rates of substance use behaviors (Bonferroni adjusted p<.05). The groups with the highest prevalence for each substance were examined. Results: The overall prevalence of past 30-day substance use was 10.4% for alcohol, 9.7% for e-cigarettes, and 9.7% for marijuana, with substantial disparities across intersecting groups. For example, although 10.5% of Latina/x/o-identified youth and 20.8% of TGD-identified youth reported drinking alcohol, Latina/x/o TGD youth were among those with the highest prevalence of use, particularly those who also identified with a newer sexual orientation label (e.g. pansexual, queer) and were assigned male at birth (26.2%) or Latina/x/o TGD youth who did not indicate their sexual orientation (31.7%). This pattern was also evident for e-cigarette and marijuana use. Similarly, Black TGD youth had significantly higher rates of alcohol (26.9%), e-cigarette (29.2%, in California), and marijuana use (24.4%, straight-identified;29.5%, missing sexual orientation). Conclusions: Using the power and diversity of large population-based datasets and an innovative analytic technique specifically recommended for studies of intersectionality, we found significant disparities in substance use, with the burden varying by unique intersecting marginalized identities. This approach is recommended to examine disparities in groups often treated as homogeneous, as a precursor to developing relevant and appropriate prevention strategies. Further research is needed to identify structural factors contributing to these high rates. Clinicians, educators, and others working with youth should address intersecting types of stigma and oppression that may contribute to substance use. Sources of Support: National Institute of Minority Health and Health Disparities grant #R01MD015722.

School Connectedness and e-cigarette Susceptibility and Use in a Diverse Urban Adolescent Sample

Purpose: Adolescent school connectedness, particularly positive relationships with teachers, generally protects from health risk behaviors such as tobacco use, yet how this relates to adolescent e-cigarette use has not yet been described. This study examines the relationship between school connectedness and e-cigarette susceptibility and use in a diverse adolescent longitudinal sample. Methods: This is a secondary analysis of a school-based intervention including ten public schools in one urban school district. We surveyed 661 middle (66.6% eighth grade) and high school (33.4% eleventh grade) student participants at three time points between spring 2019 and spring 2020. The 2020 surveys were completed early in the COVID-19 pandemic, prior to the transition to remote learning. Respondents had a mean age of 14.1 years, were 53% female, and 28% identified as non-Hispanic white,15.6% as Hispanic, 23.8% as Black, 29.8% as Asian, and 2.9% as American Indian/Alaska Native. Ordinal logistic regression models examined unadjusted and adjusted associations between school connectedness (both baseline and concurrent) and an ordinal measure of e-cigarette susceptibility (any vs. none) and use (any vs. no past 30-day use) at all three time points. Covariates in the adjusted models included grade, intervention condition, English language learner status, gender, race/ethnicity, baseline use of any tobacco, and baseline weighted grade point average. Results: Levels of any tobacco use were low in the spring of 2019 (3.8%), e-cigarettes represented the predominant form of tobacco use (2.4%), and most respondents reported no e-cigarette susceptibility (69%). E-cigarette susceptibility and use remained relatively stable during the follow-up period. Higher levels of baseline school connectedness were consistently associated with lower odds of e-cigarette susceptibility/use in spring 2019 (OR: 0.37, 95% CI: 0.26, 0.53), fall 2019 (OR: 0.51, 95% CI: 0.35, 0.74), and spring 2020 (OR: 0.47, 95% CI: 0.30, 0.73). Higher levels of concurrent school connectedness were also associated with lower odds of e-cigarette susceptibility/use over time: spring 2019 (OR: 0.36, 95% CI: 0.25, 0.51), fall 2019 (OR: 0.48, 95% CI: 0.34, 0.66), and spring 2020 (OR: 0.65, 95% CI: 0.42, 0.99). Findings were similar for eighth and eleventh graders and did not differ significantly both before and after adjusting for other covariates. Conclusions: Both adolescents’ baseline levels of connection to their schools and their connectedness over time appear to serve as protective factors for e-cigarette susceptibility and use. These findings highlight the importance of promoting positive school experiences and strong teacher-student relationships as a mechanism of reducing adolescent risk behaviors such as e-cigarette use among diverse adolescent populations. Sources of Support: This project was funded by a grant from the National Institute of Minority Health and Health Disparities (NIMHD) grant number R01MD010586 (PI: Allen).

Adolescent Perceptions of Different e-Cigarette Marketing Characteristics in Retail, Online and Social Media

Purpose: Nearly 4 million U.S. adolescents use e-cigarettes, despite known health harms and laws prohibiting sales to people below 21 years. National surveys show that adolescents self-report buying e-cigarettes from retail stores and online. Although studies show that e-cigarette marketing is associated with adolescent e-cigarette use, these studies have not directly asked adolescents their perception of whether e-cigarette marketing in retail, online and social media influences their browsing, purchasing and use-related behavior. Methods: 90-minute, online focus groups with 14-19 year olds (May-Aug 2021). Photographs were used to help participants recall e-cigarette marketing. Participants were recruited through an Instagram post targeting 30 major U.S. cities (n=27 recruited in 3 focus groups from 10 cities thus far;recruitment ongoing). Thematic analysis was used to identify themes related to appealing marketing characteristics. Results: In addition to bright colors of e-cigarette advertising and names of flavors, participants described appealing e-cigarette marketing characteristics. Appealing characteristics in retails stores: pricing coupons, free smelling samples, individual brands displayed in separate containers, displays at the checkout counter (e.g., “there's a big difference between being at the counter, where you can pick it up yourself, and being behind the counter because I don't want to have to ask the person at the Walgreens –‘can you hand me that?’”). On social media: AYAs were attracted by youth/influencers explaining product safety (e.g., “A lot of influencers market like ‘Oh yeah, they don't have any cancer-causing chemicals”);and inability to trace messages (e.g., Snapchat). Participants also listed ways to purchase e-cigarettes using gift cards, debit cards and using fake or other people’s IDs. Conclusions: Our data show that specific appealing e-cigarette marketing characteristics in retail stores and online can and should inform FDA, state, and local regulation. Notifications on social media, similar to those created to combat misinformation about COVID-19 vaccines, may be developed and tested to prevent AYAs from accessing e-cigarette-related misinformation. Sources of Support: The research reported in this was supported by the Taube Research Faculty Scholar Endowment and the ASPiRE D&I Pilot Award.

Impact of Influenza Virus and E-cigarette Vaping Pre-Exposures on Outcomes of SARS-CoV-2 Infection in Hamster

Rationale. Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is the third leading cause of death in the United States. While many risk factors for severe COVID-19 are emerging, the effects by which other inhalational exposures affect susceptibility are not well defined. Patients with COVID-19 demonstrate high rates of co-infection with respiratory viruses, including influenza A (IAV). When infected with IAV, human small airway epithelial cells (SAEC) exhibit increased abundance of angiotensin-converting enzyme 2 (ACE2), the primary receptor for SARS-CoV-2. However, it remains unknown if this effect increases the risk for COVID-19. Similarly, there are conflicting reports of the effect of e-cigarette (E-cig) vaping on COVID-19 manifestations. We hypothesized that exposures to IAV or E-cig increase the severity of SARS-CoV-2 infection. Methods. Golden Syrian hamsters (male and female) were exposed to E-cig vapor via nebulization for 5d. IAV was administered intranasally once on day 6 (A/California/07/2009 H1N1, 106 PFU/hamster). On day 3 post-IAV infection, SARSCoV- 2 was administered intranasally (WA01;104 PFU/hamster). On day 7 post-SARS-CoV-2 infection animals were sacrificed, bronchoalveolar lavage fluid (BALF) cell differentials were obtained, and inflated lung sections were stained and scored for immunohistology. Lung RNA was quantified for ACE2, TMPRSS2, STAT1, CXCL10, IFN-gamma, gene expression using RT-qPCR. Results: SARS-CoV-2 infection caused progressive weight loss that was less pronounced in animals pre-infected with IAV. SARS-CoV-2 titers from nasal swabs peaked at day 2 in both groups. IAV pre-infection reduced PMN and eosinophils in the BALF, and the overall inflammatory cell infiltration in the lung parenchyma of SARS-CoV-2-infected animals. IAV pre-infection reduced lung levels of STAT1, CXCL10 (2.5-fold;p<0.01), CCL5, and IFN-gamma in SARS-CoV-2-infected animals compared to animals that were only infected with SARS-CoV-2. Pre-exposure to E-cig worsened the SARS-CoV-2-induced weight loss in female animals only. E-cig pre-exposure increased lymphocytes and decreased PMN and eosinophils in the BALF compared to animals that were only infected with SARS-CoV-2. E-cig pre-exposure increased lung levels of STAT1, CXCL10 (2.5-fold;p<0.05), CCL5, and IFN-gamma in SARS-CoV-2-infected animals compared to animals that were only infected with SARS-CoV-2. Conclusion: Pre-infection with IAV resulted in decreased inflammatory response to SARS-CoV-2 infection. In contrast, pre-exposure to E-cig vaping increased the severity of the inflammatory response to SARS-CoV-2 with notable differences between sexes. Whereas anti-viral priming effects of prior viral infection are well described, the mechanisms that explain the worsening effects of E-cig on SARS-CoV-2 outcomes remain unknown.

An Elusive Case of E-Cigarette, or Vaping, Product Use Associated Lung Injury (EVALI) Lacking Respiratory Symptoms

Introduction: Electronic vaping-associated lung injury (EVALI), attributed to inhalation through E-cigarettes and other devices was first characterized in the US in July 2019. By February 2020, 2807 cases were reported. Patients often present with respiratory, gastrointestinal, and constitutional symptoms. The presence of EVALI without respiratory complaints is under-recognized, only reported three times in the literature thus far. Case: A 22-year-old female student presented with five days of fever, watery, nonmucoid, non-bloody diarrhea, nausea, 3-4 episodes of vomiting, and generalized weakness, without cough, dyspnea, chest or abdominal pain. Social history revealed vaping e-cigarettes containing nicotine and tetrahydrocannabinol for the past 3-4 years with increased use recently due to upcoming exams. She denied smoking traditional cigarettes, marijuana, or illicit drugs. A temperature of 101oF and 98% SaO2 were recorded. Physical examination was notable for bilateral diffuse crackles with a normal abdominal examination. Initial labs demonstrated a WBC of 14,600 without a shift and the remaining labs were within normal limits. Despite the absence of respiratory symptoms, her chest radiograph revealed bilateral multifocal airspace disease. Further investigation with Chest CT showed extensive multifocal bilateral infiltrates and predominantly peripheral ground-glass opacities. COVID-19 PCR was negative three times. Influenza A and B, RSV, mycoplasma, and legionella testing were negative. She was unable to provide sputum for culture. Stool cultures were negative and an abdominal and pelvic CT was normal. She denied any history of dietary intolerances, prior diarrhea, or chronic colitis. Empiric treatment for atypical community-acquired pneumonia with intravenous ceftriaxone and azithromycin was initiated, with little improvement over the subsequent 4 days. Lack of clinical effect with antibiotics prompted a suspicion for EVALI and intravenous methylprednisolone 1mg/kg every 8 hours was initiated. There was a significant improvement of her gastrointestinal and constitutional symptoms within 24 hours. After three days of IV steroids, she was discharged on an enteral taper. A repeat Chest CT scan 2 weeks later demonstrated complete resolution of the previously identified ground-glass opacities. Discussion: The use of E-cigarettes has grown by 900% between 2011 and 2019 among young adults but used by older individuals as well. This has contributed to the burgeoning EVALI epidemic. Although COVID has taken the centre stage while identifying diffuse interstitial lung abnormalities, there must be a high index of suspicion regarding the incidence of EVALI, especially in young patients, considering the varied presentations and the potential absence of respiratory symptoms.