If you feel like you see a vape shop on every corner, you’re not imagining things. The use of e-cigarettes has exploded in the past several years, especially among young people.
Between 2011 and 2019, the number of high school students using e-cigarettes grew from 1.5% to 27.5%, according to the 2019 National Youth Tobacco Survey.
Cigarette smoking rates, meanwhile, continue to drop — 5.8% of high school students smoked in 2019, down from 15.8% in 2011. So while many teens wouldn’t give traditional cigarettes the time of day, many are clearly willing to try e-cigarettes.
Today’s e-cigarettes are discreet, have a high-tech look, and contain more nicotine than before, all of which drives their popularity.
“Advertising brings the horse to water, flavors is what gets them to drink, and nicotine is what keeps them coming back,” says Brian King, PhD, deputy director for research translation for the Centers for Disease Control and Prevention’s Office on Smoking and Health.
A false sense of safety
E-cigarettes first came on the market in 2007 in a no-man’s land of regulation. The Food and Drug Administration (FDA) didn’t have the authority to regulate them as a tobacco product until 2016. That’s when it became illegal to sell e-cigarettes to anyone younger than 18 (the FDA has since changed the age limit to 21 for all tobacco products, including e-cigarettes).
E-cigarette companies have also marketed their products as a cleaner or safer alternative to cigarettes. All of which reinforced the misconception of e-cigarettes as safe, says Azure Thompson, PhD, assistant professor in the School of Public Health at SUNY Downstate Health Sciences University in New York City.
Teens are especially prone to underestimate the risk. When students were asked in the 2019 National Youth Tobacco Survey which tobacco products they perceived as causing no harm or little harm when used some days, but not every day, 28.2% said e-cigarettes, compared to 9.5% for cigarettes. The Centers for Disease Control and Prevention (CDC) notes that many young people report using e-cigarettes because they think they are less harmful than traditional cigarettes.
“There was so much success in preventing teen cigarette use and stigmatizing cigarettes,” Thompson says, that e-cigarettes “felt like a safer product.”
Many of the efforts that worked to knock down cigarette smoking rates in adults and teens — health campaigns, higher taxes, age restrictions, and making smoking hard to do both indoors and even out — also left an opening for e-cigarettes.
Many people don’t know that almost all e-cigarettes contain nicotine. A CDC study found that 99% of all e-cigarette products have nicotine, even those claiming not to. In a 2019 study in Pediatrics, 40% of the survey participants (all between the ages of 12 and 21), who said they were using nicotine-free products, showed high levels of cotinine, a compound found in tobacco, in their systems.
“A lot of people think e-cigarettes are just harmless water vapor with yummy flavors,” says Linda Richter, PhD, director of policy research and analysis at the Center on Addiction.
And despite the fact that the target audience for e-cigarettes was supposed to be existing adult cigarette smokers, the look, taste and branding of e-cigarettes all have a very youthful appeal, Richter says.
Lured by flavors
When it comes to why teens themselves say they vape, many of their reasons have a social connection. In the 2019 National Youth Tobacco Survey, middle and high school students named their top reasons for trying e-cigarettes as:
“They see a friend or family member vaping, and they want to try it,” Richter says. “They like to do the vaping tricks, like making big clouds, and they really, really like the flavors.”
When most teens try an e-cigarette for the first time, it’s one with flavoring, according to the CDC, and teens who use e-cigarettes with flavored liquid vape longer, too.
The FDA recently announced that it was banning the sale of all flavors, except menthol and tobacco, in prepackaged pods and cartridges used in rechargeable devices. In response, some top brands have stopped selling fruit, candy, and mint flavors. There is some worry, though, that if menthol is still in the mix, teens will simply make the switch. In 2019, 57.3% of high school students who vaped used mint or menthol e-cigarettes.
There are also some very large loopholes in the flavor ban. Disposable e-cigarettes can still be sold in flavors like fruit or candy. Vape shops can also still sell flavored e-liquids for refillable devices. Physical retail stores, including vape shops, are where 74% of young people buy e-cigarettes, according to a 2018 survey by the Truth Initiative.
The loophole has led to the rise in popularity among flavored disposable e-cigarettes that come pre-charged and pre-filled, according to the Truth Initiative. Most of these disposable e-cigarettes are cheaper than non-disposable devices and contain as much nicotine as some popular pods.
The draw of devices The change in the way e-cigarettes look has also made it easier for teens to vape more often. “E-cigarettes look cool, they look like tech devices, and they’re easy to hide,” Richter says.
Between 2017 and 2018, e-cigarette use surged among high school students by 78%. The CDC says this “is likely because of the recent popularity of e-cigarettes shaped like a USB flash drive. These products can be used discreetly, have a high nicotine content, and come in flavors that appeal to youths.”
Some e-cigarettes also now produce less aerosol and very little scent, making them much easier to use indoors without being detected, Thompson says. “People can take a puff or two, and put it right back in their pocket,” she says.
And the more kids who vape, the more it becomes a normal part of a teen’s experience, increasing the likelihood of more kids who will try vaping, Richter says.
“When you ask kids how many kids are vaping in their school, they say, ‘Everyone,’” she says. “The numbers are high, but it’s not everyone, it’s still a minority. But kids’ perception of how common something is is a subtle form of peer pressure.”
A “nicotine arms race”
The nicotine content in e-cigarettes also has continued to go up. That’s largely because some e-cigarettes contain nicotine salts instead of freebase nicotine, which allows for a higher level to be absorbed more quickly, and with less irritation.
“There’s a nicotine arms race going on,” Richter says. “Companies are busy upping their doses of nicotine.”
A study that looked at e-cigarette sales between 2013-2018 found that not only did the average nicotine concentration in e-cigarettes go up, but sales of e-cigarettes with 4% or greater nicotine concentration increased from 12.3% of the market to 74.7%. Zero-nicotine products made up less than 1% of the market share for all years.
The United States doesn’t restrict the amount of nicotine in e-cigarettes.
Nicotine is very addictive, King says, and young, developing brains are especially susceptible. “Nicotine salts deliver nicotine more efficiently across the blood/brain barrier. That means greater potential for nicotine addiction among kids,” he says.
Using e-cigarettes to vape cannabis is rising, too. From 2018 to 2019, the percentage of high school seniors who vaped cannabis in the past month increased from 7.5% to 14%, according to the National Institutes of Health’s 2019 Monitoring the Future survey.
To lower the number of young people who vape, many states and cities have enacted restrictions on the sale of flavored e-cigarettes and have increased taxes on e-cigarette sales.
“Some of these products have very high doses of nicotine; it’s easy to get hooked quickly,” Richter says. “The best thing we can do is try to prevent young people from starting vaping or help them quit before they get too involved.”
JENNIFER THOMAS
Rally Health
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