Clinical Issues to Consider for Clozapine Patients Who Vape: A Case Illustration

Vaping uses an electronic nicotine delivery system (ENDS) for inhaling vaporized and aerosolized ingredients. A significant subset of the psychiatric patient population will use ENDS and may have concurrent cigarette usage. In the clinical case highlighted here, a patient with significant nicotine use is prescribed clozapine. He typically inhales vaporized nicotine solution, but during a chemical dependency treatment, he was provided cigarettes instead of ENDS to prevent him from consuming substances other than nicotine. Exposure to cigarette smoke led to clinically worsening psychotic symptoms that reversed when he was discharged from treatment, stopped cigarette use, and resumed ENDS use. However, his extremely high nicotine exposure then led to symptoms resembling an anxiety disorder, which resolved when ENDS use decreased. Psychiatrists must become familiar with patients' vaping and smoking habits and be alert to altered plasma drug levels in patients whose method of nicotine ingestion changes over time.