Vaping: A Looming Health Crisis

The use of e-cigarettes among teenagers is on the rise in the U.S., a trend that's exposing millions to nicotine addiction.

A vape pen

Until a couple of years ago, Dr. Jonathan Avery, director of addiction psychiatry at NewYork-Presbyterian/Weill Cornell Medical Center, hadn’t had much exposure to electronic nicotine delivery systems, commonly referred to as e-cigarettes.

“In 2017, I wasn’t seeing anyone who was vaping nicotine, or I was seeing very few folks,” he says of people using devices to inhale an aerosol, or “vapor,” that typically contains nicotine, flavorings, and certain carcinogenic compounds.

That has since changed.

“Now you almost can’t meet an adolescent who hasn’t had some exposure to vaping,” he says.

While data shows a steady increase in the use of e-cigarettes among teens — 3.62 million middle and high school students were current users of e-cigarettes in 2018, up from 280,000 in 2011, according to the Centers for Disease Control and Prevention — addiction medicine specialists like Dr. Avery have noticed a worrying trend hidden within this rise: Teens don’t appreciate the addictive nature of vaping.

“A lot of kids don’t realize that nicotine is in their vaping product,” Dr. Avery says, despite the fact that some brands claim to deliver as much nicotine as a pack of cigarettes. “And nicotine, especially in the developing brains of adolescents and young adults, may be one of the hardest substances to quit over time. It activates the addiction pathways, making it very tough to stop. We do think that an early introduction to nicotine from these new devices can lead to the use of other substances.”

Addiction pathways, Dr. Avery explains, are certain circuits and centers of the brain that light up when people use substances and drive the brain to want to use more, until you get to a point where it’s very hard to stop use. Once a substance like nicotine activates these pathways, and then you introduce another substance, your risk of further addiction can increase.


“Nicotine, especially in the developing brains of adolescents and young adults, may be one of the hardest substances to quit over time. It activates the addiction pathways, making it very tough to stop.”

— Dr. Jonathan Avery


Recent statistics support Dr. Avery’s concerns.

Results from the 2018 Monitoring the Future survey, conducted by the University of Michigan Institute for Social Research, indicated that about 80 percent of youth do not see great risk of harm from regular use of e-cigarettes. But the Food and Drug Administration, which classified e-cigarettes as tobacco products in 2016, has warned that their use may cause changes to lungs that could be a precursor to cancer.

To bridge this information gap, Dr. Avery and his colleagues have begun holding free counseling sessions for kids and parents on the risks of using electronic nicotine delivery systems, and Dr. Avery is working with advocacy groups like PAVE (Parents Against Vaping E-Cigarettes) to raise awareness about the harmful effects.

“We’re doing a lot at NewYork-Presbyterian to raise awareness of these new devices that deliver nicotine,” he says. “We’re informing pediatricians and helping them learn to ask questions and screen for it. We’re holding different events that are open to the public where they can learn about these devices from myself and from parents that have experience with their own children and what they’ve learned about the devices.”

The surge in vaping’s popularity has accelerated in the last year, motivating both Dr. Avery and federal agencies like the FDA to sound the alarm about their use. From 2017 to 2018, the prevalence of 12th graders who reported vaping nicotine in a 30-day period was 30 percent, an increase of 11 percentage points from 2017, according to the Monitoring the Future survey. For eighth graders, the rate was 11 percent, up 3.4 points from 2017, and 25 percent of 10th graders said they vaped nicotine, up 8.9 points. This annual survey has tracked national substance use among U.S. adolescents every year since 1975, and this increase in nicotine vaping is the largest year-to-year increase they have recorded in the past 44 years for any substance used by teens.

Dr. Avery points to a few factors that might be driving the dramatic increase in vaping. One is peer pressure.

“Vaping looks fun, it looks techy,” he says of devices that can look like a portable USB drive. “It looks almost like the anti-cigarette, and in that way it can be very seductive for a peer group and for a teenager wanting to do the next coolest thing.”

Portrait of Dr. Jonathan Avery

Dr. Jonathan Avery

Another factor is that for adolescents who would have a hard time smoking cigarettes, e-cigarettes are easier to justify.

“These are kids that may have totally avoided nicotine given all the public health and other interventions to decrease cigarette use, and now suddenly they’re using nicotine,” Dr. Avery explains. “These new devices allow adolescents to get exposure all the time, which we think increases the risk of developing nicotine use disorders.”
Since these devices may not look like a tobacco product, Dr. Avery says parents should go online to become familiar with what’s in them and what they look like. And because vaping can be odorless, parents can look for clues to indicate their child might be addicted to nicotine and e-cigarettes.

“Vaping devices and products aren’t cheap, especially if kids are using them often, so the bills will pile up in terms of purchasing more,” he says. Cartridges for reusable e-cigarettes can cost upward of hundreds of dollars a year. “Even though it’s easier to use in your room or without parents being aware, it does come with an increase in secretive behavior. And if they do become dependent, parents may notice withdrawal symptoms like anxiety or irritability.”

If parents notice these behaviors, Dr. Avery says it’s important to ask questions and be open to the possibility that a substance like nicotine might be contributing. If parents are better equipped to know what signs to look for, he says, they can identify the problem and help their child treat the addiction.

“This is all new for everyone, for the medical community, for parents, for kids,” Dr. Avery adds. “Everyone is sort of hungry for information. I think now we’re working together to figure it out, curb the use, and raise awareness about the addictive nature of vaping.”

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