The Community Pharmacist: Frontline Care Provider for Vaping

The first double lung transplant due to injuries sustained from vaping was given to a boy, age 17 years, on October 15, 2019. The CDC has reported 2172 cases of e-cigarette and vaping lung injury (EVALI), with 42 confirmed deaths based on reports received from 49 states, the District of Columbia, and 2 US territories, through November 13, 2019.¹

As more vaping cases are reported, patients may desire answers from their trusted providers. As front-line health care professionals, pharmacists have a unique opportunity to intervene in this public health crisis.

Rise of Vaping

Overwhelming evidence on the negative effects of smoking cigarettes has created a market for alternatives. The modern iteration of the commercially successful e-cigarette was created by a Chinese pharmacist, Hon Lik, in 2003.² Originally designed to assist chain smokers in decreasing their cigarette intake, health care professionals became increasingly concerned over e-cigarette’s potential for abuse by perpetuating nicotine addiction, and increasing total nicotine consumption. One aspect of this market is the modifiable “open-system” vaping devices that allow the consumer to add an assortment of unregulated e-liquids, including cannabinoids.³

Toxicity and Consequences of Vaping

While initially considered a harmless alternative to smoking, research and case reports are revealing a more complex narrative. Diacetyl, a commonly used sweet-flavoring agent, has been associated with chronic cough, bronchitis, asthma, and bronchiolitis obliterans. Diacetyl, and a similarly related compound—acetyl propionyl—were found in 74.2% of tested e-liquids.⁴

Most recently, the CDC linked Vitamin E acetate, an additive used as a thickening agent in THC-containing e-cigarettes, with several cases of EVALI. While safely used as a vitamin supplement or in various cosmetic products, the honey-like substance is reported to remain in the lungs, impairing normal function.¹ Also, FDA reports reveal that 79% of the CDC EVALI cases were related to patients vaping with THC products, with a higher incidence of death in patients using THC-containing products.⁵

Inhaling the vapor from e-cigarettes can result in a proinflammatory response and subsequent immunosuppression.⁶ Even acute aerosol inhalation can lead to oxidative stress, and inflammation.⁷ In an acute setting, clinical presentation of EVALI includes respiratory symptoms, such as shortness of breath and cough, constitutional symptoms, and gastrointestinal symptoms in a patient who has vaped in the last 90 days. Approximately 1/3 of patients required mechanical ventilation.⁸

Long-term risks of inhaling these vapors include development of chronic obstructive lung disease, chronic bronchitis, asthma, emphysema, and bronchiolitis obliterans. Researchers have also surmised that e-cigarette smoke could induce lung and bladder cancer.⁹

Call to Action

With pharmacists being the most accessible health care professional to the general population, there are opportunities for helping tackle this public health concern.

• Pharmacists must educate themselves regarding the signs, symptoms, and consequences of vaping in order to strengthen their patient counseling. The CDC provides constant updates and guidance for health care providers in diagnosing and treating EVALI patients.
• When counseling on smoking cessation, patients must understand the risks of using e-cigarettes as a nicotine-replacement. It is essential to provide resources regarding other nicotine replacement options, such as patches and gum. Utilizing the 5As of ask, advise, assess, assist, and arrange, is a helpful technique to incorporate motivational interviewing into counseling.
• Patients who vape should be heavily encouraged to receive their annual flu vaccine due to their immunocompromised state. All adults, ages 19-64, who smoke are also recommended to receive the pneumococcal polysaccharide vaccine (PPSV23).
• As antibiotics continue to be prescribed for outpatient management of EVALI patients, it is always important to remind patients to take all of their antibiotics as directed by their physician.
• When working with EVALI patients, it is imperative to tackle this issue from an interprofessional perspective. Opening dialogue with local providers can establish working relationships that can maximize resources to combat EVALI.

Overall, providing education regarding the risks and consequences to patients along with a personalized plan to impart the support necessary to hollow the epidemic of vaping is key. It is essential that pharmacists are on the front lines of this health crisis as an essential member of the healthcare team.

References

• Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#what-is-new. Published November 19, 2019. Accessed November 20, 2019.
• E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/pdfs/2016_sgr_entire_report_508.pdf. Published December 8, 2016. Accessed November 20, 2019.
• Baldassarri SR, Fiellin DA, Friedman AS. Vaping—Seeking Clarity in a Time of Uncertainty. JAMA. Published November 07, 2019. doi: https://doi.org/10.1001/jama.2019.16493
• Farsalinos KE, Kistler KA, Gillman G, Voudris V. Evaluation of electronic cigarette liquids and aerosol for the presence of selected inhalation toxins. Nicotine Tob Res. 2015;17(2):168-74. doi: 10.1093/ntr/ntu176
• Respiratory Illnesses Associated with Use of Vaping Products. U.S. Food and Drug Administration. https://www.fda.gov/news-events/public-health-focus/lung-illnesses-associated-use-vaping-products. Published November 4, 2019. Accessed November 20, 2019.
• Martin EM, Clapp PW, Rebuli ME, et al. E-cigarette use results in suppression of immune and inflammatory-response genes in nasal epithelial cells similar to cigarette smoke. Am J Physiol Lung Cell Mol Physiol. 2016;311(1):L135-44. doi: 10.1152/ajplung.00170.2016
• Chatterjee S, Tao JQ, Johncola A, et al. Acute exposure to e-cigarettes causes inflammation and pulmonary endothelial oxidative stress in nonsmoking, healthy young subjects. Am J Physiol Lung Cell Mol Physiol. 2019;317(2):L155-L166. doi: 10.1152/ajplung.00110.2019
• Baldassarri, S. Vaping—Seeking Clarity in a Time of Uncertainty [podcast]. JN Learning. https://edhub.ama-assn.org/jn-learning/audio-player/18010914?utm_content=weekly_highlights&utm_term=110919&utm_source=silverchair&utm_campaign=jama_network&cmp=1&utm_medium=email. Published November 7, 2019. Accessed November 20, 2019.
• Tang MS, Wu XR, Lee HW, et al. Electronic-cigarette smoke induces lung adenocarcinoma and bladder urothelial hyperplasia in mice. Proc Natl Acad Sci USA. 2019;116(43):21727-21731. doi: 10.1073/pnas.19