Anna Carey, 16, spoke at a roundtable discussion about e-cigarettes and vaping on Friday, Dec. 6, 2019, at the UNT Health Science Center. Anna was an invited guest of U.S. Sen. John Cornyn and was joined by Fort Worth Mayor Betsy Price, Karen Schultz, M.D., medical director of Pulmonology at Cook Children's, UNT President Michael Williams and others. Anna made quite an impact. We were so impressed with Anna, we asked her to tell her story. 

My name is Anna Carey, and I am 16 years old. I was hospitalized at Cook Children’s for five days because of vaping and dabbing.

I used to play volleyball and tennis, but now I will never be able to play sports again. I started vaping when I was a freshman in high school with a Vuse Vibe that I got from a senior. I switched to the Juul a few months later just because it was “cooler” than the vibe.

I got caught by my parents too many times to count my freshman year, but I never stopped vaping. The summer going into my sophomore year, I stopped because I had no one to buy pods for me. When school started back up in the fall, I started vaping again. This time, seniors would buy pods for me.

Honestly, anyone who is over 18 would buy for me. It really was not hard at all. Around November of my sophomore year, I started to use THC carts, and I began selling pods and carts to my whole school.

I was known for vaping, and it became my entire reputation. We even had a talent show, and my friends and I were called “The Starter Pack” (which is what Juul calls their packages), and my shirt said “salesman.”

Halfway through the year, I switched to Njoy because it was way cheaper than Juul. I lost a lot of friends from middle school because of this, and a relationship ended because of vaping and dabbing. But I didn’t care. Nothing could make me stop. Not even the random pains in my chest when I would use my dab pen, which I mostly ignored.

I feel like I got the entire freshman class addicted to vaping. This past summer, my mom found all of my vapes and dab pens and threw them all away. Since I had been having some pains and lost some friendships, I decided it was time to quit dabbing. But I didn’t stop vaping.

On the first day of school of my junior year, so many people came up to me asking to buy for them, but I was done selling. The guilt of causing all of these addictions had become too much, and I could not escape my reputation at the school.

I left school and became homeschooled, but now I could use my njoy all day. My siblings bought the pods for me because I would get so angry if I did not have pods, and the withdrawals were not worth quitting to me. I saw the news of people dying or getting hospitalized, and I still didn’t care. Literally, nothing would make me stop. I would say things like, “I guess I’m going to vape more” or “I’m not going to stop until I’m hooked up.”

After about two months of me stopping dabbing, I decided to start again because “why not?” I was completely broke, but every penny would go toward vaping and dabbing. I had a system created in my head. I knew I needed $10 every four days because I would go through two njoy pods in about three to four days. I also needed $35 every two weeks for two carts because one THC cartridge would last me one week.

About one month before I was hospitalized, I went to the doctors and got an X-ray on my lungs, and it came back clear. They gave me an inhaler and told me to stop vaping, but I didn’t listen. The pain was insignificant to me since the X-ray came back clear, and I barely used the inhaler.

Then, one day, I was cleaning my room, and all of a sudden, a wave of exhaustion hit me. I was completely drained of all my energy and laid in bed for two days. I had the most awful pain when I breathed and moved, I honestly thought I broke a rib somehow. The day the pain started, I stopped using my THC carts and cut back on my vaping to about three hits a day just to feed my addiction.

I had the worst aches of my life. We still don’t know if that was from withdrawing or the disease, but the pains lasted a week and a half.

I completely lost my appetite and couldn’t eat anything but a piece of fruit a day. About two days after the pain started, we decided to go to Cook Children’s. We waited in the waiting room while I cried my eyes out because of the pain. They did an X-ray on my lungs and an EKG, and it all came back clear. They sent me home, just as I came, and I laid in bed for the rest of the week, just hoping that the pain would go away with time.

Six days from when the pain started, I decided to go to a basketball game with my friend. We had to go up and down stairs where I had to take breaks every couple of minutes so I could catch my breath. It felt like I was running a marathon, even though I just went up a small hill.

The next day we decided to go to urgent care. Still, they couldn’t find anything wrong with me, so they sent me to the local emergency room and did an X-ray where they found that I had pneumonia.

They immediately sent me in an ambulance to Cook Children’s, where they diagnosed me with chemical pneumonia. I was placed on oxygen and monitoring, and it was the worst pain I have ever felt in my entire life. I could not move without gasping for air, my chest constantly ached, and every time I breathed, a sharp pain went through my entire chest. I felt completely helpless.

The scariest part of this whole situation was how little everyone still knows about this disease or how dangerous vaping is for kids. The doctors didn’t know if I would be OK or how much my lungs would heal or anything. The unknown was definitely not worth the vaping at all. I think I needed to be hospitalized to stop vaping, and I think there is a lot of other people who are the same way. It’s hard for a news article to really make a change with a teenager, and I think the only way to end this, is to end vaping.

I caused so many people to be addicted to this. Now I need to help them stop.

Related To This Topic:

• What Parents Need to Know About E-Cigarettes and Vaping
• Why Doctors Believe Vaping Landed 17 Year Old In ICU
• Tobaccoa Use Increases by More than 38% Among High School Students
• Juul, Other E-Cigarettes Called an 'Epidemic' By FDA Chief
• E-Cigarettes Expose Teens to Cancer-Causing Chemicals, Future Cigarette Smoking

It's hard to turn on the news and not see a story about the dangers of e-cigarettes or vaping. 

As of Aug. 28, 2019, there have been nearly 200 reported incidents of vaping-related illness in 22 states, resulting in at least one death. 

Earlier this summer, 17-year-old Tryston spent 18 days in Cook Children's ICU, needing machines to keep him alive. He lost 30 pounds, and had to re-learn to walk normally again because he had no muscle mass in his legs anymore from being bedridden for almost three weeks. He is still coughing at times and feels tired. A clear answer for why his lungs failed him was never found, but doctors believe it was because of his vaping.  

“We don't know for sure. But there are literature reports of hypersensitivity pneumonitis from vaping. I told him no inhaling anything again, ever. We still don't know for sure what the trigger was. But it is very plausible that it could be due to his vaping,” Suzanne Whitworth, M.D., medical director of Infectious Disease at Cook Children's said.

Tryston was one of a growing number of teens who are vaping. Statistics show 45% of U.S. teens have tried it. 

While the Centers for Disease Control and Prevention (CDC) says E-Cigarettes may have the potential to benefit adult smokers if used as a complete substitute for regular cigarettes and other smokeless tobacco products, they are not safe for youth, young adults, pregnant women or adults who are currently using tobacco products. 

The CDC adds there is "a lot to learn about whether e-cigarettes are effective for quiting smoking" and "if you've never smoked or used other tobacco products or e-cigarettes, don't start."

Diane Arnaout, M.D., a Cook Children's pediatrician in Fort Worth, wrote the first story about Tryston. He was her patient and he asked Dr. Arnaout to get the word out about the potential dangers of vaping. 

"And though they claim to be a “healthier option” to regular cigarettes, I beg to differ. Inhaling chemicals is inhaling chemicals. There are over 40 different chemicals in vaping liquids. And they can cause some major damage," Dr. Arnaout wrote. "They can hurt delicate lung tissue. We are seeing more and more reports of teenagers and young adults suffering severe lung injuries and seizures coming out in the news lately.

"I’m really worried about how addictive these things are. Kids who want to quit are finding it more difficult to do so than if they’d smoked a pack a day."

Don Wilson, M.D., an endocrinologist at Cook Children's, has been speaking out about the dangers of e-cigarettes for quite some time. Dr. Wilson, who is an an Endowed Chair of Cardiovascular Health and Risk Prevention, offers this basic information for parents:

More On This Topic:

• Why Doctors Believe Vaping Landed 17 Year Old In ICU
• Surgeon General’s Advisory on E-cigarette Use Among Youth
  • Download pdf icon[PDF–572 KB]external icon
• E-cigarettes Shaped Like Flash Drives: Information for Parents, Educators, and Health Care Providers
• Teachers and Parents: That USB Stick Might Be an E-cigarette
• E-cigarettes.surgeongeneral.govexternal icon
  • Information from the Surgeon General on the risks of e-cigarettes for young people, and includes free tools such as a parent tip sheet for talking to teens about e-cigarettespdf iconexternal icon [PDF – 5.2MB].
• Teen.smokefree.govexternal icon
  • Information for teens who use tobacco products, including tips on how to quit.
• Electronic Cigarettes
  • Basic information about e-cigarettes from CDC’s Office on Smoking and Health.

Earlier this summer, my 17-year-old patient Tryston just wasn’t feeling like himself.

“I was tired all the time. My energy was low. I was losing some weight.”

Then, things quickly turned downhill. He started having chills. He was feeling really exhausted all the time, was nauseous, and had some fevers.

When he started becoming short of breath and having some chest pain, he and his mother decided it was time to head to an urgent care clinic, where he was given antibiotics and flu medications.

In 24 hours, he felt worse. His breathing became more difficult. Something was definitely wrong.

He came to Cook Children’s, and the doctors and nurses quickly realized what poor shape he was in. X-rays showed something that looked like pneumonia on both sides of his chest. But the specialists were confused, because it just wasn’t obvious.

Within 48 hours however, what WAS obvious was that Tryston was getting worse.

As his Cook Children’s pediatrician, I was sent daily updates about him. I found myself holding my breath every time I opened the update – and audibly gasped the moment I realized that he was intubated.

This means a tube was stuck down into his windpipe to breathe for him.

And the tube stayed there for the next 10 days. Machines were keeping Tryston alive. He was in the ICU, where the sickest children in the hospital stay.

“I lost a lot of sleep over this kid,” said Mary Suzanne Whitworth, M.D., medical director of Infectious Diseases at Cook Children’s. Dr. Whitworth wasn’t sure what was going on, and became very close with the family.

Was it an infection? No organism seemed to grow from cultures. Was it an autoimmune disease? The rheumatologists didn’t think so.

Even a lung biopsy – a piece of his lung which was cut out and examined under a microscope – didn’t seem to hold any clear and obvious clue as to why he was so sick. His lungs just failed, and he was in something called respiratory distress.

He was put on numerous antibiotics and antifungal medications to see if they’d help. He was needing more and more oxygen. He even needed special high-frequency ventilations (think little tiny rapid puffs of air) to keep his lungs open and working.

There’s one thing I haven’t mentioned yet. The one thing that was in the back of everyone’s minds.

One thing that Tryston mentioned to the staff of Cook Children’s before he got very ill is something I already knew, and had talked to him about the year prior.

Tryston liked to vape.

Most of you have heard about “vaping” in some way or another, but if you haven’t watched the news lately (or been in my office lately - because jeez, I am hearing more and more about it daily), “vaping” is when someone smokes an aerosolized chemical, usually from something called an e-cigarette.

Vaping is becoming VERY popular amongst teenagers. Statistics show 45% of U.S. teens have tried it. The Centers for Disease Control and Prevention is now investigating the "sudden emergence of severe lung disease linked to vaping in 14 states. Ninety-four possible cases of severe lung illness associated with vaping have been reported from the end of June to Aug. 15, the CDC reports.

Corwin Warmink, M.D., the medical director of Emergency Services at Cook Children’s, says he has seen multiple patients come through the ER and his team sees a child every week for vaping. But it’s not just teens, we are also seeing younger children, 5 and under, who have ingested vaping liquid. Scary stuff.

The most popular types look like USB devices. They’re super easy to hide. They have different “fun flavors” like mango, crème brulee and fruit medley. Some of the devices are even cute, with teddy bears on them.

They are more addictive than cigarettes. One Juul pod (currently the most popular brand) has the same amount of nicotine as an entire pack of cigarettes! “And I know lots of kids smoking 2 or 3 pods a week,” Tryston told me.

And though they claim to be a “healthier option” to regular cigarettes, I beg to differ. Inhaling chemicals is inhaling chemicals. There are over 40 different chemicals in vaping liquids. And they can cause some major damage.

They can hurt delicate lung tissue. We are seeing more and more reports of teenagers and young adults suffering severe lung injuries and seizures coming out in the news lately.

I’m really worried about how addictive these things are. Kids who want to quit are finding it more difficult to do so than if they’d smoked a pack a day.

Want to know why you should quit?

Tryston spent 18 days at Cook Children’s.

He lost almost 30 pounds. He is re-learning how to walk normally again. He has no muscle mass in his legs anymore from being bedridden for almost three weeks. He is still coughing at times. He feels very tired.

A clear answer for why his lungs failed him was never found.

“We don't know for sure. But there are literature reports of hypersensitivity pneumonitis from vaping. I told him no inhaling anything again, ever. We still don't know for sure what the trigger was. But it is very plausible that it could be due to his vaping,” Dr. Whitworth said.

The general consensus was that his lungs were severely injured, and I believe his vaping habits had a lot to do with it.

Two days after going home, he walked into my office for a follow-up visit. We had a very real, very brutal heart-to-heart.

I said, “Tryston, buddy…you know you could have died, right?” and he looked me in the eye and said “I’ll never touch the stuff again, Dr. Diane. And I want everyone to know that. I want to tell my story. And if I can just keep one kid from going through what I did, it’ll all be worth it.”

So here I am, telling you his story. Tryston is a great kid with a great heart. He made a mistake, one that LOTS of kids are making, because they assume e-cigarettes are “healthier” than regular cigarettes.

And Tryston wants us all to learn from it. Do me a favor and do what he has asked: print this out, and give it to your teenage son or daughter. Ask them to read it.

Let them know it’s just not worth it.

Learn More About This Topic:

• Vaping, Juuling, Dabbing (AAP Environmental Health) - Source for statistics in article
• New York Times: Dozens of Young People Hospitalized for Breathing and Lung Problems After Vaping
• Huffington Post: CDC Launches Probe Into Surge of Severe Lung Disease Cases Linked To Vaping
• Juul, Other E-Cigarettes Called an 'Epidemic' By FDA Chief
• E-Cigarettes Exposes Teens to Cancer-Causing Chemicals, Future Cigarette Smoking
• Adding flavors to e-cigarette liquids changes chemistry, creates irritants (Duke University)
• Tobacco Use Increases By More Than 38 Percent Among High School Students

That's the question CNN recently asked, based on a question from a substance abuse counselor. 

Research from Truth Initiative shows that 25 percent of 15- to 24-year-old JUUL users refer to their behavior as “JUULING.”

The Juul e-cigarettes closely resemble flash drives. So much so that some schools have banned flash drives from their campuses. The vapor cloud from the Juul is "so small and dissapates so quickly that teachers are usually none the wiser," 16-year-old student told CNN.

Scott Gottlieb, the Food and Drug Administrator Commissioner, called teenage vaping an "epidemic" and announced his group would work to stop retailers from selling e-cigarettes to minors and warned of a possible ban on flavored e-cigarette liquids.

The scary part is that kids may not even be aware of what they are inhaling when they JUUL.

The nicotine cartridge inserted into the Juul gives about 200 puffs, about as much nicotine as a pack of cigarettes, according to the product's website. In five weeks, that's about 100 cigarettes.

In a survey of 1,018 15- to 24-year olds, the Truth Initiative found that 37 percent of teens were uncertain if they were inhaling nicotine, even though it states on the JUUL website that each pods is equal to 200 cigarette puffs, the equivalent of a pack a day.

The Boston Globe calls Juuling “the most widespread phenomenon you’ve never heard of.”

While you may not know about this form of vaping, there’s a good bet your kids have.

“Juuling in the bathroom” has become so widespread among young people, some school administrators are warning parents about the dangers of e-cigarettes, including the brand called Juul.

BuzzFeedNews describes the Juul as a “portable nicotine-delivery device” designed to mimic the physical and sensory experience of a cigarette, without looking like one.

Men’s Fitness magazine described the Juul as the “iPhone of E-Cigs.” The author of the story said he asked a dozen people to guess what the Juul was, and all of them guessed a USB stick.

The fact that it delivers nicotine designed to mimic the experience of a cigarette, but doesn’t look like one, makes the Juul popular among teens.

BuzzFeed estimates over 50,000 posts under the hashtag #Juul on Instagram alone.

Juul is still too new to have any data specific to its risk as a product, but recent research has shown the dangers of teens vaping. But researchers from the University of California, San Francisco challenge the idea that e-cigarette vapor is safe. They found that teens who use e-cigarettes are in danger of inhaling cancer-causing chemicals, especially in fruit flavors.

“The presence of harmful ingredients in e-cigarette vapor has been established; we can now say that these chemicals are found in the body of human adolescents who use these products,” authors wrote.

The UC San Francisco researchers found that adolescents who smoke e-cigarettes expose themselves to a high levels of the potentially cancer-causing chemicals also found in tobacco cigarettes, even when the e-cigarettes do not contain nicotine.

"Teenagers need to be warned that the vapor produced by e-cigarettes is not harmless water vapor, but actually contains some of the same toxic chemicals found in smoke from traditional cigarettes," said lead author Mark L. Rubinstein, MD, a professor of pediatrics at UCSF. "Teenagers should be inhaling air, not products with toxins in them."

This was the first known study to report on the potentially cancer-causing compounds in the bodies of adolescents use e-cigarettes, according to UCSF. The lists of compounds include acrylonitrile, acrolein, propylene oxide, acrylamide and crotonaldehyde.

Another study from the same institution and also published in Pediatrics found that “e-cigarette use is more likely to encourage youth smoking than to divert youth from smoking.”

The team found those who had ever used e-cigarettes were significantly more likely than never users to have smoked at least 100 cigarettes at follow-up, have smoked during the past 30 days or both.

To learn more about e-cigarettes, we talked to Don Wilson, M.D., an endocrinologist and an Endowed Chair of Cardiovascular Health and Risk Prevention at Cook Children’s.

What do e-cigarettes do?

E-cigarettes are designed to simulate the act of smoking and deliver nicotine without the toxic chemicals produced by burning tobacco. The use of nicotine, however, is highly addictive. Recent research suggested nicotine exposure may also cause the brain to become addicted to other substances. Vapor from some e-cigarettes has also been shown to contain known cancer producing and toxic chemicals, such as diethylene glycol and nitrosamines, as well as small particles of toxic metals. Although not well studied, there is the potential for second hand exposure by others in the environment.

How do e-cigarettes work?

E-cigarettes are smokeless, battery operated devices designed to deliver nicotine mixed with a variety of flavorings (fruit, mint, chocolate, etc.) and other chemicals via an inhaled aerosol. They typically resemble regular tobacco cigarettes, cigars, pipes or everyday items like pins or USB memory sticks.

Most e-cigarettes generally contain three components: a cartridge that contains a liquid solution containing various amounts of nicotine, flavoring and other chemicals, a heating device or vaporizer, and a rechargeable battery. Puffing on the e-cigarette activates the battery powered heating device causing the liquid to vaporize. The vapor is inhaled by the user. E-cigarette vapor may include metals, rubber and ceramics which may be aerosolized and have adverse health effects.

Are e-cigarettes safe?

Although a limited number of studies have been conducted, the safety of e-cigarettes has not thoroughly been evaluated in scientific studies.

Here are a few points to consider:

• Nicotine is highly addictive and has negative effects on brain development from infancy to teens.
• Potential consequences of using e-cigarettes among youth include nicotine addiction, withdrawal and the potential for overdose.
• The use of a variety of flavoring in the liquid solution of e-cigarettes has created concern for accidental ingestion by smaller children.
• With the rapid increase in use of electronic nicotine delivery systems (ENDS), users and nonusers are exposed to the aerosol product. While e-cigarette aerosol may contain fewer toxins than cigarette smoke, studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive.

Bottom line: e-cigarettes are often promoted as safer alternatives to cigarette smoking. Although very little is known about their safety, they are increasingly being used by youth and young adults.

What about second hand exposure?

The potential exists for secondhand nicotine and other tobacco-related toxin exposures to others. Studies have shown that e-cigarettes are a source of secondhand exposure to nicotine but not to combustion toxins. Thus, while use of e-cigarettes in indoor environments may involuntarily expose nonsmokers to nicotine, it does not seem to expose them to toxic, tobacco-specific combustion products.

What does the American Academy of Pediatrics recommend?

To protect the health of youth, the American Academy of Pediatrics has made the following recommendations:

• Sales of e-cigarettes to minors (under 18 years of age) should be prohibited.
• Candy and fruit flavored e-cigarettes, which encouraged youth smoking initiation, should be banded.
• To avoid exposing others to potential harm, laws should mandate smoke-free environments which include e-cigarette vapor.
• To prevent poisoning, all e-liquids should be required to be sold in child-proof packaging.

Two new studies emphasize the dangers of teens using e-cigarettes

The studies published in Pediatrics magazine showed teens who only vape have the highest level of cancer causing chemicals in their bodies and the e-cigarettes are associated with future smoking in teens.

The researchers from the University of California, San Francisco challenge the idea that e-cigarette vapor is safe. They found that teens who use e-cigarettes are in danger of inhaling cancer-causing chemicals, especially in fruit flavors.

“The presence of harmful ingredients in e-cigarette vapor has been established; we can now say that these chemicals are found in the body of human adolescents who use these products,” authors wrote.

The UC San Francisco researchers found that adolescents who smoke e-cigarettes expose themselves to a high levels of the potentially cancer-causing chemicals also found in tobacco cigarettes, even when the e-cigarettes do not contain nicotine.

"Teenagers need to be warned that the vapor produced by e-cigarettes is not harmless water vapor, but actually contains some of the same toxic chemicals found in smoke from traditional cigarettes," said lead author Mark L. Rubinstein, MD, a professor of pediatrics at UCSF. "Teenagers should be inhaling air, not products with toxins in them."

This was the first known study to report on the potentially cancer-causing compounds in the bodies of adolescents use e-cigarettes, according to UCSF. The lists of compounds include acrylonitrile, acrolein, propylene oxide, acrylamide and crotonaldehyde.

Another study from the same institution and also published in Pediatrics found that “e-cigarette use is more likely to encourage youth smoking that to divert youth form smoking.”

The team found those who had ever used e-cigarettes were significantly more likely than never users to have smoked at least 100 cigarettes at follow-up, have smoked during the past 30 days or both.

To learn more about e-cigarettes, we talked to Don Wilson, M.D., an endocrinologist and an Endowed Chair of Cardiovascular Health and Risk Prevention at Cook Children’s.

What do e-cigarettes do?

E-cigarettes are designed to simulate the act of smoking and deliver nicotine without the toxic chemicals produced by burning tobacco. The use of nicotine, however, is highly addictive. Recent research suggested nicotine exposure may also cause the brain to become addicted to other substances. Vapor from some e-cigarettes has also been shown to contain known cancer producing and toxic chemicals, such as diethylene glycol and nitrosamines, as well as small particles of toxic metals. Although not well studied, there is the potential for second hand exposure by others in the environment.

How do e-cigarettes work?

E-cigarettes are smokeless, battery operated devices designed to deliver nicotine mixed with a variety of flavorings (fruit, mint, chocolate, etc.) and other chemicals via an inhaled aerosol. They typically resemble regular tobacco cigarettes, cigars, pipes or everyday items like pins or USB memory sticks.

Most e-cigarettes generally contain three components: a cartridge that contains a liquid solution containing various amounts of nicotine, flavoring and other chemicals, a heating device or vaporizer, and a rechargeable battery. Puffing on the e-cigarette activates the battery powered heating device causing the liquid to vaporize. The vapor is inhaled by the user. E-cigarette vapor may include metals, rubber and ceramics which may be aerosolized and have adverse health effects.

Are e-cigarettes safe?

Although a limited number of studies have been conducted, the safety of e-cigarettes has not thoroughly been evaluated in scientific studies.

Here are a few points to consider:

• Nicotine is highly addictive and has negative effects on brain development from infancy to teens.
• Potential consequences of using e-cigarettes among youth include nicotine addiction, withdrawal and the potential for overdose.
• The use of a variety of flavoring in the liquid solution of e-cigarettes has created concern for accidental ingestion by smaller children.
• With the rapid increase in use of electronic nicotine delivery systems (ENDS), users and nonusers are exposed to the aerosol product. While e-cigarette aerosol may contain fewer toxins than cigarette smoke, studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive.

Bottom line: e-cigarettes are often promoted as safer alternatives to cigarette smoking. Although very little is known about their safety, they are increasingly being used by youth and young adults.

What about second hand exposure?

The potential exists for secondhand nicotine and other tobacco-related toxin exposures to others. Studies have shown that e-cigarettes are a source of secondhand exposure to nicotine but not to combustion toxins. Thus, while use of e-cigarettes in indoor environments may involuntarily expose nonsmokers to nicotine, it does not seem to expose them to toxic, tobacco-specific combustion products.

What does the American Academy of Pediatrics recommend?

To protect the health of youth, the American Academy of Pediatrics has made the following recommendations:

• Sales of e-cigarettes to minors (under 18 years of age) should be prohibited.
• Candy and fruit flavored e-cigarettes, which encouraged youth smoking initiation, should be banded.
• To avoid exposing others to potential harm, laws should mandate smoke-free environments which include e-cigarette vapor.
• To prevent poisoning, all e-liquids should be required to be sold in child-proof packaging.