Health Policy Brief

Re: What necessary federal actions can be made to prevent the use of electronic cigarettes by adolescents?

Statement of Issue: Electronic cigarettes resemble cigarettes, cigars or pipes that deliver nicotine or similar substances to individuals in the from of vapor (1). Due to marketing claims that promote them as less hazardous alternatives to cigarette smoking, these products have become highly popular (1). As of December 2018, the Surgeon General declared that e-cigarettes use as become an epidemic among adolescents. Their use has increased dramatically over the past 5 years, and is higher among high school students than adults (3). Steps have to be taken to protect children from becoming addicted to nicotine and other associated health risks caused by these devices (1). State and local governments have attempted to regulate the sale, marketing and use of the devices to protect the health of individuals, however, better policies must be enforced to prevent the use of e-cigarettes by adolescents.  

E-cigarettes are unsafe for adolescents. E-cigarettes contain nicotine, heavy metals, ultrafine particles and volatile organic compounds (3). Nicotine is harmful for children and young adults, and they are increasing their risk of addiction and long-term harm to respiratory health and brain development (3).  

Teens are more likely to use e-cigarettes than cigarettes. Over the span of one month, 3.6 % of 8th graders, 6.3 % of 10th graders, ad 11.4 % of 12th graders smoked cigarettes (2). During the same month, 9.5 % of 8th graders, 14 % of 10th graders, and 16.2 % of 12th graders used e-cigarettes (2).

Manufacturers don’t report e-cigarette ingredients. During a study reported by the NIH, 66% of teens said just flavoring was in their e-cigarettes, 13.2% said nicotine, 5.8% said marijuana, 13.7% said they did not know, and 1.3% said other (2). Many users are unaware of what is actually in e-cigarettes. 

Teens exposure to e-cigarettes advertising. According to the NIH, 7 in 10 teens are exposed to e-cigarette advertisements (2). 52.8% of middle school students are exposed to retail ads, 35.8% to internet ads, 34.1% to movie and television ads, and 25% to magazine and newspaper ads (2). Among high school students, those percentages were even greater. 

The JUUL, an e-cigarette, has made it’s way into schools. The JUUL is small and resembles a USB flash drive, making it easier for adolescents to smoke in places like schools. The JUUL heats the cartridge of fluid to create a vapor (4). The smell of the smoke quickly goes away when the vapor is blown into the air or a backpack, making it a problem in middle schools and high schools (4). In addition, one JUUL cartridge has the same amount of nicotine as a pack of cigarettes, which many adolescents don’t know (4).

Stakeholders

The U.S. Department of Health and Human Services. The HHS works to protect the health of Americans and provides human services that are needed (10). They are able to create policies and strategies to prevent and decrease nicotine use among adolescents (5). 

The U.S. Food and Drug Administration. The FDA has the authority to regulate these products in how they are manufactured, marketed, and sold (5).

Researchers. Research on e-cigarettes is continuous and continues to change (5). Many health risks are known and the evidence of harms of nicotine are provided. Researching more about e-cigarette use and other associated health risks will educate adolescents and help implement laws.

School administrators. School administrators have the power to implement tobacco-free schools (12). They can issue advisories to parents and guardians regarding e-cigarette use, strengthen current school policies on e-cigarettes, promote messages through the school, and implement lesson plans that address the health risks of nicotine and e-cigarettes (12). 

Parents/ guardians. Parents and guardians can protect their children by educating them on the harms of e-cigarettes and also express that adolescents should not smoke any tobacco products or e-cigarettes of any kind (5). Parents can also make sure their cars and homes are completely smoke free, including no use by friends or family members while indoors (5). Parents can also set an example for their children by remaining tobacco free and stay supportive and encouraging to those trying to quit (5). 

Options Analysis

1. National mandate to include e-cigarettes in smoke free indoor policies. Many smoke free indoor policies only include traditional cigarettes. The aerosol produced from e-cigarettes is harmful and should be prohibited across the country.
2. Pros: E-cigarettes being included in these indoor air policies can remove health risks of secondhand aerosol, discourage individuals from using any tobacco products, and maintain the tobacco-free norms (5). In addition, these laws can help decrease the use of e-cigarettes by adolescents (5). 
3. Cons: Restricting individuals from using e-cigarettes in restaurants and other public places could drive away customers and business (11). It may also drive individuals to smoke elsewhere, and take away their autonomy to decide their personal choices (11). 
4. Federal mandate to restrict advertising and marketing that can encourage children and adolescents to use e-cigarettes (5). E-cigarette advertising has increased over the last few years, while advertising for regular cigarettes on television is prohibited (5). E-cigarettes are shown on television and other sources of media, which is how children and young adults are being exposed to it (5). Research suggests that television advertisement of e-cigarettes actually increases the likelihood that adolescents will use them and actually believe they are allowed to smoke indoors (5). It is marketed about safety and smoking cessation, and also serves as a trigger to current and former smokers to begin smoking again (5). 
5. Pros: According to research, 1/3 of adolescents experimenting with tobacco occurred as a result of exposure to advertising, sponsorship, and promotion (7). Banning these advertisements were one of the most effective ways to decrease the amount of tobacco consumption, and it may be just as effective for e-cigarettes (7). 
6. Cons: In a study conducted at Northwestern, an increase in the number of TV commercials for e-cigarettes decreased the sale of traditional cigarettes (6). In the study, a 10% increase of e-cigarette ads was linked to a decrease in regular cigarette sales by 0.2% (6). Many are worried that banning such advertisements will cause individuals to smoke traditional cigarettes.
7. National policy to implement educational programs on e-cigarette use in public schools. Adolescents who start to use these products that contain nicotine can become addicted. Implementing educational programs that can warn children and adolescents about the dangers of e-cigarettes could decrease their chance of trying it. The policy should provide education about the negative physiologic and social consequences of using e-cigarettes, and the social influences on using them. In addition, parents and faculty should be educated on the products.
8. Pros: School-based programs can prevent the start of e-cigarette use and can help individuals avoid difficulties of nicotine addiction (8). Educational programs will offer children and adolescents the knowledge of e-cigarette’s harms, understand deceptive advertisements, and how to practice acceptable refusal skills (9). Students will realize they are addictive devices and are unhealthy. Students may even influence their friends not to use the devices. 
9. Cons: Implementing these educational programs into every public school system could be very costly. In addition, it may be difficult to get such programs to be mandatory. 

 

Recommendation

The number of teenagers using e-cigarettes is increasing dramatically. Although a national policy to implement e-cigarette educational programs in schools would be beneficial, the cost may prevent it from being a mandatory action in all schools. While a national mandate to include e-cigarettes in smoke free indoor policies benefits society, it is not a recommended action to prevent adolescents from using e-cigarettes. E-cigarette ads are appealing to young adults because they use tactics such as themes of freedom, health claims, and use celebrity endorsements (13). Teens are constantly being exposed to these advertisements via television, radio, magazines, and apps on their phones. If there is a federal mandate to restrict advertising and marketing of e-cigarettes, it may decrease the likelihood that teens will use the devices. 

 

Sources

(1) https://publichealthlawcenter.org/topics/tobacco-control/e-cigarettes

(2)https://www.drugabuse.gov/related-topics/trends-statistics/infographics/teens-e-cigarettes

(3) https://e-cigarettes.surgeongeneral.gov/knowtherisks.html#behavior-risks

(4)https://medium.com/@BethelSD/e-cigarette-usage-on-the-rise-in-schools-3ca7ab3803d4

(5)https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/pdfs/2016_sgr_the_call-508.pdf

(6)https://insight.kellogg.northwestern.edu/article/why-banning-e-cigarette-ads-on-tv-could-backfire

(7) https://www.who.int/mediacentre/news/releases/2013/who_ban_tobacco/en/

(8) https://www.cdc.gov/MMWR/PREVIEW/MMWRHTML/00026213.htm

(9) https://catchinfo.org/modules/e-cigarettes/

(10)https://www.usa.gov/federal-agencies/u-s-department-of-health-and-human-services

(11) https://connectusfund.org/14-central-pros-and-cons-of-smoking-bans

(12) http://www.health.state.mn.us/divs/hpcd/tpc/topics/ecig_docs/2018_school_ecig_toolkit.pdf

(13) https://www.cancer.org/latest-news/report-more-and-more-teens-seeing-e-cigarette-ads.html