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Home » News

Publish Date September 24, 2021


E-CIGARETTE USE AMONG ADOLESCENTS

Britney Lilley, BSN, RN

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The AAP recommends that clinicians screen for e-cigarette use during primary
care visits. Credit: Getty Images


Tobacco use is the leading cause of preventable morbidity and mortality in the
United States, and use most often begins during adolescence and early
adulthood.1 The use of battery-operated electronic cigarettes (e-cigarettes or
ECs) among children and teens has become a public health epidemic.2,3
E-cigarettes are the leading tobacco product used by the US adolescent
population.1,4 Health care providers should consistently screen for and counsel
patients regarding EC use to aid in health promotion and disease prevention as
the use of these products can lead to serious comorbidities and adverse events.

Acceptance for EC use is likely attributed to the perception that they are safer
to consume and also may be used as a smoking cessation tool. This common
perception, along with ease of access to ECs has led to the introduction of and
addiction to nicotine products among adolescents.5





Hartmann et al conducted a systematic review aimed to determine if ECs can aid
in smoking cessation.6 Patients who received nicotine ECs experienced higher
quit rates than those who received nicotine replacement therapy (risk ratio
[RR], 1.69; CI 1.25-2.27) or non-nicotine ECs (RR 1.71; CI 1.00-2.92). Mild to
moderate adverse events were reported such as throat and/or mouth irritation,
headache, cough, and nausea. These adverse effects tended to dissipate with
consistent use; however, there was no mention of long-term effects associated
with continued use of ECs.





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--------------------------------------------------------------------------------

Continue Reading




E-CIGARETTES MAY LEAD TO SMOKING COMBUSTIBLE CIGARETTES IN TEENS

Findings from a prospective cohort study by Barrington-Trimis et al show that
adolescent EC users are over 6 times as likely to initiate traditional cigarette
use compared with adolescents who have never used ECs. In addition, after only a
16-month follow-up period, initiation of combustible cigarette use was reported
by 40.4% of adolescents who previously used e-cigarettes vs 10.5% of those who
had never used ECs.7 This suggests the experimentation with ECs may lead to
transition to combustible cigarette use at an early age.

COMPOSITION OF E-CIGARETTES

E-cigarettes, unlike combustible cigarettes, use an electric element to heat and
vaporize a liquid-based flavorant (e-liquid). This e-liquid is composed of
water, flavoring, and other ingredients such as glycerol, ethylene glycol,
polyethylene glycol, and propylene glycol. Solutions with nicotine also contain
organic tobacco substances and impurities. Despite the labeling of e-liquid
contents for consumers, inconsistencies in e-liquid production and labeling have
been reported such as false advertising of nicotine-free liquid when nicotine is
present or vice versa.8

HEALTH RISKS OF E-CIGARETTES

Use of ECs has been shown to have adverse systemic effects, most notably within
the oral cavity, respiratory, cardiovascular, and immune systems.9 The vapor
produced by ECs directly affects the remodeling of extracellular matrix gingival
fibroblasts, which play a significant role in repairing periodontal tissues, and
obstructs components that aid in cell proliferation, apoptosis, migration, and
wound closure.9 Exposure to either nicotine-containing or nicotine-free fluids
and vapors in ECs has been demonstrated to increase production of free radicals
called reactive oxygen species (ROS).9  

The airway epithelium is the next site of contact for inhaled substances.
Inhaled substances from ECs increase the permeability of the airway epithelium,
creating a cascade of events leading to airway inflammation and destruction of
lung tissue.9 This occurs with both nicotine-containing and
non-nicotine-containing ECs.9 Like combustible cigarettes, chronic EC use causes
a shift in cardiac autonomic balance toward greater sympathetic superiority and
increased oxidative stress levels, both of which are known risk factors for the
development of cardiovascular disease.9 Adolescents potentially absorb higher
concentrations of EC vapors because of their higher resting respiratory rates
and inability to clear nicotine as effectively as adults.9 Increased dermal
absorption in this population is also a risk due to second-hand vapor exposure.9

Inhalation of EC vapor also increases levels of platelet-activating factor
receptors (PAFRs). Pneumococci bacteria utilize these receptors to bind to host
epithelial cells and facilitate pneumococcal disease.9 The use of ECs also
increases the risk for other infections such as methicillin-resistant
Staphylococcus aureus, rhinovirus, influenza, and Streptococcus pneumoniae.9

Classic ECs containing nicotine flavoring have a lower ROS production than ECs
containing other flavorings.9 The release of ROS from ECs containing
fruit-flavored e-liquids can be 3 times greater than that of ECs containing
tobacco flavor.9

SCREENING FOR E-CIGARETTE USE

As ECs have become the most widely used tobacco products by adolescents, the
American Academy of Pediatrics (AAP) recommends screening, education, and
cessation counseling for EC use in the primary care setting starting at age 11
years.10 E-cigarettes should not be recommended as a tobacco-dependence
treatment product, according to the AAP guidelines.10 In addition, providers
must become familiar with language used among this population (ie, vaping,
JUULing, and e-cig) to keep an open line of communication and prevent missed
opportunities for counseling.

The AAP recommends using the 5As Model for Tobacco Screening and Counseling
(Figure).10 Clinicians should ensure consistency in asking about tobacco use at
each appointment and use standardized documentation. Patients should be advised
to quit using tobacco or EC products and clinicians should assess the patients’
willingness to quit. Assistance with either pharmacotherapy or counseling
resources should be provided and a follow-up appointment should be arranged to
monitor progress towards cessation.

Figure. 5As Model for Tobacco Screening and Counseling10

In addition, adolescents should be provided one-on-one time with clinicians to
speak freely and confidentially, without parents in the room. As always, this
information between the patient and clinician should be kept confidential unless
permission is granted by the patient.11 The AAP’s e-cigarette curriculum
includes ICD-10-CM and CPT billing codes that can be used for tobacco use and
exposure counseling.

CONCLUSION

Advanced practice providers, along with all members of the health care team,
have an inherent duty to screen and educate patients regarding health promotion
and disease prevention, as it pertains to the use of vaping products. Education
on the serious risks associated with ECs should be provided by school and campus
nurses as well as primary care clinicians. Adolescents and young adults are at
an important stage of development, as lifestyle habits and routines are
developed during these crucial years. Clinicians should be not only educated but
empowered by current evidence supporting the need for cessation of vaping and
other tobacco products.

Britney Lilley BSN, RN, is a labor and delivery nurse at Orange Park Medical
Center, Florida. She is currently studying to become a doctor of nursing
practice-family nurse practitioner at the University of North Florida.

REFERENCES

1. Jamal A, Gentzke A, Hu SS, et al. Tobacco use among middle and high school
students: United States, 2011-2016. MMWR Morb Mortal Wkly Rep.
2017;66(23):597-603. doi:10.15585/mmwr.mm6623a1

2. Hwang C, O’Neil J. E-cigarette use among adolescents. J Nurse Practitioners.
2020;16(6):453-456. doi.org/10.1016/j.nurpra.2020.02.021

3. American Medical Association. AMA and public health community united on bold
action to prevent e-cigarettes from addicting kids. November 22, 2019. Accessed
September 22, 2021.
https://www.ama-assn.org/press-center/ama-statements/ama-and-public-health-community-united-bold-action-prevent-e-cigarettes

4. Pepper JK, Gilkey MB, Brewer NT. Physicians’ counseling of adolescents
regarding E-cigarette use. J Adolesc Health. 2015;57(6):580-586.
doi:10.1016/j.jadohealth.2015.06.017

5. Bhatnagar A, Payne TJ, Robertson RM. Is there a role for electronic
cigarettes in tobacco cessation? J Am Heart Assoc. 2019;8(12):e012742.
doi:10.1161/JAHA.119.012742

6. Hartmann-Boyce J, McRobbie H, Lindson N, et al. Electronic cigarettes for
smoking cessation. Cochrane Database Syst Rev. 2020;10(10):CD010216.
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7. Barrington-Trimis JL, Urman R, Berhane K, et al. E-cigarettes and future
cigarette use. Pediatrics. 2016;138(1):e20160379. doi:10.1542/peds.2016-0379

8. Hahn J, Monakhova YB, Hengen J, et al. Electronic cigarettes: overview of
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doi:10.1186/s12971-014-0023-6

9. Chen IL, Todd I, Fairclough LC. Immunological and pathological effects of
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10. Jenssen BP, Walley SC; Section on Tobacco Control. E-cigarettes and similar
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11. American Academy of Pediatrics. E-cigarette curriculum. Accessed September
23, 2021. https://www.aap.org/en/learning/e-cigarette-curriculum/


TOPICS:

Pediatrics Smoking Tobacco Use Disorder


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