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The effect of anxiety on nicotine dependence among university students during the COVID‐19 pandemic

Gülsün ayran.

1 Department of Child Health and Disease Nursing, Faculty of Health Sciences, Erzincan Binali Yıldırım University, Erzincan Turkey

Semra Köse

2 Department of Child Health and Disease Nursing, Faculty of Nursing, Necmettin Erbakan University, Konya Turkey

Sibel Küçükoğlu

3 Department of Child Health and Disease Nursing, Faculty of Nursing, Selçuk University, Konya Turkey

Aynur Aytekin Özdemir

4 Department of Child Health and Disease Nursing, Faculty of Health Sciences, Istanbul Medeniyet University, Istanbul Turkey

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

This study investigated the effect of anxiety on nicotine dependence among university students during the COVID‐19 pandemic.

Design and Methods

This was a descriptive and correlational study. The sample consisted of 503 university students in Turkey. Data were collected online using a demographic characteristics form, the State‐Trait Anxiety Inventory (STAI), and the Fagerström Test for Nicotine Dependence (FTND).

FTND scores differed by gender, family type, and grade level, while STAI scores differed by gender, income, and region of residence ( p  < 0.05). Fifty‐one percent of the participants had moderate anxiety, while 65.2% had low nicotine dependence. FTND and STAI mean scores were strongly correlated ( p  < 0.05).

Practical Implications

The higher the anxiety, the higher the nicotine dependence among university students during the COVID‐19 pandemic.

1. INTRODUCTION

Coronavirus disease (COVID‐19) broke out in Wuhan, the capital of Central China's Hubei province, at the end of 2019 and spread across the world rapidly and turned into a pandemic. 1 , 2 In about 120 million people in the world and Turkey 3 million people have been affected due to COVID‐19. 3

Countries have taken several preventive measures to prevent the spread of COVID‐19, such as social distancing, hygiene measures, quarantine, curfew, travel restrictions, and closures (institutions and workplaces). Face‐to‐face education has also been largely suspended and shifted to distance education due to school closures in response to the pandemic. However, online education increases academic stress in students. 4 Isolation and school closures due to the spread of COVID‐19 change students' daily lives drastically and make them less motivated to study, 5 resulting in anxiety and depression. 6 , 7 Such multiple stressors also put university students at risk of anxiety and depression. 7 Kaparounakia et al. 8 reported an increase in anxiety symptoms (42.5%) and anxiety levels (73%) in Greek university students due to the COVID‐19 pandemic. Wang and Zhao 7 also found that university students experienced high levels of anxiety during the COVID‐19 pandemic.

Anxiety and boredom are known emotional triggers for smoking. Increasing anxiety at unexpected and unusual times can be an important risk factor for smoking. Especially the psychological effects of social isolation, increasing anxiety levels and its effects on smoking can explain the increase in the rate of use. 9 It has been stated that individuals started to smoke more as a form of defense during difficult processes such as epidemics, due to the feeling of relief that occurs during smoking, emphasized by most cigarette addicts. 10 Social isolation applied during the epidemic process is a risk factor, stressful situations can exacerbate the desire to smoke and create a greater risk of relapse. 11 Studies on smoking after the COVID‐19 outbreak appear to increase smoking rates. 9 , 12 , 13

It is estimated that lifestyle changes, disruption of education, quarantine, and isolation due to the COVID‐19 pandemic lead to mental disorders and nicotine dependence among young people. However, there is no sufficient empirical evidence to support the correlation between anxiety and nicotine dependence. Therefore, the aim of this study is to examine the effect of anxiety on nicotine dependence among university students during the COVID‐19 pandemic.

• What characteristics of university students affect their anxiety levels?
• What characteristics of university students affect their nicotine addiction levels?
• Does the level of anxiety experienced during the pandemic process affect the nicotine addiction rate of university students?

2.1. Type of the study

This was a descriptive and correlational study.

2.2. Time and place of the study

The study was conducted between May and June 2020.

2.3. Population and sample of the study

The study population consisted of all private and public university students (seven regions of Turkey) who had been smoking for at least 6 months. The inclusion criteria were (1) having been receiving online education during the study, (2) having Internet access, and (3) agreeing to participate. The exclusion criteria were (1) withdrawal from courses due to the COVID‐19 pandemic, (2) having received treatment for nicotine dependence before, and (3) having a mental disorder. A power analysis was performed using GPower (version 3.1.9.2) to determine the appropriate sample size for significant differences. Both male and female participants' mean State‐Trait Anxiety Inventory (STAI) scores were used for the analysis. The post hoc power analysis revealed a power of 95% with an effect size of 0.33 ( α  = 0.05), indicating that the sample ( n  = 501) was large enough to detect significant differences (Figure  1 ). Since the study was collected online, only the participants who completely filled out the questionnaires were included in the study. The study was terminated when a sufficient sample size was reached ( n  = 503).

Power analysis [Color figure can be viewed at wileyonlinelibrary.com ]

2.4. Data collection tools

Data were collected online using a demographic characteristics form (DCF), the STAI, and the Fagerström Test for Nicotine Dependence (FTND).

2.4.1. Demographic characteristics

The DCF was based on a literature review conducted by the researcher. 14 , 15 , 16 The form consisted of 26 items and three sections. The first section consisted of items on participants' demographic characteristics and health status (gender, family type, perceived income, place of residence, region of residence, housing type, grade level, and chronic disease in themselves and/or in family members). The second section consisted of items on participants' experiences with the COVID‐19 pandemic (having tested or having any family members tested positive for COVID‐19, adaptation to social isolation, and home activities during the pandemic). The third section consisted of items on nicotine dependence and changes in it during the pandemic. Data were collected online (5 min for each participant). Three experts were consulted for the items of the second and third sections.

2.4.2. State‐Trait Anxiety Inventory

The STAI was developed by Spielberger et al. 17 to evaluate how one feels at a particular moment and situation. The STAI was adapted to Turkish by Öner and Le Comte. 18 The STAI consists of 20 items scored on a 4‐point Likert‐type scale of 1 (almost never) to 4 (almost always). The total score ranges from 20 to 80. Higher scores indicate greater anxiety. Ten items (1, 2, 5, 8, 10, 11, 15, 16, 19, and 20) are reverse scored. The Turkish version of the STAI has a Kuder–Richardson reliability coefficient (Cronbach's alpha) of 0.94 to 0.96, 18 which was 0.96 in this study.

2.4.3. Fagerström Test for Nicotine Dependence

The FTND was developed by Fagerström (1978) and revised by Heatherton et al. 19 It was adapted to Turkish by Uysal et al. 20 It consists of six items scored on a 2‐ and 4‐point Likert type scale. An FTND total score of ≤3 indicates low dependence, 4 < FTND score < 6 moderate dependence, and an FTND total score of ≥7 high dependence. The scale has a Cronbach's alpha of 0.61, which was 0.72 in this study.

2.5. Ethical considerations

The study was approved by the Human Research Ethics Committee (Date: April 30, 2020; No: 04/23). Written permission was obtained from the Ministry of Health of the Republic of Turkey. Students were informed about the study, and online informed consent was obtained from those who agreed to participate.

2.6. Data collection

After the researchers obtained the necessary permission, they created online versions of the DCF, STAI, and FTND and shared the link to the questionnaires on WhatsApp groups. They asked participants to complete the questionnaires accurately and send the link to other university students (snowballing sampling). Data collection lasted 10–15 min (Figure  2 ).

A flow chart of subjects' enrollment. DCF, demographic characteristics form; FTND, Fagerström Test for Nicotine Dependence; STAI, State‐Trait Anxiety Inventory

2.7. Data analysis and evaluation

Data were analyzed using the Statistical Package for Social Sciences (SPSS; version 22.0) at a significance level of 0.05. Percentages, means, the independent‐samples t ‐test, analysis of variance test, and Pearson correlation coefficient were used for analysis. The Bonferroni test was used for post hoc comparisons.

2.8. Limitations

The study had two limitations. First, the survey relied on participants' self‐reports, and therefore, data accuracy was not verified. Second, levels of anxiety and nicotine dependence were measured only using the STAI and FTND.

The mean age of participants was 21.57 ± 2.46. The mean number of people they had lived with during the pandemic was 4.88 ± 1.81. Of participants, 53.5% were men, 78.5% had a nuclear family, 45.3% had a neutral income, 58.4% were living in the city center, 28.4% were from Eastern Anatolia, 62.4% were living in apartments, and 33% were freshmen. Participants' FTND scores differed by gender, family type, and grade level, while their STAI scores differed by gender, income, and region of residence ( p  < 0.05). The post hoc test result showed that participants from the Marmara region had higher STAI scores than those from the Black Sea region (Table  1 ).

Mean FTND and STAI scores by demographic characteristics ( n  = 503)

Abbreviations: FTND, Fagerström Test for Nicotine Dependence; STAI, State‐Trait Anxiety Inventory.

* p  < 0.05.

Of participants, 12.1% had a chronic disease, 44.5% had a family member with a chronic disease, 1.8% had tested positive for COVID‐19, 2% had a family member who had tested positive for COVID‐19, and 76.9% was able to adapt to social isolation. Participants' mean FTND and STAI scores were compared by chronic disease, having been tested positive for COVID‐19, and adaptation to social isolation. Chronic disease and adaptation to social isolation affected their mean FTND scores ( p  < 0.05, Table  2 ). During social isolation, participants mostly spent time on social media (77.1%), followed by sleeping (71.4%), watching TV (64.2), and listening to music (65.6%). Participants who did nothing during social isolation had a significantly higher mean STAI score than those who read books during social isolation (Table  2 ).

Distribution of mean FTND and STAI scores by chronic disease, testing positive for COVID‐19, and adaptation to social isolation ( n  = 503)

Note : More than one option marked. “Yes” responses were taken into account. An independent sample t ‐test was used.

Of participants, 60% had smokers in the family, and 52.7% perceived their relationships with family members as “normal.” Less than half of the participants (32.4%) smoked more cigarettes, 57.7% stockpiled packs of cigarettes, 41.7% experienced anxiety/stress about not being able to buy cigarettes, 64.8% did not regret smoking, and 58.1% made no effort to reduce smoking during social isolation (Table  3 ). Participants' mean FTND and STAI scores differed by “other smokers in the family,” “perceived relationship with family members,” “increased smoking during social isolation,” “stockpiling cigarettes during curfews,” and “anxiety and stress caused by not being able to buy cigarettes during social isolation” ( p  < 0.05, Table  3 ).

Distribution of mean FTND and STAI scores by smoking during the COVID‐19 pandemic ( n  = 503)

Participants had a mean STAI of 43.42 ± 12.06. Slightly more than half of the participants (51%) had moderate anxiety. Participants had a mean FTND score of 2.7 ± 2.5. More than half of them (65.2%) had low nicotine dependence (Table  4 ).

Mean FTND and STAI scores ( n  = 503)

In Table  5 , whether there is a relationship between the nicotine addiction and state level of the students was examined; a statistically positive and very strong significant correlation was found between FNBT and DAÖ mean scores ( r  = 0.106, p  = 0.017).

Correlation evaluation of students' FNBT and STAI scores ( n  = 503)

A multi‐logit model was established to determine the factors affecting nicotine addiction. When the likelihood ratio in the model was examined, it was found that the model was statistically significant. It is also calculated as 0.119 for R 2 Cox–Snell and 0.145 for Nagelkerke, which shows the explanation power for the model. When the individual estimation results for the levels of the dependent variable were examined, two models were estimated for nicotine levels as medium and high. For those with moderate nicotine levels, the anxiety level of the individual, having a broken family and gender are influencing factors. In addition, those with a fragmented family structure are more likely to have moderate nicotine addiction than those who do not, and men are more likely than women. For those with high nicotine levels, the age and gender of the individual are influencing factors. As the age of the person increases, the possibility of having a high level of nicotine addiction increases. In addition, men are the categories that are more likely to have moderate nicotine addiction than women. The variables that are significant in both models are the person's gender. Men are more likely to have a moderate to high nicotine addiction than women are more likely to have both moderate and high nicotine addiction (Table  6 ).

Multinomial logit model analysis for nicotine addiction ( n  = 503)

Abbreviations: AIC, Akaike information criterion; BIC, Bayesian information criteria; FTND, Fagerström Test for Nicotine Dependence; LR, likelihood ratio.

4. DISCUSSION

University students are a group at high risk for symptoms of depression and anxiety. 7 The mental health of university students is adversely affected due to the spread of the epidemic throughout the country, strict isolation measures and the closure of schools, colleges and universities, decrease in students' motivation to study, increasing pressures for independent learning, and abandonment of daily routines. 5 Increasing anxiety at unexpected and unusual times can be an important risk factor for smoking. 9 For this reason, in this study, the effect of anxiety experienced by university students during the COVID‐19 process on nicotine addiction was discussed, and the findings were discussed in line with the literature.

Most of our participants had been smoking during the COVID‐19 pandemic. Male participants had significantly higher nicotine dependence than females (Table  1 ). Research on Turkish university students shows in general that male students have significantly higher nicotine dependence than females. 21 , 22 , 23 Provenzano et al. 16 reported that male nursing students had significantly higher nicotine dependence than females. Mallet and Dubertret 24 found that men had significantly higher nicotine dependence than women during the COVID‐19 pandemic. Male and female behaviors are shaped according to certain stereotypes within the structure of the society they are in. For this reason, men more independent. Starting from a young age, raising men in a more liberal nature, putting a cigarette in the mouth of a boy gives rise to the idea of “I am strong, I am free” in boys and triggers nicotine addiction in men. 25 As a result of the regression analysis performed in our study, it was found that our variable, which was significant in the model in which nicotine addiction was moderate and high, was the gender of the person (Table  6 ). The probability of nicotine addiction was found to be higher in men than in women, and this finding is consistent with the literature and analysis. Our female participants experienced more anxiety than males (Table  1 ), which was consistent with the literature. Yakar et al. 14 reported that female medical students suffered from anxiety more than males during the COVID‐19 pandemic. Wu et al. 26 and Zhao et al. 27 also found that Chinese female university students experienced more anxiety than males during the COVID‐19 pandemic. Women are more emotional than men due to physiological differences between men and women, such as genetic sensitivity, hormone, and cortisol levels. Because of these differences, women were more vulnerable to stress and pain than men, so they may experience more sadness and anxiety. 28

Participants from broken families had higher nicotine dependence than those from nuclear families (Table  1 ). Research, in general, shows that people from broken families have higher nicotine dependence than others. 21 , 29 A study from Italy has found a correlation between nicotine dependence and nonconventional family types (single‐parent, broken families, etc.). 30 Young people from broken families are more likely to develop nicotine dependence and criminal behavior due to socioeconomic problems and limited parental control. 31 As a result of the regression analysis performed in our study, our variable, which was significant in the model with moderate nicotine addiction, was found to be the family type of the person (Table  6 ). The probability of nicotine addiction was found to be higher in the fragmented family‐type compared to other family types, and this finding is consistent with the literature and analysis. It is noteworthy that participants from broken families had higher nicotine dependence during the pandemic. Therefore, more research is warranted on factors affecting nicotine dependence in people from broken families.

Participants with a negative income had higher anxiety than those with a positive income (Table  1 ). Low socioeconomic status is associated with both increased nicotine dependence and anxiety. 32 The loss of job and income makes the COVID‐19 curfews more challenging and stressful for all family members. 33 The pandemic has adverse financial impacts on thousands of people. 32 Negative income may have put the participants in a vicious cycle; not being able to afford to buy cigarettes caused more anxiety, which resulted in increased nicotine dependence.

Participants from the Marmara region experienced higher levels of anxiety than those from the other regions (Table  1 ). The World Health Organization (WHO) 34 conducted an epidemiological study involving people of all age groups from Turkey and found that respondents from Eastern Anatolia (50%), Aegean (49%), and Marmara regions had the highest pandemic‐related anxiety. 34 Participants from the Marmara region reported the highest levels of anxiety, probably because it is the region with the highest number of COVID‐19 cases. It is also because Marmara has coastal cities with good climatic conditions, social opportunities, and a large young university‐educated population, which we believe has been severely affected by social isolation during the pandemic.

Participants with chronic diseases had higher nicotine dependence than others (Table  2 ). WHO states that people with chronic diseases are more likely to develop severe or critical COVID‐19. 35 Those participants may have developed more nicotine dependence because they were unable to access health services, buy their prescription drugs, and socialize due to quarantine constraints during the COVID‐19 pandemic while at the same time having to cope with their chronic diseases.

Participants who had difficulty adapting to social isolation had higher FTND scores (Table  2 ). Günay 36 found that children quarantined during the COVID‐19 pandemic had posttraumatic stress scores four times as high as those who were not. Moreover, changes in lifestyle and psychosocial stress caused by quarantine may lead to a vicious cycle, exacerbating the already existing physical and mental health issues. 37 This may have resulted in increased nicotine dependence among our participants.

Participants mostly spent time on social media, slept, watched TV, or listened to music. Participants who read books or did nothing at home during the COVID‐19 pandemic had significantly high anxiety (Table  2 ). People play video games, watch TV shows, use social media, or browse the internet to reduce the symptoms of epidemic‐related stress, anxiety, and depression. 38 An international study on media consumption at home during the COVID‐19 pandemic have reported that people watch news broadcasts more (67%) and spend more time on messaging apps (45%) and social media (44%), with the highest increases observed in Generation Z. 39 Loss of interest in activities is a sign of anxiety among adolescents. Therefore, it is not surprising that participants who did nothing at home during the pandemic had significantly high anxiety.

Participants who had other smokers in the family had higher nicotine dependence and anxiety (Table  3 ), which is consistent with the literature. Having family members who smoke affects nicotine dependence among students. 40 Oğuz et al. 41 found that students with smoking mothers and sisters had higher nicotine dependence. Birinci and Bulut 33 also reported that students with smoking parents or siblings had higher nicotine dependence. Elbi et al. 42 detected a positive correlation between the nicotine dependence rates of students and their family members.

Participants with conflicting relationships with family members had higher nicotine dependence and anxiety (Table  3 ). Many people were in constant contact with family members during the quarantine. Having to spend more time at home with family during the COVID‐19 pandemic is frustrating and inhibiting for young people who are used to socializing and connecting with their friends, which inevitably resulted in increased anger and anxiety. 37 , 43 , 44 Therefore, young people with conflicting relationships with family members may turn to smoke, which is frowned upon by parents.

Participants who smoked more cigarettes, stockpiled packs of cigarettes, and were worried about the possibility of not being able to go out and get cigarettes during the COVID‐19 pandemic had higher nicotine dependence and anxiety (Table  3 ). Social isolation is as serious a risk factor as nicotine dependence, obesity, and a sedentary lifestyle. 45 Social isolation, voluntary social distancing, and lockdowns make smoking and exposure to secondhand smoke more likely. 46 Health and social measures for COVID‐19 may have caused participants to experience more anxiety, making them smoke more and stockpile more packs of cigarettes to cope with stress and anxiety.

Participants had a mean STAI of 43.42 ± 12.06. Slightly more than half of the participants (51%) had moderate anxiety (Table  4 ). Söğüt et al. 46 investigated midwifery students' pandemic‐related knowledge and anxiety and found that most students experienced mild anxiety. 46 Yakar et al. 14 looked into medical students' pandemic‐related knowledge and anxiety and reported that they had a mean STAI of 43.54, which was similar to our result. Rakhmanov and Dane 15 also examined the knowledge and anxiety levels of African university students regarding the COVID‐19 pandemic and determined that they experienced severe (24%), moderate (22%), or mild anxiety (30%). Zhao et al. 27 also found that 37.4% of Chinese university students experienced anxiety during the COVID‐19 pandemic. The differences in results may be due to differences in regions of residence, infection and death rates and measures by country, and social and familial factors. As a result of the regression analysis performed in our study, our variable, which was significant in the model with moderate nicotine addiction, was found to be the person's anxiety level (Table  5 ). The possibility of nicotine addiction was found to be higher in those with high anxiety levels than those with low levels, and this finding is consistent with the literature and analysis.

Many adolescents smoke less than adults. However, adolescents who smoke, especially those who regularly smoke, experience nicotine dependence and withdrawal. 47 Participants had a mean FTND score of 2.7. More than half of them (65.2%) had low nicotine dependence (Table  4 ). Elbi et al. 42 and Provenzano et al. 16 also reported low nicotine dependence among more than half of university students. Chinwong et al. 47 looked into the prevalence of nicotine dependence in Thai university students and found that 71.7% of the male students (mean FTND = 2.3) and 88.4% of the female students (mean FTND = 1.8) had low nicotine dependence. 48

There is a correlation between anxiety and nicotine dependence. 46 , 49 In this study, it was found that as the anxiety levels of the students increased, the rate of nicotine addiction also increased (Table  5 ). Izadpanah et al. 49 found that young people with nicotine dependence had high anxiety. Zvolensky et al. 50 reported a moderate correlation between anxiety sensitivity and nicotine dependence among Latin smokers. Many smokers argue that smoking helps them cope with stress. Therefore, people who wanted to cope with stress during the pandemic turned to smoking. 10 The results showed that the participants were trapped in a vicious circle. On the one hand, they smoked more to reduce anxiety, but on the other hand, they experienced more anxiety as they feared that they would not be able to find or afford to buy cigarettes during the pandemic. Therefore, students should be informed about strategies to cope with stress and anxiety during pandemics.

5. CONCLUSION

There was a positive correlation between anxiety and nicotine dependence among smoking participants. The severity of nicotine dependence depended on the gender, family type, chronic disease, adaptation to social isolation, other smokers in the family, quality of relationship with family members, stockpiling packs of cigarettes, and anxiety about not being able to find or afford to buy cigarettes during the pandemic. The severity of anxiety depended on the gender, income, region of residence, activities at home during social isolation, other smokers in the family, quality of relationship with family members, increase in nicotine dependence, stockpiling packs of cigarettes, and anxiety about not being able to find or afford to buy cigarettes during the pandemic.

6. IMPLICATIONS FOR NURSING PRACTICE

Experts and parents should pay attention to young people concerning pandemic‐related physical and mental issues. Young people going through difficult times are more prone to substance and tobacco use. Therefore, online courses should address not only the subjects in the curriculum but also physical and mental issues and provide content to raise students' awareness of the dangers of substance and tobacco use. Telehealth services should be provided to university students. COVID‐19 pandemic has taken hold of the whole world rapidly and continues to change our lives drastically. Therefore, we need more studies with larger samples to examine its effects on substance and tobacco use among adolescents.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

ACKNOWLEDGMENT

The authors would like to thank the university students who participated in the study.

Ayran G, Köse S, Küçükoğlu S, Aytekin Özdemir A. The effect of anxiety on nicotine dependence among university students during the COVID‐19 pandemic . Perspect Psychiatr Care . 2022; 58 :114‐123. 10.1111/ppc.12825 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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What Nicotine Does to Your Body

Effects, Risks, and How to Get Help

John C. Umhau, MD, MPH, CPE is board-certified in addiction medicine and preventative medicine. He is the medical director at Alcohol Recovery Medicine. For over 20 years Dr. Umhau was a senior clinical investigator at the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (NIH).

Verywell / Zoe Hansen

• Nicotine's Impact
• Side Effects

Signs of Use

• Addiction & Withdrawal

How to Get Help

History of nicotine.

Nicotine, a stimulant found in tobacco plants, is one of the most heavily used drugs in the United States—and it's just as addictive as cocaine or heroin , according to the surgeon general. Nicotine products are regulated by the Federal Drug Administration (FDA). While nicotine is legal, as of 2019, it is illegal to sell or distribute nicotine-containing products to people under 21.

Cigarette smoking is the primary source of nicotine, with one pack of cigarettes providing some 250 "hits" of the extremely addictive substance.

Fewer people over the age of 18 are smoking today than ever before, but smoking still remains the most preventable cause of death in the United States accounting for 480,000 deaths annually. Estimates from the Centers for Disease Control and Prevention (CDC) for 2018 indicate that 13.7% of the U.S. adult population smoke cigarettes.

Also Known As : Nicotine products include cigarettes (also known as "smokes"), pipes, cigars (sometimes referred to as "stogies"), chewing tobacco (also known as "dip" or "chew"), snuff , hookahs , and e-cigarettes (also known as "e-cigs" and " vapes ").

Drug Class : Nicotine is classified as a stimulant.

Common Side Effects : Nicotine is known to cause decreased appetite, heightened mood, increased heart rate and blood pressure, nausea, diarrhea, better memory, and increased alertness.

How to Recognize Nicotine

Nicotine is rarely sold as a singular product, rather it's most often found as an ingredient in tobacco products like cigarettes and some smoking cessation products like nicotine gum and patches. Nicotine is sold as a liquid for use in e-cigarettes.

The FDA requires warning statement labels on tobacco products: “WARNING: This product contains nicotine. Nicotine is an addictive chemical.”

What Does Nicotine Do to Your Body?

When a person inhales cigarette smoke, the nicotine in the smoke is rapidly absorbed into the blood and starts affecting the brain within 10 seconds. Once there, nicotine triggers a number of chemical reactions that create temporary feelings of pleasure and concentration. But these sensations are short-lived, subsiding within minutes.

These chemical reactions include the release of catecholamines such as adrenaline , the "fight or flight" hormone. Physically, adrenaline increases heart rate and blood pressure. When this occurs, the person may experience rapid, shallow breathing and the feeling of a racing heartbeat. Adrenaline also tells the body to dump excess glucose into the bloodstream.

Nicotine also curbs appetite and may contribute to weight loss in complex ways.

How Does Nicotine Make You Feel?

Nicotine may produce feelings of pleasure for a few minutes, but you may also feel your heart rate increase. If your body builds up a tolerance, you'll likely feel tired, edgy, or even depressed when the nicotine wears off, and you'll crave another cigarette.

Nicotine has effects on many different parts of the body:

• The brain : Nicotine can change the chemistry in your brain and is linked with an increased risk of psychiatric disorders such as major depressive disorder and bipolar disorder .
• Skin : Nicotine constricts the blood vessels, which prevent nutrients from getting to the skin. This may cause premature aging and wrinkles.
• Heart : In addition to an increase in heart rate and blood pressure, nicotine narrows the arteries, which increases the risk of a heart attack.
• Lungs : Smoking cigarettes or using vapes limits your lung capacity over time, which can also cause illnesses like chronic obstructive pulmonary disease (COPD) later on.

What the Experts Say

To date, there have been studies showing benefits of nicotine, including decreased tension and increased thinking, as well as the stimulant's potential in warding off cognitive decline into Alzheimer's, delaying the progression of Parkinson's disease , and as a therapeutic approach for ADHD and schizophrenia .

Still, health professionals continue to warn about the dangers of nicotine, especially when used by adolescents whose brains are still developing (until age 25). Nicotine may negatively impact the parts of the brain that play a role in attention , memory, learning, and brain plasticity .

While cigarette smoking is on the decline, vaping and e-cigarettes are on the rise. The American Academy of Pediatrics (AAP) warns that "e-cigarettes are threatening to addict a new generation to nicotine."

Off-Label and Approved Uses

Nicotine replacement therapy (NRT) was the first pharmacological treatment approved by the FDA for smoking cessation. In fact, studies show that using the nicotine patch can double the rate of a person's smoking cessation success, especially when combined with support.

There are a variety of available NRT products, including:

• Nicotine gum
• Nicotine inhaler
• Nicotine lozenges
• Nicotine nasal spray
• Nicotine patch

Common Side Effects

Nicotine causes a range of effects on both the body and mind, including:

• Decreased appetite
• Gastrointestinal distress
• Heightened mood
• Improved memory and alertness
• Increased blood pressure
• Increased heart rate
• Increased production of saliva and phlegm

If your loved one is smoking cigarettes, you’ll likely be able to smell it on them. Detecting vaping can be a bit more difficult, but there are still some signs of use:

• Devices : E-cigarettes or "vape pens" can look like a thumb drive, pen, or stylus with holes on each end.
• Drinking more liquids : The vaporized liquid in e-cigs contains propylene glycol, which attracts and holds water molecules from the mouth, causing constant dry mouth.
• Irritability : This is a classic sign of nicotine withdrawal.
• Nosebleeds : Vaping can dry out the nasal passages and cause nose bleeds.
• Sweet smells : Vapor juice is often flavored, so if you suddenly catch a whiff of fruit punch or bubble gum and there’s no candy around, it could be a red flag.

Tolerance, Dependence, and Withdrawal

Nicotine is extremely addictive, and when used regularly, your body and mind learn to expect a certain amount of nicotine each day.

If you don't fulfill these cravings, withdrawal symptoms can be intense. You can quickly build a tolerance to nicotine, needing more to reach the desired effect. This is one reason why it's so hard (but not impossible) to quit smoking .

How Long Does Nicotine Stay in Your System?

Nicotine (in the form of a cigarette, pipe, or e-cigarette smoke) is mostly absorbed into the body through the lungs as well as the membranes in the mouth and throat. It can also be absorbed in your gastrointestinal tract (via chewing tobacco, nicotine gum, and lozenges) or your skin if you use a nicotine patch.

Nicotine is mainly metabolized in the liver and is excreted via urine through the kidneys as well as in feces. How long it stays in your system depends on many factors, including your age and weight; the type of nicotine product; frequency of use; and your hydration and physical activity levels.

That said, the following are estimates for how long nicotine is detectable in your system:

• Saliva test : One to four days
• Blood test : Two to four days
• Urine test : Two to four days
• Hair follicle test : Up to 90 days

Many routine drug tests screen for nicotine.

Nicotine is a highly addictive substance that's found in all tobacco products, including cigarettes, pipes, cigars, chewing tobacco, snuff, hookahs , e-cigarettes, and other vaping devices.

Nicotine activates the same reward pathways in the brain that other drugs such as cocaine or amphetamines do, although to a lesser degree. Research has shown that nicotine increases the level of dopamine in the brain, a neurotransmitter that is responsible for feelings of pleasure and well-being.

Unfortunately, it is the release of dopamine that contributes to the cycle of addiction, as the dopamine receptors in your brain crave more nicotine over time.

As the level of nicotine in the blood drops, people may begin to feel edgy and agitated. The acute effects of nicotine wear off within minutes, so people who smoke must continue dosing themselves frequently throughout the day to maintain the pleasurable effects of nicotine and to prevent nicotine withdrawal, which causes a host of physical and psychological symptoms:

• Constipation, gas, stomach pain
• Cravings to smoke
• Inability to concentrate
• Irritability, crankiness
• Postnasal drip
• Sore throat
• Sore tongue and/or gums
• Tightness in the chest

Treatment for Addiction and Withdrawal

Overcoming nicotine addiction is hard, but it is very possible. To set yourself up for success, try to prepare yourself to stop using nicotine by choosing a quit day.

Mark your quit day on your calendar, and from that point on, do your best to discontinue the use of any nicotine product (other than a nicotine replacement therapy product, if you're using one as a quit aid).

Cognitive behavioral therapy (CBT) can be an effective treatment for people who are looking to quit using nicotine. During a CBT session, a therapist will help you understand your triggers for using nicotine products and teach you healthy coping mechanisms to turn to instead.

Motivational interviewing is another therapeutic technique during which a counselor will help you become more motivated or inspired to pursue your goal of quitting smoking. They will help you answer important questions, such as: What is getting in your way of quitting? How can you align your values with your actions?

In a mindfulness session, a counselor teaches you how to detach yourself from your cravings for nicotine. Mindfulness practices can help you learn to tolerate your cravings and triggers to smoke instead of giving in to them.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, Betterhelp, and Regain. Find out which option is the best for you.

Medications

A doctor may recommend a prescription medication to quit smoking such as Chantix (varenicline) or Zyban (bupropion) .

Chantix works by reducing the feeling of pleasure a person gets when they use nicotine. Both Chantix and Zyban can also help relieve the symptoms of nicotine withdrawal. Zyban can also help reduce nicotine cravings.

There are potential side effects of Chantix and Zyban including headache, nausea, mood changes , trouble sleeping, and seizures.

A doctor might also recommend nicotine replacement therapy (NRT) separately or in addition to another quit smoking medication. NRT administers small amounts of nicotine without the other toxins in cigarettes and other nicotine products. It can help reduce cravings during nicotine cessation and lessen nicotine withdrawal symptoms.

Lifestyle Changes

Let your friends and family know that you're quitting. By enlisting their support, you improve your chances of success. If you have friends or family who use nicotine, you might request that they don't use nicotine around you.

Try making a list of smoke-free social activities to engage in , such as going to the movies or to a museum. Know your triggers to use nicotine, and have a plan to avoid or cope with them. If you associate alcohol with cigarettes, for example, you might avoid drinking or going to bars until you can manage your cravings.

There is evidence that behavioral support will likely increase the success rate by 10% to 20% for those who are already using pharmacotherapy for quitting smoking.

Whether you prefer to quit cold turkey or choose to use a quit aid to help you stop smoking, it's important to recognize that recovery from nicotine addiction is a process of gradual release over time.

Quitting nicotine doesn't happen overnight, but with perseverance, freedom from nicotine addiction is doable and will pay you back with benefits that go well beyond what you can probably imagine.

If you or a loved one are struggling with substance use or addiction, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 for information on support and treatment facilities in your area. 

For more mental health resources, see our National Helpline Database .

Nicotine is a substance found in the tobacco plant. Tobacco use likely began in the first century in Central America.

Native Americans would chew or smoke tobacco leaves. They used tobacco for religious rites of passage and medicinal cures for asthma, fever, depression, and more.

By the 1500s, Portuguese and Spanish sailors brought tobacco from the Americas to Europe. The French ambassador to Lisbon, Nicot de Villemain, introduced tobacco to the French court. His name would be used to create the name nicotine. In the 1600s, tobacco was cultivated in the present-day United States. By 1880, the first cigarette-rolling machine was invented.

In the 1950s, researchers were already linking smoking tobacco with diseases like lung cancer. By the 1970s, they found that nicotine was an extremely addictive substance.

Since the 1970s, there have been many landmark legislations in the United States to regulate smoking and educate people on the hazards of smoking. Still, the World Health Organization (WHO) reports that there are 1.3 billion people in the world who currently smoke tobacco.

Frequently Asked Questions

It is unclear. Some research suggests that nicotine can increase the risk of cancer because it damages DNA. However, tar and other toxic chemicals in cigarettes are more closely linked to cancer than nicotine.

Still, people who are addicted to nicotine and smoke heavily are at a greater risk of developing lung cancer than those who do not use nicotine products.

While it's possible, most people find it easy to stop using nicotine medicine after several months. In general, these products deliver nicotine to your body more slowly and in smaller doses than smoking.

Technically, e-cigarettes contain fewer chemicals than those found in cigarettes. But e-cigarettes still contain harmful substances like nicotine, heavy metals, and cancer-causing agents.

Nicotine is poisonous and overdose is possible, though not common. Most often, nicotine poisoning occurs when children mistake nicotine gum or lozenges for candy. Exposure to liquid nicotine in e-cigarettes is also a concern for people of all ages because of its high nicotine concentration.

If you or someone you care about experiences the following signs of nicotine overdose, call 911 or poison control (800-222-1222) immediately:

• Difficulty breathing
• Increased or decreased heart rate

Food and Drug Administration. Newly signed legislation raises federal minimum age of sale of tobacco products to 21 .

Centers for Disease Control and Prevention. Current cigarette smoking among adults in the United States .

National Institute on Drug Abuse. Mind matters: The body's response to nicotine, tobacco, and vaping .

Audrain-McGovern J, Benowitz NL. Cigarette smoking, nicotine, and body weight .  Clin Pharmacol Ther . 2011;90(1):164-168. doi:10.1038/clpt.2011.105

National Institutes of Health. Reasons people smoke .

Yuan S, Yao H, Larsson SC. Associations of cigarette smoking with psychiatric disorders: evidence from a two-sample Mendelian randomization study .  Sci Rep.  2020;10:13807. doi:10.1038/s41598-020-70458-4

Mayo Clinic. Is it true that smoking causes wrinkles?

American Heart Association. How smoking and nicotine damage your body .

Food and Drug Administration. Keep your air clear: How tobacco can harm your lungs .

Nicholatos JW, Francisco AB, Bender CA, et al.  Nicotine promotes neuron survival and partially protects from Parkinson’s disease by suppressing SIRT6 .  Acta neuropathol commun. 2018;6:120. doi:10.1186/s40478-018-0625-y

Spasova V, Mehmood S, Minhas A, et al. Impact of nicotine on cognition in patients with schizophrenia: A narrative review .  Cureus . 2022;14(4):e24306. doi:10.7759/cureus.24306

Yuan M, Cross SJ, Loughlin SE, Leslie FM. Nicotine and the adolescent brain .  J Physiol . 2015;593(16):3397-3412. doi:10.1113/JP270492

The American College of Obstetricians and Gynecologists. Leading medical groups applaud Surgeon General's report on e-cigarettes and youth .

Duke University Health System. Smokers double their quit rate by wearing nicotine patch before stopping .

Mishra A, Chaturvedi P, Datta S, Sinukumar S, Joshi P, Garg A. Harmful effects of nicotine .  Indian J Med Paediatr Oncol . 2015;36(1):24-31. doi:10.4103/0971-5851.151771

Valentine G, Sofuoglu M. Cognitive effects of nicotine: Recent progress .  Curr Neuropharmacol . 2018;16(4):403-414. doi:10.2174/1570159X15666171103152136

Cho JH. The association between electronic-cigarette use and self-reported oral symptoms including cracked or broken teeth and tongue and/or inside-cheek pain among adolescents: A cross-sectional study .  PLoS One . 2017;12(7):e0180506. doi:10.1371/journal.pone.0180506

National Cancer Institute. Handling withdrawal symptoms and triggers when you decide to quit smoking .

Pankhania R, Liu A, Grounds R. Oropharyngeal bleeding due to cannabidiol oil vape use .  Cureus . 2021;13(1):e12676. doi:10.7759/cureus.12676

Moerke MJ, McMahon LR. Rapid nicotine tolerance and cross-tolerance to varenicline in rhesus monkeys: Drug discrimination .  Exp Clin Psychopharmacol . 2018;26(6):541-548. doi:10.1037/pha0000226

National Institute on Drug Abuse. How does tobacco deliver its effects? .

Mishra A, Chaturvedi P, Datta S, Sinukumar S, Joshi P, Garg A. Harmful effects of nicotine . Indian J Med Paediatr Oncol. 2015;36(1):24-31. doi:10.4103/0971-5851.151771

National Institutes of Health. Managing withdrawal .

National Institute on Drug Abuse. What are treatments for tobacco dependence? .

American Cancer Society. Prescription medicines to help you quit tobacco .

National Institutes of Health. Prepare to quit .

Hartmann-Boyce J, Hong B, Livingstone-Banks J, Wheat H, Fanshawe TR. Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation . Cochrane Database of Systematic Reviews. 2019;6. doi:10.1002/14651858.CD009670.pub4

Mishra S, Mishra MB. Tobacco: Its historical, cultural, oral, and periodontal health association .  J Int Soc Prev Community Dent . 2013;3(1):12-18. doi:10.4103/2231-0762.115708

Dani JA, Balfour DJ. Historical and current perspective on tobacco use and nicotine addiction .  Trends Neurosci . 2011;34(7):383-392. doi:10.1016/j.tins.2011.05.001

American Lung Association. Tobacco control milestones .

World Health Organization. Tobacco .

National Cancer Institute. Study finds stronger nicotine dependency associated with higher risk of lung cancer .

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Centers for Disease Control and Prevention. About electronic cigarettes (e-cigarettes) .

American Association of Poison Control Centers. Tobacco and liquid nicotine .

By Terry Martin Terry Martin quit smoking after 26 years and is now an advocate for those seeking freedom from nicotine addiction.

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Article Contents

Introduction, conclusions, supplementary material, declaration of interests.

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Systematic Review of Electronic Cigarette Use (Vaping) and Mental Health Comorbidity Among Adolescents and Young Adults

• Article contents
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Timothy D Becker, Melanie K Arnold, Vicky Ro, Lily Martin, Timothy R Rice, Systematic Review of Electronic Cigarette Use (Vaping) and Mental Health Comorbidity Among Adolescents and Young Adults, Nicotine & Tobacco Research , Volume 23, Issue 3, March 2021, Pages 415–425, https://doi.org/10.1093/ntr/ntaa171

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The prevalence of electronic cigarette (EC) use has risen dramatically among adolescents and young adults (AYA, ages 12–26) over the past decade. Despite extensive established relationships between combustible cigarette use and mental health problems, the mental health comorbidities of EC use remain unclear.

To provide a systematic review of existing literature on mental health comorbidities of EC use among AYA. Database searches using search terms related to EC, AYA, and mental health identified 1168 unique articles, 87 of which prompted full-text screening. Multiple authors extracted data, applied the Effective Public Health Practice Project Quality Assessment Tool to evaluate the evidence, and synthesized findings.

Forty articles met eligibility criteria ( n = 24 predominantly adolescent and 16 predominantly young adult). Analyses yielded three main categories of focus: internalizing disorders (including depression, anxiety, suicidality, eating disorders, post-traumatic stress disorder), externalizing disorders (attention-deficit/hyperactivity disorder and conduct disorder), and transdiagnostic concepts (impulsivity and perceived stress). Significant methodological limitations were noted.

Youth EC use is associated with greater mental health problems (compared with nonuse) across several domains, particularly among adolescents. Because many existing studies are cross-sectional, directionality remains uncertain. Well-designed longitudinal studies to investigate long-term mental health sequelae of EC use remain needed.

Forty recent studies demonstrate a variety of mental health comorbidities with AYA EC use, particularly among adolescents. Mental health comorbidities of EC use generally parallel those of combustible cigarette use, with a few exceptions. Future EC prevention and treatment strategies may be enhanced by addressing mental health.

The use of electronic cigarette (EC) has risen dramatically among adolescents and young adults (AYA, youth aged 12–26) over the past decade in countries around the world. 1 A nationwide survey of US high school students found that current use of EC increased from 1.5% in 2011 to 20.8% in 2018, despite a decrease in combustible cigarette (CC) use during this period. 2 In 2019, lifetime EC use among high school age youth exceeded 40% in the United States and Canada. 3

ECs are battery-powered devices that heat a liquid to produce an inhalable aerosol that creates sensations mimicking CC smoking. 4 The devices are alternatively referred to as vaporizers, vape-pens, vape pod systems, JUULs (a popular North American brand), and electronic nicotine delivery systems; inhalation may be described as vaping or blowing smoke. 5 The increasing popularity of ECs among youth has been attributed to aggressive marketing, 6 enticing flavors, 7 perceptions of lower harm, 8 , 9 social media influences, 10 and discreet designs that enable furtive use. 9

EC liquids can contain mixtures of solvents (eg, propylene glycol), nicotine, tetrahydrocannabinol or hash oil, hundreds of flavoring compounds, and trace heavy metals. 11–13 Some ECs (eg, JUUL) use nicotine salts, enabling consumption of very high doses of nicotine 14 , 15 that have been associated with high rates of continued use. 5 EC are a vehicle for nicotine use, but do not always contain nicotine. In a national survey of US high school students, a majority reported vaping only flavoring (59%–63%), followed by nicotine (13%–20%), and cannabis compounds (6%) 12 ; however, actual nicotine use may be higher than reported because subsequent studies have indicated that youth misperceive nicotine content of products they use. 5

Leading health organizations initially supported ECs as a possible smoking cessation aid for adults. 4 , 16 Though initially presumed less toxic than CC, EC use can cause carcinogen exposure, 17 respiratory toxicity, 18 declining oral health, 19 and other adverse effects. 11 Among AYA, EC use may act as a gateway to use of CCs 20 , 21 and to alcohol and illicit substances. 22 , 23 Some youth may be more susceptible to harmful effects than others.

AYA with mental illness are a population of specific concern. Adults with mental illness use tobacco products at high rates and die prematurely from tobacco-related illnesses, 24 a disparity attracting calls for further study. 25 Adolescence is a vulnerable developmental period for the onset of nicotine use and mental illness, 26 warranting special attention. Yet, to date, no article has yet to systematically review the evidence base concerning EC use and mental illness in youth.

CC use among adolescents is associated with externalizing (eg, attention-deficit/hyperactivity disorder [ADHD], oppositional defiant disorder, conduct disorder), internalizing (eg, depression, anxiety), and substance use disorders. 26–28 AYA with mental illness use nicotine at higher rates than peers without mental illness. 29 This may occur due to (1) attempts to self-medicate symptoms, such as cognitive deficits in ADHD or low mood, 30 (2) efforts to counteract sedating side effects of psychotropic medications, 30 (3) common underlying genetic or environmental risk factors for smoking and mental illness, 31 , 32 or (4) neurotoxic impacts of nicotine on mental health. 33 A combination of individual-specific factors likely contributes.

Nicotine adversely affects adolescent neurodevelopment 34 and increases the risk of cognitive and psychiatric disorders. 35 Although much of the available evidence derives from animal and preclinical research, we can nonetheless mobilize this knowledge while awaiting further clinical youth studies. During adolescence, brain regions that underlie executive functions undergo significant reorganization, 36 , 37 regulated in part by nicotinic acetylcholine receptors. 33 Evidence from animal models suggests that prolonged nicotine exposure may also induce epigenetic changes 33 and increase vulnerability to stress sensitivity. 38 , 39 These biological changes may, in part, underlie associations between adolescent nicotine use and subsequent development of mood disorders, 39 , 40 schizophrenia, 41 and substance use disorders. 33 Furthermore, reliance on nicotine to overcome challenges interferes with the development of adaptive coping skills. 42

Although nicotine remains the most commonly vaped substance, a substantial proportion of youth EC users vape cannabis 12 and nicotine vaping is highly comorbid with cannabis use among adolescents. 43 Vaped cannabis often comes in high-potency concentrates, leading to greater amounts consumed by vaping than other modes. 44 Like nicotine, cannabis use is associated with adverse mental health outcomes, including psychotic disorders, depression, worse symptoms of mania/hypomania in individuals with bipolar disorder, and suicidality. 45

We aim to assess the current evidence describing mental health comorbidities of EC use among AYA. Although prior reviews have assessed the mental health correlates of EC use among adults, 46 the evidence concerning relationships between EC use and AYA with mental illness remains unreviewed. As 99% of tobacco users initiate use before age 26, effective prevention and treatment efforts depend on understanding risks for use among AYA. 47

The research protocol was developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 48 and registered with the International Prospective Register of Systematic Reviews (PROSPERO) (Registration ID CRD42020177159).

Data Sources and Searches

A search of studies that evaluated psychiatric comorbidities associated with EC use among adolescents and young adults was conducted on March 23, 2020, within MEDLINE, EMBASE, PsycINFO, Web of Science Core Collection, and Scopus. The search strategy included appropriate controlled vocabulary and keywords for (1) mental illness, (2) AYA (ages 12–26), and (3) EC use (see Supplementary Appendix A ). Publication date was limited from January 2011 to present, and no language or article-type restrictions were included in the search strategy. Reference lists of included studies were reviewed by hand to identify any additional studies.

Study Selection

Search results were uploaded into Covidence, 49 a systematic review software package. Two authors independently assessed articles based on title and abstract using screening criteria, with a third author resolving eligibility disagreements. We chose wide eligibility criteria ( Table 1 ), since research on mental health among EC users is just emerging. Full texts of selected articles were screened to finalize decisions on eligibility ( Figure 1 ).

Inclusion and Exclusion Criteria

AYA = adolescents and young adults; EC = electronic cigarette.

a The authors agreed to add this criterion during full-text screening because the analyses presented in these papers did not contribute significantly to answering the main research question of this review.

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.

Data Extraction

The authors developed and piloted a standardized data extraction tool including first author and year of publication, study aim, participants and setting, study design, response and follow-up rates, EC measurements, mental health measures, prevalence of EC use, findings related to mental health, and covariates adjusted for in analyses. The aspects pertaining to the methods were extracted by a single author and reviewed by a second author. Results were extracted independently by two authors, who discussed each article, including additional team members as needed.

Following extraction of key data, two authors independently rated the quality of each article using the Effective Public Health Practice Project Quality Assessment Tool, a valid and reliable method for assessing a diversity of research designs. 50 Studies were rated across five domains, including selection bias, study design, confounders, data collection methods, and withdrawals and dropouts ( Table 2 , Supplementary Table 1 ). Last, a global quality rating inclusive of data in all domains was assigned.

Quality Rating of Included Studies ( n = 40)

Following data extraction and discussion of included studies, findings were qualitatively synthesized by mental illness categories. Substantial methodological heterogeneity precluded quantitative meta-analysis. Key statistics are reported.

Searches identified 1706 articles, of which 1167 were unique, and 1 article was identified by hand search. Of the 1168 articles screened, 87 met eligibility by title and abstract, of which 40 were ultimately included for qualitative synthesis ( Figure 1 ).

The included articles were published from 2015 through 2020 and pertained to 29 unique cohorts ( Supplementary Table 1 ). Most articles report on data collected between 2013 and 2017. Six cohorts were described by 17 articles, whereas the remaining 23 cohorts were described by single articles. More articles studied predominantly adolescents ( n = 24 studies, representing 16 cohorts) than young adults ( n = 16 studies, representing 13 cohorts).

Most studies were conducted in the United States ( n = 23 cohorts); others included South Korea ( n = 3 cohorts), the United Kingdom ( n = 2 cohorts), and Taiwan ( n = 1 cohort). A minority of cohorts were nationally representative ( n = 7/16, 44% of adolescent cohorts, n = 2/13, 15% of YA cohorts), two were clinical samples, 51 , 52 two focused on youth at high-risk for substance use, 53 , 54 and most others were school- or university-based samples.

More than half utilized cross-sectional designs ( n = 23 articles), although a substantial number were longitudinal ( n = 16 articles, representing 11 unique cohorts), and one reported a case series. 52 All studies used self-report measures of EC use, none of which were reported to have been established as reliable and valid. EC measures varied in assessing lifetime use, current use, age of use onset, and frequency of use. Most studies ( n = 37) referred to nicotine use in EC, whereas three explicitly investigated vaporizing other substances. 51 , 55 , 56

Mental health outcomes were subgrouped by syndrome (eg, depression, anxiety, ADHD) and age under three main categories: internalizing disorders, externalizing disorders, transdiagnostic concepts. Several additional findings that did not fit the main categories are briefly presented in Table 3 . 51 , 52 , 55–59

Additional Findings

Internalizing Disorders

Internalizing symptoms (composite), adolescents:.

Composite measures of internalizing symptoms were associated with EC use among adolescents in both the Population Assessment of Tobacco and Health (PATH) study 60–64 and a study of at-risk US high school students. 54 Quality of evidence was weak to moderate, with a mix of cross-sectional and longitudinal designs.

Cross-sectional analysis of baseline PATH data revealed that high-severity lifetime internalizing problems were similarly associated with both lifetime EC (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.3–1.8, p < .05) and CC use (aOR = 1.7, 95% CI: 1.5–2.0, p < .05). 61 In a 1-year follow-up longitudinal analysis of baseline nicotine-naive adolescents, high past-year internalizing problems were significantly associated with initiation of EC use (adjusted relative risk ratio [aRRR] = 1.61, 95% CI: 1.12–2.33, p < .05), but not initiation of CC-only or dual EC and CC use. 60 In a cross-sectional study of students in alternative high schools (ie, schools providing nontraditional learning experiences for youth with prior educational and/or behavioral difficulties) internalizing symptoms related significantly to EC use ( B = 0.100, standard error [SE] = 0.041, OR = 1.105, p < .05) and use frequency ( B = 0.204, SE = 0.095, β = 0.0128). 54

Young Adults:

Two articles examined and found relationships between internalizing symptoms and EC use among YA respondents in the PATH study. 62 , 65 Evidence quality was similarly weak to moderate. Similar to the adolescent PATH findings, high-severity past-year internalizing problems (compared with low severity) significantly related to current EC use (aOR = 1.97, 95% CI: 1.46–2.65, p < .001) and CC use (aOR = 1.92, 95% CI: 1.64–2.24, p < .001) in cross-sectional analysis of baseline data, 65 and high-severity lifetime internalizing problems predicted onset of EC (aOR = 1.4, 95% CI: 1.1–1.8, p < .05) and CC use (aOR = 2.2, 95% CI: 1.5–3.3, p < .05) among nonusers in a 1-year longitudinal analysis. 62

Seven studies, including four distinct national cohorts (United States, Taiwan, and Korea) 66–69 and one California-based cohort 70–72 examined associations between EC use and depression among adolescents. Most found positive associations 66–69 , 71 ,72 and one suggested a bidirectional relationship. 70 Evidence quality was weak to moderate due to cross-sectional designs, single-item measures, and minimal adjustment for confounders.

In a 1-year longitudinal analysis of a California cohort, sustained EC use was associated with the escalation of depressive symptoms over time ( b = 1.272, SE = 0.513, p = .01), and past-month use frequency was positively associated with depressive symptoms ( b = 1.611, SE = 0.782, p = .04) among sustained users. 70 The remaining studies were cross-sectional. Three national studies found EC use associated with depressive symptoms, 66 , 68 , 69 although the Taiwanese study found no relationship for exclusive EC use. 67 In the Taiwan study, depression was associated with exclusive CC use (aOR = 2.2, 95% CI: 1.1–5.0) but not EC use 67 ; however, in the Korean study depression was associated with both current EC use (current use: aOR = 2.21, 95% CI: 1.67–2.93) and CC use (current use: aOR = 2.04, 95% CI: 1.86–2.24). 69

Eight studies, among six cohorts, investigated relationships between depression and EC use, with mixed results. 21 , 53 , 59 , 73–76 Most studies were weak, due to cross-sectional designs and risk of selection bias.

A Texas-based cohort provides the strongest evidence (moderate). 59 , 75 , 76 Over 2.5 years of biannual longitudinal follow-up, depressive symptoms were significantly but modestly associated with frequency of past-month use for both EC (adjusted rate ratio [aRR] = 1.01, 95% CI: 1.00–1.03, p = .02) and CC (aRR = 1.03, 95% CI: 1.02–1.04, p < .001). 75 A cross-lagged path analysis of three waves found significant paths from Wave 1 depression to Wave 2 EC use ( B = 0.06, p < .01) and Wave 2 depression to Wave 3 EC use ( B = 0.08, p < .01), but no paths from EC use to subsequent depressive symptoms. 76

Two cross-sectional studies, among college students 58 and homeless youth smokers 53 found depressive symptoms associated with current EC use (college: aOR = 1.04, 95% CI: 1.01–1.08, p = .022 58 ; homeless: aOR = 3.06, 95% CI: 1.68–5.57, p < .05 53 ). In these studies, depression was also associated with CC use in the student cohort (aOR = 1.03, 95% CI: 1.01–1.06, p = .015), but not the homeless cohort.

Finally, two longitudinal 21 , 73 and one cross-sectional study 74 found no relationships between EC use and depression. In a 2-year follow-up of Georgia college students, depressive symptoms predicted subsequent CC use (aOR = 1.05, 95% CI: 1.02–1.09, p = .001) but not EC use. 73 In study of Virginia college students, baseline depression did not predict EC initiation during 1-year of follow-up. 21

One cross-sectional study, with weak quality evidence, assessed anxiety among adolescents, using scales for several anxiety subtypes, finding EC-only use less strongly related with anxiety than CC-only use. 71 Lifetime EC-only users had higher levels of panic disorder than lifetime nicotine abstainers, but lower levels of generalized anxiety, panic, social phobia, OCD, and anxiety sensitivity than CC-only users. 71

Four studies among three cohorts have examined anxiety among YA, yielding mostly negative results. 21 , 73 , 74 , 77 Quality of evidence was weak to moderate with risks of selection bias across studies. Studies of two longitudinal cohorts of college students, in Georgia and Virginia, followed over 1–2 years found no relationship between anxiety and subsequent EC use. 21 , 73 Among the Georgia 73 but not the Virginia cohort, 21 anxiety predicted CC use (aOR = 1.02, 95% CI: 1.00–1.04, p = .02). On a smaller scale, an ecological momentary analysis among a currently smoking subset of the Georgia cohort found no relationship between anxiety and EC use. 77 A cross-sectional study found EC use associated with generalized anxiety (likelihood ratio χ   2 = 14.0, p = .001, Cramer’s V = 0.066) in a primary unadjusted analysis that resolved with secondary analysis controlling for covariates. 74

Suicidality

Four national cross-sectional studies in the United States 66 and Korea 68 , 69 , 78 investigated suicidality, consistently finding current EC use associated with suicidal ideation, plans, and attempts. Evidence quality is again weak and is limited by cross-sectional designs, possible confounding, and single-item measures.

In an analysis of the US Youth Risk Behavior Survey (2015–2017), current EC-only use associated with past-year suicidal ideation (aOR = 1.23, 95% CI: 1.03–1.47). 66 Analyses across 3 years (2015–2017) of the Korean Youth Risk Behavior Survey found similar associations. 68 , 69 , 78 The 2016 Korean survey found significant associations between current EC use (vs. nonuse) and past-year suicidal ideation (aOR = 1.58, 95% CI: 1.31–1.89, p < .05), plans (aOR = 2.44, 95% CI: 1.94–3.08, p < .05), attempts (aOR = 2.44, 95% CI: 1.85–3.22, p < .05), and serious attempts (aOR = 3.09, 95% CI: 1.51–6.32, p < .05). 78 In the 2017 Korean survey, lifetime and current CC use, EC use, and dual CC and EC use (vs. never use) were all associated with suicidal ideation, planning, and attempts, although the magnitude of associations for CC-only users seemed consistently lower than those for EC and dual users—with greater OR, but wide CIs, limiting some comparisons between groups. Furthermore, associations between suicidality and EC use were consistently stronger among women than men. 69

No studies identified.

Eating Disorders

One South Korean study examined the comorbidity between EC use and past-month report of unhealthy weight control behaviors, including one-food dieting, fasting, diet pill use, and purging, and found significant relationships among both young men and women. 79 Although the study included a large nationally representative sample, overall quality was weak, due to a cross-sectional design, possible confounding, and single-item measures. Female lifetime and current EC adolescent users (compared with lifetime EC abstainers) had significantly higher rates of all unhealthy weight control behaviors (lifetime EC use: aORs = 1.87–2.40, current EC use: aORs = 2.32–3.76), whereas male current EC users, but not lifetime users had significantly higher rates of all unhealthy weight control behaviors (aORs = 2.05–3.18). Similar associations were found for CC use.

In one weak-quality US university-based sample, EC use was not associated with binge-eating disorder. 74

Post-traumatic Stress Disorder

Two studies were found examining relationships between aspects of post-traumatic stress disorder and EC use. 74 , 80 Findings were mixed and quality of evidence was weak, both studies used cross-sectional designs, and there was risk of sampling bias and potential confounding. Among college students, EC use significantly related to post-traumatic stress disorder (likelihood ratio χ   2 = 13.0, p = .002, Cramer’s V = 0.064) in the primary unadjusted analysis, but not after controlling for covariates. 74 In a small sample of YA, self-reported history of childhood mistreatment directly related to lifetime EC use (β = 0.19, p = .02), but not current use, a relationship that subsequent analysis found fully mediated by negative urgency, a dimension of impulsivity reflecting the tendency to act rashly while distressed (β = 0.11, p = .04). 80

Externalizing Disorders

Externalizing disorders (composite).

Analyses of adolescents in the PATH study found externalizing symptoms significantly associated with EC use. 60–64 Evidence quality was weak to moderate. In cross-sectional analysis of baseline data, high-severity lifetime externalizing problems were similarly associated with lifetime EC (aOR = 1.5, 95% CI: 1.3–1.7, p < .05) and CC use (aOR = 1.5, 95% CI: 1.3–1.7, p < .05). 61 In a 1-year longitudinal analysis of baseline nicotine-naive adolescents, high past-year externalizing problems were significantly associated with initiation of EC use (aRRR = 2.78, 95% CI: 1.76–4.40, p < .05), with relative risk ratios not significantly different from initiation of dual use (aRRR = 2.23, 95% CI: 1.15–4.31, p < .05) and CC use (aRRR = 5.59, 95% CI: 2.63–11.90, p < .05). 60

One longitudinal analysis of baseline nicotine-naive YA participants in the PATH study (moderate-quality evidence) similarly found that high-severity lifetime externalizing symptoms predicted EC onset (aOR = 1.4, 95% CI: 1.1–1.7, p < .05) at 1-year follow-up. 62 The relationship between externalizing symptoms and CC onset was not significant among these YAs.

Attention-Deficit/Hyperactivity Disorder

Two studies examined longitudinal relationships between ADHD symptoms and EC use among US high school students. 72 , 81 Both were moderate in quality, utilizing longitudinal designs with minimal attrition over 12–18 months while adjusting for covariates. Both studies found that ADHD symptoms predicted subsequent EC use, but not CC use. In a California-based cohort, overall ADHD symptoms (aOR = 1.22, 95% CI: 1.04–1.42) and hyperactivity–impulsivity subscale symptoms (aOR = 1.26, 95% CI: 1.09–1.47), but not inattentive subscale symptoms predicted initiation of EC over 18-month follow-up. 72 Similarly, in a small study of college-bound seniors, using a cross-lagged path model, ADHD symptoms at Time 1 (T1) predicted EC use at Time 2 (β = 0.206, p < .001) and ADHD symptoms at Time 2 predicted EC use at Time 3 (β = 0.350, p < .001), but EC use frequency was not associated with subsequent ADHD symptoms. 81

In contrast to the findings of adolescent samples, two studies examined ADHD symptoms and EC use among college students, both finding no associations when controlling for covariates. 73 , 74 The quality of evidence was weak-moderate in strength, due to only one longitudinal design and self-report measures. In a cross-sectional study, ADHD symptoms were significantly associated with EC use status (likelihood ratio χ   2 = 16.778, p < .001, Cramer’s V = 0.073) in the primary unadjusted analysis, but there was no significant association when controlling for covariates. 74 In a 2-year longitudinal study, neither ADHD nor any other psychological factors measured predicted EC use after controlling for covariates. 73

Conduct Disorder and Delinquency

Three articles examined conduct disorder symptoms and found significant relationships with subsequent EC use. 64 , 72 , 82 All were moderate-quality longitudinal studies, and two were nationally representative (United States, United Kingdom). An analysis of baseline nicotine-naive adolescents in the PATH study found that baseline rule-breaking tendency independently predicted EC use in the subsequent year (aOR = 1.93, 95% CI: 1.58–2.34). 64 Similarly, past 6-month delinquent behavior was associated with later EC use (aOR = 1.32, p < .001) and CC use (aOR = 1.41, p < .05) among a cohort of nicotine-naive US high school students. 72 Reports of various delinquent behaviors (eg, theft, vandalism, graffiti) were significantly higher for lifetime EC-only users (vs. never users) (aORs range 3.9–6.0, p < .001) but to less extent than among CC users and dual-EC and CC users (aORs range 5.7–11.9, p < .001). 82

Transdiagnostic Constructs

Impulsivity and executive function.

Impulsivity describes a predisposition toward rapid, unplanned actions without regard for long-term consequences and has been implicated in ADHD, conduct disorder, bipolar disorder, and personality disorders. 83 Executive function describes closely related capacities for planning, working memory, self-control, and attention shifting.

Adolescent:

Three studies examined impulsivity and EC use 71 , 84 , 85 and two studies among one cohort examined executive function. 86 , 87 These studies consistently found EC use related to impulsivity and executive function deficits. Overall, quality of evidence was weak, with nonprobability samples and cross-sectional designs.

In a cross-sectional analysis of California high school students, impulsivity was elevated similarly among EC and CC users. 71 In longitudinal analysis of British high school students, baseline impulsivity predicted onset of EC use (aOR = 1.263, 95% CI: 1.183–1.349) and CC use (aOR = 1.452, 95% CI: 1.286–1.638) at 24-month follow-up. 84 In a cross-sectional study using a mediation model, impulsivity was associated with more frequent EC use through an early age of EC initiation. 85

In a cross-sectional study of 12-year-old children in California, lifetime EC use was strongly associated with executive function deficits (aOR = 4.99, 95% CI: 1.80–13.96, p < .01), 86 with subsequent analysis finding the relationship between low inhibitory control and EC use most applicable among low-socioeconomic status respondents. 87

Four studies, also weak in overall quality, investigating EC use and various subcomponents of impulsivity (eg, sensation seeking, negative urgency, lack of premeditation, and perseverance) have had mixed results, with studies most consistently supporting a relationship between sensation seeking and EC use. 21 , 80 , 88 , 89 Two longitudinal studies 88 , 89 found relationships between sensation seeking and subsequent EC use (eg, ever JUUL use: aOR = 1.76, 95% CI: 1.52–2.05, p < .01; current use: aOR = 2.16, 95% CI: 1.81–2.58, p < .01), 89 and one cross-sectional study 80 found a correlation between sensation seeking and EC use, although relationships with other subcomponents of impulsivity were generally not significant (one small study found significance for negative urgency 80 ). One study found lack of perseverance predicted CC use (aOR = 1.52, 95% CI: 1.11–2.07, p < .05), but not EC use at 1-year follow-up. 21 In addition, in a cross-sectional study assessing impulse control disorders, EC use was related to gambling disorder (likelihood ratio χ   2 = 37.2, p = .000, Cramer’s V = 0.081), but not other impulse control disorders. 74

Perceived Stress

Perceived stress describes a heritable tendency to deem negative events as unpredictable and uncontrollable and has been implicated in anhedonic depression, anxious dysthymia, psychosis, post-traumatic stress, and various personality disorders. 90

One moderate-quality study assessed perceived stress in adolescents. 90 In a 4-year longitudinal follow-up of California teenagers, baseline (age 13) perceived stress was associated with lifetime and past-month EC use (aOR = 1.25, 95% CI: 1.07–1.47, p < .01) at age 17 as well as lifetime and past-month CC use (aOR = 1.32, 95% CI = 1.08–1.61, p < .01).

One study, weak, limited by cross-sectional design, assessed past-week perceived stress among college students, finding perceived stress associated with past 30-day EC use (aOR = 1.03, 95% CI: 1.00–1.05, p = .03) and CC use (aOR = 1.02, 95% CI: 1.00–1.04, p = .04).

Forty existing studies assess mental health comorbidities of EC use among AYA. This review of the current evidence, the first on this topic, summarizes our current knowledge base and facilitates future investigation.

Among adolescent studies, EC use is associated with internalizing problems, depression, suicidality, disordered eating, externalizing problems, ADHD, conduct disorder, impulsivity, and perceived stress, with additional limited evidence for an association with anxiety. These findings largely align with prior findings regarding mental health and CC use. 26 , 27 , 91–93 Among YA specifically, EC use has been associated with internalizing problems, externalizing problems, depression, sensation seeking, and perceived stress, whereas existing evidence does not support relationships with ADHD or anxiety.

The finding that ADHD was associated with EC use among adolescents but not YA may reflect methodological differences. Alternatively, ADHD may represent a risk factor for EC initiation among adolescents that becomes attenuated by young adulthood, due to neurobiological and psychosocial factors. Given well-established risks for substance use among AYA with untreated ADHD, 94 adolescents may gravitate toward ECs, influenced by social media 95 and availability, 96 whereas YA tend toward other substances (eg, alcohol). Brain maturation and resulting improvements in self-regulation, may also contribute to the observed difference.

Most adolescent cohorts (6/7), but only half of YA cohorts (3/6) found relationships between EC use and depression. Most of the adolescent studies were national cohorts, versus university-based samples in YA studies, and some adolescent studies used single-item measures for past-year depressive episodes. 66 , 69 These methodological differences may underly the difference in findings. Alternatively, the clear association in adults between depression and alcohol and substance use 97 again supports the hypothesis that depressed adolescents may turn to ECs whereas YAs access other substances.

Findings were similar for both EC and CC with a few notable exceptions. ADHD predicted onset of EC use but not CC use among adolescents. 72 , 81 This difference may reflect the role of sensation seeking in EC use, as youth with ADHD may be particularly attracted to their novel flavors. Although minimal associations were found between EC use and anxiety, associations were somewhat stronger for CC use and anxiety among adolescents and YA. 71 , 73 Externalizing symptoms were more strongly associated with onset of CC use than EC use among adolescents, 60 but not YA. 65 Adolescents with conduct problems may view CC use as a greater act of rebellion and risk-taking, given longstanding regulations against CC use, which have only recently begun for EC. Among YA, many high externalizing respondents were probably excluded for prior nicotine use, 62 so the negative finding may reflect that high externalizing youth had an earlier age of onset.

Implications for Practice

Clinicians should have a low threshold for providing mental health screening and referrals when treating youth using EC, as EC use may be an indicator of behavioral health risk. At this time, it seems reasonable to counsel AYA with depression and other mental health problems against vaping, warning that vaping and other substance use may exacerbate their mental illness. Although the longitudinal evidence linking vaping to subsequent psychopathology remains limited, there is some evidence of a relationship, 70 which would be consistent with relationships between CC use and mental illness, 98 and with existing models of nicotine and neurodevelopment (as described in the introduction). In addition, it is important to emphasize vaping cessation in AYA with mental illness to prevent potential progression to CC and other substance use 20–23 and associated long-term health sequelae, 24 which disproportionately affect adults with mental illness.

Further research is needed to better understand how comorbid mental illness influences uptake, use patterns, and cessation among AYA with mental illness to appropriately counsel and treat this population. There are no known effective treatments for youth EC cessation. Although EC manufacturers have created “curricula” to reduce underage abuse, these have many limitations. 99 Parents and school administrators struggle in implementing restrictions to curb use. 100 , 101 Although there exists a need for additional studies to enlarge the evidence base for adolescent CC smoking cessation, existing evidence best supports group-based behavioral interventions. 102 Adapting these programs to EC use may be effective alongside policies targeting specific problematic practices in EC marketing. 103 However, in developing interventions to mitigate EC use, it will also be important to monitor for the possible unintended consequence of diverting youth toward other, potentially riskier, substances. The results of this review highlight the importance of interventions to take into account AYA with mental illness as a special vulnerable population, which may benefit from tailored practices on both the intervention and public health policy levels.

Limitations of Evidence and Directions for Further Research

The quality of evidence among included studies varied, with several consistent limitations. The young adult studies were largely among college-based samples, raising the risk of selection bias. Given high prevalence of EC use among other groups of YA, 53 further study of high-risk YAs remains warranted. In addition, few studies have adjusted for use of other substances (see Supplementary Table 1 ), despite high comorbidity between vaping and other substance use 43 and the potential impacts of other substance use on mental health. Most studies that included substance use as a covariate still found significant relationships between EC use and mental health comorbidities. 57 , 60 , 70 , 78 , 82

Most studies were cross-sectional, or longitudinal studies with short-term follow-up. As a result, important questions about the impact of EC use on the trajectory of mental health symptoms remain unanswered. One study presented data to support a bidirectional relationship, 70 whereas two found no evidence for EC affecting subsequent mental health. 76 , 81 Given that EC use may alter cognitive and emotional health through multiple pathways, 13 further longitudinal studies remain important.

Future studies should develop more nuanced measures of EC use and establish their validity and reliability. Most studies measured either lifetime use or current use by self-report. Factors such as frequency and patterns of use, dose of nicotine (which varies considerably among products), and nicotine dependence remain relatively uninvestigated and will be important to identifying factors of youth most at risk of adverse outcomes. In addition, most studies relied on mental health screening measures, which were not designed to be diagnostic.

We expect EC use to remain an active area of investigation, given evolving legal restrictions on EC use and changing youth behavioral trends. Although youth vape numerous substances, we only found a few studies assessing vaping of cannabis and illicit drugs. In the United States, the rise of ECs over the past decade has coincided with loosening of restrictions on cannabis use. 104 Although studies indicate nicotine remains the main psychoactive substance inhaled by AYA EC users, use of cannabis in ECs is not inconsequential. 12 Like nicotine, cannabis use during adolescence influences development of depression and psychosis. 105 , 106

Although we found studies examining EC use across a range of psychopathology, we found no studies assessing psychosis. Given high rates of nicotine-associated long-term mortality and the potential etiologic role of nicotine in development of psychosis, 41 this subgroup may be most at risk of long-term adverse outcomes from EC addiction, and thus most in need of early intervention.

Limitations of Review

We acknowledge several limitations of this review. We defined inclusion criteria broadly to permit a wider view of the existing literature, but one which precluded quantitative meta-analysis, since each subcategory of results ultimately includes only a few studies, using a variety of mental health measures and covariates (see Supplementary Table 1 ). We anticipate this review will provide a horizon to permit future systematic studies to evaluate narrower questions. We excluded studies focused only on substance use disorder comorbidities, an important topic needing a dedicated review. Although we included all internalizing and externalizing mental health conditions and transdiagnostic concepts reported in this literature, we did not include search terms for transdiagnostic concepts. Our review yielded mostly US-based studies, which may in part reflect our exclusion of non-English studies; thus, it is not clear to what extent results generalize to other settings.

We identified 40 recent articles investigating the relationship between mental health and EC use among AYA. EC use correlates with several domains of AYA mental health problems. Much remains unknown about the particular use patterns of high-risk youth and the long-term neuropsychiatric sequelae of EC use during AYA development. Given the elevated rates of EC use among AYA with mental health problems, further research remains warranted.

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr .

This research was not supported by external funding.

None declared.

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Nicotine Addiction From Vaping Is a Bigger Problem Than Teens Realize

March 19, 2019

Data show clearly that young people are vaping in record numbers. And despite the onslaught of reports and articles highlighting not only its dangers but the marketing tactics seemingly aimed to hook teens and young adults, the number of vaping users continues to climb. 

These teens may be overlooking (or underestimating) a key ingredient in the vapors they inhale: nicotine. Though it’s possible to buy liquid or pod refills without nicotine, the truth is you have to look much harder to find them. Teens may not realize that nicotine is deeply addictive. What’s more, studies show that young people who vape are far likelier to move on to cigarettes, which cause cancer and other diseases.

So, why is nicotine so addictive for teens?

Nicotine can spell trouble at any life stage, but it is particularly dangerous before the brain is fully developed, which happens around age 25.

“Adolescents don’t think they will get addicted to nicotine, but when they do want to stop, they find it’s very difficult,” says Yale neuroscientist Marina Picciotto, PhD, who has studied the basic science behind nicotine addiction for decades. A key reason for this is that “the adolescent brain is more sensitive to rewards,” she explains. 

The reward system, called the mesolimbic dopamine system, is one of the more primitive parts of the brain. It developed as a positive reinforcement for behavior we need to survive, like eating. Because the mechanism is so engrained in the brain, it is especially hard to resist. 

When a teen inhales vapor laced with nicotine, the drug is quickly absorbed through the blood vessels lining the lungs. It reaches the brain in about 10 seconds. There, nicotine particles fit lock-and-key into a type of acetylcholine receptor located on neurons (nerve cells) throughout the brain.   

The unique attributes that make nicotine cravings persist

“Nicotine, alcohol, heroin, or any drug of abuse works by hijacking the brain’s reward system,” says Yale researcher Nii Addy, PhD, who specializes in the neurobiology of addiction. The reward system wasn’t meant for drugs—it evolved to interact with natural neurotransmitters already present in the body, like acetylcholine. This neurotransmitter is used to activate muscles in our body. The reason nicotine fits into a receptor meant for acetylcholine is because the two have very similar shapes, biochemically speaking, Addy explains. 

Once nicotine binds to that receptor, it sends a signal to the brain to release a well-known neurotransmitter—dopamine—which helps create a ‘feel-good’ feeling. Dopamine is part of the brain’s feedback system that says “whatever just happened felt good” and trains the brain to repeat the action. But nicotine, unlike other drugs such as alcohol, quickly leaves the body once it is broken down by the liver. Once it’s gone, the brain craves nicotine again. 

When an addicted teen tries to quit nicotine, the problem of cravings is of course tied to the drug that causes the dopamine rush, Addy says. What’s more, recent animal study research and human brain imaging studies have shown that “environmental cues, especially those associated with drug use, can change dopamine concentrations in the brain,” he says. This means that simply seeing a person you vape with, or visiting a school restroom—where teens say they vape during the school day—can unleash intense cravings. “In the presence of these cues, it’s difficult not to relapse,” Addy says.  

Physical changes caused by nicotine

Nicotine can also cause physical changes in the brain, some temporary, and others that some researchers, like Picciotto, worry could be long-lasting. 

Decades of cigarette smoking research have shown that, in the short term, the number of acetylcholine receptors in the brain increases as the brain is continuously exposed to nicotine. The fact that there are more of these receptors may make nicotine cravings all the more intense. However, those same studies found that the number of receptors decreases after the brain is no longer exposed to nicotine, meaning that these changes can be reversed. 

But animal studies show nicotine also can cause issues with brain function, leading to problems with focus, memory, and learning—and these may be long-lasting. In animals, nicotine can cause a developing brain to have an increased number of connections between cells in the cerebral cortex region, says Picciotto. “If this is also true for humans, the increased connections would interfere with a person’s cognitive abilities,” Picciotto says. 

To illustrate how this might work, Picciotto gives an example. A student sitting in a noisy classroom, with traffic passing by the window, needs to be able to focus her attention away from the distracting sounds so she can understand what the teacher says. “Brains not exposed to nicotine learn to decrease connections, and refinement within the brain can happen efficiently,” Picciotto says. “But when you flood the system with nicotine, this refinement doesn’t happen as efficiently.” 

“There’s hope that the current vaping epidemic won’t lead to major health problems like lung cancer or pulmonary disease,” Picciotto says. “But we may still see an epidemic of cognitive function problems and attention problems. The changes made in the brain could persist.” 

Vaping vs. regular cigarettes

Weighing the pros and cons of vaping versus smoking is difficult to do. On the one hand, e-cigarettes likely do not produce 7,000 chemicals—some of which cause cancer—when they are activated, like regular combustible cigarettes do. However, the aerosol from a vape device has not been proven safe. Studies have found that it contains lead and volatile organic compounds, some of which are linked to cancer. Researchers are still gathering data on the possible long-term health effects from vaping. It’s notable that e-cigarettes have not been approved by the Food and Drug Administration (FDA) as smoking cessation devices. However, e-cigarettes may be a better choice for adult smokers if they completely replace smoking, according to the Centers for Disease Control and Prevention (CDC). 

But where nicotine levels are concerned, a newer and popular type of vape device, called a “pod mod,” outcompetes many other e-cigarette devices. The form of nicotine in these pods is estimated to be 2 to 10 times more concentrated than most free-base nicotine found in other vape liquids. A single pod from one vape manufacturer contains 0.7 mL of nicotine, which is about the same as 20 regular cigarettes.

Despite its extremely addictive nature, people can successfully quit using nicotine with personalized approaches, especially under the guidance of physicians who understand addiction. 

For young people, intervening early in a vaping habit could make an important difference in the quality of life they have throughout their adult years. It could also mean they won’t become part of next year’s statistics.

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Nicotine dependence occurs when you need nicotine and can't stop using it. Nicotine is the chemical in tobacco that makes it hard to quit. Nicotine produces pleasing effects in your brain, but these effects are temporary. So you reach for another cigarette.

The more you smoke, the more nicotine you need to feel good. When you try to stop, you experience unpleasant mental and physical changes. These are symptoms of nicotine withdrawal.

Regardless of how long you've smoked, stopping can improve your health. It isn't easy but you can break your dependence on nicotine. Many effective treatments are available. Ask your doctor for help.

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For some people, using any amount of tobacco can quickly lead to nicotine dependence. Signs that you may be addicted include:

• You can't stop smoking. You've made one or more serious, but unsuccessful, attempts to stop.
• You have withdrawal symptoms when you try to stop. Your attempts at stopping have caused physical and mood-related symptoms, such as strong cravings, anxiety, irritability, restlessness, difficulty concentrating, depressed mood, frustration, anger, increased hunger, insomnia, constipation or diarrhea.
• You keep smoking despite health problems. Even though you've developed health problems with your lungs or your heart, you haven't been able to stop.
• You give up social activities. You may stop going to smoke-free restaurants or stop socializing with family or friends because you can't smoke in these situations.

When to see a doctor

You're not alone if you've tried to stop smoking but haven't been able to stop for good. Most smokers make many attempts to stop smoking before they achieve stable, long-term abstinence from smoking.

You're more likely to stop for good if you follow a treatment plan that addresses both the physical and the behavioral aspects of nicotine dependence. Using medications and working with a counselor specially trained to help people stop smoking (a tobacco treatment specialist) will significantly boost your chances of success.

Ask your health care team to help you develop a treatment plan that works for you or to advise you on where to get help to stop smoking.

Video: Smoking — Anatomy of nicotine addiction

In many people, nicotine from cigarettes stimulates receptors in the brain to release dopamine, triggering a pleasure response. Over time, the number of nicotine receptors increases and changes your brain's anatomy. When you quit smoking, you cut off the brain's pleasure response because the receptors don't get nicotine, triggering nicotine withdrawal symptoms. If you stick it out and use stop-smoking products to help with withdrawal symptoms and cravings, the number of nicotine receptors returns to normal, helping you quit smoking for good.

Nicotine is the chemical in tobacco that keeps you smoking. Nicotine reaches the brain within seconds of taking a puff. In the brain, nicotine increases the release of brain chemicals called neurotransmitters, which help regulate mood and behavior.

Dopamine, one of these neurotransmitters, is released in the reward center of the brain and causes feelings of pleasure and improved mood.

The more you smoke, the more nicotine you need to feel good. Nicotine quickly becomes part of your daily routine and intertwined with your habits and feelings.

Common situations that trigger the urge to smoke include:

• Drinking coffee or taking breaks at work
• Talking on the phone
• Drinking alcohol
• Driving your car
• Spending time with friends

To overcome your nicotine dependence, you need to become aware of your triggers and make a plan for dealing with them.

Risk factors

Anyone who smokes or uses other forms of tobacco is at risk of becoming dependent. Factors that influence who will use tobacco include:

• Age. Most people begin smoking during childhood or the teen years. The younger you are when you begin smoking, the greater the chance that you'll become addicted.
• Genetics. The likelihood that you will start smoking and keep smoking may be partly inherited. Genetic factors may influence how receptors on the surface of your brain's nerve cells respond to high doses of nicotine delivered by cigarettes.
• Parents and peers. Children who grow up with parents who smoke are more likely to become smokers. Children with friends who smoke are also more likely to try it.
• Depression or other mental illness. Many studies show an association between depression and smoking. People who have depression, schizophrenia, post-traumatic stress disorder or other forms of mental illness are more likely to be smokers.
• Substance use. People who abuse alcohol and illegal drugs are more likely to be smokers.

Complications

Tobacco smoke contains more than 60 known cancer-causing chemicals and thousands of other harmful substances. Even "all natural" or herbal cigarettes have harmful chemicals.

You already know that people who smoke cigarettes are much more likely to develop and die of certain diseases than people who don't smoke. But you may not realize just how many different health problems smoking causes:

• Lung cancer and lung disease. Smoking is the leading cause of lung cancer deaths. In addition, smoking causes lung diseases, such as emphysema and chronic bronchitis. Smoking also makes asthma worse.
• Other cancers. Smoking increases the risk of many types of cancer, including cancer of the mouth, throat (pharynx), esophagus, larynx, bladder, pancreas, kidney, cervix and some types of leukemia. Overall, smoking causes 30% of all cancer deaths.
• Heart and circulatory system problems. Smoking increases your risk of dying of heart and blood vessel (cardiovascular) disease, including heart attacks and strokes. If you have heart or blood vessel disease, such as heart failure, smoking worsens your condition.
• Diabetes. Smoking increases insulin resistance, which can set the stage for type 2 diabetes. If you have diabetes, smoking can speed the progress of complications, such as kidney disease and eye problems.
• Eye problems. Smoking can increase your risk of serious eye problems such as cataracts and loss of eyesight from macular degeneration.
• Infertility and impotence. Smoking increases the risk of reduced fertility in women and the risk of impotence in men.
• Complications during pregnancy. Mothers who smoke while pregnant face a higher risk of preterm delivery and giving birth to lower birth weight babies.
• Cold, flu and other illnesses. Smokers are more prone to respiratory infections, such as colds, the flu and bronchitis.
• Tooth and gum disease. Smoking is associated with an increased risk of developing inflammation of the gum and a serious gum infection that can destroy the support system for teeth (periodontitis).

Smoking also poses health risks to those around you. Nonsmoking spouses and partners of smokers have a higher risk of lung cancer and heart disease compared with people who don't live with a smoker. Children whose parents smoke are more prone to worsening asthma, ear infections and colds.

The best way to prevent nicotine dependence is to not use tobacco in the first place.

The best way to keep children from smoking is to not smoke yourself. Research has shown that children whose parents do not smoke or who successfully quit smoking are much less likely to take up smoking.

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Mayo Clinic's unique tobacco program brings hope for long-term addiction

Thomas Bennett had tried to quit chewing tobacco 75 to 100 times before he came to Mayo Clinic. Even a precancerous lesion in his mouth hadn’t stopped him. Before every doctor’s appointment, “I’d throw my can of chew out, she would say I don’t have cancer, and then I would go get a can of chew again,” Thomas recalls. “That’s how strong my addiction was.” It was in April 2021 that Thomas joined Mayo Clinic’s…

• Tobacco and cancer fact sheet. American Cancer Society. https://www.cancer.org/content/dam/cancer-org/cancer-control/en/booklets-flyers/tobacco-and-cancer-factsheet.pdf. Accessed Feb. 12, 2020.
• Benefits of quitting over time. American Cancer Society. https://www.cancer.org/healthy/stay-away-from-tobacco/benefits-of-quitting-smoking-over-time.html. Accessed Feb. 12, 2020.
• Why people start using tobacco and why it's hard to stop. American Cancer Society. https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/why-people-start-using-tobacco.html. Accessed Jan. 17, 2020.
• DrugFacts: Cigarettes and other tobacco products. National Institute on Drug Abuse. https://www.drugabuse.gov/publications/drugfacts/cigarettes-other-tobacco-products. Accessed Jan. 17, 2020.
• WHO report on the global tobacco epidemic 2019. https://www.who.int/tobacco/global_report/en/. Accessed Jan. 17, 2020.
• Rigotti NA. Overview of smoking cessation management in adults. http://www.uptodate.com/search. Accessed Feb. 24, 2020.
• Park ER. Behavioral approaches to smoking cessation. http://www.uptodate.com/search. Accessed Feb. 24, 2020.
• Rigotti NA, et al. Benefits and risks of smoking cessation. http://www.uptodate.com/search. Accessed Jan. 20, 2020.
• Goldman L, et al., eds. Nicotine and tobacco. In: Goldman-Cecil Medicine. 26th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Jan. 17, 2020.
• Press HI, et al., eds. Tobacco control and primary prevention. In: IASLC Thoracic Oncology. 2nd ed. Elsevier; 2018. https://www.clinicalkey.com. Accessed Jan. 17, 2020.
• Get free help: Speak to an expert. Smokefree.gov. http://smokefree.gov/talk-to-an-expert. Accessed Jan. 20, 2020.
• Quit guide: Clearing the air. Smokefree.gov. https://www.cancer.gov/publications/patient-education/clearing-the-air. Accessed Jan. 20, 2020.
• Prepare to quit. https://www.becomeanex.org/prepare-to-quit/. Accessed Jan. 17, 2020.
• I want to quit smoking. American Lung Association. https://www.lung.org/stop-smoking/i-want-to-quit/. Accessed Jan. 20, 2020.
• AskMayoExpert. Tobacco use (adult). Mayo Clinic; 2019.
• Let's make the next generation tobacco-free. Your guide to the 50th anniversary Surgeon General's report on smoking and health. https://www.hhs.gov/sites/default/files/consequences-smoking-consumer-guide.pdf. Accessed Jan. 17, 2020.
• Office of Patient Education. My smoke-free future. Mayo Clinic; 2020.
• Tobacco and kids. American Academy of Child & Adolescent Psychiatry. http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Tobacco-And-Kids-068.aspx. Accessed Jan. 20, 2020.
• Parker MA, et al. Higher smoking prevalence among United States adults with co-occurring affective and drug use diagnoses. Addictive Behaviors. 2019; doi: 10.1016/j.addbeh.2019.106112.
• Secondhand Smoke (SHS) Facts. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/index.htm. Accessed Feb. 26, 2020.
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Home — Essay Samples — Social Issues — Vaping — A Closer Look at Youth and Nicotine Addiction

A Closer Look at Youth and Nicotine Addiction

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Words: 1154 |

Published: Feb 13, 2024

Words: 1154 | Pages: 3 | 6 min read

• Vaporfi. Gianna Delmonte. https://www.vaporfi.com/blog/the-evolution-of-the-vape-industry/
• Breathe Pennsylvania. Rebecca Kishlock. August 25, 2017. https://www.breathepa.org/3523
• Truth Initiative. August 9, 2018. https://truthinitiative.org/research-resources/tobacco-industry-marketing/4-marketing-tactics-e-cigarette-companies-use-target
• NPR. Sean Mcminn, Connie Hanzhang Jin. November 6, 2019. https://www.npr.org/sections/health-shots/2019/11/06/776397270/more-teens-than-ever-are-vaping-heres-what-we-know-about-their-habits
• New York Post. Bernadette Hogan, Gabrielle Fonrouge. September 17, 2019. https://nypost.com/2019/09/17/flavored-e-cigarettes-are-officially-illegal-in-new-york/

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Teenage Smoking and Solution to This Problem Essay

Introduction, the underlying causes of teenage smoking and possible solutions, conclusions.

Nicotine addiction among teenagers has recently become one of the most pressing problems in the modern American society. Overall, the attempts made by anti-smoking campaigners hardly yield any results, because they mostly focus on harmfulness of tobacco smoking and the publics’ awareness of the problem, itself, but they do not eradicate the underlying causes of teenage smoking. It is possible to single out three factors that contribute to teenage addiction to nicotine. The considerable shift in social and political thought should be made in order to eliminate these factors. Furthermore, it is worth mentioning that it cannot be done it by compulsion. Perhaps it would more prudent to illustrate this statement.

Accessibility of tobacco products. Children can easily purchase cigarettes in vending machines, and in this case, no one can prevent them from doing it. Additionally, every shop places tobacco products in the forefront, which certainly attracts the attention of the would-be buyer (such technique can be applied not only to children or teenagers, but also to adults). Tobacco manufactures produce such commercials that make smoking look fashionable or even attractive.

Anti-smoking campaigners state that tobacco products should be made more expensive. Such method can be effective; however, it may arouse a wave of protest from manufactures, because the government cannot prohibit them to display their products. As regards price increase, it should be mentioned that such policy can have adverse effects on the economy of the country. Many amendments to the existing legislation should be made, in order to implement such policy. The measures that have already been taken can only reduce the effects of the advertising campaign, though they cannot eliminate the root cause, accessibility of tobacco products.

The impact of parents. It is estimated that approximately seventy three percent of teenagers, addicted to nicotine, have smoking parents. Psychologists believe, that we are inclined to emulate the behavior of our parents (at least subconsciously). The major problem is that very often parents do not realize that they incite their children to smoke. As the Department of Health states, various programs should be launched in order to increase parents awareness of this fact. It is believed that educators can make a considerable contribution, because they can influence not only the students but also their parents.

The influence of popular culture. As it has already been mentioned earlier, we tend to emulate the behavior of other people. Recent researches have proved that there is direct relation between nicotine addiction among teenagers and the tendencies in modern pop culture. Unwillingly some of Hollywood stars make smoking habits almost fashionable. For instance, when John Travolta smokes on television, smoking, itself inevitable becomes an inseparable part of the so-called “cool” behavior. The power that popular icons exercise over the unmolded minds of the young generation is immense. However, the government can hardly affect film industry, because such intervention verges on censorship and it can be viewed as the violation of the Fourth Amendment. It is considered that some of these films, featuring movie stars smoking should rated as R. However, such measures can make Hollywood production literally unavailable, to teenagers.

Now, that the major causes of cause of teenage smoking are identified, it is quite possible to conclude that the government is not able to eradicate all of them by force, the only possible solution is to increase public awareness of the problem, especially parents. Moreover, popular icons should understand that their behavior often drives children or teenagers to smoking. Nevertheless, it should be borne in mind that the existing legislation cannot change current situation.

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1. IvyPanda . "Teenage Smoking and Solution to This Problem." March 10, 2024. https://ivypanda.com/essays/teenage-smoking-and-solution-to-this-problem/.

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Study suggests that estrogen may drive nicotine addiction in women

by American Society for Biochemistry and Molecular Biology

A newly discovered feedback loop involving estrogen may explain why women might become dependent on nicotine more quickly and with less nicotine exposure than men. The research could lead to new treatments for women who are having trouble quitting nicotine-containing products such as cigarettes.

Sally Pauss is a doctoral student at the University of Kentucky College of Medicine in Lexington. She led the project.

"Studies show that women have a higher propensity to develop addiction to nicotine than men and are less successful at quitting," said Pauss, who is working under the supervision of Terry D. Hinds Jr., an associate professor. "Our work aims to understand what makes women more susceptible to nicotine use disorder to reduce the gender disparity in treating nicotine addiction."

The researchers found that the sex hormone estrogen induces the expression of olfactomedins, proteins that are suppressed by nicotine in key areas of the brain involved in reward and addiction. The findings suggest that estrogen–nicotine–olfactomedin interactions could be targeted with therapies to help control nicotine consumption.

Pauss will present the research at Discover BMB , the annual meeting of the American Society for Biochemistry and Molecular Biology, which will be held March 23–26 in San Antonio.

"Our research has the potential to better the lives and health of women struggling with substance use," she said. "If we can confirm that estrogen drives nicotine seeking and consumption through olfactomedins, we can design drugs that might block that effect by targeting the altered pathways. These drugs would hopefully make it easier for women to quit nicotine."

For the new study, the researchers used large sequencing datasets of estrogen-induced genes to identify genes that are expressed in the brain and exhibit a hormone function. They found just one class of genes that met these criteria: those coding for olfactomedins.

They then performed a series of studies with human uterine cells and rats to better understand the interactions between olfactomedins, estrogen and nicotine. The results suggested that estrogen activation of olfactomedins—which is suppressed when nicotine is present—might serve as a feedback loop for driving nicotine addiction processes by activating areas of the brain's reward circuitry such as the nucleus accumbens.

The researchers are now working to replicate their findings and definitively determine the role of estrogen. This knowledge could be useful for those taking estrogen in the form of oral contraceptives or hormone replacement therapy , which might increase the risk of developing a nicotine use disorder.

The investigators also want to determine the exact olfactomedin-regulated signaling pathways that drive nicotine consumption and plan to conduct behavioral animal studies to find out how manipulation of the feedback loop affects nicotine consumption.

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Despite the harm, young people are using nicotine pouches. Experts say it's giving them déjà vu

Nicotine pouches are available at convenience stores in most canadian provinces.

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Read transcribed audio.

They come in brightly-coloured tins with flavours like tropic breeze and berry frost, and in most of the country, they're sold at convenience stores. If you don't look closely, you might mistake them for gum or candy. 

Nicotine pouches, under the brand Zonnic, are the latest nicotine product to be approved for sale in Canada. Earlier in March, Health Minister Mark Holland vowed to crack down on their sale to young people. 

Despite the product's claim that it's a nicotine replacement therapy and not intended for those under 18, experts say youth are fast becoming their main market — and that raises troubling questions about how young people's health could be affected.

Health Canada approved Zonnic last July as a smoking cessation aid under the country's natural health product regulations, with no restrictions on how it's advertised, where it's sold, or at what age someone can buy it.

"If they could reach the counter, a toddler could wander in and buy some," said David Hammond, a public health professor at the University of Waterloo who researches tobacco control. 

The pouches can cause a host of health problems for young people, experts say, and the current lack of regulations is creating a sense of déjà vu for those who study tobacco control, including Laura Struik, an assistant professor in the school of nursing at UBC Okanagan.  

"The tobacco industry is very good at releasing kid-friendly, nicotine-based cessation products — and these nicotine pouches are no exception," said Struik. 

Quebec and B.C. have changed the regulations so nicotine pouches can only be sold behind the counter at pharmacies, and Health Canada has announced it will explore regulatory options to protect youth. 

What are the health concerns? 

Zonnic pouches — small bags filled with nicotine powder that users place against their gums — contain up to four milligrams of nicotine. 

They're often sold 10 to a package, which is roughly the amount of nicotine in a pack of cigarettes, Dr. Nicholas Chadi told Dr. Brian Goldman, host of CBC's The Dose .

"You can become addicted to nicotine after only a few days or weeks of use if you're a young person," said Chadi, a pediatrician and researcher at CHU Sainte-Justine hospital in Montreal who specializes in adolescent and addiction medicine. 

"Your brain is a little bit more vulnerable to the effects of different substances."

Nicotine's effect on the brain 

There is more and more research into how nicotine affects the developing brain , said Chadi, which includes impacts on memorization, emotional regulation and sleep. 

"More and more studies are showing that young people who use nicotine also may be more likely to have mental health issues ," Chadi said. 

Nicotine can limit impulse control and inhibit cognitive processing and decision making, said Struik. 

"It not only alters the way that your brain communicates, but [early use] also enhances the addictive potential of nicotine," she said. 

The younger someone starts using nicotine, the harder it is to quit, Struik said. 

Oral health and cancer concerns

There are also concerns around users' gum health, experts say. 

"When you're using these pouches, you're inflaming your gums, you're inflaming your oral cavities," said Struik.

"That can result in a whole host of risks: mouth cancers, throat cancers."

The pouches contain other ingredients that haven't been tested for efficacy, said Chadi, so it's unclear if they could have potential negative health effects. 

"We really know very little about these emerging synthetic nicotine products," Chadi said. 

WATCH /  Health Minister vows to regulate nicotine pouches

Marketing of nicotine pouches must stay ‘away from our kids,’ says health minister

Some of the pouches have been found to contain tobacco-specific nitrosamines , said Struik, carcinogens found in tobacco and tobacco smoke. 

"These are cancer-causing chemicals," said Struik. "So there is that risk for seeing future cancer rates go up."

We've been here before 

Experts say it's baffling that these pouches are being sold in corner stores without age regulations, given what happened with e-cigarettes several years ago. 

In 2018, Canada introduced a new Tobacco and Vaping Products Act that allowed e-cigarettes to be sold to anyone 18 and older. Five years later, Canada had some of the highest teen vaping rates in the world. 

After the act changed in 2018, "we had marketing immediately in corner stores, and vaping went up three times among young people," said Hammond. 

Some provinces have since banned non-tobacco flavours of e-cigarettes. 

• Second Opinion Health Canada 'missing in action' on youth vaping crisis, experts say
• 'We were duped': Health minister vows to close 'loophole' on flavoured nicotine pouches

The advertising of nicotine pouches looks similar to what we saw with e-cigarettes, experts say. 

"If you look at the original social media campaign [for the pouches], it's all about young people and partying and using it whenever you can. This doesn't look like a therapeutic product," said Hammond. 

These are the same tactics the tobacco industry used to market cigarettes, he noted. 

Earlier this month, a spokesperson for Imperial Tobacco, the company that makes Zonnic, told CBC News that after speaking with Health Canada, the company has voluntarily removed parts of its advertising campaign featuring young people and placed the 18+ age label more clearly on its package.

How to talk to your kids 

Chadi and Struik both say parents and caregivers should be having open conversations with their children about nicotine pouches. 

"We can't just go into it with, 'These are bad for you; don't do it,'" said Struik.

Instead, she suggests staying curious and asking your teen or preteen what they've heard about the products or whether friends are using them. 

• Vape Fail 'It is not harmless:' Dentists voice concern over vaping

Struik even bought some vaping devices to show her 10-year-old daughter what they are and how they look. 

"A lot of parents don't even know what these devices or these pouches even look like," she said. 

Having those conversations "can go a long way in terms of building that trust."

ABOUT THE AUTHOR

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Isabelle Gallant is an Acadian radio producer and web writer based in Prince Edward Island. She has worked at the CBC since 2008.

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Prevalence = (number of members/total member months) × 1 000 000.

a Production of Chantix halted by Pfizer; US Food and Drug Administration (FDA) allows use of Canadian generic Apo-varenicline in the US.

b All lots of Chantix recalled by Pfizer; FDA approves generic varenicline in the US.

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Lang AE , Patel U , Fitzpatrick J , Lee T , McFarland M , Good CB. Association of the Chantix Recall With US Prescribing of Varenicline and Other Medications for Nicotine Dependence. JAMA Netw Open. 2023;6(2):e2254655. doi:10.1001/jamanetworkopen.2022.54655

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Association of the Chantix Recall With US Prescribing of Varenicline and Other Medications for Nicotine Dependence

• 1 Department of Primary Care, McDonald Army Health Center, Ft Eustis, Virginia
• 2 Department of Family Medicine and Population Health, Virginia Commonwealth University School of Medicine, Richmond
• 3 Research Institute Department, Evernorth Health Services, St Louis, Missouri
• 4 Department of Client Solution Product Strategy, Evernorth Health Services, St Louis, Missouri
• 5 Pharmacy Services, Insurance Services Division, UPMC Health Plan, Pittsburgh, Pennsylvania
• 6 Centers for High Value Health Care and Value Based Pharmacy Initiatives, Insurance Services Division, UPMC Health Plan, Pittsburgh, Pennsylvania

In July 2021, Pfizer halted the production of Chantix (varenicline tartrate) and recalled select lots due to elevated nitrosamine levels. 1 This recall created a shortage of an effective treatment for tobacco and nicotine dependence. 2 , 3 Later that month the US Food and Drug Administration (FDA) allowed the US distribution of the Canadian generic Apo-varenicline (varenicline tartrate). 1 In September 2021, all lots of Chantix were recalled by Pfizer. 1 Shortly thereafter, the first FDA-approved generic varenicline became available. Our objective was to evaluate the Chantix recall in terms of prescribing of varenicline and other medications for nicotine dependence in a large US national patient cohort.

Data for this cross-sectional study were extracted from a national pharmacy benefit database (of which 73.3% patients had commercial insurance) from January 1, 2021, to June 30, 2022. The search was limited to patients with commercial insurance and a prescription for a medication to treat nicotine dependence. Medications included were varenicline (generic, branded generic Apo-varenicline, and Chantix), nicotine replacement therapy (NRT) (all forms), and sustained-release bupropion (150-mg tablets only). Metrics of use and prevalence were created for each month for each medication. This study was deemed exempt by the University of Pittsburgh institutional review board because all data were deidentified administrative data. This study followed the STROBE reporting guideline for cross-sectional studies.

An interrupted time series analysis was conducted using SAS, version 9.4 (SAS Institute Inc), including covariates for time and a binary indicator for intervention period or not and time after intervention. All P values were from 2-sided tests and results were deemed statistically significant at P  < .05. The prerecall period was defined as January 1 to June 30, 2021, and the postrecall period was October 1, 2021, to June 30, 2022. A washout period was defined as July 1 to September 30, 2021.

Among 21 653 835 patients in 2021 and 19 978 911 in 2022, 312 708 prescriptions (30-day equivalent) for varenicline were filled by 238 258 patients. In August 2021, the month after the production halt of Chantix, the prevalence of patients prescribed varenicline decreased from 536 per 1 million in June to 146 per 1 million ( Figure 1 ). By September 2021, use of varenicline was 136 per 1 million, which represented a 74.7% absolute reduction ( P  < .001) compared with the prewashout period before increasing monthly thereafter. There was a significant increase in varenicline use in the period starting October 2021; however, by June 2022, the use of varenicline was still lower than in June 2021. There was no significant change in the use of sustained-release bupropion or NRT throughout the study period ( Figure 2 ).

Tobacco cessation is associated with immediate and long-term improvement in clinical outcomes, including morbidity and mortality. 4 Prescriptions of varenicline, an effective strategy for treating nicotine dependence, were reduced by the limitation and subsequent removal of Chantix from the market in 2021. Furthermore, there was no concomitant increase in the prescribing of NRT or sustained-release bupropion. Limitations to this study include that these results cannot account for over-the-counter NRT purchases and that the population was limited to those with commercial insurance.

In the US, the continuing dearth of varenicline claims through June 2022 was not due to a lack of drug availability but to accessibility. The lack of clinician and patient awareness regarding the availability of varenicline after the recall and concerns about nitrosamine were likely factors. The US could benefit from FDA-initiated public service announcements to spread knowledge of the availability of generic varenicline and to counter myths that nitrosamines in varenicline products outweigh harms from cigarettes. Policy changes to improve medication recall procedures and communication could help mitigate recurrence of an event at this magnitude. The substantial decrease in varenicline use after the Chantix recall represented potential lost opportunities for nicotine cessation with likely immediate and long-term adverse health outcomes.

Accepted for Publication: December 17, 2022.

Published: February 6, 2023. doi:10.1001/jamanetworkopen.2022.54655

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License . © 2023 Lang AE et al. JAMA Network Open .

Corresponding Author: Adam Edward Lang, PharmD, Department of Primary Care, McDonald Army Health Center, 576 Jefferson Ave, Ft Eustis, VA 23604 ( [email protected] ).

Author Contributions: Drs Lee and Good had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Lang, Patel, Fitzpatrick, McFarland, Good.

Acquisition, analysis, or interpretation of data: Lang, Patel, Fitzpatrick, Lee, Good.

Drafting of the manuscript: Lang, Fitzpatrick, Good.

Critical revision of the manuscript for important intellectual content: Patel, Fitzpatrick, Lee, McFarland, Good.

Statistical analysis: Fitzpatrick, Lee.

Administrative, technical, or material support: Lang, Patel, Good.

Supervision: Lang, Patel, Good.

Conflict of Interest Disclosures: Dr Lang reported previously owning stock in Walmart, Target, and Johnson & Johnson outside the submitted work. No other disclosures were reported.

Disclaimer: The views expressed in this publication are those of the authors and do not necessarily reflect the official policy of the Department of Defense, Department of the Army, US Army Medical Department, Defense Health Agency, or the US government.

Data Sharing Statement: See the Supplement .

Additional Contributions: The authors thank Mark Eatherly, BS, Evernorth Research Institute, for his assistance with data pulls and presentation of those data. He did not receive compensation for his assistance.

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Guest Essay

The D.E.A. Needs to Stay Out of Medicine

By Shravani Durbhakula

Dr. Durbhakula is an anesthesiologist and pain medicine physician from Nashville.

Even when her pancreatic cancer began to invade her spine in the summer of 2021, my mother-in-law maintained an image of grace, never letting her pain stop her from prioritizing the needs of others. Her appointment for a nerve block was a month away, but her pain medications enabled her to continue serving her community through her church. Until they didn’t.

Her medical condition quickly deteriorated, and her pain rapidly progressed. No one questioned that she needed opioid medications to live with dignity. But hydrocodone and then oxycodone became short at her usual pharmacy and then at two other pharmacies. My mother-in-law’s 30-day prescriptions were filled with only enough medication to last a few days, and her care team required in-person visits for new scripts. Despite being riddled with painful tumors, she endured a tortuous cycle of uncertainty and travel, stressing her already immunocompromised body to secure her medications.

My mother-in-law’s anguish before she died in July 2022 mirrors the broader struggle of countless individuals grappling with pain. I’m still haunted by the fact that my husband and I, both anesthesiologists and pain physicians who have made it our life’s work to alleviate the suffering of those in pain, could not help her. It is no wonder that our patients are frustrated. They do not understand why we, doctors whom they trust, send them on wild goose chases. They do not understand how pharmacies fail to provide the medications they need to function. They do not understand why the system makes them feel like drug seekers.

Health care professionals and pharmacies in this country are chained by the Drug Enforcement Administration. Our patients’ stress is the result not of an orchestrated set of practice guidelines or a comprehensive clinical policy but rather of one government agency’s crude, broad-stroke technique to mitigate a public health crisis through manufacturing limits — the gradual and repeated rationing of how much opioids can be produced by legitimate entities. This is a bad and ineffective strategy for solving the opioid crisis, and it’s incumbent on us to hand the reins of authority over to public health institutions better suited to the task.

Since 2015, the D.E.A. has decreased manufacturing quotas for oxycodone by more than 60 percent and for hydrocodone by about 72 percent. Despite thousands of public comments from concerned stakeholders, the agency has finalized even more reductions throughout 2024 for these drugs and other commonly prescribed prescription opioids .

In theory, fewer opioids sold means fewer inappropriate scripts filled, which should curb the diversion of prescription opioids for illicit purposes and decrease overdose deaths — right?

I can tell you from the front lines that that’s not quite right. Prescription opioids once drove the opioid crisis. But in recent years opioid prescriptions have significantly fallen, while overdose deaths have been at a record high. America’s new wave of fatalities is largely a result of the illicit market, specifically illicit fentanyl . And as production cuts contribute to the reduction of the already strained supply of legal, regulated prescription opioids, drug shortages stand to affect the more than 50 million people suffering from chronic pain in more ways than at the pharmacy counter.

Doctors may be forced to ration medications or choose which patients out of a qualifying group receive scripts, and drug prices may increase for consumers. In an aging population with increasing pain medication needs, more patients may struggle more frequently to fill prescriptions that treat their pain, and because of known treatment biases in pain medicine, women and people of color could be disproportionately affected, widening existing disparities .

Paradoxically, the D.E.A.’s production cuts may drive patients to seek opioids on the illicit market, where access is easy but drugs are laced unpredictably with fentanyl, xylazine and other deadly synthetics. My patients confide that they cannot go through cycles of pain relief and withdrawal and cannot spend hours in the emergency room; in their minds, they have no choice but to turn to the streets.

We’ve seen this play out before: When the D.E.A. made legal access to products containing hydrocodone more difficult in 2014, the sale of opioids through online illicit markets increased to 13.7 percent of all drug sales from an estimated 6.7 percent, and sales shifted toward more potent opioids like fentanyl.

The D.E.A. isn’t new to this criticism. As recently as January, it insisted that manufacturing issues or other supply-chain disruptions were the real issues limiting patient access to pain medication, not manufacturing quotas or the imposition of limits. And the agency suggested that action would be taken if the Food and Drug Administration told it about shortages, which the F.D.A. hasn’t so far. But when more than a third of health care professionals attest that their patients struggle to fill opioid scripts, something is clearly not working. The D.E.A.’s responses read more like a deflection of blame than a serious strategy.

My profession makes me acutely aware of opioid risks, including addiction and overdose, but at times and under careful dosing and monitoring, opioids are the right choice for our patients. Still, some health care providers are reluctant to prescribe them , even for cancer pain, for which opioids are a mainstay of treatment. Many cited opioid dispensing at pharmacies as a barrier.

This is concerning, since untreated pain is associated with decreased immunity , a worsening of depression , reduced mobility and adverse effects on quality of life . Ineffective pain management has also been associated with increased medical costs. Among people with sickle cell disease , for instance, 10 percent of patients account for 50 percent of emergency room visits. Although they suffer from other possibly contributing disorders, the common feature among them is chronic pain.

Dangerous prescription drugs require safeguards, but a scalpel has more promise than a sledgehammer. The D.E.A., an agency staffed with law enforcement officials, is not equipped to distinguish appropriate from inappropriate prescribing, and it has apparently confused inappropriate with criminal . Instead of defining medical aptness, the D.E.A. should pass the baton to our nation’s public health agencies.

Collaboratively, the Centers for Disease Control and Prevention, the Food and Drug Administration and the Department of Health and Human Services can take a tailored, more precise approach to opioids that is informed by medical and clinical acumen. The F.D.A., in particular, should strengthen existing risk evaluation and mitigation strategies programs, which place controls on individual medications and respond to signs of inappropriate prescribing. Although such programs have not always responded effectively , they can be improved with planning, time and resources. And lastly, the government should strip the D.E.A. of its authority to suspend providers’ controlled substance licenses when dangers arise and should hand that power over to these public health agencies.

As the rates of chronic pain rise, I fear the future. Our medical students report reservations about treating pain patients, and while a dedicated medical school pain curriculum can shift attitudes, few schools offer one. The number of unfilled pain medicine fellowship training positions has more than doubled in the past three years , and pain physicians are leaving the specialty . For the field to recover, the thoughtful consideration of clinicians must be empowered by our nation’s health entities. It is time for the D.E.A. to stop meddling in medicine.

Shravani Durbhakula is an anesthesiologist and pain medicine physician. She serves on the board of directors of the American Academy of Pain Medicine Foundation and is a former director of the pain medicine fellowship and of the medical school pain course at Johns Hopkins School of Medicine.

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A GP opposed to the government’s vaping reforms and whose nicotine prescription website is being assessed by the drug regulator has given school vaping education sessions and spoken at a student conference without declaring she has received financial support from a tobacco company.

Dr Carolyn Beaumont owns the vaping telehealth service medicalnicotine.com.au, which allows people to obtain a prescription for nicotine vapes in minutes, without speaking directly to a doctor or pharmacist.

The Medical Board of Australia confirmed that this was legal but said the lack of real-time direct consultation was not good practice.

The platform is among a number of vaping prescription websites under assessment by the Therapeutic Goods Administration for potentially encouraging patients to request a particular prescription medicine.

In September 2023 Beaumont spoke at the tobacco industry’s Global Forum on Nicotine in Seoul, South Korea, with the forum covering her expenses to attend.

She is also a recipient of a Knowledge-Action-Change tobacco harm reduction scholarship. KAC has received funding from the Foundation for a Smoke-Free World , which in turn is funded by Philip Morris International .

Beaumont’s biography for the Global Forum on Nicotine says that as a recipient of the scholarship she is “creating an educational presentation on tobacco harm reduction for Australian medical students”.

In June Beaumont spoke on a panel titled Media, Medicine and the Vaping Epidemic at the University of Melbourne’s medical student conference.

A University of Melbourne spokesperson said the panellists had been asked to declare any conflicts of interest.

“Dr Beaumont declared that she had no conflicts of interest,” the spokesperson said. “At the commencement of the panel session at the conference, all speakers were asked to identify any relationships with industry/research funding. As Dr Beaumont declared no conflict of interest, no declaration was included in the visual display nor was a verbal declaration made.”

On her medicalnicotine.com.au website, Beaumont says she runs education sessions for secondary school students and parents about “teenage vaping concerns, and the dangers of becoming addicted to nicotine”.

Her website previously included an endorsement from Beaumaris Secondary College, a Victorian government school.

A Victorian government spokesperson said Beaumont “proactively approached Beaumaris Secondary College, volunteering to present”.

The spokesperson said Beaumont did not declare to the school benefits received from the tobacco or vaping industry: “She did not seek the school’s approval to reference it in promotional materials, and was not paid for her services.”

There is no policy requiring guest speakers who are running an education program in schools to disclose any potential conflicts of interests. Guardian Australia understands that policy is now under review.

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Beaumont declined to answer questions from Guardian Australia. After she was contacted for a response, a conflict of interest declaration was added to her website. It says that due to the cost of international travel, and without research institution funding, “it has been necessary on occasion to have travel costs covered in part by [the] tobacco industry”.

“Note that any such arrangements have been completely unconditional, and have never influenced my clinical decisions.”

In the statement Beaumont says “on the balance of evidence” she supports tobacco harm reduction and the role of vaping for adult smokers, as well as reducing youth uptake and “removing the blackmarket”.

“Occasional unconditional tobacco-industry funded travel costs are required to achieve these aims, in the absence of alternative sources of funding.”

She says the decision to accept such funding is “never made lightly”, and she has “never sought to hide” these sources of funding.

Telehealth platform

Beaumont is opposed to federal government efforts aimed at reducing the supply of nicotine vaping products, including an import ban on disposable vapes . The government has said the aim of its reforms is to reduce supply to children, and they are not intended to criminalise individuals who use vapes, whether adults or children.

On her website Beaumont states: “I am passionate about educating teenagers about the real risks of blackmarket vaping – unregulated products with unknown nicotine content, electrical safety hazards, no quality control and unknown levels of harmful contaminants.”

In an interview with the Global Forum on Nicotine’s media channel in December, Beaumont spoke of her hopes for 2024, saying: “What I most wish for is for the Australian ban on disposable vapes scheduled to occur on New Year’s Day to be stopped.

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“I wish for the planned ban on all personal importation of any vapes scheduled for March to be stopped. I wish for the Australian prescription model of vaping to stop and for the barriers to accessing a doctor to be truly understood and acknowledged.”

Despite this, Beaumont operates her own prescription vaping telehealth platform, medicalnicotine.com.au.

Guardian Australia followed the steps for obtaining a script online through the site in late February.

A Medicare number was not required to be entered, nor was a phone or video consultation needed.

After declaring that they are over 16 (which has since been changed to 18) and paying $40, patients are directed to fill out a short questionnaire to receive a script for a six-month supply of vapes, which must be used at the online pharmacy QuickRx. Patients can choose their own vape strength as part of this process, along with their preferred product – pods, disposable vapes or liquid nicotine.

Patients are not required to try first-line, evidence-based treatments first. They can simply tick a box stating: “I am not interested in nicotine replacement therapies.”

Guardian Australia selected “I wasn’t a regular smoker, but have started vaping instead of taking up smoking (because I have found other benefits to it)” as the reason for wanting a prescription.

A spokesperson for the Royal Australian College of General Practitioners said: “Nicotine vaping products are not recommended for first-line smoking cessation, but may be suitable for smoking cessation in conjunction with behavioural support where first-line therapies have failed.

“It is not recommended that non-smokers or non-vapers start vaping.”

The spokesperson said patients should also be informed that due to the lack of available evidence, the long-term health effects of nicotine vaping products are unknown; that their safety and quality have not been established; that the lack of uniformity in vaping devices increases the uncertainties and risks associated with their use; and dual use of tobacco and vapes should be avoided. The importance of the patient returning for regular review and monitoring should be emphasised, they said.

None of these were communicated in the process of obtaining a prescription from Beaumont’s site. Some parts of the form and questions have been updated since inquiries were made by Guardian Australia.

Beaumont did not respond to questions from Guardian Australia about accessing a prescription but did comment on an article about vaping on the Medical Republic site.

In the comments section, she appeared to refer to some of the questions put to her by Guardian Australia.

Beaumont set out why she did not do phone or video consults: “Firstly, timezones.

“I’m in Victoria, and many patients are from WA,” she wrote.

“There’s a 3 hour gap, so realistically I can’t make calls until midday. Consider also that as a whole, heavy smokers are more likely to work jobs such as construction, mining or hospitality. These jobs don’t lend themselves to taking time out for a phone consult.”

She wrote that she disagreed with the Medical Board that telehealth without a phone or video consult was not best medical practice.

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Prospero B. Gogo Jr: Preventable nicotine-product-related illnesses cost Vermont money and suffering

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This commentary is by Prospero Gogo Jr. M.D. of Burlington. He is a cardiologist with the University of Vermont Medical Center and chair for state advocacy with the Vermont Chapter of the American Heart Association.

The Vermont Legislature has passed S.18 and soon the bill will make its way to the desk of Gov. Phil Scott.

What is the aim of S.18? By banning the sale of addictive flavored products containing nicotine, such as vapes and menthol-flavored cigarettes, the bill would, in short, save money, save lives and prevent suffering.

While acknowledging the latter two results, the governor has expressed some hesitancy regarding whether the bill will save money. The short-term cost to the state, in the form of lost tax revenue, may be as high as $12 million in the first year after it takes effect.

I will not belittle how important $12 million is to our state government with its relatively small budget. But compare this estimate with the actual cost to taxpayers each year for the treatment of preventable nicotine product-related illnesses, including heart attacks and cancers.

Let’s look at heart disease.

In my recent testimony to members of the Vermont House, I demonstrated that the low-end estimate of how much money was spent to treat coronary heart disease in hospitalized patients in one year at the University of Vermont Medical Center was close to $35 million. More than half of Vermonters who carry the diagnosis of coronary heart disease are also current or former smokers, according to data collected by the Vermont Department of Health. 

Another analysis showed that tobacco-associated cancer costs the state’s health insurance payors (and inevitably its citizens) $188 million each year. That far exceeds the annual tobacco tax revenue of $75 million (the $12 million in lost tax revenue would come out of this sum in the form of decreased sales of menthol cigarettes and flavored vaping products).

Many of these diseases develop later in life driven by years of nicotine use, and thus a lot of the health care cost savings would be delayed. But they would be huge. If we put together all the attributable health care costs related to tobacco in Vermont, it may be as high as $400 million. How much will $400 million in cost savings be in 2045 dollars? Close to a billion?

We don’t have to wait until 2045 to see significant health care cost savings from this $12 million lost revenue. The Department of Health recently reported that 16.8% of pregnant women in Vermont reported using tobacco products during their pregnancy, which is twice the national average. The use of tobacco products during pregnancy is associated with pre-term birth, miscarriage, impaired fertility, congenital malformations and low birth weight. It is also linked with sudden infant death syndrome. 

These are near-term health problems occurring in young Vermont women and their babies not long after getting hooked on these harmful products.  A flavor ban could make health benefits — and cost savings — evident in just a few years.

I hope that Scott takes into consideration these savings, not only in dollars, but in the human costs of suffering and misery when contemplating putting his signature on S.18.

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Zyn Was 100 Years in the Making

Nicotine has been on a long journey to become candy.

For something that isn’t candy, Zyn nicotine pouches sure look a lot like it. The packaging, a small metal can, looks more than a little like a tin of mints. The pouches come in a wide variety of flavors: citrus, cinnamon, “chill,” “smooth.” And they’re consumed orally, more like jawbreakers or Warheads than cigarettes.

America has found itself in the beginnings of a Zyn panic. As cigarette and vape use have trailed off in recent years, Zyn and other nicotine pouches are gaining traction. The absolute pouch-usage numbers are still not that high, but sales have more than quadrupled from late 2019 to early 2022. Although only adults 21 and older can legally purchase them—a fact that the product’s website directly points out—they are reportedly catching on with teens . “I’m delivering a warning to parents,” Senate Majority Leader Chuck Schumer said in January, calling for a crackdown , “because these nicotine pouches seem to lock their sights on young kids.” Earlier this month, a group of plaintiffs filed a class-action lawsuit accusing the tobacco giant Philip Morris International (PMI), which also makes Zyn, of purposefully targeting kids. (“We believe the complaints are without merit and will be vigorously defended,” a PMI spokesperson told me over email, adding that Zyn offers “adult-orientated flavors.”)

On their surface, nicotine pouches seem to be a fad like any other, but they are the end result of a century of nicotine marketing and development that began with cigarettes and has now moved beyond. “It’s basically part of the long history of the candification of nicotine,” Robert Proctor, a Stanford historian who has written multiple books on tobacco, told me. Over the years, the tobacco industry has gradually introduced more and more products flavored and packaged like sweet treats. Now, with Zyn, the industry has finally devised a near-perfect one.

Read: The easy way for Joe Biden to save lives

Once, nicotine wanted to be the opposite of candy. In the 1920s, weight loss—or “reducing,” as it was then known—became a major craze, and the tobacco industry moved to market its products as a healthier alternative to candy. “Reach for a Lucky instead of a sweet!” read one ad . Candymakers were understandably aggrieved about this slight, but the industries made nice in 1930, when Lucky’s maker dropped “instead of a sweet!” from its slogan. Candy and cigarettes had commonalities. Both relied on sugar—candy because, well, obviously, and cigarettes to cut the bitter taste of tobacco. Both were placed near the checkout register, to encourage impulse purchases. Soon, the makers of both products established joint trade journals and labor unions, at least one of which exists to this day. (Yes, some of the workers who make Ghirardelli chocolate and Marlboro cigarettes are represented by the same union.)

Around this time, tobacco companies warmed up to the potential of cigarettes made out of chocolate, bubblegum, or pure sugar. Candy cigarettes, they seem to have realized, were free advertising, a gateway for kids into the world of smoking. (“Just Like Daddy!” read the slogan on one brand’s boxes.) The more similar the candy replicas looked to the real deal, the better. By the 1950s, most of the top cigarette brands—Lucky Strike, Chesterfield, Philip Morris—had their candy equivalent made by other companies, with packaging that very closely matched the real thing.

This was roughly the equivalent of a modern apple-juice maker packaging its product in a Jack Daniel’s bottle. These tobacco companies claim never to have encouraged this, but as Proctor details in his 2011 book, Golden Holocaust , they did nothing to discourage it either. The goal, he writes, was to “create Philip Morris in the minds of our future smokers.” ( That Philip Morris and the current Philip Morris International are not technically the same company, having since rebranded and then split apart.)

Over time, cigarettes themselves became more and more candylike—and the government has responded by cracking down. Menthol cigarettes went big in the 1950s and ’60s, and starting in the ’70s, companies introduced a wider range of even more candylike flavors: chocolate , strawberry , Twista Lime, Warm Winter Toffee . Flavored cigarettes were eventually banned in 2009—with the exception of menthol—because of their disproportionate popularity among kids. But flavored e-cigarettes such as Juul took their place just a few years later and quickly became the most popular tobacco product among American youth—until they, too, were mostly banned in 2020.

Now, with products such as Zyn, the candification of nicotine is pretty much complete. Pouches don’t just taste like candy; they’re also packaged like candy and consumed like candy (don’t swallow them, though). Proctor told me he’s talked with people for hours before realizing they had a nicotine pouch in their mouth. “It’s the ultimate merger of two of the leading hazards of modernity,” he said. Other companies such as Velo and Lucy are selling nicotine pouches too. Lucy even calls one of its special pouch lines “Breakers” (which sounds suspiciously close to Icebreakers, though a spokesperson for the company told me in an email, “They are in no way intended to resemble ice breakers the mints or any other type of candy.”). And it’s not just pouches: Nicotine chewing gum and lozenges have become available in wide varieties of flavors and are packaged in candy-colored pastels . Nicotine gummies have been on the rise as well.

Read: Gummy vitamins are just candy

Unlike with cigarette-shaped candies or candy-flavored cigarettes, both of which were uncomplicatedly bad, there actually is a legitimate, good-faith argument to be had about the merits of Zyn and similar flavored products. On the one hand, they do not contain tobacco and are not smoked, which is largely what makes cigarettes so deadly. The tobacco industry has positioned these products as a way for adults to wean themselves off of cigarettes, and they sure seem to be much safer than cigarettes, which kill more than 480,000 Americans each year—more than the combined deaths from COVID and car-crash fatalities in 2021. So the more people popping flavored pouches or gummies rather than smoking cigarettes, the better. On the other hand, they are addictive, and flavored products have been shown to play a major role in hooking kids. The PMI spokesperson told me, “If you’re worried about your health, the best thing is to never start using nicotine or”—if you already do—“stop using it.”

Whether the increase in the number of kids using nicotine is worth the decrease in the number of adults using cigarettes is hotly debated. There’s a dark irony to the fact we’re having this debate at all. A hundred years ago, tobacco companies invoked the idea, if not the specific language, of harm reduction when they marketed their cigarettes as a healthy alternative to candy. Now they’re making their own nicotine products more candylike and marketing them as a healthy alternative to cigarettes. The harm reducer has become the harm to be reduced.

After all this, flavored nicotine pouches might end up banned, just like flavored cigarettes and vapes before them. But in the cat-and-mouse game that the tobacco industry has been playing with regulators, Zyn may have a better chance of persisting than anything before it.