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What’s in Store for ‘Nico-Teens’?

Vaping is no longer a passing fad among teenagers, and has turned into a national epidemic, said experts contacted by MedPage Today.

A growing body of literature confirms these fears. Most recently, the large Monitoring the Future survey in 2018 found “the largest single-year increase in use of a monitored substance ever recorded” among high school students in the program’s four-decade history.

Looking forward, pediatricians will likely be seeing a new generation of adolescent patients addicted to nicotine, and there is a need for updated guidelines that outline prevention and cessation therapies that can be used to minimize the harm done by e-cigarettes in these vulnerable populations, said Sharon McGrath-Morrow, MD, of Johns Hopkins School of Medicine in Baltimore.

What We Know

Thus far, the most recent research has shown that teens using e-cigarettes are actually more likely to transition to other substances, such as marijuana, alcohol, or tobacco cigarettes. Additionally, the vapor expelled from e-cigarettes may contain cancer-causing chemicals.

McGrath-Morrow said tobacco-naive kids who try e-cigarettes will not experience the initial adverse effect in the throat that is felt with tobacco smoking, which makes it much more likely they will continue use and become addicted to the nicotine often packaged in small pods that can contain as much nicotine as up to 20 cigarettes.

“I think this is our opportunity to not let what happened with tobacco products happen, but we only have a small window of opportunity to really push,” McGrath-Morrow told MedPage Today. “Even if we don’t have all the information, it’s pointing in the direction that kids are highly addicted to nicotine and that this could be a gateway to tobacco use, and we know how bad tobacco use is.”

But research that determines long-term cardiovascular, respiratory, or neurological effects of nicotine use in adolescents has not been conducted. And this research is likely what will motivate more restrictive guidelines, dispel the notion that e-cigarettes are healthy or benign, and discourage youth from vaping, said Michael Weaver, MD, of McGovern Medical School at UTHealth in Houston.

The problem is that research that could observe these longitudinal changes in adolescent health might take up to a decade to complete, Weaver said.

“We’ve got at least another 5-10 years before we have good, long-term data on the effects of e-cigarettes on the lungs, the heart, the brain, or something else we hadn’t considered, so unless something new emerges early and unexpectedly, [such as] higher doses of vegetable glycerin causes cancer or allergic reactions or something, we’re going to have to wait for more data to accumulate,” Weaver told MedPage Today. “I think the trend is going to have to run its course for at least a few more years.”

What Can Be Done?

The FDA is taking multiple steps to limit the marketing and advertising of e-cigarettes towards children and decrease adolescent use, with increased warnings to industry as well as proposed changes in policy.

Weaver said he anticipates groups such as the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) will begin weighing in on this issue once more research is published, joining public service announcements published this year by organizations like, which may build pressure for larger movements to address the issue. Already, the AAP released a statement in October recommending that smoke-free laws targeting secondhand smoke be expanded to include e-cigarettes.

In the time it takes for more data to accrue, Weaver said it might be more important to decrease the appeal of e-cigarettes in youth populations through different advertising, educating adolescents on the harmful effects of vaping, and making the devices less transportable and “cool.” Most notably, Juul pods, the USB-shaped vaporizers that had the greatest market share of any e-cigarettes in the U.S. at the end of 2017, according to a statement from Surgeon General Jerome Adams, MD.

Recent results from the National Youth Tobacco Survey found “a dramatic increase” in e-cigarette use. According to a statement, the results were released preemptively to “encourage e-cigarette companies and retailers, state, county and local health departments, public health organizations, and parents and educators to act immediately to curtail this crisis,” and the remaining data will be released in early 2019.

More recently, the FDA announced a public hearing in January to “obtain the public’s perspectives on the potential role drug therapies may play in the broader effort to eliminate youth e-cigarette and other tobacco product use.”

McGrath-Morrow said although it’s hard to predict what will happen in the future regarding restrictions on e-cigarette products, she anticipates that use amongst adolescents will continue to go up in the near future. But she added that some of the prevention strategies being implemented now may cause the trend to flatten out after several years.

“We were thinking this would continue to be a niche thing, that it’s going to be small groups of people using e-cigs,” McGrath-Morrow said. “Young kids didn’t find these pods were cool, but then Juul came out and presented this device that’s super cool to young people, and all of a sudden everything changed.”


Experts have criticized the marketing strategies of several e-cigarette brands, specifically Juul products. A recent CNN investigation found that e-cigarette manufacturers may be “following in the footsteps of Big Tobacco,” which targeted young populations to gain lifelong customers.

After the FDA published its updated guidelines preventing e-cigarette manufacturers from targeting youth, Juul phased out much of its social media content, but other entities, as well as individuals, may continue to advertise them on Instagram or Twitter. In this way, these products have developed the ability to “self-promote,” said Nicholas Chadi, MD, of Boston Children’s Hospital.

For example, one study published in May found that seven major Juul-related Instagram accounts that posted Juul-related content amassed over a quarter of a million followers total. However, the majority of these accounts may have been created by online vendors, according to the study.

Chadi said that social media could also be used to the advantage of the CDC or other regulatory bodies since it has the ability to reach millions of people very quickly and effectively.

“There’s definitely been a clear movement by the FDA to restrict the sale of e-cigarette products in many places such as corner stores and gas stations, so I do think e-cigarettes will become harder to purchase for younger people,” Chadi told MedPage Today. “But will that lead to decreased use? I’m not sure about that.”

“I would have a hard time imagining seeing such a large increase in 2019 as in 2018, but, if anything, I’m hoping rates will stabilize and eventually fall back down as there is more awareness about the issue,” he said.


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