E-Cigarettes: What Healthcare Professionals Need to Know
Smoking is deadly, but its dangers are preventable. The devastating harm caused by smoking, and the resulting litigation and regulations, has brought about a change to industry strategies, leading to the creation of alternative products that may be less harmful than smoking. Since 2007, e-cigarettes and novel nicotine products have significantly shifted the US tobacco/nicotine market and how tobacco products are used. Due to the changing products, market, and new patterns of use, different health messages are required for various patient groups. This slideshow will help healthcare professionals (HCPs) better understand e-cigarettes and vaping, how patients are using these products, and how to talk to each category of patients about these products.
Disclaimer: Research reported in this presentation was supported, in part, by grant number P50DA036128 from the National Institute on Drug Abuse (NIDA) and the US Food and Drug Administration (FDA) Center for Tobacco Products (CTP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH) or the FDA.
Disclaimer: Research reported in this presentation was supported, in part, by a grant from Pfizer, Inc. for the "Diffusion of Tobacco Control Fundamentals to Other Large Chinese Cities." The content is solely the responsibility of the authors and does not necessarily represent the official views of Pfizer, Inc.
E-Cigarettes: What Healthcare Professionals Need to Know
Executive Summary
Fundamentally, the following guidance is recommended:
- No nicotine products of any kind should be used by youth or teens.
- Fully educate adult smokers so they can make informed decisions regarding nicotine and tobacco use. HCPs should ensure patients understand that neither combustible cigarettes nor electronic cigarettes (e-cigarettes) are safe, but that noncombustible products are likely less harmful than smoking. Advise patients that if they transition to an alternate noncombustible product, the only way to reduce the devastating risks from smoking is to cease using combusted cigarettes and only use the alternative product. Dual use (ie, using two tobacco products at the same time) should also be avoided.
- Much debate exists around whether e-cigarettes help smoking cessation. The products available constantly change, and there are conflicting findings from studies. Although the results are mixed, it is possible that e-cigarettes—used properly, daily, and exclusively—could benefit smokers. If e-cigarettes are used, they should be used exclusively (no polytobacco use of e-cigarettes and other nicotine products, including cigarettes). Once smoking cessation is achieved and there is no chance of relapse, every effort should be made to also stop e-cigarette use.
- It is important for HCPs to step beyond the clinical setting and engage in policy changes that potentially prevent nicotine use, especially among young people. In addition, HCPs should advocate for regulation of all nicotine products to improve population health. Research, education, and communication are needed to help ensure the public has the most up-to-date, science-based information available to make informed decisions about use.
- HCPs should have real, meaningful conversations with patients about their nicotine or tobacco use during every encounter. E-cigarette use has grown in the United States over the last decade, and HCPs should feel confident discussing e-cigarettes and vaping with their patients.
- Vaping is an incredibly dynamic situation, as evidenced by the youth epidemic of e-cigarette use and the recent US respiratory illness outbreak, which was likely associated with the illicit sale of contaminated tetrahydrocannabinol (THC) products.[1] It is crucial for clinicians to stay updated on findings from credible medical and public health resources to monitor changes in the environment, use/misuse of vaping products, and regulatory action. The patient encounter is one of the best ways for HCPs to understand how consumers are using these products.
- HCPs are encouraged to remain focused on reducing and eliminating cigarette use by any means feasible and discussing e-cigarettes to ensure a net public health benefit.
E-Cigarettes: What Healthcare Professionals Need to Know
Smoking Is Deadly; Combustion Is the Primary Reason
Cigarette smoking causes 480,000 deaths each year in the United States.[2] Most of the harm from smoking is the result of chemicals generated from combustion. Burning a cigarette creates thousands of chemicals and compounds, hundreds of which are toxic, and at least 70 of which are known carcinogens (eg, tobacco-specific nitrosamines [TSNAs]).[3] TSNAs are repeatedly inhaled into the body, and habitual exposure over decades can lead to the development of cancer.[4-7]
The smoking of combustible cigarettes has been one of the largest public health challenges in recent US history. Smoking cigarettes results in death in half of all users and costs more than $300 billion in lost life and productivity (nearly $170 billion in medical care for US adults, and over $156 billion in lost productivity due to premature death and secondhand smoke exposure).[2,8,9]
E-Cigarettes: What Healthcare Professionals Need to Know
The History of E-Cigarettes and Today's Booming Industry
The first e-cigarette was introduced in China in 2004 as a smoking alternative or smoking cessation device[10]; it was first marketed in the United States in 2007.[11]
Most e-cigarettes deliver nicotine, but not all contain nicotine. Some individuals, particularly young people, may use these for vaping flavors without nicotine. Others may vape to deliver psychoactive substances, such as THC (the primary psychoactive compound in marijuana) or cannabidiol (CBD) (a common ingredient in marijuana).[12]
In the past few years, e-cigarette use has expanded significantly and represents a huge global industry (valued at US $13 billion in 2019).[13] Not surprisingly, the rapid growth of these products has caused a disruption to the traditional tobacco market.
E-Cigarettes: What Healthcare Professionals Need to Know
E-Cigarette Market: Youth Use Versus Adult Use
Although e-cigarettes were purportedly intended for adults as a smoking cessation product, it is no surprise they have become particularly popular with young people.
In the United States, JUUL, founded in 2016, is the dominant e-cigarette of choice for young people. As of late 2019, JUUL held 64.4% of the e-cigarette market share, and its products have become so popular its name is now used as a verb: "juuling."[14] Juuling is a phenomenon among youth: Those aged 15-17 years are more than 16 times as likely to be current JUUL users compared to adults aged 25-34 years.[15]
Relatively recent events have resulted in JUUL taking financial write-downs in 2019 and again in early 2020[16] (eg, replacement of the chief executive officer, proposed regulation of e-cigarette flavors, other regulatory and marketing factors[17]). The devaluation of JUUL is almost wholly due to youth use and the actions taken by local, state, and federal authorities to mitigate youth e-cigarette use. While the focus has been on JUUL and addressing youth use of these items, other products have become increasingly popular and have mostly escaped regulation.
E-Cigarettes: What Healthcare Professionals Need to Know
Regarding adult smokers, tobacco companies are now in the race to develop potentially less harmful products. All major tobacco companies have their own brands and are marketing e-cigarettes and alternative products with a focus on appealing to a more appropriate audience, specifically current smokers. For example, Philip Morris International has a marketing campaign titled "It's Time to Unsmoke," which encourages smokers who don't quit to change products.[18] However, owing to the deceptive legacy of tobacco companies, many question the sincerity of these efforts.
E-Cigarettes: What Healthcare Professionals Need to Know
Absolute Versus Relative Risk for Adult Use:
Are E-Cigarettes Safe? Safer Than Smoking?
Many individuals, especially adult smokers, want to know if e-cigarettes are safer than combustible cigarettes. Frequent and recent news coverage on the harms associated with vaping has made it clear that there are health risks from e-cigarette use and vaping. Let's call this absolute risk.
HCPs should communicate to adult smokers that although there continues to be disagreement, it is likely that noncombusted nicotine products are relatively less harmful than combusted products. Let's call this relative risk. Although e-cigarettes may be less harmful than cigarettes, no adequate trend data exist yet for understanding the long-term health consequences of e-cigarettes and vaping.
A 2018 report by the US National Academy of Sciences demonstrates the relative and absolute risk of e-cigarettes with the following statements[19]:
- "Overall, e-cigarette aerosol contains fewer numbers and lower levels of toxicants than smoke from combustible tobacco cigarettes."
- "Overall, the evidence reviewed by the committee suggests that e-cigarettes are not without biological effects in humans."
E-Cigarettes: What Healthcare Professionals Need to Know
Other countries (eg, United Kingdom) embraced e-cigarettes from an early stage. In 2015, Public Health England cited a 2013 expert panel review stating "…e-cigarettes are around 95% less harmful than smoking."[20] This statistic has been highly controversial, yet the United Kingdom has maintained its position of the relative safety of e-cigarettes over traditional cigarettes.[21] In 2020, the American Journal of Public Health released their review of this 95% statistic, noting the differences in vaping products and technology since 2013 as well as the evolving research indicating harm from aerosols and e-cigarette use.[22]
In the United States, the debate surrounding e-cigarettes remains. Additional research is needed regarding the long-term health effects of e-cigarette use. The epidemic of youth e-cigarette use makes it difficult to embrace e-cigarettes, yet these products may have a role in helping adult smokers quit a deadly habit. This calculation of the harm caused by youth vaping balanced by the potential benefit from adult cessation is at the center of the FDA's need to determine whether there is a net public health benefit prior to authorizing these novel products for domestic sale.
E-Cigarettes: What Healthcare Professionals Need to Know
Prevalence of E-Cigarette Use in Youth and Young Adults
Adolescent smoking rates are decreasing. The Healthy People 2020 goal for teens (grades 9-12) who smoked cigarettes in the past 30 days was 16%; the actual prevalence in 2017 was only 8.8%.[23] Unfortunately, this drop has been accompanied by a rapid increase of e-cigarette use among youth. In 2014, e-cigarette use surpassed cigarettes as the most used tobacco product among youth.[11] The 2019 National Youth Tobacco Survey found that 27.5% of high school students and 10.5% of middle school students were current e-cigarette users (past 30-day use),[24] the equivalent of 5 million youth reporting e-cigarette use in the past month and nearly 1 million youth reporting daily e-cigarette use.[24]
The percentage of young adults (ages 18-24) who currently smoked cigarettes fell from 16.7% to 7.8% between 2014 and 2018.[25] At the same time, the percentage of young adults who currently used e-cigarettes rose from 5.1% to 7.6%. In 2016, the Behavioral Risk Factor Surveillance System Survey found that 44.3% of young adult current e-cigarette users were never smokers before trying e-cigarettes.[26] This age group is particularly interesting to assess as they do not fall completely in the category of youth or adults, and their changing nicotine use patterns may be predicative of future use trends among adults.
E-Cigarettes: What Healthcare Professionals Need to Know
Polytobacco use (use of ≥2 tobacco products) among youth and young adults is a major concern as it exposes them to higher levels of nicotine, and trying a larger number of tobacco products is associated with a lower perception of their harm.[27] Polytobacco use also includes vaping other products, such as THC or CBD and other substances (see slides 12 and 13), which complicates not only health effects but also diagnosis and clinician counseling.
This age group is unique as they were never subjected to minimal cigarette advertisements over the years but are now exposed to e-cigarette advertising. A study funded by the National Institute on Drug Abuse (NIDA) found that young people aged 12-21 years who had not previously smoked but were receptive to e-cigarette advertising were 60% more likely to try cigarettes 1 year later.[29]
As of December 20, 2019, it is illegal in the United States to sell tobacco products to individuals younger than 21 years.[29] A 2015 Institute of Medicine report estimated that raising the minimum age of legal access to tobacco products from 18 to 21 years would result in 249,000 fewer premature deaths for those born between 2000 and 2019.[30] Future research and surveillance will help clinicians and policy makers understand if this new law reduces initiation of tobacco products among young adults. Meanwhile, it is important that HCPs reinforce with young adult patients that the sale of tobacco products to those under age 21 is criminal.
E-Cigarettes: What Healthcare Professionals Need to Know
How Adults Use E-Cigarettes
Cigarette smoking is gradually declining among US adults aged 18 years and older as revealed by the National Health Institute Survey (NHIS), which has recorded adult cigarette prevalence since 1965. Between 2009 and 2017, smoking prevalence in this population fell from 20.6% to 14%[31]; in 2018, it reached an all-time low at 13.7%.[32] However, despite the gradual drop in the rate of cigarette smoking, tens of millions of adults still smoke and other tobacco products have gained popularity. In 2017, 6.9 million adults (2.8%) used e-cigarettes every day or some days.[33]
Unfortunately, US adults are also polytobacco users. This is a major public health concern as it may result in addiction to higher levels of nicotine and continued tobacco use, while not providing any health benefit. In 2017, 9 million (19%) current tobacco users used two or more tobacco products, with e-cigarettes and traditional cigarettes the most frequent dual product combination (31%).[33] Dual use typically occurs when an adult smoker uses e-cigarettes to help with cessation or to use in locations where they cannot smoke (eg, work, restaurants).
Interestingly, youth are more likely to use e-cigarettes than smoke, young adults use both products almost equally, and adults are more likely to smoke than vape. HCPs should be aware of these general product usage trends among their patients.
E-Cigarettes: What Healthcare Professionals Need to Know
Unknowns of Aerosolizing
It can be difficult for consumers to know exactly what is in their e-cigarette product. Indeed, some devices that claim to have 0% nicotine do in fact contain nicotine.[34] E-cigarettes do not create the same toxins as combustion, but current evidence suggests that vaping (inhaling highly heated chemicals, particularly propylene glycol), irritates the cardiovascular and respiratory systems and imposes health risks.[35,36] Vapers can inhale and exhale substances in the aerosol such as those shown in the image above.[11]
Research is still required to understand the long-term health effects of e-cigarette use. Flavors may seem benign because they can be safely added to food and are on the FDA's list of "Generally Recognized as Safe" (GRAS) substances.[37] However, this standard only applies to ingesting these chemicals; it is not known what health effects may be caused by heating, aerosolizing, and inhaling a product deeply into the lungs. For example, cinnamon is a flavor that is safe in food but shows evidence of lung cell damage when aerosolized and inhaled in e-cigarettes.[38]
To reiterate, although likely safer than smoking, the long-term health consequences of e-cigarette use and vaping are unknown. HCPs should communicate this uncertainty to patients.
E-Cigarettes: What Healthcare Professionals Need to Know
E-Cigarette Flavors Abound and Complicate
In early 2014, more than 7,700 e-cigarette flavors were available[39]; in 2017, there were over 15,500.[40] HCPs should consider the youth versus adult pendulum when evaluating flavors. Findings from a 2019 systematic review support indications that nonmenthol flavors in e-cigarettes lower harm perceptions and raise willingness to try e-cigarettes among youth and adults.[41] Although flavors are most appealing to young people and contribute to their experimentation with and initiation of e-cigarette use, adults trying to quit smoking also find them attractive. Thus, policy makers should consider regulating flavors in such a way to prevent youth from trying e-cigarettes but also does not discourage adults from smoking cessation.[42]
Youth most commonly use e-cigarettes because a friend or family member uses these devices (39%), the abundant availability of flavors (31%), and the belief that these products are less harmful than other tobacco products, such as cigarettes (17.1%).[24] Due to the increasing number of youth who vape, flavors are particularly concerning to the medical, advocacy, and public health communities—the lack of available evidence about the potential harm from some e-cigarette flavorings is worrisome.
E-Cigarettes: What Healthcare Professionals Need to Know
In 2019, Bloomberg Philanthropies dedicated $160 million to fund an initiative titled "Protect Kids: Fight Flavored E-Cigarettes."[43] In January 2020, the FDA prioritized enforcement against the marketing of any flavored, cartridge-based electronic nicotine delivery systems (ENDS) product (excluding a tobacco- or menthol-flavored ENDS product [shown]) that does not have premarket authorization.[44,45] If an e-cigarette company wishes to reintroduce flavors, it must meet the "appropriate for the protection of public health" standard for marketing and provide research showing a net public health benefit (specifically that their products will help lessen the adverse impact on youth use).[46]
Regulatory and congressional action has been initiated and is continuing to evolve around e-cigarette flavorings and the requirement for companies to provide research on the safety of flavors. HCPs should be aware of these developments and share health information about flavors with their patients.
E-Cigarettes: What Healthcare Professionals Need to Know
Unintended Consequences: US Respiratory Outbreak
Despite the relative recency of widespread vaping in the United States, a major public health crisis has already occurred as a consequence. In the fall of 2019, a tragic outbreak of acute lung disease affected vapers, eventually known as "e-cigarette or vaping product use-associated lung injury" (EVALI).[1] A clear risk from vaping was identified, largely associated with the use of illicit, illegal vaping products containing vitamin E acetate and additives such as THC and CBD.[1] As of February 18, 2020, there were 2,807 hospitalized EVALI cases or deaths from all 50 states, the District of Columbia, and two US territories (68 deaths were in 29 states and the District of Columbia).[1] Sporadic cases still occur, but the EVALI outbreak appears to have peaked in September 2019.[1]
Early in the investigation, the CDC recommended against using e-cigarettes; that guidance changed in early 2020 when the CDC advised avoiding products containing illicit THC.[1,47] If patients are concerned about the risk from vaping, they should be counseled that the only way to prevent illness or harm from vaping is to not vape. Moreover, consumers should be aware of the source of their products and not tamper with or purchase street products.
E-Cigarettes: What Healthcare Professionals Need to Know
Messaging to Youth: Do Not Vape…EVER
HCPs must know their target audience. When counseling patients on e-cigarette use, it is important to base conversations and topics on the age of the patient.
Many young people start using tobacco by age 11 and are addicted by age 14.[48] During one-on-ones with young patients, an age group in which vaping is common, HCPs should have a candid, confidential, and objective conversation about vaping. HCPs should be very clear to patients: Do not vape, do not vape nicotine-containing products, and do not vape illicit products or tamper with products. Also reinforce this message to parents to ensure the dialogue continues at home.
HCPs can and should talk about topics that include the following:
- Nicotine effects: Educate youth about effects of nicotine on the brain and the risk of addiction.[49] Brain development continues until age 25; early nicotine exposure may predispose the teen brain to other addictive substances.[11,50]
- Nicotine levels/addiction: Discuss the nicotine content in products such as JUUL to help patients understand their intake of nicotine may be more than they realize. Nicotine levels in e-cigarettes are often higher than would be obtained from smoking a cigarette.
- Polytobacco use: Youth commonly use two or more tobacco products. This is particularly concerning because polytobacco use complicates health effects, diagnosis, and clinician counseling. Specifically ask youth about multiple product use.
- Product type and illicit use: It is critical to ask about what products youth are using and where they obtain these items. Inform young patients of the risks associated with certain products, and explicitly state that the use of street products containing THC, CBD, or vitamin E acetate can permanently damage the lungs, resulting in extreme illness or death.
E-Cigarettes: What Healthcare Professionals Need to Know
Some people tolerate or accept teen vaping under the assumption that it will decrease the likelihood of smoking, but there is no evidence this is true. In fact, research suggests that for youth who otherwise would not have smoked, if they try vaping, they are more likely to eventually become smokers.[19]
HCPs should remind youth about the health effects and addictive nature of nicotine. Unfortunately, it is well known that youth do not necessarily connect with or respond to information regarding long-term health effects of dangerous habits or actions. This reaction was previously seen in association with the consequences of cigarette smoking and is again occurring regarding the effects of e-cigarettes and vaping. The Truth Initiative has expanded its quit-smoking resources to include the first of its kind e-cigarette quit program, using text messages and social media messaging, among other efforts. This is a useful resource for youth patients and their parents.
E-Cigarettes: What Healthcare Professionals Need to Know
Messaging to Adults
A July 2019 Gallup Poll found that 8% of Americans reported vaping in the past week.[51] In addition, NHIS data show that a large proportion of current smokers have tried vaping: Among adult e-cigarette users in 2015, 58.8% were also current cigarette smokers and 29.8% were former cigarette smokers.[52] Seventy percent of all smokers want to quit smoking.[53]
Counsel adult current smokers to quit smoking combustible cigarettes as quickly as possible. If they are considering e-cigarettes for cessation, inform them about the risks of nicotine addiction and the unknown long-term health effects of using these products. Although the primary goal is to have patients stop using combustible cigarettes, HCPs should also be prepared to discuss the following with patients:
- Polytobacco use: Advise patients to avoid the use of multiple nicotine products. Adult smokers most often combine the use of e-cigarettes and combustible cigarettes, which can result in addiction to higher levels of nicotine. If patients use e-cigarettes for tobacco cessation, they should stop using these products as soon as this aim is achieved, as long as they are certain they will not start using combustible products again.
- Vaping other substances: Stress the dangers and health risks involved in vaping substances other than nicotine. Advise patients to never tamper with vaping liquids, to not add other products to vaping liquids, and to avoid street or illicit products, etc.
E-Cigarettes: What Healthcare Professionals Need to Know
Special message to nonsmokers
Many former smokers enjoyed smoking but quit due to health concerns. Adult ex-smokers should not consider reinitiating nicotine use because of the potential for returning to nicotine addiction. Additionally, HCPs should advise never-smokers to not consider using or experimenting with e-cigarettes or other forms of nicotine.
There are now more former smokers than current smokers in the United States.[2] This amounts to approximately 50 million ex-smokers who have quit smoking and understand how challenging it is to stop. These individuals can help and empower current smokers to quit.
E-Cigarettes: What Healthcare Professionals Need to Know
Interplay Between State, Local, and Federal Regulations
HCPs have a role to play outside of the individual, clinical interaction. Although it is important that clinicians engage with patients about tobacco use at every interaction as well as provide evidence-based advice, it is also essential that they engage at the community level and are aware of existing policies—or the absence of policies and regulation. HCPs should stay abreast of evolving regulations and the loopholes in prevailing regulations.
The FDA has authority over e-cigarettes, but meaningful regulation has been slow to evolve. At the federal level, there is a general consensus that the FDA needs to exert its existing power and authority to regulate these products, which it received through the 2016 Deeming Regulation.[54] This regulation extended the scope of tobacco products under the FDA's regulatory authority from the 2009 Family Smoking Prevention and Tobacco Control Act.[55]
In late 2019, the federal minimum age for sale of tobacco products was raised from 18 to 21 years.[56] In January 2020, the FDA prioritized enforcement against the marketing of flavored, cartridge-based ENDS products (except for those with tobacco or menthol flavor) without premarket authorization.[44,45]
E-Cigarettes: What Healthcare Professionals Need to Know
Federal regulation of e-cigarettes is only beginning. In the absence of overarching, comprehensive federal regulation, state and local laws have promulgated and they vary widely depending on the state or local jurisdiction. For example, in mid-2019, San Francisco became the first US city to ban all flavored tobacco products, including e-cigarettes[57]; that fall, Massachusetts limited the sale of flavored nicotine vaping products and introduced a 75% excise tax on e-cigarettes.[58]
Dozens, if not hundreds, of municipalities are regulating e-cigarettes for two reasons: The recent epidemic of teen use and the 2019 respiratory crisis resulting from vaping (EVALI), even though the latter was caused by exposure to vitamin E acetate contained in illicit THC vaping devices. Both are significant concerns and have created a cause for alarm, further confusing the issue of how HCPs should discuss vaping and e-cigarettes with their patients. Clinicians should remember that the overriding goal is to help current smokers quit using combustible cigarettes.
E-Cigarettes: What Healthcare Professionals Need to Know
The Call for US Regulation: Stepping Outside the Exam Room
The image above shows a range of policy options exist regarding e-cigarette use. Unfortunately, e-cigarette regulation in the United States is minimal. HCPs should engage in policy action and development as well as inform patients about existing regulations and their possible limitations. For example, with a youth audience, it would be useful to explain the following about regulation:
- Age restrictions: Inform young patients that as of late 2019, it is illegal to sell any tobacco or nicotine products to youth younger than 21 years. The FDA provides detailed information here.
- Manufacture/production regulatory vacuum: Inform patients that the manufacture and production of e-cigarette/vaping products is relatively unregulated in the United States, and that the use of "dirty" or illicit street products can cause significant harm or death, as evidenced by the EVALI outbreak in 2019. Even products that the FDA has allowed to be sold have not been determined to be safe to use; the use of any tobacco product raises the risk of disease. Patients should also not modify their products or mix their own e-liquids, because many flavors are not intended to be inhaled and can be very harmful if done so.
It is also helpful for HCPs to understand how e-cigarettes are marketed and that most tobacco companies not only carry their own brand of e-cigarettes but are also encouraging smokers to consider switching to their electronic or smokeless products, which would continue users' nicotine addiction.
E-Cigarettes: What Healthcare Professionals Need to Know
The concept of where e-cigarettes can be used remains highly controversial. Allowing the use of e-cigarettes in places that ban the use of traditional cigarettes may renormalize the concept of smoking and make existing smoke-free laws harder to enforce. The unintended public health consequences of e-cigarette use are significant and complicated, and they play a role in helping HCPs understand the environment surrounding e-cigarette use and how to talk with patients.
In the future, regulation and product review decisions could consider reducing the high-tech appearance and inconspicuousness of e-cigarettes, making them less appealing to and less easily concealable by youth,[59] as well as creating more difficulty for this group to use the e-cigarettes that they do obtain.
E-Cigarettes: What Healthcare Professionals Need to Know
Regulation Proportionate to Harm
In considering tobacco product regulation, it may be useful to think about regulatory policies that are proportionate to the harm caused by the product. Thus, the most harmful products (eg, cigarettes) should be regulated more heavily than those that may be considered as less harmful (eg, e-cigarettes). This example suggests that traditional cigarettes should be taxed at a higher level than e-cigarettes. It is not in the public interest to advocate for policies that encourage individuals who are exclusively using novel products to once again smoke cigarettes, the most deadly method of consuming nicotine.
There is a clear problem with e-cigarettes and youth use; US federal regulation alone will not be adequate to address youth use. Moreover, the answers to many of these regulation issues are not obvious and they may vary by the age of the patient. It is critical that HCPs understand the policy implications regarding e-cigarettes and step beyond the clinical encounter to engage in local policy development and communicate critical information to patients. HCPs can help advise local decision makers on community policies aimed at preventing youth use of e-cigarettes, such as connecting with local school boards to ensure proper health education is included in school curriculums and guiding officials in the creation of effective policies and enforcement.
E-Cigarettes: What Healthcare Professionals Need to Know
Prevention Versus Cessation and Call to Action for HCPs
When discussing tobacco or nicotine use, it is crucial to know that the conversation and issues related to youth or teen tobacco use are very different from those related to adult use. With adults, prevention is less relevant, and cessation or switching products is the key point most often addressed in the clinical setting. Thus, the goal is complete cessation from nicotine use when working with this group; if they are encouraged to switch from smoking to exclusively using alternative products (ie, no dual use of nicotine products), they should also be urged to ultimately cease using all nicotine delivery products.
With youth, the primary goal is prevention of any tobacco use. However, the recent surge in youth vaping has also made attention to cessation programs relevant, with public policy essential. About 5 million youth already vape.[24] It is critical to prevent more youth from trying these products while also supporting cessation for those who use nicotine. Unfortunately, youth tobacco cessation research is not well developed. Little research exists for successful, evidence-based cigarette cessation for this population, and even less research is available for teen vaping.
Youth vaping and e-cigarette use is a unique public health concern. In addition to having a social dimension and social media pressure that is not present in other public health issues, youth may be getting addicted earlier due to higher levels of nicotine, a novel phenomenon, as there can be greater nicotine exposure from these products than in traditional cigarettes. The Truth Initiative provides comprehensive cessation information and a one-of-a-kind e-cigarette quit program.
E-Cigarettes: What Healthcare Professionals Need to Know
Conclusion
HCPs are faced with a serious task as the primary and most trusted source of healthcare information for smokers, ex-smokers, never smokers, vapers, and youth experimenters. From a public health standpoint, the goal should be to achieve a net public health benefit. The critical first step is to have patients stop smoking. If all other resources have failed, then use of e-cigarettes may be considered to stop smoking completely (with HCP guidance and support), with a move to exclusive e-cigarette use until they can quit nicotine altogether.
Nicotine products should be considered within a continuum of risk. Although no product is safe, it is necessary to consider patients who will otherwise not quit nicotine switching to a less harmful alternative. Do not give up on total cessation: It is achievable, apparent in the fact that there are more ex-smokers than current smokers in the nation. Remind patients that even though e-cigarettes may be less harmful than smoking, these products are not without risk and that it is harmful to inhale heated vapor and chemicals into the lungs.
E-cigarettes and vaping represent an evolving health issue. We challenge HCPs to step out of the clinical encounter of one-on-one cessation advice to consider and act on the societal issues and public policy that will promote cessation. It is critical to understand that while it is clear that young people should never use these products, this is not as straightforward for adult smokers. This dynamic situation requires continuing education, regular review of developing scientific research, and monitoring of medical association guidelines to help advise patients about whether or not to use these products and under what circumstances.
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