Managing the serious risks of vaping among youth

Medicus pension plan established by MD Financial Management and Scosure Bank is a multi-employer pension plan designed specifically for corporate physicians in Canada. The sooner you get started, the larger your pension benefit will be when it's time to retire. That's peace of mind for you and your family. Start the journey to a future well planned.

Visit medicuspensionplan.com to learn more. I'm Blair Regan. I'm Magiola Malay. This is the C.M.A.J. podcast. Joel at today, we're talking about vaping, particularly in adolescence. And this is sort of like wildfire right now.

Everyone seems to have a vape and I went down a rabbit hole getting ready for this episode. Vapings been around longer than I thought, 17 years and it's regulated. Like there are rules around it.

“Question for you, why did you go down a rabbit hole?”

Like what made you so fascinating about vaping? Well, today, obviously, we're going to be talking to the authors of a practice paper in C.M.A. about how we can help youth who vape because a lot of them don't want to be vaping anymore. And it's kind of fascinating how all of this went off the rails. Vaping was supposed to be this big promise that you could get off the cigarettes and not get lung cancer.

And instead, it sort of created its whole other problem that the world has to do with it.

I never understood the why it was marketed that way.

Like it was confusing to me. I was like, oh, you're still like you're still inhaling a substance that you don't naturally inhale. So how is it going to be better for you? Some people just ask them that question. Yeah, so we're going to talk to the authors about this very, very timely article.

So timely, in fact, that just recently at least one government in Canada, the Ontario government, announced it was going to ban vapes in schools. So we're going to be speaking to the two cool authors about the problem talking to, I'm going to ask them the question about, what can we do to help adolescents who inadvertently

“have become addicted and dependent on icy, frosty, flavored watermelon vapes?”

And what we can do to help them. That's coming up on the CMAJ podcast. All right, let's get into it. Dr. Madeline Hanna and Dr. Trisha Taluk are two of the co-authors of the practice article in CMAJ entitled, E-Sigarette Use in Adolescence, the paper is brief, but it's packed with troubling facts.

Maddie is a clinical pharmacist and Trish is a pediatrician who focuses on adolescent and addiction medicine, both work at Camage and Sitt Kids Hospital in Toronto. Maddie and Trish, thank you so much for joining us. Thanks for having us. Thank you. Maddie, I want to start with a question for you.

What were you seeing around you that prompted you to dig into this and write an article about it? Yeah, that's a great question. I think to start off, I've been at Sitt Kids for almost a couple years now. I started in September of 2022 and so that meant starting a new practice on the psychiatry and adolescent medicine in patient unit and I was coming from more adult practice at Camage before and I think what really started at all is as I was there seeing patients kind of

information gathering, getting a history from them. Substance use is always something that I asked

and I was finding more and more that patients were coming in, they were vaping in the community, vaping nicotine specifically and they would come in and now that they're in an inpatient unit and don't have access to a vape or cigarettes can't really leave the unit at that time.

“They were then experiencing nicotine withdrawal and so that's what prompted this article is.”

We had some questions from the physician groups specifically on the psychiatry side asking like, how do we manage this and it's a little bit the dosing to provide withdrawal management is a little bit different than people who smoke conventional cigarettes. So there was a bit of a question there of how do we appropriately and safely do this and so that's where we started looking into what what guidance is out there right now and thought that there could be more guidance out there

for providers across Canada. So what's the nitty gritty here? How does nicotine exposure differ

between vaping and traditional cigarettes? Yeah, it's a good question. So I think the first piece

is that these vape pens really contain a ton of nicotine that I think a lot of people don't recognize. For example, one conventional cigarette when we're thinking about conversion to milligrams of nicotine is considered to be about one milligrams of nicotine. It's a one-to-one ratio. It's very straightforward. So pack 20 cigarettes is 20 milligrams of nicotine. That's what we go by with vaping products though. You have kind of a vast array of different vaping products containing

nicotine liquids of various concentrations and we've seen concentrations of up to, you know, it's not legal but up to 50 milligrams per milliliter in a cartridge and about a two milliliter cartridge. So that one pen contains about 100 milligrams of nicotine. And so it's just a huge difference

have a lot of great data on how much nicotine somebody is actually being exposed to from vaping

compared to cigarettes. We don't really know. It's kind of unpredictable. Why do people think think? Because I have often times people come into me and say, well, I don't smoke. I just vape and that vaping is better for them. Why? Like, it doesn't seem like it's better for you.

“But why is that the marketing around it? No, so absolutely. I think we've had kids come in,”

you know, like, oh, I'm only vaping water vapor. It's nothing. It's really just safe. They don't even know if there's nicotine or whatever is in it. They think it's just like a flavored water vapor. But it's definitely not the case vaping products were originally introduced to the Canadian market as a means of smoking cessation as being advertised as a safer alternative to smoking

cigarettes. And it does contain fewer carcinogens that we know of at this time. But those kind of

substances or those chemicals are certainly still in those vaping products. So at this time, we think it is a little bit safer than being exposed to kind of the hundreds of of carcinogens that are in cigarette smoke. But that certainly not the case. And we don't have the full safety, kind of data on e-sigarettes at this time. And I just just add that the intent was to create a device that would support smoking cessation. And so although that was the intent or at least how

it's been advertised, what we see is a normalization in terms of the discourse that many adults in fact have. And we see this clinically, parents with their their child, their teen. What I've often heard from parents is a very similar message that, oh, it's just vaping. So the understanding really is that this is a smoking cessation device. And therefore, this is safer. And just similar

“to what Maddie's mentioned is that there isn't, I think, sufficient education that we've been”

providing adults and patients with respect to the amount of nicotine and the additional chemical that are within the e-liquid. And safety aside, it sounds like the addictiveness with the nicotine is a real concern as well. So when I ask patients how much they smoke cigarettes, they say, oh, smoke a pack a day, smoke half a pack a day. Should I be asking, how often do you go through a cartridge like and know that a cartridge is two mills and one mill could have anywhere between

what 10 to 50 milligrams of nicotine is up kind of the right way to frame it in my own mind? Yeah, it's a good way to think about it. I think the most often times when we're asking patients what they're vaping, you really have to do some investigative work to figure out what they're actually using. There are a ton of different products available across the market. Um, not all cartridges are two mills. It can range seen cartridges of like 3.6 mill leaders just

to make it a little bit more confusing for you. So asking them, you know, the type or the brand that they're vaping, what actual substance are they vaping? Because sure, there are lots of nicotine vapes out there and that's most commonly what I would see. But there are some that advertise like there's it's just flavoring. There's no kind of addictive substance in there. Some of it is cannabis. So just clarifying that you know what they're vaping specifically. But then once you

know that they're vaping nicotine and you kind of have that product, you can kind of ask a few questions to gather a little bit more information about their use. So one of the examples like you mentioned is well, how long will it take you to get through this pod like of whatever two mills or 3.6 mill leaders or how many puffs are you using a day? Some of the vape pens count by number of puffs that are available in the pen. How much money are they spending per week on these vape pens?

There's kind of various ways that you can get at it and you can ask it in multiple different ways so that you can check your math and make sure that it all kind of makes sense and that it's

“aligning with their report. And Maddy, why is this important for you? Like, why do you need to know”

how much nicotine they're consuming? How does this affect your treatment for people who are hospitalized or people seeking addiction treatment? Yeah, so of course people that are using more nicotine like they have that fire level of dependence to nicotine at this point. And so if they're coming into hospital, they've been admitted through the emergency department. They're now on an inpatient unit. They haven't had access to nicotine in maybe several hours if no one has asked them

at that point. A, they're going to be super uncomfortable. They're going to be in nicotine withdrawal and that can lead especially in psychiatry and adolescent medicine and if patients are experiencing mental health difficulties as well at that time, that can lead to something like anxiety, agitation, things like that and it complicates the clinical picture. But in terms of treatment for withdrawal management, we use nicotine replacement therapy or NRT product. And so we

try to estimate how much nicotine a person is being exposed to per day to be able to estimate how much NRT we think that they would require in hospital. That's getting pretty practical and we're going

to come back to nicotine replacement in a few minutes. But first, I just want to get more into

seeing from nicotine exposure? In terms of the physiological effects from a cardiovascular standpoint, young people who come in with elevated blood pressures, palpitations, I don't really suspect that this is probably on the top of mind in terms of whether it be pediatric surgery primary care, but we do certainly know that that's an effective high levels of nicotine. The other things to consider in terms of health effects, we do know that it can decrease the seizure thresholds. So the

first time presentation of seizures could very well be the exposure to nicotine, so that's not

anything to consider. There've been a lot of literature, some of the studies around injuries, and so the injuries related to burns or devices that have malfunctioned. So we certainly, there's a list of concerns related to nicotine. I think the most concerning pieces that really these are

“marketed to the younger population, and that's what we see in terms of the numbers,”

irrespective of the fact that the intent was for some conversation. So you said that they're marketed for the teens. Is that part of the appeal of vaping over cigarettes for young people? Yeah, and I think it's really interesting if you look at flavors that they have all the various

flavors, whether it be bubblegum, cotton candy, etc. You don't see a lot of young people who are

using tobacco flavored vaping products. It's rare, at least we can say that clinically again, but even in some of the more recent studies, it's not the highest proportion of vaping products that young people are consuming. But for the adult population, in fact that is, we do see, we do see more of that. So that alone is, as a great example of where this is definitively marketed towards the younger. There are certain demographics that's more affected

or that tend to be more like is this seen in different socioeconomic groups, or is just across

“teens or gets adolescents, it's all of them. I think it's a really great question, and I have”

to say I've been thinking about this. I haven't seen anything in the literature that speaks to

this. However, when we see that correlation in terms of young people with comorbid or concurrent mental health concerns, we certainly know that that's a subset of the population. It's probably more largely impacted by the marketing of these vaping products. And when you talk to youth, are they aware of the fact that they're addicted to their vaping? Are they aware that they're smoking nicotine? So those who are aware, and I would say more so in the setting of treatment

seeking adolescents, which we're seeing more and more, and there's actually a lot of great data that supports this, aware and unable to reduce or stop their use, and actually seeking services to be able to do so. They're coming to you specifically saying, "Help me get off that ape." Well, well, and it's really interesting because they actually, what I find actually quite fascinating is the fact that they are trying to find different ways. I thought it was going to interesting

examples, a young person who came to clinic and said that they really liked to start in flavor

“and the only way they could think about being able to not think about the flavor associated with”

their vape product was to find something else that had that flavor. I think it was bubblegum or something else, but the idea was they were finding different ways of really working towards reducing their use. Some are quite motivated by the environmental impact. You can see a really a whole host of different approaches that they're using, but we're seeing more and more a young people who are coming and presenting with how can I reduce my use, how can I stop? So we've got a plethora of reasons

why people are saying, "Help me get off of this." Why is Canada such an outlier? Like we have one of the highest rates of vaping in the world. What's going on here? Complicated question. I would say in the sense that, I mean, if we were to think about this in a very simplistic way, you have these products that are marketed to younger people and we have a lot of a fair bit of challenges in terms of being able to enforce the regulations and policies that are in place. So there certainly

are policies with respect to the percentage of nicotine. However, that being said, we still see the number of young people who are presenting with the order of 50 milligrams per a mile amount of nicotine, which is, and the upper limit is 20. So we're still seeing that despite. So it's really, you know, those loopholes that, and understandably that's, but adolescents do, they find ways, and that's the least we're, I think, we put a misdemear. So I get that teenagers are

going to find ways to skirt the rules, but there are rules. This is regulated in Canada. It's

at 18 or 21 to sell vaping products. And there's a limit on how potent the nicotine can be.

“It's not kids going out. They're not stealing these. They're not concocting concentrations of 50 milligrams”

per mil. This is an adult problem. We aren't regulating this well. What's the deal with the regulatory framework in Canada? You've saved it accurately. It exists. And it is exactly how you've described it. It is exactly it. How it is in terms of the amount, how the potency in terms of the nicotine, the flavors, and the access. Yet we see young people purchasing devices all the time. The other thing that's interesting is to your point about adults is that parents, I think, in their best

efforts to support a young person where they're not sure how to work towards reducing the harms,

they may be purchasing as well. So back to that point about the adult. Maddie, what about recent

changes in Ontario? They've announced banning vapes in schools? What about those types of approaches? Do they work? Yeah. It's a good question. I think from the World Health Organization perspective,

“they have said, if a country is not willing to ban e-cigarettes, you need to at least strictly”

regulate e-cigarettes, which I think maybe we have good intentions, but I don't think we're enforcing it appropriately. The last time I checked, I think there were 34 countries that had banned e-cigarettes at this time, but I haven't seen a ton of data to know whether it's as effective as something as taxation has been in the literature. Taxation is known to be from the tobacco

control strategy perspective, the most effective and cost-effective way of reducing tobacco use.

And so I think that's definitely a way forward that we need to go, but I think also we need to consider how to more strictly enforce these things if not consider banning them in schools or more widely as well. So Maddie, someone comes and says I want to stop vaping. I'm trying to do this in my head. I look at their cartridge. It's a two-mill cartridge. It's the regulated 20 milligrams per mill and they say they go through a cartridge every two days. So they're using 20 milligrams a day.

“So I prescribe them a 21 milligrams nicotine patch and I'm done. Not necessarily, so I think that”

kind of comes back. That's a good way of thinking about it. So you've gained the history. You've been able to quantify how much nicotine approximately this person is being exposed to. But now there's also that point of like, we actually don't know from these products. There's various products unregulated products across the market. What's actually in that compared to what's on the label, how much are they being exposed to? We don't really know. And so from a more practical standpoint,

at least at sick kids that we've been employing is really to kind of start lower, be more conservative, because you also don't want to give the person way too much nicotine where they either experience nicotine toxicity or we actually worsen their nicotine dependence. And so there's a couple of things to this. If you think they're using a ton of nicotine like 20 milligrams more per day, they're certainly an option to start with a patch. We tend to start if we start a patch. We

start on the lower end. So the lower kind of side would be a 7 milligrams patch. And then in addition to that, which provides a study level of nicotine, you know, throughout the day while that patch is on, you can then add on a short acting nicotine replacement therapy option as well. So an example would be nicotine gum or a nicotine law zinge, and that really helps us. We can look at with the frequent follow-ups, how often are they using those extra doses of the short acting

product, and then how can we titrate them up to a dose that they actually need of like a combination regimen consisting of a patch and say a gum or a law zinge that will keep them comfortable, and then talk about how we then taper this down over several weeks if they're interested in actually in vaping cessation. And can I just prescribe this to a 10 year old or a 12 year old, are there any other limitations or contraindications that need to be taken in mind when

prescribing nicotine replacement to a teenager? Yeah, so really like the of course these products as with any almost any medication in the pediatric population, this is an off-label use of the product. It's been approved by Health Canada for 18 and older as most medications are. But certainly from a physician's perspective, you absolutely can prescribe nicotine replacement therapy and really like comparing the risks and benefits of the person continuing to vape or smoke or whatever they're

doing, you have no idea what's in that cartridge that they're smoking compared to offering pharmaceutical grade nicotine that you know exactly what's in it and slowly tapering them down, it's going to be the safer option. And should a nicotine patch come off at night? I've heard mixed reviews that they have to get the full dose over 24 hours, but also that it can stir up

So you're right. So both of those answers are correct. So certainly the, yeah, it just to make it

a little bit more difficult. So certainly the product has been designed to provide that medication over the dose over 24 hours. But if the person is experiencing insomnia, they can't fall asleep now. They have nicotine kind of running through their system at night or they have those like vivid dreams or nightmares, then certainly like take it off an hour before going to bed and then put a new one on in the morning. And so really like on the inpatient unit, we do both. We offer

both options. And we might start using it 24 hours a day, especially in somebody that's saying that they're using quite a bit of nicotine throughout the day. And if they kind of experience those side effects will just adjust accordingly. Outside of nicotine replacement, how can we engage patients in maybe non-pharmacological approaches and even bring their parents into this so that they can achieve the level of use, which I guess is ideally no use. And at least cut back

“if not eliminate their vaping. So I think it's important to mention that it's actually the”

non-pharmacitical approaches that are still first-line. So that is really where we're thinking

about the behavioral interventions specifically from a psychological therapy, perspective whether that be individual or group approaches. And then from a behavioral intervention standpoint, there is some data that is emerging with respect to the use of technology. So the use of apps, there are some data from the US through the truth initiative. They're where they've looked at the efficacy and uptake of using more of a text-based

technology through an app. And there's a couple of other apps that we have that we typically offer our youth that we see in clinic. So I'd say that's really the standard of care at this point in time. And then if we need to add a pharmacological component, then we would. The parent piece is

“really key. There's enough evidence of supports the approach of integrating parents within the”

care plan. And so it goes back to that initial piece and question around asking the question, certainly we're asking questions confidently. But if parents are aware, we really should be engaging in the dialogue with parents because at the end of the day, I've seen more times than not that this dialogue is happening with parents. And once they're aware and they have enough education, they also can be really important. And really key piece to being able to support

the young person with respect to either cessation or reduction, or both. Tell me about this app. What does the app do? I'll speak to the Canadian apps that we have. So the idea is that it's a way for a young person to interface with information, so education around vaping and vaping cessation. The app that we currently tend to recommend is through the lung health foundation. There are other few other apps that have been offered more of the younger adults. But the idea is that

it provides information. There is a coaching element as well. And the idea is that it's interactive and it's in real time. So one of the features of the app through the young, the lung health

“foundation, sorry. And that app is called a quash. It was informed by youth as well. So I think that's”

a really important piece to this. But they have built in a mechanism to monitor the monetary perspective of youth. So it's certainly helpful for a young person to see how much they're actually spending as they're purchasing their products. Interesting. I think we'll just emphasize for the NRTP, like Trish had mentioned, like really from a pediatric organization, kind of perspective,

the Canadian Pediatric Society or American Academy of Pediatrics. Really, the first line is

those behavioral interventions. And then the first line of the pharmacological therapy would be nicotine replacement therapy, providing them that pharmaceutical grade nicotine. And then really from RN, like when you're starting kind of low and titrating up, you could do a patch in a short acting agent and kind of titrating up relatively quickly to get them comfortable more quickly. Or you can start with just the as needed short acting product as well and see how much they're

using to be able to inform whether you think a patch is reasonable as well. So really working with that person to see how they're doing, assessing the effectiveness and the tolerability, things like that and making sure that you're frequently following up to be able to keep that person comfortable and safe. Got it. And if we were to wave a magic wand, would we want a ban on vaping products? I'm a yes and pouches and the pouches. Okay, well thank you so much

both for joining us today. Thank you. Madeleine Hanna is a clinical pharmacist and Trisha Taluk is a pediatrician, both work at Camage and Sick Kids Hospital in Toronto. So, Blade, what were your initial thoughts after speaking to Trisha and Maddie?

aren't. And I just don't understand where the failure is. Like we know that cigarettes are locked

“up behind all these cabinets who can't even see them. You know, it's basically impossible to”

buy them from a convenience store without having ID. I just don't know how vaping stuff can be so easily accessible. It's just on display being marketed to teenagers and they can just soak it all in.

I'm going to get my tin foil hat out and be a cancerist. I think part of it honestly is that

the government allows it because vaping everyone says, "Well, vaping is so much better for you." And I'm like, doesn't really seem like it's better for me from like a, from just thinking about it

“from that perspective, but that's how you get the sold. If the public were better informed,”

then there would be more pressure for proper regulation, proper monitoring and enforcement. Yeah.

I mean, the tobacco company knows that it's going to have deleterious effects on people. Like it's still nicotine. Because we're like, well, it's too smoking. That's the problem. Like the nicotine is also kind of bad for you, too. But there is a little bit of mixed messaging going on, eh? Because like, yeah, so there's less carcinogens. Like people kind of acknowledge in the medical community that it's maybe not as toxic, even though it could be as or more addictive. So I wonder if

kind of get need to look inside our own house and say, well, wait a minute, we need to come out maybe with a stronger position on vaping being dangerous. And if we can all say that, then maybe there'll be less of this hedging. Like, well, at least certain not on cigarettes.

“I agree with you. I think that we just didn't catch up to like we haven't caught up”

to what the public is doing is similar to cannabis. You know, I am for decriminalization, illegalization of many drugs. But there also has to be warnings with them, right? And similar to cannabis, there's not great warnings around cannabis, especially in like youth using cannabis. So I think that esigarettes and vaping is in the same realm. It seems like governments need to do more here.

That's it for this episode of the CMAJ podcast. If you like what you heard, please give us a 5 star rating wherever you get your podcast. Share it with your networks, leave a comment, and help us get the word out. The CMAJ podcast is produced for the CMAJ by podcast productions. Thank you so much for listening. I'm Blair Bigham. I'm Mojela Moly. Until next time, be well.