clinical scenario: During a routine return medication visit, your patient, a 45-year-old man with bipolar disorder, asks you about using an e-cigarette. You recall that he is a pack-a-day smoker, and when you last discussed his smoking about a year ago, he wanted to quit.
This clinical scenario is increasingly common for psychiatrists. Among people with mental illness, 15% have tried e-cigarettes compared with 7% of the general population, and use rates are on the rise.1 In a study comprising 956 cigarette smokers hospitalized for mental illness, trial use of e-cigarettes went from 0% in 2009 to 25% in 2013.2 In the general US population, among smokers, lifetime use of e-cigarettes increased from 10% in 2010 to 37% in 2013.3
Given the disproportionate burden of tobacco health harms in psychiatric patients, e-cigarettes are being considered as a potential tool for harm reduction. This article summarizes recent data on e-cigarettes, provides recommendations and resources to learn more, and emphasizes the evidence for treating tobacco (traditional cigarettes) addiction in people with mental illness.
E-cigarettes (ie, vaporizers, vape pens, e-hookah) are battery-operated devices that generate an aerosol from an e-liquid for inhalation. Consisting of a metal tube resembling a traditional cigarette, a battery, an atomizer, and a replaceable cartridge, e-cigarettes usually contain liquid nicotine, propylene glycol (an irritant in antifreeze), glycerin, flavoring, and other chemicals. A user puffs on an e-cigarette, and the heating element aerates the cartridge solution. Many of these are intended to simulate a cigarette. Tank or open systems, discussed below, allow users to fill the device with any substance of choice.
Developed and commercialized in China in 2003, e-cigarettes entered the US market in 2006; however, tobacco companies such as Philip Morris have been researching precursors to e-cigarettes since 1990. Over the past decade, advertising and sales of e-cigarettes have increased exponentially every year, and the major tobacco retailers now dominate the market. While tobacco advertising has been banned from television and radio since 1970, e-cigarettes are promoted widely on these media channels, on the web, and in social media, with many ads reaching youth. In August 2016—10 years after entering the US market—e-cigarettes came under the regulatory authority of the FDA, but regulatory evaluations of the products are still in progress.
Nicotine exposure. Nicotine is a psychoactive drug that can be addictive. Nicotine delivery with e-cigarettes varies by device (greater with the tank systems than with the cigarette-like products) and by experience level of the user. As the technology improves, the speed and the amount of nicotine absorbed are likely to increase over time, along with addiction. Mislabeling has been found with nicotine present in products labeled as nicotine-free or at higher concentrations than labeled.4
Flavors and appeal to youths. Flavored options (eg, candy, alcohol, unicorn vomit) can appeal to youth, whose brains are vulnerable to early addiction exposure. E-cigarettes are widely available for purchase online, in convenience stores, and in neighborhood vape shops. Past-month e-cigarette use nearly tripled from 2013 to 2014 among high school students (4.5% to 13.4%), surpassing all other tobacco use.5 For the first time in decades, the percentage of US youth exposed to any nicotine product increased, from 2013 to 2014 and again from 2014 to 2015. Moreover, e-cigarettes may be a gateway to conventional smoking. Two studies of adolescents who were never-smokers at baseline found that e-cigarette use predicted greater risk of cigarette smoking at follow-up.6,7
Vaping other substances. Modifications to e-cigarettes (“mods”) and open tank systems allow users to vape other substances, most commonly cannabis oil. In an anonymous study of more than 7000 high school students, nearly 1 in 5 adolescents who use e-cigarettes reported using the device to vape cannabis oil.8
Toxicity and poisoning risks. Nicotine in high doses, especially in children, can be dangerous and even fatal. Poison control calls for nicotine poisoning have increased from one call in September 2010 to 215 calls per month related to e-cigarette exposure in February 2014.9
Dr. Das is Clinical Assistant Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine; Dr. Prochaska is Associate Professor of Medicine at the Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA.
Dr. Prochaska has been a consultant for Pfizer, which makes smoking cessation medications, and has been an expert witness for plaintiffs’ counsel in court cases against the tobacco companies.
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