The UK's Teen Vaping Epidemic – Should we be Worried ?

The short answer to this question, I’m afraid, has to be: Yes.

Read on to find out why......

Introduction

‘Vaping’ is the administration of vaporised nicotine solution by inhalation.

This form of nicotine intake has been growing in popularity for a number of years since it was first introduced as an aid to smoking cessation.

Tobacco smoking was recognised as a major cause of death in the late 20^th century, but due to vested interests in the tobacco industry (and the associated government revenues from taxation on tobacco products) serious attempts to limit the practice did not emerge until the late 1990s with anti-smoking campaigns and ultimately the banning of smoking in public places in the early 2000s by statute.

Smoking is still widely practised, however, and the use of vaping as a smoking cessation aid remains valuable and necessary from a health perspective. There is little doubt that the well-established harmful effects of smoking far outweigh the risks of vaping for established smokers. Because of this, the restrictions around the sale of vaping devices have been relatively lax, and these devices are widely available in retail outlets and effectively tax-free, putting them within easy reach of the majority of the population - including the young.

One worrying by-product of this lack of regulation and easy availability has been the explosion of vaping in the teenage population. This is not limited to the UK – indeed the USA has been particularly badly affected in recent years, and the US Surgeon-General has issued detailed recommendations to minimise potential harm from vaping and other forms of nicotine addiction. The US authorities became concerned initially when an outbreak of respiratory illness linked to vaping occurred in early2020 (termed the EVALI outbreak). This was investigated by the USA authority (ACDCP) and found to have been caused by 'rogue' constituents in vaping fliud, which led to an outright FDA ban on all products by Juul, the manufacturer responsible.

If anything, UK is ‘behind the curve’ in regulating the vape marketplace, and may not yet have reached peak ‘exposure’.

The Australian Government have taken a particularly tough line on vaping for some time now since 2021 and are now introducing legislation which will ban import of all single use vapes and allow import of other types only for prescription use in smoking cessation.

Why should we be concerned ?

The answer to this important question this is broadly two-fold:

1) 1) Nicotine is a low molecular weight organic compound which is pharmacologically active in its own right (see Figure 1 for chemical structure, this link for details of pharmacology and properties). Chronic low dosage via inhalation is known to be associated with a number of adverse health effects; higher doses by any route of administration are toxic and can even be lethal due to nicotine’s potential to affect heart rhythm. See link for more info on nicotine poisoning.

2) 2) The additives which are used to enable nicotine solutions to be vaporised effectively within vaping devices are relatively innocuous in themselves. Examples are propylene glycol, glycerol, diacetyl and the many different flavourings used to enhance the taste. However, these substances generate other more harmful compounds such as formaldehyde and heavy metal ions during the heating process. This is because of the high temperatures required for effective vaporisation. The smallest particles generated in the resulting smoke clouds may also reach the alveoli and cause irreversible lung damage similar to that caused by diesel fume micro-particulates.

Focusing on nicotine itself, this compound is one of the most addictive substances known, rivaling class A drugs such as Cocaine and Amphetamines in its ability to ‘hook’ its users. The difficulty of weaning an established smoker off cigarettes is well known and relapses are common even after periods of complete cessation. This is one of the principal reasons for the popularity of vaping devices in smoking cessation therapy, since it provides a less harmful alternative source of nicotine to tobacco and also allows a gradual reduction in nicotine dosing over time.

We know already that there are heightened risks of nicotine addiction in the young, as compared with adults.

Epidemiological studies have shown CNS effects including early cognitive dysfunction. E-cigarettes are known to exacerbate the symptoms of patients with existing lung conditions such as COPD and asthma, and they have also been reported to cause symptoms in otherwise healthy individuals such as shortness of breath, nausea and palpitations.

Notwithstanding the known effects, the real ‘elephant in the room’ is the unknown risk of lung damage from the other components in vaping ‘smoke’, particularly when it comes to young, and still developing, lungs.

Although medium-term studies are underway, and have already confirmed evidence of early lung damage, vaping hasn’t been around long enough to establish whether the combined effects of nicotine administration and high-temperature vaping ‘by products’ administered regularly over a prolonged period time cause the irreversible lung damage that is characteristic of COPD and other incurable lung diseases. Much more work is required to establish what the long-term effects really are, and this can only be done by initiating and funding controlled clinical trials.

To gain some insight into how much long-term damage could be caused by vaping, studies have already been carried out on particle size distribution in vape smoke, and compared with that of cigarette smoke. This data indicates that penetration into the bronchial tree and in particular the alveolar sacs where gas exchange actually occurs, is governed by particle size. Basically, the smaller the particle, the more readily it will reach the alveoli intact. One such study demonstrates that far from being much less harmful than cigarette smoke, vape smoke actually produces smaller-sized particles due to enhanced evaporation of water from the heated vape solution, and up to a third of these are deposited in the lower reaches of the bronchial tree. Thus we might expect more rather than less susceptibility in vapers to particle-induced alveolar damage of the type which induce COPD and other obstructive diseases. Lung damage of this sort tends to be cumulative and irreversible, as shown in numerous tobacco smoking studies, so the sooner we wean the young off vaping the less likely they are to suffer permanent damage.

Recent studies have confirmed earlier results from as far back as 2020 that e-cig smoke has a direct effect on human neutrophils. These cells are intimately involved in mediating our response to bacterial infection - inhibition of their activity is thus likely to make vape users more prone to lung infections. This effect is present even in the absence of symptoms and may be particularly harmful to developing lungs where full immunological competence may still be developing.

Another worrying statistic which emerged recently is the high concentration of heavy metals, particularly nickel and lead, in vape smoke. These are likely to originate by leaching from the heating coil into the vape fluid during storage and particularly when the device is in use and the coil is heated. This will occur whether or not nicotine is present, so will apply equally to nicotine-free vapes. Heavy metals generally are potent enzyme poisons and are both lead and nickel are established as toxic in small doses. Lead in particular is well known for its neurotoxic properties and has a cumulative effect on intellectual development in the young.

What’s driving the 'epidemic' ?

The vape industry which has sprung up to take advantage of the new 'craze' has already contributed much to its popularity amongst teens. The attractiveness of the device packaging, bright colouring and the wide variety of flavours available, coupled with the addictiveness of nicotine itself, have all helped inspire the vaping craze our youngsters are currently experiencing. Although under an obligation to withhold sales from under 18s, have hitherto been able to exploit a loophole in the regulations by legitimately offering free samples to under 18s. Sales of nicotine-free vapes to under 18s are also allowed. Given the identification of known toxic agents in nicotine free vape smoke, this is clearly remiss of the authorities, and a very recent announcement suggests that this loophole will soon be closed.

By contrast, the attractiveness of other form of nicotine administration, such as nicotine patches,which were one of the first developed for cessation therapy, are much less attractive and therefore less likely to 'hook' teenagers on nicotine addiction. Although patches will satisfy nicotine cravings as intended, they are generally invisible and don't have the same attractiveness from a social point of view; the act of manipulating the device in a social context adds to the 'pull' of vaping.

Observational studies confirm that children as young as ten or eleven regularly vape – a walk round any of our town or city streets will reveal many of the ‘carcasses’ of the single-use vape variety that are most popular, together with even larger numbers of the discarded cartons they come in (see Figs 2-4). These are often most prevalent in areas where teenagers tend to congregate, which is indicative of their success in reaching their primary 'target' demographic.

Public perception of the risks is also patchy - a widely held view, particularly amongst vapers themselves, is that "..vaping isn't really smoking, so it should be safe..". I'll leave the reader to decide on the validity of that assumption, based on the accumulating evidence.

Vapes - the 'nuts and bolts' and how they work

A typical single-use vape is shown in Figures 2 and 3.

When fully charged it is simplicity itself to operate - the vaper inhales via the mouthpiece and this causes a pressure reduction within the body of the vape which triggers the pressure sensor switch. This in turn applies a voltage from the battery to a small wire heating element within the nicotine reservoir, which heats up rapidly and vaporises a small amount of the nicotine solution. The vapour produced then exits via the mouthpiece into the vaper's bronchial tree during inspiration. A proportion of the smoke is then released during expiration.

Note the excess nicotine solution adhering to the side of the reservoir in this example. This particular model is rated at 2% i.e. 20 mg/mL, and contains 20 mg nicotine, the maximum amount allowed in UK. It is rated at 600 puffs and claims to be equivalent to a pack of 20 cigarettes. It can be bought online for £5.99, which compares very favourably with a typical £15.95 price of 20 cigarettes, which has included a minimum of £7.87 in tax since the March budget increase.

(This particular vape-stick was discarded locally in an area adjacent to a local park and easily accessible by children. The battery registered 3.3v (nominal 3.7v when charged) when disassembled, quite sufficient to cause a fire if short-circuited. It has since been recharged and is now in use to power an LED torch as a substitute for 3 x AAA dry cells. NB If you do attempt to recycle a battery in this way, ensure you use disposable latex gloves or equivalent to prevent skin absorption of any residual nicotine, and ensure the outside of the battery is thoroughly cleaned before use).

Availability and Implications

The lack of any effective sales regulation ‘on the ground’, and the absence of tax makes these devices relatively cheap compared to cigarettes, thus bringing them well within the average teen’s budget.

One other effect of widespread vaping uptake which is more insidious and therefore less well appreciated is that it ‘re-normalises’ cigarette smoking. The statistics on this are quite revealing, showing a marked and almost coincident upward trend in both vaping and uptake or re-uptake of cigarette smoking over the past couple of years. Although a direct causative effect can’t be proven as yet, the circumstantial evidence is compelling.

As a general-purpose inhalation device, vapes can also easily be adapted to deliver other addictive agents such as cannabinoid derivatives. Cannabidiol (CBD) products are also readily available over the counter in UK in similar formats, and their pharmacological and toxicological effects when delivered by inhalation are as yet untested.

What of the environment ?

As already discussed, vaping ‘debris’ is easily visible on our town and city streets anywhere in the UK. The vast majority of vapes sold are of the single-use variety. Re-useable devices are available for sale, but they involve recharging and refilling with vape liquid and so have not ‘taken off’ in the way that the single-use variety have. Nicotine solution is also skin-absorbed, so there is a risk of poisoning if solutions are mishandled.

Apart from the more obvious general littering problem, used vapes present a number of environmental hazards:

1) 1) Each device contains a small Lithium polymer (LiPo) battery which is used to power the heating element. These are used in preference to single-use dry cell batteries because of the higher voltages and current capacity needed to power the vape’s heating element. Since the more popular devices are relatively easy to take apart (the mouthpiece can often be unscrewed manually without tools), the LiPo batteries often find their way onto pavements and into gutters. Given that they are relatively small, they could easily be ingested by inquisitive small children or pets, with disastrous results. As can be seen from the illustration in Fig 3, the nicotine reservoir and battery are both conveniently 'sweet sized' so would present a particular hazard to any inquisitive toddler. Even if this doesn’t happen the toxic chemicals in a damaged battery will slowly leach into the environment and ultimately the water supply. In certain circumstances a partially discharged vape battery may even be capable of starting a small fire if short-circuited – more of a risk than might be thought, perhaps, given recent climatological changes and the resulting bone-dry spells we’ve experienced in recent summers.

2) 2) Vapes are normally discarded when they are no longer capable of generating adequate ‘smoke’ to satisfy the user. With the smaller non-rechargeable devices, this often happens when the battery runs down, rather than when the nicotine solution in the reservoir is exhausted. Single use vapes carry the nicotine in a porous fabric mesh which tends to retain significant amounts (estd. up to 25% of total charge) even when the vape is exhausted. This means that there is likely to be a significant amount of residual nicotine solution in the body of the vape which will be released if it comes apart. This can legally contain nicotine at concentrations up to 20 mg/mL in UK, which is quite sufficient to cause accidental poisoning if ingested, and it can also be absorbed through the skin if handled directly.

3) 3) The wastage of components used in the manufacture of single-use vaping devices is obvious – this applies particularly to the element Lithium which is used in the batteries which power virtually all phones, tablets and other rechargeable devices and is already in short supply.

How do we deal with the epidemic and protect the long-term health of our offspring ?

As always where the young are concerned, getting them to behave in ways we believe are ‘good for them’ is never easy….

An outright ban on the sale and use of vaping devices in UK would almost certainly be counter-productive.

Not only would it meet combined opposition from young vapers and those vested interests in the supply industry, but it would also drive the supply underground, thus preventing any effective regulation in the future. Imports from other territories where vaping was still allowed would flood the market and possibly even attract increased usage. A more nuanced approach to restricting availability is therefore called-for.

One useful first step would be to tighten product licensing rules in UK such that the strength of nicotine solutions used was carefully regulated and strict limits placed on the maximum concentrations and the amounts of solution permissible in any one device. The MHRA do currently regulate vaping products in the UK (see link) but the limits on concentration and amounts of nicotine in devices and refill liquids are still relatively high. Reductions in these would reduce the risk of toxicity both to the vaper and the environment, and help limit availability. Any change such as this would of course require more effective monitoring and enforcement. A ban on sales of nicotine-free vapes to children is an obvious must and should shortly be in the pipeline.

The absence of definitive long-term data on the health impact of vaping needs to be remedied. Any other new formulation of a new or existing pharmaceutical compound would be subject to extensive trials before receiving a product license. Since nicotine also falls into the category of 'recreational' drugs and has no therapeutic value (other than as an aid to smoking cessation), vape manufacturers should be required to carry out and fund such trials as a condition of renewal of their product licenses.

Whether a tightening of regulation would actually make much impression however, is a moot point. The vast majority of single use vapes and other vaping products are manufactured in - yes, you guessed it - China. Although MHRA will have jurisdiction over the activities of UK importers, they will have no control over Chinese manufacturers, who will, as always, be focused as always on maximising their profits. They may well also be subsidised by the CCP government to enable their pricing to stay highly competitive and thus maximise foreign exchange revenue. Although the regulatory position is starting to change now, regulatory resourcing is likely to be an issue in the UK, at least until the 2024 election, thus we should not expect local regulation per se to solve the availability problem in the short term.

A further environmental and public health gain would be to introduce a taxation regime similar to that in force for tobacco products, and modify this to ensure that single-use devices attracted a higher tax than re-useable ones. This should be attractive to governments, given the new revenue stream it would generate. Tax exemptions could be made for those undergoing medically-prescribed smoking cessation programmes to encourage continued use for this purpose. Part of the revenue stream could also be used to support enforcement by the regulatory agencies. Last, but not least, the resulting increase in price would be a deterrent in itself, particularly now that the current cost-of living ‘crisis’ is proving to be more persistent than anticipated.

There are reports that Government is currently considering introducing such a new taxation regime – whether this will happen (or indeed be effective if it does!) before the 2024 election is another matter. Last, but not least, a specific collection scheme should be introduced with a view to recycling rechargeable vape batteries and the safe disposal of nictotine residues. Again, this should be funded by a levy on vape manufacturers and retailers.

The announcement of a new controls on the gambling industry recently are in direct response to the increasing suicide incidence in 'problem' gamblers. These are individuals who have fallen prey to another form of highly addictive behaviour pattern. A similar tightening of controls on vaping is long overdue and legislation should now be actively considered by government. The numbers involved in vaping far exceed those at risk of gambling excess, so there is a much bigger 'win' for society here.

(There is already a scheme for recycling electrical waste, and although this specifies that batteries should ideally be removed from vapes before donating for recycling, they will accept intact vapes. Local collection points can be found via their website. Figure 4 should help convince the reader of the need for a new scheme.)

Increased regulation and higher pricing might go some way at least towards keeping the epidemic in check. Ultimately, though, for a highly addictive product such as this, the only answer is, to quote a previous UK PM (though mercifully not this time in the same context - we all know where that led!): “Education, education...and education…”.

‘How are we supposed to make this happen?’, I hear some already concerned parents ask…

Although the schools and Government messaging must also play a part, the only really effective way of getting the message across is through parental influence, and this will not be at all easy.

Why ?

The average established teenage vaper will, sadly, already be a confirmed nicotine addict, and will find ways of feeding their 'habit', whatever exhortations or sanctions their parents or relatives might come up with. A subtle and relentless approach will no doubt be called for and this will depend on family circumstances. Where parents can really help stem the tide initially is by ensuring any early-teenage offspring who haven’t already succumbed…just don’t. Put your efforts into limiting the damage by prevention first, then focus on your already addicted offspring as the much tougher ‘remedial’ cases thereafter.

Final thoughts

As a society, we need to take action to protect our young people's health, and sooner rather than later…

There is plenty of evidence already that vaping is likely to be harmful to the lungs and also damages the environment, and the ‘teen epidemic’ is clearly out of control.

Any action we take now may help prevent epidemics of irreversible lung disease and cognitive defects fifteen or twenty years down the line. We just don’t know yet how serious the long-term effects of vaping might be.

The schools and government certainly have an important role to play, and the recent announcement by the Australian government of legislation to make vaping devices prescription-only and ban single-use vapes altogether suggests that the UK may well eventually go the same way.

The recent BBC news report highlighting the finding of unacceptably high lead and nicotine content in unregulated vape products circulating widely in our schools more or less guarantees that more regulation is on the way.

There is now increasing awareness that the majority of illegal single-use vapes exceed legal limits for both nicotine content and harmful by-products, and numerous reports have appeared in the last few weeks to confirm this.

It is really only parents who can provide the necessary support to ensure their children’s health is protected.

The prospect of parents outliving their children is never a pleasant one, as the obesity epidemic in our children has already taught us – let’s do what we can now to prevent it happening again…

Update 12.11.23: A ban is, I suspect, imminent now in the UK, following the collapse of an 11-year old at school directly ascribable to an illegal vape stick. Sadly, this is not an isolated incident, with no fewer than 68 vaping-associated deaths being reported so far in the US alone. Although the UK incident was caused by a single-use illegal vape laced with 'Spice', a potent cannabis derivative, it has highlighted the harm our teenagers are likely to be inflicting upon themselves by vaping.

At the very least much tougher restrictions on import and sale will be introduced soon - a complete ban on all single use products isn't out of the question.....

First Published: 22.4.23