The emergence of a new generation of people addicted to nicotine — many of them now in middle school — keeps me up at night.
A few years ago, I and many of my colleagues who have cared for people with tobacco-related diseases breathed a sigh of relief as we watched smoking rates decline. That relief has dissipated as electronic cigarettes, or vaping, sweeps through middle and high schools. We won’t know the full extent of vaping’s health consequences until it’s too late, but we can expect to see a tsunami of related diseases in 20 or 30 years.
Many health professionals agree that e-cigarettes are a useful tool for smokers when other conventional smoking-cessation approaches have failed. There’s a reason for that: Nicotine is the most addictive substance known to mankind. During the nine years I spent helping people who had been addicted to crack, heroin, and alcohol stop smoking, they all said that smoking was the hardest addiction to kick.
New information about so-called pod mod e-cigarettes, which deliver high levels of nicotine without the coughing or unpleasant taste of other tobacco products, sounds a warning for the unwitting victims of the vaping industry and Big Tobacco. A Perspective article in last week’s New England Journal of Medicine outlines the perils posed by Juul products — the most popular pod mod used by adolescents — and others like them. The report comes on the heels of a threat by Food and Drug Administration Commissioner Scott Gottlieb to pull flavored vaping products off shelves, a constructive first step in addressing the teen vaping epidemic.
Mango, cotton candy, and bubble gum flavors, to name a few, along with cunningly designed, colorfully accessorized devices, have captivated young people who would never have tried smoking conventional cigarettes. Adolescents are no match for the multibillion dollar e-cigarette industry. They are also no match for schools, since these products are easy to conceal and difficult to detect, even when used in the classroom.
There’s a lot to be concerned about: 90 percent of e-cigarettes contain highly addictive nicotine. All Juul products deliver nicotine and, according to the company’s website, a single Juul pod is the equivalent of smoking one pack of cigarettes.
Perhaps most worrisome, nicotine can affect adolescent brain development, which may lead teens to smoke conventional cigarettes, and prime young brains for later addiction. Studies have shown that adolescents and young adults who use e-cigarettes are more likely to start smoking traditional cigarettes. Up to 80 percent of 15- to 24-year-olds who try Juul continue using the product, while 63 percent of that age group have no idea that Juul products contain nicotine.
Unlike traditional e-cigarettes, Juul and other pod mods deliver addictive doses of nicotine that are two to 10 times higher than those found in most e-cigarettes without the unpleasant tastes and reaction that can discourage new smokers.
The aerosols in e-cigarettes can include metals, volatile organic compounds, and flavoring additives. Despite the conclusions in a January 2018 report from the National Academies of Sciences, Engineering, and Medicine that found the chemicals in e-cigarettes are less likely to cause health risks than those in conventional cigarettes, that doesn’t mean there are no health risks.
My hospital’s emergency department has also seen a surge in visits from teenagers who are “greening out,” experiencing vomiting, dizziness, hallucinations, sweating, and feelings of acute anxiety after vaping marijuana wax or oils, which may contain up to 80 percent tetrahydrocannabinol, the principal psychoactive constituent of marijuana.
A recent letter in JAMA Pediatrics found that among e-cigarette users, nearly 1.7 million high school students (about 1 in 3) and 425,000 middle school students (about 1 in 4) had used cannabis in e-cigarettes.
I became involved in this issue a year ago when I participated in a roundtable discussion with Rep. Nita Lowey (D-N.Y.) and school superintendents in Rockland and Westchester counties. After that I began speaking to community outreach programs and conducting vaping presentations at schools. The prevalence of vaping so alarmed the high school students on my hospital’s President’s Junior Leadership Council that they recommended that our Community Health Education and Outreach Department begin addressing the problem. Last year, the program, which previously gave anti-smoking presentations to middle and high school students, pivoted to focus almost entirely on vaping. To date, it has conducted presentations for more than 5,000 students, teachers, and parents.
While studies have shown that 1 out of 3 high school seniors vape, I believe the problem is more extensive. Every high schooler I ask tells me that more than half their schoolmates vape.
The use of e-cigarettes and pod mods won’t go away on its own. We must take a multipronged approach to curtail this looming public health catastrophe.
Regulation by the FDA and industry is one piece of the puzzle. But we need more than that, like additional studies to look at the chemicals in e-cigarettes and the effects of their use, and a concerted effort to educate kids about nicotine addiction and vaping so they can understand the risks and make more informed decisions. The FDA took an important step this week in protecting the future of our children when it unveiled “The Real Cost” Youth E-Cigarette Prevention Campaign. A well-thought-out and designed educational campaign combined with federal efforts to change marketing strategies and access to youth can have a real impact.
Such education must start early. Many middle-schoolers are introduced to vaping in seventh and eighth grade; if we wait until high school, we’ve missed the boat. It’s also important to educate parents, who may believe that vaping is less harmful than smoking. It’s heartbreaking to speak with parents who tell me, “My kid is addicted to vaping and I don’t know what to do.”
In addition, schools must look at policies around vaping and enlist the support of parents, who often blame schools for not policing kids. Finally, we must create programs to help adolescents already hooked on nicotine to stop using it.
It is encouraging to see some concrete steps being taken by the FDA, public health organizations, and a coalition of 14 U.S. senators who called for the prohibition of sales of e-cigarettes in kid-friendly flavors. Let’s hope these efforts will save our children from obvious efforts by the vaping industry and Big Tobacco to hook a new generation of youths on nicotine.
Richard Stumacher, M.D., is chief of the Division of Pulmonary/Critical Care at Northern Westchester Hospital, which is part of Northwell Health.