Clinicians and public health advocates have long recognized that tobacco and nicotine use can lead to adverse health effects. Years of public education and advocacy have steadily yielded lower rates of tobacco use among young people, but e-cigarettes and vaping devices are generating a new wave of nicotine addiction.

The e-cigarette or vaping use-associated lung injury (EVALI) epidemic led the public and policymakers to ask questions about the effects of e-cigarettes. However, the positive momentum was swallowed by the pandemic, and high-nicotine-content devices continue to counteract generations of tobacco prevention and cessation work.

Experts gathered on Wednesday, October 11, for Changing the Course of the Vaping Epidemic Through Advocacy, where they analyzed the public health implications of e-cigarette use and vaping, as well as best practices to drive deterrence among young people.

Adolescent e-cigarette use is associated with wheezing, asthma, excessive coughing, and bronchitis. People who use e-cigarettes are also at an increased risk for periodontal disease, gum disease, and even traumatic injuries or burns from device explosions.

“Unfortunately, today, we still have very limited data on the long-term effects of EVALI,” said Sarah E. Bauer, MD, Assistant Professor of Clinical Pediatrics, Indiana University School of Medicine.

Secondhand e-cigarette exposure is also hazardous for young people. Secondhand exposure is associated with increased odds of asthma attacks, bronchitic symptoms, and low birth weight when e-cigarettes are used during pregnancy.

Nicotine is also a poisonous substance. Data shared by Dr. Bauer showed only 1 mg to 4 mg of nicotine could be toxic to a child under 6 years old, depending on the child’s body weight. The number of calls to poison centers regarding e-cigarette exposure has nearly doubled since 2018.

The harmful health effects of e-cigarette use extend beyond physical manifestations. Nicotine is highly addictive and toxic to developing brains. The earlier an individual starts using nicotine-containing products, the harder it becomes to quit.

“We know that 90% of [adults who smoke] started using tobacco before 18 years of age, and the earlier you start using nicotine-containing products, the harder it is to quit and the stronger that addiction is,” Dr. Bauer said.

According to Dr. Bauer’s data, initiation of tobacco use in late childhood (9 to 10 years old) is associated with inferior cognitive performance and brain development. Adolescent nicotine use also disrupts normal brain development and primes behavioral susceptibility to drugs and addiction. It is also associated with symptoms of depression and anxiety among adolescents.

To combat youth use of e-cigarettes, it’s necessary to identify the reasons adolescents are drawn to them in the first place. Contributing factors include the variety of e-cigarette flavors and targeted marketing efforts specifically designed to appeal to young people.

“We know that 80% of adolescents who use an e-cigarette started with a flavored product,” said Susan Walley, MD, MHCM, NCTTS, Professor of Pediatrics at George Washington School of Medicine and Health Sciences.

According to Dr. Walley, there are more than 17,000 e-cigarette flavors available. Many are marketed with candy flavors that appeal to adolescents or younger children. She also shared that some e-cigarettes are designed to appear as recognizable cartoon characters, such as SpongeBob SquarePants.

While e-cigarette manufacturers have tried to differentiate their products from traditional cigarettes, they have continued to use a tried-and-true tactic with their advertising materials to glamorize smoking and associate it with sex appeal or popularity.

The challenge is daunting, but there are ways to challenge the proliferation of e-cigarette use. Many free resources are available online. The Stanford Tobacco Prevention Toolkit, the US Food and Drug Administration and Centers for Disease Control and Prevention websites, and more are filled with information that can be shared to illustrate and confront the effects of e-cigarettes and vaping. CHEST also offers an interactive tobacco dependence treatment toolkit.

Antismoking advocates can also appeal to several audiences for increased communal buy-in, said Session Chair, Evan L. Stepp, MD, FCCP, CPE, Associate Professor of Medicine, National Jewish Health. In addition to speaking with adolescents directly, advocates can discuss the harmful effects of e-cigarettes with parents, principals, and school boards. They can also appeal to local legislative bodies for popular regulatory policies like flavor bans.

Sucharita Kher, MD, Associate Professor of Medicine, Tufts University School of Medicine, emphasized that while discussing solutions to the EVALI epidemic, it’s essential to consider the health disparities among people of different races, ethnicities, socioeconomic statuses, and other factors. Tobacco-related disparities can lead to increased use and secondhand exposure, higher health care-related expenses, and poorer health outcomes.

“Health care communities such as ours should utilize the lessons learned from disparities in electronic cigarette use and combustible cigarette use to tackle the electronic cigarette epidemic,” Dr. Kher said, “and we really need a multipronged approach using clinical, research, and policy-related solutions to achieve health equity.”