The addictive qualities of vaping take users by surprise

E-cigarettes are a hard habit to break — and so new we can’t predict their longterm effects

By Sammy Ramacher

An Emory College student, who asked to go by “Ben,” slumped at his campus bus stop, exhausted after an unsuccessful day of studying. He was on his way back from the library, where he had tried and failed to focus. All he could think about since returning from his fraternity’s annual trip the previous day was an overwhelming craving for nicotine, which he had taken from his friends constantly throughout the trip.

His usual bus arrived at the stop, but he watched it drive away and stepped onto a bus headed in the opposite direction. After 20 minutes, he arrived at a corner gas station, and took a deep breath to gather himself before stepping off the bus. This was where his fraternity brother had recommended he go when he asked how to purchase an e-cigarette.

He had never owned one of these devices, and had told himself that he never would. He knew how addictive nicotine was, and didn’t want to own something that made its use easier. But there he was, about to purchase an e-cigarette, after having used it for just a few days on his trip. He forced himself not to think about it and went inside. When he finally purchased and first inhaled through the device, he relaxed fully for the first time all day. According to Ben, this was the moment that began his long struggle with nicotine addiction.

Ben’s story matches those of many other young adults and teenagers. Nicotine abuse has resurfaced rapidly through these clever devices that make inhaling nicotine discreet, convenient, and uniquely appealing. E-cigarettes, which are also often called vapes, became popular among US and European citizens almost as soon as they entered the market. Companies enticed and then hooked their especially young client base through marketing strategy, design, physical and structural techniques, and unique appeal to youth.

Gary Tedeschi, clinical director of the tobacco quitting program Kick It California, says: “The vape companies did a great job, especially at the beginning. They packaged their devices so nicely. To young people, it’s almost like [the vapes] were some cool new electronic.”

This business success destroyed decades of public health success in reducing rates of nicotine abuse from conventional cigarettes. E-cigarettes’ sudden rise in popularity triggered two developments that amplify each other: having many users and creating unknown effects. Their widespread use has reignited a youth nicotine abuse epidemic that was thought to have been eradicated, and left chronic users concerned about how their health will be affected in the future.

Photo by Shurov on Unsplash

Irresistible chemistry and psychology

E-cigarettes work by releasing vaporized liquid into the lungs, which is produced by an inhalation-activated heater inside a small handheld device. The liquid can contain a wide array of addictive chemicals, but is predominantly nicotine. They launched in high schools in the early 2010s, and their consumption continued to increase as the years passed. The 2019 National Youth Tobacco Survey found that 37 percent of high school students used e-cigarettes at least once in 2018, while only 28 percent did in 2017.

The business success of e-cigarette companies was no accident or stroke of luck. Vape industries marketed their products aggressively. The popular e-cigarette company JUUL found early success in their social media advertising campaigns. In the first two months of their Twitter campaign, people posted 73,000 tweets about e-cigarettes, most of which were promotional towards the vapes. “Organic advertising” was a common tactic that many companies, including JUUL, used to grow quickly on social media. It was essentially free for the companies because it used unpaid social media influencers as “models” who posted themselves using e-cigarettes that the companies gave them. These posts often amassed a large number of views, primarily by young social media users, thus introducing many new potential clients to the companies’ products—one of many marketing techniques used by e-cigarette companies to build the foundation of their success.

Additionally, e-cigarettes were physically designed to appeal to youth. Vape pens are sleek, comfortably hand-held devices that can vary in shape and size, depending on the brand. Some are made to be discreet, such as the small, rectangular JUUL vapes, and others are larger and brightly colored for the purpose of being seen. The discreet models allowed students to use vapes in more common settings, such as the back of a classroom or lunch tables, without being seen by authority figures. The vibrant and fragrant models were appealing to youth for the opposite reason. They were made to be a sensual experience, with strong flavors, smells, and bold colors. These two designs helped e-cigarette companies reach a larger customer base by satisfying multiple criteria that are valued by youth.

Nicotine, the main ingredient inside e-cigarettes, is a stimulant. It increases blood pressure and heart rate while restricting blood flow to the heart muscle, which can damage the heart over time. It also triggers release of epinephrine and dopamine, resulting in a pleasurable feeling. It is extremely addictive, and people experience intense withdrawal symptoms that make it very difficult to fully stop using it. “Lots of [people] treat [nicotine] like it’s something you can just put down whenever you feel like it,” says Tedeschi. “But that’s not the case; quitting is really hard. Lots of adults started using tobacco in their teen years, thinking that they would eventually quit, but never got around to it, or even to trying.”

Vapes do not leave particles or odor behind, and do not need to be ignited, so people have the flexibility to use vapes virtually wherever they want. “People walk around with them all day and can use them any time,” says Tedeschi, “but for smoking a cigarette you have to stop what you’re doing and go somewhere else to do it.” As a result, daily vapers take inhales from their e-cigarettes without paying too much attention to how frequently they do so, and end up using them more than they want. Plus, many vapes are made with nicotine salts, which vaporize at a lower temperature and makes it easier to inhale more nicotine at once.

Photo by E-Liquids UK on Unsplash

Insufficient data to predict effects

Many chronic vapers are becoming curious about the health effects of long-term vaping. “People intuitively know that vapes can’t be good, because they are still filling their lungs with a foreign substance,” says Hazel Gilbert, a principal research fellow at University College London who authored a 2019 study surveying opinions and knowledge that chronic smokers had about vapes. “And they really want to know what that foreign substance is going to do.” Several of the 14 chronic cigarette smokers she interviewed said they were afraid of the unknown compounds in e-cigarette liquid, which was one reason they didn’t want to use them. They wanted to learn because people feel more confident about reaching their health goals when they have the knowledge to make the right decisions.

A 2020 study in Cureus showed that doctors who tell their patients about general risks of vaping are more likely to incentivise quitting efforts. But Gilbert found that people have little confidence in health professionals’ knowledge about e-cigarettes, and instead obtain most of their information online or from smoke shops, assuming that people with more experience using the products have more reliable and useful information about them. Many physicians say they do not discuss vaping health consequences because they believe they lack sufficient knowledge on the topic to give accurate advice. But in fact, health professionals are truly the most informed about the physical effects of vaping because they are the ones conducting or having access to recent research.

So far, there have been few opportunities to study vape addictions. There has been only one known outbreak of deaths associated with vapes, in which teens across the US were hospitalized for symptoms including shortness of breath, cough, and chest pain. Eventually, vitamin E acetate was discovered as the cause of the lung illnesses. This substance had been present in many black-market e-cigarette products, which pass through few if any quality control measures. Teenagers were especially vulnerable to this e-cigarette poisoning because they often acquire their e-cigarettes through shady methods, given that there are legal barriers to minors purchasing nicotine products conventionally. Once the source of the poisoning was discovered and shut down, the number of reported vape-related illnesses dropped almost to zero. “We haven’t seen very many vape-linked illnesses since [the 2019 outbreak], and that was an isolated incident,” Tedeschi says.

It took decades to accumulate the extensive evidence that proved cigarettes have long-term health consequences. Unfortunately, very little of this evidence can be used to predict the effects of vaping. The gaseous substances produced by vapes and cigarettes are very different, even though they serve the same purpose of carrying nicotine. Burning tobacco creates large particles that can damage the lungs, expresses chemicals such as acrolein and carbon monoxide that are shown to cause lung damage, and deposits tar. They also build up tar in the lungs. But vapes do not produce particles or tar, though they instead shed trace amounts of metals. The only findings related to cigarettes that also can be applied to vapes are the effects of nicotine on the body and brain.

This lack of evidence for long-term health consequences makes it more difficult to influence users to give them up. “People need to have a strong reason for quitting nicotine in order to successfully quit,” Tedeschi says. “Without that, it’s pretty much impossible.” Past anti-cigarette campaigns succeeded because they could leverage years of research proving the negative health consequences from smoking. Without similar data for vaping, different incentives will have to be created for users.

Photo by CDC on Unsplash

More research and funding

Simply the vastness of the e-cigarette epidemic is concerning: So many people abusing a substance with unknown effects worries health experts. Nicholas Chadi is a pediatric addiction fellow at Boston Children’s Hospital and author of a 2019 study examining the ramifications of the e-cigarette epidemic. “Think of it like this,” he says. “One in seven are addicted now. Best case scenario, that rate stabilizes and we have just that number of teenagers to support. What can we realistically provide to that many, one in seven teenagers, if they start having lung issues? Not much.”

If e-cigarettes actually are physically dangerous — something currently assumed though not yet proven — the millions of patients who will need care and treatment will greatly burden the healthcare system. This is why it is critical to slow down vaping addiction rates before it is too late.

More work can be put into filling the e-cigarette information gap, through both medical education and research. Some education initiatives are already underway. “Campaigns like the Truth social media initiative have done a good job getting the message out to youth, but more needs to be done,” Chadi says. “What we really need is research, which will give us data to improve our initiatives, and see if they are actually working [to reduce adolescent vaping].”

Tedeschi agrees. “We can’t structure vape-specific programs [for addiction recovery] because there isn’t enough data to base them on. And it’s gonna take time to build that database.” He explained that Kick It California’s cigarette recovery plans are approved by the FDA, but that their vaping plans haven’t yet been approved because they don’t have enough clinical supporting evidence.

In order to protect the future health of our youth, we need to invest more time and resources into curbing the vaping epidemic. It will come down to the work of policymakers, physicians and campaigners to collectively create and communicate a case against chronic e-cigarette use. These methods succeeded in reducing adolescent rates of smoking cigarettes, and that ought to be achievable for vapes, too. “People want to know what they are doing to their bodies,” says Gilbert. “At the end of the day, those that want what’s best for their bodies will at least try to learn. So why wouldn’t we do everything in our power to give them that health freedom?”