What should healthcare professionals do about youth vaping?

When experts gathered virtually for the National Conference on Tobacco and Vaping in early February, questions swirled on what to do about e-cigarettes. While they’re a useful tool for smoking cessation, they’re also a gateway to nicotine dependency in youth. Results from the Vaping Dependence Cohort Study highlighted how prevalent the dependence on nicotine e-cigarettes is in Canadian youth. “There is substantial evidence that vaping causes dependence,” said Robert Schwartz, executive director of the Ontario Tobacco Research Unit, professor at the University of Toronto and senior scientist at the Centre for Addiction and Mental Health (CAMH) in Toronto. “Young people who vape have to reach for their vape more quickly in the morning than people who smoke.” “Our study does open the door for further research and for questioning what we’ve enabled to happen for the tens of thousands of young people in Canada,” Schwartz said. Youth vaping in Canada Canada has one of the highest rates of youth vaping in the world, said David Hammond, professor in the school of public health sciences at the University of Waterloo in Waterloo, Ont. The 2019 Canadian Health Survey on Children and Youth included 13,602 participants aged 12 to 17 years old. A 2022 analysis of the survey by Statistics Canada showed that 13.2% of 12- to 17-year-olds reported using e-cigarettes in the past 30 days. Of those, 23.8% said they used them daily. While e-cigarettes are known to help people stop smoking, youth in Canada tend to use them before cigarettes. Two thirds of the youth ages 12 to 17 who reported using tobacco and e-cigarettes had used e-cigarettes first. Most young e-cigarette users are using them with nicotine. Of those who used e-cigarettes within the past 30 days, 89.3% used a liquid containing nicotine. Developing dependence Similar to cigarettes, dependence on vaping builds over time. “Dependence doesn’t start on the first puff,” explained Michael Chaiton, director of research at the Ontario Tobacco Research Unit, associate professor at the University of Toronto and independent scientist at CAMH. The Vaping Dependence Cohort Study involved 3,376 participants aged 16- to 25-years-old who were recruited through social media. They were either regular, ever, or never vapers. The participants were surveyed every three months for up to 21 months, starting in August 2020. The average age of respondent was 19.7 years old and the majority were female and white. The results suggest that by 24 months, participants vaped at least monthly, then between 24 to 30 months began to vape weekly, and at 30 months, began to vape daily. The behavioural milestones were similar. At 24 months, people reported strong cravings and vaping soon after waking, and at 30 months said they find it hard to resist vaping. By 55 to 67 months, participants reported waking at night to vape. Because of this time lag to dependence, as more youth vape, we will see more and more dependence in the population, Chaiton said. Read: Clinical pearls: Cessation tips Who's most at risk for dependence? The study that those most at risk of becoming regular vapers or dependent on vaping include those who've been previously exposed to nicotine and those who'd smoked previously. Also, those who'd previously smoked were significantly more likely to get to a level of dependence, such as vaping after waking, more quickly than never smokers. Who's at risk of starting to vape in the first place? Children aged 12- to 14-years-old with a diagnosis of ADHD were more likely to vape than those without a diagnosis, the Statistics Canada analysis of the Canadian Health Survey on Children and Youth found. Being male, Canadian-born and grades lower than an A were also risk factors for vaping among 15- to 17-year-olds. What is the harm? The harm of vaping remains poorly understood. Chaiton presented findings on the number of respiratory symptoms reported by study participants. As the number of puffs per month increased, there was a significant increase in respiratory symptoms. By 800 puffs per month, vapers who had never smoked had the same number of respiratory symptoms as participants who smoked daily. Interestingly, those who were daily smokers and also vaped showed no more respiratory symptoms than those who smoked but did not vape. An increase in vaping dependence score was also associated in increase in depression, Chaiton said. A position statement on youth vaping by the Canadian Pediatric Society was published in October 2021 in Pediatrics & Child Health. It lists some of the harms caused by vaping, including respiratory problems. The position statement notes that the health risks of vaping are not fully known yet. Youth want to quit, but cessation is difficult Almost a third of the participants in the Vaping Dependence Cohort Study who used e-cigarettes intended to quit within six months. The struggle to quit was highlighted by two presenters with lived experience. One, Maya S., started vaping in grade 12 after resisting it for years, but found it helped with her symptoms of anxiety. She’s tried to quit cold turkey, but withdrawal symptoms were too much. She also quit using nicotine gum, but started again. “Treating people like children and saying 'stop this, it’s bad,' is not going to help,” Maya S. told attendees at the conference. She recommended more resources to help those with anxiety, targeted information about cessation, and education about the long-term effects of vaping. Read: New tool assists with individualizing first-line antidepressant therapy Cessation programs How, then, can practitioners help youth quit? Unfortunately, the best intervention has yet to be found. Dr. Hassan Mir, a cardiologist at the University of Ottawa Heart Institute and program chair of the Ottawa Model for Smoking Cessation, presented a review of e-cigarette cessation interventions. He found that the evidence was scarce and there was a high risk of bias. The only intervention studied that showed benefit was a text-based program that delivered social support and behavioural coping skills to young adults. It was published in JAMA Internal Medicine in 2021. Dr. Mir said his group now has two grants to research pharmacotherapy interventions for vaping cessation. CAMH’s STOP program also includes vaping cessation. It provides online resources and a free eight-week supply of nicotine, but only to those over 18 years old. Launched in 2020, it has 395 participants, 61% of whom reported vaping and 13% said they vaped in the past 30 days. A specialized online cognitive behavioural therapy intervention for e-cigarette users registered in STOP began in 2021. Unfortunately, an evaluation of the program had low numbers, with only 23 people accessing the online modules over a year, said Brooke Campus, a research coordinator at CAMH. One-on-one interviews revealed participants wanted more peer-support and check-ins. Any intervention must keep cultural diversity in mind, noted Dr. Peter Selby, a senior medical consultant and clinician scientist at the CAMH in Toronto. When it comes to intervention, “We have to think of who is vaping and why they’re vaping,” Dr. Hammond said. Regulatory measures There have been some regulatory changes made in Canada to curb vaping, including some provinces limiting the flavours of e-liquid available, and the federal government’s amendments to the Tobacco and Vaping Products Act. Regulations under the Act limit the concentration of nicotine in e-liquid to 20 mg/mL. Chaiton presented data from the Vaping Dependence Cohort Study showing that implementing the flavour restrictions significantly reduced the number of days participants vaped per month, but not the vaping dependence score or the number of puffs per month. The development of new e-cigarette devices has changed the uptake of vaping in youth over time in Canada. This is currently being seen in the U.K., which is experiencing a substantial increase in youth vaping. The Action on Smoking and Health-Youth survey of more than 2,000 youth aged 11 to 17 showed 15.8% had tried vaping in 2022 compared to 11.9% in 2021, with 7% of respondents saying they were current users in 2022. Dr. Hammond said this was due to the introduction of elf-bar vape product, a disposable vape device. The U.K. also limits the sale of vape products to those over 18-years-old. Read: Feds must enforce vaping penalties to protect kids: advocates Nicotine Flux While the concentration of the nicotine is limited in Canada, the rate at which nicotine is released by the e-cigarette device varies by brand. A study testing nicotine flux by brand found that the average nicotine flux varied from 199 micrograms per second in box mod vapes to 55 micrograms per second in disposable vapes. Pod-based vapes (like Juul) had an average nicotine flux of 73.42 micrograms per second. To really reduce harm, there should standardized manufacturing process into the devices and the liquid, Dr. Selby said. “The takeaway here is that nicotine content is probably not enough as the focus of regulation,” Chaiton said. There are ways of getting more nicotine in various devices. To help prevent youth from becoming dependent on vaping, Canadian physicians can become advocates for regulatory change, and encourage their patients not to take up vaping in the first place. Education, as Maya S. suggested, may be the key so youth know the risks. If they are already dependent, until good evidence for successful interventions exists, physicians can introduce patients to cessation programs developed for cigarette users. Read: FDA bans Juul e-cigarettes tied to teen vaping surge

What should healthcare professionals do about youth vaping?

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