Clearing the Air: The Influence of Vaping on Smoking Cessation

Electronic cigarettes (E-cigarettes) have emerged as a popular alternative to traditional smoking. This method, known as vaping, involves inhaling an aerosol that contains nicotine, flavorings, and harmful chemicals including carcinogens, toxic substances, and metals. Nicotine is a highly addictive compound that activates the brain’s reward center by increasing dopamine levels, which creates sensations of pleasure and satisfaction. These euphoric feelings are often what leads to nicotine addiction.¹

Man vaping | Image credit: © fotofabrika | stock.adobe.com

Although vaping is often perceived as a safer option, it actually carries significant health risks similar to those of traditional cigarettes. Pharmacists can play a vital role in educating patients on the dangers of vaping and providing guidance on safe and effective smoking cessation methods.

E-cigarettes trace back to the 1960s when British American Tobacco created a smoking device under the codename Ariel. At that time, researchers were already aware of nicotine's addictive properties, but new evidence linking smoking to lung cancer prompted cigarette companies to try and explore alternative products with less risks. They aimed to create an inhalation device with filters to reduce carcinogens and tar. However, it was discovered that filtered cigarettes were not a healthier alternative because all components of cigarette smoke have proven to be harmful. Additionally, if the device only contained pure nicotine, it would warrant classification as a drug-delivery system, subjecting it to stricter regulations. The company wanted to avoid this in order to bypass the stringent safety evaluations and extensive clinical trials required by drug delivery systems, which would allow the company to reduce their manufacturing costs, speed up production, and take this device to the market quicker. They were able to produce a product with 24% nicotine, which is 6 times the concentration found in traditional cigarettes. Despite this innovation, Ariel was discontinued to protect the company’s profitable traditional cigarette market. This marked the first instance of companies exploring the manipulative potential of nicotine.²

E-cigarettes were officially authorized for sale by the FDA in 2007 with over 460 brands. The most popular brand is Juul, accounting for nearly 75% of the e-cigarettes on the market.^3,4 In 2022, the FDA banned the sale of Juul products due to conflicting evidence regarding its associated risks, including the potential to cause strokes, respiratory failure, seizures, and cases of e-cigarette or vaping-use-associated lung injury (EVALI).⁴ EVALI is a condition in which the lungs become severely damaged and often results in admission to the intensive care unit (ICU) on mechanical ventilation.^3,4

Additionally, there is also a lack of long-term safety data for these products.⁵ Although originally marketed as a healthier alternative to cigarettes, e-cigarettes have not demonstrated efficacy as a smoking cessation aid and rather, have led to a rise in the youth vaping epidemic.¹

There has been a lack of data correlating successful smoking cessation rates among those who use e-cigarettes. There have been a few studies that suggest that vaping may aid in quitting tobacco but is not effective for quitting nicotine use altogether.⁶ One study found that those who utilized e-cigarettes in combination with nicotine replacement therapy (NRT) and counseling were 24.3% less likely to quit smoking compared to those who used only NRT and counseling. Additionally, those who used e-cigarettes were 15.1% more likely to become dual users utilizing both tobacco and vaping products. Those who are considered dual users are at an even higher risk for health complications including myocardial infarction and a 4-fold increase in developing lung cancer.⁶

In another survey of 800 people who utilized vaping as a smoking cessation agent, it was reported that only 9% successfully quit when asked 1 year later, compared to 19.8% who utilized NRT.^1,7 These findings help highlight that vaping is not a reliable method for eliminating nicotine use entirely and can even lead to utilizing both traditional and electronic cigarette products.⁸

Vaping is now the most commonly used form of nicotine among adolescents. A study was conducted that showed high schoolers who had used e-cigarettes were 16.7% more likely to start smoking cigarettes within the next year.⁹ Nicotine’s impact on the developing brain can cause mood disorders, affect attention and learning, and amplify the desire for other mood-enhancing drugs such as cocaine or methamphetamine.¹ In 2018, e-cigarette use among high school students increased by 78%, which led the FDA to enforce stricter regulations on the sale of nicotine products. Despite their efforts, vaping remains a leading challenge that teens face today as they have already fallen victim to nicotine addiction.⁴

The FDA currently lists 7 approved quit aids that are safe and effective for smoking cessation. These include several forms of NRT as well as pharmacologic therapy with bupropion and varenicline. Some of the agents, including the NRT gum, patch, and lozenge, are even available OTC. Pharmacists can play a vital role in smoking cessation, especially in patients who lack access to a primary care provider to obtain prescription medications. Therefore, it is crucial for pharmacists to stay up to date on the current smoking cessation guidelines, dosing recommendations, and counseling points for these agents.

The primary goal of pharmacist-driven smoking cessation should always be to support the patient’s desire to quit smoking. Pharmacists should guide patients toward the FDA-approved agents, either prescription medications through a provider, or OTC therapies in the pharmacy, rather than electronic cigarettes due to lack of supportive data and increased risk for adverse health events. The appropriate selection of FDA-approved agent should be individualized based on the patient’s specific factors, contraindications, and goals of therapy. Pharmacists should educate the patient extensively on the appropriate options for smoking cessation and should not recommend the use of e-cigarettes. However, if a patient decides to use e-cigarettes, pharmacists should still serve as a support system for the patient by being the primary educator and providing extensive counseling on the associated risks of vaping. Patients should be made aware of both the known and unknown adverse reactions associated with electronic cigarettes as well as highlighting that the goal of vaping should be to achieve complete smoking cessation.¹⁰

Vaping e-cigarettes has become a popular alternative to traditional cigarettes, with unknown efficacy and safety surrounding these products.¹⁰ Pharmacists should continue to stay up to date on new literature published on e-cigarettes and should follow the FDA’s suggestions on smoking cessation methods. Pharmacists are the most widely accessible health care professionals available to patients. Therefore, pharmacists have the power and knowledge to be the most influential providers available to advise patients on the correct paths to smoking cessation. By offering education and support, pharmacists can help patients live healthier lives and take steps towards reversing the youth smoking epidemic one education at a time.

REFERENCES

1. Vaping Devices (Electronic Cigarettes) DrugFacts. National Institute on Drug Abuse. January 2020. Accessed September 14, 2024. https://nida.nih.gov/publications/drugfacts/vaping-devices-electronic-cigarettes

2. Risi S. On the Origins of the Electronic Cigarette: British American Tobacco’s Project Ariel (1962-1967). AJPH History. 2017;107(7):1060-1067. doi:10.2105/AJPH.2017.303806

3. Salzman G, Alqawasma M, Asad H. et al. Vaping Associated Lung Injury (EVALI): An Explosive United States Epidemic. Science of Medicine Miniseries. 2019;116(6):492-496.

4. Turner T. Juul and E-Cigarettes. Drugwatch. March 28, 2024. Accessed September 14, 2024. https://www.drugwatch.com/e-cigarettes/#:~:text=Juul%20is%20the%20most%20popular%20e-cigarette%20marketed%20in,other%20four%20are%20Vuse%2C%20MarkTen%2C%20Blu%20and%20Logic

5. Sharpless N. How FDA is Regulating E-Cigarettes. FDA. September 10, 2019. Accessed September 14, 2024. https://www.fda.gov/news-events/fda-voices/how-fda-regulating-e-cigarettes

6. Feeney Susan. Vapor Trial- The Latest on E-Cigarette Risks- Frankly Speaking. September 1, 2024. https://podcasts.apple.com/us/podcast/vapor-trail-the-latest-on-e-cigarette-risks-frankly/id1194659367?i=1000667997718

7. Rosen LJ, Galili T, Kott J, et al. Diminishing Benefit of Smoking Cessation Medications During the First Year: A Meta- Analysis of Randomized Controlled Trials. Society For The Study of Addiction. May 2018; 113:805-816.doi:10.1111

8. Auer R, Schoeni A, Humair JP, et al. Electronic Nicotine-Delivery Systems for Smoking Cessation. The New England Journal of Medicine. 2024;390:601-610. doi. 10.1056/NEJMoa2308815

9. Berry KM, Fetterman JL, Benjamin EJ, et al. Association of Electronic Cigarette Use With Subsequent Initiation of Tobacco Cigarettes in US Youths. JAMA. 2019 February 2019;2(2):e187794.doi:10.1001

10. Barua, R, Rigotti, N, Benowitz, N. et al. 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment: A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. JACC. 2018 Dec, 72 (25) 3332–3365.https://doi.org/10.1016/j.jacc.2018.10.027