E-cigarettes emerged on the US market in 2015 as a potential therapy to assist adults to quit smoking. It was thought that the liquids in the devices were lower in nicotine and safer than smoking cigarettes. Because adolescents also thought it was safer than cigarettes, they began to use these products instead of cigarette smoking. At this time, there were no age restrictions on the purchase of these products. In October 2018, the Food and Drug Administration (FDA) reported that there was an epidemic in e-cigarette use among adolescents.1 In addition, data from the National Youth Tobacco Survey found a 78% increase in use of e-cigarettes in middle and high school adolescents from 2017 to 2018, accounting for 3.6 million middle and high-school students using e-cigarettes.2 In addition, according to 2019 data, 40.5% of 12th graders had vaped.3
Electronic cigarettes are commonly called e-cigarettes, e-vaporizers, or electronic nicotine delivery systems. They are battery-operated devices that include a battery pack, a heating element where the e-liquid or aerosol is heated and vaporized, an e-liquid/aerosol container for storage, and a mouthpiece from which the vapor is inhaled. The aerosol typically contains varying amounts of nicotine and a variety of flavoring choices that provides the vaper with a sweet, pleasant taste. The Table provides information on the common devices that are currently being used, including the ease of concealment, which has been a key issue in adolescent use of these products.2,4 The JUUL E-cigarette currently accounts for 73.9% of the sales of more than 460 different e-cigarette brands. One standard JUUL pod is roughly equal to the amount of nicotine in a pack of cigarettes.5,6 In a report from the National Academies of Science, e-liquids and e-liquid aerosols include nicotine (amounts vary from no nicotine [0 ng/mL] to 85 ng/mL nicotine), propylene glycol, glycerin, tobacco-specific nitrosamines, aldehydes, tobacco alkaloids, and vitamin E acetate. These are all known respiratory toxins, inflammatory agents, and carcinogens.4,7
E-cigarette devices produce aerosol vapors that differ in the levels of toxins and nicotine delivery and, therefore, varying amounts of absorption into the bloodstream. These devices can be customized by temperature and power settings for vaporization and later generation devices deliver aerosols more efficiently to the lungs.6 There are a wide variety of flavors and nicotine levels that are purchased separately for the devices. The later generation devices, more likely to be used by adolescents, include those that are not the disposable e-cigarette that looks like a cigarette, but those that resemble USB devices or pods. Because of the variety of devices, to date there is no specific data to support the danger in one device compared with others. However, in a pooled analysis of 8 studies with 2166 adolescent vapers, Barrington-Trimis et al8 found that 77% of adolescents used a later-generation device and later-generation devices were preferred regardless of age. This is in contrast to a study of adolescent (< 25 years) versus adult smokers (45 – > 65 years) that found that disposable e-cigarettes had more prevalent use by adults 65 years or older versus adolescents (66.6% vs 27.4%) and among adults aged 45 to 64 years (59.8% vs 31.4%), respectively.7
WHY ARE E-CIGARETTES ARE SO POPULAR AMONG ADOLESCENTS?
E-cigarettes are popular among adolescents because they are readily available for minors to obtain, unlike cigarettes. Currently, there are 18 states that have passed legislation to prohibit the sale of cigarettes to individuals younger than 21 years. The American Heart Association and American College of Cardiology have robust campaigns in all states to continue the effort to increase the purchasing age for cigarettes to 21 years of age. Producers of e-cigarette and vaping products have active campaigns targeted at adolescents to be “cool” and vape. According to a survey completed by the National Institute on Drug Abuse, adolescents believe that e-cigarettes are safer than regular cigarettes.2 In a scoping review printed in the Journal of Medical Internet Research (2019) about the messages presented in social media about electronic cigarettes, the authors found that there are key messages, including the following: (1) vaping is safer than traditional cigarettes; (2) vaping is efficacious as a smoking cessation aid; (3) vaping reduces cigarette cravings; (4) vaping promotes a smoking habit that is pleasant, flavorful (15 000 flavors), and easy to obtain; and (5) vaping can be used where cigarettes cannot as there are little data on second hand vaping vapors. In addition, much of the e-cigarette business is conducted on the Internet, where manufacturers try to lessen the relationship of vaping to cigarette use, distance their products from tobacco, and use attractive messages, colors, packaging, and flavorings to entice the buyer.9
Devices are sometimes categorized as basic, intermediate, or advanced. Basic devices are typically the disposable e-cigarette products that cannot be refilled with additional liquids. The intermediate devices are refillable but have no special features in temperature regulation. Advanced devices have refillable tanks and contain special features like temperature control and amount of “vaping hit” that can occur in the throat. In a study by Pepper et al, the researchers were able to ascertain the type of device used in adolescents based on age and time of vaping use. They recruited a sample of 1508 adolescents aged 15 to 17 years (57.4% female, 64.5% non-Hispanic white, 6.1% black, 15.1% Hispanic) who had used an electronic vaping device in the past 30 days. In this sample, 56.8% used advanced devices rather than basic devices (14.5%) or intermediate devices (28.7%). Seventy-six percent owned their own vaping device and would use an intermediate or advanced device, and 68.7% vaped around other people. In terms of the taste of the liquid, 68.2% preferred the sweet or fruit flavors. Approximately 46% tried dripping. In conclusion, younger age and less frequent vaping were associated with using basic devices. Adolescents who were older and male bought their own device, preferred the advanced device, and were more likely to mix their own liquids and try a variety of liquid types.10
WHAT IS THE PHYSIOLOGICAL RESPONSE TO VAPING AND NICOTINE INHALATION?
Nicotine, along with the many toxins and carcinogens, has detrimental effects on the body. In particular, in adolescents, the brain and lungs are dangerously compromised. In adolescents up to the age of 25 years, the brain is still in development. Yuan et al11 explains that that during this time, the brain is sensitive to novel experiences in the executive control and decision-making regions of the brain, particularly the prefrontal cortex. In addition, nicotine affects the brain's reward circuits and increases the level of dopamine in the brain, reinforcing rewarding behavior, which is dangerous during brain development and makes adolescents more vulnerable to developing an addiction. Lastly, nicotine has a detrimental effect on brain circuits that affect memory and attention.12 In 2019, the Centers for Disease Control and Prevention opened an investigation of lung injuries associated with vaping and have labeled it EVALI (E-Cigarette Vaping Associated Lung Injury). As of January 7, 2020, there are 1979 lung injury cases, with 33 deaths being reported. All these patients had a history of vaping. Approximately 90% of the cases required hospitalization including mechanical ventilation. In terms of product used, 77% of the cases included tetrahydrocannabinol in the aerosol.13 Symptoms of lung involvement include cough, short ness of breath, chest pain, nausea, vomiting, diarrhea, fever, fatigue, and abdominal pain. Lastly, the consumption of nicotine has many physiologic effects on the cardiovascular system. Nicotine causes a rapid increase in the levels of catecholamines in the blood, increases plasma-free fatty acids, increases respiratory rate, decreases endothelial dysfunction, and increases blood viscosity.13 These physiological changes affect blood pressure, oxygenation of the heart, and potential for thrombus formation, all of which can cause stroke and myocardial infarction.
WHAT CAN HEALTHCARE PROVIDERS DO TO PROMOTE PREVENTION?
All healthcare providers need to educate patients and families about the harmful effects of e-cigarettes on our adolescents. Families should discuss the harm nicotine can do to the brain and cardiopulmonary systems. All parents should screen the social media their children engage in to ensure they are not part of the “cool vaping” movement and/or purchasing products. Parent Teacher Organizations should develop campaigns in middle and high school environments to teach children about the harm of e-cigarette use. In the United States, e-cigarettes are regulated as tobacco products under the Family Smoking and Prevention Tobacco Control Act, which was passed in 2009. At that time, only cigarettes, cigarette tobacco, roll-your-own-tobacco, and smokeless tobacco would need FDA approval. Sales to children was enforced and warning labels were evident on these products. In 2016, the FDA extended its authority to cover all products that meet the statutory definition of “tobacco products,” including e-cigarettes, e-hookah, e-cigars, vape pens, and all related products. Again, the FDA required nicotine exposure warning and child-resistant packaging on all products, including e-liquids.14 Then in 2018, the FDA released an announcement detailing planned regulatory policies that would restrict access to flavored E-liquids in common retail locations and require stricter regulations on sales of these devices. However, the sale of these devices occurs in vape shops or online, which is not regulated by the FDA. The FDA has also launched youth prevention efforts targeting attitudes and beliefs about e-cigarettes.15 It is imperative that all healthcare providers join the efforts of the American Heart Association and American College of Cardiology to campaign at national and state levels to continue the fight to protect our children from tobacco and nicotine products.
1. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the field: use of electronic cigarettes and any tobacco product among middle and high school students—United States, 2011–2018. Morb Mortal Wkly Rep
. 2018;67:1276–1277. doi:10.15585/mmwr.mm6745a5, 1276.
2. National Institute on Drug Abuse, National Institutes of Health, US Department of Health and Human Services. Vaping devices (electric cigarettes). 2019. https://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes
. Accessed February 1, 2020.
3. Schillo DA, Cuccia AF, Patel M, Simard B, Hair EC, Vallone D. JUUL in school: teacher and administrator awareness and policies of e-cigarettes and JUUL in US middle and high schools. Health Promot Pract
. 2020;21:20–24. doi:10.1177/15248399119868222.
4. Bold KW, Krishnan-Sarin S. E-cigarettes: tobacco policy and regulation. Curr Addict Rep
. 2019;6:75–85. https://doi.org/10.1007/s40429-019-00243-5
5. Miech R, Johnston L, O’Malley PM, Bachman JG. Trends in adolescent vaping, 2017-2019. N Engl J Med
. 2019;381(15):1490–1491. doi:10.1056/NEJNc1910739.
6. Truth Initiative. One third of parents had no awareness of JUUL at start of youth e-cigarette epidemic. https://trughtinitiative.org/research-resources/emergingtobacco-progucts/one-third-hparents-had-no-awereness-juul-start-youth-e
. Accessed February 1, 2020.
7. Talih S, Balhas Z, Eissenberg T, et al. Effects of user puff topography, device voltage and liquid nicotine concentration on electronic cigarette nicotine yield: measurements and model predictions. Nicotine Tob Res
8. Barrington-Trimis JL, Gibson LA, Halpern-Felsher B, et al. Type of e-cigarette device used among adolescents and young adults: findings from a pooled analysis of eight studies of 2166 vapers. Nicotine Tob Res
. 2018;20:271–274. doi:10.1093/ntr/ntx069.
9. Eysenbach G. The messages presented in electronic cigarette-related social media promotions and discussion: scoping review. J Med Internet Res
10. Pepper JK, MacMonegle AJ, Nonnemaker JM. Adolescents’ use of basic, intermediate, and advance device types for Vaping. Nicotine Tob Res
. 2019;21:55–62. doi:10.1093/ntr/ntx279.
11. Yuan M, Cross SJ, Loughlin SE, Leslie FM. Nicotine and the adolescent brain. J Physiol
12. Chadi N, Hadland SE, Harris SK. Understanding the implications of the “vaping epidemic” among adolescents and young adults: a call for action. Subst Abus
13. Perrine CG, Pickens CM, Boehmer TK, et al. Lung Injury Response Epidemiology/Surveillance Group. Characteristics of a multistate outbreak of lung injury associated with e-cigarettes use, or vaping-United States 2019. Morb Mortal Wkly Rep
. 2019;68(39):860–864. doi:10.15585/mmwr.mm6839e1.
14. Food and Drug Administration. Deeming tobacco products to be subject to the federal food, drug, and cosmetic act, as amended by the family smoking prevention and tobacco control act; restrictions of the sale and distribution of tobacco products and required warning statement for tobacco products: final rule. Fed Regist
15. US FDA. FDA launches new campaign: “the real cost” youth e-cigarette prevention campaign. 2018. https://www.fda/gov/TobaccoProducts/PublicHealthEducation/PublicEducationCampaigns/TheRealCostCampaign/ucm620783.htm
. Accessed February 1, 2020.