For Parents Concerned with Children & Adolescents Vaping

[Episode 110 of The Intentional Clinician Podcast]

What is vaping?

Vaping is popularly known as an “alternative to smoking cigarettes.” However, in this podcast we will find out that using a vape may be as harmful, it not more harmful than smoking cigarettes due to various reasons. We are primarily talking about the use of vaping by adolescents in the US.

Vaping can be defined as the use of electronic cigarettes or other electronic nicotine delivery systems (ENDS) that heat a liquid (often containing nicotine, flavorings, and other chemicals) into an aerosol that is inhaled into the lungs.

• To inhale vapor through the mouth from a usually battery-operated electronic device (such as an electronic cigarette) that heats up and vaporizes a liquid or solid (Merriam-Webster).
• According to the National Institute of Drug Abuse (NIH), electronic nicotine delivery systems (ENDS), commonly known as vaping devices, are battery-powered devices that allow individuals to inhale an aerosol consisting of various chemicals, flavorings, and often nicotine.
• APA about e-cigarettes:
  • “E-cigarettes — also known as ENDS, or electronic nicotine delivery systems — look and act a lot like regular cigarettes. They’re plastic or metal rods that can light up at the end and release vapor that looks like smoke when puffed — an action popularly called “vaping.” When users inhale, they get a nicotine hit”.
• Vaping is often associated with e-cigarettes but it can also refer to other types of electronic nicotine delivery systems, such as vape pens, mods, and pod-based systems.

What types of vaping are there?

• E-cigarettes
  • Most common type of vaping device; often shaped like traditional tobacco cigarettes.
    • Cig-a-like: Resemble traditional tobacco cigarettes; They are high in nicotine content and provide similar effects to smoking.
    • Disposable: Intended for one-time use
    • Refillable: Designed to be refilled with e-liquid

• Vape pens
  • Slightly larger than e-cigarettes, shaped like a pen.
    • Standard: Shaped like a pen and often have a longer battery life than e-cigarettes
    • Sub-ohm: Have a lower resistance coil, which produces more vapor and flavor
    • CBD vape pens: Designed to vaporize CBD e-liquid or oil
    • THC vape pens: Designed to vaporize THC concentrates — THC, or tetrahydrocannabinol, is the main intoxicating ingredient in marijuana.

• Mods
  • Short for “modified,” larger, and more customizable than other types of vaping devices.
    • Regulated: Have a built-in chip that regulates power output and can be customized with various settings
    • Mechanical: Do not have a built-in chip and rely solely on the battery for power
    • Squonk: Have a built-in e-liquid reservoir that can be squeezed to feed e-liquid to the coil

• Pod-based systems
  • They are typically smaller and more compact than other types of vaping devices.
    • Closed system: Use pre-filled pods that cannot be refilled
    • Open system: Use refillable pods that can be filled with e-liquid

• Heat-not-burn devices
  • These devices heat tobacco instead of burning it, which produces an aerosol that is inhaled. They use actual tobacco but still fall under the category of electronic nicotine delivery systems.
    • Tobacco sticks: Contain actual tobacco and are heated to produce an aerosol
    • Loose-leaf: Use actual tobacco leaves that are heated to produce an aerosol

Note: It turns out that there are many more variations within each of these types of vaping devices, and new types of devices are constantly being developed.

Sources:

https://www.buyv2cigs.co.uk/different-types-of-vape-devices/
https://www.artisanvaporcompany.com/vaping/different-types-of-vapes/
https://vaping360.com/learn/different-types-of-vapes/
https://okvape.co.uk/blog/vaping-beginners/types-of-e-cigarette/

Different classification:

• Nicotine vapes
  • These vapes use nicotine-infused e-liquids as the primary ingredient.
  • They produce vapor that is inhaled into the lungs.
  • Nicotine vapes are primarily used as an alternative to traditional cigarettes.

• Cannabis/CBD vapes
  • These vapes use cannabis or CBD oil as the main ingredient.
  • They produce vapor that is inhaled into the lungs.
  • Cannabis/CBD vapes are primarily used for medicinal or recreational purposes.

• • Even though CBD is known for its health benefits (e.g., Morales & Reggio, 2019; Williams, 2021), a study led by Roswell Park immunologist Dr. Yasmin Thanavala proves that vaping CBD may be more dangerous than vaping nicotine (Bhat et al., 2023).
    • The reason is that vaping CBD leads to more severe lung damage than vaping nicotine.
    • CBD oil increased pulmonary inflammation and lung damage.
    • According to Thanavala, vaping with neither nicotine nor CBD is recommended for healthy lungs.

• • According to Abraham Benavides, M.DA medical advisor at Nature Bloom, CBD vapes can be especially detrimental to teenagers. This is because these products are readily available to them, and their lungs, which are still developing, are more prone to the harmful chemicals that can cause irreversible damage to their bodies (Lisa Marie Basile, MDLinx).

Most popular type of vaping among teens

• In 2021, the most popular type of e-cigarette among 26.1% of US teens was Puff Bar. 4 other popular brands were
  • JUUL
  • Suorin Vagon Black
  • Suorin Drop
  • Pen Pal Stealth Vaporizer

• Based on Truth Initiative Research, 15-17-year-old teens are 16x more likely to use JUUL compared to 25-34-year-old adults (Vallone et al., 2019).
  • Among 13,000 participants, about 10% of teens have used JUUL at least once.
  • 56% of teen JUUL users have used it more than 3 times a month.
  • Almost 50% use it more than 10 days a month.

Statistics on how many US children are impacted

Prevalence of vaping among teens in the US:

• According to the University of Michigan’s survey “Monitoring the Future”, the number of high school students vaping nicotine significantly rose between 2017 and 2019 (Miech, R., et al., 2019).

Miech, R., et al., The New England Journal of Medicine, Vol. 381, No. 15, 2019

• Daily nicotine vaping levels on at least 20 days during the previous 30 days were 12%, 7%, and 2% in 12th, 10th, and 8th-grade teens, respectively.
• More than a quarter of 12th graders reported past-month vaping in 2019, compared with 11% in 2017.
• The tendency of vaping increased in 3 of the teen groups that participated in the study (12th-grade, 10th-grade, and 8th-grade students).

Statistics on e-cigarettes

• A 2019 study published in JAMA also shows that 27.5% of high school students and 10.5% of middle schoolers reported they had used e-cigarettes (Kullen et al., 2019).
• According to the 2021 report of the Centers for Disease Control and Prevention, in 2020, the use of any tobacco product decreased (4.47 million) among middle and high school students compared to 2019 (6.20 million) (Gentzke et al., 2020).
• E-cigarettes have been the most commonly used tobacco product among youth since 2014.
• In 2022, about 1 out of every 30 middle school students (3.3%) reported that they had used electronic cigarettes in the past 30 days (Park-Lee et al., 2022).
• In 2022, about 1 of every 7 high school students (14.1%) reported that they had used electronic cigarettes in the past 30 days (Park-Lee et al., 2022).
• More data on different types of tobacco use among teens is here.

According to Cooper et al., 2022:

• In 2022, 2.55 million U.S. middle and high school students currently used e-cigarettes.
• Most reported using flavored products were fruit flavors.
• Disposable products were the most commonly reported device type.
• Among middle and high school students who used e-cigarettes, approximately 4 in 10 reported frequent use;1 in 4 reported daily use.
• According to Cornelius et al., (2020), the highest prevalence of e-cigarette use was among smokers aged 18–24 years (9.3%), with over half (56.0%) of these young adults reporting that they had never smoked cigarettes.

According to CDC:

• Nearly 9 out of 10 adults who smoke cigarettes daily first try smoking by age 18, and 99% first try smoking by age 26.
• Each day in the U.S., about 1,600 youth smoke their first cigarette and nearly 200 youth start smoking every day.
• Flavorings in tobacco products can make them more appealing to youth.

What does vaping do to the body and mind?

• The nicotine present in the e-liquids is quickly absorbed from the lungs into the bloodstream. Once in the blood, nicotine triggers the adrenal glands to release epinephrine, which stimulates the CNS, increasing blood pressure, heart rate, and breathing.The brain’s reward circuits are activated by nicotine, leading to the release of dopamine, which reinforces rewarding behaviors. As a result, individuals are compelled to repeatedly use nicotine, even though it poses risks to their health and well-being (NIDA).
• While e-cigarettes can be less harmful than combustible cigarettes, they still activate the brain’s reward system, putting vapers at risk for addiction (Levine et al., 2011).
• Vaping exposes the lungs to a variety of chemicals, including those added to e-liquids, and other chemicals produced during the heating/vaporizing process (Sleiman et al., 2016).
• A 2017 study shows that e-liquids of certain cig-a-like brands contain high levels of nickel and chromium and low levels of cadmium. This can cause breathing problems (Hess et al., 2017).
• A systematic review of the health effects of electronic cigarettes published in Preventive Medicine analyzed 76 studies to explore the content of fluid/vapor of electronic cigarettes (ECs). The researchers concluded that ECs cannot be regarded as safe, even though they probably are less harmful than conventional cigarettes (CCs). They recommend it to be restricted to smokers unable to quit (Pisinger et al., 2014).

Results of a systematic review of global evidence on e-cigarettes & health outcomes (Banks et al., 2022; Australian National University):

• Dependence and abuse of liability
  • Among non-smokers, there is substantial evidence that e-cigarette use results in dependence.
  • Among smokers, there is limited evidence that e-cigarette use results in dependence
  • E-cigarettes have lower abuse liability than combustible cigarettes. However, they have higher abuse liability than nicotine replacement therapy products among smokers.

• Cardiovascular health outcomes
  • Among smokers, there is moderate evidence that the use of e-cigarettes increases heart rate, systolic blood pressure, diastolic blood pressure, and arterial stiffness acutely after use.

• Cancer
  • There is no available evidence on the relationship between e-cigarette use to invasive cancer risk.

• Respiratory health outcomes
  • The use of e-cigarettes can cause respiratory disease (EVALI) both among smokers and non-smokers.
  • Lung injury is largely related to e-cigarettes delivering THC.

• Burns and injuries
  • E-cigarettes can cause burns and injuries, which can be severe and can result in death.

• Poisoning
  • Intentional or accidental exposure to nicotine e-liquids can lead to poisoning, which can be severe and can result in death.
  • A significant number of accidental poisonings occur in children under the age of 6.
  • The use of e-cigarettes can result in nicotine toxicity.

• Neurological outcomes
  • The use of e-cigarettes can lead to seizures.
  • There is limited evidence that injuries due to e-cigarette explosions can lead to nerve damage.

According to a systematic review published in Environmental Research and Public Health in 2022 (Pisinger & Rasmussen, 2022):

• Dual use of electronic and conventional cigarettes is associated with a significantly higher risk of self-reported symptoms than in ESCC.
• The intensity of cigarette smoking is associated with worse health.
• Therefore, dual-use is at least as harmful as ESCC.

Facts about vaping

1. Vaping is less harmful than smoking. Still, it does not qualify as a safe practice.

• While traditional cigarettes contain about 7000 chemicals and many of them are toxic, vaping exposes smokers to fewer toxic chemicals.
• However, people who smoke vaping products containing THC are at high risk of developing lung injuries (EVALI).
  • According to the CDC, 68 deaths were related to vaping THC-containing e-cigarettes in 2020.

2. Vaping negatively affects heart health and lungs

• Nicotine raises blood pressure and spikes your adrenaline, which increases your heart rate and the likelihood of having a heart attack.
• It’s also linked with chronic lung disease and asthma (Osei et al., 2020), and cardiovascular diseases (Oseu et al., 2019).

3. Electronic cigarettes are equally addictive as conventional cigarettes.

• The reason is that both of them contain nicotine.

4. E-cigarettes don’t have FDA approval

• The Food and Drug Administration hasn’t approved e-cigarettes as smoking cessation devices.

Source: Hopkins Medicine

Mental health effects of vaping

• Vaping increases the chance of developing depression
  • According to a 2019 JAMA study, frequent vaping is related to higher odds – 2.4X – of having a diagnosis of depression compared to never users (Obisesan et al., 2019).
• Vaping can worsen symptoms of depression
  • In a 2017 study, participants who used e-cigarettes at a higher frequency were associated with higher depressive symptoms (Lechner et al., 2017).
• It’s associated with higher levels of ADHD
  • A 2019 study found that vaping is significantly associated with higher levels of ADHD symptoms (Bierhoff et al., 2019).

How are Teens and Children affected by vaping?

Health effects of vaping among teens:

• Nicotine exposure through vaping can harm brain development as it develops until about age 25. Besides, it can harm the parts of the brain that control attention, learning, mood, and impulse control.
• Nicotine also changes the way these synapses are formed in the brain, leading to memory problems in children
• Using nicotine products increases the chance of addiction in children (Taylor, 2014).
• Vaping has been linked to an increased risk of depression, anxiety, and suicidal thoughts among teens (e.g., Javed et al., 2022).
• According to a report by the National Academy of Medicine in 2018, there is some evidence suggesting that the use of e-cigarettes can lead to an increase in the frequency and quantity of cigarette smoking in the future (CDC).
• Adolescents may resort to vaping as a coping mechanism for stress or anxiety, which can result in a cycle of nicotine dependence. However, nicotine addiction can also contribute to stress.
• Vaping can cause withdrawal symptoms in teenagers (Gentzke et al., 2022).

What makes children use tobacco products?

• Social and physical environments (e.g., mass media declaring it as a normal activity, seeing people their age using these products, imitating parents).
• Biological and genetic factors
  • If a woman smokes while pregnant, it may raise the chances of her child becoming a regular smoker later in life.
  • Quitting smoking may be more challenging for young individuals due to genetic factors.
• Mental health issues such as depression, anxiety, and stress.
• Positive expectations such as losing weight or stress relief.
• Lower socioeconomic status
• Having trouble saying “no”.
• Availability of tobacco products

Source: CDC

What are ways parents can work on stopping their teens from vaping?

Vaping is a concerning issue among teenagers, and parents should take steps to prevent their teens from vaping. Here are some ways that parents can work on stopping their teen from vaping:

• Know the facts about vaping: Parents should do their own research to understand the facts about vaping. This can include understanding the risks associated with vaping, such as lung damage, addiction, and exposure to harmful chemicals. Parents need to get information from credible sources, such as the CDC or American Lung Association.
• Educate your teen about the dangers of vaping: Parents should provide their teens with accurate information about the risks of vaping. For example, the CDC provides a variety of resources on vaping, including factsheets and infographics that can help parents educate their teens.
• Be a good role model: Parents should model healthy behavior and avoid vaping or using other tobacco products in front of their teens. Research has shown that parents who use tobacco products are more likely to have teens who use them as well (Kandel et al., 2015).
• Explore the reasons why your children are vaping: Parents should have open and honest conversations with their teens to understand why they may be vaping. Some common reasons teens may vape include peer pressure, stress, boredom, or curiosity. By understanding the reasons behind their teen’s vaping, parents can provide support and guidance to help their teen quit.
• Keep your house smoke-free: Create a home environment that is free from smoking by setting rules that prohibit family members or friends from smoking in your house or car. Ensure that the places where your child spends a considerable amount of time are free of tobacco smoke.
  • Always keep e-cigarettes and e-liquids locked away and out of reach of children, as even small amounts of e-liquid can be toxic if ingested.
• Encourage alternative activities: Parents can encourage their teens to participate in activities that do not involve vaping, such as sports, music, or art. Encouraging positive activities can help keep teens busy and reduce the likelihood that they will turn to vape.
• Seek professional help: If parents are concerned that their teen may be addicted to vaping, they should seek professional help. A healthcare provider can provide resources and support to help teens quit vaping.

According to Dr. Taskiran, parents should approach the conversation with their teens about vaping in a non-judgmental, curious, and open-minded way. This means starting the conversation more generally and asking questions to understand their teen’s perspective and experience with vaping, rather than making declarative statements that can shut down the conversation.

Parents can start by asking questions such as,

• What do you know about vaping?
• Have you noticed a lot of kids at school vaping?
• What is your experience with vaping?
• What are the flavors like?

This approach can help parents gain a better understanding of their teen’s knowledge and attitudes toward vaping. As a result, they’ll be able to build a trusting and open dialogue with their teen, which can be critical in preventing or addressing vaping behaviors.

How can parents know if their child is vaping?

Here are some recommendations for parents:

• Look for physical signs: Vaping can cause physical symptoms such as coughing, throat irritation, and dry mouth. If you notice that your child has these symptoms, they may be vaping.
• Check for vaping paraphernalia: Vaping devices come in various shapes and sizes, and some may be disguised as everyday objects like pens or USB drives. Look for devices or cartridges that are unexplained or seem out of place in your child’s belongings.
• Notice changes in behavior: If your child suddenly becomes more secretive, spends more time alone, or shows a lack of interest in activities they once enjoyed, they may be vaping. Vaping can also affect mood and cause irritability or anxiety.
• Smell for unusual odors: Vaping produces a distinct odor that may be sweet or fruity. If you notice an unusual smell on your child’s clothing or in their room, they may be vaping.
• Check their social media accounts: Vaping is popular among teens, and they may post pictures or videos of themselves vaping on social media. Check your child’s accounts for any posts or comments related to vaping.