Electronic Cigarettes (e-Cigarettes)

There has been a significant and alarming increase in the use of e-cigarettes (commonly referred to as vaping products) among youth. According to the U.S. Centers for Disease Control and Prevention (CDC), 27.5% of high school students (4.1 million) and 10.5% of middle school students (1.2 million) reported using e-cigarettes (vaping) in the past 30 days in 2019.^[1] This represents a 114% increase among middle school students and a 32% increase among high school students since last year, despite growing public awareness about the dangers of vaping and increasing efforts to prevent vaping among youth.

As is the case with conventional cigarettes, e-cigarettes deliver high doses of nicotine, a highly addictive drug. A growing body of evidence suggests that early use of nicotine increases the risk of addiction involving not only nicotine but also alcohol and other drugs. In fact, 95% of cases of nicotine addiction originate with substance use before age 21. Nicotine and the other chemicals in e-cigarettes, many of which are toxic, also have been linked to numerous negative health effects, including cardiovascular and respiratory disease, cancer, and mental health and cognitive problems.

Due to the emergence of e-cigarettes and their strong appeal to youth, a generation that was on the cusp of being the first to broadly reject cigarette smoking and become tobacco free, instead has become hooked on nicotine due to a decade of lax oversight of e-cigarette products.

Partnership to End Addiction recommends that the federal government adopt a number of policy changes to address the youth vaping epidemic.

First, the U.S. Food and Drug Administration (FDA) should take immediate action to assert the regulatory authority granted in the 2009 Tobacco Control Act and expanded in the 2016 deeming rule to regulate e-cigarettes as tobacco products.

Second, the federal government should ban all flavored vaping products, including mint and menthol, to address the significant increases in vaping among youth. Nearly all e-cigarettes are flavored in ways that appeal directly to children and adolescents – including candy, fruit, and mint – and use of flavored products has been shown to increase the likelihood that youth will use other addictive substances, including conventional cigarettes. The vast majority of youth who use e-cigarettes started with flavored products. A ban on flavored products is necessary to stop manufacturers from marketing products that appeal to youth and to delay the initiation of addictive substance use.

Third, the legal age of sale of all tobacco products, including e-cigarettes, should be raised to 21 years to delay initiation of use. Abundant research shows that use of any addictive substances prior to age 21 significantly increases the risk of addiction.

Fourth, manufacturers should be prohibited from marketing and advertising e-cigarettes to youth or in ways that might appeal to youth, including through social media channels. As the tobacco industry knows only too well, the best way to get lifetime customers is to start them early. This explains current e-cigarette marketing tactics that revive the glamorous promotional cues that for decades have attracted young people to the deadly habit of cigarette smoking.

Fifth, the government should impose a limit on nicotine content on e-cigarettes and other tobacco products. Currently, the amount of nicotine a vaping product can contain is unregulated, leading companies to use high nicotine levels to get customers addicted to their products and create long-term loyal customers. The high dose of nicotine in most vaping products makes it very difficult for people to quit, especially using current nicotine replacement therapies, which contain comparatively low doses of nicotine aimed at controlling cravings. It is within the FDA’s authority to limit how much nicotine a tobacco product can contain, and it should exercise that authority by setting low limits to reduce nicotine addiction – from either cigarettes, vaping, or other tobacco products – among youth and adults in the United States.

Finally, we recommend implementation of a model similar to that required for the sale of pseudoephedrine products, which are available only behind the counter in pharmacies, to allow for the sale of e-cigarette products to adults who wish to use them.^[2] These products should not be sold in convenience stores, gas stations, or other venues that make them easily accessible to youth. In addition, e-cigarettes should not be sold online where youth can easily bypass age restriction requirements.

E-cigarette manufacturers have made a number of specious claims about their products’ safety and effectiveness as a smoking cessation tool. While they might be less toxic than conventional cigarettes, there is no evidence to assure their safety, and a growing body of evidence demonstrating their negative health effects. If e-cigarettes were used only as complete replacement products for smokers who have been unable to quit smoking using medically approved cessation tools, they could possibly serve a harm reduction role. However, research shows that the majority of those who use them to quit smoking end up becoming dual users, such that e-cigarettes supplement rather than replace other tobacco use. Companies interested in marketing e-cigarettes as smoking cessation tools should be required to use the established FDA process for bringing drugs to market while assuring their safety and efficacy.

The lack of regulations and oversight of e-cigarettes since their emergence on the market over a decade ago has caused an astonishingly high number of middle and high school students and young adults, many of whom otherwise would not have been susceptible to nicotine use, to use a highly addictive product. The federal government must take urgent action to adopt these changes and address this public health crisis.