July 2024 E-cigarette Use Information for Oncology Nurse

Thank you, Lindsey, for providing these articles for discussion.

My name is Pataricia Strickland, Trish, and I am an after-hours triage nurse at the James. I don’t think I have ever had a patient ask about e-cigarettes and I don’t screen patients for this information like they do when the check in a patient at the clinics, but I am interested in the topic

1.What was the knowledge gained from the articles?
I was surprised to read in Article #2 that 65% of smokers continue to smoke even after a cancer diagnosis and the completion of their treatment. The tobacco companies promote e-cigarettes as a healthier choice even without the evidence that they are a safe or effective smoking cessation tool. This is even more concerning since the FDA doesn’t regulate them either. The e-cigarettes still contain nicotine that can cause tremors, tachycardia and elevated blood pressure. Nicotine itself has been shown to be a risk factor for strokes, vascular disease, delayed healing, and although it has not been proven to cause cancer, it does increase the growth of cancer cells and has a role in tumor progression. E-cigarettes are still allowed in public places.
2. Will the research/information in this article change or influence your practice? If so, how?
E-cigarettes have been shown in short-term studied to cause less harm than cigarettes but are not an FDA-recommended smoking cessation tool. In the second article, the WHO reports that there is a lot of smokers are using both cigarettes AND e-cigarettes together and not really using the e-cigarettes for smoking cessation. More information and long-term research studies are needed to educate the consumers of their risks associated with e-cigarettes and the environmental impact on the exhaled fumes from e-cigarettes.
3. What other questions does the articles raise about current practice?
We have long known that the effects of second- hand smoke is dangerous enough to have smoking bans, but e-cigarettes don’t fall under those same restrictions, and we don’t know the harmful effects of secondhand exposure or the environmental dangers of e-cigarettes.
4. Do you agree/disagree with the conclusions of the author, why?
More research is needed to determine the health risks of e-cigarettes and the second-hand exposure since they are permitted in open spaces. More regulation and monitoring from the FDA is needed to ensure that consumers are aware of the risks especially since they have varying amounts of nicotine released as well as other chemicals as the by-products of vaping.

Hello- My name is Jeff and I am one of the outpatient float pool RNs. Thanks for hosting Lindsey!

1) What was the knowledge gained?
I am slightly surprised the number of 65% of patients continuing to smoke after diagnosis isn’t higher. Having worked in the thoracic clinic previously I heard so many times “Oh well I already have lung cancer I might as well continue to smoke.” The statistic I found truly crazy is that 85% of people report using e-cigs for smoking cessation. I feel that everything media related is promoting e-cigs as healthier (which 80% of people surveyed reported). According to the articles there is no evidence to promote e-cigs as being healthier and could actually lead to being worse since no filters and no regulations as to what exactly is put into the cartridges or pods- especially with nicotine being known to promote growth of cancer cells/ proliferation of endothelial cells.

2) Will the research/ information change my practice? If so how?
I used to work in the thoracic oncology clinic prior to joining the float pool. I actually was a tobacco cessation specialist as part of our training. These articles reinforced what that class taught me. I already knew people were using e-cigs/ vapes as part of a smoking cessation attempt (but did not realize the numbers were THAT high). I also knew that people who tried the e-cigs/ vapes would always argue that it was healthier and felt better about smoking them vs physical cigarettes. So in some instances it will change my practice because I have more information after years of additional studies to back up that neither are good options and be able to communicate other options. My former colleague in the thoracic clinic actually developed a “quit stick” which had zero nicotine and was more to mimic the hand to mouth tendency.

3) What other questions do these articles raise?
These articles further elaborate what we have been told it’s just a matter mainstream media catching up to it/ nicotine companies not wanting the truth known. SO other questions I have from these articles are: Will further regulations come to e-cigs/ vapes/ etc where we know the exact percentages of each ingredient? Will employers actually limit the number of smoke breaks for employees (very difficult to limit a smoke break) or will the use of electronic cigarettes promote smoking while at the desk?

4) Do you agree/ disagree with authors? Why?
I would agree that having alternatives to smoking physical cigarettes is a good option. BUT I feel that e-cigs/ vapes/ etc can actually be worse for people and need to have further regulations. I disagree that the use of e-cigs should be promoted as a smoking cessation aid because it will still lead to nicotine use (even increased use since the exact amount of ingredients isn’t known. I know that as it currently stands some clinicians will promote e-cigs because of the healthier claim but are they really healthier after all the evidence points against a healthier alternative.

1. What was the knowledge gained from the article? I had no idea tobacco use remains the top preventable cause of illness and death around the world (Essenmacher et al., 2018). With the smoking cessation programs in the US, it is easy to forget how prevalent it still is. Although Zborovskaya (2017) points out that ENDS can renormalize smoking. It really makes me angry that additive chemicals are not listed or regulated. I remember seeing an article recently that many top cosmetic items contain arsenic. Is this 2024, or 1824!? I also had no idea that those with mental illness had such high rates of smoking.

2. Will the research/information in this article change or influence your practice? If so how? I would never recommend a patient to start using ENDS, even to quit smoking. Therefore, I don’t think this will change my practice. I will continue to offer patients assistance with smoking cessation.

3. What other questions does the article raise about current practice? The article raises many questions about ENDS, but as far as current nursing practice is concerned, I believe we should treat ENDS the same as other nicotine products and discourage its use while educating about and supporting cessation. Both articles repeatedly state more research is needed. My question are: how much time will that research take, and what damage will be done by then?

4. Do you agree/disagree with the conclusions of the author, why? Essenmacher, et al. (2018) sum it up when they state “To be clear, there is no safe level of tobacco use.” I would go farther than either article and state that ENDS should be regulated and treated the same as other nicotine products.

Jeff- I didn’t know you were a tobacco cessation specialist, that would be so useful in educating our patients! I remember reading somewhere that the most statistically likely method to quit smoking is cold turkey. I smoked many years ago and tried twice to quit with nicotine gum but it didn’t stick. Cold turkey was challenging but ultimately proved successful. Looking back with what I now know I can’t believe I smoked at all. Even then I knew it was bad for me, but when you’re younger you tend to think you’re invincible and problems are all “later” in life. I think many of our patients think to quite smoking while also being treated for cancer would be too challenging. But like Mindy stated, someone smoking during cancer treatment is likely undoing what we are trying to accomplish.

Mindy Blackwell, I agree that the information regarding the health concerns for e-cig should be promoted more aggressively. I think there is still a thought that they are “better” than regular cigarettes and the second hand “smoke” is also less toxic.
goodman.100, I agree that the e-cigarettes should be regulated just as all nicotine products.

Mindy, I agree that a cancer diagnosis is not enough to persuade a person to stop smoking. We have done clinical trials with thoracic patients and it is frustrating that they continue to smoke, especially when they leave the unit on a long treatment today to go outside somewhere and smoke. I do realize that it is also a way to deal with stressors and having cancer is a BIG stressor but I wish it wasn’t so addictive, and that they were able to quit.

Jeff, I also agree that having options to smoking physical cigarettes is good, but the “safer” ones like nicotine gum are not very effective. I will admit that I am very biased against e-cigs and vape pens because my two step-daughters were non-smokers and both use e-cigs all day, every day. The youngest started when she was about 16, when the marketing for them was sneakily aimed at adolescents. I am very concerned about the implications for their health in the future. I feel that the e-cigarette industry has spawned a whole new generation of non-smoking, nicotine addicts.

Hello everyone, my name is Stephanie Hsu and I work in the clinical trial units.

The knowledge that I gained from the article? As a non-smoker and never having any experience with cigarettes or any form of smoking it was interesting to learn about electronic nicotine delivery systems (ENDS) such as electronic cigarettes (e-cigarettes). I never realized that they have been around since 2007. I also was unaware that they consist of so many parts, the battery voltage determined the heat level, vapor concentration and this controlled the nicotine, and other ingredients. It was alarming to read of all the potential chemicals that may be contained in the e-liquid, as well.

Although both journals shared interesting information and I gained new knowledge I do not really see myself changing my nursing practice a great deal. I can not see myself suggesting electronic cigarettes to help patients with smoking cessation, especially since there is no evidence on its safety, and or its benefits.

Do you agree/disagree with the conclusions of the author, why? I do agree further research and information is needed to determine if ENDS are safe and/or less damaging than cigarettes, especially since there are no studies for long term use.

Jeff, I have also heard patients say, “Oh well I already have lung cancer I might as well continue to smoke.” I have even seen a patient standing outside in his hospital gown smoking through his trach, thankfully not attached to oxygen. It was also interesting to hear about your former colleague who developed a “quit stick”. I hope its successful.

Kelly, I agree that the creation of ENDS could be nicotine companies to market products to increase sales. Nicotine is such a big business and the addiction is so difficult to overcome.

Jen, I too would like to see long term studies and comparisons. It’s so difficult to educate and support our patients when we don’t have the information. Many of my patients share the alternative cessation techniques, gums, patches, etc. actually don’t work for them. I would love to give them an option that does work.