If you’re the parent of a teen—or even a “tween” who’s navigating middle school—you need to know about e-cigarettes. Odds are your child not only knows about them, but also has access to them and may be tempted to try one (if he or she hasn’t already).

Don’t be fooled. Despite being marketed and advertised as a healthier alternative to smoking, e-cigarettes pose significant health risks, which may be particularly harmful for young people with developing minds and bodies. In the United States, e-cigarette use, or vaping, among kids and teens has increased dramatically and continues to rise.

In 2018, nearly five percent of middle school students (one of every 20) reported using e-cigarettes in the previous 30 days—a jump from just 0.6 percent in 2011, according to the Centers for Disease Control and Prevention (CDC). Among high school students, nearly 21 percent admitted they used one of these devices in the previous month, compared to only 1.5 percent in 2011.

The worrisome trend prompted the U.S. Surgeon General to issue an advisory on the e-cigarette epidemic among American youth in December 2018. Some parents, however, still aren’t aware of just how pervasive e-cigarettes have become, while others may assume their child isn’t at risk, says Russell Delaney, MD, a pediatrician affiliated with LewisGale Medical Center in Salem, Virginia.

“Almost every middle schooler and high schooler that I’ve talked to tells me that they know people who are using e-cigarettes, and that they have had an opportunity to use them. And I still have a few parents who don't even know what they are,” Dr. Delaney says. “Without a doubt there are some parents who are naive about how prevalent vaping is in the schools and that their children may be doing it.”

If you’re wondering exactly how e-cigarettes work, why they are harmful and how you would even know if your child is using them, keep reading.

What is a JUUL anyway?

Brace yourself. There are more than 430 different e-cigarette brands being sold to consumers. You might hear a variety of different terms—like e-cigs, vapes, vape pens, mods and hookah pens—but they’re all e-cigarettes. JUUL, a particular brand of e-cigarettes, has emerged as one of the most popular products, holding the greatest share of the U.S. e-cigarette market as of December 2017.

Here’s where things get even more tricky. E-cigarettes come in different shapes and sizes. They may look like regular cigarettes, cigars or pipes, but some look like pens or USB memory sticks and can even be charged on a laptop.

These products all operate in a similar way. Typically, a cartridge or reservoir of e-liquid or “e-juice” is heated by a battery-powered device, allowing users to breathe in the resulting vapor. It’s important to understand that this vapor isn’t harmless.

Vaping isn’t a “safe” alternative

Like regular cigarettes, most e-cigarettes contain nicotine. JUUL also uses nicotine salts, which enable the user to inhale high levels of nicotine more quickly and easily.

Nicotine is highly addictive and exposure during childhood or adolescence poses health risks. Teens who use e-cigarettes are more likely to start smoking in the future, the CDC reports. The U.S. Surgeon General also warns that nicotine exposure can harm young brains, which continue to develop until about age 25. Nicotine can not only prime the brain for addiction early on, but also lead to mood disorders and problems with learning, impulse control, memory, decision-making and attention.

The liquid in e-cigarettes contains other potentially harmful chemicals, such as formaldehyde, acrolein, volatile organic compounds and metals, like nickel and lead, according to the American Lung Association. These chemicals could increase the risk for heart disease, lung damage, cancer and other serious health issues.

Making matters worse, e-cigarettes may also contain fruit and candy flavors, like strawberry, grape, chocolate—and even “Unicorn Cakes” and “Smurf Sauce”—that appeal to young people. Many of these e-liquids have labels that resemble kid-friendly foods, such as peanut butter and jelly and popular sugary cereals. This marketing tactic can make them appear less dangerous. Not so.

A small but striking study published in June 2019 in the Journal of the American College of Cardiology found that use of flavored e-cigarettes, in particular, damages endothelial cells (the main type of cells found in the lining of the blood vessels). Scientists suspect that such damage could lead to heart disease.

After exposing these cells to six different flavors of e-liquid in a lab, the researchers found the cells didn’t function normally. Certain flavors were more detrimental than others. The study’s authors noted that menthol tobacco-flavored e-liquid had a harmful effect, even if it was nicotine-free.

Many of the flavorings used in e-liquids are approved by the Food and Drug Administration for consumption by mouth but there isn’t enough evidence to suggest they are safe to inhale. The fact is, e-cigarettes are relatively new products and there are still many unknowns about their long-term health effects, Delaney notes.

“Kids are viewing this as a safer option because they've heard that people use e-cigarettes to try and quit smoking,” he says. “What I'm trying to impress on my patients is that e-cigarettes haven’t been around that long. What are we going to know 50 years from now about the people who started vaping and were addicted to nicotine when they were 14, 15 or 16-years old?”

Yes, it could be your child

Statistically, more boys use e-cigarettes than girls. Young people with a strong desire to “fit in” may also be more likely to try vaping, while teens with depression or anxiety may use e-cigarettes as a way to self-medicate, notes Delaney. But he urges all parents to assume their child has access to these products and will have an opportunity to try them, if they haven’t already.

“My real take-home message would be: Don't try to figure out which child is at higher risk, because all children—boys, girls, straight-A students, students who are struggling, students who are known to get in trouble or students who never get in trouble—are at risk,” Delaney cautions. “Know e-cigarettes are there, know children are seeing other kids use them and know that they will have an opportunity to try them.”

Taking action now to educate yourself and your child, empowering kids to make healthy choices and knowing how to handle tempting situations—before they arise—can help kids avoid e-cigarettes and protect their health.