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What Psychiatrists Need to Know About VapingWilliam F. Wright, M.D., F.A.P.A. “Vaping” has seemingly taken a meteoric rise in both the public and medical field’s attention over the past year with the spate of related deaths. Currently, the CDC reports the number of EVALI (e-cigarette/vaping associated lung injury) cases has hit over 2,700 with the associated death toll at 60.1 However, despite the eye and gut catching news segments covering our electronic devices 24/7, it is still often difficult to walk in public without having to wade through a pall of vapor or see a plume of white haze escaping a car like a Cheech and Chong bit. But, from someone appearing to have a Star Wars cantina scene device attached to their lips to a USB-looking fob to an old-fashioned looking cigarette, what is “vaping”? Vaping is the slang term in the common lexicon referring to the use of an electronic cigarette whereby a battery-powered heat source “vaporizes” a liquid solution (e-liquid, “juice”, “e-juice”, or “vape juice”) which is then inhaled. Some e-cigs are disposable, but most are reusable with the e-liquid being replaced in the form of a “pod,” “cartridge,” or “juice”. This aerosolized liquid is typically composed of propylene glycol, glycerin, flavoring, nicotine, and other additives2 (although sometimes the propylene glycol is solely replaced with vegetable glycerin, and sometimes nicotine is not an ingredient). Other additives have, and can include, diacetyl and vitamin E acetate (more on this particle goodie later). The general umbrella term for these devices outside of the vaping industry is e-cigarettes or from the government – electronic nicotine delivery systems (ENDS).3 However, within the industry, 4 types of vaping apparatuses exist: 1. “e-cigarettes” - resemble traditional cigarettes down to a brown “filter” mouthpiece; 2. “pocket vapes” – smaller, more portable, and designed for ease of use (resemble USB drives, popular among teens/young adults, easy to hide/conceal); 3. “vape pens” – shaped like a cylindrical pen with a mouth piece; 4. “box mods” – larger battery, adjustable settings, and for those “advanced” in vaping.4 To activate these vapes, some require nothing more than to draw or inhale on the mouthpiece end while others require depressing an activation button. As it sounds, these devices are as variable as bongs and can be nearly as open to personalization and modification (even with illicit substances, i.e. marijuana, and black-market accessories). In order to achieve aerosolization of the liquid, a temperature between 200-400 degrees Fahrenheit is required5 and, as mentioned, these devices require a battery to power the heating element. But what about the nicotine? The nicotine unit levels in the industry e-juice are typically: zero, 3mg, 6mg, 12mg, and 18mg; although, there have been some products with as high as 36mg.6 In contrast, a traditional cigarette can contain between 6mg to 28mg of nicotine; however, due to the burning process and the level of entropy in the universe, the typical inhaled amount of nicotine per cigarette ranges from 1.1 to 1.8mg which amounts to roughly 22-36mg of nicotine inhaled per standard 20 cigarette pack.7 Therefore, admittedly, if you were to utilize only one refill of e-juice per day, one would be inhaling less than a typical pack of cigarettes. Vaping seems to have appeared overnight as compared to conventional cigarette smoking. Tobacco products have been utilized by humans since their discovery by indigenous and Mesoamerican peoples of the Americas (as far back as 8,000 years ago with domestication8,9 while the earliest biological marker dates around 800BCE10). Cigarettes using wrapped paper became popular in the 17th century and like the model T Ford, boomed with the invention of the machine-rolled cigarette with James Bonsack developing one able to produce millions of cigarettes a day in 1880.11 Patents for electronic vaporizer-type devices are on file since the 1930s but the modern and commercially successful e-cigarette look is credited to a Chinese pharmacist, Hon Lik in 20032,12 but e-cigs did not seriously hit the market until 2007. Now, Juul, after hitting the market in 2015, is the largest and has 75% of the market shares sitting at a reported value of $38billion (yes, billion with a B according to Nielsen rating).12 Juul has cornered the market in the 15-17 year-old range as someone in this age bracket is 16x more likely to be a Juul user than an adult.13 But with lower nicotine concentration and less chemicals and “cancer toxins” in e-cigarettes, aren’t they healthier and safer? Although research is just now coughing up some data, early studies have found increases in chronic coughs, bronchitis, asthma diagnoses, impaired pulmonary immune cell function, link to murine cancer (lung/bladder), mixed findings on cardiovascular issues, and concern of carbonyl compounds (exposure to e-cig solvents to high heat) which have been associated with increased risks for blood clots and atherosclerosis.14 Of course, as mentioned earlier, the nearly 3000 lung injury cases and 60 deaths attributed to e-cigarettes. The current hypothesis via the CDC is that vitamin E acetate is the culprit found in many black-market, illegal, or street e-juices also containing THC while also stating other ingredients, compounds, or reactions may also be contributing but with no way of confirming at present time with available data.15,16 It is believed the vitamin E acetate causes a chemical-like burn in the lungs leading to the injuries; therefore, the FDA has recommended not to purchase any vaping device, product, or e-juice from the street, avoid using THC oil, or modifying store-bought devices.16 The use of these devices with THC as an adulterant or as an outright administration mechanism in face of these now known health injuries and deaths is highly concerning. E-cigarettes have not yet proven to be efficacious as an aid for smoking cessation although more studies are needed. At present time, there is no FDA approval for e-cigarette devices for aiding in tobacco/nicotine cessation. By the numbers, over 14.5million people are using e-cigarette devices with nearly half of these users coming from those 18 and under (~5million3; see Figure 1 below). After many years of steady decline, the current tobacco/nicotine use is at the highest rate we have seen in this age group in nearly 2 decades.17 ”JUUL has also targeted children as young as third grade by funding summer camps, visiting schools and paying community and church groups to distribute their materials.”18 A recent study found that 99% of the e-cigarettes purchased at supermarkets and convenience stores contained nicotine; however, younger population is often not aware that devices like Juul contain nicotine – nearly 2/3 (63%) were not aware of this fact.18 The rate of high school seniors using e-cigarettes has doubled in just 2 years’ time.19 Roughly 1/3 of adolescents perceived e-cigarettes as less harmful than typical cigarettes while nearly 3/4 of those currently using them felt e-cigarettes were less harmful than regular cigarettes.20 Young folks who smoke e-cigarettes are 4x more likely to start smoking a traditional tobacco cigarette,19 and those who start vaping are 3.5x more likely to use marijuana than their peers.21 1 in 10 North Carolina high school students report having vaped marijuana.21 E-cigarette/vaping companies have learned a lot of valuable tricks from their old uncle – traditional tobacco cigarettes – in marketing to this young base. From the tobacco company playbook: use celebrities (actors, musicians, and now social media “influencers”) to hock your product [check], use rugged men/glamorous women in advertising schemes [check], sex sells…always…[check], sponsoring sports and music festivals [check], use flashy cartoons reminiscent of good ol’ Joe Camel [check], and one of the last and most important recently, utilize sweet flavors that don’t remotely resemble cigarette smoke [double check].22 The PATH study has shown a prime implication for such high numbers of both youth and young adult use of vapes is “they come in flavors I like” (77.9% and 90.3% chose this as the reason) with the FDA reporting 97% of youth vapers used a flavored e-cigarette within the past month (youth/young adults are 3x more likely to use a fruit-flavored juice than an adult).18 The most common and popular Juul flavors among middle and high school-aged individuals were Cool Mint, Mango, and Fruit Medley with Cool Mint being favored by those 18-21.23 Due to the popularity of non-tobacco tasting flavors, the continued presence of nicotine in the majority of vaping products (especially Juul), and the heavy-handed advertising tilt towards younger folks… The FDA on January 2, 2020 has banned mint and fruit-flavored cartridge-based e-cigarette flavorings of these flavors24 but has NOT banned the sale of menthol or tobacco flavors NOR banning other types of e-liquid (remember from earlier, e-juice can also come in refillable tanks and packaged in small liquid vials). In addition, on December 20, 2019, the president “signed legislation to amend the Federal Food, Drug, and Cosmetic Act, and raise the federal minimum age of sale of tobacco products from 18 to 21 years. It is now illegal for a retailer to sell any tobacco product – including cigarettes, cigars, and e-cigarettes – to anyone under 21.”25 Although these measures are potentially good starts in attempting to put the proverbial vapor back into the pod, they will also need quite a bit of help on the ground. This groundwork is needed to ensure the genie does not come back out fulfilling the three wishes of death, injury, and addiction. Our youth’s vulnerable PFC (prefrontal cortex) is still in the oven baking and as we know, still needs some cooking til it’s done in their mid-20s; therefore, all of the health care community and especially, we, as psychiatrists, need to once again champion the cause of education and prevention to turn back the vaporizing horde of e-cigarette users. Perhaps…informing them their Juul use is just a tech-refurbished reboot of the old Joe Camel cigarette days. So, much like my own rising concern, this article has risen over those 1000 words, but hopefully, the vaping death toll won’t. Resources:
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