5 Things to Know About Electronic Cigarettes

Here are 5 key points on electronic cigarette use that cover industry marketing methods, harmful substances, associated health risks, regulations, and its links to mental health as well as the COVID-19 pandemic. | Image Credit: brillianata - stock.adobe.com

Electronic cigarettes, or e-cigarettes, are especially popular among youth and pose significant health risks.¹ Despite being marketed as a safer alternative to traditional cigarettes, they contain harmful substances like nicotine and heavy metals.² Critics say the industry targets young people with appealing flavors and designs, leading to addiction and long-term health problems.¹

Here are the 5 things to know about e-cigarettes.

1. Industry marketing/youth targeting

In 2024, an estimated 38.4% of students reported using e-cigarettes frequently and 26.3% reported daily use.¹ The initial version of e-cigarettes entered the market in 2007, advertised as an alternative route for smoking cessation. By 2015, the emergence of the JUUL brought the nicotine market to a high-tech level, ultimately changing the game for disposable nicotine devices.

Since the invention of the JUUL, the disposable e-cigarette industry has increased over 46% in the total number of brands between January 2020 to December 2022. Between 2017 to 2022, e-cigarettes have almost tripled in nicotine strength, quintupled in e-liquid capacity, and dropped in price by nearly 70%. With few federal restrictions in place, e-cigarettes appeal to youth by marketing as candy- and food-flavored products, sometimes resembling toys, food, or cartoon characters. Over the past year, roughly 1.63 million middle school and high school students currently used e-cigarettes.

Experts say the e-cigarette industry targets youth because they are easily manipulated, still have developing brains, and can become long-term customers, dependent on a nicotine addiction.³

2. Harmful substances

It is important to note that not all e-cigarette devices are created the same, as products often differ in harmful substances.² The most common types of vapes include disposable e-cigarettes that come prefilled, refillable e-cigarettes that are rechargeable with a tank or chamber to refill with e-liquid, and e-cigarettes with a prefilled cartridge or pod that is intended for reuse. E-cigarette aerosol can include nicotine, cancer-causing chemicals, heavy metals, volatile organic compounds, and flavorings like diacetyl linked to serious lung disease.

In some cases, flavorings found in e-cigarettes may be safe for consumption but dangerous for inhalation because the gut and lungs process substances differently. It can also be extremely difficult to know which substances are contained in an e-cigarette because companies are not transparent with their marketing, often claiming products are nicotine-free even though they are found to contain nicotine. Additionally, a large majority of e-cigarettes contain nicotine salts that allow individuals to consume high amounts of nicotine without experiencing the harshness of freebase nicotine.

3. Health risks

Despite Big Tobacco’s efforts to advertise e-cigarettes as “safer” alternatives to cigarettes, they are still linked to various health concerns.¹ Nicotine, a key ingredient, can harm brain development and increase addiction risk. The specific health risks associated with e-cigarettes can vary depending on usage patterns and device characteristics.

Increased risks of breathing problems, frequent cases of bronchitis, and lung infections are linked to e-cigarette use.⁴ Nicotine levels in e-cigarettes increase heart rates, raise blood pressure, and irritate blood vessels, all seen in people who smoke regular cigarettes too.

E-cigarette use, especially among youth, can harm brain development and lead to long-term health consequences. While long-term studies are limited, the potential risks are significant and require further investigation.

4. Regulations

In January 2020, the FDA banned unauthorized flavored e-cigarettes appealing to youth, such as fruit and mint flavors.⁵ Companies that failed to comply faced enforcement actions within 30 days. The FDA also prioritized enforcement against manufacturers that did not prevent youth access and required companies to submit applications demonstrating product safety as well as appropriateness.

As of June 2024, all US states and territories have banned the sale of e-cigarettes to minors.⁶ Many states also require a retail license for over-the-counter sales and have included e-cigarettes in smokefree indoor air laws.

Several states have implemented taxes on e-cigarettes, either based on volume or a percentage of cost. Recently, the US Supreme Court reviewed the FDA's ban on flavored e-cigarettes, which are often marketed to youth.⁷ Concerns have been raised about potential deregulation under the Trump administration after President-elect Donald Trump vowed to “save vaping” in a Truth Social post.⁸

5. Mental health/COVID-19

The youth vaping and mental health crises are intertwined, with both worsening during the COVID-19 pandemic.⁹ Prepandemic, 70% of youth perceived anxiety and depression as major issues, a trend amplified by the pandemic. E-cigarette use may further increase mental health risks, with current users twice as likely to be diagnosed with depression.

Surveys have found many young people vape to cope with anxiety, stress, and depression, but vaping can worsen these symptoms. Nicotine withdrawal can exacerbate these mental health issues, creating a cycle of addiction and worsened mental health.

The COVID-19 pandemic has contributed to the increased levels of e-cigarette use and mental health challenges. About 78% of individuals who vaped during the pandemic reported they vape the same or more now. Despite returning to in-person learning, many students anticipate continued or increased vaping rates among their peers.

Quitting vaping can significantly improve mental health by reducing anxiety, depression, and stress. Despite high e-cigarette usage, many young vapers express interest in quitting, with a significant portion making recent quit attempts or planning to quit soon.

Given the urgent need to reduce youth e-cigarette use, especially in the postpandemic era, current efforts like flavor bans, nicotine restrictions, taxation, and premarket review are positive steps. However, further measures such as limiting adult access, regulating internet sales, and ensuring age-appropriate marketing are crucial for future public health initiatives.

References

1. E-cigarettes. News release. Truth Initiative; October 2024. Accessed December 17, 2024. https://truthinitiative.org/sites/default/files/media/files/2024/10/E-Cigarette%20Factsheet_10.24.pdf

2. About e-cigarettes (vapes). CDC. May 9, 2024. Accessed December 17, 2024. https://www.cdc.gov/tobacco/e-cigarettes/about.html

3. Marketing to the youth of America: how e-cigarette companies target young people. Addiction Prevention Coalition. June 28, 2021. Accessed December 17, 2024. https://apcbham.org/marketing-to-the-youth-of-america-how-e-cigarette-companies-target-young-people/

4. E-cigarettes and vaping. American Cancer Society. November 19, 2024. Accessed December 17, 2024. https://www.cancer.org/cancer/risk-prevention/tobacco/e-cigarettes-vaping.html

5. FDA finalizes enforcement policy on unauthorized flavored cartridge-based e-cigarettes that appeal to children, including fruit and mint. News release. FDA; January 2, 2020. Accessed December 17, 2024. https://www.fda.gov/news-events/press-announcements/fda-finalizes-enforcement-policy-unauthorized-flavored-cartridge-based-e-cigarettes-appeal-children

6. STATE system e-cigarette fact sheet. CDC. March 18, 2020. Accessed December 17, 2024. https://www.cdc.gov/statesystem/factsheets/ecigarette/ECigarette.html

7. Kruzel J, Chung A. US Supreme Court wrestles with FDA denial of flavored vape products. Reuters. December 2, 2024. Accessed December 17, 2024. https://www.reuters.com/legal/us-supreme-court-scrutinize-fda-denial-flavored-vape-products-2024-12-02/

8. Ventura J. Trump vows to “save vaping” despite previous support for ban. The Hill. September 21, 2024. Accessed December 18, 2024. https://thehill.com/policy/healthcare/4892387-trump-vaping-ban-post/

9. Colliding crises: youth mental health and nicotine use. Truth Initiative. September 19, 2021. Accessed December 17, 2024. https://truthinitiative.org/research-resources/emerging-tobacco-products/colliding-crises-youth-mental-health-and-nicotine-use