http://www.jstc.or.jp/ E-mail desk@nosmoke55.jp〒162-0063 東京都新宿区市谷薬王寺町 30-5-201
Tel 03-5360-8233 FAX 03-5360-6736

Mr. Katsunobu Kato, Minister of Health, Labor and Welfare

17 September 2019

Mr. Manabu Sakuta, Chairperson, Japan Society for Tobacco Control
1) Around the world, many victims are appearing with severe pneumonia and convulsions fromusing e-cigarettes and heated tobacco.
2) Please inform doctors nationwide, collect data, and start researching cases.
3) Please inform and warn the public about this situation.
Chronicle
Multiple cases of severe pneumonia caused by heated tobacco have been reported in Japan. 1, 2 In
the United States, hundreds of cases of severe pneumonia have been reported, causing some deaths,
from electronic cigarettes. In response, the Alberta Health Authority in Canada has issued thefollowing message:
5 September 2019
Subject: Severe Pulmonary Disease Associated with E-Cigarette Use, Surveillance andNotification
To: family physicians; emergency room physicians and staff; nurse practitioners; local healthauthorities, tobacco control specialists
From:Dr. Digby Horn, on behalf of Medical Officer of Health—Central Zone, CanadaYou may have heard of reports of cases of severe lung disease in the United States that appear to beassociated with a history of vaping.(*) While there have not been any similar cases reported inCanada to date, effective September 4, 2019, the Chief Medical Officer of Health of Alberta has
made severe pulmonary disease associated with e-cigarette(*) use notifiable under the Public HealthAct. As a result, any cases meeting the following definitions are required to be reported to theCentral Zone Medical Officer of Health (CZMOH) on call, (phone number○○).
Confirmed Case:
A: Using an e-cigarette (“vaping”) or “dabbing” in 90 days prior to symptom onset; AND
B: Pulmonary infiltrate, such as opacities on plain film, chest radiograph or ground-glass opacities
on chest CT; AND
C: Absence of pulmonary infection on initial work-up; Minimum criteria include negative
respiratory pathogen panel, influenza PCR or rapid test if local epidemiology supports testing. Allother clinically indicated respiratory ID testing (e.g., urine antigen for Streptococcus pneumonia
and Legionella, sputum culture if productive cough, Bronchoalveolar lavage (BAL) culture if done,blood culture, HIV-related opportunistic respiratory infections if appropriate) must be negative;AND
D: No evidence in medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic orneoplastic process).
Probable case: A, B and D above; AND
Infection identified via culture or PCR [polymerase chain reaction], but clinical team(**) believes
this is not the sole cause of the underlying respiratory disease process OR
Minimum criteria to rule out pulmonary infection not met (testing not performed) and clinicalteam(**) believes this is not the sole cause of the underlying respiratory disease process*

Using an electronic device (e.g., electronic nicotine delivery system (ENDS), I Quit Ordinary

Smoking (IQOS), electronic cigarette, e-cigarette, vaporizer, vape(s), vape pen, dab pen, or otherdevice) or dabbing to inhale substances (e.g., nicotine, marijuana, THC, THC concentrates, CBD,
synthetic cannabinoids, flavorings, or other substances).
**Clinical team caring for the patient

Likewise, the FDA also issued a directive on September 6 to urge hospitals nationwide to provideinformation.7)
According to FDA reports, 127 cases of convulsions caused by electronic cigarettes have also beenreported in the United States.4, 6)
The FDA continues to monitor 35 reports of convulsions by electronic cigarette users since April
this year, and 92 new reports have been received since, for a total of 127 reports. Because FDA
relies on a voluntary adverse event reporting system, there may be more unreported cases.
According to the FDA announcement, most electronic cigarette users who had convulsions wereadolescents and children, some of whom used electronic cigarettes for the first time, while others
had used them used regularly.
The FDA would like to receive the following information when reporting an adverse case.5
When reporting an adverse experience, please be sure to include:• The name of the manufacturer• The brand name, model, and serial number of the device or e-liquid, if applicable• Where the device or e-liquid was purchased• Whether the device or e-liquid was modified in any way or whether there was a device
malfunction• Whether other tobacco products, medications, supplements or other substances were used•••Whether there were any other symptoms (i.e., nausea, vomiting) or warning right before
the adverse experience, such as change in the user’s behavior, alertness, vision or hearing
Details about product use preceding the event (duration, amount and intensity ofe-cigarette use)
Details about health effects, including specific areas of the body affected, how symptoms
progressed, how long they lasted, the course of the recovery, and the medical testing or
care and decisions rendered

While adverse events from heated tobacco and electronic cigarettes are reported in detail fromaround the world, action by public health authorities in Japan might seem slow.
Thus, I think that we should establish a research team or organization to examine possible cases ofpneumonia and convulsions caused by heated cigarettes and electronic cigarettes.
Thank you for your consideration.
1) Takahiro Kamada, Yosuke Yamashita, and Hiromi Tomioka : Acute eosinophilic pneumonia
following heat‐not‐burn cigarette smoking. Respirol Case Rep. 2016 Nov; 4(6): e00190.
PMCID: PMC5167280 Published online 2016 Oct 3. doi: 10.1002/rcr2.190
2) Aokage T, Tsukahara K, Fukuda Y, Tokioka F, Taniguchi A, Naito H, Nakao A.:
Heat-not-burn cigarettes induce fulminant acute eosinophilic pneumonia requiring extracorporeal membraneoxygenation.

Respir Med Case Rep. 2018 Dec 4;26:87-90. doi: 10.1016/j.rmcr.2018.12.002. eCollection 2019.
3) Jennifer E. Layden, M.D., Ph.D., Isaac Ghinai, M.B., B.S., Ian Pray, Ph.D., Anne Kimball, M.D.,
Mark Layer, M.D., Mark Tenforde, M.D., Ph.D., Livia Navon, M.S., Brooke Hoots, Ph.D.,
Phillip P. Salvatore, Ph.D., Megan Elderbrook, M.P.H., Thomas Haupt, M.S., Je!rey Kanne,M.D., Megan T. Patel, M.P.H., Lori Saatho!-Huber, M.P.H., Brian A. King, Ph.D., M.P.H., Josh
G. Schier, M.D., Christina A. Mikosz, M.D., M.P.H., and Jonathan Meiman, M.D.et：Pulmonary
Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report | NEJM ,2019/09/11 9'324）FDA investigating 127 reports of seizures, neurological symptoms related to vaping.
https://edition.cnn.com/2019/08/07/health/ecigarette-seizure-fda-investigation/index.html

5) FDA: Some E-cigarette Users Are Having Seizures, Most Reports Involving Youth and YoungAdults.
https://www.fda.gov/tobacco-products/ctp-newsroom/some-e-cigarette-users-are-having-seizures-most-reports-involving-youth-and-young-adults6) FDA investigating 127 reports of seizures after vaping.
https://www.cnbc.com/2019/08/07/fda-investigating-127-reports-of-seizures-after-vaping.html

7)

FDA asks hospitals to report injuries, illnesses related to e-cigarette.

https://technology.inquirer.net/90546/fda-asks-hospitals-to-report-injuries-illnesses-related-to-e-cigaretteConclusion