Despite the substantial progress that has been made in reducing conventional cigarette smoking among adolescents in the United States, the use of alternative tobacco products—mainly e-cigarettes –has increased at an alarming rate among this vulnerable population. According to a 2020 CDC report, approximately one in five high school students (an estimated 3.02 million) and one in 20 middle school students (an estimated 550,000) currently use e-cigarettes. An in-depth understanding of the preparation and initiation stages of e-cigarette use has strong potential to help guide tobacco and nicotine control strategies and prevention efforts to discourage e-cigarette initiation among youth and save them from being hooked on nicotine for life. My colleagues and I hypothesized that e-cigarette curiosity and susceptibility could be predictors of future e-cigarette use among adolescents regardless of being susceptible or non-susceptible to initiate cigarette smoking. To test this hypothesis, we analyzed nationally representative data of 13,428 e-cigarette and cigarette-naïve adolescents drawn from the 2018 US National Youth Tobacco Survey. Our findings were published in Health Education & Behavior.

Concerning Numbers

Our findings indicate that an estimated 8 million e-cigarette-naïve middle and high schoolers were susceptible to and curious about e-cigarette use in 2018. This number is alarming considering the 2019 CDC report indicated the number of adolescents who reported current use of e-cigarettes increased by 32.2% among high school students and 114.2% among middle school students between 2018 and 2019. What’s more, a new study among US adolescents found that kids who were susceptible to e-cigarettes had increased odds of initiating e-cigarettes, marijuana, and alcohol consumption 1 year later. Thus, identifying and targeting adolescents who are susceptible to e-cigarettes not only could prevent e-cigarette initiation but also reduce current trends in the use of other substances.

Exposure & Susceptibility

Our study indicates that low perception of harm and high exposure to online e-cigarette advertising and secondhand e-cigarette aerosols in public places were associated with higher odds of susceptibility to, and curiosity about, e-cigarettes among adolescents, both susceptible and non-susceptible to cigarette smoking (Table). Since curiosity refers to interest—even in the absence of clear intentions to initiate use—and can be considered an early warning indicator, pediatricians, and mental health professionals, should advise parents about highly addictive nicotine and how it can harm adolescent brain development into the early-mid 20s.

The popularity of vaping may change the way physicians approach some adolescent patients. In addition to asking “Do you smoke or vape?” they also could ask patients if they are curious or susceptible to vape (eg, “Would you use an e-cigarette if one of your best friends offer it to you?”) in order to raise awareness about potential health effects of vaping and warn parents about their kids curiosity or susceptibility to initiating vaping, which could open the gate for conventional cigarette initiation and other substances. Regulatory agencies, such as the FDA, should restrict or ban online commercializing of e-cigarettes targeting youth as well as vaping in public places to block “the road to vaping” and curb increasing rates of e-cigarette use, as well as the risk of initiation among cigarette-naïve adolescents who otherwise would not be exposed to nor become dependent on nicotine.

The Future of Vaping

The rapidly changing e-cigarette marketplace necessitates future nationwide prospective studies to investigate the trajectories of e-cigarette susceptibility and curiosity among nicotine-naïve adolescents and what factors affect their vaping initiation. Additionally, future regulatory policies, tobacco control prevention campaigns, and health professionals should focus on increasing health awareness (eg, potential harm and addictiveness) of e-cigarettes among adolescents and restrict marketing and the use of e-cigarettes in public places.