From the WebMD Archives

March 15, 2019 -- Nicholas Chadi, MD, has had a front-row seat to the high-speed growth of vaping among teens.

Chadi, a pediatrician who specializes in adolescent and addiction medicine, says he didn’t have any kids coming to Boston Children’s Hospital for e-cigarette abuse 2 years ago. Now, they see someone in their clinic as often as once a week.

“For a lot of teens, it’s the main concern they or their parents have. It is becoming pretty center-stage,” he says.

Some of the teens “are completely addicted, and it’s taken over their lives,” Chadi says. “Teens who come to see us couldn’t even sit in class for an hour. They had to leave because they felt they were having withdrawal symptoms, and we’ve seen teens dropping out of sports teams because they are so focused on their e-cigarette use.”

E-cigarettes can look like traditional cigarettes, cigars, and even pipes, but they can also look like a variety of everyday items like USB flash drives and pens. They do usually contain nicotine, the same addictive drug found in traditional tobacco products. But in e-cigarettes, nicotine can be found in a liquid that’s heated to produce an aerosol.

E-cigarettes are missing much of what the CDC calls “the deadly mix of 7,000 chemicals in smoke from regular cigarettes,” but the agency stresses that they are not harmless -- not only because of the higher levels of nicotine delivered, but also the possibility that the aerosol contains “heavy metals like lead, volatile organic compounds, and cancer-causing agents.”

Newly released numbers from the 2018 National Youth Tobacco Survey show more than 3.6 million teens used e-cigarettes in 2018. Those numbers include a 78% increase from 2017 in use among high schoolers and a 48% increase among middle schoolers. A 2016 report from the U.S. surgeon general found teen use of e-cigarettes increased 900% between 2011 and 2015.

While teen use of traditional tobacco cigarettes is at an all-time low, the growth of adolescent vaping with e-cigarettes has become such a health and policy concern that it’s compelling many states to take action. Virginia recently became the seventh state to change its laws by raising the minimum age to buy tobacco products from 18 to 21.

But are solutions keeping pace with the problem? Most don’t think so. “The epidemic use of e-cigarettes among children is one of the biggest public health challenges currently facing the FDA,” Commissioner Scott Gottlieb said in a statement last month.

State Action

For a detailed list of cities and counties that have raised the tobacco age to 21, visit the Campaign for Tobacco Free Kids site.

Hawaii was the first state to raise its smoking age to 21, in 2015. “Raising the minimum age as part of our comprehensive tobacco control efforts will help reduce tobacco use among our youth and increase the likelihood that our keiki [children] will grow up to be tobacco-free,” Gov. David Ige said at the time.

According to the Hawaii Department of Health, 15.3% of young adults 18-24 were regular cigarette smokers in 2015. By 2016, the first year under the new law, only 12% of 18-to-24-year-olds smoked regularly.

California, New Jersey, Maine, Oregon and Massachusetts were next, raising their minimum buying ages between 2016 and 2018.

“Raising the smoking age is an important and proven strategy in reducing the number of young people smoking,” says Lisa Morawski, a spokeswoman for Oregon Gov. Kate Brown, who took office in 2015. “Preventing young people from starting to smoke improves the health and well-being of our communities.”

Morawski said Brown wants to raise the state’s tobacco tax and to tax e-cigarettes.

In Massachusetts, Gov. Charlie Baker signed his state’s law in July 2018. He said at the time that it would help prevent addiction.

Finally, this year, Gov. Ralph Northam signed a bill making Virginia the first major tobacco-producing state to take this legislative step.

It’s not just states taking action. More than 425 cities and counties in 25 states have raised their minimum age for buying tobacco products to 21 too, according to Tobacco 21, an advocacy movement that lobbies on the issue and tracks efforts nationwide. But the federal law governing the minimum age to buy smoking products remains 18. The Campaign for Tobacco-Free Kids says that means states can’t lower the age below 18, but they can raise it if they want to. Gottlieb, who announced his resignation this month, has said he supports raising that to 21.

The push to raise the minimum buying age for tobacco products from 18 to 21 is centered on the idea that the move will keep these products out of high schools. This is seen as a critical step by anti-tobacco advocates because data show:

  • 95% of adult smokers start before the age of 21.
  • Nearly nine out of 10 cigarette smokers first tried it by the age of 18.
  • Every day in the U.S., about 2,000 people under the age of 18 smoke their first cigarette.
  • Flavorings in tobacco products are an allure for teens. In 2014, 74% of high school students and 56% of middle school students said they’d used a flavored tobacco product in the last month.
  • People ages 18 to 21 are the ones who most commonly buy tobacco products for their underage friends.

A 2015 report by the Institute of Medicine found that raising the tobacco purchase age lowers the number of young people who start smoking and cuts down on smoking-related deaths. It will also, a study found, “improve the health of Americans across the lifespan; and save lives.”

While advocates acknowledge that things like increased awareness and education may support change, when it comes to teen use of these products, they say raising the minimum buying age is critical. The Tobacco-Free Kids Campaign says there have been major reductions in sales of tobacco products to underage buyers and declining smoking rates among teens after minimum buying ages have been raised. For example, in Chicago, which raised the minimum age to buy tobacco to 21 in 2016, an all-time low of just 6% of high school students said they smoked cigarettes in 2017, a 56% decrease since 2011.

Tobacco giant Altria Group Inc. -- one of the largest producers and marketers of tobacco, which owns Philip Morris and invests in Juul -- along with Juul itself, are on board with the age change.

“Tobacco harm reduction for adults cannot succeed without effective measures to reduce underage use of all tobacco products,” Altria spokesman George Parman tells WebMD. “Taking this important step will address the main way underage youth gain access to tobacco products today -- from friends who are of legal age.”

Ted Kwong, a JUUL Labs spokesman, tells WebMD that’s why the company’s website requires all purchasers to be over 21. The site requires would-be users to enter personal information, including date of birth, the last four digits of their Social Security number and a home address. Absent that information, a picture ID must be scanned and uploaded before gaining entry to the site. It is not foolproof, but it is more rigorous a standard than many websites geared toward those over 21.

“JUUL is intended for current adult smokers only. … Underage use of JUUL and any other vaping products is completely unacceptable to us and is directly opposed to our mission of eliminating cigarettes by offering existing adult smokers a true alternative to combustible cigarettes,” Kwong shared in a statement to WebMD.

The Scope of the Problem

Chadi, the youth addiction specialist, says despite the incredible rise in teen use of e-cigarettes, it can be challenging for parents and schools to stay on top of the problem. He says that is in part because newer e-cigarette products like those sold by Juul, the top-selling e-cigarette brand in the U.S., are easy to conceal since they are so small. They’re often as little as a flash drive, and they emit vapor clouds that can be very small and odorless, which can make them difficult to detect.

But the nicotine is still there. Chadi says one e-cigarette reservoir or Juul pod, which typically costs $4 to $5, contains about the same amount of nicotine as a pack of cigarettes, and the device’s maker says that is consumed in about 200 puffs or breaths. But Chadi says he’s constantly meeting teens who blow through that at a shockingly fast rate.

“Teens have told me they have gone through several pods in one sitting. Why would they do that? Well, they get a huge head rush,” he explains. “It’s a high from a pretty strong stimulant, and these devices don’t have safety mechanisms that prevent teens form using them very rapidly.”

Chadi says he’s even encountered some adolescents who do challenges or party games to see how many they can stick in their mouth at once. He’s heard numbers as high as eight from the teens he works with. He says that addiction is becoming an issue for those who come to see him, and that many who try to stop on their own find they just can’t.

“When you stop using it, you feel jittery, anxious, it affects sleep. It’s the same withdrawal pattern as cigarettes, but it happens very quickly,” Chadi says. “It used to be more parents that were worried and would drag their children in for a visit, but increasingly, we’ve had teens come in willingly themselves and say, ‘I’m tired of this and need to quit. What do I do?’ ”

Despite the known risks, many say they see a widespread belief among teens that e-cigarettes aren’t harmful. “Young people don’t view e-cigarettes as risky. It was first manufactured as a smoking cessation tool for adults, so the image was positive, something to help you get healthier,” Chadi says. “But we are finding that e-cigarettes, especially for young people, are not harmless at all.”

Despite efforts to spread this awareness, Gottlieb, the FDA commissioner, has expressed concern that teen e-cigarette use will still outpace policy efforts to stop it. “Based on a growing body of evidence, I fear the youth trends will continue in 2019, forcing us to make some tough decisions about the regulatory status of e-cigarettes. The signs that we’re seeing are not encouraging. They point to continued growth in youth use of these products,” he explained in a February statement.

The FDA says it has launched education campaigns on digital and social media targeting nearly 10.7 million kids ages 12 to 17 with prevention messages. And it’s teamed up with Scholastic to get e-cigarette prevention posters in every public and private high school in the U.S. The agency is also releasing resources for doctors, youth groups, churches, health agencies, and more to better outline the risks for teens who use the devices. Gottlieb says the FDA will be stepping up its enforcement efforts too.

Kwong, the JUUL Labs spokesman, highlights the way he says the company is policing itself. It has stopped distributing certain flavored Juul pods to traditional retail stores, strengthened the age verification of its industry-leading e-commerce site, eliminated its Facebook and Instagram accounts, and developed new technology he says is aimed at further limiting youth access and use.

On the advocacy front, Rob Crane, MD, a clinical professor of family medicine at Ohio State University in Columbus and the founder of Tobacco 21, says the focus is not only on raising the minimum buying age, but also on increased enforcement. “You have to have a good law to really be effective. Altria and Juul are attempting to co-op the Tobacco 21 movement by introducing weak state laws that penalize kids and clerks while letting owner/operators off the hook. Only laws that hold the tobacco retailer accountable actually work to keep kids away from this deadly addiction."

Smoking and the Teen Brain

Adam Leventhal, PhD, director of the Health, Emotion and Addiction Laboratory at the University of Southern California, was a member of a National Academies of Sciences, Engineering, and Medicine panel that explored the public health consequences of e-cigarettes and published a report on the subject in 2018.

The report points out that since e-cigarettes only hit the market in 2006, little is known about their long-term effects in terms of morbidity and mortality. But it did find substantial evidence that e-cigarette use makes it more likely that young people will someday also use tobacco cigarettes. That is an idea supported in more recent research, too.

Leventhal says doctors also agree that since the adolescent brain is still developing into a person’s 20s, it may be more susceptible to the effects of nicotine than the brain of an adult.

He says technological innovations have also allowed e-cigarettes to deliver nicotine in a form that contains very high concentrations of the substance without a harsh or unpleasant taste. “These are really efficient nicotine delivery devices,” he says.

Maciej Goniewicz, PhD, PharmD, an associate professor of oncology and pharmacology who specializes in toxicology at Roswell Park Comprehensive Cancer Center in Buffalo, NY, agrees. He published research in 2018 that found teen e-cigarette users are getting higher doses of nicotine than previous research has shown teen cigarette smokers do.

But he says addiction risk with e-cigarettes isn’t just about concentration levels. “The drug is delivered really fast from some products. That means the product is more likely to be more addictive,” he says. “It’s about how quickly the user of the drug feels the effect.”

Other research shows:

  • Young people can feel addicted to nicotine faster than adults. The CDC says there’s evidence youths may be more sensitive to it and feel dependent faster than adults. Genetics may also make quitting harder when people start using when they are young.
  • Studies suggest e-cigarette use may also predict future marijuana use.
  • And Chadi has done research that’s found an association between e-cigarette and marijuana use and the development of suicidal thoughts and depression, compared to those not using these devices.

Tips for Parents and Teens

Think your children aren’t using e-cigarettes? Chadi says think again. “Through social contact, virtually every kid in the country could probably have pretty easy access to them,” he warns.

So health experts recommend having honest conversations with teens about the health and addiction risks that come with smoking traditional tobacco products and e-cigarettes. They recommend adults learn about e-cigarette devices so they recognize them if they see them on teens, and they say parents and caregivers should keep an eye on how and where adolescents are spending money, since a problematic e-cigarette habit might not be cheap.

If treatment is needed, Chadi says, get help from trained professionals who can discuss options like counseling as well as nicotine gum, patches, lozenges, and medications. He says that he has worked with teens who have kicked the habit and that the turnaround can be dramatic.

“We had one kid who was having severe memory and focus problems we think may have been due to using several pods a day. It’s also how quickly you use them, and that teen was using several pods in a row,” Chadi says. “He had a very motivated family. Still, it took a few months, but his memory and focus issues have improved. He’s been successful and has recovered.”

Show Sources

Nicholas Chadi, MD, Boston Children’s Hospital and Harvard Medical School, Boston.

Rob Crane, MD, Ohio State University, Columbus.

Maciej Goniewicz, PhD, PharmD, Roswell Park Comprehensive Cancer Center, Buffalo, NY.

Ted Kwong, Juul, San Francisco.

Adam Leventhal, PhD, University of Southern California, Los Angeles.

Lisa Morawski, Oregon Gov. Kate Brown’s office, Salem, OR.

George Parman, Altria, Richmond, VA.

Kaitlyn M. Berry, JAMA Network Open, Feb.1, 2019.

N. Chadi, Journal of Addiction Medicine, Jan. 24, 2019.

M. Goniewicz, BMJ Journals, Sept. 7, 2018.

Institute of Medicine: “Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products.”

2018 National Youth Tobacco Survey.

O. Owotomo, Journal of Applied Research on Children: Informing Policy for children at Risk, Volume 8, Article 5, 2017.

Richmond Times Dispatch: “Northam signs bill to raise tobacco minimum age to 21.”

Governor.Hawaii.Gov, “News Release: Governor Ige Signs Historic Smoking Measure.” “JUULpod Basics.” “Home page and Generic Fact Sheet.”

Campaign for Tobacco-Free Kids: “States and localities that have raised the minimum legal sale age for tobacco products to 21,” “Raising the tobacco age to 21,” “The path to tobacco addiction starts at very young ages.” “Photo Release: Governor Baker Signs Bill Raising Age to Purchase Tobacco Products.”

National Academies of Sciences, Engineering, and Medicine: “Public Health Consequences of E-Cigarettes.”

CDC: “Youth and Tobacco Use,” “Cigarette smoking among U.S. high school students at an all-time low, but e-cigarette use a concern,” “Electronic cigarettes: what’s the bottom line?” “Statement from FDA Commissioner Scott Gottlieb, M.D., on new data demonstrating rising youth use of tobacco products and the agency’s ongoing actions to confront the epidemic of youth e-cigarette use.” “E-cigarette use among youth and young adults.”

Hawaii Department of Health.

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