The Vagaries of Vaping

There’s still a lot to learn about the risks and consequences of the so-called safe alternative to smoking. But what is known thus far is not encouraging.

The onset can be swift and the impact can range from severe to deadly. An inability to breathe. A tightness in the chest and a pain sharp enough to make anyone of any age assume heart attack. Coughing fits that can induce vomiting. Bouts of general nausea, fever, chills, and diarrhea. This varying scale of symptoms is becoming a sudden reality for the growing number of people in the United States who “vape” with the use of electronic cigarettes and other devices. Commonly associated with lung injuries that are sending people of all ages into hospitals nationwide, vaping, or the act of inhaling a vaporized heated liquid and exhaling the resulting vapor (or aerosol), has recently been attributed to more than 1,600 hospitalizations and nearly 40 deaths across the U.S.1

Frequently marketed as a safe alternative to smoking, albeit at a time when the rate of smoking in this country is said to be as low as it has ever been since statistical tracking began, the act of vaping is anything but safe, according to Janice Selekman, DNSc, RN, NCSN, FNASN. Making matters more dangerous is that it’s very likely that the average healthcare provider is coming into contact with patients who vape on a daily basis and are missing important opportunities to assess and educate people on the potential they face for being the next patient in a long line of those facing potentially fatal consequences — even when considering the ongoing movement to regulate and ban the devices and their ingredients. Worse yet, some providers may be misinformed to the point that they are actually recommending the use of e-cigarettes to some of their patients as a tobacco-cessation approach. Selekman and other health officials insist that this practice needs to stop and that better, more constructive conversations about the risks of vaping need to begin as early as intake assessment. The problem is … nobody seems to know where the risks truly begin and end.

A Range Of Risks

Defining what is safe and what is dangerous for one’s can be a bit of a slippery slope, especially when it comes to comparing cigarettes. The vaping optimist might boast that e-cigarettes don’t include tar, or that there are no matches needed to light the device and there’s no carbon monoxide. But to declare vaping as “safe” ignores the negative consequences that have been linked to the use of the related devices and might even reach a level of deceit, said Selekman. Any general declaration of vaping being hailed, as safe also may not take into consideration the contents of the liquid that one is vaping or where the liquids, chemicals, or devices are being acquired. Vaporizer products typically contain a propylene glycol or vegetable glycerin-based liquid with nicotine, flavorings, and other chemicals and metals. The potential use of nicotine is of particular concern among healthcare officials not only because it is one of the more highly addictive substances available, but the somewhat trend or fad associated with vaping currently comes at a time when there was finally overwhelming positive evidence of a reduction of nicotine intake in the U.S., especially among school-aged children and young adults, in response to the promotion of research warning people about the myriad risks associated with the drug. Additionally, more than 7,000 flavorings are said to exist,2 which leads many to believe that the target consumer remains adolescents, among nearly 500 brands of e-cigarettes. A more common method of vaping includes the addition of the cannabinoid tetrahydrocannabinol, better known as THC, a psychoactive ingredient found in marijuana. One of the oldest hallucinogenic drugs known, THC and its usage in a vaporizer is highly responsible for the rash of hospitalizations and death in the U.S., according to the Centers for Disease Control and Prevention (CDC).3 Selekman said the use of THC is also more commonly associated with the purchase of devices and products online or off the street, which is believed to increase the chances of severe and sudden side effects, such as lung injury, as compared to purchases made in retail stores, where states tend to require licensing and permits for sales to occur to those of respective legal age. Then, of course, is the general chance of becoming addicted.

“You are still inhaling the nicotine when you vape, so the risk for addiction is equal to that of regular cigarettes,” Selekman said. “And, in some cases, the nicotine levels are even higher in the electronic cigarettes.”

The amount of nicotine intake will vary based on what is placed in the pod and how deeply one inhales, something that can be very difficult for users to regulate, regardless of whether they are vaping as a substitute to smoking or if vaping is their introduction to nicotine. Still, the use of nicotine remains somewhat of an aside when it comes to the discussion of the safety of e-cigarettes. Another major concern that Selekman sees is the promotion of vaping through the lens that in the absence of nicotine other chemicals, such as they propylene glycol or vegetable glycerin, are approved for use by the Food & Drug Administration (FDA). “They are ‘generally regarded as safe,’ but they are only approved by the FDA for ingestion,” Selekman said. “They are not generally regarded as safe for inhalation.”

A national expert on high-risk behavior among adolescents, Selekman, who has been noted as being among the first healthcare experts in the country to raise awareness about the dangers of vaping, also has concerns about the ability for the estimated 2 million teens who use some form of vaping device to hide their marijuana4 through the use of vaporizers that resemble flash drives and wearing clothes that are designed to keep their devices hidden. “There are sweatshirts being made so that the straps coming from the hood are wide enough to hold the device,” she said. “Backpacks have an insert on the straps for devices. People are emptying highlighter markers to hold their devices. It’s a fad, it is the trend, it is the ‘in thing.’ The primary reason for vaping according to most surveys and research thus far is that the flavorings ‘taste good.’ And kids are smoking in school because they think that it is cool, that it is sneaky.”

Clinician Assessment & Recommendations

While research remains ongoing and judgments still need to be determined on such considerations as effects on fetuses and brain development among adolescents, Selekman said that secondhand vaping is known to be a consequence — though it will take time to understand what the health impact is on these individuals. There are also answers needed as to the impact that vaping might have on someone who has previously been a regular or heavy smoker as compared to someone who has only vaped. Those determinations could be years away.

“It took us decades to know the side effects of smoking,” Selekman said. “It’s not going to take us that long to know the side effects of vaping, although there may be some long-term effects that we know nothing about yet.”

She encourages all healthcare providers to review their patient health history forms to ensure that assessment for vaping is appropriately addressed and to think about how they might want to discuss the topic with their patients who are known users or who might inquire about vaping as a way to try to quit smoking. She advises that this is not an easy conversation to have, however, and that certain points must be made as clear as possible, given the unavailability of deep research at this time.

“If providers want to tell their patients that vaping is experimental, that’s one thing — because vaping is experimental,” she said. “And what has to be included with that directive is – when you smoke a cigarette, you know when it’s finished, no matter how much you inhale. When you smoke an electronic cigarette, there is not an ‘end.’” Many of the available pods for vaping hold approximately the amount of nicotine that’s found in an entire pack of cigarettes, according to Selekman, who suggests that any provider who speaks with a patient who vapes as an alternative to smoking to at the very least try to not inhale too deeply. “That’s not to say that electronic cigarettes should be ‘promoted,’ but it becomes important to try to assess how deeply someone is inhaling, and recommend that if they are trying to decrease their use that they consider taking smaller drags in,” Selekman said. “There is no science to this in the literature either, because nobody wants it to seem like they are promoting vaping by suggesting types of inhales. So if a patient has decided that this is what he or she is going to do, that the healthcare provider cannot change their mind – then communicating that there is a risk, and that they can perhaps try to keep track of how long a pod lasts so that they can maybe regulate usage. But I would never say ‘try it’ to a patient without doing some research first.

As for assessment forms, Selekman suggests asking, specifically, “Do you vape?” 

“We have to be really clear of what we’re asking,” she said. “The CDC has already changed the wording of its Youth Risk Behavior Surveillance System5 – and they ask about both tobacco and electronic devices. They are conducting that survey every two years so that they can track trends, and, as professionals, the words that we use on a questionnaire will impact the data that is collected.”

References

  1.     Corum, J. Vaping illness tracker: 1,604 cases and 34 deaths. New York Times. 2019. Accessed online: www.nytimes.com/interactive/2019/health/vaping-illness-tracker.html
  2.     E-cigarette flavors decrease perception of harm among youth. Science Daily. 2019. Accessed online: www.sciencedaily.com/releases/2019/10/191024122559.htm
  3.     Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. CDC. 2019. Accessed online: www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
  4.     Johnson, C. 2 million US teens are vaping marijuana. Associated Press. 2018. Accessed online: https://apnews.com/4674bd0e5f0a4a0795dcd58febf20a5a
  5.     Youth Risk Behavior Surveillance System (YRBSS). CDC. 2018. Accessed online: www.cdc.gov/healthyyouth/data/yrbs/index.htm

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