Issue At A Glance: August 2019 INSTITUTE FOR HEALTH POLICY AND LEADERSHIP

In 2016, the US Department of Health and Human Services

released E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General, highlighting the

upward trend of e-cigarette use among the youth.4

On December 18, 2018, the United States Surgeon General issued a

public health advisory on the dangers of the e-cigarette epidemic

among youth.5

Did You Know?

E-Cigarette Use Among Youth

Electronic cigarettes (e-cigarettes) are battery-operated devices that are primarily intended to deliver vaporized nicotine, flavoring, and other additives to the user through inhalation. They are sold in many different colors, shapes, and sizes and are associated with different names such as “e-cigs,” “vape pens,” “mods,” and “e-hookahs.”1

E-cigarettes entered the marketplace in 2007. In 2015, e-cigarette sales rapidly increased due to the USB flash drive shaped e-cigarette known as JUUL. By the end of 2018, the company that owns JUUL products dominated the e-cigarette market with more than three-quarters of the sales.2

Although e-cigarettes are often advertised as smoking-cessation aids, the Food and Drug Administration (FDA) has not yet approved the products for this purpose. While some studies are beginning to find beneficial short-term effects when it comes to the efficacy of e-cigarettes in smoking cessation, the long-term health effects are not entirely understood.3 Public health experts all agree, however, that e-cigarettes are harmful to youth.4

Bringing wholeness to individuals and communities, the Institute for Health Policy and Leadership (IHPL) strives to integrate health policy research and education with

leadership development. Our goal is to improve the health of our communities by building on our strong heritage of health promotion and disease prevention.

To learn more, visit us at www.IHPL.llu.edu

In the last few years, e-cigarette use has spiked among youth because of their flavors and the marketing strategy by tobacco companies. E-cigarettes do not pose any benefits to youth. In fact, they can cause adverse health,

neurological problems, injuries, and addiction, potentially leading to use of other harmful, addictive substances. Recently, federal and state policies have begun regulating e-cigarettes to curb youth exposure and use.

An Introduction to E-cigarettes

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INSTITUTE FOR HEALTH POLICY AND LEADERSHIP August 2019

The Scope of the Problem As of July 2019, 38 states have set the minimum age for purchasing e-cigarettes to 18 years, three have set the age to 19 years, and nine have set the age to 21 years.6 Despite these laws, more high school youth use e-cigarettes than adults. According to a survey conducted by the Centers for Disease Control and Prevention (CDC), approximately 3.05 million high school students reported using e-cigarettes in 2018. This number signifies a 78 percent increase in usage among this population between 2017 and 2018. Moreover, one in 20 middle school students reported using e-cigarettes.7

The Surgeon General’s Report finds the following socio-demographic trends when it comes to e-cigarette use:

• Male youth are twice as likely as female youth to use e-cigarettes• Students who reported using e-cigarettes were less likely to have plans to attend a 4-year

college• Caucasian and Hispanic youth were far more likely to report using e-cigarettes than African

American youth4

Potential Health Effects of E-cigarettes on Youth Nicotine is a highly addictive chemical that is found in tobacco products, including e-cigarettes. On average, users consume one JUUL pod a day, and the amount of nicotine in a pod is equivalent to the amount in 20 cigarettes. For developing minds, nicotine can disrupt attention, mood, and impulse control and can alter the memory formation process. In high doses, it can lead to poisoning and even death.8 Over half of the calls to poison control hotlines for children under the age of six were attributed to exposure to liquid nicotine in 2014.9 E-cigarettes may also become a gateway into conventional tobacco products or drugs due to the addiction factor.10

Aside from nicotine, e-cigarettes may contain thousands of other harmful chemicals such as ultrafine particles, volatile organic compounds, heavy metals, and carcinogens. Such ingredients may exacerbate respiratory conditions, lead to neurodevelopmental problems, and cause allergic reactions or cancer.11,12

Moreover, e-cigarette devices themselves can be dangerous due to their construction, and those that utilize lithium-ion batteries are especially dangerous. One study estimates that there were 2,035 cases of emergency room visits due to burn injuries from exploding e-cigarettes between 2015 and 2017.13

Did You Know? Some e-cigarette products are designed to look like school products such as flash drives and pens.4 This makes it easier to conceal them from their parents and school staff.

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INSTITUTE FOR HEALTH POLICY AND LEADERSHIP August 2019

Reasons Why Youth Use E-cigarettes Data from meta-analyses indicate that youth are likely to try e-cigarettes for the following reasons:

• Flavorings/Taste • Perception that e-cigarettes are less toxic

alternative to cigarettes and tobacco products

• Usage by parent or guardian • Curiosity • Less restrictions when it comes to indoor

smoking14

Regulating E-cigarettes When it comes to youth and e-cigarettes, numerous concerns exist, indicating the need for regulation. For one, e-cigarettes vary in their amount of nicotine that is delivered. Some may contain large amounts of nicotine and can lead to nicotine poisoning. Another issue is that some e-cigarette brands contain trace amounts of nicotine despite claims that the e-cigarette brand is free of nicotine.15 In fact, two-thirds of teenagers reported believing that e-cigarettes were solely delivering flavored water vapor.16 Finally, the marketing and advertising of the products seem to be targeting youth. For instance, many of the flavorings are packaged to resemble commonly seen candies.15 Approximately 70 percent of teenagers are exposed to e-cigarette advertising through retail and online advertisements.16 A Congressional report noted that e-cigarette companies were sponsoring youth events and providing free samples to youth.17

Cracking Down to Protect Youth In 2010, Sottera, Inc. v. Food & Drug Administration held that e-cigarettes are not medical devices, but rather tobacco products. This gave the FDA the authority to regulate them as tobacco products.18 Since 2016, the FDA has passed rules regulating ingredients, marketing, and age of purchase for e-cigarette products. This includes a deeming rule that prohibited the sale of e-cigarette products in vending machines in non-adult-only facilities and banned the distribution of free samples.19

Recently, the FDA sent warning letters and fined businesses that were caught selling the products to underage customers. Moreover, the department issued rules stating that the sales of flavored products can only be carried out in adult-only stores. E-cigarette companies will be required to submit an application in order to be reviewed by the FDA starting in May 2020. The FDA will look at the ingredients listed, warning statements, and marketing strategies.19

States and local municipalities have also begun taking action. Recently, San Francisco and Beverly Hills passed ordinances that ban the sale or distribution of e-cigarettes that have not received FDA approval and the sale of flavored tobacco products.20

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INSTITUTE FOR HEALTH POLICY AND LEADERSHIP August 2019

References 1. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-

cigarettes.html 2. https://www.journalnow.com/business/juul-ends-with-percent-market-

share/article_6f50f427-19ec-50be-8b0c-d3df18d08759.html 3. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.

pub3/epdf/full 4. https://e-

cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf

5. https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf

6. https://publichealthlawcenter.org/sites/default/files/E-Cigarette-Legal-Landscape-50-State-Review-March-2019.pdf

7. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/surgeon-general-advisory/index.html

8. https://pediatrics.aappublications.org/content/144/1/e20182935 9. https://pediatrics.aappublications.org/content/141/5/e20173361.abstract 10. https://pediatrics.aappublications.org/content/141/1/e20171832 11. https://ehp.niehs.nih.gov/doi/full/10.1289/EHP2175 12. https://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-

health.html 13. https://www.sciencedirect.com/science/article/pii/S0190962219305419 14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6290379/ 15. http://www.astho.org/E-Cigarettes-Issue_Brief.aspx 16. https://www.drugabuse.gov/related-topics/trends-

statistics/infographics/teens-e-cigarettes 17. https://thehill.com/policy/healthcare/454373-house-panel-to-hold-hearing-

on-juul-role-in-youth-nicotine-addiction 18. https://publichealthlawcenter.org/content/sottera-inc-v-us-food-and-drug-

administration 19. https://www.fda.gov/news-events/fda-voices-perspectives-fda-leadership-

and-experts/how-fda-regulating-e-cigarettes 20. https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-

advisory-on-e-cigarette-use-among-youth-2018.pdf 21. https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-

advisory-on-e-cigarette-use-among-youth-2018.pdf

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Questions? Please contact Priya Vedula, MPH. Health Policy Analyst at the Institute for Health Policy & Leadership (pvedula@llu.edu)

While federal and state regulation are imperative, it is important to understand that parents, caregivers, educators, and healthcare providers have a key role to play. Parents should recognize the signs of nicotine addiction and should inform their children about the contents of e-cigarettes and their adverse health effects. Educators should also learn to recognize what e-cigarettes look like, develop awareness campaigns in schools with the help of students, and create anti-tobacco policies that protect the youth from the tobacco industry. Finally, healthcare providers can ask about e-cigarette use, educate and inform parents and teens of the dangers of vaping, and encourage those that vape or smoke to quit.21

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