E-Cigarettes: The First Step in Treating Addiction is Recognizing a Problem Exists in the First Place

Research study shows an effective way to measure nicotine addiction in teenagers.

By: Taylor Meiorin, Eden Prisoj, Rhiannon Ueberholz, Katherine Lara Derikon

Electronic cigarette (e-cigarette) consumption has been rapidly increasing among adolescents. Recent findings from the 2018-2019 Canadian Student Tobacco, Alcohol and Drugs Survey found that 20% of students in grades 7 to 12 reported using e-cigarettes in the past 30 days (Health Canada, 2019). Even though e-cigarettes are promoted as a smoking cessation tool and a healthier alternative to traditional combustible cigarettes, the risks associated with such products are vast (Vogel et al., 2019). Specifically, these products have been associated with pulmonary damage, exposure to harmful toxins, and throat cancer (Youth and tobacco use, 2020).

“Woman Vaping on Electronic Cigarette (JUUL)”  by Vaping360 is licensed under CC BY 2.0

The story of Simah Herman (Hawkins et al., 2019) provides an example of the detrimental effects that e-cigarettes can have on adolescent’s health. Herman is an 18-year-old girl who, like other teenagers, started using e-cigarettes because ‘’she thought it made her look cool’’. However, after having trouble breathing, she was rushed to the hospital and was diagnosed with what the doctors initially believed to be pneumonia. Two days after being admitted to the hospital, Herman’s health rapidly declined; she was put on a ventilator and shortly after, a medically induced coma. Her cousin revealed that Herman had been regularly smoking e-cigarettes, leading her doctors to conclude that Herman’s condition was caused by vaping. As Herman began to recover, she vowed to start a “No vaping” campaign, using her experience as an example of the terrible consequences that e-cigarettes can have on adolescents’ health.

Herman’s story highlights an interesting difference between adults and teenagers’ reasons for using e-cigarettes. Adults largely use these products to control and overcome their nicotine addiction. Conversely, teenagers may use these products because they see them as a cool trend among their peer group and are appealed by the variety of flavours (Youth and tobacco use, 2020). Stories like this also make us remember that there is a reason why consumption of nicotine is illegal for underage individuals. 

We might be shocked by a 14-year-old holding a Marlboro cigarette, but perhaps not so much when we see them smoking e-cigarettes that mainly look like ‘’cute electronic sticks’’. Moreover, 42% of adolescents who use electronic cigarettes have never smoked a traditional cigarette which shows how this trend is becoming even more popular than cigarette consumption (Health Canada, 2019). These findings make it even more imminent to establish accurate ways to assess e-cigarette intake and hazardous youth consumption patterns.  

Unfortunately, research in this area has primarily focused on adults, and there are currently no validated or rigorously tested methods for assessing levels of e-cigarette addiction and frequency of use among adolescents. For instance, The Penn State E-cigarette Dependence Index has been widely used as an assessment tool and measure of e-cigarette dependence among adults (Vogel et al., 2019). However, its ability to accurately detect e-cigarette addiction in adolescent populations remains a mystery (Vogel et al., 2019).

Studying Nicotine Addiction in Adolescents

Due to these gaps in scientific literature, researchers from the University of California devised a fascinating study to measure e-cigarette addiction and frequency of e-cigarette use among adolescents (Vogel et al., 2019). This study’s primary goal was to identify an accurate test that clinicians and researchers can administer to adolescents to assess how often they are using e-cigarettes and whether or not they are addicted to such products.

Participants enrolled in this study were asked to provide saliva samples in order to measure their levels of nicotine exposure. Participants then completed two tests which were designed to assess how often they use e-cigarettes. The first test titled, Sessions Per Day (SPD), asked participants to report how many times a day they use e-cigarettes, and the second test asked participants to estimate how many days per month they use e-cigarettes.

The researchers then had participants complete three additional tests, which were specifically designed to measure e-cigarette addiction. The first of which was the Penn State Electronic Cigarette Dependence Index (ECDI) which asked questions such as “do you use an e-cigarette now because it is really hard to quit?” and “do you ever have strong cravings to use an electronic cigarette?”. The second test participants completed was the Heaviness Vaping Index (HVI) which contained questions such as, “on days that you can use your electronic cigarette freely, how soon after you wake up do you first use your electronic cigarette?”. Lastly, participants completed the E-Cigarette Addiction Severity Index (EASI), which contained one question asking, “On a scale of 0%–100% (not addicted to extremely addicted), how addicted to e-cigarettes do you think you are?”. 

“Blu, Vuse, Njoy e-cigarette” by Sarah-Johsnon is licensed under CC BY-SA 2.0

Which Test Was The Best?

After participants completed each test, the researchers compared their responses with the actual nicotine levels in their saliva. In making these comparisons, researchers were trying to find which tests have the strongest association with actual nicotine exposure. Finding a strong association allows the researchers to determine which test can best predict how much adolescents are actually vaping compared to what they report on the tests, which is needed to accurately diagnose e-cigarette addiction. 

When testing how often adolescents were using e-cigarettes, both these tests (vaping sessions per day or days vaping per month) were equally accurate at predicting nicotine levels in saliva, but since it is a lot easier for adolescents to report how many days in a month they are vaping, this was concluded to be the best way of assessing how often e-cigarettes are being used. Out of all the tests used to assess e-cigarette addiction, the best one was the Self-Described Degree of Addiction (the EASI). This EASI did just as well as the other tests at predicting nicotine levels, but since it is the fastest to complete, having only one question, the researchers decided it was the most logical to use. 

When deciding which test is best in identifying high risk nicotine use, researchers are always looking for parsimony: the simplest and most accurate way to diagnose addiction. Sometimes a diagnostic test contains a lot of questions that aren’t needed and don’t actually relate to addiction. Parsimony helps researchers make sure the tests they’re using actually captures the thing they are trying to measure. 

The recommendations that the researchers make are that two questions are sufficient to determine how often adolescents are vaping and their level of addiction: (1) “How many days in a month do you vape?”, and (2) “Rate your perceived level of addiction”. They also state that the longer questionnaires, like how many vaping sessions a day adolescents engage in and the ECDI can be used to get a bigger picture of addiction. 

“Man Vaping Thick Clouds From His E-cigarette”  by Sarah-Johsnon is licensed under CC BY 2.

Thinking Critically

It’s important to think critically about any research study. It should therefore be noted that since the researchers are trying to define addiction and amount of vaping over a longer period of time, measuring nicotine levels only once might not be the most useful way of determining if these tests are accurate. Think about it this way: if an adolescent vaped a lot the night before coming to the experiment, they would have high levels of nicotine in their saliva. If this is out of character for them, they would still report that they don’t vape that often and wouldn’t rate their addiction as severe, so their answers on these two tests would not accurately reflect the level of nicotine found. So for future studies, it might be more beneficial to look at nicotine levels over a longer period of time.

It can also be noted that the participants in this research were mostly young, white males. To make sure the EASI accurately captures e-cigarette addiction in all adolescents, it would be important to look at a larger demographic. Factors of gender, race, and socioeconomic status might affect the way individuals perceive e-cigarette use and their willingness to admit that they have an addiction. Individuals from different groups define addiction differently, so asking everyone to rate their addiction might lead to varying interpretations of the test, meaning the EASI might not work the same for everyone.

Next Steps and Treatment 

E-cigarettes are effective at helping those with tobacco use disorder in quitting. However, they are now being viewed as a public health concern due to their misuse – particularly among youth. Adolescents tend to view e-cigarettes as less harmful than combustible cigarettes, as previously mentioned, and mistakenly believe that they entail different social and health outcomes (Chaffee et al., 2015). In reality, e-cigarette use actually heightens exposure to nicotine and several other toxic (and potentially cancerous) substances and increases risk of transitioning to using other substances, like alcohol and cannabis (Gilbert et al., 2020).

This perception of e-cigarettes is incredibly worrying, given the negative health effects that continued use can lead to. Even in the short-term, e-cigarette use can damage various organ systems, resulting in a range of adverse effects, including shortness of breath, wheezing, nausea, and ulcers (Seiler-Ramadas et al., 2020). On the extreme end, tragic circumstances similar to those of Simah Herman can ensue. E-cigarette use is particularly advised against for adolescents due the fact that their brain is still developing, and the consequences on memory and learning that follow use may end up lasting.

Vogel et al. (2019) took a step towards correcting these issues by conducting research on adolescent e-cigarette use and singled out the EASI as the best general measure of addiction. This was a considerable achievement, as there was previously little agreement among researchers regarding what tests to use when assessing e-cigarette use, so this finding allows for accurate comparison across studies.

Future research should be aimed at studying the relationships with other indicators of addiction, such as withdrawal. It may also be useful to conduct this research again using a more representative sample (with participants of differing ages, races, and so on), given how similar subjects in this study were demographic-wise.

Until such research is carried out, efforts should be focused on preventing e-cigarette use by implementing policies and laws that make it clear that they are to be used as cessation aids for adults with tobacco use disorder – they are not intended to be substitutes for smoking combustible cigarettes.

For those looking to quit using e-cigarettes, treatment typically involves prescribed medication, such as nicotine replacement therapy (NRT), in which the person uses nicotine patches that deliver constant doses of nicotine to suppress withdrawal. Behavioural counselling can also be extremely helpful. CAMH is a resource that can assist those of all ages in combating addiction, and resources like Kids Help Phone and teen.smokefree.gov are specially catered to youth seeking guidance and treatment.

References:

Brown-Johnson, C. G., Burbank, A., Daza, E. J., Wassmann, A., Chieng, A., Rutledge, G. W., & Prochaska, J. J. (2016). Online Patient–Provider E-cigarette Consultations. American Journal of Preventive Medicine, 51(6), 882–889. https://doi.org/10.1016/j.amepre.2016.06.018

Chaffee, B. W., Gansky, S. A., Halpern-Felsher, B., Couch, E. T., Essex, G., & Walsh, M. M. (2015). Conditional Risk Assessment of Adolescents’ Electronic Cigarette Perceptions. American Journal of Health Behavior, 39(3), 421–432. https://doi.org/10.5993/ajhb.39.3.14

Gilbert, P. A., Kava, C. M., & Afifi, R. (2020). High-School Students Rarely Use E-Cigarettes Alone: A Sociodemographic Analysis of Polysubstance Use Among Adolescents in the United States. Nicotine & Tobacco Research, 23(3), 505–510. https://doi.org/10.1093/ntr/ntaa037

Hawkins, S., Walker, K., Riegle, R. & Rivas, A. (2019) Teeen who was put on life-support for vaping says ‘’I didn’t think of myself as a smoker’’. ABC News. https://abcnews.go.com/US/teen-put-life-support-vaping-didnt-smoker/story?id=65522370 

Health Canada. (2019). Summary of Results for the Canadian Student Tobacco, Alcohol and  

Drugs Survey 2018-19 https://www.canada.ca/en/health-canada/services/canadian-student-tobacco-alcohol-drugs-survey/2018-2019-summary.html

Johnson, S. (2017). Blu, Vuse, Njou e-cigarette [Online image]. Flickr. 

Johnson, S (2018). Man Vaping Thick Clouds From His E-cigarette [Online image]. Flickr. 

Kids Help Phone. (2021). Substance use. https://kidshelpphone.ca/topic/emotional-well-being/substance-use

Levy, S. (2019, November 1). Vaping: It’s hard to quit, but help is available. Harvard Health 

Blog.https://www.health.harvard.edu/blog/vaping-its-hard-to-quit-but-help-is-available-2019110118248#:%7E:text=For%20people%20who%20are%20motivated,for%20children%20under%20age%2018.

Seiler-Ramadas, R., Sandner, I., Haider, S., Grabovac, I., & Dorner, T. E. (2020). Health effects of electronic cigarette (e‑cigarette) use on organ systems and its implications for public health. Wiener Klinische Wochenschrift, 1–8. https://doi.org/10.1007/s00508-020-01711-z

Smokefree Teen. (n.d.). Become a Smokefree Teen. https://teen.smokefree.gov

The Center for Addiction and Mental Health. (2021). Nicotine Dependence Clinic. https://www.camh.ca/en/your-care/programs-and-services/nicotine-dependence-clinic

Vogel, E. A., Prochaska, J. J., & Rubinstein, M. L. (2020). Measuring e-cigarette addiction among adolescents. Tobacco Control, 29(3), 258-262. http://dx.doi.org/10.1136/tobaccocontrol-2018-054900 

Woman Vaping on Electronic Cigarette (JUUL) [Online image]. (2018). Flickr. 

Youth and tobacco use. (2020, December 16). Retrieved March 10, 2021, from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm 

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