To vape or not to vape: Is that really a question?


All pediatricians are relieved that the rates of children smoking cigarettes have dropped steadily since 2011. This decline seems to be associated with education on the dangers of cigarettes and fewer parents smoking. Perhaps less modeling of cigarette use in movies (although it increased again from 2010 to 2019) and lawsuits against advertisements targeting children also have helped.

“Whew,” we may have said, “we can relax our efforts to convince children to avoid smoking.” But, as is commonly true in medicine, the next threat was right around the corner – in this case vaping or e-cigarettes, also called vapes, e-hookahs, vape pens, tank systems, mods, and electronic nicotine delivery systems. And the size of the problem is huge – over 20% of high school students report using e-cigarettes – and immediate, as vaping can kill in the short term as well as causing long-term harm.

“E-cigarette, or vaping, product use–associated Lung Injury” – EVALI for short – has killed 68 vapers and hospitalized thousands. EVALI is thought to be caused by a vitamin E acetate additive used when vaping marijuana, particularly from informal sources like friends, family, or in-person or online dealers.

Vaping increases the risk of severe COVID-19 disease

While EVALI deaths dropped in months after being explained, the COVID-19 epidemic is now a much greater threat to vapers.

  • Vaping, smoking, and even second-hand smoke are associated with a greater likelihood of infection with COVID-19.

  • Vaping increases the risk of severe COVID-19 disease because of its immediate paralysis of lung cilia.

  • Sharing vape devices and touching one’s lips while using also increase the risk of virus transmission.

  • Vaping and smoking increase the number of ACE2 receptors to which the SARS-CoV-2 virus attaches causing the characteristic cell damage, and suppresses macrophages and neutrophils, resulting in more smokers testing positive, being twice as likely to develop a severe illness, and get hospitalized because of pneumonia from COVID-19, and being less likely to recover.

Unfortunately, addressing this new threat to the immediate and long-term health of our patients appears to be more complicated than addressing smoking tobacco. First of all, vaping is much more difficult to detect than smelly cigarettes sending smoke signals from behind the garage or in the school bathrooms. Many, if not most, adults do not recognize the vaping devices when they see them, as many are tiny and some look like computer thumb drives. The aerosol emitted when in use while containing dangerous toxins has less odor than tobacco smoke.


Vaping equipment and ads have been designed to attract youth, including linking them to sports and music events. Vaping has been advertised as a way to wean off nicotine addiction, a claim that has some scientific evidence in adults, but at a lower dose of nicotine.


Warning children about the dangers of marijuana vaping has been made less credible by the rapid expansion of legalization of marijuana around the United States, eliciting “I told you it was fine” reactions from youth. And the person vaping does not know what or how much of the psychoactive components are being delivered into their bodies. One Juul pod, for example, has the equivalent in nicotine of an entire pack of 20 cigarettes. They are highly addictive, especially to the developing brain, such that youth who vape are more likely to become addicted and to smoke cigarettes in the future.

Help from federal regulation has been weak

While all 50 states ban sales to youth, adults can still buy. Food and Drug Administration limitations on kid-friendly ads, and the use of sweet, fruity, and mint flavorings that are most preferred by children, apply only to new producers.


The FDA does not yet regulate the content of vaping solutions.

So we pediatricians are on the front line for this new threat to prevent vaping or convince youth to cut down or quit. The first step in addressing vaping is being knowledgeable about its many known and emerging health risks. It may seem obvious that the dangers of vaping microscopic particles depend on the contents. Water vapor alone is not dangerous; in fact, we prescribe it in nebulizers. Unfortunately, the contents of different vaping products vary and are not well defined. The process of using an electric current to vaporize a substance can make it more toxic than the precursor, and teens have little idea about the substances they are inhaling. The psychoactive components vary from nicotine to tetrahydrocannabinol in varying amounts. These have the well-known effects of stimulation or a high, but also the potential adverse effects of poor concentration, agitation, and even psychosis. Most e-cigarettes contain nicotine, which is highly addictive and can harm adolesce