Youths and young adults are the target demographic of sleek, colorful e-cigarette devices with flavorful nicotine.
In the last few decades, the United States has made progress on smoking and lung cancer rates; however, this work is being undone by the rise of e-cigarettes among today’s youth, who are being targeted by big corporations who need new customers. During a panel at CHEST 2022, a group of experts outlined the current vaping epidemic, how pediatric populations are being affected, and the role of racial disparities.
While the first patent for e-cigarettes dates back to 1965, the devices only started to hit the marketplace in the 2000s. It wasn’t until 2015, when Juul was introduced and youth use really took off, explained Jacob Kaslow, MD, pediatric pulmonologist at Monroe Carell Jr. Children’s Hospital at Vanderbilt and assistant professor of pediatrics specializing in allergy, immunology, and pulmonary medicine at Vanderbilt University Medical Center.
In 2019, there was nationwide attention on e-cigarette/vaping-associated lung injury (EVALI). In 2021, the FDA stepped in and authorized the first e-cigarette intended to help smokers of combustible tobacco quit.
The current designs of e-cigarettes, or electronic nicotine delivery systems (ENDS), have sleek, modern designs with bright and flashy colors. “So, these are these are clearly being marketed towards a very specific demographic, and that demographic is youths,” Kaslow said.
While the number of smokers is going down, youth users of e-cigarettes is rising, because companies need a new way to get the youth addicted to their products. Recent data has highlighted that ENDS are the most common way to access nicotine for youths.1,2 There are 2.55 million kids (14.1% of high school students and 3.3% of middle school students) who are current users.
Despite public health efforts, Kaslow said, 16.6% of high school and middle school students viewed intermittent use of ENDS as having no or little harm. A survey in 2018 found that 63% of Juul users had no idea there was nicotine in the product.3
“This is vastly different than their understanding of cigarettes, right? Every child knows that cigarettes are bad,” Kaslow said. “That's just been sort of ingrained in our public health ethos now, but this has not been the case or currently is still not the case for e-cigarettes.”
When the FDA tried to prioritize enforcement of flavored prefilled pods or cartridge-based e-cigarettes, disposable devices were not included, which led to a dramatic increase between 2019 and 2022 in the use of disposable devices among high school students, he said. Furthermore, although Congress passed a law with a deadline for companies to submit e-cigarettes for marketing authorization and a deadline for FDA to grant authorization, no products have been authorized and no products have been been pulled from the market, despite both deadlines passing.
According to Kaslow, the reason why nothing is being done is because there is a lot of money in the industry. It is predicted that the market will reach $45 billion in the next 2 to 3 years, and the marketing shows that the companies continue to go after youths and young adults, he noted. Flavoring is the number one reason for use among youths and young adults.
“You can't look at [these flavors being marketed] and tell me that the 3-pack-a-day smoker, smoking for 30 years is really going to go after the candy cane [flavor] as their nicotine replacement,” Kaslow said.
Among the companies, there is a “nicotine arms race,” he said. While a regular cigarette is about 1.5% to 2% nicotine, Juul is approximately 3% to 5% nicotine with a pod being the equivalent of about 20 cigarettes. Some kids are smoking multiple pods a day.
There are multiple adverse health effects as a result of e-cigarette use, and all 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 Medicine.
Batteries have exploded and caused trauma, injury, 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 mouthpiece not being made of great materials, there are many kids sharing devices, which is spreading disease and virus.
The liquids in e-cigarettes and aerosols all contain harmful substances and “none of these really should be going into your body let alone your lungs,” Bauer said. One particular substance she tells her pediatric patients about is propylene glycol, which is also used to de-ice planes.
In 2020, the CDC stopped reporting on EVALI cases as it switched focus to COVID-19, but in 2020 there were 2807 cases reported, the majority in males (66%). The median age of EVALI cases was 24 years, but patients ranged from as young as 13 years to as old as 85 years.
Most of the time, 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 the respiratory issues, there are dental problems, including periodontal disease, bone loss, and higher odds of cracked or broken teeth, she said.
Then there is the addictive quality of nicotine. Nearly all (90%) of adults who smoke had started prior to 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 has been shown to be an independent risk factor for cigarette smoking, which we know carries a lot of negative impacts in long-term health consequences,” she said.
While targeting e-cigarette use in youths to prevent cigarette smoking, disparities need to be kept in mind. Sucharita Kher, MD, vice chair for clinical operations and quality in the Department of Medicine and assistant professor at Tufts University School of Medicine, explained that efforts to reduce smoking haven’t affected everyone equally.
The National Youth Risk Behavior Survey in 2019 found that the rates of e-cigarette smoke was highest in Whites (3.7%) and lowest among Blacks (1.6%). While it is true that e-cigarettes are a gateway drug with youths growing up to be adult smokers,4 more than just e-cigarette use needs to be targeted.
Among White, Hispanic, and total youth, a greater percentage of cigarette initiation was attributable to e-cigarettes. However, for Black youth, cigars contributed the greatest to cigarette initiation, followed by other products. For Black youths, e-cigarettes attributed for the smallest percentage of cigarette initiation.
“This is important to note, because while it's very important to target electronic cigarette policy to ensure that the youth don't get…only targeting that and not targeting cigars along with that might actually worsen the disparities,” Kher said.
Achieving health equity in the tobacco context will require a multipronged approach:
“Even if we enforce a policy, or the FDA develops a policy, we need to make sure that the downstream impacts of policy are not favoring 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, United States, 2021. MMWR Surveill Summ. 2022;71(5):1-29. doi:10.15585/mmwr.ss7105a1
2. Cooper M, Park-Lee, Ren C, Cornelius M, Jamal A, Cullen KA. Notes from the field: e-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. Tob Control. 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 of non-cigarette tobacco product use with subsequent initiation of cigarettes in US youths. Nicotine Tob Res. 2021;23(6):900-908. doi:10.1093/ntr/ntaa170