I was having a chat with a family friend over New Year’s and she was complaining about how many teenagers were vaping at her son’s school. She sees his classmates doing it all the time at the shops and outside the school. The next day, she found a USB-shaped vaping stick in his bedroom…
Electronic cigarettes (e-cigarettes), also known as “vapes”, are battery-powered devices that heat liquid to produce a vapour, a “smoky cloud” of liquid droplets. Inhaling this “smoky cloud” into your lungs is ‘vaping’. In the United States, 3.6 million young people reported using e-cigarettes in 2020. In the United Kingdom and Australia, surveys found around 11 to 14% of adolescents have tried vaping. What makes e-cigarettes different is the colourful variety of flavours they come in whilst still being harmful. Most contain nicotine, again like a cigarette, and occasionally cannabis, (THC, CBD) like a watery joint. These highly addictive substances give teenagers a rush, but are harmful to the developing adolescent brain, impacting learning, memory, and impulse control.
Why do teens like vaping so much?
It seems… safe, perhaps?. Similar to the way cigarettes were marketed as safe products a decade ago, e-cigarettes are marketed in a way that makes teenagers believe they are safer than traditional cigarette smoking. Vapes look like colourful lollies. They are inconspicuous – are often packaged to look like USB sticks or pens, and are small and light. They are not regulated in the same way as cigarettes and so may have graphic images plastered all over them. As they are hard to recognise, teenagers can vape more easily in schools because there is no lingering smell of smoke to give them away.
The myriad flavours are also a major attraction. The bitter taste of cigarettes is out, and hundreds of different flavours are in. Typical flavours like watermelon and mint, or exotic ones like papaya banana and maple waffles are readily available. In the United States, the sales of disposable e-cigarettes with “kid-appealing flavours” have increased by almost 200% since February 2020. They can be purchased in cigarette stores and online. Each disposable vape stick has a set number of puffs, ranging from 500 to 5000 before they have to be thrown away but there is also reusable vape sticks that can be refilled and re-used indefinitely.
Savvy marketing has also played a role promoting e-cigarettes. In Europe, vape sticks are advertised as a clean, harmless fruit-flavoured product. They are advertised on television, magazines, radio, and social media, often with celebrity endorsement. Popular culture has glamorized vaping with competitions encouraging young people to vape and produce the biggest “cloud” or to perform vape tricks for YouTube.
But perhaps, most significantly, they are cheap. They have avoided the heavy regulation and taxation of cigarettes for the most part. This means that, in Australia, a vape stick with 2000 puffs is about half the price of a pack of 20 cigarettes.
All this means that e-cigarettes seem to be an trendier, cleaner, and cheaper alternative to the traditional cigarette. Teenagers believe that because there is no smoke and it tastes good, they are getting a safer buzz.
Why is vaping harmful?
The ‘e-liquids’ used in e-cigarettes still contain nicotine and bring the same dangers. The number of cases of nicotine poisoning, due to exposure or ingestion of e-liquids, is on the rise. Poisoning can occur through inhalation, ingestion or topical absorption. The symptoms include dizziness, sweating, vomiting, and an increased heart rate.
One teaspoon of a liquid nicotine refill (5mL) can cause death in a child.
In 2019, there was an outbreak of hospitalisations related to e-cigarette use in the United States. 2807 people were hospitalised with vaping associated lung injury (VALI). 15% of these patients were under 18 years old. 68 of the 2807 died. Vitamin E acetate, an additive in some THC-containing e-cigarettes was found in lung fluid samples. This suggests that it may interfere with normal lung function.
American studies suggest vaping is not only associated with moderate to severe eye dryness and poorer tear film quality, but also visual impairment. A systematic review of 16 studies concluded that there may also be a risk with passive exposure to e-cigarette vapour, although this is lower than that posed by passive smoking from traditional cigarettes. Common symptoms of secondhand exposure include respiratory difficulties, eye irritation, headache, and nausea.
Vape production, import, and sales are largely unregulated and not subject to safety testing. As these devices are often purchased online, they can be made by anyone with a 3D-printer and can contain anything. Hobbyist manufacturers can be exposed to heavy metals (nickel, tin, lead), carcinogens, and a chemical used in pesticides (2-chlorophenol). The labelling of e-cigarettes is often incomplete or inaccurate. One study found that 6 out of 10 ‘nicotine-free’ e-cigarettes contained nicotine. Further research on the 65 e-liquids sold in Australia revealed that all e-liquids contained potentially harmful chemicals (benzaldehyde, menthol, trans-cinnamaldehyde and polycyclic aromatic hydrocarbons). These may enhance the addictiveness of nicotine and are potential carcinogens. There is also growing evidence that the flavourings used in most e-liquids pose a risk to health. There is still little data on the long-term health effects of e-cigarettes.
There is also lack of quality control of the small parts, such as batteries. There have been over 200 incidents involving defective e-cigarettes batteries exploding and causing fires since 2009 in the United States, resulting in life-threatening injuries requiring surgical treatment.
Is vaping a step-down from smoking cigarettes?
There is not enough evidence to recommend e-cigarettes as an effective aid for quitting smoking. Studies in Europe and North America suggest that e-cigarette use in adolescent non-smokers may be ‘gateway drug’ – associated with future uptake of tobacco cigarette smoking, marijuana use, and the use of other tobacco products like hookahs, cigars, and pipes.
This may be due to the high levels of nicotine in an e-cigarette. One packet of regular cigarettes contains approximately 22-22.5mg of nicotine. A single e-cigarette liquid pod may be equivalent to 1 to 3 packets of cigarettes! This large amount of nicotine is fuelling a new level of addiction in children that is much harder to wean.
Is vaping legal?
With skyrocketing vape stick use, there are now laws governing e-cigarette use. In the United States, Australia, the European Union, and the United Kingdom, the supply of e-cigarettes to minors is prohibited (minimum age range from 18 – 21 years old depending on country). In Australia, adults with a prescription are allowed to purchase e-liquids containing up to 100mg/mL of nicotine. The European Union and United Kingdom have limited e-liquid nicotine concentrations to 20mg/mL. On the bright side, e-liquids containing 18mg/mL have been shown to be more effective than nicotine replacement therapies to help adults to quit smoking.
What can we do as parents and clinicians?
Many parents are unaware of the risks of vaping. They are unclear about current laws and regulations around e-cigarettes use and do not talk with their teens about vaping compared to other risky behaviours, such as traditional cigarettes, drugs, and alcohol. Parents should be encouraged to discuss vaping with their children. Self-education is the first step.. Always remember to be non-judgmental and have a two-way conversation. Children model behaviour from adults, so it might be time for the adults to give up smoking smoke or vaping. E-cigarettes and e-liquids must be locked away and out of reach of children.
Health practitioners need to be aware of the risks of e-cigarettes and routinely ask their teenager patients about vaping as part of the HEADSSS screen. You may be surprised at how many young people have tried them or are using regularly. Just as you would engage young people about alcohol and cigarette smoking, get comfortable being uncomfortable and do this routinely with vaping.
Selected references
Advani IN, Perez M, Crotty Alexander LE. E-liquids and vaping devices: public policy regarding their effects on young people and health. The Medical Journal of Australia. 2021 Dec 4. doi: 10.5694/mja2.51362.
Barrington-Trimis JL, Urman R, Berhane K, Unger JB, Cruz TB, Pentz MA, Samet JM, Leventhal AM, McConnell R. E-cigarettes and future cigarette use. Pediatrics. 2016 Jul 1;138(1). doi:10.1542/peds.2016-0379.
Blount BC, Karwowski MP, Shields PG, Morel-Espinosa M, Valentin-Blasini L, Gardner M, Braselton M, Brosius CR, Caron KT, Chambers D, Corstvet J. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. New England Journal of Medicine. 2020 Feb 20;382(8):697-705. doi: 10.1056/NEJMoa1916433.
Chatterjee K, Alzghoul B, Innabi A, Meena N. Is vaping a gateway to smoking: a review of the longitudinal studies. International journal of adolescent medicine and health. 2018 Jun 1;30(3). doi:10.1515/ijamh-2016-0033.
Chivers E, Janka M, Franklin P, Mullins B, Larcombe A. Nicotine and other potentially harmful compounds in “nicotine-free” e-cigarette liquids in Australia. Med J Aust. 2019 Jan 14;210(3):127-8. doi: 10.5694/mja2.12059.
Golla A, Chen A, Tseng VL, Lee SY, Pan D, Yu F, Coleman AL. Association Between E-Cigarette Use and Visual Impairment in the United States. American Journal of Ophthalmology. 2022 Mar 1;235:229-40. doi:10.1016/j.ajo.2021.09.014.
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https://www.cdc.gov/media/releases/2020/p0909-youth-e-cigarette-use-down.html
Isa NA, Koh PY, Doraj P. The tear function in electronic cigarette smokers. Optometry and Vision Science. 2019 Sep 1;96(9):678-85. doi: 10.1097/OPX.0000000000001422.
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Leventhal AM, Strong DR, Kirkpatrick MG, Unger JB, Sussman S, Riggs NR, Stone MD, Khoddam R, Samet JM, Audrain-McGovern J. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. Jama. 2015 Aug 18;314(7):700-7. doi:10.1001/jama.2015.8950.
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The Royal Children’s Hospital National Child Health Poll (2020). E-cigarettes, vaping and teens: Do parents know the dangers? Poll Number 17. The Royal Children’s Hospital Melbourne, Parkville, Victoria.
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