The use of e-cigarettes has increased dramatically in the last few years among teens. It is estimated that 4 million adolescents are using e-cigarettes and there was a 10-fold increase between 2011 and 2016. This is Part II of a 2 part series on e-cigarettes.
There is concern that use of e-cigarettes by adolescents leads to nicotine addiction and possibly eventual dependency on tobacco cigarettes. Currently, more adolescents use e-cigarettes than tobacco cigarettes. Motivation for use by minors seems related to sensation-seeking, peer pressure, and as an outlet for stress. While most adolescents who use e-cigarettes are using it socially and are not getting addicted, a large minority is developing an addiction to nicotine from vaping.
“Juuling” has become very prevalent across high school campuses. (If you remember from Part I, a pod of the e-liquid in a Juul has the equivalent nicotine as one pack of cigarettes). It is so common that it has become a verb. The images on teen-focused social media make it seem like a fun and risk-free activity that everyone is engaging in. And it is beyond regulation because the FDA can regulate how nicotine companies advertise to consumers but not how teens “advertise” to other teens via social media. There is concern that companies are branding e-cigarettes to make them appealing to teens and have developed flavors as a way to make them more appealing to young people. Interestingly, years ago the FDA had banned tobacco companies from making flavored cigarettes because they were seen as a way to hook teenagers on cigarettes.
The FDA has some regulation over e-cigarettes but did not begin regulating ENDS as tobacco products until 2016. Currently it is illegal for minors under 18 to buy e-cigarettes. Juul cannot be sold online to anyone under 21 but there are dealers on high school campuses and some teens buy it on eBay or other online venues. There is a definite concern that the FDA and other regulatory agencies are behind the curve on this growing trend and that Juuling among adolescents is becoming a public health concern. Also, because of limited regulation by the FDA, the many companies that are sprouting up selling e-cigarettes and e-liquid are making products with varying amount of nicotine and other chemicals. It can also be challenging to know if a particular e-cigarette is laced with other psychoactive ingredients.
Because e-cigarettes are relatively new, there is limited information about the long-term side effects of their use. We know some about the long-term side effects of nicotine use, but what is not known is the long-term effect of the delivery system and other chemicals and by-products in e-cigarettes and e-liquid. We know that younger brains are more likely to become addicted to nicotine than adult brains and that nicotine can effect brain development and cognitive functioning. This lack of knowledge is similar to the concerns about cannabinoid oil – we know about the side effects of THC in cannabis, especially in adolescent brains, but we don’t know yet the long-term effects of cannabinoid oil.
As food for thought, the harm-reduction pioneer Michael Russell said in 1976, “People smoke for the nicotine, but they die from the tar”. Given that many adults believe there are benefits from nicotine, it is important for us as providers to better understand vaping, which might be a less harmful way to use nicotine, and help patients make educated decisions about using e-cigarettes. The dilemma is that the more appealing vaping is to adults who are trying to stop smoking, the more appealing it is to other populations too, like impressionable teens. Therefore it is also important as primary care providers to have careful discussions with adolescents who may be using e-cigarettes about the risks of their use. It is our hope that this 2-part primer on e-cigarettes helps begin the process of education on this topic.