The unanticipated consequences of vaping: Implications for policy

The pervasiveness of e-cigarette vaping has significantly increased among all age groups despite emerging evidence that the practice may be harmful. Some of the features of the devices contribute to these concerns. The e-cigarette inhalation system delivers nicotine as an aerosol instead of smoke. The emissions are lower than those found in combustible tobacco products. 

However, particles are smaller in vaping compared with combustible cigarettes and result in more toxic chemicals reaching deeper into the lungs. Vaping increases exposure to heavy metals, such as nickel, tin, and lead. Some “buttery” flavors contain diacetyl, a chemical linked to serious lung disease. A number of other chemicals are released during vaping which are potentially hazardous, including acetaldehyde, benzene, cadmium and formaldehyde, to name a few.

Vaping devices are easy to conceal (“pod mods” are the size of USB hard drives). Without combustion, the odor dissipates much more quickly than traditional cigarette smoking. The marketing of flavors by JUUL and other companies (such as Cotton Candy, Tutti Fruiti) is found pleasurable among youth. As a result, e-cigarettes are now the most popular tobacco product among teens. 

In adults, e-cigarettes may serve as a substitute for combustible cigarettes. Earlier models of e-cigarettes predicted a decrease in the risk for nicotine addiction compared with traditional cigarettes. However, the most popular “pod mod” products tend to contain high levels of nicotine that maintains if not reinforces the addiction.

The increasing use of e-cigarettes among young people (11-16 years) has now reversed the previous lengthy trend of declining tobacco use over the past many decades. Results from the National Youth Tobacco Survey in 2018 showed that 3.6 million students have used e-cigarettes in the last 30 days. 

E-cigarette use among youth is of dire concern. The critical development of cognitive function that occurs in children and adolescents can be disrupted by nicotine exposure. In addition, there is increased risk for subsequent use of other more dangerous nicotine-containing products such as combustible cigarettes. Importantly, E-cigarettes are also associated with an earlier onset of drug use and substance use disorders.

Fetuses are particularly susceptible to the adverse effects of nicotine. Preliminary data suggest that prenatal exposure increases inflammation in the newborn, which is associated with disorders such as autism, depression and schizophrenia. Pregnant women are more likely to have the common conception that these nicotine delivery systems are benign or less harmful than combustible cigarettes. As a result, these products lead to even greater use of e-cigarettes than traditional cigarettes, among persons for whom vaping is unwise. 

The FDA is asking e-cigarette producers to describe what steps they will take to decrease use by minors. Although sales to minors is illegal, enforcement of these laws is lax and availability is widespread. Rules limiting manufacturing is in the works; e.g., free samples are prohibited. State and local regulations vary, such as the legal age of purchase of e-cigarette products.

The National Prevention Science Coalition to Improve Lives recommends the additional evidence-based policies to stem the tide of e-cigarette use and vaping:

1. Prohibitions on advertisements targeting minors

2. Prohibitions on products that have an appearance or taste that appeals to minors;

3. Protections from exposure to secondhand smoke and e-cigarette aerosol

4. More stringent enforcement of prohibitions against access to these products by minors, at the production level, marketers, distributors, and sellers

5. Support for national marketing campaigns regarding the potential hazards of use so that consumers can make informed decisions

Similar campaigns led to significant reductions in initiation of combustible cigarettes — from 42 percent in 1965 to 18 percent in 2012 — and can be effective for these newer products. 

It is imperative that we act quickly to implement these science-based policies to end the nicotine epidemic among our youth.

Susan Andersen, Ph.D. is an associate professor in psychiatry at Harvard Medical School and director of the Laboratory for Developmental Neuropharmacology at McLean Hospital, and Board Member of the National Prevention Science Coalition to Improve Lives. Steve Sussman, Ph.D. is a professor of preventive medicine, psychology, and social work at the University of Southern California and member of the National Prevention Science Coalition to Improve Lives. Diana Fishbein, Ph.D. is a professor in Human Development and Family Studies and director of the Program for Translational Research on Adversity and Neurodevelopment at The Pennsylvania State University, and co-director of the National Prevention Science Coalition to Improve Lives.