Over the past few years, the emergence of the electronic cigarette industry has put a new generation of young people — beginning with current middle and high school students — at risk of becoming addicted to nicotine. E-cigarette use poses a significant, yet avoidable, health risk to young people. Using these products increases the possibility of nicotine addiction and long-term harm to brain development and respiratory health. Statistics also show e-cigarette use is associated with combined use of other tobacco products that can do even more damage to the body.

The 2018 National Youth Tobacco Survey (NYTS) indicated an alarming increase in the number of high school students who are current e-cigarettes users, putting that figure at 20.8 percent. That is a 78 percent increase from the 2017 survey, which indicated that 11.7 percent of high school students were e-cigarette users. The NYTS shows that e-cigarette use among middle school students is also on the rise, jumping 48 percent from 2017 to 2018.

The same study showed that between 2017 and 2018, the use of flavored e-cigarettes has increased 60 percent among high school students who currently use e-cigarettes.

The Basics An electronic cigarette (e-cigarette) is a battery-powered heating device that does not burn or use tobacco leaves but instead delivers nicotine, when nicotine is present, in the form of an aerosol that the user then inhales.

Many of these devices are manufactured overseas and are not currently regulated under the Food and Drug Administration’s (FDA) regulations. The components of an e-cigarette include the battery; which powers the atomizer. The atomizer is the heating element that heats the e-liquid and is often coil-shaped. The e-liquid is added into the cartridge; which comes in a variety of sizes. When the e-liquid is heated, it creates the aerosol that is inhaled. E-cigarettes can be disposable, for one-time use, or refillable and rechargeable for repeated use. The refillable and rechargeable e-cigarettes come in medium and large tank (cartridge) styles and are sometimes referred to as “mods.” There are also e-cigars and e-pipes. As of October, three quarters of the e-cigarette market is currently controlled by an e-cigarette product called JUUL.

2018 National Use Tobacco Survey

JUUL (pronounced “jewel”) is produced by JUUL Labs, Inc. in California and, until recently, was only available online. Now, convenience stores sell JUUL at a discounted price. JUUL is a small, slick black e-cigarette that looks like a USB flash drive and is rechargeable. They can be easily hidden in a pocket or a fist. JUUL uses prefilled “pods” of e-liquids that contain high levels of nicotine, flavorings and other substances. The terminology of using the device is called “juuling.” JUUL comes in youth-friendly flavors such as mango, cool mint, and fruit medley. The nicotine in one JUUL pod is equivalent to the amount of nicotine in an entire pack of cigarettes, putting kids at a greater risk of addiction.

The aerosol produced by JUUL is not as noticeable as other e-cigarettes, making it difficult to detect. Youth are using JUUL in schools and sharing them with their peers. USA Today reported that 63 percent of young people ages 15 – 24 who use JUUL are not aware that the product always contains nicotine.
What makes JUUL so unique is its nicotine salt formula. JUUL claims that their nicotine salt formulation increases the rate and amount of nicotine delivered into the blood, compared with other formulations, and that delivery of nicotine by a JUUL is 2.7 times faster than other e-cigs. JUUL is also one of the first major e-cig brands to rely heavily on social media to market and promote its products. JUUL’s website provides the following warnings:

  • Warning: This product contains nicotine.
  • Nicotine is an addictive chemical.
  • California Proposition 65 Warning: This product contains chemicals known to the state of California to cause cancer and birth defects or other reproductive harm.

There is a misperception that e-cigarettes do not contain nicotine and that the e-liquid is just harmless water vapor. However, the aerosol (aka “vapor”) from e-cigarettes is not harmless. It can contain harmful chemicals, including nicotine, propylene glycol or glycerin, and flavoring such as diacetyl, a chemical linked to a serious lung disease. Some e-cigarette manufacturers claim these ingredients are safe because they meet the FDA definition of “Generally Recognized as Safe” for food additives. However, they have not been approved for inhalation.

The ingredients and concentration of the nicotine in e-liquids are inconsistent and difficult to find on packaging. Currently, there are more than 15,000 flavors of e-liquid available, with names like “unicorn puke” or “fruit medley,” clearly created to attract youth. According to the Surgeon General’s report, 85 percent of e-cigarette users ages 12-17 stated that appealing flavors was a reason for initiation of e-cigarette use.

Rise in Use of Flavors

Other chemicals found in e-cigarettes can include: ultrafine particles that can be inhaled deep into the lungs; volatile organic compounds such as benzene, which is found in car exhaust; and heavy metals, such as nickel, tin, and lead. Scientists are still working to understand more fully the health effects and harmful doses of e-cigarette contents when heated and turned into an aerosol, both for active users who inhale from a device and for those who are exposed to the aerosol secondhand. The effects of many of these inhaled ingredients are largely unknown.

The National Academy of Sciences, Engineering, and Medicine’s “Public Health Consequences of E-Cigarettes” brief included the following:

  • Conclusive evidence that exposure to nicotine from e-cigarettes is highly variable and depends on product characteristics (including device and e-liquid characteristics) and how the device is operated.
  • Conclusive evidence that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances.
  • Substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults. Youth who experiment with tobacco products experiment with multiple tobacco products. The 2018 NYTS reports youth who report use of any tobacco product increased by 27 percent among high school students and 7.2 percent among middle school students from 2017.

The e-cigarette industry is using marketing tactics specifically designed to appeal to and sell to youth. According to The Truth Initiative, more than 20 million U.S. middle and high school youth were exposed to e-cigarette ads in 2016. The study also shows that 68 percent of youth were exposed to e-cigarette ads in retail stores and 41 percent saw e-cigarette ads online. Between 2014 and 2016, exposure to retail e-cigarette advertising among young people jumped nearly 20 percent. (Read the full text of this report.)

Many of these ads glamorize e-cigarettes with celebrity and sports figure endorsements that target youth, prompting concern among health officials that e-cigarettes will become a path to smoking among young people who otherwise would not have experimented.

In January 2010, New Jersey included e-cigarettes in the 2006 Clean Indoor Air Act. In November 2017, N.J. raised the age of sale to 21 of all tobacco products, including electronic devices. The New Jersey Department of Health, Office of Tobacco Free, Nutrition, and Fitness’ statewide initiative, Tobacco Free for a Healthy NJ (TFHNJ), provides education on e-cigarettes for professionals and parents as well as a statewide youth engagement initiative for young people to educate their peers. Youth can be directed to TFHNJ’s “DontgetVapedIn” website and social media outlets to learn more about the dangers and risks of experimenting with e-cigarettes.




E-Cigarette Use Among Youth and Young Adults,” U.S. Department of Health and Human Services, Office of the Surgeon General.

Talk With Your Teen About E-Cigarettes: A Tip Sheet for Parents,” Centers for Disease Control and Prevention.

E-Cigarettes and Young People: Frequently Asked Questions,” Centers for Disease Control and Prevention.

CDC Website, Electronic Cigarettes.

N.J. Department of Health Tobacco ControlTobacco-Free for a Healthy NJ American Academy of Pediatrics Tobacco webpage

Don’t Get Vaped In,”  from Tobacco-Free for a Healthy NJ

NJ Quit Online” webpage, from the N. J. Department of Health, Office of Tobacco Control

Truth Initiative E-Cigarette Fact Sheet


Cathy Butler-Witt has a National Certificate in Tobacco Treatment Practice and is a certified tobacco treatment specialist. She is the assistant director of public health programs for the Southern NJ Perinatal Cooperative. Cristina Martins, a certified health education specialist, is a health educator with the Southern N.J. Perinatal Cooperative.