What is going on with youth vaping? We’ve all seen it — the clouds of vapor pouring out car windows at a stoplight, the kids sucking on something up their sleeve. We are in the midst of a vaping epidemic, and lots of people are worried about what this will mean for the health of our community in the decades to come.
- Faith Miller
- Recent research suggests nearly 11 million people vape in the U.S. alone.
Electronic cigarettes were introduced in 2006, with hope of offering a healthier alternative for adults addicted to the nicotine in traditional cigarettes. However, studies since that time have provided little or no evidence that e-cigarettes are effective for smoking cessation.
Early products resembled conventional cigarettes, but now most e-cigarettes have refillable cartridges and are designed to look like a pen, flashlight or computer flash drive. Manufacturers began referring to these product as “vaping devices,” which helped make kids think they weren’t dangerous like cigarettes. With added flavors like candy and fruits, kids didn’t realize these cool devices contain nicotine.
Early e-cigarettes were not very popular because they contained free-base nicotine, which is harsh and irritating, so the concentration of nicotine couldn’t be any higher than about 1 percent. Smokers trying e-cigarettes complained they couldn’t get enough of a buzz. Then in about 2014, the company that would later become JUUL figured out how to make nicotine salts, which are less irritating, so the concentration of nicotine could be increased. JUUL pods now have nicotine concentrations of 3 or 5 percent, and one 3-percent pod has as much nicotine as an entire pack of cigarettes.
The popularity of JUUL exploded. In early 2017, JUUL accounted for 13.6 percent of e-cigarette sales; by the summer of 2018, JUULs claimed 72.1 percent of the market. E-cigarette were marketed on TV; in ads at mall kiosks, gas stations and convenience stores; through Web sites focused on music, entertainment and sports; with targeted ads on social media; through celebrity endorsements; and free samples at youth events. Most of these advertising tactics are illegal for conventional cigarettes — precisely because they work to get youth hooked on tobacco.
Our best data on vaping rates in Colorado comes from the Health Kids Colorado survey, conducted in the fall every two years. In 2017, 44 percent of high school students in El Paso County had tried vaping, and 28 percent were current users — twice the national rate, which was then 13 percent. Data from the 2019 Health Kids Colorado survey is not out yet, but the latest national survey shows the rate of current vaping among high school students is up to 27.5 percent. The rate among middle school students — those kids in 6th, 7th and 8th grades — is an astounding 10.5 percent. Over 5.6 million U.S. teens are now vaping.
Part of the appeal of JUUL is its sleek shape, like a flash drive, and the way it charges in a USB port. It is also easy to hide, so teenagers can use it during school, and even in the classroom. Kids talk about “JUULing,” and the Internet is full of videos of adolescents using JUUL. Special clothing for teens is now made with such features as a pocket in the sleeve to hide the device, and a drawstring on the hoodie serving as a vape tube.
The real problem is that nicotine is a highly addictive drug, and adolescents are physiologically more vulnerable to addiction. The earlier in childhood an individual uses nicotine products, the stronger the addiction and the more difficult it is to quit. Over 99 percent of commercial vaping products contain nicotine, and high school students who vape are 3.6 times more likely to be smoking cigarettes one year later.
Tobacco remains the leading cause of preventable death in the United States, causing cancer, heart disease and respiratory diseases. Smoking kills more people each year than alcohol, AIDS, car crashes, illegal drugs, murders and suicides combined — more than 480,000 Americans every year. Every day in the United States more than 300 kids become regular, daily smokers; almost one-third of them will eventually die from smoking.
For the adolescent, short-term effects of nicotine include mood disorders, lowered impulse control and decreased attention — all of which impair a teen’s ability to perform best at school. We don’t yet know the effects of long-term vaping, but there are reasons to be worried. Numerous toxicants and carcinogens have been found in e-cigarette solutions, including aldehydes, tobacco-specific nitrosamines, metals, tobacco alkaloids and polycyclic aromatic hydrocarbons. Nonusers are also exposed, just as with second-hand smoking.
Media attention has recently focused on cases of severe lung damage linked to vaping. This new disease is now called EVALI, for E-cigarette/Vaping Associated Lung Injury. As of Dec. 27 the CDC has reported more than 2,561 cases and 55 deaths, in all 50 states. There have been more than 10 cases in Colorado, and one possible death — an 18-year-old. All patients have reported a history of vaping, and most have reported inhaling THC-containing products. The lung damage looks like a chemical injury, such as what was seen with mustard gas in World War I.
This is terrible! What can we do about it?
In 2019 the American Academy of Pediatrics made these policy recommendations:
I. Tell the FDA to immediately regulate e-cigarettes like traditional cigarettes.
2. Ban the sale of all tobacco products to anyone under 21 years of age.
3. Ban Internet sales of e-cigarettes and e-cigarette solution.
4. Ban all flavors in e-cigarettes, including menthol.
5. Ban all e-cigarette advertising and promotion to children and youth.
6. Tax e-cigarettes like conventional cigarettes.
7. Ban all cigarettes, including e-cigarettes, in places where children live, learn, play, work and visit.
We know that over 95 percent of adult smokers begin smoking before they turn 21, and the age 18 to 21 is a critical period when many smokers move from experimental smoking to regular, daily use. Kids often obtain tobacco products from older friends and classmates; increasing the sales age to 21 makes this harder. When teens know that an 18-year-old at their school can buy tobacco and vaping products legally, they think it is safe and fun; when it is illegal for their older friends, the message that tobacco and vaping are dangerous is made clear.
Eighteen states — Arkansas, California, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, New Jersey, New York, Ohio, Oregon, Texas, Utah, Vermont, Virginia and Washington — have now raised the tobacco sales age to 21. So have over 500 local governments across the United States.
On Dec. 20, President Donald Trump signed a law raising the federal tobacco sales age to 21. It will take up to two years for federal rules to be developed and finalized implementing this change. It is important to note that this legislation was supported by the lobbyists for JUUL and its biggest stakeholder, Altria, formerly known as Phillip Morris, the maker of Marlboro cigarettes.
Their support may be intended to delay the enactment of state and local tobacco 21 laws, discourage strong local enforcement and forestall a federal ban on tobacco flavors, especially menthol and mint.
Across the U.S., wherever the legal age for tobacco sales has been raised to 21, rates of teen tobacco use and vaping have decreased by 25 to 45 percent. In Colorado, over 20 towns and counties have now raised the age to 21, including Denver, Boulder and most recently Manitou Springs. In 2019, Colorado changed the Clean Indoor Act to include a ban on e-cigarette use in public places. Some Colorado communities have enacted new taxes on tobacco products, and others are banning flavors.
In February the Colorado Springs City Council plans to consider an ordinance enacting Tobacco 21 and requiring a license for businesses to sell tobacco products. Such laws can assure strong enforcement of the tobacco sales age. Federal enforcement has been weak over the past 10 years, with infrequent compliance checks, lack of follow-up visits and limited fines. The new ordinance in Manitou Springs, for example, will cause the retailer to immediately lose their license for seven days if they fail to check ID and sell to anyone under age 21. Another compliance check will be conducted within 45 days, and the seller will lose the license for 30 days if there is a second offense. The tobacco license is suspended for a year if there is a third offense, and two years for a fourth.
If young men and women can join the armed forces at age 18, shouldn’t they be allowed to buy tobacco products? In a recent article in Forbes Magazine advocating for Tobacco 21, Dr. Bill Frist, heart surgeon and former Republican Senator from Tennessee, explains that “Our military leaders don’t want their new recruits to enter the service addicted to nicotine, nor do they want them to become addicted while serving. The military has publicly stated that tobacco has a negative effect on troop readiness.” As of Sept. 30 the Army, Navy and Air Force pulled all e-cigarettes and vape products from on-base commissaries.
In our community, both individuals and organizations are joining forces to address the vaping epidemic. Parents are talking with their teens, and helping them stand up to peer pressure. School superintendents, teachers and administrators are raising the alarm. Community leaders are giving talks at high schools, middle schools and even elementary schools. Pediatricians are talking with their patients, and helping them find resources for quitting nicotine. Leaders of the Colorado Black Health Collaborative are fighting to have menthol removed from all tobacco products, because over 80 percent of African-American smokers choose menthol cigarettes, and black men have the highest rate of lung cancer. Others are working on statewide legislation to tax e-cigarettes, which at this time are not subject to either state or federal taxes.
As noted by the American Academy of Pediatrics, “The increasing use of e-cigarettes among youth threatens 5 decades of public health gains in successfully deglamorizing, restricting, and decreasing the use of tobacco products. To prevent children, adolescents, and young adults from transitioning from e-cigarettes to traditional cigarettes and to minimize the potential public health harm from e-cigarette use, there is a critical need for e-cigarette regulation, legislative action, and counterpromotion to help youth live tobacco-free lives.”
For more information, go to The Campaign for Tobacco Free Kids at tobaccofreekids.org, Tobacco Free Colorado at tobaccofreeco.org, or the American Academy of Pediatrics at aap.org.
Dr. Ted Maynard is retired from Iron Horse Pediatrics, where he practiced for more than 25 years. He is currently vice president of the Colorado Chapter of the American Academy of Pediatrics.