The Rise of e-Cigarettes— What Nurses Should Know

In 2018, the US surgeon general issued an advisory calling for immediate action against the epidemic of youth electronic e-Cigarette use.¹ For the past 7 years, e-cigarettes have been the most commonly used tobacco product among US youth² with an estimated 1 in 5 high school students and 1 in 20 middle school students using them.³

Joelle Fathi, DNP, RN, ARNP, CTTS, FAAN

Nurses are on the front lines and are a direct touch point in the effort to curb e-cigarette use among children and teenagers, according to Joelle Fathi, DNP, RN, ARNP, CTTS, FAAN, chief healthcare delivery officer at the GO2 Foundation for Lung Cancer and deputy chair of the Tobacco Control and Smoking Cessation Committee at the International Association for the Study of Lung Cancer.

“Nurses [belong to] the No. 1 most trusted profession. If more nurses understand how these products hijack the brain and neurohormones, they can use this information to educate children and have [repeated] conversations about the harms before they are ever exposed,” Fathi said.

Defining the Problem

Conventional or combustible tobacco includes tobacco products designed to be burned and smoked, such as cigars or cigarettes. In contrast, e-cigarettes work by heating the tobacco product.

The FDA defines these products as electronic nicotine delivery systems (ENDS), which include vapes, vaporizers, vape pens, hookah pens, e-cigarettes, and e-pipes.⁴ To best educate their patients, it is important that all nurses understand the mechanism of addiction for nicotine.

“When someone inhales vapors from ENDS, those gases go into the depths of the lungs; they permeate across the very fine lining of the lung and into the arterial bloodstream,” Fathi noted. “From the time of inhalation it takes only about 7 seconds for any substance in that tobacco to reach the brain and other organs via the arterial blood stream.

“There are other things that cause these surges, but nothing can touch the surge that nicotine causes. It takes only as few as 3 repetitive exposures to develop nicotine dependence,” she said. “When people use nicotine, even for a short duration, their neurocircuitry never goes back to normal.”

E-Cigarette Rates, Risks

The good news, according to Mary Rezk-Hanna, PhD, NP, FAHA, an assistant professor at UCLA School of Nursing, is that there has been a clear reduction in the use of combustible cigarettes among adolescents. Unfortunately, the use of e-cigarettes and other alternative tobacco and nicotine products is offsetting that decline. Data show that from 2011 to 2018, the use of e-cigarettes increased among high school students from 1.5% in 2011 to 20.8% in 2018.³

Mary Rezk-Hanna, PhD, NP, FAHA

Nurses can raise awareness among adolescents about the amount of nicotine in e-cigarettes. For example, 1 combustible cigarette contains about 1 mg of nicotine. Smoking a pack of 20 cigarettes a day would equal 20 mg of nicotine. In comparison, one 3% JUULpod contains 35 mg of nicotine per mL, or about 23 mg of total nicotine at the time of manufacture. The 5% JUULpod contains 40 mg of nicotine.⁵

e-Cigarettes have not been around long enough to fully understand the long-term associated health risks. However, as of 2020, more than 2800 hospitalized cases or deaths from e-cigarette or vaping product use– associated lung injury (EVALI) had been reported to the Centers for Disease Control and Prevention (CDC).⁶ Symptoms of EVALI include respiratory symptoms, gastrointestinal symptoms, and constitutional symptoms such as fever, chills, and weight loss.

Role of the Nurse

“Nurses have a critical role in controlling the smoking epidemic,” Rezk-Hanna said.

Research findings have indicated that compared with smokers who receive usual care, smokers who receive assistance from a nurse have a 29% greater probability of successfully quitting for 5 or more months. This emphasizes the importance of nurses in efforts to curb tobacco use.⁷

According to Rezk-Hanna, the 5 A’s framework for promoting smoking cessation (ask, advise, assess, assist, and arrange) is highly effective and nurses should be encouraged to use it with their patients. This means that nurses should identify tobacco use status for every patient at every visit (ask). They should urge tobacco cessation (advise) and determine whether the user is willing to attempt to quit (assess). For those who are willing, nurses should provide counseling and pharmacotherapy to help (assist), and schedule a follow-up (arrange).⁸

“Assisting patients to achieve permanent [smoking] cessation is one of the most important services we can offer them to protect their health now and in the future,” Rezk-Hanna said.

Some excellent cessation resources are available, including 1-800-QUIT-NOW, a national portal to a network of state quit lines. The Truth Initiative has launched an e-cigarette quit program to address the increase in youth vaping. To access the new program, users must text “DITCHJUUL” to 88709 to enroll. The American Lung Association’s Not On Tobacco is a voluntary quit program for young people aged 14 to 19.

Treatment combined with behavioral counseling is the best way to help patients quit, Fathi said. Nurses have to be familiar with and know how to access local behavioral counseling resources and pharmaceutical treatments. For example, Yale Tobacco Center of Regulatory Science has launched a vaping cessation program for young people aged 14 to 19 years in Connecticut.

“The biggest bang for our buck will always be to prevent youth from ever picking these products up,” Fathi said. “There is clear science that demonstrates that 90% of people who have used tobacco lifelong started before the age of 18.” “If we can change that…smoking will be obliterated.”

References

1. Surgeon General’s advisory on e-cigarette use among youth. CDC. December 2018. Updated October 21, 2021. Accessed January 4, 2022. https://bit.ly/3Gg0fzN

2. E-cigarette use among youth and young adults: a report of the Surgeon General. US Department of Health and Human Services. 2016. Accessed January 4, 2022. https://bit.ly/3ffAm7j

3. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the field: increase in use of electronic cigarettes and any tobacco product among middle and high school students – United States, 2011-2018. MMWR Morb Mortal Wkly Rep. 2018;67(45):1276-1277. doi:10.15585/mmwr.mm6745a5

4. Vaporizers, e-cigarettes, and other electronic nicotine delivery systems (ENDS). US Food and Drug Administration. Updated September 17, 2020. Accessed January 6, 2022. https://bit.ly/3JV43cb

5. What is the size of a JUULPOD? JUUL. June 15, 2020. Accessed January 6, 2022. https://bit.ly/3qYHZ7M

6. Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. CDC. Updated August 3, 2021. Accessed January 6, 2022. https://bit.ly/3I7fig3

7. Rice VH, Hartmann-Boyce J, Stead LF. Nursing interventions for smoking cessation. Cochrane Database Syst Rev. 2013;(8):CD001188. doi:10.1002/14651858.CD001188.pub4

8. Five major steps to intervention (the “5 A’s”). Agency for Healthcare Research and Quality. December 2012. Accessed January 6, 2022. https://bit.ly/3ndz9Sy