Pharmacists Can Educate Patients, Provide Counseling for Smoking Cessation

Smoking is a common issue encountered in health care that can have serious serious consequences, such as increased risk of cancer and coronary heart disease and serious morbidity and mortality. With the presence of prescription and OTC smoking cessation products, pharmacists have an opportunity to help educate patients to recognize the dangers of smoking and provide opportunities to quit smoking.¹

Popular vaping devices | Image credit: lexinav - stock.adobe.com

E-cigarettes were developed in 2003 by Hon Lik, a pharmacist in China. An e-cigarette or vaping device is a device that converts liquid containing nicotine, flavor, and other additives into an aerosol that contains tiny particles that are inhaled. When the user inhales from a mouthpiece, the airflow sensor detects inhalation to activate a heating mechanism that turns the added fluid into an aerosol.² Vaping was first introduced in the United States in 2007 to be used for smoking cessation, but its popularity grew as more youth and young adults started vaping thanks to the range of appealing flavors and a lack of research on its negative effects.³ This leads to the question of whether vaping is actually safe enough to be used for smoking cessation.

The potential benefit of vaping compared to cigarette smoking is that vapes do not produce tar or carbon monoxide, 2 of the most harmful substances in tobacco smoke. A randomized controlled trial published in 2021 has shown that participants who used e-cigarettes for smoking cessation were more successful in decreasing smoking habits than those who used nicotine replacement treatment. However, these findings only showed a decrease in smoking cigarettes and did not actually help participants quit smoking entirely.⁴

However, there are notable health risks associated with vaping. Lung tissue exposure after 9 weeks of vaping has shown thickened walls, deterioration of smooth muscle organization, and an increase in cellular infiltrates in mice. Inflammatory activity increased in vaped mice as a result of cellular infiltrates without other evidence of an inflammatory process.⁵

Vaping can also cause significant cell toxicity and dysregulation of cancer-related genes due to a significant release of carcinogens compared to conventional cigarettes. These carcinogens include formaldehyde, acetaldehyde, carcinogenic nitrosamines N’-nitrosonornicotine, and nicotine-derived nitrosamine ketones in the vapors of many e-cigarette products.⁶ Heavy metals such as cadmium, nickel, and lead have also been reported.⁶

Additionally, vape liquids consist of 80% to 94% propylene glycol and glycerol which are airway irritants. A huge selection of vape liquid flavors can put smokers at risk of nicotine addiction and long-term use without assisting in smoking cessation.⁴ Nicotine poisoning in children from ingestion of e-cigarette liquid, especially if flavored, is also a potential risk for harm.

An important question that we should ask ourselves is how can we determine the most appropriate OTC smoking cessation products for patients that vape? Bridging from vaping to OTC smoking cessation products can be done by first defining the amount of nicotine present in their vaping products and then using cigarette smoking guidelines to determine the dosing of OTC smoking cessation products. The amount of nicotine in a vaping liquid should be stated on the package and 40 mg of nicotine in a vape is equivalent to 1 pack of 20 cigarettes. Once the amount of nicotine consumed per day is determined, this value can be used to determine which OTC nicotine replacement product can be used and which doses are appropriate.⁷

OTC nicotine replacement products can come in a transdermal patch, nicotine gum, or lozenges. Patients who choose to use nicotine patches and smoke more than 10 cigarettes per day, which is equivalent to more than 20 mg of nicotine in a vape, can begin with 21 mg per day for 6 weeks, followed by 14 mg per day for 2 weeks, and finish with 7 mg per day for 2 weeks. Patients that smoke less than or equal to 10 cigarettes per day, which is equivalent to 20 mg of nicotine or less in a vape, can begin with 14 mg per day for 6 weeks, followed by 7 mg per day for 2 weeks.⁷

Determining dosing for nicotine gum is quite different. Patients who smoke their first cigarette or vape within 30 minutes of waking up should use 4 mg strength; otherwise, the 2 mg strength is recommended. On weeks 1 through 6, product instructions state to chew 1 piece of gum every 1 to 2 hours and at least 9 pieces daily for 6 weeks. For weeks 7 through 9, patients should chew 1 piece of gum every 2 to 4 hours. During week 10 through 12, patients should chew 1 piece of gum every 4 to 8 hours.⁷

Within the first week of using OTC nicotine replacement therapy, withdrawal symptoms will start and slowly diminish with consistent use. Breathing will take a few months to get better, and many patients report feeling a little worse the first month.⁸

Neither smoking nor vaping is beneficial to human health. Although vaping may have a less harmful effect on one’s health than cigarette smoking, this does not mean that vaping is safe. Very few long-term studies on e-cigarettes can confirm its safety profile because it is a new product. The presence of carcinogens, heavy metals, and potential physical damage to the lungs demonstrates that vaping is still a harmful product that should be avoided.

References

1. Do the Benefits of Electronic Cigarettes Outweigh the Risks? Can J Hosp Pharm. 2018 Jan-Feb;71(1):44-47. PMID: 29531397; PMCID: PMC5842051.
2. The history of Vaping. CASAA. (2022, October 18). Retrieved April 7, 2023, from https://casaa.org/education/vaping/historical-timeline-of-electronic-cigarettes/
3. Dinardo P, Rome ES. Vaping: The new wave of nicotine addiction. Cleve Clin J Med. 2019 Dec;86(12):789-798. doi: 10.3949/ccjm.86a.19118. PMID: 31821136.
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6. Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, Prokopowicz A, Jablonska-Czapla M, Rosik-Dulewska C, Havel C, Jacob P 3rd, Benowitz N. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2014 Mar;23(2):133-9. doi: 10.1136/tobaccocontrol-2012-050859. Epub 2013 Mar 6. PMID: 23467656; PMCID: PMC4154473.
7. Silver B, Ripley-Moffitt C, Greyber J, Goldstein AO. Successful use of nicotine replacement therapy to quit e-cigarettes: lack of treatment protocol highlights need for guidelines. Clin Case Rep. 2016 Mar 11;4(4):409-11. doi: 10.1002/ccr3.477. PMID: 27099740; PMCID: PMC4831396.
8. Prochaska JJ, Vogel EA, Benowitz N. Nicotine delivery and cigarette equivalents from vaping a JUULpod. Tob Control. 2022 Aug;31(e1):e88-e93. doi: 10.1136/tobaccocontrol-2020-056367. Epub 2021 Mar 24. PMID: 33762429; PMCID: PMC8460696.