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In this e-Journal
- New drug, new risk
- History and definitions
- Emerging health risks
- The impact on your students
- Next steps in prevention
- Supporting student health when all use equals risk
New drug, new risk
Just a few short years ago we knew next to nothing about the health impact of e-cigarettes (also sometimes called e-cigs, vaporizers, or hookah pens). However, emerging facts and trends regarding e-cigarettes make it essential that we have a thorough understanding about this drug delivery system as we strive to keep our healthy kids healthy.
In this e-journal, FCD will provide an e-cigarette update for school communities. We will discuss how students are currently using e-cigarettes, the effects of that use, and what you can do to prevent use among your students.
History and definitions
E-cigarettes are battery-powered devices that heat nicotine, marijuana, flavorings, and other chemicals in solution cartridges full of "e-liquid" or "e-juice," so that users may inhale these chemicals in aerosol form (1).
Some e-cigs are made to look like traditional tobacco cigarettes, cigars, or pipes. Others resemble a modern take on the traditional cigarette or pipe, with fashionable clear or shiny metal bodies featuring sleek colors and textures. Still other versions may be crafted to look like everyday items, such as ballpoint pens or USB flash drives. Styles of electronic cigarettes very greatly among the hundreds of existing brands, and new styles enter the market regularly.
Since the 2003 invention of e-cigarettes by a Beijing pharmacist, worldwide use of, and concerns about, electronic cigarettes have grown (2). By 2007, the products' marketing had spread to Europe, with the unsubstantiated claim that the devices were tobacco-smoking cessation aids. In 2008, the World Health Organization announced that there was "no scientific evidence to confirm the product's safety and efficacy." Marketers funded their own studies and continued to make claims about the differences between traditional and electronic cigarettes. The following year, the United States' Food and Drug Administration tested e-cigs marketed as "nicotine free," and found low levels of addictive nicotine as well as carcinogenic diethylene glycol (antifreeze) among their ingredients.
By 2012, e-cigarette use among U.S. middle and high school students had doubled since the prior year, and by 2014, a greater number of students reported using e-cigarettes than traditional cigarettes in the past month (3).
The number of students reporting ever having used e-vapes had risen to 2.5 million (4).
Emerging health risks
Monitoring the Future survey results tell us that among United States students, approximately 10% of 8
th graders and 15% of 9
th through 12
th graders use e-cigarettes monthly (5). If such rapid growth in use in the U.S. is any indicator of teen use throughout the rest of the world, we all must be concerned, as e-cigarettes pose cancer, addiction, and intoxication risks.
Unknown quantities of addictive nicotine
Students are generally unclear about the contents of their e-cigarettes. Among 12th-grade students who used e-cigarettes in 2015, 65% reported their e-cigs contained only flavoring, while 22% believed they contained nicotine, 6% thought they were vaping marijuana or hash oil, and a final 6% had no idea what they were vaping (5).
Unfortunately, this confusion among students is understandable. E-cigs marketed as "nicotine free" often do contain nicotine, and even if not marketed as nicotine free, they do not specify how much nicotine or other chemicals they contain. E-cigarette companies are not obligated by any governing body to regulate or monitor the amount of each substance that goes into their products.
To highlight the inconsistency of nicotine concentration in e-cigarettes, researchers in the United Kingdom tested 16 different e-cigarettes (6). They found wide variations in nicotine levels per puff. Their findings suggested that nicotine concentration not only varies by brand, but also between inhalations of the same product!
More startling, nicotine levels per puff ranged from 0.5mg to 15.4mg in the study. The typical nicotine concentration in a puff of a tobacco cigarette is 1.54mg to 2.60mg. This means that e-cigarettes may deliver nearly six times the amount of nicotine a tobacco cigarette would to teens.
Nicotine is widely known to be an extremely addictive chemical. Biological studies show that teens are much more susceptible to the development of nicotine addiction than are adults, and may develop nicotine dependency within just a day of use (7). When students use e-cigarettes, they are gambling with their health and wellbeing, now and into the future.
Alcohol in e-cigarettes
The FCD Student Attitudes and Behavior Survey has found that in some communities, students are exposed to e-cigarettes sooner than they are to alcohol (8). Even more disturbing, new research suggests that students may be exposed to alcohol for the first time through their early use of e-cigarettes.
Many e-vaporizer liquid solutions contain alcohol
to extract their flavors from base ingredients. Yale School of Medicine found that some commercially available electronic cigarette liquids contain enough alcohol concentrations to significantly impair users' motor skills (9). When study participants were asked to perform a motor task, those under the influence of higher alcohol concentration e-cigarettes performed more poorly than those not under this influence.
This study raises many concerns. First, students who do not know that e-cigarettes can contain alcohol may unwittingly put themselves at risk not only for an addiction to nicotine, but also for an addiction to alcohol through vaping. Students using e-cigs may also drive under the influence of alcohol unknowingly or otherwise put themselves at risk for accidents and physical harm as a result of their motor impairment. E
xposure to alcohol through e-cigs puts students at a long-term risk for addiction and a short-term risk for intoxication and impairment.
Out of the dozens of e-liquids tested in the Yale study, one-third did not contain measurable alcohol, while 40% of e-liquids registered at 0.75% or less alcohol content, and another 23% contained 1-3% alcohol levels. Some brands have been known to contain e-liquids with over 23% alcohol content. As prior research has demonstrated, the concentration of such chemicals in e-cigarettes is often not regulated by manufacturers nor made known to consumers.
If we have heard any messaging about e-cigarettes, it likely includes the notion that e-cigarettes don't cause cancer. However, as of 2016, e-cigarettes remain largely unregulated, making it impossible to know exactly what chemicals are in any given product. Additionally, out of studies attempting to classify the contents of e-cigarettes, a number of troubling substances known to be carcinogenic have been revealed within the products.
For instance, a New England Journal of Medicine study reported that some e-cigarettes release formaldehyde when heated by high voltage batteries (6). A Cleveland Clinic study found that propylene glycol is a part of many e-cig's liquid (6). While considered safe to eat in food in small quantities, propylene glycol as a carcinogen has not yet been studied in a context where it is deeply and repeatedly inhaled.
E-pens marketed with "nicotine free" e-solutions have been found by a San Diego Veterans Affairs lab investigation to damage cells in ways that could lead to cancer (6). The researchers exposed cells in petri dishes to an extract from the e-cig vapor, and found that the cells showed breaks in DNA strands and a greater tendency towards cell death.
Other health risks
Further risks of e-cigarette use include the threat of a permanent condition called
bronchiolitis obliterans and
A flavoring chemical in some e-cigarettes called diacetyl is associated with a disease called b
or "popcorn lung," so named because the illness was found among
plant workers exposed to airborne diacetyl in the artificial butter flavoring of microwave popcorn (10).
Popcorn lung is a condition similar to chronic obstructive pulmonary disease (COPD), marked by cough, shortness of breath, and irreversible scarring of the lungs. A study of 51 e-cigarette varieties found higher than normal diacetyl levels in 39 of its tested flavors (10).
An outcome of inconsistent manufacturing quality among e-cigs is the risk of burn injuries related to their use. In January 2016, The Canadian Press reported on a 16-year old student who sustained significant facial and dental injury as a result of an e-cigarette explosion during use (11).
The teen has had multiple surgeries for first- and second-degree burns and two root canals resultant from the incident.
In addition to burns and other external injury, e-cigarette toxicity is a concern too.
The number of calls to U.S. Poison Control Centers involving e-cigarette liquids containing nicotine rose from one per month in September 2010 to 215 per month in February 2014, according to the CDC (12).
The impact on your students
In some school communities, a young person's first exposure to a drug, including alcohol, will be an electronic cigarette. This means that lower and middle school communities must work to educate their students about the risks of electronic cigarettes before first use or exposure occurs, and that middle and upper school communities must have initiatives in place to prevent use as students grow.
Commercial spending on e-cigs reached $115 million in 2014. The Centers on Disease Control and Prevention have noted that nearly 70% of middle and high school students are now exposed to e-cigarette advertisements in retail stores, on the Internet, in print media, and on TV and in the movies (4). Without regulations, e-cigarettes are marketed directly to youth, which explains their meteoric rise in popularity among our youngest students.
Intrigued by chocolate, bubblegum, mango, and mint flavors, students may quickly form a vaping addiction merely out of curiosity (13).
Most e-cigarette users vape because they think e-cigs are less toxic and cheaper than traditional tobacco products. Some also feel that vaping will help them quit or cut down on traditional tobacco use. It is even possible that students who have never used tobacco or marijuana before, but find such use appealing, will turn to e-cigs with the belief that this use is a less risky option.
Responses such as these reflect the false dilemma potentially created by the emergence of the e-cigarette industry. A false dilemma is a logical fallacy in which the dilemma holder feels beholden to a set of limited and unfavorable alternatives (14).
There is no mandate to use a nicotine product or to smoke. Students need not choose between one risky behavior and another. Either choice may lead to addiction and other health problems. Students need to know that the alternative to cigarette use or other smoking is not e-cigarette use, but a healthy and rewarding lifestyle free from substances.
Among the untested claims e-cigarettes often tout are that they are safer than regular cigarettes and that they help smokers quit.
Researchers Bradley Drummond and Donna Upson disagree (2). In conclusion to their work reviewing the chemical make ups of a variety of electronic vaporizers, they point out that, "there are no data regarding the long-term cancer risk associated with low-level exposure to the detected carcinogens (in e-cigarettes). Similar to cancer risk, there are no published data describing the long-term lung function or cardiovascular effects of e-cigarettes." In short, we cannot know that e-cigarettes are more or less harmful than tobacco cigarettes until we have longitudinal, epidemiological data about them across generations, as we do with traditional products. Chances are the products will share some risks and not others. For adolescents, the risk of addiction is great in either case.
On the claim that e-cigs help people quit smoking, the evidence has been minimal and inconsistent at best, and contradictory to these claims at worst. Several 2013 publications show minimal evidence that e-cigarettes help smokers quit. A cross-sectional study of 1,836 tobacco smokers finds a significant association with e-cig use and "unsuccessful quitter" status, but no association at all with "successful quitter" status (2).
Other studies suggest that e-cigs actually decrease the likelihood of successful quitting. A study of callers to state tobacco quit-lines finds e-cigarette users significantly less likely to be tobacco-free seven months after they first try vaping compared with callers from the same time period who had never tried e-cigarettes (2). Findings like these are among the reasons some researchers worry e-cigarette use might distract smokers from proven, safe, and effective methods for kicking their tobacco habit.
The wide variation between nicotine levels in e-cigarette brands, or even between e-cigs within the same brand, also has researchers puzzled as to how well any of these products can claim to function as a nicotine replacement device for hopeful quitters.
We do not yet know enough about e-cigarettes to make health claims, but from our prevention experience, we know that keeping healthy students healthy and away from vaping is by far the least risky, most rewarding alternative.
Next steps in prevention
As caring adults, we are responsible for understanding the risks of electronic cigarette use by our students and preventing that risk through effective prevention education and engagement of our teens in healthy skill building. In addition to keeping up with the latest public health information about electronic cigarettes, we challenge your school to take up the prevention effort in two key areas.
Build a curriculum
It's understandable for you to feel like the issue of electronic cigarette use by teenagers came out of left field. Most of the drugs that we work to prevent the student use of, including alcohol, have been a part of our society in one form or another for decades, or even centuries, while the commercially available e-cigarette we think of today was created only 13 years ago.
However, we cannot delay our children's health education about electronic cigarettes and vaping another moment. As discussed, e-cigarettes are currently one of the first drugs, right alongside alcohol, to which children are exposed. Millions of marketing dollars are at work to find ways to make e-cigarettes - full of nicotine, carcinogens, and other health threats - as appealing as possible to your students. Most major tobacco companies now have e-cigarette products, aiming to maintain their client base as the industry changes. Your students need to be equipped with information to make healthy decisions about this drug delivery method.
A curriculum for e-cigarette use prevention need not reinvent the wheel, but it must be up to date. Students are now vaping more than smoking, so your tobacco prevention initiatives must incorporate all nicotine products, including e-cigs. Students should be informed about addiction as a disease before they ever have a chance to use the e-cigarettes that might lead them to a struggle with chemical dependence.
Have your students take the lead
At the University of Texas San Antonio, the treasurer of the Student Government Association is leading a public service announcement campaign on her campus to inform students about the effects of tobacco products, as well as to keep UTSA nicotine-free (15). This student is in good company - at least six other student-run campus groups have also been involved in spreading awareness of tobacco products and the possible effects of e-cigs. Their PSA should be ready for release in May 2016.
While their efforts are laudable, why wait until college for students to take the lead in prevention, especially when one out of every ten 8th graders is already vaping? Instead, get together with your advisors, your life skills staff, and your health team to figure out how your students can become involved in their own prevention messaging. Teens are the industry's prime targets, and the most susceptible to the health consequences. This means they should be the leaders on this issue, with the strongest voice in prevention, guided by the wisdom and resources of caring adults in their communities.
Supporting student health when all use equals risk
There are currently over 7,000 e-cigarette flavors marketed to youth, as well as hundreds of different brands. As we have seen, the risks of use are highly varied across brands, models, and sometimes even within a single e-cigarette, due to poor regulation.
At FCD, we firmly believe that all use equals risk. For students, e-cigarettes represent another delivery system for an addictive drug. The younger a student is exposed to this behavior and substance, the more risky their use will be.
While most kids are very healthy, and the overwhelming majority of students do not use e-cigarettes, we hope the above information can help you to identify and successfully intervene upon the most common risks your students face when it comes to e-cigarettes.
Before joining FCD in 2009, Desirae Vasquez served as a consultant for the Behavioral Health Leadership Institute, advocating for Latino mental health parity within the Baltimore City Public Mental Health System and providing behavioral health education and training to a variety of Baltimore City nonprofits, including Healthy Start, Youth Opportunities, and the city's first homeless youth shelter. Internationally with FCD, she has provided numerous data-driven consultations on the evidence-based social norms approach to substance abuse prevention. Her academic training includes biostatistical approaches to community-based participatory research among academic institutions, grassroots organizations, and non-profit entities. She has a dual BA in Psychological & Brain Sciences and Public Health from the Johns Hopkins University Zanvyl Krieger School of Arts and Sciences, and an MHS in Health Education and Behavioral Science from the Johns Hopkins Bloomberg School of Public Health. Desirae is FCD's director of program services.