Is Vaping a Valid Strategy for Smoking Cessation? Myths and Facts Jaspreet S. Brar. MD, PhD
Learning Objectives What are e-cigarettes and vapes? Myths and Facts related to vaping Vaping for harm reduction & smoking cessation Regulatory perspective How should clinicians address vaping? Parental involvement for youth who vape Treatment options
Electronic Nicotine Delivery Systems Include vaporizers, vape pens, hookah pens, e-cigarettes, and e-pipes (ENDS). ENDS are manufactured to look like conventional cigarettes, cigars, or pipes. Some resemble pens. Larger devices such as tank systems are also used. They bear no resemblance to cigarettes. All ENDS use a e-liquid that is a mixture of nicotine, propylene glycol, glycerin, flavoring agents and other ingredients. 3
How Does an e-cigarette Work? Electronic Nicotine Delivery System (ENDS): Basic Mechanism Sensor detects when a user inhales Processor Heater or Atomizer LED light simulates a flame E-Liquid CARTRIDGE or CARTOMIZER RECHARGEABLE BATTERY
Standard E-Cigarettes vs. Vaporizers Vaporizers are increasingly becoming more popular, mainstream and fashionable than e- cigarettes. Some disadvantages of e-cigarettes: Difficult to tell when the cartomizer is empty Limited battery life and tank capacity May be mistaken for traditional cigarettes Inconsistent nicotine delivery Restricted to buying e-liquid, cartomizers from the same manufacturer 5
Advantages of Vaporizers Longer battery life span Far more choice of flavors, tastes, and e- liquid supply (able to mix and match) Greater customization Smoother delivery of nicotine See-thru cartomizer makes it easy to tell how much e-liquid is left Refillable, therefore cheaper in the long run than disposable e-cigarettes 6
Why is There an Increase in Vaping? Curiosity Cost of cigarettes Harm Reduction & Smoking Cessation Stealth Perception of safer product Social acceptance
MYTH or FACT 1 E-Cigarettes are used only by a small, fringe group E-cigarettes are one of the most popular quitting tool used by smokers. Ten times as many people use e-cigarettes compared to those who seek other forms of treatments for smoking cessation. Surgeon General s Report, December 2016: 900 percent increase among high school students from 2011 to 2015.
MYTH or FACT 2 E-Cigarettes are safe. E-Cigarettes are unregulated tobacco products and are not evaluated by the FDA. We don't know for sure what's in them. There are no requirements around ingredient disclosure, warning labels or youth access restrictions. Many toxic chemicals, including an ingredient used in antifreeze and formaldehyde is found in many e-cigarettes.
Risks of Using E-Cigarettes Manufacturers claim that the e-liquids in e-cigarettes (propylene glycol, glycerin and flavorings are safe because they meet the FDA definition of Generally Recognized as Safe or GRAS. GRAS status applies to additives for use in food, and not for inhalation.
MYTH or FACT 3 E-Cigarettes don t have nicotine. Most E-Cigarettes contain nicotine. The nicotine levels are inconsistent and vary from one manufacturer to another. Nicotine is an addictive substance that can have negative health impacts, including on adolescent brain development. The more nicotine a person uses, the greater the potential for addiction.
Risks of Nicotine There is no established safe level of nicotine exposure for children Nicotine exposure can cause: Upset stomach, nausea, vomiting Change in heart rate and BP Breathing problems Seizures Chronic exposure: heart problems, asthma, developmental & behavioral disorders Increased likelihood of smoking Increased risk of addiction to other drugs
Risks of Nicotine During pregnancy women may quit smoking cigarettes and take up e-cigarettes. Nicotine is toxic to developing fetuses. It impairs fetal brain development. It interferes with normal lung development. It may result in low birth weight, pre-term and still-born deliveries. In the adolescent brain, nicotine disrupts the formation of brain circuits that control attention and learning.
MYTH or FACT 4 E-cigarettes Pose no Risk of Secondhand Smoke. The aerosol (vapor) emitted by e-cigarettes and exhaled by users contains carcinogens, such as formaldehyde, according to early studies. Little is known about these emissions or the potential harm they can cause.
What s in the Vapor? Lab tests conducted by the FDA have found: Detectable levels of toxic cancer-causing chemicals, including an ingredient used in antifreeze, in two leading brands of e-cigarettes. Aerosol from e-cigarettes with a higher voltage level contains more formaldehyde, another carcinogen with the potential to cause cancer. Diacetyl, a buttery flavored chemical often added to food products such as popcorn, caramel, and dairy products. Diacetyl can cause a serious and irreversible lung disease commonly known as "popcorn lung.
Safety of Flavoring Agents A study published in June 2018 showed that e-cigarette liquids with flavoring like clove and vanilla may damage endothelial cells in the blood vessels and heart. Damage to endothelial cells impairs the production of nitric oxide increasing risk for heart attacks and strokes.
MYTH or FACT 5 E-Cigarettes can help smokers quit. Perhaps, but there is insufficient evidence to show that when used as directed: E-cigarettes are effective for smoking cessation. E-cigarettes are a safe form of treatment. The majority of people smoke regular cigarettes in addition to e-cigarettes
What is the Evidence? Mostly descriptive studies. Cumulative evidence is equivocal at best. In comparison to other NRTs, e-cigarettes have greater adherence. Study participants liked: Tactile, cigarette like quality & ease of use. Perceived health benefits. Absence of cigarette odor. E-cigarette use was unrelated to changes in smoking. Prochaska, J. J., & Grana, R. A. (2014). E-cigarette use among smokers with serious mental illness. PloS one, 9(11), e113013
Use of E-Cigarettes in People with SMI Motivations to use include: Quitting smoking: tried other meds Self-Medication: helps my anxiety Freedom & Control: it freed me Social connectedness: don t feel like a social pariah Motivation by caregivers: worked for my dad who has bipolar disorder, my therapist suggested I try it Sharma, R., Wigginton, B., Meurk, C., Ford, P., & Gartner, C. E. (2017): Motivations and Limitations Associated with Vaping among People with Mental Illness: A Qualitative Analysis of Reddit Discussions. Int. J. Environ. Res. Public Health, 14, 0007 19
What is the Evidence? Mostly descriptive studies. Cumulative evidence is equivocal at best. In comparison to other NRTs, e-cigarettes have greater adherence. Study participants liked: Tactile, cigarette like quality & ease of use. Perceived health benefits. Absence of cigarette odor. E-cigarette use was unrelated to changes in smoking. Prochaska, J. J., & Grana, R. A. (2014). E-cigarette use among smokers with serious mental illness. PloS one, 9(11), e113013 20
Vaping and Harm Reduction The safety of prolonged vapor exposure is not known The use of e-cigarettes as a harm reduction tool at stopping tobacco smoking is not uniformly successful The majority of people who use vaping as a harm reduction technique to stop tobacco use end up using both products Co-utilization of tobacco products and ENDS exposes individuals to the collective risks of both types of products
E-Cigarettes, a Smoking Cessation Aid? E-Cigarettes have not been approved by FDA's Center for Drug Evaluation and Research (C-DER) because their efficacy and safety has not been established. Seven therapies (5 NRTs, gum, patch, lozenge, inhaler and spray, Bupropion & Varenicline) have been approved as treatments for smoking cessation. These may be used in combination with individual, group or phone cessation counseling. Instead of quitting, 60% to 70% of e-cigarette users are continuing to use e-cigarettes while still using conventional cigarettes.
What do the Regulatory Authorities & Experts Say FDA (C-DER) will not approve e-cigarettes and vaping devices till such time that there is good evidence of their safety and efficacy. US Department of Health and Human Services & Surgeon General s Report (Dec 2016) discourage use.
What do the Regulatory Authorities & Experts Say United States Preventative Services Task Force (USPSTF, an independent panel of health experts that advise the government on health issues) have stated that the current evidence is insufficient to recommend ENDS for tobacco cessation including pregnant women. Not recommended by the American Lung Association or the American Heart Association.
European Perspective The Royal College of Physicians has concluded that while ENDS are more harmful than nicotine replacement treatments (NRTs), the risks of vaping are lower than the risks of smoking. In July 2006, Public Health England released a joint statement on e-cigarettes that said the public health opportunity is in helping smokers to quit, so we may encourage smokers to try vaping but we certainly encourage vapers to stop smoking tobacco completely. Switching from cigarettes to e-cigarettes is a valid tobacco harm reduction approach.
What Should Clinicians Say? Explore the member s motivation to use e- cigarettes Use information discussed in Myths vs. Facts to educate member. Review past history of quit attempts and treatment(s) used. What can be learned from previous quit attempts especially obstacles and barriers that led to an unsuccessful attempt.
What Should Clinicians Say? Review how to avoid these obstacles and barriers for future quit attempt(s). Review approved treatments especially those that may not have been used by the member previously. Schedule / arrange visit with Psychiatrist or PCP.
Parental Involvement Parents are unaware of risks posed by e-liquid. Adults tend to under-estimate the risk of exposure Children of parents who use vaping devices are at higher risk of using because of proximity to paraphernalia Nicotine poisoning due to children ingesting e- liquid are becoming more frequent Parental involvement is crucial when addressing vaping with children
What comes Close to E-Cigarettes Nicotine Inhaler (Nicorette or Nicotrol ). An FDA approved NRT. Consists of a mouthpiece and a replaceable nicotine cartridge. When a user draws on the mouthpiece, the cartridge releases nicotine that the user inhales. There is no smoke or vapor. Similar to other NRTs, it help relieve cravings and withdrawal symptoms.
Questions?