Why is it important for providers to understand how vaping devices work and what type of information should we be providing our patients with?
Published On: 06/13/2022
Duration: 30 minutes, 25 seconds
Referenced Article: “A Primer on Vaping:15 Years On,” The Carlat Addiction Treatment Report, January 2022
Dr. Capurso: The prevalence of vaping has rapidly increased in the United States, especially among adolescents. As clinicians, it is important that we stay up to date on the latest information pertaining to vaping. By doing so, we can improve our ability to appropriately identify and treat nicotine use disorders related to vaping and educate our patients.
Welcome to The Carlat Psychiatry Podcast. This is a special episode from the Carlat Report’s Addiction Treatment team.
I’m Noah Capurso, the Editor-in-Chief of The Carlat Addiction Treatment Report. I’m an assistant professor of psychiatry at the Yale University School of Medicine. And an attending psychiatrist at the West Haven Veterans Administration hospital.
And, in this episode, Dr. Kaliamurthy and I will discuss the latest developments in vaping, now that devices have been widely available in the American market for 15 years.
But first, let’s talk about some exciting news. You can now receive CME credit for listening to our podcast episodes. Earn CME credit for listening to this episode by subscribing to our Podcast CME product. Subscriptions come with access to the CME posttests for almost 40 of our previous episodes and you’ll be able to receive credit for every future episode as well. Click the link in the episode description to sign up for our new CME product and, if you’re already a subscriber, there’s a link in the description to the CME posttest for this episode. Now, here’s a preview of a CME question for this episode.
In a study by the U.K’s National Health Service, what was concluded about switching patients from regular combustible cigarettes to e-cigarettes or vaping devices for smoking cessation?
A. The majority of patients quit smoking entirely
B. The majority of patients continued to smoke regular combustible cigarettes
C. The majority of patients no longer smoked regular combustible cigarettes, but smoked e-cigarettes or vaping devices at lower doses than before
D. The majority of patients no longer smoked regular combustible cigarettes, but smoked e-cigarettes or vaping devices at equal to higher doses than before.
The latest issue of The Carlat Addiction Treatment Report contains an interview with Dr. Kaliamurthy. He finished medical school in India followed by an adult psychiatry residency and child psychiatry fellowship at the Institute of Living in Hartford, CT. Following his child psychiatry fellowship, he completed an addiction psychiatry fellowship at Yale and is now an attending psychiatrist at the Children’s National Medical Hospital in Washington D.C.
Dr. Kaliamurthy, how did you become interested in the topic of vaping?
Dr. Kaliamurthy: So with regard to the topic today, I have been following this whole e-cigarette and vaping situation since about 2016, which is when I had my addiction psychiatry rotation. And I went to a conference, and the first thing I noticed was everyone outside the conference kind of using these big devices and blowing big plumes of smoke and/or vapor. And I’m a bit of a technophile so it kind of really made me kind of investigate what these devices were and learn more about them and really start looking at why there were people using it and what are the pros and cons, and this was 2016.
And once I started my child fellowship that’s when the whole…I kind of was following this particular issue peripherally, and then when I started my child psychiatry fellowship I kind of noticed this increase in vaping use among adolescents, especially like on the inpatient unit they were coming in and they were going into withdrawal from the nicotine. And I think the general public was also catching up on this topic, but nobody really knew what to do, and I was a bit ahead of the curve having been following these devices peripherally.
So I started learning more about this particular topic and started campaigns in schools, within the hospital with the pediatrics team trying to help them more proactively ask questions and treat the nicotine withdrawal symptoms. And even before this I knew I wanted to do addiction psychiatry.
I came to the addiction psychiatry angle from a more digital perspective. One of my other interests is how humans interact with the digital media: internet and technology, etc., and I kind of wanted to learn about that from an addiction angle from a behavior perspective. So I had these multiple interests and e-cigarettes kind of fit in between with the technology piece and the substance, and also using the digital media for advertisement, etc. So that’s really what happened with regard to my interests, and now I’m at Apt Foundation and I see a wide range of patients – adolescents, adults, and older adults as well, and I’m noticing that even in my clinic (it’s a methadone clinic and a buprenorphine clinic primarily) where a lot of my adult patients are switching from regular combustible cigarettes as we call them to these e-cigarettes or vapes. And I have been actively working with my patients trying to figure out if this is good for them and what are the pros and cons, etc.
Dr. Capurso: Give us a rundown of available vaping products and tell us why it’s important for providers to understand how these devices function?
Dr. Kaliamurthy: It’s helpful to know the basics so you can understand how patients use and modify these devices, and what some consequences might be. So there are a wide variety of products out there and a range of different kinds of devices, but they all have certain components that are common to them. So all e-cigarettes and these electronic vaping devices have a battery, which they can be rechargeable or use-and-throw, and they provide different amounts of energy in terms of wattage. And they all have an atomizer or a coil. This is essentially the heating element that then heats the liquid and turns it into vapor, and you can change the resistance and the kind of metal used in these atomizers. And then you have the e-juice, which is the actual liquid that these heating elements then heat up and turn into vapor, and then finally the cartridge. The cartridge in some of these devices can come with the liquid and the coil or the atomizer inside it, and some of these cartridges just contain the liquid alone or the e-juice.
It’s an industry on its own that runs parallel with big tobacco and they are catching up in terms of market share. It’s huge; there are a lot of different products out there. So for purposes from the clinic and research perspective, we have started classifying them as “open system products” and “closed system products.”
Dr. Capurso: Can you talk more about what open system products and closed system products are?
Dr. Kaliamurthy: From the closed system products, these are things like “cigalikes” they call them. These are the first generation ones; they look like traditional cigarettes. These were present back in 2007, all over the shelf; a lot of us saw those. And then the open system products came into being; they were the vape pens. There were more like your traditional, longer cylindrical devices that you could switch the parts around. And then you had the mods. The mods simply stand for modifications. These are those huge tank-like devices that we see.
Then the closed system devices kind of became more prominent with the pod-based devices and the disposable e-cigarettes.
Now a closed system device is essentially something that the manufacturer predetermines every aspect of the device: the battery, the power, the kind of atomizer you have, the resistance in it, and the e-juice concentrate. So as a consumer in this closed system, they really don’t have a lot of flexibility. The manufacturer is like this is the setting; these are the concentrations; you can either use it or not.
But with the open system devices, there is a lot more flexibility: you have more ability to change the settings on the battery, the atomizer coils, the e-juice concentrations, etc.
Dr. Capurso: Researching vaping devices can be difficult due to their lack of standardization and just sheer diversity with new ones being developed all the time. And big tobacco has gotten into the game in the past several years, realizing that there are big profits to be had.
One important distinction is the difference between salt and freebase forms of nicotine Can you tell out listeners about that?
Dr. Kaliamurthy: Yes, sure. The nicotine, as we know, it comes from plants. It’s a naturally occurring parasympathomimetic. So over the centuries, the tobacco companies have always been trying to find a way to deliver more nicotine to sell more products. And they’ve tried different means to do it. Back in the day they used to add ammonia and other elements to the nicotine to make it more alkaline so as to make it more potent.
Now in about 2014/2015 when the pod-based companies came about given that they changed how the nicotine was being delivered into the body they developed nicotine salts, but they lowered the pH of nicotine to make it more acidic and then converted into salt forms. And what happened was that early studies showed that when you have nicotine salt that is being delivered through these vaping devices the blood-nicotine concentration is higher than what you get from a regular cigarette. But what we also saw is that it also decreases at a rapid rate. So you have a rapid upward spike in blood-nicotine concentration and a downward trend in the blood-nicotine concentration with the nicotine salt. And what this means is that we know in addiction psychiatry that any addiction substances that tend to do that causes the euphoric effects faster and then it leaves the system faster and it can have negative affective states, and that can lead to more addictive potential. So that’s what happened with the pod-based system and nicotine salt particularly, and right now in terms of products out there in the vapes you can either choose free-base on salt.
Dr. Capurso: To clarify, a pod is just another term for a cartridge. A pod is the container that holds the e-juice. The E-juice predominantly contains either propylene glycol or vegetable glycerin, which is the liquid that the nicotine is dissolved into. In closed system devices, the manufacturer determines the e-juice components. In open system devices, users can assemble their own mix.
One component of e-juice that we should touch on is flavorants. Tell us about them and why they can be so problematic.
Dr. Kaliamurthy: So flavors have really changed the landscape. When even the pod-based companies came out they were offering a multitude of flavors; at one point mango flavor was the most popular flavor of e-cigarette juice out there. So the FDA has been more recently clamping down on the access to flavors, the reason being flavors seem to be particularly marketed toward adolescents. And we have early studies now that showed that when you add flavors to the nicotine what happens is the dopamine release in the nucleus accumbens it’s more. So you have regular nicotine and then you have a product with flavorings plus nicotine, and the sweeter the flavor we know that the response in the nucleus accumbens is more and we hypothesize that this means that the addictive potential is also more. So that’s always concerning with regard to flavors. And they also tend to market unique flavor names to appeal to younger generations, especially more vape shops have like I’ve come across flavors called like “unicorn puke” or “hulk tears.” I mean like you hear the names and I’m working like in an emergency room in a children’s hospital and I know kids are vaping and they tell me they don’t know what they are vaping but this is what it is called. And I’m automatically thinking why would an adult buy a product called unicorn puke or hulk tears? Some adults do; that’s different, but when you think about the broader spectrum of who they are trying to target these are concerns that come up with flavors.
Dr. Capuroso: Another issue is that each flavorant chemical confers its own risks, and many of them haven’t been thoroughly studied. We do know that cinnamon and menthol in particular can be cytotoxic to stem cells. Since the available compounds are constantly changing, it’s best to play it safe and recommend that our patients avoid using chemical flavorants in their e-juice.
It’s becoming increasingly popular to modify open system devices. What are some of the modifications that clinicians should be aware of?
Dr. Kaliamurthy: So we tend to see modifications most commonly in like children and adolescents. They tend to be more drawn to the technology of things and also limited means, which means they have to really think out of the box to try different things and see what the end results are. So one of the most common modifications we see is called “dripping” and what this means is that kids they tend to directly drop the e-juice onto the coil. They can either remove the devices or now you can actually buy these devices called “RDAs” called rebuildable dripping atomizers that you can use to modify your device. And you drop the liquid directly onto the coil to produce the vapor and to inhale the aerosol. And my patients tell me that this tends to be more flavorful for them, which I’m not entirely sure what that means from the aerosol, and some people tell me that this is a better way to get the euphoric effects for cannabis. They call it “dripping.” Some people when they use cannabis on it they call it “dabbing” as well when they use high concentrate cannabis on the coil directly.
Dr. Capurso: What are some differences between vaping cannabis versus nicotine?
Dr. Kaliamurthy: In terms of differences itself, there are not a lot. Any of these devices that are used to vape nicotine can also be used to vape cannabis. And you find these products now available in your dispensaries both the medical dispensaries and the recreational dispensaries. Also these are available on the streets to say when you’re not buying it from a legitimate source.
So the difference with THC is that, especially this I notice more in adolescents, when they want to vape this is a more easily concealable manner in which they can vape THC versus using their regular flower and bud; making a joint, or however they’re going to do it. Because number one the paraphernalia itself is quite easy to conceal and the smoke that it emits is low and it also has less odor, and all these properties together make it an easier habit for them to pick up without having to manage the consequences, especially in schools and at home. This is the major difference between THC vaping and like regular use of THC.
And the other concern is that more and more people are moving towards using cannabis concentrates in these products, the reason being when they go and try to buy these products they are told these are cannabis concentrates; they have more concentration of THC in them up to more than 80% at times, and they are often told that because it is higher you might be using less of cannabis overall, and some people might actively seek out high concentrate products. But in the long term we know that when the THC concentration is that high it leads to more negative consequences from cannabis.
Dr. Capurso: Exactly. It’s what I tell my patients- the more THC you’re exposed to, the higher the risk of adverse effects. And a recent study showed that THC serum levels were significantly higher in patients who consumed cannabis by vaping concentrates versus smoking.
Probably the most common scenario that I encounter in the clinic is patients trying to quit smoking combustible tobacco. Should we recommend vaping instead?
Dr. Kaliamurthy: This is a tricky topic because I’m noticing and I’m waiting for the data to come out, but more adult patients are switching to vaping, and oftentimes this conversation does not happen in the clinic. They see their friends and they see that their friends have switched from cigarettes to vaping and they’ve stopped using cigarettes. And I often see my patients; they walk into the clinic and they have something fat like a pen hanging around their neck and I have to ask them what that is and then they tell me what’s really going on. So I’ve had conversations about this with patients. So it really comes down to again what are the patient’s goals. Patients usually are clear about their goals: they either want to quit smoking completely or they are just looking to quit the combust. Like they don’t want to quit the nicotine; they just want to quit the combustible cigarette use. So I try to identify that goal with the patient first.
And if it is to quit smoking I tell them we have evidence-based medicines to help with that and I usually recommend that they try that first. But I also tell them at the end of the day if they were to decide to go down this route there is some specific information that they need to know, and some of that is what we already talked about with the closed system versus the open system.
And I specify that there are other countries in the world where vapes are used for smoking cessation, particularly the U.K.’s NHS does recommend e-cigarettes as an alternative and as a smoking cessation tool, but their marketplace is well regulated and it is very different from the U.S. where we don’t have similar regulations. So I tell my patients if their goal is wanting to stop combustible cigarette use and they are okay with continuing nicotine and they are not looking to do like be an artisanal vapor, try different products, do different smoke tricks that they should really stick to simple devices, devices that they know are of good quality and they know that they are easily available and are within their economic means because these devices can be expensive depending on what kind of products you use.
And also just not modifying them because that can also lead to unknown harms. So I usually recommend these things and I also tell them to watch out for the nicotine concentration in the e-juice. Oftentimes, our patients are given false information. For example, we know that a pack of cigarettes usually contains 20 cigarettes and 1 cigarette usually on average can contain about 10 mg of nicotine which makes it about 200 mg of nicotine per pack of cigarettes. But we know that when you smoke that 1 cigarette with 10 mg of nicotine only about 1-2 mg of nicotine actually end up in your bloodstream. So in the end you’re getting about 20-22 mg of nicotine per pack of cigarettes that’s ending up in your bloodstream. So when our patients are presented with the information: a pack of cigarettes contains 200 mg of nicotine; this pod only contains 50 mg of nicotine so you’re essentially cutting down on your nicotine – that is not accurate. I tell them about what actually ends up in their bloodstream and how we really don’t know ….like depending on the setting on these devices there are changes in the blood nicotine concentration, and it is more so with the nicotine salt. So I give them this information and tell them to always try the lower dose nicotine first and only increase if they feel like they’re having cravings and not start off with a higher dose so that they kind of know where they are.
And I also tell them often I’ve seen patients who start off on these devices; the device either breaks or they’re not able to buy refills and then they go back to cigarettes, but now they end up smoking more cigarettes because they need more nicotine. So that risk is always present for a lot of these patients. This is the conversation that I have with patients.
Dr. Capurso: So you’re saying to make sure that patients understand that the number of milligrams of nicotine in combustible cigarettes and vaping devices is not necessarily 1:1. And you mentioned artisanal vapers. What’s that?
Dr. Kaliamurthy: I mean a lot of times this is more in young adults and adolescents rather than adults. And this is similar to any…it’s like a subculture on its own. A lot of time it’s more about psychoeducation. A lot of time our patients down have the right information and we ourselves don’t have the right information because this is still relatively new. These products have only been around for about 14-15 years at this time. So I try to provide them with all the information they need and what the risks that are involved. So I think that’s the most that I can do when I think about it from patient-centered care is that they’re aware of what it is exactly that they are getting into and how this can then affect their physical and mental health.
Dr. Capurso: Can you give us a run-down of some of the evidence for vaping products in terms of helping patients quit smoking?
Dr. Kaliamurthy: So most of the evidence at this point comes from the U.K.’s NHS system. They are the ones that are actively looking at it. So what they’ve found is that when patients switch from regular combustible cigarettes to e-cigarettes or vaping devices at the end of one year most of those patients had stopped using combustible cigarettes, but they were still continuing to use the e-cigarettes. So if that’s the outcome then there is promise to using this as a smoking cessation tool and that is the biggest evidence that we have. There was a paper that came out recently, I don’t have the numbers on top of my head, but this was a larger sample size and they still showed that most patients who were able to switch to these e-cigarettes were able to successfully stop the combustible cigarette use, but again they were still continuing to use the e-cigarettes and vapes. A few of them were able to stop the e-cigarettes as well, but the majority of the patients at the one year interval were still using the e-cigarettes.
Dr. Capurso: And how do the long term effects of e-cigarettes compare to combustible tobacco?
Dr. Kaliamurthy: So the heterogenicity that I spoke about with the open system and closed system makes it harder, especially in the U.S., to kind of look at the long-term risks. But as I said, it’s only been around since 2007 when it became commercially available in the U.S., so when you think of long-term data for tobacco and cigarettes have been around for like many, many decades at this time, so we are still catching up. We really don’t know and we really don’t know what all of the long-term consequences are at this time. We will hopefully find out in the next ten years or so, but that doesn’t mean there isn’t any harm either; it’s just a question of comparing cigarettes versus e-cigarettes, which is less harmful. And, anecdotally, most patients tell me that they are able to breathe better, so subjectively at least they are noticing some differences in their physical health, which is always good from a patient perspective, but without knowing the long-term risk it’s just very difficult to say one is better than the other.
Dr. Capurso: Vaping THC has been associated with serious lung injuries, specifically EVALI, which stands for E Cigarette or Vaping Use Associate Lung Injury. It was big news a few years ago.
Can you tell us about EVALI?
Dr. Kaliamurthy: Absolutely. So this happened in 2019. This was a big concern. We had a rapid uptick in patients presenting with lung injury sometime in August, and it kind of peaked in September and we saw a downward trend after that. So essentially, these were patients who were presenting with lung injury with no underlying cause that could be detected except that they all had a history of using a vaping device.
Now the CDC had been kind of tracking all these cases, and they only did it until February 2020, and unfortunately there was no single ingredient that was identified by federal authorities that they said this was directly responsible for the e-cigarette or vaping-associated lung injury. What they did say was that in the majority of these patients the common characteristics were that they had used a vape that was specifically for THC, and a majority of them had vitamin E acetate as a product in their cartridge. And they also were bought on the streets; they were not bought from sources like dispensaries. So these were the common characteristics of the vapes. There is also a specific term they used called “dank mods” and these were the devices that they associated having more risk for developing the lung injury.
And I think we had approximately as of February 2020 about 3,000 cases of this disease and approximately 68 people died at that time. We don’t have any updated data since then. And there are also geographical differences within the U.S. We know that most of these cases were in Texas and Illinois, followed by California and New York, and Connecticut and Massachusetts had about 100 or so cases, which is where we live. So this was the general pattern of this. And it was primarily a disease of exclusion at the end of the day and with the Covid pandemic we really haven’t been doing a good job of tracking these cases. The current data is mostly field notes that the CDC releases of case reports here and there, but I think the last few case reports are primarily from California.
Dr. Capurso: What are some other specific safety concerns that you worry about with patients who are using these products?
Dr. Kaliamurthy: So the first two immediate ones would be the vaping-associated lung injury and the second one is nicotine toxicity on its own because if they are using high nicotine product it can lead to toxicity. Apart from that, more specifically like it depends on the product. So it would come down to the product they are using like rechargeable batteries. There have been cases of batteries catching fire or kind of like bursting when they were using it and it caused facial injuries. So these are the three acute concerns.
And then the storage itself, once these pod-based devices and these e-liquids became more prevalent there were increased phone calls to toxicology centers for either kids having drank these liquids or pets accidentally getting into the supplies and drinking it, and it has caused injuries and death even in specific cases. So those are like the primary safety concerns that I usually discuss with patients.
Dr. Capurso: How do you counsel patients about these dangers?
Dr. Kaliamurthy: So we know that it’s usually…there are specific recommendations for them. We know that it’s like if you have a product that you are charging often, charging overnight, or if it not a reliable battery that is something that they need to be concerned about. It’s just like…again, I ask them to read the package insert if they have any with the device itself on what the charging instructions are. And also just if it’s overheating just be aware. So those are like the two things.
Dr. Capurso: Vaping is a certainly a rapidly developing field. How should providers stay up to date?
So a lot of this data is more targeted towards teens right now so there’s a lot of information about the different products and the dangers associated with these products on the FDA and CDC websites. ACAP (The American Academy of Child and Adolescent Psychiatry) and American Academy of Pediatrics they all have like websites dedicated to this particular topic, so a lot of this information about a lot of the devices’ harms is on there. There are not a lot of recognized websites and resources out there that proactively discuss the harms and benefits of it as well where we are able to provide patients with information that helps them make better decisions at the end of the day. That’s just something I think we have to continue to work on.
And it is a controversial topic because I think from a policy perspective we tend to think about it’s always about either banning these products completely or setting age limits, but we aren’t thinking about regulating the market as such and to think about how to make proper recommendations. But hopefully with the U.K. NHS system doing this we might see a difference in the future. But, unfortunately, to answer the original question there aren’t resources that talk about managing the risks versus the benefits; it’s more about just what the risks are and don’t do it.
Dr. Capurso: Definitely. Before we end, I wanted to wrap up this discussion by talking about advice we can give to a patient who vapes THC. The CDC says that the only way to definitively avoid vaping-associated lung injury is to not use these devices at all. But if patients are going to vape THC, it is recommended that they do not use products obtained off the street. It is important to encourage patients to avoid sources that they don’t know, and to get devices from dispensaries if possible.
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