When he talks about vaping, John Harrington, MD, Professor of Pediatrics at EVMS, doesn’t mince words.

“You might as well put your mouth on a car’s exhaust pipe and inhale,” he says.

Overstatement? Maybe. But Dr. Harrington is sounding the alarm because teen vaping has skyrocketed. A study published in November by the Journal of the American Medical Association says that 28% of high schoolers recently vaped, up from 10% just three years earlier.

Even worse, last summer vaping — particularly vaping THC — started killing young people who were otherwise healthy. And the number of vaping-related lung injuries and deaths is still rising. About 80% of patients have been under age 35. Of those, 40% were between 18 and 24, and 14% were under 18.

Dr. Harrington and his colleagues are deeply concerned.

Widespread destruction of lung tissue — that’s how Joshua Sill, MD, describes lung injuries related to vaping. Dr. Sill is the EVMS-Sentara Endowed Chair for Academic Leadership Advancement in Internal Medicine, Associate Professor of Internal Medicine and Chief of Pulmonary Medicine at EVMS.

“We don’t know yet what their lung function will be if they recover,” he says of patients experiencing the new disease. “They might not be able to play sports for a while, or they may end up with permanent lung damage.”

Scientists are scrambling for answers, finding potential culprits in substances like diacetyl and vitamin E acetate. Meanwhile, EVMS experts have ramped up efforts to educate parents and teachers, first, that all e-cigarettes are harmful; and second, that stealth vaping devices, masquerading as pens, flash drives and other school supplies, make the act of vaping easy to hide.

“There’s still a lot of misperception that it’s harmless water vapor,” says Dr. Harrington, who is also Division Director of Children’s Medical Group’s General Academics Pediatrics practice. “But just like tobacco cigarettes, e-cigarettes contain nicotine and dozens of other chemicals that react with each other and become toxic when heated to high temperatures.”

Her parents might not realize that the drawstrings in the hoodie are actually a stealth vaping device.

Her parents might not realize that the drawstrings in the hoodie are actually a stealth vaping device.

Even the term “vaping” is a misnomer. E-cigarette devices produce an aerosol, not a vapor. Unlike vapor, which is simply a substance in gas form, the aerosol from an e-cigarette contains tiny chemical particles from both the liquid solution and the metals from the heating coils in e-cigarettes.

They’re also unregulated.

“Vaping is like the wild, wild west now,” says Amy Paulson, MPH, Instructor of Pediatrics and Director of the Consortium for Infant and Child Health based at EVMS. Depending on where e-cigarettes are purchased, she says, a teen could be using a product made in someone’s bathtub.

“You don’t know what the product will do to you in 30 years,” Ms. Paulson says, “but you also don’t know what it might do to you in three days.”

Researchers do agree on one result: Teens who vape are more likely to end up smoking conventional cigarettes. Four times more likely, in fact, says a 2018 study by RAND Corporation. Another 2018 study, this one by the National Academies of Sciences, Engineering and Medicine, reports, “There is substantial evidence that e-cigarette use by youth and young adults increases their risk of using conventional cigarettes.”

Once a tool to quit, now a gateway to start

It’s quite a turn of events for a product promoted to help smokers quit when it was introduced in 2003. But a few popular brands, including JUUL, have been accused of targeting nonsmoking teens. As a result, Ms. Paulson says, some youth don’t think of “juuling” as using e-cigarettes even though it is.

“We’ve asked kids if they vape,” she says, “and they said no. Then we ask if they ‘juul,’ and they said, ‘Oh sure, I juul but that’s not vaping.’”

Stealth vaping devices, also marketed to teens, have escalated the problem, says EVMS researcher Paul Harrell, PhD, Assistant Professor of Pediatrics.

A vaping device disguised as a necklace allows students to easily vape in school.

A vaping device disguised as a necklace allows students to easily vape in school.

“Kids are able to hide it much easier now,” Dr. Harrell says. “Vaping is more difficult to detect, so they’re using it all the time throughout the day, even in school. That may be creating use patterns that are difficult to overcome.” With JUUL promoting its single vape cartridge as roughly equal to a pack of cigarettes, some teens self-report vaping the equivalent of two or three packs a day. That level of use, he says, can easily lead to physiological dependence and long-term addiction.

For teens whose brains are still developing, vaping’s long-term effects could be devastating. In 2016, a report by the U.S. Surgeon General found that e-cigarettes are addictive and harmful to developing brains. Yet even with that ammunition, the Food and Drug Administration opted to delay its effort to regulate the industry. August 2018 was the FDA’s original deadline for e-cigarette manufacturers to file applications to become licensed. In 2017, the FDA delayed it to 2022.

The delay spurred the American Academy of Pediatrics, American Heart Association, American Lung Association and other respected health organizations to take action. Last year, they filed a lawsuit to force the FDA to speed up its review of e-cigarettes. In May 2019, a judge ruled in their favor, admonished the FDA and ordered the deadline moved to May 2020.

And in November, the American Medical Association called for a total ban on all vaping products that do not yet meet FDA approval as smoking cessation tools.

The last few months of news about deaths and lung injuries, as well as JUUL’s removal of flavored vape pods, might help slow the rise in teen vaping. But one challenge is hard to overcome — vaping is no longer edgy. Today it’s not just troubled teens who vape. EVMS experts have found that it’s common among all types of students, even athletes and honor students. This trend has moved it off the fringe and into the realm of normal behavior.

The proliferation of vaping also has contributed to the rise in marijuana vaping among teens, which the National Institute on Drug Abuse says has more than doubled in the past two years.

That’s why Ms. Paulson cautions parents to be on the lookout.

“I know someone who found a vape device in her child’s car,” she says. “The teen said it belonged to a friend, and the parent didn’t want to get the friend in trouble, so she didn’t tell the friend’s parent.

“I have a 14-year-old and a 17-year-old,” Ms. Paulson continues. “They’re seeing this behavior every day in school, even in class. I hope they’ll make the right decision. But if they don’t, and another parent sees them vaping, I hope that parent would tell me. It might save my child’s life.”