Children as young as 11 are struggling with addictions to e-cigarettes, also known as vaping, in reference to the vapor (opposed to smoke) emitted from the device. The gradual demise of traditional cigarettes has been heralded as an achievement for better health, but the danger is the alternative many have chosen may be just as alarming.
While e-cigarettes do not expose you to thousands of toxic compounds found in conventional combustible cigarettes, researchers are only beginning to understand the toxicities involved in smoking e-cigarettes. In some ways, these man-made options may be just as dangerous, just with different consequences.
There is a perceived assurance these devices are safe and harmless as the vapors are often odorless and large e-cigarette companies spend large amounts of money on advertising to convince users they are a safe alternative to smoking, or an aid to stop smoking.
The Centers for Disease Control and Prevention1 calls tobacco use the "single largest preventable cause of death and disease in the United States," killing more than 480,000 Americans every year and 41,000 from exposure to secondhand smoke.
But even bystanders are exposed to toxic nicotine, heavy metals, fine particulate matter and formaldehyde from e-cigarette devices. Electronic cigarettes are also sometimes called e-hookahs, vape pens and electronic nicotine delivery systems. Some look like regular cigarettes, cigars or pipes, while others look like USB flash drives, pens and other everyday items.
No Treatment Options for Teenage Vaping Addicts
Some of the nation's top health authorities now believe teen vaping has reached epidemic proportions, affecting some 3.6 million underage users. But while the problem grows rapidly, no one seems to have an idea of how to best help teenagers who may be addicted to electronically delivered nicotine.
Federal law prohibits the sale of vaping devices to those under 18, although many high school students have reported getting them from older students, online or siblings. To date there has been little discussion of how to treat nicotine addiction in younger children as this is a relatively new problem.2
Inhaling cigarette smoke is harsh and not pleasurable the first several times. This sometimes discourages teenagers from picking up the habit altogether. This deterrent does not exist with vaping, a process typically smoother and laced with flavor.
The U.S. Food and Drug Administration (FDA) is considering the role new drug treatments may play in helping children give up nicotine. The medications currently on the market are not approved for use in children or young teens, leaving them without a medical option to help them quit the vape habit.
The FDA held a public hearing to allow medical organizations and the vaping industry to weigh in.3 During the hearing, FDA Commissioner Dr. Scott Gottlieb made a direct threat against the industry, saying:4
“I’ll tell you this. If the youth use continues to rise, and we see significant increases in use in 2019, on top of the dramatic rise in 2018, the entire category will face an existential threat. It will be game over for these products until they can successfully traverse the regulatory process.”
Bonnie Halpern-Felsher, who studies youth e-cigarette use at Stanford Children’s Health, also spoke before the public hearing, commenting on how the FDA is helping to muddy the waters by saying e-cigs are safer:5
“We need to stop saying that e-cigarettes are safe or safer and prevent e-cigarette companies from making these unauthorized risk claims. Youth hear them. We need to stop saying that e-cigarettes help adults stop smoking when there [is] not clear evidence that this is the case.”
But until changes are made, parents and teens are faced with the fact that quitting a nicotine habit requires patience, discipline and a willingness to follow a treatment plan. These strategies do not come easily to young minds not fully cognitively developed. Dr. Susanne Tanski, a tobacco prevention expert with the American Academy of Pediatrics, commented:6
“Teenagers have their own ideas of what might work for them, and they’re going to do what they do. But we desperately need studies to figure out what’s going to work with this population.
It’s frightening for me as a pediatrician because I really feel like there’s this uncontrolled experiment happening with our young people. They don’t perceive the harm, and we can’t show them what it’s going to be.”
Teen Vaping Rising Precipitously
In a recent study evaluating e-cigarette use in adults,7 researchers found of e-cigarette adult users, 15 percent went on to become cigarette smokers. The prevalence in the study was highest among persons aged 18 to 24 years, translating to nearly 2.8 million users in this age group. More than half the users were younger than 35.
These results support other data8 showing young people are more engaged by vaping than older adults. A recent Gallup Poll reported 9 percent of all Americans say they regularly or occasionally vape.9
However, this rate is 20 percent among those 18 to 29 years old, compared to 8 percent in those over 30. According to this poll vaping is now on par with the 18- to 29-year-old group’s use of conventional cigarettes.
Although the World Health Organization (WHO) reports a small decrease in the estimated number of smokers globally since 2000, the number who are vaping has only continued to rise, from 5 million to over 40 million.10
Estimates are the global market has reached $22.6 billion, up from $4.2 billion just five years ago. The U.S. far out distances the second largest markets — Japan and the United Kingdom. A 2016 report from the U.S. Surgeon General11 cites a 900 percent increase in vaping by high school students between 2011 and 2015.
The prevalence of vaping doubled from 2017 to 2018, as a large federally funded survey12 conducted annually by the University of Michigan in their Monitoring the Future Study13 found twice as many high school students are using electronic nicotine delivery systems this year as compared to last year.14
Experts attribute this jump to versions of the device, like those produced by Juul Labs resembling a computer flash drive that can be used discreetly at school. One bright spot in the study found teenagers are saying “no” more frequently to cocaine, LSD, Ecstasy, heroin and opioid pills.15
Juul Nicotine Salts Are Wildly Addictive
If nicotine delivered through traditional combustible cigarettes is addictive, then the delivery system Juul developed to increase their market share is super addictive. And, there is good reason for why vaping a Juul is a significantly different experience than traditional smoking or other e-cigarettes.
Morgan Stanley analyst Pamela Kaufman16 told investors “Juul’s success underscores the potential for disruptive technology to undermine U.S. tobacco’s reliable business algorithm.” Business Insider says the product is so popular, it has become a verb; it's not “smoking” or “vaping” anymore, it's “Juuling.”
Juul presents itself as the “most satisfying” and “genuine alternative to cigarettes”17 delivering a “nicotine hit that's much more like smoking a cigarette than other e-cigs.”18 The company accomplished this using their patented JuulSalts, approaching nicotine delivery much more like traditional cigarettes.
Since Juuls are less harsh to inhale and the nicotine can be absorbed directly through the mucous membranes in your mouth, those vaping agree they get a much stronger nicotine “hit” than from other e-cigs.
JuulSalts make the nicotine easier to access. According to the company website, freebase nicotine is mixed with benzoic acid to make the e-liquid, which has a chemical reaction to produce the nicotine salts. JuulPod e-liquid cartridges contain up to twice the amount of nicotine as a pack of cigarettes, and they're just as easy to inhale.19
Biggest American Cigarette Company Buys 35 Percent Stake in Juul
Although Juul Labs already has the largest market share in e-cigarette sales, this may potentially grow even larger with a new partnership with Altria, one of the world's largest tobacco companies, which owns Philip Morris, makers of Marlboro cigarettes and a number of other traditional tobacco companies.
With a minority investment of $12.8 billion for 35 percent ownership in the company, Altria announced a mission to eliminate its production of traditional cigarettes. By eliminating Marlboro cigarettes, Altria will no longer be competing against its other interest and Juul has a sure footing for greater domination in e-cigarettes sales.
This came on the heels of a $1.8 billion investment in a Canadian cannabis company. With a decline in traditional cigarette smoking, this poises Altria for rapid growth in the e-cigarette market and gives Juul access to a massive distribution network and advertising campaigns. In a statement,20 Matthew Myers, President of the Campaign for Tobacco-Free Kids, said:
"Altria has no interest in reducing the number of people who smoke cigarettes. They see Juul as their failsafe in case the cigarette market keeps declining so that they remain profitable no matter what happens.
Altria's interests are served by maximizing sales and profits from both the cigarette and e-cigarette markets, and they have every reason to push Juul to market its products in a way that does the least damage to the cigarette market."
Teen Vaping May Increase Potential to Smoke Traditional Cigarettes and Other Addictive Behavior
Despite the industry's claims to the contrary, a growing body of data continues to demonstrate damage to the user and bystander from e-cig vapor. One of the significant dangers to teens is a common misconception that the practice is not dangerous.21 FDA data also revealed that compared to 2017, in 2018:22
- There was a 78 percent increase in e-cigarette use among high school students
- There was a 48 percent increase in e-cigarette use among middle school students
- 28 percent more high school students used e-cigarettes on 20 or more days
- 68 percent more high school students used flavored e-cigarettes
Thirty-one percent of those surveyed said the availability of flavors like mint, candy, fruit or chocolate was the reason why they used e-cigarettes, while 17 percent cited the belief they're less harmful than other forms of tobacco, such as cigarettes.
Among high school seniors who have never smoked combustible cigarettes, those who vape are four times more likely to pick up a cigarette in the following year. Researchers also find those who vape are more likely to move away from the view that smoking poses a greater risk of harm than those who never pick up an e-cigarette. Results from this study contribute:23
“... to a growing body of evidence showing that teens who vape are more likely to start smoking than their peers who don’t vape. At the very least, teens who vape should be considered at high risk for future smoking, even if they believe they are vaping only flavoring.”
An animal study from the University of Pennsylvania24 determined rats exposed to nicotine during adolescence grew up to drink more alcohol than those who were not exposed. Exposure at a young age changes the neurological circuitry in the brain within the reward center, potentially explaining how exposure at a young age increases the potential for addictive behavior later in life.25
Vaping Increases Risk of Heart and Lung Disease
In addition to leading to smoking traditional cigarettes in the future, vaping also delivers an appalling amount of heavy metals and toxic chemicals. E-cigarette devices other than Juul deliver lower levels of nicotine than traditional cigarettes. Yet, people exposed to e-cigarette air pollution have similar levels of nicotine in their system as those exposed to traditional second hand smoke.26
Other toxins detected in e-cigarette vapor include diacetyl, formaldehyde, diethylene glycol, tobacco-specific nitrosamine and highly reactive free radicals. According to a study from Boston University School of Medicine, e-cigarette flavors may induce early signs of cardiovascular disease leading to heart attack, stroke and even death.27
The scientists found changes appeared almost immediately on the cellular level.28 A recent study29 found vapor from e-cigs boosts production of inflammatory chemicals and impairs the activity of macrophages, leading researchers to conclude it may damage vital immune system cells.30
Many of the effects researchers observed were similar to those seen in people who regularly smoke traditional cigarettes or those with chronic lung disease. The researchers found e-cigarette vapor disabled the ability of macrophages to engulf bacteria and protect pulmonary function.
This type of damage increases lung cells vulnerability to dust, bacteria and allergens, also increasing the risk of triggering chronic obstructive pulmonary disease. A study31 from the University of Michigan found the benefits of using vaping to quit smoking also far outweigh the health risks associated with teens who move from vaping to traditional cigarettes.
Talk with Your Children
Dr. Deepa Camenga, a pediatrician who is board certified in addiction medicine, recommends you talk early to your children about e-cigarettes in age appropriate language. She recommends:32
“When you are out and about with your children and see an advertisement, for example, take the opportunity to talk about it. It’s also important to give teens and young adults the space to ask questions.”
Dr. Patrick O'Connor, Yale School of Medicine, has dedicated his career to opioid and alcohol drug abuse research. He points out similarities between the epidemic in cigarette use in the 1940s and 1950s and the rising e-cigarette epidemic found in teens today.
Suchitra Krishnan-Sarin, Ph.D., is the co-leader of the Yale Tobacco Center for Regulatory Science, one of 14 centers in the U.S. funded by the National Institutes of Health and the FDA to foster tobacco regulatory research. She recommends parents do not purchase e-cigs under the misconception they may prevent their children from smoking traditional cigarettes, and says:33
“I think the problem is that parents lose credibility if they say something to try and convince their child, who then finds out that it isn’t true. Parents should base their information on accurate facts and also encourage their children to read about and understand the science on this issue instead of relying on what their friends and peers tell them."