Vaping and Cardiovascular Disease: Trendy but toxic?

It is no secret that traditional tobacco cigarette smoking is the leading cause of the modifiable cardiovascular disease (CVD) risk factors in the United States.¹ Electronic cigarettes, or vaping, were developed as an alternative for those who may or may not want to quit smoking. However, the health effects of these devices provide little insight into future cardiovascular disease risk and the connections between vaping and cardiovascular disease.²

Vaping and Young People

Whether intentionally targeted for marketing purposes or by sheer coincidence, electronic nicotine delivery systems (ENDS) are most popular among younger Americans. In 2018, the Centers for Disease Control and Prevention observed that the prevalence of ENDS for both current and former users was highest among men, those between 18 and 24 years of age, and non-Hispanic white adults.³ These devices have progressed quickly and the market is constantly evolving.⁴ More than 10 million Americans use ENDS, and of this populace, 3 million are middle and high school students likely enticed by the trendy new system’s sleek designs and availability of flavor varieties.^4,5

Does Vaping Help to Quit Cigarettes?

While ENDS are prevalent among the younger populace, many adults are using the vape method to help them quit smoking cigarettes.⁶ Randomized control trials suggest that there may be a correlation between ENDS use and smoking cessation, making ENDS a viable alternative for people actively seeking to quit traditional combustible products. While there are concerns about the long-term effects of these devices, the effectiveness of these systems to help current smokers quit traditional combustible cigarette smoking is unclear. Many smokers attempt to quit by using ENDS concomitantly with traditional cigarettes; unfortunately, many continue this pattern indefinitely and are therefore termed, dual users.⁷ Interestingly, the Population Assessment of Tobacco and Health (PATH) study found an association between ENDS utilization and an increase in relapse of cigarette smoking.⁸

Respiratory and Cardiovascular Effects of Vaping

Regardless of the population or the intention for their use, these products may lead to long-term health concerns. For instance, respiratory and cardiovascular effects and severe respiratory illness have been connected to the use of vaping products that contain tetrahydrocannabinol (THC) and the solvent vitamin E acetate.^5,6 E-cigarette or vaping product-use-associated lung injury (EVALI) has been observed in hundreds of events, with about 20% of the cases occurring in people under the age of 18.⁹ EVALI consists of generalized cardiovascular, gastrointestinal (GI), and respiratory symptoms such as:

Cardiovascular	Gastrointestinal	Respiratory	Constitutional
Chest pain	Nausea/vomiting	Dyspnea	Weight loss
Tachycardia	Diarrhea	Cough	Fever/chills
Pleuritic chest pain	Abdominal pain	Tachypnea	Dizziness

Although the evidence appears to be limited on vaping and cardiovascular disease, the National Health Intervention Study (NHIS) exhibited a two-fold risk of myocardial infarction (MI) with daily use and also an increase in odds for coronary artery disease (CAD), stroke, and angina.¹ Dual users showed a higher incidence of MI, angina, and CAD with a triple risk for stroke.¹

Smoking and Vaping Cessation

Since any amount of cigarette smoking increases cardiovascular disease risk, patient counseling to encourage complete abstinence from all forms of nicotine is recommended for both combustible and non-combustible products.⁷ Fortunately, most adult smokers quit without being equipped with any cessation aids, or by using a combined approach such as adding nicotine replacement therapy with a prescription medication such as varenicline or bupropion.¹⁰

Nursing advocacy is pivotal for influencing smoking cessation and for preventing vaping exposure in young adults, often through public awareness efforts and supporting anti-smoking legislation.¹¹ Additionally, nurses can empower patients to quit vaping by implementing a shared decision-making approach, implementing the teach-back method for education, and offering validation and encouragement for any degree of success achieved.⁸ It is recommended that providers have conversations about smoking cessation at every visit for individuals who smoke, as well as discuss the perils of both combustible and non-combustible products.¹ These discussions should include the following:

• an assessment of barriers to quitting and readiness for change
• assess and address social determinants of health
• inquire about current use or secondhand exposure to traditional combustible cigarettes as well as electronic cigarettes.
• discussion of the pharmacological options available to assist cessation, setting goals for a quit date,
• follow up to evaluate progress, and methods to employ for sustaining the plan.

Resources for Vaping and Cardiovascular Disease

PCNA has resources available to help clinicians with patient discussions related to vaping and cardiovascular disease.

• Hearth Healthy Toolbox – A set of downloadable behavior change resources. See the Total Health section for the “Smoke-Free Life – Resources to Support Smoking Cessation” patient handout.
• The Customizable Clinical Forms includes a section on behavior change, including “Assessing Readiness to Change: A Transtheoretical Model” and “Self-Efficacy for the Professional: Understanding the Theory Concept“

References

1. Boakye, E., Obisesan, O. H., Osei, A. D., Dzaye, O., Uddin, S. M. I., Hirsch, G. A., & Blaha, M. J. (2020). The Promise and Peril of Vaping. Current Cardiology Reports, 22(12).
2. Shahandeh, N., Chowdhary, H., & Middlekauff, H. R. (2021). Vaping and cardiac disease. Heart, heartjnl-2020-318150.
3. Centers for Disease Control and Prevention. (2020, April 28). Products – Data Briefs – Number 365 – April 2020. Www.cdc.gov.
4. Creamer, M., Case, K., Loukas, A., Cooper, M., & Perry, C. L. (2019). Patterns of sustained e-cigarette use in a sample of young adults. Addictive Behaviors, 92, 28–31.
5. Osei, A. D., Mirbolouk, M., Orimoloye, O. A., Dzaye, O., Uddin, S. M. I., Benjamin, E. J., Hall, M. E., DeFilippis, A. P., Stokes, A., Bhatnagar, A., Nasir, K., & Blaha, M. J. (2019). Association Between E-Cigarette Use and Cardiovascular Disease Among Never and Current Combustible-Cigarette Smokers. The American Journal of Medicine, 132(8), 949-954.e2.
6. Wang, J., Jacobs, P., & Pugh, H. (2021, April 10). Smoking Out E-Cigarettes. The Regulatory Review.
7. Blaha, M. J., & Ratchford, E. V. (2019). Electronic cigarettes. Vascular Medicine, 24(3), 267–269.
8. Efraimsson, E. Ö., Klang, B., Ehrenberg, A., Larsson, K., Fossum, B., & Olai, L. (2015). Nurses’ and patients’ communication in smoking cessation at nurse-led COPD clinics in primary health care. European Clinical Respiratory Journal, 2(1), 27915.
9. Matta, P., Hamati, J. N., Unno, H. L., & Fox, M. D. (2020). E-cigarette or Vaping Product Use–Associated Lung Injury (EVALI) Without Respiratory Symptoms. Pediatrics, 145(5), e20193408.
10. Tibuakuu, M., Okunrintemi, V., Jirru, E., Echouffo Tcheugui, J. B., Orimoloye, O. A., Mehta, P. K., DeFilippis, A. P., Blaha, M. J., & Michos, E. D. (2019). National Trends in Cessation Counseling, Prescription Medication Use, and Associated Costs Among US Adult Cigarette Smokers. JAMA Network Open, 2(5), e194585. https://doi.org/10.1001/jamanetworkopen.2019.4585
11. Adams, T., Morris, J., & Bomgaars, D. (2021). Europe PMC. Europepmc.org. https://europepmc.org/article/NBK/nbk568714#free-full-text