Adolescent e-cigarette use constitutes a major public health challenge that has reversed the steady progress made in the past three decades to reduce youth tobacco use in the United States (U.S.).
Although the prevalence of e-cigarette use has declined in the past two years, 24% of 12th grade students and 8.9% of 8th grade students in 2021 used e-cigarettes or engaged in vaping of any kind in the prior 30 days.
The current e-cigarette landscape is dominated by discrete and stylish pod-based e-cigarettes with varying capacity for customized nicotine delivery, vapor concealment, and child-appealing e-liquid flavors. E-cigarettes continue to evolve rapidly with innovative technology as manufacturers seek loopholes in regulatory efforts and to maximize existing marketing opportunities. Regulatory efforts so far have focused largely on marketing restrictions with enforcement decisions prioritizing smoking cessation potential of e-cigarettes for adult smokers over risk of nicotine addiction in adolescents. Disposable e-cigarette products advertising synthetic nicotine and menthol-containing products remain on the market and continue to gain popularity among adolescents. This article describes e-cigarette devices, provides an overview on epidemiology of U.S. adolescent e-cigarette use, and reviews the existing federal, state, and local e-cigarette regulations with future recommendations for stakeholders.
Introduction
E-cigarettes constitute a major public health challenge that has reversed the steady progress made in the past three decades to reduce youth tobacco use in the United States (U.S.).1,2 Rates of adolescent e-cigarette use remain remarkably high,3 largely driven by rapidly evolving e-cigarette technology,4 and aggressive youth-targeted marketing5–emphasizing the need for targeted prevention and control strategies.
E-cigarettes were first introduced to the U.S. in 20062 and in 2014 became the most common form of tobacco products used by adolescents, eclipsing other tobacco products including combustible cigarettes.2,3 In 2018, the U.S. Surgeon General declared youth e-cigarette use an epidemic due to the rapid increase in its uptake by adolescents and proliferation of potentially addictive and youth-appealing e-cigarette brands such as JUUL®.6,7
Most recently, the 2021 Monitoring the Future Survey indicated that nearly one in four (24%) 12th grade students and almost one in ten (8.9%) 8th grade students currently use e-cigarettes.3
Although the long-term adverse effects of e-cigarette use are yet to be fully established, some of the short-term clinical and public health consequences are now well-known including risk of nicotine addiction–which is harmful to the developing adolescent brain,2,8,9 progression to conventional cigarette smoking,10,11 and negative effects on respiratory health as exemplified by the EVALI (e-cigarette or vaping use-associated lung injury) outbreak that resulted in over 2800 hospitalizations and sixty-eight deaths in the U.S.12,13
Multilevel interventions to address adolescent e-cigarette use in the U.S. have included regulatory efforts on manufacturing and marketing, age and public use restriction policies, mass media campaigns, and school-based and clinical interventions.2,14Â Regulatory efforts have been delayed due to initial ambiguity on the authority of the U.S. Food and Drug Administration (FDA) to regulate e-cigarettes,15Â with subsequent postponement in the implementation of proposed regulations,16Â and regulatory bypass by e-cigarette companies through rapidly evolving product innovation.17,18Â Policy interventions to curb adolescent e-cigarette use at state and local government levels have included prohibition of sales of flavored e-cigarettes, expansion of comprehensive public smoking bans to include e-cigarettes, and increasing age-limit of tobacco purchase to age 21 years.7,18,19
This article defines and describes e-cigarette devices and use, provides an overview on epidemiology of adolescent e-cigarette use in the U.S., and reviews the existing federal, state, and local regulations to curb adolescent e-cigarette use with future recommendations for stakeholders.
Section snippets
Background and description
E-cigarettes or vaping devices utilize battery technology to generate inhalable aerosol from a solution (often called e-liquid) that typically contains nicotine, humectants (propylene glycol or vegetable glycerin), flavored chemicals, and other additives.2,3,20 The design and technology surrounding e-cigarettes vary widely but a typical e-cigarette has four primary components (Fig. 1)–a reservoir, cartridge or tank (containing the e-liquid); a heating coil; a sensor (to activate the heating
History and evolution
E-cigarettes were first introduced as battery-powered devices that resemble combustible cigarettes in design and dimensions.22Â For example, first generation e-cigarette products, also called cigalikes, shared similar design with conventional cigarettes in shape, size, and color, and came with prefilled or refillable cartridges for holding the e-liquid.2,21Â Similarly, second generation e-cigarettes are often shaped like pens but bigger than the first generation e-cigarettes because they have
Epidemiology
E-cigarettes are currently the most common tobacco products used by U.S. adolescents.3,30 The prevalence of adolescent e-cigarette use has risen steeply since it was first measured by the National Youth Tobacco Survey (NYTS) in 2011.2 Among U.S. adolescents in grades 6–12, prevalence of current e-cigarette use (past 30-day use) rose rapidly from 1.1% in 2011 to 11.3% in 2015.2 Prevalence of e-cigarette use continued to rise, peaking in 2019, with 27.5% of high school students and 10.5% of
Regulation and policies
Government regulation and policies to address adolescent e-cigarette use have revolved around three central themes—regulation of e-cigarette products including manufacturing and marketing restrictions; age-restriction on sales; and broadening existing tobacco control policies to include e-cigarettes.
Policy recommendations
More comprehensive public policy agenda and closure of existing regulatory loopholes are needed to sustain the noted decline in adolescent e-cigarette use. The FDA should further prioritize prevention of adolescent e-cigarette use in regulatory decision making. Current justification for permitting marketing of e-cigarette products, submitted through PMTAs, is that there are potential smoking cessation benefits for adults. However, adult smokers have FDA-approved evidence-based options for
Conclusion
Adolescent e-cigarette use remains a major public health challenge that requires comprehensive clinical, research and policy interventions to reverse. Although the prevalence of e-cigarette use has declined in the past two years, a sizeable proportion of U.S. adolescents still use e-cigarettes and are at risk of nicotine addiction. In 2021, more than two million middle and high school students reported current e-cigarette use.30 E-cigarettes continue to evolve rapidly with innovative technology
Olusegun Owotomo et al. – ScienceDirect – 2022-06-01.
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