To Vape or Not to Vape — Is That the Question?

By Paul Reisser
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A bearded man in the clouds of steam from electronic cigarette closeup. vaping man
iStockPhoto.com/PavelKant
What should you do if your kids have been vaping? Learn all you can about it and then start the conversation with them.

If you ask kids in middle or high school about vaping, you’ll probably hear them say that
it goes on all around them. Some may also say that they have tried it. And you may even get a “What’s the big deal?” pushback.

What, in fact, is the big deal? Why is the Centers for Disease Control and Prevention sounding alarms about the use of e-cigarettes? Why is the Food and Drug Administration seeking to regulate how, where and to whom they are sold?

Using e-cigarettes, also known as “vaping,” appears to be a safer alternative to smoking or chewing tobacco, at least for those who are struggling to quit using tobacco. For those who aren’t tobacco users — especially kids and teens — vaping is a bad idea. For some adolescents and young adults, vaping may actually be an onramp to a tobacco habit. And several tragic cases reported recently have raised new alarms. The problem: Some vaping products may provoke devastating and even deadly lung disease.

A dangerous addiction

Smoking tobacco products holds the dubious distinction of being extremely harmful to just about every part of the body. The facts are dismal. The latest (2014) version of the Surgeon General’s Report on the consequences of smoking noted:

Cigarette smoking is responsible for more than 480,000 deaths per year in the United States, including more than 41,000 deaths resulting from secondhand smoke exposure. This is about one in five deaths annually, or 1,300 deaths every day.

Worldwide, more than 7 million deaths per year are attributed to cigarette use. This habit is also linked to cancer (of the lungs, mouth, throat, vocal cords and esophagus), clogging of arteries, chronic lung disease and a wide assortment of other ailments.

If cigarettes are so harmful, why are they so hard for smokers to give up?  Because along with the many products of combustion sucked into the body with every puff, cigarettes also deliver nicotine to the bloodstream with spectacular efficiency. This substance has the unique ability to be both relaxing and stimulating, at least for adults. It is also incredibly addictive, both physically and psychologically. Those habituated to its effects will crave it, sometimes desperately, within a few hours after their last dose.

Smokers who are trying to quit will typically try various methods of delivering nicotine in order to stave off withdrawal symptoms. You no doubt have seen nicotine patches, gum and lozenges for sale. These can be helpful to varying degrees. But they don’t deliver the “hit” of nicotine delivered from cigarette smoke. And these delivery systems don’t supply the ritual of inhaling and blowing smoke that most users
find calming and enjoyable.

Enter the e-cigarette

A “smokeless, nontobacco cigarette” was patented in the United States in 1965, but the version that has more recently taken the world by storm was developed and introduced in China in 2004 and arrived in the U.S. not long thereafter. A variety of devices and brands of e-cigarettes (the “e” for “electronic”) have entered the marketplace since 2010 and have spread like (smokeless) wildfire.

E-cigarettes originally looked like cigarettes, but they have morphed into dozens of shapes and sizes. They all consist of a battery, a heating element and a liquid that is vaporized and inhaled. The liquid is water that normally contains flavoring, vegetable glycerin and propylene glycol (both of which disperse the other ingredients and create vapor when heated) — and variable amounts of nicotine. Variations in these components — along with different features, colors and styles — can dramatically impact the appeal and sales of e-cigarette devices.

Statistics about use

The National Institute on Drug Abuse’s 2018 “Monitoring the Future” survey of U.S. eighth, 10th and 12th graders reported some grim statistics. The percentage of high school seniors who said they had used vaping devices in the prior month nearly doubled between 2017 (11%) and 2018 (20.9%). Roughly one in 10 eighth graders (10.9%) reported that they had vaped in the past year.

Translated into raw numbers, that represents more than 3.5 million American middle and high school students vaping in 2018. Ask the administrators at your local high school and you will almost certainly hear that vaping — in class, in the rest rooms, inside and outside school grounds — has become a major disciplinary issue.

So what’s wrong with kids vaping? Let us count the ways:

Long-term impact

While inhaling flavored water vapor is generally recognized as less harmful than inhaling smoke, no one really knows what may be the long-term impact — on airways, lungs and the overall body — of repeated exposure to the compounds emitted by e-cigarettes. Kids and adults with asthma are likely to have their symptoms aggravated by inhaling e-cigarette vapor, for example, but that may be the tip of an iceberg whose size and destructive potential will not be recognized until decades have passed.

Lung disease

Several devastating and even lethal cases of acute lung disease linked to vaping have made headlines during the summer of 2019. No infectious organism (bacteria or virus) has been isolated as a cause, and investigators now speculate that a contaminant in some home-grown, street-purchased vaping products containing cannabinoids (marijuana’s active components) may provoke an intense reaction in the lung.

Kids’ exposure

The repeated exposure of young brains to nicotine is widely understood to be harmful. A series of “Flavors Hook Kids” commercials sponsored by the California Department of Public Health’s “TobaccoFreeCA” program vividly depicts kids with various states of agitation, isolation, learning difficulties, headaches and mood swings, all linked to the nicotine they are inhaling through their vaping devices. The tagline: “Nicotine = Brain Poison” is not a hyperbole. Nicotine is not a benign substance, especially for a young brain.

Speaking of young brains, the adolescent/young adult brain is still growing and maturing until about age 25. Not only does this affect judgment and risk-taking, but it also means that teenagers and young adults are more prone to addiction than older adults. For a real-world check, ask any long-term smoker (especially one who has had difficulty quitting) when he or she got started. You will invariably hear that it was during their teen years — or earlier. Very few people start smoking when they are 35 years old and have a spouse, kids and career.

Juuling

The e-cigarette brand Juul is the iPhone of vaping devices. It currently dominates the U.S. market. Started by two Stanford University graduate students, the San Francisco-based company burst out of the blocks in 2015. It took 2% of the U.S. e-cigarette market in 2016, 29% in 2017 and a whopping 73% in 2018. Indeed, the word Juuling has become synonymous with vaping.

By the end of 2018, Juul had 1,500 employees. In 2019, revenue hit $3 billion. This was enough for big tobacco owners to wake up and smell the vapor. The Altria Group Inc. — formerly Phillip Morris Companies, and one of the world’s largest manufacturers and marketers of tobacco products — spent $12.8 billion for a 35% stake in Juul Labs. In other words, if you can’t beat ’em, buy ’em.

Why did Juul emerge from the pack, so to speak, in such short order? Let us count the ways, because all of them impact their use by kids:

Appearance

The Juul device is slick and sleek. It looks like a flash drive. This makes it very easy to conceal.

Size

It doesn’t put out a lot of vapor or aroma. Therefore, it’s easier to use without being detected.

Flavors

To accompany the cool factor, Juul’s liquid “pods” (like hundreds of other vaping products) originally came in a variety of flavors. The flavors sounded appealing (or at least nonthreatening) to kids. Again, in response to some bad press, these have been renamed. Creme Brulee is now called Creme. Cool Mint is now Mint. Cool Cucumber is now Cucumber, and Fruit Medley is now Fruit.

Late in 2018, Juul also stopped selling fruit flavors in retail stores, though they’re still available online. They may reappear when retailers adopt a stricter age-verification system. It should be noted that the use of kid-friendly e-cigarette flavors — “cotton candy,” banana split,” “Gummy Bear,” and so on — is rampant in this industry.

Technology

Last, but definitely not least, Juul’s creators spent considerable time and effort developing and refining their technology. It made their device highly efficient at delivering nicotine. Thus, it replicated the “hit” that keeps tobacco users hooked on cigarettes.

Their website and other Juul pronouncements make this abundantly clear. Adam Bowen and James Monsees, who co-founded Juul Labs, had been long-time smokers. They “knew that a true alternative to cigarettes would have to offer a nicotine level found in no other alternative on the market.… The result was Juul.

The 5% strength Juul pods that are widely used in the U.S. and Canada each contain 59 mg of nicotine. Roughly, that is the amount contained in a pack of cigarettes (or 200 puffs worth). In Europe and Israel, lawmakers mandated that e-cigarette pods must contain one-third of that amount. This seriously impacted Juul’s international sales. Juul has introduced an alternative 3% strength pod with 35 mg of nicotine (though in fewer flavors), but is reportedly working on an alteration in its vapor. The alteration would  offer more effective delivery of nicotine despite reduced content.

Juul's purpose

Juul’s founders have stated — repeatedly and adamantly — that their sole purpose was to create a device that would allow smokers to quit. They had no interest in attracting nonsmokers or teenagers. However, their initial advertising campaigns and aggressive use of online marketing pushed all the right buttons. Their images were of attractive/hip people, slick and sleek like their product, having a great time using it. To their credit (and no doubt responding to public and governmental heat), Juul refocused its advertising. It took down those pages on Facebook and Instagram. Now its website is more than explicit about not marketing to kids and nonsmokers.  But unfortunately, a very long train has already left the station.

Talk about vaping

What should you do if you think your kid might be vaping? In a nutshell, find out. This has two components:

  • Ongoing big-picture efforts at home, including building and maintaining a loving relationship through the teen and young adult years, open and transparent communication, creating a family culture that makes drug use (of all kinds) unattractive, transmission of values, and a whole lot of prayer.
  • Opening specific dialogue about vaping in particular: Is it going on around you at school? Has anyone offered Juul or another vaping device to you? Have you tried it? Interrogation will be less effective than genuine interest, and some candid (and hopefully well-informed) discussion of the risks will go a lot further than a lecture.

If your kid is vaping

What should you do if your kid has been vaping? You’ll need to help her take this bull by the horns, which first requires understanding how big the bull really is. Again, without shaming and lecturing, try to find out what substance she’s using, how much and how often, and for how long she’s been using it. On one end of the spectrum, you may be dealing with experimentation and dabbling, which hopefully can be curtailed with some conversation about risks to be avoided. Perhaps by now she’s endured enough clouds of vapor in the lavatory, or seen some agitated behavior from a habituated vape user, and is now ready to steer clear of this product in the future.

If your adolescent or young adult is already a steady consumer of vaporized nicotine, you (and he) may have a bigger challenge ahead. Remind him that this substance is highly addictive, and that the original idea of the e-cigarette was to wean smokers to a (theoretically) safer product because they couldn’t successfully quit using nicotine gum, lozenges or patches. But once aboard the vaping train, how does one get off?

Withdrawal strategy

The skyrocketing use of these devices among adolescents, represents a whole new ballgame. There isn’t (yet) a well-established vaping withdrawal strategy, though a number of organizations are in the hunt. The Food and Drug Administration, for one, conducted hearings early in 2019 to obtain some expert opinion on possible treatments and strategies to help teens quit vaping.

For now it would appear that behavioral strategies are going to be at the first line of attack. The nonprofit Truth Initiative, which has mounted an active campaign to end tobacco (and more recently vaping) use for more than two decades, has created a text-messaging based program that teens can access by texting “DITCHJUUL” to 88709. Parents and other adults who want to help young people quit vaping can text “QUIT” to 202-899-7550.

Withdrawal symptoms

If anxiety, depression, headaches or other problems surface, visit your teen’s physician. Keep in mind that underlying anxiety and depression can contribute to a nicotine addiction rather than result from it, and these factors must not be ignored. Your teen’s doctor may or may not have an inside track on the latest approaches to nicotine withdrawal, but at the very least medical conditions such as iron deficiency or a thyroid malfunction — though rarely the primary problem, but simple to assess — can be ruled out.

You may need a referral to a professional who is qualified to provide medical management for depression and anxiety. Counseling, both for the addicted individual and his or her family, is definitely a good idea. Support from your pastor, as well as a trusted friend or relative who has had to navigate an addiction in the family, would be highly advisable. Last (but really first) and certainly not least, prayer should bathe the entire process.

Stay tuned

The story on vaping and nicotine addiction continues to unfold. For updates, continue to check websites such as:

© Paul Reisser. Used by permission. All rights reserved.

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Understand How to Respect and Love your Son Well

Why doesn’t my son listen to me? Have you ever asked that question? The truth is, how you see your son and talk to him has a significant effect on how he thinks and acts. That’s why we want to help you. In fact, we’ve created a free five-part video series called “Recognizing Your Son’s Need for Respect” that will help you understand how showing respect, rather than shaming and badgering, will serve to motivate and guide your son.
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About the Author

Paul Reisser

Dr. Paul Reisser is a private practice family physician in Thousand Oaks, Calif. Since earning his M.D. from the UCLA School of Medicine and completing his residency at Santa Monica Hospital, Dr. Reisser has accumulated more than 30 years of experience in the area of primary care medicine.

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