CEimpact Podcast

How Can Pharmacists Curb the Vaping Trend?

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The rise of electronic tobacco use, especially among young adults, poses new challenges for public health and pharmacy practice. This episode highlights the pharmacist's role in addressing vaping trends through patient education, harm reduction strategies, and community outreach. Tune in to learn how you can make a meaningful impact in curbing this growing epidemic.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Francis M. Vitale, MA
National Director
Pharmacy Partnership for Tobacco Cessation

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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe the current trends and health risks associated with electronic tobacco use.
2. Identify evidence-based strategies pharmacists can use to address vaping in their practice.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-015-H04-P
Initial release date: 1/6/2025
Expiration date: 2/6/2026
Additional CPE details can be found here.

LOOKING FOR MORE SMOKING CESSATION TRAINING? Click here to check out our advanced training course!


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Speaker 1:

Hey, ce Impact subscribers, welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and, as always, I'm excited about our conversation today. Electronic tobacco use, especially vaping, has surged in popularity, bringing significant health risks and challenges to public health. Today, we'll explore how pharmacists play a pivotal role in addressing this growing trend through education, harm reduction strategies and community outreach, and it is so great to have our resident expert in this topic, frank Vitale, as our guest expert for today's episode. So welcome, frank. Thanks for joining us.

Speaker 2:

Thank you, josh. So let me just tell you a little bit about myself before we head into this, please do. Yeah, thanks.

Speaker 2:

I have been in the smoking cessation field for 37 years now. Initially I worked on several research projects at the University of Pittsburgh, where I'm located, and that were looking at COPD and whether certain medications for asthma would help individuals who lost lung capacity from smoking regain that lung capacity. And in that project I started working with helping some of the smokers quit, and that just became an area of interest to me. Both of my parents died as a result of smoking and so I decided to specialize in that and stay in that and eventually was asked to be on the faculty of the pharmacy school at Pitt. Of the pharmacy school at Pitt, I designed what was called the International Smoking Cessation Specialist course, where I trained thousands and thousands of pharmacists all over the world in how to do cessation counseling right in their practice site. And that was spurred on by the fact that the patch and the gum had gone over the counter at that point in the 90s and nobody most pharmacists did not know how to use them.

Speaker 1:

Sure.

Speaker 2:

So that was a focus of the training, plus all the behavioral stuff. Two people from UCSF took the class and decided that, so that it would be better to create a curriculum for pharmacy students rather than wait until somebody was in practice for 20 years and try to change their practice habits. We get, you know, get them while they're young. So I was. I was instrumental in working with them Karen Hudman and Robin Corelli in creating the Rx for Change, a curriculum that has been disseminated to, I think, almost every pharmacy school in the country and, as far as we know, 80 to 90% of the schools have continued to use it. So hopefully most of the people listening to this who are pharmacists have received some training in tobacco cessation. We've recently updated to include vaping, but if you've been out of school for a while you may not have received that specific training Sure Sure.

Speaker 2:

And that's just led me to train pharmacists, doctors, nurses, respiratory therapists all kinds of people. I've probably trained 20,000 healthcare professionals all over the world. Yeah, I've had the opportunity to go to many other countries to do this, so it's fascinating. Yeah, it's been very interesting.

Speaker 1:

That's great. Well, thank you so much for spending time out of your day to chat with us. And just a quick plug in our catalog of education there is a smoking cessation, tobacco cessation course authored by Frank, and obviously you know he is clearly our resident expert on the topic, but I would venture to say internationally the expert, and so we are thrilled that your education is in our catalog, and we'll talk about that a little bit more as we go through some things. So, but again, thank you so much for being here, frank, so great to have you, so let's jump right in.

Speaker 1:

I just kind of what prompted the episode for today was there's been several articles lately and lately, as in last few months, but I think I've seen them over the last few years the use of electronic tobacco use has just skyrocketed and we're specifically seeing that prevalence in our younger adults and even our children, you know, teens, young teens.

Speaker 2:

Yeah.

Speaker 1:

Can you talk just a little bit about that, Frank, Like what have you noticed with that and maybe give some reasons why you think it has increased?

Speaker 2:

Sure, sure. Well, I think first let's define what we're talking about. Yeah, that's great, let's do that. Yeah, Vaping or electronic cigarettes, e-cigarettes, whatever you want to call them, are essentially battery operated devices that create a vapor for inhalation by heating either the tobacco or nicotine, which is either liquid or salt.

Speaker 2:

So there is no burning here, there's no combustion. So this is considered by many and this ties into your question because we're not burning tobacco. Many people consider this to be safe and in a sense it is safer than smoking. But it's still not safe, and I'll get into that as we go along today the various chemicals that are still in any kind of vaping device. Theoretically this is a good idea because all you're getting is nicotine, supposedly, and when it started out that's all that was in the devices, and we know that nicotine is not what causes the ill health effects from smoking.

Speaker 2:

It's all the chemicals that are in tobacco itself and the burning process. So the combustion of the tobacco produces all kinds of chemicals, just simply from you know any kind of burning that produces those kind of chemicals. So in that sense this is safer because you're not getting all of that stuff. And if they would have just left them alone and left them to have just nicotine in them. We wouldn't be doing this because I wouldn't really be considering them to be too bad, but the manufacturers wanted this to look like smoking, so they started adding chemicals to create smoke in quotes and flavors. And that ties in with Joshua, what you just said. The whole, the whole big problem, in my thinking, is that these were flavored with thousands and thousands of different flavors specifically to attract children. Um, if you look at the names of the flavors, my favorite one is unicorn poop. Now, who in the world knows what unicorn poop tastes like? But a 50-year-old man is not going to pick up something that says unicorn poop and use it.

Speaker 2:

They have cotton candy, birthday cake, all kinds of stuff like that. I was amazed a few years ago when I was doing my initial research in this. There are 7,000 different flavors of vaping devices and there's over 500 different vaping devices and we can barely keep track of them because they just keep coming up with new iterations of them. I always laughed. I didn't know there were 7,000 flavors of anything.

Speaker 1:

I was going to say I feel well, I mean, I guess when you're making up unicorn poop type flavors, then you can keep that number climbing. But yeah, I would tend to agree that just sounds like a far-fetched number. But wow, that's just wild.

Speaker 2:

So they've really marketed these to kids because we know from smoking that almost everybody who starts smoking does it before they're 21. And the vast majority of 14, 15, 16-year-olds that's when they start. It's very rare that you'll encounter anybody who's 30 and start smoking Just starting.

Speaker 1:

Right.

Speaker 2:

So this is really a ploy to get young people started and hooked into it quite young and then continue to use it Because, as I said, there's nicotine in there and nicotine is addictive. And the problem here, josh, is that some of these products can contain up to 40 or 50 milligrams of nicotine, whereas one cigarette generally has one to two milligrams of nicotine in it. Wow, so these devices, depending on what they look like, some of them are actually tanks. You know they actually look like tanks. You know you can fill them with these juices, juices, the liquids, and you can mix them together however you want. You can put in whatever you want, and so we really have no way of knowing exactly how much nicotine is in almost any of them, because they're many of them are made in mom and pop stores and and people can just make them themselves. They can mix the stuff together, and that's where all these flavors come from.

Speaker 1:

Yeah.

Speaker 2:

All these people mixing different ones together.

Speaker 1:

So we don't even know, really, per puff, I guess, how much nicotine people are actually getting. I mean, it varies depending on the patient, depending on the device, depending on the product. Wow, so, and and I mean it sounded like you said did you say like almost 40 times as much as a cigarette?

Speaker 2:

in some cases, yeah, yeah, absolutely so. Therefore, this becomes a very big health hazard, not only for the person using it but for kids. Um, if you look at the stats out there for calls to, uh, poison control centers, ever since these got on the market, those calls have risen dramatically because kids are getting these things that their parents have left around, not knowing what they are.

Speaker 1:

again, they probably smell really good because yeah, they well, they smell like fruit or candy, they're drinking it and they're getting really sick from it. Wow, wow, yeah, I haven't even thought about that because I mean, yeah, if it comes in, I assume some sort of a liquid bottle potentially, and so, yeah, I mean it could look like some kind of fruit juice drops that you drop in your water or something Exactly Okay.

Speaker 1:

This is very interesting and the deep dive that I wanted, so thank you. So it is obviously a public health concern. How are pharmacists poised to help? Why are we talking about this Like? Why is this a thing for pharmacy to worry about?

Speaker 2:

We know there are lots of studies and I've been involved in several of them that very clearly show that any pharmacist bringing up asking the question do you smoke or use any type of tobacco? Is an impetus for many people to consider quitting. We did all this training all these years that I've been involved in and Rx for Change was created is that we know pharmacists are very trusted and people pay attention to what pharmacists tell them. So we've shown very clearly that even just mentioning that you as a professional, you as a healthcare professional, feel somebody should quit, helps people quit and then actually creating the program and running it in your pharmacy can be an extra service that you offer and in many cases and many independent pharmacists are doing that all around the country- so we know that that works.

Speaker 2:

There are some studies now just starting because vaping is so new, but I think we can extrapolate that the same thing will work for vaping.

Speaker 1:

Yeah.

Speaker 2:

The big message that I want to get across right from the start here is that anybody listening to this don't think you have to do the entire quitting program or cessation program yourself. My point has always been just get it started.

Speaker 1:

Yeah, just initiate the conversation.

Speaker 2:

We have really pushed the protocol ask, advise, refer. So ask all your patients whether or not they use tobacco and in this case. So the question traditionally has been do you smoke or use any type of tobacco? Now you have to change it to do you smoke or use any form of nicotine. So you don't have to go into all kinds of do you use vaping and e-cigarettes? Just use any form of nicotine and that'll cover it.

Speaker 2:

If they say yes, then advise them to quit based on the illness or the condition that you're treating. We know very clearly that any of these any kind of tobacco, vaping, all that, any of those products has a negative health effect on any kind of condition. So, as a professional, as a healthcare professional, advise them to quit and then refer them to a program to help them create their quitting plan. And, generally speaking, I would recommend that you refer people to the Quitline. Every state has a free quit line. That was designed for tobacco but now, with the prevalence of vaping, all of them have had training in how to help people quit vaping.

Speaker 1:

And from a behavioral perspective.

Speaker 2:

It's the same stuff, it's the same habit, it's the same behavior. Sure, the same techniques would apply and the quit line number is 1-800-QUIT-NOW, q-u-i-t-n-o-w, 1-800-q-u-i-t-n-o-w, and that number works in every state in the country and when you call it it then routes you to your state's particular quit line and any user can get a quit plan created by a well-trained, usually master's level clinician free of charge.

Speaker 1:

Yeah, that's great. That's great, Great information. Thank you for sharing that. So you know, you've dug into a little bit some of the questions and I think it's super important that we highlight again that initial question needs to be changed. It's no longer do you smoke or do you use tobacco? We have to include the, you know, do you use any kind of nicotine products? Because we need to include that vaping. We want to be sure we're getting the right answers. So I think that's a really big take home point and I think it's also important to note, like you said, just starting the conversation works, and so you don't have to put all of this weight on your shoulders to be the one to walk them through the whole process. If that's not something you want to offer or do, it's really just a matter of starting the conversation. So I think that's super important to hear and to reiterate.

Speaker 2:

So, yeah, I had a patient tell me and I know this is just one person, but I think it really is applicable they said to me wow, when the pharmacist asked me whether or not I smoked, I knew it must be really serious.

Speaker 1:

Interesting, yeah. So, frank, you mentioned earlier, obviously the use of nicotine can affect a lot of different disease states. What are the ones that we're most, I guess, concerned about? If you could quantify it?

Speaker 2:

Sure Well, again, it's not necessarily the nicotine, well right, it's the tobacco, all those chemicals in the tobacco that are problematic.

Speaker 2:

Sure sure, but as I said, with the first generation of vaping devices, a lot of them just had nicotine in them. But, as I said, now most of them have all kinds of other chemicals to make it look like smoke, make it give it all these flavors. So to me, this is where we're seeing the problems, and the main one is propylene glycol. Propylene glycol is actually antifreeze and that is what is used on stage to create fog and that is what is used in these products to create smoke to make it look like smoking. So we know that there is an increased risk for asthma, any kind of lung disease, with propylene glycol. We shouldn't be putting that into our lungs.

Speaker 2:

There's glycerin in many of these products. There are carcinogenic substances in many of these aerosols. Dicetyl is the chemical that creates the flavors and if the listeners think back, maybe 10, 12 years ago there was this outbreak in a factory where they were making microwave popcorn and it was called popcorn lung and that was because they were inhaling the artificial butter flavoring that was used on the popcorn and what they discovered was that it actually kind of creates like cement in your lungs, to be blunt, and it was scarring the alveoli. There was impediment in lung flow and it was causing shortness of breath and coughing and wheezing. So this is what most of the flavors are made out of, so you're inhaling that into it also. And we know that there is formaldehyde in some of these chromium, nickel, other chemicals like that, and formaldehyde again.

Speaker 1:

I mean, you had me at antifreeze. I just don't think we should be inhaling antifreeze. So, yeah, right. So the idea here is that none of this stuff is good for your lungs. Yeah, yeah.

Speaker 2:

So the idea here is that none of this stuff is good for your lungs.

Speaker 2:

Yeah yeah, but the bottom line, josh, I said a few minutes ago, we don't know what's in most of these. Right With cigarettes, they've been studied long enough and, let's face it, a cigarette's a cigarette. They're pretty much the same, other than different types of tobacco, so they may have slightly different flavors. There is a lot known about them. With these products, because they're not uniformly made most of them are made in China. Many of them are just mixed by the individuals. There's no way to know exactly what, to know the details, yeah, yeah, so so we know. We do know.

Speaker 2:

with the flavors, though and I want to throw this in so I don't forget it They've all been banned other than natural tobacco flavor and menthol, because it was very clear to the FDA, who now has a purview over all these products, that it was being used to market the children. So they managed to get them slowly but surely off the market. But there are literally hundreds of thousands of variants of these products, so they're slowly but surely working their way through all these. Very few of them have actually been approved that they're safe and they can be used in adults without any problem Interesting. They can be used in adults without any problem Interesting. So yeah, so it's kind of scary. It fascinates me that people will balk at using the nicotine replacement products that are out there because they're afraid of them, but yet they'll start to use these products and they have no idea what's in them.

Speaker 1:

Yeah, Frank, I have a question. It may seem like a silly question, but do we have the same type of concern with secondhand smoke that we had with cigarettes? Like with children in the house, if you're an adult doing it, is there the same sort of issue there?

Speaker 2:

Yes, absolutely. We don't have the research on this yet in terms of the secondhand exposure to vaping and e-cigarettes, but again, we know that it's emitting the propylene glycol, the glycerin, the heavy metals into the atmosphere. So if you have a child with asthma or any kind of other problems, it can irritate them. It can cause a lot of problems. And then the other little piece that nobody thinks about is that these devices all have batteries in them, and there are incidents of where these batteries have exploded in people's pockets.

Speaker 1:

So that is done so so we have little explosive devices that are committing Wow, okay, these are not made or manufactured in any sophisticated way.

Speaker 2:

You know they're pretty basic devices. Yeah.

Speaker 1:

Interesting. So we've talked about some of the cigarettes, vaping and stuff like that. What are some of the challenges? We've talked a little bit about it the unknown of what's in these products, the marketing tactics. That's not something that we as pharmacists can control or even help to really curb can control or even help to really curb, but how can we have these meaningful conversations with young adults, with parents that have young kids who may be of that age, Like how can we combat some of this misinformation and this confusion?

Speaker 2:

Well, I think bringing it up and just addressing it as misinformation.

Speaker 2:

So the basic premise here is that these things are completely safe because they don't have any tobacco in them.

Speaker 2:

So it's focusing again not on the nicotine that's in them, but that there are all these other chemicals that can still cause issues in the lungs, in the body. The secondhand, smoke can effectively increase asthma in children and cause all kinds of other respiratory problems. And it's pointing out that nicotine is an addictive substance. So even though you're not getting all these other chemicals, you're still getting nicotine and you're getting lots of nicotine and that makes it addictive. Long term it's going to make it more difficult for you to stop using them the longer you use them, and there is some evidence to show that once the individual kind of tires of vaping, or it gets to be blasé or they're not getting the kick out of it that they used to. Or it gets to be blasé or they're not getting the kick out of it that they used to. Many people are transitioning to cigarettes because their body's already used to inhaling all this stuff. So I think the biggest thing a pharmacist can do is educate the individual that, even though these things are safer than smoking, they're not safe.

Speaker 2:

Yeah, and that they're still addicting. You could be hooked on them long-term. I think that's. Another misconception is that many people think, oh, I'll just do this for a little bit, or I can just do it for fun, or I'll do it when I'm not drinking. It's the same kind of thoughts that people have when they started smoking. And the fact is that nicotine is one of the most addictive substances on the market and you're going to get hooked. 90, you know, 95, 96% of people who start using nicotine become addicted to it.

Speaker 1:

Yeah, stay on it. Yeah, I love that. I love that sentence. I think it's it's such a great take home. They're safer, not safe, and you've said that multiple times now and I think that if our listeners take away anything today, it's that you know. Yes, what you hear is true they are safer, but they are not safe. There are still lots of issues and complications. I know from just talking with people and whatnot. In practice, a lot of people also have tried to quit smoking cigarettes by transitioning to vaping, thinking again that it's oh, it's safe and it still gives me that I have to touch something, put it in my mouth, whatever, and so that will will help them with the whole, you know, quitting program. And I mean it just sounds like it could be a vicious cycle because you're still going to be hooked, you know.

Speaker 2:

So Right and you're not addressing when you do that, josh, you're not addressing the behavioral side. So we always teach there are two parts to smoking. So there are two parts to quitting. It's both a physical addiction to nicotine and a habit and a behavior, and in order to quit successfully, the evidence is overwhelming that you have to do both parts simultaneously. So if you're just switching to vaping, you're not doing anything about the behavior, you're just pretty much vaping when you smoked, right.

Speaker 1:

Right, you're just changing out the modality. Yeah, yeah, exactly Okay. So in our last couple of minutes here, frank, before, it always surprises me how quickly our time goes when I'm talking with my guest. I feel like I could go for hours. So I mentioned earlier, we do have a course in our catalog that is kind of an introductory course on the medications that are used in cessation programs, and so that is available. But there's also an advanced training, and that advanced training goes deeper into really potentially more information on the cessation program as well as implementing it into your practice site. So if there's anyone out there that's saying I do want to do more than just ask questions, I do want to implement a program, any advice, any tips or tricks to like here's where to start, here's a common hangup you're going to endure and here's how to get through it Any advice from your years?

Speaker 2:

I think the hangup for most pharmacists is I don't have the time, and I realize that You're very busy. So, like I said, if you implement the ask, advise, refer, you can do that in two or three minutes. You can share while you're ringing somebody up or they're paying for their meds or just discussing anything with them. So it's very easy to integrate this into your practice. If you just start Again't you just say you know what I? I understand that you're vaping, I understand you're smoking. I really would advise you to quit because blah, blah, blah, blah, blah and here the quit line makes little blue cards that you could have right on your desk, on your calendar. Hand those out to any individual, yeah, and they'll have that as a reminder that has a number on it so again, just planting the seed.

Speaker 2:

Planting the seeds to continue to think yeah, and the other little editorial comment I would like to make is that if you work in a pharmacy that you own, do not sell vaping devices.

Speaker 2:

Yeah, if you work for one of the chains and I know because I've been in them. They sell vaping next to the cigarettes. We've been advocating for years to get rid of cigarettes and it has worked in one of the major chains, not the other two. But yeah, advocate to your bosses, to the company, get rid of these devices, get rid of cigarettes too.

Speaker 2:

It's a shame that we're still promoting it as a whole. I'm blocking all the words. Yeah, just the recreational activity. Yeah, the word you're promoting it is exactly right, because I mean, think about this You're at the pharmacy with the pharmacist telling you to stop doing this and then you go up front device, you know bag of potato chips, and they're the products right there. So there's a big cognitive dissonance there. So that would be the other thing I would recommend yeah, no, I love that.

Speaker 1:

That's. That's great advice. And you know again, if just really quick, have you seen anyone who's implemented a service and done well? I know a lot of questions. Probably the second question pharmacists are going to ask is, after the how do I have time for this is, how do I make money on it?

Speaker 2:

have you seen successful implementation where they're charging for this service and your patients are willing to pay for it yes, over the years I have seen many independent pharmacists put this in the practice and just have people pay cash for it. Yeah, and that's a simple math problem you can do with somebody. Most people are spending $2,000, $3,000, $4,000 a year on cigarettes, yeah, or on these vaping devices. Even if they would pay you $250, that's still a lot less Right. But to your point, josh, many, many insurance companies are now covering this and I know medical assistance is in here in pennsylvania.

Speaker 2:

I know for a fact they're paying pharmacists to do counseling um with patients who are on medicaid so it sounds like there's some opportunities there yeah, it's moving in that direction more and more and more yeah yeah that's great. The third thing that's happening is that about 24 states now allow pharmacists to prescribe the cessation medication.

Speaker 2:

So all six of them. Um, you know you can do it all right in the pharmacy, so there's another opportunity there to go under the. You know, whatever that act is in your state. Yeah, you know, I just did a survey of all the rest of the states. There's at least 10 of them that are actively pursuing legislation. Wow, in the stream to allow that. So pretty soon, I would think by the end of 2025, the majority of states are going to be allowing pharmacists to prescribe.

Speaker 1:

Yeah, that's great. So a little you know, as we always do a little plug there. Be sure that not only that you're checking with your individual state to make sure to understand, within the rules of what you can do and your scope of practice, but also prepare yourself, educate yourself, get ready for that change, or get ready for that new implementation, and access our courses in the catalog there to help you and make sure that you are the most knowledgeable in this area. We know that pharmacists are knowledgeable in so many different areas, but be sure that you're up on the most recent medications to treat in the cessation programs. So well, frank, we are out of time. What I love to do at the end of each session is just do a quick game changer, take home point. So what's the game changer here, frank? What do we want to leave our listeners with today?

Speaker 2:

We want to leave our listeners with the very real idea that pharmacists can make a difference just by asking about this, advising people to quit doing it and then referring them to a cessation program. Whether it's a local program, whether it's you in your pharmacy or the quit line, or all of the products out there have cessation programs attached to them. So there's many different places to refer and if you send somebody there, you just might be saving their life.

Speaker 1:

Yeah, that's great. I think that is definitely. The game changer here is that pharmacists are in a position and it's as simple as starting the conversation and then taking it from there. That's great. Well, that's all we have time for. Thanks again, Frank. So good to have you and all of your knowledge in this area. Thank you for sharing it with us.

Speaker 2:

Thank you, joss, it's been a pleasure.

Speaker 1:

If you're a CE Plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at CEimpactcom. And, as always, have a great week and keep learning. I can't wait to dig into another game-changing topic with you all next week.