Levy said he saw children addicted to his program showing what appear to be psychiatric symptoms rarely seen in traditional cigarettes or between adults. Some have anxiety and can not concentrate, for example.
On Friday, the agency will hold a public hearing to discuss the role of smoking cessation remedies for children in order to get them out of the vapes. Currently, there are no FDA-approved nicotine cessation products for users of electronic cigarettes under the age of 18.
Its long-term health effects are not yet clear.
"We left this Frankenstein loose without knowing what would happen," Levy said.
Vaping teenager was a "predictable problem"
"That may be true, but that is not the only consideration here," Levy said, adding that it is not yet clear "how high those spikes go and how quickly they enter the bloodstream and brain."
Levy said it is not uncommon for children to report symptoms that "sound very similar to nicotine toxicity," including headaches and stomach pains. She suspects that these devices make nicotine levels in the blood reach a higher peak than with traditional cigarettes – but experts say more research is needed to better understand how vapes work in the body and brain.
In a study last year, Goniewicz found higher levels of cotinine – a breakthrough product of nicotine – in the urine of teenage vapors than had been reported in previous surveys of adolescent cigarette smokers.
According to Goniewicz, vape makers may be able to store more nicotine in their products, creating "nicotine salts," which can mask the naturally unpleasant taste of nicotine and cause the drug to be absorbed by the body more quickly.
The leading e-cigarette company Juul, which holds about 75 percent of the US market, also said that flavors are a useful tool to help adult smokers switch from fuel cigarettes.
But Levy describes the popularity of vapes among teens as a "totally predictable problem."
The brain of adolescents may be more vulnerable to nicotine
Levy said the impact of vapes on teens is changing the way people think about nicotine products.
Smoking was seen largely as a "medical problem" that could lead to cancer and other physical ailments, she said. Vaping is now increasingly seen as a psychiatric problem because of concerns that nicotine is cultivating dependency behaviors among children and interfering with brain development.
"The circuits underlying pleasure and the pursuit of new and enjoyable experiences develop much faster than circuits that promote decision-making, impulse control, and rational thinking," said Leventhal.
We know from cigarette users that those who try nicotine products early in life are more likely to develop addiction to the drug, Leventhal said. This can also lead to the breakdown of brain circuits underlying attention and cognitive abilities, he added.
What makes children exceptionally vulnerable to vapes is not merely biological; is also psychosocial, according to Leventhal. This may come in the form of peer pressure or stress, which may increase the likelihood of addictive behaviors, he said.
More broadly, cultural and political changes that prevent many children from buying cigarettes – including FDA regulation and a "long history of prevention programs" – simply did not keep pace with the vaping expansion, Leventhal added.
Children and adults also tend to vape for different reasons, Goniewicz said. Adults tend to be ex-smokers who can handle a high dose of nicotine and want to avoid withdrawal symptoms such as inability to sleep or focus on work.
"They do not really need nicotine to feel good," he said. "They need nicotine so they do not feel bad – because they are already addicted."
But electronic cigarettes may be the first childhood experience with nicotine. "Nicotine hits the brain," he said, fixing molecules that affect mood and other avenues. And they're not used to it, he said.
"Nicotine is a potent chemical that alters our brain."
It's hard to make kids give up.
Levy said that "almost all" teens in their program have some experience with e-cigarettes, but "what's new is that now we're seeing patients in the nicotine-only substance use program."
Health experts fear that being addicted to nicotine early in life can be a gateway to cigarettes and other drugs, and there are few tried and tested resources for teenagers.
"Children are often really struggling with it, and there simply is not a lot of resources for them," said Levy, adding that many addiction programs may not be equipped to deal with some of the younger, nicotine dependent children she is seeing . Much better would be ensuring that primary care physicians are equipped to work with children in their own communities, she said.
Some parents have adopted nicotine gum and other cessation tools for their children under medical guidance. Levy said this can be tricky because some kids can use these products as a "bridge" between puffs of vapes and tobacco products.
Drugs may be important in some advanced cases, but they are not enough, she said; children also need "good and solid advice".
"We ended up having to teach kids how they can handle their desires, how they can identify high-risk situations, how they can really deal with being surrounded by people who are using those things," Levy said. "Because the reality is that for most children, we treat them and put them back in school, and then they go to the bathroom, and everyone is Juuling."
Still, she said children and their parents seem largely unaware of the potential dangers.
"To this day, I have kids saying," Well, I thought it was safe, "or" I know it's safer than cigarettes, "Levy said.
"And safer than cigarettes" is a very low bar. "