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Past Issues and Solutions: Throughout the 20th century, conventional cigarette use (e.g. non-electronic) among adolescents was more prevalent than it is today, with approximately 29% of high school students smoking in 1989 and only 16.7% in 2013 (Office on Smoking and Health & National Center for Chronic Disease Prevention and Health Promotion, 2016). According to Warner, this type of decline in adolescent smoking behavior can be attributed to the “major events” (e.g. the Surgeon General's Report) of the anti-smoking campaigns on cigarette consumption (Warner). A New Issue: However, while the Center for Disease Control (CDC) reports declines in cigarette use among adolescents, the organization reports growth in a relatively new method of smoking: electronic cigarettes (Office on Smoking and Health & National Center for Chronic Disease Prevention and Health Promotion, 2017). As explained by Grana, “electronic cigarettes (e-cigarettes) are products that deliver a nicotine-containing aerosol (commonly called vapor) to users by heating a solution typically made up of propylene glycol or glycerol (glycerin), nicotine, and flavoring agents” (Grana et al. 2014). E-cigarettes come in numerous shapes, sizes, and designs, including light displays and other personal customizations. Trends: Moreover, further surveys by the CDC report that e-cigarette use among U.S. high school students is not only growing but is growing nonlinearly with 1.5% reporting usage in 2011 and 11.7% reporting in 2017 (Wang et al. 2018). This exponential upward trend in e-cigarette use among U.S. high school students is accompanied by an exponential upward trend in e-cigarette advertising expenditures, with $6.4 million spent in 2011 and an estimated $115 million in 2014 (Singh et al. 2016). A complementary survey reveals the reach of these advertisements with 68.9% of U.S. middle and high school students reporting exposure to at least one form of e-cigarette advertisement (Singh et al. 2016). Federal Regulation: However, as the e-cigarette industry was growing in spending and awareness, the market was met with little regulation from the federal government, since the U.S. Food and Drug Administration (FDA) did not incorporate e-cigarettes into its policy authority until 2016. The FDA had to expand what was considered a “tobacco product” under the Family Smoking Prevention and Tobacco Control Act to cover “electronic nicotine delivery systems (ENDS).” However, these federal regulations still do not restrict the marketing of e-cigarettes on radio and television, the flavoring of nicotine, or the use of e-cigarettes inside public spaces (Padon et al. 2017). Current Status: While the FDA has now expanded their regulatory authority, the FDA Commissioner, Scott Gottlieb, pledged that the federal government would continue to take even more action to end the described “epidemic of e-cigarette use among teenagers” and to decrease the “disturbing” and “accelerating” usage rates (Gottlieb).

Roadblocks and Misperceptions: However, one of the main roadblocks that the federal and state governments will face when combating this “epidemic” are the frames utilized by the e-cigarette companies in advertisements and marketing to shape e-cigarettes as trendy, safe, and different from conventional smoking. These frames are presenting an issue because research is finding they are highly effective enforcers of misperceptions and stereotypes among adolescents. For example, in a study by Duke et al., teens who watched e-cigarette advertisements were more likely to perceive e-cigarettes as “cooler, more fun, healthier, and more enjoyable” (Duke et al. 2016). Furthermore, one cross-sectional survey of 6th, 8th, and 10th-grade students found that e-cigarette users had higher likelihoods of reporting that e-cigarettes were “not at all harmful” or “not all addictive” (Modesto-Lowe & Alvarado, 2017).  However, the perception of harmlessness has been continuously disproven with research that directly links negative health effects to inhaling the vapors from e-cigarettes; specifically, a study by Wang found a 30% increase in breathing problems in cases that smoked e-cigarettes (Wang et al. 2016). Additionally, the “not all addictive” perception has been disproven through the studied highly addictive nature of nicotine, no matter the method of inhalation (Grana et al. 2014). Therefore, any public health policy or initiative will have to work to overcome the youths' perception that e-cigarettes are “cool” and not as harmful or as addictive. Importantly, the policies and initiatives will also have to combat the e-cigarette companies that are spreading, explicitly or implicitly, the opposite message to adolescents. Although, the misperceptions are not only derived from the marketing. Studies show that public policy restricting cigarettes near public spaces has resulted in a more negative public opinion surrounding smoking (Rayens et al. 2007). However, according to a report by the World Health Organization, the current lack of policies that restrict e-cigarettes in public spaces  “renormalizes” smoking and may “conflict” with the previous policy messages (World Health Organization). This “renormalization of smoking” reported by WHO is linked to more positive perceptions of e-cigarettes and may result in questions surrounding the safety differences between the two methods (Voigt, 2018). However, the difference in policy is mainly present due to technical policy language that prohibits “smoke” but not the “vapor” produced electronically, not because the methods differ vastly in safety or health effects (Paradise, 2018). Finally, it is also important to note that the message from companies that e-cigarettes are smoking cessation aids produces an understanding that those who smoke e-cigarettes are previous conventional smokers who are resorting to a “healthier” alternative. However, surveys by Grana have revealed that one-third of adolescents who smoke e-cigarettes have never even tried conventional smoking (Grana et al. 2014). Moreover, Campbell-Heider discovered a common trend: smoking e-cigarettes often leads to conventional smoking (Campbell-Heider, 2016). Therefore, rather than conventional smokers switching to a “healthier” option, studies are finding that e-cigarette smokers are digressing to conventional cigarettes (Campbell-Heider, 2016).  

National Overview: Nationally, multiple states have passed legislation to combat electronic cigarette use among teens and in the general population, including North Carolina (Center for Disease Control and Prevention, 2018). Specifically—as of June 30, 2018— 47 states¬¬, including North Carolina, have passed legislation that restricts the sale of e-cigarettes to minors (e.g. must be 18 years of age with a valid ID) (Center for Disease Control and Prevention, 2018). Additionally, nine states (California, Delaware, Hawaii, New Jersey, New York, North Dakota, Oregon, Utah and Vermont) have passed legislation that prohibits smoking and the use of e-cigarettes in indoor spaces of “private worksites, restaurants, and bars” (Center for Disease Control and Prevention, 2018). Inter-State Comparison: Furthermore, in comparison with Virginia, there have been bills introduced similar to N.C. H.B. 276 that request for funds to be directed towards youth tobacco-use prevention, such as V.A. H.B. 2056 (North Carolina, 2017-18)(Virginia, 2017). However, the bill did not make it out of the Virginia House Finance Committee; in its place, the Virginia Foundation for Healthy Youth has taken on the campaign to combat e-cigarette use in the state's younger population (Virginia Foundation for Healthy Youth). Federal Response: Likewise, on the federal level, the FDA and the Department of Health and Human Services (DHHS) have recognized the issue as an “epidemic” and are diverting federal funds and efforts to combat the growing usage of e-cigarettes in children under 18, such as warning letters to e-cigarette companies and distributors (Gottlieb, 2018). Strategy Ideology: Other states and the federal government have been diverting funds into these types of programs specifically aimed at e-cigarettes only recently, so the overall effects of the programs are still ongoing and have not been thoroughly studied. However, they are basing their solutions off of what was successful with conventional smoking public health campaigns (e.g. youth awareness ads, school outreach, etc.) and off of the studied economic incentives for reducing a population's smoking habits. These economic incentives, as described by Fisherman, are the decreased “net societal costs” related to the lower average health costs for a population that has reduced tobacco use (Fisherman et al. 2005). Therefore, while it will cost states and the nation money to invest into the anti-electronic smoking campaigns, as proposed by N.C. H.B. 276, they are working under Fisherman's conclusion that these campaigns are “a relatively small investment” that “generates substantial cost savings” (Fisherman et al. 2005).



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