After years of declining tobacco use among teens in Kentucky, a new trend of products containing nicotine is skyrocketing and concerning health officials.

Teenage use of e-cigarettes and vaping products has doubled in the last year, according to research released in April.

The Kentucky Incentives for Prevention (KIP) Survey for 2018 found the sharp increase in all four grades — sixth, eighth, 10th and 12th — of students surveyed.

In 2018, 4.2 percent of sixth graders, 14.2 percent of eighth-graders, 23.2 percent of 10th graders and 26.7 percent of 12th-graders reported using e-cigarettes in the last 30 days.

E-cigarette use among 12th-graders increased by nearly 10 percent from 2014 (17.3 percent) and 15 percent from 2016 (12.2 percent).

E-cigarette use among U.S. middle and high school students increased by 900 percent from 2011 to 2015, according to a report from the U.S. Surgeon General.

There has been a 78 percent increase in e-cigarette use among high school students during the past year, from 11.7 percent in 2017 to 20.8 percent nationwide in 2018.

In 2018, more than 3.6 million U.S. youth, including 1 in 4 high school students and 1 in 20 middle school students used e-cigarettes, making e-cigs the most popular form of tobacco products among teens. E-cigarettes are more than twice as popular (20.8 percent) as cigarettes (8.1 percent) and almost four times as popular as smokeless tobacco (5.9 percent).

Health officials are calling this marked increase an epidemic, and are warning against the mostly unknown dangers of e-cigarette use.

What are e-cigarettes?

A Surgeon General’s warning issued in 2018 reported that e-cigarettes surfaced around 2007. Since 2014, they have been the most commonly used tobacco product among U.S. youth, and those rates continue to rise.

“E-cigarettes are a rapidly-changing product class and are known by many different names, including ‘e-cigs,’ ‘hookahs,’ ‘mods,’ and ‘vape pens,’” according to the report.

E-cigarettes are devices that create an aerosol by using a battery to heat liquid that usually contains nicotine, flavorings and other additives. Users inhale the aerosol and exhale, much like smoking other tobacco products. Some users also use the devices for things like cannabinoids, marijuana and other drugs.

The liquids used in the devices come in a variety of flavors, including things like mint, bubble gum, fruit, chocolate, candy and other sweets.

The devices also come in many shapes and sizes.

“Some e-cigarettes look like regular cigarettes, cigars or pipes,” according to the Centers for Disease Control and Prevention. “Some look like USB flash drives, pens and other everyday times. Larger devices, such as tank systems or mods, do not look like other tobacco products.”

Right now, the most popular device is a JUUL, which is a sleek device that resembles a USB flash drive. The device is battery-operated, can be recharged using a computer and can be decorated using stickers.

“All JUUL e-cigarettes have a high level of nicotine,” according to the CDC. “According to the manufacturer, a single JUUL pod contains as much nicotine as a pack of 20 regular cigarettes.”

Why are they appealing?

Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, said his agency has been tracking the skyrocketing use of e-cigarettes for a couple of years.

He said there are several reasons why e-cigarettes are particularly attractive to young people.

“First, you get a buzz from the nicotine,” he said. “The bad thing about that is it addicts you. Nicotine is one of the most addictive substances on the planet. It rivals opioids in terms of addictive qualities.”

The devices themselves are also attractive, he said.

“It’s sleek and thin, and they have stickers you can put on them to decorate them pretty much any way you want,” he said.

Most attractive are the flavors, though, he said.

“Because of the different flavors, kids are using them who ordinarily wouldn’t smoke,” he said.

The business behind e-cigs

According to Know The Risk, a website to promote education about the risks of e-cigarettes, e-cigarettes are a $2.5 billion business in the U.S.

“As of 2014, the e-cigarette industry spent $125 million a year to advertise their products and used many of the techniques that made traditional cigarettes such a popular consumer product,” according to the site. “Marketing and advertising of conventional tobacco products like cigarettes are proven to cause youth to use tobacco products. Scientists are also finding that youth who are exposed to e-cigarette advertisements are more likely to use the product than youth who are not exposed.”

JUUL, one of the most popular and commonly-sold e-cig devices, is a three-year-old company with a booming business, Chandler said.

“The JUUL has become the tool of choice,” Chandler said. “They’re very sleek, can be hidden in the palm of a hand and they’re really attractive devices. They come with flavors like cotton candy and bubble gum.”

Chandler said he believes JUULs and other e-cig devices are being marketed to teens and adolescents.

“It’s clear to me they are targeting young people,” he said. “It’s hard for me to believe that you would produce these kinds of flavors and not target young people.”

North Carolina Attorney General Josh Stein announced this week the state is suing JUUL for its marketing practices, which he claims target children and mask the risks of using the products.

Stein told CNN an investigation he started in October on the company’s sales and marketing practices sparked the lawsuit.

“My investigation showed two things: One; it targeted young people. And two, it misleads the public about the potency of nicotine in its products,” he said. “You only have to walk through any high school parking lot … to see how pervasive Juul is among young people in our state. Juul claims its products are for adults, but it’s business strategy clearly targeted young people and minors.”

According to the U.S. Surgeon General, JUUL experienced a 600 percent increase in sales from 2016-17. The Surgeon General also warned that approximately two-thirds of JUUL users age 15-24 didn’t know JUUL always contains nicotine.

That lack of knowledge about the risk of e-cigarettes isn’t uncommon, which is concerning or health officials, Chandler said.

“The parents, the teachers and even the kids themselves are not aware that these are bad for you,” he said.

Risk perception vs. reality

The KIP survey also revealed that older students perceive less risk or harm from e-cigarette use.

According to the survey, about 60 percent of sixth-graders said they perceived a moderate or great risk from e-cigarette use, while only about 39 percent of 12th-graders answered the same. About 50 percent of eighth-graders and 43 percent of 10th-graders said they perceived a moderate or great risk, marking a slight decrease in the perception of risk associated between each grade level surveyed.

According to the CDC, most e-cigarettes contain nicotine — the addictive drug in regular cigarettes, cigars and other tobacco products.

Nicotine can harm the developing adolescent brain, the CDC reports.

“The brain keeps developing until about age 25,” according to the CDC. “Using nicotine in adolescence can harm the parts of the brain that control attention, learning, mood and impulse control.”

“The biggest health concern is that it has been scientifically proven that the use of nicotine is damaging to the developing brain,” Chandler said. “Nicotine is addictive. So you’re talking about kids becoming addicted to a substance that is not good for them for potentially the rest of their life.”

Also of great concern is that nicotine use in adolescence can lead to addiction to other drugs, the CDC reports.

In addition to nicotine, e-cigarette aerosol contains other additives that can be dangerous.

The CDC found aerosol vapors could contain “ultrafine particles that can be inhaled deep into the lungs, flavoring such as diacetyl, a chemical linked to lung disease; volatile organic compounds, cancer-causing chemicals and heavy metals such as nickel, tin and lead.”

The CDC reports some defective e-cigarette batteries have also caused fires and explosions that have caused serious injuries.

Still much unknown

One of the biggest concerns with e-cigarettes and other “vaping” products is there is still much to learn about them, their risks and their long-term effects.

“We don’t know exactly, because the FDA hasn’t done a full review of these products, what’s in these,’ Chandler said. “We do know in some cases there are heavy metals, dangerous chemicals and aerosols. We’re just not sure of the amount or how damaging they might be to young people if they’re breathing them into their lungs.

“Lungs are very absorbent and tremendous and wonderfully efficient devices at moving oxygen through the blood, and they move anything else through the blood too.”

A concerning effect of e-cig use is future cigarette usage.

A 2018 National Academy of Medicine report revealed evidence that e-cigarette use was likely to increase the frequency and amount of smoking in the future.

That’s a heartbreaking reality in a state plagued by the effects of smoking and tobacco use for decades, Chandler said.

“That’s one of the biggest concerns we’ve got,” he said. “After having some success in reducing the rates of smoking, we’re seeing this rise in e-cigarettes now. Reducing smoking in Kentucky has been hard to come by. And we’ve seen enormous damage from tobacco use.”

Chandler said 9,000 people die in Kentucky each year from smoking-related illnesses.

“You compare that to 1,500 people that died from opioids in the worst year and that gives you a taste of just how damaging smoking and tobacco use has been in our state.

“The good news is we have over the years reduced youth smoking, but we’re still nowhere near the national average. And now, because of this vaping problem, we’re seeing the use of nicotine products spike through the roof. It’s a very troubling development. We’re sorry it’s happening and it’s my personal opinion these vaping companies are culpable for their marketing practices.”

What can be done?

Chandler said there are several approaches to reducing the use of e-cigs among youth, including education, smoke-free laws in communities, taxing e-cigs and vaping devices and statewide or even national legislation.

“We need to increase education about these devices and their risks,” he said.

The Foundation for a Healthy Kentucky has released a series of PSAs about the easily-concealed risks of these products.

The “I Just Didn’t Know” campaign can be found online at ijustdidntknow.org, and includes information from students and teachers, including Mike Hamilton, a teacher at Baker Intermediate School in Clark County.

Clark County has not been immune to the rise of e-cigarettes and vaping, Hamilton reveals.

In his PSA, Hamilton said as a fifth- and sixth-grade teacher, he was shocked vaping was happening in his school.

“With its wacky flavors and crazy names, it’s actually delivering cancer-causing chemicals to our children,” he said in the PSA.

According to Greg Hollon, director of pupil personnel and student support services for CCPS, there has been an increase locally, too.

“There is definitely an increase in vaping and e-cigarettes. One of the major issues in combating this is that the devices do not always look like vaping devices,” Hollon said in an email. “GRC is confiscating any items found, but most importantly, they are educating the students on the dangers of these devices.”

Chandler would like to see all schools adopt smoke-free campus policies.

“We could have all schools adopt smoke-free and tobacco-free campus policies that would include vaping products,” he said. “What that would mean is it would be basically illegal to use these products anywhere on campus.”

Hollon said all Clark County schools are designated as smoke-free zones, but there is not a smoke-free campus policy in place.

“During athletic events, we are still providing areas for adults and community members to smoke in smoking zones,” Hollon said in an email Friday. “In 2014, an updated board policy was adopted to include the language prohibiting all vaping devices by students. Robert D. Campbell is addressing the issue, as well.”

Chandler said another solution is to tax vaping products in Kentucky.

“There is no excise tax in Kentucky on vaping products,” he said. “That’s another proven method that will cause the vaping rates to go down. Young people, in particular, are price sensitive.”

Finally, Chandler would like to see the legal age to buy tobacco and nicotine products in the U.S. raised to 21. Sen. Mitch McConnell announced last month plans to introduce national legislation to raise the legal age to 21.

“Right now you can buy at age 18,” he said. “A lot of high school kids hang out with 18-year-olds, and many are 18 already. They have easy access right now. If they have to get them from 21-year-olds, it will be harder to get the products.”

Chandler said the approach to tackling the issue is multifaceted.

“All of these proposed solutions need to occur together. Alone, they are not enough,” he said.