Weipers' disease

"Wapers' disease"(English. Evali, fromE-Cigarette And Vaping USE-SSOCIETED Lung Injury= lung damage associated with smoking electronic cigarettes and vaypes)^[1]- non -infectious respiratory disease associated with the useelectronic cigarettes. Most similar to exogenouslipoid pneumoniaor chemicalpneumonitis. In international medical literature, abbreviations are usedEvali,Vapi(fromEnglish. Vaping-SSSOCIETED PULMONARY InJURY) AndVali(fromEnglish. Vaping-SSSOCAETED LUNG InJURY)^[2][3].

The causes and mechanism of the development of the disease have not been studied, it is only known that the cause is the accumulation of the oil tissue of the oil components of the aerosol in the cells of the pulmonary tissueelectronic cigarettes, the most likely candidates are acetatevitamin eAndTetragidrocannabinol^[1][3]. Symptoms of the disease are typical for classicallipid (lipoid) pneumonia^[Eng.][1]and turn on a cough, chest pain, difficulty breathing, nausea, vomiting anddiarrheaas well as other respiratory, constitutional andGastroenterologicaldisorders^[4]. In 2020, there were no unified manual for the treatment of “vapers disease”, the most effectiveness was shown by systemicCorticosteroids. But the medical community also admits the possibility of natural recovery in case of abandonment of electronic cigarettes^{[2][4][5] [5]}.

The first case of the disease was documented in 2012. The most widespread disease was during the outbreak inUSAIn 2019–2020, when the number of hospitalized exceeded 2.5 thousand people. 68 deaths were recorded^[6][7][1]. Medical services of developed countries talk about the growing Evali epidemic, which has become hidden against the backgroundPandemia Coronavirusdue to the similarity of the symptoms of these diseases^[1].

Symptoms and pathology

Despite the collection of data on the clinical features of the “vapers disease”, itspathologyNot enough studied^[8]. The established symptoms include respiratory, constitutional andGastroenterologicaldisorders^[4]. The most common cough, chest pain, difficulty breathing, nausea, vomiting and diarrhea. Among less common symptoms -fever, hemoptysis, shortness of breath, weight loss and fatigue, dizziness and chest pain immediately after useelectronic cigarettes^[2][6][9]. In some cases, recordedtachycardia,Tahipnoe, persistenthypoxemia. Symptoms developed a few weeks or days before hospitalization, many victims neededIntensive therapy,artificialAnd non -invasiveLight ventilation. In patients aged or with concomitant diseases, as well as in pregnant women, the risk of a rigid manifestation of symptoms was higher^[5][8][10].

Computed tomographyPatients recorded the pulmonaryinfiltrate: diffuse or located in the lower sections of the seal of the type "matte glass»With the preservation of the structure inSubpleural(78.1%),lobolar(59.4%) or peribronhovascular (40%) areas. The latter was found in younger patients and was not characteristic of acute damage to the lungs^[11][12]. When entering the hospital, all victims had an increased amountleukocyteswith a predominanceneutrophilsand absenceEosinophilia^[4][10][13].Plasmaconsumers of electronic cigarettes also showed an increased level of hydroxyeicosetraenic acid and variousEikosanoids^[6].

Initially, doctors suspected the infectious nature of the disease.Macrophages, discovered in hospitalized, could causeInflammatory immune responseleading to lipoid pneumonia and other pneumonic -like reactions^[3]. So, patients noted damage to the lungs with pathological manifestations of acute fibrinouspneumonitis, diffusealveolarlesions or organizingpneumoniausually accompaniedbronchiolite, acute eosinophilic oratypical pneumonia^[4][8][11]. Some patients were diagnosedChemical pneumonite^[Eng.], others -Coronavirus infection. But the lesions of the lungs in hospitalized with Evali were often different from those in patients with coronavirus pneumonia^[4][11]. In the course of research, no evidence of the infection was found, there was no reaction to antibiotic treatment^[13].

Causes and diagnostics

All patients with acute lung injuries reported the consumption of various electronic cigarettes before entering the hospital^[5]. Devices are a portable evaporator of a filler fluid, which may containnicotine,Propylene glycolAnd vegetableglycerol, flavors and flavor enhancers,Tetragidrocannabinol(TGK) andcannabidiol,hash oil,Mineral oiland oil withmedium -chain triglycerides^[Eng.]. The thermal element of the E-sigaret is heating the liquid, turning it into an aerosol, the effect of which on the human body is little studied^[6][14]. Animal studies show that waging can increase the hyperreactivity of the respiratory tract or susceptibility to respiratory pathogens^[7]. The toxic effects of TGC in the composition of the aerosol are considered the most likely cause of respiratory disorders^[15]. Most often with the development of Evali is associated:

• Vitamin Eused as a thickener in cartridges with TGK^[16]. The substance is usually safe when eating or applying to the skin, but in the composition of the aerosol can negatively affect the functions of the lungs^[17][18][19]. In the process of heating, exclusively toxic gas is formedKetenpresumably responsible for the growth of light injuries, as well as dangerous for humansAlkenAndbenzene^[6][20].
• Tetragidrocannabinolwhich can be associated with oxidative damage and inflammatory reactions in the respiratory system, lung tissue dysfunction^[6].
• Cannabidiolwhich is toxic tomonocytesand is related to the pro -inflammatory responseimmune systemand impaired functionepithelialbarrier^[6]. In mice tests, the effects of synthetic cannabinoids caused a pro -inflammatory state, activatingBanabinoid receptor type 1^[Eng.]In lung tissues^[21]. Presumably, it is fake devices with various cannabidiols as part of liquids that are most dangerous for users^[6].
• Oil additives that can contribute to the accumulationlipidsIn lung tissues^[15]. This group includes not only vegetable oils, but also oil distillates, which, when heated, release toxic volatile organic compounds. Mineral oils andtriglyceridesprobably cytotoxic and associated with dysfunction of the epithelial barrier^[6][17].
• Glycerin and propylene glycol, decomposition products of which are carcinogenicformaldehyde^[14].
• Nicotinewhich stimulates the developmentadrenalineRaisingblood pressure^[14].
• Flavors whose assortment in the market exceeds 7.5 thousand options. Most of them were not tested on toxicity and are considered potential pathogens^[22].
• ArsenicAnd metals, includingaluminum,Surm,cadmium,cobalt,chromium,copper,iron,lead,manganese,nickel,selenium,tinAndzinc. Their presence in the aerosols of electronic cigarettes potentially poses a serious threat to health, for example, they can lead to developmentcancer tumors^[4][23].

Nevertheless, the causative agent of Evali has not been installed, since no component is associated with all cases of the disease^[5]. Patients in different regions of the United States consumed liquids of different brands and with different composition. For example,Office for sanitary supervision of the quality of food and medicationVitamin E, most often called the culprit of the disease, did not discover, in nicotine -based liquids. It was used only by manufacturers of fillers with TGK to compact smoke^[16][19]. Although most patients reported the use of products with TGK (approximately 82%), about 14% assured that they consumed electronic cigarettes exclusively with nicotine, which means they were not exposed to vitamin E. experts that users, for example, could not know the exact composition^[5][6][24]. Some devices came from unofficial sources, for example, from friends or illegal street merchants, so it is impossible to install the composition of their cartridges^[13][18]. The more chemicals are contained in liquids for electronic cigarettes, the more toxic it can be. However, there were no studies on the long -term effects of electronic cigarettes on the human body, and in 2020 the Evali development mechanism is unknown^[14][22].

The history of distribution

A map of the number of hospitalizations or deaths from the “vapers disease” in different US states during the outbreak of 2019–2020

In 2003, the Chinese pharmacist Khon Lick registered a patent for his invention - an electronic cigarette, which was supposed to help smokers to refuse tobacco^[25]. In the US market, electronic cigarettes have been distributed since about 2007^[26]. Messages about lung diseases with symptoms without direct etiology among consumers of electronic cigarettes have been known at least since 2012. At that time, patients were given various diagnoses, including acute damage to the lungs, atypical pneumonitis, eosinophilic or lipoid pneumonia^[6]. By 2014, E-sigars have become the most commonly used tobacco product among young people in the country. In 2017-2018, Waping's prevalence increased from 11.7% to 20.8% among American high school students. Among the adult population, by that time, 3.2% of the population reported the habit^[27]. In 2018, the Office for Supervision of the Quality of Food and Medicines announced the vaping of the epidemic^[28].

The first patients whose illness officially associated with electronic cigarettes were recorded in the United States in the spring - summer 2019^[27][29][30]. In August 2019Centers for the control and prevention of diseasesWe started collecting data on cases of Evali,Department of HealthDifferent states began their own investigations. So, New York state services recognized Acetate Vitamin E as the most likely agent causing damage to the lungs. At least three companies with vitamin E thickeners in the composition were filed, court claims were filed^[9][16].

In September 2019, the number of cases of Evali disease recorded in more than 20 states of the United States was 350, the number of deaths was 6^[4][13]. By the middle of the month, the epidemic reached its peak, daily reported more than 200 cases. The weekly number of hospitalized patients has since steadily decreased^[24], in total at that time there were about 1.2 thousand victims in 21 state^[5]. Since November, centers for the control and prevention of diseases have recommended to report to doctors only about severe cases of the disease that required hospitalization^[18]. As of January 14, 2020, the total number of relevant messages was 2668 for all the time of the outbreak of the disease^[24]. 57 deaths were confirmed^[31]. By that time, the body stopped collecting information about patients with Evali due to a sharp decrease in the number of daily hospitalized. So, throughout January 2020, only 67 cases were registered^[9][27]. The dynamics was primarily associated with a quick reaction of public health, an increase in the public's knowledge of the risks of wiping and the refusal of some consumers from Vaping. A number of manufacturers removed vitamin E from the composition of liquids or completely stopped production^[2][16][24].

For February 2020, a total of 2807 hospitalized cases in 50 states were registered,County Colombia,Puerto RicoAnd onVirgin Islands. 68 deaths in 29 states and the district of Colombia were confirmed^[6][7][32].

Similarly, the outbreak of Evali disease in the United States was identified in other countries, but did not become widespread.Bloomberg agencyreported at least 15 incidents in other countries of the world, includingGuam,JapanAndGreat Britain^[33]. INCanadaThe first case of Evali was detected in September 2019 by a residentQuebec^[34]. By August 2020 inCanadian public health agencyInformation was received about 20 victims of the "vapers disease", no fatal outcome was reported^[35]. INRussiaThe first case of Evali is recorded inMoscowChildren's hospital in the summer of 2021^[32][36]. However, in July 2022Ministry of Industry and TradeHe did not support the ban on wards and electronic cigarettes in Russia, fearing an increase in smuggling and losses for the Russian budget. As an alternative measure, officials considered the introduction of mandatory marking, which was supported by manufacturers^[37].

Statistics

During the Evali outbreak in 2019–2021 in the United States, the largest number of cases were registered inTexasAndIllinois,CaliforniaAndNew York. Among more than 2.5 thousand hospitalized, 66% were men. Most had at least one concomitant pathology, for example,asthma,Chronic obstructive disease of the lungsorcystic fibrosis. So, about 22% of all patients suffered from asthma^[2][7][24].

The average age of patients Evali was 24 years, 62% of patients were aged 18 to 34, another 16% were younger than 18 years^[27]. The average age of deceased patients was 49.5 years (at least 15, maximum - 85 years)^[24][27][31]. Among the dead patients, 52% suffered from obesity. Also, mortality was high among patients over 35 years old, among patients with asthma,heart diseaseormental disorders^[2][7].

Most patients with Evali reported that they received their products from unofficial sources: acquired from hand or in online stores of resellers, received from friends or relatives^[31]. 82% of patients used tools with tetrahydrochanabinol, 57% - nicotine -containing products^[24].

Treatment and diagnostics

Microscopy of the sample of bronchoalveolar lavage of the patient Evali, 2019

Diagnostics

Initially, doctors admitted that league damage associated with vaping can be exogenous lipoid pneumonia. The alleged diagnosis was associated with oils that the smokers of electronic cigarettes inhaled with aerosol. However, in some cases, there was no appropriate pathology or radiological evidence^[8][15]. Other common diagnoses includedAcute respiratory distress syndrome,sepsis, hypoxicRespiratory failureAnd pneumonitis^[13]. But the corresponding treatment did not give positive results. During further studies, it was found that a new disease is not an infectious^[30][38].

Evali is considered a diagnosis of exception, because there is no special test or marker for its diagnosis^[5]. First of all, doctors exclude household and acute eosinophilic pneumonia: laboratory examination includes a general blood test with a differential on inflammation markers (C-reactive protein,Ery blood cell settlement rate), the level of transaminaseliver,Toxicological study of urineincluding TGK^[5]. Doctors traditionally prescribeCT angiographyorCT of the chest,BronchoscopyWithBronchoalveolar lavage^[2]. Onchest x -rayA patient of Evali is usually observed bilateral diffuse, muddy or consolidated cloudings, but patients show negative tests for respiratory infectious diseases.BiopsyLights are optional for diagnosis, but is performed in accordance with clinical indications^[39]. Among other things, it is necessary to exclude coronavirus infection, the symptoms of which are similar to Evali^[17][40]. If the patient is a vaper and there are no probable alternative diagnoses in the medical record (for example, cardiac,rheumatologicalor tumor processes), the doctor may assume the presence of a “vaper disease” in a patient^[38].

Treatment

In 2020, there was no single guide to the treatment of Evali. SystemicCorticosteroidsare the basis of therapy, their effectiveness is probably associated with the weakening of the inflammatory reaction. The course with equivalentMethylprednizoloneusually lasts 5-10 days, depending on the clinical state^[2][13]. In some cases, patients were prescribedBronchoalveolar lavage^[26]. Since the signs and symptoms of the disease coincide with household pneumonia and other infectious diseases, also recommend the appointment of empiricalantibioticsorsteroidsDepending on the clinical context. The natural development of the disease is unknown, and the medical community implies the possibility of self -procreation in case of abandonment of electronic cigarettes^[4].

In severe cases, hospitalized with hypoxic respiratory failure neededintensive therapy,trachea intubationAndartificial ventilation of the lungs. Such patients are prescribed by constant monitoring of the respiratory system after discharge, patients who received high doses of corticosteroids - helpendocrinologistTo control the functionadrenal glands^[5][10][38].

Long -term effects and risk of relapse Evali are unknown^[5]. Certain cases of re -treatment of the prescribed patients for medical help were recorded. The risk of exacerbation increases if patients continue to use electronic cigarettes. Therefore, recommendations on the rejection of wiping and behavioral counseling should be an integral part of treatment^[7][15]. Centers for the control and prevention of diseases suggest avoiding the use of any electronic cigarettes^[41]. A number of experts calls the most “healthy approach to abstinence from inhalation of something except fresh clean air”^[2][5][15].

Notes

1. Go back:^{1 2 3 4 5} Vasilieva and Akulova, 2022.
2. Go back:^{1 2 3 4 5 6 7 8 9} Adhikari, T. Koritala, R. Gotur, S. V. Malayala, N. K. Jain. Evali-E-Cigarette or Vaping Product Use-SSOSOCIATED LUNG INJURY: A Case Report. Cureus (2021). Appeal date: January 5, 2021.ArchivedJune 21, 2021.
3. Go back:^1 2 3 Are Electronic Cigarette Users at Risk for Lipid-Mediated Lung Injury?// American Journal of Respiratory and Critical Care Medicine. - 2020. - S. 1012-1013.ArchivedJuly 19, 2022.
4. Go back:^{1 2 3 4 5 6 7 8 9} G. Carlos et al. Vaping-SSSOCIETED PULMONARY ILLNESS (VAPI)// American Thoracic Society. - 2020. -Doi:10.1164/RCCM.2007P13.ArchivedDecember 10, 2021.
5. Go back:^{1 2 3 4 5 6 7 8 9 10 11 12} Siegel D. A., Jatlaoui T. C. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patents with Suspeded E-Cigarette, Product Use Associated Lung Injury-United States, October 2019// MMWR MORB MORTAL WKLY Report. - 2019. - S. 919–927.
6. Go back:^{1 2 3 4 5 6 7 8 9 10 11 12} Thivanka Muthumalage, 1 Joseph H. Lucas, 1 Qixin Wang, 1 Thomas Lamb, 1 Matthew D. McGraw, 2 and Irfan Rahman. Pulmonary Toxicity and Inflammatory Response of Vape Cartridges Containing Medium-Chain TriglyCerides and Vitamin E Actate: Implicates in the Pathogenesis of Evali// Toxics. - 2020.ArchivedNovember 1, 2020.
7. Go back:^{1 2 3 4 5 6} A. TiantafyllOu, P. J. Tiberio, R. H. Zou, M. J. Lynch, J. W. Kreit, B. J. McVerry. Long-Term Outcomes of Evali: A 1-Year Retrospective Study. Plumx Metrics (2021). Appeal date: January 5, 2021.ArchivedFebruary 4, 2022.
8. Go back:^1 2 3 4 Butt Y. M. et al. Pathology of Vaping-Sasociated Lung Injury// The New England Journal of Medicine. - 2019.ArchivedDecember 10, 2021.
9. Go back:^1 2 3 Why DID CDC Stop Reporting on the Number of Evali Cases in February 2020?Centers for Disease Control and Prevention (2020). Date of circulation: January 5ArchivedDecember 29, 2020.
10. Go back:^1 2 3 Kya Davidson, A. Brancato, P. Heetderks, W. Mansour, E. Matheis, M. Nario, S. Rajagopalan, B. Underhill, J. Wininger, D. Fox. Outbreak of Electronic-Cigarette-Sassociated Acute Lipoid Pneumonia-North Carolina, July-August 2019// mmwr. - 2019. - S. 784–786.ArchivedMay 7, 2022.
11. Go back:^1 2 3 A. Teslin. The clinical characteristics of American patients with Evali are generalized// Majesty. -2021-10-07.ArchivedOctober 8, 2021.
12. 2019 Lung Injury Surveillance Primary Case Definition (CDC). U.S. Department of Health & Human Services (September 18, 2019). Date of circulation: January 5ArchivedDecember 13, 2020.
13. Go back:^{1 2 3 4 5 6} CDPH Health Alert: Vaping-Sasociated Pulmonary Injury. California Department of Public Health (August 27, 2019). Date of circulation: January 5ArchivedSeptember 24, 2019.
14. Go back:^1 2 3 4 Lestari K. S., Humairo M. V., Agustina U. Formaldehyde Vapor Concentration in Electronic Cigarettes and Health Complains of Electronic Cigarettes Smokers in Indonesia// Journal of Environmental and Public Health. - 2018.ArchivedMay 30, 2022.
15. ↑Go back:^12 3 4 5 Boland J. M., Aesif S. W. Vaping-SSSOCIETED LUNG InJURY: NONSPECICIC HISTOPATHOLOGIC Necessitate A Clinical Diagnosis// American Journal of Clinical Pathology. - 2019. - S. 1-2.ArchivedDecember 10, 2021.
16. ↑Go back:^12 3 4 Three Companies Subpoenaed in Weed Vape Illness Investigation. RollingStone (September 10, 2019). Appeal date: January 5, 2021.ArchivedJanuary 26, 2021.
17. ↑Go back:^12 3 Transcript of CDC Telebriefing: Update on Lung Injury Associated with E-Cigarette Use, Or Vaping. U.S. Department of Health & Human Services (November 9, 2019). Date of circulation: January 5ArchivedMarch 18, 2021.
18. ↑Go back:^12 3 OverView. Centers for Disease Control and Prevention (2020). Appeal date: January 5, 2021.ArchivedDecember 29, 2020.
19. ↑Go back:¹² H. Sun. Contaminant Found in Marijuana Vaping Products Linked to Deadly Lung Illnesses, Tests Show. The Washington Post (September 16, 2019). Appeal date: January 5, 2021.ArchivedJanuary 3, 2021.
20. ↑Wua W., O’Shea D. F. Potential for Release of Pulmonary Toxic Ketene from Vaping Pyrolysis of Vitamin E Acetate// pnas. - 2020. - S. 6349-6355.ArchivedJuly 18, 2022.
21. ↑Zawatsky C. N., Abdalla J., Cinar R. Synthetic Cannabinoids Indouxte Lung Inflammedion Via Cannabinoid Reception 1 Activation// ERJ. - 2020.
22. ↑Go back:¹² Sassano M. F. Evaluation of E-Liquid Toxicity An Open-Source High-Throughput Screening Assay// PLOS BIOLOGY. - 2018.ArchivedDecember 26, 2020.
23. ↑Zhao D., Aravindakshan A., Hilpert M., Olmedo P., Rule A. N., Navas-Cien a., aherrera A. Metal/Metalloid Levels in Electronic Cigarette Liquids, Aerosols, and Human Biosamps: A Systematic Review// Environ Health Perspectives. - 2020.ArchivedAugust 13, 2022.
24. ↑Go back:^{12 3 4 5 6 7} Krishnasamy V. P., Hallowell B. D., Ko J. Y., et al. Update: Characteristics of a Nationalwide Outbreak of E-Cigarette, or Vaping, Product Use-SSOCIATED LUNG INJURY// MMWR MORB MORTAL WKLY Report. - 2020. - S. 90–94.ArchivedDecember 10, 2021.
25. ↑Speranskaya, Anastasia. Cough, shortness of breath, Ivl. What is Evali and why the Ministry of Health was worried about the disease of the wages.The Blueprint. Appeal date: September 12, 2024.ArchivedSeptember 11, 2024.
26. ↑Go back:¹² Layden J. E., Ghinai I., Pray I. et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin-Final Report(English). - 2020.ArchivedDecember 16, 2021.
27. ↑Go back:^12 3 4 5 Outbreak of Lung Injury Associated with E-Cigarette Use, Or 'Vaping'. U.S. Department of Health & Human Services (2020). Date of circulation: January 5ArchivedApril 12, 2021.
28. ↑DR Evan STEPP: Patient Concern Over Evali Appears to have Faded(English). AJMC (October 20, 2021). Appeal date: January 5, 2021.ArchivedDecember 13, 2021.
29. ↑E-Cigarette or Vaping Product Use Associated Lung Injury (Evali)(English). - 2021.ArchivedDecember 13, 2021.
30. ↑Go back:¹² Wapers' disease: Mysterious epidemic mows of lovers of electronic cigarettes. Komsomolskaya Pravda (September 19, 2019). Appeal date: January 5, 2021.ArchivedOctober 28, 2020.
31. ↑Go back:^12 3 A. King, C. M. Jones, G. T. Baldwin, P. A. Briss,. The Evali and Youth Vaping Epidemics - Implicates for Public Health(English) // The New England Journal of Medicine. - 2021.ArchivedOctober 17, 2022.
32. ↑Go back:¹² What is known about Evali - “Weeepers Diseases”, which was first recorded in Russia, the spoiler: very few.The Village(June 29, 2021). Appeal date: January 5, 2021.ArchivedJune 29, 2021.
33. ↑Langreth. How Early Signs of Lung Effects of Vaping Were Missed and Downplayed(English). Wells Media Group (September 30, 2019). Appeal date: January 5, 2021.ArchivedNovember 29, 2020.
34. ↑Quebec Resident Confirmed as Foursst Canadian Case of Vaping-Related Illness(English).CBC News(September 27, 2019). Appeal date: January 5, 2021.ArchivedNovember 11, 2020.
35. ↑Vaping-SSSOCIATED LUNG ILLNESS(English). Government of Canada (2020). Appeal date: January 5, 2021.ArchivedJanuary 2, 2021.
36. ↑Russian doctors talked about the amazing light illness Evali.ru(June 20, 2021). Appeal date: January 5, 2021.ArchivedJune 20, 2021.
37. ↑The Ministry of Industry and Trade did not support the idea of ​​the ban on vape and electronic cigarettes.Forbes(July 28, 2022). Appeal date: April 4, 2022.ArchivedJuly 28, 2022.
38. ↑Go back:^12 3 G. Schier, J. G. Meiman, J. Layden, C. A. Mikosz. Severe Pulmonary Disease Associated with Electronic-Cigarette-Product use-Interim Guidance// mmwr. - 2019.ArchivedMarch 31, 2022.
39. ↑Mukhopadhyay, M. Mehrad, P. Dammert, a. V. Arrossi, R. Sarda, D. S. Brenner, F. Maldonado, H. Choi, M. Ghobrial. Lung Biopsy Findings in Severe Pulmonary Illness Associated with E-Cigarette Use (Vaping): A Report of Eight Cases// American Journal of Clinical Pathology. - 2020. - S. 30-39.ArchivedDecember 13, 2021.
40. ↑M. Pitlick, D. K. Lang, Anne M.Meehan, C. P. McCoy. Evali: A Mimicker of Covid-19// Elsevier. - 2021. - S. 682-687.ArchivedDecember 13, 2021.
41. ↑Death on inspiration hundreds of Americans suffer from a mysterious lung disease. Vaping is blamed for everything. Lenta.ru (September 27, 2019). Appeal date: January 5, 2021.ArchivedOctober 14, 2021.

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[rule|rule the code]

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