Targeting the youth vaping epidemic and its adverse health effects

Over the past few decades, the United States has made progress on smoking rates and lung cancer; however, that work is being negated by the rise of e-cigarettes among today’s youth, who are being targeted by large corporations in need of new customers. During a panel at CHEST 2022, a panel of experts described the current vaping epidemic, how pediatric populations are affected, and the role of racial disparities.

While the first patent for e-cigarettes dates back to 1965, devices only started hitting the market in the 2000s. It wasn’t until 2015 when Juul was introduced and the use by young people really took off, explained Jacob Kaslow, MD, a pediatric pulmonologist at Monroe Carell Jr. Children’s Hospital in Vanderbilt and an assistant professor of pediatrics specializing in allergy, immunology and pulmonary medicine at Vanderbilt University Medical Center.

In 2019, national attention was paid to e-cigarette/vaping-associated lung injury (EVALI). In 2021, the FDA stepped in and licensed the first e-cigarette intended to help combustible tobacco smokers quit.

Current designs of e-cigarettes, or Electronic Nicotine Delivery Systems (ENDS), have sleek, modern designs with bright, flashy colors. “So those are the ones that are clearly marketed to a very specific demographic, and that demographic is young people,” Kaslow said.

As the number of smokers declines, young e-cigarette users are on the rise, as companies need a new way to get young people hooked on their products. Recent data has highlighted that ENDS are the most common means of accessing nicotine for young people.1.2 There are 2.55 million children (14.1% of high school students and 3.3% of college students) who are current users.

Despite public health efforts, Kaslow said, 16.6% of high school and college students considered intermittent ENDS use to be of little or no harm. A 2018 survey found that 63% of Juul users did not know there was nicotine in the product.3

“It’s very different from their understanding of cigarettes, isn’t it? Every kid knows cigarettes are bad,” Kaslow said. “It’s just kind of been entrenched in our public health ethos now, but it hasn’t been or still isn’t the case for e-cigarettes.”

When the FDA attempted to prioritize the application of flavored pre-filled pods or cartridge e-cigarettes, disposable devices were not included, leading to a dramatic increase between 2019 and 2022 in the use of disposable devices among high school students, he said. Additionally, although Congress passed legislation with a deadline for companies to submit e-cigarettes for marketing approval and a deadline for the FDA to grant approval, no products have been authorized and no product has been withdrawn from the market, despite exceeding the two deadlines.

According to Kaslow, the reason nothing is being done is that there is a lot of money in the industry. The market is expected to grow to $45 billion in the next 2-3 years, and marketing shows that companies are continuing to prey on youth and young adults, he noted. Flavoring is the primary reason for use in youth and young adults.

“You can’t watch [these flavors being marketed] and tell me that the 3 pack a day smoker who has been smoking for 30 years is really gonna go after the candy cane [flavor] as a nicotine replacement,” Kaslow said.

Among the companies, there is a “nicotine arms race”, he said. While a regular cigarette contains about 1.5% to 2% nicotine, Juul contains about 3% to 5% nicotine, one pod is equivalent to about 20 cigarettes. Some children smoke several pods a day.

E-cigarette use leads to multiple adverse health effects, and the 4 main components of these devices have their own adverse health effect, explained Sarah Bauer, MD, assistant professor of clinical pediatrics, Indiana University School of Medical.

The batteries exploded and caused trauma, injuries and burns; the atomizer can degrade and cause the user to inhale metals; the cartridges contain chemicals that are not good for the lungs; and in addition to the fact that the mouthpiece is not made of quality materials, many children share devices, which spreads diseases and viruses.

The liquids in e-cigarettes and aerosols all contain harmful substances and “none of them should really enter your body, let alone your lungs,” Bauer said. One particular substance she talks to her pediatric patients about is propylene glycol, which is also used to de-ice airplanes.

In 2020, the CDC stopped reporting EVALI cases as it focused on COVID-19, but in 2020, 2807 cases were reported, the majority in males (66%). The median age of EVALI cases was 24, but patients ranged from as young as 13 to as old as 85.

Most commonly, patients with EVALI present with cough, chest pain, and shortness of breath (85% to 95%), followed by fatigue, fever, and weight loss (76% to 85%).

In addition to respiratory problems, there are dental issues, including periodontal disease, bone loss and higher risks of cracked or broken teeth, she said.

Then there is the addictive quality of nicotine. Almost all (90%) of adult smokers started before age 18, and the earlier a person starts smoking, the stronger the addiction and the harder it is to quit, Bauer said.

“And e-cigarette use was found to be an independent risk factor for smoking, which we know has many negative long-term health impacts,” she said.

While targeting e-cigarette use among young people to prevent smoking, disparities should be kept in mind. Sucharita Kher, MD, vice president of clinical operations and quality in the Department of Medicine and assistant professor at Tufts University School of Medicine, explained that efforts to reduce smoking have not affected everyone equally. way.

The 2019 National Youth Risk Behavior Survey found that e-cigarette smoking rates were highest among whites (3.7%) and lowest among blacks (1.6%). While e-cigarettes are a gateway drug for young people who become adult smokers,4 it is not enough to target the use of electronic cigarettes.

Among white, Hispanic, and overall youth, a higher percentage of smoking initiation was attributable to e-cigarettes. However, for young blacks, cigars contributed the most to cigarette initiation, followed by other products. For black youth, e-cigarettes are attributed with the smallest percentage of cigarette initiation.

“It’s important to note because while it’s very important to target e-cigarette policy to make sure that young people don’t get…just targeting that and not targeting cigars with that could in makes disparities worse,” Kher said.

Achieving health equity in the context of tobacco use will require a multi-pronged approach:

  • Clinic—a diverse health care team; cultural competence; standardized screening; multilingual quit smoking help lines; community engagement; and culturally and culturally sensitive education
  • Research—research based on disparities; various researchers; stigma reduction and diversity, equity and inclusion training; minority stake; and support for researchers from minorities
  • Policy—data collected from all populations; smoke-free policies; tobacco price/tax increase; prohibit marketing to vulnerable populations; improving access to treatment; regulate flavors; and include e-cigarettes in all policies.

“Even if we enforce a policy, or if the FDA develops a policy, we have to make sure that the downstream impacts of the policy don’t favor one group over another group,” Kher said.


1. Gentzke AS, Wang TW, Cornelius M, et al. Tobacco product use and associated factors among middle and high school students – National Youth Tobacco Survey, USA, 2021. Checksum MMWR. 2022;71(5):1-29. doi:10.15585/mmwr.ss7105a1

2. Cooper M, Park-Lee, Ren C, Cornelius M, Jamal A, Cullen KA. Field Notes: Electronic Cigarette Use Among Middle and High School Students – United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;(71)40:1283-1285. doi:10.15585/mmwr.mm7140a3

3. Willett JG, Bennett M, Hair EC, et al. Recognition, use and perceptions of JUUL among youth and young adults. TobControl. 2019;28(1):115-116. doi:10.1136/tobaccocontrol-2018-054273

4. Stokes AC, Wilson AE, Lungberg DJ, et al. Racial/ethnic differences in associations between non-cigarette tobacco product use and subsequent cigarette initiation among American youth. Nicotine Tob Res. 2021;23(6):900-908. doi:10.1093/ntr/ntaa170

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