Electronic Cigarettes and Vaping in Adolescents: State-of-the-Art

175
REVIEW ARTICLE
Electronic Cigarettes and Vaping in Adolescents:
State-of-the-Art
Olga Lucía Morales-Múnera1 , Martha Cuellar-Santaella1 , Silvia Juliana Galvis-Blanco2 ,
Mariana Mira-Morales 3 , Stephanie Sánchez-Villa4
1 Pediatric pulmonologist, Professor, Department of Pediatrics and Childcare. Faculty of Medicine. University of
Antioquia. Medellin, Colombia.
2 Third-year Pediatrics resident, University of Antioquia. Medellin. Colombia.
3 Bioengineering student. University of Antioquia. Medellin, Colombia.
4 Pediatrician. University of Antioquia. Medellin. Colombia.
ARTICLE INFORMATION
Keywords
Asthma;
Adolescent Medicine;
E-Cigarette Vapor;
Lung Injury;
Vaping
Received: April 16, 2023
Accepted: July 18, 2023
Correspondence:
Olga Lucía Morales;
olga.morales@udea.edu.co
How to cite: Morales-Múnera OL, Cuellar-
Santaella M, Galvis-Blanco SJ, Mira-Morales
M, Sánchez-Villa S. Electronic Cigarettes and
Vaping in Adolescents: State-of-the-Art. Ia-
treia [Internet]. 2024 Apr-Jun;37(2):175-187.
https://doi.org/10.17533/udea.iatreia.240
Copyright: © 2024
Universidad de Antioquia.
ABSTRACT
Electronic cigarettes (EC) constitute a subset of electronic nicotine delivery
systems (ENDS), designed to mimic conventional cigarettes (CC). These de-
vices heat a liquid solution containing flavors, nicotine, or tetrahydrocanna-
binol to generate an aerosol that is inhaled, garnering significant interest
among adolescents from early ages, accompanied by an increased inci-
dence of usage and a lack of awareness regarding their effects, fueled by
advertising campaigns portraying EC as innocuous. EC induce pulmonary,
gastrointestinal, cardiovascular, neurological, cutaneous, and other compli-
cations, ranging from mild to fatal. The emergence of electronic cigarette
or vaping product use-associated lung injury (EVALI) was first reported in
2017, with a subsequent surge in cases prompting numerous alerts in the
United States. Despite public health measures restricting the sale of specific
EC or vaping products in certain countries, adolescent consumption rema-
ins inadequately controlled. It is imperative for pediatricians and primary
care physicians to understand the implications of vaping, facilitating timely
preventive and therapeutic interventions.
IATREIA. Vol. 37 Núm. 2. (2024). DOI 10.17533/udea.iatreia.240

176
ARTÍCULO DE REVISIÓN
Cigarrillos Electrónicos y vaping en adolescentes:
estado del arte
Olga Lucía Morales-Múnera1 , Martha Cuellar-Santaella1 , Silvia Juliana Galvis-Blanco2 ,
Mariana Mira-Morales 3 , Stephanie Sánchez-Villa4
1 Pediatra neumóloga, Docente. Departamento de Pediatría y Puericultura. Facultad de Medicina. Universidad de
Antioquia, Medellín, Colombia.
2 Residente de pediatría III año, Universidad de Antioquia. Medellín. Colombia.
3 Estudiante de Bioingeniería. Universidad de Antioquia. Medellín, Colombia.
4 Pediatra. Universidad de Antioquia. Medellín. Colombia.
INFORMACIÓN ARTÍCULO
Palabras clave
Asma;
Cigarrillo Electrónico a Vapor;
Lesión Pulmonar;
Medicina del Adolescente;
Vapeo
Recibido: abril 16 de 2023
Aceptado: julio 18 de 2023
Correspondencia:
Olga Lucía Morales;
olga.morales@udea.edu.co
Cómo citar: Morales-Múnera OL, Cuellar-
Santaella M, Galvis-Blanco SJ, Mira-Morales
M, Sánchez-Villa S. Cigarrillos Electrónicos y
vaping en adolescentes: estado del arte. Ia-
treia [Internet]. 2024 Abr-Jun;37(2):175-187.
https://doi.org/10.17533/udea.iatreia.240
Copyright: © 2024
Universidad de Antioquia.
RESUMEN
Los cigarrillos electrónicos (CE) hacen parte de los sistemas electrónicos
dispensadores de nicotina (ENDS, por la sigla en inglés de electronic nicotine
delivery systems), fabricados con características que simulan los cigarrillos
convencionales (CC). Estos dispositivos calientan una solución líquida con
sabores, nicotina o tetrahidrocanabinol para crear un aerosol, que se inhala;
esto ha generado gran interés entre adolescentes desde edades muy tem-
pranas, con aumento en la incidencia del consumo y desconocimiento de
sus efectos, por campañas publicitarias que muestran los CE como inocuos.
Los CE generan compromiso pulmonar, gastrointestinal, cardiovascular,
neurológico, tegumentario, entre otros; con diferentes grados de afección
desde leves hasta la muerte.
La enfermedad pulmonar asociada al CE o productos del vapeo (EVALI, por
sus siglas en inglés) se empezó a reportar desde el año 2017, y el aumento
de casos de EVALI en Estados Unidos generó la emisión de numerosos avi-
sos. Desde salud pública se han generado restricciones en algunos países
sobre la venta de ciertos tipos de productos de CE o vapeo, sin lograr con-
trolar el consumo entre los adolescentes.
Para el pediatra o el médico de atención primaria es indispensable conocer
las implicaciones de vapeo, para realizar acciones de prevención y trata-
miento oportunos.
IATREIA. Vol. 37 Núm. 2. (2024). DOI 10.17533/udea.iatreia.240

Morales-Múnera et al.177IATREIA. Vol. 37 Núm. 2. (2024). DOI 10.17533/udea.iatreia.240
METHODOLOGY
The information presented in this review was extracted following a search conducted between Au-
gust and November 2022 in the databases PubMed, ClinicalKey, ScienceDirect, SciELO, and LILACS.
MeSH terms used were “Electronic cigarettes,” “Electronic Nicotine Delivery Systems,” “Vaping,” “Asth-
ma,”“Lung Injury,” and “Adolescent.” Articles published in English and Spanish were included with no
publication date limitation, encompassing a range of methodological designs including case series,
controlled clinical trials, meta-analyses, systematic reviews, and observational studies. Priority was
given to studies focusing on populations of electronic cigarette (EC) users under 18 years of age.
Criteria for exclusion were non-availability of the full text and languages other than English and Spa-
nish. Initially, 232 articles were identified. The review of titles and abstracts was conducted by three
evaluators. Subsequently, 182 articles were excluded due to reasons such as unavailability of the full
text, language other than English or Spanish, duplication, or differing methodological design from
those mentioned. This resulted in a total of 50 articles being selected for analysis.
OVERVIEW
Electronic cigarettes (EC) are battery-operated devices that heat a liquid to produce an aerosol,
which the user inhales through a mouthpiece. Also known as “E-cigs” or “Pods,” the act of using EC
by inhaling the aerosol (incorrectly called vapor) generated from the device is referred to as “vaping.”
The liquid added to EC is known as “E-juice,” (1-2).
In 2003, the World Health Organization (WHO) approved the Framework Convention on Tobac-
co Control, comprising measures to reduce tobacco supply and demand through price increases,
regulation, and education. In the same year, the first commercially successful EC was created in
Beijing by Hon Lik. EC were introduced in Europe and the United States in 2006 (1).
Research and regulation of EC are challenging due to the diversity and rapid changes in no-
menclature, design, technology, and the variety of liquids used. Most EC share similar design featu-
res, consisting of three essential components: a battery, a heating element, and a liquid reservoir.
Upon inhalation by the user, negative pressure closes a switch, activating the heater that converts
part of the liquid into an aerosol for inhalation (3).
EC are classified into several ways, one of the most practical classifications divides them into
four generations. First-generation EC, or cig-a-likes, designed to resemble conventional cigarettes,
are disposable, easy to use, and ultra-portable but have short battery life and low liquid capacity.
Second-generation vape pens have longer-lasting rechargeable batteries and larger pre-filled or
refillable tanks. Third-generation devices offer more power and customization features, with lower
resistance for quicker heating. Fourth-generation pod mods use pre-filled or refillable cartridges
with nicotine salts, allowing for high nicotine concentration delivery; they are user-friendly and less
recognizable as EC (4).
EC contain numerous components, some constant like humectants and others variable like
flavorings and nicotine.
• Humectants: Propylene glycol and glycerin, used as solvent vehicles to generate aerosols,
can cause acute toxicity, dermal irritation, and respiratory tract irritation. While not toxic at
room temperature, upon heating, they form thermal degradation products like volatile or-
ganic compounds and carcinogens like formaldehyde, acetaldehyde, and acrolein (5).
• Metals: Chromium, nickel, selenium, aluminum, iron, and lead, originating from the heating
coil or other parts like wires or batteries (5).

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• Flavorings/Aromatics: Over 7000 have been described, generally recognized as safe for in-
gestion. However, they can induce inhalation toxicity as they form aldehydes and other
respiratory irritants when heated (1,4).
• Nicotine: A highly addictive chemical that reaches the brain within 15 seconds after inha-
lation, creating immediate pleasurable effects. It activates the sympathetic nervous system
and is thought to be associated with the risk of myocardial ischemia, arrhythmias, cardiac
tissue remodeling, thrombogenesis, and endothelial dysfunction. The extent of exposure
varies based on device characteristics, liquids, and usage methods. For instance, 3 ml of e-li-
quid at a concentration of 6 mg/ml nicotine equates to the nicotine in 20 cigarettes. Devices
like JUUL use nicotine salts, created by adding acid to reduce pH and increase bioavailability,
containing over 50 mg/ml of nicotine (1,4-5).
• Tetrahydrocannabinol (THC): Can be added as vaporizable cannabis oil. Due to its viscosity,
some suppliers use vitamin E acetate as a diluent, which has been linked to hyperreactivity
of the respiratory tract, lung inflammation, and lung injury associated with EC or vaping
(EVALI).
Regarding the accuracy of nicotine content labeling on e-liquid containers, a study by Buettner-
Schmidt et al. (6) found that 51% of labels in e-juice containers from 16 stores did not accurately
reflect the nicotine levels in the products. In one case, actual levels were 172% higher than indicated
on the label. 43% of e-juice containers claiming to be nicotine-free contained up to 0.48 mg/ml, and
65% of the containers were not childproof, posing a risk of easy ingestion.
Who Uses Electronic Cigarettes and Why?
In the systematic review and meta-analysis by Yoong et al. (7), which included the most recent pre-
valence data from 26 national surveys across 69 countries involving 3925 children and adolescents
(aged 8–19 years), the pooled prevalence for ever using EC was found to be 17%, and 8% for current
use. The rate was higher in high-income geographical regions; in Colombia, the prevalence was
estimated at 15% in the 13 to 15-year-old group (7).
Reports from the Food and Drug Administration (FDA) and Centers for Disease Control and
Prevention (CDC) in the United States showed a more than threefold increase in the use of tobacco
products among high school students between 2017 to 2019 (from 3% to 10.5%) and more than
twofold in senior high students (from 12% to 27.5%), with the majority of these students consuming
nicotine in the form of EC (8).
The Monitoring the Future Survey on Substance Use reported a significant increase in EC use
in 2018, with 25% of 12th graders and 20% of 10th graders participating. This represents the largest
increase for any substance recorded by the survey in its 44-year history (3).
In adults, conventional cigarettes (CC) are still the most used tobacco product, as evidenced
by the 2017 national health survey, where current EC use in adults was 3%, while CC use was 14%.
Among those over 18 years, the highest EC usage was among young adults aged 18 to 24 years,
with 5% being users (3).
In Colombia, two studies assessed the consumption of nicotine delivery systems (SEAN): the
Third Andean Epidemiological Study on Drug Use in the University Population and the 2017 Natio-
nal Youth Tobacco Survey. These studies showed that in 2016, the prevalence of participants having

Morales-Múnera et al.179IATREIA. Vol. 37 Núm. 2. (2024). DOI 10.17533/udea.iatreia.240
ever used EC was 16%. Colombia ranks second in the consumption of these products after Ecuador.
51% of schoolchildren have heard about the existence of EC, 15% of schoolchildren reported ha-
ving experience with EC use, especially in urban areas and private schools, and 14% of students in
Colombia believe these products are less harmful than CC (9).
Regarding the reasons why young people use EC, a study by Evans-Polce et al. (10) involving
7677 12th
-grade students, of which 2664 (35%) had used EC, found that the main reasons for use
were to “experiment” (55%), for the flavor (37%), out of “boredom” (22%), and to have a “good time”
(20%), among others. Only 8.5% of adolescents used EC as a strategy to quit CC. These findings were
reinforced by a systematic review of six studies among young adults aged 18 to 25 years in various
settings (United States, Romania, France, New Zealand, and Saudi Arabia) (11), where curiosity and
use by friends were the main reasons for starting EC use.
Young people are often unaware of the ingredients in their EC; 66% believe they contain only
“flavors,” and 31% report that flavors are the main reason for their use, possibly because flavors re-
duce the irritation experienced when inhaling the aerosol. Additionally, the industry targets ado-
lescents with colorful packaging and popular appealing flavors (12,13). Although the 2009 Family
Smoking Prevention and Tobacco Control Act banned flavors (except menthol) in cigarettes, the
tobacco industry has a history of using flavors to deliberately attract adolescents to their products.
Therefore, due to the great appeal of flavored EC to young people, the policy of the American Aca-
demy of Pediatrics (AAP) recommends that the FDA ban all flavors, including menthol (14).
Moreover, young people are frequently exposed to misleading advertising about these pro-
ducts. In the systematic review by Collins et al. (15), 124 publications on EC marketing and com-
munication were evaluated, showing that, compared to CC, EC were presented as healthier, less
expensive, more socially acceptable, unrestricted by smoke-free policies, and more environmen-
tally friendly. Additionally, they used “youth appeals” in advertisements, such as the depiction of
EC use by celebrities. Likewise, more than 40% of online vendors use promotional codes, loyalty
programs, and discounts for referring new customers. Information about EC was widely available
on social media, and most communications were in a positive or neutral tone, promoting their use.
The CDC reports that 4 out of 5 high school and senior high students (over 20 million) are exposed
to advertisements, 68% in stores, 41% on the internet, 38% on television, and 24% in newspapers
or magazines (16).
What Are the Health Risks?
Effects on multiple organs have been described (Table 1) (1,3,17-18). Even the genetic and epigene-
tic impact on the pulmonary system from the various chemical components derived from EC use
has been reported. Exposure to these aerosols is associated with oxidative and alkylating damage
to DNA (19). It also causes alterations in the transcriptome, such as the reduction of gene expression
related to the immune system and the increase in gene expression involved in the oxidative stress
response. In murine models, it has been demonstrated that there are not only maternal health
effects but also fetal health implications (19).

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Table 1. Described Effects of Electronic Cigarette Use on Various Organs
Pulmonary • Airway irritation, increased mucus hypersecretion, exacerbated respira-
tory symptoms in patients with asthma, cystic fibrosis
• Bronchial damage
• Decreased lung capacity (FEV1)
• Bronchiolitis obliterans
• Pulmonary fibrosis
• Pneumonitis, including lipid, eosinophilic due to hypersensitivity, and
interstitial
• Pneumothorax
• EVALI (E-cigarette or Vaping product use-Associated Lung Injury)
Cardiovascular • Increase in diastolic blood pressure
• Arrhythmias
• Decreased overall ventricular performance
• Coronary vasoconstriction
Central Nervous System • Seizures
• Circadian rhythm disturbances
• Decreased psychomotor functioning
• Mental health issues
Immune System • Proinflammatory response in epithelial cells and pulmonary fibroblasts
• Decreased survival in epithelial cell lines, dysregulation of gene expres-
sion, loss of pulmonary endothelial barrier
• Increased susceptibility to infections
Oral Cavity • Dental fractures
• Pulp necrosis
• Caries
• Oropharyngeal cancer
Skin • Burns from battery explosion
Gastrointestinal Tract • Nausea
• Vomiting
• Nicotine: Pancreatic cancer
Pregnancy • Premature birth
• Neonatal apnea
Source: Created based on (1,3,17)
In relation to the airway, Staud et al. (20) evaluated 10 non-smokers before and after 20 inhala-
tions of EC, one group with nicotine and another without. The study demonstrated an alteration in
pulmonary homeostasis, indicated by altered transcriptomes of small airway epithelium and alveo-
lar macrophages, and elevated levels of endothelial microparticles in plasma in the nicotine group,
reflecting endothelial cell injury. Reidel et al. (21) analyzed sputum samples from CC smokers, EC
users, and non-smokers using quantitative proteomics. The results showed that EC use alters the
protein profile of innate defenses in respiratory secretions and induces changes similar to those
related to smoking.
In 2019, the United States experienced an outbreak of e-cigarette or vaping use-associated
lung injury (EVALI), a term coined by the CDC. Dozens of deaths and thousands of cases of acute
respiratory compromise due to nonspecific injuries occurred. This outbreak was more closely as-
sociated with the vaping of cannabis derivatives containing vitamin E acetate, which was found in
most of the bronchoalveolar lavage (BAL) samples. However, other pathogenic components likely

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also contributed (22). In the first case series described by Layden et al. (22), 98 patients presented
respiratory symptoms such as dyspnea, cough, pleuritic chest pain, and hemoptysis, constitutio-
nal symptoms like fever and chills, and gastrointestinal symptoms like nausea, vomiting, diarrhea,
and abdominal pain. Additionally, physical examinations found tachycardia, tachypnea, fever, and
hypoxemia, often progressing to respiratory failure. From this case series, the criteria for confirmed
EVALI cases emerged (Table 2). The imaging alterations described in chest computed tomography
scans of these patients are varied, with the most frequent pattern being centrilobular nodules and
ground-glass opacities with subpleural preservation (23).
Table 2. EVALI Criteria
Confirmed Case
• Use of an electronic cigarette (“vaping”) or “dabbing” within the previous 90 days*
• Pulmonary opacities on chest radiography or computed tomography
• Exclusion of pulmonary infection based on:
• Negative PCR or rapid influenza test
• Negative respiratory viral panel
• Negative tests for clinically indicated respiratory infections (e.g., urine antigens for Legionella pneu-
mophila and Streptococcus pneumoniae, blood cultures, sputum cultures, BAL if performed)
• Negative tests for HIV-related opportunistic respiratory infections (if applicable)
• Absence of a plausible alternative diagnosis (e.g., cardiac, neoplastic, rheumatologic)
Source: Created based on (22)
Vitamin E acetate has been proposed as a causative agent of these injuries, based on evidence
from studies like that of Blount et al. (24), where BAL samples from 51 patients with EVALI and 99
healthy participants were analyzed. Vitamin E acetate was identified in 94% of BAL samples from
EVALI patients vs. 0% from the comparison group. THC or its metabolites were detected in 47 of 50
BAL samples (94%) from individuals who reported vaping THC products in the 90 days prior to the
onset of the illness. However, the role of nicotine or its metabolites, detected in 30 of 47 samples ob-
tained (64%), cannot be dismissed. The role of vitamin E acetate has also been described in murine
models (25), where vitamin E acetate in aerosol form causes pulmonary edema depending on the
dose, increased permeability of the alveolocapillary barrier to proteins, and an inflammatory pattern
with abundant multinucleated, lipid-laden macrophages.
The association between EC use and asthma has been studied (26, 27). In animal models, an
increase in bronchial hyperreactivity has been observed, with a significant increase in airway in-
flammation dominated by Th2, higher production of IL-4, IL-5, and IL-13, and greater eosinophil
infiltration, reflected in increased mucus production and the thickening of airway walls (28,29). An
increased risk of respiratory infections has been reported due to impaired ciliary function, reduced
cough receptor sensitivity, impaired neutrophil and alveolar macrophage function, and altered ex-
pression of genes and molecules involved in immune reactions (30,31).
In adolescents, EC use increases the likelihood of an asthma diagnosis, being an independent
risk factor after controlling for various covariates (32,33). This finding was reinforced by Li et al. (27) in
a meta-analysis of 10 cross-sectional studies with a population of 483,984 high school students ave-
raging 15–16 years, where the median prevalence of EC use was 11%, and a significant association
with higher odds of having asthma was found. Additionally, it has been shown that EC-using adoles-
cents have a higher risk of school absenteeism due to asthma (34) and that asthmatic adolescents

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are more likely to report an asthma attack in the previous year when exposed to second-hand
EC (35). Also, the relationship between EVALI and asthma has been studied, finding that between
30%–44% of adolescents hospitalized with EVALI were asthmatic, and asthma is a factor associated
with more severe outcomes and mortality (23% of fatal cases had a history of asthma) (36,37).
In the cardiovascular system, evidence of acute hemodynamic changes in vascular (increased
arterial stiffness, blood pressure, and sympathetic tone) and cardiac function (increased myocardial
fibrosis and coronary disease, with reduced myocardial blood flow and nitric oxide production) has
been observed. Many of these vascular effects seem to be attributable to nicotine exposure. Eviden-
ce suggests that the acute cardiovascular effects of EC can accumulate over time with prolonged
use, leading to long-term cardiovascular diseases (38).
In the nervous system, EC use has been associated with seizures (39). Faulcon et al. (40) repor-
ted 114 cases of seizures in EC users with nicotine reported to the FDA between 2010–2019. 85%
reported that the seizures occurred within 24 hours of last use, and 62% within 30 minutes of last
use. Chronic EC use with nicotine has been shown to alter the homeostasis of various neurotrans-
mitters in mesocorticolimbic areas, especially in the frontal cortex and striatum, which can lead to
the development of dependence (41).
EC use has also been associated with mental health issues in adolescents. In the systematic
review by Becker et al. (42), a higher risk of depression, anxiety, suicidal ideation, suicide attempts,
eating disorders, attention deficit hyperactivity disorder, and conduct and delinquency disorders in
adolescents was found.
Exposure to EC has also been linked to increased risk of deterioration in periodontal, dental, and
gingival health, as well as changes in the oral microbiome. Case reports have described extensive
dental damage as a result of EC explosions (43).
Liquid nicotine poisoning, especially in young children due to accidental ingestion, is another
risk described. The most frequent symptoms are vomiting, salivation, nervous appearance, truncal
ataxia, and respiratory difficulty. The lethal dose of nicotine in adults is between 30–60 mg, while in
children it is approximately 0.5 mg/kg, representing a significant risk given that EC liquid can con-
tain between 6 and 36 mg/ml of nicotine and each cartridge contains up to 50 ml (3,44).
Relationship With the Use of Other Substances
Nicotine affects neural pathways underlying pleasure and reward and can increase the brain’s sen-
sitivity to other psychoactive substances and drug-seeking behaviors. In the study by Silveira et al.
(45), 11,996 youth aged 12–17 years were followed for 10–13 months. It was found that past use of
EC predicted subsequent use of any drug, including alcohol, marijuana, and amphetamines.
There is concern that these consumers may have an increased the risk of CC use, potentially
undoing decades of progress in reducing tobacco consumption (1). In the meta-analysis by Soneji
et al. (46) of 9 longitudinal studies (n = 17,389) of youths with no prior CC experience, it was found
that EC use was significantly associated with subsequent CC use, even when known demographic
and behavioral risk factors for CC use were controlled. Chaffe et al. (47) found that among youths
who had already experimented with CC, EC use was associated with progression to current establis-
hed smoking, suggesting that in youth who begin using CC, EC may increase, rather than decrease,
the risk of sustained CC use. Baenziger et al. (48), in their meta-analysis of 25 studies of non-smokers
from age 10, found a higher risk of CC consumption with exposure to EC, for those who had never
smoked, and among ex-smokers, a higher risk of relapse into smoking was observed.

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Role of the Physician
The American Academy of Pediatrics (AAP) recommends implementing screening actions for the
use and exposure to EC starting at age 11 as well as providing prevention counseling. This includes
advising that all places where children spend time should be free of tobacco and EC use, not re-
commending EC as a product for smoking cessation, and supporting adolescents in their attempts
to quit smoking. The 5A model for screening and counseling on tobacco use has been adapted
for adolescents who use EC (Table 3) (1,49). In Table 4, a series of questions for assessing EC use in
adolescents and considerations to take are proposed (1).
Table 3. Modified 5A Model for Screening and Counseling on EC Use in Adolescents
Ask Inquire all patients about their use
Advise Provide clear, strong, and personalized advice to quit
Assess Ask if the patients is willing to stop using EC
Assist Help in quitting
Arrange Schedule follow-up
Source: Created based on (1,49,50)
Table 4. Guiding Questions to Assess EC Use in Adolescents
To everyone over 11 years old: Have you ever used an electronic cigarette?
Questions Considerations
What type of device do you use? • Higher battery voltages increase the risk of chemical
reactions creating toxic products.
What substances have you vaped? • Flavoring: Increases both the risk of continued use
and misconceptions about safety.
• Nicotine: Higher concentrations have been associa-
ted with more intense daily EC use and increased CC
use.
• Cannabis derivatives and other substances: Increa-
se the risk of dependence on alternative substances,
EVALI, and other problems.
At what age did you start vaping? • A younger age of initiation poses a greater vulnerabi-
lity to addiction.
Have you had any problems at school, with
parents, or with the police because of vaping?
• Vaping in adolescence has been associated with de-
linquency, suspension or expulsion from school, and
increased family conflicts.
Have you experienced symptoms of dependen-
ce: difficulties in reducing use or developing
withdrawal symptoms when you couldn’t
vape?
• Dependence indicates the need for closer monitoring
and consideration of pharmacological interventions.
Do you use other substances? • Vaping is a risk factor for the use of other substances.
Do your friends and family members vape? • Peer vaping is a common entry point and a factor
that perpetuates vaping.
Source: Created based on (1)

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Specific clinical interventions for vaping are still underdeveloped, so general principles and es-
tablished treatments for conventional cigarette (CC) use have been applied. It is important to assist
young individuals in maintaining a usage log and encourage them to allow family participation
(e.g., restricting access to vaping devices, supporting adherence to behavioral goals, and positi-
vely reinforcing change). Likewise, parents who smoke should be referred to smoking cessation
resources. Individual or group cognitive-behavioral therapy for nicotine use can help young people
manage symptoms and prevent relapses with good effectiveness in cessation rates and should be
evaluated by a toxicologist (1).
CONCLUSIONS
The use of electronic cigarettes is not a harmless practice. It has been associated with harmful
effects on multiple systems, as well as with the use of other substances and an increased likelihood
of using conventional cigarettes in adolescents. To date, there is no evidence to validate the use
of these devices as strategies for smoking cessation. The pediatrician plays a fundamental role in
accompanying adolescents. It is recommended to ask everyone over the age of 11 about the use of
such devices, to advise, and to support the process of cessation.
CONFLICT OF INTERESTS
We declare that there are no conflicts of interest.
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