Understanding Vaping & e-Cigarettes: Q&A with Dr. Andrea King and Dr. Renea Jablonski

Inhaling nicotine, flavorings, and other chemicals from an e-cigarette, known as vaping, has grown in popularity, particularly among young people. One in five young Americans thinks vaping is both harmless and non-addictive. However, the use of these products has been linked to an increasing number of lung injuries and even in cases, deaths. We'll speak to addiction expert, Dr. Andrea King, and pulmonologist, Dr. Renea Jablonski, about vaping and its effects on health. Remember, we'll take your questions for our experts. That's coming up now on At the Forefront Live.

And welcome to At the Forefront Live. I want to remind our viewers that we'll take your questions and answer as many as possible during the program, but please remember that today's program is not designed to take the place of a visit with your physician. Welcome to the show. Thanks for being on today. Appreciate It.

Thank you.

So let's start off with having you each introduce yourselves to our viewers, and tell us a little bit about what you do here at UChicago Medicine. And then we'll get right into the questions.

OK. I'm Andrea King. I'm a clinical psychologist. I've been on the faculty here for 23 years. I have been involved in the treatment of all addictions, everything from heroin to alcohol to tobacco. And I conducted research trials and I've done some work on cigarette use and vaping as well.

Great.

My name is Renea Jablonski. I am a pulmonologist. I take care of patients with chronic lung diseases, in particular patients with diseases related to smoking and lung fibrosis.

Great. So I think we're going to start off with just a little bit of a background on what vaping is. We've got a lot of products right here in the middle of the table. And I think probably, most of our viewers have an idea of what vaping is, but they may not know really, what it entails. And it's a little surprising when you see all the items there.

Right, right. So I have a small selection. There are over 4,000 liquids and devices. So here's a few of them. These right here are second and third generation devices. This is what people call a vape pen. And so a user would click a button to get the battery going, they heat the e-liquid, and then they inhale the aerosol from here.

And so these can be replaced. And the liquids are in tanks. These are what we call mods. These are third generation. They have a more powerful battery used by the same chemistry, where this large battery heats the aerosol, and then the person vapes that from the mouthpiece. They can be designed up in all sorts of different derivations.

Most people in the most recent few years have heard of the new technology, which is the fourth generation, product using nicotine salts. Higher nicotine levels. And these are a little more inconspicuous. And so what a user would do is they have a pod. The amount of nicotine in this tiny pod is the equivalent of about a pack of cigarettes for most users. So a user would simply click that on, and then they would tap this, and then they can inhale from here, put in your pocket, and conceal it. And then to charge the battery, you simply go here and you put it in your USB device. So it's very sleek and easy to use.

Almost looks like a big flash drive. You could easily--

It could easily be confused, right. So particularly young people, this is the most popular tobacco product out there. And I wanted to talk about the newest product, which has been approved in April of 2019 for sales in the United States. This is called the modified risk tobacco product.

This is a Philip Morris's IQOS. And so it looks very much like Apple stores. And so you pop them open. And what you do-- it's a modified tobacco risk product it heats tobacco at a lower temperature than a cigarette. So a user has a small heat stick that you purchase and you put it in. And so you're smoking tobacco, allegedly, at a lower level, and they say a modified risk compared to a combustible cigarette.

Modified risk. That sounds like-- it's a little less risky, but it's still very risky, obviously. And it's interesting because when you talk about and describe that it-- the chemicals-- you're still putting a chemical into your body, you're inhaling a chemical, which obviously, isn't particularly safe.

Right, exactly. All the nicotine is from the tobacco, leaf tobacco derived. There are chemicals, constituents, and e-liquids it's not regulated. So we know some of them. There's a lot we don't know. And its long term effects are certainly unknown.

And Dr. Jablonski, we hear people-- and I've already seen some of the comments on Facebook when we were promoting this-- people say, well, it got me off of smoking, it's safer. You're a pulmonologist, so you see this stuff up close and personal, and you know what it actually does to people. Can you tell us a little bit about that and how safe or dangerous is this?

I think the real answer is that we still don't know how safe these products are for long term use. What's being talked about in the media, particularly over the fall and summer of 2019, was this real explosion in cases of acute lung injury or acute symptoms of cough and shortness of breath that we were seeing, particularly in young people, who were using vaping products, especially those containing THC. We know, though, that the use of these products long term can be associated with more pulmonary symptoms, particularly cough. That they can make people at increased risk of developing chronic lung diseases like COPD and asthma. And as Dr. King mentioned, there are substances in these that are potentially carcinogenic and could increase the long term risk of developing lung cancer.

So a lot of the comment that people have or comments that people have say, well, it's going to be safer than smoking cigarettes. Do we know-- is it factual or not?

Well, I prefer the term potentially less harmful, but I never use the word safe when I describe any tobacco products. None of them are safe. A cigarette is probably one of the most toxic substances known to man. So when you compare anything to a tobacco combustible cigarette, you might say there is less harm. How much less harm for whom, and given we don't know what's in the e-liquids, the lungs are designed to breathe in air and not these aerosols that contain a lot of chemicals. So I don't use the word safe, ever. Never.

Yes, I think that we don't have information to make a claim one way or another about these products. Just because we don't know and can't answer the question doesn't automatically make them safe. Although if you look online, that's what a lot of these companies want you to believe.

Well, nad actually, the marketing of these products too-- it's interesting when you see some of the ads and some of the various products. There have been a lot of complaints about the fact that this is aimed at children. And have you ever seen examples of that? And you know, it seems like really get them started young on an unhealthy habit.

Yeah. The FTC is coming down on Juul and other manufacturers because the ads clearly look like they are designed to entice young people. So they who have been working closely on their pathway for regulation to help them to stop doing that. But there are still infractions, they're still looking to young people. They want to get that young brain addicted by age 18 or 19. The adolescent brain is much more sensitive to nicotine, so youth will get addicted to nicotine quicker than an adult.

And so they want to get you addicted at that age and have that lifelong customer. So they don't want to wait till somebody is in their 20s or 30s or things like that. They really want the youth to be using them.

Interesting.

And I think these companies have really exploited social media in a very sophisticated and smart way to normalize smoking in a population that might not have otherwise picked up a conventional cigarette and started smoking.

We want to remind our viewers. If you have any questions for experts, please type them in the comments section of Facebook. We'll get to as many as possible over the next half hour. So how does the amount of nicotine in a vape pen or one of these devices compared to say a cigarette?

As Dr. King mentioned, at least in Juul, the amount of nicotine in one single cartridge is comparable to a conventional pack of cigarettes or 20 cigarettes.

I mean, are you getting all of that at once or does it last a long time? How does it work?

So in Juul, you buy them by these small pods. And this pod, somebody could say they use a few of these-- I've had definitely young people, high school students and college students, say, well I only do three of these a week. And I'll tell them, that's three packs of cigarettes a week already for you. And they don't know it's that powerful. And the nicotine delivery by this chemistry is the most powerful. Even though these devices are larger and have bigger batteries, it's a different chemistry to get the nicotine. And so it gets into your brain the fastest with these types of products.

So we're hearing a lot about recreational marijuana, obviously, here in Chicago, legalized just recently. Is vaping THC-- how does that compare? Is that worse than nicotine? Is it worse than smoking just straight? How does it affect the body?

I think that vaping THC, it's safe to say that is significantly less safe than using some of these nicotine containing products. When you look at the series of patients that the CDC has reported on that have developed this severe lung injury in association with vaping, the majority of those people used a THC containing device. And interestingly, there was a subset who said they only used nicotine containing devices, but still had measurable THC, either in their systems or in the products that were obtained by the CDC for testing after the fact.

Which I think underlies another point that I wanted to make, which is that the purchase of a lot of these products from black market or informal sources has been associated with development of this lung injury. I can't say strongly enough that is something that everyone out there should avoid doing.

You know, that's an excellent point, because a lot of the ads you see on the internet and in other areas, they aren't the big brand name-- I'm not saying that those are good either, but there are companies you'd never even heard of. So you don't really know what's going into that and what you're putting in your body.

Right. And besides the lung issues, THC is highly addictive. So it's the active psychoactive ingredient in cannabis. And the amount of THC now in marijuana products is about three to four times higher than it was a few decades ago. And some people might think you can't get addicted to marijuana, but people can get addicted to it, and can find it very hard to change once they are regular users.

We are getting some questions from our viewers. Here's an interesting one. The question is, it's clear vaping can harm the lungs. But how does it affect teeth and the mouth-- gums, tongue. You often hear from smokers or people who chew tobacco, they have the various mouth cancers. Have we seen anything like that?

I haven't seen anything like that, but those are issues that often develop after years and even decades of chronic cigarette smoking or smokeless tobacco use. And I think these products haven't been on the market long enough for us to know whether they may or may not be associated with development of some of those conditions down the line.

Right.

So one of the things that I think people will be worried about, parents in particular, you know, the kids are attracted to this-- and we were talking before the show started some of these had little designs on them and things. So the kids will be attracted to this at a young age. They become addicted . How do you get them to stop? I mean, it's challenging to get a kid to stop doing anything you don't want him to do, but particularly when you add an element like this in?

Yeah. Well, you know, these products are so new. They've been the United States for less than 10 years and heavily used now with these new products just in the last three to four years. So in recent clinical research, we haven't caught up yet on this, so we don't know the most effective ways to help youth to get off of them. What we do is often used the techniques for traditional smokers. So that involves-- there's more intensive treatments going to a group or individual counseling to help them get off. I mean, essentially, it's addiction to nicotine.

There's also reputable websites, text messaging programs, and things that youth might find very helpful. We have nicotine replacement products, so you can get nicotine, and it's approved by the FDA safe ways to help you to reduce the severity of withdrawal symptoms. And so there are some medications. Those aren't approved for people under age 18. So there are some things with younger adolescents that would need to be taken into consideration. But it really is an area where we need to find out what the most effective treatments are for young people. I would certainly talk to a pediatrician or doctor to get started, though.

Can we talk a little bit about nicotine addiction in general? Because I think a lot of people, when they think of an addiction expert, they think of somebody that probably deals with you know, people who are addicted to drugs like heroin and things like that. But nicotine is incredibly addictive.

It's very addictive. Right. It kills more people than any other of the illicit substances combined. So it's a very large problem. And it can be highly addictive. And so we have approved ways to help people to treat their tobacco dependence. So we have seven approved medications by the Food and Drug Administration. We have counseling programs. We have text messaging programs Every state has a tobacco quit line with trained counselors.

So we know when you combine potentially medication approaches with counseling we get the best results. So people can quit smoking. And some of them can improve your chances two to three-fold. So there is hope. And the CDC has a campaign, Every Quit Counts. So continuing to try and learn from each quit attempts can help somebody to really, truly make an impact.

Dr. Jablonski, I know that we're kind of in the early stages of all of this, so it's difficult to tell exactly what it does do to the lungs. But there have been cases where we've seen people that have been hurt pretty badly, and as we mentioned in the intro, there have been some deaths. Is it difficult to attribute that, first of all, to the vaping? And secondly, what does it do to the lungs as far as you can you can tell?

There's been a very wide spectrum of types of lung injury that we've seen in response to use of these vaping products. And what we think is that the inhalation of some either toxic substance or substances causes irritation and inflammation in the lungs that leads to these lung injuries that we're seeing. One particular substance that's been discussed a lot in the media, particularly in the past few months, has been this vitamin E acetate, which is part of the carrier that is used to dissolve the THC and particularly used in THC containing products. And the inhalation of that causes stress and injury to the lungs themselves, leading to this severe lung disease.

Interesting. So we have another question from a viewer. And this is related to the oral health question. Are there other additives like sugar, et cetera that can affect health? You just mentioned the vitamin E additive or compound that's being used that has impact. Have you seen other things that affected people?

We know that there are carcinogens in these products. And a lot of products contain flavors as well. And those flavors can be various compounds that are used to impart that on the vape liquid. One in particular that causes concern for pulmonologists is diacetyl, which has been used in other flavorings like popcorn butter, and it's been associated with the development of a long term chronic lung disease called popcorn workers' lung.

Interesting. I hadn't heard of that one. And obviously, it's a little different. Those are folks, I'm assuming, working in the factories that are having issues?

Exactly. Exactly.

So they're breathing it in. So that's something I hadn't heard before. So this one is kind of an interesting question, and it's a tough one, because as a parent, it says, I'm a traditional tobacco user. How can I encourage my child not to do this? Because again, kind of do as I say, not as I do. And that's a hard thing when you're a parent and you want your child to maybe do a little better than you have.

Yea. Yeah, that is hard. So the parent who is a smoker, one thing to consider is how can they reduce the harm, the secondhand smoke to their child. So certainly, if they are smoking, to take it away and make sure that they're not smoking in front of their child. And to also really talk about, maybe be honest about the process when they started smoking, and how they got addicted, and how they don't want that for the child. I would hope that parent would be working on trying to quit, and may really maybe share those experiences.

And I would hope the child would see how hard it is for that parents, and they're trying. And so most smokers regret highly that they ever started. 70% want to quit and working on it. So that could be a teachable moment for them to really say, I don't want this for you, and I'm working to stop doing this.

Only 70%? I would figure that number would actually be quite a bit higher. I'm a little shocked by that.

There are some who, you know, they veer down, and they say they're going to do it. And that's their right to do it.

I just don't know people, I think.

Yeah.

So I know there been some changes-- and again, I want to remind our viewers please shoot your questions to us, we'll answer them as quickly as we can. In the meantime, there have been some changes in laws, not only in Illinois, but across the country as far as how some of these companies target children in particular, but also, adults. And the flavorings and things like that. Has any of that had any kind of a positive impact, in your opinion?

The?

The laws. Just trying to change and make this a little bit less--

So I started doing this research in 2013 and they'd only been out for two years. And there was no age requirement, no limits, no nothing. So it was like the Wild West only six, seven years ago. So since then now, nationwide, we have 18 years old and older. And people at retail shops should be asking for identification. So that is an improvement. We have a point of sale marketing restrictions and other things the FDA has imposed.

Now this year may be a very exciting year, because we may see 21 being the minimum age now to purchase. In the state of Illinois, you have to be 21 to purchase tobacco products. So we do see this. We need to have enforcement and have people at the point of sale actually really doing those things to make sure you aren't getting them. So I think these are certainly steps in the right direction to get this out of the hands of youth.

I didn't realize there was no age limit when they started. That's very interesting. And the flavorings too, there have been some laws and rules as far as restricting flavorings, if I remember correctly. Or attempts at it.

Yes, there are. Because that can be some of the harmful chemicals in the chemical reactions. So the FDA, they're talking about reducing those flavors and which ones. You have this group of adult smokers who say, you know, if they can switch and use these products, this is less harmful to them. And so the FDA has to weigh the risks across society. So to have a smoker convert and use something that they might say is less harmful. So they don't want to restrict you know the flavors that an adult may use, but yet flavors are so enticing to children, particularly those sweet flavors.

They also do use mint and menthol just like adults. So how they would go about this, they have to look and weigh the benefits and the risks across society for both adults, former smokers, never smokers, and youth. It's a lot to juggle.

Yeah. And Dr. Jablonski, you mentioned a minute ago the vitamin E being used for THC, but the flavorings, the chemicals that are involved in some of the flavorings-- you kind of touched on this a little bit earlier-- but some of those chemicals, we don't even know what they'll do to the lungs. Is that correct?

Exactly. And part of it is some of these devices can be modified so that the product is heated to can be adjusted by the user. And then we don't know at lower temperatures versus higher temperatures what chemicals might have come about from the heating of those, of what is in the vape juice or the vape cartridge itself. And since there's such a diversity of these products on the market, it's just been so difficult to get a handle on what exactly is out there and what people are using.

So if you suspect your child of vaping, how do you tell? I mean, some of these things, it looks like they're almost camouflaged, some of these items. So how do you know?

I know. That's a terrific question and it's a very hard one to answer. I think it starts with having a good dialogue with the child and the parent. And I've observed some of these, and I think the most important thing is to listen to the child. So if you're talking more than the child, I would say let them talk about things that they know, what they think, even if you don't agree. Really have them talk about it, and sort out those issues, and help them to get the most accurate information.

If you do see things that look like coils, and hardware, and things in their backpack, or flash drives-- I mean, it may be important to really understand what kinds of things you might see. And maybe where their money is going. Do you know how much-- do they get an allowance or are they earning money? And where does that go? Because they're going to find a way to get these products. And so I think having that important dialogue, and interchange with the parents, and really, again, listening to the kids, I think, is one of the most important pieces of advice I can give somebody.

And I think talking to your kids about what these are and what they contain is important, too. If you look at samples out there, almost half of kids don't even know that there's nicotine in a Juul, which is crazy to sit here and say that as a pulmonologist. But I think there needs to be more education of the children so that they know what they might be getting themselves into by picking up one of these devices.

You know, it's tough being a kid. And there are all kinds of pressures on you and your pressures from your friends. And you know, it seems like every generation has its thing that they have to work through. And it's can you prepare your child? That's the other thing. And I think that's actually good advice because it kind of prepares your child when they get these pressures.

I've given presentations to middle and high school students. And first of all, I start my presentations with congratulating them. I said, you're smarter than your parents, because combustible smoking is at its lowest rates in decades. And so I said, you're very smart. I mean, most adults I talked to say that children talk to them about quitting smoking or how bad it is, it's gross. And I said, what's happening with you is you're the first generation that is being targeted, and manipulated, and enticed to use vaping products.

And so it's a way, to, again, take your brain-- they want that brain addicted to nicotine and at these very tender ages-- so that you will be a lifelong consumer. So I give them credit for being very smart. And saying, you know, as parents and adults, we were not confronted with this as teenagers. So you know, we're trying our best to help you and support you. And let's get the information not just from your buddy at school, but really from maybe credible sources to understand what the risks and harms are.

Sounds good. Another question coming in, is there a good website or other resource to refer to patients or parents who want to learn more and learn how to deal with this?

I like Smoke Free Txt. So it's smoke free T-X-T. And that if somebody goes and looks at the CDC website, and it's through the National Institute of Health. It's very credible. It has terrific information. It can do a text program. And it also has vaping for teens. They have a link for resources and information. So that's probably my favorite of all the sites right now.

That's an excellent recommendation.

Perfect. So a question-- and we kind of touched on this a little bit earlier-- but are the-- not that I would encourage anything here-- but are the store, you know, the major brands, the ones you recognize you can buy in a store, safer than the stuff you maybe get off the internet or the no names? Again, not that I want encourage either way, but are they safer or not?

Less harmful.

Less harmful. I'm sorry, I keep using the wrong terminology.

I think potentially, with some of these nicotine-containing devices-- yes, when it comes to the THC or the CBD-containing devices, that no one really knows. And since there's no regulation for those products, you don't know the origins, no matter where you buy them.

And you know, one of the things that and again-- I'm not saying-- we'll say less harmful-- there are people that will say, and I've heard this argument many times, that you know, I've smoked three packs a week for years or two packs a day or whatever. This helped me stop. Is there any validity to that?

Well, statistically, it's a small percent of smokers who can convert completely, and vape, and not use combusitbles. So the majority of people are what we call dual users. They both continue to use combustible cigarettes and they vape. And there are some maybe additional health harms additive to the use of both. So that's really becoming an interesting area to look at. The dual use may be of concern.

I've treated hundreds of smokers, and I have yet to find one who's tried every one of the seven approved medications and gone to counseling at the same time. So I say if you've gone through every one of the approved treatments and really tried some intensive counseling and you still haven't found yourself able to make a change, then maybe we could talk. But I have no way to advise people to use these products. And I don't want to advise people to use something that isn't really approved and safe.

Dr. Jablonski, same thing?

As a pulmonologist, I will never recommend for anyone to inhale something into their lungs. And in particular for my patients who have chronic lung diseases or other diseases for which they might be thinking about using medicinal marijuana or recreational marijuana with the recent legalization of it in the state of Illinois, I just recommend that they use an adjustable form instead of something that is inhaled.

Fantastic. Well, Dr. Jablonski, Dr. King, thank you very much for being on the program. We appreciate you doing this. A lot of good information for people here today.

Thank you.

Thank you.

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