When e-cigarettes were introduced in the U.S. in 2007, they were marketed to adults as a safe alternative to traditional cigarettes, particularly for those wishing to stop smoking. But e-cigarettes have had an unintended consequence — a new generation has become addicted to nicotine. A recent study looked at how environmental, social and cultural factors fueled an increase in teen e-cigarette use, with schools emerging as an important influence on vaping behavior.

Between 2017 and 2018, the number of high school students using e-cigarettes nearly doubled, Adam Lippert, lead author on the study, told TheDoctor. When e-cigarettes were first introduced, schools were key to teens' ability to access the devices.

No dose of nicotine is safe for anyone, and that is particularly true for adolescents, because nicotine is harmful to their still-developing brains.

Data came from the 2011-2017 U.S. National Youth Tobacco Survey, a study of nicotine use among approximately 65,000 middle and high school students from more than 700 schools.

Teens who attended schools with high rates of vaping were more likely to believe that e-cigarettes are less dangerous than traditional cigarettes. Students taught one another how to use the devices properly, vaping “tricks” and promoted the idea that vaping shouldn’t be considered a bad thing. “The misconception among teens that e-cigarettes are safe is cause for alarm,” said Lippert.

As teen vaping became more common, the role of schools in e-cigarette use became less important. When new vaping technologies such as the Juul device were introduced around 2015, rates of teen vaping increased again. These devices not only offered an array of flavors, their marketing was youth-oriented.

That has put schools back in a position to influence kids' e-cig use. As Lippert put it, “When properly resourced, schools can be powerful partners against adolescent nicotine use.”

Parents need to educate their teens about the risk of e-cigarettes, too, he added. Recent data from the U.S. Centers for Disease Control and Prevention show that over 99 percent of e-cigarettes sold in the U.S. contain nicotine. No dose of nicotine is safe for anyone, and that is particularly true for adolescents, because nicotine is harmful to their still-developing brains.

“[H]aving a candid conversation with children and teens about the risks of e-cigarettes is a great first step,” Lippert indicated. He urges parents to avoid focusing that conversation on nicotine use as a mark of failure in a young person. “I would advise we all be a little more understanding when we learn one of the young people in our lives has experimented with e-cigarettes, and sit down and have a non-judgmental conversation about it.”

Tax policies can also be a disincentive to e-cigarette use. E-cigarettes are not taxed in the same way as traditional cigarettes, but previous studies have found that increasing the per-pack tax has the greatest effect on discouraging teenage use of traditional cigarettes, since teens don’t have much discretionary income.

Finally, limits need to be set on the marketing of e-cigarettes. Lippert cites a study from the Research Triangle Institute which found that between 2011 and 2013, teen exposure to television advertising of e-cigarettes rose by 256 percent. That trend has continued more recently with the introduction of Juul devices to the market. “Right now, regulations on e-cigarettes exclude limits on advertising, so introducing such limits, along with bans on flavoring agents in e-cigarettes would help discourage teen e-cigarette use,” said Lippert.

The respiratory illnesses associated with e-cigarette use have been well documented in the media. Over 1,000 hospitalizations and a number of deaths have been linked to these illnesses. Lippert and his team plan to investigate where these illnesses are most likely to happen in the U.S.

The study was published in the Journal of Youth and Adolescence.