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Provide appropriate sexual, reproductive health care for transgender patients
I recently was on a panel of experts discussing how to prevent HIV among transgender youth. Preventing HIV among transgender youth, especially transgender youth of color, remains a challenge for multiple reasons – racism, poverty, stigma, marginalization, and discrimination play a role in the HIV epidemic. A barrier to preventing HIV infections among transgender youth is a lack of knowledge on how to provide them with comprehensive sexual and reproductive health care. Here are some tips and resources that can help you ensure that transgender youth are safe and healthy.
One of the challenges of obtaining a sexual history is asking the right questions For example, if you have a transgender male assigned female at birth, ask whether their partners produce sperm instead of asking about the sex of their partners. A transgender male’s partner may identify as female but is assigned male at birth and uses her penis during sex. Furthermore, a transgender male may be on testosterone, but he still can get pregnant. Asking how they use their organs is just as important. A transgender male who has condomless penile-vaginal sex with multiple partners is at a higher risk for HIV infection than is a transgender male who shares sex toys with his only partner.
Normalizing that you ask a comprehensive sexual history to all your patients regardless of gender identity may put the patient at ease. Many transgender people are reluctant to disclose their gender identity to their provider because they are afraid that the provider may fixate on their sexuality once they do. Stating that you ask sexual health questions to all your patients may prevent the transgender patient from feeling singled out.
Finally, you don’t have to ask a sexual history with every transgender patient, just as you wouldn’t for your cisgender patients. If a patient is complaining of a sprained ankle, a sexual history may not be helpful, compared with obtaining one when a patient comes in with pelvic pain. Many transgender patients avoid care because they are frequently asked about their sexual history or gender identity when these are not relevant to their chief complaint.
Here are some helpful questions to ask when taking a sexual history, according to the University of California, San Francisco, Transgender Care & Treatment Guidelines.1
- Are you having sex? How many sex partners have you had in the past year?
- Who are you having sex with? What types of sex are you having? What parts of your anatomy do you use for sex?
- How do you protect yourself from STIs?
- What STIs have you had in the past, if any? When were you last tested for STIs?
- Has your partner(s) ever been diagnosed with any STIs?
- Do you use alcohol or any drugs when you have sex?
- Do you exchange sex for money, drugs, or a place to stay?
Also, use a trauma-informed approach when working with transgender patients. Many have been victims of sexual trauma. Always have a chaperone accompany you during the exam, explain to the patient what you plan to do and why it is necessary, and allow them to decline (and document their declining the physical exam). Also consider having your patient self-swab for STI screening if appropriate.1
Like obtaining a sexual history, routine screenings for certain types of cancers will be based on the organs the patient has. For example, a transgender woman assigned male at birth will not need a cervical cancer screening, but a transgender man assigned female at birth may need one – if the patient still has a cervix. Cervical cancer screening guidelines are similar for transgender men as it is for nontransgender women, and one should use the same guidelines endorsed by the American Cancer Society, American Society of Colposcopy and Cervical Pathology, American Society of Clinical Pathologists, U.S. Preventive Services Task Force, and the World Health Organization.2-4
Cervical screenings should never be a requirement for testosterone therapy, and no transgender male under the age of 21 years will need cervical screening. The University of California guidelines offers tips on how to make transgender men more comfortable during cervical cancer screening.5
Contraception and menstrual management also are important for transgender patients. Testosterone can induce amenorrhea for transgender men, but it is not good birth control. If a transgender male patient has sex with partners that produce sperm, then the physician should discuss effective birth control options. There is no ideal birth control option for transgender men. One must consider multiple factors including the patient’s desire for pregnancy, desire to cease periods, ease of administration, and risk for thrombosis.
Most transgender men may balk at the idea of taking estrogen-containing contraception, but it is more effective than oral progestin-only pills. Intrauterine devices are highly effective in pregnancy prevention and can achieve amenorrhea in 50% of users within 1 year,but some transmen may become dysphoric with the procedure. 6 The etonogestrel implants also are highly effective birth control, but irregular periods are common, leading to discontinuation. Depot medroxyprogesterone is highly effective in preventing pregnancy and can induce amenorrhea in 70% of users within 1 year and 80% of users in 2 years, but also is associated with weight gain in one-third of users.7 Finally, pubertal blockers can rapidly stop periods for transmen who are severely dysphoric from their menses; however, before achieving amenorrhea, a flare bleed can occur 4-6 weeks after administration.8 Support from a mental health therapist during this time is critical. Pubertal blockers, nevertheless, are not suitable birth control.
When providing affirming sexual and reproductive health care for transgender patients, key principles include focusing on organs and activities over identity. Additionally, screening for certain types of cancers also is dependent on organs. Finally, do not neglect the importance of contraception among transgender men. Taking these principles in consideration will help you provide excellent care for transgender youth.
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at the Children’s Hospital of Pittsburgh. He said he had no relevant financial disclosures. Email him at [email protected].
References
1. Transgender people and sexually transmitted infections (https://transcare.ucsf.edu/guidelines/stis).
2. CA Cancer J Clin. 2012 May-Jun;62(3):147-72.
3. Ann Intern Med. 2012;156(12):880-91.
4. Cervical cancer screening in developing countries: Report of a WHO consultation. 2002. World Health Organization, Geneva.
5. Screening for cervical cancer for transgender men (https://transcare.ucsf.edu/guidelines/cervical-cancer).
6. Contraception. 2002 Feb;65(2):129-32.
7. Rev Endocr Metab Disord. 2011 Jun;12(2):93-106.
8. Int J Womens Health. 2014 Jun 23;6:631-7.
Resources
Breast cancer screening in transgender men. (https://transcare.ucsf.edu/guidelines/breast-cancer-men).
Screening for breast cancer in transgender women. (https://transcare.ucsf.edu/guidelines/breast-cancer-women).
Transgender health and HIV (https://transcare.ucsf.edu/guidelines/hiv).
Centers for Disease Control and Prevention: HIV and Transgender People (https://www.cdc.gov/hiv/group/gender/transgender/index.html).
I recently was on a panel of experts discussing how to prevent HIV among transgender youth. Preventing HIV among transgender youth, especially transgender youth of color, remains a challenge for multiple reasons – racism, poverty, stigma, marginalization, and discrimination play a role in the HIV epidemic. A barrier to preventing HIV infections among transgender youth is a lack of knowledge on how to provide them with comprehensive sexual and reproductive health care. Here are some tips and resources that can help you ensure that transgender youth are safe and healthy.
One of the challenges of obtaining a sexual history is asking the right questions For example, if you have a transgender male assigned female at birth, ask whether their partners produce sperm instead of asking about the sex of their partners. A transgender male’s partner may identify as female but is assigned male at birth and uses her penis during sex. Furthermore, a transgender male may be on testosterone, but he still can get pregnant. Asking how they use their organs is just as important. A transgender male who has condomless penile-vaginal sex with multiple partners is at a higher risk for HIV infection than is a transgender male who shares sex toys with his only partner.
Normalizing that you ask a comprehensive sexual history to all your patients regardless of gender identity may put the patient at ease. Many transgender people are reluctant to disclose their gender identity to their provider because they are afraid that the provider may fixate on their sexuality once they do. Stating that you ask sexual health questions to all your patients may prevent the transgender patient from feeling singled out.
Finally, you don’t have to ask a sexual history with every transgender patient, just as you wouldn’t for your cisgender patients. If a patient is complaining of a sprained ankle, a sexual history may not be helpful, compared with obtaining one when a patient comes in with pelvic pain. Many transgender patients avoid care because they are frequently asked about their sexual history or gender identity when these are not relevant to their chief complaint.
Here are some helpful questions to ask when taking a sexual history, according to the University of California, San Francisco, Transgender Care & Treatment Guidelines.1
- Are you having sex? How many sex partners have you had in the past year?
- Who are you having sex with? What types of sex are you having? What parts of your anatomy do you use for sex?
- How do you protect yourself from STIs?
- What STIs have you had in the past, if any? When were you last tested for STIs?
- Has your partner(s) ever been diagnosed with any STIs?
- Do you use alcohol or any drugs when you have sex?
- Do you exchange sex for money, drugs, or a place to stay?
Also, use a trauma-informed approach when working with transgender patients. Many have been victims of sexual trauma. Always have a chaperone accompany you during the exam, explain to the patient what you plan to do and why it is necessary, and allow them to decline (and document their declining the physical exam). Also consider having your patient self-swab for STI screening if appropriate.1
Like obtaining a sexual history, routine screenings for certain types of cancers will be based on the organs the patient has. For example, a transgender woman assigned male at birth will not need a cervical cancer screening, but a transgender man assigned female at birth may need one – if the patient still has a cervix. Cervical cancer screening guidelines are similar for transgender men as it is for nontransgender women, and one should use the same guidelines endorsed by the American Cancer Society, American Society of Colposcopy and Cervical Pathology, American Society of Clinical Pathologists, U.S. Preventive Services Task Force, and the World Health Organization.2-4
Cervical screenings should never be a requirement for testosterone therapy, and no transgender male under the age of 21 years will need cervical screening. The University of California guidelines offers tips on how to make transgender men more comfortable during cervical cancer screening.5
Contraception and menstrual management also are important for transgender patients. Testosterone can induce amenorrhea for transgender men, but it is not good birth control. If a transgender male patient has sex with partners that produce sperm, then the physician should discuss effective birth control options. There is no ideal birth control option for transgender men. One must consider multiple factors including the patient’s desire for pregnancy, desire to cease periods, ease of administration, and risk for thrombosis.
Most transgender men may balk at the idea of taking estrogen-containing contraception, but it is more effective than oral progestin-only pills. Intrauterine devices are highly effective in pregnancy prevention and can achieve amenorrhea in 50% of users within 1 year,but some transmen may become dysphoric with the procedure. 6 The etonogestrel implants also are highly effective birth control, but irregular periods are common, leading to discontinuation. Depot medroxyprogesterone is highly effective in preventing pregnancy and can induce amenorrhea in 70% of users within 1 year and 80% of users in 2 years, but also is associated with weight gain in one-third of users.7 Finally, pubertal blockers can rapidly stop periods for transmen who are severely dysphoric from their menses; however, before achieving amenorrhea, a flare bleed can occur 4-6 weeks after administration.8 Support from a mental health therapist during this time is critical. Pubertal blockers, nevertheless, are not suitable birth control.
When providing affirming sexual and reproductive health care for transgender patients, key principles include focusing on organs and activities over identity. Additionally, screening for certain types of cancers also is dependent on organs. Finally, do not neglect the importance of contraception among transgender men. Taking these principles in consideration will help you provide excellent care for transgender youth.
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at the Children’s Hospital of Pittsburgh. He said he had no relevant financial disclosures. Email him at [email protected].
References
1. Transgender people and sexually transmitted infections (https://transcare.ucsf.edu/guidelines/stis).
2. CA Cancer J Clin. 2012 May-Jun;62(3):147-72.
3. Ann Intern Med. 2012;156(12):880-91.
4. Cervical cancer screening in developing countries: Report of a WHO consultation. 2002. World Health Organization, Geneva.
5. Screening for cervical cancer for transgender men (https://transcare.ucsf.edu/guidelines/cervical-cancer).
6. Contraception. 2002 Feb;65(2):129-32.
7. Rev Endocr Metab Disord. 2011 Jun;12(2):93-106.
8. Int J Womens Health. 2014 Jun 23;6:631-7.
Resources
Breast cancer screening in transgender men. (https://transcare.ucsf.edu/guidelines/breast-cancer-men).
Screening for breast cancer in transgender women. (https://transcare.ucsf.edu/guidelines/breast-cancer-women).
Transgender health and HIV (https://transcare.ucsf.edu/guidelines/hiv).
Centers for Disease Control and Prevention: HIV and Transgender People (https://www.cdc.gov/hiv/group/gender/transgender/index.html).
I recently was on a panel of experts discussing how to prevent HIV among transgender youth. Preventing HIV among transgender youth, especially transgender youth of color, remains a challenge for multiple reasons – racism, poverty, stigma, marginalization, and discrimination play a role in the HIV epidemic. A barrier to preventing HIV infections among transgender youth is a lack of knowledge on how to provide them with comprehensive sexual and reproductive health care. Here are some tips and resources that can help you ensure that transgender youth are safe and healthy.
One of the challenges of obtaining a sexual history is asking the right questions For example, if you have a transgender male assigned female at birth, ask whether their partners produce sperm instead of asking about the sex of their partners. A transgender male’s partner may identify as female but is assigned male at birth and uses her penis during sex. Furthermore, a transgender male may be on testosterone, but he still can get pregnant. Asking how they use their organs is just as important. A transgender male who has condomless penile-vaginal sex with multiple partners is at a higher risk for HIV infection than is a transgender male who shares sex toys with his only partner.
Normalizing that you ask a comprehensive sexual history to all your patients regardless of gender identity may put the patient at ease. Many transgender people are reluctant to disclose their gender identity to their provider because they are afraid that the provider may fixate on their sexuality once they do. Stating that you ask sexual health questions to all your patients may prevent the transgender patient from feeling singled out.
Finally, you don’t have to ask a sexual history with every transgender patient, just as you wouldn’t for your cisgender patients. If a patient is complaining of a sprained ankle, a sexual history may not be helpful, compared with obtaining one when a patient comes in with pelvic pain. Many transgender patients avoid care because they are frequently asked about their sexual history or gender identity when these are not relevant to their chief complaint.
Here are some helpful questions to ask when taking a sexual history, according to the University of California, San Francisco, Transgender Care & Treatment Guidelines.1
- Are you having sex? How many sex partners have you had in the past year?
- Who are you having sex with? What types of sex are you having? What parts of your anatomy do you use for sex?
- How do you protect yourself from STIs?
- What STIs have you had in the past, if any? When were you last tested for STIs?
- Has your partner(s) ever been diagnosed with any STIs?
- Do you use alcohol or any drugs when you have sex?
- Do you exchange sex for money, drugs, or a place to stay?
Also, use a trauma-informed approach when working with transgender patients. Many have been victims of sexual trauma. Always have a chaperone accompany you during the exam, explain to the patient what you plan to do and why it is necessary, and allow them to decline (and document their declining the physical exam). Also consider having your patient self-swab for STI screening if appropriate.1
Like obtaining a sexual history, routine screenings for certain types of cancers will be based on the organs the patient has. For example, a transgender woman assigned male at birth will not need a cervical cancer screening, but a transgender man assigned female at birth may need one – if the patient still has a cervix. Cervical cancer screening guidelines are similar for transgender men as it is for nontransgender women, and one should use the same guidelines endorsed by the American Cancer Society, American Society of Colposcopy and Cervical Pathology, American Society of Clinical Pathologists, U.S. Preventive Services Task Force, and the World Health Organization.2-4
Cervical screenings should never be a requirement for testosterone therapy, and no transgender male under the age of 21 years will need cervical screening. The University of California guidelines offers tips on how to make transgender men more comfortable during cervical cancer screening.5
Contraception and menstrual management also are important for transgender patients. Testosterone can induce amenorrhea for transgender men, but it is not good birth control. If a transgender male patient has sex with partners that produce sperm, then the physician should discuss effective birth control options. There is no ideal birth control option for transgender men. One must consider multiple factors including the patient’s desire for pregnancy, desire to cease periods, ease of administration, and risk for thrombosis.
Most transgender men may balk at the idea of taking estrogen-containing contraception, but it is more effective than oral progestin-only pills. Intrauterine devices are highly effective in pregnancy prevention and can achieve amenorrhea in 50% of users within 1 year,but some transmen may become dysphoric with the procedure. 6 The etonogestrel implants also are highly effective birth control, but irregular periods are common, leading to discontinuation. Depot medroxyprogesterone is highly effective in preventing pregnancy and can induce amenorrhea in 70% of users within 1 year and 80% of users in 2 years, but also is associated with weight gain in one-third of users.7 Finally, pubertal blockers can rapidly stop periods for transmen who are severely dysphoric from their menses; however, before achieving amenorrhea, a flare bleed can occur 4-6 weeks after administration.8 Support from a mental health therapist during this time is critical. Pubertal blockers, nevertheless, are not suitable birth control.
When providing affirming sexual and reproductive health care for transgender patients, key principles include focusing on organs and activities over identity. Additionally, screening for certain types of cancers also is dependent on organs. Finally, do not neglect the importance of contraception among transgender men. Taking these principles in consideration will help you provide excellent care for transgender youth.
Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at the Children’s Hospital of Pittsburgh. He said he had no relevant financial disclosures. Email him at [email protected].
References
1. Transgender people and sexually transmitted infections (https://transcare.ucsf.edu/guidelines/stis).
2. CA Cancer J Clin. 2012 May-Jun;62(3):147-72.
3. Ann Intern Med. 2012;156(12):880-91.
4. Cervical cancer screening in developing countries: Report of a WHO consultation. 2002. World Health Organization, Geneva.
5. Screening for cervical cancer for transgender men (https://transcare.ucsf.edu/guidelines/cervical-cancer).
6. Contraception. 2002 Feb;65(2):129-32.
7. Rev Endocr Metab Disord. 2011 Jun;12(2):93-106.
8. Int J Womens Health. 2014 Jun 23;6:631-7.
Resources
Breast cancer screening in transgender men. (https://transcare.ucsf.edu/guidelines/breast-cancer-men).
Screening for breast cancer in transgender women. (https://transcare.ucsf.edu/guidelines/breast-cancer-women).
Transgender health and HIV (https://transcare.ucsf.edu/guidelines/hiv).
Centers for Disease Control and Prevention: HIV and Transgender People (https://www.cdc.gov/hiv/group/gender/transgender/index.html).
Adolescent alcohol, opioid misuse linked to risky behaviors
Binge drinking and misuse of opioids led to risky behavior during adolescence, two studies from the journal Pediatrics highlighted. And the binge drinking in high school may predict risky driving behaviors up to 4 years after high school.
Federico E. Vaca, MD, of the developmental neurocognitive driving simulation research center at Yale University, New Haven, Conn., and colleagues examined the associations between risky driving behaviors and binge drinking of 2,785 adolescents in the nationally representative, longitudinal NEXT Generation Health Study. The researchers studied the effects of binge drinking on driving while impaired (DWI), riding with an impaired driver (RWI), blackouts, extreme binge drinking, and risky driving.
The adolescents were studied across seven waves, with Wave 1 beginning in the 2009-2010 school year (10th grade; mean age, 16 years), and data extended up to 4 years after high school. Of all adolescents enrolled, 91% completed Wave 1, 88% completed Wave 2, 86% completed Wave 3 (12th grade), 78% completed Wave 4, 79% completed Wave 5, 84% completed Wave 6, and 83% completed Wave 7 (4 years after leaving high school) of the study.
High school binge drinking predicts later risky behavior
About one-quarter of adolescents reported binge drinking in Waves 1-3, with an incidence of 27% in Wave 1, 24% in Wave 2, and 27% in Wave 3. Adolescents who reported binge drinking in Wave 3 had a higher likelihood of DWI in subsequent waves, with nearly six times higher odds in Wave 5 and more than twice as likely in Wave 7, researchers said. Binge drinking in Wave 3 also was associated with greater than four times higher odds of RWI in Wave 4, and more than two and a half times higher odds of RWI in Wave 7. Among adolescents who reported binge drinking across 3 years in high school, there was a higher likelihood of extreme binge drinking in Wave 7, and higher likelihood of risky driving after graduating.
Impact of parental knowledge of drinking
in some waves. Father monitoring knowledge of drinking in Waves 1-3 lowered the odds of DWI by 30% in Wave 5 and 20% in Wave 6, while also lowering the odds of RWI in Wave 4 and Wave 7 by 20%.
Mother knowledge of drinking in Waves 1-3 was associated with 60% lower odds of DWI in Wave 4, but did not lower odds in any wave for RWI.
Overall, parental support for not drinking lowered odds for DWI by 40% in Waves 4 and 5, and by 30% in Wave 7 while also lowering odds of RWI in Wave 4 by 20%.
The results are consistent with other studies examining risky driving behavior and binge drinking in adolescent populations, but researchers noted that “to an important but limited extent, parental practices while the teenager is in high school may protect against DWI, RWI, and blackouts as adolescents move into early adulthood.”
“Our findings are relevant to prevention programs that seek to incorporate alcohol screening with intentional inquiry about binge drinking. Moreover, our results may be instructive to programs that seek to leverage facets of parental practices to reduce health-risk contexts for youth,” Dr. Vaca and colleagues concluded. “Such prevention activities coupled with strengthening of policies and practices reducing adolescents’ access to alcohol could reduce later major alcohol-related health-risk behaviors and their consequences.”
Opioid misuse and risky behavior
In a second study, Devika Bhatia, MD, of the University of Colorado at Denver, Aurora, and colleagues examined opioid misuse in a nationally-representative sample of 14,765 adolescents from the Centers for Disease Control and Prevention’s 2017 Youth Risk Behavior Surveillance Survey. The researchers measured opioid misuse by categorizing adolescents into groups based on whether they had ever misused prescription opioids and whether they had engaged in risky driving behavior, violent behavior, risky sexual behavior, had a history of substance abuse, or attempted suicide.
Dr. Bhatia and colleagues found 14% of adolescents in the study reported misusing opioids, with an overrepresentation of 17-year-old and 18-year-old participants reporting opioid misuse (P less than .0001). there were no statistically significant difference between those who misused opioids and those who did not in terms of race, ethnicity, or sex.
Those adolescents who reported misusing opioids were 2.8 times more likely to not use a seatbelt; were 2.8 times more likely to have RWI; were 5.8 times more likely to have DWI; or 2.3 times more likely to have texted or emailed while driving. In each of these cases, P was less than .0001.
Adolescents who misused opioids also had significantly increased odds of engaging in risky sexual behaviors such as having sex before 13 years (3.9 times); having sex with four or more partners (4.8 times); using substances before sex (3.6 times); and not using a condom before sex (2.0 times). In each of these cases, P was less than .0001.
Additionally, adolescents in this category were between 5.4 times and 22.3 times more likely to use other substances (P less than .0001 for 10 variables); 4.9 times more likely to have attempted suicide (P less than .0001); or more likely to have engaged in violent behavior such as getting into physical fights (4.0 times), carrying a weapon (3.4 times) or a gun (5.1 times) within the last 30 days. In the four latter cases, P was less than .0001.
“With the ongoing opioid epidemic, pediatricians and child psychiatrists are likely to be more attuned to opioid misuse in their patients,” Dr. Bhatia and colleagues concluded. “If youth are screening positive for opioid misuse, pediatricians, nurses, social workers, child psychiatrists, and other providers assessing adolescents may have a new, broad range of other risky behaviors for which to screen regardless of the direction of the association.”
Substance use screening for treating substance use disorder traditionally has been is provided by a specialist, Jessica A. Kulak, PhD, MPH, said in an interview. “However, integration of care services may help to change societal norms around problematic substance use – both by decreasing stigma associated with substance use, as well as increasing clinicians’ preparedness, knowledge, and confidence in preventing and intervening on adolescents’ substance experimentation and use.” She recommended that clinicians in primary care improve their training by using the Substance Abuse and Mental Health Services Administration’s Screening, Brief Intervention, and Referral to Treatment program, which is available as a free online course.
Confidentiality is important in adolescent health, said Dr. Kulak, who is an assistant professor in the department of health, nutrition, and dietetics at State University of New York at Buffalo. “When discussing sensitive topics, such as binge drinking and opioid misuse, adolescents may fear that these or other risky activities may be disclosed to parents or law enforcement officials. Therefore, adolescent health providers should be aware of local, state, and federal laws pertaining to the confidentiality of minors.”
She added, “adolescents are often susceptible to others’ influences, so having open communication and support from a trusted adult – be it a parent or clinician – may also be protective against risky behaviors.”
The study by Vaca et al. was funded by the National Institutes of Health with support from the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute; the National Institute on Alcohol Abuse and Alcoholism; the National Institute on Drug Abuse; and the Maternal and Child Health Bureau of the Health Resources and Services Administration. The study by Bhatia et al. had no external funding. The authors from both studies reported no relevant financial disclosures. Dr. Kulak said she had no financial disclosures or other conflicts of interest.
SOURCE: Vaca FE et al. Pediatrics. 2020; doi: 10.1542/peds.2018-4095. Bhatia D et al. Pediatrics. 2020; doi: 10.1542/peds.2019-2470.
These newly published reports indicate the high prevalence of risky behaviors and their associations – cross-sectionally and longitudinally – with major threats to adolescent health – so asking about alcohol use, opioid misuse, and associated health risks is truly “in the lane” of clinicians, school professionals, and parents who see and care about adolescents.
At this point, I think it’s incontrovertible that clinicians should screen adolescents to learn about their physical, emotional, and behavioral health. And they should seek opportunities for professional training, skills development, and expansion of their professional networks so they are able to address – individually or collaboratively via referrals – the behavioral and psychosocial health risks of their patients.
The good news is that there is growing awareness of the importance of using validated screening tools to identify patient behavioral health risks – including those pertaining to adolescent and young adult alcohol use and opioid misuse. “Best practice” dictates that screening approaches rely on asking questions using structured tools; intuition and “just winging it” are not effective or reliable for identifying patient behavior. Forward-looking clinics and practices could be asking patients to report about health behaviors in the waiting room (on a computer tablet, for example), or even remotely (using a secure app or data collection tool) in advance of a visit. Asking should be periodic – since behaviors can change fairly rapidly among young people. The benefit is that patient-reported information can be processed in advance to cue clinician follow-up and intervention. And youth tend to share more about their behaviors when they are asked electronically, rather than face to face. Intelligent screens can provide near real-time estimation of risk – to support in-office brief intervention tailored to the risk level of a young person or to trigger follow-up.
These studies indicate that binge alcohol use and misuse of prescription opioids among adolescents are real, pervasive, and deserving of our considered attention. There is no magic bullet. However busy clinicians may have a significant role to play in identifying and addressing these problems.
Elissa Weitzman, ScD, MSc, is an associate professor of pediatrics at Harvard Medical School, Boston, and an associate scientist based in adolescent/young adult medicine and the computational health informatics program at Boston Children’s Hospital. She was asked to comment on the articles by Vaca et al. and Bhatia et al. Dr. Weitzman said she had no relevant financial disclosures.
These newly published reports indicate the high prevalence of risky behaviors and their associations – cross-sectionally and longitudinally – with major threats to adolescent health – so asking about alcohol use, opioid misuse, and associated health risks is truly “in the lane” of clinicians, school professionals, and parents who see and care about adolescents.
At this point, I think it’s incontrovertible that clinicians should screen adolescents to learn about their physical, emotional, and behavioral health. And they should seek opportunities for professional training, skills development, and expansion of their professional networks so they are able to address – individually or collaboratively via referrals – the behavioral and psychosocial health risks of their patients.
The good news is that there is growing awareness of the importance of using validated screening tools to identify patient behavioral health risks – including those pertaining to adolescent and young adult alcohol use and opioid misuse. “Best practice” dictates that screening approaches rely on asking questions using structured tools; intuition and “just winging it” are not effective or reliable for identifying patient behavior. Forward-looking clinics and practices could be asking patients to report about health behaviors in the waiting room (on a computer tablet, for example), or even remotely (using a secure app or data collection tool) in advance of a visit. Asking should be periodic – since behaviors can change fairly rapidly among young people. The benefit is that patient-reported information can be processed in advance to cue clinician follow-up and intervention. And youth tend to share more about their behaviors when they are asked electronically, rather than face to face. Intelligent screens can provide near real-time estimation of risk – to support in-office brief intervention tailored to the risk level of a young person or to trigger follow-up.
These studies indicate that binge alcohol use and misuse of prescription opioids among adolescents are real, pervasive, and deserving of our considered attention. There is no magic bullet. However busy clinicians may have a significant role to play in identifying and addressing these problems.
Elissa Weitzman, ScD, MSc, is an associate professor of pediatrics at Harvard Medical School, Boston, and an associate scientist based in adolescent/young adult medicine and the computational health informatics program at Boston Children’s Hospital. She was asked to comment on the articles by Vaca et al. and Bhatia et al. Dr. Weitzman said she had no relevant financial disclosures.
These newly published reports indicate the high prevalence of risky behaviors and their associations – cross-sectionally and longitudinally – with major threats to adolescent health – so asking about alcohol use, opioid misuse, and associated health risks is truly “in the lane” of clinicians, school professionals, and parents who see and care about adolescents.
At this point, I think it’s incontrovertible that clinicians should screen adolescents to learn about their physical, emotional, and behavioral health. And they should seek opportunities for professional training, skills development, and expansion of their professional networks so they are able to address – individually or collaboratively via referrals – the behavioral and psychosocial health risks of their patients.
The good news is that there is growing awareness of the importance of using validated screening tools to identify patient behavioral health risks – including those pertaining to adolescent and young adult alcohol use and opioid misuse. “Best practice” dictates that screening approaches rely on asking questions using structured tools; intuition and “just winging it” are not effective or reliable for identifying patient behavior. Forward-looking clinics and practices could be asking patients to report about health behaviors in the waiting room (on a computer tablet, for example), or even remotely (using a secure app or data collection tool) in advance of a visit. Asking should be periodic – since behaviors can change fairly rapidly among young people. The benefit is that patient-reported information can be processed in advance to cue clinician follow-up and intervention. And youth tend to share more about their behaviors when they are asked electronically, rather than face to face. Intelligent screens can provide near real-time estimation of risk – to support in-office brief intervention tailored to the risk level of a young person or to trigger follow-up.
These studies indicate that binge alcohol use and misuse of prescription opioids among adolescents are real, pervasive, and deserving of our considered attention. There is no magic bullet. However busy clinicians may have a significant role to play in identifying and addressing these problems.
Elissa Weitzman, ScD, MSc, is an associate professor of pediatrics at Harvard Medical School, Boston, and an associate scientist based in adolescent/young adult medicine and the computational health informatics program at Boston Children’s Hospital. She was asked to comment on the articles by Vaca et al. and Bhatia et al. Dr. Weitzman said she had no relevant financial disclosures.
Binge drinking and misuse of opioids led to risky behavior during adolescence, two studies from the journal Pediatrics highlighted. And the binge drinking in high school may predict risky driving behaviors up to 4 years after high school.
Federico E. Vaca, MD, of the developmental neurocognitive driving simulation research center at Yale University, New Haven, Conn., and colleagues examined the associations between risky driving behaviors and binge drinking of 2,785 adolescents in the nationally representative, longitudinal NEXT Generation Health Study. The researchers studied the effects of binge drinking on driving while impaired (DWI), riding with an impaired driver (RWI), blackouts, extreme binge drinking, and risky driving.
The adolescents were studied across seven waves, with Wave 1 beginning in the 2009-2010 school year (10th grade; mean age, 16 years), and data extended up to 4 years after high school. Of all adolescents enrolled, 91% completed Wave 1, 88% completed Wave 2, 86% completed Wave 3 (12th grade), 78% completed Wave 4, 79% completed Wave 5, 84% completed Wave 6, and 83% completed Wave 7 (4 years after leaving high school) of the study.
High school binge drinking predicts later risky behavior
About one-quarter of adolescents reported binge drinking in Waves 1-3, with an incidence of 27% in Wave 1, 24% in Wave 2, and 27% in Wave 3. Adolescents who reported binge drinking in Wave 3 had a higher likelihood of DWI in subsequent waves, with nearly six times higher odds in Wave 5 and more than twice as likely in Wave 7, researchers said. Binge drinking in Wave 3 also was associated with greater than four times higher odds of RWI in Wave 4, and more than two and a half times higher odds of RWI in Wave 7. Among adolescents who reported binge drinking across 3 years in high school, there was a higher likelihood of extreme binge drinking in Wave 7, and higher likelihood of risky driving after graduating.
Impact of parental knowledge of drinking
in some waves. Father monitoring knowledge of drinking in Waves 1-3 lowered the odds of DWI by 30% in Wave 5 and 20% in Wave 6, while also lowering the odds of RWI in Wave 4 and Wave 7 by 20%.
Mother knowledge of drinking in Waves 1-3 was associated with 60% lower odds of DWI in Wave 4, but did not lower odds in any wave for RWI.
Overall, parental support for not drinking lowered odds for DWI by 40% in Waves 4 and 5, and by 30% in Wave 7 while also lowering odds of RWI in Wave 4 by 20%.
The results are consistent with other studies examining risky driving behavior and binge drinking in adolescent populations, but researchers noted that “to an important but limited extent, parental practices while the teenager is in high school may protect against DWI, RWI, and blackouts as adolescents move into early adulthood.”
“Our findings are relevant to prevention programs that seek to incorporate alcohol screening with intentional inquiry about binge drinking. Moreover, our results may be instructive to programs that seek to leverage facets of parental practices to reduce health-risk contexts for youth,” Dr. Vaca and colleagues concluded. “Such prevention activities coupled with strengthening of policies and practices reducing adolescents’ access to alcohol could reduce later major alcohol-related health-risk behaviors and their consequences.”
Opioid misuse and risky behavior
In a second study, Devika Bhatia, MD, of the University of Colorado at Denver, Aurora, and colleagues examined opioid misuse in a nationally-representative sample of 14,765 adolescents from the Centers for Disease Control and Prevention’s 2017 Youth Risk Behavior Surveillance Survey. The researchers measured opioid misuse by categorizing adolescents into groups based on whether they had ever misused prescription opioids and whether they had engaged in risky driving behavior, violent behavior, risky sexual behavior, had a history of substance abuse, or attempted suicide.
Dr. Bhatia and colleagues found 14% of adolescents in the study reported misusing opioids, with an overrepresentation of 17-year-old and 18-year-old participants reporting opioid misuse (P less than .0001). there were no statistically significant difference between those who misused opioids and those who did not in terms of race, ethnicity, or sex.
Those adolescents who reported misusing opioids were 2.8 times more likely to not use a seatbelt; were 2.8 times more likely to have RWI; were 5.8 times more likely to have DWI; or 2.3 times more likely to have texted or emailed while driving. In each of these cases, P was less than .0001.
Adolescents who misused opioids also had significantly increased odds of engaging in risky sexual behaviors such as having sex before 13 years (3.9 times); having sex with four or more partners (4.8 times); using substances before sex (3.6 times); and not using a condom before sex (2.0 times). In each of these cases, P was less than .0001.
Additionally, adolescents in this category were between 5.4 times and 22.3 times more likely to use other substances (P less than .0001 for 10 variables); 4.9 times more likely to have attempted suicide (P less than .0001); or more likely to have engaged in violent behavior such as getting into physical fights (4.0 times), carrying a weapon (3.4 times) or a gun (5.1 times) within the last 30 days. In the four latter cases, P was less than .0001.
“With the ongoing opioid epidemic, pediatricians and child psychiatrists are likely to be more attuned to opioid misuse in their patients,” Dr. Bhatia and colleagues concluded. “If youth are screening positive for opioid misuse, pediatricians, nurses, social workers, child psychiatrists, and other providers assessing adolescents may have a new, broad range of other risky behaviors for which to screen regardless of the direction of the association.”
Substance use screening for treating substance use disorder traditionally has been is provided by a specialist, Jessica A. Kulak, PhD, MPH, said in an interview. “However, integration of care services may help to change societal norms around problematic substance use – both by decreasing stigma associated with substance use, as well as increasing clinicians’ preparedness, knowledge, and confidence in preventing and intervening on adolescents’ substance experimentation and use.” She recommended that clinicians in primary care improve their training by using the Substance Abuse and Mental Health Services Administration’s Screening, Brief Intervention, and Referral to Treatment program, which is available as a free online course.
Confidentiality is important in adolescent health, said Dr. Kulak, who is an assistant professor in the department of health, nutrition, and dietetics at State University of New York at Buffalo. “When discussing sensitive topics, such as binge drinking and opioid misuse, adolescents may fear that these or other risky activities may be disclosed to parents or law enforcement officials. Therefore, adolescent health providers should be aware of local, state, and federal laws pertaining to the confidentiality of minors.”
She added, “adolescents are often susceptible to others’ influences, so having open communication and support from a trusted adult – be it a parent or clinician – may also be protective against risky behaviors.”
The study by Vaca et al. was funded by the National Institutes of Health with support from the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute; the National Institute on Alcohol Abuse and Alcoholism; the National Institute on Drug Abuse; and the Maternal and Child Health Bureau of the Health Resources and Services Administration. The study by Bhatia et al. had no external funding. The authors from both studies reported no relevant financial disclosures. Dr. Kulak said she had no financial disclosures or other conflicts of interest.
SOURCE: Vaca FE et al. Pediatrics. 2020; doi: 10.1542/peds.2018-4095. Bhatia D et al. Pediatrics. 2020; doi: 10.1542/peds.2019-2470.
Binge drinking and misuse of opioids led to risky behavior during adolescence, two studies from the journal Pediatrics highlighted. And the binge drinking in high school may predict risky driving behaviors up to 4 years after high school.
Federico E. Vaca, MD, of the developmental neurocognitive driving simulation research center at Yale University, New Haven, Conn., and colleagues examined the associations between risky driving behaviors and binge drinking of 2,785 adolescents in the nationally representative, longitudinal NEXT Generation Health Study. The researchers studied the effects of binge drinking on driving while impaired (DWI), riding with an impaired driver (RWI), blackouts, extreme binge drinking, and risky driving.
The adolescents were studied across seven waves, with Wave 1 beginning in the 2009-2010 school year (10th grade; mean age, 16 years), and data extended up to 4 years after high school. Of all adolescents enrolled, 91% completed Wave 1, 88% completed Wave 2, 86% completed Wave 3 (12th grade), 78% completed Wave 4, 79% completed Wave 5, 84% completed Wave 6, and 83% completed Wave 7 (4 years after leaving high school) of the study.
High school binge drinking predicts later risky behavior
About one-quarter of adolescents reported binge drinking in Waves 1-3, with an incidence of 27% in Wave 1, 24% in Wave 2, and 27% in Wave 3. Adolescents who reported binge drinking in Wave 3 had a higher likelihood of DWI in subsequent waves, with nearly six times higher odds in Wave 5 and more than twice as likely in Wave 7, researchers said. Binge drinking in Wave 3 also was associated with greater than four times higher odds of RWI in Wave 4, and more than two and a half times higher odds of RWI in Wave 7. Among adolescents who reported binge drinking across 3 years in high school, there was a higher likelihood of extreme binge drinking in Wave 7, and higher likelihood of risky driving after graduating.
Impact of parental knowledge of drinking
in some waves. Father monitoring knowledge of drinking in Waves 1-3 lowered the odds of DWI by 30% in Wave 5 and 20% in Wave 6, while also lowering the odds of RWI in Wave 4 and Wave 7 by 20%.
Mother knowledge of drinking in Waves 1-3 was associated with 60% lower odds of DWI in Wave 4, but did not lower odds in any wave for RWI.
Overall, parental support for not drinking lowered odds for DWI by 40% in Waves 4 and 5, and by 30% in Wave 7 while also lowering odds of RWI in Wave 4 by 20%.
The results are consistent with other studies examining risky driving behavior and binge drinking in adolescent populations, but researchers noted that “to an important but limited extent, parental practices while the teenager is in high school may protect against DWI, RWI, and blackouts as adolescents move into early adulthood.”
“Our findings are relevant to prevention programs that seek to incorporate alcohol screening with intentional inquiry about binge drinking. Moreover, our results may be instructive to programs that seek to leverage facets of parental practices to reduce health-risk contexts for youth,” Dr. Vaca and colleagues concluded. “Such prevention activities coupled with strengthening of policies and practices reducing adolescents’ access to alcohol could reduce later major alcohol-related health-risk behaviors and their consequences.”
Opioid misuse and risky behavior
In a second study, Devika Bhatia, MD, of the University of Colorado at Denver, Aurora, and colleagues examined opioid misuse in a nationally-representative sample of 14,765 adolescents from the Centers for Disease Control and Prevention’s 2017 Youth Risk Behavior Surveillance Survey. The researchers measured opioid misuse by categorizing adolescents into groups based on whether they had ever misused prescription opioids and whether they had engaged in risky driving behavior, violent behavior, risky sexual behavior, had a history of substance abuse, or attempted suicide.
Dr. Bhatia and colleagues found 14% of adolescents in the study reported misusing opioids, with an overrepresentation of 17-year-old and 18-year-old participants reporting opioid misuse (P less than .0001). there were no statistically significant difference between those who misused opioids and those who did not in terms of race, ethnicity, or sex.
Those adolescents who reported misusing opioids were 2.8 times more likely to not use a seatbelt; were 2.8 times more likely to have RWI; were 5.8 times more likely to have DWI; or 2.3 times more likely to have texted or emailed while driving. In each of these cases, P was less than .0001.
Adolescents who misused opioids also had significantly increased odds of engaging in risky sexual behaviors such as having sex before 13 years (3.9 times); having sex with four or more partners (4.8 times); using substances before sex (3.6 times); and not using a condom before sex (2.0 times). In each of these cases, P was less than .0001.
Additionally, adolescents in this category were between 5.4 times and 22.3 times more likely to use other substances (P less than .0001 for 10 variables); 4.9 times more likely to have attempted suicide (P less than .0001); or more likely to have engaged in violent behavior such as getting into physical fights (4.0 times), carrying a weapon (3.4 times) or a gun (5.1 times) within the last 30 days. In the four latter cases, P was less than .0001.
“With the ongoing opioid epidemic, pediatricians and child psychiatrists are likely to be more attuned to opioid misuse in their patients,” Dr. Bhatia and colleagues concluded. “If youth are screening positive for opioid misuse, pediatricians, nurses, social workers, child psychiatrists, and other providers assessing adolescents may have a new, broad range of other risky behaviors for which to screen regardless of the direction of the association.”
Substance use screening for treating substance use disorder traditionally has been is provided by a specialist, Jessica A. Kulak, PhD, MPH, said in an interview. “However, integration of care services may help to change societal norms around problematic substance use – both by decreasing stigma associated with substance use, as well as increasing clinicians’ preparedness, knowledge, and confidence in preventing and intervening on adolescents’ substance experimentation and use.” She recommended that clinicians in primary care improve their training by using the Substance Abuse and Mental Health Services Administration’s Screening, Brief Intervention, and Referral to Treatment program, which is available as a free online course.
Confidentiality is important in adolescent health, said Dr. Kulak, who is an assistant professor in the department of health, nutrition, and dietetics at State University of New York at Buffalo. “When discussing sensitive topics, such as binge drinking and opioid misuse, adolescents may fear that these or other risky activities may be disclosed to parents or law enforcement officials. Therefore, adolescent health providers should be aware of local, state, and federal laws pertaining to the confidentiality of minors.”
She added, “adolescents are often susceptible to others’ influences, so having open communication and support from a trusted adult – be it a parent or clinician – may also be protective against risky behaviors.”
The study by Vaca et al. was funded by the National Institutes of Health with support from the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute; the National Institute on Alcohol Abuse and Alcoholism; the National Institute on Drug Abuse; and the Maternal and Child Health Bureau of the Health Resources and Services Administration. The study by Bhatia et al. had no external funding. The authors from both studies reported no relevant financial disclosures. Dr. Kulak said she had no financial disclosures or other conflicts of interest.
SOURCE: Vaca FE et al. Pediatrics. 2020; doi: 10.1542/peds.2018-4095. Bhatia D et al. Pediatrics. 2020; doi: 10.1542/peds.2019-2470.
FROM PEDIATRICS
Data point to bidirectional link between sleep disorders and ADHD
in a large longitudinal study of adolescents in China.
Investigators twice assessed 7,072 middle and high school students participating in the larger longitudinal Shandong Adolescent Behavior & Health Cohort – in 2015 and 1 year later in 2016 – for sleep, mental health, psychosocial factors (using the self-administered Adolescent Health Questionnaire, or AHQ), and for ADHD symptoms (using the Youth Self-Report, or YSR, of the Achenbach Child Behavior Checklist).
At baseline, ADHD symptoms were reported by 7.6% of adolescents and were significantly correlated, after adjusting for adolescent and family covariates, with all the sleep variables studied: sleep duration of 7 hours or less per night, insomnia symptoms, poor sleep quality, RLS symptoms, frequent snorting, and hypnotic use, reported Xianchen Liu, MD, PhD, of Shandong (China) University, and coinvestigators. They noted a dose-response relationship between sleep duration and the odds of having ADHD symptoms.
At 1-year follow-up, 4.5% of the 6,531 participants who did not have ADHD symptoms at baseline now reported them. After adjustments for covariates, any insomnia (odds ratio, 1.48), difficulty initiating sleep (one of the insomnia symptoms) (OR, 2.09), RLS (OR, 1.47), and frequent snoring (OR, 2.30) at baseline were each significantly associated with development of incident ADHD symptoms and with ADHD severity at 1 year, they reported in Sleep.
“Given the fact that sleep disorders in adolescents are often underdiagnosed and untreated primarily in the primary care setting, our findings highlight that clinicians should assess and manage short sleep duration and sleep problems for effective treatment of ADHD in adolescents,” as well as for prevention, they wrote.
The AHQ includes questions that assess nocturnal sleep duration and sleep problems during the past month. The adolescent and family variables that were selected as covariates and controlled for include cigarette smoking, alcohol drinking, use of mental health services, chronic physical diseases, and parental education and occupation. Depression was also a covariate but was assessed through a different scale.
The YSR measures eight ADHD symptoms during the past 6 months on a 3-point scale (not true, somewhat or sometimes true, and very true or often true). The adolescent participants of this study were in grades 7, 8, and 10 at baseline. Their mean age at baseline was 15 years; half were male. They were part of the larger Shandong Adolescent and Behavioral Cohort, a longitudinal study of almost 12,000 adolescents.
Growing evidence has demonstrated a bidirectional relationship between sleep problems and ADHD symptoms in pediatric populations, the investigators wrote, and further research is needed to examine the “mediators, moderators, and biological mechanisms of the sleep-ADHD link [in adolescents].”
While there are multiple potential pathways for this link, sleep problems may sometimes result in a cluster of behavioral and cognitive symptoms that are not true ADHD but that mimic the disorder, they noted.
The investigators also noted that approximately 67% of adolescents who had clinically relevant ADHD symptoms at baseline no longer had these symptoms at 1-year follow-up – a finding that “supports the [idea]” that ADHD symptoms with onset in adolescence may be transient or episodic rather than persistent.
The study was funded in part by the National Natural Science Foundation of China. The authors reported that they have no conflicts of interest.
SOURCE: Liu X et al. Sleep. 2019 Dec 2. doi: 10.1093/sleep/zsz294.
in a large longitudinal study of adolescents in China.
Investigators twice assessed 7,072 middle and high school students participating in the larger longitudinal Shandong Adolescent Behavior & Health Cohort – in 2015 and 1 year later in 2016 – for sleep, mental health, psychosocial factors (using the self-administered Adolescent Health Questionnaire, or AHQ), and for ADHD symptoms (using the Youth Self-Report, or YSR, of the Achenbach Child Behavior Checklist).
At baseline, ADHD symptoms were reported by 7.6% of adolescents and were significantly correlated, after adjusting for adolescent and family covariates, with all the sleep variables studied: sleep duration of 7 hours or less per night, insomnia symptoms, poor sleep quality, RLS symptoms, frequent snorting, and hypnotic use, reported Xianchen Liu, MD, PhD, of Shandong (China) University, and coinvestigators. They noted a dose-response relationship between sleep duration and the odds of having ADHD symptoms.
At 1-year follow-up, 4.5% of the 6,531 participants who did not have ADHD symptoms at baseline now reported them. After adjustments for covariates, any insomnia (odds ratio, 1.48), difficulty initiating sleep (one of the insomnia symptoms) (OR, 2.09), RLS (OR, 1.47), and frequent snoring (OR, 2.30) at baseline were each significantly associated with development of incident ADHD symptoms and with ADHD severity at 1 year, they reported in Sleep.
“Given the fact that sleep disorders in adolescents are often underdiagnosed and untreated primarily in the primary care setting, our findings highlight that clinicians should assess and manage short sleep duration and sleep problems for effective treatment of ADHD in adolescents,” as well as for prevention, they wrote.
The AHQ includes questions that assess nocturnal sleep duration and sleep problems during the past month. The adolescent and family variables that were selected as covariates and controlled for include cigarette smoking, alcohol drinking, use of mental health services, chronic physical diseases, and parental education and occupation. Depression was also a covariate but was assessed through a different scale.
The YSR measures eight ADHD symptoms during the past 6 months on a 3-point scale (not true, somewhat or sometimes true, and very true or often true). The adolescent participants of this study were in grades 7, 8, and 10 at baseline. Their mean age at baseline was 15 years; half were male. They were part of the larger Shandong Adolescent and Behavioral Cohort, a longitudinal study of almost 12,000 adolescents.
Growing evidence has demonstrated a bidirectional relationship between sleep problems and ADHD symptoms in pediatric populations, the investigators wrote, and further research is needed to examine the “mediators, moderators, and biological mechanisms of the sleep-ADHD link [in adolescents].”
While there are multiple potential pathways for this link, sleep problems may sometimes result in a cluster of behavioral and cognitive symptoms that are not true ADHD but that mimic the disorder, they noted.
The investigators also noted that approximately 67% of adolescents who had clinically relevant ADHD symptoms at baseline no longer had these symptoms at 1-year follow-up – a finding that “supports the [idea]” that ADHD symptoms with onset in adolescence may be transient or episodic rather than persistent.
The study was funded in part by the National Natural Science Foundation of China. The authors reported that they have no conflicts of interest.
SOURCE: Liu X et al. Sleep. 2019 Dec 2. doi: 10.1093/sleep/zsz294.
in a large longitudinal study of adolescents in China.
Investigators twice assessed 7,072 middle and high school students participating in the larger longitudinal Shandong Adolescent Behavior & Health Cohort – in 2015 and 1 year later in 2016 – for sleep, mental health, psychosocial factors (using the self-administered Adolescent Health Questionnaire, or AHQ), and for ADHD symptoms (using the Youth Self-Report, or YSR, of the Achenbach Child Behavior Checklist).
At baseline, ADHD symptoms were reported by 7.6% of adolescents and were significantly correlated, after adjusting for adolescent and family covariates, with all the sleep variables studied: sleep duration of 7 hours or less per night, insomnia symptoms, poor sleep quality, RLS symptoms, frequent snorting, and hypnotic use, reported Xianchen Liu, MD, PhD, of Shandong (China) University, and coinvestigators. They noted a dose-response relationship between sleep duration and the odds of having ADHD symptoms.
At 1-year follow-up, 4.5% of the 6,531 participants who did not have ADHD symptoms at baseline now reported them. After adjustments for covariates, any insomnia (odds ratio, 1.48), difficulty initiating sleep (one of the insomnia symptoms) (OR, 2.09), RLS (OR, 1.47), and frequent snoring (OR, 2.30) at baseline were each significantly associated with development of incident ADHD symptoms and with ADHD severity at 1 year, they reported in Sleep.
“Given the fact that sleep disorders in adolescents are often underdiagnosed and untreated primarily in the primary care setting, our findings highlight that clinicians should assess and manage short sleep duration and sleep problems for effective treatment of ADHD in adolescents,” as well as for prevention, they wrote.
The AHQ includes questions that assess nocturnal sleep duration and sleep problems during the past month. The adolescent and family variables that were selected as covariates and controlled for include cigarette smoking, alcohol drinking, use of mental health services, chronic physical diseases, and parental education and occupation. Depression was also a covariate but was assessed through a different scale.
The YSR measures eight ADHD symptoms during the past 6 months on a 3-point scale (not true, somewhat or sometimes true, and very true or often true). The adolescent participants of this study were in grades 7, 8, and 10 at baseline. Their mean age at baseline was 15 years; half were male. They were part of the larger Shandong Adolescent and Behavioral Cohort, a longitudinal study of almost 12,000 adolescents.
Growing evidence has demonstrated a bidirectional relationship between sleep problems and ADHD symptoms in pediatric populations, the investigators wrote, and further research is needed to examine the “mediators, moderators, and biological mechanisms of the sleep-ADHD link [in adolescents].”
While there are multiple potential pathways for this link, sleep problems may sometimes result in a cluster of behavioral and cognitive symptoms that are not true ADHD but that mimic the disorder, they noted.
The investigators also noted that approximately 67% of adolescents who had clinically relevant ADHD symptoms at baseline no longer had these symptoms at 1-year follow-up – a finding that “supports the [idea]” that ADHD symptoms with onset in adolescence may be transient or episodic rather than persistent.
The study was funded in part by the National Natural Science Foundation of China. The authors reported that they have no conflicts of interest.
SOURCE: Liu X et al. Sleep. 2019 Dec 2. doi: 10.1093/sleep/zsz294.
FROM SLEEP
Adolescents should know risks of tattoos and piercings
NEW ORLEANS – It wasn’t until her teenage daughter wanted to get her belly button pierced that Cora Breuner, MD, became interested in the safety of tattoos and piercings for adolescents.
“You’re a pediatrician,” her daughter said. “Where should I go? Should I get this done?” Although Dr. Breuner didn’t want her daughter to get the piercing, she knew saying “no” wasn’t likely to stop her teenager any more than it would another adolescent, so she looked to the medical literature … and didn’t find much.
“I couldn’t find an article summarizing complication rates or just about the legality of it or other issues around tattooing and piercing,” said Dr. Breuner a professor of pediatrics at Seattle Children’s Hospital and the University of Washington, also in Seattle. So she and the American Academy of Pediatrics’ Committee on Adolescent Health did the work themselves and wrote one.
“I want to make sure that you are talking to your teenagers about this,” she told attendees at the annual meeting of the American Academy of Pediatrics. In her presentation, she focused on knowing the legal age of consent for body modifications and what to watch for in terms of complications.
Tattoos growing in popularity
More than a third (38%) of people aged 18-29 years have at least one tattoo, according to a Pew Research Center report Dr. Breuner cited, and 23% had piercings somewhere on their body besides their ears. In fact, Americans spend about $1.65 billion on tattoos each year.
Most of the people with tattoos (72%), however, had them in places that were covered and not visible, reinforcing the need to ask about them. The popularity of tattoos has been increasing in general, Dr. Breuner noted. In just the 4 years from 2012 to 2016, the prevalence of U.S. adults with at least one tattoo increased 20%.
And people don’t appear to be sorry to have them. According to a Harris Poll that Dr. Breuner cited, 86% of respondents in 2012 did not regret getting their tattoo, and respondents listed a number of feelings they associated with their tattoos: feeling sexy, rebellious, attractive, strong, spiritual, healthier, intelligent, and athletic.
Although the techniques for tattooing have changed over the years since the first documented ones in 4,000 B.C., the basic concept of injecting ink into the dermis hasn’t changed much. By injecting the ink below the epidermis, the ink remains visible for the rest of a person’s life.
The laws for tattoos vary by state, so you need to check the laws where they live. Not much data exist on infections and complaints, but data from the Michigan Department of Health & Human Services suggests the infection rate – at least those infections reported – is low while the rate of illegally operating facilities is a bigger risk. Local health districts in Michigan have received reports of only 18 infections since 2010, but they’ve received 85 reports of illegal operations and 69 reports of social media parties centered on all attendees getting a tattoo.
Risks of tattoos
The biggest concern for adolescents is ensuring they understand the risks of tattoos and piercings and what to look for. One risk for tattoos is hepatitis C. However, the studies on the risk of contracting hepatitis C from tattooing are confounded by the fact that many people getting tattoos also may be engaging in other risky behaviors, such as intravenous drug use or risky sexual behaviors. Still, some research suggests that “commercially acquired tattoos accounted for more than twice as many infections as injection-drug use,” Dr. Breuner said.
Another risk is tattoo-associated bacterial skin infections (Clin Infect Dis. 2019 Aug 30;69[6]:949-55; MMWR Morb Mortal Wkly Rep. 2012 Aug 24;61[33]:653-6).
Risks of body piercing
Although body piercing doesn’t date back quite as far as tattoos – about 700 A.D. – its history remains long. Research suggests the top reason people get body piercings is simply liking the way it looks, as 77% of respondents reported in one study (J Am Osteopath Assoc. 2007 Oct;107[10]:432-8). Other reasons including looking fashionable, catching attention, feeling different, making a personal statement, being daring, fitting in, pressuring from peers, and defying parents.
The most serious potential complication from piercings is gangrene, but the most common is infection. Other possible complications include an allergic reaction to the metal used, a bleeding complication (estimated in 1 of 10), a scar or site reaction (estimated in 1 of 15), or, much less commonly, toxic shock syndrome. In some areas, there’s a risk of nerve damage if the nerve is pierced, such as in the eyebrow or in the bridge of the nose.
Teens particularly should be aware of the average time it takes for a piercing to heal, depending on where they get it. A navel piercing, for example, can take up to 9 months to heal. Others with long healing times include the penis (3-9 months), labia majora (2-4 months), nipple (2-4 months), and scrotum (2-3 months). Other non-ear regions range from 2 to 8 weeks.
Bleeding definitely is a risk for piercings, Dr. Breuner said, especially now that so many teens are piercing body parts besides their ears. “The one I found most disturbing was that of the uvula,” she said. Bleeding risks tend to be low with ear and nose piercings, but the risk increases with the tongue, uvula, navel, nipples, and genitalia.
Another risk of mouth piercings, particularly tongue piercing, is damage to the teeth and gums, Dr. Breuner said. Barbells, the most popular type of mouth piercing, can lead to receding gums and chipped teeth with extended wear, especially because people wearing them have a tendency to frequently bite down on them.
One study found that half the participants who wore a long barbell piercing (1.59 cm or longer) for at least 2 years had lingual recession on their mandibular central incisors (J Periodontol. 2002 Mar;73[3]:289-97). Among those with a tongue piercing of at least 4 years, 47% had tooth chipping on their molars and premolars.
Another study found gingival recession was 11 times more likely among people with tongue piercings than without (J Clin Periodontol. 2010 Aug 1;37(8):712-8). Gingival recession also is a risk with lip piercings, but the risk is greater with tongue piercing, and only tongue piercings have been associated with tooth injuries (Aust Dent J. 2012 Mar;57[1]:71-8; Int J Dent Hyg. 2016 Feb;14[1]:62-73).
Hepatitis C also is a concern with body piercing. According to a systematic review of 12 studies, body piercing was a risk factor for hepatitis C infection in the majority of them (Am J Infect Control. 2001 Aug;29[4]:271-4).
Counseling adolescents on body modifications
You should ask teens about any tattoos or piercings they have at each visit and ask whether they have any plans to get any. Then you can answer questions about them and ensure the teens are aware of risks, particularly viral and bacterial infections and, with piercing, bleeding.
Beyond the medical risks, it’s important for teens to understand that tattoos have the potential to limit their employment in the future, depending on the job and how visible their tattoo is.
Social acceptance of tattoos and piercings have been increasing, but a survey of nearly 2,700 people conducted by Salary.com in 2013 found that 76% of respondents believed tattoos and piercings could reduce a job applicant’s chances of being hired.
If you want to learn more specifically about the safest places in your community for tattoos and piercings, Dr. Breuner recommended going out and visiting the shops. Tattoo artists generally are the most knowledgeable people in the community about the risks of their industry and often welcome local physicians who want to learn and see their equipment, she said.
NEW ORLEANS – It wasn’t until her teenage daughter wanted to get her belly button pierced that Cora Breuner, MD, became interested in the safety of tattoos and piercings for adolescents.
“You’re a pediatrician,” her daughter said. “Where should I go? Should I get this done?” Although Dr. Breuner didn’t want her daughter to get the piercing, she knew saying “no” wasn’t likely to stop her teenager any more than it would another adolescent, so she looked to the medical literature … and didn’t find much.
“I couldn’t find an article summarizing complication rates or just about the legality of it or other issues around tattooing and piercing,” said Dr. Breuner a professor of pediatrics at Seattle Children’s Hospital and the University of Washington, also in Seattle. So she and the American Academy of Pediatrics’ Committee on Adolescent Health did the work themselves and wrote one.
“I want to make sure that you are talking to your teenagers about this,” she told attendees at the annual meeting of the American Academy of Pediatrics. In her presentation, she focused on knowing the legal age of consent for body modifications and what to watch for in terms of complications.
Tattoos growing in popularity
More than a third (38%) of people aged 18-29 years have at least one tattoo, according to a Pew Research Center report Dr. Breuner cited, and 23% had piercings somewhere on their body besides their ears. In fact, Americans spend about $1.65 billion on tattoos each year.
Most of the people with tattoos (72%), however, had them in places that were covered and not visible, reinforcing the need to ask about them. The popularity of tattoos has been increasing in general, Dr. Breuner noted. In just the 4 years from 2012 to 2016, the prevalence of U.S. adults with at least one tattoo increased 20%.
And people don’t appear to be sorry to have them. According to a Harris Poll that Dr. Breuner cited, 86% of respondents in 2012 did not regret getting their tattoo, and respondents listed a number of feelings they associated with their tattoos: feeling sexy, rebellious, attractive, strong, spiritual, healthier, intelligent, and athletic.
Although the techniques for tattooing have changed over the years since the first documented ones in 4,000 B.C., the basic concept of injecting ink into the dermis hasn’t changed much. By injecting the ink below the epidermis, the ink remains visible for the rest of a person’s life.
The laws for tattoos vary by state, so you need to check the laws where they live. Not much data exist on infections and complaints, but data from the Michigan Department of Health & Human Services suggests the infection rate – at least those infections reported – is low while the rate of illegally operating facilities is a bigger risk. Local health districts in Michigan have received reports of only 18 infections since 2010, but they’ve received 85 reports of illegal operations and 69 reports of social media parties centered on all attendees getting a tattoo.
Risks of tattoos
The biggest concern for adolescents is ensuring they understand the risks of tattoos and piercings and what to look for. One risk for tattoos is hepatitis C. However, the studies on the risk of contracting hepatitis C from tattooing are confounded by the fact that many people getting tattoos also may be engaging in other risky behaviors, such as intravenous drug use or risky sexual behaviors. Still, some research suggests that “commercially acquired tattoos accounted for more than twice as many infections as injection-drug use,” Dr. Breuner said.
Another risk is tattoo-associated bacterial skin infections (Clin Infect Dis. 2019 Aug 30;69[6]:949-55; MMWR Morb Mortal Wkly Rep. 2012 Aug 24;61[33]:653-6).
Risks of body piercing
Although body piercing doesn’t date back quite as far as tattoos – about 700 A.D. – its history remains long. Research suggests the top reason people get body piercings is simply liking the way it looks, as 77% of respondents reported in one study (J Am Osteopath Assoc. 2007 Oct;107[10]:432-8). Other reasons including looking fashionable, catching attention, feeling different, making a personal statement, being daring, fitting in, pressuring from peers, and defying parents.
The most serious potential complication from piercings is gangrene, but the most common is infection. Other possible complications include an allergic reaction to the metal used, a bleeding complication (estimated in 1 of 10), a scar or site reaction (estimated in 1 of 15), or, much less commonly, toxic shock syndrome. In some areas, there’s a risk of nerve damage if the nerve is pierced, such as in the eyebrow or in the bridge of the nose.
Teens particularly should be aware of the average time it takes for a piercing to heal, depending on where they get it. A navel piercing, for example, can take up to 9 months to heal. Others with long healing times include the penis (3-9 months), labia majora (2-4 months), nipple (2-4 months), and scrotum (2-3 months). Other non-ear regions range from 2 to 8 weeks.
Bleeding definitely is a risk for piercings, Dr. Breuner said, especially now that so many teens are piercing body parts besides their ears. “The one I found most disturbing was that of the uvula,” she said. Bleeding risks tend to be low with ear and nose piercings, but the risk increases with the tongue, uvula, navel, nipples, and genitalia.
Another risk of mouth piercings, particularly tongue piercing, is damage to the teeth and gums, Dr. Breuner said. Barbells, the most popular type of mouth piercing, can lead to receding gums and chipped teeth with extended wear, especially because people wearing them have a tendency to frequently bite down on them.
One study found that half the participants who wore a long barbell piercing (1.59 cm or longer) for at least 2 years had lingual recession on their mandibular central incisors (J Periodontol. 2002 Mar;73[3]:289-97). Among those with a tongue piercing of at least 4 years, 47% had tooth chipping on their molars and premolars.
Another study found gingival recession was 11 times more likely among people with tongue piercings than without (J Clin Periodontol. 2010 Aug 1;37(8):712-8). Gingival recession also is a risk with lip piercings, but the risk is greater with tongue piercing, and only tongue piercings have been associated with tooth injuries (Aust Dent J. 2012 Mar;57[1]:71-8; Int J Dent Hyg. 2016 Feb;14[1]:62-73).
Hepatitis C also is a concern with body piercing. According to a systematic review of 12 studies, body piercing was a risk factor for hepatitis C infection in the majority of them (Am J Infect Control. 2001 Aug;29[4]:271-4).
Counseling adolescents on body modifications
You should ask teens about any tattoos or piercings they have at each visit and ask whether they have any plans to get any. Then you can answer questions about them and ensure the teens are aware of risks, particularly viral and bacterial infections and, with piercing, bleeding.
Beyond the medical risks, it’s important for teens to understand that tattoos have the potential to limit their employment in the future, depending on the job and how visible their tattoo is.
Social acceptance of tattoos and piercings have been increasing, but a survey of nearly 2,700 people conducted by Salary.com in 2013 found that 76% of respondents believed tattoos and piercings could reduce a job applicant’s chances of being hired.
If you want to learn more specifically about the safest places in your community for tattoos and piercings, Dr. Breuner recommended going out and visiting the shops. Tattoo artists generally are the most knowledgeable people in the community about the risks of their industry and often welcome local physicians who want to learn and see their equipment, she said.
NEW ORLEANS – It wasn’t until her teenage daughter wanted to get her belly button pierced that Cora Breuner, MD, became interested in the safety of tattoos and piercings for adolescents.
“You’re a pediatrician,” her daughter said. “Where should I go? Should I get this done?” Although Dr. Breuner didn’t want her daughter to get the piercing, she knew saying “no” wasn’t likely to stop her teenager any more than it would another adolescent, so she looked to the medical literature … and didn’t find much.
“I couldn’t find an article summarizing complication rates or just about the legality of it or other issues around tattooing and piercing,” said Dr. Breuner a professor of pediatrics at Seattle Children’s Hospital and the University of Washington, also in Seattle. So she and the American Academy of Pediatrics’ Committee on Adolescent Health did the work themselves and wrote one.
“I want to make sure that you are talking to your teenagers about this,” she told attendees at the annual meeting of the American Academy of Pediatrics. In her presentation, she focused on knowing the legal age of consent for body modifications and what to watch for in terms of complications.
Tattoos growing in popularity
More than a third (38%) of people aged 18-29 years have at least one tattoo, according to a Pew Research Center report Dr. Breuner cited, and 23% had piercings somewhere on their body besides their ears. In fact, Americans spend about $1.65 billion on tattoos each year.
Most of the people with tattoos (72%), however, had them in places that were covered and not visible, reinforcing the need to ask about them. The popularity of tattoos has been increasing in general, Dr. Breuner noted. In just the 4 years from 2012 to 2016, the prevalence of U.S. adults with at least one tattoo increased 20%.
And people don’t appear to be sorry to have them. According to a Harris Poll that Dr. Breuner cited, 86% of respondents in 2012 did not regret getting their tattoo, and respondents listed a number of feelings they associated with their tattoos: feeling sexy, rebellious, attractive, strong, spiritual, healthier, intelligent, and athletic.
Although the techniques for tattooing have changed over the years since the first documented ones in 4,000 B.C., the basic concept of injecting ink into the dermis hasn’t changed much. By injecting the ink below the epidermis, the ink remains visible for the rest of a person’s life.
The laws for tattoos vary by state, so you need to check the laws where they live. Not much data exist on infections and complaints, but data from the Michigan Department of Health & Human Services suggests the infection rate – at least those infections reported – is low while the rate of illegally operating facilities is a bigger risk. Local health districts in Michigan have received reports of only 18 infections since 2010, but they’ve received 85 reports of illegal operations and 69 reports of social media parties centered on all attendees getting a tattoo.
Risks of tattoos
The biggest concern for adolescents is ensuring they understand the risks of tattoos and piercings and what to look for. One risk for tattoos is hepatitis C. However, the studies on the risk of contracting hepatitis C from tattooing are confounded by the fact that many people getting tattoos also may be engaging in other risky behaviors, such as intravenous drug use or risky sexual behaviors. Still, some research suggests that “commercially acquired tattoos accounted for more than twice as many infections as injection-drug use,” Dr. Breuner said.
Another risk is tattoo-associated bacterial skin infections (Clin Infect Dis. 2019 Aug 30;69[6]:949-55; MMWR Morb Mortal Wkly Rep. 2012 Aug 24;61[33]:653-6).
Risks of body piercing
Although body piercing doesn’t date back quite as far as tattoos – about 700 A.D. – its history remains long. Research suggests the top reason people get body piercings is simply liking the way it looks, as 77% of respondents reported in one study (J Am Osteopath Assoc. 2007 Oct;107[10]:432-8). Other reasons including looking fashionable, catching attention, feeling different, making a personal statement, being daring, fitting in, pressuring from peers, and defying parents.
The most serious potential complication from piercings is gangrene, but the most common is infection. Other possible complications include an allergic reaction to the metal used, a bleeding complication (estimated in 1 of 10), a scar or site reaction (estimated in 1 of 15), or, much less commonly, toxic shock syndrome. In some areas, there’s a risk of nerve damage if the nerve is pierced, such as in the eyebrow or in the bridge of the nose.
Teens particularly should be aware of the average time it takes for a piercing to heal, depending on where they get it. A navel piercing, for example, can take up to 9 months to heal. Others with long healing times include the penis (3-9 months), labia majora (2-4 months), nipple (2-4 months), and scrotum (2-3 months). Other non-ear regions range from 2 to 8 weeks.
Bleeding definitely is a risk for piercings, Dr. Breuner said, especially now that so many teens are piercing body parts besides their ears. “The one I found most disturbing was that of the uvula,” she said. Bleeding risks tend to be low with ear and nose piercings, but the risk increases with the tongue, uvula, navel, nipples, and genitalia.
Another risk of mouth piercings, particularly tongue piercing, is damage to the teeth and gums, Dr. Breuner said. Barbells, the most popular type of mouth piercing, can lead to receding gums and chipped teeth with extended wear, especially because people wearing them have a tendency to frequently bite down on them.
One study found that half the participants who wore a long barbell piercing (1.59 cm or longer) for at least 2 years had lingual recession on their mandibular central incisors (J Periodontol. 2002 Mar;73[3]:289-97). Among those with a tongue piercing of at least 4 years, 47% had tooth chipping on their molars and premolars.
Another study found gingival recession was 11 times more likely among people with tongue piercings than without (J Clin Periodontol. 2010 Aug 1;37(8):712-8). Gingival recession also is a risk with lip piercings, but the risk is greater with tongue piercing, and only tongue piercings have been associated with tooth injuries (Aust Dent J. 2012 Mar;57[1]:71-8; Int J Dent Hyg. 2016 Feb;14[1]:62-73).
Hepatitis C also is a concern with body piercing. According to a systematic review of 12 studies, body piercing was a risk factor for hepatitis C infection in the majority of them (Am J Infect Control. 2001 Aug;29[4]:271-4).
Counseling adolescents on body modifications
You should ask teens about any tattoos or piercings they have at each visit and ask whether they have any plans to get any. Then you can answer questions about them and ensure the teens are aware of risks, particularly viral and bacterial infections and, with piercing, bleeding.
Beyond the medical risks, it’s important for teens to understand that tattoos have the potential to limit their employment in the future, depending on the job and how visible their tattoo is.
Social acceptance of tattoos and piercings have been increasing, but a survey of nearly 2,700 people conducted by Salary.com in 2013 found that 76% of respondents believed tattoos and piercings could reduce a job applicant’s chances of being hired.
If you want to learn more specifically about the safest places in your community for tattoos and piercings, Dr. Breuner recommended going out and visiting the shops. Tattoo artists generally are the most knowledgeable people in the community about the risks of their industry and often welcome local physicians who want to learn and see their equipment, she said.
EXPERT ANALYSIS FROM AAP 19
The vaping problem
The first time I was sure I was witnessing someone vaping occurred when I saw an alarming cloud of smoke billowing from driver’s side window of the car in front of me. My initial concern was that vehicle was on fire. But none of the other drivers around me seemed concerned and as I pulled up next to the car I could see the driver ostentatiously inhaling deeply in preparation for releasing another monstrous cloud of vapor.
However, you probably have learned, as have I, that most vaping is done furtively. In fact, the pocketability of vaping devices is part of their appeal to teenagers. Hiding a lit cigarette in one’s pocket is something even the most risk-loving adolescent usually won’t attempt. I suspect that regardless of what is in the vapor, the high one can get by putting one over on the school administration by vaping in the school restroom or in the middle of history class is a temptation that many teenagers can’t resist.
Listening to educators, substance abuse counselors, and police officers who have first hand knowledge,
Part of the problem seems to be that vaping was flying under the radar and expanding rapidly long before educators, parents, and I fear physicians woke up to the severity and magnitude of the problem. And now everybody is playing catchup.
Of course the initial, and as yet unconfirmed, notion that e-cigarettes might provide a viable strategy for tobacco withdrawal has added confusion to the mix. It turns out that vaping can provide many orders of magnitude more nicotine in a small volume than cigarettes, which creates an outsized addiction potential for those more vulnerable users – even with a very short history of use. My experts tell me that this level of addiction has forced them to consider strategies and dosages far beyond those they are accustomed to using with patients whose addiction stems from standard cigarette use.
The recent discovery of lung damage related to vaping provided a brief glimmer of hope that fear would turn the tide in the vaping epidemic. But unfortunately the Centers for Disease Control and Prevention did its job too well. Although maybe it was a bit late to uncover the condition, the agency acted quickly to chase down the epidemiology and eventually the chemical responsible for the pulmonary injury. My local experts tell me that, while the cause of the lung damage was still a mystery, they noticed a decline in vaping generated by the fear of this unknown killer. Young people were reporting that they were rethinking their vaping usage. However, once the chemical culprit was identified, their clients felt that they could safely vape again as long as they were more careful in choosing the source of liquid in their devices.
Not surprisingly, the current administration has been providing mixed messages about how it will address vaping. There always will be the argument that if you ban a substance, it will be driven underground and become more difficult to manage. However, in the case of vaping, its appeal and risk to young people and the apparent ineffectiveness of local efforts to control it demand a firm unwavering response at the federal level.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The first time I was sure I was witnessing someone vaping occurred when I saw an alarming cloud of smoke billowing from driver’s side window of the car in front of me. My initial concern was that vehicle was on fire. But none of the other drivers around me seemed concerned and as I pulled up next to the car I could see the driver ostentatiously inhaling deeply in preparation for releasing another monstrous cloud of vapor.
However, you probably have learned, as have I, that most vaping is done furtively. In fact, the pocketability of vaping devices is part of their appeal to teenagers. Hiding a lit cigarette in one’s pocket is something even the most risk-loving adolescent usually won’t attempt. I suspect that regardless of what is in the vapor, the high one can get by putting one over on the school administration by vaping in the school restroom or in the middle of history class is a temptation that many teenagers can’t resist.
Listening to educators, substance abuse counselors, and police officers who have first hand knowledge,
Part of the problem seems to be that vaping was flying under the radar and expanding rapidly long before educators, parents, and I fear physicians woke up to the severity and magnitude of the problem. And now everybody is playing catchup.
Of course the initial, and as yet unconfirmed, notion that e-cigarettes might provide a viable strategy for tobacco withdrawal has added confusion to the mix. It turns out that vaping can provide many orders of magnitude more nicotine in a small volume than cigarettes, which creates an outsized addiction potential for those more vulnerable users – even with a very short history of use. My experts tell me that this level of addiction has forced them to consider strategies and dosages far beyond those they are accustomed to using with patients whose addiction stems from standard cigarette use.
The recent discovery of lung damage related to vaping provided a brief glimmer of hope that fear would turn the tide in the vaping epidemic. But unfortunately the Centers for Disease Control and Prevention did its job too well. Although maybe it was a bit late to uncover the condition, the agency acted quickly to chase down the epidemiology and eventually the chemical responsible for the pulmonary injury. My local experts tell me that, while the cause of the lung damage was still a mystery, they noticed a decline in vaping generated by the fear of this unknown killer. Young people were reporting that they were rethinking their vaping usage. However, once the chemical culprit was identified, their clients felt that they could safely vape again as long as they were more careful in choosing the source of liquid in their devices.
Not surprisingly, the current administration has been providing mixed messages about how it will address vaping. There always will be the argument that if you ban a substance, it will be driven underground and become more difficult to manage. However, in the case of vaping, its appeal and risk to young people and the apparent ineffectiveness of local efforts to control it demand a firm unwavering response at the federal level.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
The first time I was sure I was witnessing someone vaping occurred when I saw an alarming cloud of smoke billowing from driver’s side window of the car in front of me. My initial concern was that vehicle was on fire. But none of the other drivers around me seemed concerned and as I pulled up next to the car I could see the driver ostentatiously inhaling deeply in preparation for releasing another monstrous cloud of vapor.
However, you probably have learned, as have I, that most vaping is done furtively. In fact, the pocketability of vaping devices is part of their appeal to teenagers. Hiding a lit cigarette in one’s pocket is something even the most risk-loving adolescent usually won’t attempt. I suspect that regardless of what is in the vapor, the high one can get by putting one over on the school administration by vaping in the school restroom or in the middle of history class is a temptation that many teenagers can’t resist.
Listening to educators, substance abuse counselors, and police officers who have first hand knowledge,
Part of the problem seems to be that vaping was flying under the radar and expanding rapidly long before educators, parents, and I fear physicians woke up to the severity and magnitude of the problem. And now everybody is playing catchup.
Of course the initial, and as yet unconfirmed, notion that e-cigarettes might provide a viable strategy for tobacco withdrawal has added confusion to the mix. It turns out that vaping can provide many orders of magnitude more nicotine in a small volume than cigarettes, which creates an outsized addiction potential for those more vulnerable users – even with a very short history of use. My experts tell me that this level of addiction has forced them to consider strategies and dosages far beyond those they are accustomed to using with patients whose addiction stems from standard cigarette use.
The recent discovery of lung damage related to vaping provided a brief glimmer of hope that fear would turn the tide in the vaping epidemic. But unfortunately the Centers for Disease Control and Prevention did its job too well. Although maybe it was a bit late to uncover the condition, the agency acted quickly to chase down the epidemiology and eventually the chemical responsible for the pulmonary injury. My local experts tell me that, while the cause of the lung damage was still a mystery, they noticed a decline in vaping generated by the fear of this unknown killer. Young people were reporting that they were rethinking their vaping usage. However, once the chemical culprit was identified, their clients felt that they could safely vape again as long as they were more careful in choosing the source of liquid in their devices.
Not surprisingly, the current administration has been providing mixed messages about how it will address vaping. There always will be the argument that if you ban a substance, it will be driven underground and become more difficult to manage. However, in the case of vaping, its appeal and risk to young people and the apparent ineffectiveness of local efforts to control it demand a firm unwavering response at the federal level.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Atopic dermatitis in egg-, milk-allergic kids may up anaphylaxis risk
compared with allergic patients without atopic dermatitis, based on retrospective data from 347 individuals.
Atopic dermatitis has been associated with increased risk of food allergies, but the association and predictive factors of skin reactions to certain foods remain unclear, wrote Bryce C. Hoffman, MD, of National Jewish Health, Denver, and colleagues.
In a letter published in the Annals of Allergy, Asthma & Immunology, the researchers identified children aged 0-18 years with peanut, cow’s milk, and/or egg allergies with or without atopic dermatitis (AD) using an institutional research database and conducted a retrospective study of medical records.
Overall, children with egg and milk allergies plus AD had significantly higher rates of anaphylaxis than allergic children without AD (47% vs. 11% for egg, 50% vs. 19% for milk). Anaphylaxis rates were similar in children with peanut allergies with or without AD (27% vs. 23%).
“This finding may suggest that skin barrier dysfunction plays a role in the severity of [food allergy]. However, this is not universal to all food antigens, and other mechanisms are likely important in the association of anaphylaxis with a particular food,” the researchers noted.
Rates of tolerance for both baked egg and baked milk were similar between AD and non-AD patients (83% vs. 61% for milk; 82% vs. 67% for egg). In addition, levels of total IgE were increased in children with egg and milk allergies plus AD, compared with children without AD. However, children with peanut allergies plus AD had decreased total IgE, compared with children with peanut allergies but no AD. This “may support a link between Th2 polarization and [food allergy] severity, ” Dr. Hoffman and associates wrote.
The findings were limited by several factors, including the retrospective study design, exclusion of many patients, and lack of data on the amount of food that triggered anaphylactic reactions, the researchers noted.
Nonetheless, the results suggest that children with atopic dermatitis and allergies to eggs and milk are at increased risk and that clinicians should counsel these patients and families about the potential for more-severe reactions to oral food challenges, Dr. Hoffman and associates concluded.
The study was supported by National Jewish Health and the Edelstein Family Chair of Pediatric Allergy and Immunology. The researchers had no financial conflicts to disclose.
SOURCE: Hoffman BC et al. Ann Allergy Asthma Immunol. 2019 Sep 11. doi: 10.1016/j.anai.2019.09.008.
compared with allergic patients without atopic dermatitis, based on retrospective data from 347 individuals.
Atopic dermatitis has been associated with increased risk of food allergies, but the association and predictive factors of skin reactions to certain foods remain unclear, wrote Bryce C. Hoffman, MD, of National Jewish Health, Denver, and colleagues.
In a letter published in the Annals of Allergy, Asthma & Immunology, the researchers identified children aged 0-18 years with peanut, cow’s milk, and/or egg allergies with or without atopic dermatitis (AD) using an institutional research database and conducted a retrospective study of medical records.
Overall, children with egg and milk allergies plus AD had significantly higher rates of anaphylaxis than allergic children without AD (47% vs. 11% for egg, 50% vs. 19% for milk). Anaphylaxis rates were similar in children with peanut allergies with or without AD (27% vs. 23%).
“This finding may suggest that skin barrier dysfunction plays a role in the severity of [food allergy]. However, this is not universal to all food antigens, and other mechanisms are likely important in the association of anaphylaxis with a particular food,” the researchers noted.
Rates of tolerance for both baked egg and baked milk were similar between AD and non-AD patients (83% vs. 61% for milk; 82% vs. 67% for egg). In addition, levels of total IgE were increased in children with egg and milk allergies plus AD, compared with children without AD. However, children with peanut allergies plus AD had decreased total IgE, compared with children with peanut allergies but no AD. This “may support a link between Th2 polarization and [food allergy] severity, ” Dr. Hoffman and associates wrote.
The findings were limited by several factors, including the retrospective study design, exclusion of many patients, and lack of data on the amount of food that triggered anaphylactic reactions, the researchers noted.
Nonetheless, the results suggest that children with atopic dermatitis and allergies to eggs and milk are at increased risk and that clinicians should counsel these patients and families about the potential for more-severe reactions to oral food challenges, Dr. Hoffman and associates concluded.
The study was supported by National Jewish Health and the Edelstein Family Chair of Pediatric Allergy and Immunology. The researchers had no financial conflicts to disclose.
SOURCE: Hoffman BC et al. Ann Allergy Asthma Immunol. 2019 Sep 11. doi: 10.1016/j.anai.2019.09.008.
compared with allergic patients without atopic dermatitis, based on retrospective data from 347 individuals.
Atopic dermatitis has been associated with increased risk of food allergies, but the association and predictive factors of skin reactions to certain foods remain unclear, wrote Bryce C. Hoffman, MD, of National Jewish Health, Denver, and colleagues.
In a letter published in the Annals of Allergy, Asthma & Immunology, the researchers identified children aged 0-18 years with peanut, cow’s milk, and/or egg allergies with or without atopic dermatitis (AD) using an institutional research database and conducted a retrospective study of medical records.
Overall, children with egg and milk allergies plus AD had significantly higher rates of anaphylaxis than allergic children without AD (47% vs. 11% for egg, 50% vs. 19% for milk). Anaphylaxis rates were similar in children with peanut allergies with or without AD (27% vs. 23%).
“This finding may suggest that skin barrier dysfunction plays a role in the severity of [food allergy]. However, this is not universal to all food antigens, and other mechanisms are likely important in the association of anaphylaxis with a particular food,” the researchers noted.
Rates of tolerance for both baked egg and baked milk were similar between AD and non-AD patients (83% vs. 61% for milk; 82% vs. 67% for egg). In addition, levels of total IgE were increased in children with egg and milk allergies plus AD, compared with children without AD. However, children with peanut allergies plus AD had decreased total IgE, compared with children with peanut allergies but no AD. This “may support a link between Th2 polarization and [food allergy] severity, ” Dr. Hoffman and associates wrote.
The findings were limited by several factors, including the retrospective study design, exclusion of many patients, and lack of data on the amount of food that triggered anaphylactic reactions, the researchers noted.
Nonetheless, the results suggest that children with atopic dermatitis and allergies to eggs and milk are at increased risk and that clinicians should counsel these patients and families about the potential for more-severe reactions to oral food challenges, Dr. Hoffman and associates concluded.
The study was supported by National Jewish Health and the Edelstein Family Chair of Pediatric Allergy and Immunology. The researchers had no financial conflicts to disclose.
SOURCE: Hoffman BC et al. Ann Allergy Asthma Immunol. 2019 Sep 11. doi: 10.1016/j.anai.2019.09.008.
FROM THE ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
Reward, decision-making brain regions altered in teens with obesity
CHICAGO – according to a Brazilian study that used MRI to detect these changes.
Brain changes were significantly correlated with increased levels of insulin, leptin, and other appetite- and diet-related hormones and neurohormones, as well as with inflammatory markers.
In an interview at the annual meeting of the Radiological Society of North America, Pamela Bertolazzi, a PhD student at the University of São Paulo, explained that childhood obesity in Brazil is estimated to have climbed by up to 40% in recent years, with almost one-third of Brazilian children and adolescents experiencing obesity. Epidemiologists estimate that there’s the potential for 2.6 million premature deaths from this level of overweight and obesity, she said. Brazil has over 211 million residents.
Previous studies have established diffusion tensor imaging as an MRI technique to assess white-matter integrity and architecture. Fractional anisotropy (FA) is a measure of brain tract integrity, and decreased FA can indicate demyelination or axonal degeneration.
Ms. Bertolazzi and colleagues compared 60 healthy weight adolescents with 57 adolescents with obesity to see how cerebral connectivity differed, and further correlated MRI findings with a serum assay of 57 analytes including inflammatory markers, neuropeptides, and hormones.
Adolescents aged 12-16 years were included if they met World Health Organization criteria for obesity or for healthy weight. The z score for the participants with obesity was 2.74, and 0.25 for the healthy-weight participants (P less than .001). Individuals who were underweight or overweight (but not obese) were excluded. Those with known significant psychiatric diagnoses or prior traumatic brain injury or neurosurgery also were excluded.
The mean age of participants was 14 years, and 29 of the 57 (51%) participants with obesity were female, as were 33 of 60 (55%) healthy weight participants. There was no significant difference in socioeconomic status between the two groups.
When participants’ brain MRI results were reviewed, Ms. Bertolazzi and associates saw several regions that had decreased FA only in the adolescents with obesity. In general terms, these brain areas are known to be concerned with appetite and reward.
Decreased FA – indicating demyelination or axonal degeneration – was seen particularly on the left-hand side of the corpus callosum, “the largest association pathway in the human brain,” said Ms. Bertolazzi. Looking at the interaction between decreased FA in this area and levels of various analytes, leptin, insulin, C-peptide, and total glucagonlike peptide–1 levels all were negatively associated with FA levels. A ratio of leptin to the anti-inflammatory cytokine interleukin-10 also had a negative correlation with FA levels. All of these associations were statistically significant.
Decreased FA also was seen in the orbitofrontal gyrus, an area of the prefrontal cortex that links decision making with emotions and reward. Here, significant negative associations were seen with C-peptide, amylin, and the ratios of several other inflammatory markers to IL-10.
“Obesity was associated with a reduction of cerebral integrity in obese adolescents,” said Ms. Bertolazzi. The clinical significance of these findings is not yet known. However, she said that the disruption in regulation of reward and appetite circuitry her study found may set up adolescents with excess body mass for a maladaptive positive feedback loop: elevated insulin, leptin, and inflammatory cytokine levels may be contributing to disrupted appetite, which in turn contributes to ongoing increases in body mass index.
She and her colleagues are planning to enroll adolescents with obesity and their families in nutritional education and exercise programs, hoping to interrupt the cycle. They plan to obtain a baseline serum assay and MRI scan with diffusion tensor imaging and FA, and to repeat the studies about 3 months into an intensive intervention, to test the hypothesis that increased exercise and improved diet will result in reversal of the brain changes they found in this exploratory study. In particular, said Ms. Bertolazzi, they hope that encouraging physical activity will boost levels of HDL cholesterol, which may have a neuroprotective effect.
Ms. Bertolazzi reported no outside sources of funding and no conflicts of interest.
CHICAGO – according to a Brazilian study that used MRI to detect these changes.
Brain changes were significantly correlated with increased levels of insulin, leptin, and other appetite- and diet-related hormones and neurohormones, as well as with inflammatory markers.
In an interview at the annual meeting of the Radiological Society of North America, Pamela Bertolazzi, a PhD student at the University of São Paulo, explained that childhood obesity in Brazil is estimated to have climbed by up to 40% in recent years, with almost one-third of Brazilian children and adolescents experiencing obesity. Epidemiologists estimate that there’s the potential for 2.6 million premature deaths from this level of overweight and obesity, she said. Brazil has over 211 million residents.
Previous studies have established diffusion tensor imaging as an MRI technique to assess white-matter integrity and architecture. Fractional anisotropy (FA) is a measure of brain tract integrity, and decreased FA can indicate demyelination or axonal degeneration.
Ms. Bertolazzi and colleagues compared 60 healthy weight adolescents with 57 adolescents with obesity to see how cerebral connectivity differed, and further correlated MRI findings with a serum assay of 57 analytes including inflammatory markers, neuropeptides, and hormones.
Adolescents aged 12-16 years were included if they met World Health Organization criteria for obesity or for healthy weight. The z score for the participants with obesity was 2.74, and 0.25 for the healthy-weight participants (P less than .001). Individuals who were underweight or overweight (but not obese) were excluded. Those with known significant psychiatric diagnoses or prior traumatic brain injury or neurosurgery also were excluded.
The mean age of participants was 14 years, and 29 of the 57 (51%) participants with obesity were female, as were 33 of 60 (55%) healthy weight participants. There was no significant difference in socioeconomic status between the two groups.
When participants’ brain MRI results were reviewed, Ms. Bertolazzi and associates saw several regions that had decreased FA only in the adolescents with obesity. In general terms, these brain areas are known to be concerned with appetite and reward.
Decreased FA – indicating demyelination or axonal degeneration – was seen particularly on the left-hand side of the corpus callosum, “the largest association pathway in the human brain,” said Ms. Bertolazzi. Looking at the interaction between decreased FA in this area and levels of various analytes, leptin, insulin, C-peptide, and total glucagonlike peptide–1 levels all were negatively associated with FA levels. A ratio of leptin to the anti-inflammatory cytokine interleukin-10 also had a negative correlation with FA levels. All of these associations were statistically significant.
Decreased FA also was seen in the orbitofrontal gyrus, an area of the prefrontal cortex that links decision making with emotions and reward. Here, significant negative associations were seen with C-peptide, amylin, and the ratios of several other inflammatory markers to IL-10.
“Obesity was associated with a reduction of cerebral integrity in obese adolescents,” said Ms. Bertolazzi. The clinical significance of these findings is not yet known. However, she said that the disruption in regulation of reward and appetite circuitry her study found may set up adolescents with excess body mass for a maladaptive positive feedback loop: elevated insulin, leptin, and inflammatory cytokine levels may be contributing to disrupted appetite, which in turn contributes to ongoing increases in body mass index.
She and her colleagues are planning to enroll adolescents with obesity and their families in nutritional education and exercise programs, hoping to interrupt the cycle. They plan to obtain a baseline serum assay and MRI scan with diffusion tensor imaging and FA, and to repeat the studies about 3 months into an intensive intervention, to test the hypothesis that increased exercise and improved diet will result in reversal of the brain changes they found in this exploratory study. In particular, said Ms. Bertolazzi, they hope that encouraging physical activity will boost levels of HDL cholesterol, which may have a neuroprotective effect.
Ms. Bertolazzi reported no outside sources of funding and no conflicts of interest.
CHICAGO – according to a Brazilian study that used MRI to detect these changes.
Brain changes were significantly correlated with increased levels of insulin, leptin, and other appetite- and diet-related hormones and neurohormones, as well as with inflammatory markers.
In an interview at the annual meeting of the Radiological Society of North America, Pamela Bertolazzi, a PhD student at the University of São Paulo, explained that childhood obesity in Brazil is estimated to have climbed by up to 40% in recent years, with almost one-third of Brazilian children and adolescents experiencing obesity. Epidemiologists estimate that there’s the potential for 2.6 million premature deaths from this level of overweight and obesity, she said. Brazil has over 211 million residents.
Previous studies have established diffusion tensor imaging as an MRI technique to assess white-matter integrity and architecture. Fractional anisotropy (FA) is a measure of brain tract integrity, and decreased FA can indicate demyelination or axonal degeneration.
Ms. Bertolazzi and colleagues compared 60 healthy weight adolescents with 57 adolescents with obesity to see how cerebral connectivity differed, and further correlated MRI findings with a serum assay of 57 analytes including inflammatory markers, neuropeptides, and hormones.
Adolescents aged 12-16 years were included if they met World Health Organization criteria for obesity or for healthy weight. The z score for the participants with obesity was 2.74, and 0.25 for the healthy-weight participants (P less than .001). Individuals who were underweight or overweight (but not obese) were excluded. Those with known significant psychiatric diagnoses or prior traumatic brain injury or neurosurgery also were excluded.
The mean age of participants was 14 years, and 29 of the 57 (51%) participants with obesity were female, as were 33 of 60 (55%) healthy weight participants. There was no significant difference in socioeconomic status between the two groups.
When participants’ brain MRI results were reviewed, Ms. Bertolazzi and associates saw several regions that had decreased FA only in the adolescents with obesity. In general terms, these brain areas are known to be concerned with appetite and reward.
Decreased FA – indicating demyelination or axonal degeneration – was seen particularly on the left-hand side of the corpus callosum, “the largest association pathway in the human brain,” said Ms. Bertolazzi. Looking at the interaction between decreased FA in this area and levels of various analytes, leptin, insulin, C-peptide, and total glucagonlike peptide–1 levels all were negatively associated with FA levels. A ratio of leptin to the anti-inflammatory cytokine interleukin-10 also had a negative correlation with FA levels. All of these associations were statistically significant.
Decreased FA also was seen in the orbitofrontal gyrus, an area of the prefrontal cortex that links decision making with emotions and reward. Here, significant negative associations were seen with C-peptide, amylin, and the ratios of several other inflammatory markers to IL-10.
“Obesity was associated with a reduction of cerebral integrity in obese adolescents,” said Ms. Bertolazzi. The clinical significance of these findings is not yet known. However, she said that the disruption in regulation of reward and appetite circuitry her study found may set up adolescents with excess body mass for a maladaptive positive feedback loop: elevated insulin, leptin, and inflammatory cytokine levels may be contributing to disrupted appetite, which in turn contributes to ongoing increases in body mass index.
She and her colleagues are planning to enroll adolescents with obesity and their families in nutritional education and exercise programs, hoping to interrupt the cycle. They plan to obtain a baseline serum assay and MRI scan with diffusion tensor imaging and FA, and to repeat the studies about 3 months into an intensive intervention, to test the hypothesis that increased exercise and improved diet will result in reversal of the brain changes they found in this exploratory study. In particular, said Ms. Bertolazzi, they hope that encouraging physical activity will boost levels of HDL cholesterol, which may have a neuroprotective effect.
Ms. Bertolazzi reported no outside sources of funding and no conflicts of interest.
REPORTING FROM RSNA 2019
Nearly one in five U.S. adolescents have prediabetes
with a higher prevalence among males, a study has found.
Linda J. Andes, PhD, from the Centers for Disease Control and Prevention and coauthors reported in JAMA Pediatrics their analysis of data from 2,606 adolescent (12-18 years) and 3,180 young adult (19-34 years) participants in the 2005-2016 National Health and Nutrition Examination Surveys.
This found that the percentage with prediabetes – defined as either impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or increased hemoglobin A1c (HbA1c) level – was 18% among adolescents and 24% among young adults.
The most common condition was IFG, which was seen in 11% of adolescents and 16% of young adults. The rate of IGT was 4% in adolescents and 6% of young adults, while elevated HbA1c levels were seen in 5% of adolescents and 8% of young adults.
This information is important because “In adults, these three phenotypes increase the risk of developing type 2 diabetes as well as cardiovascular diseases,” Dr. Andes and coauthors wrote. “In 2011-2012, the overall prevalence of prediabetes among U.S. adults, defined as the presence of any of the three glucose metabolism dysregulation phenotypes, was 38% and it increased to about 50% in persons 65 years and older.”
Dr. Andes and associates noted that isolated IFG was the most common glucose dysregulation seen in both adolescents and young adults. “While individuals with IFG are at increased risk for type 2 diabetes, few primary prevention trials have included individuals selected for the presence of IFG and none have been conducted in adolescents with IFG or IGT to our knowledge.”
The study saw some key gender differences in prevalence. For example, the prevalence of IFG was significantly lower in adolescent girls than in boys (7% vs. 15%; P less than .001), and in young women, compared with young men (10% vs. 22%; P less than .001).
“These findings are consistent with those of other studies in adults; however, the underlying mechanisms for explaining this discrepancy are still unclear,” Dr. Andes and coauthors wrote.
Ethnicity also appeared to influence risk, with the prevalence of IFG significantly lower in non-Hispanic black adolescents, compared with Hispanic adolescents. However, increased HbA1c levels were significantly more prevalent in non-Hispanic black adolescents, compared with Hispanic or non-Hispanic white adolescents.
“These findings highlight the need for additional studies on the long-term consequences and preventive strategies of abnormal glucose metabolism as measured by HbA1c levels in adolescents and young adults, especially of minority racial/ethnic groups,” the authors wrote.
Adolescents with prediabetes had significantly higher systolic blood pressure, non-HDL cholesterol, waist-to-height ratio, higher body mass index, and lower insulin sensitivity, compared with those with normal glucose tolerance. Among young adults with prediabetes, there was significantly higher systolic blood pressure and non-HDL cholesterol, compared with individuals with normal glucose tolerance.
No funding or conflicts of interest were declared.
SOURCE: Andes LJ et al. JAMA Pediatr. 2019 Dec 2. doi: 10.1001/jamapediatrics.2019.4498.
with a higher prevalence among males, a study has found.
Linda J. Andes, PhD, from the Centers for Disease Control and Prevention and coauthors reported in JAMA Pediatrics their analysis of data from 2,606 adolescent (12-18 years) and 3,180 young adult (19-34 years) participants in the 2005-2016 National Health and Nutrition Examination Surveys.
This found that the percentage with prediabetes – defined as either impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or increased hemoglobin A1c (HbA1c) level – was 18% among adolescents and 24% among young adults.
The most common condition was IFG, which was seen in 11% of adolescents and 16% of young adults. The rate of IGT was 4% in adolescents and 6% of young adults, while elevated HbA1c levels were seen in 5% of adolescents and 8% of young adults.
This information is important because “In adults, these three phenotypes increase the risk of developing type 2 diabetes as well as cardiovascular diseases,” Dr. Andes and coauthors wrote. “In 2011-2012, the overall prevalence of prediabetes among U.S. adults, defined as the presence of any of the three glucose metabolism dysregulation phenotypes, was 38% and it increased to about 50% in persons 65 years and older.”
Dr. Andes and associates noted that isolated IFG was the most common glucose dysregulation seen in both adolescents and young adults. “While individuals with IFG are at increased risk for type 2 diabetes, few primary prevention trials have included individuals selected for the presence of IFG and none have been conducted in adolescents with IFG or IGT to our knowledge.”
The study saw some key gender differences in prevalence. For example, the prevalence of IFG was significantly lower in adolescent girls than in boys (7% vs. 15%; P less than .001), and in young women, compared with young men (10% vs. 22%; P less than .001).
“These findings are consistent with those of other studies in adults; however, the underlying mechanisms for explaining this discrepancy are still unclear,” Dr. Andes and coauthors wrote.
Ethnicity also appeared to influence risk, with the prevalence of IFG significantly lower in non-Hispanic black adolescents, compared with Hispanic adolescents. However, increased HbA1c levels were significantly more prevalent in non-Hispanic black adolescents, compared with Hispanic or non-Hispanic white adolescents.
“These findings highlight the need for additional studies on the long-term consequences and preventive strategies of abnormal glucose metabolism as measured by HbA1c levels in adolescents and young adults, especially of minority racial/ethnic groups,” the authors wrote.
Adolescents with prediabetes had significantly higher systolic blood pressure, non-HDL cholesterol, waist-to-height ratio, higher body mass index, and lower insulin sensitivity, compared with those with normal glucose tolerance. Among young adults with prediabetes, there was significantly higher systolic blood pressure and non-HDL cholesterol, compared with individuals with normal glucose tolerance.
No funding or conflicts of interest were declared.
SOURCE: Andes LJ et al. JAMA Pediatr. 2019 Dec 2. doi: 10.1001/jamapediatrics.2019.4498.
with a higher prevalence among males, a study has found.
Linda J. Andes, PhD, from the Centers for Disease Control and Prevention and coauthors reported in JAMA Pediatrics their analysis of data from 2,606 adolescent (12-18 years) and 3,180 young adult (19-34 years) participants in the 2005-2016 National Health and Nutrition Examination Surveys.
This found that the percentage with prediabetes – defined as either impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or increased hemoglobin A1c (HbA1c) level – was 18% among adolescents and 24% among young adults.
The most common condition was IFG, which was seen in 11% of adolescents and 16% of young adults. The rate of IGT was 4% in adolescents and 6% of young adults, while elevated HbA1c levels were seen in 5% of adolescents and 8% of young adults.
This information is important because “In adults, these three phenotypes increase the risk of developing type 2 diabetes as well as cardiovascular diseases,” Dr. Andes and coauthors wrote. “In 2011-2012, the overall prevalence of prediabetes among U.S. adults, defined as the presence of any of the three glucose metabolism dysregulation phenotypes, was 38% and it increased to about 50% in persons 65 years and older.”
Dr. Andes and associates noted that isolated IFG was the most common glucose dysregulation seen in both adolescents and young adults. “While individuals with IFG are at increased risk for type 2 diabetes, few primary prevention trials have included individuals selected for the presence of IFG and none have been conducted in adolescents with IFG or IGT to our knowledge.”
The study saw some key gender differences in prevalence. For example, the prevalence of IFG was significantly lower in adolescent girls than in boys (7% vs. 15%; P less than .001), and in young women, compared with young men (10% vs. 22%; P less than .001).
“These findings are consistent with those of other studies in adults; however, the underlying mechanisms for explaining this discrepancy are still unclear,” Dr. Andes and coauthors wrote.
Ethnicity also appeared to influence risk, with the prevalence of IFG significantly lower in non-Hispanic black adolescents, compared with Hispanic adolescents. However, increased HbA1c levels were significantly more prevalent in non-Hispanic black adolescents, compared with Hispanic or non-Hispanic white adolescents.
“These findings highlight the need for additional studies on the long-term consequences and preventive strategies of abnormal glucose metabolism as measured by HbA1c levels in adolescents and young adults, especially of minority racial/ethnic groups,” the authors wrote.
Adolescents with prediabetes had significantly higher systolic blood pressure, non-HDL cholesterol, waist-to-height ratio, higher body mass index, and lower insulin sensitivity, compared with those with normal glucose tolerance. Among young adults with prediabetes, there was significantly higher systolic blood pressure and non-HDL cholesterol, compared with individuals with normal glucose tolerance.
No funding or conflicts of interest were declared.
SOURCE: Andes LJ et al. JAMA Pediatr. 2019 Dec 2. doi: 10.1001/jamapediatrics.2019.4498.
FROM JAMA PEDIATRICS
Vaping: The new wave of nicotine addiction
Electronic cigarettes and other “vaping” devices have been increasing in popularity among youth and adults since their introduction in the US market in 2007.1 This increase is partially driven by a public perception that vaping is harmless, or at least less harmful than cigarette smoking.2 Vaping fans also argue that current smokers can use vaping as nicotine replacement therapy to help them quit smoking.3
We disagree. Research on the health effects of vaping, though still limited, is accumulating rapidly and making it increasingly clear that this habit is far from harmless. For youth, it is a gateway to addiction to nicotine and other substances. Whether it can help people quit smoking remains to be seen. And recent months have seen reports of serious respiratory illnesses and even deaths linked to vaping.4
In December 2016, the US Surgeon General warned that e-cigarette use among youth and young adults in the United States represents a “major public health concern,”5 and that more adolescents and young adults are now vaping than smoking conventional tobacco products.
This article reviews the issue of vaping in the United States, as well as available evidence regarding its safety.
YOUTH AT RISK
Retail sales of e-cigarettes and vaping devices approach an annual $7 billion.6 A 2014–2015 survey found that 2.4% of the general US population were current users of e-cigarettes, and 8.5% had tried them at least once.3
In 2014, for the first time, e-cigarette use became more common among US youth than traditional cigarettes.5
The odds of taking up vaping are higher among minority youth in the United States, particularly Hispanics.9 This trend is particularly worrisome because several longitudinal studies have shown that adolescents who use e-cigarettes are 3 times as likely to eventually become smokers of traditional cigarettes compared with adolescents who do not use e-cigarettes.10–12
If US youth continue smoking at the current rate, 5.6 million of the current population under age 18, or 1 of every 13, will die early of a smoking-related illness.13
RECENT OUTBREAK OF VAPING-ASSOCIATED LUNG INJURY
As of November 5, 2019, there had been 2,051 cases of vaping-associated lung injury in 49 states (all except Alaska), the District of Columbia, and 1 US territory reported to the US Centers for Disease Control and Prevention (CDC), with 39 confirmed deaths.4 The reported cases include respiratory injury including acute eosinophilic pneumonia, organizing pneumonia, acute respiratory distress syndrome, and hypersensitivity pneumonitis.14
Most of these patients had been vaping tetrahydrocannabinol (THC), though many used both nicotine- and THC-containing products, and others used products containing nicotine exclusively.4 Thus, it is difficult to identify the exact substance or substances that may be contributing to this sudden outbreak among vape users, and many different product sources are currently under investigation.
One substance that may be linked to the epidemic is vitamin E acetate, which the New York State Department of Health has detected in high levels in cannabis vaping cartridges used by patients who developed lung injury.15 The US Food and Drug Administration (FDA) is continuing to analyze vape cartridge samples submitted by affected patients to look for other chemicals that can contribute to the development of serious pulmonary illness.
WHAT IS AN E-CIGARETTE? WHAT IS A VAPE PEN?
Vape pens consist of similar elements but are not necessarily similar in appearance to a conventional cigarette, and may look more like a pen or a USB flash drive. In fact, the Juul device is recharged by plugging it into a USB port.
Vaping devices have many street names, including e-cigs, e-hookahs, vape pens, mods, vapes, and tank systems.
The first US patent application for a device resembling a modern e-cigarette was filed in 1963, but the product never made it to the market.16 Instead, the first commercially successful e-cigarette was created in Beijing in 2003 and introduced to US markets in 2007.
Newer-generation devices have larger batteries and can heat the liquid to higher temperatures, releasing more nicotine and forming additional toxicants such as formaldehyde. Devices lack standardization in terms of design, capacity for safely holding e-liquid, packaging of the e-liquid, and features designed to minimize hazards of use.
Not just nicotine
Many devices are designed for use with other drugs, including THC.17 In a 2018 study, 10.9% of college students reported vaping marijuana in the past 30 days, up from 5.2% in 2017.18
Other substances are being vaped as well.19 In theory, any heat-stable psychoactive recreational drug could be aerosolized and vaped. There are increasing reports of e-liquids containing recreational drugs such as synthetic cannabinoid receptor agonists, crack cocaine, LSD, and methamphetamine.17
Freedom, rebellion, glamour
Sales have risen rapidly since 2007 with widespread advertising on television and in print publications for popular brands, often featuring celebrities.20 Spending on advertising for e-cigarettes and vape devices rose from $6.4 million in 2011 to $115 million in 2014—and that was before the advent of Juul (see below).21
Marketing campaigns for vaping devices mimic the themes previously used successfully by the tobacco industry, eg, freedom, rebellion, and glamour. They also make unsubstantiated claims about health benefits and smoking cessation, though initial websites contained endorsements from physicians, similar to the strategies of tobacco companies in old cigarette ads. Cigarette ads have been prohibited since 1971—but not e-cigarette ads. Moreover, vaping products appear as product placements in television shows and movies, with advocacy groups on social media.22
By law, buyers have to be 18 or 21
Vaping devices can be purchased at vape shops, convenience stores, gas stations, and over the Internet; up to 50% of sales are conducted online.24
Fruit flavors are popular
Zhu et al25 estimated that 7,700 unique vaping flavors exist, with fruit and candy flavors predominating. The most popular flavors are tobacco and mint, followed by fruit, dessert and candy flavors, alcoholic flavors (strawberry daiquiri, margarita), and food flavors.25 These flavors have been associated with higher usage in youth, leading to increased risk of nicotine addiction.26
WHAT IS JUUL?
The Juul device (Juul Labs, www.juul.com) was developed in 2015 by 2 Stanford University graduates. Their goal was to produce a more satisfying and cigarette-like vaping experience, specifically by increasing the amount of nicotine delivered while maintaining smooth and pleasant inhalation. They created an e-liquid that could be vaporized effectively at lower temperatures.27
While more than 400 brands of vaping devices are currently available in the United States,3 Juul has held the largest market share since 2017,28 an estimated 72.1% as of August 2018.29 The surge in popularity of this particular brand is attributed to its trendy design that is similar in size and appearance to a USB flash drive,29 and its offering of sweet flavors such as “crème brûlée” and “cool mint.”
On April 24, 2018, in view of growing concern about the popularity of Juul products among youth, the FDA requested that the company submit documents regarding its marketing tactics, as well as research on the effects of this marketing on product design and public health impact, and information about adverse experiences and complaints.30 The company was forced to change its marketing to appeal less to youth. Now it offers only 3 flavors: “Virginia tobacco,” “classic tobacco,” and “menthol,” although off-brand pods containing a variety of flavors are still available. And some pods are refillable, so users can essentially vape any substance they want.
Although the Juul device delivers a strong dose of nicotine, it is small and therefore easy to hide from parents and teachers, and widespread use has been reported among youth in middle and high schools. Hoodies, hemp jewelry, and backpacks have been designed to hide the devices and allow for easy, hands-free use. YouTube searches for terms such as “Juul,” “hiding Juul at school,” and “Juul in class,” yield thousands of results.31 A 2017 survey reported that 8% of Americans age 15 to 24 had used Juul in the month prior to the survey.32 “To juul” has become a verb.
Each Juul starter kit contains the rechargeable inhalation device plus 4 flavored pods. In the United States, each Juul pod contains nearly as much nicotine as 1 pack of 20 cigarettes in a concentration of 3% or 5%. (Israel and Europe have forced the company to replace the 5% nicotine pods with 1.7% nicotine pods.33) A starter kit costs $49.99, and additional packs of 4 flavored liquid cartridges or pods cost $15.99.34 Other brands of vape pens cost between $15 and $35, and 10-mL bottles of e-liquid cost approximately $7.
What is ‘dripping’?
Hard-core vapers seeking a more intense experience are taking their vaping devices apart and modifying them for “dripping,” ie, directly dripping vape liquids onto the heated coils for inhalation. In a survey, 1 in 4 high school students using vape devices also used them for dripping, citing desires for a thicker cloud of vapor, more intense flavor, “a stronger throat hit,” curiosity, and other reasons.35 Dripping involves higher temperatures, which leads to higher amounts of nicotine delivered, along with more formaldehyde, acetaldehyde, and acetone (see below).36
BAD THINGS IN E-LIQUID AEROSOL
Studies of vape liquids consistently confirm the presence of toxic substances in the resulting vape aerosol.37–40 Depending on the combination of flavorings and solvents in a given e-liquid, a variety of chemicals can be detected in the aerosol from various vaping devices. Chemicals that may be detected include known irritants of respiratory mucosa, as well as various carcinogens. The list includes:
- Organic volatile compounds such as propylene glycol, glycerin, and toluene
- Aldehydes such as formaldehyde (released when propylene glycol is heated to high temperatures), acetaldehyde, and benzaldehyde
- Acetone and acrolein
- Carcinogenic nitrosamines
- Polycyclic aromatic hydrocarbons
- Particulate matter
- Metals including chromium, cadmium, nickel, and lead; and particles of copper, nickel, and silver have been found in electronic nicotine delivery system aerosol in higher levels than in conventional cigarette smoke.41
The specific chemicals detected can vary greatly between brands, even when the flavoring and nicotine content are equivalent, which frequently results in inconsistent and conflicting study findings. The chemicals detected also vary with the voltage or power used to generate the aerosol. Different flavors may carry varying levels of risk; for example, mint- and menthol-flavored e-cigarettes were shown to expose users to dangerous levels of pulegone, a carcinogenic compound banned as a food additive in 2018.42 The concentrations of some of these chemicals are sufficiently high to be of toxicologic concern; for example, one study reported the presence of benzaldehyde in e-cigarette aerosol at twice the workplace exposure limit.43
Biologic effects
In an in vitro study,44 57% of e-liquids studied were found to be cytotoxic to human pulmonary fibroblasts, lung epithelial cells, and human embryonic stem cells. Fruit-flavored e-liquids in particular caused a significant increase in DNA fragmentation. Cell cultures treated with e-cigarette liquids showed increased oxidative stress, reduced cell proliferation, and increased DNA damage,44 which may have implications for carcinogenic risk.
In another study,45 exposure to e-cigarette aerosol as well as conventional cigarette smoke resulted in suppression of genes related to immune and inflammatory response in respiratory epithelial cells. All genes with decreased expression after exposure to conventional cigarette smoke also showed decreased expression with exposure to e-cigarette smoke, which the study authors suggested could lead to immune suppression at the level of the nasal mucosa. Diacetyl and acetoin, chemicals found in certain flavorings, have been linked to bronchiolitis obliterans, or “popcorn lung.”46
Nicotine is not benign
The nicotine itself in many vaping liquids should also not be underestimated. Nicotine has harmful neurocognitive effects and addictive properties, particularly in the developing brains of adolescents and young adults.47 Nicotine exposure during adolescence negatively affects memory, attention, and emotional regulation,48 as well as executive functioning, reward processing, and learning.49
The brain undergoes major structural remodeling in adolescence, and nicotine acetylcholine receptors regulate neural maturation. Early exposure to nicotine disrupts this process, leading to poor executive functioning, difficulty learning, decreased memory, and issues with reward processing.
Fetal exposure, if nicotine products are used during pregnancy, has also been linked to adverse consequences such as deficits in attention and cognition, behavioral effects, and sudden infant death syndrome.5
Much to learn about toxicity
Partly because vaping devices have been available to US consumers only since 2007, limited evidence is available regarding the long-term effects of exposure to the aerosol from these devices in humans.1 Many of the studies mentioned above were in vitro studies or conducted in mouse models. Differences in device design and the composition of the e-liquid among device brands pose a challenge for developing well-designed studies of the long-term health effects of e-cigarette and vape use. Additionally, devices may have different health impacts when used to vape cannabis or other drugs besides nicotine, which requires further investigation.
E-CIGARETTES AND SMOKING CESSATION
Conventional cigarette smoking is a major public health threat, as tobacco use is responsible for 480,000 deaths annually in the United States.50
And smoking is extremely difficult to quit: as many as 80% of smokers who attempt to quit resume smoking within the first month.51 The chance of successfully quitting improves by over 50% if the individual undergoes nicotine replacement therapy, and it improves even more with counseling.50
There are currently 5 types of FDA-approved nicotine replacement therapy products (gum, patch, lozenge, inhaler, nasal spray) to help with smoking cessation. In addition, 2 non-nicotine prescription drugs (varenicline and bupropion) have been approved for treating tobacco dependence.
Can vaping devices be added to the list of nicotine replacement therapy products? Although some manufacturers try to brand their devices as smoking cessation aids, in one study,52 one-third of e-cigarette users said they had either never used conventional cigarettes or had formerly smoked them.
Bullen et al53 randomized smokers interested in quitting to receive either e-cigarettes, nicotine patches, or placebo (nicotine-free) e-cigarettes and followed them for 6 months. Rates of tobacco cessation were less than predicted for the entire study population, resulting in insufficient power to determine the superiority of any single method, but the study authors concluded that nicotine e-cigarettes were “modestly effective” at helping smokers quit, and that abstinence rates may be similar to those with nicotine patches.53
Hajek et al54 randomized 886 smokers to e-cigarette or nicotine replacement products of their choice. After 1 year, 18% of e-cigarette users had stopped smoking, compared with 9.9% of nicotine replacement product users. However, 80% of the e-cigarette users were still using e-cigarettes after 1 year, while only 9% of nicotine replacement product users were still using nicotine replacement therapy products after 1 year.
While quitting conventional cigarette smoking altogether has widely established health benefits, little is known about the health benefits of transitioning from conventional cigarette smoking to reduced conventional cigarette smoking with concomitant use of e-cigarettes.
Campagna et al55 found no beneficial health effects in smokers who partially substituted conventional cigarettes for e-cigarettes.
Many studies found that smokers use e-cigarettes to maintain their habit instead of quitting entirely.56 It has been suggested that any slight increase in effectiveness in smoking cessation by using e-cigarettes compared with other nicotine replacement products could be linked to satisfying of the habitual smoking actions, such as inhaling and bringing the hand to the mouth,24 which are absent when using other nicotine replacement methods such as a nicotine patch.
As with safety information, long-term outcomes regarding the use of vape devices for smoking cessation have not been yet established, as this option is still relatively new.
VAPING AS A GATEWAY DRUG
Another worrisome trend involving electronic nicotine delivery systems is their marketing and branding, which appear to be aimed directly at adolescents and young adults. Juul and other similar products cannot be sold to anyone under the age of 18 (or 21 in 18 states, including California, Massachusetts, New York, and now Ohio). Despite this, Juul and similar products continue to increase in popularity among middle school and high school students.57
While smoking cessation and health improvement are cited as reasons for vaping among middle-aged and older adults, adolescents and young adults more often cite flavor, enjoyment, peer use, and curiosity as reasons for use.
Adolescents are more likely to report interest in trying a vape product flavored with menthol or fruit than tobacco, and commonly hold the belief that fruit-flavored e-cigarettes are less harmful than tobacco-flavored e-cigarettes.58 Harrell et al59 polled youth and young adults who used flavored e-cigarettes, and 78% said they would no longer use the product if their preferred flavor were not available. In September 2019, Michigan became the first state to ban the sale of flavored e-cigarettes in stores and online. Similar bills have been introduced in California, Massachusetts, and New York.60
Myths and misperceptions abound among youth regarding smoking vs vaping. Young people view regular cigarette smoking negatively, as causing cancer, bad breath, and asthma exacerbations. Meanwhile, they believe marijuana is safer and less addictive than traditional cigarette smoking.61 Youth exposed to e-cigarette advertisements viewed e-cigarettes as healthier, more enjoyable, “cool,” safe, and fun.61 The overall public health impact of increasing initiation of smoking, particularly among youth and young adults, should not be underestimated.
SECONDHAND VAPE AND OTHER EXPOSURE RISKS
Cigarette smoking has been banned in many public places, in view of a large body of scientific evidence about the harmful effects of secondhand smoke. Advocates for allowing vaping in public places say that vaping emissions do not harm bystanders, but evidence is insufficient to support this claim.62 One study showed that passive exposure to e-cigarette aerosol generated increases in serum levels of cotinine (a nicotine metabolite) similar to those with passive exposure to conventional cigarette smoke.5
Accidental nicotine poisoning in children as a result of ingesting e-cigarette liquid is also a major concern,63 particularly with sweet flavors such as bubblegum or cheesecake that may be attractive to children.
Calls to US poison control centers with respect to e-cigarettes and vaping increased from 1 per month in September 2010 to 215 in February 2014, with 51% involving children under age 5.64 This trend resulted in the Child Nicotine Poisoning Prevention Act, which passed in 2015 and went into effect in 2016, requiring packaging that is difficult to open for children under age 5.5
Device malfunctions or battery failures have led to explosions that have resulted in substantial injuries to users, as well as house and car fires.49
HOW DO WE DISCOURAGE ADOLESCENT USE?
There are currently no established treatment approaches for adolescents who have become addicted to vaping. A review of the literature regarding treatment modalities used to address adolescent use of tobacco and marijuana provides insight that options such as nicotine replacement therapy and counseling modalities such as cognitive behavioral therapy may be helpful in treating teen vaping addiction. However, more research is needed to determine the effectiveness of these treatments in youth addicted to vaping.
Given that youth who vape even once are more likely to try other types of tobacco, we recommend that parents and healthcare providers start conversations by asking what the young person has seen or heard about vaping. Young people can also be asked what they think the school’s response should be: Do they think vaping should be banned in public places, as cigarettes have been banned? What about the carbon footprint? What are their thoughts on the plastic waste, batteries, and other toxins generated by the e-cigarette industry?
New US laws ban the sale of e-cigarettes and vaping devices to minors in stores and online. These policies are modeled in many cases on environmental control policies that have been previously employed to reduce tobacco use, particularly by youth. For example, changing laws to mandate sales only to individuals age 21 and older in all states can help to decrease access to these products among middle school and high school students.
As with tobacco cessation, education will not be enough. Support of legislation that bans vaping in public places, increases pricing to discourage adolescent use, and other measures used successfully to decrease conventional cigarette smoking can be deployed to decrease the public health impact of e-cigarettes. We recommend further regulation of specific harmful chemicals and clear, detailed ingredient labeling to increase consumer understanding of the risks associated with these products. Additionally, we recommend eliminating flavored e-cigarettes, which are the most appealing type for young users, and raising prices of e-cigarettes and similar products to discourage use by youth.
If current cigarette smokers want to use e-cigarettes to quit, we recommend that clinicians counsel them to eventually completely stop use of traditional cigarettes and switch to using e-cigarettes, instead of becoming a dual user of both types of products or using e-cigarettes indefinitely. After making that switch, they should then work to gradually taper usage and nicotine addiction by reducing the amount of nicotine in the e-liquid. Clinicians should ask patients about use of e-cigarettes and vaping devices specifically, and should counsel nonsmokers to avoid initiation of use.
EVIDENCE OF HARM CONTINUES TO EMERGE
Data about respiratory effects, secondhand exposure, and long-term smoking cessation efficacy are still limited, and it remains as yet unknown what combinations of solvents, flavorings, and nicotine in a given e-liquid will result in the most harmful or least harmful effects. In addition, while much of the information about the safety of these components has been obtained using in vitro or mouse models, increasing reports of serious respiratory illness and rising numbers of deaths linked to vaping make it clear that these findings likely translate to harmful effects in humans.
E-cigarettes may ultimately prove to be less harmful than traditional cigarettes, but it seems likely that with further time and research, serious health risks of e-cigarette use will continue to emerge.
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- US Public Health Services, US Department of Health and Human Services. E-cigarette use among youth and young adults: a report of the Surgeon General. Rockville, MD, U.S. Department of Health and Human Services, 2016. https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf. Accessed November 14, 2019.
- Thomas K, Kaplan S. E-cigarettes went unchecked in 10 years of federal inaction. New York Times Oct 14, 2019; updated November 1, 2019. www.nytimes.com/2019/10/14/health/vaping-e-cigarettes-fda.html.
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- Gentzke A, Creamer M, Cullen K, et al; Centers for Disease Control and Prevention. Vital signs: tobacco product use among middle and high school students—United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2019; 68(6):157–164. doi:10.15585/mmwr.mm6806e1
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- Christiani DC. Vaping-induced lung injury. N Engl J Med 2019; Sept 6. Epub ahead of print. doi:10.1056/NEJMe1912032
- Neel J, Aubrey A. Vitamin E suspected in serious lung problems among people who vaped cannabis. NPR Sept 5, 2019. www.npr.org/sections/health-shots/2019/09/05/758005409/vitamin-e-suspected-in-serious-lung-problems-among-people-who-vaped-cannabis. Accessed November 14, 2019.
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- Blundell MS, Dargan PI, Wood DM. The dark cloud of recreational drugs and vaping. QJM 2018; 111(3):145–148. doi:10.1093/qjmed/hcx049
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- Eggers ME, Lee YO, Jackson J, Wiley JL, Porter J, Nonnemaker JM. Youth use of electronic vapor products and blunts for administering cannabis. Addict Behav 2017; 70:79-82. doi:10.1016/j.addbeh.2017.02.020
- Regan AK, Promoff G, Dube SR, Arrazola R. Electronic nicotine delivery systems: adult use and awareness of the “e-cigarette”in the USA. Tob Control 2013; 22(1):19–23. doi:10.1136/tobaccocontrol-2011-050044
- Centers for Disease Control and Prevention. E-cigarette ads and youth. www.cdc.gov/vitalsigns/ecigarette-ads/index.html.
- Noel JK, Rees VW, Connolly GN. Electronic cigarettes: a new “tobacco” industry? Tob Control 2011; 20(1):81. doi:10.1136/tc.2010.038562
- US Food and Drug Administration. Deeming tobacco products to be subject to the federal food, drug, and cosmetic act, as amended by the family smoking prevention and tobacco control act; restrictions on the sale and distribution of tobacco products and required warning statements for tobacco products. Federal Register 2016; 81(90), May 10, 2016. www.govinfo.gov/content/pkg/FR-2016-05-10/pdf/2016-10685.pdf. Accessed November 14, 2019.
- Rom O, Pecorelli A, Valacchi G, Reznick AZ. Are e-cigarettes a safe and good alternative to cigarette smoking? Ann NY Acad Sci 2015; 1340:65–74. doi:10.1111/nyas.12609
- Zhu SH, Sun JY, Bonnevie E, et al. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob Control 2014; 23(suppl 3):iii3-iii9. doi:10.1136/tobaccocontrol-2014-051670
- Kong G, Morean ME, Cavallo DA, Camenga DR, Krishnan-Sarin S. Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults. Nicotine Tob Res 2015; 17(7):847–854. doi:10.1093/ntr/ntu257
- Baca MC. How two Stanford grads aimed for big tech glory and got big tobacco instead. Updated September 4, 2019. The Washington Post September 4, 2019. www.washingtonpost.com/technology/2019/09/04/how-two-stanford-grads-aimed-big-tech-glory-got-big-tobacco-instead. Accessed November 14, 2019.
- Huang J, Duan Z, Kwok J, et al. Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market. Tob Control 2019; 28(2):146–151. doi:10.1136/tobaccocontrol-2018-054382
- Walley SC, Wilson KM, Winickoff JP, Groner J. A public health crisis: electronic cigarettes, vape, and JUUL. Pediatrics 2019; 143(6):pii:e20182741. doi:10.1542/peds.2018-2741
- Zernike K. F.D.A. cracks down on “juuling” among teenagers. The New York Times April 24, 2018. www.nytimes.com/2018/04/24/health/fda-e-cigarettes-minors-juul.html. Accessed November 14, 2019.
- Ramamurthi D, Chau C, Jackler RK. JUUL and other stealth vaporisers: hiding the habit from parents and teachers. Tob Control 2018 Sep 15; pii:tobaccocontrol-2018-054455. doi:10.1136/tobaccocontrol-2018-054455. [Epub ahead of print]
- Willett JG, Bennett M, Hair EC, et al. Recognition, use and perceptions of JUUL among youth and young adults. Tob Control 2019; 28(1):115–116. doi:10.1136/tobaccocontrol-2018-054273
- Kaplan S. Juul’s new product: less nicotine, more intense vapor. New York Times Nov 27, 2018. www.nytimes.com/2018/11/27/health/juul-ecigarettes-nicotine.html.
- JUUL Labs. JUULpods. www.juul.com/shop/pods. Accessed November 14, 2019.
- Krishnan-Sarin S, Morean M, Kong G, et al. E-cigarettes and “dripping” among high-school youth. Pediatrics 2017; 139(3):pii:e20163224. doi:10.1542/peds.2016-3224
- Kosmider L, Sobczak A, Fik M, et al. Carbonyl compounds in electronic cigarette vapors: effects of nicotine solvent and battery output voltage. Nicotine Tob Res 2014; 16(10):1319–1326. doi:10.1093/ntr/ntu078
- Rawlinson C, Martin S, Frosina J, Wright C. Chemical characterisation of aerosols emitted by electronic cigarettes using thermal desorption-gas chromatography-time of flight mass spectrometry. J Chromatogr A 2017; 1497:144–154. doi:10.1016/j.chroma.2017.02.050
- Lee MS, LeBouf RF, Son YS, Koutrakis P, Christiani DC. Nicotine, aerosol particles, carbonyls and volatile organic compounds in tobacco- and menthol-flavored e-cigarettes. Environ Health 2017; 16(1):42. doi:10.1186/s12940-017-0249-x
- Williams M, Bozhilov K, Ghai S, Talbot P. Elements including metals in the atomizer and aerosol of disposable electronic cigarettes and electronic hookahs. PLoS One 2017; 12(4):e0175430. doi:10.1371/journal.pone.0175430.
- Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control 2014; 23(2):133–139. doi:10.1136/tobaccocontrol-2012-050859
- Drope J, Cahn Z, Kennedy R, et al. Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine. CA Cancer J Clin 2017; 67(6):449–471. doi:10.3322/caac.21413
- Jabba SV, Jordt SE. Risk analysis for the carcinogen pulegone in mint- and menthol-flavored e-cigarettes and smokeless tobacco products. JAMA Intern Med 2019 Sep 16 [Epub ahead of print]. doi:10.1001/jamainternmed.2019.3649
- Tierney PA, Karpinsky CD, Brown JE, Luo W, Pankow JF. Flavour chemicals in electronic cigarette fluids. Tob Control 2016; 25(e1):e10–e15. doi:10.1136/tobaccocontrol-2014-052175
- Behar RZ, Wang Y, Talbot P. Comparing the cytotoxicity of electronic cigarette fluids, aerosols and solvents. Tob Control 2017; 27(3):325–333. doi:10.1136/tobaccocontrol-2016-053472
- Martin EM, Clapp PW, Rebuli ME, et al. E-cigarette use results in suppression of immune and inflammatory-response genes in nasal epithelial cells similar to cigarette smoke. Am J Physiol Lung Cell Mol Physiol 2016; 311(1):L135–L144. doi:10.1152/ajplung.00170.2016
- Holden VK, Hines SE. Update on flavoring-induced lung disease. Curr Opin Pulm Med 2016;22(2):158–164. doi:10.1097/MCP.0000000000000250
- Siqueira L; Committee on Substance Use and Prevention. Nicotine and tobacco as substances of abuse in children and adolescents. Pediatrics 2017; 139(1):pii:e20163436. doi:10.1542/peds.2016-3436
- England LJ, Bunnell RE, Pechacek TF, Tong VT, McAfee TA. Nicotine and the developing human: a neglected element in the electronic cigarette debate. Am J Prev Med 2015; 49(2):286–293. doi:10.1016/j.amepre.2015.01.015
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- Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine replacement therapy. N Engl J Med 2019; 380(7):629–637. doi:10.1056/NEJMoa1808779
- Campagna D, Cibella F, Caponnetto P, et al. Changes in breathomics from a 1-year randomized smoking cessation trial of electronic cigarettes. Eur J Clin Invest 2016; 46(8):698–706. doi:10.1111/eci.12651
- Rehan HS, Maini J, Hungin APS. Vaping versus smoking: a quest for efficacy and safety of e-cigarette. Curr Drug Saf 2018; 13(2):92–101. doi:10.2174/1574886313666180227110556
- Zernike K. ‘I can’t stop’: schools struggle with vaping explosion. New York Times April 2, 2018. www.nytimes.com/2018/04/02/health/vaping-ecigarettes-addiction-teen.html.
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- Smith M. Amid vaping crackdown, Michigan to ban sale of flavored e-cigarettes. New York Times Sept 4, 2019. www.nytimes.com/2019/09/04/us/michigan-vaping.html?module=inline.
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Electronic cigarettes and other “vaping” devices have been increasing in popularity among youth and adults since their introduction in the US market in 2007.1 This increase is partially driven by a public perception that vaping is harmless, or at least less harmful than cigarette smoking.2 Vaping fans also argue that current smokers can use vaping as nicotine replacement therapy to help them quit smoking.3
We disagree. Research on the health effects of vaping, though still limited, is accumulating rapidly and making it increasingly clear that this habit is far from harmless. For youth, it is a gateway to addiction to nicotine and other substances. Whether it can help people quit smoking remains to be seen. And recent months have seen reports of serious respiratory illnesses and even deaths linked to vaping.4
In December 2016, the US Surgeon General warned that e-cigarette use among youth and young adults in the United States represents a “major public health concern,”5 and that more adolescents and young adults are now vaping than smoking conventional tobacco products.
This article reviews the issue of vaping in the United States, as well as available evidence regarding its safety.
YOUTH AT RISK
Retail sales of e-cigarettes and vaping devices approach an annual $7 billion.6 A 2014–2015 survey found that 2.4% of the general US population were current users of e-cigarettes, and 8.5% had tried them at least once.3
In 2014, for the first time, e-cigarette use became more common among US youth than traditional cigarettes.5
The odds of taking up vaping are higher among minority youth in the United States, particularly Hispanics.9 This trend is particularly worrisome because several longitudinal studies have shown that adolescents who use e-cigarettes are 3 times as likely to eventually become smokers of traditional cigarettes compared with adolescents who do not use e-cigarettes.10–12
If US youth continue smoking at the current rate, 5.6 million of the current population under age 18, or 1 of every 13, will die early of a smoking-related illness.13
RECENT OUTBREAK OF VAPING-ASSOCIATED LUNG INJURY
As of November 5, 2019, there had been 2,051 cases of vaping-associated lung injury in 49 states (all except Alaska), the District of Columbia, and 1 US territory reported to the US Centers for Disease Control and Prevention (CDC), with 39 confirmed deaths.4 The reported cases include respiratory injury including acute eosinophilic pneumonia, organizing pneumonia, acute respiratory distress syndrome, and hypersensitivity pneumonitis.14
Most of these patients had been vaping tetrahydrocannabinol (THC), though many used both nicotine- and THC-containing products, and others used products containing nicotine exclusively.4 Thus, it is difficult to identify the exact substance or substances that may be contributing to this sudden outbreak among vape users, and many different product sources are currently under investigation.
One substance that may be linked to the epidemic is vitamin E acetate, which the New York State Department of Health has detected in high levels in cannabis vaping cartridges used by patients who developed lung injury.15 The US Food and Drug Administration (FDA) is continuing to analyze vape cartridge samples submitted by affected patients to look for other chemicals that can contribute to the development of serious pulmonary illness.
WHAT IS AN E-CIGARETTE? WHAT IS A VAPE PEN?
Vape pens consist of similar elements but are not necessarily similar in appearance to a conventional cigarette, and may look more like a pen or a USB flash drive. In fact, the Juul device is recharged by plugging it into a USB port.
Vaping devices have many street names, including e-cigs, e-hookahs, vape pens, mods, vapes, and tank systems.
The first US patent application for a device resembling a modern e-cigarette was filed in 1963, but the product never made it to the market.16 Instead, the first commercially successful e-cigarette was created in Beijing in 2003 and introduced to US markets in 2007.
Newer-generation devices have larger batteries and can heat the liquid to higher temperatures, releasing more nicotine and forming additional toxicants such as formaldehyde. Devices lack standardization in terms of design, capacity for safely holding e-liquid, packaging of the e-liquid, and features designed to minimize hazards of use.
Not just nicotine
Many devices are designed for use with other drugs, including THC.17 In a 2018 study, 10.9% of college students reported vaping marijuana in the past 30 days, up from 5.2% in 2017.18
Other substances are being vaped as well.19 In theory, any heat-stable psychoactive recreational drug could be aerosolized and vaped. There are increasing reports of e-liquids containing recreational drugs such as synthetic cannabinoid receptor agonists, crack cocaine, LSD, and methamphetamine.17
Freedom, rebellion, glamour
Sales have risen rapidly since 2007 with widespread advertising on television and in print publications for popular brands, often featuring celebrities.20 Spending on advertising for e-cigarettes and vape devices rose from $6.4 million in 2011 to $115 million in 2014—and that was before the advent of Juul (see below).21
Marketing campaigns for vaping devices mimic the themes previously used successfully by the tobacco industry, eg, freedom, rebellion, and glamour. They also make unsubstantiated claims about health benefits and smoking cessation, though initial websites contained endorsements from physicians, similar to the strategies of tobacco companies in old cigarette ads. Cigarette ads have been prohibited since 1971—but not e-cigarette ads. Moreover, vaping products appear as product placements in television shows and movies, with advocacy groups on social media.22
By law, buyers have to be 18 or 21
Vaping devices can be purchased at vape shops, convenience stores, gas stations, and over the Internet; up to 50% of sales are conducted online.24
Fruit flavors are popular
Zhu et al25 estimated that 7,700 unique vaping flavors exist, with fruit and candy flavors predominating. The most popular flavors are tobacco and mint, followed by fruit, dessert and candy flavors, alcoholic flavors (strawberry daiquiri, margarita), and food flavors.25 These flavors have been associated with higher usage in youth, leading to increased risk of nicotine addiction.26
WHAT IS JUUL?
The Juul device (Juul Labs, www.juul.com) was developed in 2015 by 2 Stanford University graduates. Their goal was to produce a more satisfying and cigarette-like vaping experience, specifically by increasing the amount of nicotine delivered while maintaining smooth and pleasant inhalation. They created an e-liquid that could be vaporized effectively at lower temperatures.27
While more than 400 brands of vaping devices are currently available in the United States,3 Juul has held the largest market share since 2017,28 an estimated 72.1% as of August 2018.29 The surge in popularity of this particular brand is attributed to its trendy design that is similar in size and appearance to a USB flash drive,29 and its offering of sweet flavors such as “crème brûlée” and “cool mint.”
On April 24, 2018, in view of growing concern about the popularity of Juul products among youth, the FDA requested that the company submit documents regarding its marketing tactics, as well as research on the effects of this marketing on product design and public health impact, and information about adverse experiences and complaints.30 The company was forced to change its marketing to appeal less to youth. Now it offers only 3 flavors: “Virginia tobacco,” “classic tobacco,” and “menthol,” although off-brand pods containing a variety of flavors are still available. And some pods are refillable, so users can essentially vape any substance they want.
Although the Juul device delivers a strong dose of nicotine, it is small and therefore easy to hide from parents and teachers, and widespread use has been reported among youth in middle and high schools. Hoodies, hemp jewelry, and backpacks have been designed to hide the devices and allow for easy, hands-free use. YouTube searches for terms such as “Juul,” “hiding Juul at school,” and “Juul in class,” yield thousands of results.31 A 2017 survey reported that 8% of Americans age 15 to 24 had used Juul in the month prior to the survey.32 “To juul” has become a verb.
Each Juul starter kit contains the rechargeable inhalation device plus 4 flavored pods. In the United States, each Juul pod contains nearly as much nicotine as 1 pack of 20 cigarettes in a concentration of 3% or 5%. (Israel and Europe have forced the company to replace the 5% nicotine pods with 1.7% nicotine pods.33) A starter kit costs $49.99, and additional packs of 4 flavored liquid cartridges or pods cost $15.99.34 Other brands of vape pens cost between $15 and $35, and 10-mL bottles of e-liquid cost approximately $7.
What is ‘dripping’?
Hard-core vapers seeking a more intense experience are taking their vaping devices apart and modifying them for “dripping,” ie, directly dripping vape liquids onto the heated coils for inhalation. In a survey, 1 in 4 high school students using vape devices also used them for dripping, citing desires for a thicker cloud of vapor, more intense flavor, “a stronger throat hit,” curiosity, and other reasons.35 Dripping involves higher temperatures, which leads to higher amounts of nicotine delivered, along with more formaldehyde, acetaldehyde, and acetone (see below).36
BAD THINGS IN E-LIQUID AEROSOL
Studies of vape liquids consistently confirm the presence of toxic substances in the resulting vape aerosol.37–40 Depending on the combination of flavorings and solvents in a given e-liquid, a variety of chemicals can be detected in the aerosol from various vaping devices. Chemicals that may be detected include known irritants of respiratory mucosa, as well as various carcinogens. The list includes:
- Organic volatile compounds such as propylene glycol, glycerin, and toluene
- Aldehydes such as formaldehyde (released when propylene glycol is heated to high temperatures), acetaldehyde, and benzaldehyde
- Acetone and acrolein
- Carcinogenic nitrosamines
- Polycyclic aromatic hydrocarbons
- Particulate matter
- Metals including chromium, cadmium, nickel, and lead; and particles of copper, nickel, and silver have been found in electronic nicotine delivery system aerosol in higher levels than in conventional cigarette smoke.41
The specific chemicals detected can vary greatly between brands, even when the flavoring and nicotine content are equivalent, which frequently results in inconsistent and conflicting study findings. The chemicals detected also vary with the voltage or power used to generate the aerosol. Different flavors may carry varying levels of risk; for example, mint- and menthol-flavored e-cigarettes were shown to expose users to dangerous levels of pulegone, a carcinogenic compound banned as a food additive in 2018.42 The concentrations of some of these chemicals are sufficiently high to be of toxicologic concern; for example, one study reported the presence of benzaldehyde in e-cigarette aerosol at twice the workplace exposure limit.43
Biologic effects
In an in vitro study,44 57% of e-liquids studied were found to be cytotoxic to human pulmonary fibroblasts, lung epithelial cells, and human embryonic stem cells. Fruit-flavored e-liquids in particular caused a significant increase in DNA fragmentation. Cell cultures treated with e-cigarette liquids showed increased oxidative stress, reduced cell proliferation, and increased DNA damage,44 which may have implications for carcinogenic risk.
In another study,45 exposure to e-cigarette aerosol as well as conventional cigarette smoke resulted in suppression of genes related to immune and inflammatory response in respiratory epithelial cells. All genes with decreased expression after exposure to conventional cigarette smoke also showed decreased expression with exposure to e-cigarette smoke, which the study authors suggested could lead to immune suppression at the level of the nasal mucosa. Diacetyl and acetoin, chemicals found in certain flavorings, have been linked to bronchiolitis obliterans, or “popcorn lung.”46
Nicotine is not benign
The nicotine itself in many vaping liquids should also not be underestimated. Nicotine has harmful neurocognitive effects and addictive properties, particularly in the developing brains of adolescents and young adults.47 Nicotine exposure during adolescence negatively affects memory, attention, and emotional regulation,48 as well as executive functioning, reward processing, and learning.49
The brain undergoes major structural remodeling in adolescence, and nicotine acetylcholine receptors regulate neural maturation. Early exposure to nicotine disrupts this process, leading to poor executive functioning, difficulty learning, decreased memory, and issues with reward processing.
Fetal exposure, if nicotine products are used during pregnancy, has also been linked to adverse consequences such as deficits in attention and cognition, behavioral effects, and sudden infant death syndrome.5
Much to learn about toxicity
Partly because vaping devices have been available to US consumers only since 2007, limited evidence is available regarding the long-term effects of exposure to the aerosol from these devices in humans.1 Many of the studies mentioned above were in vitro studies or conducted in mouse models. Differences in device design and the composition of the e-liquid among device brands pose a challenge for developing well-designed studies of the long-term health effects of e-cigarette and vape use. Additionally, devices may have different health impacts when used to vape cannabis or other drugs besides nicotine, which requires further investigation.
E-CIGARETTES AND SMOKING CESSATION
Conventional cigarette smoking is a major public health threat, as tobacco use is responsible for 480,000 deaths annually in the United States.50
And smoking is extremely difficult to quit: as many as 80% of smokers who attempt to quit resume smoking within the first month.51 The chance of successfully quitting improves by over 50% if the individual undergoes nicotine replacement therapy, and it improves even more with counseling.50
There are currently 5 types of FDA-approved nicotine replacement therapy products (gum, patch, lozenge, inhaler, nasal spray) to help with smoking cessation. In addition, 2 non-nicotine prescription drugs (varenicline and bupropion) have been approved for treating tobacco dependence.
Can vaping devices be added to the list of nicotine replacement therapy products? Although some manufacturers try to brand their devices as smoking cessation aids, in one study,52 one-third of e-cigarette users said they had either never used conventional cigarettes or had formerly smoked them.
Bullen et al53 randomized smokers interested in quitting to receive either e-cigarettes, nicotine patches, or placebo (nicotine-free) e-cigarettes and followed them for 6 months. Rates of tobacco cessation were less than predicted for the entire study population, resulting in insufficient power to determine the superiority of any single method, but the study authors concluded that nicotine e-cigarettes were “modestly effective” at helping smokers quit, and that abstinence rates may be similar to those with nicotine patches.53
Hajek et al54 randomized 886 smokers to e-cigarette or nicotine replacement products of their choice. After 1 year, 18% of e-cigarette users had stopped smoking, compared with 9.9% of nicotine replacement product users. However, 80% of the e-cigarette users were still using e-cigarettes after 1 year, while only 9% of nicotine replacement product users were still using nicotine replacement therapy products after 1 year.
While quitting conventional cigarette smoking altogether has widely established health benefits, little is known about the health benefits of transitioning from conventional cigarette smoking to reduced conventional cigarette smoking with concomitant use of e-cigarettes.
Campagna et al55 found no beneficial health effects in smokers who partially substituted conventional cigarettes for e-cigarettes.
Many studies found that smokers use e-cigarettes to maintain their habit instead of quitting entirely.56 It has been suggested that any slight increase in effectiveness in smoking cessation by using e-cigarettes compared with other nicotine replacement products could be linked to satisfying of the habitual smoking actions, such as inhaling and bringing the hand to the mouth,24 which are absent when using other nicotine replacement methods such as a nicotine patch.
As with safety information, long-term outcomes regarding the use of vape devices for smoking cessation have not been yet established, as this option is still relatively new.
VAPING AS A GATEWAY DRUG
Another worrisome trend involving electronic nicotine delivery systems is their marketing and branding, which appear to be aimed directly at adolescents and young adults. Juul and other similar products cannot be sold to anyone under the age of 18 (or 21 in 18 states, including California, Massachusetts, New York, and now Ohio). Despite this, Juul and similar products continue to increase in popularity among middle school and high school students.57
While smoking cessation and health improvement are cited as reasons for vaping among middle-aged and older adults, adolescents and young adults more often cite flavor, enjoyment, peer use, and curiosity as reasons for use.
Adolescents are more likely to report interest in trying a vape product flavored with menthol or fruit than tobacco, and commonly hold the belief that fruit-flavored e-cigarettes are less harmful than tobacco-flavored e-cigarettes.58 Harrell et al59 polled youth and young adults who used flavored e-cigarettes, and 78% said they would no longer use the product if their preferred flavor were not available. In September 2019, Michigan became the first state to ban the sale of flavored e-cigarettes in stores and online. Similar bills have been introduced in California, Massachusetts, and New York.60
Myths and misperceptions abound among youth regarding smoking vs vaping. Young people view regular cigarette smoking negatively, as causing cancer, bad breath, and asthma exacerbations. Meanwhile, they believe marijuana is safer and less addictive than traditional cigarette smoking.61 Youth exposed to e-cigarette advertisements viewed e-cigarettes as healthier, more enjoyable, “cool,” safe, and fun.61 The overall public health impact of increasing initiation of smoking, particularly among youth and young adults, should not be underestimated.
SECONDHAND VAPE AND OTHER EXPOSURE RISKS
Cigarette smoking has been banned in many public places, in view of a large body of scientific evidence about the harmful effects of secondhand smoke. Advocates for allowing vaping in public places say that vaping emissions do not harm bystanders, but evidence is insufficient to support this claim.62 One study showed that passive exposure to e-cigarette aerosol generated increases in serum levels of cotinine (a nicotine metabolite) similar to those with passive exposure to conventional cigarette smoke.5
Accidental nicotine poisoning in children as a result of ingesting e-cigarette liquid is also a major concern,63 particularly with sweet flavors such as bubblegum or cheesecake that may be attractive to children.
Calls to US poison control centers with respect to e-cigarettes and vaping increased from 1 per month in September 2010 to 215 in February 2014, with 51% involving children under age 5.64 This trend resulted in the Child Nicotine Poisoning Prevention Act, which passed in 2015 and went into effect in 2016, requiring packaging that is difficult to open for children under age 5.5
Device malfunctions or battery failures have led to explosions that have resulted in substantial injuries to users, as well as house and car fires.49
HOW DO WE DISCOURAGE ADOLESCENT USE?
There are currently no established treatment approaches for adolescents who have become addicted to vaping. A review of the literature regarding treatment modalities used to address adolescent use of tobacco and marijuana provides insight that options such as nicotine replacement therapy and counseling modalities such as cognitive behavioral therapy may be helpful in treating teen vaping addiction. However, more research is needed to determine the effectiveness of these treatments in youth addicted to vaping.
Given that youth who vape even once are more likely to try other types of tobacco, we recommend that parents and healthcare providers start conversations by asking what the young person has seen or heard about vaping. Young people can also be asked what they think the school’s response should be: Do they think vaping should be banned in public places, as cigarettes have been banned? What about the carbon footprint? What are their thoughts on the plastic waste, batteries, and other toxins generated by the e-cigarette industry?
New US laws ban the sale of e-cigarettes and vaping devices to minors in stores and online. These policies are modeled in many cases on environmental control policies that have been previously employed to reduce tobacco use, particularly by youth. For example, changing laws to mandate sales only to individuals age 21 and older in all states can help to decrease access to these products among middle school and high school students.
As with tobacco cessation, education will not be enough. Support of legislation that bans vaping in public places, increases pricing to discourage adolescent use, and other measures used successfully to decrease conventional cigarette smoking can be deployed to decrease the public health impact of e-cigarettes. We recommend further regulation of specific harmful chemicals and clear, detailed ingredient labeling to increase consumer understanding of the risks associated with these products. Additionally, we recommend eliminating flavored e-cigarettes, which are the most appealing type for young users, and raising prices of e-cigarettes and similar products to discourage use by youth.
If current cigarette smokers want to use e-cigarettes to quit, we recommend that clinicians counsel them to eventually completely stop use of traditional cigarettes and switch to using e-cigarettes, instead of becoming a dual user of both types of products or using e-cigarettes indefinitely. After making that switch, they should then work to gradually taper usage and nicotine addiction by reducing the amount of nicotine in the e-liquid. Clinicians should ask patients about use of e-cigarettes and vaping devices specifically, and should counsel nonsmokers to avoid initiation of use.
EVIDENCE OF HARM CONTINUES TO EMERGE
Data about respiratory effects, secondhand exposure, and long-term smoking cessation efficacy are still limited, and it remains as yet unknown what combinations of solvents, flavorings, and nicotine in a given e-liquid will result in the most harmful or least harmful effects. In addition, while much of the information about the safety of these components has been obtained using in vitro or mouse models, increasing reports of serious respiratory illness and rising numbers of deaths linked to vaping make it clear that these findings likely translate to harmful effects in humans.
E-cigarettes may ultimately prove to be less harmful than traditional cigarettes, but it seems likely that with further time and research, serious health risks of e-cigarette use will continue to emerge.
Electronic cigarettes and other “vaping” devices have been increasing in popularity among youth and adults since their introduction in the US market in 2007.1 This increase is partially driven by a public perception that vaping is harmless, or at least less harmful than cigarette smoking.2 Vaping fans also argue that current smokers can use vaping as nicotine replacement therapy to help them quit smoking.3
We disagree. Research on the health effects of vaping, though still limited, is accumulating rapidly and making it increasingly clear that this habit is far from harmless. For youth, it is a gateway to addiction to nicotine and other substances. Whether it can help people quit smoking remains to be seen. And recent months have seen reports of serious respiratory illnesses and even deaths linked to vaping.4
In December 2016, the US Surgeon General warned that e-cigarette use among youth and young adults in the United States represents a “major public health concern,”5 and that more adolescents and young adults are now vaping than smoking conventional tobacco products.
This article reviews the issue of vaping in the United States, as well as available evidence regarding its safety.
YOUTH AT RISK
Retail sales of e-cigarettes and vaping devices approach an annual $7 billion.6 A 2014–2015 survey found that 2.4% of the general US population were current users of e-cigarettes, and 8.5% had tried them at least once.3
In 2014, for the first time, e-cigarette use became more common among US youth than traditional cigarettes.5
The odds of taking up vaping are higher among minority youth in the United States, particularly Hispanics.9 This trend is particularly worrisome because several longitudinal studies have shown that adolescents who use e-cigarettes are 3 times as likely to eventually become smokers of traditional cigarettes compared with adolescents who do not use e-cigarettes.10–12
If US youth continue smoking at the current rate, 5.6 million of the current population under age 18, or 1 of every 13, will die early of a smoking-related illness.13
RECENT OUTBREAK OF VAPING-ASSOCIATED LUNG INJURY
As of November 5, 2019, there had been 2,051 cases of vaping-associated lung injury in 49 states (all except Alaska), the District of Columbia, and 1 US territory reported to the US Centers for Disease Control and Prevention (CDC), with 39 confirmed deaths.4 The reported cases include respiratory injury including acute eosinophilic pneumonia, organizing pneumonia, acute respiratory distress syndrome, and hypersensitivity pneumonitis.14
Most of these patients had been vaping tetrahydrocannabinol (THC), though many used both nicotine- and THC-containing products, and others used products containing nicotine exclusively.4 Thus, it is difficult to identify the exact substance or substances that may be contributing to this sudden outbreak among vape users, and many different product sources are currently under investigation.
One substance that may be linked to the epidemic is vitamin E acetate, which the New York State Department of Health has detected in high levels in cannabis vaping cartridges used by patients who developed lung injury.15 The US Food and Drug Administration (FDA) is continuing to analyze vape cartridge samples submitted by affected patients to look for other chemicals that can contribute to the development of serious pulmonary illness.
WHAT IS AN E-CIGARETTE? WHAT IS A VAPE PEN?
Vape pens consist of similar elements but are not necessarily similar in appearance to a conventional cigarette, and may look more like a pen or a USB flash drive. In fact, the Juul device is recharged by plugging it into a USB port.
Vaping devices have many street names, including e-cigs, e-hookahs, vape pens, mods, vapes, and tank systems.
The first US patent application for a device resembling a modern e-cigarette was filed in 1963, but the product never made it to the market.16 Instead, the first commercially successful e-cigarette was created in Beijing in 2003 and introduced to US markets in 2007.
Newer-generation devices have larger batteries and can heat the liquid to higher temperatures, releasing more nicotine and forming additional toxicants such as formaldehyde. Devices lack standardization in terms of design, capacity for safely holding e-liquid, packaging of the e-liquid, and features designed to minimize hazards of use.
Not just nicotine
Many devices are designed for use with other drugs, including THC.17 In a 2018 study, 10.9% of college students reported vaping marijuana in the past 30 days, up from 5.2% in 2017.18
Other substances are being vaped as well.19 In theory, any heat-stable psychoactive recreational drug could be aerosolized and vaped. There are increasing reports of e-liquids containing recreational drugs such as synthetic cannabinoid receptor agonists, crack cocaine, LSD, and methamphetamine.17
Freedom, rebellion, glamour
Sales have risen rapidly since 2007 with widespread advertising on television and in print publications for popular brands, often featuring celebrities.20 Spending on advertising for e-cigarettes and vape devices rose from $6.4 million in 2011 to $115 million in 2014—and that was before the advent of Juul (see below).21
Marketing campaigns for vaping devices mimic the themes previously used successfully by the tobacco industry, eg, freedom, rebellion, and glamour. They also make unsubstantiated claims about health benefits and smoking cessation, though initial websites contained endorsements from physicians, similar to the strategies of tobacco companies in old cigarette ads. Cigarette ads have been prohibited since 1971—but not e-cigarette ads. Moreover, vaping products appear as product placements in television shows and movies, with advocacy groups on social media.22
By law, buyers have to be 18 or 21
Vaping devices can be purchased at vape shops, convenience stores, gas stations, and over the Internet; up to 50% of sales are conducted online.24
Fruit flavors are popular
Zhu et al25 estimated that 7,700 unique vaping flavors exist, with fruit and candy flavors predominating. The most popular flavors are tobacco and mint, followed by fruit, dessert and candy flavors, alcoholic flavors (strawberry daiquiri, margarita), and food flavors.25 These flavors have been associated with higher usage in youth, leading to increased risk of nicotine addiction.26
WHAT IS JUUL?
The Juul device (Juul Labs, www.juul.com) was developed in 2015 by 2 Stanford University graduates. Their goal was to produce a more satisfying and cigarette-like vaping experience, specifically by increasing the amount of nicotine delivered while maintaining smooth and pleasant inhalation. They created an e-liquid that could be vaporized effectively at lower temperatures.27
While more than 400 brands of vaping devices are currently available in the United States,3 Juul has held the largest market share since 2017,28 an estimated 72.1% as of August 2018.29 The surge in popularity of this particular brand is attributed to its trendy design that is similar in size and appearance to a USB flash drive,29 and its offering of sweet flavors such as “crème brûlée” and “cool mint.”
On April 24, 2018, in view of growing concern about the popularity of Juul products among youth, the FDA requested that the company submit documents regarding its marketing tactics, as well as research on the effects of this marketing on product design and public health impact, and information about adverse experiences and complaints.30 The company was forced to change its marketing to appeal less to youth. Now it offers only 3 flavors: “Virginia tobacco,” “classic tobacco,” and “menthol,” although off-brand pods containing a variety of flavors are still available. And some pods are refillable, so users can essentially vape any substance they want.
Although the Juul device delivers a strong dose of nicotine, it is small and therefore easy to hide from parents and teachers, and widespread use has been reported among youth in middle and high schools. Hoodies, hemp jewelry, and backpacks have been designed to hide the devices and allow for easy, hands-free use. YouTube searches for terms such as “Juul,” “hiding Juul at school,” and “Juul in class,” yield thousands of results.31 A 2017 survey reported that 8% of Americans age 15 to 24 had used Juul in the month prior to the survey.32 “To juul” has become a verb.
Each Juul starter kit contains the rechargeable inhalation device plus 4 flavored pods. In the United States, each Juul pod contains nearly as much nicotine as 1 pack of 20 cigarettes in a concentration of 3% or 5%. (Israel and Europe have forced the company to replace the 5% nicotine pods with 1.7% nicotine pods.33) A starter kit costs $49.99, and additional packs of 4 flavored liquid cartridges or pods cost $15.99.34 Other brands of vape pens cost between $15 and $35, and 10-mL bottles of e-liquid cost approximately $7.
What is ‘dripping’?
Hard-core vapers seeking a more intense experience are taking their vaping devices apart and modifying them for “dripping,” ie, directly dripping vape liquids onto the heated coils for inhalation. In a survey, 1 in 4 high school students using vape devices also used them for dripping, citing desires for a thicker cloud of vapor, more intense flavor, “a stronger throat hit,” curiosity, and other reasons.35 Dripping involves higher temperatures, which leads to higher amounts of nicotine delivered, along with more formaldehyde, acetaldehyde, and acetone (see below).36
BAD THINGS IN E-LIQUID AEROSOL
Studies of vape liquids consistently confirm the presence of toxic substances in the resulting vape aerosol.37–40 Depending on the combination of flavorings and solvents in a given e-liquid, a variety of chemicals can be detected in the aerosol from various vaping devices. Chemicals that may be detected include known irritants of respiratory mucosa, as well as various carcinogens. The list includes:
- Organic volatile compounds such as propylene glycol, glycerin, and toluene
- Aldehydes such as formaldehyde (released when propylene glycol is heated to high temperatures), acetaldehyde, and benzaldehyde
- Acetone and acrolein
- Carcinogenic nitrosamines
- Polycyclic aromatic hydrocarbons
- Particulate matter
- Metals including chromium, cadmium, nickel, and lead; and particles of copper, nickel, and silver have been found in electronic nicotine delivery system aerosol in higher levels than in conventional cigarette smoke.41
The specific chemicals detected can vary greatly between brands, even when the flavoring and nicotine content are equivalent, which frequently results in inconsistent and conflicting study findings. The chemicals detected also vary with the voltage or power used to generate the aerosol. Different flavors may carry varying levels of risk; for example, mint- and menthol-flavored e-cigarettes were shown to expose users to dangerous levels of pulegone, a carcinogenic compound banned as a food additive in 2018.42 The concentrations of some of these chemicals are sufficiently high to be of toxicologic concern; for example, one study reported the presence of benzaldehyde in e-cigarette aerosol at twice the workplace exposure limit.43
Biologic effects
In an in vitro study,44 57% of e-liquids studied were found to be cytotoxic to human pulmonary fibroblasts, lung epithelial cells, and human embryonic stem cells. Fruit-flavored e-liquids in particular caused a significant increase in DNA fragmentation. Cell cultures treated with e-cigarette liquids showed increased oxidative stress, reduced cell proliferation, and increased DNA damage,44 which may have implications for carcinogenic risk.
In another study,45 exposure to e-cigarette aerosol as well as conventional cigarette smoke resulted in suppression of genes related to immune and inflammatory response in respiratory epithelial cells. All genes with decreased expression after exposure to conventional cigarette smoke also showed decreased expression with exposure to e-cigarette smoke, which the study authors suggested could lead to immune suppression at the level of the nasal mucosa. Diacetyl and acetoin, chemicals found in certain flavorings, have been linked to bronchiolitis obliterans, or “popcorn lung.”46
Nicotine is not benign
The nicotine itself in many vaping liquids should also not be underestimated. Nicotine has harmful neurocognitive effects and addictive properties, particularly in the developing brains of adolescents and young adults.47 Nicotine exposure during adolescence negatively affects memory, attention, and emotional regulation,48 as well as executive functioning, reward processing, and learning.49
The brain undergoes major structural remodeling in adolescence, and nicotine acetylcholine receptors regulate neural maturation. Early exposure to nicotine disrupts this process, leading to poor executive functioning, difficulty learning, decreased memory, and issues with reward processing.
Fetal exposure, if nicotine products are used during pregnancy, has also been linked to adverse consequences such as deficits in attention and cognition, behavioral effects, and sudden infant death syndrome.5
Much to learn about toxicity
Partly because vaping devices have been available to US consumers only since 2007, limited evidence is available regarding the long-term effects of exposure to the aerosol from these devices in humans.1 Many of the studies mentioned above were in vitro studies or conducted in mouse models. Differences in device design and the composition of the e-liquid among device brands pose a challenge for developing well-designed studies of the long-term health effects of e-cigarette and vape use. Additionally, devices may have different health impacts when used to vape cannabis or other drugs besides nicotine, which requires further investigation.
E-CIGARETTES AND SMOKING CESSATION
Conventional cigarette smoking is a major public health threat, as tobacco use is responsible for 480,000 deaths annually in the United States.50
And smoking is extremely difficult to quit: as many as 80% of smokers who attempt to quit resume smoking within the first month.51 The chance of successfully quitting improves by over 50% if the individual undergoes nicotine replacement therapy, and it improves even more with counseling.50
There are currently 5 types of FDA-approved nicotine replacement therapy products (gum, patch, lozenge, inhaler, nasal spray) to help with smoking cessation. In addition, 2 non-nicotine prescription drugs (varenicline and bupropion) have been approved for treating tobacco dependence.
Can vaping devices be added to the list of nicotine replacement therapy products? Although some manufacturers try to brand their devices as smoking cessation aids, in one study,52 one-third of e-cigarette users said they had either never used conventional cigarettes or had formerly smoked them.
Bullen et al53 randomized smokers interested in quitting to receive either e-cigarettes, nicotine patches, or placebo (nicotine-free) e-cigarettes and followed them for 6 months. Rates of tobacco cessation were less than predicted for the entire study population, resulting in insufficient power to determine the superiority of any single method, but the study authors concluded that nicotine e-cigarettes were “modestly effective” at helping smokers quit, and that abstinence rates may be similar to those with nicotine patches.53
Hajek et al54 randomized 886 smokers to e-cigarette or nicotine replacement products of their choice. After 1 year, 18% of e-cigarette users had stopped smoking, compared with 9.9% of nicotine replacement product users. However, 80% of the e-cigarette users were still using e-cigarettes after 1 year, while only 9% of nicotine replacement product users were still using nicotine replacement therapy products after 1 year.
While quitting conventional cigarette smoking altogether has widely established health benefits, little is known about the health benefits of transitioning from conventional cigarette smoking to reduced conventional cigarette smoking with concomitant use of e-cigarettes.
Campagna et al55 found no beneficial health effects in smokers who partially substituted conventional cigarettes for e-cigarettes.
Many studies found that smokers use e-cigarettes to maintain their habit instead of quitting entirely.56 It has been suggested that any slight increase in effectiveness in smoking cessation by using e-cigarettes compared with other nicotine replacement products could be linked to satisfying of the habitual smoking actions, such as inhaling and bringing the hand to the mouth,24 which are absent when using other nicotine replacement methods such as a nicotine patch.
As with safety information, long-term outcomes regarding the use of vape devices for smoking cessation have not been yet established, as this option is still relatively new.
VAPING AS A GATEWAY DRUG
Another worrisome trend involving electronic nicotine delivery systems is their marketing and branding, which appear to be aimed directly at adolescents and young adults. Juul and other similar products cannot be sold to anyone under the age of 18 (or 21 in 18 states, including California, Massachusetts, New York, and now Ohio). Despite this, Juul and similar products continue to increase in popularity among middle school and high school students.57
While smoking cessation and health improvement are cited as reasons for vaping among middle-aged and older adults, adolescents and young adults more often cite flavor, enjoyment, peer use, and curiosity as reasons for use.
Adolescents are more likely to report interest in trying a vape product flavored with menthol or fruit than tobacco, and commonly hold the belief that fruit-flavored e-cigarettes are less harmful than tobacco-flavored e-cigarettes.58 Harrell et al59 polled youth and young adults who used flavored e-cigarettes, and 78% said they would no longer use the product if their preferred flavor were not available. In September 2019, Michigan became the first state to ban the sale of flavored e-cigarettes in stores and online. Similar bills have been introduced in California, Massachusetts, and New York.60
Myths and misperceptions abound among youth regarding smoking vs vaping. Young people view regular cigarette smoking negatively, as causing cancer, bad breath, and asthma exacerbations. Meanwhile, they believe marijuana is safer and less addictive than traditional cigarette smoking.61 Youth exposed to e-cigarette advertisements viewed e-cigarettes as healthier, more enjoyable, “cool,” safe, and fun.61 The overall public health impact of increasing initiation of smoking, particularly among youth and young adults, should not be underestimated.
SECONDHAND VAPE AND OTHER EXPOSURE RISKS
Cigarette smoking has been banned in many public places, in view of a large body of scientific evidence about the harmful effects of secondhand smoke. Advocates for allowing vaping in public places say that vaping emissions do not harm bystanders, but evidence is insufficient to support this claim.62 One study showed that passive exposure to e-cigarette aerosol generated increases in serum levels of cotinine (a nicotine metabolite) similar to those with passive exposure to conventional cigarette smoke.5
Accidental nicotine poisoning in children as a result of ingesting e-cigarette liquid is also a major concern,63 particularly with sweet flavors such as bubblegum or cheesecake that may be attractive to children.
Calls to US poison control centers with respect to e-cigarettes and vaping increased from 1 per month in September 2010 to 215 in February 2014, with 51% involving children under age 5.64 This trend resulted in the Child Nicotine Poisoning Prevention Act, which passed in 2015 and went into effect in 2016, requiring packaging that is difficult to open for children under age 5.5
Device malfunctions or battery failures have led to explosions that have resulted in substantial injuries to users, as well as house and car fires.49
HOW DO WE DISCOURAGE ADOLESCENT USE?
There are currently no established treatment approaches for adolescents who have become addicted to vaping. A review of the literature regarding treatment modalities used to address adolescent use of tobacco and marijuana provides insight that options such as nicotine replacement therapy and counseling modalities such as cognitive behavioral therapy may be helpful in treating teen vaping addiction. However, more research is needed to determine the effectiveness of these treatments in youth addicted to vaping.
Given that youth who vape even once are more likely to try other types of tobacco, we recommend that parents and healthcare providers start conversations by asking what the young person has seen or heard about vaping. Young people can also be asked what they think the school’s response should be: Do they think vaping should be banned in public places, as cigarettes have been banned? What about the carbon footprint? What are their thoughts on the plastic waste, batteries, and other toxins generated by the e-cigarette industry?
New US laws ban the sale of e-cigarettes and vaping devices to minors in stores and online. These policies are modeled in many cases on environmental control policies that have been previously employed to reduce tobacco use, particularly by youth. For example, changing laws to mandate sales only to individuals age 21 and older in all states can help to decrease access to these products among middle school and high school students.
As with tobacco cessation, education will not be enough. Support of legislation that bans vaping in public places, increases pricing to discourage adolescent use, and other measures used successfully to decrease conventional cigarette smoking can be deployed to decrease the public health impact of e-cigarettes. We recommend further regulation of specific harmful chemicals and clear, detailed ingredient labeling to increase consumer understanding of the risks associated with these products. Additionally, we recommend eliminating flavored e-cigarettes, which are the most appealing type for young users, and raising prices of e-cigarettes and similar products to discourage use by youth.
If current cigarette smokers want to use e-cigarettes to quit, we recommend that clinicians counsel them to eventually completely stop use of traditional cigarettes and switch to using e-cigarettes, instead of becoming a dual user of both types of products or using e-cigarettes indefinitely. After making that switch, they should then work to gradually taper usage and nicotine addiction by reducing the amount of nicotine in the e-liquid. Clinicians should ask patients about use of e-cigarettes and vaping devices specifically, and should counsel nonsmokers to avoid initiation of use.
EVIDENCE OF HARM CONTINUES TO EMERGE
Data about respiratory effects, secondhand exposure, and long-term smoking cessation efficacy are still limited, and it remains as yet unknown what combinations of solvents, flavorings, and nicotine in a given e-liquid will result in the most harmful or least harmful effects. In addition, while much of the information about the safety of these components has been obtained using in vitro or mouse models, increasing reports of serious respiratory illness and rising numbers of deaths linked to vaping make it clear that these findings likely translate to harmful effects in humans.
E-cigarettes may ultimately prove to be less harmful than traditional cigarettes, but it seems likely that with further time and research, serious health risks of e-cigarette use will continue to emerge.
- Sood A, Kesic M, Hernandez M. Electronic cigarettes: one size does not fit all. J Allergy Clin Immunol 2018; 141(6):1973-1982. doi:10.1016/j.jaci.2018.02.029
- Romijnders K, van Osch L, de Vries H, Talhout R. Perceptions and reasons regarding e-cigarette use among users and non-users: a narrative literature review. Int J Environ Res Public Health 2018; 15(6):1190. doi:10.3390/ijerph15061190
- Zhu S, Zhuang Y-L, Wong S, Cummins SE, Tedeschi GJ. E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys. BMJ 2017; 358:j3262. doi:10.1136/bmj.j3262
- Centers for Disease Control and Prevention. Outbreak of lung injury associated with e-cigarette use, or vaping. Updated November 5, 2019. www.cdc.gov/tobacco/basic_information/e-Cigarettes/severe-Lung-Disease.html. Accessed November 14, 2019.
- US Public Health Services, US Department of Health and Human Services. E-cigarette use among youth and young adults: a report of the Surgeon General. Rockville, MD, U.S. Department of Health and Human Services, 2016. https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf. Accessed November 14, 2019.
- Thomas K, Kaplan S. E-cigarettes went unchecked in 10 years of federal inaction. New York Times Oct 14, 2019; updated November 1, 2019. www.nytimes.com/2019/10/14/health/vaping-e-cigarettes-fda.html.
- Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the field: use of electronic cigarettes and any tobacco product among middle and high school students—United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2018; 67(45):1276–1277. doi:10.15585/mmwr.mm6745a5
- Gentzke A, Creamer M, Cullen K, et al; Centers for Disease Control and Prevention. Vital signs: tobacco product use among middle and high school students—United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2019; 68(6):157–164. doi:10.15585/mmwr.mm6806e1
- Hammig B, Daniel-Dobbs P, Blunt-Vinti H. Electronic cigarette initiation among minority youth in the United States. Am J Drug Alcohol Abuse 2017; 43(3):306–310. doi:10.1080/00952990.2016.1203926
- Primack BA, Soneji S, Stoolmiller M, Fine MJ, Sargent JD. Progression to traditional cigarette smoking after electronic cigarette use among U.S. adolescents and young adults. JAMA Pediatr 2015; 169(11):1018–1023. doi:10.1001/jamapediatrics.2015.1742
- Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA 2015; 314(7):700–707. doi:10.1001/jama.2015.8950
- Wills TA, Knight R, Sargent JD, Gibbons FX, Pagano I, Williams RJ. Longitudinal study of e-cigarette use and onset of cigarette smoking among high school students in Hawaii. Tob Control 2016; 26(1):34–39. doi:10.1136/tobaccocontrol-2015-052705
- National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta: Centers for Disease Control and Prevention, 2014. www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf. Accessed November 14, 2019.
- Christiani DC. Vaping-induced lung injury. N Engl J Med 2019; Sept 6. Epub ahead of print. doi:10.1056/NEJMe1912032
- Neel J, Aubrey A. Vitamin E suspected in serious lung problems among people who vaped cannabis. NPR Sept 5, 2019. www.npr.org/sections/health-shots/2019/09/05/758005409/vitamin-e-suspected-in-serious-lung-problems-among-people-who-vaped-cannabis. Accessed November 14, 2019.
- White A. Plans for the first e-cigarette went up in smoke 50 years ago. Smithsonian Magazine December 2018. www.smithsonianmag.com/innovation/plans-for-first-e-cigarette-went-up-in-smoke-50-years-ago-180970730.
- Blundell MS, Dargan PI, Wood DM. The dark cloud of recreational drugs and vaping. QJM 2018; 111(3):145–148. doi:10.1093/qjmed/hcx049
- Schulenberg JE, Johnston LD, O’Malley PM, Bachman JG, Miech RA, Patrick ME. Monitoring the future: national survey results on drug use, 1975–2018. 2018 Volume 2. College students & adults ages 19–60. www.monitoringthefuture.org/pubs/monographs/mtf-vol2_2018.pdf. Accessed November 14, 2019.
- Eggers ME, Lee YO, Jackson J, Wiley JL, Porter J, Nonnemaker JM. Youth use of electronic vapor products and blunts for administering cannabis. Addict Behav 2017; 70:79-82. doi:10.1016/j.addbeh.2017.02.020
- Regan AK, Promoff G, Dube SR, Arrazola R. Electronic nicotine delivery systems: adult use and awareness of the “e-cigarette”in the USA. Tob Control 2013; 22(1):19–23. doi:10.1136/tobaccocontrol-2011-050044
- Centers for Disease Control and Prevention. E-cigarette ads and youth. www.cdc.gov/vitalsigns/ecigarette-ads/index.html.
- Noel JK, Rees VW, Connolly GN. Electronic cigarettes: a new “tobacco” industry? Tob Control 2011; 20(1):81. doi:10.1136/tc.2010.038562
- US Food and Drug Administration. Deeming tobacco products to be subject to the federal food, drug, and cosmetic act, as amended by the family smoking prevention and tobacco control act; restrictions on the sale and distribution of tobacco products and required warning statements for tobacco products. Federal Register 2016; 81(90), May 10, 2016. www.govinfo.gov/content/pkg/FR-2016-05-10/pdf/2016-10685.pdf. Accessed November 14, 2019.
- Rom O, Pecorelli A, Valacchi G, Reznick AZ. Are e-cigarettes a safe and good alternative to cigarette smoking? Ann NY Acad Sci 2015; 1340:65–74. doi:10.1111/nyas.12609
- Zhu SH, Sun JY, Bonnevie E, et al. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob Control 2014; 23(suppl 3):iii3-iii9. doi:10.1136/tobaccocontrol-2014-051670
- Kong G, Morean ME, Cavallo DA, Camenga DR, Krishnan-Sarin S. Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults. Nicotine Tob Res 2015; 17(7):847–854. doi:10.1093/ntr/ntu257
- Baca MC. How two Stanford grads aimed for big tech glory and got big tobacco instead. Updated September 4, 2019. The Washington Post September 4, 2019. www.washingtonpost.com/technology/2019/09/04/how-two-stanford-grads-aimed-big-tech-glory-got-big-tobacco-instead. Accessed November 14, 2019.
- Huang J, Duan Z, Kwok J, et al. Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market. Tob Control 2019; 28(2):146–151. doi:10.1136/tobaccocontrol-2018-054382
- Walley SC, Wilson KM, Winickoff JP, Groner J. A public health crisis: electronic cigarettes, vape, and JUUL. Pediatrics 2019; 143(6):pii:e20182741. doi:10.1542/peds.2018-2741
- Zernike K. F.D.A. cracks down on “juuling” among teenagers. The New York Times April 24, 2018. www.nytimes.com/2018/04/24/health/fda-e-cigarettes-minors-juul.html. Accessed November 14, 2019.
- Ramamurthi D, Chau C, Jackler RK. JUUL and other stealth vaporisers: hiding the habit from parents and teachers. Tob Control 2018 Sep 15; pii:tobaccocontrol-2018-054455. doi:10.1136/tobaccocontrol-2018-054455. [Epub ahead of print]
- Willett JG, Bennett M, Hair EC, et al. Recognition, use and perceptions of JUUL among youth and young adults. Tob Control 2019; 28(1):115–116. doi:10.1136/tobaccocontrol-2018-054273
- Kaplan S. Juul’s new product: less nicotine, more intense vapor. New York Times Nov 27, 2018. www.nytimes.com/2018/11/27/health/juul-ecigarettes-nicotine.html.
- JUUL Labs. JUULpods. www.juul.com/shop/pods. Accessed November 14, 2019.
- Krishnan-Sarin S, Morean M, Kong G, et al. E-cigarettes and “dripping” among high-school youth. Pediatrics 2017; 139(3):pii:e20163224. doi:10.1542/peds.2016-3224
- Kosmider L, Sobczak A, Fik M, et al. Carbonyl compounds in electronic cigarette vapors: effects of nicotine solvent and battery output voltage. Nicotine Tob Res 2014; 16(10):1319–1326. doi:10.1093/ntr/ntu078
- Rawlinson C, Martin S, Frosina J, Wright C. Chemical characterisation of aerosols emitted by electronic cigarettes using thermal desorption-gas chromatography-time of flight mass spectrometry. J Chromatogr A 2017; 1497:144–154. doi:10.1016/j.chroma.2017.02.050
- Lee MS, LeBouf RF, Son YS, Koutrakis P, Christiani DC. Nicotine, aerosol particles, carbonyls and volatile organic compounds in tobacco- and menthol-flavored e-cigarettes. Environ Health 2017; 16(1):42. doi:10.1186/s12940-017-0249-x
- Williams M, Bozhilov K, Ghai S, Talbot P. Elements including metals in the atomizer and aerosol of disposable electronic cigarettes and electronic hookahs. PLoS One 2017; 12(4):e0175430. doi:10.1371/journal.pone.0175430.
- Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control 2014; 23(2):133–139. doi:10.1136/tobaccocontrol-2012-050859
- Drope J, Cahn Z, Kennedy R, et al. Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine. CA Cancer J Clin 2017; 67(6):449–471. doi:10.3322/caac.21413
- Jabba SV, Jordt SE. Risk analysis for the carcinogen pulegone in mint- and menthol-flavored e-cigarettes and smokeless tobacco products. JAMA Intern Med 2019 Sep 16 [Epub ahead of print]. doi:10.1001/jamainternmed.2019.3649
- Tierney PA, Karpinsky CD, Brown JE, Luo W, Pankow JF. Flavour chemicals in electronic cigarette fluids. Tob Control 2016; 25(e1):e10–e15. doi:10.1136/tobaccocontrol-2014-052175
- Behar RZ, Wang Y, Talbot P. Comparing the cytotoxicity of electronic cigarette fluids, aerosols and solvents. Tob Control 2017; 27(3):325–333. doi:10.1136/tobaccocontrol-2016-053472
- Martin EM, Clapp PW, Rebuli ME, et al. E-cigarette use results in suppression of immune and inflammatory-response genes in nasal epithelial cells similar to cigarette smoke. Am J Physiol Lung Cell Mol Physiol 2016; 311(1):L135–L144. doi:10.1152/ajplung.00170.2016
- Holden VK, Hines SE. Update on flavoring-induced lung disease. Curr Opin Pulm Med 2016;22(2):158–164. doi:10.1097/MCP.0000000000000250
- Siqueira L; Committee on Substance Use and Prevention. Nicotine and tobacco as substances of abuse in children and adolescents. Pediatrics 2017; 139(1):pii:e20163436. doi:10.1542/peds.2016-3436
- England LJ, Bunnell RE, Pechacek TF, Tong VT, McAfee TA. Nicotine and the developing human: a neglected element in the electronic cigarette debate. Am J Prev Med 2015; 49(2):286–293. doi:10.1016/j.amepre.2015.01.015
- Modesto-Lowe V, Alvarado C. E-cigs…are they cool? Talking to teens about e-cigarettes. Clin Pediatr (Phila) 2017; 51(10):947–952. doi:10.1177/0009922817705188
- Prochaska JJ, Benowitz NL. The past, present, and future of nicotine addiction therapy. Annu Rev Med 2017; 67:467–486. doi:10.1146/annurev-med-111314-033712
- Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004; 99(1):29–38. doi:10.1111/j.1360-0443.2004.00540.x
- McMillen RC, Gottlieb MA, Shaefer RM, Winickoff JP, Klein JD. Trends in electronic cigarette use among U.S. adults: use is increasing in both smokers and nonsmokers. Nicotine Tob Res 2015;17(10):119_1202. doi:10.1093/ntr/ntu213
- Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013; 382(9905):1629–1637. doi:10.1016/S0140-6736(13)61842-5
- Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine replacement therapy. N Engl J Med 2019; 380(7):629–637. doi:10.1056/NEJMoa1808779
- Campagna D, Cibella F, Caponnetto P, et al. Changes in breathomics from a 1-year randomized smoking cessation trial of electronic cigarettes. Eur J Clin Invest 2016; 46(8):698–706. doi:10.1111/eci.12651
- Rehan HS, Maini J, Hungin APS. Vaping versus smoking: a quest for efficacy and safety of e-cigarette. Curr Drug Saf 2018; 13(2):92–101. doi:10.2174/1574886313666180227110556
- Zernike K. ‘I can’t stop’: schools struggle with vaping explosion. New York Times April 2, 2018. www.nytimes.com/2018/04/02/health/vaping-ecigarettes-addiction-teen.html.
- Pepper JK, Ribisl KM, Brewer NT. Adolescents’ interest in trying flavoured e-cigarettes. Tob Control 2016; 25(suppl 2):ii62–ii66. doi:10.1136/tobaccocontrol-2016-053174
- Harrell MB, Loukas A, Jackson CD, Marti CN, Perry CL. Flavored tobacco product use among youth and young adults: what if flavors didn’t exist? Tob Regul Sci 2017; 3(2):168–173. doi:10.18001/TRS.3.2.4
- Smith M. Amid vaping crackdown, Michigan to ban sale of flavored e-cigarettes. New York Times Sept 4, 2019. www.nytimes.com/2019/09/04/us/michigan-vaping.html?module=inline.
- Roditis ML, Halpern-Felsher B. Adolescents’ perceptions of risks and benefits of conventional cigarettes, e-cigarettes, and marijuana: a qualitative analysis. J Adolesc Health 2015; 57(2):179–185. doi:10.1016/j.jadohealth.2015.04.002
- Chapman S, Daube M, Maziak W. Should e-cigarette use be permitted in smoke-free public places? No. Tob Control 2017; 26(e1):e3–e4. doi:10.1136/tobaccocontrol-2016-053359
- Marcham CL, Springston JP. Electronic cigarettes in the indoor environment. Rev Env Health 2019; 34(2):105–124. doi:10.1515/reveh-2019-0012
- Chatham-Stephens K, Law R, Taylor E, et al; Centers for Disease Control and Prevention. Notes from the field: calls to poison centers for exposures to electronic cigarettes—United States, September 2010–September 2014. MMWR Morb Mortal Wkly Report 2014; 63(13):292–293. pmid:24699766
- Sood A, Kesic M, Hernandez M. Electronic cigarettes: one size does not fit all. J Allergy Clin Immunol 2018; 141(6):1973-1982. doi:10.1016/j.jaci.2018.02.029
- Romijnders K, van Osch L, de Vries H, Talhout R. Perceptions and reasons regarding e-cigarette use among users and non-users: a narrative literature review. Int J Environ Res Public Health 2018; 15(6):1190. doi:10.3390/ijerph15061190
- Zhu S, Zhuang Y-L, Wong S, Cummins SE, Tedeschi GJ. E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys. BMJ 2017; 358:j3262. doi:10.1136/bmj.j3262
- Centers for Disease Control and Prevention. Outbreak of lung injury associated with e-cigarette use, or vaping. Updated November 5, 2019. www.cdc.gov/tobacco/basic_information/e-Cigarettes/severe-Lung-Disease.html. Accessed November 14, 2019.
- US Public Health Services, US Department of Health and Human Services. E-cigarette use among youth and young adults: a report of the Surgeon General. Rockville, MD, U.S. Department of Health and Human Services, 2016. https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf. Accessed November 14, 2019.
- Thomas K, Kaplan S. E-cigarettes went unchecked in 10 years of federal inaction. New York Times Oct 14, 2019; updated November 1, 2019. www.nytimes.com/2019/10/14/health/vaping-e-cigarettes-fda.html.
- Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the field: use of electronic cigarettes and any tobacco product among middle and high school students—United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2018; 67(45):1276–1277. doi:10.15585/mmwr.mm6745a5
- Gentzke A, Creamer M, Cullen K, et al; Centers for Disease Control and Prevention. Vital signs: tobacco product use among middle and high school students—United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2019; 68(6):157–164. doi:10.15585/mmwr.mm6806e1
- Hammig B, Daniel-Dobbs P, Blunt-Vinti H. Electronic cigarette initiation among minority youth in the United States. Am J Drug Alcohol Abuse 2017; 43(3):306–310. doi:10.1080/00952990.2016.1203926
- Primack BA, Soneji S, Stoolmiller M, Fine MJ, Sargent JD. Progression to traditional cigarette smoking after electronic cigarette use among U.S. adolescents and young adults. JAMA Pediatr 2015; 169(11):1018–1023. doi:10.1001/jamapediatrics.2015.1742
- Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA 2015; 314(7):700–707. doi:10.1001/jama.2015.8950
- Wills TA, Knight R, Sargent JD, Gibbons FX, Pagano I, Williams RJ. Longitudinal study of e-cigarette use and onset of cigarette smoking among high school students in Hawaii. Tob Control 2016; 26(1):34–39. doi:10.1136/tobaccocontrol-2015-052705
- National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta: Centers for Disease Control and Prevention, 2014. www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf. Accessed November 14, 2019.
- Christiani DC. Vaping-induced lung injury. N Engl J Med 2019; Sept 6. Epub ahead of print. doi:10.1056/NEJMe1912032
- Neel J, Aubrey A. Vitamin E suspected in serious lung problems among people who vaped cannabis. NPR Sept 5, 2019. www.npr.org/sections/health-shots/2019/09/05/758005409/vitamin-e-suspected-in-serious-lung-problems-among-people-who-vaped-cannabis. Accessed November 14, 2019.
- White A. Plans for the first e-cigarette went up in smoke 50 years ago. Smithsonian Magazine December 2018. www.smithsonianmag.com/innovation/plans-for-first-e-cigarette-went-up-in-smoke-50-years-ago-180970730.
- Blundell MS, Dargan PI, Wood DM. The dark cloud of recreational drugs and vaping. QJM 2018; 111(3):145–148. doi:10.1093/qjmed/hcx049
- Schulenberg JE, Johnston LD, O’Malley PM, Bachman JG, Miech RA, Patrick ME. Monitoring the future: national survey results on drug use, 1975–2018. 2018 Volume 2. College students & adults ages 19–60. www.monitoringthefuture.org/pubs/monographs/mtf-vol2_2018.pdf. Accessed November 14, 2019.
- Eggers ME, Lee YO, Jackson J, Wiley JL, Porter J, Nonnemaker JM. Youth use of electronic vapor products and blunts for administering cannabis. Addict Behav 2017; 70:79-82. doi:10.1016/j.addbeh.2017.02.020
- Regan AK, Promoff G, Dube SR, Arrazola R. Electronic nicotine delivery systems: adult use and awareness of the “e-cigarette”in the USA. Tob Control 2013; 22(1):19–23. doi:10.1136/tobaccocontrol-2011-050044
- Centers for Disease Control and Prevention. E-cigarette ads and youth. www.cdc.gov/vitalsigns/ecigarette-ads/index.html.
- Noel JK, Rees VW, Connolly GN. Electronic cigarettes: a new “tobacco” industry? Tob Control 2011; 20(1):81. doi:10.1136/tc.2010.038562
- US Food and Drug Administration. Deeming tobacco products to be subject to the federal food, drug, and cosmetic act, as amended by the family smoking prevention and tobacco control act; restrictions on the sale and distribution of tobacco products and required warning statements for tobacco products. Federal Register 2016; 81(90), May 10, 2016. www.govinfo.gov/content/pkg/FR-2016-05-10/pdf/2016-10685.pdf. Accessed November 14, 2019.
- Rom O, Pecorelli A, Valacchi G, Reznick AZ. Are e-cigarettes a safe and good alternative to cigarette smoking? Ann NY Acad Sci 2015; 1340:65–74. doi:10.1111/nyas.12609
- Zhu SH, Sun JY, Bonnevie E, et al. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob Control 2014; 23(suppl 3):iii3-iii9. doi:10.1136/tobaccocontrol-2014-051670
- Kong G, Morean ME, Cavallo DA, Camenga DR, Krishnan-Sarin S. Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults. Nicotine Tob Res 2015; 17(7):847–854. doi:10.1093/ntr/ntu257
- Baca MC. How two Stanford grads aimed for big tech glory and got big tobacco instead. Updated September 4, 2019. The Washington Post September 4, 2019. www.washingtonpost.com/technology/2019/09/04/how-two-stanford-grads-aimed-big-tech-glory-got-big-tobacco-instead. Accessed November 14, 2019.
- Huang J, Duan Z, Kwok J, et al. Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market. Tob Control 2019; 28(2):146–151. doi:10.1136/tobaccocontrol-2018-054382
- Walley SC, Wilson KM, Winickoff JP, Groner J. A public health crisis: electronic cigarettes, vape, and JUUL. Pediatrics 2019; 143(6):pii:e20182741. doi:10.1542/peds.2018-2741
- Zernike K. F.D.A. cracks down on “juuling” among teenagers. The New York Times April 24, 2018. www.nytimes.com/2018/04/24/health/fda-e-cigarettes-minors-juul.html. Accessed November 14, 2019.
- Ramamurthi D, Chau C, Jackler RK. JUUL and other stealth vaporisers: hiding the habit from parents and teachers. Tob Control 2018 Sep 15; pii:tobaccocontrol-2018-054455. doi:10.1136/tobaccocontrol-2018-054455. [Epub ahead of print]
- Willett JG, Bennett M, Hair EC, et al. Recognition, use and perceptions of JUUL among youth and young adults. Tob Control 2019; 28(1):115–116. doi:10.1136/tobaccocontrol-2018-054273
- Kaplan S. Juul’s new product: less nicotine, more intense vapor. New York Times Nov 27, 2018. www.nytimes.com/2018/11/27/health/juul-ecigarettes-nicotine.html.
- JUUL Labs. JUULpods. www.juul.com/shop/pods. Accessed November 14, 2019.
- Krishnan-Sarin S, Morean M, Kong G, et al. E-cigarettes and “dripping” among high-school youth. Pediatrics 2017; 139(3):pii:e20163224. doi:10.1542/peds.2016-3224
- Kosmider L, Sobczak A, Fik M, et al. Carbonyl compounds in electronic cigarette vapors: effects of nicotine solvent and battery output voltage. Nicotine Tob Res 2014; 16(10):1319–1326. doi:10.1093/ntr/ntu078
- Rawlinson C, Martin S, Frosina J, Wright C. Chemical characterisation of aerosols emitted by electronic cigarettes using thermal desorption-gas chromatography-time of flight mass spectrometry. J Chromatogr A 2017; 1497:144–154. doi:10.1016/j.chroma.2017.02.050
- Lee MS, LeBouf RF, Son YS, Koutrakis P, Christiani DC. Nicotine, aerosol particles, carbonyls and volatile organic compounds in tobacco- and menthol-flavored e-cigarettes. Environ Health 2017; 16(1):42. doi:10.1186/s12940-017-0249-x
- Williams M, Bozhilov K, Ghai S, Talbot P. Elements including metals in the atomizer and aerosol of disposable electronic cigarettes and electronic hookahs. PLoS One 2017; 12(4):e0175430. doi:10.1371/journal.pone.0175430.
- Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control 2014; 23(2):133–139. doi:10.1136/tobaccocontrol-2012-050859
- Drope J, Cahn Z, Kennedy R, et al. Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine. CA Cancer J Clin 2017; 67(6):449–471. doi:10.3322/caac.21413
- Jabba SV, Jordt SE. Risk analysis for the carcinogen pulegone in mint- and menthol-flavored e-cigarettes and smokeless tobacco products. JAMA Intern Med 2019 Sep 16 [Epub ahead of print]. doi:10.1001/jamainternmed.2019.3649
- Tierney PA, Karpinsky CD, Brown JE, Luo W, Pankow JF. Flavour chemicals in electronic cigarette fluids. Tob Control 2016; 25(e1):e10–e15. doi:10.1136/tobaccocontrol-2014-052175
- Behar RZ, Wang Y, Talbot P. Comparing the cytotoxicity of electronic cigarette fluids, aerosols and solvents. Tob Control 2017; 27(3):325–333. doi:10.1136/tobaccocontrol-2016-053472
- Martin EM, Clapp PW, Rebuli ME, et al. E-cigarette use results in suppression of immune and inflammatory-response genes in nasal epithelial cells similar to cigarette smoke. Am J Physiol Lung Cell Mol Physiol 2016; 311(1):L135–L144. doi:10.1152/ajplung.00170.2016
- Holden VK, Hines SE. Update on flavoring-induced lung disease. Curr Opin Pulm Med 2016;22(2):158–164. doi:10.1097/MCP.0000000000000250
- Siqueira L; Committee on Substance Use and Prevention. Nicotine and tobacco as substances of abuse in children and adolescents. Pediatrics 2017; 139(1):pii:e20163436. doi:10.1542/peds.2016-3436
- England LJ, Bunnell RE, Pechacek TF, Tong VT, McAfee TA. Nicotine and the developing human: a neglected element in the electronic cigarette debate. Am J Prev Med 2015; 49(2):286–293. doi:10.1016/j.amepre.2015.01.015
- Modesto-Lowe V, Alvarado C. E-cigs…are they cool? Talking to teens about e-cigarettes. Clin Pediatr (Phila) 2017; 51(10):947–952. doi:10.1177/0009922817705188
- Prochaska JJ, Benowitz NL. The past, present, and future of nicotine addiction therapy. Annu Rev Med 2017; 67:467–486. doi:10.1146/annurev-med-111314-033712
- Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004; 99(1):29–38. doi:10.1111/j.1360-0443.2004.00540.x
- McMillen RC, Gottlieb MA, Shaefer RM, Winickoff JP, Klein JD. Trends in electronic cigarette use among U.S. adults: use is increasing in both smokers and nonsmokers. Nicotine Tob Res 2015;17(10):119_1202. doi:10.1093/ntr/ntu213
- Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013; 382(9905):1629–1637. doi:10.1016/S0140-6736(13)61842-5
- Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine replacement therapy. N Engl J Med 2019; 380(7):629–637. doi:10.1056/NEJMoa1808779
- Campagna D, Cibella F, Caponnetto P, et al. Changes in breathomics from a 1-year randomized smoking cessation trial of electronic cigarettes. Eur J Clin Invest 2016; 46(8):698–706. doi:10.1111/eci.12651
- Rehan HS, Maini J, Hungin APS. Vaping versus smoking: a quest for efficacy and safety of e-cigarette. Curr Drug Saf 2018; 13(2):92–101. doi:10.2174/1574886313666180227110556
- Zernike K. ‘I can’t stop’: schools struggle with vaping explosion. New York Times April 2, 2018. www.nytimes.com/2018/04/02/health/vaping-ecigarettes-addiction-teen.html.
- Pepper JK, Ribisl KM, Brewer NT. Adolescents’ interest in trying flavoured e-cigarettes. Tob Control 2016; 25(suppl 2):ii62–ii66. doi:10.1136/tobaccocontrol-2016-053174
- Harrell MB, Loukas A, Jackson CD, Marti CN, Perry CL. Flavored tobacco product use among youth and young adults: what if flavors didn’t exist? Tob Regul Sci 2017; 3(2):168–173. doi:10.18001/TRS.3.2.4
- Smith M. Amid vaping crackdown, Michigan to ban sale of flavored e-cigarettes. New York Times Sept 4, 2019. www.nytimes.com/2019/09/04/us/michigan-vaping.html?module=inline.
- Roditis ML, Halpern-Felsher B. Adolescents’ perceptions of risks and benefits of conventional cigarettes, e-cigarettes, and marijuana: a qualitative analysis. J Adolesc Health 2015; 57(2):179–185. doi:10.1016/j.jadohealth.2015.04.002
- Chapman S, Daube M, Maziak W. Should e-cigarette use be permitted in smoke-free public places? No. Tob Control 2017; 26(e1):e3–e4. doi:10.1136/tobaccocontrol-2016-053359
- Marcham CL, Springston JP. Electronic cigarettes in the indoor environment. Rev Env Health 2019; 34(2):105–124. doi:10.1515/reveh-2019-0012
- Chatham-Stephens K, Law R, Taylor E, et al; Centers for Disease Control and Prevention. Notes from the field: calls to poison centers for exposures to electronic cigarettes—United States, September 2010–September 2014. MMWR Morb Mortal Wkly Report 2014; 63(13):292–293. pmid:24699766
KEY POINTS
- Vaping is a common gateway to tobacco and marijuana use for adolescents and adults.
- The Juul vaping device delivers high nicotine concentrations that may pose a higher risk of nicotine addiction.
- Vaping has had unintended consequences that include poisoning of children who swallowed liquid nicotine, fires and explosions from defective batteries in the devices, and effects on the developing brain.
- Vaping is associated with respiratory illness and, in rare cases, death, likely due to vaporized agents introduced into the lungs. Small amounts of heavy metals, acetone, and other carcinogenic compounds in the vaping aerosol may cause lung damage.
Inexperience is the main cause of unsafe driving among teens
NEW ORLEANS – Teens need to drive for a wide range of reasons, from going to and from school or work to overall mobility, but driving still is the most dangerous thing teenagers do, according to Brian Johnston, MD, MPH, professor of pediatrics at the University of Washington in Seattle.
Motor vehicle traffic accidents continue to be the leading cause of death of adolescents aged 15-19 years, according to 2017 data from the National Center for Health Statistics at the Centers for the Disease Control and Prevention.
“Inexperience drives the statistics we see,” Dr. Johnston said at the annual meeting of the American Academy of Pediatrics. “There is a steep learning curve among drivers of all ages, and crash rates are highest during the first few months after teens begin driving without supervision.”
Although the risk of accidents is higher than average for any new driver, it’s disproportionately higher for younger teens, compared with other ages: 16-year-old novice drivers have a higher accident risk than that of 17-year-olds, whose risk is similar to that of 18- and 19-year-old novices.
How long drivers have been licensed has a far bigger impact on crash risk, Dr. Johnston said (Traffic Inj. Prev. 2009 Jun;10[3]:209-19).
But the risk of an accident also increases with each additional passenger a teen driver has, particularly for younger and male drivers (Traffic Inj Prev. 2013;14[3]:283-92). More passengers likely means more distraction, and distraction, driving too fast for road conditions, and not scanning the roadway are the three most common errors – together accounting for about half of all teen drivers’ crashes.
Risk factors for accidents
Speed is a contributing factor in just over a third (36%) of teens’ fatal crashes. Adolescents drive faster and keep shorter following distances than adults do. But as with adults, wearing seat belts substantially reduces the risk of death in accidents.
Nationally, 90% of drivers use seat belts, with higher rates in states with primary enforcement (92%) than those in states with secondary enforcement (83%).
But barely more than half (54%) of U.S. high school students say they “always” wear a seat belt, and just under half of teens (47%) who died in crashes in 2017 weren’t wearing one. As seen in adults, teens are more likely to buckle up, by 12%, in states with primary seat belt laws.
Distraction during driving can be visual, manual, or cognitive – and handheld electronic devices such as smartphones cause all three distraction types. Cell phones nearly double the proportion of teen drivers who die in crashes, from 7% to 13%.
But if teens can keep their eyes on the roadway at all times, even the risks posed by cellphones drop considerably.
“The best evidence shows that secondary tasks only degrade driving performance when they require drivers to look away from the road,” Dr. Johnston said. Looking away for 2 seconds or longer increases crash risk more than fivefold.
Two other risk factors for teen car accidents are drowsiness and nighttime driving. Sleepiness can play a role in crashes at any time of day, and Dr. Johnston noted that some research has associated later high school start times with reduced crash risk.
Teens aged 16-19 years are about four times more likely to have a car accident at night than during the day per each mile driven, the pediatrician noted. Many licensing laws restrict teen driving starting at 11 p.m. or later, but about 50%-60% of their crashes occur between 9 and 11 p.m.
One reason for the increased risk is less experience driving in more difficult conditions, but teens also are more likely to have teen passengers, to be driving excessively fast, or to be under the influence of alcohol at night.
Adolescents’ crash risk is higher than that of adults for any level of blood alcohol content. Self-reported driving after drinking dropped by almost half – from 10% to 5.5% – from 2013 to 2017, but alcohol still is implicated in a substantial number of fatal teen crashes.
As drunk driving has declined, however, driving while under the influence of marijuana has been increasing. According to the National Highway Traffic Safety Administration, case control studies show drivers with tetrahydrocannabinol (THC) in their blood have a 25% increased risk of accidents – but the excess risk associated with THC vanishes when researchers control for age, sex, and concurrent use of alcohol. Not enough research exists to determine what the crash risk would be for adolescent drivers using THC alone.
A less-recognized risk factor for car accidents in teen drivers is ADHD, which increases a teen’s risk of crashing by 36%, particularly in the first month after getting a license, Dr. Johnston said.
ADHD medication appears to mitigate the danger, according to data: Crash risk was 40% lower in adult drivers with ADHD during months they filled their stimulant prescriptions. But one study found only 12% of teens with ADHD filled their prescriptions the month they got their license, and adolescents may not take their medications or still have them in their system on weekends or at night.
Teens recovering from concussion also may have an increased risk. Some evidence suggests driving impairment continues even when other symptoms have resolved, but not enough data exist to determine appropriate criteria for clearing teens to begin driving again.
Interventions to improve teens’ driving safety
Most teens take a basic driver education course before getting their licenses, but no evidence shows that it reduces risk of citations, crashes, or injury. In fact, “skid control training and other kinds of advanced skill training seem to increase crash risk, particularly among young males,” Dr. Johnston said.
What helps teens most is, ironically, more driving.
“If I say inexperience is the single most important risk factor for dying in a crash as a teen, driving experience is the intervention,” he said. More time spent driving – “with supervision in particular, and under diverse conditions,” Dr. Johnston said – increases the repertoire of skills and abilities.
Parents should be encouraged to ride along as their teens drive under diverse road conditions: different roads, different times of the day, and different weather conditions, for example. Parents can narrate their own driving, pointing out hazards and times when they slow down for increased caution, Dr. Johnston said. It might feel “awkward and unnatural,” but “some of the things you as a driver notice all the time are novel to teen drivers.”
Parents can influence road safety for teens in terms of their own behavior and in selecting a safer vehicle. A strong correlation exists between parental texting while driving when children are younger and what they do as teen drivers, for example.
Safer vehicles are bigger, heavier cars with electronic stability control, which reduces risk of death about as much as wearing seat belts. Parents should avoid vehicles with high horsepower and look for cars with the best safety ratings they can afford, Dr. Johnston said.
Several special features in newer cars can help reduce crash risk, such as blind spot detection, automatic breaking, collision avoidance systems, lane departure warning systems, and driver drowsiness detection. Parents may worry that relying on this technology could reduce teens’ learning, but it actually can compensate for skill deficits as they are becoming more skilled drivers.
Parents can look into feedback programs such as smartphone apps or other in-car units that allow parents to see data on teens’ speed, unsafe driving, “near-misses,” and similar driving behaviors. Research has shown that unsafe driving in newly licensed teens dropped by 66% over 4 months of using one of these feedback programs, compared with teens who didn’t use it.
Dr. Johnston also discussed the idea of prelicensure medical exams, similar to physicals that are required before playing sports. These already exist for commercial licenses in most states, but no data exist on whether it’s effective for teens. The goal would be to promote a discussion between parents and their teens about driving: reviewing medications the teen is taking and whether they affect driving; discussing safety of different vehicles; and assessing the teens’ risks, including any cognitive or other medical conditions that could affect driving safety. Even if such a “driving physical” is not currently required, pediatricians can do their own version of one with families.
Dr. Johnston had no disclosures.
NEW ORLEANS – Teens need to drive for a wide range of reasons, from going to and from school or work to overall mobility, but driving still is the most dangerous thing teenagers do, according to Brian Johnston, MD, MPH, professor of pediatrics at the University of Washington in Seattle.
Motor vehicle traffic accidents continue to be the leading cause of death of adolescents aged 15-19 years, according to 2017 data from the National Center for Health Statistics at the Centers for the Disease Control and Prevention.
“Inexperience drives the statistics we see,” Dr. Johnston said at the annual meeting of the American Academy of Pediatrics. “There is a steep learning curve among drivers of all ages, and crash rates are highest during the first few months after teens begin driving without supervision.”
Although the risk of accidents is higher than average for any new driver, it’s disproportionately higher for younger teens, compared with other ages: 16-year-old novice drivers have a higher accident risk than that of 17-year-olds, whose risk is similar to that of 18- and 19-year-old novices.
How long drivers have been licensed has a far bigger impact on crash risk, Dr. Johnston said (Traffic Inj. Prev. 2009 Jun;10[3]:209-19).
But the risk of an accident also increases with each additional passenger a teen driver has, particularly for younger and male drivers (Traffic Inj Prev. 2013;14[3]:283-92). More passengers likely means more distraction, and distraction, driving too fast for road conditions, and not scanning the roadway are the three most common errors – together accounting for about half of all teen drivers’ crashes.
Risk factors for accidents
Speed is a contributing factor in just over a third (36%) of teens’ fatal crashes. Adolescents drive faster and keep shorter following distances than adults do. But as with adults, wearing seat belts substantially reduces the risk of death in accidents.
Nationally, 90% of drivers use seat belts, with higher rates in states with primary enforcement (92%) than those in states with secondary enforcement (83%).
But barely more than half (54%) of U.S. high school students say they “always” wear a seat belt, and just under half of teens (47%) who died in crashes in 2017 weren’t wearing one. As seen in adults, teens are more likely to buckle up, by 12%, in states with primary seat belt laws.
Distraction during driving can be visual, manual, or cognitive – and handheld electronic devices such as smartphones cause all three distraction types. Cell phones nearly double the proportion of teen drivers who die in crashes, from 7% to 13%.
But if teens can keep their eyes on the roadway at all times, even the risks posed by cellphones drop considerably.
“The best evidence shows that secondary tasks only degrade driving performance when they require drivers to look away from the road,” Dr. Johnston said. Looking away for 2 seconds or longer increases crash risk more than fivefold.
Two other risk factors for teen car accidents are drowsiness and nighttime driving. Sleepiness can play a role in crashes at any time of day, and Dr. Johnston noted that some research has associated later high school start times with reduced crash risk.
Teens aged 16-19 years are about four times more likely to have a car accident at night than during the day per each mile driven, the pediatrician noted. Many licensing laws restrict teen driving starting at 11 p.m. or later, but about 50%-60% of their crashes occur between 9 and 11 p.m.
One reason for the increased risk is less experience driving in more difficult conditions, but teens also are more likely to have teen passengers, to be driving excessively fast, or to be under the influence of alcohol at night.
Adolescents’ crash risk is higher than that of adults for any level of blood alcohol content. Self-reported driving after drinking dropped by almost half – from 10% to 5.5% – from 2013 to 2017, but alcohol still is implicated in a substantial number of fatal teen crashes.
As drunk driving has declined, however, driving while under the influence of marijuana has been increasing. According to the National Highway Traffic Safety Administration, case control studies show drivers with tetrahydrocannabinol (THC) in their blood have a 25% increased risk of accidents – but the excess risk associated with THC vanishes when researchers control for age, sex, and concurrent use of alcohol. Not enough research exists to determine what the crash risk would be for adolescent drivers using THC alone.
A less-recognized risk factor for car accidents in teen drivers is ADHD, which increases a teen’s risk of crashing by 36%, particularly in the first month after getting a license, Dr. Johnston said.
ADHD medication appears to mitigate the danger, according to data: Crash risk was 40% lower in adult drivers with ADHD during months they filled their stimulant prescriptions. But one study found only 12% of teens with ADHD filled their prescriptions the month they got their license, and adolescents may not take their medications or still have them in their system on weekends or at night.
Teens recovering from concussion also may have an increased risk. Some evidence suggests driving impairment continues even when other symptoms have resolved, but not enough data exist to determine appropriate criteria for clearing teens to begin driving again.
Interventions to improve teens’ driving safety
Most teens take a basic driver education course before getting their licenses, but no evidence shows that it reduces risk of citations, crashes, or injury. In fact, “skid control training and other kinds of advanced skill training seem to increase crash risk, particularly among young males,” Dr. Johnston said.
What helps teens most is, ironically, more driving.
“If I say inexperience is the single most important risk factor for dying in a crash as a teen, driving experience is the intervention,” he said. More time spent driving – “with supervision in particular, and under diverse conditions,” Dr. Johnston said – increases the repertoire of skills and abilities.
Parents should be encouraged to ride along as their teens drive under diverse road conditions: different roads, different times of the day, and different weather conditions, for example. Parents can narrate their own driving, pointing out hazards and times when they slow down for increased caution, Dr. Johnston said. It might feel “awkward and unnatural,” but “some of the things you as a driver notice all the time are novel to teen drivers.”
Parents can influence road safety for teens in terms of their own behavior and in selecting a safer vehicle. A strong correlation exists between parental texting while driving when children are younger and what they do as teen drivers, for example.
Safer vehicles are bigger, heavier cars with electronic stability control, which reduces risk of death about as much as wearing seat belts. Parents should avoid vehicles with high horsepower and look for cars with the best safety ratings they can afford, Dr. Johnston said.
Several special features in newer cars can help reduce crash risk, such as blind spot detection, automatic breaking, collision avoidance systems, lane departure warning systems, and driver drowsiness detection. Parents may worry that relying on this technology could reduce teens’ learning, but it actually can compensate for skill deficits as they are becoming more skilled drivers.
Parents can look into feedback programs such as smartphone apps or other in-car units that allow parents to see data on teens’ speed, unsafe driving, “near-misses,” and similar driving behaviors. Research has shown that unsafe driving in newly licensed teens dropped by 66% over 4 months of using one of these feedback programs, compared with teens who didn’t use it.
Dr. Johnston also discussed the idea of prelicensure medical exams, similar to physicals that are required before playing sports. These already exist for commercial licenses in most states, but no data exist on whether it’s effective for teens. The goal would be to promote a discussion between parents and their teens about driving: reviewing medications the teen is taking and whether they affect driving; discussing safety of different vehicles; and assessing the teens’ risks, including any cognitive or other medical conditions that could affect driving safety. Even if such a “driving physical” is not currently required, pediatricians can do their own version of one with families.
Dr. Johnston had no disclosures.
NEW ORLEANS – Teens need to drive for a wide range of reasons, from going to and from school or work to overall mobility, but driving still is the most dangerous thing teenagers do, according to Brian Johnston, MD, MPH, professor of pediatrics at the University of Washington in Seattle.
Motor vehicle traffic accidents continue to be the leading cause of death of adolescents aged 15-19 years, according to 2017 data from the National Center for Health Statistics at the Centers for the Disease Control and Prevention.
“Inexperience drives the statistics we see,” Dr. Johnston said at the annual meeting of the American Academy of Pediatrics. “There is a steep learning curve among drivers of all ages, and crash rates are highest during the first few months after teens begin driving without supervision.”
Although the risk of accidents is higher than average for any new driver, it’s disproportionately higher for younger teens, compared with other ages: 16-year-old novice drivers have a higher accident risk than that of 17-year-olds, whose risk is similar to that of 18- and 19-year-old novices.
How long drivers have been licensed has a far bigger impact on crash risk, Dr. Johnston said (Traffic Inj. Prev. 2009 Jun;10[3]:209-19).
But the risk of an accident also increases with each additional passenger a teen driver has, particularly for younger and male drivers (Traffic Inj Prev. 2013;14[3]:283-92). More passengers likely means more distraction, and distraction, driving too fast for road conditions, and not scanning the roadway are the three most common errors – together accounting for about half of all teen drivers’ crashes.
Risk factors for accidents
Speed is a contributing factor in just over a third (36%) of teens’ fatal crashes. Adolescents drive faster and keep shorter following distances than adults do. But as with adults, wearing seat belts substantially reduces the risk of death in accidents.
Nationally, 90% of drivers use seat belts, with higher rates in states with primary enforcement (92%) than those in states with secondary enforcement (83%).
But barely more than half (54%) of U.S. high school students say they “always” wear a seat belt, and just under half of teens (47%) who died in crashes in 2017 weren’t wearing one. As seen in adults, teens are more likely to buckle up, by 12%, in states with primary seat belt laws.
Distraction during driving can be visual, manual, or cognitive – and handheld electronic devices such as smartphones cause all three distraction types. Cell phones nearly double the proportion of teen drivers who die in crashes, from 7% to 13%.
But if teens can keep their eyes on the roadway at all times, even the risks posed by cellphones drop considerably.
“The best evidence shows that secondary tasks only degrade driving performance when they require drivers to look away from the road,” Dr. Johnston said. Looking away for 2 seconds or longer increases crash risk more than fivefold.
Two other risk factors for teen car accidents are drowsiness and nighttime driving. Sleepiness can play a role in crashes at any time of day, and Dr. Johnston noted that some research has associated later high school start times with reduced crash risk.
Teens aged 16-19 years are about four times more likely to have a car accident at night than during the day per each mile driven, the pediatrician noted. Many licensing laws restrict teen driving starting at 11 p.m. or later, but about 50%-60% of their crashes occur between 9 and 11 p.m.
One reason for the increased risk is less experience driving in more difficult conditions, but teens also are more likely to have teen passengers, to be driving excessively fast, or to be under the influence of alcohol at night.
Adolescents’ crash risk is higher than that of adults for any level of blood alcohol content. Self-reported driving after drinking dropped by almost half – from 10% to 5.5% – from 2013 to 2017, but alcohol still is implicated in a substantial number of fatal teen crashes.
As drunk driving has declined, however, driving while under the influence of marijuana has been increasing. According to the National Highway Traffic Safety Administration, case control studies show drivers with tetrahydrocannabinol (THC) in their blood have a 25% increased risk of accidents – but the excess risk associated with THC vanishes when researchers control for age, sex, and concurrent use of alcohol. Not enough research exists to determine what the crash risk would be for adolescent drivers using THC alone.
A less-recognized risk factor for car accidents in teen drivers is ADHD, which increases a teen’s risk of crashing by 36%, particularly in the first month after getting a license, Dr. Johnston said.
ADHD medication appears to mitigate the danger, according to data: Crash risk was 40% lower in adult drivers with ADHD during months they filled their stimulant prescriptions. But one study found only 12% of teens with ADHD filled their prescriptions the month they got their license, and adolescents may not take their medications or still have them in their system on weekends or at night.
Teens recovering from concussion also may have an increased risk. Some evidence suggests driving impairment continues even when other symptoms have resolved, but not enough data exist to determine appropriate criteria for clearing teens to begin driving again.
Interventions to improve teens’ driving safety
Most teens take a basic driver education course before getting their licenses, but no evidence shows that it reduces risk of citations, crashes, or injury. In fact, “skid control training and other kinds of advanced skill training seem to increase crash risk, particularly among young males,” Dr. Johnston said.
What helps teens most is, ironically, more driving.
“If I say inexperience is the single most important risk factor for dying in a crash as a teen, driving experience is the intervention,” he said. More time spent driving – “with supervision in particular, and under diverse conditions,” Dr. Johnston said – increases the repertoire of skills and abilities.
Parents should be encouraged to ride along as their teens drive under diverse road conditions: different roads, different times of the day, and different weather conditions, for example. Parents can narrate their own driving, pointing out hazards and times when they slow down for increased caution, Dr. Johnston said. It might feel “awkward and unnatural,” but “some of the things you as a driver notice all the time are novel to teen drivers.”
Parents can influence road safety for teens in terms of their own behavior and in selecting a safer vehicle. A strong correlation exists between parental texting while driving when children are younger and what they do as teen drivers, for example.
Safer vehicles are bigger, heavier cars with electronic stability control, which reduces risk of death about as much as wearing seat belts. Parents should avoid vehicles with high horsepower and look for cars with the best safety ratings they can afford, Dr. Johnston said.
Several special features in newer cars can help reduce crash risk, such as blind spot detection, automatic breaking, collision avoidance systems, lane departure warning systems, and driver drowsiness detection. Parents may worry that relying on this technology could reduce teens’ learning, but it actually can compensate for skill deficits as they are becoming more skilled drivers.
Parents can look into feedback programs such as smartphone apps or other in-car units that allow parents to see data on teens’ speed, unsafe driving, “near-misses,” and similar driving behaviors. Research has shown that unsafe driving in newly licensed teens dropped by 66% over 4 months of using one of these feedback programs, compared with teens who didn’t use it.
Dr. Johnston also discussed the idea of prelicensure medical exams, similar to physicals that are required before playing sports. These already exist for commercial licenses in most states, but no data exist on whether it’s effective for teens. The goal would be to promote a discussion between parents and their teens about driving: reviewing medications the teen is taking and whether they affect driving; discussing safety of different vehicles; and assessing the teens’ risks, including any cognitive or other medical conditions that could affect driving safety. Even if such a “driving physical” is not currently required, pediatricians can do their own version of one with families.
Dr. Johnston had no disclosures.