The ABCs of Vaping

The word vaping can be deceptive, since the single word can represent different behaviors. Vaping refers to a method of substance inhalation that delivers anything from blueberry-flavored vitamin D to delta-9-tetrahydrocannabinol (THC) into the body. Although health professionals often refer to electronic cigarettes (e-cigarettes) and vaping synonymously, e-cigarettes represent only a small fraction of the growing market for vaping products available to consumers of all ages.

Why All the Fuss?

We know that breathing in tar and asbestos is risky, but what about zinc, lead, chromium, manganese, and copper?¹ All have been identified as components of various vaping products (eg, e-liquids, vape juice), although the long-term health consequences of these ingredients are not well defined. Although some e-liquid ingredients are considered to be safe to be ingested and processed in the gut and may thus be benign in that regard (eg, vegetable glycerin and propylene glycol), they may cause harm in the lungs.² And, beyond the lung damage it can cause, aerosol inhalation may increase cardiovascular risk.³

In addition, nicotine vaping products increase the risk for the same health consequences as any other nicotine exposures, including: subsequent development of a nicotine addiction; priming for use of other substances; changes in attention, cognition, and impulse control; and increased risk of developing mood disorders.² The risk is compounded by the ready availability of vape juices and e-liquids that have high concentrations of nicotine, beyond what are found in traditional tobacco products.⁴

Although health professionals often refer to electronic cigarettes (e-cigarettes) and vaping synonymously, e-cigarettes represent only a small fraction of the growing market for vaping products available to consumers of all ages.

Young children and developing fetuses may also be prone to indirect health consequences of vaping products. For instance, there are reports of vaping liquids being swallowed and absorbed through the skin and eyes in young children, resulting in poisoning. Fetal exposure can result in multiple adverse health consequences, including sudden infant death syndrome.³

So Why Vape?

Given the potential for harm, why do individuals vape nicotine and other harmful chemicals for purposes other than smoking cessation? Among youth, curiosity is the most common reason for vaping.⁵ Vaping may be seen an act that brings social benefit: Friends use what their friends use.⁶ Available online and in neighborhood stores, vaping products may be perceived as both fashionable and convenient.⁵ Plus, vape systems can be discreet (ie, no visible aerosol) or flashy (ie, production of large vape clouds). With advanced features such as voice control, accent lighting, and Bluetooth compatibility, there is a vaping device to appeal to almost any subculture and customer.

The ability to customize vape systems and liquids carries additional risks. Most samples obtained from the e-cigarette liquid of individuals being treated for e-cigarette or vaping product use–associated lung injury (EVALI) contained THC. Vitamin E acetate was identified in all samples, and glycerin, propylene glycol, diacetyl, aldehydes, formaldehyde, terpenes, organic compounds, and trace metals may have contributed to the more than 2800 EVALI cases and 68 associated deaths.^7,8 In our investigation of college students’ vaping data collected from the 2018 to 2019 Health Minds Study survey, we found that almost 1 in 4 students who vaped used THC,9 and an analysis of 2018 National Youth Tobacco Survey data found that about 1 in 4 of the middle and high school student sample had vaped marijuana.¹⁰

Is This Behavior Legal?

The short answer is yes. A few US states and tribal governments, and some countries, have broadened prohibitions against smoking in public places to include vaping, but most have not. The US Food and Drug Administration (FDA) regulates flavors, predominantly when marketed to children and youth and when sold without age verification or without limiting number.¹¹ Menthol, previously considered an adult flavor, is now banned per the FDA.¹²

How About Smoking Cessation?

Although vaping products are being used by nonsmokers, vaping has utility as a smoking cessation aid for adult consumers.^13,14 Given the undeniable harms of smoking, vaping provides an option for people who are ready to quit smoking.^13,14

Among youth, however, vaping is more often initiated as an addition or gateway to smoking. According to the results of one study, only 7.3% of high school seniors who vaped did so for smoking cessation.¹⁵ Furthermore, individuals with dual use (smoking and vaping) are exposed to increased harms.¹⁶

Clinical Implications

“Paul,” aged 35 with no history of psychiatric disorders, was a smoker for more than 30 years. Despite his use of numerous quit methods, Paul’s frequent attempts to stop smoking were curtailed by his anxiety and disrupted concentration. Finally, his primary care provider convinced him to give vaping a 2-week try. Although cynical at first, Paul was relieved when he discovered vaping worked for him. In addition, he was thrilled to find products that were within his budget.

Unfortunately, vaping was not a 100% panacea. One day while working at his computer, Paul felt a sudden flash of pain and his pant leg burst into fire. A visit to the emergency department and a skin graft were required after his battery exploded in his pocket. Nevertheless, he is still vaping.

Paul says he will never return to smoking cigarettes, although he misses it. He is scheduled to see a pulmonologist; he is certain that vaping has been better for his health than the 2 packs a day he used to smoke. However, family and friends are concerned, he reports. They have pointed out that he is never without his vape pen, and he has realized he uses it with no conscious knowledge of doing so, regardless of where he is.

ASSESSING THE CLINICAL SIGNIFICANCE OF VAPING. Talking to a patient about vaping may require some investigation (Table). Frequency of use and the types of products used influence the safety and clinical significance of the behavior. If the patient is distressed by their behavior, experiences functional impairment, or reports poor health outcomes including symptoms of tobacco or cannabis use disorders, you may decide to provide assistance and help your client quit, or reduce, vaping behavior.

Table. Assessing Vaping Behavior and Intentions to Quit

RESOURCES TO HELP YOUR PATIENT QUIT VAPING. The US Department of Health and Human Services^17,18 and the FDA¹⁹ have online and printed resources to assist with smoking cessation, as have most US states.²⁰ In-person and online classes and/or support groups, tailored text messaging services, a free QuitGuide app, and information related to nicotine replacement products are available. Patients can consult and access these resources when they want to quit smoking or vaping. While vaping cessation research is scant^21-23 and is primarily limited to nicotine vaping, methods used to quit are likely amenable to those used in smoking cessation.16 US Preventive Services Task Force recommendations for clinicians are to ask about use, advise quitting, and provide behavioral interventions and pharmacotherapy.²⁴

SPECIAL POPULATIONS. Teens and adolescents may require niched interventions, whether they are consuming nicotine via vaping or other methods.^21-23 To this end, the Truth Initiative²⁵ funded the development of a text-to-quit mobile application as an addition to their quit program for teens. This program is based on research of vaping patterns, quit attempts, and cessation motivation; interventions should be tailored to address social influences, outcome expectancies, and intentions to quit.²¹ Women who are pregnant also need a tailored approach to quit vaping; counseling techniques, including relaxation activities,²⁶ and monetary incentives improve outcomes.²⁷ Nicotine replacement therapy may also be helpful.²⁸

Dr Striley is an associate professor and director of psychiatric epidemiology at the University of Florida. Ms Nuttey is a PhD student in epidemiology at the University of Florida.

References

1. National Academies of Science, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems; Eaton DL, Kwan LY, Stratton K, eds. Public Health Consequences of E-Cigarettes. National Academies Press (US); 2018.

2. E-cigarette use among youth and young adults. a report of the surgeon general. US Department of Health and Human Services. 2016. Accessed August 31, 2001. e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_non-508.pdf

3. Buchanan ND, Grimmer JA, Tanwar V, et al. Cardiovascular risk of electronic cigarettes: a review of preclinical and clinical studies. Cardiovascul Res. 2020;116(1):40-50.

4. Goniewicz ML, Boykan R, Messina CR et al. High exposure to nicotine among adolescents who use Juul and other vape pod systems (‘pods’). Tob Control. 2019;28(6):676-677.

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6. Jarmul S, Aherrera A, Rule A, et al. Lost in e-cigarette clouds: a culture on the rise. Am J Public Health. 2017;107(2):265-266.

7. Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. CDC. Updated August 3, 2021. Accessed August 31, 2021. www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html

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11. FDA finalizes enforcement policy on unauthorized flavored cartridge-based e-cigarettes that appeal to children, including fruit and mint. News release. FDA; January 2, 2020. Accessed May 11, 2021. www.fda.gov/news-events/press-announcements/fda-finalizes-enforcement-policy-unauthorized-flavored-cartridge-based-e-cigarettes-appeal-children

12. FDA commits to evidence-based actions aimed at saving lives and preventing future generations of smokers. News release. FDA; April 29, 2021. Accessed May 11, 2021. www.fda.gov/news-events/press-announcements/fda-commits-evidence-based-actions-aimed-saving-lives-and-preventing-future-generations-smokers

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17. QuitGuide. Smokefree.gov. Accessed May 11, 2021. smokefree.gov/tools-tips/apps/quitguide

18. Tobacco information and tips for quitting smoking. BeTobaccoFree.gov. Accessed May 11, 2021. betobaccofree.hhs.gov/home

19. Smoking – medicines to help you quit. FDA. Updated September 25, 2018. Accessed May 11, 2021. www.fda.gov/consumers/free-publications-women/smoking-medicines-help-you-quit

20. Smoking cessation information & programs. Tobacco Free Florida. Accessed May 11, 2021.

21. Berg CJ, Krishnan N, Graham AL, Abroms LC. A synthesis of the literature to inform vaping cessation interventions for young adults. Addict Behav. 2021;119:106898.

22. Cuccia AF, Patel M, Amato MS, et al. Quitting e-cigarettes: quit attempts and quit intentions among youth and young adults. Prev Med Rep. 2021;21:101287.

23. Amato MS, Bottcher MM, Cha S, et al. “It’s really addictive and I’m trapped:” a qualitative analysis of the reasons for quitting vaping among treatment-seeking young people. Addict Behav. 2021;112:106599.

24. US Preventive Services Task Force; Krist AH, Davidson KW, Mangione CM, et al. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(3):265-279.

25. Vaping: this is quitting. a 24/7 support network. The Truth Initiative. Accessed May 11, 2021. www.thetruth.com/article/this-is-quitting

26. Chamberlain C, O’Mara-Eves A, Oliver S, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2013;10(10):CD001055.

27. Notley C, Gentry S, Livingstone-Banks J, et al. Incentives for smoking cessation. Cochrane Database Syst Rev. 2019;7(7):CD004307.

28. Livingstone-Banks J, Norris E, Hartmann-Boyce J, et al. Relapse prevention interventions for smoking cessation. Cochrane Database Syst Rev. 2019;(10):CD003999. ❒