Journal of Public Health Policy (2020) 41:63–69

https://doi.org/10.1057/s41271-019-00193-2

VIEWPOINT

Vaping among youth and young adults: a “red alert” state

Mohammed Al‑Hamdani1 · D. Brett Hopkins2 · Tristan Park3

Published online: 29 October 2019

Abstract
The use of e-cigarettes, otherwise known as ‘vaping’, has been increasing at alarm-
ing rates among youth and young adults. Although the long-term harms of vaping
are still unclear, emerging evidence brings to light potential risks associated with
vaping, especially for youth and non-smokers. This paper discusses nine viable
policy measures that could limit the appeal of vaping products to youth and young
adults and, in turn, reduce the potential harms of vaping.

Keywords E-cigarettes · Health warnings · Nicotine · Tobacco control

E-cigarettes are battery-powered devices that heat liquids, often flavored and con-
taining nicotine, into an aerosol that users inhale [1, 2]. The use of these products,
colloquially referred to as ‘vaping’, is rampant among young individuals in countries
with loose regulation (for example, United States (U.S.) 30-day prevalence: 20.8%)
in comparison to those with stricter policies (Canada 30-day prevalence: 10.0%) [3,
4]. Of special concern is how vaping affects the health of youth and young adults.
Working from epidemiological studies, this paper classifies school-age adoles-
cents (ages 19 and under) as ‘youth’ and university-age adults (ages 20 to 25) as
‘young adults’ [4, 5]. Reports suggest that the prevalence of vaping is increasing at
an alarming rate among these groups [5]. In some jurisdictions, increases in vaping
rates are associated with increases in smoking rates after years of declining use. This
Viewpoint serves as a warning for public health officials about the direct health risks
of vaping, the potential for vaping to serve as a gateway substance, and the alarming
and disproportionately high proportion of vaping among youth and young adults.
Early generation e-cigarettes closely resembled traditional cigarettes in shape and
appearance. These were later followed by square-shaped tank versions that offered

* Mohammed Al‑Hamdani
mohammed.al‑hamdani@dal.ca
1
Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
2
Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS,
Canada
3
Concordia University, Montreal, QC, Canada

Vol.:(0123456789)
64 M. Al‑Hamdani et al.

more utility to users by allowing them to modify nicotine delivery settings [6, 7].
Tank-based vaping products, however, are heavy in weight, bulky to store in the
user’s pocket, purse, or bag, and inconvenient because they require the user to re-
fill the e-juice. Newer pod-shaped products, often resembling USB drives, overcame
the issues associated with older generation vaping products because they are small,
concealable, trendy in appearance, and use disposable flavored cartridges [7]. Pods
can also deliver higher concentrations of nicotine with fewer aversive sensations
as compared to earlier-generation e-cigarettes [6, 7]. For these reasons, pod-based
product use has increased at considerable rates [7]. One example, Juul, accounts for
40% of the vaping market in the U.S. and emerging evidence suggests that the sub-
stantial increase in youth vaping could be attributed to attraction of youth to the
earlier mentioned qualities of pod-based products [5, 7]. Further, advertisement of
vaping products conveys messages of freedom, sex appeal, relaxation, and travel, all
of which resonate with youth and young adults [7]. While there may be some merit
to the arguments that these products are less harmful than cigarettes and that they
are associated with promising cessation outcomes, there are risks and concerns that
must be considered.
Vaping reminds us of the earlier social acceptance of cigarette smoking. Although
the first commercialized production of cigarettes began in 1881, it was not until the
1950s that researchers widely recognized risks of tobacco use [8]. Despite conclu-
sive evidence on the harms of cigarette smoking at that time, smoking continued to
be widely acceptable. Doctors and celebrities endorsed cigarette use, smokers lit up
indoors, and the industry advertised through unlimited marketing vehicles, includ-
ing radio, television, and sponsorships, until the 1990s [9]. The high prevalence of
cigarette smoking in the early 1990s and its serious negative health consequences
evidenced the slow public health response to the tobacco epidemic [9]. One clear
example of the lasting damage of tobacco use is the sharp increase of lung and bron-
chus cancer rates from the 1930s until 1990 among men in the U.S. [10].
We must not repeat the lethargic response towards cigarettes with vaping prod-
ucts. If not addressed quickly, vaping will likely have a damaging and lasting impact
on youth and young adults. Vaping is far from benign. Emerging evidence suggests
an association between vaping and increased odds of heart attacks [11]. The toxic
composition of vaping products and the potential for lung-related harms is also a
growing cause for concern [12–14]. An outbreak of severe pulmonary disease in
youth and young adults in the U.S. in 2019 is believed to be associated with vap-
ing [15–17]. Although a specific cause has not been identified, the outbreak has
resulted in multiple deaths and an investigation by the United States Centers for Dis-
ease Control and Prevention [17]. Concerns about vaping do not end with its direct
impact; there is evidence that vaping is also a gateway for cigarette smoking [18].
Thus, vaping is reversing decades of relentless efforts to reduce smoking rates.
Vaping may be useful for smokers who have tried evidence-based smoking cessa-
tion methods, but failed, and should be available to them only [19]. In addition to its
known harms and potential for long-term harms, evidence on the efficacy of vaping
products to serve as a smoking cessation aid is mixed, thus substantiating the need
to recommend evidence-based methods such as nicotine replacement therapy, pre-
scription drugs, and counseling as first-line treatments before recommending vaping
Vaping among youth and young adults: a “red alert” state 65

[20, 21]. Marketing vaping products, optimizing their design and physical appeal,
and offering a variety of flavors does not influence these smokers. Instead, it attracts
individuals who never smoked, many of whom are youth and young adults.
Using an evidence-based perspective, we outline conditions where vaping could
be of public health benefit, albeit under tight policy parameters. We also provide a
recipe for public health policies based on evidence. Despite the dominance of pod-
based products in the vaping market [7], these polices should apply to all vaping
products. This Viewpoint applies to countries with high vaping rates and that intend
to take policy actions to address this public health issue.

Effective public health policies

Given the concerns about vaping noted above, we recommend nine policies to limit
the exposure and use of vaping products by youth and young adults, especially
among non-smokers.

Taxation

Governments should impose high taxes, equivalent to those on tobacco products, to

No advertising of any kind

Restrict advertising to include total bans on use of all mass media, billboards,
magazines, print, and online advertisement. Evidence shows that vaping advertise-
ment increases temptation among youth to vape and reduces their perceptions of
the harms of smoking [24, 25]. Complete advertising restrictions are more effective
than partial ones, such as limiting advertisement in programs oriented toward youth,
because the latter are ambiguous in defining the programs. Also, research shows low
compliance and enforcement of partial restrictions [24, 25].

Place health warnings and information on toxic composition and emissions

Early evidence suggests that health warnings on vaping products can encourage
consumers to quit vaping [26]. Place health warnings and information of toxicity
on vaping products to warn consumers about potential harms. Use pictorial warn-
ings with bright colors, not text-only warnings, to maximize the visibility of these
messages [27]. This recommendation follows best practices from the tobacco health
warning literature [28].
66 M. Al‑Hamdani et al.

Restrict product and packaging design

Vaping products that are sleek, modern, and easily concealed have become popular
among youth [7]. Present vaping products in dull, single-colored packages and cas-
ings that limit brand imagery displays to reduce their appeal [29]. Findings from
the tobacco control literature suggest that packaging color can prompt false health
beliefs in tobacco consumers (cigarettes in lighter packaging are less harmful than
cigarettes in darker packaging) [30]. Further, removing such brand elements allows
health warnings to draw consumers’ preferential attention towards the warnings
rather than the brand elements when looking at the package [31].

Cap nicotine content

To facilitate switching from cigarettes and to allow for a step-wise reduction of vap-
ing itself, vaping products should provide equivalent, not higher, nicotine levels.
Products that deliver more nicotine than cigarettes per day for an average user per-
petuate vaping even if the user successfully quits smoking. Countries in the Euro-
pean Union have capped nicotine levels nearly three times lower than those currently
permitted in the U.S. and Canada [5]. This may explain why vaping prevalence in
England has not increased. Such regulations warrant consideration by policymakers
in countries that have not yet taken this step [5].

Ban flavors

Ninety-eight percent of youth vapers between the ages of 12 and 17 use flavored
vaping products compared to 44% of adults 30 years of age or older [32]. This evi-
dence, coupled with robust findings from the tobacco literature showing a higher
proportion of flavored product use among youth and young adults, justifies ban-
ning vaping flavors [33, 34]. One tobacco flavor for vaping products should be made
available for smokers who can get access to them as harm-reducing products.

Enforce minimum age in stores and online

Many youth purchase vaping products online [35]. There are no safeguards for
online purchases and no evidence of stringent enforcement of laws restricting sales
to youth in storefronts [35, 36]. To reinforce compliance, governments need to
impose hefty fines and ensure stringent enforcement. To prevent youth from pur-
chasing vaping products online there is a need for online safeguards for verifying an
adult’s age, beyond a simple click response of a ‘yes’ or ‘no’ to a question that asks
the consumer if the individual is an adult or not.

Regulate density of vaping outlets

Regulating the density of vaping outlets, such as retail stores, will be important to
prevent at-risk populations from being targeted by marketing campaigns. Vaping
Vaping among youth and young adults: a “red alert” state 67

outlets tend to be higher in density in urban areas, in areas with higher poverty lev-
els, and near private institutions and colleges in urban areas [37–39].

Vape‑free policies

Banning indoor use and restricting outdoor use of vaping products is crucial. Poli-
cies that restrict vaping near an employment entrance and prohibit vaping in certain
outdoor areas, such as public parks and playgrounds, are examples of best practices
for tobacco-free policies [40, 41].

Research to inform policy

Further research into vaping related harms and risk-behaviors is necessary to inform
policy and user decisions. Research on personality traits that increase the likelihood
of vaping, mechanisms that explain why youth vape, and a conceptual model to bet-
ter outline the interactions of personality, norms, economic, and other factors that
lead to vaping are necessary to identify risk factors associated with increased vaping
and to draft policies that reduce vaping product use. Clear messaging and awareness
of the known harms and caution about the early stage of assembling evidence on the
potential harms of vaping are all needed to help smokers make informed decisions
about using vaping products as a means to stop smoking.

Conclusion

Vaping rates are high among youth and young adults. Restrictive policies to reduce
vaping among these populations, to prevent vaping from serving as a gateway to
smoking, and to reduce harms of use can improve health outcomes. Such policies
are also useful to restrict the exposure, purchase, and use of vaping products by
adult smokers who have not quit with the aid of evidence-based cessation methods,
even though they have attempted to do so.

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Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.

Mohammed Al‑Hamdani Ph.D. is a Mitacs Elevate Post-Doctoral Fellow at Dalhousie University and the
Lung Association of Nova Scotia, Canada.

D. Brett Hopkins B.Sc. (Hons) is a M.Sc. student at Dalhousie University, Nova Scotia, Canada.

Tristan Park B.Sc. (Hons) is a Research Assistant at Concordia University, Montreal, Canada.
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