Is Electronic Cigarette an Aid to Quit Smoking

there are a lot of people in this
country who have given up cigarettes
according to the CDC cigarette smoking
has fallen to its lowest point in
recorded history in 2017 that's the last
records that I could find available an
estimated 14 percent of adults smoke
that's about 34 million people and
that's nearly a 70 percent decline from
1965 when just over 43 percent of
American adults smoked cigarettes
tobacco smokes
but now yeah the teens are starting to
pick up the slack Dean Jewell the most
popular east cigarette on the market was
created to help smokers switch from
cigarettes but in fact e cigarettes have
complicated this tobacco product
landscape they're not an FDA approved
quit aid and now using e cigarettes and
vaping has become an epidemic among
young people including high schoolers
here to talk about quitting smoking
nicotine addiction and east cigarettes
and vaping is dr. Johnny Bert's
associate director of the Mayo Clinic
nicotine dependence Center it's good to
see you again dr. Hebert pleasure to be
back thank you well I can't wait to hear
the Jules story but first let's talk
about congratulations to you and your
colleagues for getting the smoking rate
down to the lowest it's ever been so
how'd you do it so I think it was always
a combination between public policy and
then effective treatment most patients
who quit smoking quit on their own and I
think a lot of that was clean indoor air
and a lot of the local policies that
were implemented to kind of restrain or
constrain smokers because we know that
if you have clean and indoor air and
good public policy people are more
likely to quit in combination with that
a good effective therapies like
varenicline in bupropion and nicotine
replacement have really been
disseminated pretty well across the
country so we've done a good job on both
reducing the incidence of people
starting to smoke through public policy
but also treating effectively those
people that are chronically dependent
now for a long time we didn't really
know how detrimental smoking was wasn't
at 1960 when the Surgeon General's
report came out
they said that there was a connection a
link between cigarette smoking and lung
cancer nothing about the heart nothing
about your increased risk for stroke
right but we didn't know how bad this
was so it takes about it takes it good
it took a good long while and it's a and
that's the challenging thing I think is
when we talk about e-cigarettes that
we'll have to sort of discuss and think
about it takes a good long while for a
large population of people to be using
or abusing a substance before we can
actually start to truly understand what
the true health risks are so we started
mass-producing cigarettes for our troops
in the early 1900's but it wasn't until
1950s until jiya mckay mout with the
case control study associating smoking
with lung cancer that we were like how
there's something really going on here
so it took about what 40 30 30 or 40
years to get that data out there and
then we could start to piece the other
you know the heart and the lung and the
liver and the nerves and the brain and
all those everything else and everything
else right it took a while to get but it
takes a while to understand what the
health risks are in a broad population
of patients and today in the 21st
century if you're smoking I would say
you probably know that you should not be
smoking I don't think there's any
discussion there but it's the nicotine
that makes it so hard for people to give
up smoking correct and I think what
you're seeing - it's interesting it's
not just smoking yes or no but the types
of smokers that we're seeing so in the
back in you know in the 60s and 70s the
vast majority of smokers were daily
smokers what we're seeing now is that a
huge significant percentage of these
patients are non daily smokers so they
smoke occasionally so there may be some
differences in risk perception I think
that the message is very clear if you're
a daily smoker that you know there's
these attendant health risk but you will
get patients coming in and saying but I
don't smoke every day doctor so what is
my true health risk and and that's due
to some of these complexities of
understanding risk and communicating
risk and public policy yeah you're not a
daily smoker so actually sitting in a
restaurant for four hours is not very
hard but your risk is when you leave
that restaurant and smoke but being in
that restaurant for four hours doesn't
make you quit that's the deal is there
any drug that's more addictive than Nick
so a abuse liability is that's an
excellent question and I think we always
struggle with that when we talk about
addiction is what makes something
addictive or what makes something
reinforcing so it's all about
reinforcement nicotine and heroin and
alcohol all have different complexities
with relation to the legality of them so
how do you measure addiction is it
reinforcement reinforcement is different
for everybody and you may look at just
the prevalence across the population and
say the most prevalent drug use is
cannabis but it's not the most addictive
so there's a lot of other things that
sort of play into what addiction is and
so it's hard to say but in there's no
question nicotine is incredibly
reinforcing and it doesn't it get to
your brain pretty quickly after you
inhale correct and when we talk about
addictions and we talk about drugs of
addiction and drugs of abuse and we talk
about what is really making someone
continuing to use a substance it has
everything to do with reinforcement and
reinforcement is directly related to how
quickly you can get a drug into the
central nervous system and in what
concentration and there is nothing that
is faster than pulmonary delivery or
something a drug delivered through the
lung you know I think I remember Richard
hurt saying dr. Richard hurt who was
part of the nicotine dependence center
for so many years and did so much great
work but he said you know if alcohol got
into your system as fast as nicotine did
it would probably to be just as
addictive yes absolutely in once again
it's a speed of delivery and when people
smoke heroin compared to injecting
heroin it's a faster delivery so it's
much more reinforcing so I think that's
generally true so as I said anybody who
is smoking knows that for their health
they should not be smoking so what is it
that has changed in that in the decades
to make it easier to quit smoking what
are some of the aids that work so I
think the aids that we really talk about
are really three and I sort of lament as
a primary care clinician that smoking
kills four hundred and eighty thousand
people each year and I've got the three
drugs that I can use and
erectile-dysfunction kills no one and I
got 50 so it just shows you where we put
our priorities
anyway so I think the drugs are a
nicotine replacement and bruh propria on
which is an antidepressant and then
varenicline which is a medication that
actually blocks in the Catena receptor
those are that those are the three drugs
we have so what are the trade names of
those so x1 so chantix is varenicline
and bupropion is sold as wellbutrin or
zyban okay and then nicotine there are
many different nicotine replacement
Nicorette is one those are the different
products yeah all right and tell us
about your success rates now I know
you've got several different programs at
the nicotine dependence Center I just
outlined briefly what those programs are
in your success rate so we we know in
tobacco treatment that there's a dose
effect that is the more intervention
that you provide the higher the success
rate so for example if you talk about a
quit line where you can disseminate to a
broad population and anybody in a state
can call and quit line our quit rates in
a quit line for example or about three
you know or three to eight percent those
are low rates but but it's across a
broad population and so when you get
more intervention like face to face like
we have the outpatient nicotine
dependence enter our quit rates are
about 25% at six months six months to 12
so that's counseling counseling correct
yeah thank you yeah so it's counseling
but that's without any nicotine
replacement without any drugs right 25
percent yep and then when you get into
the residential treatment program where
you're providing nicotine replacement
and your inpatient basic basically for
eight days I know in the building to two
blocks down from here we take patients
in and put them in for eight days and we
provide them intensive counseling and
work with them with medications our quit
rates are about 50% at six to 12 months
so not a hundred percent but the more
intense the intervention the higher your
quit rates but you can also prescribe
nicotine replacement and some of those
drugs as an outpatient they don't have
to come in
correct correct then that's that's a
great point the nicotine replacement
therapies are available over-the-counter
are the gum the patch the lozenge and
then there's an inhaler and a nasal
spray which are available by
and then the appropriate which is the
antidepressant is available by
prescription then varenicline or chantix
as you mentioned is available by
prescription so some of them are
over-the-counter and some of them are
prescription all right well the lowest
smoking rates ever in the United States
pretty impressive no question about it
nicotine is extremely addictive but
millions of Americans have been able to
give up cigarettes many with the help of
people like our guest today dr. John
Ebert quitting smoking expert dr. John
Ebert time for a short break when we
come back we're gonna talk about
e-cigarettes vaping are they a public
health threat to America's youth our
guest is a quitting smoking expert dr.
John Ebert we've talked about all of the
things that he and his colleagues have
done over the past decades to get the
smoking rate at the lowest rate it has
ever been in the United States which is
pretty impressive only 14% of the
population still smoked so some 30
million people or so but now the
landscape has been muddied a little bit
by what are called ecig arrests which
have become extremely popular among
young individuals in a word what do you
think of e-cigarettes so the challenge
with these cigarettes is it really
presents a unique and really sort of
unparalleled experience in public health
where a device could be used to help one
group reduce their risk for dying from
tobacco related illness at the same time
increasing the risk in another
population yeah our e cigarettes vaping
and is all vaping e-cigarettes so most
of the time each cigarettes are kind of
referred to generally or generically as
anything you know in one of these
vaporization devices there are pipes and
east cigars but really I think that
terminology e-cigarettes refers to any
of these vaping devices generally now
what I understand about vaping and a
cigarette siz that the levels of
nicotine are so much higher than a
regular cigarettes is that true
so when you talk about higher there's
there's a couple things that you can
talk about you can talk about the
content in the eliquid or you can talk
about the delivery to the user it there
are some studies that demonstrate that
users of East
rats electronic cigarettes or e-cigs are
higher than people smoking conventional
tobacco cigarettes so yeah we have we we
do see that in some population so you're
even more addicted because you're
getting even more nicotine so there is
yet so that theoretically is is is is a
potential adverse consequence of being
exposed to more of a drug as you
potentially are more dependent well one
of the things I've heard is that the
concern is that teenagers will vape and
then they will become a cigarette smoker
but I'm not sure why they would ever
take a step back like they would use a
cigarette as their step down method from
vaping because the level of nicotine is
less yeah so I think the question really
is is if you look at so if we just take
smokers who smoke conventional
cigarettes out of the equation and just
really talk about adolescents and and
ask the question what's really happening
and what's going on in that population
we're concerned about the thing that you
mentioned which is adolescents using
e-cigs and then actually going to
conventional tobacco cigarettes harm
escalation if you will so they're
increasing their harm and you're
wondering if that is outweighed by the
likelihood of kids who otherwise would
have smoked conventional cigarettes who
don't because they can use e cigs and
unbalanced it seems to be that both
things are happening it's probably true
if you look at the population that kids
that would have wound up smoking
conventional cigarettes anyway are
probably less likely to be doing so
because they can continue on the
e-cigarettes but it's probably also true
that adolescents who never would have
smoked conventional cigarettes are more
likely to be doing that because of the
Gateway phenomenon of electronic
cigarettes both things are happening the
question is what is the population
impact overall and what do we as a
society want to do about it
so the most popular cigarette out there
is still Joule right that is correct and
and the two guys who started that
company said that they wanted to make
tobacco obsolete wanted to make
cigarettes obsolete but then what
happened I mean it all the youth and
America so it's very popular in high
schools it's very popular in colleges
they didn't really intend that but it's
turned it into a 16 billion dollar
company correct and and and I think when
you look at intent and you look at what
they say you may infer two different
things one of the things that I think
you could say is that if you hadn't
designed jewel to look like a flash
drive perhaps not as many adolescents
would use it if you hadn't made it so
small and concealable perhaps not MIT so
there's a lot of issues that when you
look at intent and you look at the
design of these products might actually
influence who takes them up let me give
you an example so there's data out there
in the literature that suggests that if
you're a smoker smoking conventional
tobacco cigarettes and switch to
e-cigarettes you're more likely to use a
device that looks like a conventional
cigarette but if you are a never
cigarette smoker you're more likely to
use something that looks like a flash
drive so so there's there so intent and
design could be a way that you think
about figuring out exactly what's
happening in the industry what's
happening the market and who's more
likely to use what product it's
truly so when we're talking about
e-cigarettes in the in the nicotine
content but there these are not
regulated so there's potentially some
other stuff in there isn't there like
carcinogens and THC and toxic chemicals
right absolutely and in when we're
looking at these devices it's
fascinating to think about how those
toxic chemicals are being created so the
devices work by using a heated coil and
that coil is metal different types of
medical nichrome and kanthal and
stainless steel and and and nickel and
titanium are the classic metals they use
and what happens is when you take in a
liquid which contains formaldehyde or if
it doesn't contain formaldehyde at
baseline but contains vegetable glycerin
and propylene glycol and you heat that
with one of those metals you produce
formaldehyde through the heating in the
oxidation process of those eliquid 's so
it is potential it is it is a potential
to think about aerosolization in a
different way not through heated that
could potentially reduce the risk
there's data out there very interesting
that suggests
when you look at eliquid before you
aerosolize it or make it a vapor and
then you actually make it a vapor what
if the heated coil you produce 18 new
chemical species that didn't exist
Wow pretty amazing so these cigarettes
as we mentioned are extremely popular
why why
I mean yep is that the is the nicotine
high is it that what it does to kids
brains so I think that it is a
fascinating and important consideration
that an electronic cigarette is the is
is a unique marriage between device and
drug so we live in an iPhone society
where a lot of these devices have
digital readouts and you can adjust
things and you get feedback and you can
track puffs and it's kind of like an app
and it also contains a drug so your
iPhone is just a is a device but if the
iPhone was you know married to a drug
that was an iPhone plus drug it would
probably be the most addictive thing or
potentially reinforcing thing out there
so I think there is a unique unique
experience a unique experience of the
device and drug and that's really what I
think explains the e-cigarette
phenomenon well now the FDA or the FTC
or whatever it was outlawed flavoring
cigarettes tobacco cigarettes but you
can flavor easing rates how does that
work so a lot of that is because the FDA
they're deeming privileges or their
their oversight of this industry has not
been currently enforced and there are
lots of interested parties out there who
want to restrict flavors so they don't
want to have any flavorings for
e-cigarettes and there are groups out
there that are advocating for that at
the that you know at the national level
but that's just because it's not
regulated as why you get seven thousand
seven hundred flavors I had to laugh
when you asked the why question because
what I've been thinking for the last ten
minutes is when I was a teenager all the
old people in my life if you ask them
about cigarettes they would say well you
look stupid when you're smoking it just
you look ridiculous and I thought whoa
no I think they look kind of you know
tough kind of cool now when I see kids
or young adults vaping I just think that
looks so stupid I can't believe it and I
think wow I am
Mutulu its you've matured well if
something about just like the old people
in my life when I was a teenager so
there's definitely something to that
what's interesting is that I've been
informally interviewing patients who
come into our treatment program and
asking them the question of you know
you're trying to quit cigarette smoking
conventional cigarettes have you ever
used an e-cigarette and you know very
frequently they'll say yeah I tried it
but it looks stupid and these are
smokers of cigarettes so there are
different perceptions and tastes have
you been dealing at the Mayo nicotine
dependence center with people who are
addicted to vaping we have not usually
people addicted to vaping are not
seeking treatment okay yeah would you
say that vaping is a safer alternative
to tobacco for adults so for adults who
are trying to quit smoking I would say
that electronic cigarettes are 95
percent safer than conventional
all right cigarette smoking has fallen
to its the lowest point ever only 14% of
Americans still smoke fewer young people
are starting to smoke older smokers are
dying and others are quitting but now
we've got a new problem ecig arete sanu
way to get addicted to nicotine and a
popular pastime among America's young
people unfortunate