What Providers Can Do to Limit the Vaping Epidemic

BY ANNA AISTRICH, MPH County of Santa Clara Public Health Department, Tobacco-Free Communities

E-cigarettes are a rapidly evolving group of products, known also as e-cigs, Juuls, vaporizers, vape pens, e-hookahs, tanks and mods. These are more broadly referred to as electronic nicotine delivery systems (ENDS). Some resemble traditional cigarettes, cigars or pipes, and some look like pens, USB flash drives or other ordinary objects.

ENDS entered the US market around 2007 but demand really grew after 2014, especially among youth. Following the introduction of Juul – now the most popular e-cigarette brand – and other cartridge-based devices, ENDS use surged among middle and high school students across the nation between 2017-2018 (48% and 78% increase, respectively). National use among youth is at a record high, going from 1 in 100 (in 2011) to 1 in 5 (in 2018) 1 – reversing previous declines in tobacco use.

In Santa Clara County, cigarette smoking is at an all-time low (1.4%) among youth, according to recently released data from the California Student Tobacco Survey. 2 However, overall tobacco use among youth is still high (13.9%), which is mainly driven by the high use rate of ENDS. E-cigarettes are the most commonly used tobacco product among high school students in Santa Clara County (13.2%). 2

These trends are no accident. With declining rates of cigarette smoking all across the US, tobacco manufacturers are attempting to expand their customer base with ENDS. By touting the benefits of these “safer” products, the tobacco industry hopes to lure in users who were too concerned about the health impacts of combustible cigarettes to smoke previously. As of 2018, all major tobacco manufacturers now have entered the ENDS market. 3

Lack of regulation of these products has enabled manufacturers to make false claims about their safety. Perpetuation of these myths (see dialog box) have motivated youth – who never would have taken up cigarettes – to initiate tobacco use.

The meteoric rise in ENDS use among youth is now deemed “epidemic” by health officials. Health and Human Services Secretary Alex Azar reported that, “In the data sets we use, we have never seen use of any substance by America’s young people rise as rapidly as e-cigarette use is rising. Combustible cigarettes remain the leading cause of preventable death in the United States, and providing an effec-

The rising popularity of vaping exposes Santa Clara County residents, especially youth, to new health harms. By being informed about the trends and the products behind them, health providers can help dispel myths and support strategies to curb the vaping epidemic.

tive off-ramp for adults who want to quit using them is a public health priority. But we cannot allow e-cigarettes to become an on-ramp to nicotine addiction for younger Americans.” 4

As health concerns around cigarette smoking increased in the mid-1900s, manufacturers attempted make cigarettes appear “safer,” “cleaner,” and “less harmful,” by introducing filtered, light and low-tar cigarettes. Each modification was accompanied by unsubstantiated claims that mislead the public on the health risks of smoking. The introduction of ENDS is no different.

ENDS were designed to reduce the health harms from the combustion process of a traditional cigarette. These devices instead use battery-power to heat liquids (e-liquid), wax, or other substances to their boiling temperature to transform them into aerosol. The process of inhaling the aerosol is referred to as “vaping.”

Although ENDS users do not inhale tar and other toxic byproducts of combustible cigarettes, the aerosol produced by ENDS is far from harmless. 5 Most ENDS products contain nicotine, which can harm the developing adolescent brain; impact learning, memory, and attention; and even increase the risk of future addiction to other drugs. 5,6 ENDS can also be used to deliver other drugs, including marijuana.5 In 2016, one-third of U.S. middle and high school students who ever used e-cigarettes had used marijuana in e-cigarettes. 7

Many of the cartridge or pod-based devices have especially high levels of nicotine. One popular brand, JUUL, uses cartridges, or “pods,” containing about as much nicotine as TWO packs of conventional cigarettes; newer devices have even more. Using nicotine salts, these devices enable users to inhale higher levels of nicotine (25-50mg) more quickly and with less irritation than via the first types of e-cigarettes (3mg). 8 This format makes it easier for youth to initiate nicotine use and more likely to progress to regular use and nicotine dependence.

In addition to nicotine, ENDS also contain other chemicals that help create the aerosol and flavorings like diacetyl, a chemical linked to serious lung disease. The aerosol can expose users and bystanders to other harmful substances, including heavy metals, volatile organic compounds, and ultrafine particles that can be inhaled deeply into the lungs.

The potential for lung damage was highlighted in August 2019, with the identification of several cases of severe lung illness in patients who were generally healthy. The Centers for Disease Control coined this “E-cigarette, or Vaping, product use-Associated Lung Injury” (EVALI). “As of Feb. 18, 2020, 2,807 cases of hospitalized EVALI or deaths were reported by all 50 states, the District of Columbia, and 2 U.S. territories (Puerto Rico, and the U.S. Virgin Islands),” and “68 deaths have been confirmed in 29 states and the District of Columbia.”

Although the majority of cases were among people who vaped marijuana, there were some patients who reported vaping exclusively nicotine products. In either case, use of e-cigarette devices has the potential to cause serious harm. Furthermore, as ENDS products have been largely unregulated, there is limited data on the longer-term effects of their use. Hundreds of e-liquid formulations and new ENDS products continue to enter the market, which makes researching a given product’s health impacts nearly impossible.

Historically, tobacco manufacturers have added menthol and other flavorings to their products to make them easier to inhale – by softening the harshness of tobacco – as well as increasing the speed at which nicotine reaches the brain. Using flavors to make tobacco more palatable clearly succeeds in attracting youth as customers. Over 80% of youth who ever tried tobacco started with a flavored product.

ENDS manufacturers are capitalizing on this tactic by developing a wide range of flavored products aimed at youth, young adults, and other vulnerable populations. E-liquids are now available in over 7,500 flavors. The 2016 Surgeon General report recognized this trend, stating that, “E-cigarettes are marketed by promoting flavors and using a wide variety of media channels and ap-

Myth: E-cigarettes produce a harmless water vapor. Reality: E-cigarettes produce an aerosol that has nicotine, harmful chemicals, and toxins known to cause cancer (and other health issues). These chemicals and toxins include formaldehyde, lead and nickel, among others. Myth: E-cigarettes can help people quit tobacco. Reality: E-cigarettes are NOT approved by the US FDA to help people quit tobacco. Many people switch to e-cigarettes from traditional cigarettes, but switching is not quitting. Scientific studies are mixed about whether e-cigarettes help people quit using tobacco and nicotine.

proaches that have been used in the past for marketing conventional tobacco products to youth and young adults.”

Not only does the marketing of flavors get youth started in using tobacco products, those who use flavored tobacco have greater odds of using multiple tobacco products. Furthermore, recent studies show that youth who start using e-cigarettes are more likely to move on to using conventional cigarettes and other combustible forms of tobacco.

In January 2020, the U.S. Food and Drug Administration issued an enforcement policy on certain unauthorized flavored e-cigarette products that appeal to youth. However, this policy exempts menthol-, tobacco-, and non-flavored ENDS products and includes only prefilled, cartridge-based products. Disposable or refillable flavored e-cigarettes, plus the 15,000+ existing flavored e-liquids, remain on the market. This resulted in a boom in the market for disposable products, such as Puff Bar, which are priced more affordably for youth than Juul.

Since we cannot rely on effective regulation of these products, preventing initiation and promoting cessation of their use is a critical step in protecting youth from addiction and future health effects. Providers can play a key role in addressing this public health epidemic.

Myth: E-cigarettes are safe and do not contain toxins. Reality: E-cigarettes are not risk-free. They still deliver nicotine (sometimes at high levels) and low levels of toxins and chemicals, many of which are present in tobacco products. Myth: E-cigarettes are not addictive. Reality: Nicotine is a highly addictive drug and is one of the main ingredients in e-cigarettes and tobacco products. Myth: Big Tobacco is not involved in making e-cigarettes. Reality: By 2021, Big Tobacco will sell the majority of e-cigarettes in the US, and sales will overtake traditional tobacco revenue.

There are proven strategies that work to protect youth from tobacco product use, which can be applied to ENDS as well. Providers can help support both individual and population level solutions towards curbing vaping.

When working with patients, Ask, Advise and Refer:

Ask patients about their ENDS product use, including discreet devices such as JUUL and Suorin, when screening patients for the use of any tobacco products.

Advise patients about the harms of ENDS products, especially to the developing adolescent brain, and help dispel myths and the misleading advertising that portrays these products as “safer.” Some free materials are available here: nobutts-catalog. org/collections/vape.

Refer for cessation services, such as those offered by the California Smokers’ Helpline (1-844-8-NO-VAPE) or by the free, youth-centered, quit-vaping mobile program called This is Quitting (thetruth.com/articles/hot-topic/quit-vaping) and encourage patients to quit.

Providers also can help advocate for the implementation of evidence-based, population-level strategies, such as including ENDS in smoke-free indoor air policies and restricting youth access to ENDS in retail settings, through retail licensing and enforcement programs. Participation by health providers in policy initiatives brings credibility that ENDS products are harmful for health, especially among adolescents.

While there are regulatory and market-driven barriers to reducing youth vaping, a coordinated effort between health providers, educators, parents and communities can make a significant impact on the local level.

1. Tobacco Product Use Among Middle and High School Students — United States, 2011-2018. Morbidity and Mortality

Weekly Report (MMWR), February 2019. 2. Zhu S-H, Lee J, Zhuang YL, Braden K, Cole A, Wolfson T,

Gamst A (2019). Tobacco use among high school students in Santa Clara County: Findings from the 2017-2018 California Student Tobacco Survey. San Diego, California: Center for Research and Intervention in Tobacco Control (CRITC), University of California, San Diego. 3. Craver R. Analyst projection: E-cigs will overtake traditional tobacco revenue at Reynolds in 2021. Winston-Salem

Journal, 2013. 4. https://www.hhs.gov/about/news/2018/12/18/surgeon-general-releases-advisory-e-cigarette-epidemic-among-youth. html 5. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal

A, King BA. Notes from the Field: Increase in use of electronic cigarettes and any tobacco product among middle and high school students — United States, 2011–2018.

MMWR Morbid Mortal Wkly Rep. 2018;67(45). 6. U.S. Department of Health and Human Services. Facing

Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Atlanta, GA, 2016. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html#one 7. Willett JG, Bennett M, Hair EC, et al. Recognition, use and perception of JUUL among youth and young adults. [published ahead of print April 18, 2018]. Tob Control.