September 5, 2013

Stanton A. Glantz, PhD

Big success for ecig companies: US kids rapidly taking them up

As one would expect given the heavy marketing of ecigs to kids, today the CDC reported that ecig use among youth doubled last year.

This effect on kids is something that has been almost completely absent from the "ecigs as harm reduction" debate within the health community.  The fact that some kids are initiating their nicotine addiction with ecigs and that, like with adults, there is very high dual use with cigarettes, increases the liklihood that, in the end, ecigs will enhance harm by increasing smoking.

Needless to say, the ecig companies, like the cigarette companies that own many of them, will be "horrified" that kids are using them and loudly claim that those cherry flavored ecigs are really meant to help 50 year old smokers quit.

The ecig companies will also likely capitalize on public concern about kids using them to push for passage of more bad bills establishing preferential treatment for ecigs under the guide of youth access, much as the tobacco companies co-opted the Synar Amendment to pass bad youth access legislation decades ago.  (The American Cancer Society has been taking the lead in fighting these bad bills.)

One response is to urge the FDA to do something, which it should.  The problem is that all Mitch Zeller, head of the FDA Center for Tobacco Products, has said is that the FDA needs to do something sometime.  (The FDA has not even asserted authority over ecigs yet.)  Moreover, given the complexities of issuing regulations and defending them in court -- something the FDA has not done very well to date -- meaningful action by the FDA is probably years away. 

As a result, as as with most things in tobacco control, people need to start acting at the local and state level.

My priorities:

1. Ecigs should not be allowed to be used anywhere cigarettes are not allowed (i.e., in smokefree environments).  Over 100 communities and several states have already done this.

2. Ecigs should be subject to all the same sales and licensing restrictions as cigarettes, i.e., they should not be sold through the mail or in mall kiosks or anywhere near schools or anywhere that youth congregate.  Local governments can do this.

3. Flavors should be banned.

4. States need to include ecigs in their anti-tobacco marketing campaigns, especially the fact that they pollute the air.

5. The Attorneys General, who have been so active on cigarettes as a form of nicotine addiction, need to start clamping down on false claims made in marketing ecigs, including that they can be used anywhere, just emit harmless water vapor, and are effective cessation aids.

Ironically, the fact that the FDA has not done anything about ecigs makes it easier for local and state governments to act.

And the health community needs to broaden the discussion of the likely impacts of these products beyond the dweeby debate over whether or not they are better than NRT.  That is not the important question.  The important question is whether they have returned nicotine addiction to the wild west of the 1950s.

Here is the CDC press release:

E-cigarette use more than doubles among U.S. middle and high school students from 2011-2012

More than 75 percent of youth users smoke conventional cigarettes too
The percentage of U.S. middle and high school students who use electronic cigarettes, or e-cigarettes, more than doubled from 2011 to 2012, according to data published by the Centers for Disease Control and Prevention.  

The findings from the National Youth Tobacco Survey, in today’s Morbidity and Mortality Weekly Report, show that the percentage of high school students who reported ever using an e-cigarette rose from 4.7 percent in 2011 to 10.0 percent in 2012. In the same time period, high school students using e-cigarettes within the past 30 days rose from 1.5 percent to 2.8 percent.  Use also doubled among middle school students.  Altogether, in 2012 more than 1.78 million middle and high school students nationwide had tried e-cigarettes.  

"The increased use of e-cigarettes by teens is deeply troubling," said CDC Director Tom Frieden, M.D., M.P.H.  "Nicotine is a highly addictive drug.  Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes."

The study also found that 76.3 percent of middle and high school students who used e-cigarettes within the past 30 days also smoked conventional cigarettes in the same period. In addition, 1 in 5 middle school students who reported ever using e-cigarettes say they have never tried conventional cigarettes. This raises concern that there may be young people for whom e-cigarettes could be an entry point to use of conventional tobacco products, including cigarettes.   

“About 90 percent of all smokers begin smoking as teenagers,” said Tim McAfee, M.D., M.P.H., director of the CDC Office on Smoking and Health.  “We must keep our youth from experimenting or using any tobacco product. These dramatic increases suggest that developing strategies to prevent marketing, sales, and use of e-cigarettes among youth is critical.”  

Electronic cigarettes, or e-cigarettes, are battery-powered devices that provide doses of nicotine and other additives to the user in an aerosol. E-cigarettes not marketed for therapeutic purposes are currently unregulated by the Food and Drug Administration. The FDA Center for Tobacco Products has announced that it intends to expand its jurisdiction over tobacco products to include e-cigarettes, but has not yet issued regulatory rules. Because e-cigarettes are largely unregulated, the agency does not have good information about them, such as the amounts and types of components and potentially harmful constituents.

“These data show a dramatic rise in usage of e-cigarettes by youth, and this is cause for great concern as we don’t yet understand the long-term effects of these novel tobacco products,” said Mitch Zeller, director of FDA’s Center for Tobacco Products. “These findings reinforce why the FDA intends to expand its authority over all tobacco products and establish a comprehensive and appropriate regulatory framework to reduce disease and death from tobacco use.”

Although some e-cigarettes have been marketed as smoking cessation aids, there is no conclusive scientific evidence that e-cigarettes promote successful long-term quitting. However, there are proven cessation strategies and treatments, including counseling and FDA-approved cessation medications.

The full CDC study is on pages 21 and 22 of



I mostly agree with your recommendations.  Even if it turns out that e-cigs have therapeutic value, there is no reason that they should be used where cigarettes smoking is not permitted.  That does not help anyone to quit. In fact, it might trigger cueing for quitters. It certainly encourages dual use.  
Likewise, there is no reason whatsoever that these products should ever be used to initiate nicotine dependence in youth or anyone else.  Even if e-cigs were non-toxic, the risk that users would migrate to conventional cigarettes is too great.  
But I'm not sure if a blanket flavor ban is practical.  Unlike tobacco products which contain tobacco, e-cigs are tobacco-free and, therefore, devoid of the taste of anything beyond the chemicals they are made from.  Without some sort of flavoring, they may not be marketable.  If the goal is simply to ban them, then a flavor ban might help to accomplish that.  But if the goal is to regulate them carefully as MRTPs should  the manufacturers' applications support approval as such, then it might make more sense to limit flavors to those that are not likely to be targeting younger pallets. 
My sense is that there is little chance of banning these products entirely.  There may, in fact, be a therapeutic use for them if they are manufactured and marketed appropriately at the federal level and their sale and use is carefully regulated at the state or local level. But those are some big "ifs."  
So while I am confident that e-cigs will not not banned by FDA, I worry that allowing them into the market as "new tobacco products" rather than modified risk tobacco products might be the sort of mistake that will promote dual use and use by youth.  But if manufacturers can demonstrate that these are indeed safer products, they should be marked as such and not marketed as products that can be used anywhere or, as Jenny McCarthy pitches them for Lorillard, products that don't leave you smelling like an ashtray to your date as they would were they allowed in as new tobacco products. 
-Mark Gottlieb
Public Health Advocacy Institute at 
Northeastern University School of Law


I'd pretty much agree. However as regards:
"If manufacturers can demonstrate that these are indeed safer products..."
avoid the trap of the narrow definition of safer!
The number one risk of e-cigs is enabling continued exposure to cigarettes: dual use undermining cessation.
Jon Krueger

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