Vaping - Is It Safer Than Smoking?

Vaping - Is it safer than smoking?

Donna Bond, DNP, RN, CCNS, AE-C, CTTS, FCNS - CRMH Clinical Nurse Specialist - Pulmonary/Trauma Focus

Electronic cigarettes appeared in the United States between 2006-2007.1 From the beginning, vape companies have advertised their products as being a safe alternative to combustible tobacco (smoking) without solid evidence of this claim. Since the beginning of the product appearing the in the United States, the FDA (US Food and Drug Administration) has tried to regulate the products; however, the companies producing the vape products, primarily tobacco companies, have been a step or two ahead of the regulations. Vaping exploded in 2014, with more than a tripling of people using vape products. More alarming was the rapid increase in youth using vape products as a first experience with nicotine, not as a method of cessation of a tobacco product. This may have been related to the products being pleasingly flavored and targeted advertising. Until that time, sales of vape products were mostly to adults who used the product as a smoking cessation aide. This all changed with the formation of Juul and advertising by young influencers on social media.1 The number of new smokers of combustible tobacco had been slowly decreasing over the decades since the first surgeon general’s report in 1988 that identified the health risks of tobacco and the addictiveness similar to heroin or cocaine.2 It was thought that by the next generation (2000’s), smoking would become almost non-existent. Vaping has changed that trajectory.

Adults (https://news.gallup.com/poll/1717/tobacco-smoking.aspx)

Youth (https://khn.org/news/vaping-by-the-numbers/)

What is vaping?

Vaping is the use of some type of base/battery and a heating element that vaporizes a liquid allowing the user to inhale the product.1 The amount of nicotine varies, and since the product is not regulated, the labeling is not reliable. There is now a fifth generation of vaping products that have been manufactured to be easier to conceal by youth using the products. The liquid used in this product is called “vape juice”. The juice contains 10% water, food flavoring, nicotine and 90% of either vegetable glycerin or propylene glycol (yes, that is the same as the chemical in antifreeze). Most products use a combination of both. Both products increase mucus production and produce toxic aldehydes when heated. The flavors are food safe, not lung safe. For example, vanilla and cinnamon flavors cause cytotoxicity and ciliary dysfunction when inhaled. Butter flavored (diacetyl) can cause pulmonary toxicity leading to bronchiolitis obliterans. When tested, it has also been found that levels of nicotine are significantly higher in US products (59 mg/ mL) when compared to products in the UK (18 mg/mL).

Is vaping safer than smoking?

Maybe. Do they help smokers quit using combustible tobacco? Again, maybe. But we have proven smoking cessation medications that have been shown to be safe and effective since 1984. The reason people may not have had success with the over-the-counter nicotine replacement therapy may be due to

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Practical Applications of Nursing Inquiry

under-dosing. This will be discussed later. So, is there evidence about vaping leading to the decreased use of combustible tobacco? In a 2019 study of 886 adult smokers, twice as many smokers quit using e-cigarettes (19% versus 9.9%) than Nicotine Replacement Therapy (NRT).3 A longitudinal study of 2 years found that people using e-cigarettes were more likely to remain cigarette free.4 In both studies, the people who quit using tobacco were still using the e-cigarette. England found in their country, with lower nicotine levels, no advertising of e-cigarette products and low youth vaping rates, e-cigarettes were a vgood substitute for smoking combustible tobacco.5 A systematic review of 577 studies identified those who used e-cigarettes had higher quit rates than those who did not use e-cigarettes6, however no major organization (US Preventative Services Task Force, American Cancer Society, American Thoracic Society or the Centers for Disease Control)7-10 have recommended using e-cigarettes as a stop smoking method. The National Academy of Science, Engineering, and Medicine acknowledges that while e-cigarettes are “not without health risks, they are likely to be far less harmful than smoking combustible tobacco cigarettes”.11

What are the risks of vaping?

The main health risk identified so far is using the vaping product as a gateway to cigarettes use. This is particularly true in youth, but other non-smokers have progressed from e-cigarettes to combustible tobacco. There was also an outbreak of E-cigarettes or Vaping Associated Lung Injury in 2019.12 This was traced to the use of vitamin E acetate in illicit THC vaping products. These injuries peaked in September of that year with 2,807 hospitalizations and 68 deaths recorded, primarily in younger 18–34-year-old people using vape products. The takeaway from this outbreak is the lack of research and regulation of the products. They cannot be assumed to be safe.

What is the best way to quit smoking?

The best way to quit using any product that contains nicotine is counseling and pharmacological support. At any time, about 50-70% of smokers want to quit using tobacco products.13 It usually takes about six quit attempts before completely stopping, but that statistic is from trying to quit “cold turkey”.10 Nicotine Replacement Therapy (NRT) is very effective in helping people control their cravings. Most people do not use enough of the NRT product. See table below for recommendations.14

The suggested weaning method of multiple NRT products is to decrease the use of the gum/lozenges; then decrease the patch amounts, but others have had success with weaning patches first, followed by reduction of the gum/lozenges. Some people may choose to keep using NRT long-term, which also occurs with e-cigarettes, and like e-cigarettes, using NRT long term is associated with less carcinogens and toxins when compared with combustible tobacco.15

Number of cigarettes/pouches smokeless tobacco

1 ½ packs per day OR > 2 cans/pouches per day ½ packs per day OR 1 can/pouch per day ½-1 pack per day OR < 1 can/pouch per day < ½ pack per day OR Weighs < 45 kg (100 lbs)

NRT Product

21 mg patch every day PLUS 1-15 pieces of 4 mg NRT gum/lozenges per day 21 mg patch every day PLUS 1-15 pieces of 2 mg NRT gum/lozenges per day 14 mg patch every day PLUS 1-15 pieces of 2 mg NRT gum/lozenges per day 14 mg patch every day PLUS 1-15 pieces of gum/lozenges per day

Weeks 1-6 Weeks 7-9 Weeks 10-12

NRT Gum Weaning

1 piece every 1-2 hours 1 piece every 2-4 hours 1 piece every 4-8 hours

Weeks 1-2 Weeks 3-4 Weeks 5-6 Weeks 7-9

NRT Patch Weaning

Strength as ordered Decrease to next lower strength Decrease to next lower strength Decrease to next lower strength or discontinue

In conclusion, use of vaping or electronic cigarettes MAY assist in people who use combustible tobacco products to quit their use; however, is the health risk to the youth of American a risk we are willing to take?

References

1. Dinardo, P., Rome, E. (2019). Vaping: The new wave of nicotine addiction. Cleveland Clinic Journal of Medicine, 86(12), 789798. 2. United States Office on Smoking and Health. (1988). The health consequences of smoking: nicotine addiction: a report of the surgeon general. DHHS publication retrieved 12/13/2022 from https://stacks.cdc.gov/view/cdc/22014. 3. Hajek, P., Phillips-Waller, A., Przulj, D., et al. (2019). A randomized trial of E-cigarettes versus nicotine replacement therapy.

New England Journal of Medicine, Retrieved 2/14/2019 from NEJM.org, 629-637. 4. Kalkhoran, S., Chang, Y., Rigotti, N. (2020). Electronic cigarettes use and cigarette abstinence over 2 years among US smokers in the population assessment of tobacco and health study. Nicotine & Tobacco Research, 728-733. 5. Whelan, S. (2017). Highest smoking quit success rates on record. Public Health England. Retrieved 12/13/2022 from: www.gov.ek/government/news/highest -smoking quit success-rates on record#. 6. Kalkhoran, S., Glanta, S. (2019). E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. Lancet Respiratory Medicine, 4(2), 116-128. 7. US Preventive Services Task Force. (2021). Interventions for tobacco smoking cessation in adults, including pregnant persons. JAMA, Retrieved 12/13/2022 from: https://www.uspreventiveservicestaskforce.org/uspstf/announcements/finalrecommendation-statement-interventions-tobacco-smoking-cessation-adults-including-pregnant-persons#:~:text=January% 2019%2C%202021%20%E2%80%94%20The%20U.S.%20Preventive%20Services,to%20proven%2C%20safe%20methods% 20to%20help%20them%20quit. 8. Leona, F., Zhang, Y., Evers-Casey, S., et al. (2020). Initiating pharmacologic treatment in tobacco dependent adults.

American Thoracic Society Documents, Retrieved 12/13/2022 from: https://www.obgproject.com/2020/10/09/americanthoracic-society-initiating-pharmacologic-treatment-in-tobacco-dependent-adults/#:~:text=ATS%20Smoking%20Cessation% 20Recommendations%201%20Varenicline%20superior%20for,patch%20No%20difference%20in%20SAEs%20compared% 20to%20bupropion.

9. American Cancer Society. (2019). E-cigarettes should not be used to quit smoking. American Cancer Society Position Statement on Electronic Cigarettes, Retrieved 12/13/2022 from: http://pressroom.cancer.org/eCigs2019#:~:text=ACS%E2%80% 99s%20new%2C%20clarified%20position%20is%3A%20No%20youth%20or,e-cigarettes%20should%20not%20be% 20used%20to%20quit%20smoking

10. Centers for Disease Control and Prevention. (2021). Electronic Cigarettes. Retrieved 12/13/2022 from: https://www.cdc.gov/ tobacco/basic_information/e-cigarettes/index.htm

11. National Academies of Science, Engineering and Medicine. (2018). New report one of the most comprehensive studies on health effects of e-cigarettes; Finds that using e-cigarettes may lead youth to start smoking , adults to stop smoking.

Retrieved 12/13/2022 from: https://www.nationalacademies.org/news/2018/01/new-report-one-of-most-comprehensive-studies -on-health-effects-of-e-cigarettes-finds-that-using-e-cigarettes-may-lead-youth-to-start-smoking-adults-to-stop-smoking.

12. Xantus, G., Gyamathy, A., Johnson, C. (2020). Smoldering ashes: burning questions after the outbreak of electronic cigarette or vaping associated lung injury. Postgraduate Medical Journal, 6(1141), 686-692. 13. Rigotti, N., Kruse, G., Livingstone-Banks, J., Hartmann-Boyce, J. (2022). Treatment of tobacco smoking: a review. JAMA, 327 (6) 566-577. 14. Lindson, N., Chepkin, S., Ye, W., et al. (2019). Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database Systematic Reviews, Issue 4. 15. Shahab, L., Goniewicz, M., Blount, B., et al. (2017). Nicotine, carcinogen, and toxin exposure in long-term e-cigarette and nicotine replacement therapy users: a cross-sectional study. Annals of Internal Medicine, 166 (6), 309-400.