This article is part of series from Medscape on vaping.
Jake Warn calls vaping "a toxic artificial love."
Jake, of Winslow, Maine, was 16 years old when he began vaping. Unlike cigarettes, vaping can be odorless, and its smoke leaves no trace, which allowed him and his friends to use the devices in school bathrooms without fear of being caught.
Jake Warn started vaping as a teenager. He is pictured here with his sister.
He would use an entire cartridge containing the vape liquid, the equivalent of smoking one pack of tobacco cigarettes, within one school day. By the fall semester of his first year in college, Jake said his use had increased even more.
"It got pricey, so that's when I really started to notice" the extent of his dependency, he said recently.
Vaping rates among teenagers in Maine doubled from 15.3% to 28.7% between 2017 and 2019, while Jake was in high school. In 2021, 11% of high schoolers across the nation said they regularly smoked e-cigarettes, and an estimated 28% have ever tried the devices, according to the Centers for Disease Control and Prevention (CDC).
The US Food and Drug Administration classifies e-cigarettes as a tobacco product because many contain nicotine, which comes from tobacco. Like Jake, the habit is likely to carry into adulthood for many who start in their teenage years, experts say.
Electronic nicotine delivery systems (ENDS) such as vapes have been touted by their manufacturers and by some in the medical field as a healthier alternative to cigarettes and as a method to help smokers give up the habit.
But, that's not how Jake ― who had never used combustible cigarettes ― picked up vaping, or how he sold the idea to his mother.
"'It's all organic and natural flavoring, it's just flavored water,'" Mary Lou Warn recalled her son saying to her. She researched the health effects of vaping but didn't find much online. "I knew they were dangerous because you don't put anything in your lungs that isn't fresh air," she said.
Jake Warn and his family
A determined athlete in high school, Jake found that his asthma worsened as he transitioned to college, especially when he ran a track meet or during a soccer game.
Mary Lou Warn noticed changes off the field, too.
"He was coughing constantly, he wasn't sleeping well, he wasn't eating well," she said. "I knew the addiction was taking over."
Vaping irritated Jake's throat, and he would get nosebleeds that he couldn't stop, she added.
Since Warn first looked into the effects of e-cigarettes on respiratory health back in 2017, many studies have been conducted of the short-term health outcomes for first-time smokers who never used combustible tobacco products. Studies suggest that vaping may worsen bronchitis and asthma, raise blood pressure, interfere with brain development in young users, suppress the immune system, and increase the risk of developing a chronic lung disease. Studies of mice and cell cultures have found that the vapor or extracts from vapes damage the chemical structure of DNA.
Still, the limited number of long-term human studies has made it hard to know what the health outcomes of e-cigarette users will be in the future. Conclusive studies linking commercial cigarette use to deaths from heart disease and cancer didn't emerge until the mid-1950s, decades after manufacturers began mass production and marketing in the early 20th century.
Years could pass before researchers gain a clearer understanding of the health implications of long-term e-cigarette use, according to Nigar Nargis, PhD, senior scientific director of tobacco control research at the American Cancer Society.
"There hasn't been any such study to establish the direct link from ENDS to cancer, but it is understood that it [vaping] may promote the development of cancer and lung damage and inflammation," Nargis said.
For decades, advocates built awareness of the harms of tobacco use, which led to a sharp decline in tobacco-related illnesses such as lung cancer. But Hilary Schneider, Maine's director of government relations for the American Cancer Society Cancer Action Network, said she fears the uptick in the use of vapes ― especially among those who never smoked or those who use both combustible cigarettes and e-cigarettes ― may reverse declines in the rates of smoking-relating diseases.
Multiple studies suggest that inhaling chemicals found in e-cigarettes — including nicotine-carrying aerosols — can damage arteries and inflame and injure the lungs.
Vapes "basically have created a pediatric tobacco-use epidemic," Schneider said. "What we're seeing is unprecedented tobacco use rates, higher rates than we've seen in decades."
One reason many young people start vaping is the attraction to flavors, which range from classic menthol to fruits and sweets. A handful of states have enacted bans or restrictions on the sale of flavored vapes.
"It's new, and it's just been marketed in a way that we're really fighting the false narrative put out there by makers of these products that are trying to make them appealing to kids," said Rachel Boykan, MD, clinical professor of pediatrics and attending physician at Stony Brook Children's Hospital in Stony Brook, New York.
The flavor Red Bull, in particular, hooked Jake. And though he wasn't aware of it at the time, nicotine packed into the pods may have kept him from quitting: The average nicotine concentration in e-cigarettes more than doubled from 2013 to 2018, according to a study by the Truth Initiative and the CDC.
The immediate risks of nicotine on the developing brain are well documented. Studies suggest that nicotine ― which is found in ENDS products ― may affect adolescents' ability to learn, remember, and maintain attention.
But many adolescents and young adults who use e-cigarettes say that vaping helps alleviate anxiety and keep them attentive, which adds to the complexity of their dependency, according to Boykan.
Nicotine "actually interrupts neural circuits, that it can be associated with more anxiety, depression, attention to learning, and susceptibility to other addictive substances," she said. "That is enough to make it very scary."
Jake also said a social environment in which so many of his friends vaped also made it difficult for him to quit.
"You're hanging out with your friends at night, and all of them are using it, and you're trying not to," he said.
Jake eventually took a semester off from college for an unrelated surgery. He moved home, away from his vaping classmates. He eventually transferred to a different college and lived at home, where no one vaped and where he wasn't allowed to smoke in the house, he said.
"He came home and we took him to a doctor, and they didn't know quite how to handle kids and addiction to e-cigarettes," Mary Lou Warn said.
Not fully understanding the long-term health implications of e-cigarette use has precluded many clinicians from offering clear messaging on the risk of vaping to current and potential users.
"It's taken pediatricians time to ask the right questions and recognize nicotine addiction" from vaping, said Boykan, who serves as chair of the Section on Nicotine and Tobacco Prevention and Treatment of the American Academy of Pediatrics. "It's just hit us so fast."
But once pediatricians do identify a nicotine dependency, it can be difficult to treat, Boykan said. Many pediatricians now recognize that e-cigarette addiction may occur in children as early as middle school.
"We don't have a lot of evidence-based treatments for kids to recommend," Boykan said.
Will Vaping Be a "Phase"?
Aware of his vaping dependency and the possible risks to his long-term health, Jake, now 23, said he's lessened his use compared to his college days but still struggles to kick the habit for good.
"I'd like to not be able to use all the time, not to feel the urge," Jake said. "But I think over time it'll just kind of phase out."
But his mother said quitting may not be that simple.
"This will be a lifelong journey," she said. "When I think of who he is, addiction is something he will always have. It's a part of him now."
Boykan, Schneider, and Nardis report no relevant financial disclosures.
Lara Salahi is a freelance journalist living in Boston.
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Images 1 & 2: Mary Lou Warn
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Cite this: What Will Vaping Lead To? Emerging Research Shows Damage, and Addiction - Medscape - Apr 13, 2023.