Electronic Cigarettes and Teen Health Risks

A few years ago we knew next to nothing about the health impact of e-cigarettes (also sometimes called e-cigs, vape pens, or hookah pens). However, emerging facts make it essential that we have a thorough understanding about this drug delivery system as we strive to keep our healthy kids healthy. In fact, the Hazelden Betty Ford's Prevention Solutions Survey Database shows that among 6th-12th grade students who took the survey within the 2015-2016 academic year:

• 17% reported using e-cigarettes in the past year
• 10% reported use in the 30 days
• More students reported e-cigarette use than traditional cigarette use
• The top four most used substances by students in the past year were:
  • 33% alcohol
  • 17% e-cigarettes
  • 12% marijuana, and
  • 11% traditional cigarettes

History and Definitions

E-cigarettes are battery-powered devices that heat nicotine, marijuana, flavorings, and other chemicals in solution cartridges full of "e-liquid" or "e-juice," so that users may inhale these chemicals in aerosol form1.

Some e-cigs are made to look like traditional tobacco cigarettes, cigars, or pipes. Others resemble a modern take on the traditional cigarette or pipe, with fashionable clear or shiny metal bodies featuring sleek colors and textures. Still other versions may be crafted to look like everyday items, such as ballpoint pens or USB flash drives. Styles of electronic cigarettes very greatly among the hundreds of existing brands, and new styles enter the market regularly.

Since the 2003 invention of e-cigarettes by a Beijing pharmacist, worldwide use of, and concerns about, electronic cigarettes have grown2. By 2007, the products' marketing had spread to Europe, with the unsubstantiated claim that the devices were tobacco-smoking cessation aids. In 2008, the World Health Organization announced that there was "no scientific evidence to confirm the product's safety and efficacy." Marketers funded their own studies to make continuing claims about the differences between traditional and electronic cigarettes. The following year, the United States' Food and Drug Administration tested e-cigs marketed as "nicotine free," and found low levels of addictive nicotine as well as carcinogenic diethylene glycol (antifreeze) among their ingredients.

By 2012, e-cigarette use among U.S. middle and high school students had doubled since the prior year, and by 2014, a greater number of students reported using e-cigarettes than traditional cigarettes in the past month3. The number of students reporting ever having used e-vapes had risen to 2.5 million4.

Electronic cigarettes remain new, relatively untested tobacco products. Until August 2016, e-cigarettes in the U.S. were commercial products without any federal regulation. Now these tobacco products, like all others (hookah, e-cigarettes, dissolvables, smokeless tobacco, cigarettes, cigars, roll-your-own tobacco, pipe tobacco, and future tobacco products that meet the statutory definition of a tobacco product) are regulated by the United States Food & Drug Administration (FDA)5.

Emerging Health Risks

The 2015 Monitoring the Future survey results tell us that among United States students, approximately 10% of 8th graders and 15% of 9th through 12th graders use e-cigarettes monthly6.

If such rapid growth in use in the U.S. is any indicator of teen use throughout the rest of the world, we all must be concerned, as e-cigarettes pose cancer, addiction, and intoxication risks.

Unknown Quantities of Addictive Nicotine

Students are generally unclear about the contents of their e-cigarettes. Among 12th-grade students who used e-cigarettes in 2015, 65% reported their e-cigs contained only flavoring, while 22% believed they contained nicotine, 6% thought they were vaping marijuana or hash oil, and a final 6% had no idea what they were vaping6.

Unfortunately, this confusion among students is understandable. E-cigs marketed as "nicotine free" often do contain nicotine. Even if not marketed as nicotine free, many brands do not specify how much nicotine or other chemicals their e-cigarettes contain. E-cigarette companies have not been obligated by any governing body to regulate or monitor the amount of each substance that goes into their products.

To highlight the inconsistency of nicotine concentration in e-cigarettes, researchers in the United Kingdom tested 16 different e-cigarettes7. They found wide variations in nicotine levels per puff. Their findings suggested that nicotine concentration not only varies by brand, but also between inhalations of the same product!

More startling, nicotine levels per puff ranged from 0.5mg to 15.4mg in the study. The typical nicotine concentration in a puff of a tobacco cigarette is 1.54mg to 2.60mg. This means that e-cigarettes may deliver nearly six times the amount of nicotine a tobacco cigarette would.

Nicotine is widely known to be an extremely addictive chemical. Biological studies show that teens are much more susceptible to the development of nicotine addiction than are adults. Adolescents may develop nicotine dependency within just a day of use8.

Alcohol in E-cigarettes

The Prevention Solutions Student Attitudes and Behavior Survey has found that in some communities, students are exposed to e-cigarettes sooner than they are to alcohol9. Even more disturbing, new research suggests that students may be exposed to alcohol for the first time through their early use of e-cigarettes.

Many e-vaporizer liquid solutions contain alcohol to extract their flavors from base ingredients. Yale School of Medicine found that some commercially available electronic cigarette liquids contain enough alcohol concentrations to significantly impair users' motor skills10. When study participants were asked to perform a motor task, those under the influence of higher alcohol concentration e-cigarettes performed more poorly than those not under this influence.

Exposure to alcohol through e-cigarettes puts students at a long-term risk for addiction and a short-term risk for intoxication and impairment. Students who do not know that e-cigarettes can contain alcohol may unwittingly put themselves at risk not only for an addiction to nicotine, but also for an addiction to alcohol through vaping. Students using e-cigs may also drive under the influence of alcohol unknowingly or otherwise put themselves at risk for accidents and physical harm as a result of motor impairment.

Out of the dozens of e-liquids tested in the Yale study, one-third did not contain measurable alcohol, while 40% of e-liquids registered at 0.75% or less alcohol content, and another 23% contained 1-3% alcohol levels. Some e-liquid brands have been measured to contain over 23% alcohol content. As prior research has demonstrated, the concentration of such chemicals in e-cigarettes has not historically been regulated by manufacturers nor made known to consumers.

Vape Pens and Cancer

If we have heard any messaging about e-cigarettes, it likely includes the notion that e-cigarettes don't cause cancer. However, studies attempting to classify the contents of e-cigarettes have revealed a number of troubling substances known to be carcinogenic within the products.

For instance, a New England Journal of Medicine study reported that some e-cigarettes release formaldehyde when heated by high voltage batteries7. A Cleveland Clinic study found that the liquid in many e-cigs contain propylene glycol7. While considered safe to eat in food in small quantities, propylene glycol as a carcinogen has not yet been longitudinally studied in a context where it is deeply and repeatedly inhaled by children and teens.

E-pens, too, marketed as "nicotine-free" e-solutions have been found by a San Diego Veterans Affairs lab investigation to damage cells in ways that could lead to cancer7. The researchers exposed cells in petri dishes to an extract of e-cigarette vapor and found that the cells showed breaks in DNA strands and a greater tendency towards cell death.

Other Health Risks

Respiratory damage, burns, and poisonings are among the additional risks of e-cigarette use.

A flavoring chemical in some e-cigarettes called diacetyl is associated with a disease called bronchiolitis obliterans or "popcorn lung," so named because the illness was found among plant workers exposed to airborne diacetyl from the artificial butter flavoring of microwave popcorn production11. Popcorn lung is a condition similar to chronic obstructive pulmonary disease (COPD), marked by cough, shortness of breath, and irreversible scarring of the lungs. A study of 51 e-cigarette varieties found higher than normal diacetyl levels in 39 of its tested flavors.11

An outcome of inconsistent manufacturing quality among e-cigs is the risk of burn injuries related to their use. In January 2016, The Canadian Press reported on a 16-year old student who sustained significant facial and dental injury as a result of an e-cigarette explosion during use12. The teen has had multiple surgeries for first- and second-degree burns and two root canals resultant from the incident.

In addition to burns and other external injury, e-cigarette toxicity is a concern too. The number of calls to U.S. Poison Control Centers involving e-cigarette liquids containing nicotine rose from one per month in September 2010 to 215 per month in February 2014, according to the CDC13.

Vape Pens: Impact on Students

In some school communities, a young person's first exposure to a drug, including alcohol, will be an electronic cigarette. This means that lower and middle school communities must work to educate their students about the risks of electronic cigarettes before first use or exposure occurs, and that middle and upper school communities must have initiatives in place to prevent use as students grow.

Marketing

Commercial spending on e-cigs reached $115 million in 2014. The Centers on Disease Control and Prevention have noted that nearly 70% of middle and high school students are now exposed to e-cigarette advertisements in retail stores, on the Internet, in print media, and on TV and in the movies4. E-cigarettes are marketed to youth, which explains their meteoric rise in popularity among our youngest students. Intrigued by chocolate, bubblegum, mango, and mint flavors, students may quickly form a vaping addiction initiated out of curiosity14.

Marketing of e-cigarettes often also makes the appeal to conventional cigarette smokers that e-cigarettes will help them to stop their use of other tobacco products. Despite such claims, as of fall 2016, the FDA does not consider e-cigarettes a tested or effective smoking cessation tool. In fact, for teens, studies show that e-cigarette use is associated with an elevated risk of other tobacco product use initiation15.

False Dilemmas

Most e-cigarette users vape because they think e-cigs are less toxic and less expensive than traditional tobacco products. They hope to lessen the risks of nicotine addiction and tobacco product exposure through vaping. It is even possible that students who have never used tobacco or marijuana before, but are considering drug use, will turn to e-cigs with the belief that this use is a less risky option.

Responses such as these reflect the false dilemma potentially created by the emergence of the e-cigarette industry. A false dilemma is a logical fallacy in which the dilemma holder feels beholden to a set of both limited and unfavorable alternatives.16

The false dilemma of e-cigarettes is this: there is no mandate that teens must choose to use one nicotine product over another. The choice to use e-cigarettes or any other nicotine delivery system may lead to addiction and other health problems. Students need to know that the alternative to cigarette use or other smoking is not e-cigarette use, but a healthy and rewarding lifestyle free from substances.

Untested E-Cigarette Claims

Among the untested claims e-cigarettes often tout are the claims that they are safer than regular cigarettes and that they help smokers quit.

Researchers Bradley Drummond and Donna Upson disagree2. In conclusion to their work reviewing the chemical make ups of a variety of electronic vaporizers, the researchers assert, "there are no data regarding the long-term cancer risk associated with low-level exposure to the detected carcinogens (in e-cigarettes). Similar to cancer risk, there are no published data describing the long-term lung function or cardiovascular effects of e-cigarettes." In other words, we cannot know that e-cigarettes are more or less harmful than tobacco cigarettes until we have longitudinal, epidemiological data about these products across generations, as we do with traditional tobacco products. Chances are, e-cigarette products will share some risks, and not others, with conventional cigarettes. For adolescents, the risk of addiction is great in either case.

On the claim that e-cigs help people quit smoking, the evidence has been minimal and inconsistent at best, and contradictory to these claims at worst. Several 2013 publications show minimal evidence that e-cigarettes help smokers quit. A cross-sectional study of 1,836 tobacco smokers suggested instead a significant association with between individuals' e-cig use and "unsuccessful quitter" status, but no association at all between e-cig use status and "successful quitter" status2.

Other studies suggest that e-cigs actually decrease the likelihood of successful quitting. A study of callers to state tobacco quit-lines found e-cigarette users significantly less likely to be tobacco-free seven months after they first tried vaping compared with callers from the same time period who had never tried e-cigarettes2. Findings like these are among the reasons some researchers worry e-cigarette use might distract smokers from proven, safe, and effective methods for kicking their tobacco habit.

The wide variation of nicotine levels in different e-cigarette brands, or even between different individual e-cigs within the same brand, also has researchers puzzled as to how well any of these products can claim to function as a nicotine replacement device for hopeful quitters.

Currently, we do not yet know enough about e-cigarettes to make any solid health claims about them. From our vast prevention experience, however, we do know with certainty that keeping healthy students healthy and away from vaping is by far a less risky, more rewarding alternative to use.

What We Do Know About Vape Pens

According to a September 2016 United States Office of Adolescent Health trends update17, prevention practitioners and other adults who care now have the following valuable information about teens and e-cigarette use available to them:

• Since e-cigarettes are a newer substance use vehicle, their use is escalating more quickly among younger students. For instance, past 30-days use of e-cigarettes by 8th graders more than doubled in 2015 from past years to 10%
• Use of one nicotine product, like an e-cigarette, does not protect students from the use of other nicotine products
• While 87% do not, 13% of high school students do currently use two or more types of tobacco
• A quarter of 8th and 10th graders who have used e-cigarettes in the past 30-days have also used conventional cigarettes during this same time. Half of all 12th graders who have used e-cigarettes in the past month have done the same
• Youth who use e-cigarettes are likely to become tobacco cigarette smokers as they age
• Eighth-grade students who now use e-cigarettes are 10 times more likely than their peers who do not use to eventually smoke tobacco cigarettes
• Students who use e-cigarettes may do so to vaporize liquid marijuana or hash oil containing marijuana's primary psychoactive agent THC
• Vaporized marijuana can be more highly potent than other forms

The introduction of THC to the teen brain can impair crucial adolescent brain development and promote marijuana addiction, to which teens are already more vulnerable than adults.

Smoking Prevention Next Steps

As caring adults, we are responsible for understanding the risks of electronic cigarette use by students and preventing that risk through effective prevention education and engagement of teens in healthy skill building. In addition to keeping up with the latest public health information about electronic cigarettes, we challenge schools to take up the prevention effort in two key areas.

Build a Prevention Curriculum

It's understandable to feel like the issue of electronic cigarette use by teenagers came out of left field. Most of the drugs that we work to prevent the student use of and addiction to, including alcohol, have been a part of our society in one form or another for decades or centuries. The commercially available e-cigarette we think of today, by contrast, was created only 13 years ago.

However, we cannot delay our children's health education about electronic cigarettes and vaping another moment. As discussed, e-cigarettes are currently one of the first drugs, right alongside alcohol, to which children are exposed. Millions of marketing dollars are at work to find ways to make e-cigarettes—full of nicotine, carcinogens, and other health threats as appealing as possible to students. Most major tobacco companies now have e-cigarette products, aiming to maintain their client base as the industry changes. Students need to be equipped with information to make healthy decisions about this drug delivery method.

A curriculum for e-cigarette use prevention need not reinvent the wheel, but it must be actively present in school communities and up to date. Students are now vaping more than smoking, so tobacco prevention initiatives must incorporate all nicotine products, including e-cigs. Students should be informed about addiction as a disease before they ever have a chance to use the e-cigarettes that might lead them to a struggle with chemical dependence.

Have Students Take the Lead

At the University of Texas San Antonio, the treasurer of the Student Government Association is creating a public service announcement campaign to inform students about the effects of tobacco products and to keep the campus nicotine-free19. This student is in good company—at least six other student-run campus groups are involved in spreading awareness of the possible effects of e-cigs at UTSA.

While their efforts are laudable, why wait until college for students to take the lead in prevention, especially when one out of every ten 8th graders is already vaping? Instead, get together with advisors, life skills staff, and health team to figure out how students can become involved in their own prevention messaging. Teens are the e-cig industry's prime targets, and the most susceptible to the health consequences of e-cig addiction. They too then should be one of  their school's leaders on the issue of e-cig use prevention, speaking with strong peer voices guided by the wisdom and resources of caring adults in their community.

Supporting Student Health When All Use Equals Risk

Across hundreds of e-cig brands, there are now over 7,000 e-cigarette flavors marketed to youth. At Prevention Solutions, we firmly believe that all use equals risk. For students, e-cigarettes represent another delivery system for an addictive drug. The younger a student is exposed to this behavior and substance, the riskier his or her use will be.

While most kids are very healthy, and the overwhelming majority of students do not use e-cigarettes, we hope the above information can help you to identify and successfully intervene upon the most common risks students face when it comes to e-cigarettes.