The rate of teens using electronic cigarettes has more than doubled in two years, the largest and quickest increase in the popularity of any substance since tracking began 45 years ago.
That data was published this week in the New England Journal of Medicine — months ahead of schedule — just as national health officials try to pinpoint why at least 530 people have been hospitalized and seven died after using vaping products. Most hospitalized were male and under age 35. One in six were under 18.
Dr. Anne Schuchat, principal deputy director of the Centers for Disease Control and Prevention, said Thursday that she is “very concerned about the occurrence of life-threatening illness in otherwise healthy young people.”
“We are working closely with state and local health departments, the FDA and the clinical community to try to learn as much as we can to try to stop this outbreak,” she said. “I wish we had more answers.”
To date, federal authorities say they have not identified a single vaping product, ingredient, device or brand that is consistent across all the cases. Nor do they expect clear answers anytime soon.
“I know that this is very frustrating for the public,” Schuchat said. “This may take some time.”
The current spotlight on vaping’s harm has brought into focus two intertwined fears of public health experts: Years without regulation let a hazardous product gain a cultural foothold, and the health risks disproportionately fell on the developing brains and bodies of young adults.
An estimated 25% of high school seniors vaped nicotine in the past month this year, up from 11% just two years ago, according to a portion of the 2019 Monitoring the Future Survey funded by the National Institute on Drug Abuse. Use grew from 8.2% to 20.2% for sophomores and 3.5% to 9% for eighth graders.
Figures tracking the popularity of other vaping products, such as those that are nicotine-free or include THC or CBD, will not be released until December.
In Texas, 10 percent of high school students reported vaping in the past month, ranking it No. 34 nationwide among 37 states reporting data in the 2017 national Youth Risk Behavior Survey.
Altogether, vaping is more popular than alcohol, marijuana or cigarettes among teens, the most recent full release of the national survey showed.
Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse, has monitored the rising and falling popularity of various substances for his whole career. Vaping stands apart, he said, for its quick adoption and the number of teens who use on a regular basis.
“We know from many, many studies that drug use that begins early progresses to addiction and continued long-term use,” he said, citing 2019 figures that have not yet been released to the public. “One of the facts that really surprised me is how frequently teens are using on a daily or near daily basis — 11.7% of the 12th graders reported near daily use of these vaping devices; 7% of the 10th graders and 2% of the eighth graders. ... This is not just a casual, occasional or experimental basis, but a much more habit-like pattern.”
Some vapers quit
At the end of August, the CDC issued a health advisory, warning that people had rapidly developed severe pulmonary disease from using e-cigarettes and that one person in Illinois had died.
Officials expect the numbers will continue to grow as new people become ill and states identify other cases that were not initially flagged as related to vaping.
Some states have reported that many of their cases involved patients who vaped THC products, but CDC officials noted that some of the people who have been hospitalized did not.
It’s possible that there are separate causes and the increased public awareness about vaping injuries has simply led doctors and patients to report them more often and more quickly.
“We don’t know if there’s a single exposure that’s the problem or multiple. We’re exploring multiple hypotheses,” Schuchat said. “We don’t want to prematurely reassure people about anything in particular in case it were to turn out to be quite risky. That’s happened before in some outbreaks where we’ve said it was a certain kind of food and it turned out to be a different kind of food.”
Some vapers defend the practice and say the media’s publicization of cases is just a scare tactic.
Carl Gula, a 27-year-old distributor of vape cotton in Oregon, said the real problems originate with people who vape illegally and use black-market products. He said he even wrote letters to Congress and called the White House hotline to complain.
For other vapers, it’s become difficult to distinguish between the health risks of each particular product and the ones they’re using. They have decided to quit altogether.
Victoria Gray, a 19-year-old roofing contractor in Oklahoma, filmed a Twitter video of her and her friend throwing their Juul devices into a trash bin with the hashtag #byebyeJuul. It has received more than 175,000 views.
“This is us saying a final goodbye and we’re starting a movement,” Gray said in the video.
Gray told GateHouse Media she started vaping two years ago because she thought it was cool, but she started getting concerned about her growing dependence on nicotine lately. Then came the recent deaths and illnesses.
“Teenagers shouldn't be getting these addictions for no reason, just because it's cool,” Gray said. “You're not smoking a vape to stop smoking cigarettes.”
The video was Gray’s effort to convince other teens to quit vaping, too.
Also recently quitting was Tony Graves, a 23-year-old from Oregon.
He started vaping two years ago when it was “the new big thing” and “a social thing to do.” But then one of his vaping friends needed lung surgery.
“He's been having really bad problems breathing,” Graves said. “He was coughing up blood.”
Both Graves and his friend smoked one pod per day, he said of the container for vaping fluid, adding that the doctor blamed vaping for his friend’s condition. Because the legal vaping age in Oregon is 21, Graves’ friend, who is 18, declined to comment for this story.
Graves recently tossed his Juul vaping device, posting a video on Twitter of him throwing the stick and several cartridges into a rain-filled gutter. He intended it to be a message to his friends, but it has since gone viral, receiving more than 136,400 likes.
“I've tried to stop a couple of times, but it never worked out,” Graves said. “And finally, I just got the motivation to completely cut it off.”
A month ago, e-cigarettes were more often seen as a cultural force than a health hazard.
Instagram influencers touted their custom mods and posed with sponsored liquid brands, up to a third of teens and young adults vaped, inhaling heated clouds of “juices” whose ingredients are unknown and unregulated. YouTube videos showed users how to adapt devices for marijuana or illicit drugs.
But now, e-cigarettes are considered a pressing public health threat by many doctors, parents and political leaders. President Donald Trump has threatened to ban their sale. At least two states — Michigan and New York — approved a new ban in recent weeks.
In July, the American Academy of Pediatrics and others won a lawsuit against the FDA, which had repeatedly pushed back a deadline for manufacturers to disclose complete ingredient lists. Now, the judge said, companies must start submitting those applications in May 2020 instead of 2022.
Deborah Arducan, a 60-year-old former phlebotomist in Missouri, counts herself among Americans who are increasingly vocal about their frustrations that federal leaders have taken so long to regulate e-cigarettes — and to protect kids, in particular, from their harms.
“The government should have jumped on that quicker,” Arducan said. “A lot quicker.”
Arducan started to smoke traditional cigarettes when she was 12 and continues to smoke despite several failed attempts to quit. About a year ago, she tried vaping nicotine for the first time, hopeful that it could finally help her break the habit.
But she said she “coughed (her) head off” and returned to burned tobacco. In hindsight, she said, she’s glad she returned to traditional cigarettes amid news reports about the ongoing outbreak of lung diseases and deaths.
“'I’m angry because anybody's child dying over this is one child too many. Cigarettes do kill but they took years and years and decades,” Arducan said. “And nobody could say what was in (vaping liquids). Nobody. Nobody cared.”
By the time the FDA set rules for vaping manufacturers and retailers in 2016, at least 15 other countries had banned their sale and even more had been regulating them for years.
In May 2016, a Wells Fargo analyst estimated the global vapor market was worth $4.1 billion. ResearchAndMarkets.com put its value at $9.4 billion in 2017 and P&S Market Research forecasted recently that it would reach $48 billion by 2023.
Analysts tie the booming growth to increased awareness about the harms of traditional tobacco smoking and “growing popularity among millennials owing to availability of large number of flavors,” wrote ResearchAndMarkets.com in March 2019.
“As the United States e-cigarette market booms, the different manufacturers are eking out new, niche flavors,” the group wrote, noting in particular that vaping has become more common among middle and high school students. “Along with that they are using social media platforms for mass marketing, to earn big profits year-on-year.”
As popularity of e-cigarettes grew, doctors and researchers started to consider the implications for public health.
Since regulators have not yet required manufacturers to disclose their ingredients, initial studies tested vapor products to better understand what is in them.
They found ultrafine particles that can be inhaled deep into lung tissue and cause damage; diacetyl, a flavoring chemical linked to a serious lung disease; volatile organic compounds known to cause causes or diseases; carcinogens like benzene and formaldehyde; and heavy metals such as nickel, tin and lead.
FDA tests also found that some liquids marketed as being nicotine-free did, in fact, contain nicotine, a chemical known for harming brain development, among other issues.
Compton, the deputy director at NIDA, also noted that most of the flavorings used in vaping liquids were tested for consumption — not for inhalation.
“Most of the flavorings used that we see have undergone very little testing when it comes to administration directly to our lungs,” he said. “That’s a new area of scientific study right now.”
He said the general consensus is that it’s safer to use e-cigarettes than to smoke traditional cigarettes, simply because they contain fewer chemicals. While some studies have suggested they are helpful for people trying to quit smoking, others have questioned how often people actually quit instead of simply substituting one substance for another.
But Compton emphasized that “safer” doesn’t mean the same thing as “safe.”
“We all know it’s not safe to jump out of the 4th or 5th story of a building but that doesn't make it safe to jump out of the 2nd story even though you’re less likely to break your leg,” he said, comparing traditional cigarettes to e-cigarettes.
And teens, in particular, should not use nicotine products in any form, he said.
“Nicotine and other addictive substances may play a particular role in the developing brain. There’s so much growth in the teen years,” he said. “That’s why everyone agrees teens should not be exposed to these addictive substances.”