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Do you remember 1964? If you need a jog down memory lane or if that’s ancient history to you, let me give you a quick rundown…the cost of new house was $13,050, a gallon of gas was 30¢, Dr. Martin Luther King, Jr. received the Nobel Peace Prize, and the Beatles held the top 5 spots on the Billboard Top 40 singles.  That was also the year that for the first time ever, the US Surgeon General issued a warning that cigarette smoking could lead to cancer.  In the 55 years since this first warning, additional research has shown just how harmful cigarette smoking can be and ultimately led to a dramatic decline in the rates of cigarette smoking here in the US.  When the “Truth Initiative” youth anti-smoking campaign was launched in 1998, 23% of teens were smokers. By 2017, that number had declined to 2.1% of middle schoolers and 7.6% of high schoolers…a successful endeavor for sure.  However, now, a new rising epidemic of electronic cigarettes and vaping is poised to cause the gains of the prior 5 decades to go up in (vapor) smoke .

“Many of those liquids which are marketed as “nicotine free” were found to, in fact, contain nicotine.”

The term “e-cigarette” encompasses a wide array of devices which can look like anything from a traditional cigarette to a sleek USB stick.  These devices use a battery powered heating coil that transforms a solution containing nicotine, flavoring chemicals and other additives into an aerosol that is inhaled into the lungs.  Currently, the top selling e-cigarette brand in the United States is JUUL which began selling their USB shaped devices in 2015. And to give you an idea of its popularity, as of last year, the company’s revenue hit the $1 billion mark.  

So what exactly is contained in these vaping liquids?  Well, to start with, nicotine. Many of those liquids which are marketed as “nicotine free” were found to, in fact, contain nicotine.  Each of the ever popular JUUL brand pods contain the same amount of nicotine as 20 cigarettes. Nicotine, which is of course highly addictive, can have detrimental effects on the still growing brain of adolescents, particularly in areas of impulse control, focus, and, most alarmingly, increased susceptibility to addiction. These liquids also contain flavoring additives which make attractive flavors such as pina colada, bubble gum, java chip, popcorn and caramel.  A recent study found that the chemicals used to create the popcorn and caramel flavors, diacetyl and 2,3-pentanedione, respectively, while safe for eating, can actually destroy the cilia of the lungs. Other ingredients include propylene glycol (a component of antifreeze), aldehydes and nitrosamines among other toxicants and carcinogens.

“The National Youth Tobacco Survey found a 78% increase in the usage of e-cigarettes in middle and high school students from 2017 to 2018.”

Beyond just the potential negative direct health aspects of e-cigarettes, there is also the issue of harmful youth consumption and addiction.  The National Youth Tobacco Survey found a 78% increase in the usage of e-cigarettes in middle and high school students from 2017 to 2018 with over 20% of high school students reporting the use of a vaping device in the past 30 days.  That means over 3.6 million high school students are smoking these devices! Studies have also found that those teens that start a nicotine addiction via e-cigarettes are almost 4 times more likely to start smoking traditional cigarettes, a worrisome trend after decades of declining teen smoking rates.

Another potential hazard of liquid nicotine that cannot be overlooked is the potential ingestion of these liquids by unassuming young children.  Many of these liquids are bright red, pink or yellow in color which can certainly be enticing to children who may mistake them for juices, candy, etc.  After the death of a child in 2014 from ingesting liquid nicotine, the Child Nicotine Poisoning Prevention Act was enacted in early 2016 which requires all liquid nicotine packaging to be child-resistant. Even with this law, the number of calls to poison control centers around the US involving ingesting vaping fluids topped 3,000 in 2018 and 340 in the first 31 days of 2019.

Prior to 2016, e-cigarettes were available for purchase to anyone including children through not only brick and mortar stores, but also gas stations, mall kiosks as well as online retailers.  The aforementioned Child Nicotine Poisoning Prevention Act of 2016 made it illegal to sell these devices to anyone under the age of 18, required photo verification of age for those under 27 years old, banned sales of these devices in vending machines, and required warning statements on products regarding the addictive nature of nicotine.  While online retailers of e-cigarette devices have the same age restrictions, Truth Initiative found that youth were 89% successful in obtaining these devices when purchasing online. The FDA has also proposed the Deeming Rule which would require e-cigarette manufacturers to submit their products for FDA review and approval prior to going to market.  The Deeming Rule was set to go in effect in 2016, however its implementation has now been delayed to 2022 which allows for another 3 years of unregulated e-cigarette products being sold to consumers.

“Our children deserve more than just warning letters and fines from the FDA to e-cigarette manufacturers who are marketing to youth.”

When I ask my teenage patients about vaping, many of them give me a little shoulder shrug and slight smile as they tell me how ubiquitous these devices are.  They appear to essentially be a daily fixture in school bathrooms these days. I have found that many teens do not even know they are smoking highly addictive nicotine, which was something that Truth Initiative verified when they found that 60% of teens thought the primary ingredient in their e-cigarette was flavoring.  

More must be done to stem the rising tide of this epidemic in our youth.  Our children deserve more than just warning letters and fines from the FDA to e-cigarette manufacturers who are marketing to youth. The Deeming Law should be enacted now rather than waiting to 2022 so that the public can know what they are being exposed to through these vaping liquids.  There needs to be a push on the state level to have meaningful laws enacted that would put e-cigarettes on a level footing with traditional cigarettes legally. Same regulations, same requirements, same advertising restrictions, same tax levels, etc. And of particular note, e-cigarettes should also be incorporated into current tobacco-free zone restrictions limiting their presence in places such as schools, restaurants, and pubic facilities.  Hopefully, implementing all of these things, combined with some particularly effective social outreach movements much like those done in earlier decades via the Surgeon General and the Truth Initiative, will help to reverse the currently rising epidemic of nicotine addiction in our youth via both e-cigarettes and the gateway they seem to provide back into an old and even more detrimental old foe - standard tobacco cigarettes.