Abstract
The United States has witnessed a growth in the prevalence of e-cigarette use among adolescents and young adults. The products are marketed in the country as safe alternatives to conventional tobacco products. Manufacturers claim that they are safe and can help smokers to quit the habit. However, researchers and other organizations, such as the U.S. Surgeon General, have indicated the potential for adverse health effects of e-cigarette. On the other hand, evidence is still inadequate to prove the actual impact. More research is critical to establish the actual prevalence and the health implications of e-cigarette marketing and use among the youth and young adults. The findings will inform interventions to reduce the incidence and protect the young people from the imminent epidemic.
E-cigarettes: Return of the Smoking Epidemic in Teenagers and Measures Needed to Prevent Another Tobacco Public Health Crisis
Introduction
Tobacco products are the leading cause of preventable diseases in the United States. The use has gradually decreased over the past 50 years due to continuing education of harmful health effects and public health opposition of tobacco products, such as combustible cigarettes (Walley et al. 1). However, recent rebranding and new products, including electronic cigarettes (e-cigarettes), have opened the door for a potential renormalization of a smoking culture, particularly by targeting the youth. Given the profound harmful health effects associated with tobacco use, the industry hypothetically needs to continue recruiting new and younger customers to replace those who become severely sick or gravely ill. Even though that is a point of contention between the government and the tobacco industry, it is evident that close to 90% of people who use tobacco products start before they turn 18 years old (Gentzke et al. 157). This trend is mostly maintained by nicotine, which is a known addictive chemical that causes dependence on tobacco users. Even with substantial public health efforts to reduce consumption of tobacco products, the industry is reintroducing a “positive” smoking culture with the advent of new products, such as e-cigarettes, which have become increasingly popular with the adolescent population.
Similar to traditional tobacco products in the past, misperceptions about the tobacco industry’s marketing and advertising strategies has yet again attracted youth users. The primary misconceptions are related to e-cigarettes, which are promoted as a less toxic tool that aids in smoking cessation but also a more socially acceptable form of smoking. In this literature review, there will be an overview of e-cigarettes with an emphasis on the impact on the youth population. Since current federal regulations are insufficient to protect youth from e-cigarette use, exposure, and nicotine addiction, there needs to be further research, education, and advocacy provided on behalf of the youth to achieve a healthy, tobacco-free lifestyle.
Background
What is E-Cigarette
E-cigarettes are battery-powered handheld devices designed to deliver emissions in the form of vapor for inhalation by heating a liquid solution. The products were initially designed to resemble conventional cigarettes, but e-cigarette technology is rapidly evolving. They have since transformed from their original design into second, third-generation products, and now even “pod-mod devices,” which resemble cigarettes and contain rechargeable batteries, heating elements, and refillable cartridges that can deliver higher concentrations of nicotine. “Pod mods” in particular have become increasing in popularity among adolescents (Mantey et al., 686). The primary appeal to these rechargeable devices is that they have replaceable cartridges that contain nicotine and copious flavoring options (Kuntawala et al. 774). A famous brand of “pod mods” is JUUL, which is a device that resembles a USB flash drive. As a result of JUUL’s small size and discreet appearance, the use of these devices may go mostly unnoticed in settings,such as schools.
The e-cigarette market has grown considerably in the last few years. The products entered the market in the United States in 2006, marketed as an alternative to traditional smoking. The products developed from cigar-like, which were an earlier generation of cigarette lookalikes. They later developed to modifiable tank-style e-cigarettes and then the sleek pods that are highly appealing to the youth (Fadus et al. 85). Various brands, such as Juul and Blu e-cig cartridge have been developed and popularized in the United States. The e-cigarette brands have emerged in the market in the last five years. For example, the manufacturer of Juul introduced it into the market in 2015. They have marketed their products aggressively to make them popular among the young audience. The product has become so popular among the young people that they have created the term “JUULing” as a synonym for “vaping” (Fadus et al. 85). Adolescents and young adults have created a social identity around e-cigarette smoking. The products have become highly socially acceptable among younger smokers.
Components of E-Cigarette
E-cigarettes have various ingredients, such as nicotine, solvents, and flavors that appeal to the youth and young adults. It contains a USB-shaped case that creates a shape highly appealing to adolescents and other youthful consumers. Juul is a small, rechargeable, battery-powered devices with e-liquid that contains “glycerol, propylene glycol, natural oils, extracts and flavors, nicotine, and benzoic acid” (Fadus et al. 85). Regardless of the apparent evidence that the products targets adolescents, the PAX Labs management (the company that manufacture Juul) has denied the claims. Regardless of their claims, they have created it in a shape that is targeted to this customer segment. They also market is on social media, which has a large number of youthful consumers. The trend has made it acceptable among the youth and young adults who no longer accept smoking of conventional cigarettes. Although there is still inadequate research on the adverse effects of e-cigarette, they potentially have a high risk of negative medical effects.
A majority of solutions in e-cigarette contain nicotine, but the concentration varies which may lead to accidental abuse, especially among teenagers. The concentrations usually range from none or nicotine-free up to 36 mg/mL, though it can be higher (Gorukanti et al. 65; Pepper et al. 600). Common nicotine concentrations of e-cigarette liquids range from 6-24 mg/l, usually 6 mg/ml increments. While some solutions may not have nicotine, others sold by companies, such as JUUL, are known to contain a much higher advertised nicotine concentration, equivalent to a pack of combustible cigarettes (Pepper et al. 600). Lastly, chemical analysis of nicotine levels is inconsistent with manufacturer’s package labeling as well as cartridges labeled nicotine-free have been found to contain nicotine (Kong et al. 1; Pepper et al. 600). Both inconsistent and mislabeled nicotine concentrations pose a significant risk for addiction, particularly among users that purchase nicotine-free cartridges that may contain nicotine after all.
Unlike conventional cigarettes, e-cigarettes can be sold in numerous flavors. More than 7,000 flavors are available, including candy, fruit, soda, and alcohol flavors (Pepper et al. 600). Another primary reason for increasing e-cigarette use in youth can likely be attributed to flavorings since such a manufacturing approach can increase the attractiveness of e-cigarettes, especially those who are not already smokers.
What they are used for
Electronic cigarettes were initially developed and retailed in 2003 in China, and shortly after were sold in the United States by 2006. When they entered the U.S. market, e-cigarettes were considered consumer products without government regulation. To start, they were produced by small businesses, but currently, tobacco companies have bought some of these companies and are developing these products (Vogel et al. 770; Gorukanti et al. 65). Furthermore, they are available both online as well as traditional retail outlets, which means adolescents have increased access to these products if they are not required to verify their age in the online platform.
The use of tobacco is one of the leading causes of preventable illness and death in the U.S. Unfortunately, most of the tobacco use in the country begins during adolescence and young adulthood. Almost 90% of the users of tobacco products start smoking before they are 18 years old (ATS 11). The trend in tobacco smoking has declined in the last two decades. Nevertheless, changes in the tobacco product landscape have been recorded because of the introduction of the electronic cigarette. The devices have changed the type of products that deliver nicotine (Kaisar et al. 67). From 2014, these products have become the standard mode of tobacco use in the country among middle and high school students in the country (Gentzke et al., 157). Although the use of e-cigarette could be useful to adults seeking to quit smoking, their use among young people could be detrimental to their health. The e-cigarette has nicotine and poses dangers just like conventional tobacco products.
Researchers have conducted a comprehensive investigation on the topic of e-cigarettes and their potential impact on the public, especially the adolescents. Studies have revealed a considerable growth of poly-tobacco marketing and smoking in the United States. The country experiences a significant issue of the “concurrent use of two or more products” (McQuoid, Keamy-Minor & Ling 1469; Gilreath et al. 184). Besides, users are addicted to nicotine, which explains the increasing prevalence of the use of multiple tobacco products. According to researchers, about 22% of young adults engage in poly-tobacco use (Villanti et al., 1346). Consequently, research has indicated the need to evaluate the factors leading to the negative use of tobacco products in the country. Most of the smokers are engaging in undesirable smoking behavior due to the need to create a smoker identity. The factor is useful for manufacturers and marketers to market tobacco products to young people who seek identity. It is a social factor that remains important in promoting negative behavior.
Initially, they were marketed as an “electronic atomizing cigarette” for those seeking to quit smoking as an alternative to combustible cigarettes and appeared similar to traditional cigarettes. The general idea was that they were safer to smoke and that an individual could control the level of nicotine concentration to decrease their dependence gradually until reaching abstinence. However, no e-cigarette products currently that have been approved by the Food and Drug Administration (FDA) for smoking cessation treatments (Walley et al. 5). In addition, recent studies have indicated that e-cigarettes have not achieved what continues to be their marketed goal of helping people quit smoking, but instead has shifted tobacco smokers to a less toxic product that they tend to use more often. This is due to many reasons, including the perceived idea that e-cigarettes are a safer alternative, less noxious, which translates to being more socially acceptable, and most importantly they have become popular in our culture.
Prevalence of Use Amongst Teens
Unfortunately, that trend in popular culture has recently translated into increased use of e-cigarettes in our adolescent population as well. Electronic cigarettes (e-cigarettes) have rapidly become the most common tobacco products used by youth and has even become an epidemic per the United States Surgeon General following the results of the 2018 National Youth Tobacco Survey. In 2011, e-cigarettes were first added to the National Youth Tobacco Survey (NYTS) on tobacco-product use, and since 2014, they have been the most frequently used tobacco products by youth. In the past few years, with the advent of social media influence and development of user-friendly and disguisable pod-devices, e-cigarette use has drastically increased among teenagers. Furthermore, many questions arise indicating that the national tobacco-usage surveys do not adequately capture the full-spectrum of e-cigarette use because questions do not have commonly recognized terms used by the youth when describing them, such as “JUULing” or “dripping.”
Furthermore, various categories of youth are most at the risk group for using e-cigarette. Male teenagers are at higher risk than their female counterparts to begin using e-cigarettes (Barrington-Trimis et al.1). The issue of marketing of e-cigarette has created a public crisis in the United States because it has encouraged young people, including high school students, to buy and use them. For example, between 2014 and 2016, the marketing information in the sector targeted middle and high school students (Marynak et al. 299). Consequently, the products are performing considerably well in the market. Research evidence reveals an increase in the use of e-cigarette among young people. Marketers, intentionally and unintentionally target adolescents and other young consumers through packaging and branding. Besides the sleek design, the product has various characteristics that are appealing to the youth, including a secure charging system and liquid-filled cartridge with attractive flavors, such as mint, crème, brulee, and fruit medley. Consequently, they are being used in various settings by adolescents, including school and parties. Hence, the possible health risks of the cigarette place many users at high risk.
Even though e-cigarettes are less toxic than traditional cigarettes, they provide a relatively new way to deliver nicotine without burning tobacco. Hence, this raises substantial public health concerns because nicotine is available in many of the e-cigarette products. Besides, adolescents who use e-cigarette may as well use combustible tobacco products. This has the potential to revert the decades of progress the country has made in decreasing tobacco product use among adolescents. Although many reasons for the increased spiked popularity are available, a significant effort through targeted marketing on unregulated social media platforms by e-cigarette and tobacco companies has potentially reintroduced a positive smoking culture to our youth.
E-Cigarette Crisis in the U.S.
The smoking of e-cigarette in the country is a significant problem due to the increased prevalence and use among adolescents. Research conducted in recent years reveals that 11.3% of students in high school had used e-cigarette in the past 30 days in 2016 (Hammond et al. 2). Many young people are consuming the products because they are marketed as safe for consumers. They are perceived as harmless and are availed in attractive flavors that entice the youth. Marketers focus on the benefits of the product and ignore the downside of e-cigarettes. Experts have argued that the e-cigarette is not discouraging people from smoking. In fact, it is a motivator of the harmful habit. Research shows a high risk of traditional smoking due to e-cigarette smoking (see appendix 2). In 2017, an investigation was conducted that revealed the danger of beginning smoking among non-smokers due to the use of Juul. The study showed that such people have a high risk of smoking the e-cigarette (Huang et al. 146). The product causes a serious challenge to society because it entices people based on the ease of use. Even individuals without prior experience or knowledge can smoke it easily.
The e-cigarette is a cause for concern among adolescents, especially those in high school. Companies manufacturing these products have denied that they explicitly target the youth. However, the sleek and attractive look has made it highly popular among this audience. For example, Juul is small, discreet, and closely looks like a USB drive. As a result, the user can conceal it and use it in different places, including in the classroom. School leaders and teachers have affirmed that the use of e-cigarette has become prevalent in schools to the extent that the management has banned USB in schools to prevent the use of the e-cigarette. Regardless of the effort, their use has grown in school, causing a public health crisis in the country.
Factors Contributing to Increased Use/Smoking Initiation
Many factors that can be attributed to smoking initiation are evident, but the most critical aspect for predicting smoking is actually youth’s attitudes toward smoking (Pepper et al. 603). The absence of a firm decision not to smoke was the strongest predictor of experimentation. Several factors that can influence attitudes are family, peer influence, age, misperceptions, and marketing.
The presence of smokers among individual’s family or friends is associated with less negative attitudes towards smoking and serves as a significant predictor for smoking during adolescence (Farber and Folan 11; Walley et al. 7). Refusing a cigarette in a situation where there is social pressure is challenging for many adolescents. Adolescents tend to overestimate the frequency of smoking among their peers and among adults as well as underestimating their smoking habits (Pepper et al. 603; Jenssen et al. 3). This, in particular, maybe a critical factor that when it comes to a teenager considering smoking an e-cigarette in a socially pressured situation.
Although the direct advertising of tobacco to youth has been banned in the United States since 1998, the federal government has not yet implemented similar regulations of e-cigarette advertising. Even with concerns raised about the appearance of these devices in entertainment events and social media, no laws have been set in place. Taking all these aspects into consideration, indirect marketing efforts and positive images of cigarette use in the media continue to have important effects on teenage smoking behavior. Many advertisements use images, videos, or other techniques to suggest that smoking is associated with good health, thinness, and social acceptance.
Marketing E-Cigarettes as Safe Alternatives
E-cigarette marketers have always taken advantage of the social aspect of smoking. The factor leads to a high rate of marketing of the products to people seeking social excitement, such as the youth. As a result, e-cigarette marketers capitalize on this fact to sell their products to young people, including adolescents. Manufacturers have created the electronic nicotine delivery system devices (ENDS) that are highly appealing and attractive to the young users (McQuoid, Keamy-Minor, and Ling 1470). Marketers are using their attractive aspects to promote the social identity culture in the country. Appendix 1 shows the high rate of teen exposure to cigarette adverts. An excellent example of such promotion is the capability to perform vape tricks using social media that attracts the youth. The tricks pose a high risk of initiation by non-smokers because of the attractive effect (Kong et al., 1; Pepper, et al. 599). Unfortunately, the products are marketed as being safer compared to conventional tobacco products and that they do not have any adverse health effects (Walley et al. 1). Therefore, they have become commonly used by youth who do not perceive them as harmful to their health.
Although controversy affects the marketing of e-cigarettes in the country, manufacturers and marketers are committed to increasing their revenue and profitability. The marketers have made concerted efforts to appeal to the target clientele. Branding has played a critical role in the situation because of the marketing power. Brand managers communicate with their target audience to create customer loyalty. They promote and sell their products, ignoring the potential danger they pose to the consumers. Marketing has led to the high popularity of e-cigarette in the market. The targeted marketing used by their manufacturers to the youthful consumer segment leads to essential questions regarding ethical advertising in the e-cigarette market.
Many marketers sometimes use misleading information to attract consumers to their products. Critics of e-cigarette have challenged the marketers for promoting their products as harmless alternatives to conventional smoking. As a result, the young people, not necessarily those trying to quit smoking, become attracted and later addicted to the new forms of cigarettes. The manufacturer of Juul has exposed the content of their product. It has an internal, regulated means of heating to create the vapor inhaled by the users. The use of this heating mechanism is suggested to be safer for the user compared to traditional smoking products. Besides, the brand managers claim that Juul is easy to use because it does not have any controlling or adjusting settings. It only has e-liquid, which the user heats to generate vapor (Huang et al. 146). While the information is vital for the consumers to decide their consumption, the management fails to consider the impact of the marketing strategy on adolescents and youthful users.
Adverse Health Effects
Individuals and organizations approach the products differently, which create the meaning and understanding of their effects on the health of the users. For instance, the Food and Drug Association tries to restrain marketing and distribution due to the potential detrimental effects. In addition, the Consumer Advocates for Smoke-free Alternatives Association (CASAA) has been created in the country to deal with the debate over smoking and the safety of the emerging cigarette products (Annechino and Antin 106). While the controversy continues, manufacturers and marketers should understand the impact of the products they are marketing to the youth. Companies continue to conceal the actual detrimental effects of the e-cigarette among the youth. Although no concrete evidence of the damaging components of e-cigarette is available, they may contain carcinogens and other harmful ingredients.
Regardless of the continued promotion of e-cigarettes as alternatives to the conventional cigarette, medical experts have warned about their potentially detrimental effects on smokers. Some claim that their effects are worse than those caused by the traditional cigarette. The public health has been struggling to address the potential impact of the changes in the tobacco industry in the country. Though traditional tobacco products cause health challenges, e-cigarettes are worse due to their health-related problems. Notably, both adolescents and young adults experience these effects because they are the leading users (de Andrade et al. 1). The product has a high level of nicotine content. For example, in Juul, the e-liquid is 5% percent nicotine. Another product, Blu e-cig cartridge, is 2.4% in nicotine content. The nicotine content in a single pod is equivalent to the content in a packet of the conventional cigarette. The high level of the nicotine content in these products places users at a high risk of addiction. In fact, they are more addictive compared to alcohol and barbiturates. The risk is too high because the young consumers use more than one pod at once, which exposes them to a high amount of nicotine.
Marketers claim that e-cigarette is safer for users compared to conventional tobacco products. However, medical experts have revealed contrary evidence concerning the use of these innovative smoking devices. The nicotine contained in the devices is as addictive as the one in the traditional cigarettes. Possibly, a very high number of young people is hooked up to the product. Besides the addiction, clinical professionals suggest other possible negative effects of the smoking device, including health effects. The inhaling of nicotine is associated with brain impairment and impact on lung development in young consumers. Previous studies focusing on brain imaging conducted on adolescents have shown that nicotine affects region of the human brain that controls decision-making and cognitive development. It causes an impact on the brain’s prefrontal cortex that leads to a higher risk of addiction to other substances and impulsivity. Therefore, the products marketed as safe alternatives to smoking have a worse effect.
Methodology
The research is a secondary review of literature on the negative effect of e-cigarette on adolescents, the imminent epidemic, and potential solutions. The articles for analysis are drawn from online databases, including Google Scholar and EBSCOhost, to locate relevant sources for the study. The review also used reliable online sources and websites with accurate data and statistics on the extent of the problem of e-cigarette in the United States. The search located 25 sources that provided data and information to create the research report.
Results
The results of the study reveal critical ethical challenges surrounding the consumption of e-cigarette. Statistical evidence shows a problematic prevalence of e-cigarette use in the country. About one in four high school students in the United States and one in 14 students in middle school had used the e-cigarette in 2018 (Gentzke et al. 167; Mantey et al., 689). The current use of the products has increased. The U.S. Surgeon General approximated that about 1.5 million additional young people have used the product in 2018, from 2.1 million in 2017 to 3.6 million in 2018 (Gentzke et al. 168). The social tendencies have caused a growth in the use of e-cigarettes in the United States. Among American adolescents and young adults, the growth has been considerable in recent years. In 2011, only 1.5% of high school-aged adolescents had consumed the product. By 2018, the percentage had increased to 20.8% (Barker et al. 1). Similar growth in the rate of e-cigarette use has been noted outside the United States. In Canada, by 2015, 25.7% and 6.3% of Canadian young people between the ages of 15 and 19 years were reported to have ever and used e-cigarette in the past 30 days, respectively (Cole et al., 1). Nevertheless, there has not been any much change in the use of conventional tobacco products in the country in the recent past. The findings are consistent with acknowledgement that the youth are more likely to take e-cigarette than conventional tobacco products (see appendix 3). The same chart shows that more boys than girls are using e-cigarette. The increased use of e-cigarette has masked the positive changes in the area of tobacco use in the country and the related adverse effects.
Self-reports have also revealed the high rate of e-cigarette use among the youth in the country. A longitudinal study indicated that adolescents continued to use the product 12 months after the initial data collection process. The percentage of daily smokers of the product increased from 14.5% to 29.8% during the follow-up period (Vogel et al. 774). The patterns of e-cigarette use show a severe problem in the country affecting the youth. The results also confirm the issue of addiction among young people from the nicotine contained in the e-cigarette. The trend also indicates that the prevalence of the products leads to frequent use, dependence, and increased exposure to nicotine, a highly addictive component of the e-cigarette. The problem has become an almost epidemic in the United States because the trend might continue to increase with time. The increase from 14.5% to 29.8% in 12 months reveals the seriousness of the problem in the country.
A few studies have explored the knowledge and attitudes of adolescents toward e-cigarette in the United States. However, some researchers have considered their attitudes and knowledge regarding various aspects of e-cigarette, including “ingredients, addictive properties, safety, perceived prevalence, acceptability, and regulation (including taxation, age requirements, and price regulation)” (Gorukanti et al. 7). The study involved 9th and 12th graders who revealed positive attitude towards the product. Besides, they perceived the products less risky to their health compared to traditional cigarettes. They also had less support for the current policies implemented to address the issue of e-cigarette. They have revealed a high prevalence of their use, similar to the national prevalence of 27.4%. The results of the study show the fact that adolescents are most likely to continue consuming cigarettes because they consider them safer compared to conventional cigarettes.
Various studies have investigated the association between perceived prevalence, initiation, and acceptability of adolescents regarding the consumption of traditional cigarettes and compared the findings to those of e-cigarette. The results are consistent with the behavioral decision-making model, which relates behavior to the risk perception in an individual (Gorukanti et al. 7). Therefore, if individuals do not perceive high risk in the use of e-cigarette, they are at a high risk of initiating their use. Since youth do not view e-cigarette as dangerous, their perspective increases the risk of initiation and subsequent use (Soneji et al., 791). The study revealed a risk of starting tobacco smoking following experimentation with e-cigarette. Therefore, the findings counter the marketing slogan that they are suitable for people determined to quit smoking.
Some of the studies consulted in the paper indicate the potential of adverse effects on the health of e-cigarette smokers. Marketers commonly focus on the ingredients, such as nicotine, flavors, and humectants (propylene glycol and/or vegetable glycerin). However, investigations into the products have revealed other harmful components, such as toxicants, ultrafine particles, and carcinogens (Walley et al. 1). The elements have the potential to affect the health of consumers negatively. However, some critics suggest that the detrimental effect of e-cigarette as proposed by organizations such as the U.S. Surgeon General is not supported by research evidence (Polosa et al. 61). Generally, adequate evidence to support the health implications of e-cigarette is missing, creating the need for continued monitoring of potential changes in the patterns of use and the effect on the health of users. The gaps call for more research to establish the actual impact of e-cigarette to reduce the risk of an epidemic among adolescents and young adults.
Prevention
Research indicates that identification of the susceptibility of youth to e-cigarette smoking is critical to implement strategies to curtain the impending public health crisis. Adapting two susceptibility items to the identification of at-risk adolescents for the future use of tobacco devices is critical to solving the problem (Bold et al. 142). Interventions should focus on at-risks youth to create effective interventions. Besides, policymakers should draw essential lessons from the Surgeon General’s result of a public health “epidemic” to address the problem and save the lives of the young people in the country (Jenssen and Boykan 30). Research is necessary to establish the possible impact of initiatives similar to tobacco control policy, such as advertising restrictions, banning flavors, Tobacco 21, and clean indoor air laws, in eliminating the looming crisis in the country. Since the e-cigarette crisis is new, more research is critical to establish the actual impact of the problem and the effective strategies to control their use among the youth.
The country might require a comprehensive tobacco prevention program targeted to the youth to protect the public from the detrimental effects of e-cigarette. Such a plan should focus on information; for example, regulating youth-oriented advertisement. The government can ban the use of youthful models when marketing e-cigarette (Marynak et al. 299). The strategy will discourage the youth from experimenting with the sleek product. They can also limit the age of access to e-cigarette in the market, such as to 21 years. Legal enforcements will prevent marketers and retailers from targeting adolescents with the product. Finally, behavior change campaigns are critical in the country to control the marketing and use of e-cigarette. More research is essential to understand other effective measures to prevent the problem from escalating to an epidemic.
Conclusion
The research reveals an increase in the marketing and use of e-cigarette in the United States. Experts also observe that the products have become highly popular among the youth in the country, including adolescents. Although the products are marketed as safe alternatives to the traditional cigarette, they have significant risks on the health and wellbeing of young users. The products are high in nicotine content, which places them at the risk of addiction, just like or even worse than the conventional tobacco products. Besides, they cause the risk of impulsivity by damaging the part of the brain responsible for decision-making and cognitive development. Unfortunately, the young brains are still developing, and the damage might affect their psychological and behavioral outcomes. The country risks an e-cigarette crisis because of the growth in the number of adolescents becoming addicted to the sleek nicotine delivery devices. Policy-makers in healthcare and the government should collaborate to develop practical solutions to avert the impending epidemic in the country.
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