Electronic Vapor Products: Alarming Trends in United States Adolescents

DISCUSSION

These findings show alarming statistically significant and clinically important increases in daily EVP use among US adolescents in the 9th through 12th grades. Daily EVP use decreased from 2019 to 2021, but virtually all percentages remained significantly increased compared to the 2015 baseline. It is tempting to speculate about the role of coronavirus disease 2019 (COVID-19) in explaining these findings. For example, COVID-19 resulted in social distancing, crowd avoidance, and even lockdowns, all of which reduced peer interactions.⁹ Decreased peer interactions and increased parental supervision with remote schooling and work may have led to limited EVP use in this population. Economic constraints and heightened health concerns may have also played a role in decreasing EVP use. These hypotheses, however, need to be tested in analytic studies designed a priori to do so.¹⁰

Public awareness of the potential dangers associated with the use of EVPs is increasing. A 2023 report concerned a medical condition called e-cigarette or vaping use-associated lung injury (EVALI) that may be caused by the vitamin E acetate used in tetrahydrocannabinol-containing e-cigarettes.¹¹ The emergence of EVALI emphasizes the importance of regulatory oversight and consumer awareness. In addition, the legal challenges faced by companies such as JUUL for allegedly marketing to minors (the legal age to purchase e-cigarettes is 21 years), and the enactment of state-level bans on the sale of flavored EVPs have received widespread publicity.

Tobacco use among high school students in the United States has evolved with the advent of EVPs, leading to a complex public health scenario. While data indicate a substantial decline in traditional cigarette smoking among adolescents,⁷ the introduction and spread of EVPs have presented new challenges. The increase in vaping, perceived by some as a safer alternative to smoking, may have contributed to the decline in combustible tobacco product use but has raised concerns about new health risks, including nicotine addiction. Almost 100% of e-cigarettes sold in the US contain nicotine,¹² and the use of these products by adolescents may lead to future abuse of and addiction to additional substances.¹³ EVPs contain a myriad of substances beyond nicotine, including propylene glycol, glycerin, flavorings, and potentially harmful chemicals such as formaldehyde and metals, which could pose significant health risks.¹² Moreover, nicotine has a variety of acute adverse effects, and long-term use increases the risks of respiratory diseases, cancer, and cardiovascular diseases.¹⁴ This complex risk profile underscores the need for stringent research and regulations to address the health impacts of EVP use, especially among vulnerable young populations.

The risks associated with EVP use by adolescents underscore the importance of targeted interventions. In a cross-sectional analysis of data from the Population Assessment on Tobacco and Health study, 44.5% of adolescent EVP users reported that they were seriously interested in quitting, and almost one-quarter had tried to quit during the prior year.¹⁵ These findings suggest considerable interest among adolescent EVP users to quit, indicating a receptive audience for cessation initiatives or intervention programs targeted at adolescents. Such initiatives/programs could leverage this interest to provide the support and resources needed to help adolescents successfully quit vaping, thereby mitigating the long-term health risks associated with continued use of EVPs.

A strength of the present study is the large sample size. In addition, the YRBS is considered the largest public health surveillance system in the United States, and the survey was conducted during the US epidemic of COVID-19.⁸ YRBS data are weighted to adjust for nonresponse and clustering so that the sample of students is representative of the population. However, our study design is descriptive and therefore useful to formulate, but not to test, hypotheses.¹⁰

While further research is warranted, the findings from this study highlight the need for targeted prevention and intervention efforts. A 2024 review that assessed vaping prevention interventions for youth found high perceived parental monitoring effective at the individual level.¹⁶ School-based programs showed inconsistent outcomes, although some social-emotional and peer leadership approaches showed promise in preventing EVP adoption among adolescents.¹⁶ Reliable evidence of the impact of community interventions is lacking. These descriptive study findings illustrate the need for analytic studies to confirm or refute the effectiveness of these interventions in preventing youth vaping.

Continued surveillance of EVP use in adolescent populations may yield important information for health care practice and policy, including guidance for prevention and control strategies. The interest in quitting expressed by adolescent EVP users¹⁵ points to a critical window for clinical interventions, including routine screening for vaping and nicotine dependence during adolescent health assessments, counseling, and tailored cessation programs. Given the adverse health effects associated with long-term nicotine use, such as increased risks of respiratory diseases, cancer, and cardiovascular disease, early and proactive clinical engagement is essential. Health care providers play a pivotal role in mitigating the impact of EVP use through education, support for cessation efforts, and advocacy for evidence-based public health policies. The literature indicates the importance of a multifaceted clinical approach to prevent initiation and promote cessation of EVP use among adolescents, thereby contributing to the broader goal of safeguarding adolescent health and well-being.