Vaping in Adolescents: Health Impacts, Screening and Intervention

Educational Objectives

The goal of this program is to improve screening and intervention for vaping in adolescents. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize various types of vaping products.
2. Counsel adolescent patients on the adverse health effects of vaping.

Summary

Components of vape or electronic cigarettes (ECs): power from the battery heats the atomizer (usually coil-shaped); e-liquid contains the nicotine and flavors; the atomizer and liquid are placed in a cartridge; heating the e-liquid results in aerosolization

Evolution of ECs: ECs were first introduced in 2007 in the United States and appeared similar to combustible cigarettes; ECs were initially developed in China to help people quit smoking; vape pens were then introduced and were longer and sleeker; mods or box mods were introduced in 2012; they were popular because they were larger than earlier vape pens and held more liquid; more modern designs became available in 2015; these were popular because of their sleekness and modern design, lack of smell, ease of use, multiple flavors, and ease of hiding

EC with protonated nicotine (JUUL): most popular EC brand until recently; a flavor pod is slid into place; “JUULing” became synonymous with vaping; modern vaping devices have a higher nicotine content; PAX Labs (owner of JUUL) invented and patented mixing of the free-base nicotine with an acid to convert it to the salt form (protonated nicotine); the nicotine delivered is high, with concentrations of ≤50 mg/mL compared with 12 mg/mL in the standard (free-base) form; the protonated form was much smoother with enhanced taste and reduced smell; one EC with protonated nicotine is equivalent to 20 cigarettes (one pack)

Regulations for vape products: the minimum age to buy any product containing tobacco or nicotine, including vapes, is 21 yr; the US Food and Drug Administration (FDA) did not regulate ECs until 2016 when the agency covered ECs under the deeming rule; in 2020, the FDA prohibited the sale of prefilled cartridge ECs in any flavor other than tobacco or menthol unless authorized by the FDA

Regulatory loophole: EC companies stopped using plant-derived nicotine and started selling synthetic nicotine; available information about nicotine manufacturing is limited and is under patent; the FDA rules do not apply to synthetic nicotine, and sellers market synthetic nicotine in various flavors

Synthetic nicotine products: by taking advantage of the regulatory loophole, synthetic nicotine vapes (Puff Bar) overtook protonated nicotine vapes as the most popular; they are tobacco-free and come with a warning “contains synthetic nicotine”; synthetic nicotine vapes are sold in fruit and candy flavors; one synthetic nicotine vape is equivalent to smoking one pack of cigarettes; its use in high school increased by ≈26% and in middle school by 30%; the use of protonated nicotine vapes was reduced by ≈5.5% among high school students and by 12.5% in middle school students; chewing tobacco is popular in some areas; synthetic nicotine pouches were created; as of 2020, ≈13% of individuals between 15 and 24 yr of age are using these pouches; users do not need to spit because they do not increase saliva production; nicotine content per pouch is ≈6 mg; pouches are available in multiple flavors

Status of synthetic nicotine: in 2022, new legislation gave the FDA’s Center for Tobacco Products authority over products containing synthetic nicotine; all products without premarket tobacco product authorization were to be removed from the market by July 13, 2022; delays in enforcement have resulted in synthetic nicotine products remaining on the market

Nicotine alternatives in vaporizers: cannabis concentrates can be used in ECs and pods

Use of vapes in adolescents: use of combustible cigarettes is declining because of spreading awareness about smoking cessation and not initiating smoking; however, vaping is still very popular; an 8-fold increase in EC use in adolescents was reported between 2011 and 2019; from 2022 to 2023, EC use decreased in teens from 14% to 10%; ECs are still the most commonly used tobacco product among adolescents; of middle- and high-school users, ≈25% used ECs daily, and 89% used flavored ECs; girls are more likely to use ECs compared with boys; lesbian, gay, bisexual, queer, and other non-heterosexual students and any student who has same-sex partners are more likely to use ECs

ECs and smoking: ECs and vapes were introduced to facilitate smoking cessation; however, studies reported they are not used for smoking cessation and that ECs normalize using tobacco products; adolescents using ECs are more likely to smoke traditional cigarettes, are heavier smokers, and are less likely to have stopped smoking combustible cigarettes

Health effects of vaping: in addition to nicotine, vapes contain carbonyls, volatile organic compounds, trace metal elements, and bacterial endotoxins; inhaling vapors may trigger inflammatory lung reactions, may cause bronchospasm and bronchiolitis in patients with asthma, and alters the airway defenses; use of EC may cause acute lung diseases, eg, acute eosinophilic pneumonia, and respiratory bronchiolitis-associated interstitial lung disease; vapes impair lung defense, cause sloughing of epithelial cells, disrupt epithelial barrier integrity, and reduce ciliary beating frequency, thereby reducing clearance of bacteria and viruses

Secondhand exposure to vapes: many users thought vapes were only water vapor; however, it is now known that harmful chemicals and ultrafine particles are present in vapes; bystanders may experience respiratory tract irritation, heart palpitations, and increased blood pressure

E-cigarette or vaping product use-associated lung injury (EVALI): was described in 2019; symptoms of EVALI include shortness of breath, cough, pleuritic chest pain, and tachypnea; systemic symptoms include fever, chills, abdominal pain, and nausea; pulmonary infiltrates with ground glass and consolidated opacity in lower lobes are reported on chest x-ray; some patients require intubation and mechanical ventilation; clinicians should rule out other causes, eg, infection or neoplastic condition, before EVALI diagnosis; 94% of the bronchoscopies done on adolescents who visited the emergency department for respiratory distress revealed vitamin E acetate; vitamin E acetate has been found in multiple, low-cost counterfeit tetrahydrocannabinol-containing cartridges; aerosolization of vitamin E produces ketene, an airway irritant, and promotes an inflammatory cascade; vitamin E also affects surfactant function and may lead to atelectasis

Effect of nicotine on the adolescent brain: nicotine action is much more rewarding to the adolescent brain; smoking 2 combustible cigarettes may cause addiction in adolescents; it negatively affects attention, impulse control, learning, and mood; nicotine addiction can increase the risk for addiction to other substances; nicotine withdrawal symptoms may include restlessness, irritability, anxiety, depression, difficulty sleeping, problems concentrating, and strong nicotine craving

Role of providers: clinicians can make a difference with a 3-min intervention; even if the adolescent is not ready to stop vaping immediately, a brief intervention by the clinician can enhance motivation to quit; the “5 A’s” of tobacco cessation include ask about vaping at every visit, advise them to quit, assess their willingness to quit, assist them with a quit plan, and arrange for follow-up

Readings

Jones K, Salzman GA. The vaping epidemic in adolescents. Mo Med. 2020;117(1):56-58; Lawson PJ, Flocke SA, Casucci B. Development of an instrument to document the 5A's for smoking cessation. Am J Prev Med. 2009;37(3):248-254. doi:10.1016/j.amepre.2009.04.027; Malas M, van der Tempel J, Schwartz R, et al. Electronic cigarettes for smoking cessation: a systematic review. Nicotine Tob Res. 2016;18(10):1926-1936. doi:10.1093/ntr/ntw119; Panse PM, Feller FF, Butt YM, et al. Pulmonary injury resulting from vaping or e-Cigarette use: imaging appearances at presentation and follow-up. Radiol Cardiothorac Imaging. 2020;2(4):e200081. Published 2020 Aug 27. doi:10.1148/ryct.2020200081; Talih S, Salman R, El-Hage R, et al. Effect of free-base and protonated nicotine on nicotine yield from electronic cigarettes with varying power and liquid vehicle. Sci Rep. 2020;10(1):16263. Published 2020 Oct 1. doi:10.1038/s41598-020-73385-6; Traboulsi H, Cherian M, Abou Rjeili M, et al. Inhalation toxicology of vaping products and implications for pulmonary health. Int J Mol Sci. 2020;21(10):3495. Published 2020 May 15. doi:10.3390/ijms21103495; Zettler PJ, Hemmerich N, Berman ML. Closing the regulatory gap for synthetic nicotine products. Boston Coll Law Rev. 2018;59(6):1933-1982.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Tanaka was recorded at Pediatrics in the Islands: Clinical Pearls 2024, held October 28, 2024, in Waikoloa, HI, and presented by the Children's Hospital Los Angeles Medical Group. For information on future CME activities from this presenter, please visit https://www.chla.org/chla-medical-group/cme-conferences. Audio Digest thanks Dr. Tanaka and the Children's Hospital Los Angeles Medical Group for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

PD710201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.