Lost in the Fog: Charting a Course Forward for Teens Who Vape

Let’s imagine a teen girl visits you, their pediatrician, for her annual physical. During the visit, her mom pulls you aside to ask about vaping. The mom has heard a lot about students at school being caught vaping, and you can hear in her voice that she’s deeply concerned about the dangers.

You’re not surprised to hear from your patient’s mother about vapes. E-cigarettes are the most commonly used tobacco products among middle and high school students. The most commonly used brands among youth and teens are often in bright, colorful packaging and have flavors that appeal to users.

To compare the dangers of vaping to traditional cigarettes, take one popular vaping device: It contains 5,000 puffs and delivers 50 milligrams of nicotine for the entire device, which costs about $13. For a pack of Marlboro Reds, each cigarette delivers about 1.2 milligrams of nicotine to the user, which totals about 24 milligrams of nicotine per pack and costs about $14.

The history of vapes, dangers, and how we got here today

E-cigarettes or vapes are devices that aerosolize liquid to deliver nicotine, cannabis, flavorings, chemicals, and other substances. They first came onto the US market in 2007, initially advertised by tobacco companies as a path to help patients quit smoking. This claim had no evidence to support it, and this label as a treatment option allowed e-cigarettes to avoid the same regulations as standard, combustible cigarettes. In the next few years, particularly 2013 to 2015, there was a steady increase in the percentage of youth who were using e-cigarettes. By 2016, the U.S. Surgeon General declared that e-cigarette use among youth was rising at “alarming” rates and called on parents, health professionals, and governmental organizations to take action for adolescents. That same year, the FDA expanded its scope to regulate vapes as tobacco products, which allowed the FDA to regulate the manufacturer, import packaging, advertising, sale, and distribution of vapes.

Take the case of Juul. Within a decade of its launch in 2007, Juul became the number one selling e-cigarette brand, in part due to a strategic marketing campaign. They appeared on popular locations for youth entertainment, such as Nick Jr., Seventeen magazine, and the Cartoon Network. Juuls were also decorated with popular brands, such as Hello Kitty, and infamously flavored their pods with fruity flavors, crème brulee, and peanut butter and jelly.

Social media influencers were also recruited to advertise Juul products and consequently, the success of these marketing techniques aligns with the rising popularity of vapes among youth. But with time came the realization that Juul had intentionally targeted underage vape users in its marketing. And starting in 2019, seven different states attorney generals filed lawsuits against the company.

After a prolonged court case, Juul reached a $462 million multi-state settlement in 2023, and the settlement money has been used toward researching vapes and prevention education programs on a state to state basis. Juul also discontinued their flavored cartridges during this backlash, but despite these changes, the brand has irreversibly set a precedent for popularizing vapes as both nicotine and marijuana delivery devices among youth today.

Though traditional advertising platforms are FDA-regulated, these products are being reviewed and promoted through other social media arenas, such as TikTok and Instagram, which evade the FDA regulations about targeting minors. So the work to address youth vape usage continues.

Why do teens say they are vaping?

Nationally, there are disparities in which teens are using e-cigarettes—with American Indian and Alaskan natives having the highest rate compared to their peers. Black, multiracial, Hispanic, Latino/a and white students use at a similar rate, while Asian students use at a significantly lower rate. In 2023, about 10% of Boston’s high school students reported using nicotine vapor products at least once a month, which amounts to many of our local students. This survey breaks the data down by race and ethnicity as well as gender identity. Locally in Boston, the rates of vaping nicotine are similar among all races and gender identities.

Similar to nicotine vaping, the rate of marijuana use for Boston students does not differ between racial and ethnic groups, but LGBTQ students tend to use marijuana at higher rates than cisgender and heterosexual students at a rate of 25% versus 15%. And while vaping is clearly a prevalent issue, it’s also important to note that cigarette use has reached some of its lowest rates ever recorded. In Boston, the rate is 2.6% in 2023 compared to as high as 20% in the nineties. So, why are youth vaping?

In a 2023 survey of 12th graders who vape near daily, these are the top reasons they said they vape, with number 1 being by far the standout reason:

1. To relax or relieve tension (71%)
2. Boredom (43%)
3. Feeling hooked (43%)
4. Taste (41%)
5. Too feel good or get high (34%)
6. More convenient than cigarettes (33%)
7. To experiment (28%)
8. To have a good time with friends (21%)
9. To lose or control my weight (19%)
10. It looks cool (13%)

When the same study was conducted in 2015, “to relax or relieve tension” was in the fifth spot. This might indicate that vaping is not only harming the body physically, but playing a role in youth mental health. Adolescents may be vaping to self-medicate for comorbid or undiagnosed mental health issues—or their mental health issues may be exacerbated by vaping.

It’s key to note that youth and teens do want to quit vaping. Another study asked youth about their intentions to quit and found that more than half expressed general intentions to quit and 33% had tried to quit in the past year. Medical professionals and school systems should be thinking about ways that we can support the many students that want to quit.

How schools are addressing youth who vape

One study from 2022, looking at risk and resilience factors related to substance use among youth, found that increased smoking, binge drinking, and cannabis use were each associated with an increased prevalence of total discipline, with cannabis use leading to the biggest increase in prevalence of school-based discipline overall.

Youths who are found vaping in school can be suspended and lose access to reliable vital supports such as technology, physical education, food and nutrition, school-based health centers, ESL classes, and IEP or individualized learning plans for young people. They may also be banned from high school sports teams, which help with their engagement in school and with peers.

A 2022 report from the Learning and Policy Institute found that suspended students are more likely to suffer academically, repeat a grade, drop out of school, and are more likely to be involved with the criminal legal system. Students who receive suspensions are generally less likely to graduate from high school and college. Differences in attainment and graduation in high school are especially critical because of how they impact an individual over their whole lifetime. Studies have shown that pivotal life events, like criminal legal contact, are aligned with life course trajectories that are associated with adverse outcomes moving forward, like incarceration, arrest, and future criminal offenses. In this view, persistent and repeated school discipline and suspension is seen as a significant life event that can disrupt the typical adult trajectories and have lasting consequences that impact future life choices and outcomes.

How healthcare systems can support students

A student may first present with substance use disorder in a school setting, rather than within a healthcare system or otherwise. By forging partnerships with school systems, healthcare institutions can better reach this population to diagnose and treat the condition, building referral pathways and implementing training programs.

Through these partnerships, experts can develop and deploy trainings to faculty and staff who may come into contact with a student presenting with substance use. The curriculum may include things like identification of signs and symptoms, how to do motivational interviewing, and how to overcome fear in opening the dialogue about substance use with a student. 

In addition to trainings, health systems could offer a resource list for youth, families, and community members on identifying and treating substance use disorder or discuss resources for youth who vape. An example of this type of resource list is BMC’s Grayken Center for Addiction’s select list of resources for youth and their families to navigate treatment options. 

Overall, hospital teams could take the lead on connecting with community stakeholders, including schools, to share observations, identify trends, and to problem solve together. This would provide the space and ability to address student needs, specific to a given district and school, in consideration of the resources available.     

Out of the fog, together

These measures are not as likely as you might think to fall on deaf ears, with more than half of students who vape expressing a desire to quit. An ecosystem of support for adolescents who vape is not only possible, but ready to be received. With strategic hospital-school partnerships, effective outreach strategies, and community activation, we can make strides toward a healthier and happier youth population.