It has long been known that nicotine is a “legal” drug among adults. In 2016, over 37 million US adults inhaled various levels of nicotine daily.1 Unfortunately, during 2018, tobacco product usage in adolescents increased.2 The greatest increase in electronic nicotine delivery systems (ENDS) was recorded among adolescents in the US from 2017 to 2018.3 ENDS use is prevalent in the high school population, with 20% vaping within the last year.2 Tobacco usage among adolescents in the US is a signal to providers to screen all young patients for nicotine use of any form, identify substance use behaviors, discuss health risks, and provide resources for nicotine cessation.
Increased use of vaping products among adolescents
With the support of the National Institute on Drug Abuse, at the National Institutes of Health, the University of Michigan Institute for Social Research distributes the annual Monitoring The Future (MTF) survey to adolescents in 8th, 10th, and 12th grades.3 In 2018, approximately 400 schools representing the public and private sector were surveyed with 44,000 respondents.4 According to the MTF survey results, electronic cigarette usage (vaping) increased dramatically. In 7 years, ENDS use had doubled with 3 million 12th grade students reporting they had used an electronic nicotine device.5 During 2017 to 2018, ENDS use rose by approximately 38% among regular monthly users. For 8th graders, it was 3.5%, 10th graders 8.2%, and 12th graders reported 11%.4 In 2018, the numbers rose to 6.1%, 16.1%, and 20.1%, respectively, nearly doubling in each population.3
Among the participants in the study, 12th graders reported that they “only vape with flavoring” and did not utilize nicotine in the past year. The use of devices without nicotine increased by 5%.3 According to the CDC, just under 5% of students in sixth to eighth grade self-reported the use of ENDS in the prior month, yet 20% of students in high school self-reported the use of ENDS in the prior month.2 The increase in vaping is a troubling trend that must be addressed by community leaders, educators, parents, and students. It is evident that education on nicotine addiction, smoking prevention, and health promotion activities should begin in middle school and continue throughout the high school years.
The latest vaping trend
Pod systems (also referred to as pod mods) are the latest technology in ENDS devices. Some of the pod system brands include Aspire, Envii Fitt, EQ Pod System, Juuls, SmokTech, and Vaporesso.6 Pod systems can be disposable or rechargeable devices that use replaceable liquid nicotine, salt-based cartridges, and temperature regulation to create an inhalable vapor.6 The newer ENDS feature a plugin pod. There are several varieties of flavors and percentages of nicotine content available for purchase with some flavors marketed toward adolescents. The average percentage of nicotine content is 5%.7,8
Although manufacturers target adults, the products' design and flavor selections (such as chocolate or fruit) appeal to adolescents.9 Many adolescents are unaware that the pods contain nicotine and falsely believe they are just inhaling vaporized flavoring. Adolescents are partial to pod systems because of their discrete usability and sleek design (resembling a flash drive) as well as the small amount of vapor (aerosol) created.10 These characteristics make pod systems an ideal choice in environments that prohibit their use, such as schools. According to one manufacturer and the Truth Initiative, the amount of nicotine in one pod may be equal to an entire pack of cigarettes.7,9
In response to the unintended purchase of newer generation ENDS by adolescents, it has been reported that one company has temporarily stopped selling the fruit- and dessert-flavored pods to retail stores. However, all flavors can still be purchased online.11 Additionally, the temporary ban that applies to retailers will be lifted once retailers comply with the company's age restriction (no sales to individuals under the age of 21) and identification policies.
According to the FDA, the 2009 Family Smoking Prevention and Tobacco Control Act omitted the regulation, dispersal, and manufacturing of e-cigarettes when developing guidelines for tobacco products.12 However, in 2016, regulations for all tobacco products, including e-cigarettes, were finalized by the FDA.13 Currently, all states with the exception of Michigan and Pennsylvania have regulations concerning youth access to electronic nicotine devices and other retail restrictions.12,14 Most recently, the FDA is deeming tobacco products to be subject to the Federal Food, Drug and Cosmetic Act, as amended by the 2009 Tobacco Control Act.13 This would require tobacco product restriction on sales and distribution, include an additive warning statement, and restrict access of youth to flavored products, plus banning menthol in tobacco products.13 A public hearing was held in January 2019 to discuss youth e-cigarette use, focusing on drug therapies for cessation and issues impacting these therapies.15 Most recently (as of July 2019), the FDA issued a statement on addressing the adolescent vaping epidemic, which included application submission deadlines for certain tobacco products, including e-cigarettes and advertisements targeting the dangers of adolescent e-cigarette use.16
Screening for ENDS use can be accomplished using the Adolescent ENDS Checklist screening tool as designed by Vincent and colleagues.17 Incorporating screening reminders in the electronic medical record is an additional prompt to probe adolescents about nicotine and/or ENDS use and may serve as a conduit to offer age-appropriate education on risks of nicotine and ENDS use.
Vaping alternatives, such as Juul pods, are an option that have piqued adolescent interest. In this population, the product is well known for its nicotine content, ease of use, and ability to conceal the device from parents or other persons of authority. It has also become evident that an increasing number of adolescents are becoming addicted to nicotine. Statistics demonstrate that nearly 40% of high school seniors report vaping within the last 12 months.18 Thus, the potential for actual nicotine dependence and addiction among adolescents has significantly increased.
Because of the increase in nicotine use among adolescents, primary care providers, parents, and educators are seeking treatment options to help adolescents overcome nicotine addiction.19 Strategies for nicotine addiction treatment have been traditionally dedicated for adults; however, adolescents are now among the population that healthcare and mental health providers are developing strategies to target smoking cessation and nicotine addiction.
Traditional cessation methods for adults with tobacco use disorder or nicotine addiction include cognitive behavioral therapy, counseling with motivational interviewing, telephone support and quit lines, use of personal computers, social media, or texting via smartphones to provide interventions and support, use of nicotine replacement therapy, or the use of oral medications.20 Two of the most common oral medications include bupropion and varenicline.20 Over-the-counter treatment options, such as nicotine gum and lozenges, are also available.
When diagnosing mental health issues among adults, nicotine dependence (known as tobacco use disorder in the Diagnostic and Statistical Manual of Mental Disorders [DSM-5] 5th Edition) is often linked in individuals with additional comorbidities, leading to dual diagnoses.21 Therefore, it can be questioned if nicotine-addicted adolescents also have comorbidities. The driving factor underlying the nicotine addiction may stem from childhood trauma, psychosocial illnesses, environmental, or behavioral contributors.22 Consequently, along with nicotine addiction, additional diagnoses may include attention-deficit hyperactivity disorder, oppositional defiant disorder, general anxiety disorder, schizophrenia, or depression.22
According to Jayarajan and Jacob, an adolescent's journey to recovery from substance use disorder is often long and toilsome.23 Treatment for nicotine addiction requires addressing the psychiatric constructs and addiction tendencies driven by genetic predisposition to addiction and the psychiatric illness together. Efficacious treatment requires dual treatment; thus, one issue cannot be addressed without addressing the other.22
It is evident that treatment of adolescent addiction should not be the same as adult addiction treatment. Jayarajan and Jacob discussed evidence-based use of pharmacologic treatment for nicotine addiction among adolescents.23 Treatment should be based on adolescent motivation to quit, the ability to participate in psychosocial therapy, and provider consideration for potential use of appropriate evidence-based pharmacotherapeutic approaches.
Implications for providers
Education is key for providers to understand the implications related to ENDS use and their impact on adolescent health, and for adolescents to become more fully aware of the consequences of ENDS use. Providers must embed the use of screening tools into practice as a prompt to address adolescent health issues that have short- and long-term health consequences. Adolescents do not possess the developmental or cognitive maturity levels to determine safe health practices, including the consequences of nicotine use. Adolescents may be unaware of the presence of nicotine in ENDS and the addictive quality of vaping. Youth must have access to multiple educational modalities to ensure information dissemination and understanding.
The US Surgeon General has called upon healthcare professionals, as well as members of the government, families, and society to help stop this expanding epidemic of vaporized nicotine use among adolescents.24 Access to treatment modalities for adolescent nicotine cessation is available at http://www.smokefree.gov and 1–800-QUIT- NOW.25 Information directed at adolescents can be incorporated into messaging on nicotine cessation efforts for providers, parents, and adolescent users and can be found at the surgeon general government website.26
A multidisciplinary treatment approach
It is incumbent upon community leaders, family members, educators, providers, legislators, and ENDS users to enhance their awareness and knowledge regarding the hazards of nicotine use in the adolescent population. Developing specific addiction treatment interventions for this unique patient population is paramount to nicotine abstinence success. The use of available nicotine addiction awareness and smoking cessation information coupled with screening all adolescents during well or acute illness visits may unearth a lack of knowledge and needed treatment resources.
Treatment options for adolescents who use nicotine delivered in the form of combustible cigarettes or ENDS must be addressed using a multidisciplinary approach. Treatment options may include pharmacologic and nonpharmacologic therapies with ongoing attention to psychiatric constructs that may affect recovery. Providers are in a unique position to assist families in addressing adolescent health impacted by nicotine addiction and support recovery efforts through ongoing screening during adolescent healthcare appointments.
1. Jamal A, Phillips E, Gentzke AS, et al Current cigarette smoking among adults—United States, 2016. MMWR Morb Mortal Wkly Rep
5. 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. MMWR Morb Mortal Wkly Rep
10. Spindle TR, Eissenberg T. Pod Mod electronic cigarettes—an emerging threat to public health. JAMA Netw Open
17. Vincent D, Potts J, Durbin J, Moore JM, Eley S. Adolescent use of electronic nicotine delivery systems. Nurse Pract
21. Han B, Compton WM, Blanco C, Colpe LJ. Prevalence, treatment, and unmet treatment needs of US adults with mental health and substance use disorders. Health Aff (Millwood)
22. Riggs PD. Treating adolescents for substance abuse and comorbid psychiatric disorders. Sci Pract Perspect
23. Jayarajan D, Jacob P. Psychosocial interventions among children and adolescents. Indian J Psychiatry
. 2018;60(suppl 4):S546–S552.
24. 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. MMWR Morb Mortal Wkly Rep
26. United States Department of Human Services. Know the Risks: E-cigarettes and Young People. Washington, DC: US Surgeon General, US Department of Health & Human Services; 2019. https://e-cigarettes.surgeongeneral.gov