key words
INTRODUCTION
Instructions
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Objectives
- 1.To identify types of e-cigarette devices.
- 2.To identify contents and additives in e-liquids.
- 3.To describe the associated effects of vaping on adolescents.
- 4.To identify terminology associated with e-cigarette use.
- 5.To identify resources for nicotine and tobacco cessation.
Posttest Questions
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Office of the Surgeon General 2018
). As of December 3, 2019, there have been 2,291 cases of hospitalization because of e-cigarette or vaping product use associated lung injury (EVALI) and 48 confirmed EVALI deaths reported to the Centers for Disease Control and Prevention. Over half of all reported EVALI cases have been of patients < 24 years old, with 16% of those < 18 years old (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Disease Prevention and Health Promotion, Office on Smoking and Health 2019
).Although cigarette smoking 30-day prevalence among 8th through 12th graders has declined from peak levels in the 1990s by up to 91%, vaping has become increasingly popular among the nation's youth (
Johnston et al., 2018
). In 2018, vaping of nicotine by adolescents had the largest increase ever for any substance tracked by the Monitoring the Future survey with use in the past 12 months rising to 11%, 35%, and 30% in the eighth, tenth, and twelfth grades, respectively (Miech et al., 2019
). Jackler and Ramamurthi, 2019
found that JUUL Labs Inc. targeted adolescents by advertising in media outlets preferred by youth, such as social media, through paid influencers and through the use of hashtags, from 2015 to 2018. JUUL Labs Inc. was the top-selling e-cigarette maker in 2018, with over 75% of the market of e-cigarette users, contributing to what can be called a JUULing epidemic. This rapid increase of nicotine use warrants a thorough understanding of the dangers of e-cigarettes for adolescents, providers, schools, and parents, including the most current products and terminology associated with e-cigarette use, health risks associated with vaping, and available tools and resources to discourage the use of e-cigarette products among adolescents.WHAT ARE ELECTRONIC CIGARETTES?
Electronic cigarettes are a broad class of products used to heat and vaporize a liquid to produce an aerosol inhaled by the user (
U.S. Department of Health and Human Services 2016
). Each product may resemble its tobacco-delivering predecessor or have a completely new form resembling common tools and modern-day technology devices. These devices are battery-powered and contain a wide variety of liquids. The liquids may contain nicotine, flavoring only, caffeine, vitamin B-12, marijuana concentrates, and additives such as psychotropic substances and opioids (e.g., fentanyl) in addition to substances that produce the actual aerosol when heated.U.S. Department of Health and Human Services
E-cigarette use among youth and young adults: A report of the Surgeon General-executive summary.
E-cigarette use among youth and young adults: A report of the Surgeon General-executive summary.
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health,
Atlanta, GA2016
Types of Electronic Cigarettes
Electronic cigarettes come in a wide array of shapes and sizes, may be disposable or rechargeable, and have changed significantly in design and appearance over the years (Table 1). E-cigarette devices and liquids are available for purchase through online retailers, in specialty tobacco and vape shops, and in convenience stores and gas stations.
TABLE 1Common vape devices and accessories
| Device/accessory | Name |
|---|---|
 | Hookah pen |
 | Pen-style |
 | Box-Mod |
 | Pod-style (JUUL, Juul Labs, Inc., San Francisco, CA) |
 | Pod-style (Suorin, Suorin USA, Chino, CA) |
 | Pod-style (Smok Novo 2, Shenzhen IVPS Technology Co Limited, Shenzhen, China) |
 | Pod-style (PHIX device and e-liquid pod, PhixVapor, Brea, CA) |
 | Cell phone vape case |
 | Box-Mod (Vape & bluetooth speaker) |
 | Vape device in key fob design |
Early generations
The first generations of e-cigarette devices range from devices that resemble an actual cigarette to larger cylinder-shaped devices and modifiable tank devices (
Dawkins et al., 2015
). Devices in these classes may be disposable or rechargeable and use a variety of e-liquids (Consumer Advocates for Smoke-Free Alternatives Association 2019b
). Users adjust tanks, atomizers, coils, and wicking materials in addition to accessorizing the modifiable devices, known as box mods, to have control over the appearance of the device as well as the amount and thickness of the vapor (Consumer Advocates for Smoke-Free Alternatives Association 2019b
).Current generation
The most current devices are pod systems. These devices use a cartridge, or pod, filled with e-liquid. The pod is inserted into the e-cigarette device and is ready for use. Most pods are closed systems, are not refillable, and contain the same amount of nicotine as 20 or more cigarettes. Once used, the pod is thrown away, and another pod inserted into the device. Some popular pod device brands among adolescents are JUUL, Phix, Nobu, and Suorin. Devices continue to evolve, and many now incorporate current technologies such as cell phone attachments, built-in speakers, and the use of Bluetooth, as seen in Table 1. JUUL, like many newer pod vaping devices, is small and slender, resembles a flash drive, recharges in a universal serial bus port, is easily concealed, and is one of the most popular devices among adolescents (
Huang et al., 2019
). Devices typically cost between $15 and $50, and pod refills cost around $4, making them about half of the price of cigarette packs.E-Liquid Solutions
Nicotine, propylene glycol, vegetable glycerin, water, and flavoring are some of the main ingredients in most e-liquid mixtures (
Grana et al., 2014
). The liquids and aerosols have also been shown to contain and produce diethylene glycol, nitrosamines, particles of tin, silver, aluminum, iron, chromium, nickel, and aldehydes, among many other respiratory irritants and cancer-causing agents (Williams et al., 2013
). There are over 15,000 e-liquid flavors currently on the market. Refillable e-liquid mixtures range in size from 30 ml to 135 ml bottles.Nicotine salts
E-liquids containing nicotine salts are increasing in popularity since the introduction of JUUL in 2015 (
Jackler and Ramamurthi, 2019
). Traditional cigarettes contain free-base or unprotonated nicotine, whereas newer e-liquids contain the protonated form of nicotine, called nicotine salt, mixed with an acid, often benzoic acid, as well as flavorings (Jackler and Ramamurthi, 2019
). The nicotine salts are known to provide a higher concentration of nicotine more smoothly and less bitterly than free-base nicotine (Bowen and Xing, 2015
; Bowen and Xing, 2015
).Other substances
Being that e-liquids can be modified, it is possible to add potentially any drug or substance that can be dissolved in a liquid (
Varlet, 2016
). Additives of concern for vaping include α-pyrrolidinovalerophenone (Flakka), gamma-hydroxybutyrate (GHB, also known as the date-rape drug), ethanol, opium, crack cocaine, amphetamines, benzodiazepines, and legal and illegal plant extracts and concentrates such as Mitragyna speciose (Kratom) and Leonotis leonorus (also called wild dagga; Varlet, 2016
). Companies have even added prescription medications such as sildenafil and tadalafil to e-liquids (The U.S. Food and Drug Administration 2018
). In 2018, adolescents who reported vaping marijuana were 4.4%, 12.4%, and 13.1% among eighth, tenth, and twelfth graders, respectively (Miech et al., 2019
). Current reports of street or illicit marijuana identifies the potential lacing of marijuana with heroin, cocaine, methamphetamine, and various other substances (American Addiction Centers 2019
). The current morbidity from illegal drugs such as fentanyl being laced in other substances of use creates a critical concern if young people are using marijuana from illicit or street dealers to make homemade e-liquids or buy illicit e-liquids from the dark web.Electronic Cigarette Terminology
The term “smoking” has long been associated with cigarette use. The term “vape” was introduced in the 1980s as a verb relating to electronic cigarette use, although the term was not widely used across the world until 2009 (
Consumer Advocates for Smoke-Free Alternatives Association 2019a
). Currently, the term “vaping” is associated with the use of tank systems and modified devices. Electronic cigarettes may be referred to as e-cigarettes, e-cigs, e-hookah, hookah sticks, mods, box mods, pens, sticks, tanks, and pods (Jenssen and Walley, 2019
).There are numerous companies in the vaping industry. JUUL (pronounced “jewel”), Phix (pronounced “fix”), and Suorin (pronounced “sore-in” or “swar-in”) are three popular e-cigarette companies that market pod systems. Many pod-based systems are often referred to as JUUL, irrespective of the devices’ actual name, and adolescents and young adults refer to the use of these devices as “JUULing” or “ripping” (
Willett et al., 2019
). “Zeroing” is a slang term used to describe holding the vapor in long enough to dispel in the lungs so no one sees anything when exhaling. “Dripping” is another term used when one drips e-liquid directly onto a coil to increase the vapor produced (American Academy of Pediatrics 2019a
). “Dabbing” and “cannavaping” are terms used for the heating of butane hash or a concentrated resin called “wax,” which is then vaporized and inhaled (Loflin and Earleywine, 2014
). “E-juice” is a term used to refer to the liquid used in electronic cigarettes (American Academy of Pediatrics 2019a
).In an interview, Dr. Susanne E. Tanski, an associate pediatrics professor at Dartmouth Geisel School of Medicine, mentions the importance of language in the assessment of adolescent tobacco and nicotine use (
Hoffman, 2018
). By asking direct questions such as “Do you smoke cigarettes?,” “Vape?,” “JUUL?,” “Use LUSH?,” “Phix?,” “Suorin?,” providers and parents will eliminate adolescent misconceptions surrounding the questions (Hoffman, 2018
). Asking questions with regards to specific devices and products common or popular in one's geographic location is imperative as all electronic cigarette-associated products vary in popularity across the nation. Being current on local products and trends is an excellent way to ensure that adolescents and young adults are certain of what the provider is asking of them.ADOLESCENT PERCEPTIONS AND USE OF ELECTRONIC CIGARETTES
Willett et al., 2019
found that approximately 25% of adolescents reported the use of an electronic cigarette as JUULing, indicating that adolescents perceive JUULing as different from smoking or vaping. Pepper et al., 2018
study indicated that adolescents are unclear if nicotine is a component of the e-liquids used and whether the nicotine is synthetic or tobacco-derived. Approximately 40% to 50% of adolescents surveyed did not know that the aerosol from e-cigarettes is more than water vapor alone (Pepper et al., 2018
). Pointing out the difference between water vapor and an aerosol may prove beneficial and could be explained using the comparison of plain water versus hair spray sprayed into one's hair. Earlier studies on flavor additives revealed that adolescents perceived different flavors as healthier than unflavored products (World Health Organization 2007
). A more recent study found that many youths believe flavored e-liquid advertisements are meant for them and not the adults the companies claim to target (McKelvey et al., 2019
).Reasons for Use
Over the years, reasons for adolescent trial and use of e-cigarettes have only grown. According to
Kong et al., 2015
, the primary reasons identified for the use of e-cigarettes include curiosity, variety of flavors, peer influence, ease of accessibility, and the perception that the devices are healthier than traditional cigarettes. A 2016 study found that 31% of middle- and high-school e-cigarette users reported using e-cigarettes because of the availability of different flavors such as candy, fruit, and chocolate (Tsai et al., 2018
). In addition to the primary reasons mentioned, Schneider and Diehl, 2016
indicate price, ability to conceal, social acceptance, and technical product designs as other possible reasons for use. Another study expounded on the popularity of producing thick clouds of vapor by the act of dripping (Krishnan-Sarin et al., 2017
). Blowing vapors into shapes, patterns, and large clouds has become known as performing vape tricks, which are now part of competitions across the nation (Pepper et al., 2017
).Social Media and Advertising
Social media, where the vast majority of adolescents spend a great deal of time, is filled with images and videos of teens and young adults performing vape tricks, posing with various devices, and even showing ways to hide devices at home and school. There are numerous advertisements for devices, liquids, and customization products such as “skins” or “wraps” and decorations that allow users to personalize their devices, increasing the appeal of the products for teenagers as well as the ability to camouflage them (
Barrington-Trimis and Leventhal, 2018
). Studies have shown that advertisements for e-cigarette companies such as JUUL specifically target adolescents. By using the internet and social media as primary advertising platforms, the companies reach audiences of all ages, especially the technology-driven generation Gen Z, who are middle- and high-school students. One study found that 25% of JUUL's Twitter followers were adolescents (Chu et al., 2018
). Chu et al., 2018
also reported that there were multiple instances of adolescents retweeting JUUL content from other adolescents as well as adults. Increased exposure to e-cigarette advertisements via multiple media channels such as the Internet, television, and retail increases the probability of use by adolescents (Mantey et al., 2016
). Moreover, exposure to advertisements via multiple social media sites such as Twitter, Instagram, YouTube, and Facebook increases the chances of e-cigarette use among adolescents (Camenga et al., 2018
).Because of the recent increase in e-cigarette use among adolescents, legislators have begun pushing for increased regulations surrounding vaping and the use of electronic cigarettes. As of July 1, 2019, only 20 states prohibit the use of e-cigarettes and vaping devices in smoke-free environments (
American Nonsmokers’ Rights Foundation 2019
). As of August 12, 2019, only 18 states have raised the minimum legal age to purchase tobacco products from 18 to 21 years. Many product manufacturers now clearly advertise the purchase age of 21 on their packaging and websites, but this does not deter many adolescent current and never users of e-cigarette from obtaining the products. Although these regulations will protect some from the effects of vapor exposure, the continuously changing e-cigarette product market warrants stricter laws surrounding the production, sale, packaging, and marketing of all products, including and related to e-cigarette use.HEALTH EFFECTS OF NICOTINE AND VAPING ON ADOLESCENTS
Although e-cigarettes and vaping devices contain fewer toxic substances than traditional cigarettes, that does not mean they are without risk (
Nguyen and Aamodt, 2018
). The most notable effects of e-cigarette use can be found in the cardiovascular system, pulmonary system, neurological system, and oral health (Table 2). Nicotine and vaping are causes of several other ill effects on health.TABLE 2Health effects of vaping
| Body System | Effects |
|---|---|
| Cardiovascular system | Elevated blood pressure |
| Elevated heart rate | |
| Increased myocardial workload | |
| Increased risk of myocardial infarction | |
| Increased risk for coronary artery disease | |
| Pulmonary system | Increased inflammatory effects that may lead to |
| Bronchiolitis obliterans | |
| Hypersensitivity pneumonitis | |
| Acute respiratory distress | |
| Eosinophilic pneumonitis | |
| Lipoid pneumonia | |
| Neurological system | Nicotine addiction |
| Nicotine withdrawal | |
| Attention deficits | |
| Increased risk for psychiatric disorders | |
| Increased risk for cognitive impairment later in life | |
| Oral health | Dry mouth |
| Decreased taste sensation | |
| Inflammation that may lead to | |
| Oral ulcerations | |
| Cellular mutations | |
| Oral cancer | |
| Other | Nicotine poisoning |
| Blast injuries | |
| Fires | |
| Burns |
Pulmonary Effects
Vaping has been found to cause increased inflammatory effects that may lead to lung disorders such as bronchiolitis obliterans, hypersensitivity pneumonitis, acute respiratory distress, eosinophilic pneumonitis, and lipoid pneumonia (
Kreiss et al., 2002
; McCauley et al., 2012
; Sommerfeld et al., 2018
; Thota and Latham, 2014
). According to King, 1998
, bronchiolitis obliterans occurs when the inhalation of certain chemicals such as diacetyl that are found in e-liquids causes swelling of the bronchioles, leading to scarring of the lungs and resulting in the loss of elasticity (lung compliance) and gas exchange. Symptoms of bronchiolitis obliterans include dry cough, shortness of breath, wheezing, and fatigue (King, 1998
). When inhaling from an e-cigarette, the aerosol is taken into the mouth and travels into the pulmonary system. In the pulmonary system, the bronchial tree endothelial barrier is breached, increasing the concentration of inflammatory cytokines (Hwang et al., 2016
). This repeated inflammatory effect can lead to alveolar injury, increased airway resistance, and risk for acute respiratory distress syndrome (Chun et al., 2017
). EVALI is the most recent diagnosis related to e-cigarette use and involves alveolar damage. EVALI is a diagnosis of exclusion with symptoms similar to those experienced with other respiratory illnesses (e.g., pneumonia or influenza), such as fever, cough, shortness of breath, headache, and fatigue (Layden et al., 2019
).Cardiovascular Effects
The effects of nicotine on the cardiovascular system include elevated heart rate and blood pressure as well as increased myocardial workload and oxygen utilization (
Adamopoulos et al., 2008
). Vaping carries similar consequences to traditional smoking. Vaping nicotine has been shown to increase oxidative stress and inflammation of tissues in the body, and users exhibit elevated homocysteine and C-reactive protein (Poussin et al., 2018
). Studies also reveal an increased risk for thrombotic events because of platelet aggregation (Qasim et al., 2018
). Vape aerosols may include heavy metal particles which put people at risk for coronary artery disease (Tellez-Plaza et al., 2013
).Neurological Effects
Neurological effects of e-cigarette use include sleep disorders, nicotine addiction, attention deficits, increased risk for psychiatric disorders, and increased risk for cognitive impairment later in life. The adolescent brain can produce long term changes because of nicotine exposure. In a brain imaging study,
Brody, 2006
demonstrated that nicotine acts on the activity of the prefrontal cortex, thalamus, and visual system as well as activates the corticobasal ganglia-thalamic brain circuitry. Stimulation of that circuitry results in the release of a variety of neurotransmitters in the brain that include dopamine. Dopaminergic neurons in the area of the midbrain signal the pleasurable experience of drug exposure and, therefore, are fundamental in the drug-induced reward system (Benowitz, 2009
). The release of the neurotransmitters in the brain is also the origin of nicotine dependence and withdrawal symptoms. Signs of nicotine dependence may include an inability to stop vaping or smoking, experiencing withdrawal symptoms when trying to stop, and a decrease in socialization and recreational activities in order to vape or smoke when one wants and without criticism from those around them.As nicotine addiction can begin within a few days of recurrent intake, many adolescents have found themselves addicted to the nicotine received through vaping and struggling with withdrawal symptoms when it comes to quitting. Symptoms of nicotine withdrawal include anger, anxiety, frustration, depression, hunger, restlessness, craving of nicotine, and difficulty with concentration (
Bailey et al., 2009
). Besides dopamine response pathways, the serotonin system may also be affected by exposure (Yu et al., 2016
). Interference in prefrontal cortex activity and a decreased presynaptic protein have also been found to lead to cognitive impairments and attention deficits in adulthood (Counotte et al., 2011
). Furthermore, studies have shown a relationship between nicotine and sleep disorders in adolescents, including difficulty falling asleep and staying asleep (Bilsky et al., 2016
). Recent advances in research using pharmacogenetics, optogenetics, and rodent fMRI have started to examine new models of treatment for nicotine addiction that are in the early stages of development (Chawla et al., 2018
). However, the effects on body systems of nicotine exposure are still a clinical concern.Oral Health Effects
From a dental health perspective, inhaling aerosols may cause a dry mouth and decreased taste sensation. The effects of vaping are also similar in the epithelium of the oropharynx to that of the lungs. The constant inflammation and damage may lead to oral ulcerations, cellular mutations, and oral cancer (
Yu et al., 2016
).Other Ill Effects
Unintentional fires and explosions are an unexpected result of e-cigarette use. Because of battery instability, e-cigarette devices have been the cause of combustion and blast injuries. There have been injuries to the face, hands, and legs resulting in bone loss and extensive surgical repairs (
Kite et al., 2016
). Smaller children who do not use e-cigarette products are at risk for nicotine poisoning, secondhand smoke exposure, and thirdhand smoke exposure when in a home or other enclosed space with someone who uses e-cigarette devices and products (Burton, 2011
). A summary of health effects can be found in Table 2.PRACTICE IMPLICATIONS
Given the unprecedented use of tobacco and e-cigarettes among youth and the potential for addiction and adverse health outcomes, providers have an obligation to communicate the risks and harm that accompany e-cigarette use. The American Academy of Pediatrics offers information to providers on continuing education, counseling, and education campaigns through their website (
American Academy of Pediatrics 2019b
). There are various steps providers can implement to ensure that patients and families have all the necessary information surrounding e-cigarette and tobacco use. These include asking specific questions about the use of e-cigarettes or tobacco, utilizing current product names, staying current with new e-cigarette devices, products available, and terminology surrounding use, discussing the contents of e-cigarettes and potential effects on the body, and providing resources throughout the clinical setting (Gibson-Young and Martinasek, 2018
). Another recommendation is that providers ensure that vaping terms are added to the tobacco section of the electronic health record to capture accurate data and remind practitioners to appropriately screen for e-cigarette use (Douglass and Solecki, 2017
). At this time, many electronic medical record systems have questions specific to tobacco and smoking only. Practitioners should be armed with the knowledge to assist patients who wish to discontinue tobacco or e-cigarette use. The recommendation for adolescent tobacco cessation from the (U.S. Preventive Services Task Force 2013
) is to provide or refer for tobacco cessation counseling. Unfortunately, no medications are approved for tobacco cessation in children and adolescents. Although the first-line recommendation at this time is behavioral therapy and prevention, pharmacotherapy studies have shown nicotine replacement and bupropion may be beneficial in some teens when other recommendations fail (Myung and Park, 2019
). According to the (U.S. Food and Drug Administration 2017
), bupropion and use of nicotine replacement products are not approved for smoking cessation use in children and adolescents, which would make their use off-label for anyone under the age of 18. Resources in Table 3 are for patients, families, and providers.TABLE 3Tobacco and nicotine cessation resources for patients, families, and health care providers
Note. AAP, American Academy of Pediatrics; CDC, Centers for Disease Control and Prevention; ENDS, electronic nicotine delivery systems.
CONCLUSION
Adolescent use of e-cigarette products and tobacco is at an all-time high in the United States. Providers have the opportunity to reach to children at an early age and potentially prevent the initiation of these products and their harmful effects but must also be prepared to assist youth in quitting e-cigarette use. Keeping up with devices, products, additives, and terminology current and relevant to the geographic location is crucial in the assessment of adolescent e-cigarette use in the community. The only treatment recommended for tobacco and e-cigarette use in children and adolescents is prevention and behavioral counseling. Preparation with factual information on the ill effects of nicotine and e-cigarette use to discuss with adolescents and parents will promote a trusting patient–provider relationship and may be beneficial in promoting compliance with counseling. Practitioners should become active in local and national organizations to lobby for legislative changes and strict regulations aimed at decreasing teen e-cigarette use.
Appendix. Supplementary materials
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Biography
Katherine Joy Hendricks, Graduate Student, Clemson University, Clemson, SC; Medical-Surgical Nurse, Prisma Health, Greenville, SC.
Heide S. Temples, Assistant Professor, Clemson University, Clemson, SC; Pediatric Primary Care Nurse Practitioner, Blue Ridge Pediatrics, Seneca, SC.
Mary Ellen Wright, PhD, APRN, CPNP-BC, Assistant Professor, Clemson University, Clemson, SC; CUSHR Scholar, Clemson University Scholar in Health Research, Clemson, SC.
Article info
Footnotes
Conflicts of interest: None to report.
Identification
Copyright
Copyright © 2019 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
