Teen Vaping of Nicotine, Marijuana Surge

Alicia Ault

December 19, 2018

The latest survey on teen substance use reports a massive increase in the use of e-cigarettes — even as use of combustible cigarettes and opioids, as well as binge drinking, has declined.

The 2018 Monitoring the Future (MTF) survey, which was funded by the National Institute on Drug Abuse (NIDA) and conducted by researchers at the University of Michigan's Institute for Social Research, tracks substance use among some 45,000 8th, 10th, and 12th graders.

A summary of results released December 17 showed that while cigarette smoking declined among 12th graders in 2018, putting it on track with a 20-year downturn, the decline leveled off among 8th and 10th graders.

However, some 21% of 12th graders reported vaping nicotine during the past 30 days, which is a dramatic rise from the 11% reported in 2017. Sixteen percent of 10th graders (up from 8% in 2017) and 6% of 8th graders (up from 3.5%) said they had vaped nicotine in the previous month.

"These are — by far — the biggest 1-year increases ever seen for any substance in the history of the MTF survey," NIDA Director Nora Volkow, MD, said in a blog post.

In addition, teens are reporting that they are vaping "flavoring only" in higher numbers, but Volkow said "it is likely that many young users do not know what is in the liquid they are vaping."

The survey also showed that teens are increasingly using e-cigarettes to vape marijuana. Almost 8% of 12th graders (up from 5%), 7% of 10th graders (up from 4%), and almost 3% of 8th graders (up from 1.6%) said they had vaped marijuana in the past 30 days.

Vaping "Epidemic"

E-cigarette devices and liquids are also easy to obtain, teens said. Forty-six percent of 8th graders and 66% of 10th graders said the devices are "fairly easy" or "very easy" to get.

"The 1-year increases in the prevalence of nicotine vaping translate into approximately 1.3 million additional adolescents who vaped in 2018, as compared with 2017," MTF lead author Richard Miech, PhD, University of Michigan, Ann Arbor, writes in a letter about the findings published online December 17 in the New England Journal of Medicine.

The MTF data was one reason why US Surgeon General Jerome Adams, MD, issued an advisory on December 18 calling vaping an "epidemic." He urged health professionals; federal, state, and local agencies; and parents to intervene.

American Academy of Family Physicians president John Cullen, MD, told Medscape Medical News that physicians can help by asking every patient about nicotine use.

"This includes specifically asking 'Do you vape or use electronic cigarettes?' Not all patients associate the use of those devices with nicotine or view it as a form of tobacco," Cullen said.

He noted that the question is especially important with younger patients.

"Tobacco cessation interventions do not have to be lengthy, but they are perfect for 'teachable moments' when you can present a patient with information that requires him or her to pay attention to or process new information," said Cullen.

Pointing A Finger At Juul

Adams and others cited the Juul brand of e-cigarettes, and what appears to be its marketing directed at children, as a huge challenge.

"We need new policies and strategies, such as the FDA's actions announced last month to curb the sales of the Juul-branded vaping devices," Miech said in a statement.

Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, was more pointed.

"The responsibility for this epidemic lies squarely with Juul, the e-cigarette that has become wildly popular with young people across the country," Myers said in a press release.

"Juul is sleek, small, and easy for kids to hide, comes in appealing flavors like mango and mint, and delivers a potent dose of nicotine, increasing kids' risk of addiction," he said. Myers added that the Juul manufacturer has used social media to enhance its standing with children.

Flavors are a big attraction for children, said the Surgeon General and others.

The US Food and Drug Administration (FDA) in November moved to restrict sales of flavored e-cigarettes to children younger than age 18 years, but many say this doesn't go far enough.

"FDA must take immediate steps to fully enforce its 2016 'deeming' rule and remove all flavored tobacco products, including flavored e-cigarettes, from the market," Harold P. Wimmer, national president and CEO of the American Lung Association, said in a statement.

Opioid Use Down, Marijuana Use Steady

In the new MTF survey, teens seem to be less interested in misusing prescription opioids or other scheduled pharmaceuticals.

Just over 3% of high school seniors said they had used narcotics other than heroin (ie, prescription opioids) in the past year, which was down from 4.2% in 2017.

In 2003, 10.5% of 12th graders reported misuse of Vicodin; in 2018, that figure was 1.7%. Heroin use remained low, with only 0.4% of 12th graders reporting past-year use.

About 4% of high school seniors said they had misused tranquilizers in the past year, which was about half the peak of 7.7% in 2002.

Meanwhile, binge drinking, defined as having five or more drinks in a row at least once in the previous 2 weeks, significantly declined among 12th graders. Fourteen percent said they engaged in binge drinking compared with 11% in 2017.

Use of marijuana was a good news/bad news situation.

The perception of marijuana as being harmful has declined. In the late 1980s and early 1990s, almost 80% of 12th graders said that daily use put users at great risk of harm. By 2008, that figure had declined to about 50%. Today, 29% of 12th graders said daily use of marijuana was a great risk to users.

Meanwhile, 5.8% of 12th graders said they used marijuana daily — a percentage that has remained essentially unchanged for the past 20 years, Volkow said. About 36% of seniors and 28% of 10th graders reported marijuana use in the past year.

That is despite the fact that marijuana is legal for adult recreational use in 10 states and Washington, DC, said Volkow.

The advent of vaping marijuana may change how many use the drug, she said. "It is unclear if the teens who vape marijuana are also smoking it, or if they are a growing cohort of young people being exposed to marijuana for the first time through vaping," Volkow said.

"There is a continuing trend among teens of a perceived lack of harm from regular marijuana use, and while use has not increased, potency has significantly increased," Fred Muench, PhD, president and CEO of the Partnership for Drug-Free Kids, said in a statement.

"As teen and young adult brains are still developing, efforts in prevention and early intervention are important in the middle and high school years, but also as our youth transition into college and young adulthood," Muench said.

NIDA noted that all survey findings "will be published by the end of January in a forthcoming volume that will appear on the project website."

The survey was funded by the National Institute on Drug Abuse.

N Engl J Med. Published online December 17, 2018. Letter

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