The use of electronic nicotine delivery systems (or ENDS) among youth in the United States has become a serious public health concern for many reasons. These systems — commonly referred to as electronic cigarettes (or just, “e-cigarettes”), vape pens, or even “juuls” — work by heating nicotine-containing fluid to form an aerosol that users inhale. The recent experiences of the US might offer insight to other countries where youth use of e-cigarettes is only beginning to become popular.

Trends in E-cigarette Use Among U.S. Teens

 Nicotine, the primary psychoactive chemical found in cigarettes, e-cigarettes, and other tobacco products, is highly addictive and can be particularly damaging for adolescents. The evidence suggests that young brains exposed to nicotine are at an increased risk for long-term issues, including mood disorders, lowered impulse control, and learning deficits. Both the National Academies of Sciences, Engineering, and Medicine 2018 report on the public health consequences of e-cigarettes and the US Surgeon General’s 2016 report on e-cigarette use among youth and young adults have thorough discussions of these issues.

The health risks posed by nicotine for youth make recent dramatic upward trends in youth e-cigarette use that much more concerning. The proportion of US high school and middle school students reportedly using e-cigarettes first started climbing in 2011. While numbers retreated slightly in 2015-16, they began spiking again in 2017 and are now at an all-time high.

A recent analysis published by the US Centers for Disease Control and Prevention (CDC) found that more than a quarter (27.5%) of US high schoolers (teens generally ages 14-18 years old) surveyed in 2019 said they used e-cigarettes in the past 30 days — up from 20.8% in 2018. There were also increases among U.S. middle schoolers (typically ages 11-14 years old), where use jumped from 4.9% in 2018 to 10.5% in 2019.

Many health officials have expressed concern that increased vaping could cause a subsequent increase in smoking. Cohort studies have found that nonsmoking youth who vape are more likely than their non-vaping peers to subsequently initiate smoking. But the causal evidence is far from definitive. This murkiness is evident in population-level trends in different countries. ENDS use and smoking rates have increased substantially in Canada — rising an alarming 74% and 45% respectively from 2017 to 2018 — but smoking rates declined in the U.S. during and immediately after periods when vaping skyrocketed.  Continued monitoring will be important to determine the impact of current e-cigarette use on future smoking rates.

Vaping Nicotine vs. Vaping THC

 Even though this is the Tobacco Atlas, and our emphasis is tobacco, another ongoing and emerging public health concern in the US is the increase in the youth vaping of substances other than nicotine, particularly tetrahydrocannabinol or THC, the psychoactive compound found in marijuana. The link between youth nicotine vaping and THC vaping is not well established, but given the surface-level similarity between these activities, it is worth paying attention to the trends of each product. The number of teens vaping THC appears to be climbing faster than nicotine vaping. According to a survey done by the National Institutes of Health, 14% of US 12th graders (generally 17-18 years old) reported vaping THC in 2019, compared to around 5% in 2017.

A major reason for concern about vaping THC cartridges is that these products have now been established as the most likely cause of the recent epidemic of e-cigarette or vaping product use-associated lung injury (or EVALI), a serious lung condition that hospitalized more than 2,800 people and killed 68 between March 2019 and February 2020 in the U.S. EVALI has been strongly linked to THC vaping products, particularly those sold on the black market. Youth and young adults are more likely to obtain products from informal and possibly illicit sources, which may have contributed to the disproportionate impact of EVALI on youth and young adults (over half of hospitalized patients were under 25).

Policy Considerations to Curb Youth Vaping

Initiatives to curb smoking among teens could provide some guidance for policymakers looking to address teen vaping. Increasing the unit price of tobacco products (for example, through minimum pricing laws and/or excise taxes) is typically associated with a significant drop in young people initiating tobacco use, as are vigorous mass media campaigns (for example, through digital media or at the point of sale) and laws that raise the minimum age of sale for tobacco products from 18 to 21.

In general, e-cigarettes have faced few marketing restrictions. Restricting marketing could play a substantial role in reducing youth use. Similarly, including e-cigarettes in smokefree laws could reduce opportunities for youth to use e-cigarettes or be exposed to others using these devices.

Reducing youth use might also require regulating the physical products themselves, potentially including curbs on nicotine delivery speed to reduce addictiveness or “smart” devices that do not function on school grounds. Many states and localities have enacted policies to restrict the flavorings that are available, since young vapers are least likely to prefer tobacco flavoring and most likely to prefer sweet and mint flavors. Policymakers will need to consider whether the benefits of such restrictions outweigh potential costs. The science on how well these interventions translate from reducing smoking to decreasing vaping among youth is slowly becoming clear as jurisdictions implement different measures.

Given the substantial health concerns posed by nicotine use during adolescence, policymakers need to act quickly to reverse current trends in the United States and prevent similarly rapid uptake among youth in other countries.

By Robyn Correll-Carlyle, Zachary Cahn, and Melissa Maitin-Shepard