Adolescents’ Perceptions, Experiences, and Reactions to “Fake” Vaping Devices

Abstract

Use of electronic cigarette (vaping) devices, whether to inhale nicotine, cannabis, or other substances, may pose health risks to adolescents. Those risks could be heightened when a vaping device is “fake,” a term we use to include inauthentic, knockoff, counterfeit, and/or adulterated devices, an issue exemplified by the Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) outbreak of 2019-2020.

Methods:

Investigators completed in-depth, semi-structured interviews in 2020-2021 with 47 California adolescents (ages 13-17) who used nicotine products. Investigators used thematic analysis to examine participants’ perceptions and reactions to fake vaping products, including devices to inhale nicotine or cannabis.

Results:

Participants were familiar with fake vaping devices, which they considered to be low-quality and potentially dangerous, learning about them from peers, their own experience, seeing other young people affected by them, social media, and occasionally from classes in school. Some had heard about health emergencies after using a fake product, but few were specifically familiar with EVALI. Some adolescents were confident that they could detect fake products, although others perceived encountering and using fake devices to be unavoidable. Participants believed that profit motives drove the existence of fake products, especially from informal sellers, and assumed that large companies and government agencies were actively protecting consumers.

Conclusions:

Adolescents are aware of and may encounter fake vaping devices, potentially exposing them to elevated health risks. Effective public messaging and stronger actions to curb the fake product supply would better protect this population.

1. INTRODUCTION

Vaping devices can be used to inhale nicotine or other psychoactive substances, including tetrahydrocannabinol (THC), the psychoactive component of cannabis. Vaping among adolescents is especially concerning to public health. In 2023, 10.0% of US high school students currently used nicotine e-cigarettes (Birdsey et al., 2023). A metanalysis of adolescents in the US and Canada estimated that the past 30-day prevalence of cannabis vaping rose from 1.6% in 2013 to 8.4% in 2020 (Lim et al., 2022). Use of nicotine e-cigarettes has been associated with adverse health outcomes among adolescents, including mental and respiratory problems (Becker et al., 2021; Tackett et al., 2024). Likewise, cannabis use during adolescence may increase the risk for mental health issues and substance use disorders (Hurd et al., 2019). Consuming THC via vaping is less well studied than cannabis use generally, but emerging evidence suggests harms of high-concentration THC product use, including psychosis (McDonald et al., 2024) and hyperemesis (Lathrop et al., 2023).

The Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) outbreak in 2019 and 2020 resulted in at least 2,807 hospitalizations and 68 deaths and has been connected to the presence of vitamin E acetate in THC-containing vaping devices (Marrocco et al., 2022; Werner et al., 2020). Patients with EVALI were disproportionately adolescents or young adults who had obtained THC vaping devices via informal or illicit channels (Adkins et al., 2020; Marrocco et al., 2022). Vitamin E acetate was presumably used as a cutting agent, allowing illicit sellers to dilute the THC content while maintaining the high viscosity consumers would expect in an unadulterated product (Cao et al., 2020). While vitamin E acetate is not the only potential toxicant that could contribute to EVALI (Marrocco et al., 2022), nor the only dilutant found in cannabis products (Cao et al., 2020), the EVALI outbreak placed new attention on the potentially elevated health risks posed by altered, illicit, or counterfeit vaping products.

Such vaping products may be described by different terms. For this study, we use the word “fake” to encompass several meanings in the context of nicotine or cannabis vaping devices, including a product that is 1) made to look authentic to deceive people; 2) a more affordable imitation of a popular product (knockoff); 3) created to resemble the original item, typically for fraudulent or unlawful reasons (counterfeit or off-market); or 4) hacked or modified after original purchase in a way that exceeds the manufacturer's intended use (altered or adulterated).

Adolescents and young adults may be particularly susceptible to encountering fake vaping products, as they are more likely than older adults to obtain nicotine e-cigarettes and cannabis vape devices from informal or loosely regulated sources, such as friends, dealers, and online sellers (Adkins et al., 2020; Gaiha et al., 2020; Schiff et al., 2021). Adolescents, who by circumstance are often price-sensitive, may seek out less expensive products, including knockoff or counterfeit versions. There is no shortage of such vaping products in circulation; in December 2023, for example, US Customs and Border Protection and Food and Drug Administration (FDA) seized nearly 1.4 million unauthorized units of e-cigarette products in a single operation (FDA News Release, 2023). Despite the prevalence of these products, there is limited research on how adolescents perceive and navigate potential risks associated with fake vaping devices. This investigation examined the perceptions and experiences of adolescents with fake vaping products, including awareness, health perceptions, and any measures taken to identify and avoid such products.

2. METHODS

We conducted semi-structured, in-depth videoconference interviews with a purposeful sample of N=47 adolescents, ages 13-17, residing in California (USA) who had self-reported having used any type of tobacco product (N=45 had used e-cigarettes multiple times). Interviews lasted approximately 60 minutes. All participants signed an assent form, and parents provided consent on behalf of their children. Participants received a $20 e-gift card for participation, which was later increased to $40 to enhance recruitment. The University of California San Francisco Institutional Review Board approved all study procedures. The Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007) guideline was followed.

2.1. Participant Recruitment

Twenty-five adolescents interviewed between May and June 2020 were recruited from a larger study of students attending rural California high schools (Chaffee et al., 2021). Additionally, to increase geographic diversity and examine further themes uncovered after initial analysis of the first set of interviews, an additional 22 adolescents were recruited and interviewed between December 2020 and February 2021 via social media advertisements directed to parents of adolescents ages 13-17 throughout California (advertisements were directed to parents, who must consent for their child to participate). Eligibility questions differed slightly between the recruitment methods, but all eligible participants reported use of ≥1 tobacco product (e.g., e-cigarettes, cigars, cigarettes) ≥3 times in their lifetime. While not every participant had used a vaping device to consume cannabis, nearly all had vaped nicotine, and all were familiar with these behaviors among their peers. All participants were invited to a second interview, which occurred between August and December 2021. Seventeen participants were interviewed a second time (n=11 from school-based sample; n=6 social media sample). Non-response was the single-largest reason for non-participation. Among all 47 participants, mean age at first interview was 15.4 years, 31 (66%) identified as female, 21 (45%) stated they received free or reduced-price lunch at school (a proxy for household income), and 31 (66%) lived in a household with two parents.

2.2. Interview Topics

Overall, interviews centered on general knowledge about cannabis and tobacco products (including e-cigarettes), as well as daily routines, relationships, health, and tobacco, nicotine, and cannabis use (see Supplemental Appendix for details). Relevant to this analysis, in the context of tobacco and cannabis products, participants were asked, “Do you ever worry about bad products? Tell me about that.” and “What do you do to check that your product is safe?” Interview guides were updated between recruitment phases to ask additional structured questions specific to fake products and EVALI (Supplemental Appendix), allowing more in-depth exploration of these topics, including familiarity, beliefs, risk perceptions, and whether or how their beliefs about fake products influenced their behaviors. For participants from the first recruitment phase who completed a second interview (n=11), these additional questions were analyzed alongside their first interview answers. Interviewers used the terms “bad” or “fake” products. In the context of conversations, participants would often take these terms to include knockoff, counterfeit, and/or modified products.

2.3. Data Analysis

All interviews were audio recorded over videoconference, transcribed verbatim professionally, and the transcripts de-identified. Transcripts were imported into Dedoose (version 9.0.17) and thematically analyzed following an inductive approach (Braun & Clarke, 2006). The Supplemental Appendix contains coding process details and a list of codes. All interviews were analyzed together, regardless of recruitment method. After a set of codes was created, data were further analyzed by examining five major themes uncovered in the data:

• Knowledge and Beliefs about Fake Vaping Products

• Risk Perceptions and Reactions to Fake Products

• Checking Product Authenticity

• E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI)

• Market Forces Affecting Fake Products

Representative supporting quotes appear within the manuscript text or tables, organized by theme.

3. RESULTS

3.1. Knowledge about Fake Vaping Products

When asked about fake products, adolescents talked about devices to vape nicotine (e-cigarettes) and devices to vape cannabis (often referred to as “smoking”) in distinct ways.

3.1.1. Nicotine E-Cigarettes

Fake e-cigarettes were described in broad terms, encompassing hacked or modified versions, knockoffs, and counterfeits. There was a sense that nicotine vaping products could be altered with added ingredients, but participants did not identify any specific ingredients. References were made to harsh, hazardous chemicals used to modify the vaping experience.

Several adolescents talked about fake e-cigarettes as attempts to “imitate the flavor and the feel” of an original product. Fake e-cigarettes were associated with poor quality and lower prices than authentic ones (referred to as “knockoffs” or “bootleg”). Despite quality concerns, imitation or potentially counterfeit items offered a favorable price (Table 1). Participants also described e-cigarettes being recycled and resold; such devices were perceived to be dangerous (Table 1).

Table 1.

Representative Participant Quotes: Knowledge about Fake Vaping Products

Participant	Themes, Subthemes, and Quotes
	Theme I. Knowledge about Fake Vaping Products
	Subtheme I.A. THC Vaping Devices
#26, male, age 16	There was this kid who was selling fish oils. So, he was basically filling it [THC vaping device] up with fish oil after [exhausting the original content], and then he would sell it to other people and then they would be basically smoking fish oil.
	Subtheme I.B. Nicotine E-Cigarettes
#27, female, age 16	[On Instagram] they're saying they're fake. They have harsher chemicals than what are in actual vapes.
#38, male, age 13	Fake products have more hazardous chemicals in them; that's why they're faked. …I think [in] the juice they add stuff to make the smoke clouds bigger or to try to up the buzz a little bit.
#23, female, age 14	But when it is the off-brand, I do get a little bit worried because, well, they're cheaper. So, that's… what they [peers who vape] get most of the time 'cause you can get Pop Bars and all of those for 20 bucks instead of 25.
#39, male, age 16	The only thing I've heard about vapes being fake or really harmful is when the coils are burned. There's big Suorin Pods you can buy off these websites… …Once those coils are burned, it's really, really bad for you to inhale it. Yeah, it's brand new and then [after coils burn] just sell it to kids because kids don't know any better. 13-year-old kids, they're just trying to buy a vape. And they just don't know.
	Subtheme I.C. Information Sources
#25, female, age 15	It [fake e-cigarettes] came up on TikTok saying, "Oh, we don't recommend you doing any [nicotine] vape, but if you do, we don't recommend you this because they're fake and they could give you…" I don't know what it was. I don't know what the cons [downsides] are… but I know that it was something that could worsen your health in some bad ways or forms.
#16, female, age 15	Every now and then I used it, like a wax pen, but then, there was a couple ODs [overdoses] at my school where people would put something that's fake, that has fentanyl in it… and the ambulance would get called, and they'd get taken off campus and taken to the hospital… I witnessed one of them pretty much a minute after they hit the fake cart [vaping cartridge]. She turned really pale and she was, "I don't feel good." And we're, "What do you mean?" And then all of a sudden, she passed out and just fell over and I started freaking out.
#43, female, age 16	I had friends who sold a lot. They'll just be telling me about it [fake THC vapes]. I'm, "Oh, cool." They're, "Yeah, watch out for this." And I was, "Okay, for sure." And, yeah. It was posted everywhere. Everyone's story on social media would have it posted: "You don't buy these, don't buy from this person, they sell these," or "Don't, these are laced and stuff like that."

3.1.2. THC Vaping Devices

Regarding “fake” THC vaping devices, participants spoke primarily about additives to dilute THC concentrations. They mentioned specific ingredients, including honey, water, vitamin E acetate, and fish oil as diluting agents. At times, ingredients might replace THC altogether in attempts to trick younger or inexperienced users (Table 1). Participants also described fake THC vaping devices as being laced or tainted with unidentified metals or pesticides and with more dangerous drugs, such as fentanyl or cocaine.

3.1.3. Information Sources

Adolescents in the study learned about fake products from a range of sources. Many participants generically affirmed that they had “heard” or “read about” fake products, often from social media (Table 1). Less often, but in more detail, participants knew someone with direct experience with a fake product, claimed to have witnessed someone experiencing health effects after using a fake product, or heard secondhand about someone in their school encountering a fake product. Some had encountered fake products themselves, more often e-cigarettes than THC vaping devices. One participant trusted her own accumulated experience to identify vaping products that “felt off” after inhaling. Some participants learned about fake products in health class or through a class assignment, while a few had witnessed schoolmates being physically and mentally affected by unsafe products (Table 1). Participants also relied on extended social networks, including more experienced friends, to identify and avoid fake products (Table 1).

3.2. Risk Perceptions and Reactions to Fake Products

Many adolescents viewed fake nicotine e-cigarettes and THC vaping devices as risky, with the potential to cause mild to severe illnesses. Often, participants considered the risks associated with fake THC vaping devices as higher than the risks from fake e-cigarettes (Table 2).

Table 2.

Representative Participant Quotes: Risk Perceptions and Reactions to Fake Products

Participant	Themes, Subthemes, and Quotes
	Theme II. Risk Perceptions and Reactions to Fake Products
#45, female, age 17	So, the wax pens [THC vapes] itself can be laced; it's just as dangerous [as a blunt]. It can be laced with a way more harmful drug. If you don't know where you're getting it from, it could be laced with something so harmful that could maybe result in death.
#4, female, age 16	It was a bit conflicting, but I figured, you know, the risk of having a fake one would far outweigh, you know, the pleasure I get from it …I'm trying to think [of the] visually pleasing part, like being able to do tricks and stuff. So, if smoke isn't barely there [because the device is fake], then, you know, it wasn't worth it to me.
#34, male, age 16	Interviewer: Then has hearing about the existence of these fake products made you change any of your behaviors or habits at all? Adolescent: Um, habits. I wouldn't say so. I still do it [vaping]. I think, well, if I could do it just as often I would, I just keep an eye out more [for] it, 'cause I have seen like on Snapchat, people will post that they're selling stuff, and I'd see those ones that people said to look out for. And so, I'm, "Okay, now I know that I shouldn't be getting anywhere near that."
#44, female, age 17	… I just feel like I wouldn't really make a difference [if a product is fake], 'cause either way I'm putting chemicals in my body… Yeah.

Among those adolescents who had heard about fake products, most, but not all, expressed approaching the products they use with caution. Some participants stopped using or got rid of a vape device if they suspected it was fake, stating that use “wasn’t worth it” given the potential health consequences (Table 2). While not all participants changed their behaviors, some became more vigilant. One participant mentioned that although he continued to vape frequently, he started to “keep an eye out” for dangerous products (Table 2).

In contrast, some participants were unconcerned. One participant said that her friends did not try to authenticate products because of nicotine addiction; once addicted, it did not matter to them if the product was fake or not. For others, once they had already spent money on a product, they rationalized that authenticity made little difference because they were ingesting harmful chemicals regardless (Table 2).

3.3. Checking Product Authenticity

Adolescents reported several strategies to check whether vaping products were authentic or fake. Strategies were largely similar for nicotine and THC-containing devices, with the addition of two distinct visual tests for THC vaping devices.

3.3.1. Visual Clues

Participants attempted to identify fake products by discrepancies in packaging colors, font styles, and the presence of Chinese characters, which were thought to indicate that a product was fake. A variety of product details were thought to reveal fake products, including missing labels, a sticker on the packaging, incorrect brand colors, or a logo that was printed rather than engraved (Table 3).

Table 3.

Representative Participant Quotes: Checking Product Authenticity

Participant	Themes, Subthemes, and Quotes
	Theme III. Checking Product Authenticity
	Subtheme III.A. Visual Clues
#26, male, age 16	The packaging can be the way [to identify a fake product]. …here was this little mark, so there'd be the box and then there would be a little line right in the middle. And if it didn't have that, then it was considered fake.
#31, female, age 17	Basically, if you hold it [THC vape device] upside down, and then you watch the liquid, because the wax thing, it has a little tube of wax, if you hold it down the way [the liquid] falls down, I think if it falls like faster, there's water in it, and if it's too slow, it's because it has honey because the honey's stickier or something like that.
	Subtheme III.B. QR Codes
#44, female, age 17	…On the boxes [packaging], there are QR codes that you can go onto their website and there's a serial number on the thing. So, I'm sure you could search it up, but I've never checked it. I just feel it's too much work and I also didn't want that in my search history or anything.
	Subtheme III.C. Device Performance
#43, female, age 16	Basically, if you move [a THC vape pen] around, and it doesn't move, if the bubble doesn't move a lot, you know, it's good. There won't be a lot of smoke, but [if] it's moving around like syrup, it definitely has pesticides in it and you shouldn't touch it, and it'll make a lot of smoke.
#4, female, age 16	But one of my biggest clues was that the actual smoke of it [nicotine e-cigarette] was not very heavy. I know an authentic one to [make more aerosol]. The thickness of it… you know? I think the juice was also little bit harsh, which is another indication that it could definitely be a fake.
#26, male, age 16	[I can identify a fake nicotine e-cigarette] mostly honestly by the way it hits. The way it hits is the way you can tell.
#23, female, age 14	One time, my friend got this dab pen [THC vape] cart. And… [she] was talking about how it wasn't hitting. So, I brought it inside. And I was, “Yo, [friend], what's wrong with this?” And she was, “This is literally just nicotine and honey, don't use this… this smells like honey and it hits like nic.”
	Subtheme III.D. Accepting the Limitations of Available Tests
#11, male, age 15	The sticker started peeling off. It's supposed to be engraved into the glass. And that's how I realized that it was completely fake. I went online and I looked it up, and sure enough there's fake ones that have stickers on them. So, I went to the real website and I ordered one that engraved into it, and you can just tell that it's [authentic]… but at the same time, you can't.
#34, male, age 16	Another way to test the product is… a lab test, getting the actual liquid tested via a lab, which isn't possible for us [teenagers]. That's the only other way that we can really tell if it's good or bad.
#38, male, age 13	I don't know. I just thought it's the only thing I have, so I might as well use it.
#11, male, age 15	A lot of my friends are buying all this vape stuff off the market, off the black market and stuff, because that's all they have access to.

Participants considered the liquid inside THC vaping devices as an important indicator of authenticity. A yellow liquid was considered more likely to be high-quality, whereas a dark, syrupy yellow or brown liquid was likely to indicate a fake or off-brand product. The “bubble test” consists of flipping the device upside down and observing the movement of bubbles inside to assess viscosity (Table 3). Bubbles moving too quickly or too slowly were believed to indicate that product contents had been substituted, replaced, or cut with harmful additives. If bubbles stayed still upon shaking, the product was considered “good.”

3.3.2. QR Codes

QR codes on e-cigarette or THC vaping device packaging could be used to verify products on manufacturer websites. Sometimes, this required downloading an application to scan the product; alternatively, QR codes led to the brand webpage to enter a product code. Most of the adolescents who were aware of this authentication method chose not to use it, citing the effort involved and a lack of perceived benefit. One adolescent cited privacy concerns; she did not want her browser history to reveal e-cigarette websites (Table 3).

3.3.3. Device Performance

A few participants attested that the only way to tell if a product was fake was by using it and observing its effects. Adolescents considered the smell and smoke that the device produced (Table 3). According to one participant, lots of smoke could indicate the product is laced with pesticides. Issues with flavor intensity, smoke/aerosol production, harshness, and the high or buzz experienced were all potential indicators of a fake device. A few participants said they could tell if one kind of substance had been substituted for another. Overall, device underperformance or poor user experience were considered signs of a fake product (Table 3).

3.3.4. Accepting the Limitations of Available Tests

A few participants spoke about how difficult it is to be certain that a product is authentic, even when taking steps to verify it. Two adolescents mentioned lab testing, one acknowledging that this was not accessible to people their age (Table 3). A small number of participants had never heard of anyone worrying about or checking for fake vaping products. A few said that they used products even when they knew they were fake, sometimes citing their limited options to obtain nicotine or cannabis (Table 3).

3.4. E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI)

Only two participants recalled hearing or reading news reports about EVALI, and only one recognized the EVALI acronym. A few acknowledged having heard news reports about teenagers being hospitalized during the time of the EVALI outbreak, which they attributed to nicotine e-cigarette use (Table 4).

Table 4.

Representative Participant Quotes: E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI)

	Themes, Subthemes, and Quotes
Participant	Theme IV. E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI)
#35, male, age 17	I heard that [there] were actually people getting hospitalized from [nicotine vaping], I didn't know it had a name.
#42, female, age 14	One close friend vaped a lot, and he got hospitalized 'cause he was just [vaping] 24/7. He got addicted really quick. [News of his hospitalization] spread like wildfire. The admins of the school were using that as an example… I think it's the ones with the nicotine when the nicotine gets in their lungs and then it, I think it just builds up and then they can't breathe or they have little attacks.
#34, male, age 16	I've seen [THC vaping devices] online, people posting things that are obviously very fake. So, I try not to use those ones that look like they have a lot of additives, and a popular one that people talk about is vitamin E, which apparently can build up in your lungs. And after using it for a while can really hurt you.
#20, male, age 15	I read something about the vitamin E acetate or something like that. It's something that is pretty common that you put into [THC vape devices]. …But that is why it's causing some of the health scares and stuff.

A few adolescents said they knew schoolmates or friends who had been hospitalized due to excessive nicotine e-cigarette use (Table 4). One participant described a hospitalization following use of a THC vape pen laced with fentanyl; another described seizures after nicotine exposure. No participant associated EVALI by name with vitamin E acetate in THC vaping devices. However, two participants mentioned having heard warnings about vitamin E in THC vape pens (Table 4).

3.5. Market Forces Affecting Fake Products

3.5.1. Profit Motives

According to participants, fake products are profitable to sellers, often to the detriment of young or inexperienced buyers who have limited purchasing options. Sellers of fake products were viewed as willing to do whatever it takes to earn money. Most comments about profit motives referred to fellow adolescents who resold vaping products informally (dealers), as opposed to manufacturers or other commercial entities (Table 5).

Table 5.

Representative Participant Quotes: Market Forces Affecting Fake Products

Participant	Themes, Subthemes, and Quotes
	Theme V. Market Forces Affecting Fake Products
	Subtheme V.A. Profit Motives
#31, female, age 17	I've heard of people on wax pens putting honey [inside] instead and selling it to the younger classmates who didn't know…or they would give them a half used one and fill it up with water, so it looked like it was full.
#43, female, age 16	Having friends who sell [vapes], basically taught me a lot about it, 'cause people, they'll do anything for money. So, they'll sell… [to] people who are doing it for the first time.
#39, male, age 16	And there's a lot of people like 18-year-old kids that just buy that stuff online… You can buy a bunch of fake knockoff versions of the Suorin Air and the Suorin Drop that are $10 and sell them for $30. That’s what a lot of people started doing.
	Subtheme V.B. Perceived Consumer Protections
#20, male, age 17	I know that if you're legally growing marijuana, there's certain health standards from the FDA and stuff that you have to follow.
#36, female, age 15	[When you know a product is fake] is even scarier because then it definitely has not been approved by the FDA, and you don't know what they're putting in them.
#4, female, age 16	When you have a big company, there is a liability reassurance there… They’re going to try and make sure their product is fairly good for people… Fake [manufacturer] didn’t put as much thought into it as this big franchise.
#35, male, age 17	‘Cause at least the actual Puff Bar from the company are tested and they have certain rules that they have to follow, but if it is a fake product, then they don’t really have to follow those rules.
#5, male, age 17	I feel if you're getting weed from a sketchy person, it's better to go to a dispensary or someone who you know who has a grow facility or is just a trusted person really. Someone who wouldn't sell you something fake.

3.5.2. Perceived Consumer Protections

Adolescents in this study trusted entities, such as large companies and the FDA to help keep dangerous products off the market. Participants assumed that manufacturers and government agencies were actively testing products and working to keep unsafe products from reaching consumers. Many believed that the FDA checks the safety of products sold via legitimate channels, including cannabis and nicotine e-cigarettes (Table 5).

Participants believed that fake products circumvent this process, making them more likely to contain dangerous chemicals (Table 5). Participants perceived that companies need to develop a loyal customer base and avoid litigation, and therefore would have rigorous quality control practices. Some participants believed that products sold in stores or dispensaries were safer than products from informal sources because the government regulated formal sellers (Table 5).

4. DISCUSSION

Adolescent participants in this study were familiar with fake devices for vaping nicotine and cannabis, viewing them both as potentially dangerous and as a common, even unavoidable, part of the vaping product marketplace accessible to youth. Although all participants expressed being wary of fake products, they differed in their confidence to identify such products and their motivation to avoid them, with a few participants resigned to having no other options to use. Some participants reported hearing about serious health emergencies caused by fake vape devices but continued to vape cannabis or nicotine themselves. Adolescents generally assumed that informal sellers, including fellow adolescents, were responsible for fake products and that large companies and government agencies were taking steps to ensure product safety and quality. These findings suggest that young people may encounter products that may place them at elevated risk and that further actions are needed to protect them adequately.

This investigation used the word “fake” to encompass several different types of products, including deceptive, knockoff, counterfeit, hacked, and/or altered products. Participants likewise discussed different contexts for encountering fake devices, such as other youth reselling used or empty devices, low-cost knockoff brands, and hacked devices that could be laced with dangerous chemicals. A recent study confirmed a high level of familiarity with hacking or modifying vape devices among youth, including refilling or replacing contents, often informed by peers and social media (Kong et al., 2024).

Participants in this study mentioned a wide range of risks from fake device use, ranging from unsatisfying user experience to severe illness or death. THC-containing products were generally seen as more likely than e-cigarettes to be diluted or otherwise intentionally altered, whereas the market for e-cigarettes was generally viewed as more liable to low-quality, inexpensive imitation products. Adolescents often cast themselves (or their peers collectively) as naïve or desperate buyers, without the finances or legal-age status to buy e-cigarettes or cannabis from more reputable sources, offering them little choice but to accept fake products as an unavoidable part of their vaping experience.

Many participants said that heard about or even witnessed serious medical emergencies that they attributed to using fake vaping products. Few recognized EVALI by name, but some appeared to describe it in other terms. Uncertainty and misperceptions about EVALI were also evident, with several participants assuming the condition was primarily caused by vaping nicotine, not unlike what has been reported among adults (Wackowski et al., 2023). Despite their general awareness of EVALI and/or similar symptoms, participants did not express interest in quitting vaping, although some described becoming more vigilant and claimed that they would discard a device that they suspected was fake. However, in a recent survey-based study of adolescents and young adults, perceived lung injury risk was associated with e-cigarette quitting interest (Kreslake et al., 2022).

Participants largely relied on word-of-mouth, visual clues, or their own sensations upon use to identify a fake product. They were not inclined to use QR codes or take other similar steps for external verification of product authenticity. From a public health viewpoint, youth engagement with vape brands online should be avoided (Soneji et al., 2017). However, this finding also suggests that any similar future verification method from a government source might not be received enthusiastically. In fact, statements of government regulation or authorization and could be confused as an endorsement that a product is safe (Wackowski et al., 2024).

Indeed, adolescents sometimes misperceived the regulatory authorities of federal agencies to protect consumers from fake tobacco or cannabis products. The FDA does not approve e-cigarettes or other tobacco products as safe (Food and Drug Administration, n.d.), and the vast majority of e-cigarettes sold in the United States have not been authorized by the FDA for legal sales. No federal agency regulates cannabis as a consumer product; any such regulation occurs within states that have authorized medical or adult-use marijuana sales. Nonetheless, some participants assumed that government oversight assured the relative safety of authentic products. Government regulations could help to improve the safety of products across the marketplace but present challenging policy tradeoffs (Hall, 2020).

Participants generally placed blame for fake vaping products on proximate sellers, such as informal dealers, potentially including fellow adolescents, who would attempt to sell used, diluted, or adulterated products to gullible teenagers. Not mentioned in interviews were the large, difficult-to-track manufacturers, importers, and distributors who profit from trade in unauthorized e-cigarettes. Instead, participants assumed that larger companies would adhere to strict internal quality standards to maintain good relationships with customers.

The major strength of this study is its use of qualitative methods to provide in-depth insight into a multifaceted topic that had previously been underexamined in the literature. Among limitations, as with any qualitative research, findings from participants in this study do not necessarily generalize broadly. Recruitment was restricted to one US state, and because all participants included had experience using tobacco products, importantly missing from the study population were any adolescents who had chosen never to use nicotine or cannabis, potentially due to fake product concerns. Additional perspectives, such as from parents and educators, could provide further information on the topic. Future research to develop messaging tailored to adolescents about fake vaping products should work to uncover the specific terminology adolescents use to refer to these devices.

4.1. Conclusions

In summary, this investigation revealed that adolescents are aware of imitation, off-market, or adulterated (“fake”) vaping products that could expose them to serious health risks. Possible public health actions to address this issue should be explored further, including: 1) Packaging and/or manufacturing requirements that make it harder to tamper with or alter product contents; 2) Cutting off import and distribution channels; 3) Public messaging campaigns to inform potential consumers, both about potential product-related risks and also to clarify whether and how government agencies regulate them; and 4) Simple, reliable methods to verify product authenticity that do not encourage youth engagement with the tobacco or cannabis industries and are not taken to imply that any tobacco or cannabis product is safe. The complexity and implementation challenges of such actions should not be reason to avoid taking steps to protect consumers, especially youth.

Abbreviations:

EVALI

Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury

FDA

Food and Drug Administration

THC

tetrahydrocannabinol

USA

United States of America