What is the Epidemiology of Adolescent E-Cigarette Use?

Patient Presentation
A 14-year-old male came to clinic for a sports physical. He played soccer and baseball and denied any significant sports injuries or concussions. He was doing well in school and had several friends that he liked to play sports or video games with. During the interview, he said that he had tried smoking with an e-cigarette that an older student had given him. He said that it was chocolate flavored and tasted “okay” but he really didn’t like it much and hasn’t tried it since. He denied any other tobacco, drugs or alcohol use. The past medical history showed a broken arm in the 2nd grade. The social history revealed maternal grandparents that smoked.

The pertinent physical exam showed a well appearing male with normal vital signs and growth parameters in the 25-75%. His physical examination had no focal findings. The diagnosis of a healthy male with what appears to be low risk, risk-taking was made. The physician reiterated that tobacco use in all forms was not healthy. “Although using e-cigarettes isn’t illegal in our state, buying them is. Plus your soccer and baseball teams have rules against using them and sports are important to you. You probably don’t want to get kicked off the team, so I would try to stay away from it if possible,” the physician said. They then discussed some ways that the teen could say no to substances if he was in a similar situation, and brainstormed who he might call to pick him up from a friend’s house or party if he wanted to get out of the situation.

Electronic cigarettes, e-cigarettes or electronic nicotine delivery devices (ENDS) are battery-powered devices that vaporize nicotine or non-nicotine containing solutions by a heating element. They were originally introduced into the global market around 2004 and in the United States market in 2007. Their use is commonly called vaping. The vaporized solutions are called e-liquids which usually contain propylene glycol, glycerin, water, nicotine, and flavorings, but variations without different components are sold as well. The devices can also be modified to vaporize other combustible materials such as oils, wax, and dried materials such as tobacco or cannibas.

The potential risks of e-cigarettes are not fully elucidated to date, but potential risks include:

  • Nicotine addiction
  • Inhalation, ingestion, or absorption of harmful chemicals including various carcinogens, nicotine, formaldehyde and acetylaldehyde
  • Potential use of other drugs and/or alcohol
  • Burns from the heating elements
  • Long-term effects that are currently unknown

Potential benefits of e-cigarettes could be decreased risks compared to combustible cigarettes or for smoking cessation, but again data is unproven to date.

Countries worldwide are recognizing the unknown but potential effects of e-cigarettes and are increasing their regulation. The United States Food and Drug Administration is currently seeking to extend its legal authority to regulate e-cigarettes in addition to the numerous tobacco products that it already oversees and regulates. Additionally, US state legislatures and local municipalities may or may not have laws that regulate e-cigarette purchase and use, particularly for minors. The American Academy of Pediatrics recommends children not be exposed or use any tobacco products in any form and the minimum age to purchase products be consistent across the US at age 21 years.

As with all potentially hazardous materials, e-cigarettes and liquid nicotine should be kept locked up and out of the reach of children. E-cigarette users should follow the package label for appropriate disposal.

Learning Point

The use of e-cigarettes by minors in the United States is rapidly increasing. Many data sources cite ~20% use of e-cigarettes by teens with a current trend that is increasing, and a stable or decreasing trends (~10-15%) for cigarette use. A study of high school students in Hawaii with data collected in 2013 found that 17% used e-cigarettes, 12% had dual use of e-cigarette’s and conventional combustible cigarettes (cigarettes), and only 3% used combustible cigarettes. A study of high school students in California with data collected in 2014 found 24% used e-cigarettes, 3.2% reported dual use, and 18.7% used cigarettes. The National Youth Tobacco Survey found an increase in e-cigarette use from 2011 to 2014 (2011 = 1.5% and 2014 = 13.4%). Cigarette and e-cigarette use has been strongly associated but during the same time, there has been a decrease in cigarette use among teens (2011 = 15.8% and 2014 = 9.2%). A study of high school students in Connecticut with data collected in 2014 found 18% e-cigarette usage. A significent number of the teens had also used the devices to vaporize cannibas variants including hash oil (15-23%), wax fused with the cannibas’s active ingredient (10-15%) or used dry cannabis leaves (20-29%).

Questions for Further Discussion
1. What are the acute affects of nicotine overdose?
2. What are risk factors for use of e-cigarettes and other tobacco products?
3. How much do e-cigarettes devices and e-liquid cost?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Smoking and Youth and Smoking.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Wills TA, Knight R, Williams RJ, Pagano I, Sargent JD. Risk factors for exclusive e-cigarette use and dual e-cigarette use and tobacco use in adolescents. Pediatrics. 2015 Jan;135(1):e43-51.

Pbert L, Farber H, Horn K, Lando HA, Muramoto M, O’Loughlin J, Tanski S, Wellman RJ, Winickoff JP, Klein JD; American Academy of Pediatrics, Julius B. Richmond Center of Excellence Tobacco Consortium. State-of-the-art office-based interventions to eliminate youth tobacco use: the past decade. Pediatrics. 2015 Apr;135(4):734-47.

Barrington-Trimis JL, Berhane K, Unger JB, Cruz TB, Huh J, Leventhal AM, et.al. Psychosocial Factors Associated With Adolescent Electronic Cigarette and Cigarette Use. Pediatrics. 2015 Aug;136(2):308-17.

Morean ME, Kong G, Camenga DR, Cavallo DA, Krishnan-Sarin S. High School Students’ Use of Electronic Cigarettes to Vaporize Cannabis. Pediatrics. 2015 Sep 7. pii: peds.2015-1727.

American Non Smokers Rights Foundation. States and Municipalities with Laws Regulating Use of Electronic Cigarettes. Available from the Internet at http://www.no-smoke.org/pdf/ecigslaws.pdf (rev. 6/1/15, cited 9/16/15).

National Convention of State Legislatures. Alternative Nicotine Products, Electronic Cigarettes. Available from the Internet at http://www.ncsl.org/research/health/alternative-nicotine-products-e-cigarettes.aspx (rev. 8/11/15, cited 9/16/15).

American Academy of Pediatrics. AAP Statement on New E-Cigarette Poisoning Data, Need for Government Action. Available from the Internet at https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/EcigarettePoisoning.aspx (rev. no date, cited 9/16/15).

American Academy of Pediatrics. Electronic Nicotine Delivery Systems. Available from the Internet at http://www2.aap.org/richmondcenter/ENDS.html (rev. no date, cited 9/16/15).

American Academy of Pediatrics. Clinical Practice Policy to Protect Children From Tobacco, Nicotine,and Tobacco Smoke. Available from the Internet at: http://pediatrics.aappublications.org/content/early/2015/10/21/peds.2015-3108.full.pdf+html (rev. 10/26/2015, cited 10/26/2015).


Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital