No One Is Ready for the Teen Vape Addiction Crisis

Ryan Kasak never thought he’d get addicted to vaping.

For nearly a year after his first e-cigarette hit at a club in Tallahassee when he was 18, the Florida State University business student thought he had his smoking under control. His Juul was nothing more than a “party item,” he told The Daily Beast—a way to signal “I’m cool, too” when he didn’t have a drink in his hand.

“I’m never gonna get addicted to this,” he remembers thinking.  

But while Kasak studied for accounting and statistics finals last December, that changed. He started using his Juul to alleviate stress, taking hits to motivate himself between hours of scribbling notes or to reward himself for finishing a math problem. After every problem, he said, he’d take five hits of his Juul—about half a cigarette’s worth of nicotine—which he always kept charged on his desk.

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Soon, he started smoking every day, almost always vaping his favorite flavor, mint, although he once sampled blueberry. He routinely went through four pods a week—the nicotine equivalent of about four packs of cigarettes—even after finals ended. That’s when he realized he couldn’t stop.

“It’s not fun. You want to hit it all the time,” he said.

“You tell yourself [addiction] is never gonna happen. And then it does.”

Kasak isn’t alone. In recent years, multiple lawsuits have been filed against e-cigarette companies by plaintiffs claiming that they were unwittingly induced into getting hooked on nicotine. Most recently, 44 plaintiffs—many of them minors—filed a class-action lawsuit against Juul alleging that the company caused their nicotine addiction.  

The FDA has taken notice. On April 1, the agency announced a public scientific workshop to be held this May to investigate teen nicotine addiction.

“The need is clear,” then-FDA Commissioner Scott Gottlieb wrote in a statement announcing the workshop. “We’ve heard too many painful stories from parents of teenagers, pediatricians, and young people themselves; and, they reinforce what we all already know—for many young e-cigarette users, addiction has already taken hold.”  

It’s one of the latest steps the agency has taken to curb minors’ use of e-cigarettes, a product which was originally intended to help adults kick traditional, tobacco-based cigarettes. According to the FDA’s statement, approximately 3.6 million middle and high school students have vaped in the past 30 days—a number that the FDA says signifies an “epidemic” of teen use.

Addiction specialists say the workshop can’t come soon enough. While the FDA is clear that kids are getting addicted to e-cigs, no one really knows how it will affect their health.  

“It’s a nightmare,” Sharon Levy, an associate professor of pediatrics at Harvard Medical School and the director of an adolescent substance abuse clinic, told The Daily Beast. “It’s a nightmare because we’ve unleashed this massive experiment on our population—on our children.”

When Levy started working at her Boston-based clinic nearly two decades ago, she dealt mostly with opioid addiction and cigarette use. Now, she said, “Just about every kid who comes in is reporting Juul use” and that “It’s the rare kid who doesn’t.” Out of the 30 kids her clinic admitted in March, she estimated that 27 had a problem with e-cig use. Her youngest-ever patient, she said, was just 12 years old.

It’s not yet clear exactly how many teens are addicted to e-cigs. A spokesperson for the FDA told The Daily Beast that the administration was unable to provide an estimate.

The fundamentals of nicotine addiction are well-established. Just seconds after inhaling from a cigarette, nicotine surges through the bloodstream and into the brain, where it binds to a receptor intended for the neurotransmitter acetylcholine. That bond stimulates the release of other neurotransmitters, like dopamine and serotonin, in the parts of the brain that control pleasure and motivation.

That process is particularly powerful in adolescents, who are “uniquely susceptible” to developing a nicotine addiction, Susanne Tanski, an associate professor of pediatrics at Dartmouth, told The Daily Beast. Studies have shown that in some cases, kids have gotten hooked after just a few uses.

That’s due in part to a process called synaptic pruning. As an adolescent’s brain develops, it “prunes” connections it barely uses, and coats connections it uses more often in a fatty myelin sheath that helps signals travel faster, Bonnie Halpern-Felsher, a Stanford University pediatrics professor, told The Daily Beast. If an adolescent never tries nicotine, the receptors become more dormant—but if they do, the receptors get “primed” for future use.

“[That’s] why we’re particularly worried about adolescents,” Halpern-Felsher said. “Because you’re so much more likely to become addicted.”  

Those fundamentals are well-understood. But when it comes to how that nicotine impacts an adolescent’s developing brain, Levy said, “there’s not a lot known.”

The scientific literature is extremely sparse. One Mar. 2007 study in the journal Psychopharmacology found that several years of chronic nicotine abuse in adolescence led to reduced activity in the prefrontal cortex, a part of the brain that regulates decision-making and personality. The study, however, followed only 15 smokers and 22 non-smokers.

Similar results have been demonstrated more consistently in animals, Neal Benowitz, a nicotine pharmacology expert and a professor of medicine at The University of California, San Francisco, told The Daily Beast. When rats were exposed to nicotine, Benowitz explained, their brains matured more slowly. In the long term, the animals proved to be more impulsive, which could indicate an underdeveloped prefrontal cortex.

But Benowitz emphasized that rat studies don’t translate reliably to humans, and that there’s still very little known about how nicotine impacts a developing adolescent human’s brain.

“It’s a big unknown,” he said. “It’s a big question.”

Levy agrees. “We really don’t know [what is happening] when your brain is developing. We really have no idea.”

What’s worse is that Levy says she’s seen many adolescents at her clinic that have “totally different” symptoms from kids addicted to traditional cigarettes. Old-fashioned cigarette users complained of physical problems like coughing and shortness of breath, but her e-cig patients have reported mental health symptoms like unexplained bursts of anger, mood swings, and dissociative episodes. And although there’s no way to link those symptoms definitively with e-cigarette use, the cases are scary: Levy described one patient who was afraid to go back on the sports field for fear they’d dissociate mid-game and get injured.  

“It is a completely different product with very little relation,” she said. “We are seeing kids who are just completely collapsing. They’re not functioning.”

Then there’s the risk of physical consequences. An Oct. 2018 study published in Nicotine and Tobacco Research found that certain flavor additives create irritants that could damage airways and lungs, and e-cigarettes have been tenuously linked to a higher risk of strokes (although the results haven’t yet been peer-reviewed, and the authors cautioned that more research is needed). At least one study has shown that some e-cigarettes contain cancer-causing agents.  Patients have suffered serious burns from spontaneously exploding e-cigs. And just last week, the FDA warned of a potential risk of seizures stemming from nicotine poisoning.

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Blame for the epidemic has largely fallen on the shoulders of e-cigarette companies—most notably Juul, due to its dominant grip on the market.  The popular e-cigarette brand has been criticized for advertisements that experts claim are designed to appeal to children and don’t adequately detail the potential risks. The FDA is investigating those claims. The brand has also been slammed for allegedly sparking a “nicotine arms race” among competitors by ramping up nicotine content in its own products.

In response to detailed questions, a spokesperson for Juul said told The Daily Beast via email that  “[the company’s] mission is to improve the lives of the world’s one billion smokers by offering a satisfying alternative to combustible cigarettes. To help adult smokers switch, we knew a product should generally mimic the experience of a cigarette (the amount of nicotine delivered and the rate at which the nicotine enters the bloodstream). A 5% JUULpod delivers nicotine roughly equivalent to the average pack of “full flavor” or regular cigarettes [...] Precise nicotine absorption will vary person by person, as it does with cigarettes.”

The spokesperson also pointed The Daily Beast to an op-ed in The Washington Post written by CEO Kevin Burns, in which Burns wrote that “use by minors of vapor products, including Juul products, is a serious problem that threatens the opportunity our industry offers,” and noted that the company has suspended sale and distribution of non-menthol flavored products to curb teen use.

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Part of the problem, Tanski said, is that it can be difficult to tell exactly how much nicotine you’re inhaling every time you take a hit. Different e-cigs have different voltages, and pods vary in nicotine content—and mods only complicate the situation.

“One person vaping isn’t another person vaping,” she said.

There are other problems, too. There’s evidence that e-cig smoking can lead to a higher risk of traditional cigarette use: A report from the National Institute on Drug Abuse, for example, found that 30.7 percent of e-cig users started smoking within 6 months of their first hit, compared to only 8.1 percent of non-e-cig users.

Katherine Snedaker, a New-York based CEO of a brain injury nonprofit, knows this all too well. Her father died of cancer at 53 after smoking 3 and a half packs a day throughout her childhood, Snedaker told The Daily Beast. Because of that, she strived to raise her three sons to be smoke-free.

But in 2017, she said, all three of them picked up e-cigs; one started smoking up to two pods a day. It wasn’t until one son tried to quit with nicotine gum and patches that she realized how serious his addiction had become.

“Three days into [treatment], he said ‘Mom, I slept through the night for the first time in years,’” Snedaker said. “And I said, ‘What do you mean?’ and he goes ‘I wake up twice a night to Juul.’”

One son has since kicked the habit. But the other two have switched to cigarettes, and one smokes a pack and a half a day. He’s convinced, Snedaker said, that “they’re less addictive than the Juul.”

“It’s depressing,” Snedaker said, “that as a parent, there wasn’t a way to head this off.”

Part of the problem, she added, is that the medical community hasn’t caught up to the epidemic. When she tried to seek treatment for her son, she said, physicians didn’t know what to do.

Levy agrees. There’s “not a lot” out there for struggling teens, she explained, because no adult nicotine replacement products have been approved for adolescent use. Levy emphasized the need for more studies about adolescent nicotine cessation to develop better treatments—but acknowledged that “We simply don’t have the luxury of sitting around and waiting for those studies to be done.”

Kasak had better luck than most. He signed up for daily text messages from Truth Initiative, and returned often to the reason he was quitting: to avoid any chance of getting sick. It wasn’t easy—almost immediately after setting a concrete quit date, he slid back into hitting his Juul—but he stopped for good, he said, on Apr. 7.

Now, he’s shut his Juul in an empty Jack Daniels bottle in his room—an homage to both a whiskey-laden 19th birthday that landed him in the hospital, and the nicotine addiction he’s determined to leave behind.

“I keep those around just to remind myself,” he said. “Never do that again.”