Though they have fewer chemicals than traditional cigarettes, electronic cigarettes are not considered a healthy or safe alternative by local or national medical experts, yet they are becoming increasingly popular with youth.
Electronic cigarettes (also called e-cigarettes, vape pens, electronic nicotine delivery systems, or ENDS) are battery-powered inhalers that heat a liquid solution to create an aerosol mist which the user then inhales.
On the rise
In December 2018, the surgeon general declared youth e-cigarette usage to be an epidemic, saying that we must take "aggressive steps to protect our children from these highly potent products that risk exposing a new generation of people to nicotine."
According to the Center for Disease Control and Prevention statistics, vaping is on the rise among high schoolers. It found that between 2017 and 2018, vaping by high schoolers increased by 78%.
Marketing to youth
E-cigarette companies have been accused of marketing to youth. In 2016, the surgeon general report stated: "E-cigarettes are marketed by promoting flavors and using a wide variety of media channels and approaches that have been used in the past for marketing conventional tobacco products to youth and young adults."
A study published by the American Academy of Pediatrics in 2014 found that e-cigarette advertisements appeared frequently on television networks with youth appeal including Comedy Central, ABC Family and MTV.
In a foreword for the 2016 surgeon general's report, CDC Director Thomas Frieden said, "Companies are promoting their products through television and radio advertisements that use celebrities, sexual content and claims of independence to glamorize these addictive products and make them appealing to young people."
In addition to advertising, Jennifer Schaeffer, tobacco prevention coordinator at Southwest District Health Unit, said e-liquid comes in many kid-friendly flavors, such as bubblegum, gummy bear and Juicy Fruit.
The 2016-17 Population Assessment of Tobacco and Health Study found that 70.3% of respondents said they used e-cigarettes because they come in flavors they like.
Many of these products are not shaped like traditional cigarettes. Shapes similar to cellphones and USB drives make them easier to conceal from parents.
"I think what's appealing also to students is the many different ways you can vape and use devices. They don't necessarily look like a cigarette," said Schaeffer.
The amount and effects of Nicotine
Vaping can be harmful to teens due to the nicotine contained in many of the liquids. Nicotine is highly addictive and can affect the development of the prefrontal cortex — the area of the brain responsible for emotions — which doesn't finish developing until about the age of 25.
"The effects (of nicotine) include addiction, priming for use of other addictive substances, reduced impulse control, deficits in attention and cognition and mood disorders," stated U.S. Surgeon General Vivek Murthy in his 2016 report.
Some teens who vape may actually consume more nicotine than if they were to smoke traditional cigarettes.
"Some of the pods, one pod is equivalent to more than a pack of cigarettes. We do have some students report that they are using two pods a day ... These students don't realize how much nicotine they are getting," Schaeffer said.
It can be impossible to know whether your e-liquid even contains nicotine, and if it does, how much it contains — even though the bottles are labeled.
Kelly Buettner-Schmidt, an assistant professor of nursing at North Dakota State University, conducted research with her colleagues at NDSU in 2015 on the labeling of e-liquid bottles. She provided testimony to the North Dakota House Industry, Business and Labor Standing Committee on her findings on Jan. 28, 2019.
In a chemistry lab at NDSU, they analyzed 70 e-liquid refills with nicotine and determined that in many cases, the nicotine content was not labeled correctly on the bottle.
"Of the 70 bottles claiming nicotine, and allowing for a 10% variance from the labeled quantity of nicotine, 36 bottles, or 51%, were outside the labeled concentration. For these 36 bottles, 24 contained less nicotine and 12 contained more nicotine. Variation ranged from 66% below the labeled amount (2.0 mg/ml rather than the labeled amount of 6.0 mg/ml) to 172% above the labeled amount (13.6 mg/ml rather than the 5.0 mg/ml labeled amount)," Buettner-Schmidt told the committee.
Ten of the 23 bottles that were labeled as nicotine-free did have nicotine, with the average nicotine content being 0.19 mg/ml and the highest being 0.48 mg/ml.
In addition to nicotine, the U.S. Department of Health and Human Services found that e-cigarette liquids can contain volatile organic compounds such as benzene; ultrafine particles; heavy metals such as nickel, tin and lead; and cancer-causing chemicals such as benzene, formaldehyde and acetaldehyde.
"There are at least 10 chemicals within the liquid nicotine that may cause cancer," Schaeffer said.
The inhaled vapor can be harmful to lungs, as well. The U.S. Department of Health and Human Services links the chemical diacetyl, a flavoring in e-liquid, to lung disease.
"We are hearing of reports of a 19-year-old female having COPD, and she used vaping or ENDS for approximately one year ... Where we generally would see someone with COPD in their early 50s from using tobacco, we're seeing onset of COPD and those airway obstructions much earlier (with e-cigarettes)," Schaeffer said.
The North Dakota Department of Health and the US surgeon general acknowledge the need for further research on the effects of vaping, but both do not consider it harmless.
"The health effects and potentially harmful doses of heated and aerosolized constituents of e-cigarette liquids — including solvents, flavorants and toxicants — are not completely understood," stated Murthy in his 2016 report. "However, although e-cigarettes generally emit fewer toxicants than combustible tobacco products, we know that aerosol from e-cigarettes is not harmless."