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Less than 4% of high school seniors report daily tobacco smoking this year, hardly a fifth of where that figure was 20 years ago. It's a downward trend representing one of the most successful public health campaigns ever waged - but it comes alongside another trend, one in which many experts see tobacco's disturbing reflection.
"It's common knowledge that traditional cigarettes are unsafe," says pediatric pulmonologist Grace Houser, MD. "Unfortunately, there's not the same perception about e-cigarettes."
Teen vaping is on the rise - skyrocketing, even, at a rate far steeper than tobacco's decline. In a national study published in December 2018, 37.3% of twelfth graders reported they'd tried vaping, up from 27.8% in 2017. And the number who'd vaped within the last 30 days nearly doubled, jumping from 11% to 20.9% in just one year.
In Colorado, about half of teens have tried it - the highest share of any state, as measured by the Centers for Disease Control.
At least part of that uptick seems to owe to misinformation.
"Teens don't always know that e-cigarettes even contain nicotine," says Dr. Houser.
But the vast majority of vape products do. JUUL, far and away the most popular product (with a whopping 73% current market share), doesn't even offer a nicotine-free option. In fact, one JUUL cartridge contains about as much nicotine as a pack of cigarettes.
And nicotine - even apart from the tar and carcinogens of traditional cigarettes - has some troubling effects, particularly on the adolescent brain.
Human brains undergo a prolonged period of reorganization during the high school years. That makes teens especially vulnerable to nicotine, which exerts a powerful influence on their limbic system, the brain's center for cognition and emotional regulation.
By adulthood, teen nicotine users have lower cognitive function, more impulsivity and shorter attention spans. They have more depression and anxiety. Teens who use nicotine are more likely to engage in risky sexual behavior and use drugs.
Although the medical effects of tobacco use are pretty conclusive, it's more difficult to isolate the behavioral causes and effects of nicotine, Dr. Houser acknowledges. But in controlled studies of animals, scientists have found rats who got regular doses of nicotine used more opioids, amphetamines and cocaine when offered than those who didn't. In fact, rats treated with just one dose of nicotine showed measurably more sensitivity to adverse events later in life.
And on the pulmonary side, e-cigarettes don't look great either. They contain a wide range of chemicals, some carcinogens. One recent study shows e-vapor increases the production of inflammatory chemicals and disables immune cells in the lungs.
"The research is still evolving," says Dr. Houser, "but it's certainly not safe."
For Dr. Houser, it's a no-brainer. Teens who vape face a future of nicotine addiction, worse cognition and emotional regulation, and as-yet undiscovered consequences for the heart and lungs. There is no upside. Dr. Houser wants to spread that word.
"Identifying these cause-and-effect relationships takes a long time," she says. "As a medical community, it took us 30 years to recognize the connection between smoking and lung cancer. We want to warn people about the potential consequences of e-cigarettes now. We don't want to wait for those kind of studies to come out."
Listen to Dr. Houser's Dec. 27 interview.
To help combat youth vaping, Children's Colorado's Government Affairs team is advocating for an update to the Colorado Clean Indoor Act that would prohibit the use of e-cigarettes in public indoor spaces. Learn more and join us in asking your local legislators to support House Bill 1076.