Rising e-cigarette use among adolescents has made national headlines over the past year and become a pressing public health crisis. Currently, the federal government and several state governments are considering new regulations on e-cigarette products. Meanwhile, medical research into the effects of e-cigarette use—or vaping, as it is commonly known—is ongoing, with much left to learn.
In this episode of Kentucky Health, host Dr. Wayne Tuckson welcomes a Louisville pediatrician to discuss the health dangers e-cigarettes pose to children and adolescents and what adults can do to keep kids from trying them.
Dr. Patricia Purcell, MD, is a pediatrician practicing in Louisville and the immediate past president of the Kentucky chapter of the American Academy of Pediatricians.
Purcell says using e-cigarettes and “vaping” essentially refer to the same products and behavior. All products, whether older model e-cigarettes that resembled a traditional cigarette or the newer “pods” manufactured by JUUL and other companies, are what the tobacco industry calls electronic nicotine delivery systems (ENDS).
“It’s important to point out that it’s not vapor that comes from these e-cigarettes, it’s an aerosol. There’s a difference,” Purcell says. While vapor is the gaseous phase of a substance and particles are diffused through whatever space the vapor exists in, in an aerosol very small particles, or droplets, remain solid once the aerosol is activated.
“E-cigarettes have a small atomizer in them,” Purcell says. “If you’re looking at the e-cigarette, someone draws on it, they inhale, that triggers the atomizer to heat up, and that triggers the liquid that’s inside of it, and then subsequently the individuals then ‘vape,’ or breathe in the aerosol.”
How e-Cigarettes Work, and Dangers to Teens
Traditional, combustible cigarettes heat up tobacco which releases nicotine along with many other chemicals, over 60 of which have been found to be carcinogenic. E-cigarettes contain nicotine as well as other chemicals but do not contain the carcinogenic products that are activated when smoking combustible cigarettes.
Still, as Purcell says, “Nicotine is a drug. It is highly addictive. And it is incredibly addictive not only to an adult, but also to an adolescent. If you look at the data that’s been done looking at combustible cigarettes, we know that if someone can make it to age 21 without ever smoking, the likelihood that they’re ever going to smoke a combustible cigarette is almost nil. The majority of adults that smoke combustible cigarettes started before the age of 21.”
Youth are a captive audience for marketers of e-cigarettes, which were introduced in the U.S. during 2007-08, Purcell says. E-cigarettes were originally marketed to adults as a means to quit using combustible cigarettes and therefore reduce cancer risks. But over this decade, and especially after the market-dominant JUUL products were introduced 2015-16, e-cigarettes have increasingly been marketed to young adults and even to adolescents, who have been led to believe that they are a safe alternative to traditional cigarettes. While using e-cigarettes does reduce the risk of getting lung cancer or COPD (chronic obstructive pulmonary disease), Purcell points out that these new products contain additives and chemicals that may also pose long-term health risks that have yet to be fully understood.
“I have to be honest with you, I can’t tell you all of the risks associated with using these products, simply because they haven’t been on the market long enough,” Purcell says. “We don’t know (enough) and the Food and Drug Administration doesn’t have the ability to regulate them. So we’re kind of in the dark about what’s in them.”
Purcell explains that e-cigarettes came under FDA guidelines in 2016, and the agency “is playing catch-up” in terms of regulation. Currently, makers of e-cigarettes still are not required to disclose what ingredients are in their products, but that should change next year as a federal court order enforcing the Tobacco Control Act has mandated any manufacturer of e-cigarettes whose products were on the market as of August 2016 must submit an application to the FDA.
“In May 2020, supposedly, these e-cigarette manufacturers are going to have to put information and make it available to the FDA – this is what’s in our products, this is why we’re doing it, this is what we think and what we’re aiming for,” Purcell says. “But as of now, there is little to no regulation.”
In recent months, a spike in vaping-related lung illnesses along with several deaths has received national media coverage. According to information from Centers for Disease Control, as of Oct. 31 more than 1,800 cases of lung damage associated with using e-cigarettes have been reported. It’s a growing health crisis that is particularly troubling because no definite ingredient has been identified as the root cause of these problems. CDC reports that the majority of these cases came from persons using e-cigarette products that contain THC (tetrahydrocannabinol), the psychoactive ingredient in cannabis that produces a “high,” and furthermore, that the majority of THC cases involve persons buying their products through informal means or “off the street” rather than from a commercial manufacturer.
Purcell acknowledges this, saying that her most recent reading of the research suggests that around 70 percent of individuals hospitalized with pulmonary damage are connected to THC. “But that leaves somewhere around 20 or 30 percent where we don’t know what product it was that actually caused (the problems).”
The most important point to be made, Purcell argues, is that a growing number of young people are becoming exposed to nicotine through e-cigarettes and becoming addicted.
“You have the long-term consequence of nicotine addiction, which I think is one of the biggest risk factors. And it tends to be, I don’t want to say forgotten, but we tend to focus on these acute events that we’re seeing right now, but the long-term addiction I think is frightening,” she says.
Educating Young and Old Alike About the Health Risks of Vaping
Purcell says that the youngest patient she has seen who has admitted to using e-cigarettes is age 12. Treating adolescents for e-cigarette addiction is difficult, she explains, because the products have been marketed so effectively, and the trend of escalating use among teens is so recent.
“We know in adolescents that it takes less nicotine to create addiction than it does in an adult,” she says. “They are so primed for this, that I think the side effects are going to be the same to weaning off of a combustible cigarette. And the problem is that we are very limited in what we can do for these adolescents, because we’ve not ever used nicotine replacement therapy on them – we’ve not used patches on children, on adolescents. So how are we going to get them off of these products? Our goal should be to stop them before, because we don’t want to have to play catch-up.”
That preventive strategy starts with learning as much as possible about the appeal of e-cigarettes, Purcell explains. She recently visited a store for e-cigarettes, or “vape shop,” to sample some of the different flavorings created to use with JUUL pods. (JUUL recently announced that it would discontinue production of many flavorings. Meanwhile, other manufacturers continue to produce a wide variety of flavorings.)
Purcell says that she did not particularly like the flavors she tried, after sampling five of them for $5. But she admitted that e-cigarette makers’ marketing practices—many of which are currently under regulatory scrutiny—are very effective. She also points out that one way adults can find out if teens are using e-cigarettes is to examine their hands. She explains that while JUUL does not give off much of a plume (puff) when inhaled through a pod, the residue from the liquid solvents in e-cigarettes such as propylene glycol and vegetable glycerin can gather on a person’s fingers.
Parents, teachers, and other concerned adults must realize that vaping e-cigarettes is not a safe alternative for smoking traditional cigarettes when it comes to children and adolescents, Purcell maintains. She cites a 2017 study that found teens who started using e-cigarettes were at higher risk of eventually smoking combustible cigarettes. Research is ongoing into whether e-cigarettes can truly be an effective, permanent replacement product for traditional cigarettes, but those studies are directed at the adult population, Purcell says, not children.
Purcell tells her pediatric residents to approach teens about e-cigarettes by asking them both if they smoke and if they vape. Many adolescents don’t consider vaping to be using nicotine, she explains, and some aren’t even aware that their JUUL pod or other container is an electronic nicotine delivery device. Her advice for parents who want to discuss vaping with their kids is to take a roundabout path toward initiating conversation, and then being supportive once their child opens up.
“I encourage my parents to, if they listen to a webinar (on vaping), if they listen to this show, then they can open the conversation with their adolescent by saying, ‘You know, I was watching KET and they were talking about e-cigarettes. Do you know anyone who’s doing that?’” she explains. “So you don’t confront them, you try to see if it’s on the periphery, if they’ll admit to (knowing someone). And that opens up a dialogue to have with your adolescent. We must tell them that they’re losing their sense of autonomy, they’re definitely at risk for disease process, and then of course there’s the nicotine addiction.”
