By Lilanthi Balasuriya MD MMS and Eliza Buelt MD
The use of electronic cigarettes and vaping related products continues to be a serious concern, as the Center for Disease Control (CDC) has reported over 2,807 cases of electronic cigarette or vaping product use associated lung injury (EVALI) nationwide and 68 deaths.1 These devices can deliver nicotine, cannabis, and contain other additives that can be dangerous to inhale.1 Electronic cigarettes and vaping products are also known as “e-cigarettes”, “e-cigs”, “vapes” “JUUL” and “electronic nicotine delivery systems (ENDS)”.1 What is unique to these devices is their ability to heat liquids that then become aerosolized and inhaled into the lungs. The contents of these liquids can contain a multitude of substances including nicotine, tetrahydrocannabinol (THC), cannabidiol (CBD) oil, diacetyl found in flavoring, formaldehyde, acrolein, vegetable glycerin, propylene glycol, and other compounds such as benzene (as found in car exhaust), and heavy metals.1 The particles created by these products are ultrafine and can cause serious harm as they are inhaled deeply into the lungs. 1 What adds to the danger of these products is that even though they may be advertised as containing no nicotine, the content may still be found to have nicotine.2
The health effects of using electronic cigarettes and vaping products are still under close investigation. Acutely, we have seen nearly 3,000 people hospitalized from electronic cigarette or vaping product use associated lung injury (EVALI). The most common presentations with EVALI have been respiratory in nature, along with gastrointestinal, and constitutional symptoms such as chills, fevers and weight loss.3
The substances that have been associated with EVALI cases are still under investigation, including a substance known as vitamin E acetate, which is known to be an additive in the vaping related products containing THC.3 Other acute impacts of vaping and electronic cigarette use include respiratory tract irritation, asthma exacerbation, wheezing, and coughing.4 Additionally, the use of electronic cigarettes causes oxidative stress as well as endothelial dysfunction and these are known factors that play a role in cardiovascular disease.5 There are also several elements found in the content of electronic cigarettes that have not been studied in the context of being heated and inhaled, such as heavy metals, propylene glycol (which when degraded can become propylene oxide, a class 2B carcinogen), and formalydege.4 It has also been found that electronic cigarette use is linked to higher risk of chronic lung disease such as asthma, immunosuppression, chronic bronchitis and emphysema.6 Further research is still needed to fully understand the short and long term health effects of electronic cigarette and vaping related products use.1 THC containing vaping related products have also been associated with difficulties in attention, learning and memory disturbances, and have also been associated with long term health disorders such as substance use, psychosis, anxiety, and depression.7
A great concern is the link between electronic cigarette use and the further use of traditional cigarettes, marijuana, alcohol, and other illicit substances.8 Electronic cigarettes can have similar levels of nicotine as compared to traditional cigarettes. The addictive potential of electronic cigarettes has been found to be comparable to traditional cigarettes and those who use electronic cigarettes also report stronger dependence.9
As mental health care providers, we know that our patients suffering from mental health conditions have higher rates of tobacco and smoking rates, and often smoke more heavily and have a more difficult time with smoking cessation.10-12 Patients with mental health conditions are also more likely to try electronic cigarettes.10 There are studies that show that electronic cigarette use is also associated with worse mental health status.13,14 Those who reported using electronic cigarettes in the past year also reported having histories of low self-esteem, impulsivity, PTSD, ADHD and anxiety.14 Use of electronic cigarettes over the course of 12 months was also associated with depression.15 The impacts of vaping products with marijuana, which often contain THC, can also be devastating on the developing brain, and has been associated with poor school performance, use of illicit substances, and substance use disorders, oppositional behavior, and impaired social relationships.7
As electronic cigarette and vaping related product use becomes more common in middle and high school, with over 27% of high school and 10% of middle school students indicating that they are using electronic cigarettes, it is imperative to educate our communities.16 Given the abundance of adverse effects, we must understand the role that prevention has, particularly in children and young adults when brain development is occurring.17
Everyone has a role to play in prevention, including healthcare providers, parents, teachers, and others who work with patients. It is important to ask all patients about their tobacco and substance use, including electronic cigarettes and vaping related products. The sensitivity of these topics requires that providers approach these questions with the utmost care, creating a non-judgmental and supportive environment.2 When educating, avoid criticism, and encourage open dialogue and know that conversations may occur over a period.1,18 Set a positive example yourself by not using electronic cigarettes or vaping related products.18
Connect your patient or the individual to resources such as the CDC or the Surgeon General’s webpage.17 Continue to remind and repeat recommendations, and provide facts and resources, as this is an ongoing conversation.1,18 Encourage patients and parents to use other resources that may exist in your area such as physicians, nurses, or school counselors.1,18 School based programs have also been found to be effective for youth.18 The take home message is talk to your patient about electronic cigarette and vaping related product use, educate on the dangers and risks, and make it an ongoing dialogue. Don’t wait, as the time is now for our patients to begin living their healthiest lives.
About the authors: Dr. Lily Balasuriya is a substance abuse and mental health services administration fellow for the American Psychiatric Association, a public psychiatry fellow at Yale, and chief of medical education in the Yale Department of Psychiatry. Dr. Eliza Buelt is a public psychiatry fellow and an instructor in psychiatry at the Yale School of Medicine.
References:
1. Center for Disease Control and Prevention. Smoking and Tobacco Use: Electronic Cigarettes. 2019; https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm. Accessed November, 2019.
2. Center for Diseaes Control and Prevention. Smoking and Tobacco Use- For Healthcare Providers https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.html. Accessed January, 2020.
3. Prevention. CfDCa. Smoking and Tobacco Use. For the Public: What you need to know. 2019; https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/need-to-know/index.html. Accessed Deember, 2019.
4. Qasim H, Karim ZA, Rivera JO, Khasawneh FT, Alshbool FZ. Impact of Electronic Cigarettes on the Cardiovascular System. J Am Heart Assoc. 2017;6(9).
5. Carnevale R, Sciarretta S, Violi F, et al. Acute Impact of Tobacco vs Electronic Cigarette Smoking on Oxidative Stress and Vascular Function. Chest. 2016;150(3):606-612.
6. Bhatta DN, Glantz SA. Association of E-Cigarette Use With Respiratory Disease Among Adults: A Longitudinal Analysis. Am J Prev Med. 2019.
7. General. OotS. U.S. Surgeon General’s Advisory: Marijuana Use and the Developing Brain. 2019.; https://www.hhs.gov/surgeongeneral/reports-and-publications/addiction-and-substance-misuse/advisory-on-marijuana-use-and-developing-brain/index.html. Accessed November, 2019.
8. Temple JR, Shorey RC, Lu Y, Torres E, Stuart GL, Le VD. E-cigarette use of young adults motivations and associations with combustible cigarette alcohol, marijuana, and other illicit drugs. Am J Addict. 2017;26(4):343-348.
9. Morean ME, Krishnan-Sarin S, Sussman S, et al. Psychometric Evaluation of the E-cigarette Dependence Scale. Nicotine Tob Res. 2019;21(11):1556-1564.
10. Cummins SE, Zhu SH, Tedeschi GJ, Gamst AC, Myers MG. Use of e-cigarettes by individuals with mental health conditions. Tob Control. 2014;23 Suppl 3:iii48-53.
11. Tidey JW, Miller ME. Smoking cessation and reduction in people with chronic mental illness. BMJ. 2015;351:h4065.
12. Spears CA, Jones DM, Weaver SR, Pechacek TF, Eriksen MP. Use of Electronic Nicotine Delivery Systems among Adults with Mental Health Conditions, 2015. Int J Environ Res Public Health. 2016;14(1).
13. Pham T, Williams JVA, Bhattarai A, Dores AK, Isherwood LJ, Patten SB. Electronic cigarette use and mental health: A Canadian population-based study. J Affect Disord. 2020;260:646-652.
14. Grant JE, Lust K, Fridberg DJ, King AC, Chamberlain SR. E-cigarette use (vaping) is associated with illicit drug use, mental health problems, and impulsivity in university students. Ann Clin Psychiatry. 2019;31(1):27-35.
15. Obisesan OH, Mirbolouk M, Osei AD, et al. Association Between e-Cigarette Use and Depression in the Behavioral Risk Factor Surveillance System, 2016-2017. JAMA Netw Open. 2019;2(12):e1916800.
16. Cullen KA, Gentzke AS, Sawdey MD, et al. e-Cigarette Use Among Youth in the United States, 2019. JAMA. 2019.
17. U.S. Department of Health and Human Services (USDHHS). E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_non-508.pdf. Accessed November, 2019.
18. Know the Risk. E-Cigarettes and Young People. Take Action. https://e-cigarettes.surgeongeneral.gov/takeaction.html. Accessed February 19, 2020.
