How to Approach Your Patients on Vaping and Smoking Cessation

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Physicians should remember that electronic nicotine is not an FDA-approved method for smoking cessation.
Physicians should remember that electronic nicotine is not an FDA-approved method for smoking cessation.

The ENDS — electronic nicotine delivery systems — are not just near, but already here. As a family physician, I spend a significant portion of my day trying to get patients to quit smoking, or trying to get adolescents to not begin smoking. This has been a thorn in the physician's side for years. 

While there is no doubt that there has been significant progress, 25% of adults still smoke cigarettes, down from approximately 50% of adults in the 1960s. 

This is rather ridiculous, since the first connection between cigarette smoke inhalation and lung cancer was initially suggested more than 90 years ago. So if we know the dangers of cigarettes are so great, why do people still begin smoking? While there are many contributing factors — including socioeconomic status, parental exposure, lack of education — I am convinced that in adolescents, the main reason they begin to smoke is to look older or cooler. 

Unfortunately, as we know, if one wishes to age more rapidly, physiologically speaking, smoking is a great way to speed up that process. 

When patients come in to work on smoking cessation, they frequently inquire about my thoughts on electronic cigarettes or vape pens and whether they are a viable aid for smoking cessation.  Many are already using vape pens or e-cigarettes by the time they get to me. Often they begin with dual usage in conjunction with combustible cigarettes.

While I am always happy when a patient expresses motivation to quit smoking, e-cigarettes (or ENDS) are not an FDA-approved method for smoking cessation.

“Vaping” is a new word in the dictionary — a verb meaning to inhale the vapor of an electronic cigarette or vapor pen. Who is using ENDS? A lot of people, including approximately 3 million high school- and middle school-age children. Most are under the impression that e-cigarettes and vape pens are not harmful.  

What is in these pens? Generally, a combination of nicotine, flavoring — which is made up of chemicals — and a solvent of glycerin or propylene glycol. A battery heats the solution to vapor, which is then inhaled. There are approximately 7700 different flavors available, making ENDS attractive to people, particularly to adolescents. 

The substances contained in ENDS, however, are far from benign since some of their byproducts are potential carcinogens.

Many people, including adolescents, are frequently under the impression that they are just inhaling water vapor and nicotine; this is not the case. There are no good studies available to support the safety or efficacy of ENDS as an option for smoking cessation.   

There is good data, however, that nicotine replacement and varenicline together are effective in smoking cessation. Bupropion is another potential option, and is better than just nicotine replacement alone. Can e-cigarettes be used here? Possibly. However, other delivery methods, such as the patch, lozenges, or gum, when used as directed or prescribed, have a more proven safety record.

On the other end of the spectrum, it is important to screen adolescents at their visits for any form of nicotine use, including vaping, due to the staggering numbers of adolescents using ENDS that I mentioned. While adults may use e-cigarettes to aid in smoking cessation, adolescents may start with vaping, become dependent on nicotine, and then move to combustible nicotine. 

They are often under the impression that there is no risk to them from using these vapor products. There is some evidence, also, that vaping may increase their risk for substance use down the line. 

In 2016, the US Food and Drug Administration (FDA) ruled that ENDS could not be sold to individuals younger than 18. Now, there is actually a black market for selling vape pens in high schools. 

Whatever the reasons our patients start vaping, whether it is an adolescent trying to be cool, or an adult working on smoking cessation, one thing is for sure: vaping is likely here to stay as this is a rapidly growing market.

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