Electronic cigarettes, or e-cigarettes, are battery-operated smoking devices. These devices work by applying heat to a liquid-filled cartridge. The liquid, which is converted to an aerosol by the heat, contains nicotine. Inhalation of the aerosol is often called vaping. E-liquids come in a variety of flavors that turn out to be quite appealing to teenagers, like watermelon, cappuccino, and mango. While there are many different brands of e-cigarettes, the JUUL brand is by far the most popular, and the term “juuling” is now pretty much synonymous with vaping. E-cigarettes come in many sleek and user-friendly designs, most often resembling cigarettes, pens, or USB flash drives. An important aspect of these devices is that they mask unwanted tastes and smells commonly associated with smoking.
First introduced in the United States in 2006 (JUUL was introduced in 2015), e-cigarettes were designed to deliver lower levels of toxic substances than traditional (combustible) cigarettes. The combustion process of traditional cigarettes releases pulmonary carcinogens and other harmful chemicals, which helps to explain why traditional cigarette smoking is the leading preventable cause of death. People who switch from traditional cigarettes to exclusive e-cigarette use can dramatically lower their risk for contracting lung cancer and other diseases associated with chronic smoking. Some adults use e-cigarettes as a strategy to quit smoking altogether, though the scientific merit of this approach is not yet known.
Teenagers and E-Cigarettes
Most teenagers who use e-cigarettes are not interested in reducing nicotine or smoking-related harms. Instead, their use of e-cigarettes offers an introduction to the effects of nicotine. Although e-cigarettes cannot be sold to those under the age of 18 (21 in some states), their use has become increasingly popular among middle and high school students. About 20% of high school students use e-cigarettes, a figure that is rising from year to year. For example, compared to 2017, 2018 saw a 78% increase in e-cigarette use among high school students. The immense popularity of e-cigarettes suggests that they are being used by kids who would not ordinarily be at risk for smoking traditional cigarettes.
When surveying teenagers about their reasons for using e-cigarettes, they most frequently cite the influence of peers, advertising campaigns, and of course the wide variety of fruity flavors. It is interesting that major surveys have demonstrated that most teenagers believe that e-cigarettes pose few to no health hazards, with a majority unaware that e-cigarettes even contain nicotine!
What Are the Major Concerns?
The primary worry about smoking e-cigarettes is the inhalation of nicotine. Nicotine is a highly addictive drug. It enhances feelings of pleasure and, like other stimulants, increases heart rate, blood pressure, and respiration. E-cigarettes expose teenagers to a potent dose of nicotine at a time when their brains are still developing and most prone to addiction. For instance, a “pod” of e-liquid contains the nicotine equivalent of a pack of cigarettes. Most teenagers are simply unaware of how much nicotine they are inhaling and how quickly they might develop dependence to it. We worry that e-cigarette use will start teenagers on the road to more frequent smoking, which might include the use of traditional cigarettes. This worry is quite realistic – the earlier a person begins smoking, the greater the risk of nicotine-use disorder in adulthood.
There may be other risks associated with e-cigarette use. Little is known at this point about the long-term effects of heating the e-liquids, and there is concern that they contain some carcinogens. It should be noted that FDA approval of e-liquids applies to consumption of these chemicals, not inhalation. A variety of short-term effects, like coughing and throat/mouth irritation, are also possible, though these problems often resolve quickly. There have been incidents of small children ingesting e-liquids, so careful storage is important.
Inhaling other Drugs
With only a little bit of effort, e-cigarette devices can be used to smoke marijuana and other substances. For example, there is plenty of information online to help people prepare cannabis-based liquids for use in the e-cigarette devices. The current research shows that about 8% of high school students use e-cigarette devices to smoke marijuana, and that e-cigarette users are four times more likely to smoke marijuana. Another advantage of smoking marijuana in these devices is that the smell is concealed – a kid standing next to you might be smoking marijuana and you would not know it (with the exception of the red eyes and constant giggling).
What Can Parents Do?
The most important thing parents can do is to educate their children about e-cigarettes. Because many kids are beginning to experiment with e-cigarettes in middle school, we advocate starting the conversation as early as possible. The good news is that the scientific literature seems to suggest that children who understand that e-cigarettes are risky will be much less likely to use them.
For parents of teenagers who are already using e-cigarettes, it is important to understand its appeal to them. For instance, there will be some kids who say that e-cigarettes improve their concentration, enhance their mood, or facilitate relaxation. What they may be hinting to are health conditions like ADHD, depression, or anxiety that would be addressed more successfully with prescribed medications. This is a good topic to discuss with the pediatrician.
The final point is that because nicotine is a highly addictive drug, there will be many teenagers who will want to stop using e-cigarettes but are simply unable to. In fact, some forms of physical dependence can be observed in kids who use e-cigarettes only a few times per month. In these cases, treating e-cigarette misuse and dependence would be similar to treating other addictive disorders, often requiring a combination of medicine and counseling approaches.
Dr. Kidorf is Associate Director of Addiction Treatment Services and Associate Professor, Psychiatry and Behavioral Sciences, at Johns Hopkins University School of Medicine. This article is part of the series presented by Chayeinu, a new organization dedicated to providing education and guidance to our community regarding substance use disorder.
