Electronic cigarettes were the most used tobacco product among middle school and high school students in the U.S. during 2023, according to a report from the Centers for Disease Control and Prevention.

More than 2.1 million students reported current use of e-cigarettes, based on data from the 2023 National Youth Tobacco Survey. While the number of high school students using tobacco products declined nearly 4%, the CDC reported a 2.1% increase in tobacco use among middle school students.

Dr. Devika Rao, pediatric pulmonologist at Children’s Health and associate professor at UT Southwestern Medical Center, breaks down how e-cigarettes can be harmful to children. She also gives advice about how parents can talk to their children about vaping and lists informational resources to learn more about e-cigarettes.

Answers have been edited for style, length and clarity.

How can vaping affect a child’s health in the long term?

Unfortunately, we don't have any data on what the health effects of e-cigarette use in the long term are, especially on kids. We definitely have decades of research and medical evidence when it comes to combustible cigarettes but we just don't have that with e-cigarettes.

E-cigarettes came onto the market in 2007. They really exploded in popularity between 2017 and 2019. They really skyrocketed, to the point where 1 in 4 high schoolers were reporting use of e-cigarettes in 2019. Since then, we've had an overall drop in the number of adolescents that have reported use of e-cigarettes.

The most recent data suggests that there has been an increase in use of e-cigarettes in middle schoolers. As a medical community and as a scientific community, we're really starting to begin to understand some of the health effects of e-cigarettes, and we just don't have any long-term data for that reason.

Can you speak to how e-cigarettes can be harmful in general?

The harm of e-cigarettes on the lungs is definitely clear. A lot of the toxins present in the aerosol that e-cigarettes produce are harmful to the lungs. The aerosol in e-cigarettes contain many different harmful substances, including heavy metals like tin and lead and chromium and nickel. It also contains chemicals that are akin to substances found in antifreeze and even pesticides.

There are ultra-fine particles that are really tiny and penetrate deep into the lungs. We have medical evidence to suggest that all of these chemicals can actually cause cell death in the lungs. They can impair the lungs' natural ability to clear mucus and infection, predisposing kids to viral and bacterial infections. There are some studies that have been done both cross-sectional and retrospective that show that use of e-cigarettes in young people is associated with increased asthma problems.

In my clinical practice, I've seen the same where e-cigarettes seem to cause respiratory symptoms like coughing and wheezing and breathlessness. What I'm [also] seeing is that a lot of parents don't really know about their kids vaping, and they definitely don't know what to do when they find out. It can be a really difficult conversation to have with your child. I do recommend that parents begin a discussion about what their kids know about vaping pretty early on.

How do you recommend parents talk to their children about vaping?

I recommend that parents start with very open-ended, nonjudgmental questions. The one I like to start with is, "Hey, what do you know about vaping?" That can really open up a discussion. Does your child know what that is? And if they do, the follow-up question would be "Do you know about how it can be harmful to the body?"

A lot of kids tend to find out information about these substances and these devices on social media. There can be some misinformation that indicates e-cigarettes are not very harmful or less harmful than cigarettes. While it's true that e-cigarette aerosol contains a lower amount of substances and [carcinogens] that cause harm to the lungs, that doesn't mean that they're entirely safe. Especially for kids—they're absolutely not safe for kids.

You definitely want to make sure that your child is gaining the correct information from the internet. Great places to refer to [for] gaining knowledge about e-cigarettes and their harm: I always recommend the American Lung Association. The Truth Initiative is another great website that has a lot of information geared towards teens. Even the American Heart Association has good information, and then the American Academy of Pediatrics has a lot of great information about the harms of vaping.

What signs should parents watch out for that may indicate their child is vaping?

You want to be on the lookout for packaging that's been disposed of in garbage cans, or packaging that's kind of lying around the house. E-cigarettes come in various forms, shapes, sizes and colors. The most common type of e-cigarette device among young people are disposable e-cigarettes, and they come in boxes with colorful packaging and fruity flavors. If you see something like that discarded in your home, that can be a red flag.

Other things to look for would be a decrease in performance at school. Some kids who start vaping become addicted pretty quickly. The type of nicotine contained in these e-cigarettes is very potent, and adolescent brains are vulnerable to addiction. Use of one of these devices can actually predispose kids to addiction.

As they become more and more addicted, they want to use them more, and sometimes that can affect their performance in school. I've also seen e-cigarettes lead to poor sports performance. If your child is not performing as well in their activity and it's an abrupt change, then that can be a sign that they may be using an e-cigarette.