Vaping, e-cigarettes, JUULing: what parents, teens need to know

Vaping, JUULing, e-cigarettes — for consumers, parents and even teens, understanding terminology and the truth about e-cigarettes can be confusing. With inaccurate information wildly being spread about the safety of vaping, the intentions of e-cigarette companies and ingredients in e-cigarettes, University of Alabama at Birmingham physicians answer common questions and debunk myths that cloud the conversation about these harmful products.

What is vaping? How is it different from an e-cigarette?

“The terms vaping and e-cigarettes are synonymous. An electronic cigarette, or e-cigarette, is an alternative smoking device that takes a liquid — commonly referred to as e-liquid — and heats it into an aerosol, which is commonly called a vapor,” said Steven Rowe, M.D., director of the Gregory Fleming James Cystic Fibrosis Center, professor in the Division of Pulmonary, Allergy and Critical Medicine. “Instead of inhaling combusted tobacco smoke from a cigarette, an e-cigarette’s e-liquid contains harmful chemicals and addictive chemical nicotine that is inhaled and ultimately reaches the blood stream.”

Many people believe that smoking an e-cigarette is a safer alternative to a traditional cigarette, a myth that is easily misunderstood. Because e-cigarettes are easily concealable and do not present the outward negative stigmas associated with smoking such as scent, leftover cigarette butts, and the physical burning of the tobacco and paper, many mistake e-cigarettes as a cleaner and safer option.

According to the American Lung Association, nearly 500 brands and 7,700 flavors of e-cigarettes are on the market and none of them have been evaluated by the FDA. 

“The really scary thing is there are toxins and carcinogens in the e-liquids that have been found in scientific studies but aren’t advertised in ingredients because, at this point, FDA regulation of manufacturers to list product ingredients is on hold,” said Susan Walley, M.D., professor in UAB’s Department of Pediatrics and chair of the Section on Tobacco Control for the American Academy of Pediatrics.

Rowe explains that since the science and data behind the health effects of e-cigarettes and market is new and emerging, there are clear erroneous assumptions about their safety that must be addressed.

“There is clearly a perception that is being encouraged by e-cigarette manufacturers that this must be a safer alternative,” Rowe explained. “If you look at the content of the e-liquids, there are no safety regulations, and the information we have about what is being used is quite poor compared to the decades of knowledge that we have gained from traditional cigarette smoking use.”

Nicotine is the primary agent in both regular cigarettes and e-cigarettes, although deceptive marketing tactics mislead users — primarily teenagers — that their e-cigarette is a safe alternative.

“Some 63 percent of youth JUUL users 15-24 years of age did not realize that JUUL contains nicotine,” Walley said, in reference to a Tobacco Control study. “I speak with parents all the time who say ‘my child told me JUUL doesn’t have nicotine,’ and that’s not an accident; the packaging is very deceptive and has in very small print ‘5 percent strength’ with no mention of nicotine.”

In August 2018, FDA regulation went into effect that requires JUUL and other tobacco products to include a warning label that their product contains nicotine and is addictive. 

Specifically, one JUUL pod that traditionally is packaged in a set of four has 59 milligrams per milliliter of nicotine. This is twice the nicotine concentration of many previous e-cigarette liquids. As a comparison, the amount of nicotine absorbed in one traditional cigarette is 1 to 2 milligrams total, although e-cigarette companies advertise one pod to equal one pack of cigarettes.

“It’s a huge amount of nicotine that people using e-cigarettes — especially kids — are potentially being becoming exposed to, and the addiction potential is increased because of the high nicotine concentrations,” Walley said. “Deceptive marketing and advertising are furthering the confusion among teens and parents. They are led to believe by companies like JUUL that these products aren’t harmful. That couldn’t be further from the truth.”

“In addition, some e-cigarette manufacturers advertise that their product has 0 percent nicotine but actually has been found to contain nicotine in quantitative studies,” Walley added.

Among teens, vaping or JUULing has become socially accepted, while they still understand and recognize the harmful and life-threatening effects of traditional smoking.

“The message has gotten through that cigarettes are bad; but so many teens I speak with say ‘it’s OK, though. I JUUL, I don’t smoke,’” Walley explained. “Because of the appeal of e-liquid flavor offerings and the sleek look of e-cigarettes like JUUL and others, this really is a tremendous public health concern that both parents and teens need to be aware of.”

To experts like Walley and Rowe, e-cigarette manufacturers are clearly marketing to vulnerable children with e-liquid flavors ranging from doughnut and crème brûlée to an assortment of fruit flavors — even options that mimic popular candy like Sour Patch Kids. Accompanying the kid-centered flavor options are bright, cartoonish branding, which heightens the attraction to children and teens. It is known that flavors entice youth to use tobacco products, which is the reason flavors were banned in 2009 from traditional cigarettes.

“The longitudinal data is clear that adolescents who use e-cigarettes are more likely to be using traditional combusted cigarettes a year later versus people who never used e-cigarettes at all — that is really frightening to us pediatricians,” Walley said.

While the accessibility of e-cigarettes at gas stations, grocery stores and local vape shops across cities can be seen as normalizing this issue, UAB experts want parents to be hyperaware that their children are being targeted and need to have e-cigarette conversations with their teens.

In a recent editorial published by Rowe and S. Vamsee Raju, Ph.D., assistant professor in UAB’s Division of Pulmonary, Allergy and Critical Medicine, they explain that smoking e-cigarettes as an alternative or a cessation to traditional smoking is not necessarily the lesser of two evils.

“If the justification is that e-cigarettes are a smoking cessation device, there is no evidence that it actually is helping,” Raju said. In fact, there is more data to suggest that the use of e-cigarettes has led to more nicotine use, not less. Most importantly, if we want to view e-cigarettes as true nicotine cessation devices, they need to go through the same FDA testing that other cessation devices go through and effectively prove that people quit smoking compared to others. Instead of being able to purchase e-cigarettes at a gas station, you would need to purchase through a pharmacist, just like similar cessation methods.”

Both Walley and Raju explain that evidence shows adult smokers who use e-cigarettes end up being dual-smokers (i.e., use both e-cigarettes and traditional cigarettes), rather than quitting the traditional cigarettes.

If people are looking to quit smoking altogether, UAB has great resources and experts available to help make a lifestyle change.

Nicotine is highly addictive and causes extreme dependence, regardless of the way it is consumed, be it traditional cigarettes or e-cigarettes.

“My message to parents all the time is that we know that nicotine changes adolescent brain chemistry, which can have damaging effects long-term,” Walley explained. “Children and adolescents are more likely to become addicted as a result of any tobacco exposure, so we need to be having those conversations that these are not safe products, the end outcome is not good, and at the end of the day, we need to strive for a tobacco- and nicotine-free society.”