A Guide to Teen Vaping

A Guide to Teen Vaping

Last Edited: 09/23/2021

Author: Heidi Bitsoli Heidi Bitsoli

Clinically Reviewed:

09/23/2021

Medical Reviewer:

Dr. Tasnova Malek

Dr. Tasnova Malek

  • Vaping products, often known as vapes, e-cigarettes, and other names, are popular products with teens and are often seen as safer alternatives to cigarettes and other traditional tobacco products, but they can pose their own dangers.
  • E-cigarettes and other vaping devices or vapes once held promise as a smoking cessation tool or at least a safer alternative to smoking. Alarmist stories exaggerated the dangers and benefits of vaping. Worse, vaping may be a gateway to smoking. Like tobacco, alcohol, and other drugs, vaping is especially damaging to the young brain (age 25 and younger). Bottom line, vaping is preferable to smoking but not vaping or smoking is better still. If you vape or smoke, quit. If you aren’t doing either, don’t start.

Cigarettes and cigars aren’t the only way to experience nicotine. Since 2007, a variety of electronic or e-cigarettes and other vaping devices—collectively known as electronic nicotine delivery systems (ENDS)—have been on the market in the United States. This has raised health and substance use concerns.

ENDS are sometimes touted as a safer alternative to smoking cigarettes, even by some anti-smoking advocates. The inventor of the first commercially successful e-cigarette claims he was motivated by his father’s death from lung cancer.

That safety hasn’t been established by the U.S. Food and Drug Administration (FDA), which has repeatedly delayed regulating ENDS. Consequently, most information comes from either the manufacturers or anti-smoking advocacy groups, both of whom are accused of cherry-picking data to bolster their case.

Even if vapes are safer, however, that doesn’t make them safe.

What is clear is that vaping is increasingly popular, including among underage youth. As of 2018, more than two-and-a-half times as many young people vaped (21%) compared to the number who smoked cigarettes (8.1%).

The problems with that rise are that:

  • Vaping’s use as a treatment to end smoking cigarettes lacks adequate scientific research to back claims that it is effective or harmless.
  • Teens who never smoked are vaping, and sometimes go on to smoke traditional cigarettes as well.
  • Since July 2019, health authorities have been aware of an outbreak of severe lung injuries among previously healthy people who vape, including young ones. Some adult vapers have died. These health problems have been dubbed e-cigarette or vaping product use-associated lung injuries (EVALI).

What Is Vaping?

Vaping is a smokeless alternative to smoking. Instead of burning tobacco, it heats a liquid that sometimes contains nicotine plus other chemicals, including flavorings. The resulting aerosol spray or vapor is then inhaled.

Although it varies, one pod of e-liquid is roughly equivalent to a pack of cigarettes. For some users, that might last for days or a week, but others go through several in a day.

When one smokes, one inhales and exhales the smoke from burning tobacco, paper, and many chemicals. When one vapes, one only inhales an aerosol, commonly referred to as a vapor, produced by heating the nicotine-infused liquid in an electronic device that is usually designated as an electronic or e-cigarette or a vaporizer.

Although there are preloaded and precharged disposable e-cigarettes, ENDS usually consists of:

  • A mouthpiece
  • A battery that is replaceable or rechargeable
  • A pod, cartridge, or tank for e-liquid that is refillable or replaceable
  • A heating component.

Types of Vapes

There are many brands and a few types of e-cigarettes on the market, including some the size and shape of a cigarette, as well as vape pens and more bulky vape mods. One of the most popular is made by JUUL and resembles a USB flash drive.

Disposable e-cigarettes have dramatically risen in popularity from 2019 to 2020: among high school students, an eleven-fold increase, from 2.4% to 26.5%; among middle school students, a five-fold increase from 3.0% to 15.2%.

Another e-cigarette device, the IQOS by Philip Morris International, heats actual tobacco, not an e-liquid. IQOS has been sold in dozens of markets worldwide and was approved for sale in the U.S. by the FDA in April 2019. A patent infringement suit in July 2021 halted expansion plans.

Other Cigarette Alternatives

Two other cigarette alternatives include hookahs for tobacco and bongs for marijuana. Both filter their vapor through water, but they still burn their product and produce smoke.

In addition to nicotine, hookahs have many of the same health deficits as smoking, including tar and other toxins.

For a look at the various types of vapes, see the Centers for Disease Control and Prevention (CDC)’s E-Cigarette, or Vaping, Products Visual Dictionary.

Do Vapes Explode?

There have been a few high-profile incidents where an e-cigarette has exploded. Officials say it is usually due to the lithium-ion battery being damaged, mishandled, or overcharged.

There have been a few cases involving old-school mechanical mods with no safety features or when components from two or more different types of e-cigarettes are incorrectly or inexpertly combined.

Does Vaping Help Smokers Quit?

Sometimes vaping is promoted as a means to encourage cigarette smokers to switch to e-cigarettes and eventually quit using all products entirely.

However, while there is anecdotal evidence that this approach works with older adult smokers, with younger smokers it seems to have the reverse effect.

Adult smokers who take up vaping intending to quit smoking succeed, at least sometimes. Vaping allows them to control how much nicotine they inhale and lets them taper off.

Two 2020 studies found little to no difference between long-term (12 months or longer) smoking cessation rates based on e-cigarette use. Many who did achieve abstinence continued to vape, minimizing its health benefits.

If vaping transitions smokers to quitting nicotine altogether, that’s a good thing. If vaping is less harmful than smoking, it may still be a better alternative even if people continue to vape.

Is Vaping Dangerous?

Better doesn’t mean good. Other than in a harm reduction sense, no one argues that vaping tobacco is good for anybody. In an absolute sense, just like any form of smoking or use of nicotine, vaping is bad.

According to pulmonary medicine specialist MeiLan K. Han, “the lungs were not designed to breathe anything other than clean air. Anything other than that is a potential health risk.”

Aside from chemicals, most commercially available e-liquids contain nicotine, one of the most addictive substances on Earth, which may be especially dangerous for young people with developing brains. Vaping may have other health risks.

Vaping seems to have many of the bad health effects of smoking. E-cigarettes may have the same drawbacks as traditional tobacco smoking. Both produce carcinogenic tar and dangerous gases such as carbon monoxide that cause negative effects such as:

  • High blood pressure
  • Respiratory illnesses
  • Heart disease

Although vapes only heat a nicotine-infused liquid, the resulting aerosols may still contain harmful chemicals from the liquid or even metals and chemicals from the e-cigarette device. The tobacco used for the IQOS device is chemically-treated, producing similar toxins and health concerns as cigarettes and e-cigarettes.

Harmful Effects of Vaping

Some researchers say that even without producing tar, e-cigarettes may create similar health risks as smoking, including COPD (chronic obstructive pulmonary disease) and lung cancer. Higher levels of carcinogens, materials that cause cancer, have been found in the urine of teens who vape.

Others say that those risks are greatly reduced, but other potential dangers remain. Those risks include:

Type 2 diabetes

While there have been no conclusive studies that vaping increases the risk of type 2 diabetes, smoking increases the risk of type 2 diabetes by 30% to 40%, according to the CDC.

Nicotine and other chemicals released by smoking cause inflammation and oxidative stress throughout the body and affect the way the body’s cells respond to insulin. Blood sugar levels rise, increasing the risk of type 2 diabetes.

One small study (32 people) concluded that vaping for 30 minutes can cause oxidative stress.

Smoking also increases the risk of belly fat, another type 2 diabetes risk.

Heart disease

The evidence is mixed. Nicotine can increase blood pressure, heart rate, and adrenaline levels, and contribute to heart attacks and disease. In particular, flavored e-cigarette liquids may contribute to cardiovascular disease.

But two 2019 studies came to opposite conclusions. One found no significant risk of heart disease from vapers who didn’t smoke. The other found that vapers faced increased risks of strokes, angina, and heart attacks.

Another study found a 34% greater risk of heart disease and 25% greater risk of coronary artery disease for e-cigarette users but no greater risk of stroke, high blood pressure, or circulatory problems.

Bone density

Although smoking causes lower bone density, a greater risk of fracture, and a slower healing rate, there is still little research into the effects of vaping nicotine. Likewise, while marijuana component CBD (cannabidiol) has positive effects on bone health, whether vaping CBD has a similar effect remains to be proven.

The best evidence so far suggests that while there may be damage from vaping—including bone loss, tooth loss or decay, dry mouth, and bad breath—it produces much less damage than smoking.

Tooth decay and gum disease

Evidence that vaping can lead to tooth decay and loss is much clearer. Aerosol from vaping causes four times as much bacteria to build up on teeth. Flavored vaping liquids also soften tooth enamel by 27%. The effect is similar to sugary candies and acidic drinks. If vapers want to keep their teeth, they better brush and floss.

A 2020 study found fewer vapers with gum disease than smokers (43% to 73%) but more than people who did neither (28%).

Addiction

There is no doubt that e-liquids containing nicotine are as addictive as tobacco or that addiction harm is as bad as lung cancer. Nicotine addiction is not as immediately deadly as heroin or fentanyl, but it still harms teens.

Addiction leads to cravings that, if not satisfied, make it difficult to concentrate. Because the brain is developing until about the age of 25, such distractions can affect later behavior and health, including possibly making one more susceptible to other addictions.

Vapers are 55% more likely to have depression or anxiety, which can co-occur and possibly lead to addiction.

While there is a lot not known, vaping seems at least 95% less deadly than smoking cigarettes. We don’t know for sure because the U.S. Food and Drug Administration hasn’t reached a determination.

Lung disease

Although vaping does release some of the same chemicals and contaminants as smoking—including chromium, linked to asthma, reduced lung function, and respiratory cancer—the bulk of attention has been on the EVALI cases reported in 2019.

Starting in July 2019, emergency room staff noticed a rash of pneumonia-like symptoms in people who vaped. Patients ranged from ages 15 to 75, with a median age of 49.5.

Some of the people who died also had long-term respiratory problems, but it was the high number of young people that raised red flags.

The death rate steadily declined after September 2019. The CDC reported 68 deaths due to EVALI as of February 2020 and then stopped updating.

The culprit turned out to be not vaping per se but rather the vitamin E acetate used in bootleg e-liquids containing THC (tetrahydrocannabinol) and CBD (cannabidiol). No mainstream manufacturers used that thickening agent.

Do Vapers in Other Countries Have Health Problems?

Other areas, including Canada and the United Kingdom (UK), have not experienced a similar rash of illnesses or deaths. The National Health Service (NHS) says this is because they have tighter regulations than the U.S.

For example, the UK bans some chemicals permitted in the U.S. out of an abundance of caution. One, diacetyl, in high concentrations, may cause a condition called bronchiolitis obliterans or popcorn lung.

(Cigarettes have hundreds of times as much diacetyl as mainstream e-cigarettes in the U.S., but neither are likely to produce popcorn lung.)

The NHS still recommends e-cigarettes for stopping smoking because vapers don’t ingest the most hazardous elements of cigarette smoke, such as tar or carbon monoxide, and only lower levels of others.

Vaping Lawsuits

In June 2021, leading vaping company JUUL (an estimated 40-75% of the market) settled a 2019 lawsuit brought by North Carolina’s attorney general for $40 million.

The lawsuit alleged that JUUL violated the state’s unfair or deceptive trade practices act. The AG previously argued that JUUL recklessly and illegally promoted underage vaping and sales to minors, encouraging addiction with flavored e-liquids containing nicotine levels three times as high as allowed for adults in some other countries.

According to the Final Consent Judgment, JUUL admits no wrongdoing but agrees to the financial settlement and trade restrictions.

Of the remaining (as of July 2021) 2,339 active lawsuits, including as many as nine other states, JUUL said:

  • The suits are without merit.
  • JUUL does not market to underage consumers.
  • It didn’t want non-nicotine users to try their products.

Is Vaping Regulated?

Although the FDA has been able to regulate e-cigarettes as a tobacco product since 2007, in 2017, it elected not to do so until 2022. In the meantime, they allowed the products to be marketed and sold.

In June 2021, in testimony before Congress, acting FDA commissioner of Food and Drugs Janet Woodcock stated that “no ENDS product in the United States is on the market legally.”

So, instead of solid, unbiased scientific evidence, we have pro-vaping advocates, in and out of the industry, and anti-smoking absolutists who are cherry-picking data to suit their arguments while ignoring other data.

That may be changing. The courts have gotten involved. In May 2019, a federal judge ordered the FDA to expedite the process.

In July 2019, a U.S. District Court judge ruled that all applications for such products—those already on the market by Aug. 8, 2016—be submitted to the FDA by May 12, 2020, though they could remain on the market another year pending FDA approval.

On Sept. 9, 2021, the FDA delayed its ruling on JUUL products. The agency also blocked other vape makers from marketing their products because it believed that the benefits to adult smokers who use vaping products to wean from tobacco products don’t outweigh the potential risks to young vape users.

Some local governments stopped waiting for the FDA.

Charging that the FDA had failed to exercise its public duties by not regulating e-cigarettes, in June 2018, the city of San Francisco—home of JUUL headquarters—banned flavored vaping liquids. San Francisco extended the ban to all e-cigarettes in July 2019.

On Sept. 4, 2019, Michigan became the first U.S. state to ban flavored vape liquids and pods, and the FDA said it would do likewise a week later.

If the goal was to prevent EVALI, research from Yale suggests that such bans might be counterproductive. The JUUL-manufactured flavor pods did not cause EVALI; it was the vitamin E acetate in bootleg pods. Since JUUL-compatible pods made by other hands remain available, by banning JUUL’s pods, EVALI becomes more likely.

Also, bans on flavored e-liquid pods for vaping in San Francisco may have increased the number of underage teens who took up smoking.

How Many Teens Vape?

Teen smoking has been declining steadily for years, at least for cigarette smoking, but vaping or e-cigarette use has been dramatically rising.

According to the National Youth Tobacco Survey, from 2011 to 2019, cigarette use among high school students dropped almost steadily from 15.8% to 5.8%. In 2020, it dropped further to 4.6%.

Meanwhile, nicotine vaping rose almost as steadily, with a couple of bumps, from 1.5% to 27.5%. For 2020, there was a dip, down to 19.6%.

While it’s too soon to determine how many people smoked in 2021 compared to past years, preliminary data suggests that while fewer people smoked, one out of four (25%) of smokers increased their habit. Half (50.9%) smoked just as much as before, while one in five (20.2%) said they smoked less.

The rate of people looking for help quitting smoking declined by 27% in 2020.

Marijuana vaping also increased. While figures for 2020 and 2021 weren’t available, the percentage of high school students who reported frequent marijuana vaping rose from 2.1% in 2018 to 4.9% in 2019. Those who reported any marijuana vaping in the past month also rose from 7.5% to 14.0%.

Why Do Young People Vape?

Now middle-school-aged and high-school-aged young people who had never smoked have started vaping. Some have gone on to smoke cigarettes as well.

Vape Flavors

One reason is that makers of vaping products, of which JUUL is one of the largest and most successful, seem to be following the old tobacco company strategy of deliberately marketing nicotine products to teens. The companies promote their products using colorful packaging, sleek designs, and teen-friendly flavors.

Vaping pods and cartridges don’t necessarily taste like cigarettes. There are tobacco flavors, but most sales are for fruity and minty flavors.

A test of flavored e-cigarette liquids found that they caused damage to blood vessels, especially menthol and cinnamon, even when they didn’t contain nicotine.

JUUL voluntarily pulled most of its flavored pods from U.S. brick-and-mortar stores on Nov. 13, 2018, ahead of a feared FDA ban (it did likewise in Canada in January 2020), except for menthol, but not all companies followed suit.

Disposable e-cigarettes—popular with new users because they are inexpensive and can be used out of the box—are still available in multiple teen-friendly flavors. Of youths who vape, 80% vape flavored pods, including:

  • Fruit: 73% high school; 76% middle school,
  • Mint: 56%; 47%
  • Menthol: 37%; 23%
  • Candy: 36%; 47%

Less conspicuous

Another reason for vaping’s popularity among the young is that it is not as noticeable as smoking. It is easier to not get caught when vaping and not be treated as a pariah because:

  • E-cigarettes can look like a pen or a flash drive.
  • The vapor doesn’t spread as far as cigarette smoke.
  • Vape products don’t smell like or as much as cigarettes.

It’s Not Smoking

Anti-smoking campaigns haven’t eliminated smoking, but they have reduced it and made it seem less cool. Many who vape are offended by the idea that they might smoke.

To them, vaping seems different. The vapes look attractive. The clouds of vapor are cool.

Teens consider smoking and vaping two entirely separate things. Some teens’ thinking is so compartmentalized that they don’t even think of using a JUUL as vaping; it’s JUULing.

How Can Parents Tell If Their Child Is Vaping?

Recognizing the signs that a teen is vaping requires keen observational skills. The scent of the aerosol cloud quickly fades, and the cloud disperses. Look for some of the often subtle side effects of vaping, such as:

  • Drinking more water. Vaping can cause dry mouth.
  • Drinking less coffee or cola. Vaping can cause sensitivity to caffeine.
  • Using more salt or spices. Vaping can reduce the sense of taste.
  • Nosebleeds. Vaping can dry the inside of the nose.
  • Oral problems. Vaping may cause sores in the mouth that don’t heal, more frequent clearing of the throat, and a smoker’s cough.
  • Vaping paraphernalia. Vaping products come in different forms. If people constantly carry or handle some object resembling a pen or flash drive (it may be attached to a keychain), it could be a vape. Pods also come in multiple shapes. Look online or in a store and learn how to spot them.

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