Teen vaping: There is no vapour without fire

Abstract

E-cigarettes have become the most important source of nicotine exposure among adolescents. While e-cigarettes may have the potential to help some adults quit smoking, there is a lack of reliable evidence that this would apply to adolescents. On the contrary, e-cigarette use is associated with subsequent use of cigarettes and other tobacco products in teens and is also associated with increased use of alcohol, marijuana, and other drugs. Research on the health effects of e-cigarettes is rapidly emerging suggesting that they carry several acute and long-term risks, particularly for adolescents’ still-developing bodies and brains. While several strategies to help youth quit smoking exist, much less is known about effective clinical interventions for adolescents presenting with an addiction to nicotine consumed through e-cigarettes. We discuss the latest research on e-cigarettes with a focus on health effects in youth and propose potential avenues for concerted action among paediatric providers and decision makers.

In less than a decade, electronic cigarettes or ‘e-cigarettes’ have dramatically changed the landscape of nicotine use among Canadian youth. E-cigarettes represent an interesting paradox: initially conceived as a less harmful alternative to cigarettes for adult smokers and a potential way to help them quit smoking, they are currently significantly more popular among adolescents and young adults. Recent studies make a strong case for the consideration of nicotine-containing e-cigarettes as a gateway for the use of tobacco products and other substances (1) and reveal that many harmful chemicals can be found in first and secondhand e-cigarette aerosols (2). The perceived riskiness of e-cigarettes is significantly lower than that of tobacco cigarettes, which combined with youth-friendly flavours and an often high nicotine content, makes them very appealing to adolescents (3).

The abundance of advertising and easy access to e-cigarettes, together with a lack of clear regulations around e-cigarette products, creates a near-perfect recipe for recruitment of new and vulnerable young e-cigarette users. Although there may be a time and place for e-cigarette use as a cigarette cessation strategy, there is no reliable evidence that e-cigarettes are an effective harm reduction tool for adolescents (4). As paediatric health providers, we have an opportunity to help prevent a resurgence of nicotine addiction among youth through e-cigarettes use.

PRODUCTS AND TRENDS

E-cigarettes are now significantly more popular than traditional cigarettes among Canadian youth (5). In fact, 10% of middle and high school students in Canada reported using an e-cigarette in the past 30 days in 2016 to 2017 compared to 6.2% for tobacco cigarettes (5). This represents a nearly twofold increase in past 30-day e-cigarette use from 5.7% in 2014 to 2015. Vaping—a term describing the use of an e-cigarette (or a similar device) to inhale a heated aerosol—can be done with substances other than nicotine. For instance, 20 to 30% of teens reporting e-cigarette use also report using a vaping device to consume high-potency cannabis products (3), often unbeknownst to their parents and health providers.

E-cigarettes come in a variety of shapes and sizes, but they share a similar mechanism: a battery-powered heating element connected to a vaporization chamber in which a substance (usually in liquid form) is heated, producing an aerosol. While older e-cigarette models were usually large ‘tank-like’ devices with a refillable e-liquid reservoir, newer generations can be as small as a flash drive and are often sold with disposable cartridges or ‘pods’ that come prefilled with e-cigarette liquid. Although many adolescents claim that they are using e-cigarettes containing ‘only flavouring’, a recent study showed that the vast majority of e-cigarette liquids sold in Canada contain nicotine, often in high concentrations (6). For example, the e-cigarette sold by JUUL Labs (currently the top-selling e-cigarette brand in North America) comes with cartridges that contain as much nicotine as a full pack of cigarettes and can usually be purchased for less than half the price.

HEALTH EFFECTS

Although this remains controversial, recent studies have suggested that substituting e-cigarettes for tobacco cigarettes may be an effective way for adults to quit smoking (but not necessarily quit nicotine use) (4). This is not the case in youth under the age of 25 years who may respond differently to the rewarding effects of nicotine (2). In fact, there is now a growing consensus that e-cigarette use is an independent predictor of future use of cigarettes and other tobacco products (4). This also holds true for the risk of subsequent use of alcohol, marijuana, and other drugs (7,8).

Nicotine exposure can lead to several health effects independent of cigarette smoke, including increased risk of cardiovascular, respiratory, and gastrointestinal disorders as well as a decreased immune response (2). Chronic exposure to nicotine during adolescence has also been shown to lead to negative long-term impacts on memory and attention, thought to be attributed to a permanent inhibitory effect on neuronal connectivity (9).

Youth are highly vulnerable to nicotine dependence and withdrawal. In fact, after smoking only 100 cigarettes, or using five nicotine-containing e-cigarette cartridges, adolescents can experience withdrawal symptoms within hours from last use including headaches, jitteriness, anxiety, irritability, lack of concentration, and sleep difficulties (10). These symptoms can be severe, representing an important barrier to cessation and a major source of interference with school and sports participation.

Although there is currently little-to-no evidence looking at the potential risks of long-term exposure to e-cigarette aerosols, e-cigarette liquids often contain several toxic substances and carcinogens (4). For instance, diacetyl, a molecule found in some flavoured e-cigarette liquids has been shown to be toxic for the cells of the respiratory tract (11). At least one in four adolescents are exposed to secondhand e-cigarette aerosols, many of whom have never used e-cigarettes or tobacco products (12). While secondhand e-cigarette aerosols have been hypothesized to be less harmful than secondhand cigarette smoke, they still contain significant levels of nicotine and other chemicals (2). The acute and long-term effects of secondhand e-cigarette aerosols exposure remain poorly understood, but secondhand aerosols exposure has been associated with increased asthma symptoms (13) and use of e-cigarettes and tobacco products in youth.

Finally, several accounts of e-cigarette-associated injuries including acute lung injuries from inhalation of e-cigarette aerosols, facial and limb burns often linked to device malfunction, as well as poisonings due to ingestion of e-cigarette liquids have been reported across the country (14).

SOCIAL AND POLICY CONTEXT

E-cigarette advertising and availability of youth-friendly flavours are both independently associated with adolescent e-cigarette use (15). Furthermore, youth exposed to e-cigarette advertising are more likely to use not only e-cigarettes, but also traditional cigarettes (15). Receptivity to e-cigarette advertising and lower perceived riskiness of e-cigarettes are two important risk factors for progression to regular cigarette smoking, highlighting the importance of controlling exposure to this type of marketing.

Internationally, e-cigarette policies vary widely ranging from a complete ban in countries like Turkey and Thailand, to legal sales (generally for adults over the age of 18–21 years) in most parts of Europe and in the USA. In Canada, the Tobacco and Vaping Act allows adults over the age of 18 or 19 years (depending on the province) to legally purchase vaping products in vape shops or online as a ‘less harmful alternative to smoking’. However, since no nicotine-containing e-cigarette product is approved by Health Canada, control and monitoring of e-cigarette products is highly variable and relies primarily on the e-cigarette industry.

An important challenge surrounding e-cigarette sales to minors is the regulation of Internet sales. While some larger e-cigarette companies have mechanisms in place for age and identity verification, several smaller retailers or resellers lack these controls, and for the companies that do have controls, it remains relatively easy for young people to order e-cigarette products online. Student resale of vaping products in schools has also become commonplace and increasingly problematic.

A CALL FOR ACTION

In line with the positions of the Canadian Paediatric Society, we fully support the adoption of stricter policies surrounding the sale, marketing and taxation of e-cigarette products. Many successful policies and initiatives have been applied to tobacco cigarettes in the past and are an excellent starting point for the development of new e-cigarette-specific measures. For instance, vape shops should not be situated close to schools, vaping or e-cigarette websites should have strict age verification mechanisms and youth-oriented e-cigarette advertising and publications (including online and in social media) should be prohibited.

Given the low perceived riskiness of e-cigarettes among youth and their parents, there is a pressing need for public health education campaigns warning about the risks of e-cigarette use. These campaigns should be developed in collaboration with youth to ensure that they are relevant and well-received by this population. School curricula should also be amended to include e-cigarette-related content. In the health care setting, paediatric health providers should remain informed about new data regarding the health effects of e-cigarettes and screen for e-cigarette use with short validated screening tools such as the Car-Relax-Annoyed-Family/Friends-Forget-Trouble (CRAFFT) tool.

There is currently a lack of evidence on effective strategies for youth with e-cigarette addiction. While the literature on youth smoking cessation can inform practice, research is needed to help identify the best strategies for youth with e-cigarette use. In the meantime, providers can use individual counselling based on motivational interviewing and consider using nicotine replacement therapy and medications such as bupropion to help reduce nicotine cravings, regardless of the source of exposure.

CONCLUSION

The ‘e-cigarette epidemic’ has taken many by surprise and effectively reversed three decades of public health efforts to reduce nicotine addiction among adolescents, bringing back rates of adolescent nicotine use like those seen in the 90s. From our point of view, as paediatricians and adolescent medicine physicians, this is far from the victory against tobacco smoking predicted by early e-cigarette proponents. As teen vaping becomes less of a new trend and more of a long-term occurrence, a better understanding of the acute and long-term health effects of e-cigarettes and adoption of effective clinical, public health, and legislative measures will be needed to protect the health of our youth.

More information and resources about vaping and e-cigarettes are available at: https://www.canada.ca/en/health-canada/services/smoking-tobacco/vaping.html.

Contributor’s statements: NC drafted the initial manuscript and approved the final manuscript as submitted. REB reviewed and revised the manuscript and approved the final manuscript as submitted. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Funding: There are no funders to report for this submission.

Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.

Potential Conflicts of Interest: All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.