The use of e-cigarettes, also known as “vaping,” has become a popular alternative form of nicotine consumption. An electronic cigarette is a battery-operated device that holds a cartridge containing a liquid solvent and the substance intended to be inhaled, such as nicotine, marijuana or a variety of other substances. The battery heats both the liquid and the substance contained within the cartridge creating a vapor that is then inhaled by the user. To increase palatability and user-enjoyment, these cartridges are also often infused with flavors. There are more than 150 flavors available so there is often something for everyone.
E-cigarette companies, the largest of which is Juul, advertise their product as a safer alternative to traditional smoking and a method for smokers to wean themselves from tobacco products. Juul had a very popular campaign, which has recently been withdrawn, called “Make the Switch” that encouraged traditional smokers to switch to e-cigarettes as a safer alternative. They also advertised that one can vape without the negative effects often associated with smoking: no bad breath, no cigarette burns, less risk of cancer and other smoking-related diseases.
These false statements give users the impression that e-cigarettes are not as toxic as smoking. However, not only can e-cigarettes have more nicotine than ordinary cigarettes, the fact that the additives are unregulated means that there is a risk for exposure to potentially lethal chemicals.
High school-aged students are unique and complicated. While trying to establish their independence and autonomy, they often turn away from adult influencers and toward their peers and may not know how to find or utilize the best possible resources to make decisions. This may make teenagers particularly susceptible to peer-pressure and advertising. Recent studies show that one in five high schoolers and one in 20 middle schoolers report having used e-cigarettes, a 78 percent increase from 2017 to 2018.
When surveyed, teenagers hold many misconceptions about vaping. They believe it is safer than smoking because they believe it delivers low or no levels of nicotine, and they believe it is more “natural” than smoking. Furthermore, with pervasive advertisement and name-branding and the myriad of flavors available, many adolescents aren’t aware that some brands such as Juul are in fact e-cigarettes.
The e-cig is easier to disguise than cigarettes and the smoke/ odor and the devices used are not readily identified by authority figures, with some even resembling USB drives. While states have a minimum smoking age, these restrictions do not necessarily apply to these nicotine products. Finally, vaping does not leave a residual odor on clothing and does not smell like cigarettes or marijuana, making it hard to detect. As a result, it has been identified that 40 percent of vapers (people who vape) had never smoked cigarettes, suggesting that the vaping advertising is actually creating a new generation of vapers who normally had not smoked.
Despite the industry’s pervasive marketing campaign, e-cigarettes are not safe and are not regulated by the FDA. A regular cigarette contains 9mg of nicotine, and the cartridges can contain up to 42 mg/ml of nicotine, depending on the strength of the cartridge. When compared to cigarettes, which are held and lit and only expose the user to nicotine when inhaled, the vaper is exposed to the full strength of the nicotine as it is not released until the unit is inhaled. Also, besides nicotine or marijuana, the liquid solvents expose the user to a plethora of unique toxic chemicals not present in smoking tobacco. Consequently, when compared to a cigarette, the vaper is exposed to a much more concentrated nicotine load that is delivered more efficiently than traditional cigarettes.
The cartridges contain chemical solvents that help aerosolize the substance. These solvents have been linked to severe lung damage and death. As of October 15, 2019, 33 deaths and 1,479 cases of lung-injury cases related to e-cigarette use have been recorded in the United States. Alarmingly, 79 percent of these cases involve patients under the age of 35, and 36 percent are aged 16-20.
Vaping and Athletes
The effect of vaping on athletic health and performance is becoming increasingly evident. Specifically, vaping leads to a decreased lung capacity, which makes it more difficult to perform at competitive levels. In many schools, students are facing punishment for e-cigarette use. Suspensions are derailing athletes from achieving optimal athletic development, lessening their chances for success and advancement beyond their high school careers.
To curtail the increase in popularity of vaping, educational campaigns aimed at deterring use among students and counteracting misconceptions may be more valuable than punitive measures. Some school districts are addressing use as a substance abuse issue rather than a disciplinary one and are offering programs to help students quit. Targeting efforts toward student-athletes may be beneficial as these students are often perceived as leaders among their peers.
Neha P. Raukar, MD, is an emergency medicine and sports medicine specialist at the Mayo Clinic in Rochester, Minnesota, and a member of the NFHS Sports Medicine Advisory Committee. Jennifer D. Rheeling, MS, ATC is an athletic trainer for the District of Columbia Public School system, the chair-elect of the NATA Secondary School Athletic Trainers’ Committee, and a member of the NFHS Sports Medicine Advisory Committee. Michael C. Koester, MD, is a nonsurgical sports medicine specialist for the Slocum Center for Orthopedics and Sports Medicine in Eugene, Oregon, and is chair of the NFHS Sports Medicine Advisory Committee.