In 2007, New York was shocked by the image of Ronaldo Martinez, a smoker who gave his message to the state in a synthesized voice because cancer from smoking required the removal of his larynx. Martinez related his sadness that he could never go swimming because water could enter his tracheostomy site and drown him. This anti-smoking campaign, officially titled “Nothing Will Ever Be the Same,” prompted thousands of people to quit smoking (Atkinson p. 1). Cigarette smoking in general has declined in the last decade from 20.9% (nearly 21 of every 100 adults) in 2005 to 15.5% (more than 15 of every 100 adults) in 2016 (Surgeon General 1 p. 17). However, a new epidemic is sweeping the nation and threatens to reverse all the progress made in tobacco control. This epidemic is the use of electronic cigarettes by teenagers.
An electronic cigarette or e-cigarette is a handheld electronic device that simulates the feeling of smoking. It works by heating a liquid to generate an aerosol, commonly called a "vapor," that the user inhales. Using e-cigarettes is also called vaping. E-liquid is the mixture used in e-cigarettes, made up of propylene glycol, glycerin, water, nicotine, and flavorings. While the ingredients vary, the liquid typically contains 95% propylene glycol and glycerin. There are many e-liquid manufacturers worldwide and upwards of 8,000 flavors. Industry standards have been created and published by the American E-liquid Manufacturing Standards Association (AEMSA) (STEPP p. 1).
The modern e-cigarette was invented in 2003 by Chinese pharmacist Hon Lik, and as of 2018 most e-cigarettes are made in China. Since first entering the market in 2004 their global use has risen exponentially and is now widespread. Among middle and high school students, both ever and past-30-day e-cigarette use have more than tripled since 2011. The most commonly cited reasons for the use of e-cigarettes by young adults are curiosity, taste (the attraction of different flavorings), and the perception that e-cigarettes are safe compared to other tobacco products. The use of e-cigarettes as an aid to quit conventional cigarettes is not reported as a primary reason for use among youth and young adults (Surgeon General 2 p. 8).
The greatest public health concern that has surfaced with the increasing use of electronic cigarettes is the idea of e-cigarettes as a “gateway” product to the use of conventional cigarettes. E-cigarette use is strongly associated with the use of other tobacco products among youth and young adults, particularly the use of traditional cigarettes. For example, in 2015, 58.8% of high school students who were current users of cigarettes were also current users of e-cigarettes (Surgeon General 2 p. 16). Concurrent use of both products may only indicate that high risk youth start either or both. However, a study published in the journal Tobacco Control goes further and states that "e-cigarette use is a risk factor for smoking onset, not just a marker of high risk for smoking . . . e-cigarettes are recruiting lower risk adolescents to smoking, which has public health implications” (Willis p. 536).
According to this study, teens who begin e-cigarette use become addicted to the nicotine in the e-liquid. Searching for a faster delivery method, these same teens may go on to use regular cigarettes. A study published last year in JAMA looked at 17,389 teens and young adults and found "strong and consistent evidence of an association between initial e-cigarette use and subsequent cigarette smoking” (p. 788). This means that low risk young people who would not otherwise have used cigarettes are lured into using e-cigarettes and are then more likely to go on to use regular cigarettes, increasing their risk of cancer, lung disease, and a whole host of other medical problems.
With the decreasing rates of traditional cigarette use, manufacturers have a problem – they need to recruit more smokers to replace those who are quitting or dying, or they will see profits decline. Many companies that market cigarettes have also moved into the e-cigarette market. According to the Surgeon General, "E-cigarette manufacturers are using tactics similar to those used to market conventional cigarettes to youth, including offering candy-flavored products; employing youth-minded themes, such as rebellion, glamour, and sex; getting celebrity endorsements; and obtaining sports and music sponsorships. Some groups have called for extending to e-cigarettes the same marketing restrictions that already apply to conventional cigarettes and other tobacco products (Surgeon General 2 p. 245).
E-cigarettes may have their place in helping adults who smoke traditional cigarettes to quit or at least to use a less harmful method of nicotine ingestion, but clearly their use by young adults is a public health issue. In the Surgeon General's report E-Cigarette Use by Youth and Young Adults, several strategies for the reduction of use of e-cigarettes by young people are suggested. One of this is to increase education about e-cigarettes. Colorado already has a home-grown program called Tar Wars that teaches fifth graders about the dangers of tobacco use. This program could be modified to include education about e-cigarettes as well. The Colorado Quitline has used billboards and ads to advertise its services. The same venues could be used to educate Coloradans about e-cigarettes (Surgeon General 2 p.5).
Another strategy for this problem would be to incorporate e-cigarettes into smoke free policies. According to the Surgeon General, the likelihood that young people will use e-cigarettes is increased by the belief that they can be used in places where conventional cigarette smoking is not allowed. E-cigarette marketing has included statements that e-cigarettes are exempt from clean air policies that restrict smoking (Surgeon General 2 p. 246). However, according to the State Tobacco Education and Prevention Partnership, "It is illegal for anyone — youth or adult — to use an electronic cigarette on school property in Colorado at any time (STEPP p. 2)." If e-cigarettes were included in smoking bans in all public places, we would likely see a decline in use like the decline in cigarette smoking in the last decade.
Finally, health care agencies and public policy makers could push the FDA for stronger regulation of e-cigarettes. According to the Surgeon General, "E-cigarette manufacturers are using tactics similar to those used to market conventional cigarettes to youth, including offering candy-flavored products; employing youth-minded themes, such as rebellion, glamour, and sex; getting celebrity endorsements; and obtaining sports and music sponsorships. Some groups have called for extending to e-cigarettes the same marketing restrictions that already apply to conventional cigarettes and other tobacco products (Surgeon General 2 p. 246)." Wills et al argue that "lobbying for regulation of e-cigarette marketing to adolescents has a sound public health rationale (p. 8)."
The Tobacco Control Act covers cigarettes, cigarette tobacco, roll-your-own tobacco, and smokeless tobacco and regulates content, mandates warning signs, and limits sales to minors. In 2016, the FDA became authorized to issue regulations “deeming” other products such as e-cigarettes to be tobacco products and therefore subject to the same authority. Consistent with the statute, once a tobacco product is deemed, the FDA may put in place “restrictions on the sale and distribution of a tobacco product,” including age-related access restrictions and advertising and promotion restrictions, if FDA determines the restrictions are appropriate for the protection of the public health (US Congress p. 28975). While the extension of the Tobacco Control Act to cover e-cigarettes is a great first step, there are still a lot of loopholes, including a grace period for companies to comply that can extend until 2022.
We know many valid ways to help prevent the use of cigarettes in teens and adolescents. What we need to do now is go forward with the application of these strategies and apply them to the use of other tobacco products, including electronic cigarettes. To be successful, we must approach the problem from many different angles: research, legislation, public health measures, advertising, and education campaigns. We must engage physicians, schools, families, and individuals. If we do not want to lose the battle for our nation's health, we must save our teenagers from a life of nicotine addiction. The time to act is now!
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