Vaping: A Growing Concern

In the past decade, vaping has become a ubiquitous phenomenon, with millions of Americans turning to e-cigarettes as a supposed safer alternative to traditional tobacco products. However, the reality is far more complex, and the risks associated with vaping are still not fully understood.

According to a recent study, approximately 7.2 million Americans believe vaping is harmless, while 57 million more think it’s less harmful than smoking. However, the truth is that we still don’t know the full extent of the harm caused by aerosolized nicotine compared to freebase nicotine.

The Science of Nicotine Addiction

Nicotine is a highly addictive substance that hijacks the brain’s reward system, leading to physical, emotional, and mental dependence. When a person consumes nicotine in any form, it binds to the body’s nicotinic acetylcholine receptors, stimulating dopamine release in the nucleus accumbens, the brain’s reward system ‘boss.’

This dopamine release drives reinforcement, eventually leading to dependency if consumption is repeated over time. Researchers believe that the addiction potential of aerosolized nicotine salts as a delivery mechanism may be unique, with a 2019 study finding that e-cigarette users and dual users had higher nicotine dependency scores compared to those of smokers.

The Withdrawal Process

The nature of addiction is such that users often continue long after they stop wanting to, because withdrawal is physically, emotionally, and mentally torturous. Nicotine withdrawal is known to bring intense cravings, irritability, mental health changes, sleep disruption, digestive disruption, and respiratory symptoms.

One study found that people quitting e-cigarettes reported fewer withdrawal symptoms than those quitting conventional cigarettes. This brings us back to the idea of harm reduction, where a product that is more appealing to the brain chemistry than cigarettes but easier to quit may have benefits.

Intervention and Quitting

The U.S. Public Health Service recommends that primary care physicians ask patients at every visit about tobacco use as part of a ‘five A’s’ approach: Ask about tobacco use, Advise on behavior modification, Assess severity and the patient’s disposition toward quitting, Assist with resources, referrals, prescriptions as needed, or a plan to quit, and Arrange a follow-up, check-in, or labs as needed.

Several screening methods fit into the Assess step, including the Fagerström Test for Nicotine Dependence (FTND) for adults and CRAFFT screening for adolescents. Limited research indicates that of those who attempt to quit vaping, about a quarter are successful. Many methods and combinations are available to those wishing to stop, but the top choices according to the research are as follows:

• Most effective stand-alone methods: Varenicline (Chantix), cytisinicline (used widely in Europe and expected to receive U.S. Food and Drug Administration [FDA] approval in 2027)
• Most effective approach overall: A combination of medication—specifically nicotine replacement therapy (NRT) or bupropion—and behavioral therapy

How Families Can Help

Nicotine dependency is very much a physical phenomenon that often requires medication, but environmental and emotional factors matter, at least to those attempting to quit. Research finds little to no statistical difference in cessation success resulting from strong family support, but a 2017 study of smokers found individual preferences in three main categories:

• Practical support: Helping pay for NRT or medication, assistance with environmental changes, such as removing triggers
• Emotional encouragement: Verbal praise or encouragement, calls or texts, compassion and grace around withdrawal and relapse, gentle reminders about goals and purpose
• Behavior modification: Not using nicotine in their presence, not inviting them to places that might be triggering

Community Interventions

Promoting prevention or cessation of youth vaping is crucial. State agencies must work to prevent illegal tobacco sales to minors, and citizens can pressure them to do so. Retailers can make the responsible choice not to sell those products to minors, and anyone who knows a retailer is selling to minors should report them to their state’s Alcohol Beverage Control (ABC) agency.

School Interventions

The Substance Abuse and Mental Health Services Administration (SAMHSA) and other federal agencies are recommending schools adopt a Multi-Tiered System of Support (MTSS), which provides a framework for educators to match their intervention to students’ specific needs:

• Universal Prevention (Tier 1): Schools implement evidence-based programs like CATCH My Breath or the Truth Initiative’s curriculum
• Targeted Interventions (Tier 2): For students at higher risk, schools can implement more focused small-group supports, including interactive digital tools like SmokeSCREEN
• Individualized Support (Tier 3): For students dealing with active dependence, school counselors provide one-on-one counseling that focuses on individual risk factors and self-efficacy

Restorative accountability, focusing on positive supports, has been shown to be more effective than punitive measures in addressing nicotine dependency among youth.