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Young adults who started vaping as teens still can't shake the habit.

John Daley - Colorado Public Radio

Many young people who started vaping nicotine as teens several years ago haven't quit the habit, data show. Daisy-Daisy/Getty Images hide caption

Many young people who started vaping nicotine as teens several years ago haven't quit the habit, data show.

G Kumar's vaping addiction peaked in college at the University of Colorado, when flavored, disposable vapes were taking off.

The disposables would have more than a thousand puffs in them. "I'd go through, let's say, 1,200 puffs in a week," said Kumar, who uses they/them pronouns.

Vaping became a crutch. Like losing a cell phone, losing a vape pen would set off a mad scramble. "It needs to be right next to my head when I fall asleep at night and then in the morning I have to thrash through the sheets and pick it up and find it," Kumar recalled.

They got sick often, including catching COVID — and vaping through all of it.

Kumar, now 24, did end up quitting. But many of their generation can't shake the habit.

"Everyone knows it's not good for you and everyone wants to stop," said CU senior Jacob Garza who works to raise awareness about substance use as part of the school's Health Promotion program.

"But at this point, doing it all these years ... it's just second nature now," he said. "They're hooked on it."

Shots - Health News

They're illegal. so why is it so easy to buy the disposable vapes favored by teens.

For years, slick marketing by e-cigarette companies, and the allure of sweet, fruity or even candy-like flavors and names, led teens to try vaping. As more high schoolers and even younger kids picked up the behavior, doctors and researchers warned it could lead to widespread addiction, creating a 'Generation Vape.'

Now, new data about substance use among young adults suggests that many of those former teen vapers haven't quit.

Vaping use drops among teens, rises among young adults

In Colorado, the share of those aged 18 to 24 who regularly vaped rose by about 61% from 2020 to 2022 – to nearly a quarter of that age group.

"That's an astounding increase in just two years," says Dr. Delaney Ruston , a primary care physician and documentary filmmaker.

Nationally, vaping rates for young adults increased from 7.6% in 2018 to 11% in 2021 .

Disposable electronic cigarette devices displayed for sale on June 26, 2023. While most flavored disposables are officially banned in the U.S., they continue to be sold. Rebecca Blackwell/AP hide caption

Disposable electronic cigarette devices displayed for sale on June 26, 2023. While most flavored disposables are officially banned in the U.S., they continue to be sold.

Research has shown nicotine is highly rewarding to the brains of young people.

"It's not surprising that many of them start in high school for social reasons, for all sorts of reasons," says Ruston, whose latest film is Screenagers Under the Influence: Addressing Vaping, Drugs, and Alcohol in the Digital Ag e . "And many of them now — we're seeing this — have continued to college and beyond."

Meanwhile, vape rates have actually dropped among Colorado high schoolers, said Tiffany Schommer, the tobacco cessation supervisor with Colorado's state health department.

At one point, before the pandemic, Colorado led the nation in youth vaping, topping 37 states surveyed for use of electronic cigarettes among high school students.

Vaping peaked among minors in Colorado in 2017 with 27% of Colorado youth reporting they had vaped in the past month, according to the Healthy Kids Colorado Survey . But by 2021, the most recent year for which there's data, that dropped to 16%.

Nationally vaping rates among high schoolers dropped from 28% in 2019 to 12.6% in 2023 , according to the Annual National Youth Tobacco Survey.

But for many young people who started vaping at the height of the trend, a habit was set.

"E-cigarette use has increased, particularly among people who have never smoked [traditional cigarettes,]" said Schommer. "So these are folks who started with vapes, continue with vapes."

Preliminary data indicates that almost half of those vaping 18- to 24-year-olds started vaping before they turned 18, according to the Colorado 2022 Tobacco Attitudes and Behaviors Survey.

'They weren't able to stop.'

At Children's Hospital Colorado, pediatric pulmonologist Dr. Heather De Keyser pulls up on her screen a clouded X-ray of the lung of a young adult damaged by vaping.

"This is a patient with vaping-related lung injury," she says.

For years, doctors like her and public health experts wondered about the potential harmful impact of vaping on pre-adult bodies and brains — especially the big risk of addiction

Dr. Heather De Keyser, pediatric pulmonologist at Children's Hospital Colorado, points to the X-ray of a lung of a young adult damaged by vaping. John Daley/CPR News hide caption

Dr. Heather De Keyser, pediatric pulmonologist at Children's Hospital Colorado, points to the X-ray of a lung of a young adult damaged by vaping.

"I think, unfortunately those lessons that we were worried we were going to be learning, we're learning. The data is bearing out in that," said De Keyser, an associate professor of pediatrics in the Breathing Institute at Children's Hospital Colorado . "We're seeing increases in those young adults. They weren't able to stop."

It's no coincidence the vaping rates soared during the pandemic, according to several public health experts.

For the past couple of years, undergraduates have talked about the challenges of isolation and using more substances, said Alyssa Wright, Early Intervention program manager at Health Promotion at CU Boulder .

"Just being home, being bored, being a little bit anxious, not knowing what's happening in the world," Wright said. "We don't have that social connection, and it feels like people are still even trying to catch up from that experience."

Other factors driving addiction are the high nicotine levels in vaping devices, and "stealth culture," says Chris Lord, CU Boulder's associate director of the Collegiate Recovery Center .

"The products they were using had five times more nicotine than previous vapes had," he says. "So getting hooked on that was ... almost impossible to avoid."

As far as "stealth culture," Lord means that vaping is exciting, something forbidden and secret. "I think as an adolescent, our brains are kind of wired that way, a lot of us," Lord said.

The Juul effect

Wind the clock back half a decade and one could see the seeds of these current vaping rates.

In 2019, if you typed the word "Juul" into the search bar on YouTube, you could find an endless stream of videos of young people showing off how cool it was to use the company's sleek, high-tech-looking vaping device.

Juul packages are seen on a shop shelf on December 07, 2022. Michael M. Santiago/Getty Images hide caption

Juul packages are seen on a shop shelf on December 07, 2022.

In one video Colorado Public Radio found in 2019, two young women show how they "make parties more fun."

"We just chillin',' one says, laughing. "We vapin' and we Juul-in'."

Many of those videos are no longer available, pulled off the platform once the trend took off. Searching for Juul now brings up many videos warning of the dangers and how to talk to kids .

All over the U.S., state and local governments, including Colorado, filed suit, alleging Juul Labs misrepresented the health risks of its products.

Juul agreed to pay hundreds of millions in settlements , including a nearly $32 million settlement last year with Colorado.

Juul had become No. 1, the top e-cigarette company, the lawsuits argued, by first aggressively marketing directly to kids, who then spread the word themselves by posting to social media sites like YouTube, Instagram and TikTok.

"What vaping has done, getting high schoolers, in some cases even middle schoolers, hooked on vaping, is now playing out," says Colorado attorney general Phil Weiser , a parent of two teens himself. He said vape companies followed the tobacco industry playbook — with a similar impact on young consumers. "They're still hooked. This is a very addictive product."

Juul did not respond to requests for comment.

R.J. Reynolds, which makes another popular brand , Vuse, sent NPR this statement: "We steer clear of youth enticing flavors, such as bubble gum and cotton candy, providing a stark juxtaposition to illicit disposable vapor products."

Other big vape companies , like Esco Bar, Elf Bar, Breeze Smoke and Puff Bar didn't respond to requests for comment.

"If we lived in an ideal world, adults would reach the age of 24 without ever having experimented with adult substances. In reality, young adults experiment," said Greg Conley, director of legislative & external affairs with American Vapor Manufacturers. "This predates the advent of nicotine vaping."

The FDA banned flavored vape cartridges in 2020 in an effort to crack down on marketing to minors, but the products are still easy to find .

Debate over vaping's role in smoking cessation

One claim often made in defense of vaping is that it can help users quit cigarette smoking.

Joe Miklosi, a consultant to the Rocky Mountain Smoke-Free Alliance, a trade group for vape shops contends the shops are not driving vaping rates among young adults in Colorado.

"We keep demographic data in our 125 stores. Our average age (of customers) is 42," he says.

Vape shops sell products to help adult smokers quit, Miklosi says, with lower levels of nicotine than big companies like Juul. Miklosi claims he's talked to thousands of consumers who claimed vaping helped them quit smoking cigarettes.

But the Colorado data belies that, according to longtime tobacco researcher Stanton Glantz.

The 18-24 age group leads all age groups in regular use, and use gradually dropped with each age cohort, up to the 65+ demographic, of which just 1% use e-cigarettes.

The data are "completely inconsistent with the argument that most e-cigarette use is adult smokers trying to use them to quit," said Glantz, the now-retired director of the Center for Tobacco Control Research and Education at the University of California San Francisco.

Glantz says because of the onslaught of sleek technology, flavors, and marketing used by Juul and other companies "the kids are getting addicted younger and faster," compared to earlier decades when traditional cigarettes dominated the tobacco market.

Finding the will to quit

For recent college graduate G Kumar, now a rock climber, the impetus to quit vaping was more ecological than health-related. It was "knowing the amount of trash [from used up vape devices] that I was accumulating and the amount of money I was spending," they said.

Kumar got some help from a package of cessation literature and quitting aids from CU's Health Promotion program. It included two boxes of eucalyptus-flavored toothpicks, which tasted awful to Kumar, but provided a distraction and helped with oral cravings.

"The fact that I could just gnaw on toothpicks for weeks on end was, I think, what kept me sane," Kumar said.

It took a while and a lot of willpower to overcome the intense psychological craving, something many others in that generation know all too well.

This story was produced in partnership with CPR News and KFF Health News.

• nicotine addiction
• youth vaping
• young adults

Study: College Students Vape Much More Than They Realize

The research, led by Dr. Anne Buu and colleagues from the University of Texas Health Science Center in Houston, in collaboration with UW-CTRI Director of Research Dr. Megan Piper , was published in Nicotine & Tobacco Research.

“What came out of this is that what we think we do and what we actually do are very different,” Piper said.

It was the first study to find that college students tended to vape much more than they thought—nine times more. While Piper expected a discrepancy, she didn’t think it’d be that big.

“But it’s difficult with e-cigarettes to figure out what a ‘Use Event’ is,” Piper said. “With a cigarette, you smoke it until it’s done. With e-cigarettes, some take a couple hits or puffs and that’s it. My guess is, they remember the times when their use is longer or more intentional, not the quick or automatic ones.”

It’s akin to the difference between tracking every potato chip you eat versus sitting down with a huge bowl while watching TV and not really paying attention to how many you’re eating.

Piper said some may underreport for other reasons. “We use all sorts of schemas or mental shortcuts to understand our world. We think we’re healthy, we think we eat four helpings of vegetables. But when we actually measure it, it’s only two.” Or maybe one of the “helpings” of veggies is actually two shards of mushrooms on a slice of pizza.

“We see the goal,” she said, like having one serving of ice cream. “But then when we look at the size of the bowl, it’s actually five servings.”

Human error and fuzzy memory could also be factors. “As a species, we’re terrible estimators,” Piper said. Ever try to estimate the number of gumdrops in a jar?

“It’s not until we start keeping track of what we do that we can actually change.”

The study team established 10 to 15 puffs on an e-cigarette or 10 minutes of vaping as a use event, somewhat like the use of one cigarette. “But if the study participants never smoked,” Piper said, “and are native vapers, then they’ve never used their product like that. Some have never taken 15 puffs in one sitting. There can be very different use patterns.”

There can also be variability in the length and depth of a drag or puff, Piper said. Researchers also concluded that the more dependent a college student is on vaping, the more they tended to underestimate how much they vape. Flavors can also entice people to vape.

“A lot of factors can drive use, but I think dependence was one of the key factors driving the mismatch” between the self-report and real-time tracking, Piper said.

UW-CTRI has used tools for real-time vaping reporting for past studies like Exhale and Options , and plans to continue doing so in future research.

Of course, even real-time reporting could be underestimated.

UW-CTRI researchers have considered testing a device that records use puff by puff. But such a measurement tool would need to be brand agnostic and affordable.

Piper said she was grateful to be part of the research. “Dr. Anne Buu and her colleagues have worked with our Exhale study data as well, and she has been a fantastic collaborator and methodology expert.”

Yang JJ, Ou T-S, Lin H-C, Nam JK, Piper ME , Buu A. (2023) Retrospective and Real-Time Measures of the Quantity of E-Cigarette Use: An Ecological Momentary Assessment Study . Nicotine & Tobacco Research . Online June 16, 2023.

The youth vaping epidemic: Addressing the rise of e-cigarettes in schools

Subscribe to the brown center on education policy newsletter, nandeeni patel and np nandeeni patel intern, the brown center on education policy - the brookings institution diana quintero diana quintero former senior research analyst, brown center on education policy - the brookings institution, ph.d. student - vanderbilt university @quintero05diana.

November 22, 2019

Last December, the U.S. surgeon general raised an alarm regarding the rise in e-cigarette use among the nation’s youth, saying it has increased “at a rate of epidemic proportions.” According to the 2019 National Youth Tobacco Survey , over 5 million youth are currently using e-cigarettes, primarily the JUUL brand, with nearly 1 million youth using the product daily. This substantial increase in teenage vaping is seriously impacting middle and high schools across America.

Teen vaping has gained a significant amount of media attention since President Trump expressed concern about vaping’s public health effects in a September meeting with the FDA. While Trump had suggested a ban on flavored e-cigarettes, it seems that he has backed away from that idea due to political fallout among voters .

Vaping is on the rise in schools

Of the youth population, 27.5% regularly use e-cigarettes, approximately 22 percentage points higher than high schoolers who smoke normal cigarettes. These numbers are alarming because vaping has various types of negative impacts on health. First , e-cigarettes have been linked to severe lung and heart diseases. Second , e-cigarettes with high levels of nicotine can put youth at risk for developing a nicotine addiction which subsequently hinders brain development. Third, e-cigarettes expose youth users to harmful substances, like heavy metals, and are a gateway to smoking cigarettes.

E-cigarettes are causing public health and disciplinary concerns in schools nationwide. Teenagers are being hospitalized for vaping-related diseases, with at least one confirmed death . Teachers and school administrators are trying, yet failing, to prevent students from vaping in classrooms and on school campuses. Administrators are struggling to combat vaping with both punitive and restorative disciplinary measures , and students continue to vape even when facing penalties as serious as suspension. With the number of youth e-cigarette users increasing in the last decade and roughly doubling since 2017 , there may be a need for new policies that could standardize an approach to combating teenage vaping and help curb the impact on students.

President Trump proposed two routes to tackle vaping: a ban on flavored e-cigarettes , and raising the minimum age of purchase on e-cigarettes from 18 to 21. According to recent reporting , Trump has delayed a flavor ban. In response to Trump’s inaction, the House Energy and Commerce Committee passed a bill on Tuesday that would ban flavored tobacco products, raise the minimum age of purchase to 21, and restrict online sales of tobacco products. Despite the bill in the House, Trump is meeting with vaping industry executives and public health advocates. It is unclear how vaping regulations will unfold, but it is worthwhile to examine potential plans and their implications on students.

Examining a potential ban of flavored e-cigarettes

Major vaping companies, like JUUL Labs, have pushed against the flavor ban, which may have influenced Trump’s sudden decision to pull back from the policy. JUUL, which controls three-fourths of the e-cigarette market and has a forecasted 2019 revenue of $3.4 billion , is being investigated by the Food and Drug Administration (FDA) for allegedly illegally advertising its products as less harmful than regular cigarettes. Consequently , JUUL altered its leadership and marketing practices by suspending all advertising in the U.S. and replacing its CEO.

Banning the sale of flavored e-cigarettes would have hefty implications on vaping companies since they employ thousands of small shop owners and hardware designers. Banning the legal sale of flavored vaping products would also create a robust black market for e-cigarettes. A black market for vapes could be lethal for youth who find themselves smoking from cartridges cut with cheaper substances.

Trump faced pressures from the vaping lobby, which flocked to the nation’s capital claiming, among other things, that flavored e-cigarettes help smokers quit regular cigarettes. It is unproven , however, if there are health benefits to a regular smoker who instead becomes a long-term vaper. Research further suggests that while e-cigarette use was associated with high rates of smoking cessation, more than 80% of smokers who entered a randomized trial to stop smoking with the help of e-cigarettes continued to smoke e-cigarettes a year later. This is especially concerning given that smoking e-cigarettes has a negative impact on health.

Should the age limit be increased?

Whether by congressional action or Trump’s executive authority, the age minimum to purchase e-cigarettes can be changed from 18 to 21. Some vaping advocates believe that youth vape because of the nicotine in e-cigarettes. While the nicotine content in e-cigarettes can get students addicted to vaping, our analysis of the 2018 National Youth Tobacco Survey indicates that the most students report vaping for the flavor (about 35%) and because their family and friends use e-cigarettes (about 30%). Increasing the age of purchase to 21 would not address either of those incentives to vape.

Changing the age limit to 21 might fail to prevent many minors from getting their hands on e-cigarettes; in fact, 19% of youth report first trying an e-cigarette before the age of 13. Starting at the age of 13, rates of youth vaping in each age group increase. In 2018, 22% of 16-year-olds and 24% of 17-year-olds reported smoking an e-cigarette. This is an increase from 2017, when 11% of 16-year-olds and 14% of 17-year-olds reported smoking an e-cigarette. This shows that students are gaining access to and using e-cigarette products at an age well below the current age limit of 18. Further, over 70% of youth e-cigarette users report buying e-cigarettes from people rather than a shop, and 27% of frequent users reported living with someone who smoked. Youth vapers are typically not going to shops to buy vapes, they are buying vapes from their peers. Thus, minors who vape may still have access, although slightly restricted, to flavored e-cigarettes from friends and family who are over the age of 21.

We cannot know what will happen to e-cigarettes if the minimum age increases, but we can look to the experience of increasing the minimum age on alcohol for some suggestive evidence. According to the 2017 Youth Risk Behavior Survey, 30% of youth drank some amount of alcohol while 14% of youth engaged in binge drinking. Though raising the age limit for purchasing alcohol helped reduce youth alcohol consumption , youth consumption of alcohol persists.

State and local action

Federal action to stop the teenage vaping epidemic will likely fall short on some, if not most, metrics. Consequently, the onus will fall on state governments, boards of education, and local school districts to combat the issue of teen vaping. Several localities have already taken vaping into their own hands. For example, four states have banned vaping on school grounds, seven states have enacted or will enact a ban on flavored vaping products, and 18 states have raised the legal smoking age from 18 to 21 in the past three years. While the numbers show that vaping has increased drastically even with these state-level bans placed in populous states like New York and Texas, the effect of these state policies is largely unknown.

Beyond traditional tactics like monitoring bathrooms and hallways to confiscate vaping devices, states could also take a new approach to fighting the e-cigarette epidemic, like offering grants to schools to invest in on-site counseling. South Portland High School has been addressing teen vaping by offering mental health services and guiding students away from the social influences that encourage vaping. This school—and others, like Arrowhead High School in Milwaukee—have also been getting students involved in their anti-vaping campaign via peer-to-peer education.

The teenage vaping crisis calls for innovative solutions. In collaboration with federal and state action, local actors can look at the FDA’s Youth Tobacco Prevention Plan for insight on ways to initiate community-supported approaches that restrict access to vaping products, curb teenage-focused marketing tactics, and educate teenagers about the harmful, long-term effects of vaping.

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Impact of vaping on respiratory health

Linked editorial.

Protecting children from harms of vaping

• Related content
• Peer review
• Andrea Jonas , clinical assistant professor
• Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Stanford University, Stanford, CA, USA
• Correspondence to A Jonas andreajonas{at}stanford.edu

Widespread uptake of vaping has signaled a sea change in the future of nicotine consumption. Vaping has grown in popularity over the past decade, in part propelled by innovations in vape pen design and nicotine flavoring. Teens and young adults have seen the biggest uptake in use of vape pens, which have superseded conventional cigarettes as the preferred modality of nicotine consumption. Relatively little is known, however, about the potential effects of chronic vaping on the respiratory system. Further, the role of vaping as a tool of smoking cessation and tobacco harm reduction remains controversial. The 2019 E-cigarette or Vaping Use-Associated Lung Injury (EVALI) outbreak highlighted the potential harms of vaping, and the consequences of long term use remain unknown. Here, we review the growing body of literature investigating the impacts of vaping on respiratory health. We review the clinical manifestations of vaping related lung injury, including the EVALI outbreak, as well as the effects of chronic vaping on respiratory health and covid-19 outcomes. We conclude that vaping is not without risk, and that further investigation is required to establish clear public policy guidance and regulation.

Abbreviations

BAL bronchoalveolar lavage

CBD cannabidiol

CDC Centers for Disease Control and Prevention

DLCO diffusing capacity of the lung for carbon monoxide

EMR electronic medical record

END electronic nicotine delivery systems

EVALI E-cigarette or Vaping product Use-Associated Lung Injury

LLM lipid laden macrophages

THC tetrahydrocannabinol

V/Q ventilation perfusion

Introduction

The introduction of vape pens to international markets in the mid 2000s signaled a sea change in the future of nicotine consumption. Long the mainstay of nicotine use, conventional cigarette smoking was on the decline for decades in the US, 1 2 largely owing to generational shifts in attitudes toward smoking. 3 With the advent of vape pens, trends in nicotine use have reversed, and the past two decades have seen a steady uptake of vaping among young, never smokers. 4 5 6 Vaping is now the preferred modality of nicotine consumption among young people, 7 and 2020 surveys indicate that one in five US high school students currently vape. 8 These trends are reflected internationally, where the prevalence of vape products has grown in both China and the UK. 9 Relatively little is known, however, regarding the health consequences of chronic vape pen use. 10 11 Although vaping was initially heralded as a safer alternative to cigarette smoking, 12 13 the toxic substances found in vape aerosols have raised new questions about the long term safety of vaping. 14 15 16 17 The 2019 E-cigarette or Vaping product Use-Associated Lung Injury (EVALI) outbreak, ultimately linked to vitamin E acetate in THC vapes, raised further concerns about the health effects of vaping, 18 19 20 and has led to increased scientific interest in the health consequences of chronic vaping. This review summarizes the history and epidemiology of vaping, and the clinical manifestations and proposed pathophysiology of lung injury caused by vaping. The public health consequences of widespread vaping remain to be seen and are compounded by young users of vape pens later transitioning to combustible cigarettes. 4 21 22 Deepened scientific understanding and public awareness of the potential harms of vaping are imperative to confront the challenges posed by a new generation of nicotine users.

Sources and selection criteria

We searched PubMed and Ovid Medline databases for the terms “vape”, “vaping”, “e-cigarette”, “electronic cigarette”, “electronic nicotine delivery”, “electronic nicotine device”, “END”, “EVALI”, “lung injury, diagnosis, management, and treatment” to find articles published between January 2000 and December 2021. We also identified references from the Centers for Disease Control and Prevention (CDC) website, as well as relevant review articles and public policy resources. Prioritization was given to peer reviewed articles written in English in moderate-to-high impact journals, consensus statements, guidelines, and included randomized controlled trials, systematic reviews, meta-analyses, and case series. We excluded publications that had a qualitative research design, or for which a conflict of interest in funding could be identified, as defined by any funding source or consulting fee from nicotine manufacturers or distributors. Search terms were chosen to generate a broad selection of literature that reflected historic and current understanding of the effects of vaping on respiratory health.

The origins of vaping

Vaping achieved widespread popularity over the past decade, but its origins date back almost a century and are summarized in figure 1 . The first known patent for an “electric vaporizer” was granted in 1930, intended for aerosolizing medicinal compounds. 23 Subsequent patents and prototypes never made it to market, 24 and it wasn’t until 1979 that the first vape pen was commercialized. Dubbed the “Favor” cigarette, the device was heralded as a smokeless alternative to cigarettes and led to the term “vaping” being coined to differentiate the “new age” method of nicotine consumption from conventional, combustible cigarettes. 25 “Favor” cigarettes did not achieve widespread appeal, in part because of the bitter taste of the aerosolized freebase nicotine; however, the term vaping persisted and would go on to be used by the myriad products that have since been developed.

Timeline of vape pen invention to widespread use (1970s-2020)

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The forerunner of the modern vape pen was developed in Beijing in 2003 and later introduced to US markets around 2006. 26 27 Around this time, the future Juul Laboratories founders developed the precursor of the current Juul vape pen while they were students at the Stanford Byers-Center for Biodesign. 28 Their model included disposable cartridges of flavored nicotine solution (pods) that could be inserted into the vape pen, which itself resembled a USB flash drive. Key to their work was the chemical alteration of freebase nicotine to a benzoate nicotine salt. 29 The lower pH of the nicotine salt resulted in an aerosolized nicotine product that lacked a bitter taste, 30 and enabled manufacturers to expand the range of flavored vape products. 31 Juul Laboratories was founded a decade later and quickly rose to dominate the US market, 32 accounting for an estimated 13-59% of the vape products used among teens by 2020. 6 8 Part of the Juul vape pen’s appeal stems from its discreet design, as well as its ability to deliver nicotine with an efficiency matching that of conventional cigarettes. 33 34 Subsequent generations of vape pens have included innovations such as the tank system, which allowed users to select from the wide range of different vape solutions on the market, rather than the relatively limited selection available in traditional pod based systems. Further customizations include the ability to select different vape pen components such as atomizers, heating coils, and fluid wicks, allowing users to calibrate the way in which the vape aerosol is produced. Tobacco companies have taken note of the shifting demographics of nicotine users, as evidenced in 2018 by Altria’s $12.8bn investment in Juul Laboratories. 35

Vaping terminology

At present, vaping serves as an umbrella term that describes multiple modalities of aerosolized nicotine consumption. Vape pens are alternatively called e-cigarettes, electronic nicotine delivery systems (END), e-cigars, and e-hookahs. Additional vernacular terms have emerged to describe both the various vape pen devices (eg, tank, mod, dab pen), vape solution (eg, e-liquid, vape juice), as well as the act of vaping (eg, ripping, juuling, puffing, hitting). 36 A conventional vape pen is a battery operated handheld device that contains a storage chamber for the vape solution and an internal element for generating the characteristic vape aerosol. Multiple generations of vape pens have entered the market, including single use, disposable varieties, as well as reusable models that have either a refillable fluid reservoir or a disposable cartridge for the vape solution. Aerosol generation entails a heating coil that atomizes the vape solution, and it is increasingly popular for devices to include advanced settings that allow users to adjust features of the aerosolized nicotine delivery. 37 38 Various devices allow for coil temperatures ranging from 110 °C to over 1000 °C, creating a wide range of conditions for thermal degradation of the vape solution itself. 39 40

The sheer number of vape solutions on the market poses a challenge in understanding the impact of vaping on respiratory health. The spectrum of vape solutions available encompasses thousands of varieties of flavors, additives, and nicotine concentrations. 41 Most vape solutions contain an active ingredient, commonly nicotine 42 ; however, alternative agents include tetrahydrocannabinol (THC) or cannabidiol (CBD). Vape solutions are typically composed of a combination of a flavorant, nicotine, and a carrier, commonly propylene glycol or vegetable glycerin, that generates the characteristic smoke appearance of vape aerosols. Some 450 brands of vape now offer more than 8000 flavors, 41 a figure that nearly doubled over a three year period. 43 Such tremendous variety does not account for third party sellers who offer users the option to customize a vape solution blend. Addition of marijuana based products such as THC or CBD requires the use of an oil based vape solution carrier to allow for extraction of the psychoactive elements. Despite THC vaping use in nearly 9% of high schoolers, 44 THC vape solutions are subject to minimal market regulation. Finally, a related modality of THC consumption is termed dabbing, and describes the process of inhaling aerosolized THC wax concentrate.

Epidemiology of vaping

Since the early 2000s, vaping has grown in popularity in the US and elsewhere. 8 45 Most of the 68 million vape pen users are concentrated in China, the US, and Europe. 46 Uptake among young people has been particularly pronounced, and in the US vaping has overtaken cigarettes as the most common modality of nicotine consumption among adolescents and young adults. 47 Studies estimate that 20% of US high school students are regular vape pen users, 6 48 in contrast to the 5% of adults who use vape products. 2 Teen uptake of vaping has been driven in part by a perception of vaping as a safer alternative to cigarettes, 49 50 as well as marketing strategies that target adolescents. 33 Teen use of vape pens is further driven by the low financial cost of initiation, with “starter kits” costing less than $25, 51 as well as easy access through peer sales and inconsistent age verification at in-person and online retailers. 52 After sustained growth in use over the 2010s, recent survey data from 2020 suggest that the number of vape pen users has leveled off among teens, perhaps in part owing to increased perceived risk of vaping after the EVALI outbreak. 8 53 The public health implications of teen vaping are compounded by the prevalence of vaping among never smokers (defined as having smoked fewer than 100 lifetime cigarettes), 54 and subsequent uptake of cigarette smoking among vaping teens. 4 55 Similarly, half of adults who currently vape have never used cigarettes, 2 and concern remains that vaping serves as a gateway to conventional cigarette use, 56 57 although these results have been disputed. 58 59 Despite regulation limiting the sale of flavored vape products, 60 a 2020 survey found that high school students were still predominantly using fruit, mint, menthol, and dessert flavored vape solutions. 48 While most data available surround the use of nicotine-containing vape products, a recent meta-analysis showed growing prevalence of adolescents using cannabis-containing products as well. 61

Vaping as harm reduction

Despite facing ongoing questions about safety, vaping has emerged as a potential tool for harm reduction among cigarette smokers. 12 27 An NHS report determined that vaping nicotine is “around 95% less harmful than cigarettes,” 62 leading to the development of programs that promote vaping as a tool of risk reduction among current smokers. A 2020 Cochrane review found that vaping nicotine assisted with smoking cessation over placebo 63 and recent work found increased rates of cigarette abstinence (18% v 9.9%) among those switching to vaping compared with conventional nicotine replacement (eg, gum, patch, lozenge). 64 US CDC guidance suggests that vaping nicotine may benefit current adult smokers who are able to achieve complete cigarette cessation by switching to vaping. 65 66

The public health benefit of vaping for smoking cessation is counterbalanced by vaping uptake among never smokers, 2 54 and questions surrounding the safety of chronic vaping. 10 11 Controversy surrounding the NHS claim of vaping as 95% safer than cigarettes has emerged, 67 68 and multiple leading health organizations have concluded that vaping is harmful. 42 69 Studies have demonstrated airborne particulate matter in the proximity of active vapers, 70 and concern remains that secondhand exposure to vaped aerosols may cause adverse effects, complicating the notion of vaping as a net gain for public health. 71 72 Uncertainty about the potential chronic consequences of vaping combined with vaping uptake among never smokers has complicated attempts to generate clear policy guidance. 73 74 Further, many smokers may exhibit “dual use” of conventional cigarettes and vape pens simultaneously, further complicating efforts to understand the impact of vape exposure on respiratory health, and the role vape use may play in smoking cessation. 12 We are unable to know with certainty the extent of nicotine uptake among young people that would have been seen in the absence of vaping availability, and it remains possible that some young vape pen users may have started on conventional cigarettes regardless. That said, declining nicotine use over the past several decades would argue that many young vape pen users would have never had nicotine uptake had vape pens not been introduced. 1 2 It remains an open question whether public health measures encouraging vaping for nicotine cessation will benefit current smokers enough to offset the impact of vaping uptake among young, never smokers. 75

Vaping lung injury—clinical presentations

Vaping related lung injury: 2012-19.

The potential health effects of vape pen use are varied and centered on injury to the airways and lung parenchyma. Before the 2019 EVALI outbreak, the medical literature detailed case reports of sporadic vaping related acute lung injury. The first known case was reported in 2012, when a patient presented with cough, diffuse ground glass opacities, and lipid laden macrophages (LLM) on bronchoalveolar lavage (BAL) return in the context of vape pen use. 76 Over the following seven years, an additional 15 cases of vaping related acute lung injury were reported in the literature. These cases included a wide range of diffuse parenchymal lung disease without any clear unifying features, and included cases of eosinophilic pneumonia, 77 78 79 hypersensitivity pneumonitis, 80 organizing pneumonia, 81 82 diffuse alveolar hemorrhage, 83 84 and giant cell foreign body reaction. 85 Although parenchymal lung injury predominated the cases reported, additional cases detailed episodes of status asthmaticus 86 and pneumothoraces 87 attributed to vaping. Non-respiratory vape pen injury has also been described, including cases of nicotine toxicity from vape solution ingestion, 88 89 and injuries sustained owing to vape pen device explosions. 90

The 2019 EVALI outbreak

In the summer of 2019 the EVALI outbreak led to 2807 cases of idiopathic acute lung injury in predominantly young, healthy individuals, which resulted in 68 deaths. 19 91 Epidemiological work to uncover the cause of the outbreak identified an association with vaping, particularly the use of THC-containing products, among affected individuals. CDC criteria for EVALI ( box 1 ) included individuals presenting with respiratory symptoms who had pulmonary infiltrates on imaging in the context of having vaped or dabbed within 90 days of symptom onset, without an alternative identifiable cause. 92 93 After peaking in September 2019, EVALI case numbers steadily declined, 91 likely owing to identification of a link with vaping, and subsequent removal of offending agents from circulation. Regardless, sporadic cases continue to be reported, and a high index of suspicion is required to differentiate EVALI from covid-19 pneumonia. 94 95 A strong association emerged between EVALI cases and the presence of vitamin E acetate in the BAL return of affected individuals 96 ; however, no definitive causal link has been established. Interestingly, the EVALI outbreak was nearly entirely contained within the US with the exception of several dozen cases, at least one of which was caused by an imported US product. 97 98 99 The pattern of cases and lung injury is most suggestive of a vape solution contaminant that was introduced into the distribution pipeline in US markets, leading to a geographically contained pattern of lung injury among users. CDC case criteria for EVALI may have obscured a potential link between viral pneumonia and EVALI, and cases may have been under-recognized following the onset of the covid-19 pandemic.

CDC criteria for establishing EVALI diagnosis

Cdc lung injury surveillance, primary case definitions, confirmed case.

Vape use* in 90 days prior to symptom onset; and

Pulmonary infiltrate on chest radiograph or ground glass opacities on chest computed tomography (CT) scan; and

Absence of pulmonary infection on initial investigation†; and

Absence of alternative plausible diagnosis (eg, cardiac, rheumatological, or neoplastic process).

Probable case

Pulmonary infiltrate on chest radiograph or ground glass opacities on chest CT; and

Infection has been identified; however is not thought to represent the sole cause of lung injury OR minimum criteria** to exclude infection have not been performed but infection is not thought to be the sole cause of lung injury

*Use of e-cigarette, vape pen, or dabbing.

†Minimum criteria for absence of pulmonary infection: negative respiratory viral panel, negative influenza testing (if supported by local epidemiological data), and all other clinically indicated infectious respiratory disease testing is negative.

EVALI—clinical, radiographic, and pathologic features

In the right clinical context, diagnosis of EVALI includes identification of characteristic radiographic and pathologic features. EVALI patients largely fit a pattern of diffuse, acute lung injury in the context of vape pen exposure. A systematic review of 200 reported cases of EVALI showed that those affected were predominantly men in their teens to early 30s, and most (80%) had been using THC-containing products. 100 Presentations included predominantly respiratory (95%), constitutional (87%), and gastrointestinal symptoms (73%). Radiological studies mostly featured diffuse ground glass opacities bilaterally. Of 92 cases that underwent BAL, alveolar fluid samples were most commonly neutrophil predominant, and 81% were additionally positive for LLM on Oil Red O staining. Lung biopsy was not required to achieve the diagnosis; however, of 33 cases that underwent tissue biopsy, common features included organizing pneumonia, inflammation, foamy macrophages, and fibrinous exudates.

EVALI—outcomes

Most patients with EVALI recovered, and prognosis was generally favorable. A systematic review of identified cases found that most patients with confirmed disease required admission to hospital (94%), and a quarter were intubated. 100 Mortality among EVALI patients was low, with estimates around 2-3% across multiple studies. 101 102 103 Mortality was associated with age over 35 and underlying asthma, cardiac disease, or mental health conditions. 103 Notably, the cohorts studied only included patients who presented for medical care, and the samples are likely biased toward a more symptomatic population. It is likely that many individuals experiencing mild symptoms of EVALI did not present for medical care, and would have self-discontinued vaping following extensive media coverage of the outbreak at that time. Although most EVALI survivors recovered well, case series of some individuals show persistent radiographic abnormalities 101 and sustained reductions in DLCO. 104 105 Pulmonary function evaluation of EVALI survivors showed normalization in FEV 1 /FVC on spirometry in some, 106 while others had more variable outcomes. 105 107 108

Vaping induced lung injury—pathophysiology

The causes underlying vaping related acute lung injury remain interesting to clinicians, scientists, and public health officials; multiple mechanisms of injury have been proposed and are summarized in figure 2 . 31 109 110 Despite increased scientific interest in vaping related lung injury following the EVALI outbreak, the pool of data from which to draw meaningful conclusions is limited because of small scale human studies and ongoing conflicts due to tobacco industry funding. 111 Further, insufficient time has elapsed since widespread vaping uptake, and available studies reflect the effects of vaping on lung health over a maximum 10-15 year timespan. The longitudinal effects of vaping may take decades to fully manifest and ongoing prospective work is required to better understand the impacts of vaping on respiratory health.

Schematic illustrating pathophysiology of vaping lung injury

Pro-inflammatory vape aerosol effects

While multiple pathophysiological pathways have been proposed for vaping related lung injury, they all center on the vape aerosol itself as the conduit of lung inflammation. Vape aerosols have been found to harbor a number of toxic substances, including thermal degradation products of the various vape solution components. 112 Mass spectrometry analysis of vape aerosols has identified a variety of oxidative and pro-inflammatory substances including benzene, acrolein, volatile organic compounds, and propylene oxide. 16 17 Vaping additionally leads to airway deposition of ultrafine particles, 14 113 as well as the heavy metals manganese and zinc which are emitted from the vaping coils. 15 114 Fourth generation vape pens allow for high wattage aerosol generation, which can cause airway epithelial injury and tissue hypoxia, 115 116 as well as formaldehyde exposure similar to that of cigarette smoke. 117 Common carrier solutions such as propylene glycol have been associated with increased airway hyper-reactivity among vape pen users, 31 118 119 and have been associated with chronic respiratory conditions among theater workers exposed to aerosolized propylene glycol used in the generation of artificial fog. 120 Nicotine salts used in pod based vape pen solutions, including Juul, have been found to penetrate the cell membrane and have cytotoxic effects. 121

The myriad available vape pen flavors correlate with an expansive list of chemical compounds with potential adverse respiratory effects. Flavorants have come under increased scrutiny in recent years and have been found to contribute to the majority of aldehyde production during vape aerosol production. 122 Compounds such as cinnamaldehyde, 123 124 2,5-dimethylpyrazine (chocolate flavoring), 125 and 2,3-pentanedione 126 are common flavor additives and have been found to contribute to airway inflammation and altered immunological responses. The flavorant diacetyl garnered particular attention after it was identified on mass spectrometry in most vape solutions tested. 127 Diacetyl is most widely associated with an outbreak of diacetyl associated bronchiolitis obliterans (“popcorn lung”) among workers at a microwave popcorn plant in 2002. 128 Identification of diacetyl in vape solutions raises the possibility of development of a similar pattern of bronchiolitis obliterans among individuals who have chronic vape aerosol exposure to diacetyl-containing vape solutions. 129

Studies of vape aerosols have suggested multiple pro-inflammatory effects on the respiratory system. This includes increased airway resistance, 130 impaired response to infection, 131 and impaired mucociliary clearance. 132 Vape aerosols have further been found to induce oxidative stress in lung epithelial cells, 133 and to both induce DNA damage and impair DNA repair, consistent with a potential carcinogenic effect. 134 Mice chronically exposed to vape aerosols developed increased airway hyper-reactivity and parenchymal changes consistent with chronic obstructive pulmonary disease. 135 Human studies have been more limited, but reveal increased airway edema and friability among vape pen users, as well as altered gene transcription and decreased innate immunity. 136 137 138 Upregulation of neutrophil elastase and matrix metalloproteases among vape users suggests increased proteolysis, potentially putting those patients at risk of chronic respiratory conditions. 139

THC-containing products

Of particular interest during the 2019 EVALI outbreak was the high prevalence of THC use among EVALI cases, 19 raising questions about a novel mechanism of lung injury specific to THC-containing vape solutions. These solutions differ from conventional nicotine based products because of the need for a carrier capable of emulsifying the lipid based THC component. In this context, additional vape solution ingredients rose to attention as potential culprits—namely, THC itself, which has been found to degrade to methacrolein and benzene, 140 as well as vitamin E acetate which was found to be a common oil based diluent. 141

Vitamin E acetate has garnered increasing attention as a potential culprit in the pathophysiology of the EVALI outbreak. Vitamin E acetate was found in 94% of BAL samples collected from EVALI patients, compared with none identified in unaffected vape pen users. 96 Thermal degradation of vitamin E acetate under conditions similar to those in THC vape pens has shown production of ketene, alkene, and benzene, which may mediate epithelial lung injury when inhaled. 39 Previous work had found that vitamin E acetate impairs pulmonary surfactant function, 142 and subsequent studies have shown a dose dependent adverse effect on lung parenchyma by vitamin E acetate, including toxicity to type II pneumocytes, and increased inflammatory cytokines. 143 Mice exposed to aerosols containing vitamin E acetate developed LLM and increased alveolar protein content, suggesting epithelial injury. 140 143

The pathophysiological insult underlying vaping related lung injury may be multitudinous, including potentially compound effects from multiple ingredients comprising a vape aerosol. The heterogeneity of available vape solutions on the market further complicates efforts to pinpoint particular elements of the vape aerosol that may be pathogenic, as no two users are likely to be exposed to the same combination of vape solution products. Further, vape users may be exposed to vape solutions containing terpenes, medium chain triglycerides, or coconut oil, the effects of which on respiratory epithelium remain under investigation. 144

Lipid laden macrophages

Lipid laden alveolar macrophages have risen to prominence as potential markers of vaping related lung injury. Alveolar macrophages describe a scavenger white blood cell responsible for clearing alveolar spaces of particulate matter and modulating the inflammatory response in the lung parenchyma. 145 LLM describe alveolar macrophages that have phagocytosed fat containing deposits, as seen on Oil Red O staining, and have been described in a wide variety of pulmonary conditions, including aspiration, lipoid pneumonia, organizing pneumonia, and medication induced pneumonitis. 146 147 During the EVALI outbreak, LLM were identified in the alveolar spaces of affected patients, both in the BAL fluid and on both transbronchial and surgical lung biopsies. 148 149 Of 52 EVALI cases reported in the literature who underwent BAL, LLM were identified in over 80%. 19 100 101 148 149 150 151 152 153 Accordingly, attention turned to LLM as not only a potential marker of lung injury in EVALI, but as a possible contributor to lung inflammation itself. This concern was compounded by the frequent reported use of oil based THC vape products among EVALI patients, raising the possibility of lipid deposits in the alveolus resulting from inhalation of THC-containing vape aerosols. 154 The combination of LLM, acute lung injury, and inhalational exposure to an oil based substance raised the concern for exogenous lipoid pneumonia. 152 153 However, further evaluation of the radiographic and histopathologic findings failed to identify cardinal features that would support a diagnosis of exogenous lipoid pneumonia—namely, low attenuation areas on CT imaging and foreign body giant cells on histopathology. 155 156 However, differences in the particle size and distribution between vape aerosol exposure and traditional causes of lipoid pneumonia (ie, aspiration of a large volume of an oil-containing substance), could reasonably lead to differences in radiographic appearance, although this would not account for the lack of characteristic histopathologic features on biopsy that would support a diagnosis of lipoid pneumonia.

Recent work suggests that LLM reflect a non-specific marker of vaping, rather than a marker of lung injury. One study found that LLM were not unique to EVALI and could be identified in healthy vape pen users, as well as conventional cigarette smokers, but not in never smokers. 157 Interestingly, this work showed increased cytokines IL-4 and IL-10 among healthy vape users, suggesting that cigarette and vape pen use are associated with a pro-inflammatory state in the lung. 157 An alternative theory supports LLM presence reflecting macrophage clearance of intra-alveolar cell debris rather than exogenous lipid exposure. 149 150 Such a pattern would be in keeping with the role of alveolar macrophages as modulating the inflammatory response in the lung parenchyma. 158 Taken together, available data would support LLM serving as a non-specific marker of vape product use, rather than playing a direct role in vaping related lung injury pathogenesis. 102

Clinical aspects

A high index of suspicion is required in establishing a diagnosis of vaping related lung injury, and a general approach is summarized in figure 3 . Clinicians may consider the diagnosis when faced with a patient with new respiratory symptoms in the context of vape pen use, without an alternative cause to account for their symptoms. Suspicion should be especially high if respiratory complaints are coupled with constitutional and gastrointestinal symptoms. Patients may present with non-specific markers indicative of an ongoing inflammatory process: fevers, leukocytosis, elevated C reactive protein, or elevated erythrocyte sedimentation rate. 19

Flowchart outlining the procedure for diagnosing a vaping related lung injury

Vaping related lung injury is a diagnosis of exclusion. Chest imaging via radiograph or CT may identify a variety of patterns, although diffuse ground glass opacities remain the most common radiographic finding. Generally, patients with an abnormal chest radiograph should undergo a chest CT for further evaluation of possible vaping related lung injury.

Exclusion of infectious causes is recommended. Testing should include evaluation for bacterial and viral causes of pneumonia, as deemed appropriate by clinical judgment and epidemiological data. Exclusion of common viral causes of pneumonia is imperative, particularly influenza and SARS-CoV-2. Bronchoscopy with BAL should be considered on a case-by-case basis for those with more severe disease and may be helpful to identify patients with vaping mediated eosinophilic lung injury. Further, lung biopsy may be beneficial to exclude alternative causes of lung injury in severe cases. 92

No definitive therapy has been identified for the treatment of vaping related lung injury, and data are limited to case reports and public health guidance on the topic. Management includes supportive care and strong consideration for systemic corticosteroids for severe cases of vaping related lung injury. CDC guidance encourages consideration of systemic corticosteroids for patients requiring admission to hospital, or those with higher risk factors for adverse outcomes, including age over 50, immunosuppressed status, or underlying cardiopulmonary disease. 100 Further, given case reports of vaping mediated acute eosinophilic pneumonia, steroids should be implemented in those patients who have undergone a confirmatory BAL. 77 79

Additional therapeutic options include empiric antibiotics and/or antivirals, depending on the clinical scenario. For patients requiring admission to hospital, prompt subspecialty consultation with a pulmonologist can help guide management. Outpatient follow-up with chest imaging and spirometry is recommended, as well as referral to a pulmonologist. Counseling regarding vaping cessation is also a core component in the post-discharge care for this patient population. Interventions specific to vaping cessation remain under investigation; however, literature supports the use of behavioral counseling and/or pharmacotherapy to support nicotine cessation efforts. 66

Health outcomes among vape pen users

Health outcomes among chronic vape pen users remains an open question. To date, no large scale prospective cohort studies exist that can establish a causal link between vape use and adverse respiratory outcomes. One small scale prospective cohort study did not identify any spirometric or radiographic changes among vape pen users over a 3.5 year period. 159 Given that vaping remains a relatively novel phenomenon, many users will have a less than 10 “pack year” history of vape pen use, arguably too brief an exposure period to reflect the potential harmful nature of chronic vaping. Studies encompassing a longer period of observation of vape pen users have not yet taken place, although advances in electronic medical record (EMR) data collection on vaping habits make such work within reach.

Current understanding of the health effects of vaping is largely limited to case reports of acute lung injury, and health surveys drawing associations between vaping exposure and patient reported outcomes. Within these limitations, however, early work suggests a correlation between vape pen use and poorer cardiopulmonary outcomes. Survey studies of teens who regularly vape found increased frequencies of respiratory symptoms, including productive cough, that were independent of smoking status. 160 161 These findings were corroborated in a survey series identifying more severe asthma symptoms and more days of school missed owing to asthma among vape pen users, regardless of cigarette smoking status. 162 163 164 Studies among adults have shown a similar pattern, with increased prevalence of chronic respiratory conditions (ie, asthma or chronic obstructive pulmonary disease) among vape pen users, 165 166 and higher risk of myocardial infarction and stroke, but lower risk of diabetes. 167

The effects of vaping on lung function as determined by spirometric studies are more varied. Reported studies have assessed lung function after a brief exposure to vape aerosols, varying from 5-60 minutes in duration, and no longer term observational cohort studies exist. While some studies have shown increased airway resistance after vaping exposure, 130 168 169 others have shown no change in lung function. 137 170 171 The cumulative exposure of habitual vape pen users to vape aerosols is much longer than the period evaluated in these studies, and the impact of vaping on longer term respiratory heath remains to be seen. Recent work evaluating ventilation-perfusion matching among chronic vapers compared with healthy controls found increased ventilation-perfusion mismatch, despite normal spirometry in both groups. 172 Such work reinforces the notion that changes in spirometry are a feature of more advanced airways disease, and early studies, although inconsistent, may foreshadow future respiratory impairment in chronic vapers.

Covid-19 and vaping

The covid-19 pandemic brought renewed attention to the potential health impacts of vaping. Studies investigating the role of vaping in covid-19 prevalence and outcomes have been limited by the small size of the populations studied and results have been inconsistent. Early work noted a geographic association in the US between vaping prevalence and covid-19 cases, 173 and a subsequent survey study found that a covid-19 diagnosis was five times more likely among teens who had ever vaped. 174 In contrast, a UK survey study found no association between vaping status and covid-19 infection rates, although captured a much smaller population of vape pen users. 175 Reports of nicotine use upregulating the angiotensin converting enzyme 2 (ACE-2) receptor, 176 which serves as the binding site for SARS-CoV-2 entry, raised the possibility of increased susceptibility to covid-19 among chronic nicotine vape pen users. 177 178 Further, vape use associated with sharing devices and frequent touching of the mouth and face were posited as potential confounders contributing to increased prevalence of covid-19 in this population. 179

Covid-19 outcomes among chronic vape pen users remain an open question. While smoking has been associated with progression to more severe infections, 180 181 no investigation has been performed to date among vaping cohorts. The young average age of chronic vape pen users may prove a protective factor, as risk of severe covid-19 infection has been shown to increase with age. 182 Regardless, a prudent recommendation remains to abstain from vaping to mitigate risk of progression to severe covid-19 infection. 183

Increased awareness of respiratory health brought about by covid-19 and EVALI is galvanizing the changing patterns in vape pen use. 184 Survey studies have consistently shown trends toward decreasing use among adolescents and young adults. 174 185 186 In one study, up to two thirds of participants endorsed decreasing or quitting vaping owing to a combination of factors including difficulty purchasing vape products during the pandemic, concerns about vaping effects on lung health, and difficulty concealing vape use while living with family. 174 Such results are reflected in nationwide trends that show halting growth in vaping use among high school students. 8 These trends are encouraging in that public health interventions countering nicotine use among teens may be meeting some measure of success.

Clinical impact—collecting and recording a vaping history

Vaping history in electronic medical records.

Efforts to prevent, diagnose, and treat vaping related lung injury begin with the ability of our healthcare system to identify vape users. Since vaping related lung injury remains a diagnosis of exclusion, clinicians must have a high index of suspicion when confronted with idiopathic lung injury in a patient with vaping exposure. Unlike cigarette use, vape pen use is not built into most EMR systems, and is not included in meaningful use criteria for EMRs. 187 Retrospective analysis of outpatient visits showed that a vaping history was collected in less than 0.1% of patients in 2015, 188 although this number has been increasing. 189 190 In part augmented by EMR frameworks that prompt collection of data on vaping history, more recent estimates indicate that a vaping history is being collected in up to 6% of patients. 191 Compared with the widespread use of vaping, particularly among adolescent and young adult populations, this number remains low. Considering generational trends in nicotine use, vaping will likely eventually overcome cigarettes as the most common mode of nicotine use, raising the importance of collecting a vaping related history. Further, EMR integration of vaping history is imperative to allow for retrospective, large scale analyses of vape exposure on longitudinal health outcomes at a population level.

Practical considerations—gathering a vaping history

As vaping becomes more common, the clinician’s ability to accurately collect a vaping history and identify patients who may benefit from nicotine cessation programs becomes more important. Reassuringly, gathering a vaping history is not dissimilar to asking about smoking and use of other tobacco products, and is summarized in box 2 . Collecting a vaping history is of particular importance for providers caring for adolescents and young adults who are among the highest risk demographics for vape pen use. Adolescents and young adults may be reluctant to share their vaping history, particularly if they are using THC-containing or CBD-containing vape solutions. Familiarity with vernacular terms to describe vaping, assuming a non-judgmental approach, and asking parents or guardians to step away during history taking will help to break down these barriers. 192

Practical guide to collecting a vaping history

Ask with empathy.

Young adults may be reluctant to share history of vaping use. Familiarity with vaping terminology, asking in a non-judgmental manner, and asking in a confidential space may help.

Ask what they are vaping

Vape products— vape pens commonly contain nicotine or an alternative active ingredient, such as THC or CBD. Providers may also inquire about flavorants, or other vape solution additives, that their patient is consuming, particularly if vaping related lung injury is suspected.

Source— ask where they source their product from. Sources may include commercially available products, third party distributors, or friends or local contacts.

Ask how they are vaping

Device— What style of device are they using?

Frequency— How many times a day do they use their vape pen (with frequent use considered >5 times a day)? Alternatively, providers may inquire how long it takes to deplete a vape solution cartridge (with use of one or more pods a day considered heavy use).

Nicotine concentration— For individuals consuming nicotine-containing products, clinicians may inquire about concentration and frequency of use, as this may allow for development of a nicotine replacement therapy plan.

Ask about other inhaled products

Clinicians should ask patients who vape about use of other inhaled products, particularly cigarettes. Further, clinicians may ask about use of water pipes, heat-not-burn devices, THC-containing products, or dabbing.

The following provides a practical guide on considerations when collecting a vaping history. Of note, collecting a partial history is preferable to no history at all, and simply recording whether a patient is vaping or not adds valuable information to the medical record.

Vape use— age at time of vaping onset and frequency of vape pen use. Vape pen use >5 times a day would be considered frequent. Alternatively, clinicians may inquire how long it takes to deplete a vape solution pod (use of one or more pods a day would be considered heavy use), or how frequently users are refilling their vape pens for refillable models.

Vape products— given significant variation in vape solutions available on the market, and variable risk profiles of the multitude of additives, inquiring as to which products a patient is using may add useful information. Further, clinicians may inquire about use of nicotine versus THC-containing vape solutions, and whether said products are commercially available or are customized by third party sellers.

Concurrent smoking— simultaneous use of multiple inhaled products is common among vape users, including concurrent use of conventional cigarettes, water pipes, heat-not-burn devices, and THC-containing or CBD-containing products. Among those using marijuana products, gathering a history regarding the type of product use, the device, and the modality of aerosol generation may be warranted. Gathering such detailed information may be challenging in the face of rapidly evolving product availability and changing popular terminology. Lastly, clinicians may wish to inquire about “dabbing”—the practice of inhaling heated butane hash oil, a concentrated THC wax—which may also be associated with lung injury. 193

Future directions

Our understanding of the effects of vaping on respiratory health is in its early stages and multiple trials are under way. Future work requires enhanced understanding of the effects of vape aerosols on lung biology, such as ongoing investigations into biomarkers of oxidative stress and inflammation among vape users (clinicaltrials.gov NCT03823885 ). Additional studies seek to elucidate the relation between vape aerosol exposure and cardiopulmonary outcomes among vape pen users ( NCT03863509 , NCT05199480 ), while an ongoing prospective cohort study will allow for longitudinal assessment of airway reactivity and spirometric changes among chronic vape pen users ( NCT04395274 ).

Public health and policy interventions are vital in supporting both our understanding of vaping on respiratory health and curbing the vaping epidemic among teens. Ongoing, large scale randomized controlled studies seek to assess the impact of the FDA’s “The Real Cost” advertisement campaign for vaping prevention ( NCT04836455 ) and another trial is assessing the impact of a vaping prevention curriculum among adolescents ( NCT04843501 ). Current trials are seeking to understand the potential for various therapies as tools for vaping cessation, including nicotine patches ( NCT04974580 ), varenicline ( NCT04602494 ), and text message intervention ( NCT04919590 ).

Finally, evaluation of vaping as a potential tool for harm reduction among current cigarette smokers is undergoing further evaluation ( NCT03235505 ), which will add to the body of work and eventually lead to clear policy guidance.

Several guidelines on the management of vaping related lung injury have been published and are summarized in table 1 . 194 195 196 Given the relatively small number of cases, the fact that vaping related lung injury remains a newer clinical entity, and the lack of clinical trials on the topic, guideline recommendations reflect best practices and expert opinion. Further, published guidelines focus on the diagnosis and management of EVALI, and no guidelines exist to date for the management of vaping related lung injury more generally.

Summary of clinical guidelines

• View inline

Conclusions

Vaping has grown in popularity internationally over the past decade, in part propelled by innovations in vape pen design and nicotine flavoring. Teens and young adults have seen the biggest uptake in use of vape pens, which have superseded conventional cigarettes as the preferred modality of nicotine consumption. Despite their widespread popularity, relatively little is known about the potential effects of chronic vaping on the respiratory system, and a growing body of literature supports the notion that vaping is not without risk. The 2019 EVALI outbreak highlighted the potential harms of vaping, and the consequences of long term use remain unknown.

Discussions regarding the potential harms of vaping are reminiscent of scientific debates about the health effects of cigarette use in the 1940s. Interesting parallels persist, including the fact that only a minority of conventional cigarette users develop acute lung injury, yet the health impact of sustained, longitudinal cigarette use is unquestioned. The true impact of vaping on respiratory health will manifest over the coming decades, but in the interval a prudent and time tested recommendation remains to abstain from consumption of inhaled nicotine and other products.

Questions for future research

How does chronic vape aerosol exposure affect respiratory health?

Does use of vape pens affect respiratory physiology (airway resistance, V/Q matching, etc) in those with underlying lung disease?

What is the role for vape pen use in promoting smoking cessation?

What is the significance of pulmonary alveolar macrophages in the pathophysiology of vaping related lung injury?

Are particular populations more susceptible to vaping related lung injury (ie, by sex, demographic, underlying comorbidity, or age)?

Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

Contributors: AJ conceived of, researched, and wrote the piece. She is the guarantor.

Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: AJ receives consulting fees from DawnLight, Inc for work unrelated to this piece.

Patient involvement: No patients were directly involved in the creation of this article.

Provenance and peer review: Commissioned; externally peer reviewed.

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How colleges can help their students quit vaping

QUITTING RESOURCES 

The EX Program

This is Quitting

As e-cigarette use among young people continues to escalate, colleges are grappling with how to address vaping on campus.

Recent data show that more than a quarter — 25.4% — of high school seniors have used e-cigarettes in the past 30 days, with 40.5% reporting that they have ever used e-cigarettes. Many of these young people are continuing, or starting, regular e-cigarette use in college, putting them at increased risk for long-term, long-lasting effects of exposing their developing brains to nicotine.

Some schools are implementing programs to help e-cigarette users quit. Here are three ways that colleges and universities across the United States, including institutions that Truth Initiative ® works with through its Tobacco-Free College Program, are addressing e-cigarette use and quitting on their campuses.

Survey students

Is there a difference between saying e-cigarette and vape.

Many schools began to see an increase in vaping a few years ago, but many did not have accurate information about use on campus.

At the University of Arizona, for example, Campus Health first asked about e-cigarette use in a 2016 health and wellness survey and saw rates of about 6.3% . The following year, staff updated the question to include other names for devices, such as JUUL, and verbs such as “vape,” and saw that about 24% of students were using e-cigarette devices within the last 30 days. The takeaway: there are a variety of terms that young people use to refer to vaping and using e-cigarettes. Schools should make sure survey efforts are capturing the right data by using a variety of terms.

Another approach is to survey at a campus health or wellness center. At SUNY Sullivan, a Truth Initiative Tobacco-Free College Program grantee , the school nurse is now implementing a questionnaire to ask about e-cigarette use so that counseling can be provided during regular wellness visits.

Use peer-to-peer approaches

Best way to get teens to stop vaping.

Getting students to come to the table to talk about e-cigarette use and quitting can be difficult, both literally and figuratively. Research has shown that young people are more receptive to information when it comes from peers.

At Chaminade University of Honolulu, another school in the Tobacco-Free College Program, masters students in counseling have been trained to provide quitting counseling to their peers. During these counseling sessions, they teach students about the quitting process, help them establish a quit plan and then follow up with them throughout their quit process to assist with any difficulties. They have also created a program where they train two undergraduate students  to talk about quitting. These students then go into dorms and talk with their peers about tobacco, its health risks and how to quit if they are addicted to nicotine.

Include e-cigarette use in campus policies

Do smoke-free policies work for vaping.

A growing number of U.S. colleges and universities are adopting  smoke-free policies   — the number of schools with such policies more than doubled between 2012 and 2017 .

Many of these tobacco- and smoke-free policies include e-cigarettes and similar devices and go on to help create a culture of rejecting tobacco, protect community members from secondhand smoke and vape exposure, and create opportunities to engage students about quitting. For example, the Truth Initiative Tobacco-Free College Program uses community organizing and direct action to work with  truth ®  college leaders at participating schools to engage peers and build momentum for change on their campuses. 

Truth Initiative also launched a first-of-its kind e-cigarette quit program called This is Quitting that colleges and universities can provide as a resource. The free text message program was created with input from teens, college students and young adults who have attempted to, or successfully, quit e-cigarettes.

Youth and young adults can access the e-cigarette quit program by texting DITCHJUUL to 88709. Parents and other adults looking to help young people quit should text QUIT to (202) 899-7550.

More than 70,000 young people enrolled in the program in 2019, and, according to preliminary data published in Nicotine & Tobacco Research, after just two weeks of using the program, more than half — 60.8% — reported that they had reduced or stopped using e-cigarettes. Schools, as well as youth-serving organizations and state and local governments, can also partner with This is Quitting to customize it for their unique populations.

Learn more about This is Quitting and the Tobacco-Free College Program .

More in quitting smoking / vaping

Quitting Tobacco: Facts and Stats

4 tips for quitting tobacco from Millie Martinez, a former menthol smoker

How to support someone who wants to break up with their vape

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Explainer: More teens are vaping. This is why that’s a concern.

E-cigarette use, or vaping, among adolescents has skyrocketed in the last decade, prompting calls to action from the nation’s top health leaders. However, the harms of vaping don’t seem to be sinking in with Georgia youth. A 2019 survey of Georgia teens revealed that nearly 1 in 5 high school students have vaped and 11% of students reported vaping in the past 30 days.

Christina Proctor is a clinical assistant professor in the department of health promotion and behavior at UGA’s College of Public Health. She studies teen substance use, and below, Dr. Proctor provides more details on the harms of vaping and the strategies we can use to reduce teen vaping.

What is vaping, and how does it differ from using cigarettes?

Smoking delivers nicotine by burning tobacco, which we know is associated with many chronic conditions and diseases. Vaping delivers nicotine by heating a liquid that contains nicotine extracted from tobacco, flavors, and other chemicals. Research shows that vaping exposes you to less toxins than smoking cigarettes, but there’s still risk. There’s a lot we don’t know about the chemicals that are contained in vaping products, and we still don’t have enough research about product safety.

Why is there a lot of concern around teens and vaping right now?

E-cigarettes were initially developed to help people quit smoking and were used as a harm reduction strategy for individuals who had a hard time quitting tobacco use. Since then, there have been many different types of electronic cigarettes and vaping devices created to deliver nicotine. Many of these products are developed by the tobacco industry, and the same marketing strategies used to push tobacco on to people have been used to try to get individuals to start using vaping products. More than 2 million U.S. middle and high school students reported using e-cigarettes in 2021, with more than 80% of those youth using flavored e-cigarettes. There are a lot of teens who vape that never had any intention of using tobacco products. Essentially the tobacco companies have found a way to get a new group of people addicted to nicotine just as we were closing in on goals to decrease tobacco product use in this country.

What are some misconceptions about vaping that people need to be aware of?

I think the biggest misconception is that vaping isn’t as harmful as tobacco use. There’s harm in vaping, too. Nicotine is a powerful psychoactive substance, toxic, and is highly addictive. It raises your blood pressure and spikes your adrenaline, which increases your heart rate and the likelihood of having heart issues and heart attacks. A lot of the new vaping devices allow modification of nicotine delivery and often are delivering way more nicotine to the body than a normal cigarette would. You can buy extra strength cartridges or increase the voltage on the devices to get a higher hit of the substance. The high intake of nicotine is concerning, and many people will have a hard time quitting vaping once they start.

What are some of the current public health interventions for vaping?

They are very similar to our public health interventions to decrease tobacco use. Policies restricting access are key to decreasing e-cigarette use in young populations. The federal minimum age to buy e-cigarettes and electronic nicotine delivery systems was raised from 18 to 21 years of age. Advertisements must include a warning about the dangers of nicotine. Increasing prices by adding taxes and restricting e-cigarette or electronic nicotine delivery systems in public spaces or at workplaces are good strategies to decrease use. In addition, there are now mass media campaigns that discourage use. Current use of vaping products has decreased in the past two years, so public health efforts and policies could be contributing to those declines.

– Chancey Phillips

Posted April 12, 2023.

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• v.117(1); Jan-Feb 2020

The Vaping Epidemic in Adolescents

Electronic cigarette (e-cigarette) use has recently risen to the forefront of medical discussions across the country. A significant increase in e-cigarette use by adolescents has been observed over the last decade. This article discusses the targeting of adolescents by e-cigarette companies. It looks at how teenagers are uniquely affected by nicotine and at risk for progressing to using combustible cigarettes and marijuana. Lastly, it discusses the role of physicians in combating the spread of e-cigarettes.

Introduction

Every medical student is taught the three basic questions to ask for social history. “Do you drink any alcohol? Do you do any drugs? Do you smoke cigarettes?” While these are three very important questions to help us address potential health hazards with patients, they fail to identify some of the most significant factors in the lives of adolescent patients. Specifically, vaping in adolescents poses a grave risk to patients’ health and is a topic that physicians have to confront.

Over the last 20 years, there has been a decrease in the number of teenagers smoking combustible cigarettes. The Youth Risk Behavior Survey demonstrated a decrease in the number of teens trying combustible cigarettes from 70% in 1991 down to 58.4% in 2003 and even further down to 28.9% in 2017. 1 The decrease is largely a response to exhaustive work done by physicians, advocacy groups and lawmakers. Physicians have worked diligently to improve education on the dangers of smoking and fought to pass new regulations to protect patients. The United States is seeing an explosive rise of adolescents’ vaping and the renormalization of smoking ( Table 1 ). Recent national surveys demonstrate a drastic increase in e-cigarette use among high schoolers. An article from the New England Journal of Medicine reported a 10% increase in adolescents using e-cigarettes between 2017 and 2018 alone, which is approximately 1.3 million teenagers. 2

The rise of adolescents’ vaping and the renormalization of smoking.

Source: Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Products Among Middle and High School Students – United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2018;67:1276–1277

Electronic cigarettes are battery-operated devices that use an electric pulse to heat and aerosolize a flavored liquid that typically contains nicotine. They were first introduced to the U.S. in 2007, and they were advertised by the tobacco companies as an adjunct method to help patients quit smoking. This claim never had evidence to support it, as studies comparing the use of electronic cigarettes, placebos, and nicotine patches demonstrated no significant differences in abstinence rates. 3 But because e-cigarettes were seen as a treatment option, they were not subjected to the same regulations as combustible cigarettes. It wasn’t until 2016 that the Congress passed the Child Nicotine Poisoning Prevention Act, giving the FDA the authority to regulate e-cigarette packaging. 1

Advertising Directed to Teens

Advertising for e-cigarettes has been heavily aimed at adolescents. Everything from the billboards to the packaging to the product itself has been aimed at teens. Ads on social media were widely distributed. From 2014 to 2016, advertising for vaping exploded and one study found that 78% of middle and high school students had been exposed to at least one advertisement. 1 Pods come in fun packaging and the different pods are flavored to be attractive to adolescents, with everything from mint to gummi bear to frosted sugar cookie. This is especially concerning because studies have shown that flavor is one of the most important factors adolescents consider in trying e-cigarettes. 4 The devices to aerosolize the pods are designed to look like anything from USBs to pens to inhalers. They can be personalized much like a cell phone case and backpacks have special pockets for the mod devices.

Health Risks for Adolescents

This targeted marketing of e-cigarettes is particularly harmful given the significant health risks these products pose to teens. Many people know that nicotine causes lots of problems for the developing brain. However, it is not widely recognized that many e-cigarettes contain higher concentrations of nicotine than combustible cigarettes. JUUL is the most common e-cigarette brand used in the U.S.; it is so popular that teens use JUULing as a verb. 1 JUUL pods contain 5%, or 59mg/ml, of nicotine. 5 This is approximately equal to the nicotine contained in 20 combustible cigarettes. 6 To make this more concerning, one study demonstrated that 39% of adolescents did not consider JUULs to be e-cigarettes at all. 6 Another survey suggested that 63% of adolescents did not know that JUUL pods contained nicotine at all. 7

Many studies, primarily based on the use of combustible cigarettes, have demonstrated the adverse health effects of nicotine. Adolescent brains are still developing, and nicotine exposure has been linked with cognitive deficits and impairment in memory and executive function. Electronic cigarettes have been connected with increased impulsivity, with one animal study demonstrating that exposure to e-cigarette vapor during times of rapid brain growth (like during adolescence) can cause hyperactivity and impulsive behavior changes. 4 Another study looking specifically at the teen population found increased risks of physical fighting, attempted suicide, and alcohol/marijuana use when comparing non-users to teens who smoked or vaped. 8

Nicotine Addiction in Teens

There has also been evidence that suggests e-cigarette use increases an individual’s chance of using combustible cigarettes. Adolescents who use e-cigarettes are 3.6 times more likely to report using combustible cigarettes later in life. 9 Teens have also been shown to be more susceptible to addiction. We know that nicotine addiction often originates in adolescence with studies showing that close to 90% of adult daily smokers started before the age of 18. 10 Thus, e-cigarettes are effectively helping to create a new generation addicted to nicotine.

Gateway to Marijuana Use

Many vaping devices can also be used to inhale cannabinoids. One study demonstrated that teens who use nicotine liquid in e-cigarettes were 3.6 to 4 times more likely to use marijuana in the next two years. 1 Another study demonstrated that 1 in 10 seniors in high school vape cannabis. 6 This should be extremely distressing to physicians and medical providers because it is known that marijuana is extremely harmful to the development of the adolescent brain and studies have actually shown changes in brain structure. As a result, deficits in attention, learning, and memory associated with cannabis use in adolescents has been reported. 11 One study demonstrated that high schoolers who use marijuana were four times more likely to have multiple sexual partners when compared to students who only use tobacco or alcohol. 12 A sizable portion of adolescents who use marijuana report symptoms of paranoia, anxiety and hallucinations. 13 . Adverse effects from marijuana use, including cannabis hyperemesis syndrome have become common among pediatric patients. 14

Flavors and Additives

Beyond the nicotine, the flavoring chemicals and additives present their own danger. Currently there are no federal laws to ensure that the labels on e-cigarettes are accurate. Until August 2018 they did not even have to include the nicotine concentration on labels. Testing has demonstrated different carcinogens in e-cigarettes including aldehydes, metals, and polycyclic aromatic hydrocarbons. 6 One recent study looking at the different additives found that that vapes containing cinnamaldehyde for cinnamon flavor were associated with impaired mucociliary function in bronchial epithelial cells. Biopsies from chronic vapers demonstrate structural changes in lung tissue. 1

Physicians caring for adolescent patients are quickly realizing the health hazards associated with vaping and are looking for ways to combat the epidemic. First and foremost is education for both the teen and their parents. Teens obtain most of their knowledge on e-cigarettes from social media and their peers. One in three adolescents in the U.S. still consider electronic cigarettes to be less harmful than traditional combustible cigarettes. 4 It is imperative that teens are given accurate information on e-cigarettes.

Unfortunately, parents often face the same challenges in finding resources for vaping education as their children. They rely on schools to educate both the parent and their child on e-cigarettes, yet studies have shown that most parents receive little communication from their school on the topic. 15 This is an area where physicians can help fill the knowledge gap. One study found that while parents understood that nicotine exposure is detrimental for teens, most did not know that JUUL pods contain nicotine. Less than half of the middle school and high school parents could identify a JUUL mod in a picture. 15 Most parents were concerned about the use of e-cigarettes in teens but only two in five were concerned about use in their own child. 15 Parents who do not feel that their children are at risk are less likely to talk to their children about the risks associated with vaping. It is imperative that physicians encourage parents to discuss vaping with their teens and provide tools to facilitate that discussion.

The other way physicians can help address vaping in adolescents is by participating in advocacy at a local, state or national level. Currently in the state of Missouri, e-cigarettes are not included in the definition of “Tobacco Products” and thus are not subject to the same restrictions as combustible cigarettes. The sale of e-cigarettes to those under 18 years of age is prohibited, just as with tobacco. But the only regulation in place for e-cigarette packaging is that the liquid must be in child-resistant containers. The American Academy of Pediatrics is currently advocating for Missouri to include e-cigarettes in smoke-free laws and to increase the minimum age to purchase electronic cigarettes to 21 years. 16 Organizations like the American Academy of Pediatrics and the American College of Physicians have both released position papers on vaping and offer further ways to join the fight. It is time for physicians to ask their adolescent patients about vaping and to provide education to the child and parents on the dangers of vaping. Physicians have the responsibility to be advocates for their patients working with medical organizations, state and local governments to address the adolescent vaping epidemic.

Kristen Jones, DO, (left ), is a Pediatrics Resident in Internal Medicine; Gary A. Salzman, MD, (right), MSMA member since 2007, is Professor of Medicine; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.

Contact: ude.ckmu@gnamzlas

None reported.

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Before recent outbreak, vaping was on the rise in U.S., especially among young people

An outbreak of lung injuries among e-cigarette users across much of the United States has focused national attention on the potential dangers of vaping, prompting the federal government and some states to take policy steps in response.

The exact cause of the respiratory illness has not yet been determined, and there is  still uncertainty  surrounding the specific health risks associated with vaping.  E-cigarettes  create a water vapor that users inhale, using cartridges that typically contain nicotine, flavorings or cannabis products along with chemicals.

As medical professionals and policymakers grapple with questions over e-cigarettes and public health, here’s a look at what survey data – gathered before the recent outbreak – shows about e-cigarette use in the United States.

The shares of secondary students who have vaped nicotine in the past month have roughly doubled since 2017. From 2017 to 2019, the shares who had done so increased among 12th graders (11% to 25%), 10th graders (8% to 20%) and 8th graders (4% to 9%), according to preliminary data from the University of Michigan’s Monitoring the Future (MTF) survey .

In addition, vaping increased among college students from 2017 to 2018, the most recent year for which MTF has released data for this group. In fact, the uptick in vaping among college students for nicotine (from 6% in 2017 to 16% in 2018) and marijuana (from 5% to 11%) were among the greatest one-year increases for any substance asked about since the survey was first administered in 1975. (The long-running annual survey is first distributed to a nationally representative sample of students in eighth, 10th and 12th grades, and a randomly selected sample from each senior class continues to receive surveys biannually after finishing high school.)

Nicotine was the most commonly cited substance being used in e-cigarettes for most groups of students in 2018. Vaping just flavoring, by comparison, was more common for 12th graders (14%), 10th graders (13%) and eighth graders (8%) than for college students (5%) in the previous month.

Across all four student levels, the overall shares who report vaping any substance during the last 30 days have increased since 2015.

Young adults are more likely than older people to vape, but less likely to smoke cigarettes. In a July 2018 Gallup poll , 9% of U.S. adults said they “regularly or occasionally” vape – still below the 20% who said they “regularly or occasionally” smoke cigarettes . Two-in-ten Americans ages 18 to 29 said they vape, compared with 8% of those ages 30 to 64 and fewer than 0.5% among those 65 and older.

Although adults are more likely to smoke than to vape, the share of 18- to 29-year-olds who smoke traditional cigarettes has fallen over time. In the early 2000s, about a third of young adults (34%) reported smoking cigarettes in the past week – the largest percentage of any age group, according to Gallup. In July, just 14% of young adults said they smoked in the previous week, compared with 19% of those ages 30 to 49 and 18% of those 50 to 64.

As of summer 2018, those under 30 were less likely than older Americans to believe vaping is harmful to one’s health. Roughly one-fifth of U.S. adults (22%) under age 30 said vaping is “very harmful” to one’s health, compared with 40% of adults ages 30 to 64 and 48% of those 65 and older, according to the same July 2018 Gallup survey . Comparatively, large majorities of Americans say smoking conventional cigarettes is very harmful to one’s health, but there were no significant differences by age: Eight-in-ten or more in each age group said that smoking cigarettes is “very harmful” to one’s health.

As of this past summer, roughly two-thirds of Americans said they would like to see tighter e-cigarette regulations. In a July 2019 Gallup survey , 64% of U.S. adults said laws and regulations covering e-cigarettes should be made more strict, while around a quarter (26%) said regulations should stay as they are now. Just 5% said these laws and regulations should be less strict.

Younger Americans – those ages 18 to 29 – were split on laws surrounding e-cigarettes: While roughly half (49%) said laws should be made more strict, 42% said laws should be kept as they are. By comparison, roughly two-thirds or more of older adult groups said regulations covering e-cigarettes should be made more strict.

Women were also more likely than men to favor stricter laws and regulations (71% vs. 57%).

Vaping by friends or family is a common reason why some students choose to do it. Among students in grades six through 12 who said they had ever used an e-cigarette, the most common reason given was use by a friend or family member (39%), according to the 2016 National Youth Tobacco Survey .

Roughly one-third of these students (31%) said they used an e-cigarette because of availability of “flavors such as mint, candy, fruit, or chocolate,” while 17% said they used it because they perceived them to be “less harmful than other forms of tobacco such as cigarettes.”

Less common reasons cited by middle and high schoolers for using e-cigarettes were because “they are easier to get than other tobacco products, such as cigarettes” (5%), “they cost less than other tobacco products such as cigarettes” (3%) and “famous people on TV or in movies use them” (2%).

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Katherine Schaeffer is a research analyst at Pew Research Center

9 facts about Americans and marijuana

Most americans favor legalizing marijuana for medical, recreational use, most americans now live in a legal marijuana state – and most have at least one dispensary in their county, americans overwhelmingly say marijuana should be legal for medical or recreational use, clear majorities of black americans favor marijuana legalization, easing of criminal penalties, most popular.

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Argumentative Essay on Vaping

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Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults

• The use of e-cigarettes is unsafe for kids, teens, and young adults.
• Most e-cigarettes contain nicotine. Nicotine is highly addictive and can harm adolescent brain development, which continues into the early to mid-20s. 1
• E-cigarettes can contain other harmful substances besides nicotine.
• Young people who use e-cigarettes may be more likely to smoke cigarettes in the future.

• E-cigarettes are electronic devices that heat a liquid and produce an aerosol, or mix of small particles in the air.
• E-cigarettes come in many shapes and sizes. Most have a battery, a heating element, and a place to hold a liquid.
• Some e-cigarettes look like regular cigarettes, cigars, or pipes. Some look like USB flash drives, pens, and other everyday items. Larger devices such as tank systems, or “mods,” do not look like other tobacco products.
• E-cigarettes are known by many different names. They are sometimes called “e-cigs,” “e-hookahs,” “mods,” “vape pens,” “vapes,” “tank systems,” and “electronic nicotine delivery systems (ENDS).”
• Using an e-cigarette is sometimes called “vaping.”

Some e-cigarettes look like regular cigarettes, cigars, or pipes. Some look like USB flash drives, pens, and other everyday items.

• E-cigarettes produce an aerosol by heating a liquid that usually contains nicotine, flavorings, and other chemicals that help to make the aerosol.
• The liquid used in e-cigarettes often contains nicotine and flavorings. This liquid is sometimes called “e-juice,” “e-liquid,” “vape juice,” or “vape liquid.”
• Users inhale e-cigarette aerosol into their lungs. Bystanders can also breathe in this aerosol when the user exhales it into the air.
• E-cigarette devices can be used to deliver marijuana and other drugs.
• What Are E-cigarettes?
• How Do E-cigarettes Work?
• What Is JUUL?
• Why Is Nicotine Unsafe for Kids, Teens, and Young Adults?
• How Does Nicotine Addiction Affect Youth Mental Health?
• Do symptoms of nicotine withdrawal improve after quitting?
• Does quitting vaping improve mental health?
• What Are the Other Risks of E-cigarettes for Kids, Teens, and Young Adults?
• What Is in E-cigarette Aerosol?
• Flavors and Marketing Make E-cigarettes Appealing to Youth
• Can Using E-cigarettes Lead to Future Cigarette Smoking Among Kids, Teens, and Young Adults?
• Aren’t E-cigarettes Safer Than Cigarettes?
• Are E-cigarettes Regulated at the Federal Level?
• Are There Any National Public Education Prevention Campaigns Focused on Youth and E-cigarettes?
• What Do We Know About Heated Tobacco Products?
• What Can I Do to Prevent My Child from Using E-cigarettes or to Help Them Stop?
• Where Can I Learn More?

• News outlets and social media sites report widespread use of JUUL by students in schools, including classrooms and bathrooms.
• JUUL is a brand of e-cigarette that is shaped like a USB flash drive. Like other e-cigarettes, JUUL is a battery-powered device that heats a nicotine-containing liquid to produce an aerosol that is inhaled.
• All JUUL e-cigarettes have a high level of nicotine. According to the manufacturer, a single JUUL pod contains as much nicotine as a pack of 20 regular cigarettes. 2
• JUUL is one of a few e-cigarettes that use nicotine salts, which allow particularly high levels of nicotine to be inhaled more easily and with less irritation than the free-base nicotine that has traditionally been used in tobacco products, including e-cigarettes.
• Approximately two-thirds of JUUL users aged 15 – 24 do not know that JUUL always contains nicotine.
• Although JUUL is currently the top-selling e-cigarette brand in the United States, other companies sell e-cigarettes that look like USB flash drives. Examples include the MarkTen Elite, a nicotine delivery device, and the PAX Era, a marijuana delivery device that looks like JUUL.
• Additional information about USB-shaped e-cigarettes and actions that parents, educators, and health care providers can take to protect kids is available at CDC’s Infographic [PDF – 1.2MB]

• Most e-cigarettes (vapes) contain nicotine—the addictive drug in regular cigarettes, cigars, and other tobacco products.
• A CDC study found that 99% of the e-cigarettes sold in assessed venues in the United States contained nicotine. 1
• Some vape product labels do not disclose that they contain nicotine, and some vape liquids marketed as containing 0% nicotine have been found to contain nicotine.
• Nicotine can harm the developing adolescent brain. 2 The brain keeps developing until about age 25.
• Using nicotine in adolescence can harm the parts of the brain that control attention, learning, mood, and impulse control. 2
• Each time a new memory is created or a new skill is learned, stronger connections – or synapses – are built between brain cells. Young people’s brains build synapses faster than adult brains. Nicotine changes the way these synapses are formed.
• Using nicotine in adolescence may also increase risk for future addiction to other drugs. 2

• When a person is dependent on (or addicted to) nicotine and stops using it, their body and brain have to get used to not having nicotine. This can result in temporary symptoms of nicotine withdrawal.
• Nicotine withdrawal symptoms include irritability, restlessness, feeling anxious or depressed, trouble sleeping, problems concentrating, and craving nicotine. 3 People may keep using tobacco products to help relieve these symptoms. 4
• Youth may turn to vaping to try to deal with stress or anxiety, creating a cycle of nicotine dependence. But nicotine addiction can be a source of stress.
• The most common reason U.S. middle and high school students give for trying an e-cigarette is “a friend used them.” 5
• The most common reason youth give for continuing to use e-cigarettes is “I am feeling anxious, stressed, or depressed.” 5
• Youth e-cigarette and cigarette use have been associated with mental health symptoms such as depression. 9, 10
• Yes. As long as a person stays quit, withdrawal symptoms will fade over time as the brain gets used to not having nicotine.
• Scientists are still learning about the effects of quitting vaping on mental health. Quitting smoking cigarettes is associated with lower levels of anxiety, depression, and stress, as well as improved positive mood and quality of life. 9
• Scientists are still learning about the long-term health effects of e-cigarettes.
• Some of the ingredients in e-cigarette aerosol could also be harmful to the lungs in the long-term. For example, some e-cigarette flavorings may be safe to eat but not to inhale because the gut can process more substances than the lungs. 1
• Defective e-cigarette batteries have caused some fires and explosions, a few of which have resulted in serious injuries.
• Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes. Nationally, approximately 50% of calls to poison control centers for e-cigarettes are for kids 5 years of age or younger.
• E-cigarette aerosol is NOT harmless “water vapor.”
• Ultrafine particles that can be inhaled deep into the lungs
• Flavorings such as diacetyl, a chemical linked to a serious lung disease
• Volatile organic compounds
• Cancer-causing chemicals
• Heavy metals such as nickel, tin, and lead 1
• The aerosol that users inhale and exhale from e-cigarettes can expose both themselves and bystanders to harmful substances.
• It is difficult for consumers to know what e-cigarette products contain. For example, some e-cigarettes marketed as containing zero percent nicotine have been found to contain nicotine. 3

• E-cigarettes come in various flavors, including fruit, candy, mint, and menthol.
• A study from 2013-2014 showed that most youth who use e-cigarettes first start with a flavored variety, and flavors are the primary reason youth report using e-cigarettes. 6
• In 2023, most youth who reported using e-cigarettes used flavored varieties (89.4%). Among middle and high school students who currently used any type of flavored e-cigarette in 2023, the most commonly used flavors were fruit (63.4%), candy, desserts, or other sweets (35%), mint (27.8%), and menthol (20.1%). 11
• On January 2, 2020, the U.S. Food and Drug Administration (FDA) finalized an enforcement policy that prohibits the sale of prefilled cartridge e-cigarettes in any flavor other than tobacco or menthol, unless authorized by FDA. FDA has since taken additional steps to prohibit certain companies from selling youth-appealing, flavored disposable e-cigarettes and flavored e-liquids without authorization. 7
• Several states and communities have restricted the sale of flavored tobacco products, including menthol-flavored products. 8
• E-cigarettes are also advertised using the same themes and tactics that have been shown to increase youth initiation of other tobacco products, including cigarettes. In 2021, approximately 76% of students reported exposure to tobacco product marketing through traditional sources and approximately 74% of students who used social media had seen e-cigarette–related posts or content. 12
• Widespread advertising for e-cigarettes, including via media for which advertising for conventional tobacco products is prohibited (e.g., TV), and the lower costs of some e-cigarettes relative to regular cigarettes has contributed to use among youth. 1
• Many youth also report using e-cigarettes because they are curious about these products. 1
• Many young people who use e-cigarettes also smoke cigarettes. 1 There is some evidence that young people who use e-cigarettes may be more likely to smoke cigarettes in the future.
• Specifically, a 2018 National Academy of Medicine report found that there was some evidence that e-cigarette use increases the frequency and amount of cigarette smoking in the future. 4
• E-cigarettes also can be used to deliver other drugs, including marijuana; in 2016, approximately one-third of U.S. middle and high school students who have ever used an e-cigarette reported using marijuana in the device.
• But e-cigarette use among young people is still unsafe, even if they do not progress to future cigarette smoking.
• E-cigarettes expose users to fewer harmful chemicals than burned cigarettes. 1
• But burned cigarettes are very dangerous, killing half of all people who smoke long-term.
• The use of any tobacco product, including e-cigarettes, is unsafe for young people.
• Yes. In August 2016, the regulatory authority of the FDA was extended to cover e-cigarettes through the agency’s “deeming rule.”
• Through authority granted by the Family Smoking Prevention and Tobacco Control Act (FSPTCA), FDA has authority to develop regulations that address the manufacturing, marketing, and sale of e-cigarettes.
• There are some strategies that the FDA does not have authority to implement, such as including e-cigarettes in smoke-free policies or increasing the minimum legal sales age for these products, unless directed to do so by Congress. However, the FSPTCA does not prevent states and communities from including e-cigarettes in smoke-free policies or from regulating the sale and distribution of e-cigarettes. These types of strategies can include further raising the minimum legal sales age, licensing retailers, implementing price policies, and restricting or prohibiting the sale of tobacco products.
• Yes. In 2018, the FDA expanded its successful youth tobacco prevention campaign , “The Real Cost,” to reach the more than 10 million youth aged 12–17 who have used e-cigarettes or are open to trying them. The campaign educates youth about the potential risks of using e-cigarettes.
• The “Real Cost” reaches teens where they spend most of their time: in school and online. The campaign is also placing e-cigarette prevention materials in high schools across the nation, both in school bathrooms and on educational digital platforms accessed by students during the school day.
• Heated tobacco products (HTPs) like IQOS and Eclipse, sometimes marketed as “heat-not-burn” technology, represent a diverse class of products that heat the tobacco leaf to produce an inhaled aerosol. They are different from e-cigarettes, which heat a liquid that can contain nicotine derived from tobacco.
• HTPs are available in at least 40 countries and several have been authorized for sale in the United States by the FDA. In 2018, few U.S. adults (2.4% of all surveyed, including 6.7% of people who currently smoke surveyed) had ever used HTPs. In 2023, 1.0% of U.S. middle and high school students, combined, reported having used heated tobacco products in the past 30 days. 11
• Scientists are still learning about the short-term and long-term health effects of HTPs, but the available science shows they contain harmful and potentially harmful ingredients. Youth use of any tobacco products, including heated products, is unsafe.
• It is important that we continue to modernize proven tobacco prevention and control strategies to include newer products entering the market such as HTPs.

• Talk to your child or teen about why e-cigarettes are harmful for them. It’s never too late.
• Set a good example by being tobacco-free and ensure that your kid is not exposed to the secondhand emissions from any tobacco products, including e-cigarettes.
• If you use tobacco, it’s never too late to quit. For free help, visit smokefree.gov or call 1-800-QUIT-NOW .
• Get the Talk With Your Teen About E-cigarettes [PDF – 5.2MB] tip sheet for parents. Start the conversation early with children about why e-cigarettes are harmful for them.
• Set up an appointment with your child’s health care provider so that they can hear from a medical professional about the health risks of tobacco products, including e-cigarettes.
• Speak with your child’s teacher and school administrator about enforcement of tobacco-free school grounds policies and tobacco prevention curriculum.
• Encourage your child to learn the facts and get tips for quitting tobacco products at Teen.smokefree.gov .
• Model tobacco policies and administrative guidance to support school districts in creating and sustaining 100% tobacco-free school environments by the American Heart Association.
• This page on the American Academy of Pediatrics site contains a list of behavioral supports that can help youth quit smoking, vaping and/or using other tobacco products.
• This cessation program from the American Lung Association is designed to help youth ages 14 to 19 quit e-cigarettes. The program consists of 10 sessions to be delivered in a small group format. A mobile-friendly online version for youth is available at https://notforme.org
• Developed by the American Lung Association in partnership with the Prevention Research Center of West Virginia University, this education program is available for schools and communities to establish to help youth make healthier choices when it comes to e-cigarette use.
• These resources from the FDA include lesson plans, activity sheets, videos and educational information for middle and high school educators to help inform students about the health consequences associated with vaping.
• This self-led, interactive curriculum provided by the Truth Initiative encourages youth to live vape-free lives.
• E-cigarettes and Youth: Toolkit for Partners [PDF–13 MB]
• Download [PDF–572 KB]
• Information from the Surgeon General on the risks of e-cigarettes for young people, and includes free tools such as a parent tip sheet for talking to teens about e-cigarettes [PDF – 5.2MB].
• Information to help teens who want to quit using e-cigarettes.
• This free mobile program is designed to help young people quit e-cigarettes. Resources are available for teens and young adults as well as parents.
• Find a list of addiction treatment centers using the SAMHSA website. Please contact a center directly to ask if they treat e-cigarette dependence.
• Basic information about e-cigarettes from CDC’s Office on Smoking and Health.
• CATCH My Breath
• Stanford University Tobacco Prevention Toolkit
• Substance Abuse and Mental Health Services Administration Reducing Vaping Among Youth and Young Adults Guide
• This resource provides policy and advocacy tools for communities, public health practitioners, educators, and others to help address youth e-cigarette use.

Download the PDF or order free hard copies

Download the PDF or order a free hard copy

This resource informs educators on e-cigarette use among youth and provides alternatives to out-of-school suspension for students who violate a school’s tobacco-free policy.

This product is intended for educational purposes only for public health officials and healthcare providers. The devices and brands presented in this pamphlet are intended to highlight the different e-cigarette, or vaping, product generations and substances used in these devices.

• Marynak KL, Gammon DG, Rogers T, Coats EM, Singh T, King BA. Sales of Nicotine-Containing Electronic Cigarette Products: United States, 2015 . American Journal of Public Health 2017; 107(5):702-705.
• Taylor G, McNeill A, Girling A, et al. Change in mental health after smoking cessation: systematic review and meta-analysis . British Medical Journal 2014;348:g1151.
• U.S. Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020 [accessed 2022 April 4].
• Truth Initiative Mental Health x Vaping Headline Survey Internal Data – August 2021.
• Gentzke AS, Wang TW, Cornelius M, et al. Tobacco Product Use and Associated Factors Among Middle and High School Students — National Youth Tobacco Survey, United States, 2021. MMWR Surveill Summ 2022;71(No. SS-5):1–29. DOI: http://dx.doi.org/10.15585/mmwr.ss7105a1 .
• Hughes JR. Effects of abstinence from tobacco: valid symptoms and time course . Nicotine & Tobacco Research 2007;9(3):315-27.
• Guthrie SK, Ni L, Zubieta J-K, Teter CJ, Domino EF. Changes in craving for a cigarette and arterial nicotine plasma concentrations in abstinent smokers.  Progress in Neuro-Psychopharmacology and Biological Psychiatry 2004;28(4):617-23.
• U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 years of Progress: A Report of the Surgeon General.  Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
• Lechner WV, Janssen T, Kahler CW, Audrain-McGovern J, Leventhal AM. Bi-directional associations of electronic and combustible cigarette use onset patterns with depressive symptoms in adolescents.  Preventive Medicine 2017;96:73-78.
• Obisesan OH, Mirbolouk M, Osei AD, et al. Association between e-cigarette use and depression in the behavioral risk factor surveillance system, 2016-2017 . JAMA Network Open 2019;2(12):e1916800-e00.
• Birdsey J, Cornelius M, Jamal A, et al. Tobacco Product Use Among U.S. Middle and High School Students — National Youth Tobacco Survey, 2023. MMWR Morb Mortal Wkly Rep 2023; 72(44);1173–1182.
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E-cig companies are giving out college scholarships for essays on vaping.

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Vaping essays: E-cigarette sellers offering scholarships

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A growing number of e-cigarette and vaporizer sellers have started offering college scholarships as a way to get their brands listed on university websites and to get students to write essays about the potential benefits of vaping.

The tactic is taken from a method that was once believed to improve a site’s ranking in search results, and it has successfully landed vaping brands on the sites of some of the nation’s best-known universities, including Harvard. It also has drawn criticism that the scholarships are a thinly disguised ploy to attract young customers.

The scholarships, ranging from $250 to $5,000, mostly involve essay contests that ask students to write about the dangers of tobacco or whether vaping could be a safer alternative. At least one company asks applicants to write about different types of e-cigarettes and which one they recommend. Some seek papers in support of medical marijuana.

Over the past two years, the grants have been posted online by e-cigarette retailers and review websites such as Slick Vapes, SmokeTastic and DaVinci Vaporizer.

Robert Pagano, owner of the Las Vegas-based review site Vapor Vanity, said he was offering new scholarships of up to $1,500 this year. He acknowledged it’s partly a marketing tool, but he also says many in the industry are former smokers and want to help teens avoid tobacco.

“It’s a little bit of being genuine, a little bit of self-interest,” said Pagano, whose company does not sell vaping products. “This is probably the best way to get people to actually focus on the issues that we’re trying to write about.”

Days after Pagano was interviewed by The Associated Press, the scholarships were removed from his site without explanation. He did not return calls or emails seeking further comment.

The grants have emerged as high schools struggle to rein in booming teen use of the devices, sometimes threatening students with suspensions or installing alarms that can detect the devices’ discreet vapor. Federal agencies have attempted to crack down on underage sales and are investigating marketing efforts by the brand Juul, which has become especially popular among teens.

Although some of the scholarships are limited to students 18 and older — the nation’s legal age to buy vaping products — many are open to younger teens or have no age limit.

Most companies behind the essay contests did not return calls or declined interview requests. But the American Vaping Association trade group defended the practice, saying it allows companies to boost their brand while offering college students a helping hand.

The head of the association, Gregory Conley, compared it with scholarship programs that have long been offered by alcohol makers like Anheuser-Busch, which distributes tens of thousands of dollars each year for minority students.

Some anti-tobacco groups were unaware of the scholarships until asked about them by the AP, but they sharply criticized efforts to get teens writing in favor of vaping.

“They’re trying to use youth as their marketing surrogates,” said Gregg Haifley, director of federal relations for the American Cancer Society’s lobbying arm in Washington. “They can gussy it up any way they want, try to put lipstick on that pig, but this is about marketing.”

Opponents say the scholarships could test federal rules forbidding tobacco and e-cigarette companies from marketing to minors. The Food and Drug Administration, which oversees regulation of e-cigarettes, declined to comment on the issue but said in a statement that businesses “have an obligation to act responsibly to protect youth from the dangers of these products.”

Most medical experts agree that vaping is safer than smoking traditional cigarettes, but little is known about its long-term health effects.

Manufacturers often say vaping products are meant only for adults trying to quit smoking, and some of the essay contests note that they aren’t meant to promote vaping. But some anti-tobacco groups say there’s no other reason the companies would reach out to young people.

“Most of these kids are not smokers,” said Robin Koval, president of the Truth Initiative, a Washington-based nonprofit that opposes the tobacco and vaping industries. “What they’re saying and what they’re doing don’t seem to agree here. But that’s not surprising.”

It’s unclear how many — if any — of the scholarships have been awarded. Several websites promise to publicize winners and their essays, but it doesn’t appear any have done so. None of the 15 companies contacted by the AP would disclose winners, and only one agreed to an interview.

Marketing experts say the vaping industry isn’t the first to use college scholarships as a form of cheap advertising. The internet is teeming with similar offers from websites that sell weight-loss pills and protein powders, as well as payday lenders and companies that pay cash for gold.

The tactic was created years ago, at a time when websites thought getting their link on a college or government site would boost their rankings in Google search results. Some created scholarships purely to get their links on university financial-aid pages.

“This is almost a backdoor way to get your name on a university website, and from the point of view of the student, it would look like the university is supporting this effort,” said Ron Berman, who teaches marketing at the University of Pennsylvania’s business school.

The tactic worked. Vaping scholarships have ended up on financial-aid directories compiled by Harvard, the University of California at Berkeley, the University of Pittsburgh and others, including institutions that have taken a stance against e-cigarettes.

Harvard and California State University at Long Beach immediately removed the listings after being asked about them by the AP, saying they had been posted inadvertently.

“We’re not interested in being a platform for tobacco or vaping,” said Jeff Bliss, a spokesman for CSU Long Beach.

Some marketing firms advise against the strategy, calling it outdated. Google has updated its algorithm to defeat similar tactics, and it penalizes sites that try to manipulate search rankings.

Wil Reynolds, founder of the Philadelphia-based marketing agency Seer Interactive, said his company employed the strategy years ago for clients connected to the education world, but he abandoned it after other industries started exploiting it.

“It is a shady practice when you really can’t back it up with a legitimate reason,” he said.

Collin Binkley can be reached on Twitter at www.twitter.com/cbinkley .

Dangers Of Youth Vaping: Parsippany Teens Tackle Issue, Urge Awareness

P ARSIPPANY, NJ — Students in Parsippany encouraged parents to have frank conversations with their children about using vapes and e-cigarettes, as they said these devices continue to be prevalent in local schools.

Parsippany Hills High School students Anushka, Shreeji and Tanvi shared their research on the subject with parents and other students at the Parsippany Public Library last week.

The students are in an AP Research class together, and have been working on the project for several months along with classmate Aleena, who was out of the country during the presentation.

These four students explored the issue of vaping from an economic, social and cultural, health, and ethical perspective. Their mission was to help stimulate conversation to de-normalize vaping around school and in the community.

E-cigarette use has been rising among youth in New Jersey as cigarette smoking has declined, according to statistics from the state Department of Health.

These devices heat up a liquid that contains nicotine, as well as flavoring and other chemicals, to produce a vapor that users inhale. E-cigarettes can also deliver marijuana or other drugs.

"We really need parents' help too," said Anushka as the students showed examples of e-cigarette models in an array of shapes, sizes, and colors.

When looking out for a vape, a key detail for parents and teachers to check for is a charging port, the students said — many e-cigarettes are able to be plugged in to a USB cable to charge. Shreeji told attendees about product that is designed to look and function like a highlighter — while concealing a vape, as well.

He shared the impacts that vaping these chemicals can have on people's lungs, heart, and other organs — as well as how nicotine addiction can affect mental health and even brain development.

"It's your choice, and if you vape it will affect you mentally and physically," he said. "And instead of reducing your stress, it will make you gain stress."

Tanvi shared stats that showed 27.5 percent of high schoolers reported using e-cigarettes, and more than half said they had seen targeted marketing on social media about vaping.

The legal age for purchasing tobacco/nicotine is 21, which includes all oral, tobacco, nicotine, and synthetic nicotine products.

The students encouraged parents to continue learning about vaping so they may have an educated conversation with students about how it will affect them.

You may watch the full presentation here on the Parsippany Video on the Go channel.

Students at Brooklawn Middle School also made an anti-vaping PSA earlier this spring, which also reminds students that they can face a fine for smoking on campus.

The article Dangers Of Youth Vaping: Parsippany Teens Tackle Issue, Urge Awareness appeared first on Parsippany Patch .

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Guest Essay

Why Biden Has a Narrower Path to the Presidency Than Trump, in 11 Maps

Illustration by Akshita Chandra/The New York Times; Images by PhotoObjects.net, Yuji Sakai, and THEPALMER/Getty Images

By Doug Sosnik Graphics by Quoctrung Bui

Mr. Sosnik was a senior adviser to President Bill Clinton from 1994 to 2000 and has advised over 50 governors and U.S. senators.

While polls show the race for president is tightening, Joe Biden still has a narrower and more challenging path to winning the election than Donald Trump. The reason is the Electoral College: My analysis of voter history and polling shows a map that currently favors Mr. Trump, even though recent developments in Arizona improve Mr. Biden’s chances. The Biden campaign will need to decide this summer which states to contest hardest. Our Electoral College maps below lay out the best scenarios for him and Mr. Trump.

Seven states with close results determined who won both the 2020 and the 2016 presidential elections, and those same seven states will most likely play the same battleground role this fall: three industrial states – Michigan, Pennsylvania and Wisconsin – and four Sun Belt states – Arizona, Georgia, Nevada and North Carolina.

The seven states that will most likely decide the 2024 presidential election

Mr. Biden’s declining popularity in the Sun Belt states is the main reason Mr. Trump has an edge right now. He is especially struggling with young and nonwhite voters there. Let’s take a closer look:

According to 2020 exit polls , Mr. Biden won 65 percent of Latino voters, who comprised roughly a fifth of voters in Arizona and Nevada. And Mr. Biden won 87 percent of Black voters, who made up 29 percent of the Georgia vote and 23 percent of the North Carolina vote. He also won 60 percent of voters aged 18 to 29. Now look at this year: A New York Times/Siena College poll released last weekend showed support for Mr. Biden had dropped 18 points with Black voters, 15 points with Latinos and 14 points with younger voters nationally.

Abortion could be a decisive issue in Mr. Biden stemming this erosion of support in Arizona and Nevada. The Arizona Supreme Court’s ruling last week that largely bans abortions raises the stakes of a likely ballot initiative on the issue there in November. It also appears likely that there will be a similar ballot measure in Nevada.

Nevertheless, the key to Mr. Biden’s victory is to perform well in the three industrial states. If Mr. Trump is able to win one or more of Pennsylvania, Michigan and Wisconsin, Mr. Biden’s path to 270 electoral votes becomes even narrower.

If Mr. Biden and Mr. Trump remain ahead in the states where they are currently running strongest, the outcome of the election could come down to who wins Michigan and the two Sun Belt states where abortion will very likely be on the ballot, Arizona and Nevada.

Based on past voting, Mr. Trump will start out the general election with 219 electoral votes, compared to 226 votes for Mr. Biden, with 93 votes up for grabs.

Voter history and recent polling suggest that Mr. Trump is in a strong position to win North Carolina . Republicans have carried the state in every presidential election since 1976 except in 2008. In a Wall Street Journal battleground poll taken in March, Mr. Biden had only 37 percent job approval in the state. By winning North Carolina , Mr. Trump would have 235 electoral votes and two strong paths to 270.

The first path involves carrying Georgia , a state he lost by fewer than 12,000 votes in 2020. Before then, Republicans won Georgia in every election since 1992. If Mr. Trump carries North Carolina and Georgia , he would have a base of 251 electoral votes with four scenarios that get him to 270.

Scenario 1 Then all Mr. Trump needs is Pennsylvania …

Scenario 2 … or Michigan and Nevada …

Scenario 3 … or Michigan and Arizona …

Scenario 4 … or Arizona and Wisconsin.

The second and harder path for Mr. Trump would be if he carried only one Southern swing state – most likely North Carolina . He would have only 235 electoral votes and would need to win three of the six remaining battleground states.

Scenario 5 Then he would need to win Arizona , Michigan and Wisconsin …

Scenario 6 … or Arizona , Nevada and Pennsylvania .

How Biden Can Win

It is difficult to see how Mr. Biden gets re-elected without doing well in the industrial battleground states – the so-called “ Blue Wall ” for Democrats. This is particularly true of Pennsylvania, given the state’s 19 electoral votes and Mr. Biden’s ties there and appeal to middle-class and blue-collar voters. That’s why he’s spending three days in Pennsylvania this week.

Mr. Biden will most likely need to win at least one other industrial battleground – with Wisconsin the most probable, since his polling numbers there are stronger than in the other battleground states.

A combination of factors have made winning Michigan much more challenging for Mr. Biden. Hamas’s attack on Israel and the war in Gaza have ripped apart the coalitions that enabled Democrats to do so well in the state since 2018. There are over 300,000 Arab Americans there, as well as a large Jewish population. Both groups were crucial to Mr. Biden’s success there in 2020.

In addition, Michigan voters’ perception of the economy is more negative compared with the other battleground states. In the Journal battleground poll , two-thirds of Michigan voters described the national economy negatively; more than half had a negative opinion of the state’s economy.

Now let’s look at Mr. Biden’s map.

Mr. Biden’s best strategy is based on winning Pennsylvania and Wisconsin, which would give him 255 electoral votes (assuming that he carries the 2nd Congressional District in Nebraska). By carrying these states, Mr. Biden has several paths to 270, but the first three scenarios are his most viable.

Scenario 1 He just needs to win Michigan …

Scenario 2 … or Arizona and Nevada …

Scenario 3 ... or Georgia .

There are two other scenarios where Mr. Biden loses Wisconsin and keeps Pennsylvania . But that would mean winning states where Mr. Biden is polling much worse.

Scenario 4 They involve Mr. Biden winning Georgia and Arizona …

Scenario 5 … or Michigan and Georgia .

A Look Ahead

With over six months to go until Election Day, given the volatility in the world and the weaknesses of Mr. Biden and Mr. Trump, it would be foolish to make firm predictions about specific results. And other electoral map scenarios are possible: Recent polling shows Mr. Biden with a narrow lead in Minnesota, a state that usually votes for Democrats for president. While it is mathematically possible for Mr. Biden to win without carrying Minnesota, it is unlikely he will be elected if he cannot carry this traditionally Democratic state.

For the third election cycle in a row, a small number of voters in a handful of states could determine the next president of the United States.

If the election remains close but Mr. Biden is unable to regain support from the core group of voters who propelled him to victory in 2020 — young and nonwhite voters — then we could be headed to a repeat of the 2016 election. The outcome of that election was decided by fewer than 80,000 votes in Michigan, Pennsylvania and Wisconsin.

Last week’s abortion ruling in Arizona, and the likely abortion ballot initiatives in that state and Nevada, give Mr. Biden the possibility of being re-elected even if he loses Michigan. That’s why, if we have another close presidential election, I think Arizona, Michigan and Nevada will likely determine the outcome for Mr. Biden or Mr. Trump.

Based on my experience as Bill Clinton’s White House political director in his 1996 re-election campaign, I would take immediate advantage of Mr. Biden’s significant fund-raising advantage over Mr. Trump to focus on shoring up the president’s chances in Michigan and the must-win states of Pennsylvania and Wisconsin, while at the same time trying to keep Georgia and North Carolina in play. Mr. Biden does not need to win either of those Sun Belt states to get re-elected, but draining Mr. Trump’s resources there could help him in other battleground states.

More on the 2024 presidential election

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The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

Follow the New York Times Opinion section on Facebook , Instagram , TikTok , WhatsApp , X and Threads .

So Your High School Doesn’t Offer APs—Are AP Exams Still Important For College Admissions?

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Advanced Placement courses are offered at thousands of high schools across the U.S.— approximately 35% of public high school graduates in the Class of 2023 took at least one AP exam, and approximately 2.8 million students sat for AP exams in 2023. However, a large number of schools do not offer AP courses. In many cases, this is due to a lack of resources—though strides have been made to increase access to AP courses in underprivileged schools, a gap in access persists along racial and socioeconomic lines. In other cases, schools are ditching the AP curriculum as a result of their educational philosophy. In 2018, elite private schools in the D.C. area such as Sidwell Friends and Georgetown Prep announced their intention to phase out AP classes, citing their desire for a more independent curriculum and a growing frustration with the AP’s orientation toward testing rather than other metrics for success.

Despite these drawbacks, AP courses and exams remain highly regarded by many colleges and universities, as they offer insight into students’ academic acumen and potential to complete college coursework successfully. As a result, many students without access to AP courses are left wondering whether they should still register, study and sit for AP exams.

First and foremost, students should know that colleges and universities evaluate their applications in the context of their school and the opportunities available to them. This means that if students did not have AP classes available to them at their schools, admissions officers will not expect to see AP courses or AP exam scores included in their applications. As such, these students’ applications will not be disadvantaged in any way by not including AP exams.

That being said, there are some scenarios in which a student may still wish to take an AP exam despite not having taken an AP course. These are the top three reasons that students might consider sitting for one or more AP exams:

1. To Earn College Credit

One of the main reasons students take AP exams is to earn college credit. Many colleges and universities grant credit for high AP exam scores (typically for 4s or 5s). By earning credit through AP exams, you may be able to fulfill prerequisites, skip introductory courses, or accelerate your progress toward graduation once you enroll in college. However, this is not the case at every school. In order to determine whether the time and effort you will put into studying and taking an AP exam will be justified, you should research whether the schools you are considering applying to give college credit for high AP exam scores. You can often find this information on admissions or departmental websites, or by contacting admissions representatives at each respective school. You can also check the College Board website to see if the schools on your list accept AP credits, but note that these policies change frequently, so you should still follow up with the schools for verification. If a handful of the schools on your list do accept high scores for credit, it may be a strategic choice to sit for one or more exam.

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Litter robot 4 review the best self cleaning litter box on the market, the trump media stock price djt is about to adjust down by 22 7, 2. to use exam scores in lieu of the sat or act.

As Ivy League and other top schools reinstate their standardized testing requirements, some schools have announced their intention to allow students to submit test scores from AP examinations in place of ACT or SAT scores. Dartmouth allows students applying from schools outside of the U.S. to satisfy their testing requirement by submitting three AP exam scores. Meanwhile, Yale’s new test-flexible policy also allows students applying domestically to submit AP and IB scores in lieu of other standardized tests. If you are applying internationally or if you have reason to believe that you will achieve a stronger score on AP exams than on the SAT or ACT, you can consider sitting for the exams. Note that not all schools have such flexible testing policies, so you will likely still need to sit for the SAT or the ACT.

3. To Demonstrate Your Academic Abilities

It is important to remember that while they are not the only way to demonstrate their academic capabilities, AP exams are an unbiased and quantifiable way to assess students’ preparedness for college coursework. Students who struggled academically earlier in their high school years or who want to highlight their skills in a specific discipline may benefit from the inclusion of AP scores in their applicant profiles.

Finally, while students who do not have access to AP classes should consider their options and make a strategic decision about taking exams on the basis of their applicant profiles and academic goals, students who have taken AP courses absolutely should take AP exams. Failing to sit for the exams will not only foreclose the possibility of earning college credit, but it will also reflect poorly on your application and raise questions with admissions committees.

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