THE HEALTH | JULY , 2023

BY PROF DR MOHAMAD HANIKI NIK MOHAMED

ELECTRONIC NICOTINE delivery systems ( ENDS ), also known as electronic cigarettes ( e-cigs ), are increasingly used in Malaysia among adults and adolescents .

The 2019 National Health and Morbidity Survey ( NHMS ) reported 1.1 million e-cig smokers or adult vapers , compared to 600,000 or 3.2 per cent vapers found in 2016 from the National Electronic-Cigarette Survey ( NECS ). Alarmingly , the 2022 NHMS found an increase in vaping among Malaysian adolescents between 13-17 years old , from 9.8 per cent in 2017 to 14.9 per cent in 2022 with 23.3 per cent males and 6.2 per cent among females .

Vapers dependent on nicotine , the main addictive chemical in ENDS , often exhibit craving and withdrawal symptoms upon temporary or abrupt cessation of vaping , similar to those experienced by smokers with tobacco use disorder ( TUD ). According to the 5th Edition of Diagnostic and Statistical Manual of Mental Disorders ( DSM-5 ), TUD is diagnosed when a person uses tobacco for more than 12 months , with a minimum of two of the 11 following features : 1 . More amounts of tobacco over a longer time frame than planned

2 . Inability to quit or lessen the amount of tobacco use despite efforts to do so

3 . An excessive amount of time spent on attaining or using tobacco

4 . Craving or a strong desire or urge to use tobacco

5 . Relinquishing responsibilities because of tobacco use

6 . Persistent use of tobacco despite its negative impact both socially and in relationships

7 . Abandoning career , social , and other activities to use tobacco 8 . Use of tobacco in harmful situations / settings

9 . Persistent use of tobacco , even in the face of physical or emotional difficulties related to tobacco use

10 . Tolerance , as defined by either the need for markedly increased amounts of tobacco to achieve the desired effect or a markedly diminished effect with continued use of the same amount of tobacco

11 . Withdrawal , as manifested by either the characteristic withdrawal syndrome or the use of tobacco to relieve or avoid withdrawal symptoms Tobacco withdrawal symptoms which appear upon cessation include craving , irritability , mood changes , trouble sleeping and increased appetite . Most of these symptoms peak in the first few days and gradually dissipate around four to eight weeks . The majority of vapers , similar to conventional cigarette smokers ,

( Sahr , Kelsh , & Blower , 2019 ).

cannot stop due to the intensity of urges and withdrawal symptoms which are correlated to the severity of nicotine dependence .

Based on the Malaysian Clinical Practice Guidelines Treatment of TUD 2016 , approved first-line pharmacological intervention for conventional cigarettes includes nicotine replacement therapy ( NRT ) products ( gums , patches , etc ) and varenicline . These medications help to reduce craving and withdrawal symptoms to aid successful cessation .

All forms of NRT increase the probability of successful cigarette quitting attempts . Generally , monotherapy NRT increase the chances of successful abstinence by 50 per cent to 70 per cent , and it is similar between products .

Monotherapy varenicline is shown to yield about 50 per cent higher cessation rate than monotherapy NRT . Still , evidence shows that the combination of two NRT products , e . g ., gum plus patch , yield similar efficacy as monotherapy varenicline .

PHARMACOLOGICAL AND BEHAVIOURAL INTERVENTIONS

For best results , pharmacotherapy for TUD is combined with behavioural intervention . Intensive behavioural support for smokers using cessation medication improves the probability of long-term abstinence by approximately 10 per cent to 25 per cent .

E-cigs mimic the rapid delivery of nicotine by combustible cigarettes , yielding high nicotine levels in the plasma . Vapers are also reported to titrate or compensate their nicotine needs by adjusting the nicotine concentration of the liquid and the ‘ topography ’ of vaping , i . e ., by inhaling deeper , taking more puffs , and breath-holding .

Like cigarette smokers , rates of metabolising nicotine and numbers of nicotinic acetylcholine receptors ( nAchRs ) in the brain also affect the topography of vaping . More nicotine is consumed by fast metabolisers than slow metabolisers , as well as in those with higher number of upregulated nAchRs due to nicotine intake .

Related to these , nicotine withdrawals from vaping have been described both in adults as well as adolescent vapers . Hence , it seems logical that both pharmacological and behavioural interventions approved for TUD should also be beneficial for e-cig cessation .

However , unlike cigarette smoking cessation where protocols exist for assessment of dependence and severity of withdrawals , drug selection , dosing and duration , as well as for special populations including adolescents , it is not so apparent for e-cig cessation .

There have been few questionnaires developed to assess dependence among adult vapers , including Fould ’ s Penn State ( Electronic ) Cigarette Dependence Index and Fagerstrom Test for Nicotine Dependence ( FTND ) modified for e-cigs , where time to first cigarette ( TTFC ) is replaced with time to first vape and number of cigarette / day is substituted by number of puff / session and number of session / day .

However , it has been reported that most vapers are unsure of the number of puffs and sessions vaped per day . Additionally , the nicotine concentration used vary greatly among vapers , with rampant mislabelling .

For adolescents , the Hooked on Nicotine Checklist ( HONC ) adolescent ( cigarette ) smoking dependence questionnaire has been edited for adolescent vapers .

ASSISTANCE FOR VAPING CESSATION

The use of NRT for e-cig smoking cessation seems intuitive , and adaptation for vaped nicotine withdrawals seems plausible . However , it is still off-label for such use .

As with smoking cessation , NRT underdosing occurs frequently . Therefore , mono or combination therapy of NRT products can be considered in vapers according to their level of dependence and adjusted to the severity of withdrawal symptoms .

Vapers with high nicotine dependence can start with a 21mg patch per day , while lesser dependence was recommended with a 14mg patch , subsequently tapered down until the participants stopped vaping .

Some studies utilised 2mg or 4mg of nicotine lozenge and gum with no tapering , or nicotine nasal spray . Side effects reported by study participants include itching and redness at the site of nicotine patch application , and heartburn in those who used nicotine gum . All studies that employed NRT reported participants successfully quit vaping after three and six months .

Varenicline has been confirmed to be effective during the three months follow-up by successfully preventing participants from smoking e-cigarettes totally , resulting in improved health . The subjects also reported having minor side effects , including vivid dreams and weight gain .

Tapering of nicotine concentration in e-cig as a method of quitting has been reported . A pilot study found that the efficacy of the vape-taper method is comparable to NRT ( Sahr , Kelsh , & Blower , 2019 ).

A text message vaping cessation intervention was found to be effective in promoting dual abstinence from e-cigarettes and combustible cigarettes among young adults . Such intervention provided participants with encouragement and support , skill training , self-efficacy building exercises , coping methods , and information about the risks of vaping and the benefits of stopping for nine weeks after they selected their quit date .

The advantage of this intervention over control was equivalent for exclusive e-cigarette users and dual users . Rates of dual abstinence were higher among exclusive vapers than dual users , suggesting the importance for further research for poly-tobacco users .

Behavioural interventions for quitting combustible cigarettes such as practical counselling ( problem solving or skills training ) and intra-treatment social support is an integral part of e-cigarette cessation intervention while waiting for approved e-cig medications .

CONCLUSION

Evidence on vaping assessment tool and cessation interventions are currently limited . Nicotine replacement treatment products and varenicline have been shown to increase vaping cessation with minor side effects . No medication is currently approved for e-cigarette cessation .

Vape-taper is also useful while interactive text message demonstrated significant success in e-cigarette cessation . Counselling successfully assisted in vaping discontinuation by pairing it with other interventions .

More research is needed to determine the optimum option for e-cigarette quitting , including in special populations . – The Health

Dr Mohamad Haniki Nik Mohamed is Professor , Pharmacy Practice Department , Kulliyyah of Pharmacy , IIUM and the Head , Smoking Cessation Task Force , Academy of Professors Malaysia . He is also the Past President of the Malaysian Association of Adolescent Health .