Vaping is now more popular than cigarette smoking in teens and young adults, and its use is growing rapidly. Research suggests this is bad news for the lungs and for cardiovascular health, and much is still unknown about how vaping will affect this young population in the long-term.
A highly addictive habit, vaping — also known as the use of electronic nicotine-delivery systems (ENDS) or e-cigarettes — is “a public health concern” that “has been linked to a recent outbreak of lung injury and deaths among adults,” according to a Centers for Disease Control and Prevention (CDC) 2020 data brief.1
Vaping has increased exponentially among adolescents2:
- E-cigarette use increased by 1733% among high school students — from 1.5% of all students in 2011, to 20.7% in 2018, and 27.5% in 2019.
- E-cigarette use increased by 1650% among middle school students — from 0.6% in 2011 to 10.5% in 2019.
During roughly the same time period, cigarette smoking among youth declined by 44% — to 8.8% of all high school students in 2018.2
Moreover, by 2019, the number of students using e-cigarettes within 5 minutes of waking up (an indication of addiction) was exponentially greater than the number of students reaching for a traditional cigarette within 5 minutes of waking (approximately 177,000 vs 23,000, respectively), according to a 2022 analysis of data on students in 6th to 12th grade published in JAMA Network Open.3
Among adults 18 to 24 years of age, approximately 7.6% use e-cigarettes, a percentage that is higher than that of adults of older ages: use of e-cigarettes was 4.3% in those aged 25 to 44 years; 2.1% in those aged 45 to 64 years; and 0.8% in those aged 65 years and older, according to survey data reported by the National Center for Health Statistics (NCHS).1
NCHS also found that:
- those who vape are almost 2 times more likely to be male vs female;
- differences in e-cigarette use by income are not significant; and
- e-cigarette use is higher among non-Hispanic White adults (3.7%) than among Hispanic adults (2.5%), non-Hispanic Black adults (1.6%), and non-Hispanic Asian adults (2.2%) in the US.1
“Electronic cigarettes (e-cigarettes) are one of the most controversial products in the tobacco world,” noted Gholap and colleagues in a 2020 review.4 “Unlike conventional cigarettes, these battery-powered devices deliver nicotine without combustion. The vehicle of nicotine in these products is e-liquid, which is a mixture of propylene glycol (PG) and vegetable glycerin (VG) in varying ratios. The nicotine concentration in these e-liquids can vary from 0 to >50 mg/mL with actual content often deviating from the label claim.”4
These e-liquids may also contain a huge variety of flavoring chemicals, which can add appeal for younger users.4 According to the American Lung Association, approximately 69% of middle and high school students who vaped used flavored e-cigarettes in 2019.2 Although the US Food and Drug Administration (FDA) began banning “certain unauthorized flavored cartridge-based e-cigarettes” in 2020,5 that ban has proved difficult to enforce.6
Notably, the FDA only began regulating e-cigarettes in 2016.7 Under those regulations, companies selling e-cigarettes were required to submit an application to the FDA by September 2020 in order to either continue or begin selling vaping products. Since then, the FDA has been reviewing applications for almost 6.7 million products — although as an FDA spokesperson acknowledged, there are still products being sold that have not been FDA-approved and for which companies have not submitted applications.7
Increased Nicotine Delivery
The protonated nicotine commonly used in e-cigarettes offers a smooth sensory effect and high nicotine absorption compared with free base nicotine.4 This protonated nicotine can be delivered to the lungs in higher doses through vaping vs conventional cigarette smoking, noted Hilary Tindle, MD, MPH, associate professor of medicine at Vanderbilt University, Nashville, Tennessee, and founding director of the Vanderbilt Center for Tobacco, Addiction and Lifestyle.
“The e-cigarette manufacturers achieve this by adding the chemical benzoic acid to the nicotine e-liquid, which makes the e-liquid more acidic and the protonated nicotine easier to inhale,” she explained in an exclusive interview. “Greater nicotine delivery to the lungs, and then on to the brain, makes nicotine more addictive.”
While earlier generations of e-cigarettes were not as efficient as the cigarette in delivering nicotine, newer generations are as efficient or more efficient at this task, said Steven Fu, MD, MSCE, director of the Center for Care Delivery and Outcomes Research at the Minneapolis Veterans Health Care System and professor of medicine at the University of Minnesota, Minneapolis. “So, you’re really getting a pretty intense dose of nicotine with vaping, particularly with the newer generations,” he said.
“There is a large variability among the different types of vapes, but the newer generations are really efficient,” Dr Fu commented, “and I think that’s why we see this high-level addiction among adolescents and young adults, particularly because they’re using the newer generations of vape products.”
In addition to enhanced delivery, Dr Tindle noted that flavoring entices young people and “hooks” them to e-cigarettes. “These design features of e-cigarettes, in combination with the advertising campaigns aimed at young people, set the conditions for greater use of e-cigarettes by young people,” she added.
Health Risks of Vaping in Teens and Young Adults
While the risks associated with traditional, combustible cigarette smoking are “well-established,” there are few long-term studies on the risks of vaping because of its relative newness, said Dr Fu.
“While many young people may understand that ‘smoking is bad for you,’ there are persistent, widespread misconceptions among young people that vaping is safe,” Dr Tindle explained. “We don’t have long-term information on e-cigarette use to the same extent as we do for smoking, where we have followed the same people for years and measured the increased risk of heart disease, cancer, stroke, diabetes, and death in the people who smoke vs those who did not,” Dr Tindle added.
Still, growing evidence suggests that e-cigarettes can cause harm, such as impaired blood vessel relaxation, which may lead to cardiovascular disease over time.8,9 Laboratory studies and clinical studies of short-term e-cigarette use show that exposure to these products is associated with reduced nitric oxide release, resulting in greater permeability and subsequent “leakiness” of cells that line the blood vessels, and lead to increased release of hydrogen peroxide.10,11
“We’re starting to learn that vaping is having some respiratory effects,” Dr. Fu added. “So particularly in kids and young adults with asthma, it makes their asthma more difficult to manage.”
Furthermore, Dr Fu noted that prior to the COVID-19 pandemic, there was an outbreak of acute lung injury dubbed “e-cigarettes and vaping-associated lung injury” (EVALI). “There were a number of cases where adolescents or young adults who were vaping presented to emergency rooms with EVALI in respiratory distress, sometimes ending up in the intensive care unit,” he said. According to the CDC, of 2,668 hospitalized EVALI cases or deaths reported, 15% of patients were under 18 years of age and 37% were 18 to 24 years old. The EVALI cases have been strongly linked to vitamin E-acetate, which has been an ingredient in tetrahydrocannabinol (THC)-containing e-cigarettes, and THC-containing products were used in 82% of EVALI cases reported to the CDC.12
In addition to physical health effects, Dr Fu added that there is significant concern with respect to an association between vaping and a possible increased risk for neuropsychiatric effects. “Because adolescents are receiving nicotine when they vape,” he explained, “they’re being exposed to high levels of nicotine intensity that’s affecting their memory, concentration, and their ability to pay attention in class.”
Research has also identified a link between vaping and other types of smoking. A 2017 systematic review and meta-analysis found that e-cigarette use was associated with an increased risk for subsequent cigarette smoking in adolescents and young adults, placing these individuals at increased risks of exposure to further health risks from tobacco.13
Additionally, findings from a 2019 systematic review and meta-analysis showed that adolescents and young adults who used e-cigarettes had a significantly increased odds of past or current and subsequent marijuana use.14 Evidence points to long-term harmful effects of marijuana use in adolescents, including associations with reduced cognitive abilities, motivation, life satisfaction, and life achievement, in addition to increased rates of mental health disorders including anxiety, depression, and schizophrenia.14
“Generally, the same principles of treating nicotine dependence hold for helping people quit vaping,” Dr Tindle said. “Thus, it is clinically reasonable to use the same medications, although this is technically ‘off label.’”
However, according to Dr Fu, caution is warranted in the off-label use of some approved smoking cessation therapies to help individuals quit vaping. For example, although varenicline and bupropion have been approved by the FDA for smoking,15 much is unknown about the effects of varenicline or bupropion on vaping cessation, said Dr Fu. Accordingly, these therapies are not generally recommended to help wean individuals off e-cigarettes, he noted.
Common smoking cessation aids that can be used by those under 18 years of age as well as adults include nicotine patches, gums, and lozenges, said Dr Fu.
Smoking cessation counseling can also be helpful. Individuals trying to quit vaping who do not receive counseling through their doctor’s office or from their health care provider can access a network of state “quit-lines” offering free care to people in all 50 states, Puerto Rico, and some other US territories, said Dr Tindle. This counseling can be accessed by calling 1-800-QUIT-NOW. Most of these quit-lines will offer counseling to adolescents, she added; although ages for these services vary by state, some parts of the US offer this service for individuals as young as 12 years old, said Dr Tindle.
What else can health care providers (HCPs) do to address the explosion of vaping among teens and young adults? “Health care providers can address the dangers simply by talking about the risk of vaping during the health care visit and when corresponding by other means, such as the health portal,” Dr Tindle suggested. “In addition, HCPs can suggest resources such as ‘The Truth Initiative’ to provide teens with correct information about vaping, so they can learn and make good decisions.”
Current media campaigns aimed at helping teens understand the harms and risks of vaping are also valuable and should continue, added Dr Tindle. At the policy level, she further suggested that greater and “more far-reaching regulations are needed to help protect kids from e-cigarettes, including the barrage of ‘Big Tobacco’ advertising.”
Restrictions that limit the amount of nicotine in vaping products and eliminate flavorings that make these products more appealing to young people are also key steps to reducing vaping in adolescents, said Dr Tindle.
- Centers for Disease Control and Prevention, National Center for Health Statistics. Electronic Cigarette Use Among US Adults, 2018. Updated April 30, 2020. Accessed August 2, 2023.
- American Lung Association. Overall Tobacco Trends. Accessed August 2, 2023.
- Glantz S, Jeffers A, Winickoff JP. Nicotine addiction and intensity of e-cigarette use by adolescents in the US, 2014 to 2021. JAMA Netw Open. 2022;5(11):e2240671. doi:10.1001/jamanetworkopen.2022.40671
- Gholap VV, Kosmider L, Golshahi L, Halquist MS. Nicotine forms: why and how do they matter in nicotine delivery from electronic cigarettes? Expert Opin Drug Deliv. 2020;17(12):1727-1736. doi:10.1080/17425247.2020
- US Food and Drug Administration. FDA finalizes enforcement policy on unauthorized flavored cartridge-based e-cigarettes that appeal to children, including fruit and mint. Published January 2, 2020. Accessed August 1, 2023.
- Noguchi Y. Flavored vapes are supposed to be illegal, but they’re still widely available. July 12, 2023. Accessed August 1, 2023.
- Phillips C. FDA Oversight of E-Cigarettes Gathers Speed: A Conversation with Mitch Zeller. Published January 5, 2022. Accessed August 3, 2023.
- Buchanan ND, Grimmer JA, Tanwar V, Schwieterman N, Mohler PJ, Wold LE.Cardiovascular risk of electronic cigarettes: a review of preclinical and clinical studies. Cardiovasc Res. 2020;116(1):40-50. doi:10.1093/cvr/cvz256
- Espinoza-Derout J, Shao XM, Lao CJ, et al. Electronic cigarette use and the risk of cardiovascular diseases. Front Cardiovasc Med. 2022;9:879726. doi:10.3389/fcvm.2022.879726
- Mohammadi L, Han DD, Xu F, et al. Chronic e-cigarette use impairs endothelial function on the physiological and cellular levels. Arterioscler Thromb Vasc Biol. 2022;42(11):1333-1350. doi:1161/ATVBAHA.121.317749
- Nabavizadeh P, Liu J, Rao P, et al. Impairment of endothelial function by cigarette smoke is not caused by a specific smoke constituent, but by vagal input from the airway. Arterioscler Thromb Vasc Biol. 2022;42(11):1324-1332. doi:10.1161/ATVBAHA.122.318051
- Centers for Disease Control and Prevention. Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. Updated February 25, 2020. Accessed August 4, 2023.
- Soneji S, Barrington-Trimis JL, Wills TA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: A systematic review and meta-analysis JAMA Pediatr. 2017;171(8):788-797. doi:1001/jamapediatrics.2017.1488
- Chadi N, Schroeder R, Jensen JW, Levy S. Association between electronic cigarette use and marijuana use among adolescents and young adults: A systematic review and meta-analysis. JAMA Pediatr. 2019;173(10):e192574. doi:10.1001/jamapediatrics.2019.2574
- Kim N, McCarthy DE, Piper ME, Baker TB. Comparative effects of varenicline or combination nicotine replacement therapy versus patch monotherapy on candidate mediators of early abstinence in a smoking cessation attempt. Addiction. 2021;116(4):926-935. doi:10.1111/add.15248
This article originally appeared on Pulmonology Advisor