E-cigarettes and Vaping: What Pediatricians Need to Know

Educational Objectives

The goal of this program is to improve patient outcomes through counseling on electronic cigarettes (e-cigarettes) and vaping in the pediatric population. After hearing and assimilating this program, the clinicians will be better able to:

1. Cite data for e-cigarette or vaping use-associated lung injury (EVALI) in pediatric patients.
2. Optimize care in the physician’s office for pediatric patients who are vaping or using e-cigarettes.

Summary

Overview: e-liquid in electronic cigarettes (e-cigarettes), vapes, and other devices contains vegetable glycerin to create vapor, propylene glycol to spread nicotine and flavor throughout the liquid, flavoring, water, and nicotine; e-juice — the liquid in the vape pen; may contain nicotine; nearly 8000 flavors (designed for teens); the liquid gets heated inside the device; most vapes have ≥80 chemicals; contains a variety of substances that are harmful to the lung (eg, fat) and many that children know should not be consumed, eg, nail polish remover (acetone), weed killer

Vaping prevalence: Monitoring the Future website provides useful information; when people do not know the adverse effects, use rises; when adverse effects become known, use declines somewhat; then “generational forgetting” occurs; vaping is currently in ebb, but flow will pick up soon; >25% of high school students think e-cigarettes are benign (vs 16% for hookahs, 11.5% for smokeless tobacco, and <10% for cigarettes); e-cigarettes initially looked like cigarettes, then were changed to devices that would appeal to children (eg, able to be hidden in clothing); “pod mods” are prefilled devices containing nicotine; children have no idea that vaping products contain nicotine and other substances; most think vaping devices contain only flavoring

Myths and misperceptions: marijuana is now viewed as safer and less addictive than cigarettes, although it is physiologically and psychologically addictive; arsenic and other harmful chemicals deposit at the bottom of the lungs as a result of the heating device, and interferes with oxygenation; during the pandemic, more children were coming to the hospital with cannabinoid hyperemesis syndrome and not realizing it is from increased marijuana use

Reasons for addiction: hardwiring of the frontal cortex does not occur until late in adolescence; when Juul came to market, each pod had 3 times the nicotine of a pack of cigarettes; in Israel, Juul is required to contain only 1 pack-worth of nicotine per pod; Europe and the United States have subsequently adopted this restriction; the teenage brain is undergoing cognitive remodeling; nicotine acetylcholine receptors regulate neural maturation, so early exposure disrupts the process, leading to worse decision-making, difficulty learning, troubles recoding short-term memory to long-term memory, and issues with reward processing; marijuana further complicates this situation; many adolescents are refilling pods with marijuana-containing e-juice

E-cigarette or vaping use-associated lung injury (EVALI): strongly linked to vitamin E acetate (a fat and not supposed to be in the lungs) but there are likely other offending agents; 82% reported they had used tetrahydrocannabinol (THC)-containing products (33% said they were vaping only THC); >50% reported vaping nicotine (14% reported vaping only nicotine); worsens asthma and COVID; oxygenation at the base of the lungs is disrupted (oxygen levels may rapidly drop to 80%)

History: in 2014, e-cigarette use became more common than regular cigarettes for teenagers; marketed mainly to youths with enticing flavors and misleading claims (eg, e-cigarette use does not lead to a smoking addiction)

Vaping vocabulary: hacking — using the device in a way that was not intended by the manufacturer (eg, refilling single-use cartridges with illicit or homemade substances); children generally do not wear gloves and masks while refilling toxic substances; dripping — means dropping the liquid directly onto the heating coil to attain a higher concentration in the aerosol; dabbing — is superheating the substances containing high concentrations of THC or other cannabinoids; as per children, dripping produces a thicker cloud of vapor, flavor tastes more intense or better, and has a stronger throat hit

Motivation: children who vape or Juul only once are more likely to be “tasters”; e-cigarettes are not useful for helping individuals to quit tobacco; ask what they know about vaping and Juuling; discuss secondhand and thirdhand smoke; harmful effect of toxins and carcinogens in the vape cloud; poison control calls for children are increasing; make them realize the impact on the environment; these tangible pollutants do nothing useful for the environment; economic arguments may also help them quit vaping (ask what else can they spend that money on)

Advocating on policy: the US Food and Drug Administration (FDA) denied applications >1 million flavored e-cigarette in September 2021, but as of December 15, they had not decided what to do about prior brands that already had “cool” flavors and were popular with children; FDA has not yet banned menthol-flavored e-cigarettes (also popular with youth)

Providing care in the physician’s office: “quadruple A” model; ask, advise and counsel, assess, and arrange follow up; ask about details of usage; acknowledge pandemic stress and how it might lead to vaping; provide facts (“myth-busting”); ask — routinely and systematically, starting in junior high; ask about friends’ use and discuss peer pressure; document use as a vital sign; advise and counsel — use motivational interviewing; use questions that can resonate with the teenager (eg, impact of vaping on sports); discuss economic impact, media literacy (impact of marketing), and the carbon footprint; assess — patient's ability and choice between quitting and long-term nicotine addiction; assess their stage of change (precontemplation, contemplation, action, and maintenance); arrange follow up — with any behavior change; for serious problems, have the patient come back in 1 to 2 wk; for quitting vaping, make it 2 to 4 wk but no longer; assist them with reasoning; find teachable moments (eg, hospitalization with COVID); do not schedule quit dates during a stressful time (eg, during exams); talks or partnering with schools also educates children

Readings

Blount BC, Karwowski MP, Shields PG, et al. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. N Engl J Med. 2020; 382:697-705; Dinardo P, Rome ES. Vaping: The new wave of nicotine addiction. Cleve Clin J Med. 2019 Dec; 86(12):789-798; Drummond MB, Upson D. Electronic cigarettes. Potential harms and benefits. Ann Am Thorac Soc. 2014 Feb; 11(2):236–242; Hajek P, Pittaccio K, Pesola F, et al. Nicotine delivery and users' reactions to Juul compared with cigarettes and other e-cigarette products. Addiction. 2020 Jun; 115(6):1141-1148; Kong G, Morean ME, Bold KW, et al. Dripping and vape tricks: Alternative e-cigarette use behaviors among adolescents. Addict Behav. 2020 Aug; 107:106394; Martínez C, Castellano Y, Andrés A, et al. Factors associated with implementation of the 5A's smoking cessation model. Tob Induc Dis. 2017; 15:41; Sood AK, Kesic MJ, Hernandez ML. Electronic cigarettes: One size does not fit all. J Allergy Clin Immunol. 2018 Jun; 141(6):1973-1982; Walley SC, Wilson KM, Winickoff JP, et al. A public health crisis: Electronic cigarettes, vape, and JUUL. Pediatrics. 2019 Jun; 143(6):e20182741.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Rome was recorded at Pediatric Potpourri: State of the Art 2022, held on Maui, HI, on February 26 to March 4, 2022, and presented by The American Academy of Pediatrics, California Chapter 2, in association with Children's Hospital Los Angeles Medical Group. For information on future CME activities from this presenter, please visit https://www.chla.org/cme conferences. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

PD682702

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.