Addressing psychiatric and psychosocial issues related to children and adolescents
The purpose of this article is to review the phenomenon of electronic cigarettes (e-cigarettes), summarize potential health risks, and offer guidance regarding their use in adolescents. The vignette below is an example of this increasing concern.
While 14-year-old Casey is waiting for his friends at the mall, his curiosity draws him to a kiosk advertising e-cigarettes. He is surprised to see the array of colors and designs for the smoking device and the variety of vapor flavors (e.g., chocolate, cherry, vanilla, cola). The salesperson tries to convince Casey to buy the product. Casey does not smoke, so why should he start now, he asks? The retailer tells him that the “e-cigs” will give him energy to compete in sports. Casey wants to improve his performance in soccer and begins to consider the possibility.
What Is An E-Cigarette?
Electronic nicotine delivery systems (ENDS), or more commonly known as electronic or e-cigarettes, were first patented in China in 2004 (Yamin, Bitton, & Bates, 2010) and debuted in the United States in 2007 (Regan, Promoff, Dube, & Arrazola, 2013). An e-cigarette is a battery-operated apparatus that provides nicotine and other ingredients (without tobacco) delivered via aerosol or vapor (Centers for Disease Control and Prevention [CDC], 2013a). E-cigarettes commonly consist of a cartridge containing a solvent (e.g., propylene glycol) and nicotine. A battery-powered heating element draws the solution up to a tube and the user inhales the vapor (Cobb, Byron, Abrams, & Shields, 2010). Slang terms used for e-cigarettes include e-cigs, vaping, PVs (personal vaporizers), and mods (modified e-cigarettes) (McQueen, Tower, & Sumner, 2011). Currently, the U.S. Food and Drug Administration (FDA) (2014) does not regulate the manufacturing or marketing of e-cigarettes unless they are designed for therapeutic use in smoking cessation.
There is ongoing debate regarding e-cigarettes in the market. For example, although e-cigarettes may have been designed as a tool for smoking cessation (Siegel, Tanwar, & Wood, 2011), their effectiveness has not been established (Cahn & Siegel, 2011). In fact, e-cigarettes are attracting non-smokers to nicotine use (Cobb et al., 2010; Pepper et al., 2013; Regan et al., 2013). As an attorney for one e-cigarette manufacturer stated, “We don’t want people weaned from e-cigarettes, rather we want them to smoke them as long as they smoked conventional cigarettes” (Cobb et al., 2010, p. 2340).
There seems to be a general consensus that FDA regulations are needed for e-cigarettes. These issues notwithstanding, this article asserts that adolescents, both smokers and non-smokers, are using e-cigarettes with greater frequency (Sutfin, McCoy, Morrell, Hoeppner, & Wolfson, 2013). In fact, e-cigarette use among middle and high school students doubled from 2011 to 2012, to approximately 1.78 million, of which 160,000 had never smoked conventional cigarettes (CDC, 2013b). One reason for this increase could be the marketing practices, which appeal to younger populations (Grana, 2013). These products come in various colors and flavors (e.g., fruit, chocolate, mint) and with decorative carrying cases (McQueen et al., 2011). Approximately 90% of all individuals who smoke started in their teens (CDC, 2013a), and teens who begin using e-cigarettes risk establishing a life-long addiction to nicotine, whether with electronic or conventional cigarettes (CDC, 2013a). Studies regarding e-cigarettes are limited, whereas studies focusing on adolescent use of e-cigarettes are even scarcer (Cho, Shin, & Moon, 2011).
The National Youth Tobacco Survey reported by the CDC (2013a) indicates that the use of e-cigarettes by middle and high school students more than doubled from 2011 to 2012 (4.7% to 10%). Similarly, the use of these devices during the previous 30 days increased from 1.5% to 2.8% for the same time period (CDC, 2013a). Especially troubling is that 76.3% of study participants admitted they had smoked conventional cigarettes as well, something they would not have done prior to using these electronic devices (CDC, 2013a,b).
Cho et al. (2011) attempted to identify the information sources and factors that affected adolescent e-cigarette use in their study of more than 400 middle and high school Korean students. They found that the major information sources were the Internet (46.4%) and friends (27.9%), whereas the most significant factors of influence were gender (male) and the perception of peer influence. Pepper et al. (2013) studied adolescent males’ awareness and willingness to try e-cigarettes. Their findings revealed that although smokers were more willing to try an e-cigarette than nonsmokers (74% versus 13%), nearly one fifth (18%) of the study participants were willing to try an e-cigarette (Pepper et al., 2013). The authors concluded that factors such as secrecy of use might actually mask the true prevalence.
Similar to the studies by Cho et al. (2011) and Pepper et al. (2013), Sutfin et al. (2013) found that male adolescent college students were more likely to use e-cigarettes than their female counterparts. Men are known to be at risk for smoking initiation, thus a major concern is that e-cigarettes may be a “gateway” to a higher prevalence of risky smoking behaviors (Pepper et al., 2013, p. 144). However, Regan et al. (2013) found that more women had used e-cigarettes than men (10.5% versus 6.5%) in their adult sample. A disturbing finding in all of these studies is that the users did not choose e-cigarettes to quit their smoking habits and had no intention to quit in the near future.
Psychosocial Developmental Considerations
Adolescence is often marked by the desire for immediate gratification, experimentation, risk-taking, and an underdeveloped comprehension of the foreseeable consequences of “living in the moment” (Erikson, 1968). Likewise, peer pressure and a desire to be accepted are likely key contributors to smoking initiation. Cho et al. (2011) conducted a study of 4,321 middle and high school students and found that factors such as male gender, perceived peer influence, dissatisfaction with school-life, having family members who smoke, and having smoked conventional cigarettes themselves increased the likelihood of an adolescent trying an e-cigarette. Sensation-seeking and positive smoking expectancies, such as appearing “cool” around friends, have been shown to be predictors to initiating smoking (Grana, 2013).
Adolescents are also attracted to technology. Easily accessible, e-cigarettes can be ordered anonymously online (Cho et al., 2011; Yamin et al., 2010) and are readily available in places such as shopping malls (Grana, 2013; Yamin et al., 2010). Marketing strategies often use celebrities to promote their products as well as designs, colors, and flavors, which appeal to youth (Pepper et al., 2013). Adolescent perceptions of e-cigarettes are primarily positive (Pepper et al., 2013; Trumbo & Harper, 2013). Although adolescents have a positive orientation to public use of e-cigarettes, most do not realize that nicotine is highly addictive (Pepper et al., 2013; Sutfin et al., 2013).
Advantages and Disadvantages of E-Cigarettes
Advantages of e-cigarettes include use where conventional cigarettes are banned and their ability to address physiological, psychological, and behavioral (e.g., holding a cigarette) aspects of smoking addiction (Cahn & Siegel, 2011; Siegel et al., 2011). E-cigarettes do not contain tobacco or produce second-hand smoke and, to date, there is little substantial evidence showing that e-cigarettes contain carcinogens (Cobb et al., 2010). However, the risks and dangers of e-cigarettes are largely unverified. Although the average conventional cigarette contains approximately 8 mg of nicotine (but delivers only 1 to 2 mg to the smoker), e-cigarettes vary from 0 mg (or nicotine-free) to 18 mg of nicotine, and the amount delivered to the smoker can vary (Cahn & Siegel, 2011). Cobb et al. (2010) reported that because there is no standard definition of ENDS, companies have increased flexibility in design and constituents of e-cigarettes. Currently, there are more than 250 e-cigarette brands available in the market (Benowitz & Goniewicz, 2013). Unfortunately, not only do e-cigarette solutions, nicotine content, and quality control vary from brand to brand (Benowitz & Goniewicz, 2013), but often product labels are misleading regarding e-cigarette ingredients (Grana, 2013). In actuality, consumers may not even know what they are buying—a zero-nicotine device or one that actually contains some amount of nicotine and other potentially harmful substances. McQueen et al. (2011) found that e-cigarette users may modify or build their own apparatuses with higher voltage batteries. In addition, e-cigarette cartridges can leak and actually cause nicotine overdose (Grana, 2013; Wagener, Siegel, & Borrelli, 2012). An overdose of liquid nicotine was the method of suicide for one adult; accidental poisoning among young children who have consumed the liquid have also been reported recently (Richtel, 2014).
Although the FDA requires mandatory reporting of tobacco product complaints, it does not require reporting of non-tobacco device issues. A recent Morbidity and Mortality Weekly Report from the CDC (2014) reported an increase of monthly calls (1 in 2010 to 215 in 2014) to poison control centers for issues related to e-cigarettes (i.e., nausea and vomiting, skin and eye irritation). The CDC (2014) suggests that such exposures are dramatically under-reported.
Concerns About Toxicity Of Ingredients
Smoking continues to be the top preventable cause of disease and death in the United States (CDC, 2013a). Accidental poisoning or nicotine overdose, especially given the uncertainty of the amount of nicotine contained in e-cigarettes, is a concern (Yamin et al., 2010). Nicotine likely has detrimental effects on body systems, including documented negative effects on a teenager’s developing brain (CDC, 2013a,b). Little is known about the other ingredients contained within e-cigarettes; these components are inhaled by the user and spread to others through the vapor released into the air (Pepper et al., 2013; Yamin et al., 2010). Further, there is no regulation on the manufacturing of liquid nicotine in China, which is a major source country for the substance; purity and concentrations are unverifiable (Richtel, 2014).
Although e-cigarettes have been posited to have less harmful effects than conventional cigarettes, research regarding the short- and long-term effects of e-cigarettes is scarce (Table 1). Mental health consequences must also be considered. Anxiety and depression have been associated with nicotine use and nicotine withdrawal (Hua, Alfi, & Talbot, 2013). There is strong evidence showing a relationship between adolescent smoking, mental health symptoms, and other addictions (Cho et al., 2011).
Potential Short-term Versus Long-term Health Effects from Using E-Cigarettes
The empirical evidence indicates that adolescents are trying e-cigarettes at a staggering rate, whether they smoke conventional cigarettes or not (CDC, 2013a,b). Peer perceptions and the media are major predictors for youth trying e-cigarettes (Cho et al., 2011). Marketing of these devices through the Internet and at malls make purchasing easy for youth (Pepper et al., 2013). Especially disturbing is that adolescents admit they do not pay attention to the evidence of the dangers of this smoking behavior because they believe e-cigarettes to be safe (Sutfin et al., 2013). Thus, prevention measures must be directed at marketing techniques used by the manufacturers and retailers of these devices (Benowitz & Goniewicz, 2013).
Implications for Psychiatric Nurses
Psychiatric nurses must advocate for youth participating in this risky behavior by raising awareness of the dangers and consequences of e-cigarette use with adolescents, parents, schools, and health care professionals. Unfortunately, there is little awareness among psychiatric nurses and other health care providers about the potential dangers of this risky behavior. Table 2 outlines the practice, education, and research implications for psychiatric nurses.
Implications for Practice, Education, and Research
Nontherapeutic e-cigarette use is currently unregulated. With the staggering increasing use of these devices by adolescents coupled with the marketing strategies aimed at youth, there are serious concerns regarding the potential negative impact of e-cigarettes on adolescents and public health. Psychiatric nurses must develop an awareness of this risky behavior when assessing, educating, treating, and referring adolescents.
- Benowitz, N.L. & Goniewicz, M.L. (2013). The regulatory challenges of electronic cigarettes. Journal of the American Medical Association, 310, 685–686. doi:10.1001/jama.2013.109501 [CrossRef]
- Cahn, Z. & Siegel, M. (2011). Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes?Journal of Public Health Policy, 32, 16–31. doi:10.1057/jphp.2010.41 [CrossRef]
- Centers for Disease Control and Prevention. (2013a, September5). E-cigarette use more than doubles among U.S. middle and high school students from 2011–2012 [Press release]. Retrieved from http://www.cdc.gov/media/releases/2013/p0905-ecigarette-use.html
- Centers for Disease Control and Prevention. (2013b, September6). Notes from the field: E-cigarette use among middle and high school students from – United States, 2011–2012. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6235a6.htm
- Centers for Disease Control and Prevention. (2014). Notes from the field: Calls to poison centers for exposures to electronic cigarettes – United States, September 2010 – February 2014. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm
- Cho, J.H., Shin, E. & Moon, S.S. (2011). Electronic-cigarette smoking experience among adolescents. Journal of Adolescent Health, 49, 542–546. doi:10.1016/j.jadohealth.2011.08.001 [CrossRef]
- Cobb, N.K., Byron, M.J., Abrams, D.B. & Shields, P.G. (2010). Novel nicotine delivery systems and public health: The rise of the “e-cigarette.”American Journal of Public Health, 100, 2340–2342. doi:10.2105/AJPH.2010.199281 [CrossRef]
- Erikson, E.H. (1968). Identity: Youth and crisis. New York, NY: W.W. Norton.
- Grana, R.A. (2013). Electronic cigarettes: A new nicotine gateway?Journal of Adolescent Health, 52, 135–136. doi:10.1016/j.jadohealth.2012.11.007 [CrossRef]
- Hua, M., Alfi, M. & Talbot, P. (2013). Health-related effects reported by electronic cigarette users in online forums. Journal of Medical Internet Research, 15, e59. doi:10.2196/jmir.2324 [CrossRef]
- McQueen, A., Tower, S. & Sumner, W. (2011). Interviews with “vapers”: Implications for future research with electronic cigarettes. Nicotine & Tobacco Research, 13, 860–867. doi:10.1093/ntr/ntr088 [CrossRef]
- Pepper, J.K., Reiter, P.L., McRee, A.L., Cameron, L.D., Gilkey, M.B. & Brewer, N.T. (2013). Adolescent males’ awareness of and willingness to try electronic cigarettes. Journal of Adolescent Health, 52, 144–150. doi:10.1016/j.jadohealth.2012.09.014 [CrossRef]
- Regan, A.K., Promoff, G., Dube, S.R. & Arrazola, R. (2013). Electronic nicotine delivery systems: Adult use and awareness of the ‘e-cigarette’ in the USA. Tobacco Control, 22, 19–23. doi:10.1136/tobaccocontrol-2011-050044 [CrossRef]
- Richtel, M. (2014, March23). Selling a poison by the barrel: Liquid nicotine for e-cigarettes. Retrieved from http://www.nytimes.com/2014/03/24/business/selling-a-poison-by-the-barrel-liquid-nicotine-for-e-cigarettes.html
- Siegel, M.B., Tanwar, K.L. & Wood, K.S. (2011). Electronic cigarettes as a smoking-cessation tool: Tool results from an online survey. American Journal of Preventive Medicine, 40, 472–475. doi:10.1016/j.amepre.2010.12.006 [CrossRef]
- Sutfin, E.L., McCoy, T.P., Morrell, H.E., Hoeppner, B.B. & Wolfson, M. (2013). Electronic cigarette use by college students. Drug and Alcohol Dependence, 131, 214–221. doi:10.1016/j.drugalcdep.2013.05.001 [CrossRef]
- Trumbo, C.W. & Harper, R. (2013). Use and perception of electronic cigarettes among college students. Journal of American College Health, 61, 149–155. doi:10.1080/07448481.2013.776052 [CrossRef]
- U.S. Food and Drug Administration. (2014). Electronic cigarettes (e-cigarettes). Retrieved from http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm
- Wagener, T.L., Siegel, M. & Borrelli, B. (2012). Electronic cigarettes: Achieving a balanced perspective. Addiction, 107, 1545–1548. doi:10.1111/j.1360-0443.2012.03826.x [CrossRef]
- Yamin, C.K., Bitton, A. & Bates, D.W. (2010). E-cigarettes: A rapidly growing Internet phenomenon. Annals of Internal Medicine, 153, 607–609. doi:10.7326/0003-4819-153-9-201011020-00011 [CrossRef]
Potential Short-term Versus Long-term Health Effects from Using E-Cigarettesa
|Short-Term Effects||Long-Term Effects|
|Nausea||Cardiac rhythm changes|
|Confusion||Congestive heart failure|
Implications for Practice, Education, and Research
|Advocate for increased FDA surveillance and regulation (CDC, 2013b)|
|Contribute to the development of policy advocating for the FDA regulation of marketing strategies (Benowitz & Goniewicz, 2013)|
|Include e-cigarettes in addition to conventional cigarettes in any countermarketing campaigns and educational literature (Trumbo & Harper, 2013)|
|Campaign for e-cigarettes to be included in no-smoking areas (Benowitz & Goniewicz, 2013)|
|Psychiatric nurses and health care providers|
Counsel health care professionals about popularity, questionable efficacy, and safety concerns (Yamin, Bitton, & Bates, 2010)
Educate school-based health professionals to be aware of use by their students and potential risks (Trumbo & Harper, 2013)
Educate adolescents about the dangers and potential consequences of use (Pepper et al., 2013)
Discourage youth to fall for extreme marketing strategies for these devices (Benowitz & Goniewicz, 2013; Cho, Shin, & Moon, 2011)
Warn adolescents that e-cigarettes may be the gateway to the use of conventional cigarettes (Pepper et al., 2013)
Teach families to monitor Internet use, given the secrecy of using e-cigarettes (Yamin et al., 2010)
Encourage families to develop an awareness about this risky behavior (Pepper et al., 2013)
|Conduct empirical studies to answer questions about use, including disease risk and toxicity (Cobb, Byron, Abrams, & Shields, 2010; Sutfin, McCoy, Morrell, Hoeppner, & Wolfson, 2013)|
|Explore further the factors that explain increased use by boys/men (Pepper et al., 2013; Sutfin et al., 2013)|
|Perform longitudinal research showing comparison and continuum from ages and gender (Pepper et al., 2013; Trumbo & Harper, 2013)|
|Perform transdisciplinary research to evaluate use, efficacy, and safety of devices (McQueen, Tower, & Summer, 2011; Regan, Promoff, Dube, & Arrazola, 2013)|
|Investigate safer device alternatives for smoking cessation (Cobb et al., 2010)|