Up in Smoke

A parade of restless clouds moved along the still-gray morning sky as 13-year-old Kaylee Musick waited for the school bus. Huddled in a small group of friends, the girl pushed wisps of strawberry blond hair off her freckled face and rolled her eyes toward two teenage boys standing 20 feet to her left.

A donut-shaped puff of smoke spun upward from the center of the group. There were no cigarettes, no lighters. Only the slender metal tube of an e-cigarette wobbling between the lips of her schoolmate.

It is illegal to sell e-cigarettes to anyone under the age of 18 in Virginia. It is even illegal for those under 18 to be in possession of them. Still, standing there on the street corner waiting for the school bus, the boys take turns inhaling wild cherry-flavored vapors from the battery-operated device.

“Vaping is the cool thing to do right now, so a lot of kids are trying it just to say they have,” Miss Musick says. “It’s new and different and I guess the flavors and the cool tricks make vaping popular.”

E-cigarettes are battery-operated metal tubes that heat up flavored liquids (often marketed as "juice") and are typically laced with nicotine. They deliver vapor when inhaled.

An avid middle-school track runner, Miss Musick hasn’t tried e-cigarettes. She doesn’t intend to, either. With a long line of smokers in her family, she knows all too well that nicotine is an addictive substance.

“I don’t see it being safe, no matter what they try to tell you,” she says. “They used to say cigarettes were safe, too, right?”

Teen use rises at alarming rate

Miss Musick’s disdain for vaping is in stark contrast to the growing trend of U.S. teenagers whose e-cigarette use has tripled in the last year alone. Figures recently released by the Centers for Disease Control and Prevention (CDC) show that e-cigarette use by U.S. tweens and teens tripled in 2014 to 13.4 percent, up from just 4.5 percent in 2013. Today, an estimated 2 million high-school students and 450,000 middle-school students nationwide are experimenting with vaping.

According to the CDC survey, there is a pervasive belief among teens that vaping is a safe alternative to smoking. E-cigarette kiosks have popped up at malls and in convenience stores — places teens frequent. All of them market flavors like pina colada, cola, blueberry muffin and gummy bear, which appeal to younger consumers.

“What is alarming is that we are seeing teens picking up e-cigarettes who have never smoked before, so this is a whole new generation of smokers being created,” says Kelli England Will, PhD, Associate Professor of Pediatrics. “There has been so much successful work done to curb tobacco use and now we are seeing this trend unravel some of that work.”

Dr. Will recently was awarded a three-year, $430,000 grant by the Virginia Foundation for Healthy Youth to study Hampton Roads tween and teen experiences with and perspectives on e-cigarettes. This community-wide research, which began July 1, includes partnerships with CINCH (Consortium for Infant and Child Health) and the YMCA of South Hampton Roads. Together, they are exploring why youth are picking up the vaping habit at such alarming rates. They also will develop outreach campaigns to help turn the tide on the trendiness of e-cigarettes.

“We need to get at the root of what teenagers know and what their attitudes are toward vaping,” Dr. Will says. She believes the research will lead to much more work that can be valuable at the regional, state and national levels.

Amy Paulson, MPH, Instructor of Pediatrics; Matt Herman, MPH, Instructor of Pediatrics; and Andrew Plunk, PhD, Assistant Professor of Pediatrics, all from the division of Pediatrics Community Health and Research, will work with Dr. Will on the project. A 25-member Teen Advisory Council and a community panel of subject matter experts in public health and the related sciences also will play key roles in the research process.

Nearly 8,000 flavors are available through e-cigarette websites and in non-specialty stores, including gas stations and convenience stores.

“The power of community engagement and partnership is invaluable for this research because no one has done this type of research yet, so there are big implications nationally, ” Ms. Paulson says. “We need teenagers to help us develop messages that will resonate with their peers and then tell us the best ways to reach them with those messages, whether that’s on social media or some other type of campaign.”

The YMCA of South Hampton Roads is helping to organize the Teen Council and has agreed to pilot the outreach campaigns once developed.

“When there is something of this magnitude affecting the youth of today, we know we have a responsibility to get involved,” says Lynn Skeele-Flynn, Senior Vice President of Leadership Development for the regional YMCA. “We want to be an educational resource for teens in the community and help them to make good choices about their health and well-being.”

To vape or not to vape

Researchers at EVMS aren’t the only ones concerned about the rise in popularity of vaping.

Patients being seen by Joshua Sill, MD, Associate Professor of Internal Medicine, are often eager to talk about alternatives to traditional cigarette use. Many ask about vaping and wonder if it is a safer option. He is hesitant to endorse patient use of e-cigarettes as a cessation tool, because, as he points out, no nicotine is still the best answer.

Especially since research from the University of Toronto finds that e-cigarettes don’t help smokers quit.

“Often people are replacing one habit for another or both vaping and smoking,” Dr. Sill says. “Plus, people — especially teenagers — are using them even if they haven’t smoked before, and that is introducing a nicotine habit where there wasn’t one to begin with.”

The 2012 Surgeon General’s Report found that about 90 percent of smokers first tried cigarettes as teens; and that about 75 percent of teen smokers continue into adulthood. National campaigns such as The Truth target ending teen cigarette use and have been lauded as highly successful. Officials like Mitch Zeller, JD, Director of the U.S. Food and Drug Administration’s Center for Tobacco Products, are worried about what the new statistics may indicate.

“The surge in youth use of novel products like e-cigarettes,” Mr. Zellar says, “forces us to confront the reality that the progress we have made in reducing youth cigarette smoking rates is being threatened.”

As a country, we have done a good job of teaching the dangers of tobacco use, but the perception that e-cigarettes are OK from an overall health perspective is a dangerous thing.

Part of the problem, experts argue, is the insufficient research on the safety or hazards of vaping. “We just don’t have the experience of people vaping for 30 years the way we do chain smoking,” Dr. Sill says. “We may very well find out 30 years from now that it is just as problematic.”

Some recent studies found that heating the liquids in e-cigarettes to very high temperatures could release formaldehyde, a carcinogen. Medical experts have long known that nicotine taxes the cardiovascular system and can contribute to hypertension, heart attacks and strokes.

Plus, an overdose of nicotine can be toxic, especially in children. Last year the American Association of Poison Control Centers reported nearly 4,000 liquid nicotine poison cases — over half involving children younger than 6.

“As a country,” Dr. Sill says, “we have done a good job of teaching the dangers of tobacco use, but the perception that e-cigarettes are OK from an overall health perspective is a dangerous thing.”

Especially for teenagers, says Miss Musick.

“I’m lucky,” she says, “because I know from watching my grandpa and my parents that I don’t ever want to smoke, and vaping, in my mind, could lead to that. Not all my friends think like that, though. If kids think it is safe and cool, they might just try it —and that is what people should be worried about.”