49 Unintended consequences of e-cigarette use: a public health epidemic

Michelle DeGeeter Chaplin, PharmD, BCACP, CDCES

Miranda Law, PharmD, MPH, BCPS

Introduction

Electronic cigarettes, also known as e-cigarettes, were first introduced by Herbert A. Gilbert, who patented a “smokeless tobacco cigarette” in August 1965 with a goal of providing a safe and harmless method for smoking.¹ First-generation e-cigarettes looked similar to traditional cigarettes, composed of a battery and a component to house nicotine solution (also called e-liquid or e-juice).¹ Over time, e-cigarette devices have evolved to resemble pens or USB flash drives, with availability of over thousands of e-liquid flavors.²

Initially marketed by companies as harmless, emerging research has shown that e-cigarettes are anything but. The majority of e-cigarettes contain nicotine in their e-liquid, which remains an addictive substance that can be detrimental to the development of learning, memory, and attention of youth.³ A commonly sold e-cigarette called JUUL provides its e-liquid in what is known as a pod, which can contain as much nicotine as a regular pack of 20 cigarettes.⁴ Unfortunately, an estimated two-thirds of youth choosing to use JUUL are also unaware that JUUL pods always contain nicotine, and therefore, may view it as harmless.⁵ Not only can the use of e-cigarettes cause nicotine addiction, but in 2020, the Centers for Disease Control and Prevention reported over 2,800 cases of vaping-associate lung injury across the United States.⁶

In the United States, the e-cigarette entered the market in the mid-2000s, and sales have rapidly increased since 2007. E-cigarettes are referred to by many different names, including “e-cigs,” “mods,” “vape pens,” and “vapes,” resulting in the term “vaping” to describe the use of an e-cigarette. Although companies selling e-cigarettes intended their products to be used as a safe way to deliver nicotine to adults who were already using traditional cigarettes, widespread advertisement campaigns of e-cigarettes pushed in both television and print promoting fruity flavors of e-liquid attractive to young people resulted in a very different reality. Accordingly, in 2013, it was estimated that 13.1 million middle school and high school students were aware of e-cigarettes, and by 2018, e-cigarette use among high school students was 20.8%, equating to an estimated 3.6 million youth.^3,7 E-cigarette use has now surpassed that of traditional cigarette use and is the most used tobacco product among youth.¹ E-cigarette use during youth has been shown to progress to traditional cigarette use later in life.^8,9 This can be particularly concerning as research shows this trend holds true for youth who begin e-cigarette use with no intentions of using traditional cigarettes in the future, resulting in a new population of cigarette users.⁸

Pharmacists have played an important role in tobacco cessation through motivational patient interviewing and counseling; similarly, there is also a role that the profession can play to address the growing public health epidemic of e-cigarette use, particularly among youth users. As health care professionals, we can emphasize recommendations from the Centers of Disease Control and Prevention to provide education on the potential for e-cigarettes to benefit adult non-pregnant smokers, and urge against the use of e-cigarettes for youth, young adults, pregnant women, and those who do not currently use tobacco products, emphasizing the harm they may cause.¹⁰ Importantly, although patient education and counseling are vital, it is also necessary to recognize education and counseling alone may be insufficient to fully address the current e-cigarette epidemic in the United States. Laws and policies, such as the Tobacco 21 law put into place in 2019, may need stricter enforcement to control the sales of such products to individuals under the age of 21.¹¹

Case

CC: “My child keeps getting in trouble for vaping at school and I need them to stop vaping.”

Patient: JL (they/them) is a 17-year-old patient (66 in, 50.1 kg) brought to the clinic by their mother for help in quitting vaping.

HPI: JL has been vaping for the past three years. They initially started vaping occasionally on the weekends when staying at friends’ houses, but now uses throughout the day every day, mostly related to stress and anxiety. They state they go through about 1 gram cartridge in 3-4 days. They use a variety of types, but most commonly JUUL. They either buy it from stores that they know will sell it to them or has their 18-year-old friends purchase it. JL’s mother has also purchased them several pens in the past when they were feeling anxious due to being out.

PMH: GAD

FH:

• Mother: current smoker; asthma
• Father: HTN; hyperlipidemia
• Two younger siblings: both healthy

SH:

• Vapes daily: mainly uses JUUL pods; occasionally borrows other types from friends
• Denies alcohol, cigarette, and illicit substance use
• Denies use of products with THC to their knowledge

Medications:

• Apri (ethinyl estradiol 0.03 mg and desogestrel 0.15 mg) one tablet daily

Allergies: NKDA

Vitals:

• BP 110/76 mmHg
• HR 96bpm
• RR 16/min
• Temp: 97.6°F
• Pain: 0 out of 10

Surgical history: none

Additional context: JL doesn’t understand why they are getting in trouble for vaping at school when they know that there aren’t any harms to using it. They say, “it’s not like smoking cigarettes like my mom does.” They keep the pen in their locker and uses it between classes at school. JL is interested in being able to reduce their use of vaping as they do not want to put their college plans in jeopardy with any more punishments but feels they can still safely vape after school and on weekends. They state by using it, they don’t feel they need to go to their counselor anymore for anxiety, because they use vaping to calm themself down.

Case Questions

1. What are the risks of using e-cigarettes in a teenager?

2. Does JL qualify for use of nicotine replacement therapy, Chantix, or Zyban?

3. What are the social and behavioral factors that may make quitting use of e-cigarettes difficult for JL? How might you help them to address them?

4. What are the risks of using e-cigarettes and their current medications together?

5. How does the marketing and availability of e-cigarette products affect their use by teenagers?

6. What are some action steps that pharmacists can take to help address this public health issue? Consider a variety of practice settings: community, hospital, outpatient, public health department, research.

Author Commentary

Addressing the use of tobacco and tobacco products is a role that pharmacists already play. By utilizing the Transtheoretical Model for Change or the 5 A’s approach, pharmacists can help a patient understand where they are at in their desire to make the change and meet them there to best help them achieve success. Understanding the importance of tobacco cessation and the negative consequences of nicotine addiction, pharmacists can also address rising e-cigarette use in youth and adults. It is important for pharmacists to stay abreast of emerging data regarding e-cigarette use. The CDC provides updates on e-cigarette, or vaping, product use-associated lung injury (EVALI) that are useful for pharmacists to be aware of. Equally important is staying up to date on the long-term consequences of vaping and its impact on comorbid health conditions.

Patient Approaches and Opportunities

Pharmacists have tools (Transtheoretical Model for Change or the 5 A’s approach) available to provide education to youth and adults in multiple settings regarding the dangers of e-cigarettes. Pharmacists may collaborate with schools to provide classroom education on the potential consequences of vaping. These education sessions may help in addressing some of the myths about vaping (i.e., JUUL pods not containing nicotine) and lead youth to make smarter decisions regarding vaping. Education should be unbiased, and evidence based. Pharmacists should address the influences of peer pressure and include tips on how to combat it and should include motivational messages to discourage youth from picking up potentially addictive and detrimental behaviors. With each encounter, either individual or in group settings, pharmacists can assess the use of vaping devices and if a patient desires to quit. As the scope of pharmacists continue to expand to prescribing pharmacotherapy for tobacco and vaping cessation, pharmacists will play an even larger role in serving patients. Under current regulations, pharmacists can still be valuable in assess and recommending OTC products as well as connecting patients with prescribers and resources.

As scopes of practice expand, pharmacists prescribing appropriate pharmacotherapy to tobacco users trying to quit will also be key. Additionally, if and when possible, pharmacists can also be part of the larger movement to enact policies that increase enforcement on the sale of e-cigarettes to minors. The e-cigarette pandemic must be tackled from multiple perspectives to really be able to find a sustainable solution.