[00:00:00] non: You are listening to the ATS Breathe Easy podcast brought to you by the American Thoracic Society.
[00:00:18] Erika: Welcome to the ATS Breathe Easy podcast. I'm your host, Dr. Erika Moseson, a pulmonary and critical care medicine physician in Portland, Oregon, and host of the Air Health R Health podcast. I'm here today with Dr. Laura Crotty Alexander. Dr. Alexander, will you please introduce yourself?
[00:00:32] Laura: Sure. so I'm a physician, adult, and a scientist here at, university of California San Diego.
And I've studied e-cigarettes for over 12 years now. One of my favorite topics,
[00:00:45] Erika: well, we are here today to discuss e-cigarettes and it's use among children and adolescents, as well as what we can do to help them break free of nicotine addiction. So first, tell us about your own professional and research background and how you became interested in this topic of e-cigarettes.
[00:00:59] Laura: Sure. [00:01:00] so it was kind of interesting because I'm classically a bench researcher, meaning I work with mice, I work with cells, and I had. Started looking at the effects of cigarette smoke on bacteria because most research has been done in the arena of cigarette smoke effects on humans across the body.
and when I was doing this, I was also in pulmonary clinic and. Patients kept asking me more and more frequently whether they should be trying e-cigarettes to help them quit smoking. And I was like, I don't know. There's like no data out there. I have no idea if they're safe. I don't feel comfortable giving recommendations.
And then I was like, what am I doing? Like I am set up to study this. Like what is, let's take this to the binge. And I started vaping mice and vaping cells and. Just really, I hope you weren't vaping
[00:01:53] Erika: mice in cells, but exploring the vape effects on the mice and the cells. There we go. Let's, let's call it that.[00:02:00]
Yeah. Well, the first study we are going to discuss today is titled Vaping and Harm in Young People, an Umbrella Review, which was published in the Journal of Tobacco Control from the BMJ. and I found it really eye-opening myself, as the, parent of a young adolescent. can you describe how the study was done and the questions it aimed to answer?
[00:02:20] Laura: Along your point that you just made. I'm a parent of a 13 and a 15-year-old, and I feel like that has driven my passion for this area quite a bit and led me to be a little bit more involved in like advocacy and policy, as well. Um. Yeah, so this article was very interesting to me as well. I never really looked at an umbrella review, so systematic reviews, meta-analyses, you know, I've read plenty of those.
but this one was special being an umbrella review. Meaning it's a review of review articles. So they were trying to capture as much information, like very broadly, and trying to target it down [00:03:00] to adolescents. So by utilizing, other researchers, um. Efforts to sort of condense what is known about e-cigarettes.
They use all of these existing reviews to condense the knowledge about what are the effects of e-cigarettes on adolescents down to this one paper. And what did
[00:03:23] Erika: the study find about the link between e-cigarette use and using traditional combustible cigarettes? 'cause that part has always been a concern of mine.
[00:03:31] Laura: Exactly, and that has been one of the consistent questions I get asked by parents and, policy groups, schools. And they found a very strong association between initiation of e-cigarette vaping and adolescents, and subsequent smoking of combustible tobacco, cigarettes and hookah, shisha and. They also went a step further to say that it truly [00:04:00] was like, you know, that the vaping increases the odds of them adding in the combustible use by about threefold.
And I was excited to see that because I'd been sort of presenting similar data. But from multiple different papers. And I felt like this way that they sort of took all the data out there and really synthesized it down just for adolescents, I felt like it was like pretty powerful the way that they, stated it.
[00:04:28] Erika: And so the special thing about this umbrella review, it sounds like is because they were able to look at all these other reviews that had already looked at this question and pull out the adolescent data, their finding is actually much stronger than any one of these individual studies because they're so consistent.
Is that correct?
[00:04:44] Laura: Agreed. It's like an amplified signal where all 21 systematic reviews that they included. Did find that association between e-cigarette use and subsequent initiation of smoking, and that, beyond that, they could [00:05:00] really tie it to a causal relationship, whereas a lot of these individual studies or individual reviews, would say there's an association, but we are not sure that it's causal.
But this umbrella really kind of solidifies our knowledge of it to say yes. Adolescents who vape like that is causal, they are way more likely to initiate three times more likely to initiate combustibles.
[00:05:24] Erika: And even just as someone who's also done advocacy in this, when you start talking to, you know, the youth who are affected, you know, a lot of them say they grew up with a message that cigarettes are so bad, but you could totally see how this would be a gateway, right?
Well, this is just, you know, some bubblegum favorite thing that I'm sucking on. And then they realize, you know, okay, gosh, I'm addicted to nicotine. Well, hey, here's the old fashioned version, and just moving right along in kids that maybe never would've gone straight to a cigarette.
[00:05:46] Laura: Right. And actually, I know we're gonna talk about this a little bit later, but the unique thing about this article where they actually did involve use in like how to frame these messages, like, one of the things the youth were really upset by [00:06:00] was the messaging they had heard to date being that e-cigarettes are safer, than cigarettes.
And you know, they're hearing that they're not addictive, that there's no problems with it. And it was interesting that they were so upset about it.
[00:06:14] Erika: Yeah. Well I'm a parent. I'm pretty upset about it.
[00:06:17] Laura: Yeah. So
[00:06:18] Erika: what's the study find about the risk of e-cigarette use and the use of other substances?
[00:06:22] Laura: Yes, and this has been an area that's really been up and coming in the last few years, since the association with Combustibles.
It's kind of been there for several years now. But that sort of raised, eyebrows about, well, maybe this is leading to marijuana use, alcohol use, and even more illegal substances. And this umbrella review did find an association between, all of those basically. So marijuana, alcohol, binge drinking, in particular all being higher in adolescents who vape.
[00:06:58] Erika: Yeah. And again, you know, when we think about [00:07:00] nicotine on the developing brain, one of the concerns that everybody always raises is the potential impact for mood problems, mental health concerns. And so if you're gonna be using a substance that changes those, it's not surprising that other associated substances would follow.
[00:07:14] Laura: Nicotine being one of the most addictive substances of all time. And it is so, has such a powerful activation of the dopamine reward system. And, you know, all of these other drugs activate that system too. And so of course if you don't have a vape available or you know, somebody's drinking alcohol next to you and you use that as a substitute and it will do the same thing.
You know, slightly different effects of course. but again, like this kind of gateway effect. Absolutely.
[00:07:42] Erika: Well, so speaking of that, what were the mental health impacts associated with e-cigarette use in adolescents?
[00:07:48] Laura: so that was a really frightening section of the article because they found, that e-cigarette vaping was associated with not only greater rates of depression.
[00:08:00] Suicidality. And they went even deeper with that in terms of, you know, suicide, attempts, versus suicidal ideation. And they found increases in both of those. and in particular, the suicide plans were found to be greater in female adolescents. Which brings up another topic that there are sex effects, gender effects, in.
Tobacco combustible tobacco that are very well known, less is known for the vapes. and so this is like scary, but you know, highly relevant information that the impact on the brain in these areas that are really powerful for mood, are likely different between, boys and girls.
[00:08:43] Erika: And, you know, beyond the mental health effects, what other risks to physical health, come with e-cigarette use?
[00:08:50] Laura: So the most, the biggest signal to date is asthma. and I felt like these authors really did a fantastic [00:09:00] review of existing data along those lines because that data had been a bit patchy across the board. And by doing this sort of like more broad analysis. they did find 47 primary studies that, concluded there was an increased risk of adolescents who vape developing asthma or having an asthma exacerbation.
So this is actually one of the strongest associations, found in this umbrella review, was that incidents of asthma slash, you know, worsening of asthma in e-cigarette vapors.
[00:09:34] Erika: And one of the things you had already touched on. That I found really surprising and actually I think important is that this study included patients and the community.
and I found that really powerful because, you know, normally I'm reading a, a journal and I'm instantly thinking about my own patients in my community. But I do think we've seen in the world right now, or at least in our country, that the process of doing science and the medical. [00:10:00] Community sometimes feels very, very far away from the people we're actually trying to help.
So is this typical for tobacco research or what do you think this adds?
[00:10:08] Laura: I think it's becoming much more typical. So I was really excited to see it in this one. And in the next paper we're about to discuss, and as an e-cigarette researcher, I have always, engaged with the community, with young people because.
I didn't know what I was talking about when I got into the field, you know, I was like, oh, e-cigarettes. And I'd read up on it and then we started recruiting human subjects and they were like, what are you talking about? We don't call them that. That's not how we use them. and I was like, oh, wow. Like I need to be engaging with, this demographic, like on a very regular basis.
Otherwise I'm not gonna be studying the right things. Or in the right way. So I was really glad that, yeah, in this review article of all things they, you know, involved this youth advisory panel of the UK Association for Young People's Health, [00:11:00] and got their advice on. What their concerns were and how they should do their messaging.
Like what was the best way to convey the message that they found. And so I thought that was just a really cool way to involve, this sort of target population and the population most affected by these results.
[00:11:21] Erika: Absolutely. I mean, you make a better question, you're gonna get a better answer.
[00:11:24] Laura: Right? And like, you know, as, as scientists and physicians, like, we're not always the best at speaking at the lay person level, you know, really communicating what we know so that they can really understand it.
And I felt like that is also a key reason to engage, with. Lay people in general and your target demographic in the hopes that your work will actually translate, you know, to the community, rapidly.
[00:11:54] Erika: You don't find it helpful to walk into your office and start talking about hazard ratios with your patients?[00:12:00]
No. I think that gets them to quit right away.
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[00:12:38] Erika: well, as a parent. one of the things that was so sad reading this analysis is actually how many kids were in the studies that they had, you know, treating adult smokers and trying to help them quit is already so hard. But at least we have all this trial evidence and just thinking about my poor pediatric colleagues who are just, you know.
Floating in the wind without really good data. So [00:13:00] the, the second thing we're here to talk about is a, great document that the American Thoracic Society put together to try to help provide guidance for our pediatrician colleagues. And they've released a guideline called treatment of nicotine use in adolescents under 18 years of age and official American Thoracic Society Clinical Practice Guideline.
So can you review their key recommendations with
[00:13:18] Laura: us? Sure. and first of all, I think that their methodology was also very strong, in this era of, you know, getting experts together and discussing a topic and then giving recommendations. Like old school, that's exactly what would've been done, and people would've just written down what they, you know, recommended.
Now in the modern era, like they have these specific techniques. For developing the questions, like vetting the questions and then like working to see if you actually get consensus or not. And so I was really, proud of this group for the work that they put in to, to give these recommendations. and what they came up were [00:14:00] with was like five main recommendations.
and it. They basically all have to do with, you know, caring for adolescents who have a nicotine addiction and what's the best way to try and help them. And so the first one is, you know, whether we should offer counseling. And that was the strongest recommendation agreed with by, almost everybody, even though there was low certainty of evidence.
And that comes back to your point that. It's the reason they convened this panel of experts is that there's not a lot of data out there, and so they had to utilize. As much adolescent data that they could, but also adult data to try and come up with these recommendations. Recommendation two was whether, they should use technology based interventions like apps.
So now there's actually several different, quit apps, available on the market. some of them are better than others, so for that one they conditionally recommended it, and [00:15:00] say again, very low certainty evidence. Then three, four, and five are all medication based. So recommendation three is whether they should give nicotine replacement therapy to adolescents who are trying to quit.
and they did not reach consensus on that one. So that one is actually not recommended as part of the guidelines. But interestingly, when they did. Interview a mom and her son who had gone through an addiction. that was the one thing that they disagreed with, the mom disagreed with. So she felt like nicotine replacement share therapy should be offered and that primary care.
Physicians, pediatricians should be trained better on how to do that. And then four and five are both, the big drugs that we use, with adults. So Varenicline and Bupropion. And both of those were conditionally recommended. again, very low certainty [00:16:00] evidence, but because they're so powerful, at helping adults with, tobacco.
Addictions, the panel decided that this should be an option for pediatricians to treat their patients. Yeah.
[00:16:15] Erika: what in particular struck you about this document?
[00:16:18] Laura: I thought it was very thorough, so I felt like somebody who is outside of the field or maybe hasn't done a lot of tobacco counseling, they can really find everything they would need in this document.
So the introduction, like very. You know, is written very high and tight, but really goes into detail about, you know, all the different use patterns in adolescents and, you know, what people should be looking for in terms of the types of things that they're using. And then they really went into detail about, you know, who should be screened for tobacco use, how you should do it, the differences [00:17:00] in terminology.
And then for each question they give a little bit of background and then they really summarize like every single piece of evidence that they used to make their recommendations. and again, they did it in a very concise way that I felt was really. Readable, so to speak. And then at the end they sort of said their recommendation, the quality of evidence, the benefits versus harms, and then they also added in like what other groups are recommending, which I thought was great because yes, we all love the ATS at S is great.
They give really good guidelines, but it's also nice to see like where they fall, across the world, and across just other societies. And so they put their. Guidelines in context of what the other groups are, also recommending.
[00:17:53] Erika: And that just helps us see, you know, which areas are crying out for research.
You know, it's heartbreaking to see a guideline about [00:18:00] how to help kids starting at the age of 10, which is the age of my youngest. but it just shows how much we need to invest in research in this area until hopefully we can just. Stop having nicotine use in adolescents entirely would be great.
Wouldn't that be amazing? So, you know the
[00:18:17] Laura: stars.
[00:18:18] Erika: Exactly. so based on, you know, your entire career, which obviously has been exploring this, and then with these two powerful new documents that have come into the, world of literature on e-cigarettes, what key takeaways do you think people need to understand about the health risks of e-cigarettes in young people and what we can do to help them quit?
[00:18:37] Laura: I think number one, the key, the most important takeaway that. I feel everyone should know, and very much so, kids themselves, teenagers, young adults, and parents, is that if you start to vape, you're much more likely to use other inhalants, including combustible tobacco, and [00:19:00] cannabis products. and that it also increases your rates of picking up alcohol and even binge drinking.
So. When I've worked with groups that specialize in interacting with children and, teenagers, they've really made the point that, you know. Educating them is critical. So providing them information so that they can make their own decisions, because of course you can't tell them what to do. my kids of course are like, oh, I'll never vape mom.
And I'm like, can you write that down and sign it and date it? And yeah, I'm gonna hold you to that. but yeah, providing that data and making sure that they know about. Those risks in particular, they're not as responsive to some of the downstream health effects. So I personally think the asthma data is like the second point that I would take away that just how we know that people with asthma like cigarette smoke is a big [00:20:00] trigger for a lot of them.
they have lower cigarette smoking rates, and we. They're more of them are picking up vaping. but now it looks like there is, you know, a clear tie between getting diagnosed with asthma, having exacerbations and vaping. But when I tell kids, teenagers, young adults like that just is not as impactful in their mind.
And so I think the third point would be the mental health. because that's such a huge problem in our young people right now with like extremely high rates of, you know, anxiety and depression. And unfortunately a lot of them like, think that they're self-treating with vaped nicotine or vaped, cannabis.
'cause in that moment it makes them feel better, but they don't understand that it actually drives. Both anxiety and depression and you know, it'll get much, much worse. And then it's, you know, very hard to quit. so yeah, all of those are like really important points. [00:21:00] And I think the other one is one we talked about quite a bit, being that researchers.
Policy makers, physicians, like really need to engage with our target populations so that our communications are clearer and that we each understand, each other better, and that that's gonna lead to better, outcomes, overall.
[00:21:22] Erika: Absolutely. Well, I wanna thank you for your career trying to help us understand these e-cigarettes and for taking care of patients and, you know, raising kids probably the hardest job fair.
Is there anything else you wanna add?
[00:21:37] Laura: I guess like in terms of the data that I really think is missing, is the effects on neuro development and even lung development. and that's mentioned in, these articles as well. so, you know, kids, their brains develop and their lungs develop until their mid twenties.
so if they [00:22:00] start vaping, you know, when they're 15, that could lead to 10 years of, you know, effects on the brain and the lungs. And at least in mice, we're seeing profound effects on the neurologic system, including behavior and, yeah, behavior and, uh. Intellectual capacity basically. and I am just really worried that we're gonna see the same thing in young people, that they're gonna end up with decreased lung function at, you know, their peak of like being around 25.
They're gonna start with a lower peak. And so then in. Decades down the line, this is gonna lead to more symptomatic disease, in them. And then of course, the brain. We just have no idea what's gonna happen. But, really worried about that. Need a lot more data.
[00:22:48] Erika: Absolutely. Well, that's always the answer,
[00:22:51] Laura: right?
Right. That's so easy too.
[00:22:55] Erika: Well, thanks everyone for joining us for this ATS Breathe Easy podcast and make sure to [00:23:00] be a voice in your own community for clean air and tobacco control.
[00:23:07] non: Thank you for joining us today. To learn more, visit our website@thoracic.org. Find more ats, breathe Easy podcasts on transistor, YouTube, apple podcasts and Spotify. Don't forget to like, comment, and subscribe, so you never miss a show.