
Addressing the Adolescent Vaping Epidemic
Despite declining cigarette use, vaping among youth is surging, raising significant health concerns and emphasizing the need for education, advocacy, and targeted cessation strategies.
This course was published in the January/February 2025 issue and expires February 2028. The author has no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
AGD Subject Code: 158
EDUCATIONAL OBJECTIVES
After reading this course, the participant should be able to:
- Identify the reasons why adolescents vape.
- Discuss the negative health consequences of vaping among the adolescent population.
- Apply the 5 A’s for behavior change as part of tobacco cessation programs.
- Compare and contrast the pharmacological and nonpharmacological tobacco cessation methods.
While the use of combustible cigarettes has declined over the years, the use of electronic cigarettes has notably increased — especially among adolescents.1 E-cigarettes, e-cigs, vape pens, vaporizers, and vapes all fall under the category of electronic nicotine delivery systems (ENDS). ENDS became available in the United States in 2006. They were originally marketed as a safer alternative to combustible cigarettes and a means to aid in cessation; however, to date, no ENDS have been approved as a cessation device.2
Vaping devices contain a battery and heating element (atomizer) to heat e-liquid, primarily containing nicotine and other substances. When inhaled, aerosol is drawn into the lungs through the mouth, and upon exhalation, aerosol particles are released into the air, potentially exposing bystanders.
Causes for Increased E-Cigarette Usage
Over the past decade, e-cigarette use has continued to rise among adolescents.1 A 900% increase was noted between 2011 and 2015.3 The US Centers for Disease Control and Prevention’s 2023 National Youth Tobacco Survey reported 10% of middle- and high-school students used e-cigarettes, with 25.2% reporting daily use and almost 90% using flavored e-liquid.5 Contributing factors include the perception that e-cigarettes are not harmful as combustible cigarettes as many are unaware of the inclusion of nicotine and other noxious chemical components.1,4,6
Approximately 99% of e-liquid contains nicotine as well as more than 2,000 chemicals. Many of these chemicals are considered carcinogens such as propylene glycol, cadmium, heavy metals, diacetyl, and formaldehyde.3,6 Research suggests that a lower perception of harm increases the likelihood of initiating e-cigarette use.1 E-cigarette users are also more likely to begin using combustible cigarettes as well as marijuana in the future.3
E-cigarette companies began targeting adolescents in marketing campaigns with imagery of youth enjoying e-cigarettes in social situations. Some companies have offered college scholarships and served as sponsors at music and teen festivals.7,8 Research indicates adolescents find advertising campaigns interesting, thus increasing the likelihood they will try tobacco products.4
Electronic e-liquid comes in appealing flavors, such as lemonade, whipped cream, cola, and sugar cookie, that entice adolescents to use these products. Ranjit et al9 reported 81.5% of adolescents started using e-cigarettes due to the enticing flavor profiles. This also provides an increased social dynamic as youths were excited to discuss the flavors they had tried with peers.
Vaping devices come in a variety of shapes and sizes and are easily concealed. Recently devices that emulate a highlighter, a USB connector, and a smartwatch in which the face is removed to access the vaping device have been introduced.
ENDS do not emit a cloud of smoke or smell upon exhalation like combustible cigarettes, rather a colorless and odorless vapor is released keeping use virtually undetectable. The secret nature of e-cigarettes makes them ideal for adolescents. While the legal age to purchase ENDS is 21, many retailers sell to underage youth.6,9
While the US Food and Drug Administration (FDA) became responsible for regulating the packaging and labeling of ENDS and e-liquids in 2016, no federal laws ensure the accuracy of labels on these products.2 Additionally, no current US laws regulate the nicotine concentration permitted in e-liquid. Other countries limit nicotine concentration to ≤ 20 mg/mL which is comparable to the level of nicotine in combustible cigarettes. One combustible pod of e-liquid is equal to approximately 20 combustible cigarettes; however, some e-liquid has nicotine concentrations up to 59 mg/mL.10
Product labels are not always accurate. Beuttner-Schmidt et al11 found that among 70 collected e-liquid samples labeled as containing nicotine, 17% had nicotine levels exceeding the stated amount, 34% had lower levels than indicated, and one sample contained 172% more nicotine than the labeled quantity.
Health Concerns and Risks
Tobacco use is a precursor to health risks for individuals of any age. However, the adolescent population presents with unique concerns. As the brain continues to develop into the mid-twenties, damage can occur from nicotine use during this developmental phase, specifically hampering the development of the cerebral cortex and hippocampus.4
The cerebral cortex is responsible for a wide range of cognitive functions including processing information related to language, reasoning, problem-solving, judgment, and impulse control. The hippocampus plays a crucial role in forming and consolidating new memories and spatial navigation. Nicotine use can have severe and permanent consequences on the adolescent brain. Following are some of the negative impacts of e-cigarette use.
Cognitive impairment. Nicotine use is associated with decreases in memory and cognitive and executive functions, all negatively impacting academic performance.4
Mental health concerns. Anxiety, depression, and suicidal ideation are associated with tobacco use. Over the past decade, the prevalence of these mental health conditions has increased among the adolescent population as has the use of e-cigarettes.4
Oral health concerns. The mouth is the portal of entry for e-cigarettes, which experiences initial contact with the device’s vapor, nicotine, chemicals, and additives. The impact of e-cigarettes on oral health can include throat irritation, dryness, ulcerations, burns, lesions, hairy tongue, deeper probing depths, higher levels of plaque biofilm, an increased risk of developing oral cancers, and unbalances in pro-inflammatory cytokines, leading to an increase in inflammatory markers.12
E-cigarette users are nearly three times as likely to experience gingival disease when compared to nonusers.12 An increase in dental caries is also a concern. Propylene glycol and vegetable glycerin are two additives in e-liquid that provide its viscous nature. Increased viscosity can foster bacterial plaque adhesion on tooth surfaces, leading to dental caries. In addition, the sweet flavors of e-liquid contain sugar, which can further promote decay. Flavored e-liquid aerosols are also associated with decreased enamel hardness when compared to unflavored e-liquid aerosols.12
Respiratory issues. E-cigarette use increases risk of chronic obstructive pulmonary disease, asthma, and e-cigarette or vaping use-associated lung injury (EVALI). Hospitalizations involving EVALI are highest among individuals ages 18 to 24 with more than 80% of hospitalizations associated with those using e-cigarettes containing tetrahydrocannabinol.6 Adolescents who vape experience more bronchitis symptoms, coughing, wheezing, and phlegm production than nonusers.10
Safety concerns. Aftermarket and modified ENDS and e-liquid sold at off-brand retailers fail to adhere to FDA guidelines. Wax or dab pens are used specifically for the use of cannabis concentrates. Lacing e-liquid with fentanyl or other harmful substances is causing hospitalizations and death among adolescents. Modified and bootleg devices have proven defective in some instances causing overheating and battery explosions leading to burns, teeth fractures, and other injuries.2,12
Addictive Nature of Nicotine
When using e-cigarettes, nicotine — an addictive substance — is inhaled into the lungs, enters the blood, and reaches the brain within seconds of the first inhalation. Nicotine attaches to nicotine receptors on the neurons awakening the reward pathway system in the brain causing dopamine to be released, eliciting feelings of euphoria and relaxation. The more nicotine consumed, the more receptors formed, each craving nicotine to trigger the reward system.6 This causes individuals to desire more nicotine, ultimately, leading to addiction. Adolescents may experience more intense pleasurable effects from nicotine due to increased sensitivity in the developing brain.3,4
Tobacco Cessation
Oral health professionals must be prepared to engage in conversations with adolescents to assess tobacco use and their readiness to make a behavior change. A thorough detailed assessment of previous and current tobacco history is fundamental. Using open-ended questions, plain, culturally competent language, showing support and empathy, and engaging in conversations free of judgment tailored to meet the patient’s unique needs, can increase willingness to make a behavior change toward a successful quit attempt.
The 5 A’s is an evidence-based framework for behavior change outlined by the US Department of Health and Human Services and Agency for Healthcare Research and Quality. It outlines five steps a healthcare provider can take to assess a patient’s current level of tobacco use and readiness to quit as well as assist patients in making a behavior change (Table 1). Research demonstrates adolescents who had clinicians trained in the 5 A’s framework were more likely to receive tobacco cessation screenings, had increased quit attempts, and were more likely to have quit at 1 year when compared to clinicians who were not trained in using the 5 A’s.13
Nonpharmacological tobacco cessation methods focus on behavioral, psychological, and lifestyle changes to address habits and patterns associated with tobacco use. When discussing nonpharmacological methods with adolescents, interventions must be tailored to the individual’s unique needs.
Due to the high percentage of adolescents who use social media and smart devices, tobacco cessation apps are a great resource for cessation. The quitSTART app was developed by the Tobacco Control Research Branch at the National Cancer Institute in collaboration with the FDA specifically for teens.14 The app offers motivational tips and inspiration, a place to monitor progress toward quitting, healthy habit tips, games, and a platform where users can find support and share their cessation journey.
The Truth Initiative has developed an anonymous text messaging program aimed at assisting youth with support in quitting vaping. Texting DITCHVAPE to 88709 prompts users to enter relevant age and product use information, select a quit date if ready, and receive daily tailored messages to build confidence and provide skills for a successful quit attempt.15
Other nonpharmacological interventions include quit helplines, counseling, therapy, hypnosis, acupuncture, and seeking support from family and friends.16 Keeping distracted by focusing on something other than vaping can also help with successful cessation attempts. Examples can include exercise, yoga, positive self-talk, mindfulness practices such as relaxation and purposeful breathing, and volunteering in the community.
Pharmacological interventions for tobacco cessation fall into two categories: nicotine replacement therapies (NRTs) and non-nicotine replacement therapies (non-NRTs). NRTs include nicotine-based transdermal patches (long-acting), nasal sprays, inhalers, lozenges, and gum (short-acting).
Non-NRTs include prescription bupropion or varenicline. The FDA has not approved pharmacological interventions for adolescents younger than 18.17 Evidence-based research regarding cessation methods specific to ENDS and the use of pharmacological therapies in adolescents is limited and warrants future study.17,18 However, the American Academy of Pediatrics recommends the consideration of off-label NRTs for adolescents who are considered moderately to severely addicted to nicotine.17
Nonpharmacological interventions are recommended for first-time adolescent smokers. The success of NRTs increases when utilized in combination with nonpharmacological interventions such as counseling and individual or group therapy.17 Regardless of the cessation method used, healthcare providers should be forthcoming and realistic with patients about the potential obstacles surrounding quitting. Every day will not be perfect and may present some challenges, it’s planning for when those challenges occur that will help promote success.
Conclusion
To mitigate the vaping epidemic among youth, increased advocacy and educational efforts are needed. Community-based strategies, such as providing educational presentations to middle and high school students and parents, can help disseminate information and dispel the myths associated with using ENDS. Including ENDS in the health education curriculum can offer valuable opportunities to enhance adolescents’ understanding and awareness of e-cigarette use. Legislative advocacy efforts aimed at reducing marketing efforts to adolescents and limiting vape flavors to plain varieties may also help impede the enticement and eagerness of adolescents to try e-cigarettes.
Conversations surrounding past and present tobacco use should be implemented with each patient at every visit. The 5 A’s can provide a framework to begin and guide conversations surrounding tobacco use. Oral health professionals should offer cessation methods and tools that will best meet patients’ unique needs to promote a successful quit attempt.
References
- Aly AS, Mamikutty R, Marhazlinda J. Association between harmful and addictive perceptions of e-cigarettes and e-cigarette use among adolescents and youth—a systematic review and meta-analysis. Children. 2022;9:1678.
- United States Food and Drug Administration. E-cigarettes, vapes, and other electronic nicotine delivery systems (ENDS). Available at f/a.gov/tobacco-products/products-ingredients-components/e-cigarettes-vapes-and-other-electronic-nicotine-delivery-systems-ends. Accessed December 8, 2024.
- Chadi N, Hadland SE, Harris SK. Understanding the implications of the “vaping epidemic” among adolescents and young adults: a call for action. Subst Abus. 2019;40:7-10.
- Tobore TO. On the potential harmful effects of e‐cigarettes (EC) on the developing brain: The relationship between vaping‐induced oxidative stress and adolescent/young adults social maladjustJ nt. J Adolesc. 2019;76:202-209.
- Birdsey J, Cornelius M, Jamal A, et al. Tobacco product use among U.S. middle and high school students – National Youth Tobacco Survey, 2023. MMWR Morb Mortal Wkly Rep. 2023;72:1173-1182.
- Hwang C, O’Neil J. E-cigarette use among adolescents. The Journal for Nurse Practitioners. 2020;16(6):453-456.
- Truth Initiative. E-cigarettes as accessories: How vaping companies market products as stylish. Available at truthinitiative.org/research-resources/tobacco-industry-marketing/e-cigarettes-accessories-how-vaping-companies-market. Accessed December 8, 2024.
- Office of the US Surgeon General. Social Media and Youth Mental Health. Available at hhs.gov/surgeongeneral/priorities/youth-mental-health/social-media/index.html. Accessed December 8, 2024.
- Ranjit A, McCutchan G, Brain K, Poole R. “That’s the whole thing about vaping, it’s custom tasty goodness”: A meta-ethnography of young adults’ perceptions and experiences of e-cigarette use. Subst Abuse Treat Prev Policy. 2021;16:85.
- Wold LE, Tarran R, Crotty Alexander LE, et al. Cardiopulmonary consequences of vaping in adolescents: A scientific statement from the American Heart Association. Circ Res. 2022;131:e70-e78.
- Buettner-Schmidt K, Miller DR, Balasubramanian N. Electronic cigarette refill liquids: Child-resistant packaging, nicotine content, and sales to minors. J Pediatr Nurs. 2016;31:373-379.
- Yang I, Sandeep S, Rodriguez J. The oral health impact of electronic cigarette use: A systematic review. Crit Rev Toxicol. 2020;50:97-127.
- Klein JD, Gorzkowski J, Resnick EA, et al. Delivery and impact of a motivational intervention for Smoking Cessation: a pros study. Pediatrics. 2020;146:e20200644.
- Smokefree.gov. Download quitSTART. Smokefree teen. Available at teen.smokefree.gov/become-smokefree/quitstart-app. Accessed December 8, 2024.
- Truth Initiative. This Is Quitting. Available at truthinitiative.org/thisisquitting. Accessed December 8, 2024.
- Hadland SE, Chadi N. Through the haze: What clinicians can do to address youth vaping. J Adolesc Health. 2020;66:10-14.
- American Academy of Pediatrics. Nicotine Replacement Therapy and Adolescent Patients. Available at aap.org/en/patient-care/tobacco-control-and-prevention/youth-tobacco-cessation/nicotine-replacement-therapy-and-adolescent-patients. Accessed December 8, 2024.
- Amin S, Pokhrel P, Elwir T, Mettias H, Kawamoto CT. A systematic review of experimental and longitudinal studies on e-cigarette use cessation. Addict Behav. 2023;146:107787.
From Dimensions of Dental Hygiene. January/February 2025; 23(1):42-45.