Lisabeth Bennett is the clinical director of Tobacco Cessation Services of Rhode Island, a service offered through CODAC Behavioral Healthcare. As a board certified health coach and tobacco treatment provider, Bennett has worked with thousands of patients dealing with behavior issues and tobacco and nicotine dependency.
She shares her thoughts on the widespread impacts of vaping, and how treatment for vaping-related nicotine addiction could begin to take shape.
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PBN: Have you seen people who are trying to stop vaping come to CODAC for help? If so, did headlines about vaping-related lung disease increase the numbers of people seeking help?
BENNETT: Most of our patients are long-term smokers. Many of these individuals originally considered vaping as a viable cessation tool, but their views are changing as the lung-disease crisis gains public attention. Consumers are no longer confident in vaping as a safe alternative to smoking or an aid to nicotine cessation.
It’s too soon to draw conclusions about an increase. Vaping has really only become popular over the last five years or so. It took years for cigarette users to recognize and acknowledge the negative effects of smoking and to come to treatment centers for tobacco cessation services. Individuals who vape may take more time to seek cessation services because vaping products are still widely available. It could take further government intervention before many users accept that they have a dangerous, uncharted addiction to nicotine. However, the recently and widely reported incidents of vaping-related lung illnesses and deaths will probably accelerate this process.
PBN: How does treatment for vaping-related nicotine addiction differ from treatment for people who are hooked on cigarettes?
BENNETT: Currently, there are no proven effective programs designed specifically for vaping cessation. Although the level of nicotine dependence is often higher among vapers, we are using the same protocols for adult vaping cessation that are used for cigarette and smokeless tobacco cessation.
Evidence-based practice for tobacco cessation combines the use of FDA [Food and Drug Administration] approved nicotine replacement therapies – nicotine gum, lozenges and inhalers – with counseling, allowing people to gradually taper down their level of nicotine and remain comfortable as they quit. However, because nicotine dependence can be significantly stronger in vapers than traditional smokers, cessation may require expanded use of NRT, counseling and other protocols for long-term success.
Finding a health care provider trained in the most up-to-date treatment approaches is crucial. To help improve the likelihood of a successful outcome, it is recommended that vapers who wish to quit work with a credentialed tobacco treatment specialist.
CODAC Behavioral Healthcare, with its decades of experience treating substance use, recognized the need for a specialized team to address nicotine dependence. This team at CODAC is skilled in helping people quit and customizing treatment to suit both the person’s level of biological dependence and the behavioral changes that support quitting.
Despite the impact vaping has had on our youth, people under 18 years of age don’t have any FDA-approved treatments available. As a result, many families have turned to digital platforms for behavioral support.
Platforms that are currently popular in the digital space are “This is Quitting” from the Truth Initiative and “My Life, My Quit.” Both offer free quit-vaping mobile programs tailored for teens and young adults. While it is too soon to determine whether these programs will have long-term success with vaping cessation, we do know that they meet teens in their comfort zone: digital and telephonic, interactive platforms. They are certainly a good place to engage adolescents about addressing nicotine dependence.
PBN: What, if any, is the difference between the demographic of those who come to CODAC for help with a nicotine addiction from cigarettes versus those who have developed a vaping-related nicotine dependency?
BENNETT: Given the general popularity of e-cigarettes, and particularly the spike in e-cigarette use, among adolescents, we are deeply concerned that we have not been able to reach individuals who are strictly only using vaping devices.
The Centers for Disease Control and Prevention found that e-cigarette use surged in 2018 to 20.8%, up from 11.7[%] in 2017. Despite steady declines in traditional tobacco product use among younger demographics, statistics from the National Youth Tobacco Survey suggest that there are now more than 5 million kids using e-cigarettes in 2019. Their report suggests that any progress being made on reducing overall tobacco use is being undermined by the rise of e-cigarettes. For example, 1 in 4 high school students and 1 in 10 middle school students are now vaping. It is difficult to quantify whether adolescents would like to receive treatment for nicotine dependence – especially since there is no FDA treatment for this population of users.
Based on these statistics and what we know, people of nearly all ages are vaping. And, while the rate of adolescent cigarette smoking has declined considerably over the last decade, we are noticing a disturbing trend: many adolescents whose first exposure to nicotine is with e-cigarettes later begin using traditional tobacco products, as well. This dual-use is beginning to impact smoking rates and statistics may begin to show an increase in cigarette smoking over the next few years – even as e-cigarette use continues to climb.
PBN: Other than vaping-related lung disease, does vaping carry the risk of potential health effects that concern you?
BENNETT: Vaping is only recently the focus of research. It’s a relatively new technology, but the science is catching up.
According to the CDC, in 2011 only 1.5% of high school students had vaped in the last month. The 2019 Youth Risk Behavior Survey shows that number now stands at 30.1% in R.I., a rise from 20.1% in 2017. Numbers of vaping-related lung disease cases are already dramatic, and there will most certainly be a larger group of people impacted as time goes by.
It is important to note that the term “vaping” itself is misleading. What is released from e-cigarettes is not vapor but an aerosol that contains ultrafine particles that can be inhaled deep into the lungs. Concerns continue to emerge about the risks of inhaling this aerosol, especially since the ingredients used in pods and cartridges designed for e-cigarettes are currently not regulated. Studies have shown them to contain heavy metals such as nickel, tin and lead, and carcinogens, including things [such as] formaldehyde and chlorine. Many “buttery” flavored pods contain diacetyl, a chemical linked to serious lung disease.
Also of concern is the use of FDA-approved flavorings that are approved for oral consumption but not for inhalation. While appealing to young people, they are added to vape “juice” to create a dazzling variety of choices, including – Strawberry WaterFelons, Tiramisu and Mango Peach Tango. Food flavorings were not designed to be inhaled and the potential effects are unknown.
Increasingly, national studies list other serious consequences of vaping: damage to the brain, heart and lungs; cancerous tumor development; preterm deliveries and stillbirths in pregnant women; and harmful effects on brain and lung development when use occurs during fetal development or adolescence.
The type of nicotine used in vaping products formerly contained between 30-60 milligrams/milliliter. JUUL uses 59 milligrams/milliliter of nicotine salts, a smoother-tasting form of nicotine that rockets to the brain as quickly as combustible tobacco. Within 7-10 seconds, that nicotine impacts the brain, causing biochemical and physical changes that lead to dependence. This dependence causes a desire to continue using the product – not only to stimulate the brain’s reward center by giving it nicotine, but to avoid the agony of withdrawal. Once the cycle of dependence is established, people need to continue to use these products just to feel comfortable.
These devices were specifically designed to contain high levels of easily metabolized nicotine to establish that cycle and drive profits. As mentioned earlier, vaping cartridges generally contain significantly more nicotine than cigarettes. For example, a single JUUL pod contains as much nicotine as a pack of cigarettes. Other brands contain as much as two or three packs. Exposure to this level of nicotine creates a powerful addiction.
PBN: Is CODAC working with any other agencies or partners on preventative or public awareness messages designed to deter young people especially from vaping?
BENNETT: CODAC works closely with an extensive network of partners, including the R.I. Department of Health Office of Tobacco Control, R.I. Department of Behavioral Health, Developmental Disabilities and Hospitals, and Tobacco-Free Rhode Island.
We offer educational programs to a wide variety of agencies and train clinicians to become tobacco treatment specialists. In the last year, we have trained school nurses, medical residents, substance use counselors, physician assistants and respiratory therapists. We have even taught school nurses how to effectively discuss nicotine dependence with their students.
Opening the lines of discussion about vaping and nicotine dependence is the first step toward appropriate referrals to treatment and helping people quit for good. We are hopeful that our efforts will help curb addiction among today’s youth.
Elizabeth Graham is a PBN staff writer. She can be reached at graham@pbn.com.
