Dr. Rania Habib (Host): Vaping is taking the US by storm. The FDA estimates that one in 10 or more than 2.5 million US middle and high school students reported e-cigarette use in 2022. The CDC estimates that nine out of 10 adults that use tobacco start by age 18.

Welcome to WakeMed Voices, a podcast discussing important topics to optimize your health, brought to you by WakeMed Children's and WakeMed Health and Hospitals in Raleigh, North Carolina.

Today's guest is Dr. Matthew Bruehl, a Pediatric Pulmonologist at WakeMed Children's, and he is here to discuss vaping in children, teens and young adults. Welcome, Dr. Bruehl. We are honored to have you on the podcast today.

Matthew Bruehl, MD: Thank you so much, Dr. Habib. Thank you for having me.

Host: With the rise of vaping in the US, this is such an important and timely topic. Let's begin with the basics. What is vaping? How does it work? And how does it differ from cigarettes?

Matthew Bruehl, MD: So when we're talking about vaping, we're referring usually to the electronic devices that heat up a liquid containing often nicotine and other compounds to create an aerosol. Even though it's called vaping, it's not actually a vapor, but it's a suspended liquid in the air with small droplets. And vaping refers to the act of heating up a liquid and inhaling it into your lungs.

And how it's different from combusted cigarettes is in the name. Nothing is lit on fire with vaping devices, but it's heated to a temperature where the particles are easily absorbed into your bloodstream through your lungs.

Host: Okay. So, obviously when people are vaping, we see this kind of moisture or almost like smoke coming from the end of that e-cigarette. How does that differ from the smoke coming from the tobacco lit cigarette?

Matthew Bruehl, MD: They're actually similar in many ways. Both vaping liquid and cigarette smoke contain many known carcinogens, heavy metals, preservatives, including some ingredients that are found in antifreeze, formaldehyde, which is used to preserve corpses and all these chemicals do have harmful effects when human bodies are exposed to them long term.

Host: So, do all e-cigarettes contain nicotine?

Matthew Bruehl, MD: Some e-cigarettes are advertised as containing 0% nicotine, but a recent study by the CDC or survey by the CDC, should I say, showed that over 99% of products sold in the United States do contain nicotine. And even those that are advertised as 0% nicotine, when tested in independent laboratories do contain trace amounts of nicotine.

So as a rule, I would say all e-cigarette containing liquids that you can purchase commercially are nicotine containing.

Host: Wow, that's fascinating. I actually had no clue. So would you say that there's minimal oversight in the actual production of these e-cigarettes?

Matthew Bruehl, MD: Yes. The oversight of tobacco and tobacco containing products is undergoing a change in the United States. The Tobacco Control Act of 2009, gave the FDA authority over tobacco containing products. And there's a messy regulatory process that over the last decade has played out to extend that to nicotine containing products like e-cigarettes, but it's a little murky.

So the manufacturer and regulation of the production of those liquids is a bit of a black hole, where it's not tightly regulated and there are not FDA or other governmental inspectors going into these facilities to make sure that the product is pure. In fact, most e-cigarette liquid is manufactured overseas with the vast majority of it being manufactured in China.

Host: Wow. That's actually terrifying that there's not more oversight by the FDA on something that people are inhaling into their lungs.

Matthew Bruehl, MD: Yeah, that's true for a lot of other products in the United States as well. And it's actually, if you look back, that method of regulation or lack thereof is repeated over and over again throughout the history of the United States with cigarettes and other quote health products.

Host: Wow. Well, I really hope that they actually get a hold on it because we want to know what's in these products. In your professional opinion, is vaping safer than cigarettes?

Matthew Bruehl, MD: The answer is complicated. I know professionally that inhaling e-cigarette vapor exposes people to fewer harmful chemicals than cigarettes, but in my professional opinion, that is not saying much because cigarettes are so deadly. So even if there is less exposure, by no means are e-cigarettes safe, especially for youth, due to the contents that we know that we discussed earlier, and also especially for teens and adolescents because of the effect of nicotine on developing brains.

Host: Can you go into a little bit more detail about those harmful effects nicotine, specifically in kids, teens, and young adults?

Matthew Bruehl, MD: So, nicotine is an addictive compound that has effects in a lot of different brain pathways, including those that regulate memory and attention. In young people, a lot of what the brain is doing is forming new connections, having new experiences, neurons connecting to each other, and over time, those connections are either reinforced or pruned as needed, and the introduction of nicotine to the central nervous system completely wrecks that process.

It changes the process by which neurons make connections and form these abnormal connections that might not actually, or might, or that are not useful and result in increased impulsivity and addictive behaviors and thoughts over time.

Host: Wow. So do you think vaping is as addictive as regular cigarette use? I know that's a complicated question, but I'm sure a lot of people are asking that.

Matthew Bruehl, MD: It's a complicated question but, in my opinion, in some ways, vaping nicotine can be more addictive than combusting nicotine. And there are a few different scientific basises for that. The way you release the compound so it can be absorbed into your blood with combustible tobacco also creates a lot of harsh side effects or harsh compounds that actually with the uncombusted heated component in e-cigarettes, you actually can deliver more nicotine without the harsh flavor with e-cigarettes, which is what makes them one of the greatest health concerns in these days, because people can be exposed to eight, 10 times the amount of nicotine with using e-cigarette or vape product use compared to an equivalent tobacco component. And, even though we know that exposure to nicotine is dangerous, actually long term, we still don't know a lot of the long term health effects for this level of nicotine that is made available to the general public through e-cigarette and other vape product uses.

Host: That's an incredible amount. Eight to ten times higher. I actually didn't even know that statistic myself. So in your opinion, why do you think vaping is so attractive to the youth? Why do kids turn to vaping?

Matthew Bruehl, MD: Also a complicated question, and we do not have enough time, but the short answer is through social media pressures, their own interactions with their peers, this is a thing that can set people apart or conversely make them feel like part of and in-group. So, humans and teenagers in general, a lot of puberty and adolescence is finding out who you are in the world and how you relate to the world.

And on some level it's a lot of determining how you identify, which groups you identify with, which groups you do not identify with both locally and globally, and this offers a tangible act that can help define people's identity. And I think that's why it's been taken up so much by young people and adolescents and precisely the reason why this is an urgent health issue.

Host: Absolutely. How should we talk to kids about smoking and vaping? Obviously, as you said, it's in social media. It's right in their face. So how as healthcare professionals or parents should we bring up that topic?

Matthew Bruehl, MD: So I think the first thing parents and health professionals need to know is you are not the only one talking to your kids about vaping. And, the other people who are talking to your kids, with your kids, probably might have started earlier than you, and it's absolutely more pervasive than you.

So I think the first, the first step for parents and healthcare providers is to recognize the environment you're coming into. A recent study published in the International Journal of Environmental Research and Public Health looked at almost 300 TikTok videos that mention or demonstrate vaping products.

And an analysis showed that vaping products are portrayed with positive connotations in a positive light 97-98% of the time.

And additionally, these social media stars or influencers may actually be being paid by companies and do not have the obligation to disclose this during the videos. And even if that's in violation of certain social media platforms terms of service, as we've talked about before, the regulation of that issue can be dicey at best. So for parents, recognizing that your kids are being exposed to this, whether through social media or through their peers is the best way to start to approach it.

And then the other main piece of advice I would give is don't approach it like a lecture because that will get you nowhere. Use shared experiences that you have, observations that you make in public, actually looking at videos together or observing other people vaping, and using that as an introduction to the conversation and really trying to treat your child or the person you're talking to, trying to as much as possible, equalize the power differential, because this is one of those, those things where we as a society are still learning the long term effects and the initial science is coming down very strongly on the negative effects of vaping. But talking to people as what do you think about this? Or what have you heard? Or tell me stories from your friend group or from school or from people you've heard about get your teen's or the patient's reaction to that and what they think, and really try and pull out their own thoughts about this. Cause, because as we've talked about before, they will have them because this is pervasive. They have thought about this, even if they haven't expressed it so far.

So, that's the pillars of starting the conversation is realizing you're not the first one. Don't treat it like a lecture. And then the other main point I would really emphasize to parents is, demonstrate good behavior. If you yourself smoke or vape don't try and hide it because they know, uh, but

Host: They'll always find out.

Matthew Bruehl, MD: They'll always find out, but acknowledge it, you know, this is something I'm, I'm working through and enlist them as an ally in your journey to quit. And there's lots of resources available for adults and teens. The 1 800 QUIT NOW website or smokefree.gov are both excellent resources for adults and teens trying to quit and also just wanting more scientifically solid information about vaping and tobacco product use.

Host: Absolutely. What are some signs that a child is vaping? Because I know a lot of parents will be looking out for that.

Matthew Bruehl, MD: A lot of times, finding vaping devices around the home is what the traditional story for what happens. But actually studies have shown that most teens who vape actually don't own a vape device. They borrow one from friends. So it might not be anything that you're looking for in the home, but if you do find it, there are lots of different shapes and sizes of these devices and it's an ever changing market. It can look like a USB device or a USB stick, sometimes they can look like pens. Sometimes they're called tanks or mods.

Some actually, as a pediatric pulmonologist, this is the one that makes me pull out my fainting couch is there is brand of e-cigarette device that is specifically designed to look like an inhaler, like a medical inhaler, except it does not have medicine in it. It has e-cigarette liquid.

So, that's one of the ways that may be an opening for a conversation. And then a lot of the other signs that a teen or someone is vaping is, is going to be pretty hard to distinguish from other pretty typical adolescent behavior.

So I would not, I would discourage parents from thinking that a sudden lack of sharing or changes in conversation automatically mean that vaping is occurring. But just establishing, keeping an open and honest communication. And again, have a neutral tone and not be judgmental about it, but just come from a place of loving, cherishing and respecting your child and trying to make them into the best person they can be.

Host: Yeah. Open communication and showing that love, is so important. Now if a child has started vaping, how can they quit? I know that you gave two resources already, but if you have any other tips, and will they experience withdrawal?

Matthew Bruehl, MD: Once someone has started using vaping products containing nicotine, it can be a powerful stimulant and a powerful addictive substance that, as we've talked about, alters brain chemistry almost immediately and can be one of the toughest things to quit.

But, again, going back to just open, honest communication and being patient. So for, parents and teens, those resources I talked about earlier, are a great find and a great way to start the journey. The other thing I tell people to do is try and be a detective in your own life.

I try and remove the impetus to quit vaping, from the investigation of what triggers vaping episodes. So I, tell people, all right, be your own Sherlock Holmes, or your own detective, and as you go through a day and as you use or vape, think about the situation in the minutes preceding your use.

Are there patterns that show up? Is it always when you arrive to a certain place? Is it always after other non vaping activities? After a meal? Is it around certain people? And that's not to say not to do those activities. But it's to just start to get a roadmap of what your use looks like in a completely non judgmental and not even asking that you stop, way, but just being aware of it and building that road map, that list of known triggers and known situations as you move down the path of quitting, which is often fractured and often back and forth. Sometimes when cravings strike and you will get cravings, including withdrawal symptoms. So shakiness, irritability, fast heart rate and other signs of, think of fight or flight, just where you're antsy and you don't know why. When those happen, you can be a little more informed about anticipating them because Oh, of course I'm having a craving because I just got home in the afternoon and this is the time when I typically would vape.

And being able to anticipate that can help not make it so terrible. Just as an aside too for how difficult but worthwhile it is to quit. So my own mother did not smoke when she was pregnant with me, but she smoked cigarettes, combusted cigarettes throughout most of my childhood.

And she attempted to quit many times through my own probably not helpful efforts when I was a teenager. But as soon as I turned 18 and left the home, that was when she found the willpower to quit. So it's almost as if a source of stress left her life when I moved out, but I'm sure it's a coincidence.

Host: It's got to be a coincidence. You couldn't have been that stressful on your mother.

Matthew Bruehl, MD: Certainly not. But my mom very typical in that it took her eight to 10 really prolonged trials of being tobacco free before it finally stuck. And, she's been smoke free for about over 20 years now.

Host: That's fantastic. So proud of her. And thank you for sharing that very personal story. So you did mention that they may experience nicotine withdrawal if the actual vaping device had nicotine. So do you think the nicotine replacement gum or patches are useful in someone who's really determined to quit vaping?

Matthew Bruehl, MD: Those help quitting devices and methods can be very helpful. For people less than 18 years, you should talk with your family physician or pediatrician about the appropriate use of those. But, for those over 18, yes those types of devices and methods are available and have been proven to reduce dependence on nicotine if used appropriately.

And those quitting devices have been FDA vetted and approved and that is in contrast actually to vaping as a tobacco cessation device, which has not been adequately studied and at this time cannot be recommended even though anecdotally that is what a lot of people do. They step down from combusted tobacco to vaping products. And at this time that, while their heart is in the right place, it cannot be recommended by a medical professional until more studies about the long term health effects of vaping are known.

Host: Right. And that's a really important take home message is, because I see a lot of friends who are trying to quit combustible cigarette use and they're switching to e-cigarette use. So now I can tell them, hey, it hasn't actually been studied, let's not use that as a successful method to step down. So thank you for sharing that.

Well, this has been a really fascinating episode. As a physician and a pulmonologist who specializes in the health of lungs, especially those of our pediatric patients, what is your message to parents and kids about vaping?

Matthew Bruehl, MD: My message to parents and kids about vaping is you need to find your own reasons to quit or to not start using those kinds of products. I see it as my job as a medical professional to inform you, to answer questions that you have, and be a resource for you.

But at the end of the day, I'm just kind of a weird guy that you meet sometimes. And, I'm not going to be ever present in your life. So, I see myself as a launch pad, but the rocket fuel has got to come from you. So I encourage people, like I said, to be a detective in your own life. Think about situations that you're in, and this is true not just for vaping, but, how you interact with your peers and with teachers and mentors and loved ones, try and go through what are you saying and what are you hearing in this, and what are the reasons behind that and what makes sense to you and what doesn't and what are others motivations and what are your motivations, and is what you're doing helping you be the person you want to be. Or is it a distraction and in the way? So if you can find that motivation within yourself, then you're going to be set up for life.

Host: I love that. Thank you so much for sharing your knowledge with us today about vaping. And to all our patients out there, thank you so much for listening to us today about all things vaping. Thanks to Dr. Bruehl. I'm Dr. Rania Habib with WakeMed Voices, brought to you by WakeMed Children's and WakeMed Health and Hospitals in Raleigh, North Carolina. To learn more about WakeMed Children's Pediatric Pulmonology and sleep medicine, please visit www.wakemed.org/cure.