Tobacco use is the leading cause of preventable morbidity and mortality in the United States, and use most often begins during adolescence and early adulthood.1 The use of battery-operated electronic cigarettes (e-cigarettes or ECs) among children and teens has become a public health epidemic.2,3 E-cigarettes are the leading tobacco product used by the US adolescent population.1,4 Health care providers should consistently screen for and counsel patients regarding EC use to aid in health promotion and disease prevention as the use of these products can lead to serious comorbidities and adverse events.

Acceptance for EC use is likely attributed to the perception that they are safer to consume and also may be used as a smoking cessation tool. This common perception, along with ease of access to ECs has led to the introduction of and addiction to nicotine products among adolescents.5

Hartmann et al conducted a systematic review aimed to determine if ECs can aid in smoking cessation.6 Patients who received nicotine ECs experienced higher quit rates than those who received nicotine replacement therapy (risk ratio [RR], 1.69; CI 1.25-2.27) or non-nicotine ECs (RR 1.71; CI 1.00-2.92). Mild to moderate adverse events were reported such as throat and/or mouth irritation, headache, cough, and nausea. These adverse effects tended to dissipate with consistent use; however, there was no mention of long-term effects associated with continued use of ECs.


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E-Cigarettes May Lead to Smoking Combustible Cigarettes in Teens

Findings from a prospective cohort study by Barrington-Trimis et al show that adolescent EC users are over 6 times as likely to initiate traditional cigarette use compared with adolescents who have never used ECs. In addition, after only a 16-month follow-up period, initiation of combustible cigarette use was reported by 40.4% of adolescents who previously used e-cigarettes vs 10.5% of those who had never used ECs.7 This suggests the experimentation with ECs may lead to transition to combustible cigarette use at an early age.

Composition of E-Cigarettes

E-cigarettes, unlike combustible cigarettes, use an electric element to heat and vaporize a liquid-based flavorant (e-liquid). This e-liquid is composed of water, flavoring, and other ingredients such as glycerol, ethylene glycol, polyethylene glycol, and propylene glycol. Solutions with nicotine also contain organic tobacco substances and impurities. Despite the labeling of e-liquid contents for consumers, inconsistencies in e-liquid production and labeling have been reported such as false advertising of nicotine-free liquid when nicotine is present or vice versa.8

Health Risks of E-Cigarettes

Use of ECs has been shown to have adverse systemic effects, most notably within the oral cavity, respiratory, cardiovascular, and immune systems.9 The vapor produced by ECs directly affects the remodeling of extracellular matrix gingival fibroblasts, which play a significant role in repairing periodontal tissues, and obstructs components that aid in cell proliferation, apoptosis, migration, and wound closure.9 Exposure to either nicotine-containing or nicotine-free fluids and vapors in ECs has been demonstrated to increase production of free radicals called reactive oxygen species (ROS).9  

The airway epithelium is the next site of contact for inhaled substances. Inhaled substances from ECs increase the permeability of the airway epithelium, creating a cascade of events leading to airway inflammation and destruction of lung tissue.9 This occurs with both nicotine-containing and non-nicotine-containing ECs.9 Like combustible cigarettes, chronic EC use causes a shift in cardiac autonomic balance toward greater sympathetic superiority and increased oxidative stress levels, both of which are known risk factors for the development of cardiovascular disease.9 Adolescents potentially absorb higher concentrations of EC vapors because of their higher resting respiratory rates and inability to clear nicotine as effectively as adults.9 Increased dermal absorption in this population is also a risk due to second-hand vapor exposure.9

Inhalation of EC vapor also increases levels of platelet-activating factor receptors (PAFRs). Pneumococci bacteria utilize these receptors to bind to host epithelial cells and facilitate pneumococcal disease.9 The use of ECs also increases the risk for other infections such as methicillin-resistant Staphylococcus aureus, rhinovirus, influenza, and Streptococcus pneumoniae.9

Classic ECs containing nicotine flavoring have a lower ROS production than ECs containing other flavorings.9 The release of ROS from ECs containing fruit-flavored e-liquids can be 3 times greater than that of ECs containing tobacco flavor.9

Screening for E-Cigarette Use

As ECs have become the most widely used tobacco products by adolescents, the American Academy of Pediatrics (AAP) recommends screening, education, and cessation counseling for EC use in the primary care setting starting at age 11 years.10 E-cigarettes should not be recommended as a tobacco-dependence treatment product, according to the AAP guidelines.10 In addition, providers must become familiar with language used among this population (ie, vaping, JUULing, and e-cig) to keep an open line of communication and prevent missed opportunities for counseling.

The AAP recommends using the 5As Model for Tobacco Screening and Counseling (Figure).10 Clinicians should ensure consistency in asking about tobacco use at each appointment and use standardized documentation. Patients should be advised to quit using tobacco or EC products and clinicians should assess the patients’ willingness to quit. Assistance with either pharmacotherapy or counseling resources should be provided and a follow-up appointment should be arranged to monitor progress towards cessation.

Figure. 5As Model for Tobacco Screening and Counseling10

In addition, adolescents should be provided one-on-one time with clinicians to speak freely and confidentially, without parents in the room. As always, this information between the patient and clinician should be kept confidential unless permission is granted by the patient.11 The AAP’s e-cigarette curriculum includes ICD-10-CM and CPT billing codes that can be used for tobacco use and exposure counseling.

Conclusion

Advanced practice providers, along with all members of the health care team, have an inherent duty to screen and educate patients regarding health promotion and disease prevention, as it pertains to the use of vaping products. Education on the serious risks associated with ECs should be provided by school and campus nurses as well as primary care clinicians. Adolescents and young adults are at an important stage of development, as lifestyle habits and routines are developed during these crucial years. Clinicians should be not only educated but empowered by current evidence supporting the need for cessation of vaping and other tobacco products.

Britney Lilley BSN, RN, is a labor and delivery nurse at Orange Park Medical Center, Florida. She is currently studying to become a doctor of nursing practice-family nurse practitioner at the University of North Florida.

References

1. Jamal A, Gentzke A, Hu SS, et al. Tobacco use among middle and high school students: United States, 2011-2016. MMWR Morb Mortal Wkly Rep. 2017;66(23):597-603. doi:10.15585/mmwr.mm6623a1

2. Hwang C, O’Neil J. E-cigarette use among adolescents. J Nurse Practitioners. 2020;16(6):453-456. doi.org/10.1016/j.nurpra.2020.02.021

3. American Medical Association. AMA and public health community united on bold action to prevent e-cigarettes from addicting kids. November 22, 2019. Accessed September 22, 2021. https://www.ama-assn.org/press-center/ama-statements/ama-and-public-health-community-united-bold-action-prevent-e-cigarettes

4. Pepper JK, Gilkey MB, Brewer NT. Physicians’ counseling of adolescents regarding E-cigarette use. J Adolesc Health. 2015;57(6):580-586. doi:10.1016/j.jadohealth.2015.06.017

5. Bhatnagar A, Payne TJ, Robertson RM. Is there a role for electronic cigarettes in tobacco cessation? J Am Heart Assoc. 2019;8(12):e012742. doi:10.1161/JAHA.119.012742

6. Hartmann-Boyce J, McRobbie H, Lindson N, et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. 2020;10(10):CD010216. doi:10.1002/14651858.CD010216.pub4

7. Barrington-Trimis JL, Urman R, Berhane K, et al. E-cigarettes and future cigarette use. Pediatrics. 2016;138(1):e20160379. doi:10.1542/peds.2016-0379

8. Hahn J, Monakhova YB, Hengen J, et al. Electronic cigarettes: overview of chemical composition and exposure estimation. Tob Induc Dis. 2014;12(1):23. doi:10.1186/s12971-014-0023-6

9. Chen IL, Todd I, Fairclough LC. Immunological and pathological effects of electronic cigarettes. Basic Clin Pharmacol Toxicol. 2019;125(3):237-252. doi:10.1111/bcpt.13225

10. Jenssen BP, Walley SC; Section on Tobacco Control. E-cigarettes and similar devices. Pediatrics. 2019;143(2):e20183652. doi:10.1542/peds.2018-3652

11. American Academy of Pediatrics. E-cigarette curriculum. Accessed September 23, 2021. https://www.aap.org/en/learning/e-cigarette-curriculum/

This article originally appeared on Clinical Advisor