Youth Vaping and Associated Risk Behaviors — A Snapshot of Colorado

To the Editor:

In 2017, Colorado had the dubious distinction of leading the nation in the use of nicotine-containing vapor products (electronic cigarettes), or vaping, among young people under the age of 18 years. According to the national Youth Risk Behavior Survey (YRBS) for that year, one in four students in the 9th through 12th grades reported vaping, a rate that was twice the national average.¹ Nicotine affects the developing brain by increasing the risk of addiction, mood disorders, lowered impulse control, and cognitive impairment.² Furthermore, a 2018 report by the National Academies of Sciences, Engineering, and Medicine showed substantial evidence that youth who vape are more likely to later smoke cigarettes than are nonusers.³

In response, the Colorado Department of Public Health and Environment conducted analyses of a larger, state-specific youth survey. The Healthy Kids Colorado Survey is conducted every 2 years among separate, random samples of middle-school and high-school students, using methods that are consistent with those used in the YRBS.⁴ (Details about the methods that were used are provided in the Supplementary Appendix, available with the full text of this letter at NEJM.org.) For this analysis, the 2017 high-school sample was examined, with data from 47,146 students enrolled at 157 public high schools in the state (response rate, 59%). Among the students in all four grades, 27% reported the use of an electronic device for inhaling a vapor product other than marijuana during the past 30 days (as compared with 26% in 2015). Asian and black students had a lower prevalence of use (16.9% and 17.2%, respectively) than white (29.0%) or Hispanic (25.4%) students. The prevalence of vaping was 31.8% among gay, lesbian, or bisexual students and 26.8% among heterosexual students. The prevalence increased with grade, with 18.5% reporting use in 9th grade, 25.3% in 10th grade, 31.7% in 11th grade, and 33.6% in 12th grade.

Table 1. Table 1. Substance Use and Sexual Behavior among Colorado High-School Students, According to Use or Nonuse of Electronic Vapor Products, in 2017.

The students who were current vape users were more likely to use other substances or to engage in sexual activity than were nonusers (Table 1). These data corroborate a recent study that showed an association between vaping and risky sexual, substance-use, and violence behaviors.⁵ These associations are not causal but suggest that certain students are inclined toward a variety of risky behaviors.

On the basis of these data, the state of Colorado has created a health advisory recommending that health care providers screen all youth specifically for vaping, in addition to tobacco use, because young people may not necessarily associate tobacco with vaping. The advisory recommends counseling on the health effects of nicotine and referral to developmentally appropriate nicotine addiction treatment if needed. Free counseling has been made available through the Colorado QuitLine for children as young as 12 years of age who are attempting to quit any nicotine product. In addition, the advisory recommends screening patients for other high-risk behaviors, including alcohol, drugs, and risky sexual behaviors. If indicated, a vaping counseling session may offer opportunities to discuss contraception, preexposure prophylaxis for the prevention of HIV infection, and other substance-abuse prevention.

Tista S. Ghosh, M.D., M.P.H.
Rickey Tolliver, M.P.H.
Alison Reidmohr, B.A.
Michelle Lynch, B.A.
Colorado Department of Public Health and Environment, Denver, CO

This letter contains data from the Healthy Kids Colorado Survey, which is funded by four Colorado agencies: the Colorado Department of Education, Colorado Department of Public Health and Environment, Colorado Department of Human Services Office of Behavioral Health, and Colorado Department of Safety.

This letter was published on January 30, 2019, at NEJM.org.