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Dangers Don't Deter Vaping's Appeal to Teens

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Editors Note, April 24, 2018:  The FDA announced a "large-scale, undercover nationwide blitz to crack down on the sale of e-cigarettes – specifically JUUL products – to minors at both brick-and-mortar and online retailers," Commissioner Scott Gottleib, MD, said in a statement. The crackdown focuses on JUUL e-cigarettes as well as other brands and includes raids on retail stores suspected of selling the products to minors. Forty stores have already been cited for making illegal sales. 

Justin Olsen doesn’t have any interest in cigarettes.

But the 18-year-old Georgia resident loves vaping. Olsen estimates he vapes every day and takes about 20 hits an hour.

While cigarette smoking rates among teens have dropped over the last few decades, the use of electronic cigarettes (e-cigarettes) -- also called vaping -- has risen in this age group. Surveys show that many teens don't know about the dangers of these products, and a few popular vaping trends could increase the risks even more.

One of the most popular products among teens -- a flash drive-shaped system called JUUL -- contains roughly the same amount of nicotine as an entire pack of cigarettes. In the 2 years since JUUL was introduced, it has captured almost half of the entire e-cigarette market. And that worries some researchers.

"Everything is different about JUUL -- the shape and design of the product. It's smaller and can be hidden in the hand. It looks like a high-tech device," says, Maciej Goniewicz, PhD, PharmD, who has studied e-cigarette safety. "We know that it contains a really high concentration of nicotine. It's a few times higher than what we see in other e-cigarette products."

In 2017, nearly 30% of high school seniors said they'd used e-cigarettes.

Many kids start vaping even younger. Although laws prohibit kids under age 18 from buying e-cigarettes, nearly 10% of eighth-graders and 14% of 10th-graders said they've used these products.

Olsen started vaping when he was 17.

“I think it was in the summer of 2017,” he says. “I was at my friend’s house and he had it, and I started using it. And I thought it was pretty cool. We were passing it around, and I just tried it.”

“I didn’t really like getting buzzed at first -- from the nicotine. But I liked blowing it out of my mouth and doing tricks. Blowing clouds and stuff,” Olsen says.

Teens are attracted to vaping for a few reasons, says Bonnie Halpern-Felsher, PhD, a Stanford University pediatrics professor who's studied young people's attitudes toward e-cigarettes. "One is it's cool to them. It's novel. It's high-tech and it has flavors. The other thing is they perceive it to be less risky [than cigarette smoking]."

That’s because e-cigarettes are marketed that way, she says. Seven in 10 teens say they've seen e-cigarette ads -- often in retail stores or online. And the kind of public health campaign that has warned kids about the risks of tobacco cigarettes doesn't exist for e-cigarettes.

“I’ve heard people like my friend’s mom talk about the risks of vaping, but I’ve been kind of like, ‘Eh, it doesn’t really matter,’ ” Olsen says. “I think that smoking in general could be a lot worse for you than just vaping.”

"When you talk to teens, they'll say, 'It's just vapor. It's just water,' " Halpern-Felsher says. "It's not vapor. It's an aerosol. And there are harmful ingredients."

What's In an E-Cigarette?

When you light a traditional cigarette and the tobacco burns, it produces toxic chemicals like carbon monoxide and formaldehyde, which you inhale. An e-cigarette instead uses a coil to heat a liquid (called e-liquid or e-juice) until it produces an aerosol vapor.

The main chemicals in e-cigarettes -- including propylene glycol and glycerin -- are technically less toxic than those in tobacco cigarettes. "But if the product temperature gets too high -- if it's overheated -- then the safe compounds start to decompose. And they can generate very dangerous compounds like formaldehyde," says Goniewicz, an associate professor of oncology at Roswell Park Comprehensive Cancer Center.

A study by Yale School of Medicine researchers found that 1 in 4 high schoolers who use e-cigarettes manually drip the e-liquid directly onto the exposed heating coils, instead of letting the device feed the liquid into the coil. The practice, known as dripping, makes a bigger cloud of vapor and a stronger hit. Yet it could also raise kids' exposure to formaldehyde and other toxic chemicals, Goniewicz says.

A new study found that teens who use e-cigarettes are exposed to more harmful chemicals like benzene, ethylene oxide, and acrylamide than nonusers. These chemicals -- known collectively as volatile organic compounds -- are linked to cancer and nervous system damage, among other health effects.

Another study in Environmental Health Perspectives found that e-cigarette users also inhale large amounts of toxic metals, including lead, in the aerosols. These metals leak from the e-cigarette coils, the authors say.

E-cigarettes deliver ultra-fine chemical particles into the lungs. A few studies that have looked at the effects on lungs have shown that teens who use these products have higher rates of asthma, more frequent asthma attacks, and more school absences due to breathing troubles. E-cigarettes seem to trigger the same kinds of inflammatory responses in the lungs as cigarettes -- as well as a few additional responses of their own.

Young people use e-cigarettes in other ways that weren't intended -- for example, replacing the e-liquid with marijuana or other drugs. Vaping marijuana is more discreet than smoking it, lowering the odds of being caught. Yet researchers don't yet know how delivering drugs via e-cigarette might change their effects on the body, Halpern-Felsher says.

A Rainbow of Flavors

E-juice comes in a variety of flavors that make the vapor taste like everything from blue raspberry to cinnamon breakfast cereal. In one survey, nearly 82% of young e-cigarette users said the reason they vape is "because they come in flavors I like."

Olsen is partial to two flavors.

“I like the flavors,” he says. “I have mango frost with menthol in it. It tastes really good, and it relaxes your throat when you inhale it. Raspberry is also pretty good. I use flavored liquid all the time.”

Although the FDA considers most of these flavorings safe to eat, much less is known about their health effects when inhaled. "These chemicals aren't meant to be heated and breathed into your lungs," Halpern-Felsher says.

Some flavors are more toxic than others. Goniewicz and his research team exposed human cells to different flavoring chemicals in the lab and discovered that strawberry was one of the worst offenders. It contains the chemical benzaldehyde, which is known to irritate the lungs.

Also worrisome are vanilla, maple, and coconut. They contain the buttery-flavored chemical diacetyl, which causes scarring of the airways known as "popcorn lung."

Health Risks of Vaping

E-cigarettes have only been around for about a decade, so scientists don't yet have any long-term evidence of their risks. "There aren't any studies that would tell you the lifetime risk of heart disease or cancer -- some of the things we would potentially worry about," says David Eaton, PhD, who led a National Academies of Sciences, Engineering, and Medicine study on the effects of e-cigarettes.

One component that e-cigarettes and tobacco cigarettes share is nicotine. How much nicotine kids get when they vape depends on which product they use and how they use it.

Studies suggest nicotine may have long-term effects on a teen's developing brain. And since it can be addictive, kids could be more likely to have future substance abuse.

"The human brain loves nicotine," says Lauren Dutra, ScD, a research scientist at RTI International, a nonprofit research institute in Berkeley, CA. "There's the potential that if you use nicotine, it can essentially change the way your brain works when you're young, and you're going to have the potential to become addicted to these products in adulthood."

One open question is whether e-cigarettes act as a gateway to tobacco cigarettes. There is evidence that young people who use e-cigarettes are more likely to try smoking tobacco in the future, says Eaton, a University of Washington professor of environmental and occupational health sciences. A JAMA Pediatrics study found that young people  who used e-cigarettes were more likely to have smoked cigarettes a year later.

"The theory is that e-cigarettes are easier to smoke than a cigarette -- especially the ones with the flavors," says one of the study's authors, Stanton Glantz, PhD, a professor of medicine and director of the University of California, San Francisco, Center for Tobacco Control Research and Education. "It's a way to ease kids into nicotine. Their body gets adjusted to the nicotine … and then they graduate to cigarettes."

Yet the vaping industry says the evidence doesn't prove e-cigarettes drive kids into smoking. "What you are seeing in studies is the not-so-shocking finding that a teen who is willing to experiment with a vapor product is more likely to experiment with cigarettes," says Gregory Conley, president of the American Vaping Association. "It's like looking at whether somebody who is willing to drink wine is willing to try hard liquor."

In fact, he says the opposite is true. "That has been the number one warning point -- that these products are going to be gateways to traditional cigarettes. What has happened during this time? Big declines in youth smoking."

In 2017, 4% of high school seniors said they smoke cigarettes.

The Bottom Line

E-cigarette use does have some merit for adults. Research finds it could help long-term cigarette smokers quit -- and potentially live longer. And while Conley says e-cigarettes are "far less hazardous than smoking," there's no long-term research yet to confirm that claim.

For young people, the risks of vaping greatly outweigh the benefits. And those who start on e-cigarettes might have a hard time stopping. "For children who don't smoke, there is no reason to use electronic cigarettes," Goniewicz says. "They contain chemicals. They might expose them to toxins. And they will expose them to nicotine."

One way to curb teen vaping is with a mass media campaign that educates kids about the dangers, along with better oversight. "We really need age requirements on all tobacco products, and they need to be enforced," Dutra says. "Smoke-free laws are also really important for protecting kids."

WebMD Health News Reviewed by Brunilda Nazario, MD on April 11, 2018


American Lung Association: "Popcorn Lung: A Dangerous Risk of Flavored E-Cigarettes."

Gregory Conley, president, American Vaping Association.

Consumer Advocates for Smoke-Free Alternatives Association: "Historical Timeline of Electronic Cigarettes."

Lauren Dutra, ScD, research scientist, RTI International.

David Eaton, PhD, professor of environmental and occupational health sciences, University of Washington.

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Stanton Glantz, PhD, professor of medicine; director, University of California, San Francisco, Center for Tobacco Control Research and Education.

Maciej Goniewicz, PhD, PharmD, associate professor of oncology, Roswell Park Comprehensive Cancer Center.

Bonnie Halpern-Felsher, PhD, professor of pediatrics, Stanford University.

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