E-cigs . . . Are They Cool? Talking to Teens About E-Cigarettes

Introduction

Electronic cigarettes or e-cigarettes (e-cig) as they are commonly called are becoming increasingly popular worldwide. ¹ These devices have been popularized in mainstream media and are advertised as being less harmful than combustible cigarettes, with some proponents asserting that they can assist smokers quit traditional cigarettes.^2,3Although efforts to regulate e-cigarette advertising and sales are emerging, many youth continue to think that e-cigarettes are healthy alternatives to combustible cigarettes. ⁴ As a pediatrician, it is important to understand the use of e-cigarettes in adolescent patients as a way to better assess if adolescents are vaping, to understand what perceived benefits they attribute to e-cigarettes and to see whether they have any health problems induced by using e-cigarettes.^5,6 When speaking to teens about e-cigarettes we propose pediatricians practice the principles of motivational interviewing to elicit change in a nonjudgmental manner. This article will review the basics of e-cigarettes and their potential harmful health effects, along with reviewing teens’ perception of e-cigarettes. Finally, we will discuss how motivational interviewing can be used to inform youth of the harmful effects of e-cigarettes and encourage them to stop vaping.

Overview of Electronic Cigarettes

E-cigarettes have evolved over time with first generation e-cigarettes resembling traditional cigarettes to easily simulate cigarette smoking to now e-cigarettes that come in various shapes and sizes that deliver nicotine and/or a diversity of flavorings. They are battery-powered devices that are activated by puffing into the e-cigarette. This action heats and vaporizes a liquid, such as nicotine or flavorings, for the users to inhale. ⁷ Along with the nicotine or flavorings, the e-liquid also contains propylene glycol and/or glycerin. By using e-cigarettes individuals are not exposed to the many toxicants, carcinogens, and abundant free radicals formed when tobacco is burned in conventional cigarettes. ⁸

Since their inception in 2003 by a Chinese pharmacist whose father died of lung cancer, “e-cigs” have quickly ascended in popularity. ⁹ Adolescents are often more accepting of e-cigarettes and enthusiastically research e-cigarettes on social media and YouTube where they learn about new and exotic tastes, new e-cig models, and “vaping tricks.” ⁴ E-cigarettes appeal to adults because the device simulates the experience of smoking and delivers the nicotine without combustion, which is responsible for most carcinogens in traditional cigarettes, while also mimicking the hand to mouth aspects of smoking. ¹⁰

E-cigarettes have become popular among teenagers. E-cigs that use sweet flavorings such as bubble gum, cherry, and cheesecake appear to be more popular among teens. ¹¹ Plus, aggressive marketing that portrays e-cigs as “new and improved” nicotine delivery systems are geared toward adolescents and although efforts to regulate e-cigs advertising and sales are emerging, many youth continue to think that e-cigs are healthy alternatives to combustible cigarettes. ¹² Consequently, this form of nicotine consumption has gained acceptance among young people, far more so than conventional cigarettes. In fact, the use of conventional cigarettes among teens has steadily declined, whereas the use of e-cigarettes has soared, rising from 3% to 20% among 6th to 12th graders since 2006. ¹³

Health Effects of E-Cigarettes

Historically, e-cigarettes have been loosely regulated and although they are often depicted as being a healthier alternative to cigarettes, each brand varies in the exact concentration of additives and nicotine in each unit. ⁷ As such, little is known about how much each brand has to offer in terms of health risks to the developing brains of youth. However, knowing the basics about e-cigarettes will allow physicians to educate their patients regarding the basic side effects of e-cigarettes. ⁵ Most e-cigarettes are typically operated by lithium-ion batteries, which in some occasions have exploded causing mixed partial- and full-thickness burns, along with causing house fires.^14,15 The e-liquid is composed of a mixture of water, propylene glycol, glycerin, and flavorings with and without variable amounts of nicotine. Aerosolization of these components produces the “smoke” that users and bystanders inhale. Both the propylene glycol and glycerin in e-cigs may produce mouth and throat irritation as well as dry mouth. ⁸ The newer generation devices (tank-type) may at times heat the e-liquid to very high temperatures yielding formaldehyde from the propylene glycol; formaldehyde is a known carcinogen.^8,16 More commonly, exposure to fine particles in the e-cigarettes may worsen respiratory ailments such as asthma and bronchitis.^17,18 Another concern is that relatively high concentrations of nicotine in the cartridges pose increased risk of nicotine toxicity, especially in pets and children who may be attracted to the flavorings if e-cigarettes are left unattended. ¹⁹

Most important, however, the use of e-cigarettes increases a teen’s exposure to nicotine products with adolescents who use e-cigarettes becoming more likely to start smoking conventional cigarettes in the future. ²⁰ For example, although smoking prevalence in Southern California among adolescents has declined over the past 2 decades, the use of e-cigarettes among middle and high school students doubled between 2011 and 2012. ²¹ The high prevalence of e-cigarette use among teens indicates that e-cigarettes are not merely a substitute for cigarettes but in fact adolescents who would not have used nicotine products in the first place are now using e-cigarettes. ²² Physicians worry about the role of e-cigarettes as a “gateway” to traditional cigarettes in adolescents. ²³ A study completed by University of California–San Francisco found that adolescents that used e-cigarettes were more likely to eventually smoke traditional cigarettes and were also less likely to quit smoking. ²¹

Given the role of e-cigarettes as a “gateway” to nicotine products, it is important for physicians to understand the effects of nicotine on developing adolescent brains so that they can educate their patients. ²⁴ Major structural remodeling of the brain occurs during adolescence, particularly in regions implicated in the maturation of emotional and cognitive control and associated neurotransmitter systems, including dopamine. These include the nucleus accubens (reward processing), prefrontal cortex (executive function), and amygdala (emotional maturation). Moreover, strengthened connectivity among these brain areas appears to contribute to improved executive function abilities. Nicotine acetylcholine receptors serve as regulators of neural maturation. Preclinical data suggest that nicotine exposure during the teenage years disrupt these processes, leading to long-term changes in these neural circuits. Clinically, this may manifest as abnormalities in cognition, executive functioning, learning, memory, and reward processing. Overall, animal data suggests that exposure to nicotine during adolescence induces persistent changes in neural connectivity among brain areas responsible for cognitive maturation not to mention that they are more likely to become long-term smokers, which unquestionably carries with it excessive morbidity and mortality.^25,26

Therefore, it is important to note that efforts to regulate e-cigs advertising and sales are emerging. ¹³ In 2016, the Food and Drug Administration (FDA) expanded their authority to regulate all tobacco-related products, including e-cigarettes and vape-pens. Since May 2016, the FDA limits how and when these products can be sold. It is now illegal to sell e-cigs to anyone younger than 18 years. ²⁷ Despite these efforts, perceptions of benefits may linger and available data suggest that perceptions of safety, curiosity, harm and addictiveness appear relevant when making a decision to try or not try a new drug.

Adolescent Perceptions

Teens’ perceptions regarding e-cigs have attracted some interest since perceptions are part of the decision-making equation of whether to use e-cigarettes or not. Studies suggest that the perceived health risks, product features, such as the assortment of flavors, easy accessibility, price, and peer validation make e-cigarettes initially more appealing to adolescents than combustible cigarettes.^28,29 In one cross-sectional survey of 6th-, 8th-, and 10th-grade students (N = 434 601), researchers discovered that e-cigarette users had higher odds of reporting that e-cigarettes were “not at all harmful” to health and “not at all addictive.” Current e-cigarette users also had higher odds of reporting that flavored e-cigarettes were “less harmful” than nonflavored e-cigarettes. ³⁰

Roditis and Halpern-Felsher ³¹ examined adolescents’ perceptions of risks and benefits of conventional cigarettes, e-cigs, and marijuana. Teens were asked to report the good or bad aspects associated with smoking cigarettes, e-cigarettes, or marijuana. Not surprisingly, they reported that nothing good would come from smoking cigarettes and attributed a number of negative effects to traditional cigarettes, including cancer and halitosis. Marijuana was considered safer and less addictive than conventional cigarettes. However, they were uncertain about risks of e-cigarettes. They reported getting their information from peers, family, and school, along with advertisements. ³¹

It is important, therefore, to examine the effects of advertisements on the perception of e-cigarettes among teens. Duke et al ³² explored the association between e-cigarette ads and attitudes and intent to use e-cigarettes among e-cigarettes naïve adolescents aged 13 to 17 years. Teens were randomly assigned to complete an online survey that asked questions about their attitudes toward e-cigs and their intentions to use e-cigarettes before and after watching e-cigarette commercials. Among teens that never used e-cigarettes, the advertisements had a greater influence on creating positive attitudes toward e-cigarettes and intentions to use e-cigarettes. More specifically, after watching the ads, teens who had never consumed e-cigarettes perceived the e-cigarettes as cooler, more fun, healthier, and more enjoyable. The authors concluded that limiting TV e-cigarette marketing may decrease e-cigarette initiation among teens. ³²

Additionally, Camenga et al ³³ conducted 18 focus groups in 1 middle school, 2 high schools, and 2 colleges in Connecticut to evaluate themes related to trying and stopping e-cigarette use. The study showed that the chief motivations for experimentation were curiosity (54.4%), attractive flavors (43.8%), and peer encouragement (31.6%), and the major reasons for cessation were loss of interest (23.6%), perceiving e-cigarettes as “uncool” (16.3%), and health concerns (12.1%). Therefore, it is important to restrict flavors, educate teens on the health risks, and change social norms in a preventative efforts. ³³ Motivational interviewing allows physicians to educate teens about the health risks and help change social norms by targeting the ambivalence teens may have about e-cigarettes.

Motivational Interviewing

Research on motivational interviewing (MI) indicates that providers can effectively help patients move along a spectrum of readiness to modify maladaptive behaviors. MI employs strategies such as reflective listening, affirmations, supporting the patient’s autonomy, and understanding where the patient is along the readiness to change continuum. ³⁴ MI has to be individually tailored, taking into account the stage of change. The stages of change model posit that individuals cycle through distinct stages in the process of changing their behaviors. When speaking to teens about their use of e-cigarettes, pediatricians need to first ascertain what stage of change the teen is currently in. The stages of change are as follows: precontemplation (unaware that vaping is a problem), contemplation (ambivalence about vaping), preparation (getting ready to stop but may face barriers), action (moves from thinking to taking the first steps), or maintenance (stays on course but may have set backs). ³⁵

One way to employ MI and determine a teen’s stage of change would be to practice the approach suggested by the acronym OARS: (a) Open questions; (b) Affirmation and support; (c) Reflections of a patient’s thoughts, desires, abilities, and reasons to change; and (d) Summaries of the patient’s history intended to promote consideration of change. ³⁶

For example, during the course of an interview, a doctor can approach the subject of e-cigarettes with Jack, his patient, with an open question such as, “What do you think of vaping?” to which Jack may respond, “Did my parents tell you? I love using e-cigs. They make me feel older and they are a total chick magnet. Plus all my friends are vaping. Also they’re much safer than smoking cigarettes.” At this point one may issue an affirmation, a sincere and accurate statement of appreciation or encouragement, such as “Thank you for your honesty, it would be easier to lie to me.” ³⁶

Alternatively, one could employ reflective listening, restating what the teen has said in your own words, by saying “So vaping helps you fit in with friends and makes you look attractive to girls.” Reflective listening helps build rapport because it shows an understanding of a patient’s perspective, fostering disclosure. ³⁴ For example, Jack may say “Yeah and it is totally safe, I don’t even use nicotine, just flavors and yet it makes me feel grown up because you pick it up and puff like a cigarette and the vapor looks like smoke.” The doctor could go on reflecting “A pretend cigarette with all the good features and none of the unhealthy stuff.”

Using the scenario detailed above, Jack is in the precontemplation stage of change since he believes e-cigs are safe and has no intention to quit. In Jack’s case, the task is to help him develop some ambivalence about using e-cigarettes by creating some discrepancy or doubts about the safety of vaping. The goal of developing discrepancy is to help the teen become a contemplator. Contemplators have already begun to evaluate the pros and cons of their maladaptive behavior. ³⁴ One way for Jack’s pediatrician to develop discrepancies is to say “You told me that one good thing about vaping is that it helps you fit in, makes you feel cool. However, on the other hand, how do you feel about vaping when it triggers your asthma? Does that ever make you think about quitting?”

An attempt to develop discrepancies, may lead teens to rebel or exhibit varying levels of resistance. A physician’s natural inclination may be to lecture on the dangers of using e-cigarettes. However, MI theory teaches to resist the urge to lecture and instead “roll with the resistance” and avoid direct confrontation. By rolling with the resistance, a physician is offering reflections of the adolescent’s perspective that conveys understanding and acceptance. Additionally, it allows physicians to adopt a collaborative instead of a prescriptive style. ³⁴ MI may, therefore, be uniquely welcome by teens as they typically strive for autonomy and individuation. One approach to “roll with the resistance” is to use a strategy called “agreement with a twist.” ³⁷ For example, Jack may respond to his doctor’s attempt to develop discrepancies by saying “No way. I never thought about quitting…why are you and my parents so stuck on my e-cigs? You would vape too if all your friends vaped.” Jack’s doctor could then respond by saying “You’ve got a point, fitting is important to teens but I just wish it did not trigger your asthma attacks.” To which Jack may respond, “I know I shouldn’t vape but I deserve to have fun.”

One way to enhance motivation for change is to help teens recognize a discrepancy or gap between their future goals and their current behavior. ³⁴ For example, if Jack also wants to make the varsity soccer team, his doctor might ask Jack “Does smoking e-cigarettes ever trigger your asthma and make it difficult for you to play soccer? How does vaping fit in with having more playing time on the soccer field?” In this case, Jack is worried about making the soccer varsity team. It is important to point out a discrepancy between his goals of making the varsity soccer team and his use of e-cigarettes as vaping may exacerbate his respiratory problems and is considered substance use by most schools.

By using these techniques, teens such as Jack may become more aware of the risks of e-cigarettes on their health causing their risk/benefit perceptions to shift. This ambivalence is at the core of MI and viewed as a normative step on the road to change. Physicians must listen carefully for any change talk so that it can be reinforced. MI uses reflective listening to reinforce change talk even in the context of ambivalent statements. ³⁴ The acronym DARN can help one recognize change talk by focusing on a person’s Desire to change, Ability to change, Reasons for change, and Need for change. It is also important to look for teachable moments in clinical encounters. ³⁸ Let us say that Jack experiences an exacerbation of asthma triggered by e-cigs. This provides an opportunity to draw links between vaping and his respiratory status, by asking “What connection do you see between vaping and asthma attacks?” The goal of creating discrepancy is to promote ambivalence so you can bring it to the forefront and then listen for change talk that can be reinforced. ³⁸

One strategy to elicit change talk is to ask Jack to imagine the worst thing that could happen if he were to continue to vape. Jack may say “Well my friend started vaping with flavors then with nicotine and started smoking real cigarettes. Now he can’t stop even if he wanted to because he craves it all the time. I guess that could happen to me.” MI may offer a way to intervene with e-cigs early on and positively alter a trajectory toward nicotine dependence. Teens in the preparation stage want to quit vaping and express willingness, but may have obstacles to address before they can quit. If Jack is now in the preparation stage, ambivalence may resurface as well as self-doubt about his ability to change as he is getting ready to stop vaping. During this stage, it is important to support the teen by expressing confidence in his or her ability to carry out their plan. ³⁵ Ultimately, MI allows pediatricians to personalize the discussion about e-cigarettes with their patients, taking into account the stage of change a patient is in and the individual health risks a teen is experiencing due to e-cigarettes, along with discussing how the use of e-cigarettes may be incompatible with a teen’s aspirations.

Conclusion

The use of e-cigarettes among adolescents has attracted attention due to an increasing number of teens who are vaping. Unfortunately, the health effects of e-cigarettes have not been well characterized apart for worsening of respiratory status among those with preexisting vulnerabilities. Pediatric and pet nicotine poisoning have increased and occasional explosions due to malfunctioning batteries are also of concern. Additionally, tank e-cigarettes may yield formaldehyde, a known carcinogen. Another important issue is the possibility that teens who begin using e-cigarettes may start with flavors but progress to nicotine leading teens to smoke combustible cigarettes. This is of interest because of the morbidity and mortality related to smoking cigarettes as well as the effects of nicotine on the young brain. Even though teens are gradually becoming aware of the potential hazards of e-cigarettes, they may still be ambivalent or uncertain about vaping. We discussed the use of motivational interviewing to individualize discussions regarding e-cigarettes with the hopes of advancing preventive efforts in this area.

Author Contributions

VML and CA contributed equally to the research and preparation of this article.