NCAD Spotlight: Youth Drawn to E-Cigarette Products, Despite Higher Risks

Despite the increased risks e-cigarettes and other vaping products pose to youth and young adults, use of the devices by younger populations has skyrocketed in recent years, says Brian King, PhD, MPH.

Flavorings and easier-to-consume nicotine formulations have been two key drivers of use among young people, says King, the deputy director for research translation at the CDC’s Office on Smoking and Health.

King will present on the rise of vaping at the upcoming virtual National Conference on Addiction Disorders. Ahead of the event, he spoke with Addiction Professional about why e-cigarettes are a greater risk to youth and young adults, why they are appealing to young people, and what interventions are being implemented to combat the challenge.

Editor’s note: This interview has been edited for length and clarity.

Why are e-cigarettes and other electronic tobacco products of particular to risk youth and young adults?

One of the common factors in all of e-cigarettes is that they contain nicotine. We know nicotine is not only highly addictive, but also particularly problematic with youth and young adults because nicotine can harm the developing brain, which continues to develop until about age 25. It specifically impacts the part of the brain called the prefrontal cortex, which is responsible for memory, learning and cognition. Assaulting the brain with a psychoactive substance like nicotine during this vulnerable period can have long-lasting effects.

But it’s not just the nicotine in e-cigarettes that can be dangerous. We also know the aerosol emitted by these products is not harmless. It can contain other harmful ingredients, including ultrafine particles that can get into the lungs, cancer-causing materials, heavy metals, as well as other potential concerns. The bottom line is the use of e-cigarettes is unsafe in young adults, primarily because of nicotine exposure, but there are other harmful ingredients in the aerosol for these populations.

Do you find these populations are more interested in trying these products?

If you look at the different factors that influence use of e-cigarettes among young people, the advertising will lead a horse to water, the flavors will get them to drink, and the nicotine will keep them coming back for more. That’s the trifecta of factors influencing the use of these products. It’s the prominent advertising, particularly via social media and using themes we’ve previously known have influenced use of other types of tobacco products, like cigarettes. It’s also the flavoring in these products, which are frequently kid-friendly. We know about 70% of youth e-cigarette users report using flavored varieties, and we know flavors are among the primary reasons for using these products. In addition to flavors, we know there are high levels of nicotine.

The products have changed in terms of nicotine formulations in recent years. They no longer use the free-base nicotine we’re used to for e-cigarettes and regular cigarettes. They now use the new type called nicotine salts. These nicotine salts allow higher levels of nicotine and can go down a lot easier. The reason that’s a concern, particularly for youths and young adults, is that these are people who have never been exposed to nicotine. If you have a device delivering higher levels of nicotine more efficiently across the blood-brain barrier, there’s a higher likelihood of dependence and addiction. In recent years, since nicotine salt products have entered the marketplace, we not only see higher numbers of youth using e-cigarettes, but among those who are using the product, there’s also higher frequency of use. That demonstrates the higher levels of nicotine is resulting in higher levels of dependency among youth, which is highly problematic because we know how addictive nicotine is to begin with. If you institute factors that make it more likely someone is going to initiate and stick with it, that ultimately has long-term implications.

What other trends around use have you observed within the past couple years? Do you see any alarming indicators about where we’re heading?

The e-cigarette landscape in the United States has been incredibly volatile. These products entered the marketplace in 2007, but we didn’t start to see an increase in use of the products until 2011-12. Since that time, we’ve seen astronomical increases in use among youth in particular, to the point in 2018 that the surgeon general called e-cigarette use among youth an epidemic.

The reason was because we’ve seen unprecedented use of the product in recent years. From 2011-15, we saw about a 600% increase in the use of e-cigarettes among youth. That started to decline in 2016-17. We believe that’s because we started to implement interventions like youth access restrictions, increasing the price and media campaigns warning about the risk. And then something happened around 2017, and that was the advent of these new types of e-cigarettes called “pod mods,” like Juul, that have a pod the user replaces with the e-liquid of their preference. And with the advent of those products, there has been nicotine salts and we saw a considerable increase in youth use. Just to put it into context, between 2017-18, we saw an 80% increase in e-cigarette use among high school students and a 30% increase among middle school students. We’ve been measuring youth substance use in this country for the past 40 years, and that was the single greatest year-over-year increase for any substance ever. It’s simply unprecedented, these increases. In 2019, we saw even higher levels of use of these products among youth to the point where about 27% of U.S. high school students reported using e-cigarettes.

What’s very startling is that’s markedly higher than what we see among adults. In comparison, we see about 3% of U.S. adults report using e-cigarettes. That’s why it’s so essential we have public health interventions in place to prevent youth use and access to these products. You have exceedingly prominent use among a population for which there is absolutely no redeeming aspects of these products.

We’ve seen the work of a lot of the presenters at NCAD has been impacted by the COVID-19 pandemic in recent months. Is there anything related e-cigarettes that has changed or been impacted as a result of the pandemic?

We have data emerging from a variety of sources in terms of people who are getting COVID-19 and what their tobacco use patterns are and also the broader landscape around use patterns. Unfortunately, we’re still in the preliminary stages of receiving data, so it’s hard to put a picture around patterns of use. When it comes to the actual sales of products, including cigarettes and e-cigarettes, the available data we have shows there was a marked uptick in sales of these products. We believe that was stockpiling behaviors where people knew stay-at-home orders were occurring, so they initially purchased large volumes of these products. But shortly after, as the pandemic continued, we saw declines in the sales of these products, which was likely a period when people were utilizing their stockpiles they had amassed. Over time, we’re now seeing declining rates of sales following that initial spike.

That being said, we don’t yet have strong data in terms of the actual self-reported use behaviors of these products. It could go either way in terms of with the stay-at-home restrictions. It may be more difficult for people to access these products unless they get them from the Internet. But on balance, people may have more disposable time on their hands where they could be home and not otherwise at school and using these products. The jury’s still out on what the ultimate impact will be.

In term of the potential impact of e-cigarettes on COVID-19 risk, the current available evidence is inconclusive in terms of any potential relationship. We do know people who smoke regular cigarettes may be at greater risk for more severe disease from COVID-19, but we continue to investigate those potential associations as data come in from various sources. In terms of the e-cigarette landscape, it’s likely to be later this year as we have more data at the national and state levels to really see what the population-level impact of COVID-19 has been on a variety of substance use behaviors, including e-cigarettes.