We need to raise the awareness of electronic nicotine delivery systems.


by Rachel Civale

Picture this: A cloud of vapor swirls in the air with the light smell of cotton candy to disguise the dangers lurking within. How could something that smells so sweet and reminiscent of childhood be so dangerous? With every sweet inhale you are exposed to chemicals linked to serious lung disease without even realizing it. These vapor clouds are only going to continue to increase. As of 2022, 2.55 million U.S. middle and high school students used e-cigarettes in the past 30 days.

Electronic nicotine delivery systems, also known as ENDS, come in many varieties, flavors, and names. Most contain a battery, heating element, and mechanism to hold the nicotine-containing liquid and go by many names such as “e-cig”, “e-hookahs”, “vapes”, and the list only goes on. The industry for these products has gone above and beyond to heavily target our youth and has succeeded in aggressively reeling them in by introducing appealing flavors, cool designs, and even offering college scholarships. Despite the federal restrictions on e-cigarette marketing these companies still promote their products to children via the Internet, retail environments, and recreational venues and events. These e-cigarettes are the most popular tobacco product amongst our youth with one in five high school students using them in 2020.

Unfortunately, despite the FDA’s efforts to prioritize enforcement against the sales of most youth-appealing candy or fruit flavors, the e-cigarette industry has responded by offering new products that aren’t covered in the existing enforcement guidelines. Unfortunately, four out of five middle and high school students, more than 20 million youth, saw at least one e-cigarette advertisement by 2016 and young people were most likely to see ads at retail stores (58.4%), followed by the internet (44.6%), newspapers and magazines (34.8%), and TV, streaming services, or movies (26.2%).

On top of this heavy marketing it is also difficult to see the ingredients of these products. Vape liquids often contain nicotine, ultrafine particles, diacetyl, volatile organic compounds, cancer-causing chemicals, vitamin E acetate, Tetrahydrocannabinol (THC), and heavy metals such as nickel, tin, and lead. The nicotine serves to create an addictive property and the ultrafine particles and diacetyl uses for flavoring are linked to serious lung injury amongst the other harmful contents. There is an outbreak of Electronic Vape Associated Lung Injury (EVALI) associated with vape products containing vitamin E acetate and is most often found in vapes containing THC which are especially popular amongst the youth.

As a nurse, I have personally seen teenagers end up in the Intensive Care Unit on life support from these lung injuries and require lung transplantation. The fact that vaping is causing children to need new lungs brings even more urgency to ENDS this epidemic. Despite nicotine being highly addictive it can also harm development of the adolescent brain and continues up to age 20. While a Cochrane review found evidence that e-cigarettes with nicotine can help adults who smoke stop smoking in the long term compared with placebo (non-nicotine) e-cigarettes this is not the target population being marketed by this industry.

This industry needs to be held accountable for the dangers their products hold for youth. If we do not put an ENDS to the lack of direct and strict enforcement, this industry will continue to find loopholes to market their products to our youth. It is time for the federal government to step in and comprehensively restrict this industry. In terms of marketing, they must impose restrictions so that it does not target or appeal to youth. The same marketing restrictions the FDA imposed on combustible cigarettes but me used on e-cigarettes immediately which are inclusive of restricting: Sponsorships of sports and cultural events, self-service access to the products, and free gifts with purchase (i.e. no free branded t-shirts or hats with purchase).

Social media and influencers on these platforms must also be restricted to limit youth exposure via the internet to these products. Lastly, the Federal Trade Commission (FTC) must improve monitoring to ensure that all industry-funded influencer endorsements clearly indicate that they are paid advertisements and clearly define risks associated with nicotine use. Data must also be collected from on all marketing spending just as it does for cigarettes and smokeless tobacco.

We need to raise the awareness of our legislators and ask them to create policies to hold this industry accountable. If we can promote a decrease in marketing alone we can put an end to ENDS’ toxic grip on our nation’s youth and the epidemic it has created.

Rachel Civale BSN, RN, CCRN is a is a senior graduate student in Duke University’s Nurse Anesthesia Doctor of Nursing Practice Program and a former Cardiothoracic Surgery Intensive Care Unit Nurse.

-Rachel Civale (rachel.civale@duke.edu)

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