When her son was a high school freshman, Kristin Beauparlant noticed a change. The hockey player began getting gassed more easily on the ice. Beauparlant could hear her son’s coughing and wheezing from the stands. But it was his demeanor that scared her most. Cade Beauparlant’s anxiety and mood swings worsened, his outbursts so sudden and so explosive that his mother said she came to fear him.
It took more than three years - and help from a renowned pediatrician - to understand what was going on: Her son was addicted to nicotine, delivered by a Juul, a sleek e-cigarette that looks like a USB drive.
As e-cigarettes have skyrocketed in popularity among teenagers in the past two years, pediatricians report seeing teens who behave less like tobacco users and more like patients with substance-abuse disorders.
Some young people have resorted to stealing from their parents or selling e-cigarette paraphernalia to support their habits, addiction treatment specialists said. And even though many teens assume e-cigarettes are safe, some turn up with signs of nicotine toxicity, a condition previously seen in young children who accidentally ingested nicotine gum. Others are reporting respiratory problems. After more than three years of vaping daily, Beauparlant was diagnosed with restrictive lung disease. His mother said she is working with an attorney to file a class-action lawsuit against Juul that would force it to set up treatment centers.
"We were thinking about vapes just like we thought about cigarettes. Over time we realized no, no. This is something really different," said Sharon Levy, director of the Adolescent Substance Use and Addiction Program at Boston Children's Hospital. She and other doctors said they believe they are witnessing for the first time the damage that repeated exposure to high levels of nicotine wreaks on young bodies.
Although the phenomenon has yet to be described in medical literature, anecdotal evidence from leading addiction specialists in Boston and New York and from families grappling with adolescent e-cigarette addiction points to previously unseen consequences of use among teens. Several families have sued Juul, accusing it of causing nicotine addiction in their children and describing extreme addiction symptoms.
Doctors said they believe the behaviors of teens addicted to e-cigarettes could be linked to their design: Many products, including Juul, allow users to ingest far more nicotine than they would with traditional cigarettes. Concerns over teen use fueled a ban on e-cigarette sales that was adopted in June by San Francisco - a move that made it the first major city to prohibit the nicotine-delivery devices.
"With the Juuls, kids are able to get a much higher dose of nicotine - and dose matters," Levy said. "These kids have behaviors that we often see in patients who have opioid or marijuana addiction, but we didn't typically see with kids who developed addiction to traditional tobacco cigarettes."
This week, a House subcommittee accused Juul Labs of targeting children and teens, including at schools and summer camp. Company officials said the effort - involving about a half-dozen schools and youth programs - ceased last fall and was designed to educate youths about the dangers of nicotine addiction.
Juul has defended the design of its products, saying they were engineered with adult smokers in mind. The company says its own clinical trials show that nicotine is absorbed more slowly through use of its e-cigarette than through traditional cigarettes.
But doctors say teens consume e-cigarettes at far faster rates than they do traditional cigarettes, with some consuming a pod or more a day - equivalent to the amount of nicotine in a pack of cigarettes. E-cigarette vapor does not burn the throat as much as cigarette smoke does, and its discretion allows consumers to use e-cigarettes more frequently.
In 2018, more than 37 percent of 12th-graders reported vaping at least once in the past 12 months, according to findings released by the National Institute on Drug Abuse, even though many were too young to legally purchase the products. A year earlier, the figure was about 28 percent. When teens were asked about use in the 30 days before the survey, 21 percent said they had vaped, which was nearly double the rate from 2017.
Because of a variety of factors - genetics, trauma, peer behavior - some teens develop a strong attachment to the products, bonds that are unshakable even in the face of escalating consequences. Experts say teen brains are particularly vulnerable to addiction because they are still developing and that it is easier for teens to fall victim to addictive products because they have less impulse control.
They worry the chemical will shape the brains of teens, priming their "reward pathways" and making them more vulnerable to other kinds of substance abuse. They worry, too, that many pediatricians lack the expertise and treatments to help young people who cannot quit. And there are few treatment options for teens addicted to nicotine. While adult smokers seeking to quit have benefited from nicotine patches and the drug varenicline, better known as Chantix, there is scant evidence those treatments work for young people, according to Jonathan Winickoff, a pediatrician and researcher at Massachusetts General Hospital who specializes in tobacco cessation and who treated Cade Beauparlant.
"We have millions of kids now, millions of adolescents who are using mostly Juul - and in some cases other devices - who are unable to quit," Winickoff said. "It's something we don't have the infrastructure to deal with."
In response to criticism and scrutiny from the Food and Drug Administration, Juul Labs has taken steps to counter teen use. The company has removed fruit-flavored pods, the cartridges filled with nicotine-laced liquids, from retail stores - although they remain available online. The company has also shifted marketing to feature adults using the device to quit smoking, abandoned social media and backed laws that raise the minimum age of purchase for e-cigarettes to 21.
"As a father of teenagers myself, it is absolutely heartbreaking to watch any young person struggling with addiction," Kevin Burns, CEO of Juul Labs, said in a statement. "We are working aggressively to be a meaningful part of the solution to underage use of nicotine products."
E-cigarettes were introduced as a way for smokers to quit, allowing them to satisfy their nicotine cravings without lighting up.
But many teens report that vaping has maneuvered its way into school life and adolescent culture in the form of jokes, memes and lingo. Teens say their peers sometimes refer to the bathroom as the "Juul room," a nod to the frequent sight of teens passing around an e-cigarette in school bathrooms. And videos of students pranking their peers by passing a USB drive instead of a Juul circulate on teen social media accounts. Words such as "ghosting," which refers to holding in a Juul puff to absorb more of the nicotine, and "nic sick" have become part of the teen lexicon.
The surge in use has led members of Congress to call for raising the minimum age of purchase nationwide from 18 to 21. The FDA has worked to curb underage e-cigarette use, threatening companies with sanctions if they do not work harder to keep their products out of teen hands.
Many schools are at a loss for how to deal with Juuls and other e-cigarettes. Some educators report increases in the number of students being suspended after they're caught with e-cigarettes.
Desperate school administrators have banned USB drives because they're indistinguishable from Juuls. Others removed bathroom doors because teens were regularly gathering there to vape, and some have even started searching students.
Jonathan Bryant, chief administrator of Lincoln Charter School in North Carolina, estimated that three-quarters of suspensions in the just-completed academic year were related to vaping, and some students were suspended more than once. After noting the rise in suspensions, he said he is considering alternatives to punishment, recognizing that a day out of school could mean a day spent at home vaping. Instead, he is contemplating mandatory education on the perils of vaping.
"It is obvious, in some capacity, that suspension is ultimately not solving the problem," Bryant said.
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Luka Kinard took his first puff of a Juul during the homecoming football game his freshman year at High Point High School in North Carolina. Within a couple of weeks, he said it had become a habit, and within a few months, he had started selling the pods. His classmates called him "The Fiend," he said.
At home, he said, he grew erratic, sometimes punching walls, destroying furniture or throwing things when he was angry at his parents for confiscating his e-cigarettes. He once kicked down the back door of his house when his parents had told him to go outside to cool off.
"I became very explosive," said Luka, now 16.
Parents seeking help have encountered pediatricians who did not understand the magnitude of the addiction or had few answers. Eventually, Luka's mother, Kelly Kinard, started researching inpatient substance abuse programs, but struggled to find one that would take a teenager dependent on nicotine.
In Martinsburg, West Virginia, a community reeling from the opioid crisis, Martinsburg High suspended 27 students in the just-completed school year - 20 more than the previous school year - in connection with vaping. The school's resource officer also gave out criminal citations to many of those students under the state's ban on tobacco on public school campuses.
About 70 percent of students at Martinsburg High come from low-income households, and about a third of students are people of color, demographics that contradict earlier assumptions about the epidemic being confined to wealthier white communities where smoking rates had dropped steeply.
When Principal Trent Sherman began catching students with e-cigarettes, he would sometimes call home and learn that parents had purchased them for their children, trying to wean them off smoking. He was unsure how to deal with students caught with e-cigarettes, so he decided to treat the devices like he did cigarettes, suspending students for a day. Students caught a second time could be suspended for five to 10 days.
Now, the school is reexamining how it disciplines students and considering revamping its approach to teens caught vaping at school after the principal noticed many repeat offenders.
Cade Beauparlant was a freshman at Newburyport High School in Massachusetts when he went to the boys' bathroom and saw classmates passing around a tiny device, putting their lips on the end and inhaling deeply. He decided to try it. As the mint-flavored vapor entered his lungs, he got a head buzz and a rush of euphoria.
"I just felt amazing," said Beauparlant, now 18. "I just wanted to do it again."
Beauparlant said he vaped nearly every day of high school, but it was not until his senior year that he got caught. By then, nicotine had come to rule his life. He spent hundreds of dollars feeding a habit that cost up to $5 a day - no small amount for a teen working at a pizza shop - and began giving rides to friends in exchange for them scoring him a pod.
After getting caught with the Juul, Beauparlant was barred from playing hockey for much of the season, ending his prospects of playing the sport at a collegiate level. Winickoff, the Boston pediatrician, prescribed nicotine gum to help the teen reduce e-cigarette use. Slowly, Kristin Beauparlant said, she saw another young man emerge. Her son no longer exploded in anger. He was no longer distant. Even his teachers and school principal noticed a shift.
"We kind of lost four years of Cade to this addiction," Kristin Beauparlant said. Now that he has cut back, "He just seems like a different kid. You can't help but say there's a correlation."
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The Washington Post’s Laurie McGinley and William Wan contributed to this report.