My knowledge of vaping, juuling, and e-cigarettes was fairly limited until this past September. I had heard some of the words; however, honestly, I could not have defined most of the terms being used in the media. However, vaping did concern me as it appeared to be another "trendy" thing for adolescents to explore. And frankly, I might have stayed on the outskirts of this public health problem had not one of my high school-aged grandsons admitted to vaping.

In October 2018, the Food and Drug Administration acknowledged the existence of a youth e-cigarette use epidemic after the National Youth Tobacco Survey noted a 78% increase in use from 2017 to 2018 (Cullen et al., 2018). Prevalence in 2019 indicated that 40.5% of 12th graders had vaped, with 35.1% doing so in the last 12 months and 25.4% doing it within the last 30 days (Miech, Johnston, O'Malley, & Bachman, 2019). Vaping is becoming a public health crisis affecting primarily adolescents and young adults.

As we look at this epidemic, let us first define terms. Electronic cigarettes, also known as e-cigarettes, e-vaporizers, or electronic nicotine delivery systems (ENDS), are battery-operated devices that individuals use to inhale an aerosol, which typically contains nicotine (although not always), flavorings, and other chemicals (National Institute on Drug Abuse [NIDA], 2019). Although some ENDS may look like a cigarette, most resemble a pen or a USB memory stick, allowing such devices to easily go undetected by others. E-cigarettes consist of four different components: a cartridge or reservoir that holds a liquid solution containing nicotine, flavorings, and other chemicals; a heating element (atomizer); a power source (usually a battery); and a mouthpiece for inhaling. Puffing activates the battery-powered heating device, which vaporizes the liquid resulting in inhaling the aerosol or vapor and thus is called vaping (NIDA, 2019). Dripping is another term associated with vaping. Dripping involves placing the e-liquid drops directly onto heated atomizer coils. By doing so, it creates a thicker vapor, improves the flavor, and produces a stronger throat hit (NIDA, 2019). Initially, ENDS were produced as an alternative to cigarettes and to be used as a deterrent to stop traditional cigarette smoking. However, their popularity grew with adolescents and young adults because of the flavorings available as well as the device being easy-to-conceal.

The JUUL e-cigarette came to market in 2015 and currently accounts for 73.9% of the sales of over 460 different e-cigarette brands (Schillo et al., 2019). Thus, the term JUULing is another term for vaping. JUUL e-cigarettes always contain nicotine and may include a variety of sweet or fruity flavors. One standard JUUL pod is roughly equal to the amount of nicotine in a pack of cigarettes (Barrington-Trimis & Leventhal, 2018; Truth Initiative, 2019). Electronic nicotine delivery systems were unregulated by the Food and Drug Administration until 2016. At that time, e-cigarettes became subject to tobacco regulations, including the requirement that purchasers be 18 years of age.

E-cigarettes appeal to adolescents for several reasons. Primarily, they are easily available, even for minors; the alluring ads make it sound "cool" to smoke; there are various flavors that may resemble fruit or candy; and adolescents believe that e-cigarettes are safer than traditional cigarettes (NIDA, 2019). In addition, self-promotion of ENDS through social media has become rampant (Perrine et al., 2019). However, the health risks to adolescents are great.

The developing brains of adolescents are particularly vulnerable to the effects of vaping. From physiology, we know that the brain continues to develop until the age of 25 years. During this time, the brain is sensitive to novel experiences with major experience-dependent plasticity that occurs in the executive control and decision-making regions of the brain, particularly the prefrontal cortex (Yuan, Cross, Loughlin, & Leslie, 2015, p. 3397). For adolescents, there is also a negative long-term effect to the development of brain circuits that affect memory and attention. Nicotine affects the brain's reward circuits and increases the level of dopamine in the brain, which reinforces rewarding behaviors. Although this happens in adults as well, it is dangerous in the developing brain. Lastly, adolescents are more vulnerable to developing an addiction (Barrington-Trimis & Leventhal, 2018; Chadi, Hadland, & Harris, 2019).

On September 16, 2019, the Centers for Disease Control and Prevention (CDC) activated their Emergency Operations Center to enhance the interagency response to the investigation of lung injury associated with vaping (CDC, 2019a). On October 17, there are 1,479 lung injury cases with 33 deaths being reported (CDC, 2019b). Some of the lung injuries have been minor; however, approximately 90% of all cases have required hospitalization and, for some patients, mechanical ventilation. No single product or substance has been linked to all lung injury cases; however, all patients have a history of vaping. Tetrahydrocannabinol has played a role in 77% of the reported cases to date (Perrine et al., 2019). Symptoms of lung involvement include cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fever, fatigue, and abdominal pain. Some patients have reported symptoms coming on within a few days, whereas others report that symptoms appeared over a period of several weeks (CDC, 2019c). The CDC has named the lung illness associated with vaping "EVALI" (e-cigarette vaping-associated lung injury; Siegel et al., 2019).

This editorial goes to publication at the end of October; thus, the numbers stated here are not current. Current data about the epidemic are available weekly on the CDC website. Other actions associated with the epidemic are happening. The governor of Massachusetts banned the sale of e-cigarettes for 4 months (Bogel-Burroughs, Richtel, & Thomas, 2019), and JUUL ended its advertising (broadcast, print, and digital) and lobbying efforts of e-cigarettes (Perrone & Chapman, 2019). Stay tuned for the latest information as the CDC and other agencies continue to track this epidemic.

Conflict of Interest

The author declares no conflict of interest.

Pamala D. Larsen, PhD, RN

Editor-in-Chief, Rehabilitation Nursing, Loveland,

CO, USA

References