Tobacco and Vaping

By: Madison Davis MPH Candidate, Brown University School of Public Health

Background

Vaping is an ongoing, dangerous, trend among adolescents. The increase in harmful side effects associated with vaping has led to concern among providers and public health officials. A vape, or an e-cigarette, allows individuals inhale a heated aerosol that usually contains nicotine¹. A monitoring study in 2019 concluded that the prevalence of vaping increased two-fold among eighth grade, tenth grade, and twelfth grade students between 2017 and 2019¹. It is important to observe the increase in vaping among young individuals because of the detrimental effects nicotine has on developing teenagers². During the adolescent period, generally defined as between 12 and 18 years of age, there are critical changes in cognitive and executive function, working memory, reward processing, emotional regulation, and motivated behavior². 

Going all the way back to your biochemistry class you took years ago, we are going to dive into the specific physiological effects of nicotine on the developing brain. The nicotinic acetylcholine receptors (nAChRs) are ligand-gated ion channels found throughout the brain². These channels are responsible for regulating agonist affinity, ion selectivity, desensitization, and downstream signaling². Given its versatile function, nAChRs plays a vital role in the central and peripheral nervous system². However, these receptors have a high affinity for (or really enjoy binding to) nicotine which causes desensitization in the brain of a smoker². There are other subtypes of the receptor that experience similar effects in the caudal brain region which plays an important role in the nicotine addiction pathway². The activation of regions involved with the nicotine addiction pathway (that have high concentrations of nAChR receptors) causes nicotine-induced firing and activity of dopamine neurons in the brain². This process occurs in many different brain regions affecting a variety of systems². Nicotine also plays a similar and important role in the ascending serotonin system³.

All of this means that the limbic system, which controls cognition, emotion, and drug reward, is very vulnerable to developmental issues when exposed to nicotine particularly during adolescence². This sensitivity to nicotine suggests that smoking is not only associated with mood disorders, but may also be the cause⁴.

Not only are there severe effects on the brain and nervous system, but also there can be major damage to the lungs of those who smoke. A 2019 study looked at the vaping-associated lung injuries in individuals who using vapes/e-cigerettes⁵. The presence of diacetyl in vapes is known to cause lung injuries⁵. The warning signs for providers is discussed further below. 

Health Law

In 2009, the Tobacco Control Act and “Deeming Rule” were passed to allow the FDA to establish regulations on cigarettes and new tobacco products including e-cigarettes⁶. More recently, in 2019, the federal government increased the age requirement to purchase e-cigarettes from 18 to 21 years of age⁶. In 2020, they went a step further to halt the sale of flavored cartridges and prevent the online sale of e-cigarettes in order to dissuade younger people from purchasing them⁶. Future law directions include a proposed regulation on the amount of nicotine that can be present in an e-cigarettes⁶. 

Details for Providers

Individuals who begin smoking during their adolescent life are more likely to use other drugs, engage in high-risk sexual behavior, and develop psychiatric disorders when compared to nonsmoking adolescents^7,8. Given the clear developmental impact that nicotine has on the emotional, cognitive, and addiction pathways of the brain, this is where providers may see deficits in their patients who smoke².  

For patients with vaping-associated lung injuries, they may present with mild respiratory symptoms including persistent cough, shortness of breath, or chest pain⁵. However, there is not a clear clinic guideline for this type of illness. Instead, as a provider, you can make the diagnosis by establishing a temporal relationship between vaping and symptoms, rule-out other potential causes for symptoms, and determine if there is improvement with the cessation of smoking⁵. In regard to radiological findings, a hypersensitive pneumonitis pattern that was improved with cessation of smoking has been reported⁵. Additionally, diffuse alveolar hemorrhage, which presents with cough, fever, difficulty breathing, and sometimes coughing up blood, has been found as well⁵. Other conditions include acute lung injury, acute eosinophilic pneumonia organizing pneumonia, lipoid pneumonia, and giant cell interstitial pneumonia⁷.

As a provider it is important to screen patients for smoking history and advise on the potential dangers of vaping particularly between the ages of 12 and 18 years. Furthermore, the cessation of smoking has been found to help improve associated symptoms and may be a valuable first step in treatment⁷. 

References

1. Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME. Trends in adolescent vaping, 2017–2019. New England Journal of Medicine. 2019;381(15):1490-1491.
2. Yuan M, Cross SJ, Loughlin SE, Leslie FM. Nicotine and the adolescent brain. The Journal of physiology. 2015;593(16):3397-3412.
3. Bang SJ, Commons KG. Age-dependent effects of initial exposure to nicotine on serotonin neurons. 2011;179:1-8.
4. John U, Meyer C, Rumpf H-J, Hapke U. Smoking, nicotine dependence and psychiatric comorbidity—a population-based study including smoking cessation after three years. Drug and alcohol dependence. 2004;76(3):287-295.
5. Henry TS, Kligerman SJ, Raptis CA, Mann H, Sechrist JW, Kanne JP. Imaging findings of vaping-associated lung injury. AJR Am J Roentgenol. 2020;214(3):498-505.
6. Laura Summers M. Curbing the Youth Vaping Pandemic: A Review of How Utah’s Laws and Policies Compare Nationally and to Other States. 2021.
7. Lai S, Lai H, Page JB, McCoy CB. The association between cigarette smoking and drug abuse in the United States. Journal of addictive diseases. 2000;19(4):11-24.
8. Rashad I, Kaestner R. Teenage sex, drugs and alcohol use: problems identifying the cause of risky behaviors. Journal of health economics. 2004;23(3):493-503.