Hi all,
Long time follower, first time poster. I was wondering if anyone had a suggestion for factoring in vaping / eCigarettes into smoking history. Would it be incorrect to add “eCigarettes” to the ValueSet on the Template for Type which lists “tobacco” smoking types. If this is considered incorrect given vaping is not actually tobacco, please could someone recommend an alternative approach? Creating an additional archetype is less than ideal here.
Thanks,
Ian
Hi Ian,
Explicitly ‘NO’ - - after long and painful discussions we felt that eCigs do not really belong with Tobacco smoking or other forms of tobacco use as tobacco smoking has uniquely very high-risk associations with ill-health, not just cancer and hear t disease but post-op lung infection etc.
There is smokeless tobacco archetype for chewed forms of tobacco but vapes do not contain tobacco at all and there is separate substance use archetype
that we would suggest you use, though I wonder if a specific vaping/eCigs ‘?? smoked nicotine’ archetype might become necessary in future, given some of the subtleties around vaping technology which themselves have different risk profiles, or at least need tracked and researched.
Can you tell us more about the context - is just a simple record of used/ not used or are other factors being recorded?
@varntzen @heather.leslie @siljelb - any thoughts on the need to have specific smoked nicotine archetypes, as concerns about risk of some of those products emerges?
Use case is that we want to capture smoking status as a single CODED text field that can be continually updated - i.e. it is captured and then AQL shows previously recorded information and can be revalidated and resubmitted
I think ultimately, we are seeing if we can have a CODED text field archetype to reflect the above to avoid using generic fields to present information held based on multiple AQL queries and dependencies.
Generally in agreement with Ian. I’m not sure “smoked nicotine” is right either, though.
Vaping is, as far as my thinking on it has gone, more like a route of administration for any number of, or no, active substances, with some sort of additive (vaping oil). The health effects are as far as I understand different from smoking tobacco, and inhaling the oil in itself may have some specific effects which are also different from smoking.
For now I agree with the suggestion to use one of the “substance use” archetypes:
EVALUATION.substance_use_summary for a generic summary about vaping habits and historyOBSERVATION.substance_use_screening for questionnaire type questions about vapingOBSERVATION.substance_use for actual vaping usage, including amounts, for a specific interval of time, a “vaping diary” in effectNote that the first two archetypes are close to publication, while the third is in draft and hasn’t been touched in more than 5 years
Is the context front-line use or registry / reporting?
If front-line I would be holding out strongly to do it ‘properly’ i.e 2 different archetypes ,even if that is hidden for convenience behind a single drop-down facade in the UI. eCigs and smoking are really a very, very different things from a risk pov.
This option makes me think “registry form”; it’s in effect “no information, because [reason]”.
If this is intended for primary clinical recording (ie not for research/registries only) I’d advise strongly to leave this out of the actual persisted data, and rather use the null_flavour and null_reason reference model elements.
(see https://specifications.openehr.org/releases/RM/latest/data_structures.html#_overview_2 and https://specifications.openehr.org/releases/RM/latest/data_structures.html#_element_class)
Thanks for all the info, it is for primary data capture (i.e. will be captured across multiple assessment forms) so will reflect the recommendations.
This is almost scary. It’s just some hours ago I raised the question in our Norway modelling team, about how to record the “White snus” pouches, among them the brand “ZYN”. These pouches contains almost no tobacco, only nicotine. The first idea was to use EVAL.substance_use_summary, name the substance ‘Nicotine’ and use the form and route elements to differentiate between vaping, snus, chewing gum, patches, whatever.
Perhaps nicotine is so important that we need another group of archetypes to deal with it, as @heather.leslie suggested.
Smoking stuff isn’t just tobacco, there are a lot of substances possible to smoke, including crack. So recording ‘Current smoker’ or ‘Current vaper’ without identifying the substance doesn’t really say much.
As Ian and Silje have pointed out, vaping and putting something on fire and inhale the fume, has different risk profiles.
Hi Ian,
I agree pretty much with the previous answers and considerations from my colleagues.
I would suggest that vaping a liquid with variable knowledge about the constituent chemicals warrants its’ own assertion, well separated from tobacco smoking. Consider ‘current vaper’, ‘never vaped’, and ‘previous vaper’ as a starting point for proper risk assessment/screening, rather than munging it in with tobacco smoking. Then the issue becomes how to identify the substance and/or active constituents - some might be quite benign, others much more harmful and contain nicotine, and others totally unknown. Nicotine consumption may be a more important consideration for this model - either as part of the summary, as a separate OBSERVATION or both.
When designing the ‘Tobacco smoking summary’ the scope was very carefully selected. Not any smoking, not all tobacco use, and the underlying premise was to support the identification of patterns of behaviour/use that might be targetted with behaviour change intervention towards quitting, related to the prevention of high-risk cardiovascular and respiratory disease. The archetype reflected that clinicians prioritise recording types of tobacco smoked and overall exposure, ahead of specific episodes. Recording nicotine consumption has not seemed to be a significant factor in recording tobacco smoking to date, and we always wondered if one day we might need to record nicotine consumption/use as a separate archetype. Maybe the time is now, for both vaping and recording other forms of consumption.
The alcohol consumption summary was heavily based on the prior published tobacco summary, although there were some significant adjustments to the tobacco smoking pattern to reflect the way clinicians prioritise episodes ahead of the type of alcohol.
‘Substance use summary’ is another separate archetype currently out for review and has a same same, but slightly different pattern again, but it is still focused on identifying patterns of use for different forms and routes of administration of each substance/drug.
When this tobacco smoking archetype was designed, vaping was a relatively new phenomenon. It was not well understood, especially the mechanisms by which it causes harm, yet it was quite apparent that the focus would not be on the tobacco smoking patterns. It is probably timely for vaping to be investigated and modelled. Does anyone know of an expert on vaping who could guide this modelling?
And in the meantime, we should add a change request for Vaping/e-cigarettes to be added the ‘Tobacco smoking summary’ as an example of Misuse - it will help others who have the same query.
Lots of thoughts, not very specific guidance, sorry.
Ian, I think the underlying premise of a single coded field for this is flawed. Smoking needs to be defined much more specifically - ‘Vaping’ and “smoking” have inhaling into lungs in common, but that is about all. Someone can simultaneously be a vaper and a smoker, may have smoked and/or vaped in the past, or we also need to record that they have done neither - all important to know if someone presents with lung conditions. IMO they should definitely be modelled separately.
I agree. From my understanding the effects of nicotine regardless of how it is consumed are pretty minimal and the anxieties about vaping are much more about the other constituents involved. (Other than gateway to smoking, of course but that’s a different argument!!
The oil and its consistuents are the reason I’ve proposed in my review a SLOT in EVAL.substance_use.
Pondering this further, the alcohol consumption archetype seems the best archetype pattern to reuse as the basis for a vaping or e-cigarette smoking archetype, excluding binging/intoxication details of course.
The focus for vaping (at least at the moment) is probably best focused on identifying episodes and patterns of vaping overall, rather than substance or form/type. I may be wrong but as far as I understand, especially for ‘over the counter’ purchases of flavoured vaping fluid, details about type or substance as far as constituent (especially harmful) oils/chemicals are still quite obscure and non-standard and therefore not so valuable. The exception is prescribed nicotine, which is a bit of an enigma. Perhaps typical Nicotine ranges could be included as a data element to provide guidance, but actual Nicotine or other harmful substance consumption should probably be recorded using an OBSERVATION designed for the purpose.
Another way of thinking would be to see ‘Vaping’ as a route, use the EVAL.substance_use_summary, Evaluation Archetype: Substance use summary [openEHR Clinical Knowledge Manager], and add a repeating SLOT for the oil and its constituents. Possibly using CLUSTER.Medication, Cluster Archetype: Medication details [openEHR Clinical Knowledge Manager], or a similar CLUSTER for solvents/constituents.
The same SLOT could also be used to record in which solvent heroin powder or other powdered drugs/substances is dissolved. Also when mixing hashish and tobacco.
I’m not sure ‘Vaping’ deserves an archetype of itself, as it probably is the substance being vaped and/or conjunct agents we are interested in.
I think this may be the nub of the problem. Within the substance use archetype the substance is the ‘index’ item around which all of the rest of the archetype content is recorded.
If we reuse the substance archetype for vaping, then the ‘Substance name’ will be recorded as the vaped e-liquid eg 'Applemint’, ‘Rebirth Ice’, ‘Classic’ or ‘American way’ with the behaviour recorded as status, episodes and amounts related to the specific brand/formulation of ‘Rebirth Ice’ etc; it is not focused on vaping as a behavioural choice/activity. We will be recording the use of a specific e-liquid (substance) via vaping (route) and that the patient is a Current user, Never used, Former user of ‘Rebirth ice’.
I guess we could record the substance as a generic ‘e-liquid’ however then the archetype concept is still focused on the generic e-liquid (substance) use, rather than vaping behaviour. The overall status would be Current user, Never used, Former user - I’d recommend more specific semantics for vaping, given the current health impacts recorded.
On the other hand, mimicking the pattern of ‘Alcohol use summary’ as ‘Vaping summary’ (or e-cigarette use summary), we would be recording ‘overall status’ as Current vaper, Never vaped or Former vaper etc, then use the optional CLUSTER detail about specific episodes of vaping and also potentially record details about the e-liquids used.
My understanding is that e-liquid formulations are not well-regulated. In that context, identifying and recording details about specific e-liquids may only be useful if we want to record nicotine consumption at the moment.
According to Wikipedia:
“A typical e-liquid is composed of propylene glycol and glycerin (95%) and a combination of flavorings, nicotine, and other additives (5%). The flavorings may be natural, artificial, or organic. Over 80 harmful chemicals such as formaldehyde and metallic nanoparticles have been found in e-liquids at trace quantities. There are many e-liquid manufacturers, and more than 15,000 flavors.”
This makes sense to me. Although there may be an overlap with the Substance use summary archetype in cases where the focus is on both the specific substances used (via vaping or other routes) and vaping as a behaviour, I think this is reasonable.
I see the points made above by Heather and Silje. Still a bit uncertain of where to go further, as, in my opinion, vaping TCH, nicotine and other known substances that can cause harm and/or addiction, surely belong in the Substance use group of archetypes, and where ‘vaping’ is just another route. And on the other hand, the potentially emerging requirement to record vaping and the individuals behaviour related to vaping, as a separate concept, due to the health risk introduced by the other substances in the vaping juice, apart from the recreational/stimulating substances.
I fear that we can introduce uncertainty of where to record and retrieve “substance use/abuse” of TCH, opioids, metamphetamine, hallucinogens, etc. Vaping drugs: the rise of people using vapes to smoke illicit substances - ABC News
I think the crux of the matter is the reason for collecting the data.
Are you collecting information about…
…?
If #1, I think this requires a new archetype focused on vaping, as Heather suggests. Using Substance use summary for this purpose, and expecting to be able to reuse the data, would require all implementers to use the exact same codes for recording both the substance used (“e-juice”?) and the route (inhalation of aerosol).
If #2, I think the Substance use summary archetype is a better fit.
In some cases you’ll need both, if both #1 and #2 are true.
Yep, that will be the case. Agree. And it must be the responsibility for the implementer to use them correctly. It has to be thoroughly described in both archetype’s Use section.
Yes, the focus of the documentation will determine what to put where.
A given substance could be consumed by vaping and other routes., eg nicotine.
Vaping behaviour needs to be understood to support interventions and potentially identify substances at a later date eg the ingredients of ‘Brand X’ may be found to be highly carcinogenic, and this documentation will support some insight into the amount of exposure to the carcinogen via vaping.