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JUULing Epidemic Among Youth: A Guide to Devices, Terminology, and Interventions

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      INTRODUCTION

      Instructions

      To obtain continuing education credit:
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        Read the article carefully.
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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.
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      In December 2018, the surgeon general warned of the e-cigarette epidemic among the youth of the United States (). 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
      Outbreak of lung injury associated with the use of e-cigarette, or vaping, products.
      ).
      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 L.D.
      • Miech R.A.
      • O'Malley P.M.
      • Bachman J.G.
      • Schulenberg J.E.
      • Patrick M.E.
      Monitoring the Future national survey results on drug use 1975-2017: 2017 overview, key findings on adolescent drug use.
      ). 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 R.A.
      • Johnston L.D.
      • O'Malley P.M.
      • Bachman J.G.
      • Schulenberg J.E.
      • Patrick M.E.
      Monitoring the Future national survey results on drug use, 1975–2018: Volume I, secondary school students.
      ).
      • Jackler R.K.
      • Ramamurthi D.
      Nicotine arms race: JUUL and the high-nicotine product market.
      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
      E-cigarette use among youth and young adults: A report of the Surgeon General-executive summary.
      ). 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.

      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/accessoryName
      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 L.
      • Kimber C.
      • Puwanesarasa Y.
      • Soar K.
      First- versus second-generation electronic cigarettes: Predictors of choice and effects on urge to smoke and withdrawal symptoms.
      ). Devices in these classes may be disposable or rechargeable and use a variety of e-liquids (
      Consumer Advocates for Smoke-Free Alternatives Association
      Electronic cigarette overview.
      ). 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
      Electronic cigarette overview.
      ).

      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 J.
      • Duan Z.
      • Kwok J.
      • Binns S.
      • Vera L.E.
      • Kim Y.
      • Emery S.L.
      Vaping versus JUULing: How the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market.
      ). 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 R.
      • Benowitz N.
      • Glantz S.A.
      E-cigarettes: A scientific review.
      ). 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 M.
      • Villarreal A.
      • Bozhilov K.
      • Lin S.
      • Talbot P.
      Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol.
      ). 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 R.K.
      • Ramamurthi D.
      Nicotine arms race: JUUL and the high-nicotine product market.
      ). 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 R.K.
      • Ramamurthi D.
      Nicotine arms race: JUUL and the high-nicotine product market.
      ). The nicotine salts are known to provide a higher concentration of nicotine more smoothly and less bitterly than free-base nicotine (
      • Bowen A.
      • Xing C.
      U.S. Patent No. 9,215,895.
      ;
      • Bowen A.
      • Xing C.
      U.S. Patent No. 9,215,895.
      ).

      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 V.
      Drug vaping: From the dangers of misuse to new therapeutic devices.
      ). 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 V.
      Drug vaping: From the dangers of misuse to new therapeutic devices.
      ). Companies have even added prescription medications such as sildenafil and tadalafil to e-liquids (The
      U.S. Food and Drug Administration
      FDA in brief: FDA warns company illegally selling e-liquid products intended for vaping that contain unapproved drugs for erectile dysfunction, weight loss and falsely claim to be FDA-approved.
      ). In 2018, adolescents who reported vaping marijuana were 4.4%, 12.4%, and 13.1% among eighth, tenth, and twelfth graders, respectively (
      • Miech R.A.
      • Johnston L.D.
      • O'Malley P.M.
      • Bachman J.G.
      • Schulenberg J.E.
      • Patrick M.E.
      Monitoring the Future national survey results on drug use, 1975–2018: Volume I, secondary school students.
      ). Current reports of street or illicit marijuana identifies the potential lacing of marijuana with heroin, cocaine, methamphetamine, and various other substances (). 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
      A historical timeline of electronic cigarettes.
      ). 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 B.P.
      • Walley S.C.
      Section on Tobacco Control
      E-cigarettes and similar devices.
      ).
      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 J.G.
      • Bennett M.
      • Hair E.C.
      • Xiao H.
      • Greenberg M.S.
      • Harvey E.
      • Vallone D.
      Recognition, use and perceptions of JUUL among youth and young adults.
      ). “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 (). “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 M.
      • Earleywine M.
      A new method of cannabis ingestion: The dangers of dabs.
      ). “E-juice” is a term used to refer to the liquid used in electronic cigarettes ().
      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 J.
      Addicted to vaped nicotine, teenagers have no clear path to quitting.
      ). 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 J.
      Addicted to vaped nicotine, teenagers have no clear path to quitting.
      ). 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 J.G.
      • Bennett M.
      • Hair E.C.
      • Xiao H.
      • Greenberg M.S.
      • Harvey E.
      • Vallone D.
      Recognition, use and perceptions of JUUL among youth and young adults.
      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 J.K.
      • Farrelly M.C.
      • Watson K.A.
      Adolescents’ understanding and use of nicotine in e-cigarettes.
      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 J.K.
      • Farrelly M.C.
      • Watson K.A.
      Adolescents’ understanding and use of nicotine in e-cigarettes.
      ). 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
      The scientific basis of tobacco product regulation: Report of a WHO study group (945).
      ). 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 K.
      • Baiocchi M.
      • Ramamurthi D.
      • McLaughlin S.
      • Halpern-Felsher B.
      Youth say ads for flavored e-liquids are for them.
      ).

      Reasons for Use

      Over the years, reasons for adolescent trial and use of e-cigarettes have only grown. According to
      • Kong G.
      • Morean M.E.
      • Cavallo D.A.
      • Camenga D.R.
      • Krishnan-Sarin S.
      Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults.
      , 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 J.
      • Walton K.
      • Coleman B.N.
      • Sharapova S.R.
      • Johnson S.E.
      • Kennedy S.M.
      • Caraballo R.S.
      Reasons for electronic cigarette use among middle and high school students—National Youth Tobacco Survey, United States, 2016.
      ). In addition to the primary reasons mentioned,
      • Schneider S.
      • Diehl K.
      Vaping as a catalyst for smoking? An initial model on the initiation of electronic cigarette use and the transition to tobacco smoking among adolescents.
      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 S.
      • Morean M.
      • Kong G.
      • Bold K.W.
      • Camenga D.R.
      • Cavallo D.A.
      • Wu R.
      E-cigarettes and “dripping” among high-school youth.
      ). 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 J.K.
      • Lee Y.O.
      • Watson K.A.
      • Kim A.E.
      • Nonnemaker J.M.
      • Farrelly M.C.
      Risk factors for youth e-cigarette “vape trick” behavior.
      ).

      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 J.L.
      • Leventhal A.M.
      Adolescents’ use of “pod mod” e-cigarettes—urgent concerns.
      ). 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 K.H.
      • Colditz J.B.
      • Primack B.A.
      • Shensa A.
      • Allem J.P.
      • Miller E.
      • Cruz T.B.
      JUUL: Spreading online and offline.
      ).
      • Chu K.H.
      • Colditz J.B.
      • Primack B.A.
      • Shensa A.
      • Allem J.P.
      • Miller E.
      • Cruz T.B.
      JUUL: Spreading online and offline.
      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 D.S.
      • Cooper M.R.
      • Clendennen S.L.
      • Pasch K.E.
      • Perry C.L.
      E-Cigarette Marketing Exposure Is Associated With E-Cigarette Use Among US Youth.
      ). 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 D.
      • Gutierrez K.M.
      • Kong G.
      • Cavallo D.
      • Simon P.
      • Krishnan-Sarin S.
      E-cigarette advertising exposure in e-cigarette naïve adolescents and subsequent e-cigarette use: A longitudinal cohort study.
      ).
      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
      States and municipalities with laws regulating use of electronic cigarettes.
      ). 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 D.
      • Aamodt G.
      Electronic cigarettes the past, present and future.
      ). 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 SystemEffects
      Cardiovascular systemElevated blood pressure
      Elevated heart rate
      Increased myocardial workload
      Increased risk of myocardial infarction
      Increased risk for coronary artery disease
      Pulmonary systemIncreased inflammatory effects that may lead to
       Bronchiolitis obliterans
       Hypersensitivity pneumonitis
       Acute respiratory distress
       Eosinophilic pneumonitis
       Lipoid pneumonia
      Neurological systemNicotine addiction
      Nicotine withdrawal
      Attention deficits
      Increased risk for psychiatric disorders
      Increased risk for cognitive impairment later in life
      Oral healthDry mouth
      Decreased taste sensation
      Inflammation that may lead to
       Oral ulcerations
       Cellular mutations
       Oral cancer
      OtherNicotine 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 K.
      • Gomaa A.
      • Kullman G.
      • Fedan K.
      • Simoes E.J.
      • Enright P.L.
      Clinical bronchiolitis obliterans in workers at a microwave-popcorn plant.
      ;
      • McCauley L.
      • Markin C.
      • Hosmer D.
      An unexpected consequence of electronic cigarette use.
      ;
      • Sommerfeld C.G.
      • Weiner D.J.
      • Nowalk A.
      • Larkin A.
      Hypersensitivity pneumonitis and acute respiratory distress syndrome from e-cigarette use.
      ;
      • Thota D.
      • Latham E.
      Case report of electronic cigarettes possibly associated with eosinophilic pneumonitis in a previously healthy active-duty sailor.
      ). According to
      • King T.E.
      Bronchiolitis.
      , 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 T.E.
      Bronchiolitis.
      ). 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 J.H.
      • Lyes M.
      • Sladewski K.
      • Enany S.
      • McEachern E.
      • Mathew D.P.
      • Crotty Alexander L.E.
      Electronic cigarette inhalation alters innate immunity and airway cytokines while increasing the virulence of colonizing bacteria.
      ). This repeated inflammatory effect can lead to alveolar injury, increased airway resistance, and risk for acute respiratory distress syndrome (
      • Chun L.F.
      • Moazed F.
      • Calfee C.S.
      • Matthay M.A.
      • Gotts J.E.
      Pulmonary toxicity of e-cigarettes.
      ). 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 J.E.
      • Ghinai I.
      • Pray I.
      • Kimball A.
      • Layer M.
      • Tenforde M.
      • Meiman J.
      Pulmonary illness related to e-cigarette use in Illinois and Wisconsin - preliminary report.
      ).

      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 D.
      • van de Borne P.
      • Argacha J.F.
      New insights into the sympathetic, endothelial and coronary effects of nicotine.
      ). 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 C.
      • Spinelli S.L.
      • Curran T.M.
      • Baglia L.A.
      • Berg R.
      • Ansari S.
      • Hoeng J.
      A clinical research investigation on the effects of cigarette smoking, e- cigarette vaping and smoking cessation on vascular cell biology.
      ). Studies also reveal an increased risk for thrombotic events because of platelet aggregation (
      • Qasim H.
      • Karim Z.A.
      • Silva-Espinoza J.C.
      • Khasawneh F.T.
      • Rivera J.O.
      • Ellis C.C.
      • Alshbool F.Z.
      Short-term e-cigarette exposure increases the risk of thrombogenesis and enhances platelet function in mice.
      ). Vape aerosols may include heavy metal particles which put people at risk for coronary artery disease (
      • Tellez-Plaza M.
      • Jones M.R.
      • Dominguez-Lucas A.
      • Guallar E.
      • Navas-Acien A.
      Cadmium exposure and clinical cardiovascular disease: A systematic review.
      ).

      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 A.L.
      Functional brain imaging of tobacco use and dependence.
      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 N.L.
      Pharmacology of nicotine: Addiction, smoking-induced disease, and therapeutics.
      ). 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 S.R.
      • Harrison C.T.
      • Jeffery C.J.
      • Ammerman S.
      • Bryson S.W.
      • Killen D.T.
      • Killen J.D.
      Withdrawal symptoms over time among adolescents in a smoking cessation intervention: Do symptoms vary by level of nicotine dependence.
      ). Besides dopamine response pathways, the serotonin system may also be affected by exposure (
      • Yuan M.
      • Cross S.J.
      • Loughlin S.E.
      • Leslie F.M.
      Nicotine and the adolescent brain.
      ). 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 D.S.
      • Goriounova N.A.
      • Li K.W.
      • Loos M.
      • van der Schors R.C.
      • Schetters D.
      • Spijker S.
      Lasting synaptic changes underlie attention deficits caused by nicotine exposure during adolescence.
      ). Furthermore, studies have shown a relationship between nicotine and sleep disorders in adolescents, including difficulty falling asleep and staying asleep (
      • Bilsky S.A.
      • Feldner M.T.
      • Knapp A.A.
      • Babson K.A.
      • Leen-Feldner E.W.
      The interaction between anxiety sensitivity and cigarette smoking level in relation to sleep onset latency among adolescent cigarette smokers.
      ). 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 M.
      • Garrison K.A.
      Neurobiological considerations for tobacco use disorder.
      ). 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 V.
      • Rahimy M.
      • Korrapati A.
      • Xuan Y.
      • Zou A.E.
      • Krishnan A.R.
      • Ongkeko W.M.
      Electronic cigarettes induce DNA strand breaks and cell death independently of nicotine in cell lines.
      ).

      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 A.C.
      • Le B.Q.
      • Cumpston K.L.
      • Hieger M.A.
      • Feldman M.J.
      • Pozez A.L.
      Blast injuries caused by vape devices: 2 case reports.
      ). 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 A.
      Does the smoke ever really clear? Thirdhand smoke exposure raises new concerns.
      ). 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 (). 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 L.M.
      • Martinasek M.
      JUULING: What kids don't know will hurt them.
      ). 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 B.L.
      • Solecki S.
      Teen vaping: Time to clear the air.
      ). 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 () 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 S.
      • Park J.
      Efficacy of Pharmacotherapy for Smoking Cessation in Adolescent Smokers: A Meta-analysis of Randomized Controlled Trials.
      ). According to the (), 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
      ResourceWebsite
      AAP: ENDS: What physicians should know about ENDShttps://www.aap.org/en-us/Documents/5AsENDSfactsheet.pdf
      AAP: E-Cigarettes and Vaping: What Parents Need to Knowhttps://downloads.aap.org/RCE/ENDShandout_Parents.pdf
      AAP: JUULing: What Pediatricians and Families Need to Knowhttps://www.aap.org/en-us/Documents/AAP-JUUL-Factsheet.pdf
      AAP: Web sites that help teens quit tobaccohttps://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Richmond-Center/Documents/YouthCessationHandout.pdf
      CDC: Quit Smoking Resourceshttps://www.cdc.gov/tobacco/quit_smoking/how_to_quit/resources/index.htm
      CDC: Youth and Tobacco Use –Information and Fact Sheetshttps://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm
      Smokefree.gov: Telephone number: 1-800-QUIT-NOWhttps://smokefree.gov/tools-tips/get-extra-help/speak-to-an-expert
      Substance Abuse and Mental Health Services Administration-Prevention Strategies for Teenshttps://www.samhsa.gov/sites/default/files/programs_campaigns/nation_prevention_week/samhsa-npw-february-webinar-deck.pdf
      Surgeon General—Know the Risks—Health Care Provider Cardhttps://e-cigarettes.surgeongeneral.gov/documents/SGR_E-Cig_Health_Care_Provider_Card_508.pdf
      Truth Initiative: Inspiring Tobacco-free Lives; Resource on vaping and JUULhttps://truthinitiative.org
      This Is Quittinghttp://www.thisisquitting.com
      Truth.com Test “DITCHJUUL” to 887-09 for a text to quit programhttps://www.thetruth.com/articles/hot-topic/quit-vaping
      U.S. Food and Drug Administration, Center for Tobacco Products -Real Cost Campaignhttps://www.fda.gov/tobacco-products/public-health-education-campaigns/real-cost-campaign
      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.