Gone are the days of Joe Camel, the mascot of tobacco marketers, which was retired in 1997 following heavy criticism that the cartoon animal appealed to youth. But ads promoting vaping products (also known as e-cigarettes or vapes) are aggressively targeting teens via their smart phones.
In December 2018, then-U.S. Surgeon General Jerome Adams declared youth vaping an epidemic. The good news—since then, youth e-cigarette use has hit its lowest point in a decade. But today, 1.6 million middle and high school students nationwide (5.9%), including 410,000 as young as 11 to 14 years old (3.5%), are still using these products.
Social media is in part to blame. Studies have shown adolescents who see tobacco-related content on social media channels are significantly more susceptible to start vaping than peers who did not come across these advertisements. Researchers are investigating how the tobacco industry is using social media to promote vaping to teens and developing interventions for deterring e-cigarette use.
“Kids today are spending a lot of time on social media, and they’re getting exposed to a significant amount of inappropriate content, including tobacco promotion,” says Grace Kong, PhD, associate professor of psychiatry at Yale School of Medicine. “We need innovative, creative, powerful ways to combat some of these promotional strategies.”
Vaping is a safer alternative to cigarettes—but not risk-free
E-cigarettes are battery-operated devices that deliver substances such as nicotine in an aerosol form instead of smoke. Manufacturers originally created the vaping devices as a purported safer alternative to smoking cigarettes. Indeed, e-cigarettes contain fewer harmful chemicals than combustible ones, which contain at least 250 known harmful chemicals, including 69 carcinogens. “When you do an apples-to-apples comparison, e-cigarettes may be less harmful than cigarettes,” says Suchitra Krishnan-Sarin, PhD, Albert E. Kent Professor of Psychiatry at Yale School of Medicine. “But that doesn’t mean that they are without harm themselves.”
A common misconception about e-cigarettes is that they simply produce water vapor, and that therefore they are safe to inhale. But individuals aren’t breathing in water vapor at all. Rather, they are ingesting an aerosol composed of many suspended potentially harmful particles, clinicians say. The active ingredient in most vaping devices is nicotine, a highly addictive chemical that is especially detrimental to teens’ developing brains.
However, even nicotine-free vapes contain concerning substances. Glycerin and propylene glycol, for example, are common ingredients in e-cigarettes. Although the Food and Drug Administration has classified these substances as “generally recognized as safe” to eat, there is little research on the safety of inhaling these chemicals. Many e-cigarettes also contain alcohol—sometimes in high levels—which can have toxic effects on the brain if inhaled. They may also contain metallic particles including chromium, cadmium, and lead from the heating coil, which can be harmful to the lungs, brain, and other vital organs.
“We should not be advocating for people to use this type of device unless they’re using it to quit smoking,” Krishnan-Sarin says. “But even then, it should still be used with a plan to eventually quit vaping as well.”
However, unlike other smoking cessation aids such as the medication varenicline (Chantix), nicotine patches, and nicotine gum, e-cigarettes are not marketed as a way to stop smoking. This is because it would require tobacco companies to seek approval from the FDA of e-cigarettes as a drug delivery device—a lengthy process involving numerous safety and efficacy studies. “They’re regulated by the FDA as a tobacco product, not as a drug delivery device, and they are not sold by prescription,” Krishnan-Sarin says. “So, they cannot be marketed as an aid to quit smoking.”
E-cigarette retailers use range of tactics to advertise to youth
Nearly 50 years after the U.S. Congress first banned cigarette advertisements on television and radio, tobacco advertisements are re-emerging, especially in online spaces, because e-cigarettes were not included in this ban. In 2019, as many as three-quarters of teens were exposed to e-cigarette marketing, one nationwide study found. These advertisements are often eye-catching to adolescents, featuring young people vaping a variety of devices with trendy shapes, vivid colors, and endless flavors.
At Yale School of Medicine, Kong’s team analyzes social media content to understand emerging trends in e-cigarette marketing. “Social media does not have the same regulations as most traditional media, so marketers can go under the radar in ways they cannot do on television or on a billboard,” Kong says.
Tobacco companies use a wide range of marketing techniques on social media, her team has found. Often, they advertise from their own social media platforms, where they offer coupons, discounts, and giveaways to sometimes hundreds of thousands of followers. One common promotional technique, Kong’s team has found, is “incentivized friend tagging,” in which e-cigarette companies encourage their followers to tag other social media accounts on their brand’s posts to win free or discounted products. Brands also frequently tag celebrities such as athletes, actors, and musicians in their content.
Other times, brands use additional tactics that appeal to youth, such as marketing fun flavors or even cartoon characters. E-liquids come in a variety of flavors that are attractive to young people, including bubble gum, glazed donut, and fruity pebbles. Furthermore, in August 2023, the FDA delivered warnings to 15 online retailers for selling products resembling youth-appealing animated characters including Spongebob and Super Mario.
Social media does not have the same regulations as most traditional media, so marketers can go under the radar in ways they cannot do on television or on a billboard.
Grace Kong, PhD
Social media is also full of “influencers”—content creators with large followings whom advertisers pay to show off a wide range of products. E-cigarettes are no exception. Some advertisements are easy to spot, with hashtags such as “#ad” or “#sponsored.” But at other times, the marketing is more subtle. “Sometimes it’s placed very surreptitiously in content not as the main focus, but as an aspect of something an influencer is doing that young people perceive as interesting or cool,” says Deepa Camenga, MD, associate professor of emergency medicine. A video game influencer, for example, may casually take a hit of a vape in a promotion for a new game. This subtle product placement exposes adolescents to vaping content even if they are not actively searching for it.
“If you’re searching for video gaming or you’re searching for something else and you’re seeing people vape, it’s very persuasive to a lot of demographics,” says Dhiraj Murthy, PhD, professor of media studies and director of the Computational Media Lab at the University of Texas at Austin, and Kong’s colleague. “It’s literally in the air.”
The rise of dangerous vaping trends
Kong’s team has revealed other concerning trends. One is the rising promotion of “stealth vaping.” Some manufacturers are now marketing e-cigarette devices available that not only resemble everyday products (such as USB drives, pens, and candy containers), but also emit low levels of vapor and odor. The researchers uncovered numerous videos on YouTube that instruct young users how to vape discreetly in class and school bathrooms, and at home.
Other YouTube videos, the researchers found, teach people how to “hack” e-cigarettes, in which users modify their devices in potentially dangerous ways. These modifications include refilling non-refillable devices, recharging disposable pods, and mixing nicotine with cannabis liquids. “Hacking or using e-cigarettes in ways other than their intended purpose is putting young people at an even greater risk,” Kong says. Hacking practices, for example, can increase the risk of burns, lung injury, and exposure to multiple harmful substances.
Researchers use technology to combat youth vaping
Vaping may be especially risky because there is limited research into the development of interventions for young people who want to quit. “Vaping has been around for about 10 years now, and many people who started as kids in high school are now young adults, addicted to this product, and they want to quit,” says Krishnan-Sarin. “And we have almost no established methods for helping them.”
However, for those looking to kick the habit, there are free interventions available online. The Centers for Disease Control and Prevention (CDC), for example, offers a “Quit Line” where individuals can speak with trained coaches, as well as text messaging services that provide confidential help and support. Emerging research suggests that quitlines are effective in helping people quit e-cigarettes.
Furthermore, the American Lung Association offers an evidence-based online, self-guided program for teens who want to quit vaping. For those who need some extra support, nicotine replacement therapy (such as gum and patches) used under the supervision of a pediatrician can help young people struggling with withdrawal and cravings.
Vaping has been around for about 10 years now, and many people who started as kids in high school are now young adults, addicted to this product, and they want to quit.
Suchitra Krishnan-Sarin, PhD
And new interventions are in the works. Camenga, in collaboration with Kimberly Hieftje, PhD, associate professor of pediatrics (general pediatrics) at Yale School of Medicine, is developing a virtual reality-based program for middle school students that addresses both nicotine and cannabis vaping. “This is a newer phenomenon—what we’re seeing is that kids are vaping both substances,” Camenga says. “But a lot of the prevention curricula and approaches today focus solely on the risks of tobacco.” She and Hieftje launched the program in three Connecticut middle schools this fall.
Furthermore, Krishnan-Sarin and Kong are in the process of testing an app that provides a virtual form of cognitive behavioral therapy (CBT) for vaping cessation. Their team designed the app to teach youth about the harms of vaping and to use role-playing to promote skills that can help them quit, such as how to manage withdrawal symptoms and resist peer offers to vape. The technology also helps teens cope with the reasons that drive their use. “So many adolescents that we speak to say that they use nicotine vapes because it helps them deal with stress or anxiety,” Krishnan-Sarin says. “Our app teaches them other how to handle stress and anxiety without using nicotine.”
Initial testing suggests that the app was well-liked by teens and it reduced use of e-cigarettes. Her team will begin a large-scale clinical trial to test the app in early 2025.
A person’s teenage years are a time full of exploration and experimentation. But 87% of adult smokers got hooked on nicotine by the time they were 18, and 95% by 21. Thus, educating middle and high school students—and their parents—on the dangers of vaping and the risks of e-cigarette addiction could be critical for improving not only the overall health of young people, but society as a whole. While it will take years for studies to establish the long-term impacts of these devices, letting them get into the hands of youth is a very dangerous gamble.
“We have to remember that it took us almost 10 to 20 years after cigarettes came on the market to actually establish the link between cigarettes and cancer,” says Krishnan-Sarin. “We need to develop a better understanding of the long-term health impact of these products.”