The effects of electronic cigarette smoking in adolescents
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Electronic nicotine delivery systems (ENDS), or electronic cigarettes (e-cigarettes), are battery-powered handheld devices designed to aerosolize a solution of nicotine and other chemicals for inhalation. The specific mechanical and chemical features of different ENDS affect the systemic exposure and bioavailability of the different chemicals in e-juices. E-cigarettes can come with different cartridge sizes, power outputs, e-liquid constituents, and nicotine delivery. User puff topography also contributes to varying toxicant exposure. ENDS have demonstrated potential as a cessation tool or alternative cigarette product due to its safety profile relative to the combustible cigarette. E-cigarettes have significantly lower concentrations of biomarkers of tobacco-related toxicant exposure and produce less and less harmful second-hand smoke compared to CC. However, ENDS users have significantly greater concentrations of those same biomarkers, highlighting that e-cigarettes do pose a harm to users’ health, even if that may be lower than CC. The same is observed in e-cigarette second-hand smoke as nicotine and aerosol particles were detected in statistically significant amounts. Its toxicity is only amplified by the misconception that they are safer than CC and thus pose no absolute risk, misleading users to use without caution. Therefore, although ENDS do have the potential in reducing smoking in adults who are already addicted to nicotine, it comes with the risk of dual use of conventional and electronic cigarettes and of attracting non-smokers, especially as seen in the youth. The rise in adolescent e-cigarette use can be attributed to its appeal, of both its flavored e-liquids and its image amongst youth that is perpetuated through the intentional marketing of e-cigarette manufacturers. The latent consequences of e-cigarettes are compounded in adolescents, who are in critical stages of brain development, habit formation, and social development. Youth report having experienced short-term clinical symptoms such as cough, lightheadedness, headache, and shortness of breath. Physiologically, vaping has been found to affect the pulmonary and cardiovascular systems. Vaping alters the equilibrium of the mucociliary clearance system in the pulmonary system and increases the risk of chronic bronchitis, cough, and phlegm. There is increased in pro-inflammatory cytokine secretions, increased alveolar macrophage apoptosis, impairment of phagocytosis, decreased ciliary beating, inhibition of the CFTR channel, and increased mucin expression. In the cardiovascular system, e-cigarette aerosol extract alters angiogenesis, oxidative stress, endothelial dysfunction, sympathetic nerve system activation, platelet activation and anticoagulation inhibition, and cardiac remodeling. E-cigarettes and e-cigarette smoke have also been associated with carcinogenesis in lung epithelium and possibly urothelium. Although e-cigarettes have, on average, less nicotine compared to CC, the significant risk for adolescents to graduate to combustible cigarettes renders this moot. The factors influencing this graduation is modeled through the catalyst model, which details the transition from ‘no use’ to ‘e-cigarette use’ and the transition from ‘e-cigarette use’ to ‘tobacco use.’ Schneider and Diehl hypothesized that the first transition is facilitated through a variety of factors, including flavor, health, price, role models, concealment, and acceptance. The subsequent transition can be attributed to the addiction hypothesis, accessibility hypothesis, and the experience hypothesis. It is clear from the numerous studies conducted, which show students who used e-cigarettes were 4-7 times more likely to report CC use, that e-cigarettes play a catalytic role in enabling the transition to conventional cigarettes. And with increased nicotine exposure, adolescents are subject to impairments in working and verbal memory during abstinence, changes in drug sensitivity and reward-related manifestations in adulthood, more severe dependence during adolescence, and deficits in attentional performance, impaired serial pattern learning, impaired context conditioning and increased anxiety and depressive-like behaviors in adults. They also have reduced control of motivation, reward, and pleasure. This culminates to the gateway hypothesis which states that nicotine can serve as a gateway drug that lowers the youths’ threshold for addiction to opioids, alcohol, and other agents. Recently, there has been a dramatic increase in cases of EVALI or e-cigarette or vaping associated lung injury, particularly in the adolescent population that is more likely to use illicit e-cigarettes than their adult counterparts. EVALI presents with a wide range of respiratory, gastrointestinal, and constitutional symptoms and is characterized as a sterile exogenous pneumonitis-like reaction with variable degrees of diffuse alveolar damage. Vitamin E acetate, common in illicit products, is strongly linked to this outbreak due to its presence in a vast majority of bronchoalveolar lavage fluid samples of confirmed EVALI cases. As ENDS use has increased amongst adolescents, so have its latent consequences. A coordinated effort from policy makers, public health agencies, healthcare providers, researchers, and especially parents and educators is essential for successful protection of this vulnerable population.
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