Vaping Synthetic Nicotine in Disposable Devices

When we last wrote an article about e-cigarettes and vaping nicotine, the news was more positive than negative. We published that article – Cigarettes, E-Cigarettes, and Substance Use in Adolescents – shortly after the public outcry around the most popular e-cigarette at the time, called Juul. The widespread animosity toward Juul arose from the perception that the company designed their flavors and advertising campaigns to target the adolescent population.

The public – parents of teens first and foremost – objected to Juul based on a combination of personal knowledge and data published in well-respected reports like the nationwide Monitoring the Future Survey (MTF).

The short story on vaping, e-cigarettes, and Juul is straightforward. As public awareness around the physical risks of cigarettes – the old-fashioned kind people smoke – became widespread and indisputable, cigarette use among teens plummeted. Then, with the invention and popularity of vaping, nicotine vaping products took over. Data from surveys like the MTF 2020 showed teens vaped at alarming rates.

But regulators stepped in, and effectively reversed the teen vaping trend.

Here’s the data on how that played out.

Nicotine Vaping: 10^th and 12^th Graders, 2017-2020

• 2017:
  • Daily: n/a
  • Past Month: 8%
  • Past Year: 17%
  • Lifetime: 23%
• 2018:
  • Daily: n/a
  • Past Month: 18%
  • Past Year: 27%
  • Lifetime: 31%
• 2019:
  • Daily: 9%
  • Past Month: 22%
  • Past Year: 32%
  • Lifetime: 39%
• 2020:
  • Daily: 7%
  • Past Month: 21%
  • Past Year: 31%
  • Lifetime: 41%

We can see that after enormous increases between 2017 and 2019, vaping among teens from 2019-2020 leveled out. It increased, yes. However, the increases from 2017 to 2019 dwarf the increases from 2017-2019.

That was a positive development, but we need to qualify that:

Any nicotine vaping is bad for teen health.

Simply because the sharp increases plateaued, thta doesn’t chnge the fact that significant percentages of teens report vaping at least once, more report vaping monthly, and seven percent of teens vape every day.

That is not good.

Federal Legislation Limiting Vape Sales to People Under 21

The data above beg a question:

What happened to stop the trend?

All available data point to two things:

1. The Tobacco 21 Act.
   • This act (yes, it took an act of Congress to halt the increases), passed in 2019, made the sale of tobacco products to anyone under 21 illegal. Restrictions apply to cigarettes, chewing tobacco, tobacco for hookahs and pipes, cigars, and any reusable electronic nicotine delivery systems, i.e. vaping products.
2. Public Awareness Campaigns.
   • Additional data from the MTF 2020 survey showed that as vaping among teens leveled off, perceived harm from vaping among teens increased dramatically. In 2017, 28.6% of 10^th and 12^th graders thought daily vaping caused “great harm.” That number increased to 49.3% in 2020.

That last point says awareness campaigns, including articles like this one, can have a positive impact on how teens think about using tobacco. This change in perspective, in turn, affects behavior, as the plateau in prevalence numbers indicates.

That’s where we were before the pandemic hit in 2020. Juul stopped selling fruity flavored e-cigarettes to minors in late 2019, and the out-of-control increases topped. Then two things happened: the pandemic arrived, and a company called Puff Bar found a loophole in the new law which allowed them to skirt the new rules established by the Food and Drug Administration (FDA).

The Puff Bar Phenomenon + The Pandemic

An informative podcast recorded and released by The Wall Street Journal in November 2021 details the rise of a company called Puff Bar, which sells nicotine vaping products. What got the attention of the WSJ, parents, and regulatory authorities was the aggressive marketing of fruity flavors that appeal to teens – and how Puff Bar managed to enter the e-cig market despite the Tobacco 21 Act.

Puff Bar sells the following flavors (this list is not comprehensive):

• Blueberry Ice
• Banana Ice
• Cool Mint
• Watermelon
• Peach Ice
• Grape
• Mango
• Strawberry
• Strawberry Banana
• Passion Fruit
• Menthol

It’s flavors like these that sparked the resistance to Juul and led to the passage of Tobacco 21.

If selling products like these mobilized the U.S. Congress in 2019, then how did Puff Bar go from total obscurity to a company that – according to the New York Times – sold an estimated 300,000 vape devices per week in mid-2021?

Here’s what we learned from the WSJ podcast. Fair warning: the reason is simple. It’s frustrating. And, if you’re the parent of a teen, probably maddening.

Ready?

The 2019 law forbade the sale of reusable electronic nicotine vaping products to people under the age of 21.

Puff Bars are disposable.

That’s it. That’s the loophole: they’re not reusable.

And that’s what led to the teen vaping numbers collected during the pandemic, which are a mix of good and not-so-good news.

Teen Vaping During COVID

We’ll lead with the good.

A survey conducted by the American Journal of Public Health collected data from over five thousand teens in the U.S. about their tobacco use. Researchers compared data from January-March 2020 (pre-COVID) to data from March-June 2020 (mid-COVID).

Here’s what they found.

Teen Nicotine Vaping Pre- and During COVID

During COVID:

• Young adults (18-20) had a 35% lower likelihood of current nicotine vaping than before COVID
• Teens (15-17) had a 28% lower likelihood of current nicotine vaping than before COVID

Among those who vaped nicotine during COVID:

• Teens reported vaping nicotine an average of 11 days per month, compared to 12.3 before COVID
• 48.6% of teens who regularly vape nicotine reported vaping less during COVID than before
  • Teens reported that lack of access to retail sales reduced their nicotine vaping
  • Teens reported that the absence of sharing vaping products at/after school contributed to their reduced vaping
• 25.6% of teens who regularly vape nicotine reported vaping more during COVID than before

We’ll repeat again that any vaping of nicotine among teens is not a good thing. However, we will label any reductions we see – like those above – as good news.

Now we’ll move on to the not-so-good news. This data is from a report published by the Centers for Disease Control (CDC) in late 2020.

Among high school teens who self-report as regular or current e-cig/nicotine vape users:

• 48.5% use prefilled cartridges with reusable devices
• 26.5% use disposable nicotine vaping devices (e.g. Puff Bar)

Among high school teens who self-report as using flavored e-cigs/nicotine vape devices:

• 78.3% use fruit flavors
• 55.8% use mint
• 37% use menthol
• 36.4% use candy, dessert, or other sweet flavors

And now, the data point that raises alarm bells with regards to Puff Bar. Among high school teens:

• Use of disposable nicotine vape devices increased from 2.4% to 26.5%
  • That’s a jump of 1,000%

In response to the phenomenon of disposable nicotine vaping devices, the FDA sent letters to ten companies requesting them to stop selling flavored disposable e-cigs – and they stopped. However, companies that did not receive the letter continue to sell them.

Is Vaping Nicotine That Big a Deal?

That’s a question you may have asked yourself while reading this article. After all, we are a mental health and substance use disorder treatment center. Why make a fuss over nicotine?

Our first answer is easy. Not only is vaping nicotine illegal for people under 21 in most U.S. states, it’s also bad for their health. Research shows vaping nicotine can increase the risk of:

• Lung disease
• Lung damage
• Heart disease
• Heart attack
• Asthma complications
• Chronic coughing and wheezing

Our second answer comes from new data published in peer-reviewed journal articles on adolescent mental health and substance use. That new data tells us two things:

1. There’s a connection between adolescent nicotine use and subsequent substance use and substance use disorders.
2. There’s also a connection between adolescent nicotine use and adolescent mental health disorders.

We’ll look at the connection between vaping nicotine and adolescent substance use disorders first. Then we’ll offer the data on the connection between vaping nicotine and adolescent mental health. Here’s a disclaimer: no data indicated vaping causes addiction or mental health disorders. The data we present below discusses strong correlations that are important for parents, teachers, and mental health professionals to understand.

Nicotine, Adolescent Substance Use Disorder, and Adolescent Mental Health: The Connections

An article published in 2019 confirms a hypothesis made in 2011, which asserts that exposure to nicotine during adolescence increases vulnerability to substance use disorder – i.e. addiction – later in adolescence and in adulthood. Initial studies confirmed the relationship between adolescent nicotine use and subsequent cocaine addiction.

We wrote about those initial studies from 2011 in this article:

Cigarettes, E-Cigarettes, and Substance Use in Adolescents

The new data from 2019, published in the article “Nicotine Gateway Effects on Adolescent Substance Use” enhances and expands on the data from 2011. The new article shows the following:

• While drugs of misuse act on different signaling systems in the brain, they all converge in the reward system in the brain, known as the mesolimbic system.
• Adolescent nicotine changes the brain and increases vulnerability to future drug use.
• Drugs nicotine can increase vulnerability to include:
  • Stimulants such as methamphetamine and cocaine
  • Alcohol
  • Marijuana
  • Opioids
    • The connection to opioids is less clear than for the first three drugs we mention
  • The earlier the exposure to nicotine, the greater the risk for subsequent drug misuse

Now let’s look at the connection between nicotine use and adolescent mental health. A report published by The Truth Initiative in September 2021 indicates:

• Nicotine use can exacerbate anxiety symptoms
• Nicotine use can amplify feelings of depression
• Teens who vape nicotine are twice as likely to have a diagnosis of depression, compared to teens who don’t vape nicotine
• 81% of teens who vape nicotine initiated their use to deal with stress, anxiety, or depression
• Quitting nicotine vaping is associated with improved mental health

That’s why we make a fuss about vaping nicotine. Data shows it’s bad for physical health, can increase vulnerability to addiction, and correlates with mental health issues such as anxiety and depression. Everyone knows about that first point, but we suspect many parents do not know about the connection between nicotine and subsequent substance use, or the correlation between nicotine use and mental health issues.

Now the material is here to read and consider. We encourage all parents and mental health professionals to take time with this information for this important reason:

It appears that nicotine vaping device companies target teens.

While some people may dispute this claim, we’ll offer an ad from Puff Bar created during the pandemic, and let our readers decide what they think. The following text accompanied a photo of a typical teen bedroom:

“We know that the inside-vibes have been…quite a challenge. Stay sane with Puff Bar this solo-break. We know you’ll love it. It’s the perfect escape from the back-to-back zoom calls, parental texts, and WFH stress.”

We realize there’s plausible deniability there. However, this ad was a key piece of evidence representatives in the U.S. Congress used when they urged the FDA to regulate the sale of flavored, disposable, synthetic nicotine vaping devices – which they did. We’re hopeful that they’ll expand those regulations and restrict new companies from selling fruit flavored vape products in the future.

It’s Not Easy to Quit

For teens or parents of teens who vape nicotine and want to stop, we understand that there’s nothing easy about it. Nicotine is an addictive drug. Increased use reinforces the addiction. Starting use during adolescence makes quitting more difficult. Using nicotine over a long period of time also makes it more difficult to stop.

For teens or parents of teens who want to stop vaping nicotine, the Truth Initiative maintains an anonymous, text-based program called This is Quitting.

We recommend parents who think their teen uses nicotine to handle stress, the symptoms of anxiety, or the symptoms of depression to arrange a full psychiatric evaluation administered by a mental health professional. The American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in any area of the U.S.

Finally, parents seeking treatment for their teen can navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.