Why vaping is so dangerous for teens

Most of what we know about nicotine addiction in teens, we know from cigarettes. But experts say the technology and chemistry of vaping might pose an entirel...

Posted: Jan 17, 2019 7:30 AM

Most of what we know about nicotine addiction in teens, we know from cigarettes. But experts say the technology and chemistry of vaping might pose an entirely different threat.

"It turns out that e-cigarette use by kids doesn't look the same at all," said Dr. Sharon Levy, director of the Adolescent Substance Use and Addiction Program at Boston Children's Hospital. "How you're delivering [nicotine] and how much you're delivering ... everything you change really matters."

Levy said she's seen vape-addicted kids in her program showing what appear to be psychiatric symptoms rarely seen with traditional cigarettes or among adults. Some have anxiety and cannot focus, for example.

Meanwhile, vaping has become ubiquitous in many high schools, prompting the US Food and Drug Administration to tackle "epidemic" levels of use among minors.

On Friday, the agency will hold a public hearing to discuss the role of smoking cessation drugs for kids in order to get them off vapes. There currently are no FDA-approved nicotine cessation products for e-cigarette users under 18.

Despite early fanfare that e-cigarettes might offer a less harmful alternative to adult smokers, experts say youth are being hit hard by a combination of how vapes deliver nicotine, how kids' brains are wired and developing, and the gadgets' unique appeal to kids.

Their long-term health effects are still unclear.

"We let this Frankenstein loose without knowing what was going to happen," Levy said.

Teen vaping was a 'predictable problem'

Experts say that one Juul pod -- a cartridge of nicotine-rich liquid that users plug into the dominant e-cig brand -- contains the same amount of nicotine as a pack of cigarettes.

"That may be true, but that's not the only consideration here," said Levy, adding that it's yet unclear "how high those peaks go and how quickly it gets into the bloodstream and into the brain."

Levy said that it's not uncommon for kids to report symptoms that "sound a lot like nicotine toxicity," including headaches and stomach aches. She suspects these devices cause nicotine levels in the blood to peak higher than they do with traditional cigarettes -- but experts say more research is needed to better understand how vapes work on the body and brain.

"These new generations of electronic cigarettes, like Juul ... they actually deliver a really high dose of nicotine, probably even higher than tobacco cigarettes," said Maciej Goniewicz, an associate professor of oncology and pharmacology at Roswell Park Comprehensive Cancer Center who specializes in toxicology.

In a study last year, Goniewicz found higher levels of cotinine -- a breakdown product of nicotine -- in the urine of adolescent vapers than had been reported in prior research of teenage cigarette smokers.

According to Goniewicz, vape manufacturers may be able to pack more nicotine into their products by creating "nicotine salts," which may mask nicotine's naturally unpleasant taste and lead the drug to be absorbed by the body quicker.

The salt is created by combining nicotine -- a base in its natural form -- with an organic acid, he said. Experts worry that inhaling these and other added ingredients may cause other health problems down the line, but e-cigarettes haven't been around long enough to know.

Beyond the chemistry of the nicotine itself, e-cigarette companies have come under fire for adding pleasant, often sweet flavors to their "e-liquid" that are known to appeal to young people. And the absence of the harshness of inhaling combustible cigarettes may allow vapers to take deeper or more frequent puffs, Levy added.

FDA commissioner Dr. Scott Gottlieb proposed in November to strengthen the agency's policies against flavored e-cigarette products. These proposals could ultimately prompt their removal from shelves and websites that are accessible to minors. But the proposed changes do not include mint, menthol and tobacco flavors. Gottlieb said he wanted to leave the door open for adults who might use these products to quit smoking cigarettes, "but it can't come at the expense of addicting a generation of kids on nicotine," he previously told CNN.

Leading e-cigarette company Juul, which holds about 75% of the market in the United States, has also maintained that flavors are a useful tool to help adult smokers to switch from combustible cigarettes.

Ashley Gould, chief administrative officer at Juul Labs, told CNN last year, "We were completely surprised by the youth usage of the product." The company has maintained that its product is intended to convert adult former smokers to what Juul describes as a less-harmful alternative, and it says it is taking steps to limit kids' use of e-cigarettes.

But Levy describes vapes' popularity among teens as an "entirely predictable problem."

Teens' brains might be more vulnerable to nicotine

Levy said the impact of vapes on teens is changing the way people think about nicotine products.

Smoking was largely seen as a "medical problem" that could lead to cancer and other physical ailments, she said. Now, vaping is increasingly being seen as a psychiatric problem over concerns that nicotine is cultivating addictive behaviors among kids and interfering with their brain development.

"There's concern that the adolescent brain may be more vulnerable to the addictive effects of nicotine," said Adam Leventhal, director of the Health, Emotion, and Addiction Laboratory at the University of Southern California.

"The circuits underlying pleasure and the pursuit of novel, enjoyable experiences develop much faster than the circuits that promote decision making, impulse control and rational thinking," Leventhal said.

We know from cigarette users that those who try nicotine products early in life are more likely to develop dependence to the drug, said Leventhal. This may also lead to the disruption of brain circuits that underlie attention and cognitive skills, he added.

What makes kids uniquely vulnerable to vapes is not merely biological; it's also psychosocial, according to Leventhal. This may come in the form of peer pressure or stress, which may increase the likelihood of addictive behaviors, he said.

More broadly, the cultural and policy shifts that prevent many kids from picking up cigarettes -- including FDA regulation and a "long history of prevention programs" -- simply haven't kept pace with the vaping boom, Leventhal added.

Kids and adults also tend to vape for different reasons, Goniewicz said. Adults tend to be former smokers who can handle a high dose of nicotine and want to avoid withdrawal symptoms, such as the inability to sleep or focus on work.

"They don't really need nicotine to feel good," he said. "They need nicotine not to feel bad -- because they are already addicted."

But e-cigarettes may be kids' first experience with nicotine. "Nicotine hits the brain," he said, tinkering with molecules that affect mood and other pathways. And they aren't used to it, he said.

"Nicotine is a potent chemical that changes our brain."

It's hard to get kids to quit

Levy said that "nearly all" adolescents in her program have some experience with e-cigarettes, but "what's new is that now, we're seeing patients in the substance use program whose only substance is nicotine."

Health experts worry that getting hooked on nicotine early in life may be a gateway to cigarette smoking and other drugs, and there are few tried-and-true resources out there for teens.

"Kids are often really struggling with this, and there are just not a lot of resources for them," Levy said, adding that many addiction programs may not be equipped to deal with some of the younger, nicotine-addicted kids she's seeing. Far better would be to ensure that primary care doctors are equipped to work with kids in their own communities, she said.

Some parents have pursued nicotine gum and other cessation tools off-label for their children under doctors' guidance. Levy said that can be tricky because some kids may use these products as a "bridge" between puffs of vapes and tobacco products.

Medications can be important in some advanced cases, but they're not enough, she said; kids also need "good, solid counseling."

"We end up needing to teach kids how they can deal with cravings, how they can identify high-risk situations, how they can actually deal with being surrounded by people who are using these things," Levy said. "Because the reality is that, for most kids, we treat them and put them back in school, and then they go to the bathroom, and everybody's Juuling."

Still, she said kids and their parents seem largely unaware of the potential dangers.

"Even to this day, I have kids saying, 'well, I thought it was safe' or 'I know it's safer than cigarettes,' " Levy said.

"And 'safer than cigarettes' is a really low bar."

Minnesota Coronavirus Cases

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Reported Deaths: 9462
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Ramsey722701040
Dakota66032572
Anoka62513568
Washington39357355
Stearns32821275
St. Louis28761399
Wright25354211
Scott25329181
Olmsted21750127
Sherburne18478126
Carver1629166
Clay11923103
Blue Earth1126366
Rice11234138
Crow Wing11003122
Chisago974676
Kandiyohi9660106
Otter Tail9611126
Benton8815124
Beltrami801794
Goodhue786596
Douglas7689100
Itasca752796
Mower721349
Winona702756
McLeod694483
Isanti681383
Steele669431
Morrison663479
Becker620873
Polk591684
Freeborn550846
Carlton529474
Nobles521654
Lyon518761
Mille Lacs516573
Nicollet510960
Pine500641
Cass491252
Todd483642
Brown465057
Le Sueur445933
Meeker422357
Martin378143
Wabasha366010
Waseca365132
Dodge351511
Hubbard349848
Roseau307931
Fillmore299115
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Redwood277845
Houston266817
Renville264151
Faribault253032
Pennington247529
Sibley246917
Kanabec241536
Cottonwood225032
Chippewa216342
Aitkin215850
Pope203210
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Rock174728
Swift169322
Koochiching168123
Stevens164511
Jackson159216
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Marshall151122
Murray150911
Pipestone148329
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Wilkin119416
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Norman10389
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Cook3020

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Cases: 520452

Reported Deaths: 7289
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Polk80319799
Linn32142424
Scott26637292
Black Hawk21974378
Woodbury20490258
Johnson19778105
Dubuque18515241
Pottawattamie15890213
Dallas15320113
Story1380258
Warren8450104
Cerro Gordo7964123
Clinton7725114
Webster7326122
Des Moines7098105
Marshall669093
Muscatine6645117
Wapello6441144
Jasper619591
Sioux610177
Lee5908105
Marion557897
Buena Vista502149
Plymouth488388
Henry418655
Benton404859
Jones404862
Unassigned40470
Bremer395372
Washington391463
Boone389739
Carroll367755
Mahaska365365
Crawford353747
Dickinson314655
Jackson307747
Buchanan305741
Clay295536
Delaware294654
Kossuth289077
Fayette286353
Hardin284353
Tama279777
Page272533
Wright266149
Cedar265527
Hamilton259857
Winneshiek258143
Floyd255449
Clayton244459
Poweshiek237243
Madison234525
Harrison234379
Cass233466
Butler232744
Iowa229634
Jefferson223043
Mills220930
Winnebago215938
Hancock214639
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Lyon206142
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Allamakee203955
Calhoun196919
Shelby196442
Union191141
Humboldt185130
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Franklin183029
Mitchell182043
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Emmet178246
Louisa176953
Sac171026
Guthrie168137
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