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The Youth E-Cigarette Epidemic

FRANKFORT The US Surgeon General has declared electronic cigarette use an epidemic among youth because of an unprecedented rise in e-cigarette products in the past two years. Increasingly, doctors are asked to provide information to worried parents about the products and to provide treatment to teens who have already become addicted to nicotine.

Electronic cigarettes, also known as alternative nicotine products, vapor products, vape pens, and electronic hookahs, are devices that heat a liquid containing nicotine, flavorings, and other chemicals to be turned into an aerosol and inhaled by the user. While older generations of e-cigarettes can have large batteries and create huge plumes, newer pod-based products such as JUUL, Suorin, and Smok® are small enough to hide in a hand and create discrete aerosol clouds that are easily concealed.

Here are the facts healthcare providers need to know:

According to the Kentucky Incentives for Prevention Survey, there has been a 200% increase in 10th grade e-cigarette use between 2016 and 2018.1

Four out of five youth who have used tobacco products started with a flavored product.2

E-cigarettes containing nicotine salts can be very strong. A 3% strength JUUL pod has 23 mg of nicotine, equivalent to approximately a package of cigarettes. A 5% JUUL pod has 40 mg of nicotine, the nicotine equivalent of about two packages of cigarettes.3

Young adults who use e-cigarettes are four times as likely to become conventional cigarette users compared to non-e-cigarette users.4

Daily e-cigarette users have twice the risk of heart attack as non-e-cigarette users.5 E-cigarette aerosol contain ultrafine particles, heavy metals, cancer-causing chemicals, and nicotine.
JUUL and other electronic cigarettes can be used to consume marijuana. Nearly 1 in 11 US students, including one third of those who have ever used e-cigarettes, had used cannabis in an e-cigarette in 2016.6

Healthcare professionals, communities, and families need to come together to ensure our youth do not become addicted to a new generation of tobacco products.

Screen for tobacco use with every patient visit. Include e-cigarettes, such as JUUL and other pod-based systems, in your screening. Ask young people what types of products are being used in their schools, as new products emerge on the market all the time.
Educate patients about the risks of tobacco use, particularly for young people. While there is debate about the benefits of e-cigarettes for adult smokers, the research is very clear that no teen should be using an e-cigarette. Education on e-cigarettes should start with elementary school aged youth.
Educate patients about the risks of secondhand smoke and secondhand aerosol exposure. Smoking, including e-cigarettes, should not be allowed in homes, cars, or workplaces.
Encourage patients to quit all forms of tobacco. Free help is available at,
Carefully consider when nicotine replacement therapy may be appropriate to use with a teen and how to scale dosage.

For more information on e-cigarettes, JUUL, and other pod-based devices, please visit the CDC website: or the Surgeon General’s E-cigarette page:

Elizabeth Anderson-Hoagland is the supervisor in the health promotion section at the Kentucky Department for Public Health. She was a policy analyst with the Kentucky Tobacco Prevention and Cessation Program for seven years. As part of her position, she focuses on a variety of issues related to youth tobacco use, including 100% Tobacco Free School policies and the tobacco retailer underage sales training (TRUST) initiative.

Previously she was at Bluegrass Regional Prevention Center and Kentucky Child Now. She graduated from Berea College and has a master’s degree in public health from George Washington University.


1Kentucky Incentives for Prevention. Statewide Trends (2010–2018) Related to Youth Substance Abuse, Mental Health, and School Safety. 2018. Available at:

2Villanti AC, et al. Flavored tobacco product use in youth and adults: Findings from the first wave of the PATH study (2013–2014). Am J Prev Med. 2017 Aug; 53(2):139–151. doi: 10.1016/j.amepre.2017.01.026.

3JUULpod Basics. Available at: Accessed April 26, 2019.

4Brian A. Primack, Ariel Shensa, Jaime E. Sidani, Beth L. Hoffman, Samir Soneji, James D. Sargent, Robert Hoffman, Michael J. Fine. Initiation of Traditional Cigarette Smoking after Electronic Cigarette Use among Tobacco-Naïve U.S. Young Adults. The American Journal of Medicine, 2017; DOI: 10.1016/j.amjmed.2017.11.005

5Alzahrani, Talal et al. Association Between Electronic Cigarette Use and Myocardial Infarction. American Journal of Preventive Medicine. Volume 55, Issue 4, 455–461.

6Singh T, Kennedy S, Marynak K, Persoskie A, Melstrom P, King BA. Characteristics of Electronic Cigarette Use Among Middle and High School Students — United States, 2015. MMWR Morb Mortal Wkly Rep 2016;65:1425–1429. Trivers KF, Phillips E, Gentzke AS, Tynan MA, Neff LJ. Prevalence of Cannabis Use in Electronic Cigarettes Among US Youth. JAMA Pediatr. Published online September 17, 2018. doi:10.1001/jamapediatrics.2018.1920