NIDA Live: The Science of Vaping

Video length: 30:19

Transcript

[Music]

[Dr. Einstein speaking]

Hi, I'm thanks for joining us today. I'm doctor Dr. Emily Einstein with the National Institute on Drug Abuse, Office of Science Policy and communication with me today we have the director of the national institute on Drug Abuse, Doctor Nora Volkow and tobacco expert Doctor Heather Kimmel. We're excited to share with you what NIH is doing in this space, but first let's turn to our panelists is how to start the discussion. Dr Volkow, how big a problem is vaping for the health of the country?

[Dr. Nora Volkow speaking]

Actually, good morning. Thanks for having me here. And, uh, vaping is of concern because it's actually first of all, a relatively new technology and yet we're seeing it being taken up very, very rapidly across all ages on, [inaudible]. So therefore we don't completely understand the, ultimately how it's going to be used. But what we know already is that first of all, there initially there was a lot of excitement by the fact that by vaping you may be able to help people stop smoking. And that is one aspect of, of vaping that is necessary to look into. But in the meantime, many more people are vaping that were otherwise not smoking. And therefore is one of the concern has been whether vaping, when you use it for nicotine, could actually increase the risk of people then trans at transition into combustible tobacco. The other issue that we do not really know is that to what extent introducing chemicals that are part of the, the electronic cigarette itself may actually be toxic to the body.

And because they are, until now, there has been very limited regulation in how you manufacture or these electronic devices. Uh, there's very poor, control of quality and you are exposing a certain of these instruments are exposing people to toxic substances. So that's the second element. And the third issue of concern has to do with the fact that you are introducing a vaping device. The only thing that it's doing is heating the substance and so you are introducing vapor or at very, very high temperatures. And that by itself can be damaging to their respiratory track. And in order to actually deliver the substance, you have to combine it with other chemicals that by themselves also may have irritants and produce inflammatory process into the respiratory tract. And then on, I think that um, Dr Kimmel is going to be answering this question is that the notion is these vaping devices, these are really devices for administering drugs in very effective ways.

What you're doing is delivering them directly into the lungs and the lung is this massive organ that is surrounded by blood vessels that immediately absorbs the drug. So it gets into your brain very, very rapidly. So you get much higher and faster concentrations into the brain than by other routes of administration other than smoking. If you smoke, you get the same effect. Um, so that in and of itself is going to make a drug more dangerous as it relates to its addictiveness. So these four characteristics of vaping devices are one of the issues why we need to be concerned about it and why we have to look carefully at regulating quality and ensuring that people that are at risk don't get exposed to them.

[Dr. Heather Kimmel speaking]

I think one of the other issues too that you're going to don't know what the long-term effects of vaping are and we have some idea of what happens at, um, short term or acute exposure. We really don't know when people use these devices multiple times a day, many days a week, many days throughout the year. What kind of an effect that's going to have on the respiratory system or other parts of your body?

[Dr. Emily Einstein speaking]

Yeah, that's a great point. It's a fairly new technology, so we just don't know.

[Dr. Nora Volkow speaking]

But what, what we have been seeing and the manufacturers have been seeing is that you are delivering these devices with a whole host of extraordinary appealing flavors. So that's very attractive to young people and makes you, gives you that sense, sort of believed that these things are safe. So, uh, in, uh, at the beginning, I mean last year we basically were asking for the first time when you vape, what do you think you are vaping? And most teenagers stated or they thought they were vaping only flavors. Now but, 11% said that they were vaping nicotine.

The issue is that when one, basically one looks at it more carefully, one finds out they didn't really know what they were vaping.

[Dr. Emily Einstein speaking]

Exactly.

[Dr. Nora Volkow speaking]

And second, devices that tell you this device, does not have nicotine when [inaudible] studies have actually evaluated, found that 17% of them in fact have nicotine they were advertising has no nicotine. So there is that other element that can without the person realizing them make them condition to these products either by their flavors, which are creating these strong memories that you want, that's actually makes you desire them or through the nicotine, which further enhances that conditioning.

[Dr. Emily Einstein speaking]

Right, exactly. And the most popular kind of vape pen doesn't even offer options that don't have nicotine. So the idea that it's just flavoring is perhaps not true. So let's get a little bit deeper into what exactly is in the vaping liquid and is that the same as what's in the vapor and then what do these things do to the brain and the body.

[Dr. Heather Kimmel speaking]

So, the vaping liquid does not contain nearly the same number of chemicals as we would find in a combustible tobacco product. However, one issue that although many of these chemicals are labeled they are generally recognized as safe, or GRAS by the FDA, they are generally recognized as safe for ingestion in food, but not necessarily to be inhaled as a vapor. And this is one of those cases, have you really don't know what the long-term effects of exposure to these chemicals are in vapor, in addition, the other chemicals in the vapor such as dioxitol , which has already been shown to produce very serious and chronic pulmonary affects, meaning effects on the lungs in people that are exposed to them, to have those kinds of chemicals that are found in vapor and addition. Because the delivery device is an electronic products, metal product. Oftentimes in the favor you will find various metals. And so, you are actually being exposed to different metals when they're using these products as well.

[Dr. Nora Volkow speaking]

Yeah. No. And I think that the issue that is important again to recognize why, because it's exactly of this, it's so very important to establish standards of quality on these devices because that will, can determine if you start to control and regulate that these devices will not have, uh, they have to demonstrate that they are safe. But, um, I think that at the same time what's interesting is of course the manufacturers are saying no, the, the vaping devices are very, very safe and they can actually protect from the harmful effects of tobacco smoke. And there is truth in each one of them, I mean, there is truth in that there may be less carcinogenic compounds overall, but there is no complete truth in the fact that these, the sense that these devices are safe. No, they do have chemicals that can produce untoward effects.

[Dr. Heather Kimmel speaking]

And, and another issue too, that even though the FDA is starting to regulate this product, both the device with an, the vaping liquid, the labels are not necessarily accurate. A lot of mislabeling that goes on. And so, in some cases products that were said to contain no nicotine and they actually do contain nicotine or they contain much higher levels are much lower levels of nicotine that are on the label. So, until we can work through these regulatory issues, you can't really depend on the label to tell you what is in the product.

[Dr. Emily Einstein speaking]

Yeah, and I think it's an interesting thing to keep in mind that the vapor that comes out of these doesn't smell the same way that cigarette smoke smells. So, it sort of gives the impression, but it doesn't have dangerous things in it. It's a great point that there are other chemicals involved and that they're also possible heavy metal exposures involved as well.

[Dr. Nora Volkow speaking]

I know it's good that you mentioned these because it's, one of the things that is clearly has me then most attracted is that you can vape and nobody will notice that you're vaping. And so, in the past where someone was compelled to not be able to light a cigarette because they actually will notice when someone was smoking, then that issue is no longer pertinent. And you're seeing that, for example, among teenagers--- teenagers are telling you, I mean my friends are vaping in the middle of class because nobody can pick it up, right? So, there is the element of not having, a smell, which also relates not just for nicotine but also for marijuana where you can smell when somebody is actually smoking marijuana. But where someone who is vaping 9-THC, you can’t.

[Dr. Emily Einstein speaking]

Exactly. So, it lacks both the social pressure and the detectability. So, vaping has often referred to as a tool to quit smoking cigarettes. Does the research support this and do we know whether it's less harmful than smoking?

[Dr. Nora Volkow speaking]

I think this is, again, one of those areas that immediately has polarized the field that’s so interesting because we want to look at things as terrible, or this is the salvation - the best thing that has ever happened to us. But if you look at it in a critical way, you can see and there is evidence that on individuals that have had difficulty on quitting smoking, that have tried multiple methods. Um, vaping may provide them a mechanism by which they can actually decrease the consumption of those products. And there is data that are done individual level. When you look at particular patient types, it can have benefits. At the same time when you look at it in terms of the overall population and says you can actually forget about any harmful effects, then you raised the other aspect of just opening up access to um, nicotine vaping devices made then--- and we know we also have data to show this…If you start vaping as an adult and  nicotine and you follow them longitudinally, prospectively, that risk of becoming, um, it's starting to get a smoking, uh, tobacco is much greater. So, studies have shown, yes, there is benefit for patients that are, have not been able to stop other ways. But all studies have also shown that if you were not addicted to tobacco and just started vaping, then your risk of transitioning into combustible tobacco is significantly higher. And so here you have evidence of two realities, something that could be in certain instances beneficial and something that clearly without that context could be very harmful.

[Dr. Heather Kimmel speaking]

And I wanted to add to this that um, right now the FDA does not recognized e-cigarettes as a legitimate cessation device. There are other ways to help reduce or quit smoking, but right now the FDA does not recognize e-cigarettes or related devices as one of those products.

[Dr. Nora Volkow speaking]

Very, very important point. And I think that, I mean the, the studies have to be done, the randomized clinical trials have to be done to actually demonstrate the outcomes that are necessary for the FDA to recognize that at this as an indication for smoking cessation. So, and we of course as an institute, we're very interested on seeing those trials being done. And, uh, it also, for those trials, of course it will be important to actually standardize the device that you're going be using because devices are not synonymous with one another and there are significant differences. So, but absolutely. And I'm glad you're bringing it up. We do need more research.

[Dr. Heather Kimmel speaking]

Yeah, absolutely.

[Dr. Emily Einstein speaking]

So, while these devices we still don't know but could potentially have utility to help some populations quit. Let's talk a little bit about how vaping affects young people. So we've discussed that vaping is very popular among teens. What are some of the specific issues for that population?

[Dr. Nora Volkow speaking]

Well, the teenagers are particularly vulnerable to exposures to drugs, and to the appeal of, of new technologies and salient stimuli. And I think that vaping devices have really maximized that sleekness of their product. So here you have a product that is really, some of the products are very, very appealing even to my eye. On top of that, they have all of these really appealing flavors, also to my brain. I imagine those of adolescents. So, I do see the other kids doing it and you see it in social media. So, as an adolescent, you are very prone to learning and wanting to be from others and wanting to be part of that group and be cool. And so by, through social media or through in parties where you see that it becomes the norm. And so, you of course want to--- and kids endorse that they, they do it because they want to have a good time with their friends.

But the other components that we have to be mindful in adolescence is that the brain is still developing, and it will continue to develop actually until they are in their early twenties. And what that means is that the brain of an adult is different from that of an adolescent. And, and it is the experiences in life through those adolescent years that ultimately will fixate more or less because the brain still continues to change, as we are adults was, but not as, as markedly. Um, so that you are prepared to optimize your performance in a given environment. So that's why the brain takes so long in developing to maximize the likelihood that you will have a brain structure and architecture, and function that would be optimal for your environment. And the problem is that drugs disturb that architecture and that development and while, um, I mean vaping, nicotine, nicotine is a very active substance in the brain and we have the receptors that are activated by nicotine appear very early on in development.

Just like the receptors that are necessary for cannabis to exert its effects appear very, very early on in development. And we know that both nicotine and the cannabinoid, the cannabinoid receptors that are activated by marijuana are necessary for brain development. So, the concern is that by exposing teenagers when the brain is in full development to these substances, you will disrupt that developmental trajectory. And we do know also lots of work has been done there, that the younger you start taking a drug, the greater the likelihood that you will become addicted. So if you, if, if kids would have not smoked cigarettes because the level of smoking is still very low among teenagers “combustible,” but then they, now that they are taking nicotine through vaping, does that put them at higher risk of addiction because they are getting exposed to the nicotine in very early on in life. And so I actually, we're seeing pretty high levels of rate of just in 8th graders and on Monday we'll know exactly the numbers, what they are, but eighth graders already are having significant utilization of vaping. So that those are some of the important aspects of why we need to be so particularly concerned about vaping among teenagers.

[Dr. Heather Kimmel speaking]

And generally, we found at NIDA, too that if children are exposed to different drugs, when they're younger it puts them at risk of them using those substances when they get older and using other substances as well.

[Dr. Nora Volkow speaking]

Absolutely.

[Dr. Heather Kimmel speaking]

So, you are putting these children at risk when they continue to use nicotine, as well as others. And so that becomes an issue in and of itself. And in addition, um, the vaping devices are often times used to vape nicotine, disguised with flavoring. But they can ask to be used to vape other substances like cannabis or marijuana though they kind of opened up another avenue, another route of delivery for these kids to take these different drugs.

[Dr. Nora Volkow speaking]

Yes. I mean, so it is, you have diversity, you have a very appealing product and you have a very easy transition because you may want to actually just do it for the flavor of curiosity unbeknownst to you who that, that, that device that are taking has nicotine and you nearly get conditioned or even if you are not has nicotine, it's once you start to use it and you try it and says, well what's the big deal then when someone offers you one with nicotine and so you've already done this. I mean, the way that the brain works, it's just sort of daring. Daring in more and more. I mean, we go incrementally. So these are some of the issues of why we're taking very seriously the patterns and the very fast uptake of the vaping devices by teenagers.

[Dr. Emily Einstein speaking]

Excellent. So why don't we open it up to questions from our viewers. Um, someone wrote in to say that they have seen it stated that vaping, um, causes people to start smoking who may never have smoked before. Do you have any information from scientific research about that?

[Dr. Nora Volkow speaking]

There, there are a couple of studies that as I mentioned before, that had been done actually prospectively where they evaluated a group of people --- this was done in adults--- who actually were vaping versus those that were not vaping and who had not been exposed to tobacco, or those who have been exposed to a combustible tobacco that started vaping to see if that will lead them to decrease their smoking. And what they found was those that in subsequent years, those that were starting by vaping were more likely to be using combustible tobacco. But they also saw that those that were smoking combustible, combustible tobacco and then went into vaping, did not stop but actually used to combine both drugs. And certainly, I mean, you need to expand. As mentioned, there are two or three studies, but there is evidence that at least one to be concerned about it. And again, to my knowledge, there are no studies in adolescents, but based on what these studies are showing in adults. I mean you cannot ignore the possibility that as teenagers get exposed to nicotine by vaping, that also may increase their risk of then transitioning into smoking tobacco. And we need to do those studies to evaluate and to understand the level of risk.

[Dr. Emily Einstein speaking]

So, what do we know about patterns of co-use such as using alcohol while they vape and how could this maybe change the risk profiles or health outcomes?

[Dr. Heather Kimmel speaking]

Well, I think generally as we mentioned before, when you use one drug, you have a tendency to use other drugs partly because of the social environment, surrounding one, the use of one drug. So I think it sort of normalizing that, that drug behavior. Then you think, oh, this isn’t so bad, so I can try something out. So, I think we've looked to add, um, co-use patterns as you mentioned. And there's not only co-use patterns between different types of products, so tobacco products and alcohol. Also, within the landscape of tobacco products. Now we have many products. We were just discussing, this phenomenon of using combustible products along with vaping. But then a lot of people also use cigars, Cigarillos and hookah as another product that really is coming to the mainstream, particularly for young people in recent years. And so people do tend to use multiple products, um, when they start using one.

[Dr. Nora Volkow speaking]

But I think one other aspect about the issue of the vaping devices is that you have a cartridge and that gives you the opportunity to generate a cocktail. So, in the cartridge you can put not just nicotine but you can combine alcohol so you now can go vape alcohol. And even though vaping of alcohol through these devices is still not, it's not very frequent, one can see it, um, perhaps increasing, like it was not very frequent initially to see vaping of 9-THC. And now we see it more frequently. So now you can start to think about doing drug combinations. And I, I predict that that is something that perhaps in the future we'll start to see more. And then when you start to combine drugs like that, and certainly as a Dr. Kimmel was saying there is very frequent, it's more frequent than the exception that people drink and smoke and, and when they smoke marijuana, they smoke nicotine or they combine drugs.

But, but usually sometimes what happens is sequentially and what we don't necessarily know sometimes is when you are directly combining them and administering it at the same time, at a very high in a route of administration that's going to lead to very, very high concentrations of both very rapidly. That is an aspect that, um, that we'll start to see. I mean because that's the, I mean already we know from the epidemiological studies, but we do not completely understand that. We don't know. I mean we are going to be surprised about what people are going to be combining, but we need to keep an eye on that.

[Dr. Emily Einstein speaking]

Absolutely. And route of administration matters so much for drug effects. So if people are vaping alcohol instead of ingesting it, the effects could be quite different.

[Dr. Nora Volkow speaking]

Yes, indeed. And they come up faster because again, that concept of you go from your lungs, from your lungs, it goes directly to your left heart and the left heart blood goes directly into your brain. Whereas if you take it orally, you have to go to a stomach and then from the stomach it's absorbed, then it basically goes to the liver and then it goes into the pulmonary circulation. So, it's a much, much slower process than when you take it a vape.

[Dr. Emily Einstein speaking]

Absolutely. All right. Someone has asked, “Everyday people are dying from fentanyl. Why is that not an epidemic but vaping that had killed no one is?”

[Dr. Nora Volkow speaking]

I will say that the, I mean we call the opioid epidemic crisis and that that the issue, we don't call the fentanyl epidemic because fentanyl is extremely important in this epidemic, but it's not the only one. So we have prescription opioids, we have heroin, and we have fentanyl and its analogs and it's devastating and it's clearly an epidemic. The fact that we call one epidemic doesn't mean we cannot have another epidemic and it'll be wonderful that we will not on right now having to address these issues of uh, the epidemic from the opioid crisis. I think that uh, the, we need to recognize with respect to the vaping is that again, it has of taken us by surprise because it's a new technology. So we didn't know how it was going to be accepted. Just like cell phones took off. So are these vaping devices taking off and I'm on cell phones of course have mostly very positive effects and with the vaping, while there may be potential benefits are perhaps in people too as smoking cessations that cannot stop otherwise we are starting to recognize that there's potential of misuse of these devices that can have ill intended consequences. And the concern is because it's been taken up so rapidly by young people that--- who are the most vulnerable that we cannot ignore it.

[Dr. Emily Einstein speaking]

Exactly. And that rapid uptake is a very important point to have an epidemic. It's not related to mortality or people dying. It's related to the, the rate of increase. And so, it's been a very rapid rate of increase of vaping.

Someone else has asked what are the chemicals involved in vaping? We've touched on that a bit.

[Dr. Heather Kimmel speaking]

There are many um, chemicals involved in, in vaping. Um, for example propylene glycol. That's one of the most common solvents, as a kind of the base liquid. We can find all sorts of chemicals in vaping. And one thing that's important to recognize that the flavors that are in vaping, are actually manufactured by chemicals to provide this an addition at that particular flavor so for example you may have a vaping liquid that is labeled margarita, it's not as though someone actually took a margarita and put it in the vaping liquid, but they put together a combination of chemicals in a liquid to provide that sensation or that, um, that um, take feeling of taking… right. That feeling that you are drinking at margarita. And so, there are many more liquids, many more than we can possibly go through, go through here in terms of the ingredients that they put in liquids. Um, one thing to recognize too with some of these, some of these chemicals in the vaping, like was as we talked about before, that are generally recognized to be safe to be ingested, but some of them we do not actually have carcinogenic properties, meaning that they can actually cause cancer if they’re taken in at the um, vaped or used in high enough quantities, over long enough periods of time. Again, we don't quite know enough about the long-term effects of using the chemicals. But this just giving you some examples of the chemicals that are in the vaping liquid.

[Dr. Nora Volkow speaking]

And you're saying something, Kimmel that I think um, mentions worthwhile looking into, because I mean I state in one of the issues that characterizes addiction: So, if you become addicted to vaping, nicotine, what it means is compulsive escalation of that behavior. So, by default, these individuals that become addicted to nicotine and are vaping are going to be consuming huge quantities. So something that may be okay to inhale once in a while that may not be okay to inhale when you are doing it throughout the whole day, day after day after day. And I think that that compulsive repetitive patterns of behavior that characterizing these can, is likely to be responsible for what we will see a lot of that toxicity with these devices ---that it will be chronic and it will be actually very frequent constantly throughout the day.

[Dr. Heather Kimmel speaking]

Right, right.

[Dr. Emily Einstein speaking]

Someone else has asked if there was a faster drop off in cigarette use. As you said, e-cigarettes has increased.

[Dr. Nora Volkow speaking]

And that question actually has been asked to in in respect of, um, we're seeing that some of the drugs that, uh, and particularly in teenagers will last year we had said that they were very, very low rates of drug use in teenagers in 2017. And the question was, would these be in part related to the fact that they are vaping and we don't, I mean we've seen that decreases in certainly, and I'm speaking again in adolescents because that's where we're seeing lower levels. But um, in adults, we're not seeing for example, decreases in drug use. In, adults we're seeing increases in marijuana use, we're seeing increases in use of opioids, the consumption of alcohol, high levels of alcohol consumption, beer binging or beer drinking, it's actually going up… not down.

So, we cannot say that there is a decrease in the pattern of drug use because of the vaping devices because that's not what we're seeing in the adult population. And certainly not what we saw last year among teenagers. And plus the decreases in drugs among teenagers actually proceeded the uptick into the vaping. So these are these appear to be different processes going on. And I would, I would basically venture to say, based on the studies that we in, in laboratory animals, that when you expose them to nicotine, and particularly as Kimmel said, when you expose them early on in adolescence, it primes your brain not just to become addicted to nicotine, but it primes your brain to become addicted to other drugs. So, the, the, the vaping may in fact may render your brain--- they're vaping nicotine ---render, your brain more vulnerable to the rewarding effects of other drugs.

[Dr. Emily Einstein speaking]

This person has asked, why is nicotine exposure in adolescence a bigger issue than alcohol?

[Dr. Nora Volkow speaking]

I wouldn't say that a nicotine exposure is a bigger issue than alcohol. And I think that we like to say which one is worse. Uh, I mean certainly the problem with alcohol, if you look at it in, in terms of morbidity and mortality, the number one possible morbidity and mortality among teenagers is one of the main causes is driven by alcohol intoxication. So driving under the influence as being in a car with someone else actually engaging in very risky behaviors with very untoward consequences;  increases in in infectious diseases from risky sexual practices. So the alcohol intoxication modifies the mental state of the adolescent, making them even more impulsive. So no--- alcohol cause very, very damaging effects. Nicotine, on the other hand, has to be looked from a different view. First of all, if it does create the risk for tobacco smoking, we do know that tobacco smoking decreases your life expectancy because of its effects in cancer before it actually affects multiple organs, not just the lungs, the heart, the blood vessels.

It's, I think that is basically not a single tissue in our body is not affected, but it takes time. It's a chronic effect so you won't see it immediately. You will see it when you turn 50, 60 and that is different from what you are seeing right now with alcohol in adolescence. But as I mentioned before, what we cannot ignore is that by taking nicotine as an adolescent, you may be priming your brain to all other drugs. And so, it may facilitate you using alcohol, or marijuana, or other drugs in the future that then may have more of an immediate negative effects.

[Dr. Emily Einstein speaking]

Exactly. So, the negative effects of alcohol are much more acute and easier to see…in adolescence. Yes. All right, one last question. Can you get addicted to vaping with non-nicotine liquid?

[Dr. Nora Volkow speaking]

I mean, and again, what is it that we call addiction and sort of like would I, I would say you call addiction: When you engage in a pattern of compulsive behavior, repetitive behavior that you cannot terminate even though you want to do it. And that is associated with negative consequences. And we don't know that, that behavior, that compulsive part and kind of cure for behaviors that don't have drugs. And we see it with gambling, video gaming with compulsive eating. So it is, it is plausible that by getting conditioned to these various lit devices, as you could get conditioned to the flavors and then you are driven by actually that--- to repeat itself. And in that respect, uh, could it reach the behavioral disruption as addiction? I mean potentially it could, but again this is, I do not, I have not read, so I, I and I want to base my statements on evidence. I am not familiar with any paper that has published a case where clearly indicating that a person had become addicted to vaping of flavors with no drugs in them. But theoretically it is plausible,

 [Dr. Heather Kimmel speaking]

And I think one concern though, that the um, using the vaping liquid, vaping devices even if it doesn't have nicotine and it would normalize that behavior so at some point along the way if you do then, start using nicotine, it’s become a normalized behavior and then you run into some issues that Dr. Volkow was talking about.

[Dr. Emily Einstein speaking]

Excellent.

I'd like to thank our panelists and all of you for your participation in today's discussion. We've mentioned a lot of research and data today, so please be sure to check the comments for resources and of course the night a website for more information, which is drug abuse.gov.