Vaping and E-Cigarette Use in Children and Adolescents

Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine

Deborah A. Rusy, MD, MBA, FASA; Anita Honkanen, MD; Mary F. Landrigan-Ossar, MD, PhD, FASA, FAAP; Debnath Chatterjee, MD, FAAP, FASA; Lawrence I. Schwartz, MD; Kirk Lalwani, MBBS, FRCA, MCR; Jennifer R. Dollar, MD; Randall Clark, MD, FASA; Christina D. Diaz, MD, FASA, FAAP; Nina Deutsch, MD; David O. Warner, MD; Sulpicio G. Soriano, MD


Anesth Analg. 2021;133(3):562-568. 

In This Article

Abstract and Introduction


Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population. E-cigarettes have become the most commonly used tobacco products among youth in the United States. Fruit and mint flavors and additives such as marijuana have enticed children and adolescents. E-cigarette, or vaping, product use–associated lung injury (EVALI) is a newly identified lung disease linked to vaping. Clinical presentation of EVALI can be varied, but most commonly includes the respiratory system, gastrointestinal (GI) tract, and constitutional symptoms. Clinical management of EVALI has consisted of vaping cessation and supportive therapy, including supplemental oxygen, noninvasive ventilation, mechanical ventilation, glucocorticoids, and empiric antibiotics, until infectious causes are eliminated, and in the most severe cases, extracorporeal membrane oxygenation (ECMO). Currently, although there is an insufficient evidence to determine the safety and the efficacy of e-cigarettes for perioperative smoking cessation, EVALI clearly places these patients at an increased risk of perioperative morbidity. Given the relatively recent introduction of e-cigarettes, the long-term impact on adolescent health is unknown. As a result, the paucity of postoperative outcomes in this potentially vulnerable population does not support evidence-based recommendations for the management of these patients. Clinicians should identify "at-risk" individuals during preanesthetic evaluations and adjust the risk stratification accordingly. Our societies encourage continued education of the public and health care providers of the risks associated with vaping and nicotine use and encourage regular preoperative screening and postoperative outcome studies of patients with regard to smoking and vaping use.


Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population.[1,2] Vaping is a term referring to the inhalation of aerosols produced by a variety of devices that heat a liquid generally containing nicotine, flavoring, and various other chemicals. Other names for vaping devices, or electronic nicotine delivery systems (ENDS), include mods, vapes, subohms, vape pens, e-hookahs, tank systems, and e-cigarettes. Over 460 brands of vaping devices were described in an article published in 2014.[3] They are marketed with the trendy names, such as GeekVape Aegis (Shenzhen, China), Baton V2 (Baton Vapor, Seattle, WA), Suorin Shine (Suorin USA, Brea, CA), Mango Ice (Vaporlax, Shenzhen, China), and Strawberry Ice (Tripl3, Ft. Mill, SC), and contain flavor additives targeting the appetites of children and teens.

These devices function through 4 key components, such as a container for the liquid solution, a heating element to vaporize the liquid, a power source, and a mouthpiece to channel the vapor to the user. They are often not only made to resemble a variety of traditional nicotine-producing products, such as cigarettes, cigars, and pipes, but also disguised in many everyday object designs, such as pens or memory sticks, enabling surreptitious use.

Vaping products may have significantly higher nicotine levels when compared to traditional cigarettes, and no consensus exists on how the strength of nicotine is reported on these products. Vaping liquid nicotine strength is often characterized as low (6–12 mg/mL), medium (18 mg/mL), and high (24 mg/mL). Products exceeding 24 mg/mL are also commercially available.[4] In comparison, the average cigarette has 10–12 mg of nicotine.

Since 2014, e-cigarettes have become the most commonly used tobacco-based products among youth in the United States. E-cigarette use among the US middle and high school students increased by 900% during 2011–2015.[5] Following a decline in use between 2015 and 2017, e-cigarette use again increased by 78% between 2017 and 2018.[6] In 2019, an estimated 27.5% of high school students and 10.5% of middle school students reported using e-cigarettes within the past 30 days. Among those e-cigarette users, an estimated 34% of high school students and 18% of middle school students reported frequent use (20 or more days in the past 30 days), and 21% of high school students and 8.8% of middle school students reported daily use.[7] JUUL (San Francisco, CA) was the most popular brand among the youth e-cigarette users. Seventy-eight percent of young users have seen a television advertisement for e-cigarettes.[8] Furthermore, the use of flavored products, such as fruit, candy, and mint, has been successful in marketing to children and adolescents. Notably, 72% of high school students who vape and 59% of middle school students used flavored products.[5] Children and adolescents are 3–4 times more likely to use these flavored substances than adults.[9] Marijuana products are also becoming increasingly popular among students who vape. From 2017 to 2018, the reported prevalence of marijuana use in e-cigarettes among all students increased by 3.6%.[10] Furthermore, youth who use e-cigarettes are more likely to use traditional cigarettes or other tobacco products. In a recent meta-analysis, adolescents and young adults who have used e-cigarettes are 3.6 times more likely to report subsequent cigarette smoking compared with those who have not.[11]

The addictive nature of e-cigarettes is at least equivalent to the addictive nature of conventional cigarettes, if not more.[5] Multiple studies continue to confirm the increased risk of long-term nicotine use, including conventional cigarettes, in youth who use e-cigarettes. Nicotine is a central nervous system stimulant that activates the release of multiple neurotransmitters throughout the brain with subsequent positive mood–modulating effects.[12] Adding to the risk of addiction, at least 1 study has determined that e-cigarettes are less irritating during use compared to the Food and Drug Administration (FDA)–approved nicotine inhalers for smoking cessation.[13] The availability of enticing flavors for e-cigarettes in addition to less noticeable irritation with possibly higher inhaled nicotine levels makes these products much more attractive to youth and young adults leading to an increased risk of long-term nicotine addiction.