Vaping and Cancer Risk

March 23, 2020

Information

Dr. Suchitra Krishnan-Sarin

March 22, 2020

Yale Cancer Center

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email: canceranswers@yale.edu

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00:19Welcome to Yale Cancer Answers with doctors Anees Chagpar and Steven Gore,
00:23Yale Cancer Answers features the latest information on cancer care by welcoming oncologists and specialists who are on the forefront of the battle to fight cancer. This week
00:34it's a conversation about E cigarettes, vaping and cancer risk with Doctor Suchitra Krishnan-Sarin
00:39Doctor Suchitra Krishnan-Sarin is a professor of psychiatry at the Yale School of Medicine.
00:44Dr Gore is a professor of internal Medicine in hematology at Yale and director of hematologic malignancies at Yale Cancer Center.
00:52Well, this is really a timely topic with all that's going on with the recent tough crisis with vaping that came out of the blue it seems.
01:02Yeah, vaping has evolved or E cigarette users evolved over the years,
01:07and it's unfortunate that we had all these crises and especially young people who experienced a lot of lung damage and inflammatory conditions,
01:16and it's rather unfortunate. But you know,
01:18there are multiple devices
01:20on the market and they were generated with with a good cause in mind.
01:27And unfortunetely
01:28they have taken on a life of their own.
01:32Do you think that the original motivation was to be able to wean people off cigarettes?
01:37Absolutely, I think the original devices which were developed by a Chinese pharmacist were actually created to offer smokers a cleaner form of Nicotine to help with their cigarette
01:50addiction. As most people who are in the cancer field know very well,
01:54tobacco, combustible cigarette smoke is one of the worst
01:59well known causes of cancer and a variety of other inflammatory conditions.
02:03So there has always been the hope that we would be able to get smokers to quit using their cigarettes.
02:10That has not always played out the way that we like it to.
02:14A lot of smokers still smoke despite having multiple health problems, despite knowing the health risks of smoking.
02:21So the idea here was that perhaps if you have a cleaner form of nicotine available to them,
02:27the underlying thought being that nicotine is the addictive substance in cigarettes and
02:33if you can replace
02:34that addiction with something else
02:37then perhaps smokers will be able to quit this combustible product,
02:41which is of course fraught with so many problems.
02:44And as you know, as everybody's heard, it has 4000 chemicals and causes combustion and has a variety of respiratory
02:51issues so I think the concept behind it was a positive one and the idea of potentially helping smokers quit with the cleaner form of nicotine,
03:00also called harm reduction, is not an idea that we should throw out.
03:04And yet, the success with either nicotine patches or nicotine gum, which are those that come to mind has not been terrific,
03:12right? Or not that many people are successful using patches or gum.
03:16Some people are. Yeah, absolutely.
03:18So there are a couple of problems with patches and gum.
03:21The main problem is that they do not deliver nicotine the same way that a cigarette does.
03:26One of the things that is most reinforcing about somebody smoking a cigarette is that initial peak in blood nicotine levels you get when you
03:34combust the product and you get an elevation in blood nicotine levels in your body.
03:39You don't get the same kind of delivery with the nicotine Patch or nicotine gum and most people who use these products don't like them because it's not satisfying their craving
03:49and their withdrawal symptoms. There are there have been studies which have shown that if you combine the two,
03:56for example, if you combine nicotine Patch and gum together,
03:59you have better outcomes because essentially what you're doing is you're boosting up that nicotine level.
04:06So there are ways of manipulating the existing products to make them work,
04:10but people are always on the lookout for something new that could be even more helpful now.
04:16Is there a difference between an E cigarette and Vaping?
04:20Are they just the same?
04:22It's a very good question.
04:23No, they are essentially the same.
04:25E cigarette is the device,
04:27vaping is the behavior that said people are vaping,
04:30you can vape whatever you put in the E cigarette device so they were originally created for nicotine.
04:36You can get them with nicotine.
04:39You can get them without nicotine.
04:41You can get them with a variety of flavors or without flavors.
04:45And nowadays you also get products which are easily manipulated and are being used to administer things like marijuana and a variety of other things,
04:56which in in a sense I feel is what the CDC is saying has led to the current crisis that we have right now.
05:04This so called black market or manipulative values of these devices now.
05:09The E cigarettes that one can purchase in some drug stores,
05:13for example. Can those be refilled with stuff from Vaping stores,
05:17or is it a separate device?
05:22There are a variety of devices on the market and each one of them can be manipulated.
05:32We started out with a device which was very rudimentary,
05:36which really did not even deliver nicotine that well.
05:40It was called a cigalike when it initially came out, the nicotine solution.
05:44And the device was not formulated very well,
05:49so people didn't really get enough nicotine from these devices.
05:53Overtime these formulations have become a lot better,
05:56so you have these closed systems which look almost like a cigarette and are called Cigalikes.
06:01Then they evolved into a variety of other systems.
06:05You have things called tanks which are refillable clear tanks that you can fill
06:10with any liiquid that's on the market,
06:12you have things called mods,
06:14which are basically if you've seen people use them,
06:17these don't even look like cigarettes.
06:20It's a rectangular box like jewel thing.
06:33It's called box mods and you can put a variety of attachments onto them
06:37to make the vapor better,
06:38you know you can produce more vapor.
06:41You can change the resistance of the devices.
06:43You can change the temperature of the devices so you can make your vape experience a lot better and a lot of people who use these kinds of devices use
06:52them for shows. You know there are competitions that you can participate in, vape competitions for creating the smoke rings and smell.
07:01You're going back to school pranks,
07:03but you know they can do a lot fancier things with these devices.
07:07And now the newer generation device is the one that you probably heard the most about,
07:13which are the pod like devices.
07:15These are the jewel device,
07:16the jewel devices, the way they vary from the other devices is in multiple aspects.
07:21First they are very small and they are discrete so they can be easily hidden.
07:26The jewel is a closed system which means you cannot technically manipulate it.
07:32It comes with nicotine and it comes,
07:34with a variety of flavors,
07:38but now those have been taken off the market.
07:41The jewel also differs from the earlier devices because they use a nicotine salt in the device.
07:48It's called benzoic acid salt and this causes faster absorption and a faster peak blood.
07:56Nicotine level as opposed to freebase nicotine which is what is in all the other nicotine liquids that exist in the market now.
08:06Freebase, nicotine and salt differ.
08:09As I said most cigarettes contain freebase,
08:12nicotine
08:16which increase blood levels a lot faster.
08:18They are also supposed to be more palatable.
08:21Now this is what is said.
08:23I have not seen evidence of this,
08:25but it said that Iiquid's that contain nicotine salts can be used a lot more easily because they do not produce that harsh undertone that most freebase nicotine has.
08:36It stings right, it stings in the back of your throat or makes you cough.
08:41Or you know just tastes better.
08:43Jewe like devices. Just to follow up and answer the question you asked earlier.
08:50As I said, the market has evolved to now where there are jewel knock off pods where you can actually buy
09:00slower open pods and fill them with whatever you want and use them with the jewel device and then this has evolved into even other products which like the dualan
09:10dualan come in multiple flavors.
09:12So I think the problem with this market is in the quest to come up with the product that works for smokers,
09:20with the idea being that it needs to produce the maximum nicotine level it needs to be palatable.
09:26It needs to satisfy the smokers we have created.
09:30This market that is producing.
09:32all these devices, which unfortunately are also very attractive to youth,
09:37which is what has led to the huge youth epidemic that we have with the current CDC number.
09:43Saying that almost 27.5% of high school youth are using these devices regularly in the past month.
09:51Those are the numbers.
09:53So there are all these kids
09:56who have used these devices in the past month and
10:02I'm sure that not all 27.5%
10:04have used them every day in the past month,
10:07but a significant number did.
10:09And how does that compare to what cigarette users used to be like in that population say 20 years ago?
10:15So it's probably I would say coming up to equivalent standards and it's a little hard to make an apples to apples comparison with these two products.
10:24The reason being that a cigarette is a combustible product.
10:29You light it and then you have to use it up before it burns out.
10:33With these devices you have the option of charging it,
10:35taking a puff and then putting it back in your pocket an then using it whenever you want,
10:40so it's not like it runs out at the same rate that a cigarette does,
10:44which is one of the big problems that we have in this field because we don't know how to quantify use of these devices and
10:51equate them to cigarettes. At this point,
10:54the only thing I can really think of is looking at things like nicotine and cotinine levels which exist in both,
11:00so it's a different beast.
11:02I would say that cigarettes are.
11:03But I would say the users are about the same and the scary thing about these products is how much they appeal to youth number one.
11:12And my area of research is really an understanding of youth substance.
11:17Youth risk behaviors and developing interventions for it.
11:20So I have worked with a lot of substances in the past,
11:24but I've never seen anything grow so exponentially as I have these products and it's pretty amazing how the appeal of these products has just grown exponentially over the past
11:35few years. So what is the appeal?
11:37Is it that they seem cool?
11:39I mean, I understand the flavors,
11:41but you know, kids can get flavors from chewing gum and all sorts of candy and other garbage,
11:46So we've been
11:48looking into this quite a bit in our work.
11:51And we still need to
11:53understand the full picture,
11:56but here's what I think is going on.
11:58First of all, you get multiple kinds of devices,
12:01right? So it's very innovative.
12:03You can do smoke tricks with these devices,
12:05or vape tricks with these devices.
12:07That's another innovative aspect of things.
12:10Kids who are that in that age range,
12:12teenagers are really looking for things that they can make their own and yet give them this innovative aspect of it
12:22There always being told,
12:24don't do this or don't do that.
12:26Here is something that they can manipulate to kind of make their own.
12:31They can choose from anywhere between 7 and 15,000 flavors.
12:35There's an amazing range of flavors out there.
12:38They can choose to use it with or without nicotine.
12:42They can choose to put marijuana in it if they want,
12:46or they can choose to add things
12:48or use it with other things,
12:51so I think the innovative aspect of these devices is really what draws kids to these products.
12:58The flavors are a huge,
13:00appealing aspect of it. We have asked many about this over the years.
13:05We conduct longitudinal surveys in schools in Indiana
13:09and the New Haven County and flavors are one of the top reasons why kids like these devices,
13:16like using them. They taste good.
13:18The other aspect, which they really like,
13:21is the fact that they're very discreet.
13:24One of the things we hear a lot from,
13:28teachers in schools, and we do a lot of work in schools too,
13:32is that they're easily hidden.
13:34Believe it or not, there are actually sweat shirts you can buy with holes
13:40where you can hide
13:42a jewel and so in class you can take a quick puff from it if you if you need to.
13:49And they don't produce as much smoke as cigarettes.
13:52So again, they're very discreet.
13:55All these together make it a perfect storm for youth.
14:00Wow, this is a very fascinating and important topic, but right now
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14:58You're listening to Connecticut public radio.
15:02Welcome back to Yale Cancer Answers.
15:05This is doctor Steven Gore.
15:06I'm joined tonight by my guest doctor Krishnan-Sarin.
15:10We've been discussing vaping, particularly among adolescents and youth,
15:15so it was really fascinating.
15:17But before the break,
15:18when you were telling me that how much flavor really is drawing the youth and this whole idea of discretion,
15:26I can certainly imagine the idea that you're getting away with something, and in the place where I get my haircut
15:34I think most of the stylists vape and they mostly use jewel and
15:42the person who cuts my hair is trying to get off of it
15:46but sometimes it is kind of hard to know whether he just took a drag or not.
15:50He isn't hiding it, but I mean it's so discreet.
15:53No, it's very true. I think one of the problems with these products is that it is discrete and also unlike cigarettes which give you the cues where
16:03there's smoke, it's irritating in the back of your throat.
16:07Things like that you don't have those cues here which are telling you OK stop.
16:12You know, maybe you shouldn't be doing this,
16:15and I say kudos to all the smokers who have quit cigarettes and who have quit using these products.
16:24If if they have quit and this product has been helpful to help them quit,
16:29that's wonderful and I think that's a great tool,
16:32but I would also add that this should not be an addiction that they should maintain for the rest of their life.
16:39We have studied for many years
16:41cigarette addiction.
16:43We have never really studied nicotine addiction and this is now opening up a whole bunch of problems and concerns that have been raised with the idea that somebody might
16:53be dependent on nicotine for the rest of their life.
16:56And you know, I think we all know that nicotine is an essential receptor on the human body and is involved in
17:03almost every bodily function the nicotinic acetylcholine receptors are everywhere.
17:08And if you are using nicotine,
17:09you're basically altering any systems that are related to the presence of this receptor.
17:15Is there anything known about the long-term health risk
17:21even if it didn't have nicotine or anything else?
17:24I mean, does that harm the lungs?
17:27Do we know?
17:28I mentioned earlier that there was exponential rise.
17:32and the science has not kept up with the marketing and the rise in the use of these products.
17:39So we're learning every day about what these products can do or what harm they can do or not.
17:45I will tell you that the products contain substances like propylene glycol and glycerin,
17:51which are used as solvents in the product.
17:53Some of them contain ethanol.
17:55You know these are all solvents that are used to dissolve the nicotine and or the various flavor chemicals that are put in there.
18:03The problem with glycol and glycerin,
18:05we're learning that they can have inflammatory reactions of their own,
18:10but they also, it appears create additional compounds when they're just sitting in there in the E liquid
18:21called acetals, and these acetals are also known to have inflammatory potential.
18:27I see now in addition to that,
18:29the flavor chemicals themselves are not benign,
18:32they're chemicals. They are things like benzaldehyde.
18:36You know all these things you find in your chemistry lab.
18:40Yeah exactly, and for those who don't know about diacetyl.
18:44Diacetyl is also what was in buttered popcorn flavor and it was found many years ago to be associated with bronchiolitis obliterans,
18:53which is a
18:55inflammatory condition, and so these flavor chemicals are not benign as of themselves.
19:01You know, they can have potentially inflammatory effects on the human body and the vape also contains
19:09metal particles which are generated from the battery or the heating element.
19:15That you're also inhaling.
19:18So there is a plethora of things you're being exposed to now.
19:22Do we have clear cut evidence that all these are leading to cancer?
19:28No, we don't have it as yet.
19:30There is a lot of emerging evidence that suggests that exposure in cellular models or in preclinical models leads to DNA damage which could potentially cause bladder cancer,
19:44or lung cancer in animal models,
19:47But we have not. I would say unfortunately, had the time frame of exposure in human to really see this emerge, it may take 10 or 20 years before
19:57we see that like it did with cigarettes,
20:00it took a long time with cigarettes for us to start linking cigarette use to lung cancer rates.
20:06But there is a very clear evidence that lung cancer rates parallel cigarette use rates and lagged by about 10 or 12 years.
20:14So there's a natural experiment going on here which is concerning and it's also concerning that
20:20a majority of the use of these product seems to be by youth,
20:24right? What interventions have you found,
20:28if any? Are you working to either help stop using or even preferably not start using?
20:34I would say unfortunately the interventional area has lagged even further behind than the other science because developing interventions takes time.
20:45Developing interventions takes understanding of the behavior so you can
20:50develop appropriate interventions to know whether you have to treat withdrawal symptoms of the medication,
20:57or behavioral intervention will suffice.
21:00You know things like that.
21:02That said, the FDA has had a lot of prevention programs in place where they're really trying to educate people through ads.
21:10Enter prevention programs about these products.
21:13We here in Connecticut are doing a lot of work with local schools.
21:18I think my group has probably visited
21:2040 to 50 local schools just in the past year.
21:23Talking to students and teachers and explaining to them and making them understand that this is not just water vapor,
21:31which is what most kids think.
21:33They think this is just water vapor.
21:35It's not going to harm me.
21:37It's not producing any combustion products or smoke,
21:40so why should it be of harm to me?
21:42So I think education is the first step, we need to make parents and children and everybody understand that you don't just start using these products because they are there.
21:53The second thing we really need to do is regulate the product's well.
21:59THe product's have not
22:01unfortunately been regulated.
22:04I would be all for a marketplace where products like these are made available to smokers who might want to use them to quit smoking but are sold in
22:14such a way that they are not available to youth who may want to initiate use of these products from an actual interventional perspective via just starting down that path
22:24where we are. There has been some huge initiatives that have come out from a variety of organizations,
22:31and the NIH is also starting to organize conferences on this issue to try to identify the holes and where money needs to be put.
22:41We're just starting down that path of developing interventions for E cigarettes,
22:46but I think most of these would probably draw some principles or ideas from what has been done for smoking cessation and things that work for smoking cessation as
22:57there's a wide variety of things that have worked.
23:00Behavioral interventions like calling to behavioral therapy,
23:04motivational interventions. The nicotine Patch and gum and of course things like Chantix and zyban have also worked in adults.
23:13Unfortunately most of these interventions I talked about have worked primarily for adults and they have not worked very well for kids,
23:23so we still have this huge hole where we need to do a lot more work to develop interventions for you then we are.
23:31My group is starting down that path but we're not there yet.
23:35It seems like. I'm certainly not deep in this field at all,
23:39but it seems like at some point in the last 20 years smoking became not cool.
23:44Yes, it became kind of gross.
23:45It was excluded from bars and restaurants and there were all these ads about what smokers look like and it was disgusting and I have to imagine the kids
23:55don't want to look like that person,
23:58right? Yeah that ad they used with this guy,
24:02he was really decrepit. And awful right?
24:04But right now what you're saying is these devices are seen as cool and that's
24:09the big problem I would think.
24:11Yeah, there's an essential problem here in that we don't have the signs that tell us what these devices actually do to you.
24:19One of the things that I have learned over many years of working with kids,
24:22is you do not just go in and tell them this device is going to cause cancer because especially in this day and age of social media,
24:29they'll open up an app and they'll tell you it does not.
24:32There's no evidence it does this,
24:34so I think we have to be very careful how we approach this.
24:37I'm glad you brought up the issue about cigarette.
24:39And how it kind of became a non cigarette culture.
24:42Overtime this was because of all the regulatory work that we did.
24:46All the education we did over a number of years which basically made people realize that they did not want to be a smoker.
24:54And you know, there was a whole change in culture in terms of whether you want to be a smoker or not,
25:00and being a smoker was not considered cool anymore and with these devices
25:05we need to go down that path.
25:06I'm hoping it doesn't take us 10 years to get there.
25:10Because at this point I cannot take that man,
25:14you know, with a hole in their throat or the woman with a heart problem and say,
25:19hey, if you use this device,
25:21this is what's going to happen to you because I don't have the signs supporting that message.
25:27So we have to base it on evidence that we know from preclinical models,
25:32especially for nicotine. And there is so much evidence of the damage that nicotine can do,
25:38after long term exposure from a lot of animal models.
25:42Nicotine, especially in the adolescent brain,
25:45the brain is not only known to be highly sensitive to the effects of nicotine,
25:50which means you get addicted more easily
25:53but nicotine is also a neurotoxin in adolescence,
25:55so it can cause cognitive changes it can.
25:59It has been shown to cause epigenetic changes,
26:02especially in genes that are involved in things like asthma and anxiety and depression.
26:07So there is a lot of evidence that we have from animal data that we need to find a way
26:12of transforming that into public messages and conveying that to youth and parents,
26:18it's very difficult to motivate kids to quit using anything.
26:21And we have a very tough battle on our hands here.
26:24Yeah, I just think about,
26:26you know the long history of marijuana use,
26:29and certainly nobody ever thought that was good for adolescent brains.
26:33But that probably isn't enough to know,
26:36especially convince your peers. Saying,
26:38it's no big deal, blah blah blah.
26:40Who are going to believe right?
26:42And on that note, I will say that
26:44a lot of people are also using these devices for administering marijuana.
26:49In fact,
26:50if you've heard about it recently,
26:53the lung inflammatory conditions that were being observed and the deaths that we've had ,very unfortunate deaths we've had in the US over the past year have been related to
27:03black market use of these devices is what the CDC is telling us now,
27:07and potentially could be related to the use of things like marijuana and other compounds that might be in the solution like vitamin E acetate.
27:16I don't quite understand how vitamin E acetate and I've had conversations about this with a lot of my chemistry friends and trying to understand why it would cause the
27:27kind of damage that they are observing,
27:29but that seems to be the culprit that has been found in many E liquids that are associated with these lung inflammatory conditions.
27:38So I think the other message to really get out there is tell people don't change these devices,
27:45use them if you're using them,
27:47use them as they are available on the market.
27:49Because at least there is some control over what goes into them,
27:53even though they're not technically regulated as yet.
27:56The companies have a certain degree of responsibility to try to make sure that they have good products that go in there,
28:04but don't use black market products.
28:06And does the black market include those vape shops you see everywhere,
28:10or is that safer?
28:11The vape shops are not black market
28:13The vape shops actually have licenses,
28:15their local businesses that have licenses to sell these products,
28:19You can walk into a vape shop if you're 21 and older.
28:27You can try out different vaping,
28:29liquid's it's almost like as I say it
28:32walking into an Apple store where you can walk in and you can try out what what liquids you like and what you might want.
28:41You might like to use so they're not
28:43technically illegal.
28:51If you have questions, the address is canceranswers@yale.edu and past editions of the program are available in audio and written form at Yalecancercenter.org.
29:01We hope you'll join us next week to learn more about the fight against cancer here on Connecticut public radio.