European Journal of Pediatrics (2022) 181:453–462

https://doi.org/10.1007/s00431-021-04220-x

REVIEW

Youth vaping: a review and update on global epidemiology, physical

and behavioral health risks, and clinical considerations
Timothy D. Becker1 · Timothy R. Rice1

Received: 8 March 2021 / Revised: 24 May 2021 / Accepted: 21 July 2021 / Published online: 15 August 2021
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Worldwide, youth electronic cigarette use (vaping) has risen significantly over the past decade. This public health concern
has spurred many high-quality studies characterizing country-specific prevalence, risk factors, physical and behavioral health
complications, and optimal methods of assessment and counseling for youth vaping. Clinicians remain underexposed to this
recent work, limiting translation of evidence into higher quality patient care. This review aims to provide pediatricians and
other clinicians working with youth a clinically focused survey of key research findings and considerations based on recent
evidence. This narrative review surveys emerging trends in EC use across different countries, reasons for youth vaping,
characteristics of vaping materials that promote youth use, associations with combustible cigarette use, relation with can-
nabis and other illicit substances, physical and behavioral health risks associated with vaping, and methods of assessment,
counseling, and intervention for problematic vaping in youth. Since vaping remains a relatively new phenomenon, long-term
health consequences remain unknown.
Conclusion: Youth vaping is an increasingly well-studied phenomenon with both physical and behavioral health risks.
Pediatricians and other youth-focused clinicians can apply the lessons of recent research in work with youth and their families.

What is Known:
• Youth vaping is an increasingly prevalent public health concern.
• Recent research demonstrates physical and behavioral health risks associated with vaping as well as methods for assessment, counseling,
and intervention.
What is New:
• The current review summarizes the latest evidence in a clinically focused framework to facilitate translation of emerging knowledge to prac-
tice.

Keywords Adolescents · E-cigarettes · Vaping · Mental health · Review

Abbreviations ENDS Electronic nicotine delivery systems

ADHD Attention-deficit/hyperactivity disorder EVALI Electronic cigarette or vaping-associated acute
CC Combustible cigarette lung injury
EC Electronic cigarette

Screening, prevention, and treatment of substance use are

core functions of adolescent healthcare [1]. Worldwide,
Communicated by Nicole Ritz. youth electronic cigarette (EC) use, or vaping, has increased
substantially over the past decade [2]. ECs are now often
* Timothy D. Becker
[email protected]
the first psychoactive substance used by youth in some set-
tings [3], generating a surge in new research on health con-
* Timothy R. Rice
[email protected]
sequences of this trend. Adolescent use rates vary across
Europe [4], and other countries [5] and clinician beliefs and
1
Department of Psychiatry, Icahn School of Medicine At practices regarding ECs vary considerably across settings
Mount Sinai, One Gustave Levy Place, Box 1230, New York, [6–8].
NY 10019, USA

13
Vol.:(0123456789)
454 European Journal of Pediatrics (2022) 181:453–462

To consolidate recent data concerning global epidemi- ECs are battery-powered devices that contain a liquid
ology, physical and behavioral health risks, and clinical that becomes aerosolized when heated, providing nicotine
considerations, we review key facts and considerations for to users with less irritation than CCs [18]. ECs are also
pediatricians based on recent studies, systematic reviews, known as E-cigs and vape pens and are a type of electronic
and guidelines and recommendations. Adolescent vaping nicotine delivery systems (ENDS). E-liquids may contain a
practices are ever-evolving, including during the COVID- combination of propylene glycol or glycerin bases, flavoring
19 pandemic [9]. To provide best practices in their care, compounds, nicotine, and/or other psychoactive substances
pediatricians must be familiar with the most recent evidence such as cannabis derivates. EC design has evolved from
on this global public health concern. single-use devices that resembled CCs, to rechargeable and
refillable “vape pens,” to increasingly personalizable modu-
lar products (“pod mods”) [19]. Pod mod devices, initially
marketed by JUUL Labs, Inc. and now sold by numerous
What is vaping and what distinguishes it vaping brands, have become particularly popular among
from conventional cigarette use? youth. These devices were designed and marketed for their
ability to deliver nicotine faster than competing ENDS [13]
Contemporary ECs were introduced in 2003 by a Chinese and can deliver particularly high levels of nicotine [18, 20].
inventor and spread to Europe and North America in 2006, While nicotine concentration in traditional CCs is approxi-
initially promoted as a smoking cessation aid in adults [10]. mately 1.5–2% (1.5–2 mg/ml) ([21], as cited in [18]), the
However, ECs have become particularly popular among concentration of nicotine in some pod-based devices is as
nicotine-naïve youth, with use reaching epidemic propor- high as 5%, and daily use of one-quarter of a pod meets the
tions in some areas [11, 12]. EC use became particularly addictive threshold of nicotine [18]. The increased use of
popular among North American adolescents, with rates often high-dose nicotine products has raised alarm among health
exceeding rates of combustible cigarette (CC) use [13]. In experts that a new generation may become addicted to nico-
Canada, lifetime EC use rates reached 37%, and current use tine [12].
rates reached 14.6% among adolescents in 2018 [13]. In the
USA, current use rates reached a peak of 27.5% among high
school students in 2019, before decreasing to 19.6% in 2020 Why do youth vape?
(data collected from January through March, prior to the
onset of COVID-19 restrictions in the USA) [14]. Among Youth uptake of ECs has occurred in the context of youth-
currently using US adolescents, 38.9% reported using at targeted marketing, social media promotion of ECs, and
least 20 days per month, and 83% reported use of flavored peer influences. A study of US high school seniors identi-
ECs [14]. EC use has also been popular among UK adoles- fied three main motivations to vape: taste and entertainment
cents, with lifetime use rates of 32.7% and current use rate (63%), experimentation (29%), and to replace CCs (7%) [22].
of 8.9% in 2018, which in contrast to the USA were slightly In comparison, a German study found that the vast majority
lower than the CC use rate among UK youth [13]. Limited of German youth (aged 14–19) cited curiosity (73.1%) as
comparable data exist to make reliable cross-national com- their reason for EC use, followed by quitting tobacco use
parisons of use rates between European countries, although (14.9%) and as a complement to tobacco use (7.5%) [23].
rates generally appear lower than in North America [4]. In In a systematic review of six studies among young adults in
a 2016–2017 study among adolescents in seven Western varied settings (i.e., USA, Romania, France, New Zealand,
European cities, 35.5% endorsed lifetime EC use (ranging and Saudi Arabia), curiosity and EC use by friends were the
from 23% in Germany to nearly 50% in Italy and Belgium), primary reasons for EC initiation among non-smokers [24].
with 6.6% reporting EC current use (i.e., monthly or more Among former and current CC users, ECs were used due to
frequently), compared to 17.2% current CC use [4]. Among perceptions of harm reduction, to aid smoking cessation, to
university students across several Central and Eastern Euro- use in smoking-restricted areas, for lower cost compared to
pean countries in 2017–2018, while 43.7% reported lifetime CCs, or for flavoring [24]. Studies in Europe and Taiwan
use of EC, only 2.9% were current EC users, well below rates have identified male gender, older age, and parental and peer
of current CC use (12.3%) [15]. South Korean adolescents’ smoking as risk factors for EC use and dual use of ECs and
current use rates (3% and 1% among young men and women, CCs [4, 25, 26].
respectively) are also comparatively lower and have remained Some countries have been slow to regulate EC market-
stable from 2016 to 2018 [16]. Restrictiveness of policies ing [27], leaving youth vulnerable to advertisers. Advertis-
around mass marketing and sale to minors has been identified ing has consistently been associated with youths’ intention
as a factor contributing to differences in EC uptake across to use ECs [28]. A systematic review found that in addi-
locales [5, 17]. tion to traditional marketing, often utilizing youth-directed

13
European Journal of Pediatrics (2022) 181:453–462 455

strategies, social media platforms have been widely used for ECs with nontraditional flavors (e.g., candy, fruit) by ado-
public discussion of ECs in a manner that produces largely lescents was associated with vaping continuation and puffs
positive or neutral EC portrayals [29]. per use 6 months later compared to traditional flavors (e.g.,
Although policy environments seem to account for some menthol, tobacco, and flavorless) [40].
cross-country variation in EC use [5, 17], legal restrictions Although many locales restrict the sale of ECs to
alone do not fully explain variation across countries. For adolescents [27], underage youth find ways of obtaining
example, Germany has one of the least restrictive nicotine devices. Most US adolescents who vape own their own
product environments according to the Tobacco Control device, although they also frequently share devices with
Scale [30]. Yet, Germany has lower youth EC use rates than peers [41]. One study found that most US youth obtained
Finland and Ireland, two of the most restrictive European ECs through online or brick-and-mortar store purchases,
countries [30]. These findings demonstrate the need to fur- while informal purchases, having others purchase for
ther study other factors accounting for cross-country vari- them, or receipt as gifts were less common [41]. In
ation [4]. another study, e-liquids were most often obtained by US
Youth EC use is also influenced by the attitudes and adolescents through social sources [42]. In a recent study
behaviors of others around them toward CC use. In Europe, undertaken during the COVID-19 pandemic following
EC use rates have correlated with city-level CC use rates heightened regulations in the US surrounding EC market-
[4]. Peer influence is important [31]. Parent CC use is a risk ing, a majority of US youth reported reduction in EC use
factor for youth EC use, and parents’ attitudes around EC due to difficulties obtaining EC products. However, youth
use influence adolescent use [32]. Certain family systems who continued using ECs shifted toward buying products
may have difficulty setting appropriate limits on adolescent online, including by receiving deliveries without undergo-
access to and use of ECs: In one study, adolescents with ing age verification [43].
divorced parents were 51% more likely to use ECs than those
with married parents [33].

Does vaping lead to, or help prevent,

Candy or drugs? What youth vape combustible cigarette use?
and how they get it
Many studies have investigated the concern that youth EC
Although ECs are most associated with nicotine, they are a use may increase risk for initiation of CCs, threatening to
vehicle for substance use that may or may not contain nico- undo decades of progress in reducing population level young
tine. In a 2017 nationally representative survey among US adult tobacco use [44]. ECs are being used by youth with a
adolescents, 25% of current EC users reported vaping only lower risk profile than recent youth CC users: one analysis
flavoring, while the rest reported vaping nicotine (45%), of nationally representative US data found that only 11–23%
marijuana (13%), or both (17%) [34]. Among European of EC-only users would have been predicted by risk factors
adolescents who had ever used ECs, 43% reported vaping to be CC users [45].
non-nicotine liquids, 37% nicotine, and 19.6% reported not Additionally, ECs may be an independent risk factor for
knowing what they vaped [4]. CC use, suggesting a “gateway effect,” although this remains
Many youth may misperceive or do not know what they subject to debate. A meta-analysis of 9 longitudinal studies
are vaping. US adolescents commonly misunderstand that (n = 17,389) of CC-naïve youth found that EC use was signifi-
nicotine is a tobacco derivative, and those who report vaping cantly associated with subsequent CC use, even when con-
only flavoring have been found to have particularly limited trolling for known demographic and behavioral risk factors
knowledge about nicotine use [35]. In one study, 40% of for CC use [46]. A subsequent meta-analysis of 11 studies,
youth reporting use of nicotine-free products had urinary though finding the same effect, raised concern that existing
evidence of nicotine [36]. evidence remains limited by attrition, publication bias, and
Flavors both attract youth to EC use and perpetuate ongo- inadequate adjustment for confounders [47]. However, stud-
ing use. US adolescents reported more interest in trying ECs ies extensively controlling for smoking risk factors still find
offered by a friend if flavored like fruit, candy, or menthol ECs independently associated with later CC use [48]. A small
than tobacco [37]. US and UK adolescents have expressed longitudinal study found that nicotine doses in ECs were asso-
the belief that fruity flavored ECs are less harmful than ciated with frequency and intensity of subsequent EC and CC
tobacco-flavored ECs [37, 38]. Adolescents whose first EC is use [49]. Among youth who had already experimented with
flavored progress to current and more frequent use faster than CCs, use of ECs positively associated with progression to
peers whose initial exposure was unflavored [39], and use of current established smoking, suggesting that in youth already

13
456 European Journal of Pediatrics (2022) 181:453–462

starting to use CCs, ECs may contribute to rather than reduce What are the physical health risks of vaping?
the risk of progression to regular CC use [50].
Although EC aerosols appear less cytotoxic than compounds
inhaled during CC use [106], they pose their own physical
How does vaping relate to use of marijuana health risks, especially on the respiratory system [61]. ECs
and other substances? may potentially expose users to heavy metals from batter-
ies and heating coils that may be carcinogenic or toxic to
Nicotine affects the neural pathways underlying pleasure and the heart and lungs, though the long-term effects of these
reward and may increase the brain’s long-term sensitivity exposures among vapers remain unclear [62]. E-liquid bases
to other psychoactive substances and drug-seeking behav- (e.g., propylene glycol) can be respiratory irritants [63, 64]
iors throughout adulthood [51, 52]. In the USA, the surge (see Table 1).
in EC popularity happened concurrently with a loosening During the summer of 2019, North America underwent
of cannabis regulations, and studies have found that many an outbreak of EC- or vaping-associated acute lung injury
youth use both ECs and cannabis [3]. A recent US study (EVALI). Dozens of deaths and thousands of cases of acute
using cross-sectional data from 2000 to 2019 suggests that respiratory compromise due to nonspecific acute injury
adolescents who use cannabis have declining rates of CC occurred [11]. EVALI was most closely associated with
use and increasing rates of EC use [53]. In a meta-analysis, vaping cannabis derivates with vitamin E acetate, which
the odds of current or past cannabis use were significantly was found present in a large majority of bronchoalveolar
higher among youth who had used ECs, with particularly lavage samples in one case series of patients with EVALI
strong associations among adolescents [3], whose brains are [65]; however other pathogenic components have also likely
viewed as more vulnerable to addiction than older youth contributed [66]. Radiographic findings in adolescents with
[54]. Three longitudinal studies suggested a temporal rela- EVALI include centrilobular ground-glass nodules and
tionship in which EC use predates cannabis use [55–57], ground-glass opacities with subpleural sparing [67].
suggesting that addressing EC use is an important means of Additional vaping-related health risks have also been
preventing youth cannabis use and of mitigating the adverse described. Vaping and ingesting e-liquids have been
neuropsychological effects of cannabis [58, 59]. Addition- associated with seizures [68]. ECs adversely impact oral
ally, another meta-analysis found EC use associated with a health, though possibly less severely than CC [69]. Like
six-fold risk of alcohol use and binge drinking in adoles- CCs, secondhand EC vapor exposure may also pose a
cents, though most included studies were cross-sectional and health risk and contaminate indoor air quality, although
did not sufficiently adjust for confounders [60]. also seemingly less so than secondhand CC smoke [70].

Table 1  Major toxic constituents in e-cigarettes

1. Nicotine 4. Carbonyl compounds—e.g., formaldehyde, acetaldehyde, acrolein
- Reaches brain within 15 s after puff on a CC, likely similar with EC - Generated by the heating of humectants and flavorings in e-liq-
use—creates immediate pleasurable effects that reinforce use uids, particularly in devices with battery power greater than 3 V
- Not alone thought to be a human carcinogen - Known to be carcinogenic and respiratory irritants
- Activates the sympathetic nervous system—thought to be associated - Comparison to CCs: Under typical use, exposure to toxic carbon-
with risk of myocardial ischemia, arrythmias, cardiac tissue remod- yls in ECs appears significantly less than with CC use.
eling, thrombogenesis, and endothelial dysfunction 5. Metals—lead, nickel, chromium, manganese, aluminum, tin, and
- Comparison to CCs: Degree of exposure to nicotine varies consider- iron have been found in EC emissions
ably depending on device characteristics, e-liquids, and how ECs are - Originate from the heating coil or other device parts, such as
used wires, joints, or batteries
2. Humectants—EC liquids usually contain propylene glycol and glyc- - Metal levels vary considerably across products and studies and are
erol as solvent carriers to generate aerosols theoretically toxic to multiple organ systems.
- When overheated both humectants decompose into toxic carbonyl - Comparison to CCs: Limited evidence suggests that metal
compounds exposure is greater in ECs than CCs, except for cadmium which is
- Additionally, inhaled propylene glycol at concentrations in ECs can markedly higher in CCs.
cause eye and throat irritation
3. Flavorings—dozens of flavoring compounds have been used in ECs
(e.g., menthol, benzaldehyde, vanillin, diacetyl)
- These compounds are generally considered safe as food additives.
The effects of inhaled flavoring compounds on the pulmonary system
are less clear
- Flavorings have been found to form aldehydes and other respiratory
irritants when heated

National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. The National Academies

13
European Journal of Pediatrics (2022) 181:453–462 457

During the COVID-19 pandemic, adolescents may vio- Counseling youth and families about vaping
late social distancing and risk viral exposure as mediated
through neurobiologically determined [71] valuation of outh often have misconceptions about vaping, and par-
risks [51]: sharing of vaping devices and mask-free use ents may mistake the possible benefits of ECs among adult
increases the risk of transmission, increasing the risk of smokers [72, 89] for harmlessness in youth. ECs have not
morbidity for the family upon return to home. been established as an effective intervention for nicotine
cessation in youth [89]. Clinicians can provide information
about the risks of vaping, while acknowledging that some
long-term risks remain unclear. Possible points to discuss
How does vaping relate to mental health? with families are listed in Table 3.

Adults with mental illness suffer disproportionately from

tobacco-related morbidity and mortality, and most begin
smoking before age 21, making tobacco prevention in Interventions for problematic vaping
young people with mental illness an important priority
[73, 74]. Youth with mental illness may be attracted to Many youth want to quit vaping [88]. At the individual
ECs due to beliefs that ECs may help to modify their psy- patient level, clinical interventions specific to vaping
chiatric symptoms, in attempts to offset side effects of psy- remain underdeveloped. To date, general principles and
chotropic medications, or due to common underlying risk established treatments for CC use have been applied. This
factors for mental illness and substance use (e.g., executive approach carries potential limitations: a qualitative study
function deficits) [75, 76]. In a recent systematic review of of Canadian youth and young adults identified several dif-
vaping and mental health comorbidities in youth, vaping ferences between vaping and CC use that may influence
has been consistently associated with depression, suicidal- the cessation process [90]. In this study, unlike CC users,
ity, attention-deficit/hyperactivity disorder (ADHD), and EC users reported their enjoyment of flavors as a reason
conduct disorder in adolescents [75]. Nicotine exposure for ongoing use. The convenience and discreetness of vap-
adversely affects brain development in animal models ing (e.g., lack of distinct smell) contribute to ease of EC
and increases risk of further substance use [77–79] and use throughout the day and in many locations, leading to
broader mental illness [80–82], as well as problems with a lack of awareness of how much they are vaping. Lastly,
learning and memory [83]. Due to a lack of longitudi- youth in this study also cited a lack of trusted information
nal studies examining mental health among EC users, it about health risks of vaping compared to CCs and greater
remains unclear to what extent vaping effects the long- perceived social acceptability of vaping compared to CC
term trajectory of psychopathology [75]. Among extant as factors complicating EC cessation.
small longitudinal studies in youth, one study suggested Like all substance use disorders, clinicians can begin
a bidirectional relationship between EC use and depres- by engaging youth in strength-based motivational inter-
sive symptoms [84], while another found that ADHD viewing, weighing the risks of vaping against perceived
symptoms predicted onset of EC use but not worsening of benefits, and identifying specific goals for use reduction
ADHD symptoms [85]. or cessation with youth who wish to quit [86]. Youth often
cite health, cost, freedom from addiction, social considera-
tions, and academic performance as reasons for wishing
to quit vaping [88, 90]. These goals may include elimi-
Assessment of vaping in youth nating use of favored flavors that although not addictive
seem to reinforce use in youth. Social media information
Clinicians can most effectively manage the potential risks of and misinformation about EC has caused confusion for
EC use on physical health, mental health, and substance use some youth that may reduce motivation for cessation
by routinely assessing patients for EC use. Screening tools [90]; medical professionals can provide credible informa-
for youth EC use have not yet been developed and validated, tion about health risks to reinforce motivation for change.
but questions about EC use can be easily integrated into Since youth EC users may be less aware of how much they
existing assessment methods [86]. The absence of electronic are using (e.g., how many pods per week) than CC users,
medical record prompts for the assessment of EC use has helping the youth keep a log of use may provide a use-
been identified as an area requiring attention in adolescent ful means of developing insight into their use [90]. Clini-
primary care visits [87]. Table 2 offers items to consider for cians should encourage youth to allow family involvement
assessment based on available evidence [1, 19, 86]. (e.g., by restricting access to vaping devices, supporting

13
458 European Journal of Pediatrics (2022) 181:453–462

Table 2  Questions for assessing EC use

Question Considerations

Have you ever used an e-cig, vape pen, or mod pod (e.g., JUUL,
MYLE, NJoy)?
What type of device do you use? Higher battery output voltages increase risk of chemical reactions that
create toxic products [95, 96]. Devices with user-adjustable voltages
may lead to adolescents using higher voltages (to attain greater vapor
intensities) and therefore inhaling more toxic products
What substance have you vaped? Flavoring: Flavoring increases the risk of both ongoing use and higher
amounts of usage [40] as well as misperceptions of harmlessness [37]
Nicotine: Higher nicotine concentration has been associated with
increased intensity of daily EC use and greater CC and EC use six
months later [49]
Cannabis derivatives and other substances: Non-nicotine substances
can increase the risk of alternate substance dependencies, EVALI,
and other problems [66, 97]
Have you had any problems at school, with parents, or the police Adolescent vaping is associated with delinquency [98], while use in
because of vaping? school can provoke consequences including suspension or expul-
sion, even while school administrators and teachers may have limited
awareness of policies [99]
Vaping may heighten family conflict around EC use
Legal consequences can derive from use in prohibited locations or
underage purchase/distribution of vaping products
Social consequences can result from media posts surrounding vaping
[100, 101]. In one study, 1 in 25 social media posts referenced use
during school hours [100]
Where do you obtain ECs and EC products, such as e-liquids? Access from the black market may be more hazardous [102]
What age did you start vaping? Younger age of onset poses greater vulnerability to addiction [51, 54]
How often do you vape (days/week, times/day, puffs/use)? Use may range from infrequent use that requires counseling and moni-
How often do you have to replace cartridges or refill the device? toring to dependence that necessitates treatment
Screen for symptoms of dependence: have you had cravings, difficulty Dependence indicates need for closer follow-up and consideration of
cutting back use, or developed withdrawal symptoms when you were pharmacologic interventions [86]
not able to vape?
Do you use other substances? Vaping is a risk factor for other substance use [56, 57]
Do your friends or relatives vape, including parents in the home? Peer vaping is a common entry point and perpetuating factor for ado-
lescent vaping [41] that may complicate quit efforts
Parental modeling is important, and as vaping becomes more prevalent
among parents with inconsistent smoke-free and vape-free struc-
tures in the home and car [88], assessment of family use patterns is
indicated
What risks do you take to vape? Questioning of practices during the COVID-19 pandemic may be par-
ticularly important for protecting adolescent and family health [9]

adherence to behavioral goals, and positively reinforcing effectiveness in adolescents is more limited, and effective-
change) [86]. Parents who smoke should also be referred ness seems enhanced when combined with psychosocial
to smoking cessation resources. When available, individ- interventions [91]. Despite limited evidence for pharma-
ual or group cognitive behavioral therapy for nicotine use cotherapy, given the relative safety of the medications and
can help youth manage symptoms and prevent relapse with the potential harms of nicotine dependence, combination
good efficacy on quit rates [91]. Mobile apps, such as the long-acting patch and short-acting as needed gum or loz-
“quitSTART” app, can help teens track cessation goals enges have been recommended for youth under 18 looking
and manage symptoms [107], and text messaging-based to quit vaping [86].
programs such as “This is Quitting” have shown effec- On the population level, school-based interventions,
tiveness for facilitating abstinence in a recent randomized media campaigns, and policy proposals have been proposed
trial [92, 93]. to help mitigate EC use [94, 95]. Peer-led network-informed
Nicotine replacement therapies and bupropion have intervention programs show promise [31]. Clinicians can
been found safe and effective in adults, but evidence of advocate for policies that restrict where vaping products are

13
European Journal of Pediatrics (2022) 181:453–462 459

Table 3  Counseling Youth and Families about ECs

• E-liquids often contain nicotine even if they have fruity flavors. • EC aerosols contain heavy metals, fine particles, and other substances
Youth sometimes do not realize that their ECs contain nicotine [35, that may be toxic or cancer-causing to vapers and bystanders [70], so
36] vaping indoors should be avoided
• Nicotine in ECs is the same predominant addictive compound found • Nicotine and cannabis both affect neurodevelopment and may lead to
in tobacco products and can quickly lead to dependence, especially problems with sleep, concentration, memory, and mental health [75].
in youth. Nicotine dependence places you at risk of withdrawal Earlier substance use likely increases these risks [51, 54]
symptoms such as irritability, difficulty concentrating, and depressed • Peer influence is important [31], and adolescents’ perceptions of the
mood [91] importance of peer influence predicts EC use [105]. Counseling teens
• Although vaping is considered safer than CC in some ways, it has its and their families on the benefits of distancing from negative peer
own risks. Some ECs lead to very high doses of nicotine used, creat- groups may reduce risk of initiating or sustaining vaping
ing stronger addiction risk • Vaping may increase your child’s risk of getting and spreading
• Youth who vape are at risk of acute health problems such as EVALI COVID-19 [9]
[66], seizures [68]. bad oral health [69], or injury from exploding
devices [103, 104]
• Vaping appears to increase the risk of becoming a CC smoker [44,
46] and may also increase the risk of other substance use problems
[3, 60]

sold (e.g., banning sales near schools), restrict sales to youth, 2. Gentzke AS, Creamer M, Cullen KA, et al (2019) Vital Signs:
restrict vaping indoors or in public places, ban advertising, tobacco product use among middle and high school students —
United States, 2011–2018. MMWR Morb Mortal Wkly Rep
require warning labels on packaging, and ban flavors that are 68:157–164. https://​doi.​org/​10.​15585/​mmwr.​mm680​6e1
attractive to youth [94, 95]. 3. Chadi N, Schroeder R, Jensen JW, Levy S (2019) Association
between electronic cigarette use and marijuana use among
adolescents and young adults: a systematic review and meta-
analysis. JAMA Pediatr 173:e192574. https://​doi.​org/​10.​1001/​
Conclusion jamap​ediat​rics.​2019.​2574
4. Kinnunen JM, Rimpelä AH, Lindfors PL et al (2021) Electronic
Youth vaping is now a well-studied phenomenon with vari- cigarette use among 14- to 17-year-olds in Europe. Eur J Public
ous physical and behavioral health risks, some of which Health 31:402–408. https://​doi.​org/​10.​1093/​eurpub/​ckaa1​45
5. Cho H-J, Dutra LM, Glantz SA (2018) Differences in adolescent
differ from traditional smoking. Although vaping-specific e-cigarette and cigarette prevalence in two policy environments:
treatments remain underdeveloped, pediatricians and other South Korea and the United States. Nicotine Tob Res 20:949–
youth clinicians can apply the lessons of recent research to 953. https://​doi.​org/​10.​1093/​ntr/​ntx198
counsel youth and their families and prevent long-term com- 6. Koprivnikar H, Zupanič T, Farkas J (2020) Beliefs and prac-
tices regarding electronic cigarettes in smoking cessation among
plications of vaping-related nicotine addiction. healthcare professionals in Slovenia. Tob Prev Cessat 6:3. https://​
doi.​org/​10.​18332/​tpc/​115029
7. Ferrara P, Shantikumar S, Cabral Veríssimo V et al (2019)
Authors' Contributions TDB: Developed idea and strategy and wrote Knowledge about e-cigarettes and tobacco harm reduction among
first draft of paper. TRR: Participated in the development of the idea public health residents in Europe. Int J Environ Res Public Health
and design, co-wrote and revised the article, checked all the processes 16:2071. https://​doi.​org/​10.​3390/​ijerp​h1612​2071
of the article. 8. Erku DA, Gartner CE, Morphett K, Steadman KJ (2020) Beliefs
and self-reported practices of health care professionals regarding
electronic nicotine delivery systems: a mixed-methods systematic
Declarations review and synthesis. Nicotine Tob Res 22:619–629
9. Dumas TM, Ellis W, Litt DM (2020) What does adolescent sub-
Ethics approval This article does not contain any studies with human stance use look like during the COVID-19 pandemic? Examin-
participants or animals performed by any of the authors. ing changes in frequency, social contexts, and pandemic-related
predictors. J Adolesc Heal 67:354–361. https://d​ oi.o​ rg/1​ 0.1​ 016/j.​
Conflict of interest The authors declare no competing interests. jadoh​ealth.​2020.​06.​018
10. CASAA (2012) E-cigarette history: a historical timeline of elec-
tronic cigarettes. In: Consum. Advocates Smokefree Altern.
Assoc. https://​casaa.​org/​educa​tion/​vaping/​histo​r ical-​timel​ine-​
of-​elect​ronic-​cigar​ettes/. Accessed 28 Feb 2021
References 11. King BA, Jones CM, Baldwin GT, Briss PA (2020) The EVALI
and youth vaping epidemics — implications for Public Health. N
1. Michaud P-A, Bélanger R, Mazur A et al (2020) How can pri- Engl J Med 382:689–691. https://d​ oi.o​ rg/1​ 0.1​ 056/n​ ejmp1​ 91617​ 1
mary care practitioners address substance use by adolescents? 12. Besaratinia A, Tommasi S (2020) Vaping epidemic: challenges
A position paper of the EUROPEAN academy of PAEDIAT- and opportunities. Cancer Causes Control 31:663–667. https://​
RICS. Eur J Pediatr 179:1297–1305. https://​doi.​org/​10.​1007/​ doi.​org/​10.​1007/​s10552-​020-​01307-y
s00431-​020-​03596-6

13
460 European Journal of Pediatrics (2022) 181:453–462

13. Hammond D, Reid JL, Rynard VL, et al (2019) Prevalence of 30. Joossens L, Feliu A, Fernandez E. The Tobacco Control Scale
vaping and smoking among adolescents in Canada, England, and 2019 in Europe. Brussels: Association of European Cancer
the United States: repeat national cross sectional surveys. BMJ Leagues, Catalan Institute of Oncology; 2020. Available from:
365:12219. https://​doi.​org/​10.​1136/​bmj.​l2219 http://​www.​tobac​cocon​trols​cale.​org/​TCS20​19.​pdf
14. Wang TW, Neff LJ, Park-Lee E, et al (2020) E-cigarette use 31. Wyman PA, Rulison K, Pisani AR et al (2021) Above the influ-
among middle and high school students — United States, 2020. ence of vaping: Peer leader influence and diffusion of a network-
MMWR Morb Mortal Wkly Rep 69:1310–1312. https://​doi.​org/​ informed preventive intervention. Addict Behav 113:106693.
10.​15585/​mmwr.​mm693​7e1 https://​doi.​org/​10.​1016/j.​addbeh.​2020.​106693
15. Brożek GM, Jankowski M, Lawson KA, et al 2019 The prevalence 32. Trucco EM, Cristello JV, Sutherland MT (2021) Do parents still
of cigarette and e-cigarette smoking among students in central and matter? The impact of parents and peers on adolescent electronic
eastern Europe-results of the YUPESS study. Int J Environ Res cigarette use. J Adolesc Heal 68:780–786. https://​doi.​org/​10.​
Public Health 16:2297. https://​doi.​org/​10.​3390/​ijerp​h1613​2297 1016/j.​jadoh​ealth.​2020.​12.​002
16. Lee ES, Paek YJ (2020) Prevalence and correlates of the dual 33. Watkins NK, Ohannessian CMC (2020) Timing of vape use among
use of conventional and electronic cigarettes among Korean adolescents: differences by family structure. Drug Alcohol Depend
adolescents: 2016–2018 Korean youth risk behavior survey. 209:107953. https://​doi.​org/​10.​1016/j.​druga​lcdep.​2020.​107953
J Korean Soc Res Nicotine Tob 11:64–74. https://​doi.​org/​10.​ 34. Dai H, Siahpush M (2020) Use of e-cigarettes for nicotine, mar-
25055/​JKSRNT.​2020.​11.2.​64 ijuana, and just flavoring among U.S. Youth Am J Prev Med
17. Hammond D, Reid JL, Burkhalter R, Rynard VL (2020) E-cigarette 58:244–249. https://​doi.​org/​10.​1016/j.​amepre.​2019.​09.​006
marketing regulations and youth vaping: cross-sectional surveys, 35. Pepper JK, Farrelly MC, Watson KA (2018) Adolescents’
2017–2019. Pediatrics 146:e20194020. https://​doi.​org/​10.​1542/​ understanding and use of nicotine in e-cigarettes. Addict Behav
peds.​2019-​4020 82:109–113. https://​doi.​org/​10.​1016/j.​addbeh.​2018.​02.​015
18. Jackler RK, Ramamurthi D (2019) Nicotine arms race: JUUL 36. Boykan R, Messina CR, Chateau G et al (2019) Self-reported
and the high-nicotine product market. Tob Control 28:623–628. use of tobacco, E-cigarettes, and marijuana versus urinary bio-
https://​doi.​org/​10.​1136/​tobac​cocon​trol-​2018-​054796 markers. Pediatrics 143:e20183531. https://d​ oi.o​ rg/1​ 0.1​ 542/p​ eds.​
19. Ker S, Peckham E, Gilbody S, Bonner S (2019) Everything you 2018-​3531
wanted to know about e-cigarettes and vaping but were afraid to 37. Pepper JK, Ribisl KM, Brewer NT (2016) Adolescents’ interest
ask: a guide for mental health clinicians. BJPsych Adv 25:279– in trying flavoured e-cigarettes. Tob Control 25:ii62–ii66. https://​
286. https://​doi.​org/​10.​1192/​bja.​2019.​36 doi.​org/​10.​1136/​tobac​cocon​trol-​2016-​053174
20. Goniewicz ML, Boykan R, Messina CR et al (2019) High expo- 38. Ford A, MacKintosh AM, Bauld L et al (2016) Adolescents’
sure to nicotine among adolescents who use Juul and other vape responses to the promotion and flavouring of e-cigarettes.
pod systems (‘pods’). Tob Control 28:676–677. https://​doi.​org/​ Int J Public Health 61:215–224. https:// ​ d oi. ​ o rg/ ​ 1 0. ​ 1 007/​
10.​1136/​tobac​cocon​trol-​2018-​054565 s00038-​015-​0769-5
21. Benowitz NL, Henningfield JE (1994) Establishing a nicotine 39. Audrain-McGovern J, Rodriguez D, Pianin S, Alexander E
threshold for addiction – the implications for tobacco regu- (2019) Initial e-cigarette flavoring and nicotine exposure and
lation. N Engl J Med 331:123–125. https://​doi.​org/​10.​1056/​ e-cigarette uptake among adolescents. Drug Alcohol Depend
NEJM1​99407​14331​0212 202:149–155. https://​doi.​org/​10.​1016/j.​druga​lcdep.​2019.​04.​037
22. Evans-Polce RJ, Patrick ME, Lanza ST et al (2018) Reasons for 40. Leventhal AM, Goldenson NI, Cho J et al (2019) Flavored
vaping among U.S. 12th Graders. J Adolesc Health 62:457–462. e-cigarette use and progression of vaping in adolescents. Pedi-
https://​doi.​org/​10.​1016/j.​jadoh​ealth.​2017.​10.​009 atrics 144:e20190789. https://​doi.​org/​10.​1542/​peds.​2019-​0789
23. Eichler M, Blettner M, Singer S (2016) The use of e-cigarettes. 41. Pepper JK, Coats EM, Nonnemaker JM, Loomis BR (2019) How
Dtsch Aerzteblatt Online. 113:847-854. https://​doi.​org/​10.​3238/​ do adolescents get their e-cigarettes and other electronic vaping
arzte​bl.​2016.​0847 devices? Am J Heal Promot 33:420–429. https://d​ oi.o​ rg/1​ 0.1​ 177/​
24. Kinouani S, Leflot C, Vanderkam P et al (2020) Motivations for 08901​17118​790366
using electronic cigarettes in young adults: a systematic review. 42. McKeganey N, Russell C, Katsampouris E, Haseen F (2019)
Subst Abus 41:315–322 Sources of youth access to JUUL vaping products in the United
25. Hanewinkel R, Isensee B (2015) Risk factors for e-cigarette, States. Addict Behav Reports 10:100232. https://​doi.​org/​10.​
conventional cigarette, and dual use in German adolescents: a 1016/j.​abrep.​2019.​100232
cohort study. Prev Med (Baltim) 74:59–62. https://​doi.​org/​10.​ 43. Gaiha SM, Lempert LK, Halpern-Felsher B (2020) Underage
1016/j.​ypmed.​2015.​03.​006 youth and young adult e-cigarette use and access before and dur-
26. Chen P-C, Chang L-C, Hsu C, Lee Y-C (2019) Dual use of ing the coronavirus disease 2019 pandemic. JAMA Netw Open
e-cigarettes and traditional cigarettes among adolescents in Tai- 3:e2027572. https://​doi.​org/​10.​1001/​jaman​etwor​kopen.​2020.​27572
wan, 2014–2016. Nicotine Tob Res 21:48–54. https://d​ oi.o​ rg/1​ 0.​ 44. Pierce JP, Chen R, Leas EC et al (2021) Use of e-cigarettes and
1093/​ntr/​nty003 other tobacco products and progression to daily cigarette smok-
27. Kennedy RD, Awopegba A, De León E, Cohen JE (2017) Global ing. Pediatrics 147:e2020025122. https://​doi.​org/​10.​1542/​peds.​
approaches to regulating electronic cigarettes. Tob Control 2020-​025122
26:440–445. https://d​ oi.o​ rg/1​ 0.1​ 136/t​ obacc​ ocont​ rol-2​ 016-​053179 45. Dutra LM, Glantz SA (2017) E-cigarettes and national adolescent
28. Amin S, Dunn AG, Laranjo L (2020) Social influence in the cigarette use: 2004–2014. Pediatrics 139:e20162450. https://d​ oi.​
uptake and use of electronic Cigarettes: a systematic review. Am org/​10.​1542/​peds.​2016-​2450
J Prev Med 58:129–141. https://​doi.​org/​10.​1016/j.​amepre.​2019.​ 46. Soneji S, Barrington-Trimis JL, Wills TA et al (2017) Associa-
08.​023 tion between initial use of e-cigarettes and subsequent cigarette
29. Collins L, Glasser AM, Abudayyeh H et al (2019) E-cigarette smoking among adolescents and young adults. JAMA Pediatr
marketing and communication: how e-cigarette companies mar- 171:788. https://​doi.​org/​10.​1001/​jamap​ediat​rics.​2017.​1488
ket e-cigarettes and the public engages with e-cigarette informa- 47. Chan GCK, Stjepanović D, Lim C, et al (2020) Gateway or com-
tion. Nicotine Tob Res 21:14–24 mon liability? A systematic review and meta-analysis of studies

13
European Journal of Pediatrics (2022) 181:453–462 461

of adolescent e-cigarette use and future smoking initiation. 65. Blount BC, Karwowski MP, Shields PG et al (2020) Vitamin e acetate
Addiction 116:743-756. https://​doi.​org/​10.​1111/​add.​15246 in bronchoalveolar-lavage fluid associated with EVALI. N Engl J
48. Epstein M, Bailey JA, Kosterman R, et al (2020) E-cigarette use Med 382:697–705. https://​doi.​org/​10.​1056/​NEJMo​a1916​433
is associated with subsequent cigarette use among young adult 66. Jonas AM, Raj R (2020) Vaping-related acute parenchymal lung
non-smokers, over and above a range of antecedent risk factors: injury: a systematic review. Chest 158:1555–1565
a propensity score analysis. Addiction add.15317. https://d​ oi.o​ rg/​ 67. Thakrar PD, Boyd KP, Swanson CP et al (2020) E-cigarette,
10.​1111/​add.​15317 or vaping, product use-associated lung injury in adolescents: a
49. Goldenson NI, Leventhal AM, Stone MD et al (2017) Associa- review of imaging features. Pediatr Radiol 50:338–344. https://​
tions of electronic cigarette nicotine concentration with subse- doi.​org/​10.​1007/​s00247-​019-​04572-5
quent cigarette smoking and vaping levels in adolescents. JAMA 68. Faulcon LM, Rudy S, Limpert J et al (2020) Adverse experience
Pediatr 171:1192. https://​doi.​org/​10.​1001/​jamap​ediat​rics.​2017.​ reports of seizures in youth and young adult electronic nicotine
3209 delivery systems users. J Adolesc Heal 66:15–17. https://d​ oi.o​ rg/​
50. Chaffee BW, Watkins SL, Glantz SA (2018) Electronic cigarette 10.​1016/j.​jadoh​ealth.​2019.​10.​002
use and progression from experimentation to established smok- 69. Yang I, Sandeep S, Rodriguez J (2020) The oral health impact
ing. Pediatrics 141:e20173594. https://​doi.​org/​10.​1542/​peds.​ of electronic cigarette use: a systematic review. Crit Rev Toxicol
2017-​3594 50:97–127. https://​doi.​org/​10.​1080/​10408​444.​2020.​17137​26
51. Casey BJ, Jones RM (2010) Neurobiology of the adolescent brain 70. Hess IMR, Lachireddy K, Capon A (2016) A systematic review
and behavior: Implications for substance use disorders. J Am of the health risks from passive exposure to electronic cigarette
Acad Child Adolesc Psychiatry 49:1189–1201 vapour. Public Heal Res Pract 26:e2621617. https://​doi.​org/​10.​
52. Ren M, Lotfipour S (2019) Nicotine gateway effects on adoles- 17061/​phrp2​621617
cent substance use. West J Emerg Med 20:696–709. https://​doi.​ 71. Casey BJ, Jones RM, Somerville LH (2011) Braking and accel-
org/​10.​5811/​westj​em.​2019.7.​41661 erating of the adolescent brain. J Res Adolesc 21:21–33. https://​
53. Terry-McElrath YM, O’Malley PM, Johnston LD (2020) doi.​org/​10.​1111/j.​1532-​7795.​2010.​00712.x
Changes in the order of cigarette and marijuana initiation and 72. Hajek P, Phillips-Waller A, Przulj D et al (2019) A randomized
associations with cigarette use, nicotine vaping, and marijuana trial of e-cigarettes versus nicotine-replacement therapy. N Engl
use: U.S. 12th Grade Students, 2000–2019. Prev Sci 21:960–971. J Med 380:629–637. https://​doi.​org/​10.​1056/​nejmo​a1808​779
https://​doi.​org/​10.​1007/​s11121-​020-​01150-2 73. Williams JM, Steinberg ML, Griffiths KG, Cooperman N
54. Gray KM, Squeglia LM (2018) Research review: what have we (2013) Smokers with behavioral health comorbidity should be
learned about adolescent substance use? J Child Psychol Psychia- designated a tobacco use disparity group. Am J Public Health
try Allied Discip 59:618–627 103:1549–1555. https://​doi.​org/​10.​2105/​AJPH.​2013.​301232
55. Unger JB, Soto DW, Leventhal A (2016) E-cigarette use and 74. Prochaska JJ, Das S, Young-Wolff KC (2017) Smoking, mental
subsequent cigarette and marijuana use among Hispanic young illness, and public health. Annu Rev Public Health 38:165–185.
adults. Drug Alcohol Depend 163:261–264. https://​doi.​org/​10.​ https://​doi.​org/​10.​1146/​annur​ev-​publh​ealth-​031816-​044618
1016/j.​druga​lcdep.​2016.​04.​027 75. Becker TD, Arnold MK, Ro V et al (2020) Systematic review
56. Dai H, Catley D, Richter KP et al (2018) Electronic cigarettes of electronic cigarette use (vaping) and mental health comor-
and future marijuana use: a longitudinal study. Pediatrics bidity among adolescents and young adults. Nicotine Tob Res
141:e20173787. https://​doi.​org/​10.​1542/​peds.​2017-​3787 23:415–425. https://​doi.​org/​10.​1093/​ntr/​ntaa1​71
57. Audrain-Mcgovern J, Stone MD, Barrington-Trimis J et al (2018) 76. Pentz MA, Shin H, Riggs N et al (2015) Parent, peer, and execu-
Adolescent e-cigarette, hookah, and conventional cigarette use tive function relationships to early adolescent e-cigarette use: a
and subsequent marijuana use. Pediatrics 142:e20173616. https://​ substance use pathway? Addict Behav 42:73–78. https://​doi.​org/​
doi.​org/​10.​1542/​peds.​2017-​3616 10.​1016/j.​addbeh.​2014.​10.​040
58. Bagot KS, Milin R, Kaminer Y (2015) Adolescent initiation of 77. Lai S, Lai H, Page JB, McCoy CB (2000) The association
cannabis use and early-onset psychosis. Subst Abus 36:524–533 between cigarette smoking and drug abuse in the United States.
59. Meier MH, Caspi A, Ambler A et al (2012) Persistent canna- J Addict Dis 19:11–24. https://​doi.​org/​10.​1300/​J069v​19n04_​
bis users show neuropsychological decline from childhood to 02
midlife. Proc Natl Acad Sci U S A 109:E2657–E2664. https://​ 78. Kandel D, Kandel E (2015) The gateway hypothesis of substance
doi.​org/​10.​1073/​pnas.​12068​20109 abuse: developmental, biological and societal perspectives. Acta
60. Rothrock AN, Andris H, Swetland SB et al (2020) Association Paediatr 104:130–137. https://​doi.​org/​10.​1111/​apa.​12851
of e-cigarettes with adolescent alcohol use and binge drinking- 79. Degenhardt L, Dierker L, Chiu WT et al (2010) Evaluating
drunkenness: a systematic review and meta-analysis. Am J Drug the drug use “gateway” theory using cross-national data: con-
Alcohol Abuse 46:684–698. https://​doi.​org/​10.​1080/​00952​990.​ sistency and associations of the order of initiation of drug use
2020.​17717​23 among participants in the WHO World Mental Health Surveys.
61. Hamberger ES, Halpern-Felsher B (2020) Vaping in adolescents. Drug Alcohol Depend 108:84–97. https://​doi.​org/​10.​1016/j.​
Curr Opin Pediatr 32:378–383. https://​doi.​org/​10.​1097/​MOP.​ druga​lcdep.​2009.​12.​001
00000​00000​000896 80. Yuan M, Cross SJ, Loughlin SE, Leslie FM (2015) Nicotine and
62. Gaur S, Agnihotri R (2019) Health effects of trace metals in the adolescent brain. J Physiol 593:3397–3412. https://​doi.​org/​
electronic cigarette aerosols—a systematic review. Biol Trace 10.​1113/​JP270​492
Elem Res 188:295–315 81. Goriounova NA, Mansvelder HD (2012) Short- and long-term
63. Ratajczak A, Feleszko W, Smith DM, Goniewicz M (2018) How consequences of nicotine exposure during adolescence for pre-
close are we to definitively identifying the respiratory health frontal cortex neuronal network function. Cold Spring Harb
effects of e-cigarettes? Expert Rev Respir Med 12:549–556. Perspect Med 2:a012120–a012120. https://​doi.​org/​10.​1101/​
https://​doi.​org/​10.​1080/​17476​348.​2018.​14837​24 cshpe​rspect.​a0121​20
64. Marini S, Buonanno G, Stabile L, Ficco G (2014) Short-term 82. Smith RF, McDonald CG, Bergstrom HC et al (2015) Adoles-
effects of electronic and tobacco cigarettes on exhaled nitric cent nicotine induces persisting changes in development of neural
oxide. Toxicol Appl Pharmacol 278:9–15. https://​doi.​org/​10.​ connectivity. Neurosci Biobehav Rev 55:432–443. https://​doi.​
1016/j.​taap.​2014.​04.​004 org/​10.​1016/j.​neubi​orev.​2015.​05.​019

13
462 European Journal of Pediatrics (2022) 181:453–462

83. Slotkin TA (2002) Nicotine and the adolescent brain: insights 96. Kosmider L, Sobczak A, Fik M et al (2014) Carbonyl compounds
from an animal model. Neurotoxicol Teratol 24:369–384. https://​ in electronic cigarette vapors: effects of nicotine solvent and bat-
doi.​org/​10.​1016/​S0892-​0362(02)​00199-X tery output voltage. Nicotine Tob Res 16:1319–1326. https://d​ oi.​
84. Lechner WV, Janssen T, Kahler CW et al (2017) Bi-directional org/​10.​1093/​ntr/​ntu078
associations of electronic and combustible cigarette use onset 97. Abeles M, Popofsky S, Wen A et al (2020) Vaping-associated
patterns with depressive symptoms in adolescents. Prev Med lung injury caused by inhalation of cannabis oil. Pediatr Pulmo-
(Baltim) 96:73-78. https://​doi.o​ rg/1​ 0.1​ 016/j.​ypmed.2​ 016.​12.0​ 34 nol 55:226–228. https://​doi.​org/​10.​1002/​ppul.​24579
85. Dvorsky MR, Langberg JM (2019) Cigarette and e-cigarette use 98. Jackson DB, Boccio CM, Leal WE, Vaughn MG (2019) It’s all
and social perceptions over the transition to college: The Role of the rage! Exploring the nuances in the link between vaping and
ADHD Symptoms. Psychol Addict Behav 33:318-330. https://​ adolescent delinquency. J Crim Justice 63:58–69. https://d​ oi.o​ rg/​
doi.​org/​10.​1037/​adb00​00450 10.​1016/j.​jcrim​jus.​2019.​04.​004
86. Hadland SE, Chadi N (2020) Through the haze: what clinicians 99. Schillo BA, Cuccia AF, Patel M, et al (2020) JUUL in school:
can do to address youth VAPING. J Adolesc Heal 66:10–14. teacher and administrator awareness and policies of e-cigarettes
https://​doi.​org/​10.​1016/j.​jadoh​ealth.​2019.​10.​009 and JUUL in U.S. Middle and High Schools. Health Promot Pract
87. LeLaurin JH, Theis RP, Thompson LA et al (2020) Tobacco- 21:20-24. https://​doi.​org/​10.​1177/​15248​39919​868222
related counseling and documentation in adolescent primary 100. Allem J-P, Dharmapuri L, Unger JB, Cruz TB (2018) Charac-
care practice: challenges and opportunities. Nicotine Tob Res terizing JUUL-related posts on Twitter. Drug Alcohol Depend
22:1023–1029. https://​doi.​org/​10.​1093/​ntr/​ntz076 190:1–5. https://​doi.​org/​10.​1016/j.​druga​lcdep.​2018.​05.​018
88. Amato MS, Bottcher MM, Cha S et al (2021) “It’s really addic- 101. Kavuluru R, Han S, Hahn EJ (2019) On the popularity of the USB
tive and I’m trapped:” a qualitative analysis of the reasons for flash drive-shaped electronic cigarette Juul. Tob. Control 28:110–
quitting vaping among treatment-seeking young people. Addict 112. https://​doi.​org/​10.​1136/​tobac​cocon​trol-​2018-​054259
Behav 112:106599. https://​d oi.​o rg/​1 0.​1 016/j.​a ddbeh.​2 020.​ 102. Centers for Disease Control and Prevention (2020) Outbreak
106599 of lung injury associated with the use of e-cigarette, or vaping,
89. Hartmann-Boyce J, McRobbie H, Lindson N et al (2021) Elec- products. https://​www.​cdc.​gov/​tobac​co/​basic_​infor ​mation/​e-​
tronic cigarettes for smoking cessation. Cochrane Database Syst cigar​ettes/​severe-​lung-​disea​se.​html. Accessed 3 Mar 2021.
Rev. https://​doi.​org/​10.​1002/​14651​858.​CD010​216.​pub5 103. Rossheim ME, Livingston MD, Soule EK et al (2019) Electronic
90. Sanchez S, Kaufman P, Pelletier H et al (2021) Is vaping ces- cigarette explosion and burn injuries, US Emergency Depart-
sation like smoking cessation? A qualitative study exploring ments 2015–2017. Tob Control 28:472–474. https://​doi.​org/​10.​
the responses of youth and young adults who vape e-cigarettes. 1136/​tobac​cocon​trol-​2018-​054518
Addict Behav 113:106687. https://​doi.​org/​10.​1016/j.​addbeh.​ 104. Kumetz EA, Hurst ND, Cudnik RJ, Rudinsky SL (2016) Elec-
2020.​106687 tronic cigarette explosion injuries. Am J Emerg Med 34:2252.
91. Cavallo DA, Krishnan-Sarin S (2019) Nicotine use disorders in e1-2252.e3. https://​doi.​org/​10.​1016/j.​ajem.​2016.​04.​010
adolescents. Pediatr Clin North Am 66:1053–1062. https://​doi.​ 105. Cho JH, Shin E, Moon S-S (2011) Electronic-cigarette smok-
org/​10.​1016/j.​pcl.​2019.​08.​002 ing experience among adolescents. J Adolesc Heal 49:542–546.
92. Graham AL, Jacobs MA, Amato MS (2020) Engagement and https://​doi.​org/​10.​1016/j.​jadoh​ealth.​2011.​08.​001
3-month outcomes from a digital e-cigarette cessation program 106. Farsalinos KE, Romagna G, Allifranchini E, et al. Comparison of
in a cohort of 27 000 teens and young adults. Nicotine Tob Res the cytotoxic potential of cigarette smoke and electronic cigarette
22:859–860. https://​doi.​org/​10.​1093/​ntr/​ntz097 vapour extract on cultured myocardial cells. Int J Environ Res
93. Graham AL, Amato MS, Cha S et al (2021) Effectiveness of Public Health. 2013;10(10):5146–5162.
a vaping cessation text message program among young adult 107. US Department of Health and Human Services. (2021). quit-
e-cigarette users: a randomized clinical trial. JAMA Intern Med START. https:// ​ s moke ​ f ree. ​ g ov/ ​ t ools- ​ t ips/ ​ a pps/ ​ q uits ​ t art.
181:923-930. https://​doi.​org/​10.​1001/​jamai​ntern​med.​2021.​1793 Accessed 31 July 2021.
94. Al-Hamdani M, Hopkins DB, Park T (2020) Vaping among
youth and young adults: a “red alert” state. J Public Health Policy Publisher's Note Springer Nature remains neutral with regard to
41:63–69. https://​doi.​org/​10.​1057/​s41271-​019-​00193-2 jurisdictional claims in published maps and institutional affiliations.
95. Substance Abuse and Mental Health Services Administration
(SAMHSA): (2020) Reducing vaping among youth and young
adults. SAMHSA Publication No. PEP20–06–01–003.

13