4 minute read
Access to Treatment for Young Adult E-cigarette Users
Although the fight to mitigate the health risks of e-cigarette use (vaping) has remained hypervigilant regarding adolescents and youth in general, it has tended to focus less on the important demographic of young adults. While their use of harmful e-cigarettes continues to increase, young adults face unique barriers to evidence-based cessation treatment, placing additional stress on clinical settings for effective provider intervention.
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In a recent study on a nationally representative sample, a 42% increase in e-cigarette use was observed in young adults from 2017 to 2018. This paralleled an increase among middle and high school students in the US. Although this growing cohort of vape users is exposed to fewer toxicants than traditional cigarette smokers, they are nevertheless exposed to significantly higher levels of known human carcinogens and heavy metals than never-users.
Given this alarming increase in addiction and toxicant exposure from vaping, it is essential to the health of each community to provide young adults with proven cessation tools such as Nicotine Replacement Therapy (NRT). NRTs include the inhaler, nasal spray, patches, gum, and lozenges, which have all been FDA-approved for sale to people 18+.
A substantial barrier to access to over-the-counter (OTC) NRT for young adults was explored in a recent study by the University of Rochester Smoking Research Program, which uncovered a substantial barrier to young adults’ access to over-the-counter (OTC) NRT in Monroe County. Contact with nearly 50 local pharmacies revealed that a majority of big chains had incorrectly increased the purchasing age of OTC NRT from 18 to 21. This change was widely attributed (mistakenly) to the recent laws raising the minimum sales age of tobacco products (both traditional and electronic) from 18 to 21. Though designed to ban the sale of “tobacco products”, the law did not explicitly include any NRT, whether via prescription or OTC. As a consequence, more responsibility may be placed on provider clinical interactions to provide NRT via prescriptions, rather via OTC, for young adult e-cigarette users wanting to quit.
Because of the novelty and highly variable nicotine content of e-cigarettes and the paucity of published research studies, there are no standardized guidelines for NRT use for vaping cessation. To better understand NRT best practices for e-cigarette users, a follow-up qualitative study was conducted by the Smoking Research Program involving interviews with local primary care providers and local and national vaping experts to identify emerging themes that lead to successful treatment. Resulting recommendations include:
1.Asking patients specifically about “vaping” 2.Using an e-cigarette dependence scale to gauge the severity of nicotine addiction 3.Combination therapy (e.g., patch plus gum) 4. Referral to the New York State Smokers Quitline and
Quitsite
It is important to ask patients specifically if they are “vaping” as opposed to “smoking” or “using tobacco” because patients may not consider their vaping as either “smoking" or “tobacco”. This was seen as vital to starting the conversation about health risks, and for leading patients to effective treatment. And good news, as of July 2020, Medicaid now allows for as “many sessions as medically necessary” for tobacco cessation counseling sessions.
There are several validated scales to assess the severity of nicotine addiction. For example, the “Four-Item E-cigarette Dependence Scale” quantifies the level of nicotine dependence and guides how aggressively to treat nicotine dependence with NRT. A patient that is highly dependent on e-cigarettes may need higher doses of NRT to successfully moderate cravings.
Finally, for the best treatment outcomes, combination therapy is recommended. Combination therapy uses both a long-acting nicotine formula, like the patch, with an episodic nicotine formula, such as with the gum or lozenge. It is also important to be sure that patients know they should be using their episodic NRT on a schedule of at least 8x a day to maintain nicotine levels required to curb cravings and prevent relapse. Generally, patients should begin to taper their NRT use based on their comfort and severity of withdrawal symptoms after 4-8 weeks with complete cessation in 8-12 weeks.
The biggest downside to combination therapy is cost. However, physicians in New York should be aware that, at the time of this publication (Fall, 2020), the NYS Smokers Quitline is giving out 3 months of free nicotine gum (a full course of treatment) until January 2021 (for more information go to nysmokefree.com). By increasing young adult’s access to NRT, providers can help increase cessation, improve the health of the community, and prevent adverse health outcomes.
Authors:
Elijah M. Goldberg, Reena Caplash, Manpreet Kaur, Emily Lewis, Astghik Baghinyan, Matt Quick, Jacqueline Attia, Krystalyn Bates, Jaqueline Attia, Molly McNulty, Deborah J. Ossip, Scott McIntosh University of Rochester Medical Center
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