Gen Z Is Hooked on Vaping

Exploring the obstacles to nicotine cessation among teens

By Denny Watkins
August 25, 2023 | SUMMER 2023 ISSUE

Pulmonologist, Evan Stepp, MD, FCCP, has a teenage daughter who doesn’t smoke or vape—as far as he knows, Stepp will admit—but the statistics on youth smoking are alarming enough to have him worried.

On one hand, fewer Americans are smoking today than ever before. Since 1992, the percentage of people who told Gallup that they’d had a cigarette in the past week has dropped from 28% to 11%. Meanwhile, the rate of new lung cancer cases declined from 65 per every 100,000 people in 1992 to 34 per 100,000 in 2020, according to the National Cancer Institute.

While those statistics are worth celebrating, they hide an alarming reality: A disproportionate number of teens and young adults today are addicted to nicotine. According to a November 2022 report from the Centers for Disease Control and Prevention (CDC), one in six high school students and one in 20 middle schoolers are using a nicotine product at least once every day.

“It’s a completely different picture for nicotine cessation in youth,” Dr. Stepp, who is an associate professor at National Jewish Health in Denver, said. “Because of the fact that the nicotine addiction is occurring in a developing brain, which raises many other nicotine-related harms.”

Why teens vape

Tobacco is a well-documented carcinogen, and studies estimate that 90% of lung cancer cases are caused by smoking. Smokers are also more likely to develop cardiovascular disease, type 2 diabetes, and cognitive decline. But tobacco is a slow-working poison, and most deaths attributable to smoking occur late in life—which can make the risks of smoking seem too far in the future to matter to young people.

What’s more, today’s teens are smoking less actual tobacco, and, instead, overwhelmingly prefer e-cigarettes or vaping. In fact, 85% of high school-aged smokers and 72% of middle school smokers reach for a vape over regular cigarettes or smokeless tobacco, according to the CDC.

Middle and high school students say they...

have tried a tobacco
product at least once
have tried vaping
have tried cigarettes
at least once

Source: Centers for Disease Control and Prevention. 2022.

It’s not hard to understand why: e-Cigarettes use a heating element to turn a nicotine-infused liquid into an aerosol, with no open flame, ash, or lingering smoke. The vapes themselves are easy to conceal, and if someone needed to hide an e-cigarette from particularly perceptive parents or teachers, they can find vapes built into hoodies, fake smartwatches, and USB drives. Unlike smokeless tobacco, there’s no need to constantly spit.

Plus, the liquids often come in flavors like fruit, bubble gum, mint, and vanilla, because unflavored nicotine isn’t exactly appealing. “Huge concentrations of nicotine salts are just miserable to breathe in,” Dr. Stepp said. “Flavors are necessary to make these products palatable, and those flavors end up being a huge draw for youth users to get exposed to nicotine addiction.” Instead of the acrid odor of an ashtray, vapes might leave behind the faint whiff of a candy store or an ice cream shop.

Data on health risks of vaping still emerging

e-Cigarettes are a relatively new technology. Chinese pharmacist, Hon Lik, invented electronic nicotine delivery systems just after the turn of the millennium, with some of the first models entering the market in 2004. Smokers started turning to vapes in greater numbers by the mid-2010s. Yet nearly 20 years after the introduction of e-cigarettes, scientists still aren’t certain about the long-term harms of vaping nicotine.

Inhaling aerosolized nicotine-infused liquid has been shown to have some shorter-term health consequences, including worsening asthma, impaired performance in sports, coughing/wheezing, and behavioral health effects. In 2019, the first reported incidents of e-cigarette or vaping-associated lung injury, or EVALI, ballooned to more than 2,800 cases by 2020 (when the CDC stopped recording data) and at least 68 deaths. The median age of EVALI victims was just 24 years old.

No matter how it enters the body, nicotine makes immediate changes to the central nervous system, binding to nicotinic acetylcholine receptors and upregulating new receptors, which simultaneously creates both increased tolerance and cravings for more nicotine. “One of the things that is important to keep at the forefront of the conversation is that nicotine addiction is a chronic medical disease, and it’s a form of substance abuse,” pediatrician, Susan Walley, MD, a co-author of the American Academy of Pediatrics’ recent position papers on children and smoking, said. “Substance abuse is a mental health issue.”

“Nicotine addiction is a chronic medical disease.”

Young people are particularly sensitive to nicotine. One study from the University of Massachusetts Medical School found that 22% of middle school-aged teens experienced one or more symptoms of nicotine withdrawal—such as cravings, irritability, and difficulty concentrating—within just the first month of occasionally smoking. Teens who use tobacco are at higher risk of anxiety and depression, attention-deficit/hyperactivity disorder, poor impulse control, and reduced executive function. Studies have shown that nicotine also makes changes in the brain regions associated with learning and memory.

It’s no wonder why 88% of adult tobacco users say their habit started before they turned 18 years old, according to the National Survey on Drug Use and Health.

Challenges surrounding smoking cessation in youth

The powerful effect of nicotine in youth means the need for effective cessation strategies is both more urgent and more difficult. But while physicians can prescribe to adults the antidepressants varenicline and bupropion, along with nicotine replacement therapy, to help ease withdrawal symptoms, the Food and Drug Administration (FDA) has not approved those medications for anyone under the age of 18.

Research on cessation medications in young people is limited: A recent meta-analysis found only four studies on people between the ages of 12 and 21. In teens, the antidepressants seem to help quitting for the first few weeks but are unproven as a long-term solution. “That really has been a challenge for the one in six high school students who are current users of tobacco products,” Dr. Walley said. “We know that we need more research in adolescent tobacco cessation, and it really is about the funding, about research dollars.”

“We know that we need more research in adolescent tobacco cessation, and it really is about the funding, about research dollars.”

Without medications, smoking cessation in teens relies largely on counseling strategies. A 2017 review published by Cochrane Library found that group counseling was the most effective quitting method, with teens participating in group sessions 35% more likely to stop using nicotine products up to a year later, compared with teens who did not receive any counseling. Counseling over text messages was 18% more effective, while the review found that one-on-one counseling was only 7% more effective in teens than quitting by themselves.

Counseling can help educate teens (and parents) on some of the realities of e-cigarettes, bridging the gap between well-established anti-smoking campaigns and the anti-vape campaigns that have yet to catch up. “We have done a great job promoting cigarette use as dangerous,” Dr. Walley said. “Many teens who would never pick up a cigarette—because they know the health risks—are vaping.”

In a 2019 study on nearly 14,000 teens conducted by the University of California, San Diego, young people rated e-cigarettes significantly less harmful than tobacco cigarettes—an average of 1.95 compared with 2.79 on a scale of 1 to 3—and as less addictive than other tobacco products.

Cessation counseling also helps addicts work through the social and environmental factors that contribute to their habit. Young people who face discrimination or other pervasive hardships are even more vulnerable to nicotine. Teens who identify as gay, lesbian, or transgender, for example, are twice as likely to pick up a smoking or vaping habit than their straight and cisgender peers.

“Tobacco use serves as a coping mechanism for youth and adults to deal with the daily stressors of discrimination and harassment,” Isaias Guzman, manager of programs at the California LGBTQ Health and Human Services Network, said.

Tobacco companies have a long history of marketing to gay and lesbian consumers through bars, through Pride events, and by financially supporting LGBTQ+ advocacy organizations. That effort helped create a culture around smoking in the LGBTQ+ community. “When you see your friends smoking, you want to be part of the in-group,” Guzman said. “You’re dealing with rejection from home and from school, so you want to be included in your friends.”

At the same time, LGBTQ+ youth and adults can also face discrimination from their own health care providers. Guzman suggested that physicians should be overt in their support for LGBTQ patients, such as displaying rainbow flags or informational brochures that include same-sex couples, to help allay fears.

“Tobacco use serves as a coping mechanism for youth and adults to deal with the daily stressors of discrimination and harassment.”

Young smokers who come into a doctor's office with their parents might not be "out" to their family, which means that physicians who are trying to talk to closeted LGBTQ youth about quitting smoking could be missing an important underlying factor. “Our recommendation is that adolescents start having conversations with their pediatrician [one on one] at age 11,” Dr. Walley said.

How to convince a teen to quit

Cessation and prevention strategies are closely linked, and interventions can start in middle school-aged children up through high school and young adults. Simply asking a 12-year-old, “Do you know anyone who smokes?” can help start a conversation that leads to an attempt to quit.

Teens may be compelled to smoke through digital advertising and influencer endorsements on social media platforms, but Gen Z is turned off by the idea that it’s being manipulated by the tobacco industry. Juul, for example, is partially owned by Altria, which makes Marlboros, and Vuse is wholly owned by R.J. Reynolds, which makes Camel cigarettes.

“If you can get somebody to understand that Big Tobacco is trying to manipulate you as a young person to want to illegally obtain and use their products, which are incredibly addictive, thus ensuring you will remain a loyal customer, that could be the thing that pushes them over the hump,” Dr. Stepp said. “You push it away like you would push away a parent trying to tell you how to park a car in the driveway.”

And while nicotine replacement therapy is not FDA-approved for those less than 18 years of age, off-label nicotine gum, lozenges, and patches—but not e-cigarettes, for all the reasons mentioned above—is an option (with a prescription) for adolescents who are struggling with withdrawal. “Nicotine replacement therapy is extremely safe and also has few side effects beyond what a nicotine user experiences, if any,” Dr. Walley said. “It’s not exposing them, if you will, to a different drug than what they are already getting.”

And just because a smoker relapses, it doesn’t mean the cessation was a complete failure. One Canadian study estimated that it takes an average of 30 attempts to successfully quit smoking for one year or longer. And the younger someone is when they stop smoking, the less likely they are to suffer from the long-term health consequences of smoking, according to a 2021 study in the Journal of the American Medical Association.

“With the right counseling,” Dr. Walley said, “each relapse is an opportunity for losing the habit permanently.”