HEALTH EFFECTS OF VAPING What Parents and School Leaders Should Know About E-Cigarettes and Vaping TABLE OF CONTENTS

Project Overview ..... P 3

Findings and Recommendations ..... P 4

Defining Vaping ..... P 6

Vaping Among Youth ..... P 11

Direct and Secondhand Health ..... P 15 Effects of Vaping

Other Effects of E-Cigarettes ..... P 21 Resources ..... P 26

Works Cited ..... P 28

2 PROJECT OVERVIEW

Vaping continues to increase in popularity and has become an area of concern for many districts in the United States. Students are able to easily hide vaping accessories, and parents are often unaware of their child’s participation or of the negative impacts of vaping.

To address this concern, this report: ✓ Defines vaping and discusses the prevalence of vaping among youth. ✓ Identifies the short-term and long-term health effects of e-cigarette use and secondhand exposure to e-cigarettes. ✓ Discusses other potential harms associated with e-cigarette use, such as unintended injuries, poisoning, and increased smoking initiation.

3 FINDINGS AND RECOMMENDATIONS

Young people should not use e-cigarettes. Nearly all e-cigarettes contain nicotine, which can cause changes in the brain. Young people are particularly vulnerable to the effects of nicotine because their brains are still developing. The U.S. Surgeon General has stated that the use of any nicotine products, including e-cigarettes, is unsafe for adolescents.

Students should be aware of the potential health risks of using e-cigarettes. E-cigarettes do not produce a harmless “water vapor.” They produce a vapor that contains nicotine as well as potentially harmful chemicals, metals, and small particles. Scientists are still trying to understand the long-term health effects of e-cigarette use, but we know that e-cigarettes can cause coughing, breathing problems, and increased heart rate and blood pressure in the short-term.

4 FINDINGS AND RECOMMENDATIONS

E-cigarettes can cause other harmful effects, such as: ▪ Injuries. Defective batteries can cause e-cigarettes to explode or cause fires. ▪ Poisoning. People who accidentally swallow e- cigarette liquids or spill the liquid on their skin can get nicotine poisoning, which can be deadly, especially for young children. ▪ Addiction. Nicotine is highly addictive, and young people who use e-cigarettes are more likely to become addicted to nicotine and to start smoking regular cigarettes later in life.

5 DEFINING VAPING WHAT IS VAPING?

MOUTHPIECE How it works. E-cigarettes are battery- Allows users to operated devices that produce an inhale vapor. aerosol, or vapor. The device heats a liquid containing nicotine, flavorings, and other chemicals. The heated liquid produces a vapor, and users inhale this CARTRIDGE vapor into their lungs. If you are near Stores liquid someone using an e-cigarette, you that produces the vapor. may also inhale this vapor. Other names. E-cigarettes may also be known as “e-cigs,” “electronic nicotine delivery systems,” “vaporizers,” “vaping devices,” “mods,” “tank systems,” or ATOMIZER “e-hookahs.” E-cigarettes can be used Heats liquid. for vaping nicotine as well as marijuana and other drugs.

Image: Pixabay BATTERY Source: Centers for Disease Control and Prevention (CDC), Powers device. n.d.; Office of the Surgeon General, n.d.

7 MANY SHAPES & SIZES Some e-cigarettes look similar to regular cigarettes or pipes. Others resemble household objects such as pens. Juul—a very popular type of e-cigarette—is small and looks like USB stick/flash drive, making it easy for teens to hide from parents and teachers. Some e-cigarettes are built as “tanks” that do not look like traditional tobacco products.

Text sources: Blad, 2018; CDC, n.d. Image source: CDC.

8 WHAT ARE E-CIGS MADE OF? NICOTINE Nicotine is an addictive substance found in nearly all e-cigarettes. Although some e-cigarettes are labeled as having 0% nicotine, they may still contain some nicotine. FLAVORS AND PRESERVATIVES E-cigarette liquids often contain flavors and preservatives to make them more appealing and last longer. Although these flavor additives may be safe when consumed in small amounts in a food or drink, researchers do not know if the flavorings in e-cigarettes are safe when they are inhaled as a vapor. POTENTIALLY HARMFUL CHEMICALS, COMPOUNDS, METALS, AND PARTICLES E-cigarette vapor is not simply a harmless “water vapor.” The vapor can contain many different chemicals and toxins, including substances linked to cancer:

▪ Formaldehyde ▪ Nitrosamines (cancer-causing chemicals) ▪ Acetone (a chemical in nail polish remover) ▪ Metals such as nickel and lead ▪ Propylene glycol (a chemical in anti-freeze) ▪ Particles that can be inhaled into lungs Many of these substances in e-cigarettes are also found—in larger amounts—in smoke produced from tobacco products.

Sources: Arnold, 2014; CDC; Goniewicz et al., 2013; Office of the Surgeon General, 2016.

9 E-CIGS VS. REGULAR CIGARETTES

E-cigarettes do not contain tobacco. When a person smokes a regular cigarette, the burning tobacco produces toxic gases (such as carbon monoxide) and also causes the smoker to inhale harmful tar. E-cigarettes are less harmful than regular cigarettes because they do not contain tobacco, and therefore do not produce carbon monoxide or tar.

However, this does not mean that e-cigarettes are completely safe. E-cigarette liquids and vapors contain many of the same harmful substances found in regular cigarettes (albeit in smaller amounts). In addition, e-cigarettes contain chemicals not found in regular cigarettes. Scientists are still trying to understand the long-term effects of exposure to these substances.

BOTH E-CIGARETTES CIGARETTES ▪ Nicotine ▪ Propylene glycol ▪ Metals ▪ Tobacco ▪ Glycerin ▪ Carbonyls and ▪ Tar ▪ Wider range of flavor volatile compounds ▪ Carbon monoxide additives ▪ Formaldehyde ▪ Menthol flavor only ▪ Small particles

Sources: Carroll, 2016; Pisinger and Dossing, 2014; Ross, 2016.

10 VAPING AMONG YOUTH HISTORY OF VAPING

▪ 2003: E-cigarettes developed in China. ▪ 2007: E-cigarettes become available in United Despite their popularity, States. ▪ 2011-2014: Youth e-cigarette use doubles or E-CIGARETTES ARE NOT triples each year. DESIGNED TO BE USED ▪ 2014: E-cigarettes surpass regular cigarettes as BY YOUNG PEOPLE. the most popular tobacco product among middle and high school students. Minors are prohibited from ▪ 2016: All major tobacco companies sell e- purchasing e-cigarettes. The cigarettes, and e-cigarettes are widely U.S. Surgeon General states available at convenience stores, online retailers, “big box” stores, and dedicated that “the use of products “vape” shops. containing nicotine in any ▪ 2017-2018: Juul becomes the most popular e- form among youth, including cigarette brand on the market. One-fifth of in e-cigarettes, is unsafe.” youth ages 12-17 report having seen Juul used at their school. Sources: Campaign for Tobacco-Free Kids, 2018; Glantz and Bareham, 2018; Schraufnagel, 2015; Office of the Surgeon General, 2016. 12 E-CIGS APPEAL TO YOUTH

KEY FACTS Companies have designed e-cigarette flavors and ads to appeal to youth. 85% of youth e- Federal regulations prevent the sale of all flavored, cigarette users (ages traditional cigarettes except for menthol. However, 12-17) use flavors, companies are able to sell e-cigarettes in many fruit and 7 out of 10 middle candy flavors that appeal to children and teens. and high school Popular brand Juul, for example, offers flavors such as students were crème brulee, mango, and “cool cucumber.” exposed to e- cigarette advertising Companies also market e-cigarettes in ways that in 2014. appeal to youth. They use ads with slogans like “cool” or “high-tech,” and publish ads in places where youth are Students exposed to likely to see them, like retail stores, mobile websites, e-cigarette marketing Instagram, and YouTube. have an increased chance of using e- Minors are not allowed to buy e-cigarettes. cigarettes. In California, those under 21 cannot purchase e- cigarettes. However, underage youth are often able to Sources: CDC, 2017; Mantey et al., 2016; Office of the Surgeon purchase e-cigarettes via online vendors or in-person General, 2016. retailers that do not verify their customers’ ages. Sources: CDC, 2017; Food and Drug Administration, 2018a; Huant et al., 2018; Public Health Law Center, n.d.; Truth Initiative 2017, 2018a, 2018b; University of North Carolina, n.d. 13 YOUTH E-CIG USE HAS INCREAED

TOP 3 REASONS YOUTH Overall youth tobacco use has decreased. In 2017, 3.6 million U.S. middle and high school students USE E-CIGARETTES reported using any type of tobacco product, a decrease from 4.5 million in 2011. 1. Because a friend of family member uses E-cigarette use, however, has increased. them (39%). Just 1.5% of all high school students reported using e- 2. The availability of cigarettes in 2011; this figure increased to 16 percent in flavors, such as 2015 and declined to 11.7 percent in 2017. E-cigarettes mint, candy, fruit, or are now the most popular tobacco product among chocolate (31%) youth, more popular than conventional cigarettes. High School Student Tobacco Use (Past 30 Days), 2011-2017 3. Belief that e- 30% 25.3% cigarettes are less 24.2% 22.9% Any tobacco harmful than other 19.6% product (including forms of tobacco, 20% 16.0% e-cigarettes) 11.7% such as cigarettes E-cigarette (17%). 10% 4.5% 1.5%

Source: Truth Initiative, 2018a 0% 2011 2013 2015 2017 Source: Arrazola, 2014; CDC, 2018; Singh et all, 2016; Office of the Surgeon General, 2016; Wang et al., 2018 14 DIRECT AND SECONDHAND HEALTH EFFECTS OF VAPING DIRECT HEALTH EFFECTS- SUMMARY

HEALTH EFFECTS THE STATE OF RESEARCH ON E-CIGARETTES E-cigarette use is There is much that researchers still do not associated with: understand about how e-cigarettes work and how they affect the body. It is difficult to 1 Respiratory health determine the health effects of e-cigarettes issues. for several reasons: Heart and blood ▪ E-cigarettes are relatively new. Scientists do not 2 yet know how using e-cigarettes for years or vessel issues. decades could affect an individual’s health.

3 Changes in the ▪ There are many different types of e-cigarettes on brain. the market, and these products vary widely in terms of the specific chemicals and substances they are made of. It is possible that some e- cigarettes may be more or less harmful than “…e-cigarettes are not others, depending on what they contain. without ▪ Many studies of e-cigarettes have been funded biological effects in by e-cigarette manufacturers, who have an humans.” incentive to publish only positive findings. –National Academy of Sciences, 2018b Sources: Martinez et al., 2018; Pisinger and Dossing, 2014

16 SHORT-TERM EFFECTS

RESPIRATORY SYSTEM Studies have found that e-cigarette use is associated with respiratory symptoms such as: ➢ Throat irritation and sore throat. ➢ Increased coughing and wheezing, especially among adolescent users. ➢ Increased asthma symptoms or difficulty breathing among users with asthma or chronic obstructive pulmonary disease.

HEART AND BLOOD VESSELS E-cigarettes are also associated with short-term effects on the cardiovascular system: ➢ Short-term increase in heart rate and blood pressure. ➢ Endothelial cell dysfunction (changes in cells lining the blood vessels).

Text Sources: National Academy of Sciences, 2018a; Pisinger, 2015; Pisinger and Dossing, 2014. Schweitzer et al., 2017. Image Sources: Pixabay. 17 LONG-TERM EFFECTS – BRAIN CHANGES

Nicotine exposure cause long- lasting changes in the brain. DID YOU KNOW? The brain continues developing until ▪ Nearly all (99%) e- around age 25. Regular nicotine cigarettes sold in 2015 exposure during adolescence can contained nicotine. lead to long-lasting changes in the ▪ The amount of brain that can cause: nicotine in one Juul e- ▪ Mood disorders, such as anxiety and depression. cigarette is equivalent to about ▪ Lowered impulse control. 200 cigarette puffs. ▪ Cognitive effects such as decreased attention span ▪ Almost two-thirds and working memory. (63%) of Juul users ages 15-24 are not Adolescents are also more prone to addiction than aware that the adults—young people who are exposed to nicotine product always are likely to become addicted. Nicotine addiction contains nicotine. can lead to use of more harmful tobacco products Source: Blad, 2018; (e.g. cigarettes, smokeless/chewing tobacco, etc.). Campaign for Tobacco-Free Kids, 2018; Marynak, 2017 Text Source: Office of the Surgeon General, 2016. Image Source: Pixabay.

18 OTHER POTENTIAL LONG-TERM EFFECTS E-cigarettes contain many substances that cause changes in cells in the body. Over time, changes in cells of the blood, heart, lung, and other parts of the body could lead to heart disease, lung disease, or cancer. Researchers are investigating whether there is a causal relationship between e-cigarette use and long-term, negative health consequences. RISK OF HEART DISEASE AND HEART ATTACK A recent survey found that daily e-cigarette use was associated with increased odds of heart attack, high blood pressure, and high cholesterol. Additional studies are needed to establish a causal link between e-cigarette use and heart attacks. RISK OF LUNG DISEASE E-cigarettes contain many substances (e.g. propylene glycol, diacetyl, fine particles) that can be harmful when inhaled. To date, however, no studies have shown that long-term e- cigarette use causes lung disease. RISK OF CANCER E-cigarette flavorings such as cinnamon have been found to be toxic to cells. Other chemicals and compounds found in e-cigarettes (e.g. formaldehyde, nitrosamines) are known carcinogens, or cancer-causing substances. DNA damage has been found in human and mice cells exposed to e-cigarette vapor.

Sources: Alzahrani et al., 2018; Fetterman et al., 2018; Lee et al., 2018; National Academy of Sciences, 2018a; Qasim et al., 2017; Office of the Surgeon General, 2016. 19 SECONDHAND EFFECTS

Individuals who do not use e-cigarettes can still be exposed to e-cigarette vapor. DID YOU KNOW? When a person is actively using an e-cigarette, ▪ In 2015, 1 out of 4 people who are nearby (either indoors or outdoors), middle and high can inhale the vapor that the user exhales. school students reported secondhand It is unclear whether secondhand exposure to e- exposure to e- cigarette vapor leads to negative health effects. cigarettes. This However, we do know that e-cigarette vapor releases translates to 6.5 nicotine and other chemicals into the air. Studies have million students. found that secondhand exposure to e-cigarettes ▪ One-third of U.S. causes non-users to absorb nicotine and breathe in adults do not know fine particles. whether secondhand exposure to e- To prevent non-users from potential harm and to cigarettes causes maintain clean indoor air, the U.S. Surgeon General harm to children. recommends banning the use of e-cigarettes indoors.

Source: National Academy of Sciences, 2018a, 2018b; Office of the Source: Nguyen et al., 2017; Surgeon General, 2016. Wang et al., 2017

20 OTHER EFFECTS OF E-CIGARETTES OTHER HEALTH EFFECTS- SUMMARY

E-cigarettes can have other harmful effects including:

Injuries or even death as a result of e- 1 cigarette explosions or fires.

Poisoning due to accidental swallowing of 2 the e-cigarette liquid or spilling the liquid on the skin.

Increased risk of smoking conventional 3 cigarettes or using other drugs.

Image: Pixabay

22 EXPLODING E-CIGARETTES

KEY FACTS E-cigarettes can sometimes cause explosions and fires. E-cigarette explosions and fires can occur when: The cause of these explosions is unknown, but they are likely due to issues with the batteries in the ▪ The device is in a devices. Explosions can result in serious flame and person’s pocket (61 out of 195 incidents). chemical burns, smoke inhalation, and blast injuries (e.g. cuts, tissue damage, loss of teeth or other body ▪ The user is actively parts). One death has been reported from e- vaping (60 out of 195 cigarette explosions (a Florida man in May 2018). incidents). ▪ The battery is being The U.S. Fire Administration recorded 195 fires charged (48 out of 195 and explosions related to e-cigarettes from incidents). 2009 to 2016. Explosions can also occur This figure is likely an underestimation of the actual when the device is in number of fires caused by e-cigarettes because storage or when it is being many fires are extinguished quickly and not reported transported. to the fire department. Source: U.S. Fire Administration, 2017. Source: Brownson et al., 2016; Fortin, 2018; Patterson et al., 2017; Ramirez et al., 2017; U.S. Fire Administration, 2017.

23 E-CIGARETTES AND POISONING

KEY FACTS E-cigarette liquids are harmful if swallowed or absorbed through skin. ▪ More than 7,600 children under age 6 Humans and animals can get nicotine poisoning if they accidentally swallowed 1) accidentally swallow e-cigarette liquids containing e-cigarette liquids from nicotine or 2) if they spill the liquid on their skin or other 2012 to 2017. Around a parts of the body. Less severe cases of nicotine third were hospitalized. poisoning cause nausea, vomiting, headaches, and ▪ Several companies in dizziness. More severe cases cause seizures, increased the United States sell e- heart rate, confusion, and sometimes even death. cigarette liquids in packages that look like “kid-friendly food E-cigarette liquids can be especially dangerous to products” such as juice children. The American Academy of Pediatrics warns boxes, candy, and that liquid nicotine can be poisonous for children cookies. This packaging “within a matter of minutes” if spilled on the skin, and can confuse children that just a teaspoon of the liquid can kill a one-year and increase the likelihood of poisoning. old child. E-cigarette liquids are currently required to be sold in child-resistant packaging. However, many Source: Food and Drug children are still accidentally exposed to liquid nicotine Administration, 2018b; Govindarajan et al, 2018. each year. Source: Govindarajan et al., 2018; Korioth, 2014; Office of the Surgeon General, 2016. 24 VAPING AND SMOKING

Vaping at a young age can lead to smoking later in life. Youth and young adults E-cigarettes have the potential to serve as cessation aids for adults who want to quit smoking. ages 14 to 30 who use For youth who have never smoked cigarettes, e-cigarettes are however, e-cigarettes can have the opposite effect—e-cigarettes can be a “gateway to 4 times more likely traditional smoking.” Studies have consistently shown that youth who use e-cigarettes have an increased likelihood of starting smoking within one to start smoking than to two years. peers who do not use e-

There are many reasons that e-cigarette use could cigarettes. lead to future cigarette use. E-cigarettes mimic “the behavior of smoking traditional cigarettes,” flavored vapes are a “gentle introduction to Sources: Bold et al., 2017; Hartmann-Boyce et al., 2016; Klein, smoking,” and nicotine addition can lead e- 2018; National Academy of cigarette users to seek out cigarettes or other Sciences, 2018a; Primack et al., products with higher concentrations of nicotine. 2018; ScienceDaily, 2017; Soneji et al., 2017; Watkins et al., 2018.

25 RESOURCES RESOURCES FOR PARENTS & EDUCATORS

U.S. Surgeon General Resources ▪ Fact Sheet about Youth and Young Adult E-Cigarette Use ▪ Public Service Announcement (Video) ▪ Tip Sheet for Parents for Talking with Teens About E-Cigarettes

Other Resources ▪ CATCH my Breath E-Cigarette Prevention Program Resources (University of Texas) ▪ E-Cigarettes and Teens – A Guide for Parents and Educators (Safe Kids America) ▪ Expert Views on E-Cigarettes (Center on Addiction) ▪ Not So Safe Campaign (Orange County Department of Education) ▪ Quick Facts About Juul (University of Texas) ▪ Tobacco Prevention Toolkit – E-Cigarettes and Vapes (Toolkit for health educators from Stanford University)

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