The Risks of Another Epidemic: Teenage Vaping

While most of us strive to avoid inhaling aerosols that could harbor a deadly virus, millions of teens and young adults are deliberately bathing their lungs in aerosols rich in chemicals with known or suspected health hazards.

I’m referring to vaping (or “juuling”): the use of e-cigarettes that is hooking young people on a highly addictive drug — nicotine — and will be likely to keep them hooked for decades. Meanwhile, e-cigarettes and other vaping devices are legally sold with few restrictions while producers and sellers reap the monetary rewards. Although many states prohibit e-cigarette sales to persons younger than 18 or 21, youngsters have little trouble accessing the products online or from friends and relatives.

In just one year, from 2017 to 2018, vaping by high school seniors increased more than “for any substance we’ve ever monitored in 45 years, and the next year it rose again almost as much,” said Richard Miech, principal investigator for the national survey Monitoring the Future.

By 2019, a quarter of 12th graders were vaping nicotine, nearly half of them daily. Daily vaping rose in all three grades surveyed — eighth, 10th and 12th — “with accompanying increases in the proportions of youth who are physically addicted to nicotine,” Dr. Miech and colleagues reported in The New England Journal of Medicine last year.

Although self-reported use of e-cigarettes by high school and middle school students decreased over the past year, Dr. Robert R. Redfield, director of the Centers for Disease Control and Prevention, cautioned, “Youth e-cigarette use remains an epidemic.”

“We’re stepping backward from all the advances we’ve made in tobacco control,” Dr. Miech, professor at the Institute for Social Research at the University of Michigan, said in an interview. “I’m worried that we will eventually return to the tobacco situation of yore. There’s evidence that kids who vape are four to five times more likely the next year to experiment with cigarettes for the first time.”

As someone who witnessed the persuasive tactics the tobacco industry used to get nearly half of American adults hooked on regular cigarettes in the 1950s, I see similar efforts being used today to promote these new delivery systems for nicotine: sex, glamour, endorsements by celebrities and doctors, and sponsorship of popular sports and musical events. Only now there are even more pervasive avenues of influence through websites and social media.

In 2016, ads for e-cigarettes reached nearly four in five middle and high school students in the United States, Dr. Ellen S. Rome noted.

As in decades past, the nation’s regulatory agencies have been slow — some say negligent — to recognize this fast-growing threat to the health and development of young Americans. Dr. Rome, a pediatrician who heads the Center for Adolescent Medicine at the Cleveland Clinic, explained that nicotine forms addictive pathways in the brain that can increase a youngster’s susceptibility to addiction throughout life. The adolescent brain is still developing, she told me, and e-cigarette use is often a gateway to vaping of marijuana, which can affect the brain centers responsible for attention, memory, learning, cognition, self-control and decision-making.

In a review published last December in the Cleveland Clinic Journal of Medicine, Dr. Rome and her co-author, Perry Dinardo, challenged the public perception that vaping is harmless, or “at least less harmful than cigarette smoking.”

While it’s likely to be true that vaping may be less hazardous than tobacco cigarettes, since the vaped aerosols that reach the lungs are devoid of the thousands of tobacco-derived toxic and carcinogenic substances inhaled by cigarette smokers, vaping still introduces a fair share of potentially harmful chemicals. In addition to nicotine, some of the chemicals, like the carcinogen formaldehyde, are created when the nicotine-rich liquid in some vaping devices is heated to high temperatures.

“E-cigarettes might have their own unique health effects we haven’t discovered yet,” said Theodore L. Wagener, director of the Center for Tobacco Research at Ohio State University. “Although compared to tobacco cigarettes, e-cigarettes without a doubt expose users to much lower levels of harmful chemicals, we still don’t know how the body handles them and what their long-term effects might be.”

Remember, it took many decades of smoking by tens of millions of people before the deadly hazards of tobacco cigarettes were recognized.

The surge in the use of electronic cigarettes was tied to a game-changing product, Juul, a cartridge device introduced in 2017 in a slew of enticing flavors. Flavors especially attractive to youngsters are now banned from use in closed-system devices like Juul, which now is sold only in tobacco and menthol flavors, but can still be used in the open-system products sold in vape shops. And now, taking advantage of a loophole in regulations, a disposable product called Puff Bar, which comes in more than 20 flavors, has replaced Juul as the vape of choice among young people.

Concerns about vaping grew after a 2019 outbreak of severe lung injuries, which were subsequently linked to vitamin E acetate, an additive found in some vaping devices that deliver THC, the psychoactive ingredient in marijuana. Juul pods are not designed to be refillable with substances like THC or other chemicals.

Producers of Juul introduced changes that enhanced the palatability and safety of vaping, but at the same time “made it easier for kids to start using nicotine,” Dr. Wagener said. Instead of freebase nicotine that is very harsh to inhale, Juul contains a nicotine salt, “a very palatable form of nicotine that makes inhaling high doses of nicotine easy,” he explained. And Juul doesn’t require the high temperatures that produce toxic substances like formaldehyde. A single pod contains the nicotine equivalent of a pack of conventional cigarettes.

“Juul made it cool, and young people who had never smoked cigarettes are becoming addicted to nicotine,” said Erika R. Cheng, a public health epidemiologist at Indiana University School of Medicine. In addition to nicotine, Juul pods contain a mix of glycerol, propylene glycol, benzoic acid and flavoring agents, the long-term health effects of which have yet to be determined, she said.

“E-cigarettes were initially advertised as a means to help people transition from harmful tobacco smoking,” Dr. Cheng said. “A lot of early users didn’t even know they contained nicotine.” Although a small minority of smokers have used e-cigarettes to help them quit or reduce their dependence on tobacco, most who use the devices vape to get their nicotine fix when they can’t smoke regular cigarettes.

Although there have been calls for bans on e-cigarettes, Abigail S. Friedman, a health economist at Yale University School of Public Health, cautioned that “bans can push people into the black market looking for something that can be acutely dangerous.”

Dr. Friedman said that rather than outright bans that can have unanticipated costs, she favors better regulations. Currently, other than flavors, what is inhaled from e-cigarettes is unregulated. Still, she and other experts are very concerned about the explosive uptake of vaping by young people. In the 2019 Youth Risk Behavior Survey of 4.9 million high school students, she said, 6 percent reported smoking conventional cigarettes while 33 percent puffed e-cigarettes in the past 30 days. In December 2018, the U.S. Surgeon General, Dr. Jerome Adams, declared e-cigarette use by youth an epidemic.

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