What to do about the fact that e-cig use among kids is exploding

Yesterday (April 16, 2015), the CDC and FDA released the 2014 data on youth smoking in the MMWR.
 
Consistent with earlier results from the Monitoring the Future and several state studies, e-cigarettes are now the leading form of recreational nicotine use among kids.  Hookahs also increased.  (Some of this may be e-cigarettes because some kids call e-cigarettes “e-hookahs’.)  Use of conventional cigarettes dropped.
 
E-cigarette advocates are making a big deal about the drop in cigarette use, claiming that this shows that e-cigarettes are a good thing because they are keeping kids from smoking.
 
A close look at the data, however, shows that:
 

• The increase in e-cigarette use was much larger than the drop in cigarette smoking
• Total tobacco product use increased compared to the last three years (when it had still been trending down)

 
The e-cigarette advocates have also ignored the fact that there have been major national tobacco control media campaigns during the last couple years (the CDC Tips from Former Smokers, the FDA Real Cost, and the relaunch of the Legacy truth campaign).  In addition, state efforts have been continuing.  These campaigns are all using proven messages, which have been demonstrated to reduce cigarette smoking among youth.
 
Most important, the increase in e-cigarette use was larger than the drop in conventional cigarette use.
 
Given that meaningful regulation of e-cigarettes by the FDA is years away, what should we do about it?
 
Include e-cigarettes in clean indoor air laws. 
 
One of the main reasons that both youth and adults use e-cigarettes is as a way to use recreational nicotine in places they can’t smoke cigarettes.  Including e-cigarettes in clean indoor air laws will not only protect bystanders to exposure to secondhand e-cigarette aerosol, it will reduce their appeal to kids.  This is something only localities and states can do; the FDA has no legal authority over where e-cigarettes (or any other tobacco product) are used.
 
E-cigarettes should be included in all tobacco control media campaigns.
 

• The CDC is already including an e-cigarette ad in its Tips from Former Smokers campaign warning smokers about dual use (the dominant pattern among both kids and adults), but this ad is not part of the television campaign.  It should be added to the TV campaign, as well as ads warning people that e-cigarettes pollute the air. 
• Legacy should include e-cigarettes in its truth campaign.  (While in its press release Legacy said that “we want to be clear that we absolutely know that any nicotine use by youth is unacceptable,” I was very troubled by this statement in about the new data: "Longitudinal studies like the National Institute of Health’s Population Assessment of Tobacco and Health and Legacy’s Teen Longitudinal Cohort will be coming out in the next few years. Those studies will deepen our understanding of e-cigarette use and help us answer what are still open questions today as to whether e-cigarette use is a gateway to smoking combustible products or to lifelong nicotine addiction.") 
• FDA should complement CDC efforts by warning youth about dual use.  This is an important health effect of smoking conventional cigarettes and can be done now, without waiting for the years that “deeming” jurisdiction over e-cigarettes will likely take.

 
State and local tobacco control media campaigns should follow the leads of Alaska, California, and San Francisco and integrate e-cigarettes into their media campaigns.  E-cigarette interests have been going berserk, particularly over the new California campaign (including a well-financed parody campaign attacking the California ads – compare the industry’s Notblowingsmoke.org with California’s Stillblowingsmoke.org -- which is probably the best evidence that the California Department of Public Health is on the right track).
 
Localities and states should include e-cigarettes in their tobacco licensing laws and only allow e-cigarettes to be sold in a limited number of specialty businesses that only sell e-cigarettes.  
 
Licenses should not be awarded to businesses near schools and playgrounds and such businesses should not be allowed to sell cigarettes or food and drink.  Some may argue that it is not logical to put more restrictions on where e-cigarettes are sold than more dangerous conventional cigarettes, but the fact is that conventional cigarettes cannot be advertised on television the way that e-cigarettes are.  (I think that such restrictions on sales locations should also be applied to cigarettes and other tobacco products, but that is a fight for another day.)
 
Tax e-cigarettes at levels high enough to deter youth use.
 
This is a no-brainer and one that the tobacco companies are aggressively moving to block by supporting very low state taxes to preempt meaningful taxation, as they did in Virginia a few months ago.
 
Given the exploding youth use and the evidence that, as used in the real world, the net effect of e-cigarettes is to keep adults smoking, these taxes should be at least as high as they are for cigarettes.
 
The FDA should include policies to limit the appeal and marketing of e-cigarettes to kids in its deeming rule that were recommended by health authorities.
 
While it will likely be years before the FDA secures authority over e-cigarettes (because tobacco interests will almost certainly sue no matter what FDA does), the not-yet issued rule should prohibit flavors and internet sales (something the FDA wanted to do that the White House removed from the draft rule before it was released for public comment), and limit advertising of e-cigarettes to direct-to-consumer marketing to established smokers.
 
Such a strengthening of the rule compared to the proposed rule released for public comment would be unusual, since the normal practice is that rules are only weakened in response to public comment and industry will complain that the FDA is going beyond its original proposal, but the fact is that there were many public comments submitted by health authorities calling the for FDA to strengthen the rule, so the necessary material is in the public comment docket to justify such strengthening.
 
Here are CDC and FDA’s precise findings:
 

“In 2014, e-cigarettes were the most commonly used tobacco product among middle (3.9%) and high (13.4%) school students. Between 2011 and 2014, statistically significant increases were observed among these students for current use of both e-cigarettes and hookahs (p1), causes addiction (3), and might lead to sustained tobacco use. For this reason, comprehensive and sustained strategies are needed to prevent and reduce the use of all tobacco products among youths in the United States.”

 
The full report is available here.