Transcript

Lee Tetreault:

Welcome to Frequently Asked Questions from the session, e-Cigarettes and Vaping: The Good, the Bad, and the Ugly. We are joined by Dr. Susan Feeney. Susan, before we begin with these questions, would you be able to reiterate a few key pointers from today's session to our audience?

Dr. Feeney:  

Sure, I'd be happy to. So basically, in quick summary, the electronic cigarette or the electronic nicotine delivery system, ENDS, has been rapidly increasing, especially over the last two years with the advent of some of the fourth generation vape tools that are sleek and easy to use. Our concern is there's a whole group of people who would never have been exposed to nicotine, teenagers who wouldn't have smoked, who are now vaping. And the rate has gone up from over 2 million to over 3 million, almost 3.5 million in a year of teenagers who admit to have vaping. And so that's a concern, and it is a concern with the FDA, the CDC, and you're starting to see regulation on that.

We've also seen that marijuana, through an oil or wax that can be put into this vaping liquid, is being used pretty frequently. And in the California area, there was up to one in three high-schoolers and one and four middle-schoolers were vaping marijuana. So that's a concern. The other concern is, is this an effective, efficient smoking cessation tool? And the verdict is still out. We have some data that came out this year that may indicate that it's more efficacious and helps people stay off cigarettes longer than the established nicotine replacement therapies. But again, we need more data.

So what are the harms? We know that if somebody is smoking a lot, we think that vaping is less harmful, but vaping has... Is aero-sized, and there's toxicants and carcinogens, nicotine is an addictive substance. So what the FDA and the CDC are recommending to try the established nicotine replacement therapies. If that fails for your smokers, they can try the e-cigarette. It may be helpful knowing that it may also have its own harms. And then people who are non-smokers, we need to do everything we can to help them stop, not start and to stop vaping.

Lee Tetreault:

Great. Let's get into some of these frequently asked questions. First, what is the cost of an e-cigarette?

Dr. Feeney:  

Well, there are four generations of e-cigarettes. So the one that's the most common, the one that's gone up 600% in sales, in the past year, is that fourth generation. If you go to the website of that particular manufacturer, you can get a starter pack for about $50 and a starter pack has the vape pen, has a battery, and has four pods of pre-filled nicotine fluid. Each pod is approximately the amount of nicotine that's in a pack of cigarettes, so you're basically getting four packs of cigarettes with that. You can get it as cheap as $35, however. And a replacement pack, so you get the pods. The pods are anywhere between $4 and $5 a pod, so depending on where you live and what the tax is, and how much you smoke, it may cost less to smoke cigarettes, it may cost more smoke cigarettes, but it's not, it's not exorbitantly more expensive.

Lee Tetreault:

How would you advise someone to use e-cigarettes to quit smoking?

Dr. Feeney:  

Well, there's really... There's no evidence on or any written advice anywhere. So I actually had to... I talked to the folks at a vape shop, I went online and looked at blogs. And there was some information from the FDA, what they say is, "If you're going to recommend it, you should, first of all, find out exactly how much the person is smoking in a day." So you try to simulate the amount of nicotine that they get in a day, knowing that the deposition of nicotine from a vape is probably gonna be higher than a cigarette. So let's say, someone smokes two packs of cigarettes a day and they've been smoking for a long time, that would be two pods in your typical vape stick. Then depending on how long somebody has smoked and how much they've smoked, you may want to decrease their nicotine intake slowly over time so that they can sustain that decrease. So one of the recommendations was decreasing the nicotine amount by a couple of milligrams, every month. So let's say, 12 milligrams is considered a very high level of nicotine per day and that would be somebody who's a long-time smoker. So you'd start at that, and then maybe go down two milligrams, each month. Somebody who may be smokes a pack and a half, you probably can do a little bit less.

Lee Tetreault:

How is marijuana vaped?

Dr. Feeney:  

Well, it can be vaped in various ways, but probably the most common way that I've seen in the literature is either an oil or wax or they call them dabs. And you would put it into the liquid, the vaping liquid or what they call the vape juice, and then you... It would become dissolved in that, and then you would... It becomes an aerosol and you would vape that. You can actually, they actually have a whole bunch of vaping tools that are coming out now and there's a couple of... There's several companies throughout the country, but a couple in California that you can get the vape pen with the marijuana in it. And so you can actually put leaves in there, into the cartridge and you can suspend it, I guess, in the nicotine, but you can also get a marijuana cartridge. Again, depending on if you're in a state where it's legal, this might be something that's being produced. If they're going to use the... You could put the oil and the wax into any cartridge but some of the companies that have the pre-made cartridges, they have to be hacked to be put in. So they'd have to... There's a little more sophistication to try it.

Lee Tetreault:

How would you counsel an adolescent about vaping?

Dr. Feeney:  

Well, like everything else, we have to counsel them about it. It's not easy. First of all, I think we all need to realize that most kids that are vaping don't see vaping as dangerous, that kind of goes with their mindset. But they kind of know cigarette are dangerous, they cause cancer, but vaping is not a dangerous thing, and they may not think that nicotine is anything to worry about. So that's kind of the knowledge we need to have when we sit down and talk to them. So the first thing you'd wanna do is, first of all, find out if they're vaping. So we have to ask every teenager, when they come in, we ask them all the other high-risk behaviors, we wanna say, "Do you vape?" And if they say, "No," and they are truly not vaping, then you wanna counsel them about it as prevention. So you wanna ask, "What do you know about it?" And then let them finish. "Do you have friends that vape? Do you feel included or excluded because you are not vaping?"

We know that bathrooms are where most of these kids vape and because of the frequency and the prevalence of vaping in bathrooms, the kids who don't vape may not wanna use the bathroom. This is actually becoming a little bit of an issue. So asking them about that and then if they're receptive, give them some information on facts and websites. There's a, Partnership for Drug-Free Kids, John Hopkins has a great website, the UMass Medical School has a great website, CDC. But you would counsel them very similar that you would about smoking cigarette, doing drugs, high-risk sexual behaviors, that kind of thing.

If they are currently vaping, you really would have to sort of get a feel for how frequently they're vaping. Is it a social activity, are they using it daily, and then kind of figure out are they ready to quit, are they in the pre-contemplative stage, where are they in it? If they're sort of like, "Eh, it's not a big deal, it's not a... " Then you wanna use some motivational interviewing. "Well, tell me about... Tell me why you like vaping? What about it do you enjoy?" And try to do it as non-judgmental as possible. And, "What does it do for your daily life? What's the benefit to it?" And, "What do you know about vaping?" And, "Do you have any worries about vaping?" Or "Has anybody talked to you, that they're worried about you vaping?"

A lot of schools have a zero tolerance now. So they are like, expelling kids from school, they're taking kids off of sports teams. So, sometimes saying, "What type of policies do you have in your school about that?" So basically, getting any information before... You can't do anything about changing behavior until you understand where they're at. So that's how I would, I would start.

Lee Tetreault:

And lastly, would you recommend vaping as smoking cessation?

Dr. Feeney:  

Well, again, like everything else in healthcare it depends. So if this is someone who is very motivated to stop smoking and has not tried any of the typical over-the-counter nicotine replacement therapies, like patches and gum or they may be willing to use one of the medications like Chantix or Bupropion, you really do want to start with those first because this has not been approved by the FDA, we don't know the long-term harms of this, we have an idea that there may be some. We think it's less harmful than smoking. Sort of intuitively, it makes sense, it'd be less harmful than smoking, but there is certainly harm related to it. So I would recommend starting with that, but if it's... But what generally happens, people come in and say, "I've done the patch, I've done the gum, I've been hypnotized, I've done everything I can to stop smoking and I keep going back." Then, this might be somebody you could say, "Look, you can try an e-cigarette because," and you tell them to get the fourth generation, you wanna start at the highest level of nicotine. And that... Something that would simulate how much nicotine they're getting in a day, and then say, "Try that for a couple of weeks, come back and see me, and then we'll talk about titrating down."

The thing to remember is if they're going to titrate their nicotine down, they can't do that with a preset pod. They're gonna have to find... They're gonna have to go to a vape shop and figure out how to change the concentration of the nicotine. So that's the only thing is I would caution them that, "If you go to a vape shop, they're great, they're gonna want to have you stop, they're gonna help wean off nicotine, but they don't want you to stop vaping. So let's understand it before you go in 'cause if, " that would be my goal is to have them vape and then stop that at some point.

Lee Tetreault:

This is great information, Susan. Thank you so much for your time.

Dr. Feeney:  

My pleasure.




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