Today, I review, link to, and excerpt from Addiction Medicine‘s #30 Blazing Hot Takes: The Latest in Vaping With Drs. Ling and Vijayaraghavan.*
*Kryzhanovskaya E, Ling P, Vijayaraghavan M, Huxley-Reicher Z, Sonoda K, Chan, CA. “Blazing Hot Takes: The Latest in Vaping”. The Curbsiders Addiction Medicine Podcast. https://thecurbsiders.com/addiction 8/22/24.
All that follows is from the above resource.
The Curbsiders Addiction Medicine are proud to partner with The American College of Addiction Medicine (ACAAM) to bring you this mini-series. ACAAM is the proud home for academic addiction medicine faculty and trainees and is dedicated to training and supporting the next generation of academic addiction medicine leaders. Visit their website at acaam.org to learn more about their organization.
Show Segments
- 00:11 Intro, disclaimer
- 02:22 Guest bios
- 04:28 Guest one-liners
- 10:28 Case from Kashlak
- 11:55 Vape info and definitions
- 14:32 How to discuss vaping with patients
- 17:53 FDA authority over vapes
- 20:37 Development of nicotine (via vaping) use disorder
- 23:29 Questions to ask about use disorder
- 30:53 E-cigarettes for tobacco cessation
- 35:39 Exploring ways to quit smoking (+/- vapes)
- 39:53 Screening for vaping use disorder; research measures
- 43:10 Resources for e-cigarette cessation
- 45:33 Medication approaches
- 48:25 Behavioral supports for e-cigarette cessation
- 1:00:31 Take Home Points
- 1:05:08 Outro
Vaping Pearls
- Vape/e-cigarette products are highly varied in nicotine concentration and amount per pod/cartridge
- Discuss the granular details of a patient’s vape/e-cigarette usage with them – what product, when and how are they using etc.
- Be sure to assess for nicotine use disorder when discussing vape/e-cigarette use.
- E-cigarettes are not approved as smoking cessation aids by the US Food and Drug Administration (FDA) although the latest Cochrane review suggests it can be an effective smoking cessation aid (Lindson, 2024).
- While there are no FDA approved cessation treatments for nicotine dependence/use disorder in patients using vapes/e-cigarettes, it is reasonable to consider nicotine replacement therapy (NRT) and/or varenicline at similar doses to what is recommended for smoking cessation.
- Counseling/behavioral health support should be provided either in person, via quitline services, or with digital aids when using pharmacotherapy.
Blazing Hot Takes: The Latest in Vaping – Notes
What is a vape/e-cigarette?
The basic structure of a vape or e-cigarette includes a battery, a heating device and some sort of chamber or cartridge that holds a liquid with the nicotine (or cannabis) in it. This gets aerosolized and that aerosol is what is inhaled. Over the last decade, e-cigarettes and vapes have evolved a lot in terms of shape, concentrations and size. This is rapidly changing.
Currently, the FDA has only approved a handful of vape/e-cigarette devices and so most are unauthorized (FDA). The FDA does have the ability to regulate concentration and size of the device. Currently, there is inconsistency across state legislation in the US about where you are allowed to use vape/e-cigarette products (CDC). In some states, there are exclusions from anti-smoking legislation indoors for e-cigarettes and vape products.
How to discuss vaping with patients
Our experts recommend approaching this topic with curiosity and getting into the granular details of the product that someone is using, as well as how they are using that product. Potential questions include:
- What shape, size, and brand of the product are you using? (If they have it with them, take a look at it)
- What is the nicotine concentration of the product you are using?
- Questions to be able to quantify the amount of nicotine someone is using when they use a vape: how long does a pod/cartridge last you? What concentration are you using?
- How frequently are you using the product throughout the day? When during the day are you using the product? Are you using it indoors vs. outdoors? Are you using the product first thing in the morning or in the middle of the night?
- What do you get from your use of the vape/e-cigarette and what do they enjoy about it?
- Are you vaping anything else besides nicotine (cannabis e.g.)?
- How much are you spending on products?
- Is your use of a vape/e-cigarette impacting your ability to do your job, be present in your lives etc.?
How to discuss vaping with patients
Our experts recommend approaching this topic with curiosity and getting into the granular details of the product that someone is using, as well as how they are using that product. Potential questions include:
- What shape, size, and brand of the product are you using? (If they have it with them, take a look at it)
- What is the nicotine concentration of the product you are using?
- Questions to be able to quantify the amount of nicotine someone is using when they use a vape: how long does a pod/cartridge last you? What concentration are you using?
- How frequently are you using the product throughout the day? When during the day are you using the product? Are you using it indoors vs. outdoors? Are you using the product first thing in the morning or in the middle of the night?
- What do you get from your use of the vape/e-cigarette and what do they enjoy about it?
- Are you vaping anything else besides nicotine (cannabis e.g.)?
- How much are you spending on products?
- Is your use of a vape/e-cigarette impacting your ability to do your job, be present in your lives etc.?
Consideration of nicotine use disorder
Patients may be using vape/e-cigarettes for a variety of reasons – some may be using these products to help with cigarette cessation, some may have never smoked cigarettes to begin with (this is particularly true in younger age brackets). It is helpful to start getting a sense of use patterns and impacts on a person’s life during initial conversations about their vape/e-cigarette use.
These questions can include time to first use in the morning, whether they are using overnight, whether they have to stop other activities to vape, impact of vaping on their personal and work lives, and whether they vape more prior to being somewhere where they know they won’t be able to use the vape/e-cigarette.
Often patients will be very clear about having cravings and withdrawal and may use the words dependence or addiction as it relates to their vaping. There is no agreed upon scale to assess nicotine use disorder amongst patients who are using e-cigarettes/vapes but there are a variety of research measures currently being used that include some of the questions mentioned above (4 item questionnaire from Morean 2019, 10-item Penn State Cigarette Dependence Index from Foulds 2015).
Using e-cigarettes/vapes for smoking cessation
In the US, the FDA has not approved e-cigarettes for smoking cessation for multiple reasons including the frequent dual use of cigarettes and e-cigarettes, and a lack of knowledge of the long term health and safety impacts of e-cigarette use. This has been studied with RCTs in other countries, but those RCTs used products with lower nicotine concentrations that are very different from what is generally available now. Some studies (including a Cochrane review) indicate that in randomized trials, e-cigarettes may have efficacy for smoking cessation (Lindson 2024). However, from our experts’ opinion, these trials are often difficult to replicate in the real world as many people end up using both e-cigarettes and cigarettes and newer products have much higher concentrations of nicotine.
Our experts recommend using FDA approved medications for smoking cessation (nicotine replacement therapy and varenicline) first line and considering trying these products multiple times, considering e-cigarettes as a last line tool for smoking cessation on a case-by-case basis. If this is being used, it is important to be clear from the outset that the first goal is to switch completely from use of cigarettes to use of e-cigarettes/vapes and then ultimately to completely stop use of e-cigarettes. Additionally, along with any of the medications/aids for smoking cessation, it is important to provide behavioral health support.
Treatments to help with cessation of vape/e-cigarette use
Ultimately there is limited data and evidence about how to help patients with cessation of vapes/e-cigarettes. Expert opinion suggests that in situations of vaping dependence, the recommendation is to use the agents we have for smoking cessation (see Curbsiders Internal Medicine episode 252, or Curbsiders Addiction episode #11). These include combination NRT or varenicline with associated behavioral health support and counseling. Similar to counseling around smoking cessation, it is important to discuss the fact that cessation takes time and often multiple attempts. There are some current clinical trials looking at those two medications (combination NRT and varenicline) with associated counseling for vaping cessation as well as a trial looking at cytisinicline with counseling (Rigotti 2024).
In terms of dosing NRT and varenicline for vaping cessation, Drs. Ling and Vijayaraghavan recommend starting with the same dosing as is recommended for smoking cessation – for varenicline that is 1 mg BID and for NRT dose is dependent on packs per day and time to first use in the morning. If one of these agents alone isn’t working as hoped, you can consider adding both. To estimate NRT dosage for vaping, you can use a few different markers – if people had previously been smoking cigarettes, you can use that amount to dose NRT or can try to convert the amount someone is vaping to packs per day. Our experts recommend more frequent check-ins about dose as these calculations are often imprecise and may not accurately capture someone’s nicotine requirement.
When completing check-ins, it is important to understand if they are still using the vape/e-cigarette. If they are, do they feel that their use is at all reduced while using NRT and/or varenicline? As with smoking cessation, it is always helpful to understand how someone is actually using the NRT/varenicline to make sure the medication is optimized. Another good question to ask is about side effects and whether perhaps someone is getting too much nicotine with the dose of NRT they are using.
These recommendations may be slightly different for young adults and adolescents as they are often more resistant to medications and so it may be more efficacious to start with behavioral support including counseling around how to manage cravings etc. This type of counseling can be helpful for many patients (Curbsiders Addiction Medicine Episode 19).
Links
- Kick it CA (website/hotline – patient facing)
- The National Cancer Institute – Smoke free.com (website -patient facing)
- Smoke free teen – (website – patient facing)
- The Truth Initiative (website – patient facing)
- The Tobacco Industry has no Business funding Continuing Medical Education (Commentary)
- The Smoking Cessation Leadership Center – Webinar Series (webinars)
