InstructionsTo obtain continuing education credit:1.Read the article carefully.2.Read each question and determine the correct answer.3.Visit PedsCESM, ce.napnap.org, to complete the online Posttest and evaluation.4.You must receive 70% correct responses to receive the certificate.5.Tests will be accepted until 31 August, 2021. Objectives1.To identify types of e-cigarette devices.2.To identify contents and additives in e-liquids.3.To describe the associated effects of vaping on adolescents.4.To identify terminology associated with e-cigarette use.5.To identify resources for nicotine and tobacco cessation.Posttest QuestionsContact hours: 0.75Passing score: 70%This continuing education activity is administered by the National Association of Pediatric Nurse Practitioners (NAPNAP) as an Agency providing continuing education credit. Individuals who complete this program and earn a 70% or higher score on the Posttest will be awarded 0.75 Continuing Education Credit.Earn FREE CE Contact Hours OnlineContact Hours for this online activity are FREE for NAPNAP members. Nonmembers will be charged a fee of $10 to receive contact hours for this online activity through PedsCESM. Payment can be made by credit card through PedsCESM.1.To take the Posttest for this article and earn contact hours, please go to PedsCESM at ce.napnap.org.2.In the Course Catalog, search for the name of the CE article.3.If you already have an account, log in using your username and password. If you are a NAPNAP member, log in with your username and password. If you are a first-time user and NAPNAP nonmember, click on “Log in,” and then click on “New Customer? Click Here.”4.Once you have successfully passed the Posttest and completed the evaluation form, you will be able to print out your certificate immediately.In December 2018, the surgeon general warned of the e-cigarette epidemic among the youth of the United States (Office of the Surgeon General 2018Office of the Surgeon GeneralSurgeon General's advisory on e-cigarette use among youth.2018https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdfGoogle Scholar). As of December 3, 2019, there have been 2,291 cases of hospitalization because of e-cigarette or vaping product use associated lung injury (EVALI) and 48 confirmed EVALI deaths reported to the Centers for Disease Control and Prevention. Over half of all reported EVALI cases have been of patients < 24 years old, with 16% of those < 18 years old (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Disease Prevention and Health Promotion, Office on Smoking and Health 2019U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Disease Prevention and Health Promotion, Office on Smoking and HealthOutbreak of lung injury associated with the use of e-cigarette, or vaping, products.2019https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-outbreak-informationGoogle Scholar). To obtain continuing education credit:1.Read the article carefully.2.Read each question and determine the correct answer.3.Visit PedsCESM, ce.napnap.org, to complete the online Posttest and evaluation.4.You must receive 70% correct responses to receive the certificate.5.Tests will be accepted until 31 August, 2021. 1.To identify types of e-cigarette devices.2.To identify contents and additives in e-liquids.3.To describe the associated effects of vaping on adolescents.4.To identify terminology associated with e-cigarette use.5.To identify resources for nicotine and tobacco cessation. Posttest Questions Contact hours: 0.75 Passing score: 70% This continuing education activity is administered by the National Association of Pediatric Nurse Practitioners (NAPNAP) as an Agency providing continuing education credit. Individuals who complete this program and earn a 70% or higher score on the Posttest will be awarded 0.75 Continuing Education Credit. Earn FREE CE Contact Hours Online Contact Hours for this online activity are FREE for NAPNAP members. Nonmembers will be charged a fee of $10 to receive contact hours for this online activity through PedsCESM. Payment can be made by credit card through PedsCESM.1.To take the Posttest for this article and earn contact hours, please go to PedsCESM at ce.napnap.org.2.In the Course Catalog, search for the name of the CE article.3.If you already have an account, log in using your username and password. If you are a NAPNAP member, log in with your username and password. If you are a first-time user and NAPNAP nonmember, click on “Log in,” and then click on “New Customer? Click Here.”4.Once you have successfully passed the Posttest and completed the evaluation form, you will be able to print out your certificate immediately. Although cigarette smoking 30-day prevalence among 8th through 12th graders has declined from peak levels in the 1990s by up to 91%, vaping has become increasingly popular among the nation's youth (Johnston et al., 2018Johnston L.D. Miech R.A. O'Malley P.M. Bachman J.G. Schulenberg J.E. Patrick M.E. Monitoring the Future national survey results on drug use 1975-2017: 2017 overview, key findings on adolescent drug use. Institute for Social Research, The University of Michigan, Ann Arbor, MI2018Crossref Google Scholar). In 2018, vaping of nicotine by adolescents had the largest increase ever for any substance tracked by the Monitoring the Future survey with use in the past 12 months rising to 11%, 35%, and 30% in the eighth, tenth, and twelfth grades, respectively (Miech et al., 2019Miech R.A. Johnston L.D. O'Malley P.M. Bachman J.G. Schulenberg J.E. Patrick M.E. Monitoring the Future national survey results on drug use, 1975–2018: Volume I, secondary school students. Institute for Social Research, The University of Michigan, Ann Arbor, MI2019http://www.monitoringthefuture.org/pubs/monographs/mtf-vol1_2018.pdfGoogle Scholar). Jackler and Ramamurthi, 2019Jackler R.K. Ramamurthi D. Nicotine arms race: JUUL and the high-nicotine product market.Tobacco Control. 2019; 28: 623-628Crossref PubMed Scopus (87) Google Scholar found that JUUL Labs Inc. targeted adolescents by advertising in media outlets preferred by youth, such as social media, through paid influencers and through the use of hashtags, from 2015 to 2018. JUUL Labs Inc. was the top-selling e-cigarette maker in 2018, with over 75% of the market of e-cigarette users, contributing to what can be called a JUULing epidemic. This rapid increase of nicotine use warrants a thorough understanding of the dangers of e-cigarettes for adolescents, providers, schools, and parents, including the most current products and terminology associated with e-cigarette use, health risks associated with vaping, and available tools and resources to discourage the use of e-cigarette products among adolescents. Electronic cigarettes are a broad class of products used to heat and vaporize a liquid to produce an aerosol inhaled by the user (U.S. Department of Health and Human Services 2016U.S. Department of Health and Human ServicesE-cigarette use among youth and young adults: A report of the Surgeon General-executive summary. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2016Google Scholar). Each product may resemble its tobacco-delivering predecessor or have a completely new form resembling common tools and modern-day technology devices. These devices are battery-powered and contain a wide variety of liquids. The liquids may contain nicotine, flavoring only, caffeine, vitamin B-12, marijuana concentrates, and additives such as psychotropic substances and opioids (e.g., fentanyl) in addition to substances that produce the actual aerosol when heated. Electronic cigarettes come in a wide array of shapes and sizes, may be disposable or rechargeable, and have changed significantly in design and appearance over the years (Table 1). E-cigarette devices and liquids are available for purchase through online retailers, in specialty tobacco and vape shops, and in convenience stores and gas stations.TABLE 1Common vape devices and accessoriesDevice/accessoryNameHookah penPen-styleBox-ModPod-style (JUUL, Juul Labs, Inc., San Francisco, CA)Pod-style (Suorin, Suorin USA, Chino, CA)Pod-style (Smok Novo 2, Shenzhen IVPS Technology Co Limited, Shenzhen, China)Pod-style (PHIX device and e-liquid pod, PhixVapor, Brea, CA)Cell phone vape caseBox-Mod (Vape & bluetooth speaker)Vape device in key fob design Open table in a new tab The first generations of e-cigarette devices range from devices that resemble an actual cigarette to larger cylinder-shaped devices and modifiable tank devices (Dawkins et al., 2015Dawkins L. Kimber C. Puwanesarasa Y. Soar K. First- versus second-generation electronic cigarettes: Predictors of choice and effects on urge to smoke and withdrawal symptoms.Addiction. 2015; 110: 669-677Crossref PubMed Scopus (57) Google Scholar). Devices in these classes may be disposable or rechargeable and use a variety of e-liquids (Consumer Advocates for Smoke-Free Alternatives Association 2019bConsumer Advocates for Smoke-Free Alternatives AssociationElectronic cigarette overview.2019http://www.casaa.org/electronic-cigarettes/Google Scholar). Users adjust tanks, atomizers, coils, and wicking materials in addition to accessorizing the modifiable devices, known as box mods, to have control over the appearance of the device as well as the amount and thickness of the vapor (Consumer Advocates for Smoke-Free Alternatives Association 2019bConsumer Advocates for Smoke-Free Alternatives AssociationElectronic cigarette overview.2019http://www.casaa.org/electronic-cigarettes/Google Scholar). The most current devices are pod systems. These devices use a cartridge, or pod, filled with e-liquid. The pod is inserted into the e-cigarette device and is ready for use. Most pods are closed systems, are not refillable, and contain the same amount of nicotine as 20 or more cigarettes. Once used, the pod is thrown away, and another pod inserted into the device. Some popular pod device brands among adolescents are JUUL, Phix, Nobu, and Suorin. Devices continue to evolve, and many now incorporate current technologies such as cell phone attachments, built-in speakers, and the use of Bluetooth, as seen in Table 1. JUUL, like many newer pod vaping devices, is small and slender, resembles a flash drive, recharges in a universal serial bus port, is easily concealed, and is one of the most popular devices among adolescents (Huang et al., 2019Huang J. Duan Z. Kwok J. Binns S. Vera L.E. Kim Y. Emery S.L. Vaping versus JUULing: How the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market.Tobacco Control. 2019; 28: 146-151Crossref PubMed Scopus (259) Google Scholar). Devices typically cost between $15 and $50, and pod refills cost around $4, making them about half of the price of cigarette packs. Nicotine, propylene glycol, vegetable glycerin, water, and flavoring are some of the main ingredients in most e-liquid mixtures (Grana et al., 2014Grana R. Benowitz N. Glantz S.A. E-cigarettes: A scientific review.Circulation. 2014; 129: 1972-1986Crossref PubMed Scopus (798) Google Scholar). The liquids and aerosols have also been shown to contain and produce diethylene glycol, nitrosamines, particles of tin, silver, aluminum, iron, chromium, nickel, and aldehydes, among many other respiratory irritants and cancer-causing agents (Williams et al., 2013Williams M. Villarreal A. Bozhilov K. Lin S. Talbot P. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol.PLOS ONE. 2013; 8: e57987Crossref PubMed Scopus (409) Google Scholar). There are over 15,000 e-liquid flavors currently on the market. Refillable e-liquid mixtures range in size from 30 ml to 135 ml bottles. E-liquids containing nicotine salts are increasing in popularity since the introduction of JUUL in 2015 (Jackler and Ramamurthi, 2019Jackler R.K. Ramamurthi D. Nicotine arms race: JUUL and the high-nicotine product market.Tobacco Control. 2019; 28: 623-628Crossref PubMed Scopus (87) Google Scholar). Traditional cigarettes contain free-base or unprotonated nicotine, whereas newer e-liquids contain the protonated form of nicotine, called nicotine salt, mixed with an acid, often benzoic acid, as well as flavorings (Jackler and Ramamurthi, 2019Jackler R.K. Ramamurthi D. Nicotine arms race: JUUL and the high-nicotine product market.Tobacco Control. 2019; 28: 623-628Crossref PubMed Scopus (87) Google Scholar). The nicotine salts are known to provide a higher concentration of nicotine more smoothly and less bitterly than free-base nicotine (Bowen and Xing, 2015Bowen A. Xing C. U.S. Patent No. 9,215,895. U.S. Patent and Trademark Office, Washington, DC2015Google Scholar; Bowen and Xing, 2015Bowen A. Xing C. U.S. Patent No. 9,215,895. U.S. Patent and Trademark Office, Washington, DC2015Google Scholar). Being that e-liquids can be modified, it is possible to add potentially any drug or substance that can be dissolved in a liquid (Varlet, 2016Varlet V. Drug vaping: From the dangers of misuse to new therapeutic devices.Toxics, 4. 2016; : 1-16Google Scholar). Additives of concern for vaping include α-pyrrolidinovalerophenone (Flakka), gamma-hydroxybutyrate (GHB, also known as the date-rape drug), ethanol, opium, crack cocaine, amphetamines, benzodiazepines, and legal and illegal plant extracts and concentrates such as Mitragyna speciose (Kratom) and Leonotis leonorus (also called wild dagga; Varlet, 2016Varlet V. Drug vaping: From the dangers of misuse to new therapeutic devices.Toxics, 4. 2016; : 1-16Google Scholar). Companies have even added prescription medications such as sildenafil and tadalafil to e-liquids (The U.S. Food and Drug Administration 2018U.S. Food and Drug AdministrationFDA in brief: FDA warns company illegally selling e-liquid products intended for vaping that contain unapproved drugs for erectile dysfunction, weight loss and falsely claim to be FDA-approved.2018https://www.fda.gov/news-events/fda-brief/fda-brief-fda-warns-company-illegally-selling-e-liquid-products-intended-vaping-contain-unapprovedGoogle Scholar). In 2018, adolescents who reported vaping marijuana were 4.4%, 12.4%, and 13.1% among eighth, tenth, and twelfth graders, respectively (Miech et al., 2019Miech R.A. Johnston L.D. O'Malley P.M. Bachman J.G. Schulenberg J.E. Patrick M.E. Monitoring the Future national survey results on drug use, 1975–2018: Volume I, secondary school students. Institute for Social Research, The University of Michigan, Ann Arbor, MI2019http://www.monitoringthefuture.org/pubs/monographs/mtf-vol1_2018.pdfGoogle Scholar). Current reports of street or illicit marijuana identifies the potential lacing of marijuana with heroin, cocaine, methamphetamine, and various other substances (American Addiction Centers 2019American Addiction CentersWhat can marijuana be laced with?.2019https://americanaddictioncenters.org/marijuana-rehab/what-can-marijuana-be-laced-withGoogle Scholar). The current morbidity from illegal drugs such as fentanyl being laced in other substances of use creates a critical concern if young people are using marijuana from illicit or street dealers to make homemade e-liquids or buy illicit e-liquids from the dark web. The term “smoking” has long been associated with cigarette use. The term “vape” was introduced in the 1980s as a verb relating to electronic cigarette use, although the term was not widely used across the world until 2009 (Consumer Advocates for Smoke-Free Alternatives Association 2019aConsumer Advocates for Smoke-Free Alternatives AssociationA historical timeline of electronic cigarettes.2019http://www.casaa.org/historical-timeline-of-electronic-cigarettes/Google Scholar). Currently, the term “vaping” is associated with the use of tank systems and modified devices. Electronic cigarettes may be referred to as e-cigarettes, e-cigs, e-hookah, hookah sticks, mods, box mods, pens, sticks, tanks, and pods (Jenssen and Walley, 2019Jenssen B.P. Walley S.C. Section on Tobacco ControlE-cigarettes and similar devices.Pediatrics. 2019; 143: 1-8Crossref Scopus (31) Google Scholar). There are numerous companies in the vaping industry. JUUL (pronounced “jewel”), Phix (pronounced “fix”), and Suorin (pronounced “sore-in” or “swar-in”) are three popular e-cigarette companies that market pod systems. Many pod-based systems are often referred to as JUUL, irrespective of the devices’ actual name, and adolescents and young adults refer to the use of these devices as “JUULing” or “ripping” (Willett et al., 2019Willett J.G. Bennett M. Hair E.C. Xiao H. Greenberg M.S. Harvey E. Vallone D. Recognition, use and perceptions of JUUL among youth and young adults.Tobacco Control. 2019; 28: 115-116PubMed Google Scholar). “Zeroing” is a slang term used to describe holding the vapor in long enough to dispel in the lungs so no one sees anything when exhaling. “Dripping” is another term used when one drips e-liquid directly onto a coil to increase the vapor produced (American Academy of Pediatrics 2019aAmerican Academy of PediatricsVaping: Dangerous, available & addicting.2019https://www.healthychildren.org/English/ages-stages/teen/substance-abuse/Pages/E-cigarettes.aspxGoogle Scholar). “Dabbing” and “cannavaping” are terms used for the heating of butane hash or a concentrated resin called “wax,” which is then vaporized and inhaled (Loflin and Earleywine, 2014Loflin M. Earleywine M. A new method of cannabis ingestion: The dangers of dabs.Addictive Behaviors. 2014; 39: 1430-1433Crossref PubMed Scopus (118) Google Scholar). “E-juice” is a term used to refer to the liquid used in electronic cigarettes (American Academy of Pediatrics 2019aAmerican Academy of PediatricsVaping: Dangerous, available & addicting.2019https://www.healthychildren.org/English/ages-stages/teen/substance-abuse/Pages/E-cigarettes.aspxGoogle Scholar). In an interview, Dr. Susanne E. Tanski, an associate pediatrics professor at Dartmouth Geisel School of Medicine, mentions the importance of language in the assessment of adolescent tobacco and nicotine use (Hoffman, 2018Hoffman J. Addicted to vaped nicotine, teenagers have no clear path to quitting.The New York Times. 2018; (Retrieved from)https://www.nytimes.com/2018/12/18/health/vaping-nicotine-teenagers.htmlGoogle Scholar). By asking direct questions such as “Do you smoke cigarettes?,” “Vape?,” “JUUL?,” “Use LUSH?,” “Phix?,” “Suorin?,” providers and parents will eliminate adolescent misconceptions surrounding the questions (Hoffman, 2018Hoffman J. Addicted to vaped nicotine, teenagers have no clear path to quitting.The New York Times. 2018; (Retrieved from)https://www.nytimes.com/2018/12/18/health/vaping-nicotine-teenagers.htmlGoogle Scholar). Asking questions with regards to specific devices and products common or popular in one's geographic location is imperative as all electronic cigarette-associated products vary in popularity across the nation. Being current on local products and trends is an excellent way to ensure that adolescents and young adults are certain of what the provider is asking of them. Willett et al., 2019Willett J.G. Bennett M. Hair E.C. Xiao H. Greenberg M.S. Harvey E. Vallone D. Recognition, use and perceptions of JUUL among youth and young adults.Tobacco Control. 2019; 28: 115-116PubMed Google Scholar found that approximately 25% of adolescents reported the use of an electronic cigarette as JUULing, indicating that adolescents perceive JUULing as different from smoking or vaping. Pepper et al., 2018Pepper J.K. Farrelly M.C. Watson K.A. Adolescents’ understanding and use of nicotine in e-cigarettes.Addictive Behaviors. 2018; 82: 109-113Crossref PubMed Scopus (25) Google Scholar study indicated that adolescents are unclear if nicotine is a component of the e-liquids used and whether the nicotine is synthetic or tobacco-derived. Approximately 40% to 50% of adolescents surveyed did not know that the aerosol from e-cigarettes is more than water vapor alone (Pepper et al., 2018Pepper J.K. Farrelly M.C. Watson K.A. Adolescents’ understanding and use of nicotine in e-cigarettes.Addictive Behaviors. 2018; 82: 109-113Crossref PubMed Scopus (25) Google Scholar). Pointing out the difference between water vapor and an aerosol may prove beneficial and could be explained using the comparison of plain water versus hair spray sprayed into one's hair. Earlier studies on flavor additives revealed that adolescents perceived different flavors as healthier than unflavored products (World Health Organization 2007World Health OrganizationThe scientific basis of tobacco product regulation: Report of a WHO study group (945).2007https://www.who.int/tobacco/global_interaction/tobreg/9789241209458.pdfGoogle Scholar). A more recent study found that many youths believe flavored e-liquid advertisements are meant for them and not the adults the companies claim to target (McKelvey et al., 2019McKelvey K. Baiocchi M. Ramamurthi D. McLaughlin S. Halpern-Felsher B. Youth say ads for flavored e-liquids are for them.Addictive Behaviors. 2019; 91: 164-170Crossref PubMed Scopus (14) Google Scholar). Over the years, reasons for adolescent trial and use of e-cigarettes have only grown. According to Kong et al., 2015Kong G. Morean M.E. Cavallo D.A. Camenga D.R. Krishnan-Sarin S. Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults.Nicotine and Tobacco Research. 2015; 17: 847-854Crossref PubMed Scopus (330) Google Scholar, the primary reasons identified for the use of e-cigarettes include curiosity, variety of flavors, peer influence, ease of accessibility, and the perception that the devices are healthier than traditional cigarettes. A 2016 study found that 31% of middle- and high-school e-cigarette users reported using e-cigarettes because of the availability of different flavors such as candy, fruit, and chocolate (Tsai et al., 2018Tsai J. Walton K. Coleman B.N. Sharapova S.R. Johnson S.E. Kennedy S.M. Caraballo R.S. Reasons for electronic cigarette use among middle and high school students—National Youth Tobacco Survey, United States, 2016.MMWR. Morbidity and Mortality Weekly Report. 2018; 67: 196-200Crossref PubMed Scopus (78) Google Scholar). In addition to the primary reasons mentioned, Schneider and Diehl, 2016Schneider S. Diehl K. Vaping as a catalyst for smoking? An initial model on the initiation of electronic cigarette use and the transition to tobacco smoking among adolescents.Nicotine and Tobacco Research, 18. 2016; : 647-653Crossref PubMed Scopus (93) Google Scholar indicate price, ability to conceal, social acceptance, and technical product designs as other possible reasons for use. Another study expounded on the popularity of producing thick clouds of vapor by the act of dripping (Krishnan-Sarin et al., 2017Krishnan-Sarin S. Morean M. Kong G. Bold K.W. Camenga D.R. Cavallo D.A. Wu R. E-cigarettes and “dripping” among high-school youth.Pediatrics. 2017; 139 (e20163224)Crossref PubMed Scopus (33) Google Scholar). Blowing vapors into shapes, patterns, and large clouds has become known as performing vape tricks, which are now part of competitions across the nation (Pepper et al., 2017Pepper J.K. Lee Y.O. Watson K.A. Kim A.E. Nonnemaker J.M. Farrelly M.C. Risk factors for youth e-cigarette “vape trick” behavior.Journal of Adolescent Health. 2017; 61: 599-605Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar). Social media, where the vast majority of adolescents spend a great deal of time, is filled with images and videos of teens and young adults performing vape tricks, posing with various devices, and even showing ways to hide devices at home and school. There are numerous advertisements for devices, liquids, and customization products such as “skins” or “wraps” and decorations that allow users to personalize their devices, increasing the appeal of the products for teenagers as well as the ability to camouflage them (Barrington-Trimis and Leventhal, 2018Barrington-Trimis J.L. Leventhal A.M. Adolescents’ use of “pod mod” e-cigarettes—urgent concerns.The New England Journal of Medicine. 2018; 379: 1099-1102Crossref PubMed Scopus (90) Google Scholar). Studies have shown that advertisements for e-cigarette companies such as JUUL specifically target adolescents. By using the internet and social media as primary advertising platforms, the companies reach audiences of all ages, especially the technology-driven generation Gen Z, who are middle- and high-school students. One study found that 25% of JUUL's Twitter followers were adolescents (Chu et al., 2018Chu K.H. Colditz J.B. Primack B.A. Shensa A. Allem J.P. Miller E. Cruz T.B. JUUL: Spreading online and offline.Journal of Adolescent Health. 2018; 63: 582-586Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar). Chu et al., 2018Chu K.H. Colditz J.B. Primack B.A. Shensa A. Allem J.P. Miller E. Cruz T.B. JUUL: Spreading online and offline.Journal of Adolescent Health. 2018; 63: 582-586Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar also reported that there were multiple instances of adolescents retweeting JUUL content from other adolescents as well as adults. Increased exposure to e-cigarette advertisements via multiple media channels such as the Internet, television, and retail increases the probability of use by adolescents (Mantey et al., 2016Mantey D.S. Cooper M.R. Clendennen S.L. Pasch K.E. Perry C.L. E-Cigarette Marketing Exposure Is Associated With E-Cigarette Use Among US Youth.Journal of Adolescent Health. 2016; 58: 686-690Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar). Moreover, exposure to advertisements via multiple social media sites such as Twitter, Instagram, YouTube, and Facebook increases the chances of e-cigarette use among adolescents (Camenga et al., 2018Camenga D. Gutierrez K.M. Kong G. Cavallo D. Simon P. Krishnan-Sarin S. E-cigarette advertising exposure in e-cigarette naïve adolescents and subsequent e-cigarette use: A longitudinal cohort study.Addictive Behaviors. 2018; 81: 78-83Crossref PubMed Scopus (42) Google Scholar). Because of the recent increase in e-cigarette use among adolescents, legislators have begun pushing for increased regulations surrounding vaping and the use of electronic cigarettes. As of July 1, 2019, only 20 states prohibit the use of e-cigarettes and vaping devices in smoke-free environments (American Nonsmokers’ Rights Foundation 2019American Nonsmokers’ Rights FoundationStates and municipalities with laws regulating use of electronic cigarettes.2019https://no-smoke.org/wp-content/uploads/pdf/ecigslaws.pdfGoogle Scholar). As of August 12, 2019, only 18 states have raised the minimum legal age to purchase tobacco products from 18 to 21 years. Many product manufacturers now clearly advertise the purchase age of 21 on their packaging and websites, but this does not deter many adolescent current and never users of e-cigarette from obtaining the products. Although these regulations will protect some from the effects of vapor exposure, the continuously changing e-cigarette product market warrants stricter laws surrounding the production, sale, packaging, and marketing of all products, including and related to e-cigarette use. Although e-cigarettes and vaping devices contain fewer toxic substances than traditional cigarettes, that does not mean they are without risk (Nguyen and Aamodt, 2018Nguyen D. Aamodt G. Electronic cigarettes the past, present and future.2018https://www.dentalcare.com/en-us/professional-education/ce-courses/ce451Google Scholar). The most notable effects of e-cigarette use can be found in the cardiovascular system, pulmonary system, neurological system, and oral health (Table 2). Nicotine and vaping are causes of several other ill effects on health.TABLE 2Health effects of vapingBody SystemEffectsCardiovascular systemElevated blood pressureElevated heart rateIncreased myocardial workloadIncreased risk of myocardial infarctionIncreased risk for coronary artery diseasePulmonary systemIncreased inflammatory effects that may lead to Bronchiolitis obliterans Hypersensitivity pneumonitis Acute respiratory distress Eosinophilic pneumonitis Lipoid pneumoniaNeurological systemNicotine addictionNicotine withdrawalAttention deficitsIncreased risk for psychiatric disordersIncreased risk for cognitive impairment later in lifeOral healthDry mouthDecreased taste sensationInflammation that may lead to Oral ulcerations Cellular mutations Oral cancerOtherNicotine poisoningBlast injuriesFiresBurns Open table in a new tab Vaping has been found to cause increased inflammatory effects that may lead to lung disorders such as bronchiolitis obliterans, hypersensitivity pneumonitis, acute respiratory distress, eosinophilic pneumonitis, and lipoid pneumonia (Kreiss et al., 2002Kreiss K. Gomaa A. Kullman G. Fedan K. Simoes E.J. Enright P.L. Clinical bronchiolitis obliterans in workers at a microwave-popcorn plant.The New England Journal of Medicine. 2002; 347: 330-338Crossref PubMed Scopus (339) Google Scholar; McCauley et al., 2012McCauley L. Markin C. Hosmer D. An unexpected consequence of electronic cigarette use.Chest. 2012; 141: 1110-1113Abstract Full Text Full Text PDF PubMed Scopus (170) Google Scholar; Sommerfeld et al., 2018Sommerfeld C.G. Weiner D.J. Nowalk A. Larkin A. Hypersensitivity pneumonitis and acute respiratory distress syndrome from e-cigarette use.Pediatrics. 2018; 141: 1-4Crossref Scopus (