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E-Cigarette Use Among Youth

and Young Adults: A Report of


the Surgeon General
2016

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES


Public Health Service
Office of the Surgeon General
Rockville, MD
National Library of Medicine Cataloging-in-Publication Data

Names: United States. Public Health Service. Office of the Surgeon General, issuing body. | National
Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and
Health, issuing body.
Title: E-cigarette use among youth and young adults : a report of the Surgeon General.
Description: Atlanta, GA : U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on
Smoking and Health, 2016. | Includes bibliographical references.
Subjects: MESH: Electronic Cigarettes – utilization. | Smoking – adverse effects. | Electronic Cigarettes –
adverse effects. | Tobacco Industry. | Young Adult. | Adolescent. | United States.
Classification: NLM QV 137

U.S. Department of Health and Human Services


Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Office on Smoking and Health

For more information

For more information about the Surgeon General’s report, visit www.surgeongeneral.gov.

To download copies of this document, go to www.cdc.gov/tobacco.

To order copies of this document, go to www.cdc.gov/tobacco and click on Publications


Catalog or call 1-800-CDC-INFO (1-800-232-4636); TTY: 1-888-232-6348.

Suggested Citation
U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young
Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

Use of trade names is for identification only and does not constitute endorsement by the
U.S. Department of Health and Human Services.
Message from Sylvia Burwell
Secretary, U.S. Department of Health and Human Services

The mission of the Department of Health and Human Services is to enhance and protect the
health and well-being of all Americans. This report confirms that the use of electronic cigarettes (or
e-cigarettes) is growing rapidly among American youth and young adults. While these products are
novel, we know they contain harmful ingredients that are dangerous to youth. Important strides have
been made over the past several decades in reducing conventional cigarette smoking among youth and
young adults. We must make sure this progress is not compromised by the initiation and use of new
tobacco products, such as e-cigarettes. That work is already underway.
To protect young people from initiating or continuing the use of e-cigarettes, actions must be
taken at the federal, state, and local levels. At the federal level, the U.S. Food and Drug Administration
(FDA)—under authority granted to it by Congress under the Family Smoking Prevention and Tobacco
Control Act of 2009—took a historic step to protect America’s youth from the harmful effects of using
e-cigarettes by extending its regulatory authority over the manufacturing, distribution, and marketing
of e-cigarettes. Through such action, FDA now requires minimum age restrictions to prevent sales
to minors and prohibits sales through vending machines (in any facility that admits youth), and will
require products to carry a nicotine warning.
We have more to do to help protect Americans from the dangers of tobacco and nicotine, espe-
cially our youth. As cigarette smoking among those under 18 has fallen, the use of other nicotine
products, including e-cigarettes, has taken a drastic leap. All of this is creating a new generation of
Americans who are at risk of nicotine addiction.
The findings from this report reinforce the need to support evidence-based programs to prevent
youth and young adults from using tobacco in any form, including e-cigarettes. The health and well-
being of our nation’s young people depend on it.

iii
Foreword

Tobacco use among youth and young adults in any form, including e-cigarettes, is not safe. In
recent years, e-cigarette use by youth and young adults has increased at an alarming rate. E-cigarettes
are now the most commonly used tobacco product among youth in the United States. This timely report
highlights the rapidly changing patterns of e-cigarette use among youth and young adults, assesses
what we know about the health effects of using these products, and describes strategies that tobacco
companies use to recruit our nation’s youth and young adults to try and continue using e-cigarettes.
The report also outlines interventions that can be adopted to minimize the harm these products cause
to our nation’s youth.
E-cigarettes are tobacco products that deliver nicotine. Nicotine is a highly addictive substance,
and many of today’s youth who are using e-cigarettes could become tomorrow’s cigarette smokers.
Nicotine exposure can also harm brain development in ways that may affect the health and mental
health of our kids.
E-cigarette use among youth and young adults is associated with the use of other tobacco prod-
ucts, including conventional cigarettes. Because most tobacco use is established during adolescence,
actions to prevent our nation’s young people from the potential of a lifetime of nicotine addiction are
critical.
E-cigarette companies appear to be using many of the advertising tactics the tobacco industry
used to persuade a new generation of young people to use their products. Companies are promoting
their products through television and radio advertisements that use celebrities, sexual content, and
claims of independence to glamorize these addictive products and make them appealing to young
people.
Comprehensive tobacco control and prevention strategies for youth and young adults should
address all tobacco products, including e-cigarettes. Further reductions in tobacco use and initiation
among youth and young adults are achievable by regulating the manufacturing, distribution, mar-
keting, and sales of all tobacco products—including e-cigarettes, and particularly to children—and
combining those approaches with other proven strategies. These strategies include funding tobacco
control programs at levels recommended by the Centers for Disease Control and Prevention (CDC);
increasing prices of tobacco products; implementing and enforcing comprehensive smokefree laws; and
sustaining hard-hitting media campaigns, such as CDC’s Tips from Former Smokers that encourages
smokers to quit for good, and FDA’s Real Cost that is aimed at preventing youth from trying tobacco and
reducing the number of youth who move from experimenting to regular use. We can implement these
cost-effective, evidence-based, life-saving strategies now. Together with additional effort and support,
we can protect the health of our nation’s young people.

Thomas R. Frieden, M.D., M.P.H.


Director
Centers for Disease Control and Prevention

v
Preface
from the Surgeon General

E-cigarette use among U.S. youth and young adults is now a major public health concern.
E-cigarette use has increased considerably in recent years, growing an astounding 900% among high
school students from 2011 to 2015. These products are now the most commonly used form of tobacco
among youth in the United States, surpassing conventional tobacco products, including cigarettes,
cigars, chewing tobacco, and hookahs. Most e-cigarettes contain nicotine, which can cause addiction
and can harm the developing adolescent brain.
Compared with older adults, the brain of youth and young adults is more vulnerable to the nega-
tive consequences of nicotine exposure. The effects include addiction, priming for use of other addic-
tive substances, reduced impulse control, deficits in attention and cognition, and mood disorders.
Furthermore, fetal exposure to nicotine during pregnancy can result in multiple adverse consequences,
including sudden infant death syndrome, altered corpus callosum, auditory processing deficits, effects
on behaviors and obesity, and deficits in attention and cognition. Ingestion of e-cigarette liquids con-
taining nicotine can also cause acute toxicity and possibly death if the contents of refill cartridges or
bottles containing nicotine are consumed.
This report highlights what we know and do not know about e-cigarettes. Gaps in scientific evi-
dence do exist, and this report is being issued while these products and their patterns of use continue to
change quickly. For example, the health effects and potentially harmful doses of heated and aerosolized
constituents of e-cigarette liquids—including solvents, flavorants, and toxicants—are not completely
understood. However, although e-cigarettes generally emit fewer toxicants than combustible tobacco
products, we know that aerosol from e-cigarettes is not harmless.
Although we continue to learn more about e-cigarettes with each passing day, we currently know
enough to take action to protect our nation’s young people from being harmed by these products.
Previous reports of the Surgeon General have established that nearly all habitual tobacco use begins
during youth and young adulthood. To prevent and reduce the use of e-cigarettes by youth and young
adults, we must work together as a society. We must implement proven prevention and education strat-
egies. Health care providers, parents, teachers, and other caregivers should advise youth about the
dangers of nicotine and discourage tobacco use in any form, including e-cigarettes. They can set a posi-
tive example by being tobacco-free and encouraging those who already use these products to quit. Free
help is available at 1-800-QUIT-NOW or http://www.smokefree.gov. Preventing tobacco use in any form
among youth and young adults is critical to ending the tobacco epidemic in the United States.

Vivek H. Murthy, M.D., M.B.A.


U.S. Surgeon General

vii
E-Cigarette Use Among Youth and Young Adults

Acknowledgments Melissa Harrell, Ph.D., M.P.H., Senior Scientific Editor,


Associate Professor, Department of Health Promotion and
This report was prepared by the U.S. Department of Health Behavioral Sciences and the Michael & Susan Dell Center
and Human Services under the general direction of the for Healthy Living, The University of Texas Health Science
Centers for Disease Control and Prevention, National Center at Houston (UTHealth) School of Public Health,
Center for Chronic Disease Prevention and Health Austin, Texas.
Promotion, Office on Smoking and Health.
MeLisa R. Creamer, Ph.D., M.P.H., Senior Scientific Editor,
Vice Admiral (VADM) Vivek H. Murthy, M.D., M.B.A., Faculty Associate, Department of Health Promotion and
Surgeon General, Office of the Surgeon General, Office Behavioral Sciences and the Michael & Susan Dell Center
of the Secretary, U.S. Department of Health and Human for Healthy Living, The University of Texas Health Science
Services, Washington, D.C. Center at Houston (UTHealth) School of Public Health,
Austin, Texas.
Thomas R. Frieden, M.D., M.P.H., Director, Centers for
Disease Control and Prevention, Atlanta, Georgia. Steven Kelder, Ph.D., Senior Scientific Editor, Beth Toby
Grossman Distinguished Professor of Spirituality and
Ursula E. Bauer, Ph.D., M.P.H., Director, National Center Healing; Associate Regional Dean; Co-Director, Michael &
for Chronic Disease Prevention and Health Promotion, Susan Dell Center for Healthy Living; Professor, Division
Centers for Disease Control and Prevention, Atlanta, of Epidemiology, Human Genetics, and Environmental
Georgia. Sciences, The University of Texas Health Science Center
at Houston (UTHealth) School of Public Health, Austin,
Dana Shelton, M.P.H., Deputy Director, National Center Texas.
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta, Brian King, Ph.D., Senior Associate Editor, Deputy
Georgia. Director for Research Translation, Office on Smoking and
Health, National Center for Chronic Disease Prevention
Peter A. Briss, M.D., M.P.H., Medical Director, National and Health Promotion, Centers for Disease Control and
Center for Chronic Disease Prevention and Health Prevention, Atlanta, Georgia.
Promotion, Centers for Disease Control and Prevention,
Atlanta, Georgia. Leslie A. Norman, M.B.A., Managing Editor, Office on
Smoking and Health, National Center for Chronic Disease
Rachel Kaufmann, Ph.D., M.P.H., Associate Director for Prevention and Health Promotion, Centers for Disease
Science, National Center for Chronic Disease Prevention Control and Prevention, Atlanta, Georgia.
and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia. Peter L. Taylor, M.B.A., Technical Editor, Fairfax, Virginia.

Corinne Graffunder, Dr.P.H., M.P.H., Director, Office on


Smoking and Health, National Center for Chronic Disease Contributing editors were
Prevention and Health Promotion, Centers for Disease Thomas Eissenberg, Ph.D., Director, Center for the
Control and Prevention, Atlanta, Georgia. Study of Tobacco Products; Professor of Psychology
(Health Program), College of Humanities and Sciences
and Member Scientist, Massey Cancer Center, Virginia
Editors of the report were Commonwealth University, Richmond, Virginia.
Cheryl L. Perry, Ph.D., Senior Scientific Editor, Professor
and Regional Dean, The Rockwell Distinguished Chair Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco
in Society and Health, The University of Texas Health Control Research Branch, Behavioral Research Program,
Science Center at Houston (UTHealth) School of Public Division of Cancer Control and Population Sciences,
Health, Austin, Texas. National Cancer Institute, National Institutes of Health,
Rockville, Maryland.

ix
A Report of the Surgeon General

Pamela Ling, M.D., M.P.H., Professor, Division of General Allison M. Glasser, M.P.H., Senior Project Manager, The
Internal Medicine, Department of Medicine, Center for Schroeder Institute for Tobacco Research and Policy
Tobacco Control Research and Education, University of Studies at Truth Initiative, Washington, D.C.
California, San Francisco, California.
Maciej L. Goniewicz, Ph.D., Pharm.D., Assistant Professor
Mark Parascandola, Ph.D., M.P.H., Epidemiologist, of Oncology, Department of Health Behavior, Roswell Park
Tobacco Control Research Branch, Behavioral Research Cancer Institute, Buffalo, New York.
Program, Division of Cancer Control and Population
Sciences, National Cancer Institute, National Institutes of Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco
Health, Rockville, Maryland. Control Research Branch, Behavioral Research Program,
Division of Cancer Control and Population Sciences,
Jennifer L. Pearson, Ph.D., M.P.H., Research Investigator, National Cancer Institute, National Institutes of Health,
The Schroeder Institute for Tobacco Research and Policy Rockville, Maryland.
Studies at Truth Initiative, Washington, D.C.; Adjunct
Assistant Professor, Department of Health, Behavior, Lisa Henriksen, Ph.D., Senior Research Scientist,
and Society, Bloomberg School of Public Health, Johns Stanford Prevention Research Center, Department of
Hopkins University, Baltimore, Maryland. Medicine, School of Medicine, Stanford University, Palo
Alto, California.
Jonathan M. Samet, M.D., M.S., Distinguished Professor
and Flora L. Thornton Chair, Department of Preventive Jidong Huang, Ph.D., Senior Research Scientist, Institute
Medicine, Keck School of Medicine; Director, Institute for Health Research and Policy, University of Illinois at
for Global Health, University of Southern California, Los Chicago, Chicago, Illinois.
Angeles, California.
Lauren K. Katz, M.P.H., Research Associate I, The
Andrea C. Villanti, Ph.D., M.P.H., Director for Schroeder Institute for Tobacco Research and Policy
Regulatory Science and Policy, The Schroeder Institute Studies at Truth Initiative, Washington, D.C.
for Tobacco Research and Policy Studies at Truth
Initiative, Washington, D.C.; Adjunct Assistant Professor, Frances Leslie, Ph.D., Vice Provost for Graduate Education;
Department of Health, Behavior, and Society, Bloomberg Dean of the Graduate Division; Professor of Pharmacology
School of Public Health, Johns Hopkins University, and Anatomy and Neurobiology, University of California,
Baltimore, Maryland. Irvine, California.

M. Jane Lewis, D.Ph., Associate Professor, Health


Contributing authors were Education and Behavioral Science and Center for Tobacco
Studies, School of Public Health, Rutgers University, New
Melissa D. Blank, Ph.D., Assistant Professor, Department
Brunswick, New Jersey.
of Psychology, West Virginia University, Morgantown,
West Virginia.
Kristy Marynak, M.P.P., Public Health Analyst, Office on
Smoking and Health, National Center for Chronic Disease
Frank J. Chaloupka, Ph.D., Director, Health Policy Center,
Prevention and Health Promotion, Centers for Disease
Institute for Health Research and Policy, and Distinguished
Control and Prevention, Atlanta, Georgia.
Professor, Department of Economics, University of Illinois
at Chicago, Chicago, Illinois.
Mark Parascandola, Ph.D., M.P.H., Epidemiologist,
Tobacco Control Research Branch, Behavioral Research
Shari P. Feirman, Ph.D., M.S., Project Director for
Program, Division of Cancer Control and Population
Regulatory Science and Policy, The Schroeder Institute for
Sciences, National Cancer Institute, National Institutes of
Tobacco Research and Policy Studies at Truth Initiative,
Health, Rockville, Maryland.
Washington, D.C.
Terry F. Pechacek, Ph.D., Professor and Interim Division
Jonathan Foulds, Ph.D., Professor, Departments of Public
Director of Health Management and Policy, School of
Health Sciences and Psychiatry, College of Medicine, Penn
Public Health, Georgia State University, Atlanta, Georgia.
State University, Hershey, Pennsylvania.

x
E-Cigarette Use Among Youth and Young Adults

Gabbi Promoff, M.A., Associate Director for Policy, Office Heather Rubino Althouse, Senior Regulatory Counsel,
on Smoking and Health, National Center for Chronic Office of Compliance and Enforcement, Center for
Disease Prevention and Health Promotion, Centers for Tobacco Products, U.S. Food and Drug Administration,
Disease Control and Prevention, Atlanta, Georgia. Silver Spring, Maryland.

Kurt M. Ribisl, Ph.D., Professor, Department of Health René A. Arrazola, M.P.H., Epidemiologist, Epidemiology
Behavior, University of North Carolina Gillings School Branch, Office on Smoking and Health, National Center
of Global Public Health; Program Leader in Cancer for Chronic Disease Prevention and Health Promotion,
Prevention and Control, University of North Carolina Centers for Disease Control and Prevention, Atlanta,
Lineberger Comprehensive Cancer Center, Chapel Hill, Georgia.
North Carolina.
David L. Ashley, Ph.D., Director, Office of Science, Center
April Roeseler, B.S.N., M.S.P.H., Chief, California Tobacco for Tobacco Products, U.S. Food and Drug Administration,
Control Program, California Department of Public Health, Silver Spring, Maryland.
Sacramento, California.
Cathy L. Backinger, Ph.D., M.P.H., Deputy Director for
Jonathan M. Samet, M.D., M.S., Distinguished Professor Research, Office of Science, Center for Tobacco Products,
and Flora L. Thornton Chair, Department of Preventive U.S. Food and Drug Administration, Silver Spring,
Medicine, Keck School of Medicine; Director, Institute Maryland.
for Global Health, University of Southern California, Los
Angeles, California. Tracey E. Barnett, Ph.D., Associate Professor, Department
of Epidemiology, College of Public Health and Health
Laura R. Stroud, Ph.D., Senior Research Scientist, Professions and College of Medicine, University of Florida,
Centers for Behavioral and Preventive Medicine, The Gainesville, Florida.
Miriam Hospital; Associate Professor, Department of
Psychiatry and Human Behavior, Alpert Medical School, Neal L. Benowitz, M.D., Professor of Medicine,
and Department of Behavioral and Social Sciences, School Bioengineering, and Therapeutic Sciences, Chief, Division
of Public Health, Brown University, Providence, Rhode of Clinical Pharmacology, University of California, San
Island.  Francisco, California.

Prue Talbot, Ph.D., Director, University of California, Jay M. Bernhardt, Ph.D., M.P.H., Interim Dean and
Riverside Stem Cell Center and Core; Professor of Cell Professor, Moody College of Communication; Founding
Biology, Department of Cell Biology and Neuroscience, Director, Center for Health Communication, The
University of California, Riverside, California. University of Texas, Austin, Texas.

Mark Travers, Ph.D., M.S., Assistant Professor of Oncology, Nazleen Bharmal, M.D., Ph.D., M.P.P., Director of Science
Department of Health Behavior and Air Pollution Exposure and Policy, Office of the Surgeon General, U.S. Department
Research Laboratory, Roswell Park Cancer Institute, of Health and Human Services, Washington, D.C.
Buffalo, New York.
Allan M. Brandt, Ph.D., Amalie Moses Kass Professor of
Scott Weaver, Ph.D., M.A., Assistant Professor, Division of the History of Medicine, Department of Global Health
Epidemiology and Biostatistics, School of Public Health, and Social Medicine, Harvard University Medical School,
Georgia State University, Atlanta, Georgia. Boston, Massachusetts.

April Brubach, M.A., Director, Division of Public Health


Reviewers were Education, Office of Health Communication and
Education, Center for Tobacco Products, U.S. Food and
David B. Abrams Ph.D., Executive Director, The Schroeder
Drug Administration, Silver Spring, Maryland.
Institute for Tobacco Research and Policy Studies at Truth
Initiative, Washington, D.C.; Professor, Department of
Priscilla Callahan-Lyon, M.D., Medical Branch Chief,
Health, Behavior, and Society, Bloomberg School of
Division of Individual Health Science, Office of Science,
Public Health, Johns Hopkins University, Baltimore,
Center for Tobacco Products, U.S. Food and Drug
Maryland; Professor of Oncology, Georgetown University
Administration, Silver Spring, Maryland.
Medical Center, Lombardi Comprehensive Cancer Center
(adjunct), Washington, D.C.

xi
A Report of the Surgeon General

Frank J. Chaloupka, Ph.D., Director, Health Policy Center, Neal D. Freedman, Ph.D., M.P.H., Senior Investigator,
Institute for Health Research and Policy; Distinguished Metabolic Epidemiology Branch, Division of Cancer
Professor, Department of Economics, University of Illinois Epidemiology and Genetics, National Cancer Institute,
at Chicago, Chicago, Illinois. National Institutes of Health, Rockville, Maryland.

Ii-Lun Chen, M.D., Director, Division of Individual Health Elizabeth M. Ginexi, Ph.D., Program Director, Tobacco
Science, Office of Science, Center for Tobacco Products, Control Research Branch, Division of Cancer Control and
U.S. Food and Drug Administration, Silver Spring, Population Sciences, National Cancer Institute, National
Maryland. Institutes of Health, Rockville, Maryland.

Beverly Chernaik, J.D., Director, Office of Regulations, Gary A. Giovino, Ph.D., M.S., Professor and Chair,
Center for Tobacco Products, U.S. Food and Drug Department of Community Health and Health Behavior,
Administration, Silver Spring, Maryland. School of Public Health and Health Professions, University
at Buffalo, The State University of New York, Buffalo, New
Joanna E. Cohen, Ph.D., Director, Institute for Global York.
Tobacco Control; Bloomberg Professor of Disease
Prevention, Department of Health, Behavior, and Society, Stanton A. Glantz, Ph.D., Professor of Medicine and
Bloomberg School of Public Health, Johns Hopkins American Legacy Foundation Distinguished Professor in
University, Baltimore, Maryland. Tobacco Control; Director, Center for Tobacco Control
Research and Education, University of California, San
Catherine G. Corey, M.S.P.H., Epidemiologist, Office of Francisco, California.
Science, Center for Tobacco Products, U.S. Food and Drug
Administration, Silver Spring, Maryland. Maciej L. Goniewicz, Ph.D., Pharm.D., Assistant Professor
of Oncology, Department of Health Behavior, Roswell Park
Kathleen Crosby, Director, Office of Health Communication Cancer Institute, Buffalo, New York.
and Education, Center for Tobacco Products, U.S. Food
and Drug Administration, Silver Spring, Maryland. Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco
Control Research Branch, Behavioral Research Program,
Cristine D. Delnevo, Ph.D., M.P.H., Professor and Director, Division of Cancer Control and Population Sciences,
Center for Tobacco Studies, Rutgers School of Public National Cancer Institute, National Institutes of Health,
Health, New Brunswick, New Jersey. Rockville, Maryland.

Lauren M. Dutra, Sc.D., M.A., Postdoctoral Fellow, Center Bonnie Halpern-Felsher, Ph.D., FSAHM, Director of
for Tobacco Control Research and Education, University of Research, Professor, Division of Adolescent Medicine,
California, San Francisco, California. Stanford University, Palo Alto, California.

Lucinda J. England, M.D., M.S.P.H., Medical Officer, Office Dorothy K. Hatsukami, Ph.D., Forster Family Professor in
on Smoking and Health, National Center for Chronic Cancer Prevention, Masonic Cancer Center, University of
Disease Prevention and Health Promotion, Centers for Minnesota, Minneapolis, Minnesota.
Disease Control and Prevention, Atlanta, Georgia.
Corinne Husten, M.D., M.P.H., Senior Medical Advisor,
Michael P. Eriksen, Sc.D., Sc.M., Dean and Regents’ Center for Tobacco Products, U.S. Food and Drug
Professor, Division of Health Management and Policy, Administration, Silver Spring, Maryland.
School of Public Health, Georgia State University, Atlanta,
Georgia. Ronald L. Johnson, Ph.D., Program Director, DNA and
Chromosome Aberrations Branch, Division of Cancer
Michael C. Fiore, M.D., M.P.H., M.B.A., University of Biology, National Cancer Institute, National Institutes of
Wisconsin Hilldale Professor of Medicine; Director, Center Health, Bethesda, Maryland.
for Tobacco Research and Intervention, University of
Wisconsin School of Medicine and Public Health, Madison, Sarah E. Johnson, Ph.D., Social Scientist, Office of
Wisconsin. Science, Center for Tobacco Products, U.S. Food and Drug
Administration, Silver Spring, Maryland.

xii
E-Cigarette Use Among Youth and Young Adults

Annette R. Kaufman, Ph.D., M.P.H., Health Scientist and Richard J. O’Connor, Ph.D., Member and Professor of
Program Director, Tobacco Control Research Branch, Oncology, Department of Health Behavior, Division of
Behavioral Research Program, Division of Cancer Control Cancer Prevention and Population Sciences, Roswell Park
and Population Sciences, National Cancer Institute, Cancer Institute, Buffalo, New York.
National Institutes of Health, Rockville, Maryland.
Mark Parascandola, Ph.D., M.P.H., Epidemiologist,
Ryan David Kennedy, Ph.D., Assistant Professor, Institute Tobacco Control Research Branch, Behavioral Research
for Global Tobacco Control, Department of Health, Program, Division of Cancer Control and Population
Behavior, and Society, Bloomberg School of Public Health, Sciences, National Cancer Institute, National Institutes of
Johns Hopkins University, Baltimore, Maryland. Health, Rockville, Maryland.

Jonathan D. Klein, M.D., M.P.H., F.A.A.P., Associate Terry F. Pechacek, Ph.D., Professor and Interim Division
Executive Director; Director, Julius B. Richmond Center, Director of Health Management and Policy, School of
American Academy of Pediatrics, Elk Grove Village, Public Health, Georgia State University, Atlanta, Georgia.
Illinois.
Alexander Persoskie, Ph.D., Social Scientist, Center for
Suchitra Krishnan-Sarin, Ph.D., Professor, Department Tobacco Products, U.S. Food and Drug Administration,
of Psychiatry, School of Medicine, Yale University, New Silver Spring, Maryland.
Haven, Connecticut.
John P. Pierce, Ph.D., Professor Emeritus, Department of
Lauren K. Lempert, J.D., M.P.H., Associate Specialist, Family Medicine and Public Health and the Moores Cancer
Center for Tobacco Control Research and Education, Center, University of California, San Diego, La  Jolla,
University of California, San Francisco, California. California.

Maggie Mahoney, J.D., Executive Director, Tobacco David W. Racine, M.S., Senior Program Management
Control Legal Consortium at the Public Health Law Officer, Office of Compliance and Enforcement, Center for
Center, St. Paul, Minnesota. Tobacco Products, U.S. Food and Drug Administration,
Silver Spring, Maryland.
Tim McAfee, M.D., Medical Officer, Office on Smoking and
Health, National Center for Chronic Disease Prevention Chad J. Reissig, Ph.D., Addiction Branch Chief, Office of
and Health Promotion, Centers for Disease Control and Science, Center for Tobacco Products, U.S. Food and Drug
Prevention, Atlanta, Georgia. Administration, Silver Spring, Maryland.

Daniel McGoldrick, M.A., Vice President, Global Health Joelle Robinson, M.P.H., Social Scientist, Office of
Advocacy Incubator, Campaign for Tobacco-Free Kids, Science, Center for Tobacco Products, U.S. Food and Drug
Washington, D.C. Administration, Silver Spring, Maryland.

Cindy Miner, Ph.D., Associate Director for Scientific Jonathan M. Samet, M.D., M.S., Distinguished Professor
Communication, Office of Science, Center for Tobacco and Flora L. Thornton Chair, Department of Preventive
Products, U.S. Food and Drug Administration, Silver Medicine, Keck School of Medicine; Director, Institute
Spring, Maryland. for Global Health, University of Southern California, Los
Angeles, California.
Matthew L. Myers, J.D., President, Campaign for Tobacco-
Free Kids, Washington, D.C. Peter G. Shields, M.D., Deputy Director, Comprehensive
Cancer Center, James Cancer Hospital; Professor, College
Linda J. Neff, Ph.D., Senior Epidemiologist, Epidemiology of Medicine, The Ohio State University, Columbus, Ohio.
Branch, Office on Smoking and Health, National Center
for Chronic Disease Prevention and Health Promotion, Ann Simoneau, J.D., M.B.A., Director, Office of Compliance
Centers for Disease Control and Prevention, Atlanta, and Enforcement, Center for Tobacco Products, U.S. Food
Georgia. and Drug Administration, Silver Spring, Maryland.

xiii
A Report of the Surgeon General

Theodore A. Slotkin, Ph.D., Professor, Department of Tara Christine Chu, M.P.H., Research Associate to
Pharmacology and Cancer Biology, Duke University Jonathan M. Samet, M.D., M.S., Department of Preventive
Medical Center, Durham, North Carolina. Medicine, Keck School of Medicine, University of Southern
California, Los Angeles, California.
Anne Sowell, Ph.D., Health Scientist, National Center
for Chronic Disease Prevention and Health Promotion, Stephanie L. Clendennen, M.P.H., Predoctoral Fellow,
Centers for Disease Control and Prevention, Atlanta, Tobacco Center of Regulatory Science on Youth and
Georgia. Young Adults, The University of Texas Health Science
Center at Houston (UTHealth) School of Public Health,
Erin L. Sutfin, Ph.D., Associate Professor and Vice Chair, Austin, Texas.
Department of Social Sciences and Health Policy, Division
of Public Health Sciences, Wake Forest School of Medicine, Sarah J. Cross, Graduate Student Researcher, Department
Wake Forest University, Winston-Salem, North Carolina. of Anatomy and Neurobiology, University of California,
Irvine, California.
Robert E. Vollinger, Jr., M.S.P.H., (Dr.P.H. Candidate),
Program Director and Public Health Advisor, Tobacco Nicholas J. Felicione, Graduate Research Assistant,
Control Research Branch, Behavioral Research Program, Department of Psychology, West Virginia University,
Division of Cancer Control and Population Sciences, Morgantown, West Virginia.
National Cancer Institute, National Institutes of Health,
Rockville, Maryland. Kyle R. Gregory, J.D., M.S.H.A., Postdoctoral Research
Associate, Tobacco Center of Regulatory Science, School of
Kenneth E. Warner, Ph.D., Avedis Donabedian Public Health, Georgia State University, Atlanta, Georgia.
Distinguished University Professor of Public Health,
Department of Health Management and Policy, University Emily T. Hébert, M.P.H., Doctoral Student, Michael &
of Michigan School of Public Health, Ann Arbor, Susan Dell Center for Healthy Living, The University
Michigan. of Texas Health Science Center at Houston (UTHealth)
School of Public Health, Austin, Texas.
Geoffrey Ferris Wayne, M.A., Research Consultant,
Sebastopol, California. Erin O’Connor Landau, M.S., Data Analyst, DB Consulting
Group (Contractor), Office on Smoking and Health,
Deborah M. Winn, Ph.D., Deputy Director, Division National Center for Chronic Disease Prevention and
of Cancer Control and Population Sciences, National Health Promotion, Centers for Disease Control and
Cancer Institute, National Institutes of Health, Rockville, Prevention, Atlanta, Georgia.
Maryland.
Pamela Lemos, M.S., Public Health Analyst, Office on
Mitchell Zeller, J.D., Director, Center for Tobacco Smoking and Health, National Center for Chronic Disease
Products, U.S. Food and Drug Administration, Silver Prevention and Health Promotion, Centers for Disease
Spring, Maryland. Control and Prevention, Atlanta, Georgia.

Gerald V. [Simon] McNabb, Lead Public Health Analyst,


Other contributors were Office on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Katherine J. Asman, M.S.P.H., Statistician, Biostatistics
Disease Control and Prevention, Washington, D.C.
and Epidemiology Division, RTI International, Atlanta,
Georgia.
Ronald L. Johnson, Ph.D., Program Director, DNA and
Chromosome Aberrations Branch, Division of Cancer
Adam J. Burke, M.A., Research Associate Lead, The
Biology, National Cancer Institute, National Institutes of
Monitoring the Future Study, University of Michigan, Ann
Health, Bethesda, Maryland.
Arbor, Michigan.
Hoda S. Magid, M.H.S., Center for Tobacco Control
Dayana Chanson, M.P.H., Research Associate to Jonathan
Research and Education, University of California,
M. Samet, M.D., M.S., Department of Preventive Medicine,
San Francisco, California.
Keck School of Medicine, University of Southern
California, Los Angeles, California.

xiv
E-Cigarette Use Among Youth and Young Adults

Dale Mantey, M.P.A., Predoctoral Fellow, Tobacco Center Anna Teplinskaya, M.D., M.P.H., Public Health Analyst,
of Regulatory Science on Youth and Young Adults, The Epidemiology Branch, Office on Smoking and Health,
University of Texas Health Science Center at Houston National Center for Chronic Disease Prevention and
(UTHealth) School of Public Health, Austin, Texas. Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.
Mandie Mills, Photographer, Office of the Associate
Director for Communication, Centers for Disease Control Tenecia Smith, M.P.H., Data Analyst, DB Consulting Group
and Prevention, Atlanta, Georgia. (Contractor), Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health
Richard Miech, Ph.D., Professor, Institute for Social Promotion, Centers for Disease Control and Prevention,
Research, University of Michigan, Ann Arbor, Michigan. Atlanta, Georgia.

Luz M. Moncayo, Executive Assistant to Jonathan M. Kathryn E. Szynal, Editorial Assistant, McNeal
Samet, M.D., M.S., Department of Preventive Medicine, Professional Services (Contractor), Office on Smoking and
Keck School of Medicine, Institute for Global Health, Health, National Center for Chronic Disease Prevention
University of Southern California, Los Angeles, California. and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.
Maureen O’Brien, J.D., Staff Attorney, Tobacco Control
Legal Consortium at the Public Health Law Center, Teresa Wang, Ph.D., M.S., Epidemic Intelligence Service
St. Paul, Minnesota. Officer, Lieutenant, U.S. Public Health Service, Office on
Smoking and Health, National Center for Chronic Disease
Patrick M. O’Malley, Ph.D., Research Professor, Survey Prevention and Health Promotion, Centers for Disease
Research Center, Institute for Social Research, University Control and Prevention, Atlanta, Georgia.
of Michigan, Ann Arbor, Michigan.
Jennifer Whitmill, M.P.H., Data Analyst, DB Consulting
Gabriela V. Portillo, Masters Student, Michael & Susan Group (Contractor), Office on Smoking and Health,
Dell Center for Healthy Living, The University of Texas National Center for Chronic Disease Prevention and
Health Science Center at Houston (UTHealth) School of Health Promotion, Centers for Disease Control and
Public Health, Austin, Texas. Prevention, Atlanta, Georgia

xv
E-Cigarette Use Among Youth and Young Adults

Chapter 1   Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 1


Introduction 3
Major Conclusions 5
Chapter Conclusions 6
Historical Background 8
The E-Cigarette 10
E-Cigarette Companies 14
Federal Regulation of E-Cigarettes 15
Summary 18
References 19

Chapter 2   Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 25
Introduction 27
Key Findings 28
Evidence Summary 86
Conclusions 88
References 89

Chapter 3   Health Effects of E‑Cigarette Use Among U.S. Youth and Young Adults 95
Introduction 97
Conclusions from Previous Surgeon General’s Reports 97
Health Effects of E‑Cigarette Use 100
Evidence Summary 124
Conclusions 125
References 126

Chapter 4   Activities of the E-Cigarette Companies 147


Introduction 149
Manufacturing and Price 149
Marketing and Promotion of E-Cigarettes 157
Evidence Summary 172
Conclusions 172
References 173

Chapter 5   E-Cigarette Policy and Practice Implications 181


Introduction 183
Critical Issues Related to Policies on E-Cigarettes in 2016 184
Potential Public Policy Approaches 187
Case Studies 224
Summary and Recommendations 225
Conclusions 226
References 227

xvii
The Call to Action 235
The Call to Action on E-Cigarette Use Among Youth and Young Adults 237
Goal 1. First, Do No Harm 237
Goal 2. Provide Information About the Dangers of E-Cigarette Use Among Youth
and Young Adults 239
Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to Protect Public Health 241
Goal 4. Programs and Policies to Prevent E-Cigarette Use Among Youth and Young Adults 243
Goal 5. Curb Advertising and Marketing that Encourages Youth and Young Adults
to Use E-Cigarettes 246
Goal 6. Expand Surveillance, Research, and Evaluation Related to E-Cigarettes 247
Conclusions 249
References 250

List of Abbreviations 253

List of Tables and Figures 257

Index 261

xviii
Chapter 1
Introduction, Conclusions, and Historical Background
Relative to E-Cigarettes

Introduction 3
Organization of the Report 4
Preparation of this Report 4
Scientific Basis of the Report 5

Major Conclusions 5

Chapter Conclusions 6
Chapter 1. Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 6
Chapter 2. Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 6
Chapter 3. Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 6
Chapter 4. Activities of the E-Cigarette Companies 7
Chapter 5. E-Cigarette Policy and Practice Implications 7

Historical Background 8
Early Efforts to Modify Cigarettes 8
Filters, Tar Reduction, and Light and Low-Tar Cigarettes 8
The Role of Nicotine and Nicotine Delivery 9
FDA and Nicotine Regulation 9

The E-Cigarette 10
Invention of the E-Cigarette 10
E-Cigarette Products 11
Components and Devices 11
Flavors and E-Cigarettes 11
E-Cigarette Devices 11
E-Cigarette Product Components and Risks 13

E-Cigarette Companies 14

Federal Regulation of E-Cigarettes 15


A “Two-Pronged” Approach to Comprehensive Tobacco Control 15
Legal Basis for Regulating E-Cigarettes as Tobacco Products 16
Deeming Rule 17
Future Regulatory Options 17

Summary 18

References 19

1
E-Cigarette Use Among Youth and Young Adults

Introduction

Although conventional cigarette smoking has E-cigarettes include a diverse group of devices that
declined markedly over the past several decades among allow users to inhale an aerosol, which typically contains
youth and young adults in the United States (U.S. nicotine, flavorings, and other additives. E-cigarettes vary
Department of Health and Human Services [USDHHS] widely in design and appearance, but generally operate in
2012), there have been substantial increases in the use of a similar manner and are composed of similar components
emerging tobacco products among these populations in (Figure 1.1). A key challenge for surveillance of the prod-
recent years (Centers for Disease Control and Prevention ucts and understanding their patterns of use is the diverse
[CDC] 2015c). Among these increases has been a dramatic and nonstandard nomenclature for the devices (Alexander
rise in electronic cigarette (e-cigarette) use among youth et al. 2016). These devices are referred to, by the companies
and young adults. It is crucial that the progress made themselves, and by consumers, as “e-cigarettes,” “e-cigs,”
in reducing cigarette smoking among youth and young “cigalikes,” “e-hookahs,” “mods,” “vape pens,” “vapes,”
adults not be compromised by the initiation and use of and “tank systems.” In this report, the term “e-cigarette”
e-cigarettes. This Surgeon General’s report focuses on the is used to represent all of the various products in this rap-
history, epidemiology, and health effects of e-cigarette use idly diversifying product category. The terms may differ
among youth and young adults; the companies involved by geographic region or simply by the prevailing prefer-
with marketing and promoting these products; and ences among young users. For example, some refer to all
existing and proposed public health policies regarding the cigarette-shaped products as “e-cigarettes” or as “cigalikes,”
use of these products by youth and young adults. and some may refer to the pen-style e-cigarettes as “hookah
pens” or “vape pens” (Richtel 2014; Lempert et al. 2016).

Figure 1.1 Diversity of e-cigarette products

Source: Photo by Mandie Mills, CDC.

Introduction, Conclusions, and Historical Background Relative to E-Cigarettes   3


A Report of the Surgeon General

This report focuses on research conducted among 2015). Still, the report underscores and draws its conclu-
youth and young adults because of the implications of sions from the known health risks of e-cigarette use in
e-cigarette use in this population, particularly the poten- this age group.
tial for future public health problems. Understanding
e-cigarette use among young persons is critical because
previous research suggests that about 9 in 10 adult Organization of the Report
smokers first try conventional cigarettes during adoles-
cence (USDHHS 2012). Similarly, youth e-cigarette exper- This chapter presents a brief introduction to this
imentation and use could also extend into adulthood; report and includes its major conclusions followed by the
however, e-cigarette use in this population has not been conclusions of the chapters, the historical background of
examined in previous reports of the Surgeon General. e-cigarettes, descriptions of the products, a review of the
The first Surgeon General’s report on the health conse- marketing and promotional activities of e-cigarette compa-
quences of smoking was published in 1964; of the subse- nies, and the current status of regulations from the U.S.
quent reports, those published in 1994 and 2012 focused Food and Drug Administration (FDA). Chapter 2 (“Patterns
solely on youth and young adults (USDHHS 1994, 2012). of E-Cigarette Use Among U.S. Youth and Young Adults”)
More recently, the 2012 report documented the evidence describes the epidemiology of e-cigarette use, including cur-
regarding tobacco use among youth and young adults, rent use (i.e., past 30 day); ever use; co-occurrence of using
concluding that declines in cigarette smoking had slowed e-cigarettes with other tobacco products, like cigarettes;
and that decreases in the use of smokeless tobacco had and psychosocial factors associated with using e-cigarettes,
stalled. That report also found that the tobacco industry’s relying on data from the most recent nationally representa-
advertising and promotional activities are causal to the tive studies available at the time this report was prepared.
onset of smoking in youth and young adults and the con- Chapter 3 (“Health Effects of E-Cigarette Use Among U.S.
tinuation of such use as adults (USDHHS 2012). However, Youth and Young Adults”) documents the evidence related
the 2012 report was prepared before e-cigarettes were as to the health effects of e-cigarette use, including those that
widely promoted and used in the United States as they are are associated with direct aerosol inhalation by users, the
now. Therefore, this 2016 report documents the scientific indirect health effects of e-cigarette use, other non-aerosol
literature on these new products and their marketing, health effects of e-cigarette use, and secondhand exposure
within the context of youth and young adults. This report to constituents of the aerosol. Chapter 4 (“Activities of the
also looks to the future by examining the potential impact E-Cigarette Companies”) describes e-cigarette companies’
of e-cigarette use among youth and young adults, while influences on e-cigarette use and considers manufacturing
also summarizing the research on current use, health and price; the impact of price on sales and use; the rapid
consequences, and marketing as it applies to youth and changes in the industry, particularly the e-cigarette com-
young adults. panies; and the marketing and promotion of e-cigarettes.
Evidence for this report was gathered from studies Chapter 5 (“E-Cigarette Policy and Practice Implications”)
that included one or more of three age groups. We defined discusses the implications for policy and practice at the
these age groups to be young adolescents (11–13 years of national, state, and local levels. The report ends with a Call
age), adolescents (14–17 years of age), and young adults to Action to stakeholders—including policymakers, public
(18–24 years of age). Some studies refer to the younger health practitioners and clinicians, researchers, and the
groups more generally as youth. Despite important issues public—to work to prevent harms from e-cigarette use
related to e-cigarette use in adult populations, clinical and and secondhand aerosol exposure among youth and young
otherwise (e.g., their potential for use in conventional adults.
smoking cessation), that literature will generally not be
included in this report unless it also discusses youth and
young adults (Farsalinos and Polosa 2014; Franck et al.
2014; Grana et al. 2014). Preparation of this Report
Given the recency of the research that pertains to
e-cigarettes, compared with the decades of research on This Surgeon General’s report was prepared by
cigarette smoking, the “precautionary principle” is used the Office on Smoking and Health, National Center for
to guide actions to address e-cigarette use among youth Chronic Disease Prevention and Health Promotion, CDC,
and young adults. This principle supports intervention which is part of USDHHS. The initial drafts of the chap-
to avoid possible health risks when the potential risks ters were written by 27 experts who were selected for their
remain uncertain and have been as yet partially undefined knowledge of the topics addressed. These contributions
(Bialous and Sarma 2014; Saitta et al. 2014; Hagopian et al. are summarized in five chapters that were evaluated by

4   Chapter 1
E-Cigarette Use Among Youth and Young Adults

approximately 30  peer reviewers. After peer review, the peer-reviewed journal articles, including reviews that inte-
entire manuscript was sent to more than 20 scientists grate findings from numerous studies and books that were
and other experts, who examined it for its scientific integ- published through December 2015. However, selected
rity. After each review cycle, the drafts were revised by the studies from 2016 have been added during the review pro-
report’s scientific editors on the basis of reviewers’ com- cess that provide further support for the conclusions in
ments. Subsequently, the report was reviewed by various this report. When a cited study has been accepted for pub-
institutes and agencies within USDHHS. lication, but the publication has not yet occurred because
of the delay between acceptance and final publication, the
study is referred to as “in press.” This report also refers, on
Scientific Basis of the Report occasion, to unpublished research, such as presentations
at a professional meeting, personal communications from
The statements and conclusions throughout this a researcher, or information available in various media.
report are documented by the citation of studies published These references are employed when acknowledged by
in the scientific literature. Publication lags have pre- the editors and reviewers as being from reliable sources,
vented an up-to-the-minute inclusion of all recently pub- which add to the emerging literature on a topic.
lished articles and data. This overall report primarily cites

Major Conclusions

1. E-cigarettes are a rapidly emerging and diversified 5. E-cigarette aerosol is not harmless. It can con-
product class. These devices typically deliver nico- tain harmful and potentially harmful constituents,
tine, flavorings, and other additives to users via an including nicotine. Nicotine exposure during ado-
inhaled aerosol. These devices are referred to by a lescence can cause addiction and can harm the
variety of names, including “e-cigs,” “e-hookahs,” developing adolescent brain.
“mods,” “vape pens,” “vapes,” and “tank systems.”
6. E-cigarettes are marketed by promoting flavors
2. E-cigarette use among youth and young adults has and using a wide variety of media channels and
become a public health concern. In 2014, current approaches that have been used in the past for mar-
use of e-cigarettes by young adults 18–24 years of keting conventional tobacco products to youth and
age surpassed that of adults 25 years of age and older. young adults.

3. E-cigarettes are now the most commonly used 7. Action can be taken at the national, state, local, tribal,
tobacco product among youth, surpassing conven- and territorial levels to address e-cigarette use among
tional cigarettes in 2014. E-cigarette use is strongly youth and young adults. Actions could include
associated with the use of other tobacco products incorporating e-cigarettes into smokefree policies,
among youth and young adults, including combus- preventing access to e-cigarettes by youth, price and
tible tobacco products. tax policies, retail licensure, regulation of e-cigarette
marketing likely to attract youth, and educational ini-
4. The use of products containing nicotine poses dan- tiatives targeting youth and young adults.
gers to youth, pregnant women, and fetuses. The use
of products containing nicotine in any form among
youth, including in e-cigarettes, is unsafe.

Introduction, Conclusions, and Historical Background Relative to E-Cigarettes   5


A Report of the Surgeon General

Chapter Conclusions

Chapter 1. Introduction, e-cigarettes (6.1%). For both age groups, dual use of
these products is common.
Conclusions, and Historical
Background Relative to 4. E-cigarette use is strongly associated with the use
E-Cigarettes of other tobacco products among youth and young
adults, particularly the use of combustible tobacco
1. E-cigarettes are devices that typically deliver nico- products. For example, in 2015, 58.8% of high
tine, flavorings, and other additives to users via an school students who were current users of combus-
inhaled aerosol. These devices are referred to by a tible tobacco products were also current users of
variety of names, including “e-cigs,” “e-hookahs,” e-cigarettes.
“mods,” “vape pens,” “vapes,” and “tank systems.”
5. Among youth—older students, Hispanics, and
2. E-cigarettes represent an evolution in a long history Whites are more likely to use e-cigarettes than
of tobacco products in the United States, including younger students and Blacks. Among young
conventional cigarettes. adults—males, Hispanics, Whites, and those with
lower levels of education are more likely to use
3. In May 2016, the Food and Drug Administration e-cigarettes than females, Blacks, and those with
issued the deeming rule, exercising its regulatory higher levels of education.
authority over e-cigarettes as a tobacco product.
6. The most commonly cited reasons for using
e-cigarettes among both youth and young adults are
curiosity, flavoring/taste, and low perceived harm
Chapter 2. Patterns of E-Cigarette compared to other tobacco products. The use of
Use Among U.S. Youth and Young e-cigarettes as an aid to quit conventional cigarettes
Adults is not reported as a primary reason for use among
youth and young adults.
1. Among middle and high school students, both ever
and past-30-day e-cigarette use have more than tri- 7. Flavored e-cigarette use among young adult current
pled since 2011. Among young adults 18–24 years users (18–24 years of age) exceeds that of older adult
of age, ever e-cigarette use more than doubled from current users (25 years of age and older). Moreover,
2013 to 2014 following a period of relative stability among youth who have ever tried an e-cigarette, a
from 2011 to 2013. majority used a flavored product the first time they
tried an e-cigarette.
2. The most recent data available show that the prev-
alence of past-30-day use of e-cigarettes is similar 8. E-cigarette products can be used as a delivery
among high school students (16% in 2015, 13.4% in system for cannabinoids and potentially for other
2014) and young adults 18–24 years of age (13.6% illicit drugs. More specific surveillance measures are
in 2013–2014) compared to middle school students needed to assess the use of drugs other than nicotine
(5.3% in 2015, 3.9% in 2014) and adults 25 years of in e-cigarettes.
age and older (5.7% in 2013–2014).

3. Exclusive, past-30-day use of e-cigarettes among Chapter 3. Health Effects of


8th-, 10th-, and 12th-grade students (6.8%, 10.4%,
and 10.4%, respectively) exceeded exclusive,
E-Cigarette Use Among U.S. Youth
past-30-day use of conventional cigarettes in 2015 and Young Adults
(1.4%, 2.2%, and 5.3%, respectively). In contrast—
in 2013–2014 among young adults 18–24 years of 1. Nicotine exposure during adolescence can cause addic-
age—exclusive, past-30-day use of conventional cig- tion and can harm the developing adolescent brain.
arettes (9.6%) exceeded exclusive, past-30-day use of

6   Chapter 1
E-Cigarette Use Among Youth and Young Adults

2. Nicotine can cross the placenta and has known effects Chapter 5. E-Cigarette Policy and
on fetal and postnatal development. Therefore, nico-
tine delivered by e-cigarettes during pregnancy can
Practice Implications
result in multiple adverse consequences, including
1. The dynamic nature of the e-cigarette landscape
sudden infant death syndrome, and could result in
calls for expansion and enhancement of tobacco-
altered corpus callosum, deficits in auditory pro-
related surveillance to include (a) tracking patterns
cessing, and obesity.
of use in priority populations; (b) monitoring the
characteristics of the retail market; (c) examining
3. E-cigarettes can expose users to several chemicals,
policies at the national, state, local, tribal, and ter-
including nicotine, carbonyl compounds, and vol-
ritorial levels; (d) examining the channels and mes-
atile organic compounds, known to have adverse
saging for marketing e-cigarettes in order to more
health effects. The health effects and potentially
fully understand the impact future regulations
harmful doses of heated and aerosolized constituents
could have; and (e) searching for sentinel health
of e-cigarette liquids, including solvents, flavorants,
events in youth and young adult e-cigarette users,
and toxicants, are not completely understood.
while longer-term health consequences are tracked.
4. E-cigarette aerosol is not harmless “water vapor,”
2. Strategic, comprehensive research is critical to
although it generally contains fewer toxicants than
identify and characterize the potential health risks
combustible tobacco products.
from e-cigarette use, particularly among youth and
young adults.
5. Ingestion of e-cigarette liquids containing nicotine
can cause acute toxicity and possibly death if the
3. The adoption of public health strategies that are pre-
contents of refill cartridges or bottles containing
cautionary to protect youth and young adults from
nicotine are consumed.
adverse effects related to e-cigarettes is justified.

4. A broad program of behavioral, communications,


Chapter 4. Activities of the and educational research is crucial to assess how
E-Cigarette Companies youth perceive e-cigarettes and associated mar-
keting messages, and to determine what kinds of
1. The e-cigarette market has grown and changed tobacco control communication strategies and
rapidly, with notable increases in total sales of channels are most effective.
e-cigarette products, types of products, consolida-
tion of companies, marketing expenses, and sales 5. Health professionals represent an important
channels. channel for education about e-cigarettes, particu-
larly for youth and young adults.
2. Prices of e-cigarette products are inversely related
to sales volume: as prices have declined, sales have 6. Diverse actions, modeled after evidence-based
sharply increased. tobacco control strategies, can be taken at the
state, local, tribal, and territorial levels to address
3. E-cigarette products are marketed in a wide variety e-cigarette use among youth and young adults,
of channels that have broad reach among youth and including incorporating e-cigarettes into smoke-
young adults, including television, point-of-sale, free policies; preventing the access of youth to
magazines, promotional activities, radio, and the e-cigarettes; price and tax policies; retail licensure;
Internet. regulation of e-cigarette marketing that is likely to
attract youth and young adults, to the extent feasible
4. Themes in e-cigarette marketing, including sexual under the law; and educational initiatives targeting
content and customer satisfaction, are parallel to youth and young adults. Among others, research
themes and techniques that have been found to be focused on policy, economics, and the e-cigarette
appealing to youth and young adults in conventional industry will aid in the development and imple-
cigarette advertising and promotion. mentation of evidence-based strategies and best
practices.

Introduction, Conclusions, and Historical Background Relative to E-Cigarettes   7


A Report of the Surgeon General

Historical Background

Understanding the role of e-cigarettes requires its Lucky Strike blended cigarette, and in 1918 Liggett &
understanding the long history of tobacco use in the United Myers (L&M) reformulated its Chesterfield brand to make
States, including the role of nicotine delivery, the mul- it more palatable to users. As the market grew, advertise-
tiple examples of “reduced-harm” products and associated ments for major brands routinely included health-related
health claims, and the impact of using tobacco products on statements and testimonials from physicians. During
the public’s health. Since the late nineteenth century, when the 1930s and 1940s, prominent advertising campaigns
the “modern” cigarette came into use, scientists and public included claims like “Not a cough in a carload” (Old Gold)
health officials have linked cigarette smoking to a remark- (Federal Trade Commission [FTC] 1964, p. LBA-5); “We
able number of adverse effects, and it is now recognized as removed from the tobacco harmful corrosive ACRIDS
the primary cause of premature death in the United States (pungent irritants) present in cigarettes manufactured
(USDHHS 2014). Correspondingly, for a century, manufac- in the old-fashioned way” (Lucky Strike) (FTC 1964,
turers, scientists, entrepreneurs, and public health leaders p. LBA-2); and “Smoking Camels stimulates the natural
have promoted or recommended product changes that flow of digestive fluids … increases alkalinity” (Camel)
might remove some of the harmful elements in cigarette (FTC 1964, p. LBA-1a). Thus, early modifications to the
smoke. E-cigarettes are among the latest products. cigarette were made so that it was more palatable, had a
E-cigarettes are designed for users to inhale nico- higher nicotine delivery and uptake, and could be mar-
tine, flavorings, and other additives through an aerosol. keted as “safe” (FTC 1964; Calfee 1985).
The claims and marketing strategies employed by the
e-cigarette companies, and the efforts made by others to
develop scientific and regulatory tools to deal with these Filters, Tar Reduction, and Light and
new products, both contribute to the current discourse
on e-cigarettes. Many lessons for assessing the poten- Low-Tar Cigarettes
tial (and future) consequences of these products can be
learned from examining the relevant experiences of the The landmark 1964 Surgeon General’s report on
past century, especially the introduction of novel prod- smoking and health concluded that cigarette smoking
ucts (including e-cigarettes as well as other tobacco and contributed substantially to mortality from certain spe-
nicotine products) and the claims of reduced exposure to cific diseases, including lung cancer (U.S. Department of
toxins made by the industry and elsewhere. Health, Education, and Welfare 1964). Although the 1964
report considered the topic, it found the evidence insuffi-
cient to assess the potential health benefits of cigarette fil-
ters. Cigarettes with filters became the norm by the 1960s,
Early Efforts to Modify Cigarettes and marketing them with an overt message about harm
reduction became the standard (National Cancer Institute
In the 1880s and 1890s, entrepreneurs promoted [NCI] 1996). However, the Surgeon General convened
novel products that allegedly blocked nicotine and other another group of experts on June 1, 1966, to review the
constituents of conventional cigarettes believed to be evidence on the role played by the tar and nicotine con-
poisonous. Dr. Scott’s Electric Cigarettes, advertised tent in health. The group concluded that “[t]he prepon-
in Harper’s Weekly, claimed not only to light without derance of scientific evidence strongly suggests that the
matches but also to contain a cotton filter that “strains lower the ‘tar’ and nicotine content of cigarette smoke,
and eliminates the injurious qualities from the smoke,” the less harmful are the effects” (Horn 1966, p. 16,168).
including nicotine (Harper’s Weekly 1887). Nicotine Subsequent studies have repeatedly failed to demonstrate
delivery was essential to the development of the modern health benefits of smoking light and low-tar cigarettes
cigarette in the twentieth century; early on, this substance versus full-flavor cigarettes (Herning et al. 1981; Russell
was thought to be addicting and thus vital to retaining et al. 1982; Benowitz et al. 1983, NCI 2001).
customers. In 1913, the Camel brand was a new kind of Over the years, the tobacco industry used multiple
cigarette that introduced high-nicotine content by using methods to reduce the machine-tested yields of tar and
burley tobacco, which was generally too harsh to inhale nicotine in cigarettes as a way to claim “healthier” ciga-
into the lungs, but was made more inhalable through the rettes. Beginning in the 1970s, tobacco companies adver-
addition of casings (e.g., sugars, licorice) (Tindall 1992; tised the tar and nicotine levels for their cigarettes, which
Proctor 2011). In 1916, American Tobacco introduced encouraged smokers to believe, without substantiation,

8   Chapter 1
E-Cigarette Use Among Youth and Young Adults

they could reduce their risk of exposure to these constitu- claims made through advertising and marketing as evi-
ents (Cummings et al. 2002; Pollay and Dewhirst 2002). dence of R. J. Reynolds’s intent to have the product used
In 1996, the FTC issued a statement that it would allow for the mitigation or prevention of disease (Slade and
cigarette companies to include statements about tar and Ballin 1993). Meanwhile, FDA launched an investigation
nicotine content in their advertising as long as they used a into the practices of the tobacco industry, including the
standardized machine-testing method (Peeler 1996). manipulation of nicotine delivery. FDA asserted its juris-
diction over cigarettes and smokeless tobacco and issued
certain rules governing access to and promotion of these
The Role of Nicotine and Nicotine products (Federal Register 1996). On March 21, 2000, the
U.S. Supreme Court ruled 5-4 that Congress had not yet
Delivery given FDA the necessary statutory authority to issue any
rules pertaining to tobacco products (Gottleib 2000; FDA
Although the public health community under- v. Brown & Williamson Tobacco Corp. 2000). The subse-
stood early on that nicotine was the primary psycho- quent debate over control of nicotine products, including
active ingredient in cigarette smoke, before the 1980s, their potential impact on youth, ultimately led to the pas-
little was known about the importance of nicotine in the sage of the 2009 Family Smoking Prevention and Tobacco
addiction process beyond what the cigarette manufac- Control Act, which gave FDA authority to regulate tobacco
turers had learned from their own research. Some scien- products. Thus, discussions about the introduction of
tists warned that due to nicotine addiction, a reduction novel nicotine-containing tobacco products in the market
in nicotine yields, along with decreases in tar, could lead during the 1980s and 1990s helped shape the current reg-
smokers to change their smoking behavior, such as by ulation of tobacco and nicotine products.
smoking a greater number of cigarettes to maintain their New products introduced in the 1990s or later
nicotine intake or changing their behavior in more subtle included modified tobacco cigarettes (e.g., Advance,
ways, such as varying the depth of inhalation or smoking Omni); cigarette-like products, also called cigalikes
more of the cigarette (Jarvis et al. 2001; National Cancer (e.g.,  Eclipse, Accord); and smokeless tobacco products
Institute 2001; Thun and Burns 2001). Not until the 1970s (e.g., Ariva, Exalt, Revel, snus). Advance, made by Brown
and 1980s, as researchers studying other forms of drug and Williamson, was test-marketed with the slogan “All
abuse began to apply their research methods to cigarette of the taste … Less of the toxins.” Vector launched a
smoking, did it become apparent that nicotine was similar national advertising campaign for its Omni cigarette
in its addictive capability to other drugs of abuse, such as with the slogan “Reduced carcinogens. Premium taste.”
heroin and cocaine (USDHHS 1981, 1988). As described In addition to the question of whether the claims were
in the 1988 Surgeon General’s report and in subsequent supported by sufficient evidence, scientists and tobacco
research, symptoms associated with nicotine addiction control leaders raised concerns about the potential for
include craving, withdrawal, and unconscious behaviors adverse consequences associated with novel nicotine and
to ensure consistent intake of nicotine (USDHHS 1988; tobacco products marketed for harm reduction, such as a
al’Absi et al. 2002; Hughes 2007). reduction in cessation rates or increased experimentation
Although the tobacco industry has long understood by children (Warner and Martin 2003; Joseph et al. 2004;
the importance of nicotine to maintain long-term ciga- Caraballo et al. 2006). Studies have shown that smokers
rette smokers through addiction, public health officials are interested in trying novel “reduced-exposure” products
did not fully appreciate this in a broad sense until the and perceive them to have lower health risks, even when
1988 Surgeon General’s report, The Health Consequences advertising messages do not make explicit health claims
of Smoking: Nicotine Addiction (USDHHS 1988). (Hamilton et  al. 2004; O’Connor et al. 2005; Caraballo
et al. 2006; Choi et al. 2012; Pearson et al. 2012).
At FDA’s request, the Institute of Medicine (IOM
FDA and Nicotine Regulation [now the National Academy of Medicine]) convened a
committee of experts to formulate scientific methods and
In 1988 (and again in 1994), the Coalition on standards by which potentially reduced-exposure products
Smoking OR Health and other public-interest organi- (PREPs), whether the purported reduction was pharma-
zations petitioned FDA to classify low-tar and nicotine ceutical or tobacco related, could be assessed. The com-
products as drugs and to classify Premier, the short- mittee concluded that “[f]or many diseases attributable to
lived “smokeless cigarette product” from R.J. Reynolds, tobacco use, reducing risk of disease by reducing expo-
as an alternative nicotine-delivery system (Stratton et al. sure to tobacco toxicants is feasible” (Stratton et al. 2001,
2001). The Coalition on Smoking OR Health cited indirect p. 232). However, it also cautioned that “PREPs have not

Introduction, Conclusions, and Historical Background Relative to E-Cigarettes   9


A Report of the Surgeon General

yet been evaluated comprehensively enough (including to less harm reduction for a population (as well as less risk
for a sufficient time) to provide a scientific basis for con- reduction for that individual) than would occur without
cluding that they are associated with a reduced risk of dis- the PREP, and possibly to an adverse effect on the popula-
ease compared to conventional tobacco use” (Stratton et al. tion” (Stratton et al. 2001, p. 235). Subsequently, in 2006,
2001, p. 232). The committee added that “the major con- Judge Kessler cited these findings in her decision which
cern for public health is that tobacco users who might demanded the removal of light and low-tar labeling due
otherwise quit will use PREPs instead, or others may ini- to the misleading nature of these claims (United States v.
tiate smoking, feeling that PREPs are safe. That will lead Philip Morris 2006).

The E-Cigarette

Invention of the E-Cigarette Sales of e-cigarettes in the United States have risen
rapidly since 2007. Widespread advertising via television
An early approximation of the current e-cigarette commercials and through print advertisements for pop-
appeared in a U.S. patent application submitted in 1963 by ular brands, often featuring celebrities, has contributed
Herbert A. Gilbert and was patented in August 1965 (U.S. to a large increase in e-cigarette use by both adults and
Patent No. 3,200,819) (Gilbert 1965). The application was youth since 2010 (Felberbaum 2013; King et al. 2013;
for a “smokeless nontobacco cigarette,” with the aim of Regan et al. 2013). Additionally, marketing through social
providing “a safe and harmless means for and method of media, as well as other forms of Internet marketing, has
smoking” by replacing burning tobacco and paper with been employed to market these devices (Huang et al. 2014;
heated, moist, flavored air. A battery-powered heating ele- Kim et al. 2014).
ment would heat the flavor elements without combustion In 2013, an estimated 13.1 million middle school
(Gilbert 1965). The Favor cigarette, introduced in 1986, and high school students were aware of e-cigarettes
was another early noncombustible product promoted (Wang et al. 2014). According to data from the National
as an alternative nicotine-containing tobacco product Youth Tobacco Survey, in 2011 the prevalence of current
(United Press International 1986; Ling and Glantz 2005). e-cigarette use (defined as use during at least 1 day in
The first device in the recent innovation in the past 30 days) among high school students was 1.5%;
e-cigarettes was developed in 2003 by the Chinese pharma- prevalence increased dramatically, however, to 16% by
cist Hon Lik, a former deputy director of the Institute of 2015, surpassing the rate of conventional-cigarette use
Chinese Medicine in Liaoning Province. Lik’s patent appli- among high school students (CDC 2016b; see Chapter
cation described a kind of electronic atomizing cigarette 2). This equates to 2.4 million high school students and
(Hon 2013). With support from Chinese investors, in 2004 620,000 middle school students having used an e-cigarette
the product was introduced on the Chinese market under at least one time in the past 30 days in 2015 (CDC 2016b).
the company name Ruyan (Sanford and Goebel 2014). The These trends have led to substantial concern and
product gained some attention among Chinese smokers discussion within public health communities, including
early on as a potential cessation device or an alternative state and national public health agencies, professional
cigarette product. organizations, and school administrators and teachers.
The e-cigarette was part of the U.S. market by the A primary concern is the potential for nicotine addiction
mid-2000s, and by 2010 additional brands started to among nonsmokers, especially youth and young adults,
appear in the nation’s marketplace, including Ruyan and and that this exposure to nicotine among youth and young
Janty (Regan et al. 2013). Ruyan gained a U.S. patent for adults is harmful. The diversity and novelty of e-cigarette
its product with the application stating that the product products on the market and ongoing product innova-
is “an electronic atomization cigarette that functions as tions make assessments of the biological effects of current
substitutes (sic) for quitting smoking and cigarette sub- e-cigarettes under actual conditions of use—such as their
stitutes.” (U.S. Patent No. 8,490,628 B2, 2013). In August long-term harmfulness—difficult to measure. Unanswered
2013, Imperial Tobacco Group purchased the intellectual questions remain about the risk profile of these devices,
property behind the Ruyan e-cigarette for $75 million. their potential use by young people as a first step to other
As of 2014 an estimated 90% of the world’s production nicotine products, and their total impact on public health.
of e-cigarette technology and products came from main- There are diverging opinions about the potential public
land China, mainly Guangdong Province and Zhejiang health impact of these new products. Some public health
Province (Barboza 2014). scientists have highlighted the potential for alternative

10   Chapter 1
E-Cigarette Use Among Youth and Young Adults

nicotine products to serve as a substitute for conventional unflavored products that more easily deliver more nico-
cigarettes and thus a harm reduction tool (Henningfield tine to the user (USDHHS 2012). Various studies have
et al. 2003; Abrams 2014). Others have cautioned that shown that youth are more likely than adults to choose
the use of alternative nicotine products might become flavored cigarettes and cigars (CDC 2015b). Concern over
a bridge that may lead to greater tobacco product use— these findings led Congress to include a ban on character-
including dual- or multiple-product use—or initiate nico- izing flavors for cigarettes, other than tobacco or menthol,
tine addiction among nonsmokers, especially youth (Cobb in the Tobacco Control Act. A similar concern exists about
et al. 2010; Wagener et al. 2012; Benowitz and Goniewicz e-cigarettes, and this concern is supported by studies indi-
2013; Britton 2013; Chapman 2013; Etter 2013; USDHHS cating that youth and young adults who have ever used
2014). Current evidence is insufficient to reject either of e-cigarettes begin their use with sweet flavors rather than
these hypotheses. tobacco flavors (Kong et al. 2015; Krishnan-Sarin et al.
2015). Notably, 81.5% of current youth e-cigarette users
said they used e-cigarettes “because they come in flavors I
E-Cigarette Products like” (Ambrose et al. 2015).

Components and Devices


E-cigarette devices are composed of a battery, a res-
E-Cigarette Devices
ervoir for holding a solution that typically contains nico-
First-generation e-cigarettes were often similar in
tine, a heating element or an atomizer, and a mouthpiece
size and shape to conventional cigarettes, with a design
through which the user puffs (Figure 1.2). The device
that also simulated a traditional cigarette in terms of the
heats a liquid solution (often called e-liquid or e-juice)
colors used (e.g., a white body with tan mouthpiece).
into an aerosol that is inhaled by the user. E-liquid typi-
These devices were often called cigalikes, but there were
cally uses propylene glycol and/or glycerin as a solvent for
other products designed to simulate a cigar or pipe. Other
the nicotine and flavoring chemicals
cigalikes were slightly longer or narrower than a cigarette;
they may combine white with tan or may be black or col-
Flavors and E-Cigarettes
ored brightly. These newer models use a cartridge design
The e-liquids in e-cigarettes are most often flavored; for the part of the device that holds the e-liquid, which is
a study estimated that 7,700 unique flavors exist (Zhu either prefilled with the liquid or empty and ready to be
et al. 2014) and that most of them are fruit or candy fla- filled. The user then squeezes drops of the e-liquid onto a
vors (Figure 1.3). A content analysis of the products avail- wick (or bit of cotton or polyfil) connected to the heating
able via online retail websites documented that tobacco, element and atomizer (Figure 1.4). As e-cigarettes have
mint, coffee, and fruit flavors were most common, fol- become more popular, their designs have become more
lowed by candy (e.g., bubble gum), unique flavors (e.g., diverse, as have the types of venues where they are sold
Belgian waffle), and alcoholic drink flavors (e.g., straw- (Noel et al. 2011; Zhu et al. 2014).
berry daiquiri) (Grana and Ling 2014). Some retail stores Second-generation devices include products that
are also manufacturers that create custom flavors, which are shaped like pens, are comparatively larger and cylin-
increases the variety of flavors available. drical, and are often referred to as “tank systems” in a nod
The widespread availability and popularity of fla- to the transparent reservoir that holds larger amounts
vored e-cigarettes is a key concern regarding the potential of e-liquid than previous cartridge-containing models.
public health implications of the products. The con- Third- and fourth-generation devices represent a diverse
cern, among youth, is that the availability of e-cigarettes set of products and, aesthetically, constitute the greatest
with sweet flavors will facilitate nicotine addiction and departure from the traditional cigarette shape, as many
simulated smoking behavior—which will lead to the are square or rectangular and feature customizable and
use of conventional tobacco products (Kong et al. 2015; rebuildable atomizers and batteries. In addition, since the
Krishnan-Sarin et al. 2015). Flavors have been used for beginning of the availability of e-cigarettes and their com-
decades to attract youth to tobacco products and to mask ponent parts, users have been modifying the devices or
the flavor and harshness of tobacco (USDHHS 2012). building their own devices, which are often referred to
Industry documents show that tobacco companies mar- as “mods.” The differences in design and engineering of
keted flavored little cigars and cigarillos to youth and to the products are key factors in the size, distribution, and
African Americans to facilitate their uptake of cigarettes amount of aerosol particles and the variability in levels of
(Kostygina et al. 2014). Companies also intended flavored chemicals and nicotine present in the e-liquid/aerosol and
smokeless tobacco products to facilitate “graduation” to delivered to the user (Brown and Cheng 2014).

Introduction, Conclusions, and Historical Background Relative to E-Cigarettes   11


A Report of the Surgeon General

Figure 1.2 Parts of an e-cigarette device

Source: Photo by Mandie Mills, CDC.

12   Chapter 1
E-Cigarette Use Among Youth and Young Adults

Figure 1.3 Examples of e-liquid flavors

Source: Photo by Mandie Mills, CDC.

Figure 1.4 E-liquids being poured into an e-cigarette device

Source: Photo by Mandie Mills, CDC.

E-Cigarette Product Components of tolerance of actual users to the taste of the aerosol heated
to this temperature is debated (Kosmider et al. 2014; CDC
and Risks 2015a; Flavor and Extract Manufacturers Association of
the United States 2015; Pankow et al. 2015). There is also
One of the primary features of the more recent gener-
concern regarding the safety of inhaling e-cigarette flavor-
ation of devices is that they contain larger batteries and are
ings. Although some manufacturers have claimed their
capable of heating the liquid to a higher temperature, poten-
flavorants are generally recognized as safe for food addi-
tially releasing more nicotine, forming additional toxicants,
tives (i.e., to be used in preparing foods for eating), little is
and creating larger clouds of particulate matter (Bhatnagar
known about the long-term health effects of inhaling these
et al. 2014; Kosmider et al. 2014). For instance, one study
substances into the lungs (CDC 2015a).
demonstrated that, at high temperatures (150°C), exceed-
Many devices can be readily customized by their
ingly high levels of formaldehyde—a carcinogen (found to
users, which is also leading to the concern that these
be 10 times higher than at ambient temperatures)—are
devices are often being used to deliver drugs other than
present that are formed through the heating of the e-liquid
nicotine (Brown and Cheng 2014). Most commonly
solvents (propylene glycol and glycerin), although the level
reported in the news media, on blogs, and by user anecdote

Introduction, Conclusions, and Historical Background Relative to E-Cigarettes   13


A Report of the Surgeon General

is the use of certain types of e-cigarette-related products child who drank e-liquid containing nicotine (Mohney
for delivering different forms of marijuana (Morean et al. 2014). Additionally, serious adverse reactions, including
2015; Schauer et al. 2016). The tank systems, for example, at least two deaths, have been reported to FDA in cases
have been used with liquid tetrahydrocannabinol (THC) that could be attributed to the use of e-cigarettes (FDA
or hash oil. Some personal vaporizer devices can be used 2013). This increase in poisonings prompted the Child
with marijuana plant material or a concentrated resin Nicotine Poisoning Prevention Act of 2015 (2016), which
form of marijuana called “wax.” One study describes the was enacted in January 2016. This law requires any con-
use, in Europe, of e-cigarette devices to smoke marijuana tainer of liquid nicotine that is sold, manufactured, dis-
(Etter 2015). tributed, or imported into the United States to be placed
The various e-cigarette products, viewed as a group, in packaging that is difficult to open by children under
lack standardization in terms of design, capacity for safely 5 years of age.
holding e-liquid, packaging of the e-liquid, and features Secondary risks are also of concern regarding
designed to minimize hazards with use (Yang et al. 2014). e-cigarettes, including passive exposure to nicotine and
All of these design features may have implications for the other chemicals, and adverse events due to device mal-
health impact of e-cigarette use. Notably, from 2010 to function. Nicotine is a neuroteratogen, and its use by
2014, calls to poison control centers in the United States pregnant women exposes a developing fetus to risks that
about exposures related to e-cigarettes increased dramati- are well documented in the 50th-anniversary Surgeon
cally. According to the American Association of Poison General’s report on smoking (USDHHS 2014) and include
Control Centers (2015), 271 cases were reported in 2011, impaired brain development (England et al. 2015) and
but 3,783 calls were reported in 2014. Among all calls, other serious consequences. Finally, another consequence
51%  involved exposure among children younger than of the lack of device regulation is the occurrence of battery
5 years of age (CDC 2014). Most poisonings appear to have failures and subsequent explosions. Explosions have typi-
been caused by exposure to nicotine-containing liquid cally occurred during charging, resulting in house and car
(CDC 2014). The lack of a requirement for child-resistant fires, and sometimes causing injuries to those involved.
packaging for e-liquid containers may have contrib- From 2009 to late 2014, 25 incidents of explosions and
uted to these poisonings. Since these data were released, fires involving e-cigarettes occurred in the United States
one death in the United States has been confirmed in a (Chen 2013; U.S. Fire Administration 2014; FDA 2013).

E-Cigarette Companies

E-cigarette companies include manufacturers, (e.g., a banner ad is placed on one’s website, and when
wholesalers, importers, retailers, distributors, and some someone clicks on the link and subsequently purchases
other groups that overlap with these entities (Barboza 2014; a product, the website owner gets a percentage commis-
Whelan 2015). Currently, most of the products are manu- sion). Some companies also offer rewards programs for
factured in Shenzhen, Guangdong Province, China (Cobb recruiting new customers or for brand loyalty, with web-
et al. 2010; Grana et al. 2014; Zhu et al. 2014). One study site users earning points for free or reduced-price prod-
placed the number of brands at 466 in January 2014 and ucts (Richardson et al. 2015).
found a net increase of 10.5 brands per month (Zhu et al. E-cigarettes are now in widespread national distribu-
2014). All the major tobacco companies (e.g.,  Reynolds tion through convenience stores, tobacco stores, pharma-
American, Altria; Table 1.1) and many smaller, indepen- cies, “big box” retail chains such as Costco, online retailers,
dent companies are now in the business. When e-cigarettes and shops devoted to e-cigarette products (often called
first entered the U.S. market, they were sold primarily by “vape shops”) (Giovenco et al. 2015; Public Health Law
independent companies via the Internet and in shopping Center 2015). The “vape shops” offer a place to buy custom-
malls at kiosks where those interested could sample the izable devices and e-liquid solutions in many flavors and
products. A unique feature of the e-cigarette industry, sometimes include a café or other elements that promote
compared to other tobacco and nicotine products, is the socializing, essentially making such places like a lounge.
recruitment of visitors to their websites as “affiliates” or With the rapid increase in distribution and marketing in
distributors to help market the products and, in turn, the industry, sales have increased rapidly and were pro-
receive commissions on sales (Grana and Ling 2014; Cobb jected to reach $2.5 billion in 2014 and $3.5 billion in 2015,
et al. 2015). For example, some companies offer a way for including projections for retail and online channels, as well
users to earn a commission by advertising the products as “vape shops” (Wells Fargo Securities 2015).

14   Chapter 1
E-Cigarette Use Among Youth and Young Adults

Table 1.1 Multinational tobacco companies with e-cigarette brands


Company E-cigarette brand
Altria (NuMark) MarkTen, Green Smoke
Philip Morris International Heat-not-burn, IQOS brand (Vape Ranks 2014)
E-cigs, Nicolites by Nicocigs (Philip Morris International 2014)
Reynolds (Reynolds Vapor Company) VUSE
Lorillard (Lorillard Vapor Company) blu (until 2015)
Imperial Tobacco (Fontem Ventures) Puritane (formerly Ruyan)
blu (acquired in 2015)
British American Tobacco Vype
Swisher E-swisher
Japan Tobacco International (JTI) E-Lites, offered in the United Kingdom by Zandera Ltd., which
was acquired by Japan Tobacco Inc. in 2014 (Japan Tobacco Inc.
2014)
Ploom (tobacco pods in heat-not-burn) and Ploom PAX (used for
vaporizing marijuana) (Japan Tobacco Inc. 2015)

The advertising and marketing of e-cigarette prod- cigarettes and smokeless tobacco products, which have
ucts has engendered skepticism among public health been prohibited from such sponsorships since the Master
professionals and legislators, who have noted many similar- Settlement Agreement in 1998. E-cigarettes also appear as
ities to the advertising claims and promotional tactics used product placements in television shows and movies (Grana
for decades by the tobacco industry to sell conventional et al. 2011; Grana and Ling 2014).
tobacco products (Campaign for Tobacco-Free Kids 2013; Another key avenue for e-cigarette promotion
CDC 2016a). Indeed, several of the e-cigarette marketing is social media, such as Twitter, Facebook, YouTube,
themes have been reprised from the most memorable cig- and Instagram. As is true in the tobacco industry, the
arette advertising, including those focused on freedom, e-cigarette industry organizes users through advocacy
rebellion, and glamor (Grana and Ling 2014). E-cigarette groups (Noel et al. 2011; Harris et al. 2014; Saitta et al.
products are marketed with a variety of unsubstantiated 2014; Caponnetto et al. 2015). The extensive marketing
health and cessation messages, with some websites fea- and advocacy through various channels broadens expo-
turing videos of endorsements by physicians (another sure to e-cigarette marketing messages and products;
reprisal of old tobacco industry advertising) (Grana and such activity may encourage nonsmokers, particularly
Ling 2014; Zhu et al. 2014). Unlike conventional cigarettes, youth and young adults, to perceive e-cigarette use as
for which advertising has been prohibited from radio and socially normative. The plethora of unregulated adver-
television since 1971, e-cigarette products are advertised on tising is of particular concern, as exposure to advertising
both radio and television, with many ads featuring celeb- for tobacco products among youth is associated with ciga-
rities. E-cigarettes also are promoted through sports and rette smoking in a dose-response fashion (USDHHS 2012).
music festival sponsorships, in contrast to conventional

Federal Regulation of E-Cigarettes

A “Two-Pronged” Approach to sold in the United States. FDA had immediate jurisdic-
tion over cigarettes, roll-your-own cigarette tobacco, and
Comprehensive Tobacco Control smokeless tobacco. In May 2016, FDA asserted jurisdic-
tion over products that meet the statutory definition of
Since the passage of the Tobacco Control Act in
a tobacco product, including e-cigarettes, except accesso-
2009, FDA has had the authority to regulate the manufac-
ries of these products (Federal Register 2016). That regu-
turing, distribution, and marketing of tobacco products
lation is currently under litigation.

Introduction, Conclusions, and Historical Background Relative to E-Cigarettes   15


A Report of the Surgeon General

The IOM’s 2007 report, Ending the Tobacco Problem: sale of flavored tobacco products (National Association
A Blueprint for the Nation, established a “two-pronged” of Tobacco Outlets, Inc. v. City of Providence 2013; U.S.
strategy for comprehensive tobacco control: (1) full imple- Smokeless Tobacco Manufacturing Co. v. City of New
mentation of proven, traditional tobacco control measures York 2013).
such as clean indoor air laws, taxation, and countermar-
keting campaigns; and (2) “strong federal regulation of
tobacco products and their marketing and distribution” Legal Basis for Regulating
(Bonnie et al. 2007, p. 1).
Included in FDA’s broad authority are the restric- E-Cigarettes as Tobacco Products
tion of marketing and sales to youth, requiring disclo-
sure of ingredients and harmful and potentially harmful In the United States, e-cigarettes can be regulated
constituents, setting product standards (e.g., requiring either as products marketed for therapeutic purposes or
the reduction or elimination of ingredients or constitu- as tobacco products. Since the advent of e-cigarettes in the
ents), requiring premarket approval of new tobacco prod- United States around 2007, manufacturers have had the
ucts and review of modified-risk tobacco products, and option to apply to FDA’s Center for Drug Evaluation and
requiring health warnings. The standard for FDA to use Research (CDER) or Center for Devices and Radiological
many of its regulatory authorities is whether such an Health (CDRH) for approval to market e-cigarettes for ther-
action is appropriate for the protection of public health apeutic purposes; as of August 2016, no e-cigarette manu-
(Federal Food, Drug, and Cosmetic Act, § 907(a)(3)(A)). facturers have received approval through this avenue.
The public health standard in the Tobacco Control Act In 2008 and early 2009, FDA detained multiple ship-
also requires FDA to consider the health impact of certain ments of e-cigarettes from overseas manufacturers and
regulatory actions at both the individual and population denied them entry into the United States on the grounds
levels, including their impact on nonusers, and on initia- that e-cigarettes were unapproved drug-device combina-
tion and cessation (Federal Food, Drug, and Cosmetic Act, tion products (FDA 2011). Sottera, Inc., which now does
§ 907(a)(3)(B)). business as NJOY, challenged that determination (Smoking
Importantly, the Tobacco Control Act preserves the Everywhere, Inc. and Sottera, Inc., d/b/a NJOY v. U.S. Food
authority of state, local, tribal, and territorial govern- and Drug Administration, et al. 2010; Bloomberg Business
ments to enact any policy “in addition to, or more strin- 2015). Between the filing of the lawsuit and a decision on
gent than” requirements established under the Tobacco the motion for preliminary injunction, Congress passed
Control Act “relating to or prohibiting the sale, distri- the Tobacco Control Act and the President signed it into
bution, possession, exposure to, access to, advertising law. The Tobacco Control Act defines the term “tobacco
and promotion of, or use of tobacco products by individ- product,” in part, as any product, including component
uals of any age” (Federal Food, Drug, and Cosmetic Act, parts or accessories, “made or derived from tobacco” that is
§ 916(a)(1)). This preservation of state and local authority not a “drug,” “device,” or “combination product” as defined
ensures the continuation of more local-level, compre- by the Federal Food, Drug, and Cosmetic Act (21 U.S.C.
hensive tobacco control. However, the statute expressly 321(rr)) (Family Smoking Prevention and Tobacco Control
preempts states and localities from establishing or con- Act 2009, § 101(a)). The District Court subsequently
tinuing requirements that are different from or in addi- granted a preliminary injunction relying on the Supreme
tion to FDA requirements regarding standards for tobacco Court’s decision in Brown and Williamson (1996) and the
products, premarket review, adulteration, misbranding, recently enacted Tobacco Control Act. FDA appealed the
labeling, registration, good manufacturing practices, or decision and the U.S. Court of Appeals for the D.C. Circuit
modified-risk tobacco products (Federal Food, Drug, and held that e-cigarettes and, therefore, other products “made
Cosmetic Act, § 916(a)(2)(A)). But this express preemp- or derived from tobacco” are not drug/device combinations
tion provision does not apply to state and local authority unless they are marketed for therapeutic purposes, but can
to impose requirements relating to the “sale, distribution, be regulated by FDA as tobacco products under the Tobacco
possession, information reporting to the State, exposure Control Act (Sottera, Inc. v. Food & Drug Administration
to, access to, the advertising and promotion of, or use of, 2010).
tobacco products by individuals of any age . . .” (Federal On September 25, 2015, FDA proposed regulations
Food, Drug, and Cosmetic Act, § 916(a)(2)(b)). The inter- to describe the circumstances in which a product made
action of these complex provisions related to federal pre- or derived from tobacco that is intended for human con-
emption of state law has been the subject of challenges sumption will be subject to regulation as a drug, device, or
by the tobacco industry to state and local laws. Thus far, a combination product. The comment period for this pro-
courts have upheld certain local ordinances restricting the posed regulation closed on November 24, 2015.

16   Chapter 1
E-Cigarette Use Among Youth and Young Adults

Most e-cigarettes marketed and sold in the United • Required disclosure of existing health information,
States today contain nicotine made or derived from including lists of ingredients and documents on
tobacco. Although some e-cigarettes claim that they health effects;
contain nicotine not derived from tobacco, or that they
contain no nicotine at all (Lempert et al. 2016), there may • Required registration of manufacturers;
be reason to doubt some of these claims. Currently, syn-
thetic nicotine and nicotine derived from genetically mod- • Required disclosure of a list of all tobacco prod-
ified, nontobacco plants are cost-prohibitive for e-cigarette ucts, including information related to labeling and
manufacturers, although technological advances could advertising;
eventually increase the cost-effectiveness of using nicotine
that was not derived from tobacco (Lempert et al. 2016). • Premarket review of new tobacco products
The health effects of passive exposure to e-cigarettes with (i.e., those not on the market on February 15, 2007);
no nicotine, as well as their actual use and the extent of
exposure to these products, have just begun to be studied • Restrictions on products marketed with claims
(Hall et al. 2014; Marini et al. 2014; Schweitzer et al. 2015) about modified risk.
and some states and localities are taking steps to regu-
late e-cigarettes that do not contain nicotine or tobacco In addition to the aforementioned Tobacco Control
(Lempert et al. 2016). Act provisions applicable to all deemed tobacco products,
the Tobacco Control Act grants FDA authority to under-
take a broad range of other actions on specific classes
Deeming Rule of products. In its deeming rule, FDA included the fol-
lowing additional actions for tobacco products, including
The Tobacco Control Act added a new chapter to e-cigarettes:
the Federal Food, Drug, and Cosmetic Act, which pro-
vides FDA with authority over tobacco products. The new • Minimum age restrictions to prevent sales to minors;
chapter applied immediately to all cigarettes, cigarette
tobacco, roll-your-own tobacco, and smokeless tobacco; • Requirements to include a nicotine warning; and
and the law included “any other tobacco products that
the Secretary of Health and Human Services by regula- • Prohibitions on vending machine sales, unless in a
tion deems to be subject to this chapter” (Federal Food, facility that never admits youth.
Drug, and Cosmetic Act, §901 (b)). Therefore, to regu-
late e-cigarettes as tobacco products, FDA was required to
undertake a rulemaking process to extend its regulatory Future Regulatory Options
authority to include e-cigarettes.
Consequently, in May 2016, through its Center E-cigarette manufacturers have the option to apply
for Tobacco Products (CTP), FDA issued a rule—often to FDA to authorize the marketing of their products or
referred to as the “deeming rule”—to extend its authority to be able to manufacture and sell tobacco products mar-
over all products meeting the definition of a tobacco keted with modified-risk claims, in addition to the existing
product, except accessories of the newly deemed products. option to apply to FDA’s CDER or CDRH for approval to
This rule extended FDA’s tobacco product authorities to market their products for therapeutic purposes. FDA also
include e-cigarettes and their components and parts (e.g., has authority to undertake a number of actions if the
nicotine cartridges), but also to such products as cigars, Secretary of USDHHS finds such actions to be appropriate
pipe tobacco, nicotine gels, waterpipe/hookah tobacco, for the protection of public health, including:
and dissolvables not already regulated as smokeless
tobacco products (Federal Register 2016). This regulation • Product standards, including restrictions on flavors;
is currently under litigation. The deeming rule subjects
e-cigarettes to Tobacco Control Act provisions, including: • Restrictions on promotion, marketing, and adver-
tising, and prohibitions on brand-name sponsorship
• Prohibitions on adulterated and misbranded of events;
products;
• Minimum package sizes;

• Prohibitions on self-service displays;

Introduction, Conclusions, and Historical Background Relative to E-Cigarettes   17


A Report of the Surgeon General

• Child-resistant packaging and the inclusion of purposes, or establish a federal minimum age of sale for
health warnings; and tobacco products above 18 years of age. Thus, even if FDA
fully exercises all of its existing authority over e-cigarettes,
• Regulation of nicotine levels in products. regulation will still need to be complemented at the state
and local levels, including efforts previously shown to be
Despite this broad authority, FDA is prohibited from effective for conventional tobacco products, such as compre-
certain regulatory actions, even if those actions may be hensive smokefree laws at the state and local levels, pricing
appropriate for the protection of public health. Specifically, strategies, raising the minimum age of sales to minors to
FDA generally cannot restrict tobacco use in public places, 21, and high-impact countermarketing campaigns. In the
levy taxes on tobacco products, prohibit sales by a specific current context of rising rates of use by youth, localities
category of retail outlet (e.g., pharmacies), completely elim- and states can also implement policies and programs that
inate nicotine in tobacco products, require prescriptions minimize the individual- and population-level harms of
for tobacco products unless it is marketed for therapeutic e-cigarettes (see Chapter 5).

Summary

This chapter presents the major conclusions of chapter outlines options for the regulation of e-cigarettes,
this Surgeon General’s report and the conclusions of particularly as they relate to youth and young adults,
each chapter. E-cigarettes are presented within their his- based on successful smoking policies. The need to protect
torical context, with an overview of the components of youth and young adults from initiating or continuing the
these devices and the types of products. In 2016, FDA use of nicotine-containing products forms a strong basis
announced its final rule to regulate e-cigarettes under the for the need to regulate e-cigarettes at the local, state, and
Family Smoking Prevention and Tobacco Control Act. The national levels in the future.

18   Chapter 1
E-Cigarette Use Among Youth and Young Adults

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TobaccoProducts/Labeling/RulesRegulationsGuidance/ Zhu SH, Sun JY, Bonnevie E, Cummins SE, Gamst A, Yin
ucm394909.htm>; accessed: May 16, 2016. L, Lee M. Four hundred and sixty brands of e-cigarettes
and counting: implications for product regulation.
Tobacco Control 2014;23(Suppl 3):iii3–iii9.

Introduction, Conclusions, and Historical Background Relative to E-Cigarettes   23


Chapter 2
Patterns of E-Cigarette Use Among U.S. Youth and
Young Adults

Introduction 27
Sources of Data 27
Other Literature 27

Key Findings 28
Youth 28
Current Prevalence 28
Trends in Prevalence 28
Young Adults 37
Current Prevalence 37
Trends in Prevalence 37
E-Cigarette Use and Use of Other Tobacco Products 37
Cross-Sectional Studies 37
Longitudinal Studies 53
E-Cigarette Use and Other Substance Use 57
E-Cigarettes and Marijuana 58
Use of Flavored E-Cigarettes 58
Consumer Perceptions of E-Cigarettes 59
Perceived Harm of E-Cigarettes 59
Reasons for Use and Discontinuation 75

Evidence Summary 86

Conclusions 88

References 89

25
E-Cigarette Use Among Youth and Young Adults

Introduction
This chapter documents patterns and trends in Barrington-Trimis et al. 2016; Unger et  al. 2016; Wills
awareness of electronic cigarettes (e-cigarettes), their et  al. 2016). Because e-cigarettes only became prevalent
use, and perceptions about these devices among youth in the tobacco product marketplace in recent years, min-
and young adults in the United States. Both the aware- imal data are available on their use before 2011. Given the
ness of e-cigarettes and levels of their use have increased paucity of surveillance information on e-cigarettes and the
rapidly throughout the U.S. population. Understanding low prevalence of their use in the early years of their avail-
young people’s patterns of e-cigarette use is essential ability in the United States, peer-reviewed studies with
to determining the scope of potential benefits or harms smaller subnational samples are used in this chapter to
that these products may have from a public health per- complement national surveillance data. Surveillance of
spective. This chapter summarizes the patterns of use of e-cigarette use presents a unique set of challenges, given
e-cigarettes, identifies subgroups at higher risk for using the emerging and dynamic market specific to these prod-
them, highlights the ways in which e-cigarettes are used ucts (see Chapter 4 for more on the latter topic). Appendix
with other tobacco products, and identifies correlates of 2.1 and Tables A2.2-1 and A2.2-2 in Appendix 2.2 summa-
e-cigarette use, including knowledge, attitudes, beliefs, rize the key terms and measures used in this chapter.
and sociodemographic characteristics. In most cases, the
term “e-cigarette(s)” is used, but when needed to accord
with usage in the cited literature, the acronym “ENDS” Other Literature
(electronic nicotine delivery systems) is employed.
This chapter also summarizes findings from peer-
reviewed literature on e-cigarettes that were identified
Sources of Data through a systematic review of studies of these products
from the United States and abroad. A literature search was
Data summarized in this chapter come from nation- conducted in April 2015 (Glasser et al. 2015) using the
ally representative datasets that were federally funded and National Library of Medicine’s PubMed database and the
peer-reviewed literature of subnational and international following keywords: “e-cigarette*” OR “electronic ciga-
surveillance studies of e-cigarette use that were mostly rette” OR “electronic cigarettes” OR “electronic nicotine
cross-sectional in design. Appendix 2.1. and Table A2.1-1 delivery” OR “vape” OR “vaping.” Articles were excluded
in that appendix1 describe all the years of data available from this review for any of five reasons: (1) the article was
for these data sources, but only selected years are used for not available in English; (2) the article was not relevant
this report. For youth, this report relies on data from the to e-cigarettes; (3) the study included nonhuman sub-
National Youth Tobacco Survey (NYTS) and the Monitoring jects; (4) the study did not include original data; or (5) the
the Future Study (MTF), as measures of e-cigarette study did not include findings specific to adolescents or
use were available for at least two or more time points. young adults. More details about this review’s method-
For this reason, the report also relies on data from the ology are available in Glasser and colleagues’ (2015) report.
National Adult Tobacco Survey (NATS) for young adults. The search was subsequently updated in November 2015,
More recently, the Youth Risk Behavior Surveillance January 2016, and March 2016 during continued devel-
System and other surveys from the National Center for opment of the report. For consistency, the same search
Health Statistics have added measures of e-cigarette use strategy and databases were employed at all times. Studies
to their surveys, but only one data point was available at on patterns of e-cigarette use behaviors for both youth and
the time this report was prepared. Only five longitudinal young adults are reviewed in the text and tables that follow.
studies were available on this topic at the time this report All other studies not explicitly described in the text are sum-
was prepared (Leventhal et al. 2015; Primack et al. 2015; marized in Appendix 2.3 and Tables A2.3-1 through A2.3-3.

1All appendixes and appendix tables that are cross-referenced in this chapter are available only online at http://www.surgeongeneral.gov/
library/reports/

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   27


A Report of the Surgeon General

Key Findings

Youth Frequency of Use


Among middle school students, according to the
Current Prevalence 2015 NYTS, 5.3% were current users of e-cigarettes,
and 0.6% used e-cigarettes frequently (defined as using
Ever Use an e-cigarette 20 or more days in the past 30 days pre-
According to the 2015 National Youth Tobacco Survey ceding the survey) (Table 2.1a). Among high school stu-
(NYTS), an estimated 27.1% of U.S. adolescents, repre- dents, these estimates were 15.5% and 2.5%, respectively
senting approximately 7,260,500 persons, had ever tried (Table  2.1b). Due to smaller sample sizes, confidence
e-cigarettes (Centers for Disease Control and Prevention intervals were too wide to determine sociodemographic
[CDC], unpublished data [NYTS 2015]). This included differences in these measures. These estimates are consis-
13.5% of middle school students and 37.7% of high school tent with a report by CDC (2015b).
students (Tables 2.1a and 2.1b). Among middle school stu- A recent analysis of 2014 MTF data, specific to high
dents, use was comparable between boys and girls, but it school seniors, showed the frequency of e-cigarette use
was higher among Hispanics compared with other racial/ (defined as the number of days in the past 30 days a student
ethnic groups (Table 2.1a). For high school students, use used an e-cigarette) increases with ever cigarette smoking
was also comparable between boys and girls, but higher (Warner et al. 2016). Among high school seniors who used
among both White and Hispanic youth compared with at least 1 e-cigarette in the past 30 days, the frequency
Black youth (Table 2.1b). According to data from the 2015 of e-cigarette use was almost twice as high (10.2  days)
Youth Risk Behavior Survey (YRBS), a larger percentage among those who regularly smoke conventional ciga-
of high school students (44.9%) had ever used e-cigarettes rettes, compared to those who had never smoked a con-
(Kann et al. 2016), while the Monitoring the Future (MTF) ventional cigarette (5.8 days). However, the frequency of
survey does not collect data on ever use of e-cigarettes e-cigarette use did not vary substantially among current
(Johnston et al. 2016). cigarette smokers. Among high school seniors who used
at least 1 e-cigarette in the past 30 days, the frequency
Past-30-Day Use of e-cigarette use averaged 8–10 days for “heavy cigarette
smokers” (those who smoked more than a half pack of
According to the 2015 NYTS, an estimated 620,000 cigarettes per day), “light cigarette smokers” (those who
middle school students and 2,390,000 high school students smoked 1–5 cigarettes per day), and “very light cigarette
had used e-cigarettes at least once in the past 30 days (CDC smokers” (those who smoked fewer than 1 cigarette per
2016). This was an increase from the 2014 NYTS, which day) (Warner et al. 2016).
reported 450,000 middle school students and 2,010,000 high
school students had used e-cigarettes in the past 30  days Susceptibility to Use
(CDC 2015c). Levels of past-30-day use were 5.3% for
middle school students and 16% for high school students in Among those who had never used an e-cigarette,
2015 (Tables 2.2a and 2.2b), compared with 3.9% for middle 32.1% of middle school students and 38.4% of high school
school students and 13.4% for high school students in 2014. students were susceptible to using e-cigarettes in the
Sociodemographic differences in past-30-day use for middle future. That is, these students did not have a firm resolve
and high school students had the same patterns as those for not to use e-cigarettes in the future. This is according to the
ever use (Tables 2.2a and 2.2b). In 2015, according to the 2015 NYTS (Tables 2.1a and 2.1b). No differences in suscep-
YRBS, 24.1% of high school students had used e-cigarettes tibility to use e-cigarettes were observed by gender or race/
at least once in the past 30 days (Kann et al. 2016). The 2015 ethnicity for either middle school or high school students.
MTF shows past-30-day prevalence of e-cigarette use among
adolescents was 9.5% among 8th graders, 14% among Trends in Prevalence
10th graders, and 16% among 12th graders (Johnston et al.
2016). Notably, data from NYTS, YRBS, and MTF show that Ever Use
in 2014 exclusive past-30-day use of e-cigarettes exceeded Overall, according to the NYTS, ever use of
exclusive past-30-day use of conventional cigarettes for the e-cigarettes among students in grades 6–12 increased
first time since these types of data were collected (University from 3.3% in 2011, to 6.8% in 2012, to 8.1% in 2013, to
of Michigan 2014; CDC 2015c). 19.8% in 2014, and then to 27% in 2015 (Figure 2.1). As

28   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.1a Percentage of middle school students who have used e-cigarettes, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS)
2015
Frequent usec: Susceptibility to Susceptibility to
Among current Frequent usec: used: Among never used: Among all
  Ever usea Current useb users Among all students users students
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 13.5 (11.8–15.5) 0.9 5.3 (4.6–6.2) 0.4 11.7 (8.6–15.8) 1.8 0.6 (0.4–0.9) 0.1 32.1 (29.7–34.7) 1.3 41.4 (38.3–44.5) 1.5
Gender                        
Female 12.2 (10.5–14.1) 0.9 4.8 (4.0–5.6) 0.4 11.0 (6.9–17.0) 2.5 0.5 (0.3–0.8) 0.1 33.1 (30.2–36.2) 1.5 41.4 (38.0–44.8) 1.7
Male 14.9 (12.9–17.2) 1.1 5.9 (4.7–7.2) 0.6 11.8 (8.3–16.5) 2.0 0.7 (0.5–1.0) 0.1 31.3 (28.2–34.6) 1.6 41.6 (37.9–45.4) 1.9
Race/ethnicity                      
White 12.2 (10.1–14.5) 1.1 4.4 (3.6–5.5) 0.5 10.8 (6.5–17.5) 2.7 0.5 (0.3–0.8) 0.1 29.7 (26.1–33.6) 1.9 38.0 (33.7–42.5) 2.2
Black or 11.7 (9.5–14.3) 1.2 4.1 (3.1–5.3) 0.6 14.0 (5.9–29.6) 5.7 — — 34.7 (30.7–39.0) 2.1 42.5 (39.0–46.2) 1.8
African
American
Hispanic or 18.6 (15.9–21.5) 1.4 8.3 (6.8–10.0) 0.8 12.1 (7.5–18.9) 2.8 1.0 (0.6–1.6) 0.2 38.0 (35.2–40.8) 1.4 49.8 (46.9–52.7) 1.5
Latino
Othere 11.9 (8.2–17.1) 2.2 4.6 (2.7–7.7) 1.2 — — — — 30.4 (24.7–36.8) 3.1 39.5 (33.2–46.2) 3.3
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%.
aIncludes those who reported using an e-cigarette, even once or twice.
bIncludes those who reported using e-cigarettes on 1 or more days in the past 30 days.
cIncludes those who responded “≥20 days” to the following question: “During the past 30 days, on how many days did you use electronic cigarettes or e-cigarettes?”
See CDC (2015b).
dIncludes those who failed to respond “definitely not” to any of the following questions: (a) “Do you think that you will try an electronic cigarette or e-cigarette soon?”;
(b) “If one of your best friends were to offer you an electronic cigarette or e-cigarette, would you use it?”; or (c) “Have you ever been curious about using an electronic
cigarette or e-cigarette, even once or twice?”
eIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   29


A Report of the Surgeon General

Table 2.1b Percentage of high school students who have used e-cigarettes, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS) 2015
Frequent usec: Susceptibility to Susceptibility to
Among current Frequent usec: used: Among never used: Among all
  Ever usea Current useb users Among all students users students
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 37.7 (35.3–40.2) 1.2 16 .0 (14.1–18.0) 1.0 15.5 (12.9–18.4) 1.4 2.5 (1.9–3.2) 0.3 38.4 (36.5–40.4) 1.0 61.1 (59.0–63.2) 1.0
Gender                  
Female 34.6 (31.9–37.3) 1.4 12.8 (11.0–15.0) 1.0 10.1 (7.2–14.0) 1.7 1.3 (0.9–1.8) 0.2 39.8 (37.4–42.2) 1.2 60.3 (58.1–62.5) 1.1
Male 40.7 (37.7–43.7) 1.5 19.0 (16.5–21.7) 1.3 19.1 (15.6–23.1) 1.9 3.6 (2.7–4.8) 0.5 36.9 (34.3–39.5) 1.3 61.8 (59.2–64.4) 1.3
Race/ethnicity                  
White 38.0 (35.1–41.0) 1.5 17.2 (14.7–19.9) 1.3 16.8 (13.4–20.8) 1.9 2.9 (2.1–3.9) 0.4 36.3 (33.4–39.4) 1.5 60.1 (57.4–62.7) 1.3
Black or 28.5 (25.5–31.8) 1.6 8.9 (7.4–10.8) 0.8 8.5 (3.9–17.4) 3.2 0.8 (0.3–1.7) 0.3 37.2 (32.2–42.5) 2.6 54.5 (51.0–57.9) 1.7
African
American
Hispanic or 43.0 (38.9–47.2) 2.1 16.4 (14.1–19.0) 1.2 12.8 (9.3–17.3) 2.0 2.1 (1.4–3.1) 0.4 44.6 (41.2–48.0) 1.7 67.8 (64.3–71.1) 1.7
Latino
Othere 37.4 (24.8–52.1) 7.0 18.9 (10.3–32.2) 5.5 18.2 (11.2–28.2) 4.3 3.4 (2.1–5.7) 0.9 41.2 (35.4–47.3) 3.0 62.6 (54.0–70.5) 4.2

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Note: CI = confidence interval; SE = standard error.
aIncludes those who reported using an e-cigarette, even once or twice.
bIncludes those who reported using e-cigarettes on 1 or more days in the past 30 days.
cIncludes those who responded “≥20 days” to the following question: “During the past 30 days, on how many days did you use electronic cigarettes or e-cigarettes?”
See CDC (2015b).
dIncludes those who failed to respond “definitely not” to any of the following questions: (a) “Do you think that you will try an electronic cigarette or e-cigarette soon?”;
(b) “If one of your best friends were to offer you an electronic cigarette or e-cigarette, would you use it?”; or (c) “Have you ever been curious about using an electronic
cigarette or e-cigarette, even once or twice?”
eIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.

30   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.2a Percentage of middle school students who used e-cigarettes in the past 30 daysa, by gender and race/ethnicity; National Youth Tobacco
Survey (NYTS) 2011–2015
  2011 2012 2013 2014 2015
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 0.6 (0.4–0.9) 0.1 1.1 (0.9–1.5) 0.1 1.1 (0.8–1.5) 0.2 3.9 (3.0–5.0) 0.5 5.3 (4.6–6.2) 0.4
Gender                    
Female 0.4 (0.2–0.7) 0.1 0.8 (0.5–1.1) 0.1 0.9 (0.6–1.4) 0.2 3.3 (2.5–4.3) 0.5 4.8 (4.0–5.6) 0.4
Male 0.7 (0.4–1.3) 0.2 1.5 (1.1–2.1) 0.3 1.4 (0.9–1.9) 0.2 4.5 (3.4–5.9) 0.6 5.9 (4.7–7.2) 0.6
Race/ethnicity                    
White 0.6 (0.3–1.0) 0.2 0.9 (0.6–1.3) 0.2 0.9 (0.6–1.4) 0.2 3.1 (2.2–4.2) 0.5 4.4 (3.6–5.5) 0.5
Black or African — — 1.1 (0.6–2.2) 0.4 1.4 (0.7–2.5) 0.4 3.8 (2.5–5.6) 0.7 4.1 (3.1–5.3) 0.6
American
Hispanic or 0.6 (0.4–1.1) 0.2 2.0 (1.4–2.9) 0.4 1.8 (1.1–2.7) 0.4 6.2 (4.8–7.9) 0.8 8.3 (6.8–10.0) 0.8
Latino
Otherb — — — — — — 3.2 (1.6–6.3) 1.1 4.6 (2.7–7.7) 1.2
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of
questions used to measure e-cigarette use varied from 2011 to 2015.
aIncludes those who reported using e-cigarettes on 1 or more of the past 30 days. This is also considered “current use” in this survey.
bIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   31


A Report of the Surgeon General

Table 2.2b Percentage of high school students who used e-cigarettes in the past 30 daysa, by gender and race/ethnicity; National Youth Tobacco Survey
(NYTS) 2011–2015
  2011 2012 2013 2014 2015
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 1.5 (1.2–2.0) 0.2 2.8 (2.3–3.5) 0.3 4.5 (3.8–5.3) 0.4 13.4 (11.2–16.1) 1.2 16.0 (14.1–18.0) 1.0
Gender                    
Female 0.7 (0.5–1.0) 0.1 1.9 (1.5–2.4) 0.2 3.5 (2.8–4.3) 0.4 11.9 (9.7–14.5) 1.2 12.8 (11.0–15.0) 1.0
Male 2.3 (1.7–3.2) 0.4 3.7 (2.9–4.8) 0.5 5.5 (4.5–6.8) 0.6 15.0 (12.4–18.2) 1.4 19.0 (16.5–21.7) 1.3
Race/ethnicity                    
White 1.8 (1.3–2.4) 0.3 3.4 (2.7–4.2) 0.4 4.8 (3.8–6.1) 0.6 15.3 (12.4–18.8) 1.6 17.2 (14.7–19.9) 1.3
Black or African — — 1.1 (0.7–1.9) 0.3 2.7 (1.9–3.9) 0.5 5.6 (3.7–8.5) 1.2 8.9 (7.4–10.8) 0.8
American
Hispanic or 1.3 (0.8–2.1) 0.3 2.7 (1.9–3.8) 0.5 5.3 (4.2–6.6) 0.6 15.3 (11.8–19.5) 1.9 16.4 (14.1–19.0) 1.2
Latino
Otherb — — — — 4.0 (2.3–6.9) 1.1 9.4 (6.8–12.9) 1.5 18.9 (10.3–32.2) 5.5
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of
questions used to measure e-cigarette use varied from 2011 to 2015.
a Includes those who reported using e-cigarettes on 1 or more of the past 30 days. This is also considered “current use” in this survey.
b Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.

32   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Figure 2.1 Trends in ever e-cigarette usea among U.S. middle and high school students; National Youth Tobacco
Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention 2013a, 2014b; unpublished data (data: NYTS 2015).
Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of this
estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent these differences.
aIncludes those who responded “1 or more” to the following question: During the last 30 days, on how many days did you use
electronic cigarettes or e-cigarettes?

discussed in Appendix 2.2 (see NYTS Measures—Special the prevalence of ever use did not differ significantly by
Issues), measures of e-cigarette use were changed for gender or race/ethnicity. There remained no significant dif-
the 2014 NYTS, as signaled by the dotted line in the ference in ever use by gender in the 2014 or 2015 NYTS, but
figure. Research conducted using the New Jersey Youth by 2014 and still in 2015, a greater percentage of Hispanic
Tobacco Survey suggests that the NYTS measures used middle school students (18.6%) had tried e-cigarettes than
in 2011–2013 may potentially underestimate use, com- White (12.2%) or Black (11.7%) students or students of
pared with the 2014 measure (Delnevo et al. 2016). For other races/ethnicities (11.9%) (Table 2.3a).
the 2011−2015 period, use of e-cigarettes was higher in High school students. Trends in ever use of
each year among high school students than among middle e-cigarettes among U.S. high school students are pre-
school students (Tables 2.3a and 2.3b). sented in Tables 2.3b and Figure 2.1, using data from the
Middle school students. Trends in ever use of 2011–2015 NYTS. The prevalence of ever use increased
e-cigarettes among U.S. middle school students are pre- from 4.7% in 2011 to 10% in 2012, to 11.9% in 2013,
sented in Table 2.3a and Figure 2.1, using data from the to 27.3% in 2014, and then to 37.7% in 2015. In that year,
2011–2015 NYTS. The prevalence of ever use increased an estimated 5,624,876 high school students had ever
from 1.4% in 2011 to 2.7% in 2012, to 3.0% in 2013, to used e-cigarettes (CDC, unpublished data [NYTS 2015]).
10.1% in 2014, and then to 13.5% in 2015. The jump in In 2011–2013, male high school students had a higher
prevalence between 2013 and 2014 may be an artifact of a rate of ever use each year compared with female students,
change in how the use item was asked (see Appendix 2.2. but in 2014 the genders did not differ significantly in their
Key Measures of Use). Nonetheless, prevalence of use would rates. From 2011 to 2015, White and Hispanic high school
be expected to be minimal prior to 2011, suggesting that a students were more likely each year to be ever users than
considerable increase in use was still observed during this were Black students: In 2015, these figures were 38% and
relatively short 4-year period. In 2015, among middle school 43%, respectively, for White and Hispanic students com-
students, an estimated 1,595,481 had ever tried e-cigarettes pared with 28.5% for Black students.
(CDC, unpublished data [NYTS 2015]). From 2011 to 2013,

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   33


A Report of the Surgeon General

Table 2.3a Percentage of middle school students who have ever used e-cigarettesa, by gender and race/ethnicity; National Youth Tobacco Survey
(NYTS) 2011–2015
  2011 2012 2013 2014 2015
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 1.4 (1.0–2.0) 0.2 2.7 (2.2–3.2) 0.2 3.0 (2.5–3.5) 0.2 10.1 (8.5–11.9) 0.8 13.5 (11.8–15.5) 0.9
Gender                    
Female 1.2 (0.8–1.6) 0.2 2.4 (1.9–3.0) 0.3 2.8 (2.3–3.5) 0.3 9.9 (7.8–12.6) 1.2 12.2 (10.5–14.1) 0.9
Male 1.7 (1.1–2.7) 0.4 3.0 (2.4–3.6) 0.3 3.1 (2.5–3.9) 0.3 10.3 (8.6–12.3) 0.9 14.9 (12.9–17.2) 1.1
Race/ethnicity                    
White 1.5 (0.9–2.3) 0.3 2.6 (2.1–3.3) 0.3 3.0 (2.4–3.7) 0.3 8.9 (7.2–11.1) 1.0 12.2 (10.1–14.5) 1.1
Black or African 1.2 (0.7–2.0) 0.3 2.3 (1.3–4.2) 0.7 2.7 (1.9–3.7) 0.5 9.7 (7.9–11.9) 1.0 11.7 (9.5–14.3) 1.2
American
Hispanic or Latino 1.6 (1.1–2.3) 0.3 3.3 (2.3–4.6) 0.6 3.9 (2.9–5.2) 0.6 14.6 (12.2–17.4) 1.3 18.6 (15.9–21.5) 1.4
Otherb — — 1.0 (0.5–2.2) 0.4 — — 6.5 (3.9–10.9) 1.7 11.9 (8.2–17.1) 2.2
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of
questions used to measure e-cigarette use varied from 2011 to 2015.
aIncludes those who reported ever trying e-cigarettes.
bIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.

34   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.3b Percentage of high school students who have ever used e-cigarettesa, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS)
2011–2015
  2011 2012 2013 2014 2015
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 4.7 (3.8–5.7) 0.5 10.0 (8.6–11.6) 0.7 11.9 (10.5–13.5) 0.8 27.3 (24.4–30.5) 1.5 37.7 (35.3–40.2) 1.2
Gender                    
Female 3.5 (2.7–4.4) 0.4 8.0 (6.7–9.5) 0.7 9.9 (8.3–11.7) 0.8 24.5 (21.4–27.9) 1.6 34.6 (31.9–37.3) 1.4
Male 5.9 (4.7–7.3) 0.7 12.0 (10.2–14.1) 1.0 13.8 (12.1–15.8) 0.9 30.1 (27.2–33.3) 1.5 40.7 (37.7–43.7) 1.5
Race/ethnicity                    
White 5.8 (4.6–7.4) 0.7 12.3 (10.5–14.4) 1.0 14.7 (12.8–16.9) 1.0 29.7 (26.2–33.4) 1.8 38.0 (35.1–41.0) 1.5
Black or African 1.5 (0.9–2.4) 0.4 4.0 (3.1–5.1) 0.5 4.9 (3.6–6.6) 0.7 17.6 (14.1–21.8) 1.9 28.5 (25.5–31.8) 1.6
American
Hispanic or 3.7 (2.5–5.5) 0.7 8.5 (6.6–10.8) 1.0 10.4 (8.6–12.5) 1.0 29.9 (25.4–34.9) 2.4 43.0 (38.9–47.2) 2.1
Latino
Otherb 2.8 (1.7–4.6) 0.7 6.0 (3.3–10.8) 1.8 8.3 (5.3–12.8) 1.8 18.7 (14–24.5) 2.6 37.4 (24.8–52.1) 7.0
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: CI = confidence interval; SE = standard error. Wording of questions used to measure e-cigarette use varied from 2011 to 2015.
aIncludes those who reported ever trying e-cigarettes.
bIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   35


A Report of the Surgeon General

Past-30-Day Use Middle school students. Trends in past-30-day use of


e-cigarettes among middle school students in the United
According to the NYTS, past-30-day use of
States are presented in Table 2.2a and Figure 2.2, again
e-cigarettes among students in grades 6−12 in the
using data from the 2011–2015 NYTS. The prevalence of
United States increased from 1.1% in 2011 to 2.1% in
such use in this population increased from 0.6% in 2011
2012, to 3.1% in 2013, to 9.3% in 2014, and then 11.3%
to 1.1% in 2012 and 2013, to 3.9% in 2014, and then to
in 2015 (CDC 2013b; Ambrose et al. 2014; Lippert 2015;
5.3% in 2015 (Table 2.2a) (CDC 2016). Between 2011 and
CDC, unpublished data) (Figure 2.2). In 2015, approxi-
2015, there were no significant differences in prevalence
mately 3,038,000 middle and high school students were
by gender; unstable estimates (see notes to the table)
past-30-day users of e-cigarettes (CDC, unpublished
precluded an examination of differences in past-30-day
data [NYTS 2015]). Across all years, past-30-day use of
e-cigarette use by race/ethnicity for 2011–2013. In 2014,
e-cigarettes was higher among high school students than
the prevalence of past-30-day use was higher among
middle school students (Figure 2.2; Tables 2.2a and 2.2b).
Hispanics (6.2%) than Whites (3.1%), a trend that was also
In the MTF, estimates were stable from 2014 to 2015;
seen in 2015 with 8.3% of Hispanics and 4.4% of Whites
among 8th, 10th, and 12th graders, past-30-day use went
reporting past-30-day use. From 2011 to 2015, increases
from 8.7% to 9.5%, 16.2% to 14%, and 17.1% to 16.2%,
were seen among females (0.4% to 4.8%), males (0.7% to
respectively (University of Michigan, Institute for Social
5.9%), Whites (0.6% to 4.4%), Hispanics (0.6% to 8.3%),
Research, unpublished data). Differences in trends in past-
and Blacks (1.1% in 2012 to 4.1%) (Table 2.2a) (CDC 2013b;
30-day use between the NYTS and MTF may be due to dif-
CDC 2015c; CDC 2016).
ferences in age groups (e.g., the NYTS includes all grades
High school students. Trends in past-30-day use
in middle school and all grades in high schools) and the
of e-cigarettes among high school students are also pre-
way in which these measures were asked on the instru-
sented in Table 2.2b and Figure 2.2, again using data from
ments (see Table A2.2-1 in Appendix 2.2).
the 2011−2015 NYTS. The prevalence of such use in this
population increased from 1.5% in 2011 to 2.8% in 2012,

Figure 2.2 Trends in past-30-day e-cigarette usea among U.S. middle and high school students; National Youth
Tobacco Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention 2013a, 2014b; unpublished data (data: NYTS 2015).
Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of this
estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent these differences.
aIncludes those who responded “1 or more” for the following question: “During the last 30 days, on how many days did you use
electronic cigarettes or e-cigarettes?”

36   Chapter 2
E-Cigarette Use Among Youth and Young Adults

to 4.5% in 2013, to 13.4% in 2014, and then to 16% in (King et al. 2015). In 2014, ever use of e-cigarettes or sim-
2015. From 2011 to 2013 and in 2015, males were signifi- ilar products was statistically equivalent between young
cantly more likely each year to be past-30-day users than adults (18–24 years old) at 14.3%, adults 25–44 years old
were females, but this difference was not significant in at 15%, and adults 45–64 years old at 11.9% (p  >0.05)
2014 (Table 2.2b). From 2012 to 2015, Black high school (CDC, unpublished data [Styles 2014]).
students were less likely each year to be past-30-day
users than were White or Hispanic high school stu-
dents (Table  2.2b). During 2011–2015, large increases E-Cigarette Use and Use of Other
in past-30-day use were seen among females (0.7% to
12.8%), males (2.3% to 19%), Whites (1.8% to 17.2%), Tobacco Products
and Hispanics (1.3% to 16.4%) (Table 2.2b) (CDC 2013b,
2015c, 2016). Evidence from both national and regional studies
suggests that e-cigarette use is strongly associated with
other tobacco use, especially the use of combustible prod-
ucts (including conventional cigarettes, cigar products,
Young Adults and hookahs). However, many youth and young adults
use e-cigarettes exclusively, too. Estimates from cross-
Current Prevalence sectional surveys such as the NYTS, MTF, and NATS are
According to the 2013–2014 National Adult Tobacco presented below for youth and young adults, followed by
Survey (NATS), among young U.S. adults aged 18–24 years, longitudinal studies that examine whether e-cigarette use
the prevalence of ever use and current use of e-cigarettes precedes the use of other tobacco products (Leventhal
was 35.8% and 13.6%, respectively (Table 2.4a). These et al. 2015; Primack et al. 2015; Barrington-Trimis et al.
percentages were significantly higher than for the same 2016; Unger et al. 2016; Wills et al. 2016).
measures among adults aged 25 years or over (16.4% and
5.7%, respectively) (Table 2.4b). Among young adults, Cross-Sectional Studies
ever and current use were both higher among males than
females and for Whites than in other racial/ethnic groups Youth
(Table  2.4a). By educational attainment, among young Current prevalence. Using data from the 2015 MTF
adults, both ever and current use were lowest among survey, Figure 2.4 and Table 2.5 show past-30-day use of
those with a college degree (Table 2.4a). Among all young e-cigarettes and conventional cigarettes, including both
adults, 2% reported using e-cigarettes “every day”; while exclusive and combined use of these products, among
among current users in this age group, 15% reported this 8th-, 10th-, and 12th-grade students. In the 2015 MTF
frequency (Table 2.4a). Use of e-cigarettes “every day” survey, 10.4% of 12th graders used e-cigarettes only,
among older adults (≥25 years of age) was 1.3% overall 5.3%  used conventional cigarettes only, and 5.8% used
and 22% among current users (Table 2.4b). Among young both e-cigarettes and conventional cigarettes at least once
adults, sociodemographic differences in frequent use fol- in the past 30 days (Table 2.5) (MTF 2015a,b). For all grade
lowed the same pattern as those for ever and current use levels, exclusive use of e-cigarettes was more prevalent
(Table 2.4a). (6.8%, 10.4%, and 10.4% of 8th, 10th, and 12th graders,
respectively) than exclusive use of conventional cigarettes
Trends in Prevalence alone (1.4%, 2.2%, 5.3%, respectively). In the 8th and
According to the Styles (also known as HealthStyles 10th grades, the combined or dual use of e-cigarettes and
or Summer Styles) survey, the prevalence of ever use of conventional cigarettes was also more prevalent than the
e-cigarettes among young adults aged 18–24 years was use of conventional cigarettes alone (2.4% vs. 1.4%, and
6.9% in 2011, 4.1% in 2012, 7.8% in 2013, and 14.3% in 3.5% vs. 2.2% for 8th and 10th graders, respectively); while
2014, a year that saw the addition of other products to in the 12th grade, the prevalence in the two categories was
this measure, including e-hookahs and e-pipes or e-cigars nearly identical (5.8% vs. 5.3%). As grade level increases,
(Figure 2.3). Although the prevalence of ever use of the ratio of any e-cigarette use to any conventional ciga-
e-cigarettes among young adults remained consistent rette use decreases. Among 12th graders, dual use of these
from 2010 to 2013, it doubled from 2013 to 2014, pre- products was higher among boys than girls and among
sumably reflecting in part the addition of new products Whites than Blacks. In all grade levels, dual use was much
to the definition of e-cigarettes. In 2010, young adults higher among students who planned to attend fewer
(18–24 years) were more likely than older adults (25–44 than 4 years of college compared to those who planned
and 45–64 years of age) to be ever users of e-cigarettes to attend 4 years of college. No other sociodemographic

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   37


A Report of the Surgeon General

Table 2.4a Percentage of young adults (18–24 years of age) who have used e-cigarettes, by gender, race/ethnicity, and education; National Adult
Tobacco Survey (NATS) 2013–2014
Frequent usec: Among  Frequent usec:
  Ever usea Current useb current users Among all young adults
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 35.8 (34.1–37.6) 0.9 13.6 (12.5–14.8) 0.6 15.0 (12.1–18.5) 1.6 2.0 (1.6–2.6) 0.2
Gender                
Female 28.4 (26.1–30.8) 1.2 9.8 (8.3–11.5) 0.8 10.0 (6.5–15.1) 2.2 1.0 (0.6–1.5) 0.2
Male 42.9 (40.4–45.3) 1.2 17.1 (15.4–19.0) 0.9 17.8 (13.9–22.5) 2.2 3.0 (2.3–4.0) 0.4
Race/ethnicity                
White 39.7 (37.4–41.9) 1.2 16.1 (14.5–17.8) 0.9 15.3 (11.7–19.7) 2.0 2.5 (1.9–3.2) 0.4
Black or African 23.1 (19.0–27.8) 2.3 5.4 (3.7–7.9) 1.1 — — — —
American
Hispanic or Latino 36.6 (32.6–40.7) 2.1 13.4 (10.9–16.4) 1.4 12.0 (6.8–20.2) 3.3 1.6 (0.9–2.8) 0.5
Otherd 30.8 (25.8–36.3) 2.7 10.8 (8.1–14.2) 1.6 21.5 (11.6–36.4) 6.3 2.3 (1.2–4.4) 0.8
Education                
< High school 44.8 (38.9–50.9) 3.1 15.2 (11.5–19.7) 2.1 9.8 (4.8–18.8) 3.4 1.5 (0.7–3.0) 0.5
High school 39.4 (36.7–42.2) 1.4 14.9 (13.1–17.0) 1.0 17.6 (13.0–23.4) 2.6 2.6 (1.9–3.6) 0.4
Some collegee 34.3 (31.6–37.0) 1.4 14.7 (12.8–16.8) 1.0 14.8 (10.2–21.0) 2.7 2.2 (1.5–3.2) 0.4
College degreef 16.9 (14.2–20.0) 1.5 4.5 (3.1–6.4) 0.8 — — — —
Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%.
aIncludes those who reported they had heard of e-cigarettes and tried e-cigarettes.
bIncludes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.
cIncludes those who reported they had heard of e-cigarettes, tried e-cigarettes, and reported using e-cigarettes every day at the time of the interview.
dIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.
eIncludes some college, no degree; associate’s degree, academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.
fIncludes bachelor’s degree, master’s/professional school degree, or doctoral degree.

38   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.4b Percentage of adults (≥25 years of age) who have used e-cigarettes, by gender, race/ethnicity, and education; National Adult Tobacco Survey
(NATS) 2013–2014
Frequent usec: Among  Frequent usec:
  Ever usea Current useb current users Among all adults
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 16.4 (15.9–16.8) 0.2 5.7 (5.5–6.0) 0.1 22.0 (20.1–24.0) 1.0 1.3 (1.1–1.4) 0.1
Gender                
Female 14.7 (14.2–15.3) 0.3 5.0 (4.7–5.4) 0.2 20.6 (18.1–23.3) 1.3 1.0 (0.9–1.2) 0.1
Male 18.3 (17.6–18.9) 0.3 6.6 (6.1–7.0) 0.2 23.0 (20.2–25.9) 1.5 1.5 (1.3–1.7) 0.1
Race/ethnicity                
White 16.2 (15.8–16.7) 0.2 6.0 (5.7–6.4) 0.2 23.9 (21.7–26.3) 1.2 1.4 (1.3–1.6) 0.1
Black or African 15.1 (13.9–16.5) 0.7 3.8 (3.2–4.5) 0.3 15.2 (10.2–22.2) 3.0 0.6 (0.4–0.9) 0.1
American
Hispanic or Latino 15.6 (14.3–17.0) 0.7 4.9 (4.1–5.8) 0.4 15.8 (10.4–23.4) 3.3 0.8 (0.5–1.2) 0.2
Otherd 21.0 (19.2–22.9) 0.9 8.0 (6.7–9.4) 0.7 19.4 (14.0–26.2) 3.1 1.5 (1.1–2.1) 0.3
Education                
<High school 18.2 (16.8–19.7) 0.8 5.2 (4.4–6.1) 0.4 20.8 (15.2–27.7) 3.2 1.1 (0.8–1.5) 0.2
High school 20.6 (19.7–21.6) 0.5 7.6 (7.0–8.3) 0.3 19.2 (16.1–22.7) 1.7 1.5 (1.2–1.8) 0.1
Some collegee 19.7 (18.9–20.5) 0.4 7.4 (6.8–7.9) 0.3 24.5 (21.4–27.8) 1.6 1.8 (1.6–2.1) 0.1
College degreef 8.7 (8.2–9.1) 0.2 2.8 (2.5–3.1) 0.1 22.0 (18.1–26.4) 2.1 0.6 (0.5–0.8) 0.1
Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
Note: CI = confidence interval; SE = standard error.
aIncludes those who reported they had heard of and tried e-cigarettes.
bIncludes those who reported they had heard, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.
cIncludes those who reported they had heard of, tried, and reported using e-cigarettes every day at the time of the interview.
dIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.
eIncludes some college, no degree; associate’s degree, academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.
fIncludes bachelor’s degree, master’s/professional school degree, or doctoral degree.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   39


A Report of the Surgeon General

Figure 2.3 Trends in ever e-cigarette usea among U.S. adults by age group; Styles 2010–2014

Source: King et al. (2015) (data: HealthStyles 2010–2013); Centers for Disease Control and Prevention, unpublished data (data:
HealthStyles 2014).
Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of
this estimate to those collected in previous years. The dotted lines from 2013 to 2014 represent these differences.
aIncludes those who responded “electronic cigarettes or e-cigarettes” to the following question, “Have you ever tried any of the
following products, even just one time? Electronic cigarettes or e-cigarettes, such as Ruyan or NJOY?”

Figure 2.4 Percentage of students in grades 8, 10, and 12 who used e-cigarettes and cigarettes in the past 30 days;
Monitoring the Future (MTF) 2015

Source: University of Michigan, Institute for Social Research, unpublished data (data: MTF 2015).
Note: Questions on e-cigarette use were asked on four of six questionnaire forms. Data presented here are based on those four
forms only.

40   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.5 Percentage of students in grades 8, 10, and 12 who used e-cigarettes, cigarettes, or both products in the past 30 days, by sociodemographic characteristics;
Monitoring the Future (MTF) 2015
  8th grade 10th grade 12th grade
  E-cigarettes Cigarettes E-cigarettes Cigarettes E-cigarettes Cigarettes
Neither: % only: % only: % Both: % Neither: % only: % only: % Both: % Neither: % only: % only: % Both: %
(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
Overall 89.4 6.8 1.4 2.4 83.9 10.4 2.2 3.5 78.5 10.4 5.3 5.8
(88.4–90.5) (5.8–7.8) (0.9–1.8) (1.9–2.9) (81.9–85.9) (9.0–11.8) (1.7–2.7) (2.8–4.3) (76.7–80.3) (9.1–11.8) (4.6–6.0) (5.0–6.6)
Gender                        
Female 90.2 6.2 1.4 2.2 85.6 8.6 2.4 3.4 84.4 7.1 4.7 3.8
(88.7–91.7) (4.9–7.5) (0.7–2.0) (1.6–2.9) (83.6–87.6) (7.2–10.1) (1.6–3.1) (2.5–4.3) (82.8–86.0) (6.2–8.0) (3.6–5.7) (3.1–4.6)
Male 88.9 7.2 1.4 2.5 82.2 12.2 2.0 3.6 72.9 14.1 5.6 7.5
(87.3–90.4) (6.0–8.5) (0.7–2.0) (1.7–3.3) (79.6–84.7) (10.2–14.2) (1.3–2.7) (2.6–4.7) (70.2–75.6) (11.8–16.3) (4.6–6.6) (6.1–8.9)
Race/                        
ethnicity
White 90.1 6.2 1.2 2.6 82.1 11.2 2.3 4.4 75.2 12.0 5.8 7.1
(88.6–91.6) (4.9–7.4) (0.6–1.8) (1.7–3.4) (79.5–84.7) (9.2–13.2) (1.6–2.9) (3.4–5.4) (72.7–77.7) (10.4–13.6) (4.7–6.9) (5.9–8.3)
African 91.2 5.3 2.1 1.5 89.9 6.6 1.8 1.7 87.7 5.2 5.1 2.0
American (88.2–94.1) (2.7–7.8) (0.6–3.7) (0.0–2.9) (85.7–94.1) (3.6–9.5) (0.4–3.1) (0.4–3.1) (85.1–90.3) (3.8–6.6) (3.3–6.8) (1.1–3.0)
Hispanic 88.7 8.2 0.9 2.2 84.6 10.5 2.4 2.5 80.9 10.3 4.4 4.5
(85.8–91.5) (6.1–10.4) (0.2–1.6) (1.2–3.2) (81.5–87.6) (7.6–13.4) (0.9–4.0) (0.8–4.2) (78.0–83.7) (8.0–12.5) (3.2–5.5) (3.1–6.0)
College                        
plans
None or 76.8 10.1 4.9 8.3 66.3 15.4 7.0 11.3 65.1 13.0 10.2 11.7
<4 years (71.0–82.5) (6.1–14.0) (1.7–8.1) (4.8–11.8) (61.1–71.5) (11.3–19.4) (3.8–10.2) (7.6–15.1) (61.2–68.9) (9.7–16.3) (8.2–12.3) (9.5–13.9)
Complete 90.5 6.5 1.1 2.0 85.7 9.8 1.7 2.8 81.6 9.9 4.1 4.5
4 years (89.4–91.5) (5.5–7.4) (0.7–1.5) (1.5–2.5) (83.6–87.7) (8.3–11.4) (1.3–2.2) (2.1–3.5) (79.9–83.2) (8.6–11.1) (3.4–4.8) (3.8–5.2)

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   41


A Report of the Surgeon General

Table 2.5 Continued


  8th grade 10th grade 12th grade
  E-cigarettes Cigarettes E-cigarettes Cigarettes E-cigarettes Cigarettes
Neither: % only: % only: % Both: % Neither: % only: % only: % Both: % Neither: % only: % only: % Both: %
(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
Parental                        
educationa
1–2 (Low) 88.1 5.9 1.8 4.3 77.2 12.6 4.8 5.4 77.3 10.1 7.9 4.7
(83.9–92.2) (3.3–8.4) (0.3–3.2) (2.1–6.6) (72.0–82.4) (9.0–16.2) (1.5–8.0) (3.1–7.8) (73.4–81.2) (7.3–13.0) (5.4–10.4) (3.1–6.3)
2.5–3 86.2 9.4 1.8 2.6 81.7 10.6 2.5 5.2 75.2 11.1 7.2 6.5
(83.3–89.1) (6.7–12.1) (0.6–3.1) (1.2–3.9) (78.3–85.2) (8.1–13.0) (1.3–3.7) (3.2–7.1) (72.4–78.1) (9.0–13.3) (5.5–8.8) (5.0–7.9)
3.5–4 89.6 7.3 1.3 0.8 83.5 10.0 2.8 3.7 78.7 9.9 4.6 6.8
(87.5–91.8) (5.5–9.2) (0.3–2.3) (1.7–2.7) (80.3–86.7) (7.7–12.3) (1.7–3.9) (2.5–5.0) (75.9–81.5) (7.9–11.8) (3.6–5.6) (5.3–8.4)
4.5–5 91.0 6.2 1.3 1.5 86.1 9.7 1.4 2.9 78.6 11.2 4.4 5.8
(89.1–92.8) (4.5–7.9) (0.4–2.1) (0.6–2.5) (83.5–88.8) (7.5–11.8) (0.7–2.0) (1.7–4.1) (75.7–81.5) (9.1–13.2) (3.3–5.5) (4.4–7.2)
5.5–6 91.9 5.2 1.0 1.9 87.6 9.2 1.0 2.2 82.7 10.4 3.2 3.7
(High) (89.4–94.5) (3.3–7.0) (0.0–2.1) (0.4–3.4) (83.6–91.6) (6.3–12.2) (0.2–1.8) (0.7–3.7) (79.7–85.7) (8.1–12.7) (2.1–4.3) (2.2–5.2)
Source: University of Michigan, Institute for Social Research, unpublished data (data: MTF 2015).
Notes: Questions on e-cigarette use were asked on four of six questionnaire forms. Data presented here are based on those four forms only.
aParental education is an average score of mother’s education and father’s education.

42   Chapter 2
E-Cigarette Use Among Youth and Young Adults

differences were observed among dual users (Table 2.5). the patterns of poly-tobacco use were similar between the
For 10th and 12th graders, exclusive use of e-cigarettes two groups, albeit with a larger proportion of poly-tobacco
was higher among boys than girls. use in high school. An estimated 6.6% of high school stu-
Tables 2.6a and 2.6b present data from the 2015 NYTS dents and 1.8% of middle school students were dual users
for middle and high school students. These data represent of combustible tobacco products and e-cigarettes in 2015.
the percentages of tobacco users who were either lifetime Combined use of combustible tobacco, noncombustible
or past-30-day users of e-cigarettes, by tobacco-use cat- tobacco, and e-cigarettes in the past 30 days was rare,
egory (e.g., cigarettes only, other combustibles only). In with this pattern found for just 0.7% of middle school
these data, a correlation among the increasing levels of and 2.6%  of high school students in 2015 (Figure 2.5).
tobacco use, increasing complexity of poly-tobacco use, and Longitudinal data are needed to follow individuals over
e-cigarette use is apparent, with ever use and past-30-day time, ideally for several years, to more precisely examine
use of e-cigarettes emerging as least prevalent among never both the trajectories into and out of cigarette and
tobacco users and most prevalent among the highest cat- e-cigarette use and to determine if dual use is a steady state
egory of poly-tobacco users (conventional cigarettes plus or a pathway-to-persistent-use-of-combustible-tobacco
other combustibles and noncombustibles) for both age state (Cobb et al. 2015). The small number of such studies
groups. As an example, past-30-day e-cigarette use was that currently exist are discussed below.
rare (2.8%) among middle school students who did not Trends in prevalence. Tables 2.7a and 2.7b and
use other tobacco products in that time period. However, Figures 2.6 and 2.7 present patterns of ever e-cigarette
using the standard of past-30-day-use for each category, the and poly-tobacco use over time, using the NYTS data
level of such use grew from 44.9% among those who had from 2011 to 2015. Among both middle school and high
used cigarettes only; to 61.3% among those who had used school students, the exclusive use of combustible prod-
cigarettes and other combustibles only; to 74.6% among ucts declined over time, while both the exclusive use of
those who had used cigarettes, other combustibles, and e-cigarettes and the dual use of e-cigarettes with combus-
other noncombustibles only (Table 2.6a). These data are tible products increased, especially from 2013 to 2015.
consistent with results from the 2013–2014 PATH study Middle school students. In 2011, an estimated
(n  =  13,651 youth, 12–17 years old), which showed that 21% of middle school students had ever used some form
52.6% of past-30-day tobacco users also used e-cigarettes of tobacco in their lifetimes, compared to just 1.4% of
(Kasza et al. 2016). middle school students who had ever used e-cigarettes
According to the 2015 NYTS, among high school stu- (Table 2.7a). By 2015, 13.5% of middle school students
dents, past-30-day use of e-cigarettes was also rare (3.4%) had ever tried a tobacco product, while 3.5% had tried
among never users of other tobacco products (Table 2.6b). e-cigarettes. In that year, 4.5% of middle school students
In contrast, 18.4% of ever smokers of cigarettes only; were ever users of e-cigarettes only; 6.2% were ever users
36.3% of ever smokers of cigarettes and other combustible of e-cigarettes and combustible products only; and 2.2%
products only; and 55% of ever users of cigarettes, other were ever users of combustible products, noncombustible
combustibles, and other noncombustible products only products, and e-cigarettes. This means that 70% of middle
had used e-cigarettes in the past 30  days. Although the school students who had ever used e-cigarettes had
survey found that just 7.3% of high school students were also experimented with a combustible tobacco product,
past-30-day exclusive users of e-cigarettes, many types of although which came first is unknown. In 2015, for
tobacco product users in the past 30 days were found to past-30-day use, exclusive e-cigarette use was 2.6% and
have used e-cigarettes in that period: 41.1% of cigarette- exclusive combustible tobacco use was 1.2%. Also in 2015,
only smokers; 58.8% of cigarette smokers and smokers of the prevalence of past-30-day dual use of e-cigarettes and
other combustible tobacco products only; and 77% of cig- any other combustible or noncombustible product was
arette, other combustible, and noncombustible product similar to those estimates, at 2.7% (1.8% for e-cigarettes
users only. Similarly, 27.4% of high school students who plus combustibles only, 0.2% for noncombustibles and
had not used tobacco products in the past 30 days had ever e-cigarettes only, and 0.7% for e-cigarettes plus combusti-
tried e-cigarettes, as had 80.8% of past-30-day cigarette- bles and noncombustibles only). In 2015, ever use of ciga-
only smokers and 95.5% of those who had used cigarettes, rettes in combination with combustibles (6.2%) was equal
other combustible, and other noncombustible tobacco to or higher than ever use of e-cigarettes only (4.5%) or
products only (Table 2.6b). combustibles only (4.4%) (Table 2.7a).
Figure 2.5 presents data from the 2015 NYTS on the High school students. In 2011, an estimated 47.2% of
prevalence of past-30-day use of various tobacco products high school students had ever used other tobacco prod-
among middle and high school students. Although the ucts in their lifetimes, compared to 4.7%  who had ever
overall level of tobacco use was lower in middle school, used e-cigarettes (Table 2.7b). By 2015, 50.4% of high

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   43


A Report of the Surgeon General

Table 2.6a Lifetime and past-30-day e-cigarette use among U.S. middle school students, by other tobacco product
use; National Youth Tobacco Survey (NYTS) 2015
Past-30-day
    Lifetime e-cigarette usea e-cigarette useb
  Nc % (95% CI) SE % (95% CI) SE
Ever other tobacco used (n = 1,757) 8,162        
Never 6,942 5.3 (4.5–6.2) 0.4 1.6 (1.3–2.0) 0.2
Cigarettes only 343 54.3 (46.7–61.7) 3.8 20.8 (15.7–27.0) 2.8
Other combustibles only 261 59.0 (51.5–66.1) 3.7 24.8 (19.0–31.7) 3.2
Noncombustibles only 89 30.7 (23.2–39.3) 4.1 — —
Cigarettes + other combustibles only 300 70.6 (62.9–77.3) 3.6 35.0 (27.5–43.3) 4.0
Cigarettes + noncombustibles only 67 69.5 (54.5–81.3) 6.9 21.7 (12.7–34.6) 5.5
Other combustibles + noncombustibles only 27 80.3 (56.1–92.9) 9.2 39.4 (20.3–62.3) 11.2
Cigarettes + other combustibles + noncombustibles 133 84.1 (73.3–91.1) 4.4 45.0 (34.7–55.7) 5.3
only
Past-30-day other tobacco usee (n = 417) 8,145        
No 7,728 10.5 (9.1–12.0) 0.7 2.8 (2.3–3.4) 0.3
Cigarettes only 70 80.6 (68.3–89.0) 5.2 44.9 (32.0–58.6) 6.8
Other combustibles only 153 82.8 (74.0–89.1) 3.8 69.2 (59.1–77.8) 4.7
Noncombustibles only 50 49.0 (34.9–63.3) 7.3 23.1 (12.7–38.2) 6.4
Cigarettes + other combustibles only 63 77.3 (58.8–89.0) 7.6 61.3 (43.9–76.2) 8.4
Cigarettes + noncombustibles only 18 87.2 (65.2–96.1) 7.2 67.8 (40.0–87.0) 12.6
Other combustibles + noncombustibles only 20 87.5 (63.2–96.6) 7.7 64.8 (42.2–82.3) 10.6
Cigarettes + other combustibles + noncombustibles 43 85.8 (67.5–94.6) 6.5 74.6 (43.4–91.8) 12.7
only
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = confidence interval; SE = standard error. Cigarettes Only includes those who reported trying cigarettes but not any other
tobacco product. Other combustibles includes cigars, pipes, and hookah or bidis. Noncombustibles includes smokeless tobacco, dissolv-
ables, or snus. Other Combustibles Only includes those who reported trying other combustibles but not cigarettes nor noncombustibles.
Noncombustibles Only includes those who reported trying noncombustibles but not cigarettes nor other combustibles. Cigarettes and
Other Combustibles Only includes those who reported trying cigarettes and other combustibles but not noncombustibles. Cigarettes
and Noncombustibles Only includes those who reported trying cigarettes and noncombustibles but not other combustibles. Other
Combustibles and Noncombustibles Only includes those who reported trying other combustibles and noncombustibles but not cigarettes.
Cigarettes, Other Combustibles, and Noncombustibles includes those who reported trying a product from each group.
aIncludes those who responded “yes” to the following question, “Have you ever used an electronic cigarette or e-cigarette, even once
or twice?”
bIncludes those who responded “1 or more days” to the following question, “During the past 30 days, on how many days did you use
electronic cigarettes or e-cigarettes?”
cIncludes all respondents categorized into each group. It does not exclude those missing for e-cigarette status.
dIncludes those who reported trying at least one of the following products (e-cigarettes not included in the definitions): Cigarettes Only;
Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and Noncombustibles Only;
Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.
eIncludes those who reported using at least one of the following products on 1 of the past 30 days (e-cigarettes were not included in the
definitions): Cigarettes Only; Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and
Noncombustibles Only; Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.

44   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.6b Lifetime and past-30-day e-cigarette use among U.S. high school students, by other tobacco product use;
National Youth Tobacco Survey (NYTS) 2015
Past-30-day
    Lifetime e-cigarette usea e-cigarette useb
  Nc % (95% CI) SE % (95% CI) SE
Ever other tobacco used (n = 5,094) 9,422        
Never 5,326 13.1 (11.7–14.8) 0.8 3.4 (2.5–4.4) 0.5
Cigarettes only 675 54.7 (48.5–60.6) 3.0 18.4 (13.7–24.4) 2.7
Other combustibles only 947 60.0 (54.4–65.3) 2.7 21.7 (18.0–25.9) 2.0
Noncombustibles only 137 39.8 (30.8–49.6) 4.7 20.2 (12.5–31.0) 4.6
Cigarettes + other combustibles only 1,307 79.6 (74.7–83.8) 2.3 36.3 (31.5–41.3) 2.5
Cigarettes + noncombustibles only 131 61.5 (48.7–72.9) 6.2 25.5 (18.5–34.0) 3.9
Other combustibles + noncombustibles only 171 69.5 (57.1–79.6) 5.7 35.3 (26.1–45.8) 5.0
Cigarettes + other combustibles + noncombustibles 728 89.2 (82.6–93.5) 2.7 55.0 (47.5–62.4) 3.8
only
Past-30-day other tobacco usee (n = 2,389) 9,416        
No 7,542 27.4 (25.2–29.7) 1.1 7.3 (6.1–8.8) 0.7
Cigarettes only 288 80.8 (74.2–86.0) 2.9 41.1 (32.2–50.6) 4.7
Other combustibles only 701 77.2 (71.2–82.3) 2.8 50.4 (45.0–55.8) 2.7
Noncombustibles only 192 69.6 (54.6–81.4) 6.8 31.2 (23.0–40.9) 4.5
Cigarettes + other combustibles only 353 87.1 (77.5–93.0) 3.8 58.8 (49.1–67.8) 4.7
Cigarettes + noncombustibles only 62 76.9 (59.8–88.2) 7.2 50.8 (27.9–73.5) 12.3
Other combustibles + noncombustibles only 108 88.7 (78.8–94.3) 3.8 74.1 (61.3–83.9) 5.7
Cigarettes + other combustibles + noncombustibles 170 95.9 (87.2–98.8) 2.4 77.0 (66.6–84.8) 4.6
only
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = confidence interval; SE = standard error. Cigarettes Only includes those who reported trying cigarettes but not any other
tobacco product. Other combustibles includes cigars, pipes, and hookah or bidis. Noncombustibles includes smokeless tobacco, dissolv-
ables, or snus. Other Combustibles Only includes those who reported trying other combustibles but not cigarettes nor noncombustibles.
Noncombustibles Only includes those who reported trying noncombustibles but not cigarettes nor other combustibles. Cigarettes and
Other Combustibles Only includes those who reported trying cigarettes and other combustibles but not noncombustibles. Cigarettes
and Noncombustibles Only includes those who reported trying cigarettes and noncombustibles but not other combustibles. Other
Combustibles and Noncombustibles Only includes those who reported trying other combustibles and noncombustibles but not cigarettes.
Cigarettes, Other Combustibles, and Noncombustibles includes those who reported trying a product from each group.
aIncludes those who responded “yes” to the following question, “Have you ever used an electronic cigarette or e-cigarette, even once
or twice?”
bIncludes those who responded “1 or more days” to the following question, “During the past 30 days, on how many days did you use
electronic cigarettes or e-cigarettes?”
cIncludes all respondents categorized into each group. It does not exclude those missing for e-cigarette status.
dIncludes those who reported trying at least one of the following products (e-cigarettes not included in the definitions): Cigarettes Only;
Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and Noncombustibles Only;
Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.
eIncludes those who reported using at least one of the following products on 1 of the past 30 days (e-cigarettes were not included in the
definitions): Cigarettes Only; Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and
Noncombustibles Only; Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   45


A Report of the Surgeon General

Figure 2.5 Past-30-day use of various tobacco products among U.S. middle and high school students; National
Youth Tobacco Survey (NYTS) 2015

Source: Centers for Disease Control and Prevention 2015b; unpublished data (data: NYTS 2015).
aIncludes exclusive use of e-cigarettes. It does not include use of any other product.
bIncludes exclusive use of smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products or
e‑cigarettes.
cIncludes the use of cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It includes participants who reported use of combustible
and noncombustible products but not e‑cigarettes.

46   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.7a Percentage of middle school students who have ever used tobacco, by type of product; National Youth Tobacco Survey (NYTS) 2011–2015
  2011 2012 2013 2014 2015
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Any lifetimea tobacco use 21.0 (19.2–22.9) 0.9 17.9 (15.9–20.0) 1.0 17.6 (15.6–19.9) 1.1 19.1 (16.7–21.8) 1.3 19.4 (17.0–22.0) 1.2
Any lifetime e-cigarette useb 1.4 (1.0–2.0) 0.2 2.7 (2.2–3.2) 0.2 3.0 (2.5–3.5) 0.2 10.1 (8.5–11.9) 0.8 13.5 (11.8–15.5) 0.9
Ever tobacco usec                
E-cigarettes only 0.3 (0.2–0.6) 0.1 0.4 (0.3–0.5) 0.1 0.5 (0.3–0.9) 0.1 2.9 (2.3–3.5) 0.3 4.5 (3.9–5.2) 0.3
Combustibles and e-cigarettes only 0.4 (0.3–0.6) 0.1 1.1 (0.9–1.4) 0.1 1.5 (1.1–1.9) 0.2 4.5 (3.9–5.3) 0.4 6.2 (5.4–7.2) 0.5
Noncombustibles and e-cigarettes only ND ND — — — — 0.3 (0.1–0.6) 0.1 0.4 (0.2–0.7) 0.1
Combustibles, noncombustibles, and 0.5 (0.3–0.9) 0.1 1.1 (0.8–1.4) 0.1 0.8 (0.6–1.2) 0.1 2.2 (1.45–3.2) 0.4 2.2 (1.7–2.9) 0.3
e-cigarettes
Combustibles only 13.9 (12.5–15.4) 0.7 10.7 (9.5–12.1) 0.7 11.6 (10.1–13.3) 0.8 6.9 (5.6–8.4) 0.7 4.4 (3.7–5.2) 0.4
Noncombustibles only 1.5 (1.1–1.9) 0.2 1.2 (0.9–1.6) 0.2 0.8 (0.6–1.1) 0.1 0.8 (0.5–1.2) 0.2 1.0 (0.7–1.4) 0.2
Combustibles and noncombustibles 4.3 (3.5–5.1) 0.4 3.4 (2.8–4.0) 0.3 2.4 (1.8–3.2) 0.3 1.5 (1.1–2.1) 0.2 0.7 (0.4–1.1) 0.2
only
Any past-30-day tobacco used 7.5 (6.4–8.8) 0.6 6.7 (5.8–7.7) 0.5 6.5 (5.43–7.8) 0.6 7.7 (6.7–8.9) 0.6 7.4 (6.3–8.7) 0.6
Any past-30-day e-cigarette usee 0.6 (0.4–0.9) 0.1 1.1 (0.9–1.5) 0.1 1.1 (0.8–1.5) 0.2 3.9 (3.0–5.0) 0.5 5.3 (4.6–6.2) 0.4
Past-30-day tobacco use                
E-cigarettes onlyf 0.2 (0.1–0.4) 0.1 0.3 (0.2–0.4) 0.1 0.4 (0.2–0.8) 0.1 1.9 (1.4–2.5) 0.3 2.6 (2.2–3.2) 0.3
Combustibles and e-cigarettes only 0.1 (0.1–0.3) 0.0 0.5 (0.3–0.7) 0.1 0.4 (0.3–0.6) 0.1 1.3 (1.0–1.7) 0.2 1.8 (1.4–2.2) 0.2
Noncombustibles and e-cigarettes only — — — — — — 0.1 (0.1–0.2) 0.0 0.2 (0.1–0.3) 0.0
Combustibles, noncombustibles, and 0.2 (0.1–0.3) 0.1 0.4 (0.2–0.5) 0.1 0.2 (0.1–0.4) 0.1 0.6 (0.4–0.8) 0.1 0.7 (0.4–1.1) 0.1
e-cigarettes
Combustibles only 4.5 (3.7–5.5) 0.4 3.7 (3.2–4.3) 0.3 4.0 (3.3–4.9) 0.4 2.7 (2.1–3.3) 0.3 1.2 (0.9–1.6) 0.2
Noncombustibles only 0.9 (0.6–1.3) 0.2 0.7 (0.5–1.0) 0.1 0.6 (0.3–0.9) 0.2 0.7 (0.4–1.2) 0.2 0.6 (0.3–1.2) 0.2
Combustibles and noncombustibles 1.6 (1.3–2.0) 0.2 1.2 (0.9–1.5) 0.2 0.8 (0.5–1.1) 0.1 0.5 (0.4–0.8) 0.1 0.3 (0.1–0.6) 0.1
only
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: CI = confidence interval; ND = no data for this cell; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard
error >40%. Wording of questions used to measure e-cigarette use varied from 2011 to 2015. Cigarettes were not included in this analysis. Combustibles includes cigars, pipes,
hookahs, or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Combustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and
combustibles but not noncombustibles. Noncombustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and noncombustibles but not combustibles.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   47


A Report of the Surgeon General

Table 2.7a Continued


Combustibles, Noncombustibles, and E-Cigarettes includes those who reported trying e-cigarettes, noncombustibles, and combustibles. Combustibles Only includes those
who reported trying combustibles but not noncombustibles or e-cigarettes. Noncombustibles Only includes those who reported trying noncombustibles but not combustibles or
e-cigarettes. Combustibles and Noncombustibles Only includes those who reported trying noncombustibles and combustibles but not e-cigarettes.
aIncludes those who reported having tried at least one tobacco product in their lives (e-cigarettes, combustibles, and noncombustibles).
bIncludes those who reported having tried e-cigarettes in their lives.
cIncludes those who reported having tried at least one tobacco product in their lives.
dIncludes those who reported using at least one other tobacco product on at least 1 of the past 30 days.
eIncludes those who reported using e-cigarettes on at least 1 of the past 30 days.
fIncludes those who reported using e-cigarettes only on at least 1 of the past 30 days.

48   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.7b Percentage of high school students who have ever used tobacco, by type of product; National Youth Tobacco Survey (NYTS) 2011–2015
  2011 2012 2013 2014 2015
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Any lifetimea tobacco use 47.2 (44.0–50.4) 1.6 45.7 (43.0–48.5) 1.4 46.0 (43.3–48.7) 1.4 47.1 (44.5–49.8) 1.3 50.4 (47.9–52.9) 1.3
Any lifetime e-cigarette useb 4.7 (3.8–5.7) 0.5 10.0 (8.6–11.6) 0.7 11.9 (10.5–13.5) 0.8 27.3 (24.4–30.5) 1.5 37.7 (35.3–40.2) 1.2
Ever tobacco usec                
E-cigarettes only 0.1 (0.1–0.2) 0.0 0.2 (0.2–0.4) 0.0 0.3 (0.2–0.6) 0.1 3.7 (2.9–4.8) 0.5 7.4 (6.6–8.4) 0.5
Combustibles and e-cigarettes 1.6 (1.3–2.0) 0.2 4.2 (3.5–5.0) 0.4 6.0 (5.2–6.9) 0.4 14.5 (13.2–16.0) 0.7 20.0 (18.6–21.6) 0.8
only
Noncombustibles and e-cigarettes — — — — — — 0.3 (0.1–0.4) 0.1 0.6 (0.4–0.8) 0.1
only
Combustibles, noncombustibles, 2.8 (2.2–3.6) 0.4 5.2 (4.3–6.2) 0.5 5.2 (4.2–6.3) 0.5 8.3 (7.0–9.7) 0.7 9.1 (7.6–10.9) 0.8
and e-cigarettes
Combustibles only 29.1 (27.3–30.9) 0.9 25.1 (23.1–27.1) 1.0 25.2 (22.7–27.8) 1.3 15.8 (14.3–17.5) 0.8 10.2 (8.8–11.8) 0.8
Noncombustibles only 1.8 (1.3–2.4) 0.3 1.3 (1.0–1.8) 0.2 1.5 (1.1–1.9) 0.2 1.2 (0.9–1.7) 0.2 0.9 (0.7–1.2) 0.1
Combustibles and 11.8 (9.8–13.9) 1.1 9.7 (8.6–10.9) 0.6 7.8 (6.6–9.3) 0.7 3.3 (2.6–4.2) 0.4 2.2 (1.6–3.0) 0.4
noncombustibles only
Any past-30-day tobacco used 24.0 (22.0–26.5) 1.2 23 (21.5–25.2) 0.9 22.9 (21.1–24.9) 0.9 24.6 (22.6–26.7) 1.0 25.3 (23.1–27.6) 1.1
Any past-30-day e-cigarette usee 1.5 (1.2–2.0) 0.2 2.8 (2.3–3.5) 0.3 4.5 (3.8–5.3) 0.4 13.4 (11.2–16.1) 1.2 16.0 (14.1–18.0) 1.0
Past-30-day tobacco use                    
E-cigarettes onlyf 0.1 (0.1–0.2) 0.0 0.3 (0.2–0.4) 0.1 0.7 (0.5–0.9) 0.1 4.4 (3.4–5.7) 0.6 5.9 (4.9–7.0) 0.5
Combustibles and e-cigarettes 0.7 (0.5–0.9) 0.1 1.4 (1.1–1.8) 0.2 2.6 (2.1–3.2) 0.3 5.8 (4.9–6.8) 0.5 6.6 (5.7–7.7) 0.5
only
Noncombustibles and ND ND — — — — 0.6 (0.4–0.8) 0.1 0.7 (0.5–0.9) 0.1
e-cigarettes only
Combustibles, noncombustibles, 0.6 (0.4–0.9) 0.1 1.1 (0.8–1.4) 0.1 1.1 (0.8–1.4) 0.1 2.5 (2.0–3.2) 0.3 2.6 (2.1–3.3) 0.3
and e-cigarettes
Combustibles only 15.6 (14.5–16.8) 0.6 14.4 (13.2–15.6) 0.6 13.5 (12.4–14.8) 0.6 8.1 (7.2–9.2) 0.5 6.8 (5.9–7.8) 0.5
Noncombustibles only 2.3 (1.7–3.0) 0.3 1.9 (1.4–2.4) 0.2 1.6 (1.2–2.2) 0.3 1.5 (1.1–2.0) 0.2 1.5 (1.0–2.2) 0.3
Combustibles and 4.9 (4.0–6.1) 0.5 4.3 (3.7–5.2) 0.4 3.4 (2.7–4.3) 0.4 1.6 (1.2–2.2) 0.2 1.1 (0.7–1.8) 0.2
noncombustibles only
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   49


A Report of the Surgeon General

Table 2.7b Continued


Notes: CI = confidence interval; ND = no data for this cell; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard
error >40%. Wording of questions used to measure e-cigarette use varied from 2011 to 2015. Cigarettes were not included in this analysis. Combustibles includes cigars, pipes,
hookahs, or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Combustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and
combustibles but not noncombustibles. Noncombustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and noncombustibles but not combustibles.
Combustibles, Noncombustibles, and E-Cigarettes includes those who reported trying e-cigarettes, noncombustibles, and combustibles. Combustibles Only includes those
who reported trying combustibles but not noncombustibles or e-cigarettes. Noncombustibles Only includes those who reported trying noncombustibles but not combustibles or
e-cigarettes. Combustibles and Noncombustibles Only includes those who reported trying noncombustibles and combustibles but not e-cigarettes.
aIncludes those who reported having tried at least one tobacco product in their lives (e-cigarettes, combustibles, and noncombustibles).
bIncludes those who reported having tried e-cigarettes in their lives.
cIncludes those who reported having tried at least one tobacco product in their lives.
dIncludes those who reported using at least one other tobacco product on at least 1 of the past 30 days.
eIncludes those who reported using e-cigarettes on at least 1 of the past 30 days.
fIncludes those who reported using e-cigarettes only on at least 1 of the past 30 days.

50   Chapter 2
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Figure 2.6 Percentage of U.S. middle school students who have ever used tobaccoa, by type of product; National
Youth Tobacco Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: For more information see Table 2.10a. In 2014, modifications were made to the e-cigarette measure to enhance its accuracy,
which may limit the comparability of this estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent
these differences.
aIncludes those who reported having tried at least one other tobacco product in their lives.
bIncludes exclusive use of only e-cigarettes. It does not include use of any other product. Ever e-cigarette use includes those who
responded “electronic cigarettes or e-cigarettes, such as Ruyan or NJOY” to the following question: “Which of the following tobacco
products have you ever tried, even just one time?”
cIncludes exclusive use of only cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It does not include use of noncombustible
products or e-cigarettes. They were defined using the following questions: Conventional cigarettes: “Have you ever tried cigarette
smoking, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigarettes?”; cigars: “Have you
ever tried smoking cigars, cigarillos, or little cigars, such as Black and Milds, Swisher Sweets, Dutch Masters, White Owl, or Phillies
Blunts, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?”;
pipes: “Have you ever tried smoking tobacco in a pipe, even one or two puffs?” and “During the past 30 days, on how many days did
you smoke tobacco in a pipe?”; and hookahs, kreteks, and bidis: “Which of the following tobacco products have you ever tried, even
just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the following products have you used on at
least 1 day? (CHOOSE ALL THAT APPLY).”
dIncludes exclusive use of only smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products
or e-cigarettes. They were defined using the following questions: Smokeless tobacco: “Have you ever used chewing tobacco, snuff,
or dip, such as Red Man, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen, even just a small amount?” and “During the
past 30 days, on how many days did you use chewing tobacco, snuff, or dip?”; and dissolvables and snus: “Which of the following
tobacco products have you ever tried, even just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the
following products have you used on at least 1 day? (CHOOSE ALL THAT APPLY).”

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   51


A Report of the Surgeon General

Figure 2.7 Percentage of U.S. high school students who have ever used tobaccoa, by type of product; National Youth
Tobacco Survey (NYTS) 2011–2015

Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: For more information see Table 2.10b. In 2014, modifications were made to the e-cigarette measure to enhance its accuracy,
which may limit the comparability of this estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent
these differences.
aIncludes those who reported having tried at least one other tobacco product in their lives.
bIncludes exclusive use of only e-cigarettes. It does not include use of any other product. Ever e-cigarette use includes those who
selected “electronic cigarettes or e-cigarettes, such as Ruyan or NJOY” for the following question: “Which of the following tobacco
products have you ever tried, even just one time?”
cIncludes exclusive use of only cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It does not include use of noncombustible
products or e-cigarettes. They were defined using the following questions: Conventional cigarettes: “Have you ever tried cigarette
smoking, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigarettes?”; cigars: “Have you
ever tried smoking cigars, cigarillos, or little cigars, such as Black and Milds, Swisher Sweets, Dutch Masters, White Owl, or Phillies
Blunts, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?”;
pipes: “Have you ever tried smoking tobacco in a pipe, even one or two puffs?” and “During the past 30 days, on how many days did
you smoke tobacco in a pipe?”; and hookahs, kreteks, and bidis: “Which of the following tobacco products have you ever tried, even
just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the following products have you used on at
least 1 day? (CHOOSE ALL THAT APPLY).”
dIncludes exclusive use of only smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products
or e-cigarettes. They were defined using the following questions: Smokeless tobacco: “Have you ever used chewing tobacco, snuff,
or dip, such as Red Man, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen, even just a small amount?” and “During the
past 30 days, on how many days did you use chewing tobacco, snuff, or dip?”; and dissolvables and snus: “Which of the following
tobacco products have you ever tried, even just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the
following products have you used on at least 1 day? (CHOOSE ALL THAT APPLY).”

52   Chapter 2
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school students had ever tried a tobacco product, and Table 2.8b for adults 25 years of age and older. For both
37.7% had ever used an e-cigarette. In 2015, 7.4% of high age groups, exclusive use of regular cigarettes was the
school students had ever used e-cigarettes exclusively; most prevalent pattern of behavior (9.6%, young adults;
20% were ever dual users of e-cigarettes and combustible 13%, adults), followed by dual use of cigarettes and
products; 0.6% were ever dual users of noncombustible e-cigarettes (7.5%, young adults; 4.2%, adults), and exclu-
products and e-cigarettes only; and 9.1% were ever poly sive use of e-cigarettes (6.1%, young adults; 1.6%, adults).
users of combustibles, noncombustibles, and e-cigarettes. Among young adults, combined use of the two products
However, the order of the use (i.e., which product came and exclusive use of e-cigarettes were both higher among
first) remains unknown. In 2015, 5.9% of high school stu- males than females; combined use was higher among
dents were exclusive past-30-day users of e-cigarettes; 6.6% Whites than in Hispanics or Blacks; and both combined
were past-30-day dual users of e-cigarettes and combus- use of the two products and exclusive use of e-cigarettes
tible tobacco products; 0.7% were past-30-day dual users were lowest among those with a college degree.
of e-cigarettes and noncombustible tobacco products only;
and 2.6% were past-30-day poly users of e-cigarettes, com- Longitudinal Studies
bustible, and noncombustible tobacco products. Exclusive
Understanding the role that e-cigarettes play in
use of combustible products (6.8%) remained as prevalent
the initiation of tobacco product use, especially conven-
as past-30-day dual use of e-cigarettes and combustible
tional cigarettes and other combustible tobacco prod-
products (6.6%) among high school students (Table 2.7b).
ucts, such as cigars and hookahs, is extremely important
for informing public health policy, planning, and prac-
Young Adults2
tice. It is unclear what impact e-cigarette use will have
Current prevalence. Using data from the 2013–2014 on the overall toll of tobacco use on public health (Cobb
NATS, current exclusive and combined use of e-cigarettes et al. 2015). Some researchers and policymakers are con-
and cigarettes are presented in Figure 2.8 and Table 2.8a cerned about the order in which the initiation of tobacco
for young adults (18–24 years old), and in Figure 2.8 and products takes place, positing that the use of e-cigarettes

Figure 2.8 Percentage of young adults who currently use e-cigarettesa and conventional cigarettes; National Adult
Tobacco Survey (NATS) 2013–2014

Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
aCurrent e-cigarette use was defined as those who reported they had heard of e-cigarettes and had tried e-cigarettes, and reported
using e-cigarettes every day, some days, or rarely at the time of the interview.

2Asopposed to the situation in youth, cigarettes are the most commonly used tobacco product among young adults. Therefore, this
chapter does not assess co-use of e-cigarettes and other tobacco products among young adults.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   53


A Report of the Surgeon General

Table 2.8a Percentage of young adults (18–24 years of age) who currently use e-cigarettesa, cigarettesb, or bothc products, by gender, race/ethnicity,
and education: National Adult Tobacco Survey (NATS) 2013–2014
  Neitherd E-cigarettes onlye Cigarettes onlyf Bothc
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 76.8 (75.3–78.3) 0.8 6.1 (5.3–7.0) 0.4 9.6 (8.6–10.7) 0.5 7.5 (6.6–8.4) 0.5
Gender                
Female 81.8 (79.7–83.7) 1.0 4.0 (3.1–5.2) 0.5 8.4 (7.1–9.9) 0.7 5.8 (4.7–7.2) 0.6
Male 72.3 (70.1–74.4) 1.1 8.1 (6.9–9.4) 0.6 10.6 (9.2–12.2) 0.8 9.0 (7.7–10.4) 0.7
Race/ethnicity                
White 72.8 (70.7–74.8) 1.1 6.3 (5.3–7.5) 0.6 11.2 (9.8–12.8) 0.8 9.7 (8.4–11.2) 0.7
Black or African American 84.8 (80.8–88.2) 1.9 2.9 (1.7–4.9) 0.8 9.8 (7.0–13.5) 1.6 2.5 (1.4–4.4) 0.7
Hispanic or Latino 80.5 (77.0–83.6) 1.7 7.5 (5.7–9.7) 1.0 6.1 (4.3–8.5) 1.1 5.9 (4.2–8.3) 1.1
Otherg 79.8 (75.5–83.5) 2.1 5.7 (3.8–8.6) 1.2 9.4 (6.9–12.5) 1.4 5.1 (3.4–7.6) 1.0
Education                
<High school 67.4 (61.7–72.6) 2.8 5.8 (3.7–9.1) 1.3 17.3 (13.4–22.1) 2.2 9.4 (6.6–13.3) 1.7
High school 74.4 (71.9–76.7) 1.2 6.5 (5.3–7.8) 0.6 10.7 (9.2–12.5) 0.8 8.5 (7.0–10.1) 0.8
Some collegeh 78.2 (75.8–80.4) 1.2 7.3 (5.9–9.0) 0.8 7.2 (5.9–8.7) 0.7 7.3 (6.1–8.8) 0.7
College degreei 92.5 (90.2–94.4) 1.1 2.3 (1.4–3.9) 0.6 3.1 (2.0–4.7) 0.7 2.1 (1.2–3.5) 0.6
Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
Note: CI = confidence interval; SE = standard error.
aIncludes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.
bIncludes those who smoked at least 100 cigarettes and reported using cigarettes every day or some days at the time of the interview.
cIncludes those who reported currently using both e-cigarettes and conventional cigarettes.
dIncludes those who reported currently using neither conventional cigarettes nor e-cigarettes.
eIncludes those who reported currently using e-cigarettes but not conventional cigarettes.
fIncludes those who reported currently using conventional cigarettes but not electronic e-cigarettes.
gIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.
hIncludes some college, no degree; associate’s degree, academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.
iIncludes bachelor’s degree, master’s/professional school degree, or doctoral degree.

54   Chapter 2
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Table 2.8b Percentage of adults (≥25 years of age) who currently use e-cigarettesa, cigarettesb, or bothc products, by gender, race/ethnicity, and
education: National Adult Tobacco Survey (NATS) 2013–2014
  Neitherd E-cigarettes onlye Cigarettes onlyf Bothc
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 81.3 (80.8–81.7) 0.2 1.6 (1.5–1.7) 0.1 13.0 (12.6–13.4) 0.2 4.2 (3.9–4.4) 0.1
Gender                
Female 83.4 (82.8–84.0) 0.3 1.3 (1.1–1.4) 0.1 11.5 (11.0–12.0) 0.3 3.8 (3.5–4.1) 0.2
Male 78.8 (78.1–79.5) 0.4 2.0 (1.7–2.2) 0.1 14.6 (14.0–15.3) 0.3 4.6 (4.2–5.0) 0.2
Race/ethnicity                
White 82.1 (81.6–82.6) 0.3 1.6 (1.5–1.8) 0.1 11.9 (11.5–12.3) 0.2 4.4 (4.1–4.7) 0.1
Black or African American 76.2 (74.6–77.7) 0.8 0.9 (0.7–1.3) 0.2 20.0 (18.6–21.5) 0.7 2.9 (2.4–3.5) 0.3
Hispanic or Latino 83.2 (81.6–84.6) 0.8 1.5 (1.1–2.0) 0.2 12.0 (10.7–13.3) 0.7 3.4 (2.7–4.2) 0.4
Otherg 77.5 (75.6–79.4) 1.0 2.5 (1.9–3.3) 0.4 14.5 (13.0–16.1) 0.8 5.5 (4.4–6.7) 0.6
Education                
<High school 71.3 (69.5–73.1) 0.9 1.0 (0.7–1.4) 0.2 23.5 (21.8–25.2) 0.9 4.2 (3.5–5.1) 0.4
High school 75.4 (74.4–76.4) 0.5 1.8 (1.5–2.2) 0.2 16.9 (16.1–17.8) 0.4 5.9 (5.3–6.5) 0.3
Some collegeh 79.2 (78.4–80.0) 0.4 2.0 (1.8–2.3) 0.1 13.4 (12.7–14.1) 0.3 5.3 (4.9–5.8) 0.2
College degreei 92.5 (92.1–93.0) 0.2 1.2 (1.0–1.4) 0.1 4.7 (4.3–5.0) 0.2 1.6 (1.4–1.8) 0.1
Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
Note: CI = confidence interval; SE = standard error.
aIncludes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.
bIncludes those who smoked at least 100 cigarettes and reported using cigarettes every day or some days at the time of the interview.
cIncludes those who reported currently using both e-cigarettes and conventional cigarettes.
dIncludes those who reported currently using neither conventional cigarettes nor e-cigarettes.
eIncludes those who reported currently using e-cigarettes but not conventional cigarettes.
fIncludes those who reported currently using conventional cigarettes but not e-cigarettes.
gIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.
hIncludes some college, no degree; associate’s degree: academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.
iIncludes bachelor’s degree, master’s/professional school degree, or doctoral degree.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   55


A Report of the Surgeon General

could increase the likelihood that adolescents and young not to smoke using established measures of this construct
adults who have never used any tobacco products, but ini- (Evans et al. 1995; Pierce et al. 1996).
tiate e-cigarettes, will become lifetime users of conven- Wills and colleagues (2016) followed a cohort of
tional cigarettes or other tobacco products in sufficiently 2,338 students in grades 9 and 10 in Hawaii for 1 year. At
large numbers, resulting in a net harm to public health baseline, 31% of the sample had ever used an e-cigarette,
(USDHHS 2012). Other researchers suggest that the order and 15% had ever used a conventional cigarette. One
of product initiation for tobacco products is unimportant year later, these increased to 38% and 21%, respectively.
and that experimentation with a variety of substances may Of those who had not used either of these products at
be a marker of a common vulnerability to tobacco, alcohol, baseline, 10%  initiated exclusive e-cigarette use 1 year
marijuana, and other substance-use behaviors (Vanyukov later; 2% initiated exclusive conventional cigarette use;
et al. 2012). Regardless, both of these perspectives on the and 4% initiated use of both products. Students who
effect of e-cigarette use on youth and young adults require had never smoked a conventional cigarette at baseline
longitudinal data to understand how current behaviors but had used an e-cigarette at baseline were three times
may affect health outcomes. more likely to smoke conventional cigarettes 1 year later
Five longitudinal studies to date suggest that (adjusted OR  =  2.87, p  <0.001). By comparison, among
e-cigarette use among youth (Leventhal et al. 2015; those who smoked conventional cigarettes at baseline,
Barrington-Trimis et al. 2016; Wills et al. 2016) and youth use of e-cigarettes at that same point in time was not
and young adults (Primack et al. 2015; Unger et al. 2016) related to any reduction in the use of conventional cig-
might lead to initiation of the use of combustible tobacco arettes 1  year later (p  >0.05). Moreover, students were
products in the future. The first study to appear was by more likely to transition from never use to dual use of
Leventhal and colleagues (2015). In this study, a cohort of both products 1  year later if they were older, Caucasian
9th graders in Los Angeles, California, was followed up at or Native Hawaiian (compared with Asian-American),
both 6 and 12 months, into 10th grade. Those who at base- more rebellious, and perceived e-cigarettes as healthier
line had never used combustible tobacco, but were ever (adjusted OR  =  2.05, 2.15, 3.10, 3.32, 2.59, respectively,
users of an e-cigarette, were more likely to use combus- all p <0.001).
tible tobacco products at both follow-up points (odds ratio Barrington-Trimis and colleagues (2016) followed a
[OR]  =  4.27, 95% confidence interval [CI], 3.19–5.71). cohort of 11th and 12th grade students in California for
Product-specific analyses showed that e-cigarette use in more than 1 year (median 15.6 months). In this cohort,
9th grade was associated with the use of cigars (OR = 4.85, at baseline, 146 were ever e-cigarette users and 152 were
95% CI, 3.38–6.96), hookahs (OR  =  3.25, 95% CI, never e-cigarette users; none had ever smoked a cigarette.
2.29–4.62), and cigarettes (OR = 2.65, 95% CI, 1.73–4.05) Among never e-cigarette users at baseline, 16 participants
in 10th grade. It was also associated with the number (10.5%) reported using cigarettes at follow-up; among
of different combustible products used in 10th  grade ever e-cigarette users at baseline, 59 participants (40.4%)
(OR  =  4.26, 95% CI, 3.16–5.74) (all ORs presented here reported the same (OR = 6.17; 95% CI, 3.30–11.60).
were averaged across the two time points). In these After adjusting for cigar, pipe, or hookah use at baseline,
analyses, Leventhal and colleagues (2015) adjusted for the relationship attenuated only somewhat (OR = 5.48;
demographic characteristics (age, gender, race/ethnicity, 95% CI, 2.69–11.20). When stratified by susceptibility to
highest parental education), social factors (peer smoking, cigarette smoking at baseline (defined, like Primack and
parental smoking), and intrapersonal factors (depression, colleagues [2015], as the lack of a firm commitment not
impulsivity, delinquent behaviors) linked with cigarette to smoke using established measures of this construct
smoking in previous research. [Evans et al. 1995; Pierce et al. 1996]), the relationship
Primack and colleagues (2015), in a national cohort was actually stronger among those who were not suscep-
study, followed youth and young adults, 16–26 years of age, tible (OR = 9.69; 95% CI, 4.02–23.40) compared to those
for 1 year. At baseline, only 16 participants (2.3%) had ever who were susceptible (OR = 2.12; 95% CI, 0.79–5.74). The
used e-cigarettes. In adjusted models that included only latter relationship was not statistically significant. In addi-
those who did not use conventional cigarettes at base- tional analyses that were restricted to those who reported
line and adjusted for gender, age, race/ethnicity, maternal no use of any combustible tobacco product at baseline,
educational level, sensation seeking, parental cigarette e-cigarette users were more likely to initiate use of any
smoking, and peer cigarette smoking, baseline e-cigarette combustible tobacco product at follow-up (OR  =  4.98;
use was independently associated with progression to cig- 95%  CI, 2.37–10.4), including the use of cigarettes
arette smoking (OR = 8.3, 95% CI, 1.2–58.6) and suscep- (OR  =  4.29; 95% CI; 1.84–10.0), hookahs (OR  =  2.86;
tibility to cigarette smoking (OR = 8.5, 95% CI, 1.3–57.2). 95% CI, 1.21–6.78), cigars (OR = 4.39; 95% CI, 1.72–11.2),
Susceptibility was defined as a lack of a firm commitment and pipes (OR = 8.21; 95% CI, 1.20–56.2). The models used

56   Chapter 2
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by Barrington-Trimis and colleagues (2016) adjusted for colleagues (2015) and Wills and colleagues (2016) did not
a variety of demographic characteristics (grade, gender, assess prior use at baseline of other tobacco products,
race/ethnicity, highest parental education) and social fac- marijuana, or alcohol. Though it is not highlighted prom-
tors (peer and parental smoking). Additionally, gender, inently in their article, Leventhal and colleagues (2015)
race/ethnicity (Hispanic White, non-Hispanic White, showed a bidirectional relationship between e-cigarette
other), grade (11th or 12th), and ever use of hookahs were use and other combustible tobacco product use in their
tested as potential effect modifiers of these associations, study: Use of other combustible tobacco products at
but no evidence was found for the same. baseline was significantly associated with the onset of
Unger and colleagues (2016) followed a cohort of e-cigarette use in two follow-ups. This hypothesis was not
1,332 Hispanic young adults in California who provided tested by Barrington-Trimis and colleagues (2016), Wills
survey data in 2014 and 2015. At baseline, these par- and colleagues (2016), or Primack and colleagues (2015).
ticipants were an average of 22.7 years old. E-cigarette However, at the 1-year follow-up, Wills and colleagues
use at baseline was significantly associated with ciga- (2016) did consider other demographics, personality, and
rette smoking (OR  =  3.32; 95% CI, 1.55–7.10, among psychosocial predictors of exclusive e-cigarette use and
non-cigarette smokers at baseline) and marijuana use dual use of conventional cigarettes and e-cigarettes.
(OR  =  1.97; 95% CI, 1.01–3.86, among non-marijuana Concerns about the samples for the two studies
users at baseline) at follow-up. Among those who did not can be raised as well. The samples in the studies by
smoke cigarettes at baseline (n = 1,056), 42 reported past Barrington-Trimis and colleagues (2016) and Leventhal
month e-cigarette use in 2014; 26% of those who smoked and colleagues (2015) were limited to youth in California;
e-cigarettes at baseline became cigarette smokers in 2015, the study by Primack and colleagues (2015) suffered
compared to 7% of those who did not smoke e-cigarettes. from a small sample size, with only 16 e-cigarette users
Further, among those who did not smoke marijuana at at baseline (Leventhal et al. 2015; Primack et al. 2015);
baseline (n = 1,028), 68 reported past month e-cigarette and the study by Wills and colleagues (2016) was limited
use in 2014; 24% of those who smoked e-cigarettes at to 9th- and 10th-grade students in Hawaii. Additional
baseline became marijuana smokers in 2015, compared to studies are still needed in the future to further elucidate
12% of those who did not smoke e-cigarettes. Moreover, any causal relationship in either direction between the use
in this study, e-cigarette use at baseline was not associ- of e-cigarettes and other types of tobacco products, such
ated with cessation of cigarette smoking (OR = 1.31; as combustibles.
95% CI, 0.73– 2.36) or marijuana use (OR = 1.05; 95%
CI. 0.54–2.01) at follow-up. Among those who did smoke
cigarettes at baseline (n = 276), 76% reported past month E-Cigarette Use and Other
e-cigarette use in 2014; and 63% of those who smoked
e-cigarettes at baseline were still smoking cigarettes at Substance Use
follow-up, compared to 58% of those who did not smoke
e-cigarettes. Covariates in these regression models Few studies have investigated the co-occurrence
included age, gender, past month use of alcohol, and past of e-cigarette use and other risk behaviors in adoles-
month use of other tobacco products (hookah, cigars, cents and young adults. The available evidence suggests
little cigars, smokeless tobacco). that e-cigarette use is associated not only with the use of
Despite the several strengths of these studies, other tobacco products, but also with alcohol and other
including their longitudinal nature, they had weaknesses substance use, such as marijuana. This is consistent with
as well. Rigotti (2015) notes, for example, that the study the common liability model for substance use and other
by Leventhal and colleagues (2015) could not distin- risky behaviors (Vanyukov et al. 2012). Because nearly all
guish between those who merely began experimenting currently available studies on this topic focus on regional,
with a combustible product and those who became reg- international, and at-risk samples, the conclusions from
ular smokers at follow-up. The same could be said for most studies cannot be generalized to the U.S. population
the studies by Barrington-Trimis and colleagues (2016), as a whole, however.
Primack and colleagues (2015), and Wills and colleagues In the only nationally representative study exam-
(2016). Similarly, the single exposure measure of the ining the associations between e-cigarettes, alcohol, and
independent variable (i.e., any e-cigarette use) in these other drug use in young adults 18–24 years of age, the
studies did not allow the authors to assess whether there odds of alcohol use were nine times as high and the odds
was a dose–response relationship between the extent of of everyday/some-day marijuana use were three-and-a-half
prior e-cigarette use and subsequent use of combustible times as high among past-30-day e-cigarette users as
tobacco products. In addition, the studies by Primack and they were for those who had not used these products in

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   57


A Report of the Surgeon General

that period (Cohn et al. 2015). Elsewhere, in a nonprob- E-Cigarettes and Marijuana
ability sample of college students 17–25 years of age,
Because of their design, e-cigarettes may facilitate
66% of current e-cigarette users and 67% of current dual
drug use among youth and young adults, as these prod-
users were heavy drinkers, defined as consuming at least
ucts can be used as a delivery system for cannabinoids
once, five or more drinks (men) or four or more drinks
and other illicit drugs (Giroud et al. 2015; Morean et al.
(women) in a single sitting during the course of 1 month
2015; Schauer et al. 2016). The aerosolization of cannabis
(Littlefield et al. 2015). In another study, this one of col-
is a relatively new technology used to deliver inhaled tet-
lege students in New York, past-30-day use of e-cigarettes
rahydrocannabinol (THC) and other cannabinoids while
was positively associated with current binge drinking and
reducing the toxic byproducts of smoked cannabis, which
tobacco product use, and it was less common among those
are primarily caused by combustion (Abrams et al. 2007).
20–23 years of age (versus those 18 years of age), females,
Laboratory studies of prototype aerosolizers have
non-Hispanic non-Whites (compared with non-Hispanic
demonstrated that they can provide a relatively effective
Whites), and those reporting better-than-average school
mode of delivering THC, with plasma THC concentrations
performance (Saddleson et al. 2015).
similar to those obtained from smoking a standard mari-
Data from a longitudinal cohort study of children
juana cigarette (Abrams et al. 2007; Giroud et al. 2015).
with alcoholic parents found that adolescents (both middle
In addition, thermal metered-dose cannabis inhalers
and late adolescence) who used cigarettes, marijuana, or
have been developed for medical applications; their tech-
alcohol were significantly more likely to have ever used
nology is similar to that of e-cigarettes (Eisenberg et al.
e-cigarettes. Among those who had used marijuana,
2014). While the first generation of cannabis aerosolizers
e-cigarette use was associated with greater use of mari-
was developed to aerosolize dry cannabis, the widespread
juana during the previous 30 days (Lessard et  al. 2014).
availability of e-cigarettes and rapid advances in their
In a cross-sectional pilot study of seventh-grade students
technology have led to the development of liquid/oil forms
in Southern California, ever use of e-cigarettes was 11%,
of cannabis/THC that can be used with e-cigarettes in a
compared to 6.8% for cigarettes, 38.1% for alcohol, and
fashion similar to that employed when they are filled with
39% for cigarettes or alcohol. In this study, 80% of ever
nicotine (Giroud et al. 2015). Articles explaining how to
users of e-cigarettes had used alcohol, and 42.2% had used
acquire and use THC-containing liquid using e-cigarette
conventional cigarettes (Pentz et al. 2015).
technology are accessible on the Internet and are strongly
In a 2013 sample of students (n = 2,002) in two states
suggestive of relatively widespread awareness and use
in the southeastern United States, 53.4% of e-cigarette
(Gray 2013).
users also used marijuana (Berg et al. 2015). Elsewhere,
The actual prevalence of users of marijuana aero-
in a sample of young adults (18–23 years of age) at col-
solizers and their experiences remain unclear and under-
leges and universities that was taken in 2013 in upstate
studied (Van Dam and Earleywine 2010; Malouff et al.
New York (n = 1,437), 54.2% of past-30-day marijuana
2014). In one of the few published studies on this issue
users, 23.9% of past-30-day alcohol users, and 40.3% of
specific to youth, Morean and colleagues (2015) found
past-30-day binge drinkers had ever used e-cigarettes
that, among high school students in Connecticut, vapor-
(Saddleson et al. 2015). In Switzerland, among a sample
izing cannabis was common among ever e-cigarette users
of eighth graders, nearly 60% of regular e-cigarette users
(18%), ever cannabis users (18.4%), and ever dual users
“had been drunk” at least once in the past 30 days (defined
(26.5%). This finding suggests a need for more specific
as an affirmative response to the question, “have you been
surveillance measures that take into account the use of
drunk in the previous 30 days”), and 44.8% had used mari-
drugs other than nicotine in e-cigarettes.
juana at least once during that period (Suris et al. 2015).
There are several limitations to these observational
studies. For example, when considering the associations
derived from these observational studies, the order of ini- Use of Flavored E-Cigarettes
tiation of the products of interest cannot be inferred. In
addition, some biases cannot be ruled out because of the The liquid that is vaporized in an e-cigarette is avail-
nature of the samples, and patterns of associations may able to consumers in a wide variety of flavors, including
reflect an underlying common liability to use substances tobacco, mint/menthol, and fruit flavors. Although char-
and take part in other risky behaviors. Some studies acterizing “flavors” are prohibited in cigarettes (with the
adjusted for risk taking, sensation seeking, and impul- exception of menthol and tobacco) by the Family Smoking
sivity, while others did not. Prevention and Tobacco Control Act of 2009, this prac-
tice is not currently prohibited in other tobacco prod-
ucts, like e-cigarettes. Retail sales data suggest that the

58   Chapter 2
consumption of flavored e-cigarettes and tobacco prod- alone whether it is contained in the e-cigarette products
ucts, such as flavored cigars, has increased in recent years that they are using. Moreover, even if youth were accu-
(Delnevo et  al. 2015; Giovenco et al. 2015), and recent rately reporting nicotine strength according to the label
studies show that youth and young adults may find these on the package, a study by Buettner-Schmidt and col-
flavored products more appealing than their unflavored leagues (2016) found that more than half of the labels on
counterparts (Table 2.9) (Ambrose et al. 2015; Krishnan- assessed e-cigarette products did not accurately reflect
Sarin et al. 2015; McDonald and Ling 2015). actual nicotine content in the product. Therefore, further
Data on the use of flavored e-cigarettes among research on nicotine content using objective measures
youth and young adults is presented in Table 2.9. In the (e.g., retail sales data) is warranted. Both the PATH and
2015 NYTS, participants were asked about any current use MTF studies, however, reinforce that flavorings may play
of e-cigarettes that were “flavored to taste like menthol an important role in the initiation of e-cigarette use.
(mint), alcohol (wine, cognac), candy, fruit, chocolate, or Other regional studies have reinforced the popu-
other sweets” (CDC 2015a, 1066). Among middle and high larity of flavored e-cigarette use among youth. Table 2.10
school students who were past-30-day users of e-cigarettes, summarizes these data on the use of flavored e-cigarettes
1.26 million, or 44.6%, had used a flavored e-cigarette in among youth and young adults. Krishnan-Sarin and col-
that timeframe (CDC, unpublished data [NYTS 2015]); leagues (2015), for example, found that sweet-flavored
this included 42.6% of middle school students and 45.1% e-cigarettes were popular among middle and high school
of high school students (Table 2.9) (CDC 2015a). The use students. In another study, which examined nonsmoking
of flavored e-cigarettes did not differ by gender and was middle and high school students and college-aged adults
lowest among Blacks (Table  2.9) (CDC  2015a). The use in New Haven County, Connecticut, Kong and colleagues
of flavored e-cigarettes was highest among young adults, (2015) found that “appealing flavors” was the second most
according to the 2013–2014 NATS (Table 2.9): among common reason cited for experimenting with e-cigarettes,
those who reported using e-cigarettes every day or some and in a qualitative study of young adults living in New
days, 91.6% of young adults (18–24 years old) reported York City, flavors were identified as an attractive aspect of
using an e-cigarette flavored to taste like menthol, mint, e-cigarettes (McDonald and Ling 2015). In a study exam-
clover, spice, candy, fruit, chocolate, or other sweets. ining nonsmoking teens and adult smokers, the e-cigarette
On the other hand, 66.6% of adults (≥25  years of age) flavors tested appealed more to adults than to teens; non-
who reported using e-cigarettes every day or some days smoking teens demonstrated equally low levels of interest
had used flavored e-cigarettes. No gender differences were in tobacco, fruit, and candy flavors (Shiffman et al. 2015).
noted for young adults, but Blacks, as with middle and It should be noted, however, that this study was funded by
high school students, reported the lowest rate of using fla- NJOY, an e-cigarette company and, therefore, may have
vored e-cigarette products. suffered from commercial bias. Additional concerns about
Data from the 2013–2014 wave of the PATH this study concerning selection bias, validity of the survey
study revealed that a majority of adolescents who used measures, and reliability of the findings have been raised
e-cigarettes use flavors. Of those who had ever tried (Glantz 2015).
e-cigarettes, 81% used flavors the first time they tried an
e-cigarette; of past-30-day users, 85.3% regularly used
flavored e-cigarettes (Ambrose et al. 2015). Ambrose and Consumer Perceptions of
colleagues (2015) also reported that 81.5% of respon-
dents aged 12–17 reported that they used e-cigarettes E-Cigarettes
because “they come in flavors I like.” Elsewhere, among
8th, 10th, and 12th graders in the 2015 MTF study, about Perceived Harm of E-Cigarettes
40% said that the primary reason they used e-cigarettes In the general population of U.S. adults, e-cigarettes
was “because they tasted good.” In contrast, about 10% have been perceived to be generally less harmful (Pearson
said they used e-cigarettes to quit smoking conventional et al. 2012; Czoli et al. 2014; Gallus et al. 2014; Richardson
cigarettes (University of Michigan 2015). In the 2015 MTF et al. 2014; Berg et al. 2015; Pokhrel et al. 2015) and less
study, about two-thirds of 8th-, 10th-, and 12th-grade addictive (Dockrell et al. 2013; Li et al. 2013; Brown et al.
students said that they used “just flavouring” in their 2014; Farsalinos et al. 2015; Harrell et al. 2015; Hendricks
vaporizer when they “last used” a vaporizer, while only et al. 2015; Kadimpati et al. 2015; Wackowski and Delnevo
20% reported that they used nicotine (Miech et al. 2016). 2015) than conventional cigarettes. The perceived harm
While the findings specific to nicotine are unexpected, it of e-cigarettes relative to conventional cigarettes was
is important to note that these data are self-reported. It lowest among those who were current smokers, followed
is questionable whether youth know what nicotine is, let by former smokers and then nonsmokers (Pearson et al.

59
A Report of the Surgeon General

Table 2.9 Percentage of youth (middle and high school students), young adults (18–24 years of age), and adults (≥25 years of age) using tobacco
products who reported using flavored e-cigarette products, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS)a and
National Adult Tobacco Survey (NATS)b
  NYTS 2015a (youth): NYTS 2015a (youth): High NATS 2013–2014b (young NATS 2013–2014b
Middle school students school students adults): 18–24 years of age (adults): ≥25 years of age
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 42.6 (36.1–49.3) 3.3 45.1 (40.4–49.9) 2.4 91.6 (87.0–94.6) 1.9 66.6 (63.4–69.5) 1.6
Gender                
Female 45.5 (36.2–55.2) 4.8 46.8 (40.5–53.2) 3.2 90.1 (78.6–95.7) 4.1 68.2 (63.7–72.3) 2.2
Male 40.2 (32.2–48.7) 4.2 44.0 (39.3–48.8) 2.4 92.2 (87.0–95.4) 2.1 65.2 (60.7–69.4) 2.2
Race/ethnicity                
White 52.5 (42.0–62.8) 5.3 51.4 (45.7–57.0) 2.9 90.9 (84.7–94.7) 2.5 61.2 (57.5–64.8) 1.9
Black or African American 32.9 (18.5–51.6) 8.6 20.4 (12.8–31.0) 4.5 100 (100–100)c 0.0c 92.0 (82.1–96.6) 3.5
Hispanic or Latino 28.5 (20.5–38.1) 4.4 38.8 (32.7–45.3) 3.2 89.8 (75.3–96.2)c 5.0c 85.9 (76.6–91.9) 3.8
Otherd 57.3 (39.4–73.5) 8.9 34.1 (24.8–44.9) 5.1 94.4 (82.1–98.4)c 3.5c 67.4 (57.0–76.3) 5.0
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015; NATS 2013–2014).
Note: CI = confidence interval; SE = standard error.
aFlavored e-cigarette product use in NYTS was determined by the response to the question, “Which of the following tobacco products that you used in the past 30 days
were flavored to taste like menthol (mint), alcohol (wine, cognac), candy, fruit, chocolate, or other sweets?” Participants could select from a list of options to designate the
flavored tobacco product(s) they used. (Among those who reported any use of e-cigarettes in the preceding 30 days.) Those who selected e-cigarettes were coded as “yes”
for flavored e-cigarettes. Those who did not select e-cigarettes were categorized as “no” for flavored e-cigarettes. Excludes 82 current e-cigarette users whose answers were
missing for all flavored tobacco response options.
bFlavored e-cigarette product use in NATS was determined by the response to the question, “Were any of the electronic cigarettes that you used in the past 30 days flavored
to taste like menthol, mint, clover, spice, candy, fruit, chocolate, or other sweets?” (Among those who reported using e-cigarettes every day or some days.) Those who selected
“yes” were categorized as “yes” for flavored e-cigarettes. Those who selected “no” were categorized as “no” for flavored e-cigarettes. Excludes five every-day or some-day
users who reported not using any noncigarette tobacco product in the past 30 days.
cSample size <50. No estimates had a relative SE >.40.
dIncludes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, and non-Hispanic American Indian/Alaska Native. For young adults and adults, this group
also includes multiracial.

60   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.10 Summary of studies on e-cigarette flavors among youth and young adults
Study Design/population Measures Outcomes/findings
Ambrose et al. (2015) • Cross-sectional • For each product ever used, youth • 81% of e-cigarette ever users used a
• Wave 1 of PATH study were asked if it was flavored to flavored product at first use
• Household-based, nationally representative survey taste like menthol, mint, clove, • 85.3% of past-30-day e-cigarette users
of 13,651 youth 12–17 years of age spice, candy, fruit, chocolate, used a flavored product
alcohol (such as wine or cognac), • 81.5% of past-30-day users cited “because
or other sweets they come in flavors I like” as a reason for
using e-cigarettes

Berg et al. (2015) • Cross-sectional • E-cigarette use (ever tried, • Most commonly used flavor was fruit
• Recruitment through Facebook targeting of number of days in past 30 days) flavors (67%), which was most commonly
tobacco and marijuana users and nonusers • Flavors used or of interest reported by never cigarette smokers.
• 2014 • Current smokers were most likely to
• 1,567 participants, 18–34 years of age, living in the report using tobacco flavors, but least
United States likely to report using caramel, vanilla,
chocolate, cream, or candy flavors.
CDC (2015a) • Cross-sectional • Participants were asked about any • Among current e-cigarette users,
• 2014 NYTS data current use of tobacco products 63.3% used a flavored product
• Three-stage cluster sampling procedure that were “flavored to taste like
• Nationally representative sample of 22,007 U.S. menthol (mint), alcohol (wine,
middle and high school students  cognac), candy, fruit, chocolate, or
other sweets”
• Participants could select from a
list of options
Kong et al. (2015) • Cross-sectional • Why did you try an e-cigarette? • 43.8% of e-cigarette ever users
• 18 focus groups, schoolwide survey experimented with e-cigarettes for the
• Recruitment by flyers and active recruitment availability of appealing flavors
sessions • School-level differences:
• Years sample drawn: 2012–2013 χ2(2, N = 1,157) = 18.63, p ≤0.001
• New Haven County, Connecticut • Compared with college students, high
• Youth: Middle and high school students; focus school students were more likely to
group n = 127 (youth); survey n = 4,780 experiment with e-cigarettes because of
• Young adults: New Haven County, Connecticut, flavors (47% vs. 32.8%):
college students; focus group n = 127 χ2(1, N = 1,116) = 13.61, p ≤0.001
(young adults); survey n = 625

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   61


A Report of the Surgeon General

Table 2.10 Continued


Study Design/population Measures Outcomes/findings
Krishnan-Sarin et al. (2015) • Cross-sectional • Which of the following flavors of • Most e-cigarette ever users preferred
• School-based survey e-cigarettes have you tried? sweet flavors:
• Recruitment by selected district reference groups –– Sweet flavors: 56.8%
• Year sample drawn: 2013 –– Menthol: 8.7%
• Youth: Connecticut middle (n = 1,166) and high –– Combos: 7.7%
school (n = 3,614) students –– Tobacco: 3%
• Young adults: n/a –– Other: 2.8%
• Menthol and tobacco flavors used mostly
by e-cigarette users who were also
cigarette smokers.
–– Menthol preference:
||3.5% (never smokers)

||5.5% (ever smokers)


||18.6 (current smokers)

–– Tobacco preference:
||0.5% (never smokers)

||2.4% (ever smokers)

||7.1% (current smokers)

McDonald and Ling (2015) • Focus groups and semistructured interviews • Attraction to flavors • Flavors were an attractive e-cigarette
• Recruitment from bars through screener surveys characteristic
• Years sample drawn: 2012–2013
• Youth: n/a
• Young adults: 87 young adults, 18–27 years of
age, in the boroughs of Manhattan, Brooklyn, and
Queens in New York City
Shiffman et al. (2015) • Cross-sectional • Interest in e-cigarettes paired with • Nonsmoking teens’ interest in
• Participants drawn from online research panel various flavor descriptors e-cigarettes was very low
• Year sample drawn: 2014 (mean = 0.41 ± 0.14 [SE] on 0–10 scale).
• Youth: Nonsmoking teenagers, 13–17 years of age • Teen interest did not vary by flavor
• Young adults: n/a (p = .75)

62   Chapter 2
Table 2.10 Continued
Study Design/population Measures Outcomes/findings
Ford et al. (2016) • Cross-sectional in-home survey • Awareness of e-cigarettes • 12% had tried e-cigarettes
• Wave 7 of the Youth Tobacco Policy Survey (YTPS) • E-cigarette use • 2% were regular users (confined to
• Random location quota sampling • E-cigarette flavor awareness adolescents who had also smoked
• 1,205 youth, 11–16 years of age, in the United • Perceptions of harm tobacco)
Kingdom • 82% were aware of at least one
promotional channel (82%)
• 69% were aware that e-cigarettes came in
different flavours
• Brand awareness was low
• E-cigarettes were perceived as harmful
(mean = 3.54, SD = 1.19)
Vasiljevic et al. (2016) • Randomized controlled trial • Appeal of using e-cigarettes • Exposure to e-cigarette ads did not seem
• Participants exposed to advertisements of candy- • Appeal of e-cigarette ads to increase the appeal of tobacco smoking
like flavored e-cigarettes, non-flavoured cigarettes, • Interest in buying and trying in children.
or control e-cigarettes following ad exposure • Exposure to flavoured e-cigarette ads
• Youth: 598 English children, 11–16 years of age (compared with non-flavoured ads)
increased the appeal and interest in
buying and trying e-cigarettes in children.
Note: NYTS = National Youth Tobacco Survey; PATH = Population Assessment of Tobacco and Health Study; SD = standard deviation; SE = standard error.
A Report of the Surgeon General

2012; Richardson et al. 2014). In a nationally representa- and 54.2% of adolescent past-30-day smokers believed that
tive sample of U.S. adults, young adults 18–34 years of age e-cigarettes were less harmful than cigarettes (Ambrose
were more likely than their older counterparts to perceive et al. 2014). Prior use of e-cigarettes was also associated
e-cigarettes as being less harmful than conventional ciga- with perceived harm of that product. Among students
rettes (Tan and Bigman 2014). who had ever tried e-cigarettes in 2012, 71.8% believed
Common theories of health behavior, such as that they were less harmful than cigarettes, 12.1% equally
the Theory of Reasoned Action and the Health Belief harmful, and 5% more harmful. These estimates were
Model, posit that perceptions of harm influence tobacco- similar to those for students who had used e-cigarettes in
use behavior, with lower perceived harm encouraging the past 30 days (Amrock et al. 2015). In addition, sus-
higher levels of experimentation and current tobacco ceptibility to cigarette smoking among never smokers was
use (Primack et al. 2008). Monitoring both absolute per- associated with perceptions of low harm for e-cigarettes
ceived harm and perceived harm relative to conventional (Ambrose et al. 2014).
cigarettes could be an indicator of later product adop- Although not all studies reviewed in this section
tion. Table 2.11 presents studies of the perceived harm of included “don’t know” as a response option for ques-
e-cigarettes among adolescents and young adults that are tions on the harms of e-cigarettes, those that did, found
included in this chapter. that a large number of students were unsure of the rel-
ative harmfulness of e-cigarettes compared to conven-
Youth tional cigarettes (Ambrose et al. 2014; Amrock et al.
2015). In fact, among U.S. adolescents responding to the
Table 2.12a presents NYTS data from middle
2012 NYTS, “don’t know” was the most common response
school and high school students on the perceived harm
(41.1–53.3%) across all the demographic subgroups
of using e-cigarettes on some days but not every day.
examined (gender, age, and race/ethnicity) (Amrock et al.
In 2015, 61.9%  of these students, overall, believed that
2015). In this sample, more never smokers (57.4%) than
e-cigarettes caused “little or some harm” under such con-
ever smokers (37.5%) or past-30-day smokers (24%) had
ditions; 14.5%, “no harm”; and 23.6%, “a lot of harm.”
not heard of or did not know enough about e-cigarettes to
However, when these data are stratified by students’ his-
make a judgment of harm (Ambrose et al. 2014). Future
tory of e-cigarette use, important differences become
studies will benefit from examining the effect of harm per-
clear. Notably, 34.2% of past-30-day e-cigarette users
ception on the use of e-cigarettes and other tobacco-use
believed e-cigarettes cause “no harm,” compared with
behaviors among adolescents.
22.4% of ever e-cigarette users and only 9.5% of never
e-cigarette users. Conversely, 29.4%  of never e-cigarette
Young Adults
users believed that e-cigarettes cause “a lot of harm,”
compared with 8.3% of ever e-cigarette users and 6.8% of Table 2.12d presents data from the 2013−2014
past-30-day e-cigarette users. These important differences NATS on beliefs about harm from e-cigarettes among
by e-cigarette use status, which suggest perceptions of no young adults (18–24 years old). Just over half (53.8%) of
harm related to e-cigarette use, were consistent for both young adults believed that e-cigarettes were “moderately
middle school students and high school students (Tables harmful,” 26.8% believed they were “very harmful,” and
2.12b and 2.12c). 19.4% believed they caused “no harm.” Levels of belief in
Three studies that used data from the 2012 NYTS moderate harm were quite similar by type of e-cigarette
examined the correlates of U.S. adolescents’ opinions about use: 52.8% of never users, 56.8% of ever (but not cur-
the perceived harm of e-cigarettes relative to the harm of rent) users, and 53.6% of current users. Ever and current
conventional cigarettes. Non-Hispanic Whites, students users were more likely than never users to report that
who lived with a smoker (Cardenas et al. 2015) or had e-cigarettes were “not at all harmful,” while never users
a family member who used tobacco (Amrock et al. 2015), were more likely than the other two groups to report that
and past-30-day users of tobacco products other than cig- e-cigarettes were “very harmful.”
arettes were more likely to believe that e-cigarettes were Published studies on perceived harm of e-cigarettes
safer than conventional cigarettes (Amrock et al. 2015). from regional samples, primarily of college and univer-
Conversely, girls and students 17  years of age or older sity students, are presented in Table 2.11. A large survey
were more likely to believe that e-cigarettes were more (n = 4,444) of college students in North Carolina conducted
harmful than regular cigarettes (Amrock et al. 2015). The in 2009 found that, as with adolescents, perceived harm
perceived harm of e-cigarettes decreased with increasing of e-cigarettes, compared with conventional cigarettes,
levels of cigarette smoking, such that in 2012, 25% of ado- was lower among college students who had ever used
lescent never smokers, 41.3% of adolescent ever smokers, e-cigarettes (45%) than among those who had never used

64   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.11 Summary of studies on perceptions of e-cigarette harm among youth and young adults
Study Design/population Measures Outcomes/findings Comments
Choi et al. (2012) • Focus groups • Perceived harmfulness relative • No consensus among participants • Generalizability
• Recruitment by (1) online to cigarettes • Lack of information on • Limited sample size
advertisements, (2) flyers on one (1) ingredients, (2) health impact,
4-year and two 2-year college and (3) mechanism used to vaporize
campuses, (3) announcements in nicotine
student life newsletter at a 2-year • Some noted e-cigarettes to be as
college, and (4) recruitment booth on harmful as cigarettes (“all one
a 2-year college campus product, in different forms”)
• Year sample drawn: 2010
• Youth: n/a
• Young adults: Individuals in
Minneapolis-St. Paul, MN, enrolled
in or who had graduated from
4-year colleges, or those who were
enrolled in or had graduated from
2-year colleges, or those who had not
enrolled in postsecondary education;
N = 66
Adkison et al. (2013) • Parallel prospective cohort • Are electronic cigarettes more • Not explicitly reported for young • Inclusion of only
• Telephone interview and web-based harmful than, less harmful adults current and former
surveys than, or equally harmful as cigarette smokers
• Probability sampling methods regular cigarettes to one’s • Limited set of
(random-digit dialing) health? questions
• Years sample drawn: 2010–2011
(Wave 8), 2008–2009 (Wave 7, where
available)
• Youth: n/a
• Young adults: current smokers,
≥18 years of age; N = 5,939 (Canada:
n = 1,581; United States: n = 1,520;
United Kingdom: n = 1,325;
Australia: n = 1,513)

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   65


A Report of the Surgeon General

Table 2.11 Continued


Study Design/population Measures Outcomes/findings Comments
Faletau et al. (2013) • Qualitative exploratory • Viewed tobacco cigarette and • Still allows smokers to smoke, • Generalizability
• Structured focus groups and electronic cigarette videos despite its function as a cessation aid • Unknown if
individual interviews saturation was
• Recruited from two low reached in
socioeconomic primary schools children between
in East and South Auckland, New focus groups
Zealand and individual
• Year sample drawn: 2011 interviews
• Youth: Maori, Tongan, Samoan,
Cook Island, and Niuean children,
6–10 years of age; N = 20
• Young adults: n/a
Sutfin et al. (2013) • Cross-sectional • Compared with a regular • Among the overall sample: • Low response rate
• Web-based survey (part of a cigarette, how harmful do you –– 17% indicated “as harmful” • Generalizability
randomized group trial) think e-cigarettes are? –– 23% indicated “less harmful” • Inability to
• Stratified random sample –– Less harmful –– 2% indicated “more harmful” differentiate former
• Year sample drawn: 2009 –– As harmful –– 50% indicated “do not know” smokers from
• Youth: n/a –– More harmful • Among ever e-cigarette users: experimenters
• Young adults: undergraduate students –– Do not know –– 17% indicated “as harmful” • Cross-sectional
attending eight universities in North –– 45% indicated “less harmful” analysis
Carolina; N = 4,857 (completers of –– 3% indicated “more harmful”
e-cigarette question, n = 4,444). –– 23% indicated “do not know”
• Among never e-cigarette users:
–– 16% indicated “as harmful”
–– 22% indicated “less harmful”
–– 2% indicated “more harmful”
–– 51% indicated “do not know”
• Ever e-cigarette use significantly
associated with harm perceptions
(p <0.001)

66   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.11 Continued


Study Design/population Measures Outcomes/findings Comments
Ambrose et al. (2014) • NYTS • Do you believe that electronic • 30.6% (CI, 29.3–31.9%) • Perceived graduated
• Cross-sectional cigarettes or e-cigarettes, such of respondents believed risk
• School-based survey as Ruyan or NJOY, are less e-cigarettes are less harmful • Self-reported items
• Three-stage cluster sampling harmful, equally harmful, or than cigarettes: never smokers: • Social desirability
• Year sample drawn: 2012 more harmful than regular 25% (CI, 23.9–26.2%); ever smokers: bias
• Youth: U.S. middle and high school cigarettes? 41.3% (CI, 39.1–43.6%); current • Generalizability
students (grades 6–12); N = 24,658 smokers: 54.2% (CI, 51.0–57.4%)
• Young adults: n/a • Female and Hispanics were less
likely to perceive e-cigarettes as less
harmful than cigarettes compared
with males and Whites, across all
smoking statuses
• Current smokers that had ever used
e-cigarettes were more than twice as
likely to perceive e-cigarettes as less
harmful, compared with smokers
who had never used e-cigarettes
(AOR = 2.48; CI, 1.87–3.29)
• Never smokers who had ever used
e-cigarettes were almost six times
as likely to perceive e-cigarettes
as less harmful, compared with
never smokers who had never used
e-cigarettes (AOR = 5.88;
CI, 3.07–11.25)

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   67


A Report of the Surgeon General

Table 2.11 Continued


Study Design/population Measures Outcomes/findings Comments
Czoli et al. (2014) • Cross-sectional • Is this product harmful to your • Mean score for agreement with • Cross-sectional
• Survey health? e-cigarettes as harmful to your analysis
• Recruitment through online panel • Have you ever experienced health (higher score indicates greater • Generalizability
of commercial market research any side-effects or adverse agreement):
company outcome(s) while using –– Among cigarette nonsmokers:
• Year sample drawn: 2012 e-cigarettes? 5.5 (e-cigarette nonuser) vs. 4.4
• Youth: Canadian youth recruited (e-cigarette ever user)
from online panel, 16–30 years of age; –– Among former smokers: 5.2
n = 1,188 (e-cigarette nonuser) vs. 3.6
• Young adults: Canadian young adults (e-cigarette ever user)
recruited from same online panel (see –– Among current smokers: 2.6
above) (e-cigarette nonuser) vs. 3.5
(e-cigarette ever user)
Gallus et al. (2014) • Cross-sectional • Indicate your opinion (true/ • Findings not explicitly reported for • Unstable estimates
• In-person survey false) concerning e-cigarettes young adults due to small sample
• Representative multistage sampling on the following: of e-cigarette users
• Year sample drawn: 2013 –– (1) Are not harmful for health • Unvalidated survey
• Youth: n/a –– (2) Are less harmful than
• Young adults: Italians ≥15 years of traditional cigarettes because
age; N = 3,000 they do not contain nicotine
–– (3) Are less harmful
because there is no tobacco
combustion
–– (4) Are less harmful because
they contain only nicotine
–– (5) Are more harmful than
traditional cigarettes
–– (6) Are an efficient tool to
quit smoking
–– (7) Allow smoking even
where it is forbidden

68   Chapter 2
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Table 2.11 Continued


Study Design/population Measures Outcomes/findings Comments
Tan and Bigman (2014) • Cross-sectional • Compared to smoking • Compared with younger respondents —
• Health Information National Trends cigarettes, would you say that (18–34 years of age), older
Survey 4 Cycle 2 electronic cigarettes are: respondents had 38%–72% lower
• Collected between October 2012 and –– Much less harmful odds of believing that e-cigarettes are
January 2013 –– Less harmful less harmful than regular cigarettes
• U.S. adults ≥18 years of age –– Just as harmful
• N = 3,630, 29.8% 18–34 years of age –– More harmful
–– Much more harmful
–– I’ve never heard of electronic
cigarettes
Tucker et al. (2014) • Cross-sectional • Rate whether they perceive • 44.9% viewed e-cigarettes as less • Did not collect
• Paper-based survey e-cigarettes to be less harmful, harmful than conventional cigarettes information on
• Probability-based sampling more harmful, or just as • 26.6% viewed e-cigarettes as just as youth’s attitudes
• Year sample drawn: not reported harmful as smoking cigarettes harmful as conventional cigarettes about alternate
• Youth: n/a • 3.7% viewed e-cigarettes as more tobacco products
• Young adults: homeless young adults, harmful than conventional cigarettes besides e-cigarettes
17–25 years of age; N = 292 (subset of • 24.8% did not know the relative • Did not collect
lifetime e-cigarette users, n = 83) harm information on the
conditions under
which they used
various products
Amrock et al. (2015) • NYTS • Do you believe that electronic • 34.2% (CI, 32.8–35.6%) of • Missingness
• Cross-sectional cigarettes or e-cigarettes, such adolescents considered e-cigarettes • Perceived graduated
• School-based survey as Ruyan or NJOY, are less to be less harmful than cigarettes risk
• Three-stage cluster sampling harmful, equally harmful, or • Females were less likely than males • Self-reported items
• Year sample drawn: 2012 more harmful than regular to perceive e-cigarettes as less • Social desirability
• Youth: U.S. middle and high school cigarettes? harmful than cigarettes bias
students (grades 6–12); N = 24,658 • Lifetime e-cigarette users were more • Generalizability
• Young adults: n/a likely than never users to report
e-cigarettes as less harmful than
cigarettes (71.8% vs. 31%)
• Past-30-day e-cigarette users were
more likely than nonrecent users to
report e-cigarettes as less harmful
than cigarettes (73.8% vs. 33.1%)

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   69


A Report of the Surgeon General

Table 2.11 Continued


Study Design/population Measures Outcomes/findings Comments
Berg et al. (2015) • Cross-sectional • How harmful to your health do • Respondents considered e-cigarettes • Generalizability
• Online-based survey you think electronic cigarettes among the least harmful • Responder bias
• Recruitment by random selection are? (4.26 ±1.95), addictive • Cross-sectional
• Year sample drawn: 2013 • How addictive do you think (4.29 ± 2.08), and socially acceptable analysis
• Youth: n/a electronic cigarettes are? (4.12 ± 2.03) of the products
• Young adults: U.S. university • How socially acceptable among considered
students; n = 2,002 your peers do you think • Electronic cigarettes were among the
electronic cigarettes are? most positively perceived products
(11.56 ± 4.22)
• Predictors of more favorable
perceptions included:
–– Being male (p = 0.03)
–– Parental tobacco smoking
(p = 0.02)
–– More friends who smoke cigarettes
(p <0.001)
–– More friends who use hookah
(p <0.001)
–– More friends who use electronic
cigarettes (p = 0.04)
• Recent cigarette smoking (p <0.001).
Camenga et al. (2015) • Focus groups • Discuss the comparison • Compared with nonsmokers, college • Transferability
• Purposive sampling between e-cigarettes and and high school smokers were • Generalizability
• Years sample drawn: 2012–2013 cigarettes. more likely to believe the use of • Limited definition
• Youth: middle and high school e-cigarettes could lead to a persistent of e-cigarettes
students in Connecticut; n = 68 “craving” that would prevent
• Young adults: college students in successful smoking cessation
Connecticut; n = 59 • Compared with nonsmokers, college
and high school smokers were more
likely to believe that e-cigarette use
would maintain nicotine addiction

70   Chapter 2
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Table 2.11 Continued


Study Design/population Measures Outcomes/findings Comments
Cardenas et al. (2015) • Cross-sectional • Do you believe that electronic • Participants who lived with a • No limitations
• School-based survey cigarettes or e-cigarettes, such smoker were more likely to report reported
• Three-stage cluster sampling as Ruyan or NJOY, are less e-cigarettes are less harmful than
• Year sample drawn: 2012 harmful, equally harmful, or regular cigarettes (16.2% vs. 24.8%)
• Youth: U.S. middle and high school more harmful than regular • E-cigarette users were more likely to
students; full sample size not cigarettes? believe e-cigarettes are less harmful
reported; subsample of children who than regular cigarettes
never tried smoking cigarettes, (70.9% vs. 27.5%)
n = 14,861
• Young adults: n/a
Chaffee et al. (2015) • Cross-sectional • Participants were asked to • Ever use of electronic cigarettes —
• Year sample drawn: 2014 estimate the probability was associated with lower perceived
• Youth: male high school students (0–100%) that specific health probabilities that unfavorable
from San Francisco; n = 104 or social outcomes would outcomes would happen
happen to them as a result
of e-cigarette use (e.g., heart
attack, lung cancer, get into
trouble, upset family, etc.)
Lotrean (2015) • Cross-sectional • Belief that e-cigarettes are less • 55.9% of the total sample agreed • Very small sample
• 2013 dangerous than cigarettes: or partially agreed that e-cigarettes • Measures not clearly
• Students 19–24 years of age from agree, partially agree, disagree, are less dangerous, 35.8% did not defined
Cluj-Napoca, Romania; n = 480 partially disagree, don’t know know, and 8.3% disagreed or partially
disagreed
• More smokers than nonsmokers or
ex-smokers agreed or partially agreed
that e-cigarettes are less dangerous
(62.3% vs. 58.7% and 33.3%,
respectively)

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   71


A Report of the Surgeon General

Table 2.11 Continued


Study Design/population Measures Outcomes/findings Comments
McDonald and Ling • Focus groups and semistructured • Perceived risks • Little knowledge of the devices • No limitations
(2015) interviews • Belief that e-cigarettes contain reported
• Recruitment from bars through harmless “water vapor” rather than
screener surveys smoke
• Years sample drawn: 2012–2013 • Belief that “water vapor” is less
• Youth: n/a harmful or even “good” for users
• Young adults: young adults in the
boroughs of Manhattan, Brooklyn,
and Queens in New York City,
18–27 years of age; N = 87
Roditis and Halpern- • Focus groups • Perceived risks and benefits • Little knowledge of risks of —
Felsher (2015) • Recruitment from after-school associated with conventional e-cigarette use
programs in urban Northern cigarettes versus e-cigarettes • Belief that e-cigarettes have no
California nicotine
• 2–6 participants in each group
• 24 adolescents: 9 female, 15 male

Cooper et al. (2016) • Cross-sectional • “How dangerous do you think it • Those in the e-cigarette-only group —
• Drawn from 2014 Texas Youth is for a person your age to use viewed conventional cigarettes as
Tobacco Survey, a school-based electronic cigarettes?” more harmful than did those in the
survey dual user group
• Youth: students in grades 6–12 from • No differences in how harmful those
27 counties in Texas; N = 13,602 in the e-cigarette-only group and the
dual user group rated e-cigarettes
• Those in the cigarette-only group
rated e-cigarettes as more harmful
than did those in the dual user group

Note: Studies in this table are sorted by year of publication and then alphabetically. AOR = adjusted odds ratio; CI = confidence interval; NYTS = National Youth Tobacco Survey.

72   Chapter 2
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Table 2.12a Percentage of middle school and high school students who reported that using e-cigarettes on some days
but not every day caused no harm, little/some harm, or a lot of harma, by e-cigarette smoking status;
National Youth Tobacco Survey (NYTS) 2015
  No harm Little/some harm A lot of harm
Characteristic n % (95% CI) n % (95% CI) n % (95% CI)
Overall 2,511 14.5 (13.4–15.8) 10,471 61.9 (60.3–63.5) 4,070 23.6 (22.2–25.0)
E-cigarette use            
Neverb 1,200 9.5 (8.4–10.8) 7,528 61.0 (59.4–62.6) 3,653 29.4 (28.0–30.9)
Ever, but not past 30 daysc 601 22.4 (20.3–24.6) 1,748 69.3 (66.4–72.1) 249 8.3 (7.0–9.9)
Past 30 daysd 641 34.2 (31.2–37.3) 1,089 59.0 (55.9–62.0) 126 6.8 (5.4–8.7)
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = confidence interval. There were 325 youth excluded due to missing responses for e-cigarette use.
aIncludes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not
every day?” Responses for “little harm” and “some harm” were combined.
bIncludes those who reported never trying e-cigarettes.
cIncludes those who reported trying e-cigarettes but not using e-cigarettes on 1 or more days in the past 30 days.
dIncludes those who reported using e-cigarettes on 1 or more days in the past 30 days.

Table 2.12b Percentage of middle school students who reported that using e-cigarettes on some days but not every
day caused no harm, little/some harm, or a lot of harma, by e-cigarette smoking status; National Youth
Tobacco Survey (NYTS) 2015
  No harm Little/some harm A lot of harm
Characteristic n % (95% CI) n % (95% CI) n % (95% CI)
Overall 1,089 13.5 (11.9–15.4) 4,579 57.6 (56.1–59.2) 2,260 28.8 (27.1–30.6)
E-cigarette use            
Neverb 658 9.9 (8.3–11.6) 3,927 58.0 (56.5–59.4) 2,141 32.2 (30.5–33.9)
Ever, but not past 30 daysc 211 31.9 (27.7–36.3) 383 60.6 (55.7–65.4) 60 7.5 (5.4–10.4)
Past 30 daysd 193 41.5 (35.6–47.6) 220 50.0 (44.3–55.7) 38 8.5 (6.0–12.0)
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = confidence interval. There were 132 middle students excluded due to missing responses for e-cigarette use.
aIncludes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not
every day?” Responses for “little harm” and “some harm” were combined.
bIncludes those who reported never trying e-cigarettes.
cIncludes those who reported trying e-cigarettes but not using e-cigarettes on 1 or more days in the past 30 days.
dIncludes those who reported using e-cigarettes, on 1 or more days in the past 30 days.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   73


A Report of the Surgeon General

Table 2.12c Percentage of high school students who reported that using e-cigarettes on some days but not every
day caused no harm, little/some harm, or a lot of harma, by e-cigarette smoking status; National Youth
Tobacco Survey (NYTS) 2015
  No harm Little/some harm A lot of harm
Characteristic n % (95% CI) n % (95% CI) n % (95% CI)
Overall 1,422 15.3 (14.0–16.7) 5,892 65.3 (63.2–67.3) 1,810 19.4 (18.0–20.9)
E-cigarette use            
Neverb 542 9.2 (7.8–10.9) 3,601 64.3 (62.0–66.7) 1,512 26.4 (24.6–28.3)
Ever, but not past 30 daysc 390 19.5 (17.5–21.8) 1,365 71.9 (68.6–74.9) 189 8.6 (6.9–10.6)
Past 30 daysd 448 32.3 (28.8–35.9) 869 61.3 (57.8–64.8) 88 6.4 (4.8–8.4)
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = confidence interval. There were 166 high school students excluded due to missing responses for e-cigarette use.
aIncludes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not
every day?” Responses for “little harm” and “some harm” were combined.
bIncludes those who reported never trying e-cigarettes.
cIncludes those who reported trying e-cigarettes but not using electronic cigarettes on 1 or more days in the past 30 days.
dIncludes those who reported using e-cigarettes, on 1 or more days in the past 30 days.

Table 2.12d Percentage of young adults (18–24 years of age) who reported that e-cigarettes were not at all harmful,
moderately harmful, or very harmfula, by e-cigarette smoking status; National Adult Tobacco Study
(NATS) 2013–2014
  Not at all harmful Moderately harmful Very harmful
Characteristic n % (95% CI) n % (95% CI) n % (95% CI)
Overall 796 19.4 (17.9–20.9) 2,260 53.8 (51.9–55.7) 1,053 26.8 (25.1–28.6)
E-cigarette use            
Neverb 359 14.3 (12.7–16.2) 1,423 52.8 (50.4–55.2) 814 32.9 (30.6–35.2)
Ever, but not currentc 210 22.9 (19.7–26.4) 520 56.8 (52.7–60.8) 186 20.3 (17.2–23.8)
Currentd 227 36.4 (31.8–41.2) 317 53.6 (48.6–58.5) 53 10.0 (7.2–13.9)
Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
Notes: CI = confidence interval. There were three young adults who were excluded because of missing responses for both ECIGEVER
and ECIGNOW.
aIncludes responses to the question, “How harmful do you think using e-cigarettes are to a person’s health?”
bIncludes those who reported having never tried e-cigarettes or having never heard of them.
cIncludes those who reported having heard of e-cigarettes and tried e-cigarettes but reported using them “not at all” at the time of
the interview.
dIncludes those who reported having heard of e-cigarettes, tried e-cigarettes, and using e-cigarettes some days, every day, or rarely at
the time of the interview.

74   Chapter 2
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e-cigarettes (22%) (Sutfin et al. 2013). Just over half of the et al. 2016). Data from the 2012 NYTS, however, suggest
participants in this study who had never tried e-cigarettes, that while e-cigarette use among U.S. youth may be associ-
however, said that they did not know enough to judge the ated with intentions to smoke conventional cigarettes, it is
relative harm of e-cigarettes compared to conventional not associated with intentions to quit conventional ciga-
cigarettes. In this study and another study, lack of knowl- rette smoking (Park et al. 2016). This is further reinforced
edge about the perceived harm of e-cigarettes relative to by a study of young adults from Switzerland, which found
conventional cigarettes was associated with lower odds of that after 15 months of follow-up, e-cigarette use was not
using e-cigarettes (Sutfin et  al. 2013; Choi and Forster associated with either cessation or reduction in the use of
2014b). In the study by Choi and Forster (2014b), lower conventional cigarettes (Gmel et al. 2016). There is some
perceived harm of e-cigarettes and the belief at baseline evidence to suggest that curiosity was a stronger driver of
that e-cigarettes can help people quit smoking were both an e-cigarette trial among young adults than smoking ces-
associated at follow-up with a higher likelihood of having sation, and that smoking cessation was a stronger driver
tried e-cigarettes. of such a trial among older adults (Schmidt et  al. 2014).
Other evidence suggests that reasons for use were driven
Reasons for Use and Discontinuation by tobacco-use status, with regular adolescent e-cigarette
users much more likely than adolescents who had used
Reasons for Use e-cigarettes just once to give the reason for use as smoking
cessation, smoking reduction, or avoidance of smoke-free
Table 2.13 summarizes studies of reasons for using
air regulations (Suris et al. 2015). Nationwide, according
and discontinuing e-cigarettes. The most commonly cited
to the 2015 MTF (University of Michigan 2015), “because
reasons for use by adolescent and young adult e-cigarette
they tasted good” was cited as a reason to use e-cigarettes
users included curiosity (Schmidt et al. 2014; Biener and
among 40% of 8th-, 10th-, and 12th-grade users, versus
Hargraves 2015; Biener et al. 2015; Kong et al. 2015;
just 10% who reported they used them in an attempt to
McDonald and Ling 2015; Suris et al. 2015; Sutfin et al.
quit smoking conventional cigarettes. In a New Zealand
2015), flavorings/taste (Ambrose et al. 2015; University of
study, interest in using e-cigarettes to quit using conven-
Michigan 2015), use as a less harmful/less toxic alternative
tional cigarettes was higher among young adults than
to conventional cigarettes (Peters et al. 2013; Tucker et al.
older adults (Li et al. 2013). Finally, another study, this
2014; Ambrose et al. 2015; Kong et al. 2015; McDonald
one conducted among high school, middle school, and
and Ling 2015; Sutfin et al. 2015), and avoidance of indoor
college students in Connecticut in 2012–2013, found that
smoking restrictions or disturbing people with second-
although the students were aware that e-cigarettes could
hand smoke from conventional cigarettes (Tucker et al.
be used to aid in smoking cessation, they thought that few
2014; Ambrose et al. 2015; Kong et al. 2015; McDonald
smokers had successfully used e-cigarettes to quit smoking
and Ling 2015; Suris et al. 2015; Sutfin et al. 2015). Other
(Camenga et  al. 2015). However, in an article published
reasons youth and young adults reported trying or using
by this group (Bold et al. 2016), trying e-cigarettes to
e-cigarettes included affordability and lower cost than
quit smoking was the most robust predictor of continued
conventional cigarettes (Tucker et al. 2014; Ambrose et al.
e-cigarette use 6 months later, using a multivariable model
2015); accessibility and convenience (Choi et al. 2012;
that included all reasons simultaneously, though this
Kong et al. 2015); social approval and/or offer from a
reason was only endorsed at baseline by 5.9% of youth. Low
family member or friend (Peters et al. 2013; Kong et al.
cost was the most robust predictor of more frequent use
2015; Suris et al. 2015; Sutfin et al. 2015); perception
6 months later, though only 10% of students endorsed this
that e-cigarettes are “cool,” “modern,” or “high-tech”
reason at baseline (Bold et al. 2016). Therefore, the reasons
(Choi et al. 2012; Kong et al. 2015); avoidance of smelling
to experiment with e-cigarettes are likely different from the
cigarette smoke (Peters et al. 2013; Tucker et al. 2014;
reasons to continue using them, over time.
Ambrose et al. 2015; Kong et al. 2015; Sutfin et al. 2015);
No randomized controlled trials specific to the effi-
ease of keeping hidden from parents/teachers (Peters et al.
cacy of using e-cigarettes for quitting conventional ciga-
2013; Kong et al. 2015); and weight control (Tucker et al.
rette smoking for young adults have been conducted to
2014). Young adults also perceived that e-cigarettes were
date. Although use of e-cigarettes as a potential cessation
more socially acceptable than smoking conventional ciga-
device for conventional cigarette smoking among adults is
rettes in public (Trumbo and Harper 2013).
important to examine (e.g., McRobbie et al. 2014; McNeill
Some youth and young adults also reported using
et al. 2015), none of this evidence is included here, as it
e-cigarettes as an aid to reducing and/or quitting their use of
does not directly discuss youth and young adults. Three
conventional cigarettes (Li et al. 2013; Schmidt et al. 2014;
observational studies specific to this issue, however, have
Tucker et al. 2014; Suris et al. 2015; Sutfin et al. 2015; Bold
been conducted among young adults to date. Data from

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Table 2.13 Summary of studies on reasons for use and discontinuation of e-cigarettes among youth and young adults
Study Design/population Measures Outcomes/findings
Adkison et • Parallel prospective cohort • Four questions were asked regarding • Not explicitly reported for young adults
al. (2013) • Telephone interview and web-based reasons for use (yes/no):
surveys 1. Electronic cigarettes may not be as bad as
• Probability sampling methods (random- cigarettes for your health
digit dialing) 2. Easier to cut down on the number of
• Years sample drawn: 2010–2011 (Wave cigarettes you smoke
8), 2008–2009 (Wave 7; where available) 3. Can smoke in places where smoking
• Youth: n/a conventional cigarettes is prohibited
• Young adults: current smokers, 4. Might help you quit
≥18 years of age; N = 5,939
(Canada, n = 1,581; U.S., n = 1,520;
United Kingdom, n = 1,325;
Australia, n = 1,513)
Choi et al. • Focus groups • Potential as quit aids • Ineffective as quit aids because:
(2012) • Recruitment by (1) online –– Contain nicotine
advertisements, (2) flyers on one –– Potential to be addicted to e-cigarettes
4-year and two 2-year college campuses, –– Eliminate social interaction aspect
(3) announcements in student life • Potential to help quit smoking because:
newsletter at a 2-year college, and –– Potential for gradual reduction in nicotine
(4) recruitment booth on a 2-year
college campus
• Year sample drawn: 2010
• Youth: n/a
• Young adults: Individuals in
Minneapolis-St. Paul, MN, enrolled in or
who had graduated from
4-year colleges, or those who were
enrolled in or had graduated from
2-year colleges, or those who had not
enrolled in postsecondary education;
N = 66

76   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.13 Continued


Study Design/population Measures Outcomes/findings
Choi and • Population-based prospective cohort • Indicate your level of agreement: • 44.5% agreed e-cigarettes can help quit smoking;
Forster study 1. E-cigarettes can help people quit smoking associated with the following characteristics:
(2013) • Interview 2. E-cigarettes are less harmful than –– Not being non-Hispanic White (AOR = 0.60;
• Cluster random sampling cigarettes CI, 0.44–0.84)
• Years sample drawn: 2010–2011 3. E-cigarettes are less addictive than –– Enrolled/graduated from 2-year college (AOR = 1.47;
• Youth: n/a cigarettes CI, 1.09–1.98)
• Young adults: U.S. midwestern adults, –– Current smoker (AOR = 1.35; CI, 1.05–1.73)
20–28 years of age; n = 2,624 (sample –– At least one close friend who smokes (AOR = 1.27;
from Minnesota) CI, 1.03–1.57)
• 52.9% agreed e-cigarettes are less harmful than cigarettes;
associated with the following characteristics:
–– Not being non-Hispanic White (AOR = 0.73;
CI, 0.53–0.99)
–– Male (AOR = 1.39; CI, 1.15–1.67)
–– Current smoker (AOR = 1.42; CI, 1.11–1.83)
• 26.4% agreed e-cigarettes are less addictive than cigarettes;
associated with the following characteristics:
–– Current smoker (AOR = 1.51; CI, 1.15–1.99)
–– Former smoker (AOR = 1.64; CI, 1.19–2.25)
–– At least one close friend who smokes (AOR = 1.28;
CI, 1.00–1.63)
Faletau et • Qualitative exploratory • Viewed tobacco cigarette and electronic • Stops people from smoking
al. (2013) • Structured focus groups and individual cigarette videos • People won’t die
interviews • Protects those around e-cigarette users from sickness
• Recruited from two low socioeconomic
primary schools in East and South
Auckland, New Zealand
• Year sample drawn: 2011
• Youth: Maori, Tongan, Samoan, Cook
Island, and Niuean children, 6–10 years
of age; N = 20
• Young adults: n/a

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   77


A Report of the Surgeon General

Table 2.13 Continued


Study Design/population Measures Outcomes/findings
Li et al. • Cross-sectional • Indicate your level of agreement: • OR = 1.81 (.78–4.18) among participants 18–24 years of
(2013) • Telephone-based survey 1. E-cigarettes are safer to use than tobacco age for perceived safety of e-cigarettes compared with
• Random-digit-dial sampling cigarettes (n = 317) participants ≥45 years of age
• Years sample drawn: 2011–2012 2. E-cigarettes can help people quit smoking • OR = 0.50 (0.21–1.17) among participants 18–24 years of
• Youth: n/a tobacco (n = 313) age for perceived efficacy of e-cigarettes compared with
• Young adults: current smokers and participants ≥45 years of age
recent quitters, ≥18 years of age, in New
Zealand; N = 840
Pepper et • Cross-sectional • If one of your best friends were to offer you • Overall, 18% were willing to try an e-cigarette if offered by
al. (2013) • Web-based survey an e-cigarette, would you try it? a best friend:
• Recruited through parents who were • If one of your best friends were to offer you a –– 13% willing to try a plain e-cigarette
members of an online panel assembled flavored e-cigarette (chocolate, mint, apple, –– 5% willing to try flavored e-cigarettes or both kinds
by random-digit dialing and address- etc.), would you try it? • Willingness to try e-cigarettes by age:
based sampling. –– 11–13: 11%
• Year sample drawn: 2011 –– 14–16: 15%
• Youth: U.S. males, 11–17 years of age; –– 17–19: 29%
N = 228 • OR = 3.26 (CI, 1.27–8.35) among those 17–19 years of age
• Young adults: n/a for willingness to try an e-cigarette, compared with those
11–13 years of age
• Willingness to try e-cigarettes by smoking status:
–– Nonsmoker: 13%
–– Smoker: 74%
• OR = 18.67 (6.22–55.98) among smokers for willingness to
try an e-cigarette, compared with nonsmokers
Peters et • Focus groups • Why do youth use electronic cigarettes? • Reported reasons for use among youth:
al. (2013) • Recruitment through large, diverse high • What do your friends think about electronic –– Expeditious consumption and concealment: 40%
school in southwestern United States cigarettes? –– High school approval: 26%
• Year sample drawn: 2012 • Why are electronic cigarettes so popular? –– Healthier than cigarettes: 19%
• Youth: U.S. teenage boys; N = 47 –– Odorless: 15%
• Young adults: n/a • Reported perceptions of friends:
–– High school approval: 49%
–– Healthier than cigarettes: 36%
–– Safe high: 15%
• Reported reasons for popularity:
–– Accessibility: 43%
–– Healthier than cigarettes: 30%
–– Aesthetics: 23%
• Don’t know: 4%

78   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.13 Continued


Study Design/population Measures Outcomes/findings
Trumbo • Cross-sectional • Indicate your level of agreement with • Mean score (SD) of innovation items: 36.0 (4.7)
and • Web-based survey relative advantage:
Harper • Recruitment by offer of extra credit to 1. I think e-cigarettes are safer in terms of
(2013) students in a 100-level course “secondhand” smoke compared to tobacco
• Year sample drawn: 2011 cigarettes
• Youth: n/a 2. I think e-cigarettes are not as harmful to
• Young adults: freshmen and sophomores users as tobacco cigarettes
in a 100-level mass media in society • Indicate your level of agreement with
course; n = 244 compatibility:
1. I think e-cigarette users can easily make
use of existing smoking areas
2. I believe using e-cigarettes would fit in
well with the lifestyle of most smokers
• Indicate your level of agreement with
complexity:
1. I believe it will not be difficult for smokers
to learn how to use e-cigarettes
2. Overall, e-cigarettes are no more
complicated to use than ordinary tobacco
cigarettes
• Indicate your level of agreement with
“trialability”:
1. I think it will be easy for people to
purchase e-cigarettes
2. Smokers could easily give e-cigarettes a
try to see if they like them better than
tobacco
Zhu et al. • Population • Why did you use e-cigarettes (yes/no)? • Not explicitly reported for young adults
(2013) • Online-based surveys 1. Safer than cigarettes
• National probability sample 2. Cheaper than cigarettes
• Year sample drawn: 2012 3. Easy to use when I can’t smoke
• Youth: n/a 4. To try to quit smoking cigarettes
• Young adults: U.S. adults, 5. Just because
>18 years of age; N = 10,041

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   79


A Report of the Surgeon General

Table 2.13 Continued


Study Design/population Measures Outcomes/findings
Choi and • Population-based prospective cohort • Indicate your level of agreement with the • 10% agreed that e-cigarettes can help people quit smoking;
Forster study following: associated with e-cigarette experimentation at follow-up
(2014b) • Survey 1. Using e-cigarettes can help people quit (AOR = 1.98; CI, 1.29–3.04)
• Cluster random sampling smoking • 10.1% agreed that e-cigarettes are less harmful than
• Years sample drawn: 2011–2012 2. Using e-cigarettes is less harmful to cigarettes; associated with e-cigarette experimentation at
• Youth: n/a health of the user than smoking cigarettes follow-up (AOR = 2.34; CI, 1.49–3.69)
• Young adults: participants in Minnesota 3. E-cigarettes are less addictive than • 9.3% agreed that e-cigarettes are less addictive than
Adolescent Community Cohort; cigarettes cigarettes
n = 1,379
Czoli et al. • Cross-sectional • Indicate your agreement with the following • Reasons for trying e-cigarettes among current cigarette
(2014) • Survey reasons for trying e-cigarettes: smokers:
• Recruitment through online panel of 1. In places where you can’t smoke –– To help cut back on the amount they smoked (77.7%)
commercial market research company cigarettes –– As a long-term replacement for cigarettes (77.8%)
• Year sample drawn: 2012 2. For times when you don’t want to smoke –– For the times when they don’t want to smoke around
• Youth: Canadian youth recruited around others others (78.8%)
from online panel, 16–30 years of age; 3. To help you cut back on the amount you –– To help them while they are trying to quit smoking
n = 1,188 smoke (80.4%)
• Young adults: Canadian young adults 4. To help you while you are trying to quit –– As a cheaper alternative to cigarettes (80.7%)
recruited from same online panel smoking –– In places where they can’t smoke cigarettes (80.9%)
5. As a long-term replacement for cigarettes
6. As a cheaper alternative to cigarettes
Li et al. • Cross-sectional • Indicate your level of agreement: • OR = 1.99 (CI, 0.99–3.97) among those 18–34 years of
(2014) • Telephone-based survey 1. Electronic cigarettes are for people who age for agreeing that “electronic cigarettes are for people
• Recruitment by telephone-based want to stop smoking completely who want to stop smoking completely,” compared with
omnibus survey and quitline client 2. Electronic cigarettes are for people who individuals ≥35 years of age
database want to cut down on their smoking • OR = 0.72 (CI, 0.24–2.21) among those 18–34 years of
• Year sample drawn: 2013 3. Electronic cigarettes are for people who age for agreeing that “electronic cigarettes are for people
• Youth: n/a want to still smoke in restricted public who want to cut down on their smoking,” compared with
• Young adults: current smokers and places such as inside a cafe, restaurant, individuals ≥35 years of age
recent quitters, ≥18 years of age, in New or pub • OR = 0.93 (0.47–1.85) among those 18–34 years of age for
Zealand; N = 267 agreeing that “electronic cigarettes are for people who want
to still smoke in restricted public places such as inside a
cafe, restaurant or pub,” compared with individuals ≥35
years of age

80   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.13 Continued


Study Design/population Measures Outcomes/findings
Schmidt et • Cross-sectional • Select all of the reasons you initiated use of • Among those 18–34 years of age, approximately
al. (2014) • Telephone-based survey e-cigarettes: 50% reported trying e-cigarettes to quit or reduce
• Random-digit-dial sampling 1. To quit smoking cigarettes cigarette use
• Year sample drawn: 2013 2. To reduce cigarette consumption • Among those 18–34 years of age, approximately
• Youth: n/a 3. To try something new (curiosity) 70% reported trying e-cigarettes to try something
• Young adults: noninstitutionalized 4. To not disturb other people with smoke new (curiosity)
adults in Montana; n = 5,000 5. To smoke in a place where cigarette
smoking is prohibited
6. To save money
7. E-cigarettes might be less harmful than
cigarettes
8. E-cigarettes taste better
9. Other
Tucker et • Cross-sectional • 18-item measure of reasons for using • Most common reasons for use included:
al. (2014) • Paper-based survey e-cigarettes, rating each reason on a 4-point –– Not having to go outside to smoke cigarettes (38%)
• Probability-based sampling scale (1 = not at all true, 4 = very true) –– To deal with situations or places where they cannot
• Year sample drawn: not reported smoke (36%)
• Youth: n/a –– To avoid bothering other people with tobacco smoke
• Young adults: homeless young adults, (31%)
17–25 years of age; N = 292 (subset of • Less common to report using e-cigarettes was to quit
lifetime e-cigarette users, n = 83) smoking (17–18%)
Ambrose • Cross-sectional • Past 30-day e-cigarette users were asked to • 81.5% of past-30-day users cited “because they come in
et al. • Wave 1 of PATH study report reasons for product use, including “it flavors I like” as a reason for using e-cigarettes
(2015) • Household-based, nationally comes in flavors I like” • Other common reasons for use were “they might be less
representative survey harmful to me than cigarettes” (79.1%); “they might be
• Youth: 12–17 years of age; n = 13,651 less harmful to people around me than cigarettes” (78.1%);
• Young adults: n/a and “I can smoke/use them at times when or in places
where smoking cigarettes isn’t allowed” (58.9%)
Biener et • Cross-sectional • Reasons for trying: curiosity, use by friends, • Most common reason cited was curiosity, with never
al. (2015) • Population-based mail survey health risks relative to cigarettes, absence of smokers more likely to cite this (77.3%) than former or
• Dual-frame sample smell, for use where smoking is prohibited, current cigarette smokers (59% and 61%)
• Youth: n/a and to quit or cut down on smoking
• Young adults: 18–25 years of age; • Reasons for stopping e-cigarette use: health
n = 4,740 concerns, negative reactions to taste and
feeling sick, inferiority to other forms of
tobacco, expense, lack of availability, and
social disapproval

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   81


A Report of the Surgeon General

Table 2.13 Continued


Study Design/population Measures Outcomes/findings
Camenga • Focus groups • Discuss your motivations to use e-cigarettes • Maintain smoking actions while allowing individuals to use
et al. • Purposive sampling a “healthier” nicotine product
(2015) • Years sample drawn: • Maintain tactile sensations to help with conditioned-
2012–2013 smoking cues
• Youth: middle and high school students • College students believed e-cigarettes to be healthier than
in Connecticut; n = 68 cigarettes
• Young adults: college students in
Connecticut; n = 59
Kong et al. • Cross-sectional • Focus group: • Focus group responses:
(2015) • Focus groups, schoolwide survey –– Why do you think people your age would –– Reasons for use:
• Recruitment by flyers and active use e-cigarettes? ||Influence of family and friends

recruitment sessions • Survey: ||To be “cool”

• Years sample drawn: 2012–2013 –– Why did you try an e-cigarette? ||Curiosity

• Youth: New Haven County, Connecticut, –– If you tried an e-cigarette but stopped ||Readily available

middle and high school students; focus using it, why did you stop? ||Flavors

group n = 127 (youth and young adults); –– Comparison to cigarettes:


survey n = 4,780 ||Healthier

• Young adults: New Haven County, ||Less harsh

Connecticut, college students; focus ||Cheaper

group n = 127 (youth and young adults); ||Smells better

survey n = 625 ||More convenient

||Can hide it

||Use it indoors

–– Reasons for discontinuation:


||Losing interest

||Negative physical effects (e.g., light-headed)

||Bad taste

||High cost

||Less satisfying than cigarettes

• Survey responses:
–– Reasons for experimentation (among lifetime e-cigarette
users):
||Curiosity (54.4%)

||Friends’ influence (31.6%)

–– Reasons for discontinuation:


||Uncool (16.3%)

||Health risks (12.1%)

82   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.13 Continued


Study Design/population Measures Outcomes/findings
Li et al. • Cross-sectional • Why did you try using an electronic • 57.1% of ever users cited curiosity as a reason for first
(2015) • 2014 cigarette? (Multiple responses allowed— trying, followed by 31.3% of ever users who cited wanting
• Nationwide, in-home survey in New wanted to quit smoking cigarettes to quit smoking completely
Zealand completely/wanted to replace smoking • Current e-cigarette users were more likely than noncurrent
• Multistage, stratified, clustered, and cigarettes some of the time/wanted to smoke users to report wanting to quit smoking completely as a
random probability sampling method in places where cigarette smoking is not reason for using e-cigarettes
(oversampling of Maori and Pacific allowed/cheaper than tobacco cigarettes/
peoples) safer than tobacco cigarettes/curiosity/
• Participants ≥15 years of age; n = 2,594: recommendation/other)
–– Youth: 15–17 years of age, 3.8% of
sample
–– Young adults: 18–24 years of age,
13.4% of sample
McDonald • Focus groups and semistructured • Bodily sensations • Vapor described as “harsh” or “burning”
and Ling interviews • Use in response to clean air laws • Discontinued use because believed it would cause one to
(2015) • Recruitment from bars through screener smoke more
surveys • Discontinued use due to fear of nicotine hangover
• Years sample drawn: 2012–2013 • Use to smoke in places where conventional smoking is not
• Youth: n/a allowed
• Young adults: young adults in the
boroughs of Manhattan, Brooklyn, and
Queens in New York City, 18–27 years of
age; N = 87
Pokhrel et • Cross-sectional • Fourteen items, scored on a scale of 1 (do not • Participants generally scored harm-reduction items higher
al. (2015) • Web-based survey agree) to 7 (agree), address three main • Among health benefit items, “e-cigarettes improve
• Recruitment by flyers across beliefs. E-cigarettes: breathing and reduce coughing” received the highest
three college campuses –– Are less harmful than cigarettes average score: mean (SD) = 3.9 (1.6)
• Year sample drawn: 2013 –– Improve the health of current smokers • Among smoking-cessation items, “e-cigarettes are a good
• Youth: n/a –– May be used to quit smoking compromise for people trying to quit smoking” received
• Young adults: U.S. students from the highest average score: mean (SD) = 4.6 (1.8)
a 4-year university and two 2-year • Across all items, “e-cigarettes cut down on the harmful
community colleges in Oahu, Hawaii; effects of secondhand smoke” was scored the highest: mean
n = 307 (SD) = 5.3 (1.7)
• 69% of participants agreed with the above item

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   83


A Report of the Surgeon General

Table 2.13 Continued

Study Design/population Measures Outcomes/findings


Suris • Cross-sectional • Reason for having used e-cigarettes? • Experimenters were significantly more likely to have used
(2015) • Data drawn from spring 2014 wave of –– Curiosity e-cigarettes for curiosity while users were more likely to
ado @ internet.ch, a longitudinal study –– To smoke where it is forbidden use them where it is forbidden to smoke (p<.01)
on Internet use –– To reduce smoking
• Representative sample of students in –– To do like my friends
French-speaking part of Switzerland –– To quit smoking
• Sample of 621 students included –– Other
never e-cigarette users (n = 353),
experimenters (n = 120), and users
(n = 148); mean age = 16.2 years
Sutfin • Longitudinal cohort study • Why did you try e-cigarettes? (check all • The majority (91.6%) reported curiosity as a reason for
(2015) • Data from the Smokeless Tobacco Use that apply): trying e-cigarettes
in College Students Study –– “I was curious about the product” • More than 70% tried e-cigarettes because their friends
• College students from North Carolina –– “It might be better for my health than used them
and Virginia smoking cigarettes” • About 70% tried e-cigarettes because they believed them
• Reasons for e-cigarette use were –– “My friends use e-cigarettes” to be better for their health than cigarettes
evaluated at Wave 6 of the study, n = 271 –– “I can use it in places where cigarette • Fifty percent cited, “It doesn’t smell bad,” and “I can use
smoking is not allowed” it where cigarette smoking is not allowed”
–– “To help me quit smoking” • About 31% said that they used e-cigarettes to cut down
–– “To cut down on smoking” on smoking
–– “It doesn’t smell bad” • Twenty percent said that they tried e-cigarettes to help
them quit smoking
University • Cross-sectional • “What have been the most important reasons • More than half of all students in 8th, 10th, and 12th grades
of • Data from the Monitoring the Future for your using an electronic vaporizer, such reported that curiosity to see what they were like was a
Michigan Study as an e-cigarette?” primary reason for use
(2015) • School-based, self-administered, paper- –– To help me quit regular cigarettes • Forty percent said that they used e-cigarettes because they
and-pencil questionnaire with cross- –– Because regular cigarette use is not tasted good
sectional and longitudinal components permitted • About 10% said they used them in an attempt to quit
• Students from 8th, 10th, and 12th grades –– To experiment to see what it’s like smoking regular cigarettes
• Weighted sample of students responding –– To relax or relieve tension
to the “reasons for use of electronic –– To feel good or get high
vaporizer” question: 603 (8th grade), 846 –– Because it looks cool
(10th grade), and 1,449 (12th grade) –– To have a good time with my friends
–– Because of boredom—nothing else to do
–– Because it tastes good
–– Because I am “hooked”—I have to have it

84   Chapter 2
E-Cigarette Use Among Youth and Young Adults

Table 2.13 Continued


Study Design/population Measures Outcomes/findings
Berg • Cross-sectional • Reasons for use: For what reasons do you/ • Reasons for use among current e-cigarette users:
(2016) • Recruitment through Facebook might you use e-cigarettes? –– ‘‘They might be less harmful than cigarettes’’ (77%)
targeting of tobacco and marijuana users • Reasons for discontinued use: Why have you –– ‘‘They do not smell’’ (77%)
and nonusers not used recently? –– ‘‘They help people quit smoking’’ (66%)
• 2014 –– ‘‘They cost less than other forms of tobacco’’ (62%)
• Youth: n/a • Reasons for use among nonusers:
• Young adults: 18–34 years of age, living –– “They might be less harmful than cigarettes” (41%)
in the United States; N = 1,567 –– “They don’t smell” (34%)
• Reasons for discontinuation:
–– ‘‘Using other tobacco products instead’’ (43%)
–– ‘‘They are too expensive’’ (35%)
–– ‘‘I just don’t think about it’’ (31%)
Bold • Longitudinal • Reasons for first trying e-cigarettes: • In multivariable model, including all reasons
(2016) • Youth: New Haven County, Connecticut, –– Curiosity simultaneously, trying e-cigarettes to quit smoking was
middle and high school students –– It is cool the most robust predictor of current (i.e., past 30 days)
• 2013–2014 –– Good flavors e-cigarette use 6 months later; however, this reason was
• 340 e-cigarette users at baseline –– Does not smell bad endorsed by very few youth (5.9%)
–– Can hide it from adults • In multivariable model, including all reasons
–– Low cost simultaneously, trying e-cigarettes because of low cost was
–– My friends use it the most robust predictor of more frequent e-cigarette use
–– My parents/family use it (i.e., more days/month) 6 months later; this reason was
–– Can use it anywhere endorsed by few youth (10%)
–– To quit smoking regular cigarettes
–– It is healthier than regular cigarettes
Note: Studies in this table are sorted by year of publication and then alphabetically. AOR = adjusted odds ratio; OR = odds ratio; PATH = Population Assessment of Tobacco
and Health Study; SD = standard deviation.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   85


A Report of the Surgeon General

a population-based cohort study of U.S. young adults associated with cessation of cigarette smoking (OR = 1.31;
in the Midwest suggest that e-cigarettes are not effec- 95% CI, 0.73–2.36) or marijuana use (OR = 1.05; 95% CI,
tive as a technique for quitting the use of conventional 0.54–2.01) at follow-up (2015), though e-cigarette use
cigarettes. In that study, 11% of cigarette smokers who at baseline did increase the likelihood of transitioning
had used e-cigarettes in the past 30 days at baseline quit from nonuser to user of cigarettes (OR = 3.32; 95% CI,
smoking at the 1-year follow-up, compared with 17%  of 1.55–7.10) and marijuana (OR = 1.97; 95% CI, 1.01–3.86)
cigarette smokers who had never used e-cigarettes (Unger et al. 2016). Additional research is required to
(OR = 0.93, p = 0.93) (Choi and Forster 2014a). Another determine any potential efficacy of e-cigarette use for con-
cohort study of Swiss young adult men concluded that ventional cigarette smoking cessation in young adults.
there were no beneficial effects of vaping for conventional
cigarette smoking cessation or smoking reduction (Gmel Reason for Discontinuation
et al. 2016). In this study, e-cigarette users reported lower
In the small number of published studies on reasons
cigarette smoking cessation rates at follow-up among
for discontinuation of e-cigarette use in young users, ado-
those who were occasional cigarette smokers at baseline
lescent and young adult smokers have cited lack of satis-
(OR = 0.43; 95%  CI, 0.19–0.96). No differences between
faction and e-cigarettes’ poor taste and cost (Kong et al.
e-cigarette users and nonusers were noted among those
2015) as reasons for discontinuing. Additional reasons
who were daily cigarette smokers at baseline (OR = 0.42;
have included negative physical effects (e.g., feeling light-
95%  CI, 0.15–1.18). No differential changes between
headed) (Kong et al. 2015) and loss of interest. In one study
e-cigarette users and nonusers in the number of conven-
of young adults aged 18–35, former and never smokers of
tional cigarettes smoked per week were noted at follow-
conventional cigarettes also cited the idea that e-cigarettes
up, either (Gmel et al. 2016). In a study by Unger and col-
were “bad for their health” as a reason for discontinuation
leagues (2016), which focused on Hispanic young adults
(Biener and Hargraves 2015; Biener et al. 2015).
in California, e-cigarette use at baseline (2014) was not

Evidence Summary

The most recent estimates available show that cigarettes (2.4%, 3.5%, and 5.8% in those grades) (Table 2.5;
13.5%  of middle school students (2015), 37.7% of high Figure 2.4). However, among young adults 18–24 years of
school students (2015), and 35.8% of young adults age, the patterns were different. In that group, exclusive
(2013–2014) had ever used an e-cigarette (Tables 2.1a, 2.1b, use of conventional cigarettes surpassed exclusive use of
and 2.4a). The most recent data also show that past-30-day e-cigarettes and use of both types of products (Figure 2.8).
use of e-cigarettes is higher among high school students For example, in 2013–2014, 9.6% of young adults smoked
(16% in 2015) and young adults (13.6% in 2013–2014) conventional cigarettes exclusively, 6.1% were current
than among middle school students (5.3% in 2015) and users of e-cigarettes, and 7.5% currently used both. The
adults (25  years of age and older) (5.7% in 2013–2014) use of e-cigarettes and other tobacco products, such as
(Tables  2.1b, 2.4a, and 2.4b). Among youth and young combustibles, appeared to co-vary among youth and young
adults, rates of ever and past-30-day use of e-cigarettes adults (Figures 2.6, 2.7, and 2.8). Although five longitu-
have increased greatly since the earliest e-cigarette surveil- dinal studies suggest that e-cigarette use is related to the
lance efforts began in 2011. The increases among adults onset of other tobacco product and marijuana use among
25 years of age and older, by comparison, have been less youth and young adults (Leventhal et al. 2015; Primack
steep. Among middle school and high school students, both et  al. 2015; Barrington-Trimis et  al. 2016; Unger et al.
ever use and past-30-day use of e-cigarettes more than tri- 2016; Wills et al. 2016), some studies had limitations in
pled from 2011 to 2015 (NYTS 2011–2015; Figures 2.1 and their ability to distinguish experimental smokers from reg-
2.2) (CDC 2013a; Ambrose et al. 2014; Lippert 2015), and ular smokers at follow-up (Leventhal et al. 2015; Primack
among young adults (18–24 years of age), the prevalence et al. 2015; Barrington-Trimis et al. 2016; Wills et al. 2016).
of ever use more than doubled from 2013 to 2014 (Styles Therefore, more studies are needed to elucidate the nature
2013–2014; Figure 2.3). of any true causal relationship between e-cigarette use and
Among youth, past-30-day exclusive use of combustible tobacco products. Investigation of whether
e-cigarettes among 8th, 10th, and 12 graders (6.8%, 10.4%, e-cigarette use is related to other types of substance abuse
and 10.4%, respectively) was more common than exclusive (e.g., marijuana, alcohol) might help distinguish the extent
use of conventional cigarettes (1.4%, 2.2%, and 5.3%  in to which e-cigarette use may precede or follow other forms
those grades) or dual use of e-cigarettes and conventional

86   Chapter 2
E-Cigarette Use Among Youth and Young Adults

of substance use in the context of the common liability/ equally important is determining young people’s percep-
vulnerability model (Vanyukov et al. 2012). tion of the absolute harm from e-cigarettes. National data
Although use of other tobacco products has been the show that only 23.6% of middle and high school students
strongest correlate of ever and past-30-day e-cigarette use combined believed that e-cigarettes cause “a lot of harm”
among youth and young adults, sociodemographic char- (Table  2.12a), and only 26.8% of young adults believed
acteristics have also been associated with the use of these e-cigarettes are “very harmful” (Table 2.12d). However, sig-
products. Across both ever use and past-30-day use mea- nificant differences emerge in these perceptions of harm
sures, e-cigarette use has been more common among high when examined by whether or not youth and young adults
school than middle school students, a pattern similar to use e-cigarettes. Among both middle and high school stu-
trends seen in other categories of tobacco products (CDC dents and young adults, perceptions of “no harm” were
2015c). Among middle school students in 2014 and 2015 much more prevalent among those with prior experience
(CDC 2016), ever e-cigarette use was highest for Hispanics with e-cigarettes (Tables  2.12b–2.12d). Current e-ciga-
(Table 2.1a); among high school students, ever use was rette users were two to three times more likely to report
highest among Hispanics and Whites (Table 2.1b). No differ- that e-cigarettes convey “no harm” compared to never
ences between boys and girls were observed among middle e-cigarette users, for both age groups (Tables 2.12a and
school students in 2015 (Tables 2.1a, 2.1b). However, in 2.12d).
2015 male high school students were significantly more The most commonly cited reasons that youth and
likely to report past-30-day use than their female counter- young adults reported using e-cigarettes included curi-
parts (Table 2.2b) (CDC 2016). For young adults, ever and osity (Schmidt et al. 2014; Biener and Hargraves 2015;
past-30-day use of e-cigarettes were significantly higher Biener et  al. 2015; Kong et al. 2015; McDonald and Ling
among males than females (Table 2.4a). Current e-cigarette 2015; Suris et al. 2015; Sutfin et al. 2015), flavorings/taste
use was significantly lower among Blacks than in other (Ambrose et al. 2015; University of Michigan 2015), use as
racial/ethnic groups (Table 2.4a). Ever and past-30-day a less harmful/less toxic alternative to conventional ciga-
e-cigarette use was also significantly lower among those rettes (Peters et al. 2013; Tucker et al. 2014; Ambrose et al.
with a college education. Continued research is warranted 2015; Kong et al. 2015; McDonald and Ling 2015; Sutfin
to monitor patterns of e-cigarette use across population et al. 2015), and avoidance of indoor smoking restrictions
groups by gender, age, race/ethnicity, and education, as well or disturbing people with secondhand smoke from conven-
as by sociodemographic characteristics for which dispari- tional cigarettes (Tucker et al. 2014; Ambrose et al. 2015;
ties in tobacco use have been noted. Availability of data on Kong et al. 2015; McDonald and Ling 2015; Suris et al. 2015;
e-cigarette use among youth and young adults is currently Sutfin et al. 2015). Using e-cigarettes as an aid to conven-
limited, including geography (e.g., subnational data at the tional cigarette smoking reduction/cessation (Li et al. 2013;
state or local levels), sexual orientation and gender iden- Schmidt et al. 2014; Tucker et al. 2014) was not a primary
tity (e.g., lesbian, gay, bisexual, transgender), and socioeco- motivator among youth and young adults. Youth and young
nomic status (e.g., household income, poverty status) (CDC adult smokers cited lack of satisfaction, poor taste, and cost
2014a; Johnson et al. 2016). (Kong et al. 2015) as reasons for discontinuing e-cigarette
Research on youth and young adults’ use. Additional research is needed to examine how reasons
e-cigarette-related knowledge, attitudes, and beliefs is for use, including the appeal of flavored e-cigarettes, are
still developing and remains relatively sparse. Perceived causally related to the onset and progression of e-cigarette
harm is the most developed area of research. Most youth use among youth and young adults. Data from the first
and young adults believe e-cigarettes are “less harmful” wave of the PATH study suggest that flavors may play an
than conventional cigarettes (Table 2.11). However, up to important role in the initiation of e-cigarette use among
50% of respondents in some of these studies felt they did youth (Ambrose et al. 2015), while data from the 2014
not know enough about the potential dangers associated NYTS (Corey et al. 2015) and 2013–2014 NATS (Table 2.9)
with e-cigarettes to answer questions about perceived harm underscore that use of flavored e-cigarettes remains prev-
(Ambrose et al. 2014; Amrock et al. 2015). Although rela- alent among youth and young adults who currently use
tive harm compared with cigarettes is important to assess, e-cigarettes.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   87


A Report of the Surgeon General

Conclusions

1. Among middle and high school students, both ever combustible tobacco products were also current
and past-30-day e-cigarette use have more than tri- users of e-cigarettes.
pled since 2011. Among young adults 18–24  years
of age, ever e-cigarette use more than doubled from 5. Among youth—older students, Hispanics, and
2013 to 2014 following a period of relative stability Whites are more likely to use e-cigarettes than
from 2011 to 2013. younger students and Blacks. Among young
adults—males, Hispanics, Whites, and those with
2. The most recent data available show that the preva- lower levels of education are more likely to use
lence of past-30-day use of e-cigarettes is similar e-cigarettes than females, Blacks, and those with
among high school students (16% in 2015, 13.4% in higher levels of education.
2014) and young adults 18–24 years of age (13.6% in
2013–2014) compared to middle school students 6. The most commonly cited reasons for using
(5.3% in 2015, 3.9% in 2014) and adults 25 years of e-cigarettes among both youth and young adults are
age and older (5.7% in 2013–2014). curiosity, flavoring/taste, and low perceived harm
compared to other tobacco products. The use of
3. Exclusive, past-30-day use of e-cigarettes among e-cigarettes as an aid to quit conventional cigarettes
8th-, 10th-, and 12th-grade students (6.8%, 10.4%, is not reported as a primary reason for use among
and 10.4%, respectively) exceeded exclusive, youth and young adults.
past-30-day use of conventional cigarettes in 2015
(1.4%, 2.2%, and 5.3%, respectively). In contrast— 7. Flavored e-cigarette use among young adult current
in 2013–2014 among young adults 18–24 years of users (18–24 years of age) exceeds that of older adult
age—exclusive, past-30-day use of conventional cig- current users (25 years of age and older). Moreover,
arettes (9.6%) exceeded exclusive, past-30-day use of among youth who have ever tried an e-cigarette, a
e-cigarettes (6.1%). For both age groups, dual use of majority used a flavored product the first time they
these products is common. tried an e-cigarette.

4. E-cigarette use is strongly associated with the 8. E-cigarette products can be used as a delivery
use of other tobacco products among youth and system for cannabinoids and potentially for other
young adults, particularly the use of combustible illicit drugs. More specific surveillance measures are
tobacco products. For example, in 2015, 58.8% of needed to assess the use of drugs other than nicotine
high school students who were current users of in e-cigarettes.

88   Chapter 2
E-Cigarette Use Among Youth and Young Adults

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U.S. Department of Health and Human Services. Preventing Bierut L, et al. Common liability to addiction and
Tobacco Use Among Youth and Young Adults: A Report “gateway hypothesis”: theoretical, empirical and evo-
of the Surgeon General. Atlanta (GA): U.S. Department lutionary perspective. Drug and Alcohol Dependence
of Health and Human Services, Centers for Disease 2012;123(Suppl 1):S3–S17.
Control and Prevention, National Center for Chronic Vasiljevic M, Petrescu DC, Marteau TM. Impact of adver-
Disease Prevention and Health Promotion, Office on tisements promoting candy-like flavoured e-cigarettes
Smoking and Health, 2012. on appeal of tobacco smoking among children: an
Unger JB, Soto DW, Leventhal A. E-cigarette use and experimental study. Tobacco Control 2016.
subsequent cigarette and marijuana use among Wackowski OA, Delnevo CD. Smokers’ attitudes and sup-
Hispanic young adults. Drug and Alcohol Dependence port for e-cigarette policies and regulation in the USA.
2016;163(1):261–4. Tobacco Control 2015;24(6):543–6.
University of Michigan. E-cigarettes surpass tobacco ciga- Warner KE. Frequency of e-cigarette use and cigarette
rettes among teens [press release], 2014; <http://www. smoking by American students in 2014. American
monitoringthefuture.org/pressreleases/14cigpr_com- Journal of Preventive Medicine 2016;51(2):179–84.
plete.pdf>; accessed: June 21, 2016. Wills TA, Knight R, Sargent JD, Gibbons FX, Pagano I,
University of Michigan. Most youth use e-cigarettes Williams RJ. Longitudinal study of e-cigarette use and
for novelty, flavors—not to quit smoking [press onset of cigarette smoking among high school students
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pressreleases/15ecigpr_complete.pdf>; accessed: January Zhu SH, Gamst A, Lee M, Cummins S, Yin L, Zoref L. The use
25, 2015. and perception of electronic cigarettes and snus among
Van Dam NT, Earleywine M. Pulmonary function in can- the U.S. population. PloS One 2013;8(10):e79332.
nabis users: support for a clinical trial of the vaporizer.
International Journal on Drug Policy 2010;21(6):511–3.

Patterns of E-Cigarette Use Among U.S. Youth and Young Adults   93


Chapter 3
Health Effects of E‑Cigarette Use Among U.S. Youth and
Young Adults

Introduction 97

Conclusions from Previous Surgeon General’s Reports 97

Health Effects of E‑Cigarette Use 100


Effects of Aerosol Inhalation by the E‑Cigarette User 100
Dose and Effects of Inhaling Aerosolized Nicotine 100
Aerosolized Nicotine and Cardiovascular Function 101
Aerosolized Nicotine and Dependence 102
Effects of Nicotine in Youth Users 104
Nicotine Exposure from Maternal Nicotine Consumption: Prenatal and Postnatal Health Outcomes 108
Summary 113
Effects of the Inhalation of Aerosol Constituents Other than Nicotine 114
Aerosolized Nicotine-Related Compounds 114
Aerosolized Solvents 115
Aerosolized Flavorants 115
Aerosolized Adulterants 116
Summary 117
Effects of Toxicants Produced During Aerosolization 118
Summary 119
Effects Not Involving Inhalation of Aerosol by the E‑Cigarette User 119
Health Effects Attributable to Explosions and Fires Caused by E‑Cigarettes 119
Health Effects Caused by Ingestion of E‑Cigarette Liquids 119
Secondhand Exposure to the Constituents of E‑Cigarette Aerosol 120
Exposure to Nonusers 120
Movement of E‑Cigarette Aerosol 121
Exposure to E‑Cigarette Aerosol and Considerations of Dose 121
Health Effects of Secondhand Exposure to E‑Cigarette Aerosols 122

Evidence Summary 124

Conclusions 125

References 126

95
E-Cigarette Use Among Youth and Young Adults

Introduction

This chapter focuses on the short-term and poten- regarding harmful consequences of close contact with
tial long-term health effects related to the incidence and malfunctioning e‑cigarette devices and ingestion of the
continued use of electronic cigarettes (e‑cigarettes) by nicotine-containing liquids (e-liquids) are also explored.
youth and young adults. The sharp increase in the preva- This chapter examines available data on e‑cigarettes and
lence of e‑cigarette use among youth and young adults, youth, reviews established human and animal data on
especially from 2011 to 2015 (Centers for Disease Control harmful developmental effects of nicotine (prenatal and
and Prevention [CDC] 2015, 2016), highlights the com- adolescent), and reviews data on e‑cigarettes among adults
pelling need to learn more about this evolving class of when data on youth are not available. Of note, given the
products. This chapter highlights the scientific litera- relatively recent emergence of e‑cigarettes, data are not
ture that addresses potential adverse health effects caused yet available that address the long-term health effects of
by direct exposure to aerosolized nicotine, flavorants, use or exposure over several years compared with nonuse
chemicals, and other particulates of e‑cigarettes; sec- or exposure to air free from secondhand tobacco smoke
ondhand exposure to e‑cigarette aerosol; and exposure to and aerosol from e‑cigarettes; thus, the discussion is lim-
the surface-deposited aerosol contaminants. Literature ited in that regard.

Conclusions from Previous Surgeon General’s Reports

This chapter comprehensively reviews a new and (Flouris et al. 2013) or lower than (Czogala et al. 2014)
emerging body of scientific evidence related to the use conventional cigarettes.
of e‑cigarettes by youth and young adults. The enormous The findings of scientific research on smoking
knowledge base on tobacco smoking and human health and involuntary exposure to tobacco smoke have been
is also relevant to this discussion. That literature, which reviewed thoroughly in the 32 reports on smoking and
has been accumulating for more than 50 years, provides health produced by the Surgeon General to date (there is
incontrovertible evidence that smoking is a cause of dis- one report on smokeless tobacco) (Table 3.1). The land-
ease in almost every organ of the body (U.S. Department mark first report was published in 1964 (U.S. Department
of Health and Human Services [USDHHS] 2004, 2014). of Health, Education, and Welfare [USDHEW] 1964), and
Laboratory research has characterized the components the 50th-anniversary report, released in January 2014,
of tobacco smoke and probed the mechanisms by which comprehensively covered multiple aspects of cigarette
these constituents cause addiction and injury to cells, tis- smoking and health and lengthened the list of diseases
sues, organs, and the developing fetus. caused by smoking and involuntary exposure to tobacco
The evidence on the harmful consequences of nic- smoke (USDHHS 2014). Other Surgeon General’s reports
otine exposure in conventional cigarettes, including that are particularly relevant to the present report include
addiction, and other adverse effects, is particularly rel- reports on the health consequences of smoking and
evant to e-cigarettes. Nicotine doses from e-cigarettes involuntary exposure to tobacco smoke (USDHHS 2004,
vary tremendously depending on characteristics of the 2006), on the mechanisms by which smoking causes dis-
user (experience with smoking conventional cigarettes ease (USDHHS 2010), and on the health consequences
or e-cigarettes), technical aspects of the e-cigarette, and of smoking on youth and young adults (USDHHS 1994,
levels of nicotine in the e-liquid. Although studies of nico- 2012). The Surgeon General’s reports on smoking and
tine doses in youth and young adults are lacking, studies health have provided powerful conclusions on the dangers
of adults have found delivery of nicotine from e-cigarettes of nicotine. The 1988 report, released by Surgeon General
in doses ranging from negligible to as large as (Lopez C. Everett Koop, was the first to characterize smoking
et al. 2016; Vansickel and Eissenberg 2013; Spindle et al. as addictive, and it identified nicotine as “…the drug in
2015; St. Helen et al. 2016) or larger than (Ramôa et al. tobacco that causes addiction” (Appendix 3.1)1 (USDHHS
2016) conventional cigarettes. Similarly, passive exposure 1988, p. 9).
to secondhand nicotine from e-cigarettes is just as large
1All appendixes and appendix tables that are cross-referenced in this chapter are available only online at http://www.surgeongeneral.gov/
library/reports/

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   97
A Report of the Surgeon General

Table 3.1 Relevant conclusions from previous Surgeon General’s reports on smoking and health
Report Year Conclusions
The Health 1988 Major Conclusions
Consequences of 1. Cigarettes and other forms of tobacco are addicting.
Smoking: Nicotine 2. Nicotine is the drug in tobacco that causes addiction.
Addiction (USDHHS 3. The pharmacologic and behavioral processes that determine tobacco addiction are similar
1988, p. 9) to those that determine addiction to drugs such as heroin and cocaine.

How Tobacco Smoke 2010 Chapter 4. Nicotine Addiction: Past and Present
Causes Disease: The 1. Nicotine is the key chemical compound that causes and sustains the powerful addicting
Biology and Behavioral effects of commercial tobacco products.
Basis for Smoking- 2. The powerful addicting effects of commercial tobacco products are mediated by diverse
Attributable Disease actions of nicotine at multiple types of nicotinic receptors in the brain.
(USDHHS 2010, p. 183) 3. Evidence is suggestive that there may be psychosocial, biologic, and genetic determinants
associated with different trajectories observed among population subgroups as they move
from experimentation to heavy smoking.
4. Inherited genetic variation in genes such as CYP2A6 contributes to the differing patterns of
smoking behavior and smoking cessation.
5. Evidence is consistent that individual differences in smoking histories and severity of
withdrawal symptoms are related to successful recovery from nicotine addiction.

Preventing Tobacco 2012 Major Conclusions


Use Among Youth and 1. Cigarette smoking by youth and young adults has immediate adverse health consequences,
Young Adults (USDHHS including addiction, and accelerates the development of chronic diseases across the full life
2012, pp. 8, 460) course.
2. Prevention efforts must focus on both adolescents and young adults because among adults
who become daily smokers, nearly all first use of cigarettes occurs by 18 years of age
(88%), with 99% of first use by 26 years of age.
3. Advertising and promotional activities by tobacco companies have been shown to cause the
onset and continuation of smoking among adolescents and young adults.
4. After years of steady progress, declines in the use of tobacco by youth and young adults
have slowed for cigarette smoking and stalled for smokeless tobacco use.
5. Coordinated, multicomponent interventions that combine mass media campaigns,
price increases including those that result from tax increases, school-based policies and
programs, and statewide or community-wide changes in smokefree policies and norms are
effective in reducing the initiation, prevalence, and intensity of smoking among youth and
young adults.
Chapter 4. Social, Environmental, Cognitive, and Genetic Influences on the Use of Tobacco
Among Youth
1. Given their developmental stage, adolescents and young adults are uniquely susceptible to
social and environmental influences to use tobacco.
2. Socioeconomic factors and educational attainment influence the development of youth
smoking behavior. The adolescents most likely to begin to use tobacco and progress to
regular use are those who have lower academic achievement.
3. The evidence is sufficient to conclude that there is a causal relationship between peer
group social influences and the initiation and maintenance of smoking behaviors during
adolescence.
4. Affective processes play an important role in youth smoking behavior, with a strong
association between youth smoking and negative affect.
5. The evidence is suggestive that tobacco use is a heritable trait, more so for regular use
than for onset. The expression of genetic risk for smoking among young people may be
moderated by small-group and larger social-environmental factors.

98   Chapter 3
E-Cigarette Use Among Youth and Young Adults

Table 3.1 Continued


Report Year Conclusions
The Health 2014 Chapter 5: Nicotine
Consequences of 1. The evidence is sufficient to infer that at high-enough doses nicotine has acute toxicity.
Smoking—50 Years 2. The evidence is sufficient to infer that nicotine activates multiple biological pathways
of Progress (USDHHS through which smoking increases risk for disease.
2014, p. 126) 3. The evidence is sufficient to infer that nicotine exposure during fetal development,
a critical window for brain development, has lasting adverse consequences for brain
development.
4. The evidence is sufficient to infer that nicotine adversely affects maternal and fetal health
during pregnancy, contributing to multiple adverse outcomes such as preterm delivery and
stillbirth.
5. The evidence is suggestive that nicotine exposure during adolescence, a critical window for
brain development, may have lasting adverse consequences for brain development.
6. The evidence is inadequate to infer the presence or absence of a causal relationship
between exposure to nicotine and risk for cancer.
Note: USDHHS = U.S. Department of Health and Human Services.

Subsequent reports expanded on the conclusions The review documented the broad biological activity of
in the 1988 report related to nicotine—reaffirming that nicotine, which can activate multiple biological path-
nicotine causes addiction, describing nicotine’s effects on ways, and the adverse effects of nicotine exposure during
key brain receptors (USDHHS 2010), and emphasizing pregnancy on fetal development and during adolescence
that youth are more sensitive to nicotine than adults on brain development. Of concern with regard to cur-
and can become dependent to nicotine much faster than rent trends in e‑cigarette use among youth and young
adults (USDHHS 2012). This is of particular concern in adults, the evidence suggests that exposure to nicotine
the context of e-cigarettes because blood nicotine levels during this period of life may have lasting deleterious con-
in e-cigarette users have been reported as being compa- sequences for brain development, including detrimental
rable to or higher than levels in smokers of conventional effects on cognition (USDHHS 2014).
cigarettes (Lopez et al. 2016; Spindle et al. 2015), and Finally, the aerosol from e-cigarettes may include
serum cotinine (a nicotine metabolite) levels have been other components that have been addressed in previous
reported as being equal to that found in conventional ciga- Surgeon General’s reports, such as tobacco-specific nitro-
rette users (Etter 2016; Marsot and Simon 2016). Because samines (TSNAs), acrolein, and formaldehyde (USDHEW
of their sensitivity to nicotine and subsequent addiction, 1979; USDHHS 2010). Aerosols generated with vapor-
about 3  out of 14 young smokers end up smoking into izers contain up to 31 compounds, including nicotine,
adulthood, even if they intend to quit after a few years; nicotyrine, formaldehyde, acetaldehyde glycidol, acro-
among youth who continue to smoke as adults, one- lein, acetol, and diacetyl (Sleiman et al. 2016). Glycidol
half will die prematurely from smoking (Peto et al. 1994; is a probable carcinogen not previously identified in the
CDC 1996; Hahn et al. 2002; Doll et al. 2004). Surgeon vapor, and acrolein is a powerful irritant (Sleiman et al.
General’s reports have also emphasized the critical role 2016). Although these constituents have been identified in
of environmental determinants of tobacco use, including e-cigarette aerosol, current evidence is unclear on whether
the causal roles of the tobacco industry’s advertising and typical user dosages achieve levels as high as conventional
promotional activities and of the peer social environment cigarettes, or at harmful or potentially harmful levels.
(USDHHS 2012). More information will be available in the coming years
The 2014 Surgeon General’s report included a as e-cigarette manufacturers begin reporting harmful or
chapter that addressed the numerous adverse conse- potential harmful constituents in compliance with the
quences of nicotine other than addiction (USDHHS 2014). Tobacco Control Act.

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   99
A Report of the Surgeon General

Health Effects of E‑Cigarette Use

The potential adverse health effects for youth who Dose and Effects of Inhaling Aerosolized Nicotine
inhale e‑cigarette aerosol include those on the body from
Nicotine addiction via e-cigarette use is a primary
acute administration of nicotine, flavorants, chemicals,
public health concern due to the exponential growth in
other particulates, and additional effects, such as (1) nico-
e-cigarette use among youth. The potential for widespread
tine addiction; (2) developmental effects on the brain from
nicotine addiction among youth is high, as are the harmful
nicotine exposure, which may have implications for cog-
consequences of nicotine on fetal development and the
nition, attention, and mood; (3) e‑cigarette influence ini-
developing adolescent brain (USDHHS 2014). Nicotine, a
tiating or supporting the use of conventional cigarettes
psychomotor stimulant drug, is the primary psychoactive
and dual use of conventional cigarettes and e‑cigarettes;
and addictive constituent in the smoke of conventional
(4)  e‑cigarette influence on subsequent illicit drug use;
cigarettes and an important determinant in maintaining
(5) e‑cigarette effects on psychosocial health, particularly
smoking dependence (e.g., USDHHS 2014). E-liquids
among youth with one or more comorbid mental health
typically contain nicotine, although in more widely vari-
disorders; and (6) battery explosion and accidental overdose
able concentrations than those found in conventional
of nicotine.
cigarettes (Trehy et al. 2011; Cameron et al. 2014; Cheng
2014; Goniewicz et al. 2015; Marsot and Simon 2016). The
concentration of liquid nicotine is only one factor that
Effects of Aerosol Inhalation by the influences the amount of aerosolized nicotine available
E‑Cigarette User for inhalation (Lopez et al. 2016); other factors include
the power of the device being used (e.g., battery voltage,
Determining the potential health effects of inhaling heater resistance) and user behavior (e.g., puff duration,
e-cigarette aerosol is challenging due to the number of pos- interpuff interval) (Shihadeh and Eissenberg 2015; Talih
sible combinations of customizable options (Seidenberg et al. 2016; Etter 2016). The interplay of these factors may
et al. 2016), including battery power, nicotine concentra- help to explain the variability in plasma nicotine concen-
tion, e-liquids (Goniewicz et al. 2015; Buettner-Schmidt tration when adults use e-cigarettes under controlled con-
et al. 2016), and use behaviors and puff topography (Dawkins ditions which can be higher (Ramôa et al. 2016), lower
et al. 2016; Lopez et al. 2016). The amount of nicotine, fla- (Bullen et al. 2010; Vansickel et al. 2010, 2012; Farsalinos
vorants, and other e-liquid constituents in e-cigarettes et al. 2014b; Nides et al. 2014; Oncken et al. 2015; Yan
available for consumers to purchase varies widely, and the and D’Ruiz 2015), or similar to those obtained by smoking
aerosolized constituents delivered vary by the type and conventional cigarettes (Vansickel and Eissenberg 2013;
voltage of the e-cigarette device being used (Cobb et al. Spindle et al. 2015; St. Helen et al. 2016; see Figure 3.1).
2015). Studies of commercial products have shown that Generalization across studies is difficult due to variations
e-liquids can contain as little as 0 milligrams/milliliter in devices, e-liquids, and e-cigarette use behavior within
(mg/mL) to as much as 36.6 mg/mL of nicotine (Goniewicz the study sample. As demonstrated in Figure 3.1, in studies
et al. 2015); can be mislabeled (Peace et al. 2016); can vary where a variety of products were used under similar labo-
by propylene glycol (PG)/vegetable glycerin (VG) ratio; and ratory conditions (i.e., blood sampling before and imme-
can contain one or more of several thousand available fla- diately after a 10-puff episode), there was wide variability
vorants (Zhu et al. 2014b). Some liquids intended for use in in nicotine delivery between devices, with “cigalike” prod-
e-cigarettes contain adulterants not named on ingredient ucts (cigarette-like products) delivering less nicotine than
lists (Varlet et al. 2015), and under at least some user con- “tank” products (Farsalinos et al. 2014b; Yan and D’Ruiz
ditions, the aerosolization process, which involves heating, 2015), and low-resistance, dual-coil “cartomizer” prod-
produces additional toxicants that may present health risks ucts having the capacity to deliver less or more nicotine
(Talih et al. 2015). The sections that follow comprehen- than a conventional cigarette, depending on the concen-
sively cover the effects of inhaling aerosolized nicotine and tration of liquid nicotine (Ramôa et al. 2016).
then consider what is known about solvents (i.e., PG and When the device type and liquid dose were held con-
VG, flavorants, and other chemicals) added to e-cigarettes, stant in a controlled session in one study, plasma nico-
adulterants in e-liquids formed in the nicotine extraction tine concentrations (in this case in nanograms [ng]/mL)
process (e.g., N-nitrosonornicotine), and toxicants formed varied considerably across participants (0.8 to 8.5 ng/mL)
during the heating and aerosolization process (e.g., acro- (Nides et al. 2014). This variation was likely attributable
lein and formaldehyde) (Sleiman et al. 2016). to the manner in which the users puffed when using

100   Chapter 3
E-Cigarette Use Among Youth and Young Adults

e‑cigarettes, or that person’s “puff topography,” which that nicotine induces the production of various inflam-
includes the number of puffs, the intake volume and dura- matory mediators involved with atherosclerotic patho-
tion, the interpuff interval, and the flow rate (Zacny and genesis (Lau and Baldus 2006), and that at the cellular
Stitzer 1988; Blank et al. 2009). level, nicotine induces C-reactive protein (CRP) expres-
Available data suggest that puff durations among sion in macrophages that contribute pro-inflammatory
adult cigarette smokers who are new e‑cigarette users and pro-atherosclerotic effects (Mao et al. 2012).
are comparable to those observed with conventional cig- Long-term studies on the safety of nicotine-only
arettes (at least about 2 seconds [sec]) (Farsalinos et  al. exposure (e.g., as with using e‑cigarettes rather than
2013b; Hua et  al. 2013; Norton et  al. 2014). However, smoking conventional cigarettes) among youth have not
puff durations during e‑cigarette use among experienced been conducted, and little is known about the cardiovas-
e‑cigarette users may be twice as long (~4 sec) (Farsalinos cular effects of e‑cigarette use among adults. However,
et al. 2013b; Hua et al. 2013; Spindle et al. 2015) as puff when e‑cigarettes are accompanied by a measurable
duration during conventional cigarette use. Puff duration increase in plasma nicotine concentration, it increases
is directly related to the nicotine content of the e‑cigarette heart rate (Vansickel et al. 2012; Vansickel and Eissenberg
aerosol (i.e., the yield or dose) (Talih et  al. 2016), sug- 2013; Nides et  al. 2014; Yan and D’Ruiz 2015), and dia-
gesting that smokers of conventional cigarettes who switch stolic BP rises.
to e‑cigarettes may increase the duration of their puffs Given the paucity of long-term data on the impact of
when using the new product in an attempt to extract more e‑cigarette smoking in relation to cardiovascular disease,
nicotine. Research also suggests that cigarette smokers other nicotine products offer a useful analogy. A meta-
may learn to alter other aspects of their puffing behavior analysis reported that replacing the consumption of con-
when using an e‑cigarette (Spindle et al. 2015). Relative ventional cigarettes with nicotine replacement therapy
to smokers of conventional cigarettes (Kleykamp et  al. (NRT) reduces cardiovascular risk among former smokers
2008), experienced e‑cigarette users were found to have without significant adverse consequences (compared with
puff volumes that were significantly higher (101.4 mL vs. current smokers) (Greenland et  al. 1998; Moore et  al.
51.3 mL) and puff flow rates that were significantly lower 2009). However, most NRT use is temporary (<26 months),
(24.2 mL/sec vs. 37.9 mL/sec) (Spindle et al. 2015). In a and the adverse consequences of longer term NRT therapy
different study, adult cigarette smokers who had never are unknown.
used e‑cigarettes but switched to e‑cigarettes showed sig- Elsewhere, investigators examined the relationship
nificantly increased puff durations and decreased puff flow between the use of Swedish-type moist snuff (or “snus”),
rates within 1 week (Lee et al. 2015). Elsewhere, adult cig- which contains high levels of nicotine and low levels of
arette smokers given an e‑cigarette appeared to show an TSNAs, and the incidence of acute myocardial infarction
enhanced ability to extract nicotine from their device after among men with a mean age of 35 years who had never
4 weeks of use (Hajek et al. 2015). Thus, the health effects smoked cigarettes. The researchers, who pooled data from
of aerosolized nicotine in e‑cigarette users may depend on eight prospective cohort studies, found no support for
a variety of factors, including the e-liquid used, the user’s any association between the use of snus and the develop-
behavior, and the user’s experience with the product. ment of acute myocardial infarction (Hansson et al. 2012),
regardless of timing, intensity, duration, or period of use
Aerosolized Nicotine and Cardiovascular Function among the men who were followed for 4–29 years.
In summary, despite overwhelming epidemiologic
Smoking is a major cause of death from cardiovas-
evidence linking the use of conventional cigarettes with
cular disease (USDHHS 2014), and exposure to nicotine
cardiovascular disease, the precise components of cig-
has been identified as a potential initiating factor in the
arette smoke responsible for this relationship and the
atherogenic process (Lee et al. 2011; Santanam et al. 2012;
mechanisms by which they exert their effects have not yet
Benowitz and Burbank 2016). Acute administration of
been fully explained (Hanna 2006). For e‑cigarettes, bio-
nicotine causes a variety of well-characterized, dose- and
logical data support a potential association with cardio-
route-dependent effects in adults, including cardiovascular
vascular disease, and short-term use of these products is
effects, such as increases in heart rate and blood pressure
accompanied by a measurable increase in plasma nicotine
(BP) and greater cardiac output, leading to an increase
concentrations in adults as well as increases in heart rate
in myocardial oxygen demand (Rosenberg et  al. 1980;
and blood pressure. Much more research is needed, but the
USDHHS 2014). Reports from cell biology and animal
limited data available suggest the typical cardiovascular
studies have established biologic plausibility between nic-
effects exerted by nicotine are also exerted by e‑cigarettes
otine alone and negative cardiovascular effects (Hanna
(Benowitz and Burbank 2016; Bhatnagar 2016).
2006; Santanam et  al. 2012). These studies have shown

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   101
A Report of the Surgeon General

Aerosolized Nicotine and Dependence higher than conventional cigarettes. Finally, Etter (2016)
reported cotinine levels among experienced e-cigarette
Although a great deal is known about self-
users similar to levels usually observed in conven-
administration of nicotine and the development of nicotine
tional cigarette smokers. Figure 3.1 and Table A3.1-1 in
dependence among adults (USDHHS 2014) and youth (Colby
Appendix  3.1 summarize studies on aerosolized nico-
et al. 2000; USDHHS 2012; O’Loughlin et al. 2014; Yuan et al.
tine from e-cigarettes and dependence using dependency
2015), more research is needed on nicotine dependence in
criteria.
youth and young adults as a result of using e-cigarettes.
The ability of e-cigarettes to deliver comparable or
Nicotine dependence, also referred to as nicotine addic-
higher amounts of nicotine compared to conventional
tion (USDHHS 2010) or tobacco use disorder (American
cigarettes raises concerns about e-cigarette use gener-
Psychiatric Association [APA] 2013), is defined as a neu-
ating nicotine dependence among young people (Dawkins
robiological adaptation to repeated drug exposure that is
et al. 2016; Etter 2016; St. Helen et al. 2016). The reported
manifested behaviorally by highly controlled or compulsive
blood levels of nicotine, or cotinine, in e-cigarette users
use; psychoactive effects such as tolerance, physical depen-
is likely to cause physiological changes in nicotinic ace-
dence, and pleasant effect; and nicotine-reinforced behavior,
tylcholine receptors in the brain that would sustain nico-
including an inability to quit despite harmful effects, a
tine addiction (Kandel and Kandel 2014; Yuan et al. 2015).
desire to quit, and repeated cessation attempts (USDHHS
This is particularly concerning for adolescents and young
1988; APA 2013). In tobacco-dependent users of conven-
adults, given that early exposure to nicotine increases the
tional cigarettes, a predictable consequence of short-term
severity of future nicotine dependence (St. Helen et al.
abstinence (e.g., for more than a few hours) is the onset
2016; USDHHS 2014).
of withdrawal symptoms indicated by self-reported behav-
Symptoms of nicotine dependence can occur soon
ioral, cognitive, and physiological symptoms and by clinical
after the initiation of conventional smoking, and even
signs (USDHHS 2010). Subjective withdrawal symptoms
before established use, among adolescents and young
are manifested by affective disturbance, including irrita-
adults (DiFranza et al. 2002; O’Loughlin et al. 2003;
bility and anger, anxiety, and depressed mood. The behav-
Dierker et al. 2007; Ramôa et al. 2016). Furthermore,
ioral symptoms include restlessness, sleep disturbance, and
some adolescents have reported nicotine dependence
increased appetite. Cognitive disturbances usually center
symptoms while using tobacco as little as 1–3 days per
on difficulty in concentrating (USDHHS 2010).
month (Rose et al. 2010). Using the National Comorbidity
Early studies of conventional cigarette smokers
Survey-Adolescent dataset, Dierker and colleagues (2012)
using e-cigarettes reported poor nicotine delivery with
reported that nicotine dependence in adolescents was
little to no increase in blood nicotine levels after puffing
likely to occur within 1 year of the initiation of weekly or
(Eissenberg 2010; Vansickel et al. 2010). Later studies
daily smoking, regardless of sociodemographic variables.
reported that the effect on serum cotinine levels among
Importantly, when smoking onset began at a younger
new e-cigarette users can be similar to that generated by
age, the transition to weekly and daily smoking was more
conventional cigarettes (Flouris et al. 2013; Lopez et al.
rapid, indicating a youthful neurobiological sensitivity to
2016). Studies examining this discrepancy found that
nicotine (Dierker et al. 2012). Zhan and colleagues (2012)
e-cigarette users require longer puffs to deliver equivalent
found that symptoms of nicotine dependence could be
nicotine doses (Lee et al. 2015), and within a week, inex-
detected among teenagers before they had smoked even
perienced e-cigarette users adjust their puffing patterns
100 cigarettes.
after switching (Hua et al. 2013b; Lee et al. 2015; Talih
Because few validated measures exist for assessing
et al. 2015).
dependence on e‑cigarette use, some researchers have
In more experienced e-cigarette users, blood nico-
adapted those originally developed to measure dependence
tine levels appear to be influenced by puffing patterns,
in smokers of conventional cigarettes. Among adults,
such as puff length. Volume and frequency and plasma
scores on these measures have been consistently lower
nicotine levels ranging from 2.50 to 13.4 ng/mL have
in e‑cigarette users than in smokers of conventional ciga-
been observed after 10 puffs of an e-cigarette (Dawkins
rettes (Farsalinos et al. 2013a; Etter and Eissenberg 2015;
and Corcoran 2014). Dawkins and colleagues (2016) used
Foulds et al. 2015). Still, scores for e‑cigarette dependence
24  mg/mL nicotine strength liquid and observed high
among former cigarette smokers were positively associ-
blood nicotine levels that were achieved very quickly,
ated with the nicotine concentration of the e‑cigarette
matching and even exceeding those reported in conven-
liquid and the type of device used (Etter 2015; Etter and
tional cigarette smokers. St. Helen and colleagues (2016)
Eissenberg 2015; Foulds et  al. 2015). Research in this
conducted a similar study and reported that e-cigarettes
area is challenging to interpret because measurement of
can deliver levels of nicotine that are comparable to or
youth e‑cigarette dependence has not been standardized

102   Chapter 3
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Figure 3.1 Plasma nicotine concentration from different human laboratory studies and four different products with
blood sampled before and immediately after a 10-puff bout with the products

Source: Vansickel et al. (2010); Farsalinos et al. (2014b); Yan and D’Ruiz (2015); and Ramôa et al. (2016).
Notes: Data for conventional cigarettes are from 32 tobacco cigarette smokers using their usual brand of cigarette (Vansickel et al. 2010).
E-cigarette A is a cigalike called “blu” loaded with two different concentrations of liquid nicotine (16 or 24 mg/mL, both containing 20%
propylene glycol and 50% vegetable glycerin). Data are from 23 smokers of tobacco cigarettes with 7 days of experience with the e-cigarette
product (Yan and D’Ruiz 2015). E-cigarette B is a cigalike called “V2cigs”, and E-cigarette C is a “tank” product called “EVIC” with an “Evod”
heating element; both were loaded with an 18 mg/mL liquid containing 34% propylene glycol and 66% vegetable glycerin. Data are from 23
experienced users of e-cigarettes (Farsalinos et al. 2014b). E-cigarette D uses a 3.3-volt “Ego” battery fitted with a 1.5-Ohm dual coil carto-
mizer (“Smoktech”) and filled with ~1 mL of a 70% propylene glycol, 30% vegetable glycerin liquid that varied by liquid nicotine concentra-
tion (0, 8, 18, or 36 mg/mL). Data are from 16 experienced users of e-cigarettes (Ramôa et al. 2016).

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   103
A Report of the Surgeon General

and there is a wide variation in device/e-liquid combina- in doses equivalent to those for humans (see Table A3.1-3
tions, which allow for adjustable nicotine delivery among in Appendix 3.1). These animal and human studies, taken
study participants. Regardless, among 766 adults, who together with studies of rising e‑cigarette prevalence in
were daily users of e‑cigarettes (with nicotine) and who youth (see Chapter 2), point to an age-dependent suscep-
were either former cigarette smokers (83%) or current tibility to nicotine as a neurobiological insult.
cigarette smokers (17%), 30.7% indicated that they would Limited direct human experimental data exist on
likely be unable to stop using e‑cigarettes, 28.2% that they the effects of nicotine exposure from e‑cigarettes on the
would find it “very difficult” or “impossible” to stop using developing adolescent brain, but experimental laboratory
e‑cigarettes, and 27.5% that they were unable to stop data have been found to be relevant in animal models to
e‑cigarette use (Etter and Eissenberg 2015). However, it contextualize effects in humans (Stevens and Vaccarino
is important to note that e-cigarettes were less addictive 2015). Even if the full complexity of human brain develop-
than conventional cigarettes in this sample (Etter and ment and behavioral function during adolescence cannot
Eissenberg 2015). be completely modeled in other species, the similarities
In summary, the addictive liability of e-cigarettes across adolescents of different species support the use of
has the potential to be at least equivalent to that of con- animal models of adolescence when examining neural and
ventional cigarettes, given nicotine dose levels produced environmental contributors to adolescent-characteristic
by these products, particularly among experienced users functioning (Spear 2010).
operating new-generation devices (Ramôa et al. 2016). Animal studies provide an effective method to
More generally, the delivery of nicotine in sufficient doses examine the persistent effects of prenatal, child, and ado-
and blood concentration would be expected to produce lescent nicotine exposure, in addition to human epide-
and maintain dependence in e-cigarette users. Further miologic data. When considering an epidemiologic causal
work would be useful to determine the natural course argument of exposure (risk factor) to health outcome (dis-
and history of e-cigarette use among smokers of conven- ease), one should note that animal models lend biolog-
tional cigarettes, former smokers, and never smokers and ical plausibility when experimentation with humans is not
to more accurately determine the nicotine addiction lia- possible (or ethical) (Rothman et al. 2008). Furthermore,
bility of e-cigarette use. Unfortunately, these issues have animal studies offer significant advantages compared to
not been explored in adolescents, although the prevalence human studies—with the ability to control for many con-
of e-cigarette use has increased considerably in that popu- founding factors, to limit nicotine exposure to differing
lation since 2011 (see Chapter 2). levels of physical and neural development—and are piv-
otal for understanding the neural substrates associated
Effects of Nicotine in Youth Users with adolescence. The validity of any causal argument
when examining animal models requires careful consider-
Nicotine is the prime psychoactive substance in con-
ation, and yet in combination with epidemiologic data—
ventional cigarettes (Yuan et al. 2015), and given that the
such as prevalence, incidence, and strength of association
developing adolescent brain is immature and vulnerable
between exposure and outcome—a causal argument can
to neurobiological insults (Bernheim et  al. 2013; Lydon
be constructed with literature from animal models rep-
et  al. 2014), it is important to understand how nicotine
resenting biologic plausibility. Using a variety of study
delivered by e‑cigarette use affects adolescent brain devel-
designs and research paradigms including humans and
opment and how responses to nicotine in adolescents
animals, research in this area provides evidence for neu-
differ from those seen in adults. Substantial evidence sug-
roteratogenic and neurotoxic effects on the developing
gests that nicotine can negatively influence both adoles-
adolescent brain (Lydon et al. 2014; England et al. 2015).
cent and prenatal brain development (USDHHS 2014).
The brain undergoes significant neurobiological
For example, Weiss and colleagues (2008) reported a
development during adolescence and young adulthood,
strong mechanistic link among early nicotine exposure
which are critical periods of sensitivity to neurobiolog-
(younger than 16 years of age), common genes related to
ical insults (such as nicotine) and experience-induced
the severity of nicotine addiction (CHRNA5-A3-B4 hap-
plasticity (Spear 2000; Dahl 2004; Gulley and Juraska
lotypes), and adult nicotine addiction in three indepen-
2013). Although maturation occurs in different regions of
dent populations of European origins. Although much of
the brain at different rates, a similar progression occurs
the literature on nicotine addiction arises from studies
in all areas characterized by a rapid formation of syn-
of nicotine exposure among adults, and with combus-
aptic connections in early childhood, followed by a loss
tible tobacco products (see Table A3.1-2 in Appendix 3.1),
of redundant or unnecessary synapses (called pruning)
there is a growing body of biological mechanistic litera-
and the formation of myelin. Myelination is the process
ture from animal studies that model the effects of nicotine
by which a fatty layer, called myelin, accumulates around

104   Chapter 3
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nerve cells (neurons). Because of myelin, nerve cells can of synapse elimination that occurs between early child-
transmit information faster, allowing for more complex hood and the onset of puberty) and increasing myelina-
brain processes. Pruning allows for more focused con- tion throughout the brain (Casey et al. 2005; Lenroot and
centration, and myelination allows for faster electrical Giedd 2006; Giedd and Rapoport 2010; Counotte et  al.
and neural signaling; both allow for more efficient cog- 2011).
nitive processing. During adolescence and into young Nicotine has more significant and durable damaging
adulthood, myelination occurs rapidly in the frontal lobe, effects on adolescent brains compared to adult brains,
a place in the brain that controls executive functioning, the former suffering more harmful effects. Preclinical
reasoning, decision-making skills, self-discipline, and animal studies have shown that in rodent models, nico-
impulse control. Plasticity refers to the current under- tinic acetylcholine receptor (nAChR) signaling is still
standing that the brain continues to change throughout actively changing during adolescence, with higher expres-
life, not only because of normal, maturational neural sion and functional activity of nAChRs in the forebrain
growth and development but also because of changes in of adolescent rodents compared to their adult counter-
environmental neurobiological exposures (such as nico- parts (Britton et  al. 2007; Kota et  al. 2007; Doura et  al.
tine), injuries, behaviors, thinking, and emotions (Mills 2008). Furthermore, in rodent models, nicotine actu-
and Tamnes 2014). ally enhances neuronal activity in several reward-related
Across species, and in humans, adolescence is a key regions and does so more robustly in adolescents than in
period of increased plasticity and rapid growth of brain adults (Schochet et al. 2005; Shram et al. 2007; Dao et al.
circuits that regulate social, emotional, and motivational 2011). This increased sensitivity to nicotine in the reward
processes and decision making (Spear 2000, 2011; Nelson pathways of adolescent rats is associated with enhanced
et al. 2005; Ernst and Fudge 2009; Counotte et al. 2011). behavioral responses, such as strengthening the stimulus-
The prefrontal cortex, which is involved in higher level response reward for administration of nicotine. In condi-
regulatory control of complex behaviors (such as plan- tioned place-preference tests—where reward is measured
ning, impulse control, and working memory), continues by the amount of time animals spend in an environment
normal structural and functional development into young where they receive nicotine compared to an environment
adulthood, to about 25 years of age (Giedd and Rapoport where nicotine is not administered—adolescent rodents
2010; Somerville and Casey 2010). Because of the immatu- have shown an increased sensitivity to the rewarding
rity and rapid growth of the prefrontal cortex, adolescents effects of nicotine at very low doses (0.03 mg/kg) (Vastola
and young adults normally exhibit moody, risk-taking, et  al. 2002; Belluzzi et  al. 2004; Brielmaier et  al. 2007;
and unpredictable impulsive behaviors. The combina- Kota et  al. 2007; Natarajan et  al. 2011) and exhib-
tion of delayed maturation of frontal cognitive control ited a unique vulnerability to oral self-administration
and increased reactivity of subcortical reward-related during the early-adolescent period (Adriani et  al. 2002).
and emotion-processing systems may lead to increased Adolescent rodents also have shown higher levels of nic-
risk-taking behavior and a greater susceptibility to initi- otine self-administration than adults (Levin et  al. 2003;
ating substance use and the development of dependence Chen et al. 2007; Natividad et al. 2013), decreased sensi-
(Steinberg 2008; Ernst and Fudge 2009; Counotte et  al. tivity to the aversive effects of nicotine (Adriani et al. 2002;
2011; Spear 2011). Thus, myelination is vitally important Shram et al. 2006; Torres et al. 2008), and less prominent
to the healthy functioning of the central nervous system, withdrawal symptoms following chronic nicotine expo-
and any exposure that significantly interferes with the sure (O’Dell et  al. 2006). This characteristic in rodent
myelination process can cause mild-to-severe cognitive models of increased positive and decreased negative short-
and learning problems (Brady et al. 2012). term effects of nicotine during adolescence (versus adult-
Brain development in juvenile rodents has been hood) highlights the possibility that human adolescents
reported to display patterns that resemble those of human might be particularly vulnerable to developing depen-
beings, suggesting that the rodent model might be rel- dency to and continuing to use e‑cigarettes. These bio-
evant to studying the neurobiological underpinnings logical mechanisms are of great public health importance
of brain maturation in teenagers (Spear 2000). Studies as exposure to nicotine grows among nonsmoking youth
across species have revealed unique characteristics of through the increasing prevalence of e‑cigarette use.
adolescent nonhuman brain structure, mechanisms, and Beyond their unique vulnerability to nicotine use,
function that provide biological plausibility to the hypoth- and thus smoking uptake, human adolescents may be par-
esis that human adolescents are particularly vulnerable to ticularly vulnerable to the detrimental consequences of
nicotine uptake (O’Loughlin et al. 2015; Yuan et al. 2015). nicotine exposure, including an increase in drug-seeking
There is evidence for rapid growth of gray matter, fol- behaviors (Kandel and Kandel 2014), deficits in attention
lowed by activity-dependent synaptic pruning (the process and cognition, and mood disorders (Yuan et al. 2015). In

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   105
A Report of the Surgeon General

animal models, chronic nicotine exposure during adoles- use and abuse (McQuown et al. 2007; Dao et al. 2011;
cence has been shown to produce long-lasting, unique Dickson et al. 2014; Pipkin et al. 2014; Kandel and Kandel
effects that are not observed in mature adult animals. 2014). In several rodent studies, treatment with very low
Moreover, animal models have provided substantial evi- doses of nicotine for a few days during early adolescence,
dence that the limbic system—which controls cognition, but not in late adolescence or adulthood, produced lasting
emotion, and drug-reward—is actively maturing during changes in D2 and D3 dopamine receptors and in the self-
adolescence and during this age is vulnerable to long- administration of other abused drugs (McQuown et al.
term modification by nicotine. 2007; Dao et al. 2011; Mojica et al. 2014). Nicotine expo-
Reward-Seeking Behaviors. A very strong argument sure in adolescent rats also induced rapid and long-lasting
can be made about the association between adolescent expo- dendritic remodeling in the nucleus accumbens shell, a
sure to nicotine by smoking conventional cigarettes and critical component of reward learning and addiction, via
the subsequent onset of using other dependence-producing a D1 dopamine receptor-mediated mechanism (Ehlinger
substances. Strong, temporal, and dose-dependent associa- et al. 2016). This persistent form of nicotine-induced neu-
tions have been reported (Isensee et al. 2003; John et al. roplasticity has the potential to alter synaptic connectivity
2004b; Bronisch et al. 2008; Kandel and Kandel 2015), and within reward-processing centers and enhance the addic-
a plausible biological mechanism (via rodent and human tive effects of drugs of abuse.
modeling) suggests that long-term changes in the neural Attention and Cognition. Both cognitive improve-
reward system take place as a result of adolescent smoking ments (Jasinska et  al. 2014) and cognitive deficits (Hall
(Lewinsohn et al. 1999; Huang et al. 2013; Kandel and et  al. 2014) have been reported after nicotine exposure
Kandel 2014). Adolescent smokers of conventional ciga- in healthy human adults, while smoking during adoles-
rettes have disproportionately high rates of comorbid sub- cence impairs cognition and attention processes. Results
stance abuse (Kandel et al. 1992; Lai et al. 2000; Hanna et al. of a genetically sensitive, longitudinal “concordant”
2001), and longitudinal studies have suggested that early and “discordant” twin study from the Netherlands Twin
adolescent smoking may be a starting point or “gateway” for Registry indicated a larger increase in attention prob-
substance abuse later in life (Kandel et al. 1992; Lewinsohn lems from adolescence to adulthood in twins who smoked
et al. 1999; Wagner and Anthony 2002; Brook et al. 2007), than in their never-smoking co-twins (Treur et al. 2015).
with this effect more likely for persons with attention In another study, adolescent smokers were found to have
deficit hyperactivity disorder (ADHD) (Biederman et al. chronic impairments in the accuracy of their working
2006; Wilens et al. 2008). Although factors such as genetic memory (e.g., in processing information from two sensory
comorbidity, innate propensity for risk taking, and social modalities simultaneously), which were more severe with
influences may underlie these findings (Lindsay and Rainey an earlier age of onset of smoking (Jacobsen et al. 2005).
1997; Smith et al. 2015), both human neuroimaging and Functional imaging studies have shown that 24-hour
animal studies suggest a neurobiological mechanism also smoking abstinence in adolescent smokers causes acute
plays a role. In addition, behavioral studies in adolescent impairments of verbal memory and working memory,
and young adult smokers have revealed an increased pro- along with chronic decrements in cognitive performance
pensity for risk taking, both generally and in the presence of (Jacobsen et al. 2007a). In another study, adolescent users
peers, and neuroimaging studies have shown altered frontal of conventional cigarettes showed decreased prefrontal
neural activation during a risk-taking task as compared cortex activation (versus never smokers) during attention
with nonsmokers (Lejuez et al. 2005; Cavalca et al. 2013; tasks, and duration of smoking (in years) was directly cor-
Galvan et al. 2013). Rubinstein and colleagues (2011b) used related with the extent of reduction in prefrontal cortical
neuroimaging to show decreased brain response to a nat- activity (Musso et al. 2007).
ural reinforcer (pleasurable food cues) in adolescent light Thus, longitudinal and imaging studies in humans
smokers (1–5 cigarettes per day), with their results high- provide support for the hypothesis that adolescent use of con-
lighting the possibility of neural alterations consistent with ventional cigarettes has both acute and long-term effects on
nicotine dependence and altered brain response to reward attention and memory. Although nicotine exposure cannot
even in adolescent low-level smokers. be cited as the sole cause of cognitive defects (or even one
Nicotine exposure in rodents at an age of physical of several combined effects in humans), other studies have
development corresponding to human adolescence has shown that adolescent nicotine exposure in rats induces
been found to increase the reinforcing effects of other lasting synaptic changes in the prefrontal cortical regions
drugs of abuse, including cocaine, methamphetamine, critical for normal attention, memory, and cognition that
and alcohol, without having a major impact on responding likely underlie observed impairments in attentional and
for other rewards, thus providing further evidence in sup- cognitive function (Bergstrom et  al. 2008). Adolescent
port of nicotine as an initiation toward other substance nicotine exposure in rats has induced impairments in

106   Chapter 3
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stimulus-response-discrimination-learning processes but twin and sibling discordant/concordant studies (Munafo


not in abstract rule-learning processes, which are dependent and Araya 2010; Leventhal and Zvolensky 2015), they do
on dissociable cognitive systems, thus showing the selective suggest that nicotine exposure during adolescence could
effects of nicotine (Pickens et al. 2013). In addition, adoles- contribute to long-term mental health disorders.
cent, but not postadolescent, treatment of rats with nico- Findings of animal studies support the theory that
tine resulted in diminished attention span and enhanced adolescent nicotine exposure results in long-term alter-
impulsivity in adulthood (Counotte et al. 2009, 2011). The ations in emotional response, specifically enhanced anx-
biological causes of these cognitive disturbances (reduced iety and fear (Slawecki et al. 2003; Smith et al. 2006), and
attention span and impulse control) were associated with in persistent alterations in serotonin systems involved in
reduced regulation of prefrontal cortex excitatory synapses mediating mood disorders by reprogramming the future
function in metabotropic glutamate receptor 2 (mGluR2) response of 5-HT systems to nicotine (Slotkin and Seidler
(Counotte et al. 2011; Goriounova and Mansvelder 2012). 2009). Even a single day of nicotine treatment in adoles-
In addition, hippocampal function, which is critical for cent rats can enhance sensitivity to aversive stimuli later
memory, was altered in adult mice by nicotine exposure in life and result in a depression-like state in adulthood
during adolescence. Contextual fear conditioning—a that is normalized by treatment with nicotine or antide-
hippocampus-dependent task in which animals learn and pressants (Iniguez et al. 2009).
remember to associate a fearful stimulus (e.g., a foot shock) In summary, given the existing evidence from
with a particular context—was disrupted in adult mice that human and animal studies of the detrimental impact of
had been treated during adolescence with chronic nicotine nicotine exposure on adolescent brain development, the
but not following chronic treatment with nicotine in adult- use of e-cigarettes by youth should be avoided and actively
hood (Portugal et al. 2012). Rodent studies have implica- discouraged. Both preadolescence and adolescence are
tions for human adolescents, suggesting that exposure to developmental periods associated with increased vulner-
tobacco during youth may lead to long-lasting changes in ability to nicotine addiction, and exposure to nicotine
behavioral and neuronal plasticity into adulthood. during these periods may lead to long-lasting changes in
Mood Disorders. Adolescents with symptoms of behavioral and neuronal plasticity. Studies reveal that for
mental health disorders (e.g., anxiety, aggressive and dis- most tobacco users, initial use begins before 18 years of
ruptive behaviors, mood disorders) are at increased risk age. Moreover, in some adolescents, symptoms of nico-
for initiation of conventional cigarette use and long- tine dependence can develop after exposure to very low
term nicotine dependence compared with those without levels of nicotine—less than 100 cigarettes. Cross-species
such disorders (Gehricke et al. 2007; Morris et al. 2011). studies have identified characteristics of the adolescent
Although this risk may reflect a common genetic predis- brain that may render it vulnerable at this age to nicotine
position, or the use of nicotine to self-medicate in the uptake in the form of equivalent doses via nonsmoking
hope of improving mental health symptoms, the question administration mechanisms. In addition, animal models
arises of whether the smoking of conventional cigarettes of nicotine exposure in adolescence reveal neural and
by adolescents contributes to the development of mood behavioral alterations consistent with an increased like-
disorders. A meta-analysis of existing studies showed con- lihood of future nicotine use, increased activation of
sistent evidence that both tobacco use and dependence reward pathways and, unlike in adult animals, decreased
on tobacco products among adolescents indeed increased aversive effects. Regarding e-cigarettes, data demonstrate
their risk of anxiety disorders (Moylan et al. 2012). Other adolescent use of these devices is associated with use of
studies have shown that an early onset of smoking is asso- tobacco, alcohol, and other drugs (Dutra and Glantz 2014;
ciated with a shorter time to first onset of an anxiety dis- Kristjansson et al. 2015; Wills et al. 2015a, b; Schneider
order (Jamal et al. 2011), and there is a positive association and Diehl 2016). Finally, animal and human studies sug-
between adolescent smoking, particularly through a nico- gest a bidirectional relationship between the smoking of
tine pathway, and anxiety in early adulthood (Moylan et al. conventional cigarettes and exposure to nicotine during
2013). Bidirectional relationships between adolescent adolescence and factors related to disruptive disorders,
smoking and disruptive disorders (e.g., ADHD; opposi- such as ADHD and ODD that impair academic perfor-
tional defiant disorder [ODD] [Griesler et al. 2011]) as well mance, as well as to depression. Because the adolescent
as depression (Tjora et al. 2014) also have been reported, brain is still developing, nicotine use during adolescence
while a longitudinal birth cohort found evidence to sup- can disrupt the formation of brain circuits that con-
port a causal relationship between teen smoking and onset trol attention, learning, and susceptibility to addiction.
of depression (Boden et al. 2010). Although these findings Further research is warranted to more fully understand
are complex and warrant further study using comparisons the effects of e-cigarette use on youth.
of genetic polymorphisms associated with smoking or

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   107
A Report of the Surgeon General

Nicotine Exposure from Maternal Nicotine Prenatal nicotine exposure also has been associated
Consumption: Prenatal and Postnatal Health with dysregulation of catecholaminergic, serotonergic,
Outcomes and other neurotransmitter systems. In addition, animal
work suggests significant adverse effects of nicotine alone
Prenatal nicotine exposure through maternal ciga-
at levels commensurate with exposure to secondhand
rette use during pregnancy is one of the most widespread
smoke (10-fold below those seen in active smokers), and
perinatal insults in the world (Levin and Slotkin 1998; Xiao
that the non-nicotine components of tobacco smoke can
et  al. 2008; USDHHS 2014). Despite medical and societal
exacerbate nicotine’s teratogenic effects (Slotkin et  al.
sanctions and ongoing public health campaigns, the prev-
2015). Offermann (2015) concluded that e-cigarettes
alence of maternal cigarette use during pregnancy in the
emit many harmful chemicals into the air and that indi-
United States was estimated to be 11–15% in 2013 (Tong
rect exposure to nicotine exceeded exposure-level stan-
et al. 2013). Smoking rates were even higher among women
dards for noncarcinogenic health effects established by
who were poor, young, or less educated, with rates as high
the California Environmental Protection Agency. No safe
as 25–30%, indicating that infants born to mothers who are
level of prenatal nicotine exposure has been established
poor have disproportionately higher exposure to nicotine
(England et al. 2015).
(Dietz et al. 2011; Hamilton et al. 2012; Tong et al. 2013).
Airborne nicotine exposure through secondhand
Despite these adverse consequences, an estimated one-half
aerosol from e-cigarettes has been observed, as has sali-
of pregnant smokers continue to smoke into the third tri-
vary cotinine concentrations of nonsmokers in the homes
mester (Osterman et al. 2013; Tong et al. 2013).
of e-cigarette users (Ballbe et al. 2014; Czogala et al.
Because adults who use e‑cigarettes can achieve
2014). Ballbe and colleagues (2014) reported the geo-
plasma nicotine concentrations similar to those found
metric means of airborne nicotine were 0.74 μg/m3 in the
among smokers of equivalent amounts of conventional
homes of smokers, 0.13 μg/m3 in the homes of e-cigarette
cigarettes (Vansickel et  al. 2010; Lopez et  al. 2016;
users, and 0.02 μg/m3 in the homes of nonsmoking con-
St. Helen et al. 2016), it is important that research con-
trols. While airborne nicotine exposure from combustible
tinues in this area. Nicotine has been shown to cross the
cigarette smoke was 5.7 (Ballbe et al. 2014) to 10 times
placenta and has been found in placental tissue as early
higher (Czogala et al. 2014) than e-cigarette aerosol, one
as 7 weeks of embryonic gestation, and nicotine concen-
study reported only a twofold increase in salivary cotinine
trations are higher in fetal fluids than in maternal fluids
(0.38 ng/ml in the homes of smokers versus 0.19 ng/ml in
(Luck et  al. 1985; Jauniaux et  al. 1999). nAChRs are
the homes of e-cigarette users) (Ballbe et al. 2014), and
widely distributed in the fetal brain. As has been clearly
another study found that exposure to cigarette smoke and
demonstrated in animal models, acetylcholine acts on
exposure to e-cigarette aerosol had similar effects on the
nAChRs to modulate functional connections during crit-
serum cotinine levels of bystanders (Flouris et al. 2013).
ical periods of development when regions are most sen-
Thus, the passive exposure to nicotine from e-cigarette
sitive to environmental input (Dwyer et al. 2008). When
smoking has been reported to be just as large (Flouris
nicotine in the maternal bloodstream crosses the pla-
et al. 2013; Grana et al. 2013) or lower than (Czogala et al.
cental barrier, it binds to these receptors (Pentel et  al.
2014) conventional cigarettes, but exposure to nicotine
2006; Wong et  al. 2015), and in rodents this can result
from e-cigarette smoking is not negligible and is higher
in long-term changes in neural structure and function.
than in nonsmoking environments. This evidence sug-
Results from animal studies show consistent associations
gests the importance of avoiding secondhand exposure
between prenatal nicotine exposure and upregulation of
of e-cigarette vapor and secondhand smoke during preg-
nAChRs associated with disruption of fetal brain cell rep-
nancy (Flouris et al. 2013; Grana et al. 2013; Czogala et al.
lication and differentiation (Slotkin 1998). Highlighting
2014).
the role of nicotine in the effects of maternal smoking
Of the components of tobacco smoke, nicotine
during pregnancy, nAChRs have been shown to be present
has been cited as the most important toxicant in terms
in the human embryonic brain from 5 weeks of gesta-
of interfering with fetal development. Because of the
tion (Hellstrom-Lindahl et  al. 1998), and their normal
health risks to the developing fetus associated with nico-
maturation is altered in a region- and receptor subtype-
tine exposure during pregnancy, the U.S. Food and Drug
dependent fashion by maternal cigarette smoking during
Administration (FDA) (2015) recommends that pregnant
pregnancy (Falk et al. 2005; Duncan et al. 2008). In those
women seek medical approval before using NRT, and the
brainstem nuclei important for arousal, prenatal nicotine
American College of Obstetricians and Gynecologists
exposure decreases [3H]-nicotine binding (Duncan et  al.
(2011) recommends consideration of NRT only if a woman
2008) and prevents normal age-related increases in α4
fails behavioral interventions to quit smoking conven-
and α7 mRNA (Falk et al. 2005).
tional cigarettes and has discussed the potential harms

108   Chapter 3
E-Cigarette Use Among Youth and Young Adults

and benefits of NRT with her physician. NRT is most often pathways that could be related to SIDS and is related
used during pregnancy as a last resort to avoid exposing to known risk factors, particularly lung and respira-
the fetus to the other toxic ingredients found in con- tory development (England et al. 2015; Holbrook 2016;
ventional tobacco smoke (Fiore et al. 2008). A Cochrane Spindel and McEvoy 2016). Evidence from animal models
Database systematic review concluded that both the effec- supports the hypothesis that prenatal nicotine exposure
tiveness and safety of NRT during pregnancy are unclear alters both fetal autonomic function and arousal, which
(Coleman et al. 2012). Table A3.1-4 in Appendix 3.1 pres- could increase the risk of SIDS (Slotkin 1998; Task Force
ents a summary of studies in humans on the effects of on Sudden Infant Death Syndrome and Moon 2011). In
tobacco exposure on fetal brain development. humans, a dose–response relationship between cotinine
Even with a firm understanding of the negative (the major nicotine metabolite) and altered arousal pat-
health consequences of nicotine on the developing fetus terns has been shown in preterm infants (Richardson
(Fiore et  al. 2008; USDHHS 2014; Ekblad et  al. 2015), et  al. 2009), and this relationship is suggestive of nico-
little is known about the prevalence of e‑cigarette use tine’s role in arousal deficits that could be linked to SIDS.
among pregnant women or the direct harmful effects There is widespread distribution of nAChRs in the brain-
on their fetus by other toxicants delivered by the aerosol stem nuclei in both humans and animals that control car-
from e‑cigarettes (England et al. 2015; Suter et al. 2015). diopulmonary integration and arousal in the newborn
In one of the few studies identified, a survey of 316 preg- (Dwyer et  al. 2008). In some animal studies, prenatal
nant women in a Maryland clinic found that the majority exposure to nicotine has increased mortality in newborns
had heard of e‑cigarettes, 13% had ever used them, and that were exposed to reduced oxygen (Slotkin et al. 1995;
0.6%  were current daily users (Mark et  al. 2015). These Fewell and Smith 1998). Prenatal exposure to nicotine
findings are of concern because the dose of nicotine is also associated with altered serotonin signaling in the
delivered by e‑cigarettes can be as high or higher than brainstem in the rat model, leading to an exaggerated tri-
that delivered by conventional cigarettes. Therefore, geminocardiac reflex and resulting in bradycardia, hypo-
plasma nicotine concentrations delivered while using tension, and apnea (Gorini et al. 2013).
e‑cigarettes have the potential to harm the developing Altered Development of the Corpus Callosum. The
fetus. Furthermore, in 2013 in the United States, there corpus callosum, the largest white matter structure in
were 26.5 births for every 1,000 adolescent females the brain, facilitates communication between the left and
(15–19 years of age), or 273,105 babies born to females right cerebral hemispheres. Several human studies have
in this age group (Hamilton et  al. 2013). Currently, the revealed alterations in the structure of the corpus callosum
rate of e‑cigarette use among pregnant adolescents is in offspring following their exposure to maternal cigarette
unknown, but the effects of nicotine and the potential for use during pregnancy (Jacobsen et al. 2007b; Paus et al.
harm by other e‑cigarette toxicants indicate that the use 2008). In animal models, prenatal exposure to nicotine
of e‑cigarettes is a fetal risk factor among pregnant ado- has been shown to result in widespread alterations in gene
lescent girls. expression in the brains of adolescent offspring (Cao et al.
As outlined below, the specific effects of nicotine 2011, 2013; Wei et al. 2011). In particular, the expression
on prenatal development and postnatal outcomes include of a number of genes involved in myelination—the forma-
sudden infant death syndrome (SIDS) and may include tion of white matter via the addition of protective myelin
altered development of the corpus callosum, deficits in sheaths to axons—is altered in a sex-dependent manner,
auditory processing, and alterations in appetitive behavior, with upregulation in males and downregulation in females
attention, and cognition. (Cao et al. 2013). Such changes in the expression profiles
SIDS. SIDS is the sudden and unexplained death of of myelin-related genes may influence the structure and
an infant younger than 1 year of age (Krous 2014). Maternal function of white matter, and both hypermyelination and
smoking and infant exposure to secondhand smoke have hypomyelination have been associated with cognitive defi-
been causally associated with SIDS, with 20–29% of deaths cits (Quaranta et al. 2002; Sokolov 2007).
from SIDS attributable to maternal smoking of conven- Deficits in Auditory Processing. A number of
tional cigarettes during pregnancy (Dietz et  al. 2010; human studies, using a variety of methods, have inves-
Zhang and Wang 2013; USDHHS 2014). Prenatal exposure tigated the effects of maternal cigarette smoking during
to cigarettes and to smokeless tobacco have been associ- pregnancy on auditory processing from the fetal period
ated with increased risk for apnea events, which have been through childhood (Jacobson and Morehouse 1984;
linked to increased risk for SIDS (Gunnerbeck et al. 2011; Kristjansson et  al. 1989; McCartney et  al. 1994; Franco
Zhang and Wang 2013; Inamdar et al. 2015). et al. 1999; Leech et al. 1999; Cowperthwaite et al. 2007).
Although the mechanistic pathways underlying Deficits in auditory processing in fetuses are of concern
SIDS remain largely unknown, nicotine has effects on because they affect later language development (Kisilevsky

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   109
A Report of the Surgeon General

and Davies 2007; Kisilevsky et al. 2014). Various studies in reduced coordination among brain regions during audi-
infants have investigated the brain’s physiological activity tory attention tasks.
response to auditory stimuli (the cochlea translates sound Animal studies have shown that nAChRs play a
into nerve impulses to be sent to the brain), neuroelectric critical developmental role in establishing synaptic con-
activity of the auditory nerve, and cochlear response (Key nections between sensory thalamic afferents and those
et al. 2007; Korres et al. 2007; Kable et al. 2009; Peck et al. cortical targets that are necessary for normal sensory
2010; Katbamna et  al. 2013). Key and colleagues (2007) processing (Table A3.1-5 in Appendix 3.1). Brief nicotine
reported prenatal exposure to cigarette use (compared exposure during this critical postnatal period of sensory
with nonexposed infants) to be associated with alterations cortex development disrupts glutamate transmission
in hemispheric asymmetry and suboptimal brain activity (Aramakis et al. 2000) and eliminates nAChR regulation of
related to speech processing in otherwise healthy new- signal processing in the adult auditory cortex, inhibiting
borns at least 2 days of age. Korres and associates (2007) normal auditory learning (Liang et  al. 2006). Animals
found altered cochlear responses to auditory stimuli that are prenatally exposed to nicotine also exhibit defi-
in newborns that were exposed to maternal cigarette cits in cognitive processing in response to an auditory cue,
smoking (n = 200) compared with those that were unex- which appears to be mediated by a loss of function of the
posed (n = 200), regardless of degree of cigarette exposure. nAChR β2 subunit (Liang et al. 2006; Horst et al. 2012).
Similar findings were reported by Durante and colleagues Appetitive and Consummatory Behaviors. Clinical
(2011) in two case-control studies. studies and animal studies have linked prenatal exposure
Two additional studies investigated effects of to nicotine to subsequent appetitive behaviors (an active
maternal cigarette use during pregnancy on auditory searching process that is performed consciously) and con-
brainstem responses in newborns (≤2 days old) (Peck et al. summatory behaviors (such as ingestion of food or drugs)
2010) and infants (6 months old) (Kable et al. 2009). Both in offspring. Associations have been demonstrated in
studies found greater neuroelectric response to sound humans between maternal cigarette use during pregnancy
stimuli, a phenomenon that may disrupt an infant’s ability and risk to the child of smoking uptake/nicotine depen-
to encode auditory information, potentially leading to def- dence, drug abuse, and obesity; parallel relationships have
icits in language development. Furthermore, both studies been shown in animal models between prenatal exposure
demonstrated dose–response relationships between to nicotine and similar appetitive behaviors of offspring.
altered auditory processing and maternal cotinine levels. Parental use of tobacco is one of many well-known
Finally, in a study of a small sample of newborns that risk factors for offspring initiation of tobacco, progres-
sought to understand the direct biological pathway, sion to heavy use, and nicotine dependence. Tobacco use
maternal smoking during pregnancy produced changes in by parents influences their children through social, envi-
newborn cochlear and auditory brainstem functions and ronmental, cognitive, and genetic mechanisms (USDHHS
changes in placental gene expression in genes that appear 2012). As a subset of these influences, mothers’ use of
to modulate the motility of cochlear hair cells (Katbamna tobacco during pregnancy has been studied as an inde-
et al. 2013). Thus, all three studies indicate effects based pendent risk factor and has been associated with offspring
on consumption of conventional cigarettes, and they high- susceptibility, initiation, regular use, and dependence
light the possibility of a mediating role of maternal nico- (Kandel et al. 1994; Griesler et al. 1998; Kandel and Udry
tine use in altered infant auditory processing, although 1999; Buka et  al. 2003; Lieb et  al. 2003; Oncken et  al.
further work must rule out confounding effects and effect 2004; Al Mamun et  al. 2006; O’Callaghan et  al. 2009;
modification by other constituents (e.g., arsenic, benzene, Tehranifar et  al. 2009; Agrawal et  al. 2010; Rydell et  al.
and cadmium). 2012; Weden and Miles 2012; Stroud et al. 2014; Shenassa
A study using functional magnetic resonance et al. 2015). Wakschlag and colleagues (2010, 2011) sug-
imaging (fMRI) in older offspring exposed to tobacco gest that maternal smoking during pregnancy has a ter-
in utero assessed response to auditory and visual atten- atologic effect with abnormalities stemming from the in
tion tasks in adolescent smokers (Jacobsen et al. 2007a). utero environment which disrupt neural (Kandel et  al.
Teens whose mothers smoked during pregnancy exhibited 1994; Jacobsen et  al. 2006) and dopamine systems that
decreased accuracy in the tasks, with greater activation promote sensitivity to nicotine dependence (Kandel et al.
of both the temporal lobe and the occipital lobe, regions 1994; Selya et al. 2013). For example, nicotinic receptors
of the brain that are critical for auditory and visual pro- of laboratory animals exposed to nicotine in utero are
cessing. Additive effects of maternal cigarette use during upregulated, suggesting a latent vulnerability to nicotine
pregnancy and of adolescent smoking on activation of the dependence among animals exposed to nicotine in utero
temporal and occipital lobes also emerged, indicative of (Slotkin et al. 2006, 2015).

110   Chapter 3
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At issue with all human studies investigating et  al. 2012). In a large longitudinal study that spanned
maternal use of tobacco during pregnancy and offspring 40 years, Shenassa and colleagues (2015) found evidence
use of tobacco is isolating the independent effect on the to support effects on nicotine dependence among chil-
fetus in relation to the other social, environmental, and dren of mothers who smoked during pregnancy, but no
cognitive factors that also predict offspring tobacco use. effects on their progression to marijuana dependence
After controlling for maternal smoking during the off- were observed. A possible explanation for these discordant
spring’s childhood, several studies have reported that findings is suggested by a study that found significant
maternal smoking during pregnancy is associated with effects from prenatal smoking of conventional cigarettes
higher nicotine dependence in offspring (Kardia et  al. on drug use among adolescents, but showed that these
2003; Lieb et  al. 2003; Selya et  al. 2013; Shenassa et  al. effects were restricted to a genetic subpopulation of car-
2015), increased or earlier smoking initiation, and heavier riers of a specific α6 nAChR gene (rs2304297) polymor-
smoking among adolescent girls and adult offspring phism (Lotfipour et al. 2010). In sum, a number of studies
(Kandel et al. 1994; Cornelius et al. 2005). However, the have documented associations between cigarette use by
association was attenuated and nonsignificant among sev- the mother during pregnancy and smoking initiation,
eral studies that controlled for a variety of environmental, heavy use, and nicotine dependence among her children,
social, and cognitive confounders between maternal cig- although control of confounding reduces this associa-
arette use during pregnancy and initiation of offspring tion. In addition, the literature is sparse and inconsistent
smoking (but not nicotine dependence) (Cornelius et al. regarding a connection between maternal cigarette use
2005; Roberts et al. 2005; Munafo et al. 2006; Kandel et al. during pregnancy and the use of nontobacco substances
2007; D’Onofrio et al. 2012; Rydell et al. 2014; Taylor et al. by the child.
2014), leaving speculation for the independent effect. In A large body of literature has demonstrated effects
summary, evidence from animal models offers a biologic of maternal cigarette use during pregnancy on weight
mechanism for, and human evidence is suggestive of, an levels and obesity in childhood. For example, three meta-
association between maternal tobacco use during preg- analytic reviews found a 47–64% increased risk of obe-
nancy with offspring smoking and nicotine dependence, sity in children following exposure to maternal cigarette
but is insufficient to infer causation. Further research and smoking during pregnancy (Oken et  al. 2008; Ino 2010;
longitudinal studies that examine these outcomes while Weng et  al. 2012; Behl et  al. 2013). Additional system-
assessing the full spectrum of environmental, social, and atic reviews (Bruin et al. 2010) and other studies (Harrod
cognitive mediating pathways are needed to disentangle et al. 2015; La Merrill et al. 2015; Mourtakos et al. 2015;
these issues. Bao et  al. 2016) have all concluded that prenatal expo-
A smaller set of literature has documented associa- sure to nicotine likely acts as a developmental obesogen
tions between maternal cigarette smoking during preg- in humans. However, unmeasured residual confounding
nancy and use of other substances by the child (Fergusson or confounding by familial factors, which have not been
et al. 1998; Weissman et al. 1999; Porath and Fried 2005; fully explored, could attenuate the observed associations
Nomura et  al. 2011). In utero exposure to nicotine also (Gilman et  al. 2008; Iliadou et  al. 2010). Animal studies
affects behavioral responses for drug rewards in both ado- support the epidemiologic literature suggesting a poten-
lescent and adult experimental animals. Prenatal expo- tially causal relationship here by defining biologic path-
sure to nicotine increases the preference of adolescents ways (Wong et al. 2015). Fetal and neonatal exposure to
for a saccharin solution containing nicotine compared nicotine in rodents has resulted in neurochemical, neu-
with saccharin alone (Klein et al. 2003), and it results in robehavioral, and metabolic changes in the children that
self-administration of nicotine either during acquisition are consistent with obesity and type 2 diabetes (Williams
of the task (Chistyakov et al. 2010) or after forced absti- and Kanagasabai 1984; Newman et al. 1999; Grove et al.
nence (Levin et  al. 2006). Prenatal exposure to nicotine 2001; Chen and Kelly 2005; Gao et  al. 2005; Holloway
also increases subsequent oral intake of alcohol (Chang et al. 2005).
et  al. 2013), and intravenous self-administration of both In humans, studies involving structural MRI and
cocaine and methamphetamine is enhanced in a dose- fMRI have shown alterations in the size and sensitivity of
dependent manner in adolescent rats (Franke et al. 2008) brain reward centers in the teenage offspring of maternal
and adult rats (Lacy et al. 2014). smokers. Several of these studies revealed a thinning of
In contrast, in a study that used a discordant sib- the orbitofrontal cortex among persons who were prena-
ling pair design to reduce confounding by genetic and tally exposed to maternal cigarette smoking, a thinning
environmental factors, initial associations between pre- that was associated with drug use and experimentation
natal smoking and alcohol use disorder were attenuated during adolescence (Toro et  al. 2008; Lotfipour et  al.
and were no longer statistically significant (D’Onofrio 2009); decreased amygdalar volume, which is associated

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   111
A Report of the Surgeon General

with increased fat intake (Haghighi et  al. 2013); and Attention and Cognition. Numerous human
altered response to reward anticipation in the ventral stri- studies have investigated the effects of maternal cigarette
atum, an area associated with risk taking and drug use use during pregnancy on disruptive behavior and atten-
(Muller et al. 2013). In addition, highlighting the role of tion deficits in the child. The 2014 Surgeon General’s
altered nicotinic pathways in the disruption of neural cir- report included results of a systematic review of effects
cuits from prenatal tobacco exposure, changes in striatal of maternal cigarette use during pregnancy on disrup-
volume, and a propensity for drug use in adolescent off- tive-behavior disorders—including ADHD, conduct dis-
spring have been linked to interactions between prenatal order, and ODD—in offspring (USDHHS 2014). The
exposure to cigarette smoking and a polymorphism in evidence for effects of maternal cigarette use during
the gene encoding the α6 nAChR (Lotfipour et al. 2010). pregnancy on disruptive-behavior disorders, and ADHD
Structural alterations in the orbital frontal cortex have in particular, was suggestive but not sufficient to infer
also been shown to result from interactions between a causal relationship. Several systematic reviews using
maternal cigarette smoking during pregnancy and poly- meta-analyses have found evidence for associations
morphisms of brain-derived neurotrophic factor, a growth between exposure to maternal cigarette use during preg-
factor that regulates growth and differentiation of new nancy and ADHD in offspring, including dose–response
neurons and supports existing neurons (Lotfipour et  al. relationships between number of cigarettes smoked per
2009). Although these clinical findings are specific to con- day and ADHD symptoms (Linnet et  al. 2003; Langley
ventional cigarettes, they converge with results of animal et  al. 2005; Latimer et  al. 2012; Massey et  al. 2016).
studies of the effects of prenatal nicotine on brain reward However, similar to effects on nicotine dependence and
centers and thus highlight the potential pernicious effects obesity in offspring, the possibility of unmeasured con-
of e‑cigarettes in pregnant women. founding remains (D’Onofrio et  al. 2008; Thapar et  al.
Animal studies have shown that the dopamine 2009; Langley et  al. 2012). Evidence for associations
system, which is critically involved in satisfaction-seeking with maternal cigarette use during pregnancy is perhaps
or appetitive behaviors, is modulated by nAChRs from the more consistent for offspring conduct disorders than it
fetal period to adulthood (Azam et al. 2007). Prenatal nico- is for ADHD. In particular, although some studies that
tine exposure alters dopamine’s content, turnover, release, used a gene–environment interaction design or a pro-
and receptor expression in forebrain regions, which are pensity score-matching approach to exposure to control
important for motor and cognitive functions (Navarro for confounding, they found no effect of maternal cig-
et  al. 1988; Richardson and Tizabi 1994; Muneoka et  al. arette smoking during pregnancy on conduct disorders
1999; Zhu et al. 2012) and for assigning motivational value (D’Onofrio et al. 2008; Gilman et al. 2008; Boutwell and
to natural and drug rewards (Kohlmeier 2015; McNair and Beaver 2010; Lavigne et al. 2011). However, several other
Kohlmeier 2015). Prenatal exposure to nicotine also mod- studies—including a meta-analytic review across three
ifies the structure of dendritic targets of dopamine inner- studies using “genetically sensitive”2 research designs—
vations in the nucleus accumbens (a critical component have suggested a direct causal relationship between
of reward learning and addiction) (Mychasiuk et al. 2013) maternal smoking during pregnancy and conduct disor-
and alters neuronal signaling that affects dopamine func- ders in offspring (McCrory and Layte 2012; Gaysina et al.
tion (Chang et al. 2013; Morgan et al. 2013). 2013; Kuja-Halkola et  al. 2014; Estabrook et  al. 2015;
Prenatal exposure to nicotine has been shown in Paus and Pausova 2015).
a variety of animal studies to induce complex effects on To explore the potential role of nicotine exposure in
behavioral response to natural rewards. Although adoles- these associations, a small number of studies have included
cent offspring of nicotine-exposed mothers show an ini- a prospective measure of confirmed tobacco exposure,
tial decrease in motivation to work for sucrose reward maternal cotinine levels, in addition to maternal report
(Franke et al. 2008), they exhibit enhanced sensitivity to of smoking, to study relationships with disruptive behav-
the rewarding effects as the task becomes harder (Lacy iors among offspring (Wakschlag et al. 2011; O’Brien et al.
et  al. 2012). Prenatal exposure to nicotine also results 2013; Massey et al. 2016). Wakschlag and colleagues (2011)
in enhanced intake of fatty foods, with no change in the found associations between maternal cigarette smoking
intake of normal chow (Chang et al. 2013). and aggression and noncompliance among offspring.
Studies have also shown alterations in the structure and

2Genetically sensitive designs typically include monozygotic and dizygotic twins and a broader inclusion of sibling pairs, mother–child
pairs, and grandparent–grandchild pairs. Genetically sensitive multigroup designs allow for simultaneous testing of additive and nonad-
ditive genetic, common, and specific environmental effects, including cultural transmission and twin-specific environmental influences.

112   Chapter 3
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function of the orbital frontal cortex, a  region impor- in behavioral impairments in attentional function and
tant for emotional regulation and cognition, in relation behavioral flexibility in adulthood (Aoyama et  al. 2016;
to maternal cigarette smoking during pregnancy (Toro Poon and Leibowitz 2016; Powell et al. 2016).
et al. 2008; Bennett et al. 2009). Consistent with animal
models of altered dopamine regulation, two studies have Summary
shown interactions of maternal cigarette smoking during
Because of the rising prevalence of e-cigarette use,
pregnancy with dopamine regulation genotype (DAT1) in
there is potential for widespread nicotine exposure to
influencing disruptive-behavior phenotypes in offspring
youth and young adults, resulting in nicotine addiction
(Wakschlag et  al. 2011; O’Brien et  al. 2013). In another
and related harmful consequences associated with expo-
study, Wakschlag and colleagues (2010) demonstrated a
sure to nicotine. During pregnancy, there is neural sensi-
sex-dependent interaction of maternal smoking during
tivity to the number and volume of substances, including
pregnancy with monoamine oxidase A (MAOA) geno-
nicotine, transported through the placenta. From pre-
type, which is associated with the development of anti-
natal development through adolescence and early adult-
social behavior. In this study, maternal smoking during
hood, exposure to nicotine poses a serious threat, because
pregnancy further increased the risk for conduct disorder.
these are critical times for brain development and brain
In sum, although issues of confounding remain, much
plasticity. Furthermore, youth and young adults are more
evidence from human studies is suggestive of a causal
vulnerable than adults to the long-term consequences
association between maternal cigarette smoking during
of nicotine exposure, including susceptibility to nicotine
pregnancy and disruptive behaviors among offspring.
addiction and potentially reduced impulse control, deficits
This was confirmed by the 2014 Surgeon General’s report
in attention and cognition, and mood disorders. An addi-
on tobacco (USDHHS 2014). Since then, newer studies,
tional public health concern is exposure to e-cigarettes
controlling for personal and genetic confounders, have
among persons who have never used conventional tobacco
reported significant associations as well as nonsignificant,
products. If the prevalence of e-cigarette use continues to
attenuated associations. Biologic evidence of nicotine-
rise among those who do not use conventional tobacco
induced alterations in dopamine regulation also provides
products, the harmful consequences of exposure to nico-
a possible mechanism for the role of nicotine in these
tine will rise accordingly.
outcomes.
The 2014 Surgeon General’s report (USDHHS 2014)
Animal studies have shown that cholinergic modu-
states there is sufficient evidence to infer that: (a) nicotine
lation of prefrontal cortex function, via nAChRs, is essen-
activates multiple biological pathways through which
tial for attention and cognition (Poorthuis and Mansvelder
smoking increases risk for disease; (b) nicotine expo-
2013; Proulx et  al. 2014). Prenatal exposure to nicotine
sure during fetal development, a critical window for brain
alters the morphology and nAChR functional response of
development, has lasting adverse consequences for brain
prefrontal cortical neurons (Mychasiuk et al. 2013; Bailey
development; (c) nicotine adversely affects maternal and
et al. 2014). When tested as adolescents, animals that were
fetal health during pregnancy, contributing to multiple
exposed prenatally to nicotine show some behaviors char-
adverse outcomes such as preterm delivery and stillbirth;
acteristic of ADHD. For example, exposed offspring were
and (d) nicotine exposure during adolescence, a critical
found in two studies to show less impulse control and/or
window for brain development, may have lasting adverse
slower learning acquisition on two cognitive tests that tax
consequences for brain development and cognition. The
attentional processes (Sorenson et  al. 1991; Schneider
literature presented in this section attempts to differen-
et al. 2012). In addition, some studies have found hyper-
tiate the risks to fetal and child health associated with nic-
activity in exposed offspring (Pauly et al. 2004; Schneider
otine in tobacco versus nicotine alone or in e-cigarettes.
et al. 2012; Zhu et al. 2012), which was found in another
Evidence is sufficient to conclude tobacco use increases
study to be transmitted via maternal lineage from one
the risk of SIDS (USDHHS 2014), but further research
generation to the next and to be ameliorated by methyl-
is necessary with regard to nicotine alone or nicotine in
phenidate treatment across all generations, showcasing
e-cigarettes. The review finds evidence that tobacco is
the long-term impact of prenatal nicotine exposure (Zhu
associated with structural brain changes and alterations
et al. 2014a). This transgenerational transmission of pre-
in cognition, attention, and appetitive behaviors in human
natal nicotine-induced hyperactivity must reflect long-
offspring. Less well known is the role that nicotine plays
term changes to the epigenome (Leslie 2013). Finally,
in mediating these associations, although animal models
emerging animal studies suggest that prenatal exposure
provide support for a role for nicotine in these outcomes.
to nicotine affects the proliferation and maturation of
nAChRs, the chief receptor targets for nicotine, are widely
progenitor cells to glutamatergic neurons during neu-
expressed in the fetal brain, and their normal functioning
rodevelopment in the medial prefrontal cortex, resulting

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   113
A Report of the Surgeon General

is negatively affected by smoking and, in animals, by pre- chemicals were almost exclusively liquids or creams, or
natal exposure to nicotine through experimental treat- the substance was contained in a matrix. Animal models
ment. Furthermore, both human genetic studies and have shown few toxicological effects resulting from nose-
animal studies implicate a neurotoxic effect of fetal nic- only exposure to VG aerosol, with the exception of min-
otine exposure. Pregnant women and women intending imal or mild squamous metaplasia in rats exposed to the
to become pregnant should be cautioned against using highest concentration (0.662 mg glycerol) for 13 weeks
e-cigarettes to avoid unnecessary nicotine exposure to (Anderson et  al. 1950; Renne et  al. 1992). Other inhala-
their baby. tion studies testing PG in rats and monkeys did not observe
treatment-related effects on respiratory physiology, clin-
ical chemistry, hematology, gross pathology, or respiratory
Effects of the Inhalation of Aerosol tract histology (Robertson et  al. 1947). However, neither
of these studies examined potential inhalation toxicity of
Constituents Other than Nicotine PG and VG in humans using e‑cigarette devices. In sum-
mary, other than nicotine, very little is known from human
The scientific literature on the health effects of expo- studies about the long-term health effects of inhaling PG
sure to constituents other than nicotine in the e-cigarette and VG from e‑cigarette aerosol, although adverse effects
aerosol is still developing. One study found that after have been detected in animal models. Further investigation
5 minutes of ad lib e-cigarette use, healthy adult cigarette would improve our understanding of the effects of nicotine-
smokers showed an increase in airway resistance, but related compounds, aerosolized solvents (PG and VG), aero-
no effect on other spirometry parameters such as forced solized flavorants, aerosolized adulterants in e-liquids, and
vital capacity (FVC), forced expiratory volume in 1 second toxicants produced during the aerosolization process—or a
FEV1, and ratios of these values (FEV1/FVC) (Vardavas combination of these chemicals.
et al. 2012).
A noninvasive marker of airway inflammation is Aerosolized Nicotine-Related Compounds
the fraction of exhaled nitric oxide (FeNO) (Taylor et  al.
2006; Munakata 2012). NO is a gaseous molecule that pro- The nicotine used in e-liquids is extracted from
duces vasodilation and bronchodilation (decreasing resis- tobacco. The extraction process may produce some poten-
tance in the respiratory airway and increasing airflow to tially harmful tobacco-specific impurities, including
the lungs). FeNO is reduced by acute and chronic ciga- minor alkaloids like nornicotine, anatabine, anabasine,
rette smoking (resulting in poorer vasodilation and bron- myosmine, cotinine, nicotine-N-oxides (cis and trans iso-
chodilation) and is increased among smokers following mers), β-nicotyrine, and β-nornicotyrine (Etter et al. 2013;
cessation (see Vleeming et al. 2002 for a review). Studies Farsalinos et al. 2015a; Lisko et al. 2015; Oh and Shin 2015).
examining current adult cigarette smokers revealed a The correlation between nicotine and the concentrations of
reduction in FeNO after use of an e‑cigarette with and minor alkaloids is much stronger in conventional tobacco
without nicotine (Vardavas et al. 2012; Marini et al. 2014; products (Jacob et al. 1999) than in e‑cigarettes (Lisko et al.
Ferrari et al. 2015). One study found that these reductions 2015). While the cause of these differing concentrations of
did not differ significantly between e‑cigarettes containing minor alkaloids is unknown, Lisko and colleagues (2015)
nicotine and those without nicotine (Marini et al. 2014), speculated potential reasons may derive from the e-liquid
suggesting non-nicotine factors mediated the effect. extraction process (i.e.,  purification and manufacturing)
However, a study of occasional smokers (<10 cig- used to obtain nicotine from tobacco, as well as poor quality
arettes per week), but non-e‑cigarette users, found an control of e-liquid products.
increase in FeNO after use of an e‑cigarette containing The American E-Liquid Manufacturing Standards
nicotine (Schober et  al. 2014). Furthermore, this study Association (2014), an industry group with no regula-
found no statistical difference in FeNO after use of an tory authority, has called for the use of U.S. Pharmacopeia
e‑cigarette not containing nicotine. This variation in (USP)-grade nicotine in its e‑cigarette products. USP
findings suggests the impact of e‑cigarette use on FeNO specifications for nicotine allow for a maximum of
may vary based on smoking history, nicotine content of 0.5% (5 mg/g) of a single impurity and 1% (10 mg/g) of
e-liquid, or other environmental or biological factors. total impurities (U.S. Pharmacopeia n.d.). Although the
Limited studies have examined chronic exposure health implications of nicotine-related impurities are not
on the potential inhalation toxicity of PG and VG. Prior known, toxicology studies are needed to demonstrate the
to e‑cigarettes, consumer products containing these effects of high levels of these products.

114   Chapter 3
E-Cigarette Use Among Youth and Young Adults

Aerosolized Solvents 2-second puff, an estimated 30% of the daily doses of par-
ticles for a nonsmoking person. After 10 puffs, the relevant
Although e‑cigarettes produce PG aerosols at levels
mean-layer thickness of the e-liquid on the lung epithe-
known to cause eye and respiratory irritation to both
lium was comparable to the thickness of surfactant layer
users and nonusers (Offermann 2015), only mild effects
covering the alveolar and bronchial regions, suggesting
(e.g., upper respiratory irritation) have been described
a higher susceptibility to irritant endpoints (Manigrasso
in humans exposed to PG mist for 1 minute (Wieslander
et  al. 2015). These results demonstrate that e‑cigarettes
et al. 2001), and little is known about long-term effects.
produce submicron-sized particles and highly oxidizing
Inhaling PG can increase the risk of developing asthma
free radicals that may present a potential toxicologic risk
(Choi et al. 2010). Animal studies of PG and VG aerosol-
to e‑cigarette users.
izing agents not produced by e‑cigarettes concluded that
these substances are relatively safe when inhaled by ani-
Aerosolized Flavorants
mals for up to 28 days (Werley et al. 2011) or 18 months
(Robertson et al. 1947). Little is known about the flavorants used in
Particles emitted from e‑cigarettes are assumed e‑cigarettes, and more than 7,700 unique flavors are on
to be formed from supersaturated PG (i.e., concentra- the market (Zhu et al. 2014b). Flavored e‑cigarette prod-
tion beyond the point of saturation) in e-liquids (Schripp ucts are popular with adult users, and sweet and candy-
et al. 2013). Several studies designed to characterize the like flavors may make these products attractive to children
aerosol generated by e‑cigarettes examined the chemical and adolescents (Villanti et  al. 2013; Farley et  al. 2014;
composition of the particles and their concentrations as King et al. 2014). Many of the chemicals used in e-liquid
measured by their number and distribution by size (Trehy flavorings are “generally recognized as safe” for ingesting
et al. 2011; Ingebrethsen et al. 2012; Schripp et al. 2013; (e.g.,  in food). However, these substances have not been
Zhang et al. 2013; Fuoco et al. 2014; Ruprecht et al. 2014; tested adequately for safety when heated at various tem-
Saffari et  al. 2014 ; Mikheev et al. 2016). E‑cigarettes peratures when inhaled in aerosolized form (Barrington-
are recognized as a new source of submicron-sized par- Trimis et al. 2014). The Flavor and Extract Manufacturers
ticles, leading to possible high exposure to these parti- Association of the United States (2015), in an official state-
cles in users. Concentrations in the range of 109 particles ment, notes that ingredients in flavors are evaluated for
× cm-3 were measured in the mainstream of e‑cigarette exposure through ingestion only; thus, any results cannot
aerosols (Fuoco et al. 2014). An in vitro study by Zhang be extrapolated to use through inhalation. Further, fla-
and colleagues (2013) found that under the conditions voring compounds often remain undeclared on e‑cigarette
of a single-puff experiment, an e‑cigarette generated an and e-liquid packaging (Tierney et al. 2016).
aerosol having particle sizes in the range of 100–600 nm CDC tested 36 e‑cigarette products for 10 flavor
(nanometers), similar to that of conventional cigarettes. compounds commonly used as additives in tobacco prod-
Mikheev and colleagues (2016) reported that the size dis- ucts (Lisko et al. 2015). Measurable levels of eucalyptol and
tribution of e-cigarette aerosol differs from that of com- pulegone were found in the menthol-flavored varieties for
bustible tobacco smoke and that e-cigarettes normally all manufacturers. Menthol concentrations ranged from
exhibit a bimodal particle size distribution: nanoparti- 3,700 to 12,000 μg/g in flavored e-liquids, levels similar
cles (11–25 nm count median diameter) and submicron to those found in the filler of conventional cigarettes.
particles (96–175 nm count median diameter). Each Interestingly, menthol was found at low concentrations in
mode has comparable number concentrations (107–108 40% of the tobacco-flavored nonmenthol products tested.
particles/cm3). Goel and colleagues (2015) detected radi- Other flavor compounds found were camphor, methyl,
cals in aerosols from all e‑cigarettes and e-liquids tested salicylate, pulegone, cinnamaldehyde (CAD), and eugenol
(2.5−10.3 x1013 radicals per puff at 3.3 V [voltage]), from (Lisko et al. 2015).
e-liquid solvents PG and VG, and from “dry puffing” (over- Tierney and colleagues (2016) analyzed 30 e‑cigarette
heating of e-liquid) (Farsalinos et al. 2015c). products on the U.S. market and found 13 products con-
Because the aerosols deriving from e-liquids are tained more than 1% flavor chemicals by weight. Among
mainly made of droplets that are expected to dissolve as the chemicals identified were aldehydes (e.g., benzalde-
they reach the lung’s epithelium, not only the number but hyde and vanillin), which are categorized as primary irri-
also the volume (size) of particles needs to be considered. tants of the respiratory tract (Roberts et al. 2015). Tierney
Manigrasso and colleagues (2015) found that e‑cigarettes and colleagues (2016) also found that tobacco-flavored
are a source of extremely high doses of particles in the e-liquids were derived from confection-flavored chemicals
human respiratory system. On average, 6.25 ×1010 par- (e.g., bubble gum and cotton candy flavoring) rather than
ticles were deposited in the respiratory tree after a single tobacco extract.

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   115
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Some chemicals in e‑cigarettes, although approved The analysis by Farsalinos and colleagues (2014a)
for ingestion, have established adverse health effects when found that 74.2% of the sample contained one or both
inhaled. In vitro studies of cytotoxicity suggest that dif- of these chemicals, with 69.2% of the sample containing
ferent flavored e‑cigarette products may vary in their DA. Both DA and AP were found in 28.3% of the sample
potential to adversely affect health. Bahl and colleagues e-liquids. These chemicals were detected even in samples
(2012) reported cytotoxic effects of the solutions used in coming from manufacturers that stated these flavorings
e‑cigarettes that were not attributable to the nicotine but were not present in their products. However, exposure
to the concentration of chemicals employed as flavors. to DA and AP was 100 and 10 times lower, respectively,
These effects were most pronounced on mouse neural than exposure to these chemicals from cigarette smoking.
stem cells and human embryonic stem cells compared to Few studies have examined safe levels of DA and AP via
human pulmonary fibroblast (Bahl et al. 2012). tobacco product; however, 47.3% of DA- and 41.5%  of
Similar findings were reported by Behar and col- AP-containing samples exposed consumers to levels higher
leagues (2014) who found a greater cytotoxic effect than the safety limits outlined by the National Institute
of flavored e-liquid solutions on human embryonic for Occupational Safety (NIOSH) for occupational expo-
stem cells compared to human pulmonary fibroblast. sure. This exposure threshold outlined by NIOSH is not
Further, two  cinnamon-related chemicals, CAD and intended to suggest exposure at or below that limit should
2-methoxycinnamaldehyde, were particularly cytotoxic at be considered sufficiently safe (Hubbs et al. 2015).
doses found in the refill liquids (Behar et al. 2014). CAD,
which is derived from the essential oil of cinnamon bark, is Aerosolized Adulterants
a highly bioactive compound (Jayaprakasha and Rao 2011).
TSNAs, potent carcinogens identified in tobacco
It has been used as an anticancer agent (Nagle et al. 2012),
and tobacco smoke, include N-nitrosonornicotine (NNN),
an insecticide (Cheng et al. 2009), and a bactericide (Nostro
4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK),
et al. 2012), and it is employed commercially as an additive
N-nitrosoanabasine (NAB), and N-nitrosoanatabine
in many foods and fragrances (Cocchiara et al. 2005).
(NAT) (Hecht 1998, 1999; USDHHS 2010, 2014). NNN
Farsalinos and colleagues (2014a) analyzed
and NNK are classified by the International Agency for
159 e-liquids obtained from a variety of manufacturers and
Research on Cancer (IARC) as Group 1 human carcino-
retailers in Europe and the United States for the presence
gens (IARC 2004). Their presence in e-liquids is mostly
of two flavorings: diacetyl (DA) and acetyl propionyl (AP).
attributable to the processes used in extracting nicotine
The study revealed that these substances were present in
from tobacco leaves or the addition of tobacco flavorings
the majority of the samples tested, with a significant pro-
(Kim and Shin 2013; Cheng 2014). These compounds are
portion containing both chemicals. Furthermore, Allen and
formed from their alkaloid precursors and from nitrite or
colleagues (2016) detected DA above the laboratory limit
nitrate, predominantly during tobacco curing, fermen-
of detection in 39 of 51 flavors tested. DA, also known as
tation, and aging. NNN, NAB, and NAT are formed pri-
2, 3-butanedione, is a member of a general class of organic
marily from their corresponding secondary amines (nor-
compounds referred to as diketones, α-diketones, or
nicotine, anatabine, and anabasine) in the early stages of
α-dicarbonyls. It provides a characteristic buttery flavor,
tobacco curing and processing, while the majority of NNK
is naturally found in various foods, and is used as a syn-
is formed from the tertiary amine nicotine at the later
thetic flavoring agent in food products such as butter, car-
stages of tobacco curing and fermentation (Hecht 1998).
amel, cocoa, coffee, dairy products, and alcoholic beverages.
Nitrosation reactions of corresponding amines can occur
Although it is generally recognized as safe when ingested,
in e-liquids, especially during inadequate storage or man-
it has been associated with a decline in respiratory func-
ufacturing processes; inadequate storage is believed to
tion in persons exposed to it through inhalation (Egilman
increase the levels of NNN as a consequence of the nitro-
et al. 2011; Clark and Winter 2015). Inhaling DA and arti-
sation of nornicotine converted from nicotine in liquids
ficial butter-flavored powders and aerosols can cause fixed
(Kim and Shin 2013).
obstructive lung disease in exposed workers (Chaisson et al.
Some studies have identified traces of TSNAs in
2010). In addition, it has been implicated in the develop-
e-liquids, but at levels far below those seen in combustible
ment of bronchiolitis obliterans, an irreversible respiratory
tobacco (Trehy et al. 2011; Farsalinos et al. 2015a). Further,
disease also called “popcorn lung disease” (Harber et  al.
Goniewicz and colleagues (2014b) found that the aerosol of
2006). AP, also called 2, 3-pentanedione, is a α-diketone
some e‑cigarettes contains traces of the carcinogenic nitro-
that is chemically and structurally similar to DA. Although
samines NNN and NNK, but neither was detected in aerosol
it has become a popular replacement for DA, acute inhala-
from the Nicorette inhalator (an NRT product).
tion exposure to AP has been shown to cause airway epithe-
lial damage similar to DA (Hubbs et al. 2012).

116   Chapter 3
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Several studies have reported the presence of other irritant, and a probable carcinogen (USDHHS 1999).
hazardous compounds in e-liquids or in the aerosol pro- Acrolein is toxic through all routes of administration and
duced by e‑cigarettes (Exponent Inc. 2009; Hadwiger et al. may cause respiratory and ocular irritation (Faroon et al.
2010; Lim and Shin 2013; Uchiyama et al. 2013; Williams 2008; Bein and Leikauf 2011). Acrolein in cigarette smoke
et  al. 2013; Bekki et  al. 2014; Goniewicz et  al. 2014a,b; has been linked to several pulmonary diseases, including
Kosmider et al. 2014; Jensen et al. 2015; Kavvalakis et al. increased risk of lung cancer (Feng et al. 2006), as well
2015; Laugesen 2015; Oh and Shin 2015; Varlet et al. 2015; as asthma and chronic obstructive pulmonary disease
Khlystov and Samburova 2016). For example, an FDA study (Bein and Leikauf 2011). One study found an association
detected the presence of amino-tadalafil and rimonabant in between acrolein exposure and risk of cardiovascular dis-
e-liquids (Hadwiger et al. 2010); amino-tadalafil is a struc- ease (DeJarnett et al. 2014).
tural analogue of tadalafil, the active pharmaceutical ingre- Lim and Shin (2013) detected formaldehyde and
dient in Cialis, a prescription drug approved in the United acetaldehyde in 225 replacement liquids for e‑cigarettes
States for treatment of erectile dysfunction. Rimonabant purchased in Korea, with ranges of 0.02–10.09 mg/L (mean
(trade name Zimulti) was approved in Europe for the treat- 2.16 mg/L) and 0.10–15.63 mg/L (mean = 4.98 mg/L).
ment of obesity, but its marketing authorization was with- Although the amounts of formaldehyde and acetalde-
drawn by the European Medicines Agency in 2009. FDA hyde detected in replacement liquids for e‑cigarettes are
approval of this drug has been withheld because of unre- relatively low compared to conventional cigarettes, they
solved issues involving rimonabant therapy and increased should be controlled to the lowest possible concentrations
frequencies of psychiatric adverse events, including suicide in raw materials, as they may be formed when e-liquids
and an ill-defined constellation of neurologic symptoms are heated. Furthermore, as larger capacity batteries
and seizures (FDA 2007). The presence of unapproved active and heating mechanisms are developed (Farsalinos et al.
pharmaceutical ingredients suggests that some e‑cigarettes 2014b; Sleiman et al. 2016), users will be exposed to higher
may expose users to pharmacologically active substances concentrations of formaldehyde, acetaldehyde, acro-
with undocumented and unknown effects. lein, and other carbonyls (Kosmider et al. 2014). Jensen
Oh and Shin (2015) conducted a study to identify and colleagues (2015) reported formaldehyde concentra-
and quantify the presence of diethyl phthalate (DEP) and tions higher than conventional cigarettes in high-voltage
diethylhexyl phthalate (DEHP) in e-liquids. DEP is used e-cigarettes. Havel and colleagues (2016) reported acetal-
as a solvent to bind cosmetics and fragrances and in var- dehyde, acrolein, and formaldehyde generation increased
ious industrial applications, including plasticizers, deter- markedly at voltages at or above 5 volts. Geiss and col-
gent bases, and aerosol sprays. DEHP is used widely as a leagues (2016) reported that formaldehyde exceeded safety
plasticizer in the manufacture of articles made of poly- levels at the lowest wattage (5 watts), which is the wattage
vinylchloride. DEP and DEHP were detected in 47.6% and applied in most second generation e-cigarettes.
79.1% of e-liquids, respectively, with concentration
ranges of 0.01–1745.20 mg/L and 0.06–81.89 mg/L (Oh Summary
and Shin 2015). Both DEP and DEHP have estrogenic
Although some typical constituents of the e-cigarette
and antiandrogenic activity that cause premature breast
aerosol have been identified, the potential short- and long-
development in girls. DEHP is classified by IARC as a pos-
term health consequences of inhalation of the heated and
sible carcinogen in humans (IARC 2000). Although the
aerosolized constituents of the e-liquids, including solvents,
amounts of the two phthalates detected in this study were
flavorants, and toxicants, still require further investigation
lower than the safety levels, the source of these toxicants
to quantify health effects. Commercial and custom-mixed
is unknown, perhaps coming from packaging materials
e-liquids are produced with undisclosed manufacturing
and the production procedure.
procedures, packaging materials, and purity standards for
Carbonyls are present in e‑cigarettes, and levels
their constituents, increasing the risks of potential health
increase with device voltage (Kosmider et  al. 2014;
consequences. E-cigarettes are a source of extremely high
Jensen et al. 2015). Long-term exposure to carbonyl
doses of fine particles (e.g., aerosol) in the human respira-
compounds, such as formaldehyde, acetaldehyde, and
tory system. Fine particles are emitted when the solvents
acrolein, increases the risk of cancer. IARC and the U.S.
PG and VG are aerosolized, and mild respiratory effects have
Environmental Protection Agency (EPA) have classified
been documented, but adequate assessments are lacking.
formaldehyde as “carcinogenic to humans” (USDHHS
An additional concern is the aerosolization and inhalation
1999; IARC 2009). EPA has set the acceptable daily intake
of flavor additives in e-liquids. While some of the chemicals
(ADI) of formaldehyde as 0.2 mg/kg (kilograms) body
used may be generally recognized as safe for use in foods,
weight and has warned of the potential adverse health
they have not been thoroughly tested for their potential
effects of exceeding ADI. Acetaldehyde is also toxic, an

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   117
A Report of the Surgeon General

sensitizing, toxic, or irritating characteristics when inhaled. smoke from conventional cigarettes: glyoxal and methyl-
Further, given the extent of possible variations in the ratio glyoxal. Jensen and colleagues (2015) observed that form-
of flavor additives, with up to 7,700 unique e-liquid vari- aldehyde-containing hemiacetals can be formed during
eties available (Zhu et al. 2014b), these chemicals may be the aerosolization process. These molecules are known to
toxic in the concentrations present in manufactured or release formaldehyde and are used as industrial biocides,
do-it-yourself e-liquids. Finally, other hazardous com- but it is not currently known how formaldehyde-releasing
pounds and carcinogens have been detected in e-liquids, or agents affect the respiratory tract.
in the heated aerosol produced by e-cigarettes, including The amount of carbonyl compounds in e‑cigarette
formaldehyde, acetaldehyde, and acrolein. aerosols varies substantially, not only among different
brands but also among different samples of the same prod-
ucts (Ohta et al. 2011; Bekki et al. 2014; Kosmider et al.
Effects of Toxicants Produced 2014; Jensen et al. 2015), from 100-fold less than tobacco
to nearly equivalent values. Notably, the amount of voltage
During Aerosolization the battery puts out affects the concentration of the car-
bonyl compounds in the emission. Some e‑cigarettes allow
A primary reason for investigating the health effects users to increase aerosol production and nicotine delivery
of heated and aerosolized e-liquids is that, under such con- by raising the battery’s output voltage. In addition, some
ditions, chemical reactions may result in the formation of users elect to directly drip e-liquid onto an exposed heater
new compounds (Sleiman et al. 2016). In some devices, coil, reportedly for greater aerosol production and “throat
the temperature in the center of a heating coil can exceed hit.” Talih and colleagues (2015) showed that use of such
350°C, causing changes in the chemical components of direct-drip atomizers may involve greater exposure to
the e-liquid. When carbonyl compounds are present in the toxic carbonyls, including formaldehyde, because of the
refill liquids, heating can enhance their concentrations in potentially higher temperatures reached by the coil. The
the aerosol (Talih et al. 2015). Carbonyl compounds result adverse effects of acrolein (2-propenal), an unsaturated
from dehydration and fragmentation of VG and PG, which aldehyde, depend on dose and cell type and are influenced
can be oxidized to formaldehyde and acetaldehyde during by experimental conditions (Bein and Leikauf 2011). In
heating. Hutzler and colleagues (2014) applied headspace vitro studies found that acrolein inhibits DNA repair and
gas chromatography-mass spectrometry to enable incuba- forms acrolein-deoxyguanosine DNA adducts that are
tion of liquids at various temperatures. At 150°C, the levels mutagenic (Wang et  al. 2009, 2012; Tang et  al. 2011).
of acetaldehyde and formaldehyde were found to be up to Despite the known DNA-damaging effects of acrolein, its
10-fold higher than they were at ambient temperatures for mutagenicity in mammalian cells remains uncertain, and
samples in which PG was a main component. The gen- according to an evaluation by the IARC, there is inade-
eration of carbonyl compounds seems to increase when quate evidence for carcinogenicity in humans or animals
liquids touch the heating element inside an e‑cigarette, (IARC 1995). Because of its extreme toxicity, acrolein has
which is indicated by a color change around the wire, as been difficult to characterize in standard animal carcino-
has been reported in some devices (Uchiyama et al. 2013). genicity tests. Animal experiments showed that acrolein
Evidence suggests when e-liquid touches the heating ele- can have a range of adverse effects, including a role in car-
ment (heated nichrome wire), it is oxidized to formalde- cinogenesis (Cohen et al. 1992); excessive mucus produc-
hyde, acetaldehyde, acrolein, glyoxal, and methylglyoxal tion and macrophage and neutrophil accumulation with
in the presence of oxygen (Bekki et  al. 2014; Goniewicz consequent production of proinflammatory cytokines and
et al. 2014b; Kosmider et al. 2014). proteases (Moretto et  al. 2012); damage to neurons and
Several studies have reported that short-chain alde- myelin disruption (Shi et al. 2011); and it may play a role
hydes, such as formaldehyde, acetaldehyde, or acrolein, are in the progression of atherosclerosis and cardiovascular
produced during heating. Uchiyama and colleagues (2013) disease (Park and Taniguchi 2008; DeJarnett et al. 2014).
measured carbonyl compounds in e‑cigarette aerosols Other volatile organic compounds (VOCs) found
generated according to the Canadian “intense regimen” in e‑cigarette aerosol include a variety of chemicals
(55mL puff volume, 2-second puff duration, 30  seconds (e.g., aliphatic and aromatic hydrocarbons), some of
between puffs, and a total of 10 puffs). Thirteen brands of which may have short- or long-term adverse health
e‑cigarettes were assessed, and investigators detected sev- effects. Benzene (classified as group 1 by IARC) and other
eral carbonyl compounds, such as formaldehyde, acetal- solvents (toluene, xylenes, and styrene) could be present
dehyde, acetone, acrolein, propanol, crotonaldehyde, and in e‑cigarettes because of their use in the extraction of
butanol. They also detected two other harmful carbonyl nicotine from tobacco leaves. Goniewicz and colleagues
compounds that had not been detected in the mainstream (2014b) detected both toluene and m- and p-xylene in

118   Chapter 3
E-Cigarette Use Among Youth and Young Adults

e‑cigarette aerosols. A wide variety of other VOCs in aerosol given the diversity of products currently available,
e‑cigarette liquids produce aromas and flavor through as well as those that may become available as the devices
heating (Tierney et al. 2016). continue to evolve (Farsalinos et al. 2014b).
Heavy metals such as tin, lead, and nickel were dis-
covered by Williams and colleagues (2013) in a brand of
e-liquids and the resulting aerosols. Those researchers Effects Not Involving Inhalation of
analyzed the contents of e‑cigarette cartomizers (a poly-
fill wrapped heating coil capable of longer puff durations Aerosol by the E‑Cigarette User
than an atomizer) and the aerosols by using light and elec-
tron microscopy, x-ray microanalysis, particle counting, Health effects not attributable to direct inhalation
and inductively coupled plasma optical emission spec- of e‑cigarette aerosol include explosion or fire associ-
trometry. The aerosol contained particles >1 µm that were ated with malfunctioned devices, poisoning through con-
composed of tin, silver, iron, nickel, aluminum, and sili- tact exposure or intentional or unintentional ingestion
cate, and nanoparticles (<100 nm) of tin, chromium, and of e-liquid, and exposure to secondhand aerosol or its
nickel. Small particles composed of various elements (tin, condensate.
other metals, semimetals, and silicates) passed through
the cartomizer fibers and were present in aerosols. Health Effects Attributable to Explosions and
These particles likely originated from parts of the device Fires Caused by E‑Cigarettes
(i.e., atomizer/cartomizer) (Williams et al. 2013). Most reports of explosions and fires caused by
Concentrations of 9 of the 11 elements in e‑cigarette e‑cigarettes have appeared in print and online media and
aerosol identified by Williams and colleagues (2013) on televised programs. From August 2009 to March 2014, a
were higher than or equal to concentrations in conven- search of U.S. media by the U.S. Fire Administration (2014)
tional cigarette smoke. Many of the metals identified in found 25 reports of e‑cigarette explosions or fires. These
e‑cigarette aerosol, such as lead and cadmium (Farsalinos data suggest that the number of such events is small when
et al. 2015b), are known to cause respiratory distress and compared with the number of e‑cigarette users. Of the
disease (Zalups and Ahmad 2003). These metals are pro- 25  incidents found in the search, 2 caused serious harm,
duced by the aerosolization of e-liquids (Farsalinos et al. and there were no deaths attributable to explosions. In most
2015b) and by flaws in e‑cigarette heating mechanisms cases, the resulting fires did not spread far from the site of
and poor quality control (Williams et al. 2013; Farsalinos the explosion. However, in one case an entire bedroom was
et al. 2015b; Mikheev et al. 2016). While these initial anal- lost to fire (U.S. Fire Administration 2014). As for explo-
yses indicate potential exposures, additional measures are sions, several have occurred during an e‑cigarette’s use,
needed because of challenges in measuring trace levels of causing severe facial damage or injuries to bodies and hands
metals. (Brennan 2015; Corona and Marcus 2015; Duranty 2015;
Fox 5 Digital Team 2015; Goff and Schwartz 2015; Jablow
Summary and Sexton 2015; Shastry and Langdorf 2016), but most
E-liquids produce chemical reactions that may result occurred while the device’s batteries were being charged.
in the formation of new, harmful compounds. Carcinogens Overcharging lithium batteries can lead to thermal run-
(e.g., formaldehyde, acetaldehyde, and acrolein) and toxic away, causing the e‑cigarette battery or container to be
heavy metals (e.g., lead and cadmium) have been found propelled, often with portions catching fire (U.S. Fire
in e‑cigarette aerosols in laboratory tests conducted at Administration 2014; Bohr et al. in press).
temperatures within the range of most e‑cigarette prod-
ucts. These chemicals and metals have been detected in Health Effects Caused by Ingestion of E‑Cigarette
e-liquids and e‑cigarette aerosols, signifying the need for Liquids
further study on the potential short- and long-term health The liquids in both e‑cigarettes and the con-
ramifications. tainers used to refill them can cause nicotine poisoning.
A limitation to understanding the health impact Consequences of nicotine intoxication in the e-liquid
of chemical reactions is the heterogeneity of e‑cigarette include nausea, vomiting, headaches, dizziness, and diar-
devices (e.g., voltage), e-liquids (e.g., quality, content), rhea at low doses; seizures; tachycardia; abdominal pain;
and use behaviors (e.g., puff duration), as emissions confusion; and even death (Cervellin et  al. 2013). The
may be altered by any combination of these mechanical amount of nicotine needed to cause death in humans is
and behavioral differences. Further, it is difficult to fully uncertain and, according to a reevaluation, may be higher
contextualize the carcinogenic emissions of e‑cigarette than previously thought (Mayer 2014). The total amount

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   119
A Report of the Surgeon General

of nicotine in refill liquids varies and can be as high as 2014; Guttenburg et al. 2014; Lee et al. 2014; California
1,000 mg/10 mL in do-it-yourself bottles (Davis et  al. Department of Public Health 2015).
2015), which could be lethal if consumed (Mayer 2014).
The increase in poisonings prompted enactment of
the Child Nicotine Poisoning Prevention Act of 2015 (2016) Secondhand Exposure to the
in January 2016. This law requires any container of liquid
nicotine sold, manufactured, distributed, or imported Constituents of E‑Cigarette Aerosol
into the United States be placed in special packaging
that is difficult to open by children under 5 years of age. Exposure to secondhand smoke from combustible
Although labels may indicate the concentrations of nico- tobacco products is a known cause of morbidity and mor-
tine, such labels can be incomplete, confusing, or inaccu- tality (USDHHS 2006). Secondhand smoke, a mixture of
rate (Trtchounian and Talbot 2011; Cameron et al. 2014), the sidestream smoke from a smoldering cigarette and the
and some bottles have not been labeled at all (Davis et al. mainstream smoke exhaled by a smoker, is known to con-
2015). Of most concern, some bottles of e‑cigarette refill taminate both indoor and outdoor environments. In addi-
liquids labeled “no nicotine” have been found to contain tion, when the constituents of smoke deposit on surfaces,
significant amounts of that substance (e.g., 25.6 mg/mL; nonsmokers can be exposed to them via touch, ingestion,
Trehy et al. 2011). Regardless, many e‑cigarette users may or inhalation. These deposited constituents of combustible
not be aware of the toxic effects of nicotine and may not smoke are known as “thirdhand smoke” (Matt et al. 2011;
know that refill liquids should be kept away from toddlers Protano and Vitali 2011). E‑cigarettes represent another
and children. These liquids are often sold in colorful bot- potential source of exposure to toxicants for nonusers, via
tles with flavors that are attractive to children (Bahl et al. secondhand or thirdhand exposure to aerosol.
2012). The liquids usually come in small dropper bottles
that can be mistaken for bottles containing food dye or eye Exposure to Nonusers
drops. Finally, many refill liquids are made in local “vape In contrast to combustible tobacco products,
shops,” which have only recently come under FDA regu- e‑cigarettes do not produce sidestream emissions; aerosol
lation (Federal Register 2016), with no uniform training is produced during activation of the device. Some of this
process for mixers, a lack of standards and protections, aerosol is subsequently exhaled into the environment
and unknown concentrations of nicotine. where nonusers may be exposed through inhalation, inges-
The rapid growth in popularity of e‑cigarettes and tion, or dermal contact. As previously described in this
the ease with which refill liquids can be purchased have chapter, constituents of the emissions may include nico-
made e‑cigarettes an increasingly common item in many tine, carbonyl compounds, VOCs, polyaromatic hydro-
households, thereby elevating the possibility of accidental carbons, TSNAs, heavy metals, and glycols. It is not clear
nicotine poisoning. Instances of related case reports, often how much of inhaled e‑cigarette aerosol is exhaled into
involving children or infants, are increasing. For example, the environment where nonusers can be exposed. Some
an 18-month-old girl was treated at an emergency room studies have used machines to produce e‑cigarette aero-
for hypertension and tachycardia after drinking about sols and measured the pollutants emitted (McAuley et  al.
2 mL of refill liquid from a bottle on a nightstand (Shawn 2012; Czogala et  al. 2014; Geiss et  al. 2015); others have
and Nelson 2013). Unintentional exposure to nicotine involved the use by one or more persons of an e‑cigarette
can occur through ingestion, absorption through the and measured the change in pollutants in either a room
skin, inhalation, or dropping refill liquids into one’s eyes or a test chamber after use (Schripp et al. 2013; Schober
(Cantrell 2014). et al. 2014). One study measured airborne nicotine in the
Figure 3.2 shows data from 2011 to 2016 on expo- homes of e‑cigarette users (Ballbe et al. 2014). The concen-
sures to e‑cigarettes or liquid nicotine (i.e., any con- tration of e‑cigarette aerosol in a given microenvironment
tact with e‑cigarettes or liquid nicotine, not necessarily depends primarily on the strength of the source or the
resulting in any health effects) (American Association of number of e‑cigarettes used and the emission rate of the
Poison Control Centers 2016). These data show a dramatic aerosol for that device. E‑cigarettes, however, are heteroge-
increase in exposures through 2014 with a slight reduc- neous in their design and in the liquids used, and the spe-
tion of exposures in 2015. Fifty-one percent of the calls to cific product combination significantly affects the second-
poison control centers regarding exposures to e‑cigarettes hand emissions (Kosmider et  al. 2014; Geiss et  al. 2015).
involved children 5 years of age or younger (CDC 2014). The number of puffs and depth of inhalation may be partic-
Increased e‑cigarette exposures have also been reported by ularly relevant to the amount exhaled by the user and may
state and local poison centers (Banerji et al. 2014; Cantrell also affect e‑cigarette emissions (Talih et al. 2016).

120   Chapter 3
E-Cigarette Use Among Youth and Young Adults

Figure 3.2 Data showing exponential increase in the number of cases of human exposure to e-cigarette products and
liquid nicotine between 2011 and 2016

Source: American Association of Poison Control Centers (2016).


Note: These numbers reflect the closed human exposures to e-cigarettes and liquid nicotine reported to poison centers as of July 31,
2016. The numbers may change as cases are closed and additional information is received.

Movement of E‑Cigarette Aerosol and Lee 2015). The extent of this type of thirdhand con-
tamination from e‑cigarettes in real-world settings has
Similar to the case with secondhand tobacco smoke,
not been established but would be of particular concern
e‑cigarette aerosol is an inherently dynamic mixture that
for children living in homes of e‑cigarette users, as they
changes over time in terms of constituents and concen-
spend more time indoors, are in proximity to and engage
trations. Czogala and colleagues (2014) demonstrated a
in greater activity in areas where dust collects and may be
significant signal from a laser photometer indicating the
resuspended (e.g., carpets on the floor), and insert non-
presence of ambient aerosol in a room after e‑cigarette
food items in their mouths more frequently (EPA 2008;
use. However, this aerosol disappeared in just seconds
Matt et al. 2011).
to a few minutes as it either evaporated to the gas phase
or deposited on surfaces in the room. In contrast, in the
Exposure to E‑Cigarette Aerosol and
same study, secondhand cigarette smoke exhibited a par-
Considerations of Dose
ticulate phase that stayed suspended in the room at high
concentrations for more than 30 minutes. For the VOCs A large body of studies has measured exposure to
in e‑cigarette aerosol, such as formaldehyde, acrolein, and secondhand and thirdhand smoke from conventional
acetaldehyde, the source strength and ventilation rate will cigarettes using personal or area air monitoring, sur-
largely determine their concentration in indoor air. Semi- face testing, and dust testing. Studies of the exposure
VOCs, such as nicotine and TSNAs, are also largely affected of e‑cigarette aerosol to nonusers, however, are limited.
by sorption on and subsequent desorption from surfaces Schripp and colleagues (2013) observed small increases of
and dust in a room (Singer et al. 2002, 2003; Goniewicz fine and ultrafine particles and some VOCs, including PG,

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   121
A Report of the Surgeon General

flavoring substances, and nicotine, indicating passive inha- to other constituents of secondhand smoke and to health
lation of e‑cigarette aerosols by nonusers in the presence effects (Hyland et  al. 2008; Apelberg et  al. 2013). These
of e‑cigarette users. Those authors demonstrated that the same types of particle monitors are often used in studies
distribution in the sizes of the aerosol’s component par- of e‑cigarette aerosol to compare PM levels from conven-
ticles changes in the lungs and results in the exhalation of tional cigarettes with those from e‑cigarettes, though PM
smaller particles, likely caused by the evaporation of the findings may not directly relate to the short- and long-
liquid particles in the lungs and in the environment after term health effects of each product (Czogala et al. 2014;
exhalation. Schober and colleagues (2014) found substan- Schober et al. 2014).
tially higher amounts of PG, VG, particulate matter (PM), Caution is warranted when interpreting the results
and nicotine in a 45-m3 chamber during e‑cigarette use of PM measurements comparing e‑cigarettes with conven-
sessions with volunteers compared to controlled sessions. tional cigarettes. The aerosols produced are fundamentally
They also found a 20% increase in the level of polycyclic different, with the former resulting from aerosolization of
aromatic hydrocarbons (PAHs) and a 2.4-fold increase in liquid and the latter resulting from combustion of organic
aluminum concentrations. matter. The true PM2.5 mass concentration of e‑cigarette
Williams and colleagues (2013) demonstrated con- aerosol from commonly used light-scattering instruments
tamination by metal and silicate particles in e-liquid (Czogala et al. 2014) cannot be determined without cali-
and its aerosol using scanning electron microscopy. In brating the device to a reference standard for the aerosol
a different study measuring machine-generated second- in question. Even this calibration would be questionable
hand e‑cigarette aerosol in an emission chamber, Geiss given the highly volatile nature of e‑cigarette aerosol,
and colleagues (2015) found significant levels of PG, VG, making it difficult to capture and accurately determine
and nicotine in the chamber’s air. Carbonyl compounds the mass. Real-time PM2.5 measurements such as this are
of concern (e.g., formaldehyde, acetaldehyde, acrolein, useful, however, to determine the presence of an aerosol
and acetone) were below the limits of detection in this and to see the relative changes in this aerosol over time
study. O’Connell and colleagues (2015), who assessed and under various conditions, such as changing source
secondhand e‑cigarette emissions in a small meeting strength. Figure  3.3 shows the significant increase in
room (12.8  m2) with three e‑cigarette users during a aerosol concentration from e‑cigarettes after about 1 hour
165-minute session, found a significant increase in PG but and the subsequent rapid decline, presumably from initial
did not see the expected increase in VG or nicotine. This aerosolization and deposition of this aerosol. There may
study reported no increase in PAHs, trace metals, TSNAs, still be significant amounts of this e‑cigarette aerosol in
or acrolein, but did find an increase in total VOCs, formal- the environment, but the particle monitor can no longer
dehyde, and acetaldehyde. However, the compounds were measure it, as it is either in the aerosol phase or deposited
found at levels below guidelines for the quality of indoor on surfaces. For these reasons, it is important not to rely
air from the World Health Organization or European solely on PM mass concentrations for determining expo-
Union. Ruprecht and colleagues (2014) found signifi- sure to e‑cigarette aerosol and for making comparisons
cantly lower concentrations and counts for particles from with conventional cigarettes. Measurement of the indi-
an e‑cigarette used in a 50-m3 room compared with con- vidual toxicants of concern in the aerosol phase and on
ventional cigarettes. Interestingly, they also found that surfaces is warranted.
nicotine-free e‑cigarettes produced higher particle levels
than e‑cigarettes containing nicotine. Saffari and col- Health Effects of Secondhand Exposure to
leagues (2014) found that total particulate exposure was E‑Cigarette Aerosols
10-fold lower in e‑cigarettes than it was in conventional
Flouris and colleagues (2012, 2013) conducted two
cigarettes. Emissions of heavy metals from e‑cigarettes
clinical studies of the health effects of secondhand exposure
were also dramatically less, with the exception of nickel,
to e‑cigarette aerosol. The researchers found no short-term
zinc sulfide, and silver, which showed higher emission
change in markers of complete blood count after 1  hour
rates from e‑cigarettes. PAH levels were not elevated by
of exposure to e‑cigarette aerosol in a group of 15  non-
e‑cigarette use in this study.
smokers (Flouris et al. 2012). Similarly, the same exposure
Concentrations of PM, especially PM2.5, which is
caused no significant change in short-term lung function,
fine PM, and nicotine are the two most common markers
although the results were of borderline statistical signifi-
used to measure exposure to secondhand smoke (Avila-
cance (Flouris et  al. 2013). However, these studies dem-
Tang et al. 2010; Apelberg et al. 2013). Indirect measures
onstrated that passive exposure to e‑cigarettes causes an
of the mass concentration of PM from secondhand smoke
increase in serum cotinine that is similar to that from pas-
using real-time particle monitors are well validated in
sive exposure to cigarette smoke, suggesting the need to
terms of the accuracy of these measurements in relation

122   Chapter 3
E-Cigarette Use Among Youth and Young Adults

Figure 3.3 Changes in aerosol particle PM2.5 concentrations during experiment of e-cigarette use and tobacco
cigarette smoking in an exposure chamber

Source: Czogala et al. (2014).


Note: PM = particulate matter.

examine the impact of passive aerosolized nicotine inha- are typically not appropriate to apply to the population as a
lation on long-term lung function. Furthermore, limited whole, as they are intended for a healthy working popula-
effects would likely occur in the short exposure observed tion during a typical work day, not accounting for the risks
through the methodologies used by Flouris and colleagues to children, pregnant women, or those with preexisting
(2012, 2013), as these studies did not account for prolonged health conditions. Further, standards for workplace expo-
and persistent passive exposure to e‑cigarette aerosols. sure are very different in concentration and duration than
Several researchers have modeled the health risks what is to be expected from e‑cigarette use.
of passive exposure to e‑cigarettes (Colard et al. 2015) on An additional consideration for regulating e‑cigarettes
the basis of the limited exposure data available and have in indoor environments is the potential for allergic reactions
come to various conclusions. Offermann (2015) concluded in nonusers. Dermal and oral PG exposures are known causes
that, for indirect exposure, two chemicals—nicotine and of dermatitis and allergic sensitization (Warshaw et al. 2009;
PG—exceeded California EPA exposure level standards for Al Jasser et  al. 2011). Several e-liquids contain flavorants
noncarcinogenic health effects. Burstyn (2014), who com- derived from nuts and in fact have labels cautioning persons
pared e‑cigarette aerosol exposure to workplace exposure who have nut allergies not to use these products. Research
standards, concluded that only PG and VG warrant atten- has not evaluated whether nonusers can have allergic reac-
tion in e‑cigarette users while, for bystanders, none of the tions from these potential allergens in e‑cigarette aerosol,
constituents of e‑cigarette aerosol pose apparent concern. It but this is a risk that should be explored as 8% of U.S. chil-
is important to note that standards for workplace exposure dren have food allergies (Gupta et al. 2011).

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   123
A Report of the Surgeon General

Evidence Summary

E‑cigarette use among youth and young adults in the Kalkhoran and Glantz 2016) and untested and nonexistent
United States has increased considerably in recent years (see among youth.
Chapter 2). There is little doubt that the use of e‑cigarettes Further research is warranted to focus on the
by youth and young adults represents self-administration characteristics of e‑cigarette devices, the constituents
of the drug nicotine, and this self-administration of nic- of e-liquids, and the user behaviors that can influence
otine puts youth at risk for addiction and many related the yield of nicotine and other toxicants (Shihadeh and
harmful consequences. Animal research indicates adoles- Eissenberg 2015). This close focus includes providing
cent brains are particularly sensitive to nicotine’s effects, details of devices (e.g., voltage of the power supply, heating
such that subsequent self-administration is more likely, element resistance) and components of e-liquids (e.g., pro-
and that same literature indicates that this age group is pylene glycol, vegetable glycerin, other additives), and
at risk for a constellation of nicotine-induced neural and measuring user puff topography. Standardization of pro-
behavioral alterations. Studies of the effects of maternal cedures for producing and delivering the aerosol is likely a
smoking of conventional cigarettes during pregnancy, necessary component of at least some in vivo and in vitro
coupled with preclinical literature examining the effects work. Preclinical work examining the effects of e‑cigarette
of maternal self-administration of nicotine during preg- aerosols is a clear research need and, again, the standard-
nancy, suggest that e‑cigarette use by mothers during ization of procedures for production and delivery of the
pregnancy presents a wide variety of risks to fetal, infant, aerosol is necessary. To enhance relevance, the parameters
and child brain development. of aerosol production should span the range of those seen
Users of e‑cigarettes risk respiratory exposure to a with humans (Shihadeh and Eissenberg 2011).
variety of aerosolized chemicals, including solvents and fla- The huge variety of products of different origin and
vorants added intentionally to e-liquids, adulterants added design, the rapid emergence of new products, and the
unintentionally, and other toxicants produced during the varied ways in which consumers use these products make
heating/aerosolization process. The health impacts of fre- the development of standard measurement conditions
quent exposure to the toxicants in e‑cigarette aerosol challenging (Famele et  al. 2015). Accordingly, research is
are not well understood, though several are known car- needed to understand how different design features relate
cinogens. As highlighted previously in this chapter, the to potential toxicity—for example, if the compounds in
detection and level of these carcinogens depend on several e‑cigarettes are affected by heating, changes in chemical
factors, including the concentration of the e-liquid and the composition, or pH; if these compounds are absorbed into
strength of the heating device. Although e‑cigarettes have the bloodstream; and how additives to the e-liquid affect
been used as a cessation device, the evidence supporting the the bioavailability of these compounds, among other con-
effectiveness of e‑cigarettes as an aid for quitting conven- siderations. Research is also needed to understand whether
tional cigarettes remains extremely weak for adults (Bullen potential health risks may be ameliorated by changes in
et  al. 2013; Caponnetto et  al. 2013; Grana et  al. 2014; product engineering.

124   Chapter 3
E-Cigarette Use Among Youth and Young Adults

Conclusions

1. Nicotine exposure during adolescence can cause addic- health effects. The health effects and potentially
tion and can harm the developing adolescent brain. harmful doses of heated and aerosolized constituents
of e‑cigarette liquids, including solvents, flavorants,
2. Nicotine can cross the placenta and has known effects and toxicants, are not completely understood.
on fetal and postnatal development. Therefore, nico-
tine delivered by e-cigarettes during pregnancy can 4. E-cigarette aerosol is not harmless “water vapor,”
result in multiple adverse consequences, including although it generally contains fewer toxicants than
sudden infant death syndrome, and could result in combustible tobacco products.
altered corpus callosum, deficits in auditory pro-
cessing, and obesity. 5. Ingestion of e‑cigarette liquids containing nicotine
can cause acute toxicity and possibly death if the
3. E‑cigarettes can expose users to several chemicals, contents of refill cartridges or bottles containing
including nicotine, carbonyl compounds, and vol- nicotine are consumed.
atile organic compounds, known to have adverse

Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   125
A Report of the Surgeon General

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Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults   145
Chapter 4
Activities of the E-Cigarette Companies

Introduction 149

Manufacturing and Price 149


Overview of the E-Cigarette Market in the United States 149
Distribution and Purchase Channels 149
Product Evolution 151
Evolution of Market Share in the E-Cigarette Market 152
E-Cigarette Sales in Tracked Retail Outlets 152
Production of E-Liquids 154
Impact of E-Cigarette Price on Sales and Use of These Products 155
Trends in E-Cigarette Prices over Time 155
Impact of E-Cigarette Prices on E-Cigarette Sales 156

Marketing and Promotion of E-Cigarettes 157


Marketing Expenditures 157
Magazine and Print Advertising 158
Television Advertising to Youth and Young Adults 159
Sponsorships 159
Digital Landscape for E-Cigarettes 163
E-Cigarettes in the Retail Environment 167
Conventional Tobacco Retailers (Convenience Stores, Pharmacies, Tobacco Shops) 167
“Vape Shops” 168
Exposure and Receptivity to Advertising for E-Cigarettes 169
Exposure 169
Receptivity to Advertising 169
Effect of E-Cigarette Advertising on Behavior 170
Associations with E-Cigarette Use and Intentions to Use 170
Associations with Knowledge, Risk Perceptions, and Other Attitudes 171

Evidence Summary 172

Conclusions 172

References 173

147
E-Cigarette Use Among Youth and Young Adults

Introduction

This chapter focuses on the companies that refer to the e-cigarette companies as a whole but, when
are active in the production, distribution, or marketing necessary, will distinguish between the e-cigarette brands
of e-cigarettes in the United States and examines the that are owned by tobacco companies and others that are
potential influence of these companies on the use of independently owned. The chapter covers manufacturing
e-cigarettes, particularly among youth and young adults. and price, marketing and promotional activities, the retail
The e-cigarette marketplace is complicated by the fact that environments for e-cigarette products, exposure to mar-
some brands and devices are owned by tobacco companies, keting and receptivity to such activity, and the effects of
while others are independently owned. This chapter will e-cigarette marketing activities on consumer behavior.

Manufacturing and Price

As discussed in Chapter 1, although the concept Overview of the E-Cigarette Market


of e-cigarettes was initially introduced in the 1960s, the
first-generation version of e-cigarettes was not devel-
in the United States
oped and commercialized until the mid-2000s (Grana
For 2014, the value of the e-cigarette market in the
and Ling 2014). In the short period since the first appear-
United States was estimated at $2.5 billion: 40% ($1.0 bil-
ance of e-cigarettes, the exponential growth in awareness
lion) was for cigarette-like e-cigarettes (cigalikes), and
and use of these products (Centers for Disease Control
60% ($1.5 billion) was for tank-style e-cigarettes, mods,
and Prevention [CDC] 2015), the rapid product develop-
and other types of “vaporizers” (Wells Fargo Securities
ment (Zhu et al. 2014), and the rapid evolution of both
2015a) (Table 4.1). The market was projected to grow
the e-cigarette market and the industry itself (Huang
to $3.5 billion, a rise of 40%, in 2015 (Rose et al. 2014)
and Chaloupka in press) have been unprecedented.
(Table 4.2). Total sales of e-cigarettes in convenience, food,
E-cigarettes were recently named a “disruptive innova-
drug, and big-box stores (such as Walmart), which are
tion” that may change the existing tobacco market and
tracked by commercial market research companies (such
displace conventional (combustible) cigarettes in a fore-
as Nielsen), were estimated to be $900 million in 2014.
seeable timeframe (Spielman and Azer 2013).
There was an additional estimated $500 million in online
Consumer demand for a less harmful alternative to
sales, and $1.1 billion in sales in “vape shops” and other
conventional cigarettes and the implementation of macro
channels, which are not currently tracked by commer-
policies, such as those that restrict cigarette use or man-
cial market research companies (Table 4.1) (Wells Fargo
date clean indoor air, may influence the use of e-cigarettes
Securities 2015b).
(Pepper et al. 2014b; Rose et al. 2014). However, e‑cigarette
companies may play a critical role in shaping the market,
Distribution and Purchase Channels
affecting everything from the development and innovation
of new products and brands to the manufacture, distribu- E-cigarettes entered the U.S. market around
tion, marketing, promotion, and pricing of the product— 2006–2007, and since that time the distribution and pur-
activities that parallel those in the cigarette industry. chase channels for these products have evolved greatly.
This section describes and summarizes both the Initially they were sold exclusively by Internet retailers,
rapidly changing e-cigarette market and the activities but then selling activity expanded to shopping mall kiosks
of e-cigarette companies in the United States, providing and conventional retail outlets and, more recently, to
a broad overview of the major players. These participants “vape shops” and some pharmacies (Rose et al. 2014; Lee
include the major tobacco companies and other manu- and Kim 2015).
facturers. The chapter also addresses how the companies Some companies operating in the U.S. market have
influence the e-cigarette market in the United States, their own manufacturing facilities in this country, but
focusing on the impact of product development and inno- companies generally import parts or even complete prod-
vation, distribution channels, product availability, and ucts from abroad, almost exclusively from China (Barboza
pricing strategies, as well as the role of e-cigarette trade 2014). Manufacturers and importers distribute their prod-
organizations and partnerships. ucts via a wide number of channels, such as the companies’

Activities of the E-Cigarette Companies   149


A Report of the Surgeon General

Table 4.1 Estimated e-cigarette market size in 2014 ($ billion)


Convenience, food, drug, Other channels (“vape shops” and
  and big-box stores Online other untracked retail channels) Total
E-cigarettes 0.6 0.2 0.2 1.0
Vapors/tanks/mods 0.3 0.3 0.9 1.5
Total 0.9 0.5 1.1 2.5
Source: Wells Fargo Securities (2015a).

Table 4.2 Estimated e-cigarette market size in 2015 ($ billion)


Convenience, food, drug, Other channels (“vape shops” and
  and big-box stores Online other untracked retail channels) Total
E-cigarettes 0.7 0.4 0.4 1.5
Vapors/tanks/mods 0.4 0.4 1.2 2.0
Total 1.1 0.8 1.6 3.5
Source: Wells Fargo Securities (2015a).

own e-commerce websites and/or retail outlets. In 2010, in press). This growth coincided with a surge in mar-
the most popular channels for selling e-cigarettes and keting expenditures by the e-cigarette companies across
their accessories directly to consumers were websites and all media platforms (Kim et al. 2014; Kornfield et al.
third parties, such as retail outlets (Linarch Information 2015). The products sold in these conventional channels
Solutions 2012). Many e-cigarette manufacturers and were predominantly disposable and rechargeable cigalikes
importers, including the big-brand companies and those (Giovenco et al. 2015; Huang and Chaloupka in press), but
supplying products to “vape shops,” rely on distributors retail stores started to carry tank-style e-cigarette devices
and retailers to deliver the products to the consumer as well (CSP Daily News 2014; Giovenco et al. 2015).
(Linarch Information Solutions 2012). Today, e-cigarette brands, such as MarkTen (manu-
The emergence of e-cigarette devices and products factured by Altria) and VUSE (manufactured by Reynolds
resulted from the endeavors of a few entrepreneurs and American Inc.), are available in more than 70,000 retail
widespread Internet and television advertising (Grana et al. stores across the country, and their availability is expanding
2013; Rose et al. 2014). It is noteworthy that the product rapidly (Wells Fargo Securities 2014b). E‑cigarettes were
class took hold when e-commerce was rapidly expanding more likely to be available in retail locations in neigh-
in the United States, and major social media platforms— borhoods with a higher median household income and
such as Facebook (founded in 2004), YouTube (2005), and a lower percentage of African American and Hispanic res-
Twitter (2006)—were emerging. In such an environment, idents; these sales patterns are consistent with patterns
information about a new product like e-cigarettes could be of use of these products observed among youth, young
rapidly disseminated across geographic boundaries, and adults, and adults more generally (see Chapter 2). Notably,
new products and technologies could be speedily adopted. the price of conventional cigarettes and the existence of
This process is partly reflected by the Google search comprehensive smokefree laws were inversely associated
volume of queries related to e-cigarettes; the volume of with the availability of e-cigarettes (Rose et al. 2014).
queries surpassed those for nicotine replacement therapy Through growth in their sales, tank-style e-cigarettes
products and snus by 2008 (Ayers et al. 2011). (also known as mods) and advanced personal vaporizers
Manufacturers noticed the fast rise in consumer (APVs) have begun to play an increasingly important role
interest in e-cigarettes, so they quickly pushed to expand in the e-cigarette market (Wells Fargo Securities 2015a).
the sale of their products to brick-and-mortar retail stores. “Vape shops,” which provide a range of e-cigarette devices
Sales of cigalikes and related products were first observed and products, have emerged as the primary retail channel
in Nielsen’s store-scanner database in 2007, and between for consumers seeking such products (Lee and Kim 2015).
2009 and 2012, retail sales of e-cigarettes expanded to all Unlike conventional retail outlets, “vape shops” sell a wide
major markets in the United States (Huang and Chaloupka range of more complex and powerful tank-style e-cigarettes

150   Chapter 4
E-Cigarette Use Among Youth and Young Adults

and many different types of liquids for e-cigarette devices Product Evolution
(e-liquids or e-juices) (Sussman et al. 2016).
E-cigarette products have evolved and diversified
The rise of “vape shops” can be attributed to a number
rapidly since they entered the U.S. market (see Chapter 1).
of factors. First, in the past, most of these establishments
Detailed information about different types of e-cigarette
offered a wide range of e-cigarettes and e-liquids, allowed
products has been presented elsewhere (Grana et  al.
users to sample different types of flavored e-liquids at
2014). Over time, with consolidation of e-cigarette com-
no cost, and permitted the trial use of various types of
panies and technological improvements, the manufac-
e-cigarettes. Most of these establishments sell products
turing process has become more standardized, enabling
made by independent companies, as opposed to products
the production of e-cigarette products with a more effec-
manufactured by the major conventional tobacco compa-
tive and more consistent dose and delivery of nicotine and
nies (Kamerow 2014; Sussman et al. 2016). As a result,
flavorings, and a more consistent generation of aerosol
“vape shops” can serve as an information hub where con-
(Goniewicz et  al. 2013a,b; Farsalinos and Polosa 2014;
sumers can easily obtain knowledge about (and gain
Saitta et al. 2014).
experience with) a wide range of e-cigarettes and related
Many e-cigarette manufacturers make multiple
products (Sussman et al. 2016). However, the information
types of e-cigarette products. For example, the NJOY brand
provided may be misleading or misinterpreted (Cheney
has not only disposable and rechargeable cigalikes but also
et al. 2016). Second, unlike traditional retail outlets, “vape
tank-style e-cigarette devices, which are larger than ciga-
shops” are usually equipped to provide consumers with
likes and include options for refills and batteries. In addi-
individualized information about how e-cigarette prod-
tion, NJOY sells a variety of flavored e-liquids, although
ucts can be used to best satisfy the user’s preferences;
in California, flavors appealing to minors (e.g., strawberry
this capability may be important as e-cigarette products
and cookies and cream) are prohibited (State of California
become more diversified and sophisticated. Because of
v. Sottera, Inc. 2010). Within each product type, there
the diversity of these products, some of these establish-
are many different brands, albeit the brands are often
ments provided free samples of different flavored e-liquids
very similar. For example, NJOY, blu, Logic, Mistic, and
and allowed trial use of different e-cigarettes before actual
many other brands of rechargeable e-cigarettes differ very
purchase in an attempt to compete with traditional retail
little from each other with regard to the flavors and types
outlets. Under the deeming rule published in May 2016,
of products offered (e.g., cigalike, tank style) (Zhu et al.
free samples of e-liquids containing nicotine were banned
2014). A study examining the growth of brands and flavors
(Federal Register 2016). Third, “vape shops” serve as a
between 2012 and 2014 found that older brands were more
place for e-cigarette users to socialize.
likely to involve cigalikes, while newer brands were more
Some “vape shops” also host various events,
likely to offer tank-style devices and mods (Zhu et al. 2014).
including competitions (also known as cloud chasing),
As tank systems and mods become more popular, the
that build loyal customer bases by creating a sense of com-
distinction between a closed system and an open system
munity and camaraderie among customers (Sussman et al.
becomes more important. In a closed system, components
2014; Cheney et al. 2015; Lee and Kim 2015). Additionally,
cannot be customized. In this case, the e-liquid is “locked
a 2015 study of “vape shop” owners found that customers
in”; the amounts of e-liquid, level of nicotine, and flavors
view the owners as important sources of health informa-
are dictated by the manufacturer. Because users cannot mix
tion, which could include information related to cessa-
their own e-liquids or refill the cartridges or tanks, there
tion (Cheney et al. 2016). However, the owners reported
is less risk of spillage, nicotine overdose, and accidental
(a) obtaining their information from YouTube or industry
ingestion. In addition, users cannot change the power
sources but finding the research hard to understand and
source, adjust the voltage, or customize the atomizers.
(b) looking for government sources but not finding them.
Many brands offer only closed-system devices (e.g., Vype,
Estimates of the number of “vape shops” in the
Vapestick, and FIN). Most cigalikes are closed systems, sold
United States have varied greatly due to the lack of a clear
primarily online or in conventional retail outlets, and are
definition of what constitutes such an establishment.
favored by the larger e-cigarette companies, likely because
The low end of these estimates puts the number around
of the high profit margins from the e-liquid refill cartridges
3,500 (Klein 2013; Lee and Kim 2015), while interme-
and the nature of the distribution paths.
diate estimates indicate that there are about 6,000–15,000
Open systems, in contrast, allow for personaliza-
“vape shops” in this country (Bour 2015; Wells Fargo
tion and customization: Users can mix their own e-liquid,
Securities 2015b). One high estimate is that in 2014 there
choosing different e-liquid bases, flavors, and nicotine
were as many as 35,000 such shops in the United States
concentration levels. Users can also adjust the voltage,
(Kamerow 2014).
customize the atomizers, and/or modify the aesthetics and

Activities of the E-Cigarette Companies   151


A Report of the Surgeon General

shapes/sizes of their devices (Popken 2014; Richtel 2014c; Evolution of Market Share in the E-Cigarette
Lee and Kim 2015). Tanks and mods/APVs are open systems Market
sold primarily in “vape shops” or online. While research
Although the e-cigarette market in the United States
has demonstrated that more-experienced e-cigarette users
has changed significantly since its emergence, these
prefer open system mods (Farsalinos et al. 2014), one ana-
changes have not been studied extensively. This section
lyst has suggested that closed systems may better facilitate
documents market share by brand for e-cigarette sales
consistent and enforceable product and manufacturing
in retail outlets tracked by Nielsen, using data from the
standards (Wells Fargo Securities 2014a).
forthcoming study by Huang and Chaloupka (in press)
Beyond the increased variety over time of products,
and supplemented with data from industry reports issued
their components, and related products (including acces-
by a number of investment banks. These data, available
sories such as carriers, lanyards, stickers, and sleeves),
in Appendix 4.5, clearly show the dynamic changes in the
the products continue to appeal to consumers through
e-cigarette market, and these changes are important to
the incorporation of increasingly complex technologies—
understand in terms of access to and marketing of these
including location tracking; Bluetooth connectivity;
products to youth and young adults.
social networking functions and integration with users’
social media accounts; and entertainment functions, such
E-Cigarette Sales in Tracked Retail Outlets
as playing music and videos (Bauld et al. 2014; Brown and
Cheng 2014; Honig 2014). Total sales of e-cigarettes in tracked retail channels
The terminology for e-cigarettes has also expanded. have surged exponentially since 2010, increasing from
Terms such as e-cigars, e-hookahs, vaping pens, hookah only a few million dollars per quarter in 2010 to more
pens, and personal vaporizers are used interchange- than $170 million in the last quarter of 2014 (Figure 4.1).
ably (or preferentially) by some users (Richtel 2014b). Although Reynolds American’s VUSE brand did not
In addition, the spectrum of use has broadened, as some enter the market until late 2013, its sales climbed rap-
e-cigarettes that involve open systems are also used for the idly in 2014 because of heavy promotion and price dis-
aerosolization of marijuana and cannabis oil (Bryan 2014; counts. At the end of 2014, VUSE had become the market
Morean et al. 2015) and could be adapted for other illicit leader with the highest quarterly sales at $56 million. Blu
substances (see Chapter 2). (owned by Lorillard and thus now by Imperial Tobacco)
Worldwide, more than 95% of e-cigarettes sold are was the market leader for most of 2013 and 2014, with an
thought to have been manufactured in China (Jourdan average $60 million in quarterly sales. During this time
2014), most in one city—Shenzhen (Barboza 2014). A few the number of its distribution points rose from 60,000 to
large manufacturers (e.g., Joyetech, Kimree, and First more than 150,000 because of its acquisition by Lorillard
Union) dominate the market (see Appendix 4.1 for descrip- and subsequent marketing and promotion efforts.
tions of the major e-cigarette manufacturers).1 Most of After doubling every year between 2010 and 2013
these manufacturers provide supplies to many different (Figure 4.2) in the tracked retail channels, rates of
e-cigarette companies, including American companies increase in the sales of e-cigarettes decelerated signifi-
marketing conventional cigarettes, as well as independent cantly, with total sales actually declining in the second
e-cigarette companies. Some companies (e.g., Gamucci) quarter of 2014. The deceleration may reflect, in part, the
have an exclusive manufacturer in Shenzhen. shift away from cigalikes to tank-style devices, mods, and
Some e-cigarette companies have begun to locate other e-cigarette products among users; the sales of these
their manufacturing base in the United States. Reynolds devices are not tracked as well, which makes it difficult to
American, for example, has a factory in Tobaccoville, know the true trends in sales (see Tables 4.1 and 4.2).
North Carolina, to manufacture its VUSE brand and Figure 4.2 presents sales data by product type. Sales
strongly emphasizes this location as part of its marketing of disposable e-cigarettes trended upward from 2010
strategy (CSP Daily News 2015). White Cloud, another to 2013, increasing from a minimal amount in 2010 to
U.S.-based company, moved its cartridge-filling produc- almost $100 million in the second quarter of 2013, but
tion from China to Tarpon Springs, Florida, in May 2014 2014 showed a substantial decline, with the value only
(McConnell 2014), and the U.S.-based brand Mistic has about $50 million for the final quarter of that year. The
announced plans to move its manufacturing from China figure shows a clear pattern of seasonality in sales for
to Greenville, North Carolina (Bettis 2014). disposables: sales usually rose in the first quarter of the

1All appendixes and appendix tables that are cross-referenced in this chapter are available only online at http://www.surgeongeneral.gov/
library/reports/.

152   Chapter 4
E-Cigarette Use Among Youth and Young Adults

Figure 4.1 E-cigarette sales in tracked channels by brand, 2010–2014

Source: Huang and Chaloupka (in press).


Note: Data points for this figure are shown in Table A4.4-1 in Appendix 4.4.

Activities of the E-Cigarette Companies   153


A Report of the Surgeon General

Figure 4.2 E-cigarette sales in tracked channels by product type, 2010–2014

Source: Huang and Chaloupka (in press).

year—potentially reflecting the effect of New Year’s res- Sales of different types and brands of e-cigarettes
olutions among smokers who seek to use rechargeable likely differ by demographic group. For example, anec-
e-cigarettes as a way to quit conventional cigarettes— dotal evidence suggests that youth and young adults prefer
but had subsequently declined during the rest of the year. pen-style devices, those that come in various shapes and
Sales of e-liquid refills increased steadily over the 4-year styles, and devices that may be used interchangeably with
period between 2010 and 2014 and reached $80 million in e-hookahs (Richtel 2014b). Research also suggests that
the final quarter of 2014, representing approximately half users may eventually graduate to more complex systems;
of the total e-cigarette sales in the tracked retail channels. more specifically, experienced users may be more likely to
In 2014, more than 85% of e-cigarette sales occurred use tanks and mods (Farsalinos et al. 2014). Unfortunately,
in the tracked retail and online channels, including cer- sales data by demographics are very limited, and studies
tain convenience stores and food, drug, and big-box stores have not yet examined how sales of e-cigarette products
(Wells Fargo Securities 2015a; see Table  4.1). It  was differ by demographic classification.
estimated that 20% of all e-cigarette sales (including
e-cigarettes and tanks/mods) in 2014 occurred online, Production of E-Liquids
while 44% of all e-cigarette sales occurred in “vape
E-liquids used in closed-system devices usually are
shops” and other untracked retail channels (Wells Fargo
produced in the United States and then shipped to China
Securities 2015a; see Table 4.1).
to be included in the assembly process. For example,
Another important trend in e-cigarette sales is the
MarkTen, blu, and NJOY manufacture their own e-liquids
growth of flavored products. Although some brands, such
in the United States, which then are sent to China before
as NJOY, initially did not sell flavored e-cigarette products,
the final product is assembled there.
most companies now offer some form of flavored varieties.
In the United States, one of the biggest players in
Giovenco and colleagues (2015) found that sales of men-
the premixed e-liquid market for refillable e-cigarettes is
thol-flavored e-cigarettes in traditional U.S. retail chan-
Johnson Creek Vapor Company (2011), which claims to
nels (e.g., convenience stores, grocery stores, pharmacies,
be the world’s leading manufacturer of e-liquid and the
and mass merchandisers) more than doubled between
first company to produce and manufacture e-liquid in the
2012 and 2013, increasing from $96.4 million in 2012 to
United States. Johnson Creek has not disclosed the sup-
$215.7 million in 2013. Sales of fruit-flavored e-cigarettes
pliers of its nicotine solution.
more than tripled during the same period, from $4.9 mil-
lion to $16.7 million.

154   Chapter 4
E-Cigarette Use Among Youth and Young Adults

Impact of E-Cigarette Price on Sales from far below 100,000 in the first quarter of 2010 to
almost 11 million in the first quarter of 2014, before drop-
and Use of These Products ping to about 6.3 million in the final quarter of 2014. This
graph reveals an association between real price and the
This section summarizes the limited evidence on
sales volume for disposable e-cigarettes from 2010 to the
the impact of e-cigarette prices on the sales and consump-
second quarter of 2013: As real price declined over time,
tion of these products. The sizable body of research exam-
sales volume increased. Looking back, the rapid decline in
ining the effects of taxes and prices on the sale and use
the price of disposable e-cigarettes between 2007 and 2011
of conventional cigarettes (Chaloupka and Tauras 2011;
(Huang and Chaloupka in press) may have occurred because
International Agency for Research on Cancer 2011) leads
of improvements in product technology and industry pro-
to the conclusion that price increases resulting from
motion, which significantly cut the costs of producing such
higher excise taxes are effective tools for reducing ciga-
products (Bhatnagar et al. 2014; Wells Fargo Securities
rette consumption, especially among youth.
2015c). The rather modest declines in prices since 2011
may reflect the fact that further technological improve-
Trends in E-Cigarette Prices over Time
ments became less feasible (Wells Fargo Securities 2015c).
A study by Huang and Chaloupka (in press) docu- In terms of volume, the substantial decrease in 2014
mented and analyzed the relationship between real price may be partly attributable to consumers shifting away
and sales volume for both disposable and rechargeable from cigalikes to tanks, mods, and other more powerful
e-cigarettes by using Nielsen data, which reflected the devices, for which sales were not tracked well.
e-cigarette (predominantly cigalikes) sales and prices in An inverse relationship is also evident between
retail stores tracked by Nielsen. real price and sales volume for rechargeable e-cigarettes.
Figure 4.3 presents U.S. data on real price (deter- Figure 4.4 demonstrates that when the real price went
mined by adjusting the prices to the value of the U.S. dollar down, the sales volume increased, particularly after
in the fourth quarter of 2014) and sales volume for dispos- 2012. Between 2010 and 2014, the average unit price for
able e-cigarettes between 2010 and 2014 based on data from rechargeables decreased markedly, dropping from $37
Huang and Chaloupka (in press). The average price for a in the first quarter of 2010 to $12 at the end of 2014.
single disposable e-cigarette declined from approximately However, there were more price fluctuations than were
$17 in the first quarter of 2010 to less than $9 in 2014. found for disposable e-cigarettes (Figure 4.3). The price
In terms of volume, the estimate for disposables increased fluctuations for rechargeables were likely because of the

Figure 4.3 Sales volume and price of disposable e-cigarettes, U.S. market, 2010–2014

Source: Huang and Chaloupka (in press).

Activities of the E-Cigarette Companies   155


A Report of the Surgeon General

change in product mix and the influx of various new types were approximately −1.9 [a 10% increase in price would
and brands of these devices during this period (Bhatnagar decrease sales by 19%]) and (b) that disposable e-cigarettes
et al. 2014; Wells Fargo Securities 2015c). Sales volume appeared to be emerging as substitutes for recharge-
increased dramatically between 2010 and 2014, rising ables (a 10%  increase in rechargeable e-cigarette prices
from a minimal amount at the beginning of 2010 to about increased sales of disposable e-cigarettes by about 5%).
3 million units in the last quarter of 2014. This study concluded that policies increasing the retail
prices of e-cigarettes—such as imposing taxes or lim-
Impact of E-Cigarette Prices on E-Cigarette Sales iting rebates, coupons, and discounts—could potentially
lead to significant reductions in e-cigarette sales and that
In one of the first studies to explore the effects of
variations in tax policy by product type could lead to sub-
e-cigarette prices on the sales of these products, Huang
stitution between product categories. It is important to
and colleagues (2014b) estimated, from Nielsen data,
note that “vape shops” were not included in these data, as
both the own-price elasticity and the cross-price elasticity
Nielsen collects data only from convenience, food, drug,
of demand for e-cigarettes (disposable or rechargeable)
and big-box stores.
and studied the impact of conventional cigarette prices
Although these results provide evidence that
and smokefree policies on e-cigarette sales. Own-price
changing the price of e-cigarettes affects the number
elasticity is a measure showing how much demand for a
sold, the potential effects of the price of conventional
product will change given a change in its price, while cross-
cigarettes on the purchase of e-cigarettes are less clear.
price elasticity is a measure showing how much demand
Huang and colleagues (2014b) found no consistent or
for a product will change given a change in another prod-
statistically significant relationship between the price of
uct’s price. Using data from Nielsen’s commercial retail
conventional cigarettes and the sale of e-cigarettes. In
store scanning service, this study employed fixed-effects
contrast, Grace and colleagues (2015), who measured the
models to estimate elasticity of demand and associa-
cross-price elasticity of e-cigarettes and conventional cig-
tions between e-cigarette sales and either the prices of
arettes using simulated demand for the latter in a sample
conventional cigarettes or smokefree policies from 2009
of New Zealand smokers, found that the cross-price elas-
to 2012. Results demonstrated (a) that e-cigarette sales
ticity of e-cigarettes was significantly positive, suggesting
were quite responsive to own-price changes (estimated
that e-cigarettes may be partially substitutable for con-
own-price elasticities for disposable e-cigarettes centered
ventional cigarettes. Thus, the use of e-cigarettes may
around −1.2 [a  10%  increase in price would decrease
increase as the price of conventional cigarettes increases.
sales by 12%], while those for rechargeable e-cigarettes

Figure 4.4 Sales volume and price of rechargeable e-cigarettes, U.S. market, 2010–2014

Source: Huang and Chaloupka (in press).

156   Chapter 4
E-Cigarette Use Among Youth and Young Adults

Other evidence suggests that the potential impact 2011; U.S. Department of Health and Human Services
of price changes on the use of e-cigarettes may differ by [USDHHS] 2012). Therefore, youth and young adults, as
demographic characteristics. Relationships between the well as low-SES persons, may be more price-sensitive in
smoking of conventional cigarettes and socioeconomic the purchase of e-cigarette products, and thus they may
status (SES) are well documented in the literature, and be more likely to stop using e-cigarettes as their price
additional evidence has demonstrated that youth and increases. These potential connections between the price
young adults, and those with low SES, tend to exhibit of e-cigarettes and their use should be examined carefully
higher sensitivity to changes in the price of conventional as more data become available.
cigarettes (International Agency for Research on Cancer

Marketing and Promotion of E-Cigarettes

Marketing is an important tool for industries to use to advertise and promote their products. These chan-
in influencing consumer preferences, and the potential nels have included extensive marketing on the Internet
for marketing to influence smoking behaviors has been and advertising in mainstream media, including popular
a source of public health concern for many years (DiFranza magazines, retailer point-of-sale ads, product placement
et al. 1991; USDHHS 2000, 2012; National Cancer Institute on popular media, and even television commercials—
[NCI] 2008). Research has demonstrated a causal relation- an advertising option unavailable to cigarette manufac-
ship between tobacco marketing and smoking, with the turers because of regulatory policies (Legacy for Health
majority of research focusing on the impact of tobacco 2014; Ganz et al. 2015). E-cigarette brands also use web-
marketing on the initiation of smoking by youth (Biener sites to interact directly with their customers through
and Siegel 2000; USDHHS 2012). For adolescents, studies direct-to-consumer marketing (e.g., direct mail and direct
have found cross-sectional and longitudinal associations e-mail) and social media channels, such as Facebook,
between the intensity of cigarette marketing and initiation Twitter, and Instagram (Huang et al. 2014a; Richardson
of smoking, brand awareness, brand preferences, attitudes et al. 2014; Ganz et al. 2015).
toward smoking, susceptibility to smoking, and smoking
behaviors (O’Connell et al. 1981; Chapman and Fitzgerald
1982; McNeill et al. 1985; Charlton 1986; Potts et al. 1986; Marketing Expenditures
Aitken et al. 1987; Goldstein et al. 1987; Aitken and Eadie
1990; Botvin et al. 1991; DiFranza et al. 1991; Klitzner et al. E-cigarette manufacturers currently are not
1991; Pierce et al. 1991; Botvin et al. 1993; Hastings et al. required to report marketing expenditures to any regu-
1994; Pierce et al. 1994; Coeytaux et al. 1995; Evans et al. latory agency (Boxer et al. 2013; Federal Register 2015).
1995; Pierce and Gilpin 1995; Richards et  al. 1995; Slade Using proprietary data from Kantar Media, however,
et al. 1995; Unger et al. 1995; Pollay et al. 1996; Schooler Kornfield and colleagues (2015) tracked marketing expen-
et al. 1996; Gilpin and Pierce 1997; Lam et al. 1998; Feighery ditures (television, print, radio, and Internet) back to 2008
et al. 2006). A review of these and other studies led the 2012 for approximately 130 e-cigarette brands (note that many
Surgeon General’s report to conclude that exposure to adver- e-cigarette products are not branded, and thus these data
tising causes the initiation of smoking (USDHHS 2012). are not complete). Kornfield and colleagues (2015) found
In general, product marketing is designed to minimal spending through 2010, followed by an accelera-
inform people about the products being offered (and thus tion in spending from $12 million in 2011 to $125 mil-
develop brand “awareness”) and to persuade people to lion in 2014 (Figure 4.5). Not shown in the figure is that
buy particular brands (i.e., develop brand “preference”). in 2012, more than 60% of advertising expenditures were
Branding is particularly important for products consid- for blu (then owned by Lorillard, now Imperial Tobacco),
ered to be “commodities,” such as conventional ciga- which was the market leader (Kornfield et al. 2015). The
rettes and e-cigarettes, where the offerings are similar trajectory for spending was consistent with the pattern for
and branding differentiates the products (Rossiter and product sales, particularly for the most dominant brands
Bellman 2005; NCI 2008). Marketing is particularly crit- (Figures 4.1 and 4.5).
ical for e-cigarettes, as new products must be introduced Annual marketing expenditures for conventional
to potential users (Sethuraman et al. 2011). cigarettes ($9.2 billion in 2012) dwarf the $125 million in
Like marketers of conventional cigarettes, mar- 2014 for e-cigarettes (Federal Trade Commission 2015a,b;
keters of e-cigarettes use a number of channels and tactics

Activities of the E-Cigarette Companies   157


A Report of the Surgeon General

Kornfield et al. 2015). However, the available data about Magazine and Print Advertising
e-cigarette marketing also underestimate total mar-
Print has been the dominant channel for tracked
keting expenditures. Not included are expenditures for
expenditures of traditional e-cigarette advertising, rep-
retail marketing, social media, and sponsored events, all
resenting 84% of annual expenditures in 2014 (Kornfield
of which are essential components of the industry’s inte-
et al. 2015; Figure 4.5). A study by Richardson and col-
grated marketing strategy. In the absence of regulation,
leagues (2014) collected U.S. advertisements for all
television advertising for e-cigarettes will continue, as
noncombustible tobacco products (i.e., e-cigarettes, snus,
the two largest tobacco companies moved promotions of
dissolvables, and chew/dip/snuff) for a 3-month period in
MarkTen (Altria) and VUSE (Reynolds American) from test
2012 through Mintel, which tracks direct mail and opt-in
markets to national distribution in 2014 (Kornfield et al.
e-mail ads, and Competitrack, which monitors 21  other
2015; Truth Initiative 2015; Cantrell et al. 2016).
media sources. Metadata for identified ads showed adver-
Tobacco marketing and surveillance systems—
tising for e-cigarettes in print, television, radio, online,
including the Trinkets & Trash archive maintained by
direct mail, and e-mail. The three most common media
the Rutgers University School of Public Health and the
were print, television, and e-mail, and spending was
Stanford Research into the Impact of Tobacco Advertising
highest for print ads (Richardson et al. 2014). An anal-
(SRITA) research group—collect examples of e-cigarette
ysis of industry marketing data by the American Legacy
advertising and promotions and make these available to
Foundation (now called Truth Initiative) reported that
users through image-rich websites (see Trinkets & Trash
47% of U.S. teens (12–17 years of age) and 82% of young
[http://www.trinketsandtrash.org] and Stanford Research
adults (18–21 years of age) were exposed to magazine
into the Impact of Tobacco Advertising [http://tobacco.
advertising for e-cigarettes in 2014; popular venues
stanford.edu/tobacco_main/index.php]).

Figure 4.5 Quarterly promotional spending for e-cigarettes, 2010–2014

Source: Data for 2010–2013 (Q2) from Kornfield and colleagues (2015, p. 110) and adapted with permission from BMJ Publishing
Group Limited. Data for 2013 (Q3)–2014 from Kantar Media (unpublished data).

158   Chapter 4
E-Cigarette Use Among Youth and Young Adults

included tabloids, entertainment weeklies, and men’s life- magazines with mostly White-male readers and, to a lesser
style magazines (Truth Initiative 2015). extent, magazines targeting White women. The analysis
Research indicates that e-cigarette advertising noted that ads were targeted to a magazine’s readership,
in magazines with high teen readership is on the rise with different ads shown in the White, male-oriented
(U.S. Congress 2014). From 2012 to 2013, the number Rolling Stone publication as compared with the female-
of e-cigarette advertisements in magazines with high dominated Us Weekly.
youth readership was four times the number in magazines
with high adult readership (U.S. Congress 2014). Recent Television Advertising to Youth and Young Adults
studies using data from Kantar Media and GfK MRI (the
The increasing frequency and reach of advertising
latter measures media audiences and consumer insights;
on television raises concerns about the potential impact of
see http://www.mri.gfk.com) on e-cigarette advertise-
promoting nicotine products and renormalizing smoking
ments show that blu led all e-cigarette brands in magazine
through that medium, particularly for youth (Hodge Jr
advertising and that respondents had the highest recall of
2013; Duke et al. 2014; Grana and Ling 2014). At least
blu advertisements (Legacy for Health 2014).
40 unique advertisements for e-cigarettes appeared on U.S.
A content analysis by Banerjee and colleagues (2015)
television in 2013 and early 2014 (Farrelly et al. 2015). For
of print magazine tobacco ads for 2012–2013, using data
example, e-cigarette ads were featured in the Super Bowl
collected from Kantar Media, identified 171 e-cigarette
broadcast, which reached an estimated audience of more
ads over this period, 27 of which were unique. Ads were
than 100 million persons in 2012 (Deans 2012). The Truth
found in 24 magazines, 11 of which had been identified in
Initiative (formerly the American Legacy Foundation)
prior studies as having youth and young adult readerships
found that in 2014, television advertising reached sim-
greater than 2 million per year or for which the teen por-
ilar proportions of youth (62% of 12- to 17-year-olds) and
tion of the audience was more than 10%. By number, ads for
young adults (64% of 18- to 24-year-olds) (Truth Initiative
e-cigarettes were second only to those for conventional cig-
2015). Using proprietary data from Nielsen, Duke and
arettes and higher than the numbers for moist snuff, cigars,
colleagues (2014) estimated that 50% of U.S. youth
and snus. Eighty-five percent of the content in e-cigarette
were exposed to e-cigarette ads on television in 2013
ads focused more on a theme of logos (i.e., logic or facts to
and that 80% of this advertising was for blu (Lorillard,
support a position) than on a theme of emotional appeal.
now Reynolds American). On average, those exposed
In examining persuasive themes, the study found
saw 21  ads between October 2012 and September 2013.
that ads used several approaches, including highlighting
Between 2011 and 2013, exposure to e-cigarette adver-
the conventional advantages of the product—such as
tising on television increased dramatically, by 321% for
a  focus on customer satisfaction—and emphasizing the
young adults (18–24  years of age) and 256% for adoles-
quality of the product or price (85.2%) (Banerjee et al.
cents (12–17 years of age) (Duke et al. 2014).
2015). The ads also used the comparative approach, such as
The same study (Duke et al. 2014) found that
portraying the product as being different from other prod-
more than 75% of the exposure of youth to e-cigarette
ucts, being smokefree, or being exempt from use in areas
ads occurred on cable networks. The study found televi-
where conventional cigarettes are prohibited. Figure 4.6
sion ads for several different brands—including blu, FIN,
shows examples of the claims in e-cigarette marketing.
Starfire, and NJOY—during a 9-month period in 2013.
In terms of images, 100% of the ads included the brand
The most widely aired ad was for blu, featuring a celeb-
name and an image of the product. In addition, ads were
rity and closing with the tagline “we’re all adults here. It’s
most frequently full-page advertisements (89.9%), usu-
time to take back your freedom” (Duke et al. 2014, p. 6).
ally placed the product in a way that drew attention to it
(92.6%), and most often used six or more colors (85.2%),
Sponsorships
which the authors noted increases the attention-grabbing
ability of the ads (Banerjee et al. 2015). After the Master Settlement Agreement in 1998,
A different content analysis of magazine ads for sponsorship of events with a significant youth audi-
e-cigarettes, this one for a 3-month period in 2012 ence, such as concerts and athletic events, was banned
(Richardson et al. 2014), found health-related themes and for conventional cigarettes. However, e-cigarettes do not
non-health-related attributes—such as romantic, sexual, fall under these parameters, and recalling the early mar-
or sociability content, with the highlighting of taste as the keting of conventional cigarettes, e-cigarette brands have
most frequent selling proposition (see Figure 4.6, parts used sponsorships to increase the awareness and appeal
B–D for examples). All ads in this analysis were found of their label and product. For example, in 2011 blu spon-
to contain links to a product’s website. When examined sored a NASCAR driver and had its own car in some races
by readership, e-cigarette ads were found to have run in (PRNewswire 2011). Additionally, blu has handed out free

Activities of the E-Cigarette Companies   159


A Report of the Surgeon General

Figure 4.6 E-cigarette marketing claims


A. Freedom B. Health

Source: Esquire (2014). Source: Stanford Research into the Impact of


Tobacco Advertising (n.d.b.).

C. Romance, sexuality, or sociability

Source: (Left) Maxim (2012), (middle) Men’s Journal (2014), and (right) Sports Illustrated (2014).

160   Chapter 4
E-Cigarette Use Among Youth and Young Adults

Figure 4.6 Continued


D. Taste E. Smoking cessation

Source: Soap Opera Digest (2013). Source: Rolling Stone (2013).

F. Use in smokefree environments G. Product engineering

Source: Rolling Stone (2012). Source: Rolling Stone (2015).

Activities of the E-Cigarette Companies   161


A Report of the Surgeon General

Figure 4.6 Continued


H. Cleaner than cigarettes I. Save money

Source: Car and Driver (2014). Source: FIN Electronic Cigarettes (n.d.).

J. Circumvent smokefree policies

Source: Spin (2012).

162   Chapter 4
E-Cigarette Use Among Youth and Young Adults

samples during large events and has even sponsored events number are online stores that sell many brands and vari-
at music festivals (PRNewswire 2013; blu eCigs 2014). eties of products (Zhu et al. 2014; Williams et al. in press).
Further, conservative estimates indicate that in 2012 and Although the marketers of e-cigarettes have made
2013, free samples were provided by six companies at claims that differ from those made for conventional ciga-
348  events, most of these events having high participa- rettes (such as use for smoking cessation, which is illegal
tion by youth (Durbin et al. 2014). Under the deeming rule without being an approved cessation drug or device),
published in May 2016 (currently under litigation), free a content analysis of e-cigarette marketing (Grana and
samples were banned (Federal Register 2016). Ling 2014) and the observations of tobacco marketing sur-
veillance systems point to several similarities, including
Digital Landscape for E-Cigarettes the use of young, attractive models; lifestyle claims; and
celebrities. Other claims made in e-cigarette advertising
The Internet has been widely used to promote cig-
have been used in the past by conventional cigarette
arettes, cigars, and smokeless products (Ribisl 2003;
brands (such as having fewer carcinogens, lower risk of
Freeman and Chapman 2007; USDHHS 2012). This
tobacco-related disease) or by smokeless tobacco products
medium—through websites, message forums, and social
(such as the ability to use them where smoking is prohib-
media—has been heavily used to sell and glamorize
ited) (Grana and Ling 2014). However, under the deeming
e-cigarettes and their use. Nearly all teens 13–17 years
rule that was published in May 2016, after August 8, 2016,
of age (92%) use the Internet daily, and 73% of teens
e-cigarette manufacturers cannot make modified risk
access the Internet via smartphones (Lenhart 2015). In
claims (Federal Register 2016) (although this provision
2015, a study conducted by the Truth Initiative indicated
has been challenged in pending lawsuits).
that 40% of youth (13–17 years of age) and 57% of young
Formal analyses of marketing claims of branded
adults (18–21 years of age) had seen e-cigarette adver-
e-cigarette sites that both promote and sell e-cigarettes
tising online (Truth Initiative 2015).
provide details on the types of claims made in these chan-
Price promotions are not just involved in sales at
nels. The study by Grana and Ling (2014) analyzed claims
brick-and-mortar stores; they are also offered by online
from 59 English-language websites over a 2-month period
stores and through social media. Grana and Ling (2014)
in 2011 and found four major thematic content areas:
found that 80% of websites indicated a sale price or dis-
health- and cessation-related benefits, avoiding smokefree
count, while Huang and colleagues (2014a) found that
policies, lifestyle benefits, and product-engineering claims.
34% of commercial tweets mentioned the words “price” or
Ninety-five percent of websites made explicit or implicit
“discount.” Both Facebook and Twitter provide opportuni-
health-related claims, and 64% made claims related to
ties for brands and companies to offer online coupons and
cessation, often through the use of testimonials. Almost
discounts (Discount Coupons for blu n.d.; Vapor4Life n.d.).
all (98%) included a comparison of the risks and benefits
In a study of online e-cigarette retailers, 28% of the web-
of e-cigarettes and conventional cigarettes; 95% included
sites offered a promotion, such as a discount, other free
claims that e-cigarettes are cleaner; and 93% said they
items, or a loyalty program (Williams et al. in press).
were cheaper. Claims regarding where e-cigarettes
Without age restrictions or age verification, youth can
could be used were also common—with 88%  claiming
access these websites easily and thus obtain the discount
e-cigarettes can be used anywhere, and 71% pointing to
or coupon (Williams et al. in press). However, under the
e-cigarette use as a means of circumventing clean air poli-
deeming rule, websites cannot sell e-cigarettes to youth
cies. Figure 4.6 shows advertising that exemplifies these
under the age of 18, so access will likely be curtailed as
marketing claims for e-cigarettes.
a result (Federal Register 2016). The following sections
Grana and Ling’s (2014) analysis also points to the
review three basic categories of online e-cigarette content:
common use of lifestyle-related claims, a hallmark of tra-
websites that sell e-cigarettes, manufacturer-sponsored
ditional tobacco marketing: 73% of websites contained
brand name websites, and e-cigarette promotions on
images or claims of being modern or glamorous. Websites
social media websites (including Facebook, Twitter, and
also pointed to social advantages for users of their par-
YouTube).
ticular brand: 44% of claims pointed to increased social
status and 32% to enhanced social activity, 31% suggested
Websites Selling E-Cigarettes
romantic advantages, and 22% used celebrities. Claims
Tobacco industry analysts estimate that online sales of increased social status, opportunity, and romance as
accounted for approximately 30% of e-cigarette sales well as the use of celebrities may resonate especially with
volume in the first quarter of 2015 (Wells Fargo Securities youth and young adults (Grana et al. 2011).
2015a). Some Internet vendors sell their own brands A different content analysis, this one of the mar-
exclusively (e.g., Mistic, Green Smoke), while a large keting messages of English-language branded e-cigarette

Activities of the E-Cigarette Companies   163


A Report of the Surgeon General

retail sites, examined and compared websites for two dif- 2016, due to the deeming rule, it has become illegal for
ferent time periods (May–August 2012 and December online retailers to sell e-cigarettes to those under 18
2013–January 2014) and found differences in claims between (Federal Register 2016). In a survey of purchasing by
the two timeframes (Zhu et al. 2014). In comparing claims youth, Williams and colleagues (2015) identified 98 web-
for brands available during both time periods with those sites selling e-cigarettes on which youth, 14–17 years of
that were newly available in 2013–2014, the authors found age, made purchase attempts using prepaid credit cards.
that products and advertising messages varied between the In all, 18 (of 98) order attempts failed because of technical
two samples. Brands analyzed from 2012 were significantly problems with the website or the payment system, all of
more likely than those in the later period to (a) claim that which were unrelated to age verification. Of the remaining
their products were healthier and less expensive than con- 80 orders, 75 (93.8%) were filled. Five vendors claimed to
ventional cigarettes and could be used where smoking is use a service offered by shipping companies to verify age
prohibited and (b)  indirectly claim their products were at delivery, but none actually did. Although data are not
effective for smoking cessation through testimonials and available on the proportion of youth who purchase their
other methods (Zhu et al. 2014). The study also found an e-cigarettes online versus buying them at retail outlets,
increase from one period to the next in the number of this study suggests that youth would have ready access if
branded retail websites and the number of flavors per brand they tried to purchase e-cigarettes online. The Prevent All
advertised on a website, as well as the likelihood of a web- Cigarette Trafficking Act of 2009 requires Internet sellers
site offering e-cigarette hardware and such other products of cigarettes and smokeless tobacco to, among other provi-
as e-liquids and e-hookahs or other products that did not sions, verify age of customers at the time of purchase and
resemble cigalikes (Zhu et  al. 2014). The study’s findings ensure that the deliverer checks identification at the time
suggested that the emphasis for newer brands had shifted of delivery; stop Internet sales to minors; and pay applicable
from comparing them with conventional cigarettes to a local, state, federal, and territorial taxes to reduce the price
focus on their role as new nicotine delivery systems. advantage of online sales. FDA regulation now prohibits
Williams and colleagues (in press) used a stan- the Internet sales of e-cigarettes to minors. However, there
dardized search strategy employed in their earlier study are currently no federal requirements for Internet vendors
of websites selling cigarettes (Ribisl 2003) to identify of e-cigarettes to check identification upon delivery or pay
995  English-language websites selling e-cigarettes in applicable taxes (Campaign for Tobacco Free Kids 2016).
2014. The authors performed a content analysis on the The marketing of candy and fruit flavors may be one
281  most popular websites, as judged by data on traffic. of the reasons that e-cigarettes appeal to youth (Grana
Most of the websites were based in the United States and Ling 2014; Richtel 2014a; Zhu et al. 2014). Young
(71.9%), the United Kingdom (16.7%), and China (5.3%), adults (18–24 years of age) are more likely to use flavored
and they offered a variety of products, but more sold tobacco products than are adults in the next age group
e-cigarette starter kits (92.5%) than disposables (55.2%). (25–34 years of age) (Villanti et al. 2013). Zhu and col-
Most offered flavors, with the most popular being fruit leagues (2014), who used three search engines (Google,
(79.4%), candy (75.2%), coffee (68.0%), and alcohol Yahoo!, and Bing) and various keywords from May 2012
(45.6%). Although 71.5% featured some type of health to January 2014 to identify a wide variety of e-cigarette
warning, 69.4%  claimed health advantages over other brands and flavors, found 466 brands and 7,764 unique fla-
tobacco products, and 32.7% claimed that the product vors, with 242 new flavors appearing each month. Other
helped people to quit smoking conventional cigarettes. than tobacco flavor, the most popular flavors were menthol
The sites also featured endorsements or mentions of (92.1%), fruit (84.2%), dessert/candy (79.9%), and alcohol/
celebrities using the products (Stanford Research into drinks (77.5%). Additionally, in their content analysis of
the Impact of Tobacco Advertising n.d.a.). Physicians and e-cigarette retail websites, Grana and Ling (2014) found
other health professionals provided endorsements as well. that such flavors as coffee, fruit, and candy were offered on
Elsewhere, Cobb and colleagues (2015) conducted a most sites. Further, flavors were being sold under brand
forensic analysis of websites that sold e-cigarettes and par- names similar to cereal and candy products that appeal to
ticipated in affiliate advertising on the Internet. In addi- youth, such as Wrigley’s Big Red Gum (Daniels 2015).
tion to identifying multiple layers of redirection between
online advertising by affiliates and websites selling Tobacco Industry Corporate and Brand
e-cigarettes, the authors found that online advertisements Websites
and affiliate websites included cessation claims.
Three categories of e-cigarette brands have emerged
Research suggests Internet e-cigarette vendors have
within the U.S. market: brands developed by cigarette
not routinely verified the age and identity of website visi-
manufacturers (i.e., MarkTen, VUSE), brands acquired
tors or blocked sales to minors. However, after August 8,

164   Chapter 4
E-Cigarette Use Among Youth and Young Adults

by cigarette manufacturers (i.e., blu, Green Smoke) compares and contrasts some key features of the web-
(Table 4.3), and brands that have no affiliation with a ciga- sites by manufacturer affiliation. It shows, for example,
rette manufacturer (e.g., NJOY, FIN). A content analysis that access to websites of brands developed by cigarette
of websites for these three types of brands suggested that manufacturers (or a subsidiary) was restricted to users
those developed by cigarette manufacturers may be mar- 21  years of age and older (MarkTen), and user registra-
keted more cautiously than brands acquired by cigarette tion was required (i.e., the user needed to input personal
manufacturers or brands that have no affiliation with a information such as name, address, and birthdate) for
cigarette manufacturer (Seidenberg et al. 2016). Table 4.4 VUSE. In contrast, websites for brands with no affiliation

Table 4.3 Mergers, acquisitions, partnerships, and other agreements in the e-cigarette industry
Partnerships and
Date Purchaser Acquisition target other agreements Deal sizea Geographyb
December 2011 Japan Tobacco — Ploom (partnership) Not disclosed United States
December 2012 BAT CN Creative — £40 million United Kingdom
April 2012 Lorillard blu — $135 million United States
April 2013 National Tobacco — V2 Cigs Not disclosed United States
(partnership)
August 2013 Imperial Dragonite — $75 million China
October 2013 Lorillard SKYCIG — £60 million United Kingdom
January 2014 ECIG VAPESTICK — $70 million United Kingdom
January 2014 Gilla Drinan — Not disclosed Ireland
February 2014 Altria Green Smoke — $110 million United States
March 2014 ECIG FIN — $170 million United States
April 2014 ECIG VIP — $58 million United Kingdom
June 2014 ECIG Ten Motives — $104 million United Kingdom
June 2014 PMI Nicocigs — Not disclosed United Kingdom
July 2014 ECIG Hardwire — $30 million Internet
November 2014 Japan Tobacco E-Lites — Not disclosed United Kingdom
January 2015 BreatheEcigs/DNA Breathe LLC — Not disclosed United States
February 2015 Japan Tobacco — Ploom (purchased Not disclosed United States
the intellectual
rights to some
Ploom technology)
March 2015 Gilla An undisclosed — $1.5 million United States
Florida e-liquid
company
April 2015 Japan Tobacco Logic — Not disclosed United States
June 2015 Imperial blu — $7.1 billion United States and
United Kingdom
December 2015 Gilla The Mad Alchemist — $500,000 United States,
Canada, Europe,
and United Arab
Emirates 
Source: Various news sources and companies’ websites, SEC (Securities and Exchange Commission) reports, and press releases as of
January 25, 2016.
aDeal size refers to prices at the time of the announcement, not necessarily the final transaction price.
bGeography refers to the country in which the acquisition target was registered.

Activities of the E-Cigarette Companies   165


A Report of the Surgeon General

with a cigarette manufacturer and those acquired by ciga- well (Seidenberg et al. 2016). The Green Smoke website
rette manufacturers were accessible to users 18  years of even provided a link to guide customers in finding the
age and older via self-reporting of age, with the exception proper nicotine level for their cartridges (Green Smoke
of 21st Century Smoke. In addition, VUSE e-cigarettes E-Vapor n.d.).
were not sold online (they were sold only in retail out-
lets), and they were available in a single nicotine level Social Media Promoting E-cigarettes
with limited flavor options (except for forthcoming tank
E-cigarettes have been widely promoted on social
versions), while MarkTen could be purchased online. The
media platforms such as YouTube, Twitter, Instagram, and
websites for both MarkTen and VUSE mentioned selling
Facebook; most of these social media sites do not require
flavored e-cigarettes. As far as e-cigarette brands not
age verification. YouTube is the most popular video-
having an affiliation with a cigarette manufacturer or
sharing website globally and features many e-cigarette
that were acquired by a cigarette manufacturer, all brands
videos. Luo and colleagues (2014) used various search
except Logic offered fruit, candy, or other flavors. Further,
terms to identify 196 unique videos in February 2013
all of the unaffiliated brand websites sold e-cigarettes
that were portraying e-cigarettes and found that 94%  of
online and offered multiple nicotine levels. Most websites
the videos were “pro” e-cigarettes, 4% were neutral, and
offered nicotine-free options and flavored e-cigarettes as

Table 4.4 Comparison of website access restrictions, online sales, nicotine levels, and flavors among e-cigarette
brands with no cigarette manufacturer affiliation, brands acquired by cigarette manufacturers, and brands
developed by cigarette manufacturers
  E-cigarette brands (10)
  Not affiliated with a cigarette
manufacturer: NJOY, Logic, Acquired by a cigarette Developed by a cigarette manufacturer
21st Century Smoke, FIN, manufacturer: blu and Green (or subsidiary): MarkTen and
Nicotek, and Mistic (6) Smoke (2) VUSE (2)
Website access All websites (except 21st Both sites have one-click MarkTen has age verification to restrict
Century Smoke) have one-click access or age verification to initial access to people 21 years of age
accessa or age verification to restrict initial access to people and older. Before initial access, VUSE
restrict initial access to people 18 years of age and older (blu) requires people 21 years of age and
18 years of age and older; 21st and 21 years of age and older older to register first with the website.
Century Smoke does not have (Green Smoke).
any website restrictions for
initial access.
Online sales All brands can be purchased Both brands can be purchased MarkTen can be purchased online;
online. online. VUSE cannot.
Multiple levels of Among all brands, the level Among both brands, the level of For MarkTen, the level of nicotine
nicotine of nicotine varies by product. nicotine varies by product. varies by product. VUSE e-cigarettes
Some (e.g., blu, Logic Zero, contain 4.8% nicotine (by weight).
21st Century Smoke, Nicotek) VUSE tanks, set to come out in
offer products with 0% nicotine February 2016, will have different
(by volume). levels of nicotine (Kress 2015).
Flavors (other than All brands offer a variety of Both brands offer a variety of MarkTen offers two flavors: fusion and
tobacco and/or flavors, such as fruit and candy. flavors. wintermint. VUSE offers four flavors:
menthol) crema, chai, berry, and mint (Kress
2015).
Source: Unless cited otherwise, information was obtained from the companies’ websites (January 2016): https://www.njoy.com/;
http://store.logicecig.com/; https://www.21stcenturysmoke.com/; https://www.fincigs.com/; http://www.nicotekecigs.com/;
http://www.misticecigs.com/; http://www.blucigs.com/; https://www.greensmoke.com/; https://www.markten.com/; and
https://vusevapor.com/.
aWith “one-click access,” visitors to a website self-report on their age by identifying their age from a clickable pop-up box. For
example, persons 18 years of age and older can browse the website, but those younger than 18 cannot.

166   Chapter 4
E-Cigarette Use Among Youth and Young Adults

2% were “anti” e-cigarettes. Those authors found that Sponsored Online and Video Advertising
the three most common genres were advertising of prod-
The study by Richardson and colleagues (2015)
ucts, user sharing, and product reviews. Of the “pro”
used information from the monitoring service
e-cigarette videos, 84.3% featured links to websites selling
Competitrack to analyze the volume and characteristics of
e-cigarettes, and 71.4% claimed that e-cigarettes were a
industry-sponsored tobacco and e-cigarette online banner/
healthier alternative to conventional cigarettes. Finally,
video advertisements in the United States and Canada in
the “pro” videos received more visits and were rated more
2012–2013. This study found that online banner/video
favorably than were the small number of “anti” videos.
advertising—which embeds an ad or video on a web-
The authors of another study, this one a content
site—was more commonly used for e-cigarettes than
analysis of 365 e-cigarette videos on YouTube that ran at
for conventional cigarettes. E-cigarette ads were often
some time from June 2007 to June 2011, estimated that
placed on music or entertainment (39.1%) sites, which
more than 1.2 million youth and a total of 15.5 million
the authors noted attract a sizeable number of youth and
people worldwide were exposed to these videos (Paek
young adults. The most frequent theme for the 24 online
et al. 2014). In addition to looking at viewership, the con-
banner or video e-cigarette ads (promoting five e-cigarette
tent analysis examined the type, sponsorship, and health
brands) analyzed was that the product was more “green”
claims of the videos. Just 16% of the videos were formal
or environmentally friendly than conventional cigarettes
advertisements or news clips, and 79.2% of the content
(54.2%), followed by less harmful than cigarettes (37.5%),
was coded as appearing to have been generated by users.
and being an alternative to conventional cigarettes when
Videos emphasized economic, psychological, and social
someone could not smoke (33.3%).
benefits, and health claims included e-cigarettes being
less harmful than conventional cigarettes, healthy, and
providing help in quitting smoking. Most (85.2%) videos
in the sample were sponsored by e-cigarette companies E-Cigarettes in the Retail
or their associates, with an additional 10% coming from Environment
individuals who did not mention a specific website or
company. Interestingly, videos sponsored by marketers Conventional Tobacco Retailers (Convenience
contained a significantly lower level of health claims than Stores, Pharmacies, Tobacco Shops)
did those from laypeople (users) and, not surprisingly,
contained a higher level of information cues (e.g., product As of December 2015, 48 of the 50 states prohibited
contents, price, distribution channel). sales of e-cigarettes to minors (National Conference of
A cross-sectional study of Twitter, a microblogging State Legislatures 2015), but compliance of retailers with
platform, that examined more than 74,000 tweets accessed youth-access laws has not yet been studied. FDA is actively
through a licensed Twitter data provider over a 2-month enforcing the federal minimum age requirements. As of
period in 2012, found extensive marketing of e-cigarettes August 8, 2016, the federal deeming rule bans the sale of
(Huang et al. 2014a). The majority of e-cigarette con- e-cigarettes to minors under the age of 18 and requires
tent during this period was advertising and promotion. photo identification for those under age 27 (Federal
In fact, 89.6% of the tweets contained commercial con- Register 2016). In the past few years, brick-and-mortar
tent (e.g., presence of branded promotional messages or retailers have surpassed the Internet as the dominant
hyperlinks to commercial websites), and only 11% iden- distribution channel for e-cigarettes. For example, after
tified as being non-sponsored or independent, reflecting Lorillard acquired blu in 2012, the number of retailers
individual opinions or experiences, or being linked to non- selling this brand increased from 13,000 to 127,000 in
promotional content. Commercial tweets most commonly just 1 year (Esterl 2012; Bannon 2013). In California,
contained price promotions and discounts (34.3%), with the proportion of licensed tobacco retailers that sold
cessation-related claims included in 10.8% and lower per- e-cigarettes increased from 12% in 2011 to 67% in 2014
centages for health or safety (Huang et al. 2014a). (Chapman 2015).
Jo and colleagues (2016), in a study of 2,847 tobacco- E-cigarettes are widely available in convenience
related tweets about price promotions and coupons, found stores, a type of establishment that 4.1 million U.S.
that e-cigarettes, not conventional cigarettes, were the teenagers visit at least once per week (Rose et al. 2014;
most frequently mentioned product (90.1%), and about Sanders-Jackson et al. 2015a). According to a 2013 state-
one-third of all e-cigarette-related tweets included a dis- sponsored survey that included a sample of approximately
count code. The tweets also touted the relatively low price 7,300 licensed tobacco retailers in California, e-cigarettes
of e-cigarettes and made comparative claims about the were sold in more than half of convenience stores, phar-
health risks of the product. macies, and liquor stores and in nearly all tobacco shops

Activities of the E-Cigarette Companies   167


A Report of the Surgeon General

(California Department of Public Health and California studies, which used data collected in two studies that used
Tobacco Control Program 2014). independent samples of U.S. tobacco retailers, the odds
Only three studies have examined the retail avail- of selling e-cigarettes were greater for retailers in states
ability of e-cigarettes near schools. In a 2012 nationally with weaker smokefree air policies, even after control-
representative sample of tobacco retailers, the presence of ling for store type, price of conventional cigarettes, and
a public school within 1,000 feet was not related to the neighborhood demographics (Rose et al. 2014). A similar
availability of e-cigarettes (Rose et al. 2014). In a study inverse relationship was found between sales of dispos-
that examined a much larger buffer zone in Kentucky, able e-cigarettes (as measured by retail scanner data in
88% of schools in two counties were located within 1 mile 52  U.S. markets from 2009 to 2012) and the proportion
of a retailer that sold e-cigarettes (Hahn et al. 2015). As of the population protected by 100% smokefree policies
for colleges, disposable and/or rechargeable e-cigarettes covering all indoor areas of bars, restaurants, and work-
were available at 60% of tobacco retailers near campuses places (Huang et al. 2014b). Taken together, these results
in North Carolina and Virginia in 2013, a more than two- suggest that e-cigarettes are, at least initially, more likely
fold increase from the previous year (Wagoner et al. 2014). to be sold in communities with weaker smokefree policies.
A pilot study examining tobacco point-of-sale adver- Few retail surveillance studies have characterized
tising and promotion in the central Harlem neighborhood promotion, placement, or price for e-cigarettes (Hsu et al.
of New York City found that 26% of stores had e-cigarette 2013; Wagoner et al. 2014; Ganz et al. 2015). In a study
advertising on the building’s exterior (Ganz et al. 2015). of licensed tobacco retailers in Florida, advertising for
External ads included those located less than 3 feet above e-cigarettes was more prevalent on the exterior than the
the ground at the eye level of children—a placement that interior (50% vs. 11%) (Kim et al. 2015). In the study by
was outlawed for conventional cigarettes by the Master Wagoner and colleagues (2014), the presence of e-cigarette
Settlement Agreement—and featured flavored products advertising near college campuses in North Carolina and
(Ganz et al. 2015). Virginia tripled on store exteriors and quadrupled in store
Unlike conventional cigarettes, e-cigarettes appear interiors in just 1 year. Although the price of recharge-
to be relatively less prevalent at stores in economically able units decreased significantly, there was little evidence
disadvantaged communities. In an analysis that examined of price discounting for any e-cigarettes (Wagoner et al.
data from two studies that had used representative sam- 2014). The low visibility of price discounts at the point
ples of U.S. tobacco retailers, e-cigarettes were less likely of sale suggests that marketing for e-cigarettes favors a
to be sold than conventional cigarettes at stores located in “pull” strategy, relying on direct mail and e-mail coupons
economically disadvantaged neighborhoods and in neigh- and special offers to entice customers to retail locations.
borhoods with a higher proportion of African American
residents (Rose et al. 2014). These patterns are consistent “Vape Shops”
with evidence that e-cigarette marketing in other channels
“Vape shops” specialize in the sale of refillable devices
targets higher income non-Hispanic White males (Emery
and tank systems, typically offer a tasting menu of flavors,
et al. 2014). However, the retail availability of e-cigarettes
and sometimes feature a lounge area where customers can
has changed at different rates in different neighborhoods.
“vape” while socializing (Lee and Kim 2015; Sussman et al.
In a study of U.S. food stores, only 3% of stores located
2016). “Vape shops” have been excluded from most studies
in non-Hispanic White and Hispanic neighborhoods sold
about the retail marketing of e-cigarettes, in part because
e-cigarettes in 2010; none of the stores in predominantly
the environment is so different from that of conventional
African American neighborhoods sold them (Khan et al.
tobacco retailers (Lee and Kim 2015) and because so few
2014). Three years later, the figures were 36% in pre-
states require these establishments to obtain a tobacco
dominantly non-Hispanic White neighborhoods, 18% in
retailer license, effectively keeping them out of the sam-
Hispanic-majority neighborhoods, and 19% in African
pling frame for many studies and making the monitoring
American-majority neighborhoods. Notably, these data
and enforcement of laws difficult (Lee et al. 2014).
were collected before the two largest U.S. tobacco com-
Anecdotal evidence suggests that “vape shops” cur-
panies launched MarkTen (Altria) and VUSE (Reynolds
rently do not have readily visible branded signs and displays
American) in late 2013. Thus, the industry’s current
that characterize the retail marketing of other tobacco
influence on disparities in the retail availability and mar-
products. Even though the relationship between the “vape
keting of e-cigarettes cannot be readily estimated from the
shop” industry and the tobacco industry can be adversarial
studies reviewed.
(Sussman et al. 2016), one study found that the marketing
Two studies examined retail data about e-cigarettes
practices of these establishments closely resemble the cur-
as a function of state and/or county smokefree air laws
rent and former strategies that tobacco companies have
(Huang et al. 2014b; Rose et al. 2014). In one of the

168   Chapter 4
E-Cigarette Use Among Youth and Young Adults

used to market other tobacco products (Cheney et al. 2015). seeing ads were 59%, online; 58%, television; 71%, malls;
According to this study, “vape shop” owners and managers 41%, gas stations; and 47%, convenience stores (Pokhrel
in Oklahoma used free samples, loyalty programs, spon- et al. 2015). Elsewhere, in an online experiment, 56%
sored events, direct mail, advertising through social media, of adolescents (13–17 years of age) who had never used
and price promotions targeted at particular consumers, e-cigarettes reported seeing at least one televised advertise-
such as college students (Cheney et  al. 2015). No other ment previously, and there were modest, but statistically
study about marketing by “vape shops” has been published. insignificant differences in exposure by smoking status and
Numerous gaps exist in research about “vape shops,” race/ethnicity (p<.10) (Farrelly et al. 2015).
including information on consumer behavior, the use of The National Youth Tobacco Survey reported that in
tracking systems for sales data, marketing surveillance, 2014, 18.3 million middle and high school students were
purchases by youth, and the opinions of retailers and exposed to e-cigarette advertising from at least one source
the general public about regulations. Spatial analyses (CDC 2016b). In this nationally representative sample of
are needed to determine whether “vape shops” are clus- U.S. middle and high school students, nearly 7 out of 10
tered near schools or college campuses, whether other reported seeing an e-cigarette advertisement in that year.
neighborhood demographics are correlated with the loca- The most common places for exposure among middle
tion of these establishments, and how such associations, school students were retail stores (52.8%), the Internet
if present, have changed over time and in response to state (35.8%), television and movies (34.1%), and newspapers
and local policy interventions. The proportion of “vape and magazines (25.0%). Similarly, high school students
shops” where workers mix solutions of liquid nicotine on reported the highest exposure at retail stores (56.3%) and
site is not known, and the absence of uniform safety pre- then the Internet (42.9%), television and movies (38.4%),
cautions regarding handling and spills poses additional and newspapers and magazines (34.6%). Among both
concern for regulation (ChangeLab Solutions 2014). Under middle school and high school students, exposure through
the deeming rule that was published in May 2016, “vape retail stores was higher among non-Hispanic Whites than
shops” that mix and sell e-liquids are both retailers and non-Hispanic Blacks. However, non-Hispanic Blacks had
manufacturers and, therefore, are subject to the provisions higher exposure to e-cigarette advertisements on televi-
in the deeming rule and the Tobacco Control Act that apply sion and in movies than non-Hispanic Whites. Females
to both (Federal Register 2016). had higher exposure than males to advertisements on the
Internet and in newspapers and magazines.

Exposure and Receptivity to Receptivity to Advertising

Advertising for E-Cigarettes Receptivity to tobacco marketing is a well-established


risk factor for tobacco use by adolescents and young adults
Exposure (NCI 2008; USDHHS 2012), and two studies adapted mea-
sures of receptivity to the marketing of tobacco in research
Given industry data about increasing expenditures on e-cigarettes. In one study, college students from
for e-cigarette advertising and extending its reach, the a  southwestern state who watched three advertisements
high levels of advertising awareness reported in studies of for different brands of e-cigarettes in an online survey
youth and/or young adults are not surprising. An online used a 7-point scale to rate how enjoyable, likable, and
panel of U.S. youth (13–17 years of age) and young adults appealing the ads were; results suggested moderate recep-
(18–21 years of age) conducted in February 2014 found tivity (mean of 51 on a scale ranging from 7 to 126) and
that awareness of e-cigarette advertising was greatest for significant differences between brands (Trumbo and Kim
retail advertising, followed by awareness of advertising 2015). In the other study, Pokhrel and colleagues (2015),
on television and online (Truth Initiative 2015). In this using a sample of college students from Hawaii, adapted
study, and compared with the entire population, aware- a multi-item scale of liking advertisements from studies
ness among current smokers of e-cigarette advertising about alcohol (Unger et al. 2003) and two items from the
was higher across all channels and higher for online ads most commonly used measure of receptivity to tobacco
than for television ads (Legacy for Health 2014). marketing (Pierce et al. 1998). This study observed low
In school-based surveys of middle and high school levels of liking advertisements (all below the scale mid-
students in Connecticut, gas stations and television were point) (Pokhrel et al. 2015). The extent to which youth
the dominant channels in which students reported recently and young adults who are receptive to e-cigarette mar-
seeing e-cigarettes advertised or sold (Krishnan-Sarin et al. keting are also receptive to tobacco marketing has not
2015). A different pattern was observed in a convenience been studied. However, the extent to which advertising
sample of college students in Hawaii, where the figures for

Activities of the E-Cigarette Companies   169


A Report of the Surgeon General

strategies for e-cigarettes mimic strategies used by tobacco Surveillance research that differentiates exposure to
companies suggests that the two measures of receptivity advertising for e-cigarettes from exposure to ads for con-
could be highly correlated. ventional tobacco products would be useful to establish
whether exposure to e-cigarette advertising is correlated
with product use and contributes to product initiation and
Effect of E-Cigarette Advertising on product use among young people who were not tobacco
users to start. It bears mentioning here that a genera-
Behavior tion of U.S. youth has grown up without any television or
billboard ads for conventional cigarettes. In this context,
Associations with E-Cigarette Use and Intentions research is needed to understand at what age young people
to Use understand that e-cigarette advertising depicts the use of
Evidence that advertising for conventional ciga- e-cigarettes rather than the smoking of conventional ciga-
rettes increases product initiation among never users, rettes and to examine whether there are spillover effects
discourages quit attempts in current users, and encour- of marketing for e-cigarettes on the use of conventional
ages relapse in those trying to quit is well established (NCI tobacco products.
2008; USDHHS 2012). However, while fewer studies have In the study from Hawaii (Pokhrel et al. 2015),
focused on e-cigarette advertising in particular, the avail- researchers examined the association between exposure
able evidence suggests that e-cigarette advertising has to e-cigarette advertising and product use using a conve-
similar effects, although additional research is recom- nience sample of approximately 300 college students in
mended. A search for studies of youth or adults that either that state. The study found that more frequent exposure
(a) manipulated exposure to e-cigarette advertising or mea- to e-cigarette advertising—as measured by exposure in
sured self-reported recall of advertisements, (b)  assessed any of multiple channels (e.g., newspapers, magazines,
the frequency of exposure to advertising in one or more Internet, television billboards, sporting/cultural events,
channels, or (c) measured receptivity to e-cigarette adver- convenience stores, gas stations, grocery stores, and
tising yielded 10 studies that addressed the impact of malls)—was associated with significantly higher odds
advertising on the use of or intentions to use e-cigarettes. of ever using e-cigarettes, and receptivity to e-cigarette
One experiment tested whether seeing television advertising was associated with higher odds of past-month
advertising for e-cigarettes predisposed adolescents to try use, even after adjustments for smoking status and indi-
these products (Farrelly et al. 2015). Among adolescents vidual demographics.
(13–17 years of age) who had never used e-cigarettes, Two studies strongly support the association between
a single exposure to a set of four televised advertisements exposure to e-cigarette advertising and youth suscepti-
for popular brands resulted in significantly greater inten- bility to and use of e-cigarettes (CDC 2016a; Mantey et al.
tion to try e-cigarettes—more than 50% higher in the 2016). Both studies examined data from the 2014 National
treatment group than the control group (Farrelly et al. Youth Tobacco Survey, a survey of more than 20,000 U.S.
2015). Another study examined responses to e-cigarette middle and high school students. The studies assessed
advertisements among young adults (Trumbo and Kim self-reported levels of exposure to e-cigarette ads on the
2015); among a convenience sample of college students Internet, in newspapers and magazines, at retail stores,
who watched three television ads for e-cigarettes, greater and on television or in movies, and used multivariate
receptivity to e-cigarette advertising was associated with logistic regression models to examine the relationships
significantly higher odds of intending to use e-cigarettes between marketing exposure and e-cigarette susceptibility
in the future, but the analysis did not adjust for prior use and use. Exposure to each type of e-cigarette marketing
or individual demographics (Trumbo and Kim 2015). was significantly associated with increased likelihood of
Very few cross-sectional or longitudinal surveys have ever having used and current use of e-cigarettes among
examined associations between adolescents’ exposure to middle and high school students (CDC 2016a; Mantey et
e-cigarette advertising and either trial or regular use of al. 2016). Exposure was also associated with susceptibility
such products. An analysis of the 2011 National Youth to use e-cigarettes among current nonusers. In multi-
Tobacco Survey found that adolescents who reported fre- variate models, as the number of channels of e-cigarette
quent exposure to protobacco advertising at the point marketing exposure increased, the likelihood of use and
of sale and on the Internet (e.g., seeing ads most of the susceptibility also increased (Mantey et al. 2016).
time or always) had significantly higher odds of ever using One concern is that e-cigarette advertising may
e-cigarettes, and there was a dose-response association perpetuate dual use of conventional cigarettes and
between the number of marketing channels to which they e-cigarettes, a concern that comes from the visual depic-
were exposed and ever use (Agaku and Ayo-Yusuf 2014). tions of e-cigarette use that may serve as smoking cues

170   Chapter 4
E-Cigarette Use Among Youth and Young Adults

to current and former smokers of conventional ciga- survey of U.S. adults (the Annenberg National Health
rettes, increasing the urge to smoke and decreasing inten- Communication Survey [ANHCS]) in which surveyors
tions and efficacy to quit or abstain from smoking (Glynn measured the frequency of exposure to e-cigarette adver-
2014; Grana and Ling 2014; Maloney and Cappella 2016). tising (point of sale, mass media, and social media) and
Consistent with cue-reactivity studies about conventional the degree to which participants perceived those mes-
cigarettes, exposure to e-cigarette use in a laboratory was sages as negative or positive (Tan et al. 2015a). Compared
associated with increased urge to smoke conventional cig- with those who reported no exposure to advertising,
arettes among smokers and an urge to use e-cigarettes those who held negative perceptions of these messages
among users of that product (King et al. 2015). Whether reported significantly greater perceptions of harm from
exposure to depictions in advertising of the use of breathing e-cigarette vapor. Taken together, the available
e-cigarettes triggers urges to begin or continue to smoke evidence suggests that continued exposure to unregulated
conventional cigarettes or weakens users’ resolve to quit advertising likely promotes reduced perceptions of harm
has received little attention. This is particularly important and toxicity and increased perceptions of the efficacy of
because rates of cigarette smoking among youth in the e-cigarettes for quitting conventional cigarettes.
United States are at an historic low (CDC 2014). Whether the increasing amount of advertising and
promotional activities for e-cigarettes serves to renor-
Associations with Knowledge, Risk Perceptions, malize the smoking of conventional cigarettes—that
and Other Attitudes is, to shift public norms back to acceptance of cigarette
smoking—is also not known. In focus groups of adult
Advertising is an important source of information
smokers 45 years of age and older, participants expressed
about e-cigarettes for youth and adults (de Andrade et al.
almost unanimous agreement, after seeing selected ads,
2013; Pepper et al. 2014a), and there is emerging evidence
that e-cigarette advertisements promote smoking as
about how unregulated advertising for e-cigarettes may
a socially desirable behavior (Cataldo et al. 2015). The
influence consumer perceptions about product safety.
analysis by Farrelly and colleagues (2015) also looked at
One study of adolescents (Farrelly et al. 2015) and three
outcomes for conventional cigarettes. After exposure to
studies of adults (Pokhrel et al. 2015; Sanders-Jackson
e-cigarette advertising, there were no significant differ-
et al. 2015b; Tan et al. 2015a) examined the associations
ences between the treatment and control groups on inten-
between exposure to e-cigarette advertising and knowl-
tions to smoke conventional cigarettes, attitudes toward
edge or perceptions of these products.
those products, or perceived harm from cigarettes (even
Among U.S. adolescents (13–17 years of age) who
though there were differences between groups on their
had never used e-cigarettes, a single exposure to a set of
perceptions of e-cigarettes, as noted previously).
four televised advertisements was associated with signifi-
The study that used data from the ANHCS also tested
cantly higher odds of agreeing that the products can be
the hypothesis that greater exposure to e-cigarette adver-
used without affecting those around you and with lower
tising was associated with weaker support for restricting
odds of agreeing that the products are harmful (Farrelly
cigarette smoking in public spaces (Tan et al. 2015b). Both
et al. 2015). Compared with the control group, the treat-
more frequent exposure to e-cigarette advertising and the
ment group reported significantly more positive attitudes
degree to which participants perceived those messages as
about the benefits of using e-cigarettes. Elsewhere, in an
positive correlated negatively with support for smoking
online survey representative of U.S. households, 57% of
restrictions. However, in models adjusted for demographic
young adults (18–34 years of age) were aware that some
variables, neither measure predicted support for restricting
e-cigarettes contain nicotine, but more frequent expo-
smoking. Further research is needed to address whether
sure to e-cigarette advertising at point of sale, in mass
the large amount of advertising for e-cigarettes weakens
media, and in social media (the three variables combined)
support for smokefree air laws and other tobacco control
was associated with a significantly higher likelihood of
policies or supports other potential indicators of renormal-
answering this question incorrectly (Sanders-Jackson
izing smoking, particularly those indicators that are known
et al. 2015b).
risk factors for tobacco use by adolescents and young
In the previously cited study of college students
adults, such as descriptive norms (e.g., perceived preva-
in Hawaii (Pokhrel et al. 2015), greater receptivity to
lence), injunctive norms (e.g., peer acceptance or social
e-cigarette marketing—but not more frequent exposure
acceptability), outcome expectations (e.g., perceived bene-
to the advertising of these products—was associated with
fits), and attitudes toward the tobacco industry. Additional
significantly greater endorsement of beliefs about harm
research is also needed to assess whether e-cigarette adver-
reduction for e-cigarettes (e.g., safer, improves health,
tising that draws comparisons to conventional cigarettes
helps to quit). A  different study referred to an online
could serve to undermine antismoking messages.

Activities of the E-Cigarette Companies   171


A Report of the Surgeon General

Evidence Summary

Although the e-cigarette marketplace is complicated on the current structure of the marketplace and a regula-
by the differences in brands that are owned by tobacco tory landscape where federal regulation is just beginning
companies versus independent brands, e-cigarette com- to be implemented. All of these factors create additional
panies continue to change and to influence the manufac- uncertainties and risks for both the existing independent
turing, price, marketing and promotion, and distribution e-cigarette companies and the large cigarette companies.
of e-cigarette products and accessories. The e-cigarette This chapter has shown that many of the marketing tech-
market continues to grow, with projected sales of $3.5 bil- niques used by e-cigarette companies are similar to those
lion in 2015. Consolidation of e-cigarette companies has used by the tobacco industry for conventional cigarettes,
been rapid, with the first major merger taking place in and that awareness by youth and young adults of this mar-
2012. These mergers and acquisitions are likely to con- keting, and their levels of exposure to it, is high. Further,
tinue, but the rate of consolidation may slow down as sales tracking marketing expenditures and product sales is dif-
of cigalikes decelerate, and “vape shops” could have the ficult because of the rapidly changing venues, including
potential to influence the e-cigarette marketplace based “vape shops,” use of social media, and online advertising.

Conclusions

1. The e-cigarette market has grown and changed 3. E-cigarette products are marketed in a wide variety
rapidly, with notable increases in total sales of of channels that have broad reach among youth and
e-cigarette products, types of products, consolida- young adults, including television, point-of-sale,
tion of companies, marketing expenses, and sales magazines, promotional activities, radio, and the
channels. Internet.

2. Prices of e-cigarette products are inversely related 4. Themes in e-cigarette marketing, including sexual
to sales volume: as prices have declined, sales have content and customer satisfaction, are parallel to
sharply increased. themes and techniques that have been found to be
appealing to youth and young adults in conventional
cigarette advertising and promotion.

172   Chapter 4
E-Cigarette Use Among Youth and Young Adults

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Retailer Survey—Vapor Category Growth Remains

Activities of the E-Cigarette Companies   179


Chapter 5
E-Cigarette Policy and Practice Implications

Introduction 183

Critical Issues Related to Policies on E-Cigarettes in 2016 184


The E-Cigarette Landscape Is Dynamic and Evolving 184
Risk Tradeoffs Are Inherent for E-Cigarettes 184
Additional Evidence Suggested for Future Research 185

Potential Public Policy Approaches 187


Clean Indoor Air Policies 188
Prevent Youth Access 203
Licensing 203
Taxation and Other Price Policies 204
Restrictions on Marketing 205
Educational Initiatives 206
Implications for Health Care Practice 206

Case Studies 224

Summary and Recommendations 225

Conclusions 226

References 227

181
E-Cigarette Use Among Youth and Young Adults

Introduction

The previous chapters have set out what is currently users. Secondhand exposure comes from inhaling the
known and not known about e-cigarettes. Despite the aerosol or contacting vapor-contaminated surfaces. Each
identified gaps in evidence and the dynamic, evolving pat- of the potential negative consequences of the availability
terns of the use of e-cigarettes, policy options are needed. of e-cigarettes could lead to additional disease and prema-
These policy options are particularly important as they ture mortality (Chapter 3).
affect the use of e-cigarettes by youth and young adults. Relative to efforts in cigarette and smokeless tobacco
As this report has demonstrated, e-cigarettes are widely use prevention and control, a polarized debate has been in
used by youth and young adults and are particularly risky progress for several years over the role of e-cigarettes. There
for these age groups, and efforts to prevent their use by is general agreement that exclusive use of e-cigarettes poses
young people are needed. This chapter explores the policy a lower health risk to the individual than the extremely high
landscape of e-cigarettes and sets forth recommendations health risks of using conventional, combustible tobacco
that should protect the public’s health, particularly as products (Farsalinos and Polosa 2014; Grana et al. 2014a,b),
these policies relate to the short- and long-term health of although more research is needed on this as more becomes
youth and young adults. known about the harmful constituents of e-cigarettes
The Family Smoking Prevention and Tobacco (Sleiman et al. 2016). The controversy reflects the relative
Control Act of 2009 (or Tobacco Control Act) (2009) is degree of emphasis given to the potential harm to adoles-
meant to protect the health of the public, including young cents and young adults from using e-cigarettes at one pole
people. As previously discussed, on May 10, 2016, FDA compared with the potential for reduced risk for estab-
published a final rule which deemed all other products, lished adult users of conventional cigarettes at the other (if
including e-cigarettes, meeting the definition of a tobacco they transition completely to e-cigarettes). Although this
product, except accessories of such products, to be sub- characterization does not reflect the complexity of the sit-
ject to the Federal Food, Drug, and Cosmetic Act. This uation, it is useful in defining the potential tradeoffs that
rule went into effect on August 8, 2016 (Federal Register are implicit: increased numbers of young people who are
2016). Under the Tobacco Control Act, FDA likely will be exposed to nicotine (and who may go on to conventional
required to consider the consequences of e-cigarette use tobacco products) versus reduced health risks to individ-
for those who do not use tobacco products (as well as for uals who completely switch from conventional, combus-
those who do). tible tobacco products with their extremely high health
It can be stated that public health will be harmed if risks. The discussion has become increasingly complicated
the availability of e-cigarettes: as e-cigarette use has increased, and still-incomplete evi-
dence potentially supports the views of those holding to
• Increases exposure to nicotine among youth and both poles of the argument about reducing harm for the
young adults; overall population. However, the majority of currently
available scientific evidence does not support the recom-
• Leads to the initiation of combustible tobacco mendation to use e-cigarettes for the cessation of ciga-
smoking; rette smoking (Hartmann-Boyce et al. 2016). Additionally,
the use of e-cigarettes does not pose benefits to youth and
• Slows or prevents cessation of combustible products young adults, and some data suggest that use of e-cigarettes
by nicotine-addicted smokers; or could lead to the more harmful use of conventional ciga-
rettes. In the context of young people, the precautionary
• Increases the likelihood that former smokers will principle should apply. The precautionary principle is
again become addicted to nicotine and/or use com- defined by the United Nations Educational, Scientific and
bustible products after being reintroduced to nico- Cultural Organization (2005) as appropriate “when human
tine by e-cigarettes. activities may lead to morally unacceptable harm that is sci-
entifically plausible but uncertain, actions shall be taken to
Potential harm also comes from secondhand expo- avoid or diminish that harm” (p.14).
sure to the vapor or aerosol expelled from e-cigarette

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A Report of the Surgeon General

Critical Issues Related to Policies on E-Cigarettes in 2016

The E-Cigarette Landscape Is generally unknown, and some flavorings have been shown
to cause a serious lung disease, bronchiolitis obliterans,
Dynamic and Evolving when inhaled (Kreiss et al. 2002; Barrington-Trimis et al.
2014). Whether the risk of lung disease or other disorders
Considerations of policy approaches to e-cigarettes
is truly substantial will require longer term epidemiologic
offered in this report are made in the context of a rap-
and other research (Allen et al. 2016).
idly changing marketplace for nicotine-containing prod-
Thus, policy approaches must support control mea-
ucts that now includes primarily conventional cig-
sures that (a) are as dynamic as the rapidly changing mar-
arettes, cigars, smokeless products, hookahs, and
ketplace for e-cigarettes; (b) are supported by surveillance
e-cigarettes (see Chapter 2). The manufacture and sales
data; and (c) document in timely fashion the current status
of nicotine-containing products, once dominated by a few
of the use of multiple types of tobacco products (including
large companies selling conventional cigarettes, have been
e-cigarettes); the emergence of state, local, tribal, and terri-
transformed and now include many smaller companies
torial policies; and the strategies being used to market these
that manufacture and sell through stores and “vape shops.”
products.
E-cigarettes are also sold through websites and in places
where conventional cigarettes have long been available—
convenience stores, pharmacies, gas stations, and grocery
stores. Currently, hundreds of different e-cigarette products Risk Tradeoffs Are Inherent for
are on the market: designs are evolving rapidly, and major E-Cigarettes
tobacco companies have their own lines of e-cigarette prod-
ucts. However, unlike the situation in the past in which the Policy discussions about e-cigarettes have highlighted
marketing of conventional tobacco products changed rela- the potential tradeoffs in risk that could occur, particularly
tively slowly and there were limited media outlets, informa- if e-cigarettes are positioned as a harm-reducing alterna-
tion about e-cigarettes is now promoted quickly through tive to combustible tobacco products. Some have charac-
new media, as well as television, in part to reach key target terized these products as new technologies that might lead
groups, including youth and young adults. to a dramatic decline in the use of more dangerous forms
As documented in Chapter 2, patterns of use are rap- of nicotine delivery, particularly conventional cigarettes
idly changing among adolescents and young adults, and and other combustible tobacco products (Abrams 2014;
likely among other groups within the population. For some Cobb and Abrams 2014; Fagerström and Bridgman 2014;
of the most critical issues related to e-cigarettes, longitu- Grana et al. 2014a; Hajek et al. 2014; Henningfield 2014;
dinal data are not yet available because the use of these Schraufnagel et al. 2014; West and Brown 2014; Lindblom
products is recent and constantly changing, and whether 2015). Correspondingly, e-cigarettes have been proposed by
and when the patterns of use will stabilize is uncertain. some as a harm-reduction strategy and as a tool for smoking
Additionally, surveillance data and research on the wide- cessation, but the data to date do not support e-cigarettes
ranging consequences of e-cigarette use, including such for harm reduction or cessation (Siegel et al. 2011; Abrams
key issues as the likelihood of addiction and other health 2014). By contrast, others are concerned that the avail-
problems for users and those passively exposed, are lag- ability of these new products will expand the number of
ging behind the highly dynamic changes in the nicotine- youth and young adults who are exposed to nicotine and
product marketplace and the impact of these changes on will eventually lead to exclusive use of other conventional
the use of tobacco products, including e-cigarettes. tobacco products or dual use of both (e-cigarettes and con-
With regard to the potential health consequences of ventional cigarettes) (Leventhal et al. 2015; Primack et al.
using e-cigarettes, estimates can be made based on knowl- 2015). Early longitudinal evidence provides some support
edge of the characteristics and components of the aerosols for these concerns, although further research on this issue
that are then inhaled. Unfortunately, evidence on short- is still warranted.
term risks is limited, and long-term risks have not yet been As reviewed in Chapter 3, uncertainty remains
identified because this would require monitoring users for about the health effects of e-cigarettes, particularly in the
years. For example, the impact of long-term inhalation of long term. Such effects will remain unknown until suffi-
flavorings is not yet known. While some of the flavorings cient observations can be made over time. However, cur-
used in e-cigarettes are generally recognized as safe for rent knowledge of the characteristics of the inhaled aerosol
ingestion as food, the health effects of their inhalation are from e-cigarettes suggests that if a current adult smoker of

184   Chapter 5
E-Cigarette Use Among Youth and Young Adults

conventional cigarettes or other combustible tobacco prod- evidence from the United Kingdom does not support the
ucts would use e-cigarettes exclusively instead of combusti- concern that using e-cigarettes leads to the use of other
bles as a substitute nicotine delivery system, either en route tobacco products, and they maintain that the new adoles-
to quitting tobacco completely or even as a long-term cent users of these e-cigarette products include very few
alternative, the risks of tobacco-related diseases would be never smokers. However, the marketing of e-cigarettes is
reduced substantially compared with the risk imparted by quite different between the United Kingom and the United
continued smoking of conventional cigarettes (Fiore et al. States, and the patterns of use, particularly among youth,
2014; USDHHS 2014; McNeill et al. 2015). are also quite different (European Parliament and Council
Still, as documented in Chapter 3, immediate and 2014; England et al. 2015; Klein 2015; Leventhal et al.
future health risks for youth and young adults who use 2015; Primack et al. 2015; Barrington-Trimis et al. 2016;
e-cigarettes can be anticipated from exposure to nicotine, Wills et at. 2016; Institute for Global Tobacco Control
including addiction and harmful effects on brain develop- n.d.). This pattern is also evident in some U.S. survey
ment. Research must continue to characterize and quan- data from early in the era of e-cigarette use (as reviewed
tify the full spectrum of potential health risks. Thus, in in Chapter 2), but not in more recent data, which indi-
formulating policies related to the role of e-cigarettes cate that e-cigarette products may contribute to nicotine
in tobacco control and reducing the burden of tobacco- addiction in a new generation of young people and thereby
related disease, particularly among youth and young lead to increased use of a variety of nicotine delivery prod-
adults, e-cigarette products that deliver nicotine cannot ucts, including combustible tobacco (Bauld et al. 2016;
be considered a risk-free alternative to conventional ciga- CDC 2016).
rettes or other combustible tobacco products. Fundamentally, the public health challenge and the
Any analysis of the potential increased risks and charge to policy development can be framed as balancing
reduced harms of e-cigarette use also needs to consider the potential use of e-cigarettes as a new technology to
data on the actual patterns of use because more of the reduce the use of combustible tobacco products against
risks affect youth and young adults and most of the poten- the possibility of expanding tobacco use among non-using
tial benefits from reduced risk to health largely accrue youth and young adults, long-term former smokers, and
to older cigarette smokers (Chapter 2). However, the other vulnerable populations (e.g., women of reproduc-
reports of the tobacco industry to investors indicate the tive age and individuals with significant comorbidities,
industry’s interest in maintaining a broad pattern of use including those with mental health problems). Already, the
of nicotine-containing products, including conventional e-cigarette companies are increasing the appeal of their
cigarettes, for decades to come (Calantzopoulos 2015). offerings by enhancing the efficiency of nicotine delivery
When considered in the context of the tobacco industry’s and using flavorings while they continue to advertise and
past changes to product design (e.g., the creation of so- promote their products aggressively.
called “low-tar” cigarettes), the broader array of tobacco
products now being discussed within the tobacco indus-
try’s plans (e.g.,  “Heat-Not-Burn” products) could slow Additional Evidence Suggested for
cessation (because smokers have historically been drawn
to reduced-harm products) and thus the overall decline of Future Research
tobacco-related diseases (USDHHS 2014).
The dynamic balancing between risks and potential To characterize the critical balance for public health
benefits of e-cigarette use will be swayed by the impact of between the harms and potential benefits of e-cigarettes,
such use on the use of other tobacco products by youth more evidence on each of the elements that determine
and young adults over time. The availability of e-cigarettes that balance would be useful (Table 5.1). The needed
could adversely affect the use of tobacco products in data would come from surveillance of patterns of adop-
this group by slowing the decline of smoking because tion of e-cigarettes and their use among the popula-
this population will be exposed to nicotine and possibly tion generally, and particularly among the most critical
become addicted to that substance. Indeed, data reviewed populations for uptake: youth and young adults, former
in Chapter 2 show evidence of such trends. Although smokers, smokers, and other populations that are particu-
the decline in rates of smoking conventional cigarettes larly at risk for adverse outcomes. Few studies have been
and other combustible tobacco products is viewed uni- done on the health risks posed by e-cigarettes and their
versally as positive, the increasing number of youth and potential effectiveness for smoking cessation (Hartmann-
young adults who use e-cigarettes is a serious concern for Boyce et al. 2016). However, as discussed in Chapter 2,
all the reasons cited above. West and Brown (2014) and there are still no standardized questions for research on
McNeill and colleagues (2015) suggest that the limited

E-Cigarette Policy and Practice Implications   185


A Report of the Surgeon General

Table 5.1 Comparative risk assessment: Potential harms and benefits of e-cigarettes
Harms Benefits
Increased youth exposure to nicotine and potentially greater Reduced disease risk for current smokers who completely switch
initiation of conventional cigarettes to e-cigarettes
Slowing cessation by smokers due to nicotine addiction Reduced disease morbidity for smokers with existing heart or
lung disease who switch to e-cigarettes
Nicotine addiction in former smokers who begin to use Potential for cessation of combustible products
e-cigarettes and possibly transition back to smoking
Renormalization of nicotine use and smoking as acceptable Fewer users of combustible products in the entire population
Future disease risks for youth who are exposed to nicotine  
Increasing the dual use of e-cigarettes with combustible  
products
Serving as a “gateway” to the initiation of tobacco smoking  
Increased disease risk vs. complete cessation among those who  
use both e-cigarettes and combustible products
Exposure to secondhand aerosol and lack of clean air  

e-cigarettes, and there is a need for further testing and to nicotine through e-cigarettes are uncertain. Data are still
development of e-cigarette questions and measurements. limited on the risk of starting (or not starting) to smoke con-
To characterize the harms and benefits of e-cigarettes ventional cigarettes again (after successful cessation) fol-
to public health, models are used to project their overall lowing exposure to nicotine via e-cigarettes.
impact on public health (Levy et al. 2016). The use of mod- As reviewed in Chapter 3, the long-term health risks
eling was described in detail in the 2014 Surgeon General’s of e-cigarettes will not be known for decades, although evi-
report (USDHHS 2014). Conceptual models are needed to dence to date suggests that they are generally less harmful
define the potential scenarios of changes in patterns of use than combustible products. However, less harmful is not
among youth, young adults, adult smokers, former smokers, the same as harmless. A substantial amount of evidence
and other significant vulnerable populations. Figure 5.1 dis- is available on some components of the aerosols inhaled
plays the range of patterns that are emerging with the wider by e-cigarette users. For many people, exposure to aerosol
adoption of e-cigarettes (Cobb et al. 2015; Vugrin et al. 2015). could occur across much of the life span, beginning in
Researchers and public health officials can use dynamic adolescence and even in childhood, when the lungs and
population models (Mejia et al. 2010; Kalkhoran and Glantz brain are still developing. Flavorings are of particular con-
2015; Vugrin et al. 2015; Levy et al. 2016) to analyze the cern with regard to pulmonary toxicity, as are the various
potential impact on population health of the relative prob- effects of nicotine on the brain. Although the National
abilities of these various paths. Initial modeling has shown Institutes of Health is now supporting a growing program
that the potential population health benefits are very sensi- of research on e-cigarettes, critical questions have not yet
tive to several factors: the levels of product risk, particularly been answered. Given experiences with conventional ciga-
those of e-cigarettes; patterns of initiation and switching; and rettes, long-term studies will be needed to identify the full
the extent of dual use (Mejia et al. 2010; Cobb et al. 2015; health consequences of using e-cigarettes.
Kalkhoran and Glantz 2015; Vugrin et al. 2015). The ben- Thus, policies related to e-cigarettes will necessarily
efits of smoking cessation, particularly as early in life as pos- be made in the context of accumulating but incomplete
sible, are well documented, but the epidemiologic evidence evidence. The landscape is changing rapidly and, inevi-
that reducing (but not quitting) cigarette consumption can tably, research cannot keep pace. Quoting Sir Austin
lower the risk of all-cause mortality, or mortality from car- Bradford Hill’s landmark paper on environment and dis-
diovascular diseases, remains inconclusive (USDHHS 2014). ease: “All scientific work is incomplete—whether it be
Thus, more research is needed to better characterize the observational or experimental. All scientific work is liable
health consequences of dual use, in particular, in compar- to be upset or modified by advancing knowledge. That
ison to the recognized health benefits of complete smoking does not confer on us a freedom to ignore the knowledge
cessation (or potentially only e-cigarette use). Similarly, the we already have, or to postpone the action that it appears
health risks to former smokers who become exposed again to demand at a given time” (Hill 1965, p. 300).

186   Chapter 5
E-Cigarette Use Among Youth and Young Adults

Figure 5.1 Potential patterns of use of combustible products (CPs) and e-cigarettes (e-cigs)

Source: USDHHS (2014). Adapted for this report.

Potential Public Policy Approaches

In formulating public policies related to e-cigarettes, older and requires retailers to check the age identification
the context and possibilities vary across the national, of young people under age 27, restricts vending machines
state, local, tribal, and territorial governments and public to adult-only facilities, prohibits free samples, requires a
entities. At the national level, progressive steps are being health-warning statement about nicotine on packaging
taken by FDA under the Tobacco Control Act. In 2010, and in advertisements, requires domestic manufacturers
the U.S. Court of Appeals for the D.C. Circuit determined to register their products and disclose the ingredients
that e-cigarettes and other products made or derived from of their products, requires the reporting of the levels of
tobacco may be regulated by FDA as tobacco products harmful and potentially harmful constituents to FDA,
under the Tobacco Control Act and are not drugs or devices allows FDA to review any new or changed products before
unless marketed for therapeutic purposes, such as being being sold, and requires manufacturers to show scientific
an aid to smoking cessation (Sottera, Inc. v. Food and evidence that demonstrates the overall public health ben-
Drug Administration 2010). In May 2016, FDA released efit of any product before it can be marketed as a modified
its deeming rule to regulate the sale and distribution of risk tobacco product (Federal Register 2016). The Tobacco
e-cigarettes as a tobacco product (see Chapter 1) (Federal Control Act does not provide FDA with authority to impose
Register 2016). The rule is currently under litigation. The taxes on tobacco products (Bhatnagar et al. 2014; Huang
rule restricts the age of sale to those 18 years of age and et al. 2014; Tobacco Control Legal Consortium 2015) or

E-Cigarette Policy and Practice Implications   187


A Report of the Surgeon General

regulate indoor air quality (Schripp et al. 2013; Bam et al. women, as well as from the secondhand exposure of non-
2014; Bhatnagar et al. 2014; Brandon et al. 2015a), occu- users to e-cigarette vapor.
pational health and safety (USDHHS 2015; Whitsel et al.
2015), or hazardous waste disposal (Chang 2014; Krause
and Townsend 2015). Clean Indoor Air Policies
FDA is not the only federal agency with potential
jurisdiction over some aspect of e-cigarettes (Table 5.2). Clean indoor air or smokefree policies prohibit
For example, the U.S. Department of Defense and U.S. the use of conventional tobacco products in indoor
Department of Veterans Affairs relate to specific popula- public places, such as worksites, restaurants, bars, and
tions, and other agencies relate to regulatory activities, such casinos. Because most of these policies predate the rise
as the U.S. Federal Trade Commission, U.S. Department of e-cigarettes, their language does not necessarily
of Transportation, and the U.S. Environmental Protection cover emissions from these products. To protect the
Agency. Some agencies have coverage over specific areas, public from both secondhand smoke and secondhand
such as the General Services Administration and the aerosol, smokefree air policies should be modernized
National Park Service. to include e-cigarettes. Such policies will maintain cur-
State, local, tribal, and territorial governments, as well rent standards for clean indoor air, reduce the potential
as private entities, may also address these and other mat- for renormalization of tobacco product use, and prevent
ters that are covered by the Tobacco Control Act (Freiberg involuntary exposure to nicotine and other aerosolized
2012), and since 2010 many actions have been taken at emissions from e-cigarettes (Ingebrethsen et al. 2012;
the nonfederal level. State and local governments may uti- Schripp et al. 2013; Goniewicz et al. 2014; Offermann
lize effective interventions that would also be expected to 2014; Schober et al. 2014). Updating existing policies to
apply to e-cigarettes: increasing the price of tobacco prod- cover e-cigarettes (and all electronic nicotine delivery sys-
ucts through taxation (Community Preventive Services tems) will eliminate the introduction of airborne toxins
Task Force 2012); creating and enforcing clean air policies into enclosed spaces and establish a uniform standard for
(Hopkins et al. 2010); and passing comprehensive laws pro- preventing the use of both combustible and electronic
hibiting sales to minors, combined with active enforcement tobacco products in public and private spaces, including
(Community Preventive Services Task Force 2001). In addi- schools, offices, restaurants, bars, casinos, and airplanes.
tion, based on evidence that new e-cigarette products may Prohibiting the use of e-cigarettes in enclosed
addict a generation of young people to nicotine (Bunnell spaces eliminates potential health risks to nonusers and
et al. 2015; CDC 2015b) and on mounting indications about ensures their right to clean air; may discourage the dual
potential harm from the use of these products in this popu- use of electronic and combustible tobacco products; sim-
lation (Flouris et  al. 2013; Barrington-Trimis et al. 2014; plifies public compliance with and enforcement of existing
Goniewicz et  al. 2014; Grana et al. 2014a; Pisinger and clean indoor air laws; facilitates reduced consumption of
Dossing 2014; Goniewicz and Lee 2015), numerous health these products; and maintains clear, comprehensive non-
organizations have called for the extension of smoking- smoking norms (Richardson et al. 2014; World Health
related policies to e-cigarettes (Association of State and Organization 2014a). As of January 1, 2016, six states
Territorial Health Officials 2014; Bam et al. 2014; Bhatnagar (Delaware, Hawaii, New Jersey, North Dakota, Oregon,
et al. 2014; Offermann 2014; Schraufnagel et al. 2014; World and Utah) had passed comprehensive smokefree indoor
Health Organization 2014a; Brandon et al. 2015a; USDHHS air laws that include e-cigarettes (CDC 2015a). These laws
2015). In the absence of causal findings that have guided prohibit smoking and the use of e-cigarettes in indoor
evidence-based tobacco control for decades, the “precau- areas of private worksites, restaurants, and bars. Sixteen
tionary principle” is relevant to decision makers as a guide additional states had prohibited the use of e-cigarettes on
to action to address e-cigarettes among youth and young some or all state property, and 475 local laws restricted
adults. This principle supports intervention to avoid pos- e-cigarette use in 100% smokefree venues (Americans for
sible health risks when the potential risks remain uncertain Nonsmokers’ Rights Foundation 2015). Nationwide, more
and have been as yet partially undefined (Bialous and Sarma than 400 local jurisdictions prohibit e-cigarette use in
2014; Saitta et al. 2014; Hagopian et al. 2015). However, the 100%-smokefree workplaces (Americans for Nonsmokers’
interventions should be appropriate to the currently per- Rights Foundation 2015). Major cities that have addressed
ceived risk for future health consequences, in this case e-cigarettes include Austin, Boston, El Paso, Chicago, Los
from e-cigarette use by youth, young adults, and pregnant Angeles, Minneapolis, San Francisco, and New York City.

188   Chapter 5
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Table 5.2 Principle federal policies and regulations of tobacco that emphasize e-cigarettes
Authority and
Agency description Current Potential
Executive Office — Executive Order 13058, issued on August 9, 1997 (EOP 1997), generally prohibits —
of the President the smoking of tobacco products in all interior space owned, rented, or leased by
(EOP) and Office the executive branch of the federal government, and in any outdoor areas under
of Management executive branch control in front of air intake ducts. The Executive Order carves
and Budget out an exception to its smoking prohibition for any residential accommodation for
(OMB) persons voluntarily or involuntarily residing, on a temporary or long-term basis,
in a building owned, leased, or rented by the federal government.
Executive Office — Executive Order 13193, issued January 18, 2001 (EOP 2001), prohibits all U.S. —
of the President executive branch agencies from promoting the sale or export of tobacco. It also
(EOP) and Office prohibits using U.S. trade initiatives to restrict tobacco marketing and advertising
of the U.S. Trade regulations in other countries, unless those regulations discriminate against U.S.
Representative tobacco products in favor of that country’s domestic tobacco products.
(USTR)
Federal Has broad 15 U.S.C. § 1335 (the “Broadcast Ban”), 15 U.S.C. § 4402(f): Prohibits advertising Prohibit the advertising of smoking
Communications regulatory power for cigarettes, little cigars, smokeless tobacco, and chewing tobacco on radio, TV, accessories, cigars, pipes, pipe tobacco, or
Commission over commercial or any other medium of electronic communication under FCC’s jurisdiction. cigarette-making machines on television;
(FCC) communication, prohibit the advertising of e-cigarettes on
including television, television; and regulate the advertising of
radio, and the tobacco products on the Internet.
Internet.
Federal Trade Publishes annual 15 U.S.C. § 46 authorizes FTC to require entities to file special reports. On an Collect sales, advertising, and information
Commission report on tobacco annual basis, FTC collects and publishes information on the practices of the on promotion expenditures from
(FTC) products. largest manufacturers of cigarettes and smokeless tobacco in the United States. e-cigarette companies and issue reports
Among other things, the information collected includes sales and, in several on same.
Reviews tobacco
categories, expenditures for marketing.
manufacturer- Take enforcement action against unfair or
proposed schedules 15 U.S.C. § 45: FTC has broad authority to prevent “unfair or deceptive” deceptive advertising of tobacco products
to rotate mandatory business practices. It is an unfair and deceptive act or practice for a firm to make or e-cigarettes.
package warnings. unsubstantiated claims, express or implied, about such matters as a product’s
efficacy, safety, or health benefits (FTC 1983).
Protects consumers.
Enforces antitrust FTC is broadly authorized to prevent companies from using “unfair methods of
laws. competition” that affect commerce. FTC uses its antitrust authority to review and
impose conditions on those proposed mergers of tobacco companies that raise
anticompetitive concerns.

E-Cigarette Policy and Practice Implications   189


A Report of the Surgeon General

Table 5.2 Continued


Authority and
Agency description Current Potential
General Services In its role as an GSA Order ADM, 5800. 1C: Smoking in GSA-occupied space and government- Clarify that existing policies include
Administration independent agency, owned or -leased vehicles assigned to GSA is prohibited “to protect GSA e-cigarettes.
(GSA) GSA manages and employees, GSA contractors, and the visiting public from exposure to tobacco
Implement a tobacco-free campus policy
maintains more smoke in the Federal workplace.” The Order prohibits smoking in or on all
in GSA-occupied space.
than 1,550 federally “interior GSA-occupied space, exterior GSA-occupied space, including courtyards,
owned buildings garages, loading docks, stairwells, rooftops and balconies, and other outdoor areas
and leases space under GSA control within 25 feet of doorways and building air intake ducts; and
in an additional government-owned or leased vehicles assigned to GSA” (U.S. General Services
7,100 buildings in Administration 2009).
the United States.
GSA manages
the federal
government’s
automobile fleet and
is the acquisition
arm of the federal
government.
Office of — While not regulatory in nature, OPM and GSA coordinate standard responses to —
Personnel frequently asked questions about the use of e-cigarettes in government facilities.
Management
(OPM)
U.S. Department Commodity and 7 U.S.C. § 30: USDA provides commodity standards for tobacco. —
of Agriculture inspection standards 7 U.S.C. § 2012: Under the Food and Nutrition Act of 2008, tobacco products
(USDA) for agricultural cannot be purchased with SNAP benefits. ENDS are included in the policy because
products. the USDA interprets ENDS to be tobacco products.
Administers SNAP 7 CFR 246.10: USDA identifies requirements for WIC-eligible foods.
and WIC programs.

190   Chapter 5
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Table 5.2 Continued


Authority and
Agency description Current Potential
U.S. Department May issue general DoD follows the smoking policy in federal facilities covered in 41 CFR 102-74.315, DoD-unified regulations on tobacco use in
of Defense (DoD) instructions and which states, “pursuant to Executive Order 13058, ‘Protecting Federal Employees common housing.
restrictions in and the Public From Exposure to Tobacco Smoke in the Federal Workplace’ it
Increased restrictions on commissary
regulating the is the policy of the Executive Branch to establish a smokefree environment for
sales.
sale and/or use of federal employees and members of the public visiting or using federal facilities.
tobacco products. The smoking of tobacco products is prohibited in all interior space owned, rented
Individual service or leased by the Executive Branch of the federal government” (Federal Register
branches may 2008, p. 77518).
expand these
Each of the armed services has issued statements clarifying that the prohibition on
regulations.
smoking tobacco products extends to the use of e-cigarettes.
Individual bases
may also draft The 2015 NDAA directs the sale of cigarettes, cigars, and chewing tobacco at
regulations. military commissaries. These items cannot be sold on military bases at prices
These typically lower than the most competitive prices in the local community. The NDAA
are based on DoD replaced Directive 1330.09 (U.S. Department of Defense 2005), which established
instructions, that tobacco prices on U.S. military bases should be no lower than 5% below the
directives, or service most competitive commercial price in the local community.
policies. DoD has
authority over Branches of the armed services have tobacco policies:
TRICARE. • U.S. Navy and Marines, Instruction 5100.13E (U.S. Navy 2002)
• U.S. Army, Army Health Promotion Policy Regulation 600–63 (U.S. Army 1996)
• U.S. Air Force, Instruction 40-102, Air Force Tobacco Policy (U.S. Air Force
2013)
TRICARE covers limited tobacco cessation counseling from any TRICARE-
authorized provider in the United States. This coverage includes up to
18 counseling sessions per quit attempt, with up to 4 individual counseling
sessions per quit attempt. Two quit attempts per fiscal year are automatically
covered, with coverage extending to a third with a doctor’s justification and
pre-authorization. TRICARE also covers tobacco cessation products, including
prescriptions and over-the-counter products, with 120 days’ use of a tobacco
cessation product per quit attempt.

E-Cigarette Policy and Practice Implications   191


A Report of the Surgeon General

Table 5.2 Continued


Authority and
Agency description Current Potential
U.S. Department Funding for tobacco In FY 2014, pursuant to 20 U.S.C. § 7131, Safe and Drug-Free Schools and —
of Education control programs Communities Act, ED awarded the first round of 5-year grant awards under
(ED) the School Climate Transformation Grant—Local Educational Agency Grants
program. These FY 2014, Year 1 grant awards provided more than $35.8 million
to 71 school districts in 23 states; Washington, DC; and the U.S. Virgin Islands.
The funds should be used to develop, enhance, or expand systems of support for
implementing evidence-based, multitiered behavioral frameworks for improving
behavioral outcomes and learning conditions among students. The goals of the
program are to connect children, youth, and families to appropriate services and
supports; improve conditions for learning and behavioral outcomes for school-
aged youth; and increase awareness of mental health issues and the ability to
respond to such issues among school-aged youth. School districts can also use
the funds to implement models for reform and evidence-based practices. Drug
prevention, including preventing tobacco use by youth, is an allowable activity.
Grantees are encouraged, as part of their local needs assessment, to measure
drug use among students along with other relevant issues and problems. This
assessment of local needs will also be used by grantees to help identify and
select the most appropriate evidence-based programs and practices. If the needs
assessment indicates that drug abuse is an issue for students, prevention of drug
abuse should be addressed by a multitiered behavioral framework.
U.S. Department Restrictions on 20 U.S.C. § 7181: The Pro-Children Act of 2001 prohibits smoking in any indoor —
of Education tobacco use facility that provides routine or regular kindergarten, elementary, or secondary
(ED) education and library, health, or day care services to children, if such services
and/or facilities are funded by the federal government, whether directly or through
state or local governments, by federal grant, loan, loan guarantee, or contract
programs.

192   Chapter 5
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Table 5.2 Continued


Authority and
Agency description Current Potential
U.S. Department Sets policies 42 U.S.C. § 1396r–8(d)(7): Tobacco cessation medications cannot be excluded from —
of Health regarding Medicaid coverage under Medicaid prescription drug benefits. Section 2502 of the Affordable
and Human coverage for tobacco Care Act amends section 1927(d)(2) of the Social Security Act by removing
Services, Centers cessation products barbiturates, benzodiazepines, and agents used to promote smoking cessation
for Medicare and counseling. from the list of drugs that a state Medicaid program may exclude from coverage or
& Medicaid otherwise restrict.
Services (CMS)
42 U.S.C. §§ 18021(a)(1)(B), 18022(b)(1): Tobacco use screening and cessation
(continues on
must be provided at no cost as an essential health benefit and a preventive benefit.
next page)
This includes Medicaid expansion plans, plans sold on insurance exchanges, and
private plans.
For youth: Tobacco cessation services are coverable as part of EPSDT, the Medicaid
benefit for children and adolescents. EPSDT provides a comprehensive array of
prevention, diagnostic, and treatment services for low-income infants, children,
and adolescents under age 21, as specified in Section 1905I of the Social Security
Act.
For pregnant women: Section 4107 of the Affordable Care Act amends
section 1905 of the Social Security Act to require coverage of counseling and
pharmacotherapy for cessation of tobacco use by pregnant women. Section
1905(bb)(2) of the Social Security Act defines the new tobacco cessation coverage
services for pregnant women as services recommended in the 2008 PHS Guideline,
or any subsequent modification of this Guideline, and such other services that
the Secretary recognizes to be effective for cessation of tobacco use by pregnant
women.
Affordable Care Act, Section 4108, Medicaid Incentives for Chronic Disease
Prevention Program: This is a grant program in which states apply for funds to
incentivize Medicaid recipients to prevent chronic disease, including through
tobacco cessation.

E-Cigarette Policy and Practice Implications   193


A Report of the Surgeon General

Table 5.2 Continued


Authority and
Agency description Current Potential
(continued from — 42 U.S.C. § 1395x (ddd): Medicare covers tobacco cessation programs (Centers —
previous page) for Medicare & Medicaid Services 2010): Effective for claims with dates of service
U.S. Department on or after August 25, 2010, CMS will cover tobacco cessation counseling for
of Health outpatient and hospitalized Medicare beneficiaries:
and Human • Who use tobacco, regardless of whether they have signs or symptoms of
Services, Centers tobacco-related disease;
for Medicare • Who are competent and alert at the time that counseling is provided; and
& Medicaid • Whose counseling is furnished by a qualified physician or other Medicare-
Services (CMS) recognized practitioner.
Intermediate and intensive tobacco cessation counseling services are covered
under Medicare Parts A and B when the above conditions of coverage are met,
subject to frequency and other limitations. Medicare covers two individual
tobacco cessation counseling attempts per 12-month period. Each attempt may
include a maximum of four intermediate or intensive sessions, with a total benefit
covering up to eight sessions per 12-month period per Medicare beneficiary who
uses tobacco. The practitioner and patient have the flexibility to choose between
intermediate (more than 3 minutes, up to 10 minutes) and intensive (more than
10 minutes) cessation counseling sessions for each attempt. Medicare beneficiaries
also have access to smoking cessation prescription medication through Medicare
Part D.
U.S. Department Sets policies 42 U.S.C. §§ 18021(a)(1)(B), 18022(b)(1): Tobacco cessation must be provided at —
of Health regarding private no cost as an essential health benefit. This includes Medicaid expansion plans,
and Human and marketplace plans sold on insurance exchanges, and private plans.
Services, Centers health plan
42 U.S.C. § 300gg-6 (Public Law 114-38): Tobacco cessation must be covered
for Medicare coverage of tobacco
in employer plans. Plans should cover two cessation attempts per year,
& Medicaid cessation products
including (1) all FDA-approved cessation medications (both prescription and
Services (CMS) and counseling.
over-the-counter) and (2) four tobacco cessation counseling sessions, including
telephone, group, and individual counseling.
42 U.S.C. § 300gg(a)(1(iv)): Tobacco users may be charged 50% more for
insurance than nonusers of tobacco.
42 U.S.C. § 300gg–4(j)-(k): Employers may reward or penalize employees by up to
50% of the cost of health care coverage based on their tobacco use, if the employer
offers a health-contingent wellness program designed to prevent or reduce tobacco
use.

194   Chapter 5
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Table 5.2 Continued


Authority and
Agency description Current Potential
U.S. Department NIH is a tobacco- NIH’s policy specifically includes e-cigarettes. In accordance with the tobacco-free —
of Health and free campus. initiative from HHS, the use of cigarettes, e-cigarettes, cigars, pipes, smokeless
Human Services, tobacco (“snuff”), and any other tobacco product is prohibited on the NIH campus
National in Bethesda, MD (NIH 2016).
Institutes of
Health (NIH)
U.S. Department The mission NIDA (2016) urges grantees to recognize that: —
of Health and of NIDA is to • Receiving funding from the tobacco industry may compromise the perceived
Human Services, advance science objectivity of their research results, which in turn could impact the overall
National on the causes and credibility of their research findings, including its interpretation, acceptance,
Institutes of consequences and implementation;
Health, National of drug use and • Acceptance of tobacco industry funds is viewed by many as contributing directly
Institute on addiction and or indirectly to the industry’s interests, and thus harmful to the public health;
Drug Abuse to apply that and
(NIDA), National knowledge to • Any connection between tobacco industry-supported research (or tobacco
Advisory Council improve individual industry scientists) and NIDA could negatively impact NIDA’s credibility and the
on Drug Abuse and public health. public’s trust in NIDA-funded research.
(NACDA) NACDA serves
crucial roles in
advising NIDA on
research priorities
and policy and
in providing a
secondary level
of review for
applications under
consideration for
federal funding.

E-Cigarette Policy and Practice Implications   195


A Report of the Surgeon General

Table 5.2 Continued


Authority and
Agency description Current Potential
U.S. Department Implements the More information about the Synar Program is available online: http://www. SAMHSA is exploring opportunities to
of Health and Synar Amendment, samhsa.gov/synar/about align the Synar regulation with the federal
Human Services, which requires statutory definition of tobacco products,
Substance Abuse states, in order to which includes e-cigarettes.
and Mental receive their full
Health Services Substance Abuse
Administration Prevention and
(SAMHSA) Treatment Block
Grant awards,
to enact and
enforce laws that
prohibit the sale
or distribution of
tobacco products to
individuals under
the age of 18.
U.S. Department Sales and use COMDTINST M6200.1B limits smoking to designated outdoor areas, prohibits use Implement a policy to enforce a ban on
of Homeland restrictions for the of tobacco by recruits, and prohibits tobacco use in any Coast Guard-controlled e-cigarette use on federal property.
Security (DHS) U.S. Coast Guard. living quarters, including common areas. This policy includes extensive sales and
DHS Management advertising restrictions, but it does not consider NRT to be a tobacco product.
Directorate-
Directive No. 06603
Smoking Policy.
U.S. Department Issues standards for Detainee smoking is prohibited in all buildings, including detainee-housing units. —
of Homeland facilities housing If smoking is permitted at a particular facility, the only designated smoking areas
Security (DHS), immigration are outside of all buildings (Immigration and Naturalization Service 2000).
Bureau of detainees
Immigration
and Customs
Enforcement
(ICE)

196   Chapter 5
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Table 5.2 Continued


Authority and
Agency description Current Potential
U.S. Department Resident health in Public and Indian Housing (PIH) Notice 2009-21 strongly encourages HUD-funded HUD’s Office of PIH published its
of Housing assisted housing public housing agencies to adopt smokefree policies in some or all of their public proposed rule on Instituting Smoke-
and Urban housing units. Free Public Housing (80 FR 71762) on
Development November 17, 2015, accepting comments
Housing Notice 2010-21 encourages owners and management agents of HUD-
(HUD) through January 19, 2016 (Federal
assisted multifamily housing to implement smokefree housing policies in one or
Register 2015). In addition to inviting
all of the properties they own or manage.
comments on all aspects of the proposed
Both notices focus on cigarettes that “burn” as their mechanism for generating rule, the notice specifically solicited public
smoke, and so their applicability to e-cigarettes is uncertain. comments on nine questions (e.g., should
the policy extend to electronic nicotine
Regarding its Weaver Building headquarters (the only building for which GSA has delivery systems, such as e-cigarettes,
designated HUD as the facility management authority), HUD follows GSA Order and/or to waterpipe tobacco smoking?).
ADM 5800.1C, GSA’s smoking policy for federal offices (U.S. General Services
Administration 2009). This GSA policy permits smoking in exterior space under Based on responses to HUD’s Request for
GSA control that is beyond “25 feet of doorways and building air intake ducts,” Information on Adopting Smoke-Free
except for “courtyards, garages, loading docks, stairwells, rooftops, and balconies.” Policies in PHAs and Multifamily Housing
The management of HUD’s other facilities, federally owned or leased, is not (77 FR 60712) (Federal Register 2012),
delegated to the Department, and so GSA makes the decision on smoking policy HUD may consider drafting a regulation
for those campuses. or notice that could prohibit smoking
in some or all HUD-assisted multifamily
housing. Such a proposal could cover
e-cigarettes.
HUD is beginning to prepare for the
adoption and implementation of a
campus-wide tobacco-free policy, which
would include e-cigarette use,
at the Weaver Building headquarters by
January 1, 2017.

E-Cigarette Policy and Practice Implications   197


A Report of the Surgeon General

Table 5.2 Continued


Authority and
Agency description Current Potential
U.S. Department ATF is given 18 U.S.C. § 2342: Under the CCTA, it is illegal to possess more than 10,000 —
of Justice, primary jurisdiction unstamped cigarettes in a state that requires a tax stamp.
Bureau of to combat cigarette
18 U.S.C. § 2343: Any person who distributes more than 10,000 cigarettes must
Alcohol, trafficking and
keep accurate records pertaining to the shipment, receipt, sale, and distribution of
Tobacco, administration
cigarettes.
Firearms and (via the CCTA) and
Explosives (ATF) to stop tobacco 18 U.S.C § 2320: Trafficking in counterfeit cigarettes.
diversion (via the
PACT). 15 U.S.C. § 375: It is illegal to ship cigarettes to a non-licensee in a state without
notifying the state taxation authority.
15 U.S.C. § 375–377: Requires online retailers to check the identification of
customers at purchase and delivery: section 375 covers definitions; section
376 covers reports to state tobacco administrators; and section 377 covers
penalties.
The Smuggled Tobacco Prevention (STOP) Act amends the IRC to restrict the sale,
lease, export or import, or delivery of tobacco production machines to persons
lawfully engaged in (1) the sale, lease, export or import, or delivery of such
machines; (2) the manufacture or packaging of tobacco products or processed
tobacco; or (3) the application of unique identification markings onto tobacco
products or processed tobacco packages.
U.S. Department BOP has authority 28 C.F.R. § 551.162: Smoking is generally prohibited in and on the grounds of BOP Operations Memorandum 006-
of Justice, to govern the BOP institutions and offices, with exceptions for smoking as part of an authorized 2015 (BOP 2015) sets out guidelines
Bureau of control and inmate religious activity, and for smoking only in smoking areas designated by the for e-cigarette use. Guidelines state
Prisons (BOP) management warden, for BOP staff and official visitors. that e-cigarette use is to be limited
of federal penal to designated outdoor areas that are
28 C.F.R. § 551.163: Possession of smoking apparatus and tobacco in any form is
and correctional reasonably accessible to employees and
prohibited for inmates, unless as part of an authorized inmate religious activity.
institutions. provide a measure of protection from the
elements. These areas may only be used by
employees, but must be separate from the
areas presently designated as “smoking
areas” for use of tobacco products. Indoor
use of e-cigarettes shall not be permitted
in BOP facilities, except in perimeter
towers and perimeter patrol vehicles when
occupied by one person.

198   Chapter 5
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Table 5.2 Continued


Authority and
Agency description Current Potential
U.S. Department Sets standards for 29 CFR 1910.1000, Air Contaminants: This policy restricts employee exposure to Have smokefree workplaces. In the
of Labor, indoor air quality. several of the main chemical components found in tobacco smoke. OSHA rules 1990s, OSHA proposed a regulation
Occupational apply to tobacco smoke only in rare and extreme circumstances, such as when setting indoor air quality standards for
Safety and contaminants created by a manufacturing process combine with tobacco smoke environmental tobacco smoke, but this
Health to create a dangerous air supply that fails OSHA standards for the workplace. In rulemaking was terminated (Federal
Administration normal situations, exposures would not exceed permissible exposure limits and, as Register 2001).
(OSHA) a matter of prosecutorial discretion, OSHA will not apply the General Duty Clause
to environmental tobacco smoke.
U.S. Department Sets restrictions 49 U.S.C. § 41706: Prohibits smoking on passenger flights. In early 2016, DOT issued a final rule
of Transportation on tobacco use on (RIN 2105-AE06). In keeping with
14 CFR Part 252: DOT rule implementing 49 U.S.C. § 41706, and prohibiting
(DOT) commercial and section 41706, the rule amends Part 252
smoking on most passenger flights. DOT interprets current Part 252 to include
personal aircraft. to prohibit smoking on charter flights
e-cigarettes in smokefree policies.
where a flight attendant is a required crew
Note: FAA regulations also prohibit smoking on most aircraft from an aircraft member. The rule also makes explicit the
safety perspective, not from a health perspective (see notes to 14 CFR Part 252). determination that the use of e-cigarettes
falls within the definition of smoking.
DOT’s Pipeline and Hazardous Materials
Safety Administration has proposed a rule
to prohibit the charging of e-cigarettes in
an aircraft cabin, and to prohibit stowage
of e-cigarettes in the cargo hold of an
aircraft (this is a hazardous material/safety
rule, not a health/tobacco rule).

E-Cigarette Policy and Practice Implications   199


A Report of the Surgeon General

Table 5.2 Continued


Authority and
Agency description Current Potential
U.S. Department TTB administers the 26 U.S.C. 26 § 5701–5763, Tobacco Products and Cigarette Papers and Tubes: TTB will collaborate with foreign-
of Treasury, provisions of the Under the IRC, the tobacco products that are subject to tax and TTB regulation counterpart tax administrators to share
Alcohol and Internal Revenue are cigars, cigarettes, smokeless tobacco (chewing tobacco and snuff), pipe information and best practices in the
Tobacco Tax and Code (IRC) of 1986, tobacco, and roll-your-own tobacco. Each of these tobacco products is defined with administration of tobacco excise taxes
Trade Bureau as amended, that reference to “tobacco.” TTB also has regulatory authority over processed tobacco, and their enforcement. Areas of possible
(TTB) impose federal which is not subject to tax. TTB regulations define processed tobacco to mean technical assistance include setting up an
excise taxes on any tobacco that has undergone processing but that does not include tobacco auditing system and permitting regimen
tobacco products products. The processing of tobacco includes, but is not limited to, stemming and conducting investigations.
and cigarette (i.e., removing the stem from the tobacco leaf); fermenting, threshing, cutting,
TTB’s tobacco laboratory provides
papers and tubes, or flavoring the tobacco; or otherwise combining the tobacco with nontobacco
technical assistance to TTB program
and it establishes ingredients.
offices on tobacco products for regulatory
a comprehensive
To protect revenue, the IRC and its implementing regulations establish compliance and enforcement purposes.
civil and criminal
qualification criteria to engage in businesses related to manufacturing, importing, TTB’s tobacco laboratory develops and
framework to
or exporting tobacco products or in manufacturing or importing processed validates analytical methods and protocols
protect the revenue.
tobacco, and they require that persons obtain permits to engage in these activities. on tobacco products. It also collaborates
Among other issues, Under the IRC, manufacturers of tobacco products and export warehouse with national and international tobacco
TTB investigates proprietors must file a bond that relates to the tax liability for the tobacco regulatory federal agencies and has
illegal production, products on the premises covered by the permit. The IRC and implementing established a collaborative partnership
underreporting regulations also include recordkeeping and reporting requirements designed to with the World Health Organization’s
of production, ensure that TTB can verify that the tax on tobacco products is paid or determined Tobacco Laboratory Network and the
smuggling or that adequate documentation exists to confirm that a tax exemption applies. North America Tobacco Regulatory
or unlawful The IRC also provides TTB with certain enforced-collection options (e.g., liens and Laboratory Network.
importation, levies), civil and criminal penalties, permit suspension and revocation procedures,
and diversion of and forfeiture provisions to ensure that the tax is collected.
domestic tobacco
ENDS that do not contain nicotine derived from tobacco are not tobacco products
products intended
under the IRC and are not subject to taxation or TTB regulation. ENDS containing
for export.
nicotine derived from tobacco may meet the definition of a tobacco product under
the IRC, in which case they would be regulated by TTB and taxed accordingly.

200   Chapter 5
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Table 5.2 Continued


Authority and
Agency description Current Potential
U.S. Department Can restrict the Public Law 102-585: Requires medical centers, nursing homes, and domiciliary Include language about restrictions on the
of Veterans use of e-cigarettes care facilities of the Veterans Health Administration to establish smoking areas for use of e-cigarettes in local and national
Affairs (VA) and combustible patients and residents in a way that is consistent with medical requirements and guidance regarding smokefree policies.
cigarettes on facility limitations.
grounds of the
Veterans Health
Administration to
designated outdoor
smoking areas only.
U.S. Department Provides evidence- 38 CFR Part 17: Eliminated in 2006 the copayment for smoking cessation Continue to provide clinical guidance
of Veterans based tobacco counseling for veterans in care facilities of the Veterans Health Administration for the health care professionals and
Affairs (VA) cessation treatment (Federal Register 2006). patients in facilities of the Veterans Health
to veterans Administration on the evidence base of
receiving care in (a) potential health effects of e-cigarettes
the VA health care and (b) comparisons to FDA-approved
system. NRT for cessation treatment.
U.S. Sets policies Nicotine is a commercial chemical product listed in 40 CFR 261.33(e) and is an —
Environmental regarding the acute hazardous waste (EPA waste code P075) when disposed. EPA has concluded
Protection hazardous that nicotine is the sole active ingredient of the e-liquid in e-cigarettes and thus
Agency (EPA) waste status of a commercial chemical product, that e-cigarettes are not manufactured articles,
e-cigarettes under and that e-cigarette cartridges are considered containers of nicotine. Therefore,
the RCRA. e-cigarettes may be regulated as acute hazardous waste code P075 when disposed.
If the nicotine e-liquid is legitimately recycled, it is not considered a solid
waste under 261.2 because it is considered a commercial chemical product, and
therefore it is not subject to hazardous waste regulation. E-cigarettes that are
disposed of by consumers at their residences are considered exempt household
hazardous waste under 261.4(b)(1) and are not subject to regulation as hazardous
waste under the federal RCRA regulations.
• Regulatory Citation(s): 261.2, 261.4(b)(1), 261.33.
• Statutory Citation(s): 3006 Read U.S. Code 42, Chapter 82.
Note: ATF = Bureau of Alcohol, Tobacco, Firearms and Explosives; BOP = Bureau of Prisons; CCTA = Contraband Cigarette Trafficking Act; CFR = Code of Federal
Regulations; CMS = Centers for Medicare & Medicaid Services; DHS = U.S. Department of Homeland Security; DoD = U.S. Department of Defense; DOT = U.S. Department
of Transportation; ED = U.S. Department of Education; ENDS = electronic nicotine delivery systems; EOP = Executive Office of the President; EPA = U.S. Environmental
Protection Agency; EPSDT = Early and Periodic Screening, Diagnosis and Treatment; FAA = Federal Aviation Administration; FCC = Federal Communications

E-Cigarette Policy and Practice Implications   201


A Report of the Surgeon General

Table 5.2 Continued


Commission; FDA = Food and Drug Administration; FTC = U.S. Federal Trade Commission; FY = fiscal year; GSA = General Services Administration;
HUD = U.S. Department of Housing and Urban Development; ICE = Bureau of Immigration and Customs Enforcement; IRC = Internal Revenue Code; NACDA = National
Advisory Council on Drug Abuse; NDAA = National Defense Authorization Act; NIDA = National Institute on Drug Abuse; NIH = National Institutes of Health;
NRT = nicotine replacement therapy; OMB = Office of Management and Budget; OPM = Office of Personnel Management; OSHA = Occupational Safety and Health
Administration; PACT = Prevent All Cigarette Trafficking Act; PHS = Public Health Service; PIH = Public and Indian Housing; RCRA = Resource Conservation and
Recovery Act; SAMHSA = Substance Abuse and Mental Health Services Administration; SNAP = Special Supplemental Nutrition Program; TTB = Alcohol and Tobacco Tax
and Trade Bureau; U.S.C. = United States Code; USDA = U.S. Department of Agriculture; USTR = U.S. Trade Representative; VA = U.S. Department of Veterans Affairs;
WIC = Women, Infants, and Children.

202   Chapter 5
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Prevent Youth Access (ChangeLab Solutions 2012). Repeat violators of relevant


laws may be subject to suspension or permanent revocation
Ensuring that laws on youth access include of their license, an outcome that provides a strong incentive
e-cigarettes is intended to protect youth from exposure to comply with existing requirements. As in the conven-
to nicotine, which can lead to addiction and other health tional cigarette industry, licensing of e-cigarette retailers
problems. Additionally, ensuring that these laws include and manufacturers is designed in part to prevent the use
e-cigarettes helps to capture the full diversity of the of these products by youth and to facilitate safe manufac-
tobacco product landscape, including combustible, non- turing practices. Unlike traditional tobacco products, for
combustible, and electronic tobacco products. Effective which retailers sell prepackaged products and the number
strategies to deter access to e-cigarettes by youth and the of manufacturers is limited, a growing number of busi-
use of these products in this population include restricting nesses engage in both the retail sale and manufacturing of
sales of e-cigarettes to minors, requiring verification of devices and liquids used in the devices (e-liquids). Stores
age, mandating clear signage about minimum age where devoted exclusively to the sale of e-cigarettes are known as
sales take place, prohibiting the sale of e-cigarettes from “vape shops.” These shops frequently offer a social environ-
vending machines, eliminating self-service displays of ment for using products, and they may also sell food and
e-cigarettes, and actively enforcing existing laws with a beverages (Sussman et al. 2014).
focus on retailers. Compliance with laws that regulate As of April 2015, 99 cities and counties in California
the sale and distribution of e-cigarettes is facilitated by required a retailer to obtain a license to sell e-cigarettes.
requiring retailers to be licensed. To date, 46 states have The majority of these jurisdictions did so by broadening
prohibited the sale of e-cigarettes to minors younger than the definition of tobacco products to include “electronic
a specified age (National Conference of State Legislatures smoking devices” (ChangeLab Solutions 2015a). The
2015; The Council of State Governments 2015). Federally, definition was purposely broadened to include prod-
aligning youth tobacco access control regulations with ucts that do not include nicotine to decrease the com-
the statutory definition of tobacco products in the Tobacco plexity of enforcement and in recognition of the fact
Control Act, which includes e-cigarettes, could provide that e-cigarette devices are sometimes used with liquids
consistent framework to help ensure that restrictions on that do not contain nicotine but may contain marijuana
youth access to e-cigarettes are prioritized and enforced oil (The Center for Tobacco Policy & Organizing 2015a).
(Federal Register 2016). This could include modifications Licensing requirements also may be used to restrict the
to the Synar regulation, which requires states, U.S. ter- sale of flavored products or to address issues of consumer
ritories, and jurisdictions to enact and enforce laws pro- and worker safety relative to the mixing of e-liquids.
hibiting the sale or distribution of tobacco products to Imposing a moratorium is another potential
youth. Substance Abuse Prevention and Treatment Block approach that has been used in some communities to stop
Grant recipients must comply with the Synar amendment new “vape shops” from entering the market while a more
and implement regulations in order to receive their full comprehensive approach was being considered. A morato-
awards (U.S. Food and Drug Administration, Center for rium is a land-use law that takes effect immediately to stop
Tobacco Products n.d.). temporarily the issuance of a business license, building
permit, or use permit. Typically, a moratorium is enacted
to provide a jurisdiction with time to research and study
how to regulate a type of business (ChangeLab Solutions
Licensing 2015b). In California, several communities enacted mor-
atoria that are initially 45 days but can be extended for
Licensing is used to regulate professional practice
up to 2 years (ChangeLab Solutions 2014, 2015b). A four-
and business operations and represents one strategy to con-
fifths vote, however, is required to establish a moratorium
trol the rising use of e-cigarettes among youth. In general,
in California. Hayward and Union City, California, are
in the case of tobacco-related licensing, a business is autho-
examples of cities that have enacted moratoria and later
rized to manufacture, distribute, or sell tobacco products
adopted both retail licensing requirements for existing
as long as it complies with all relevant laws (McLaughlin
e-cigarette retailers and zoning restrictions to prohibit
2010). Typically, tobacco-related licensing requirements
new vapor and hookah bars and lounges from opening
for retailers and/or manufacturers help to prevent evasion
within city limits (ChangeLab Solutions 2014; The Center
of excise taxes, ensure that licensees comply with tobacco-
for Tobacco Policy & Organizing 2015b).
related laws, and promote safe manufacturing practices

E-Cigarette Policy and Practice Implications   203


A Report of the Surgeon General

Taxation and Other Price Policies type of production (handmade versus machine made),
sales volume, packaging, or whether the products are
Taxation and other price policies directed at making domestic or imported; and mixed systems use a combi-
e-cigarettes more expensive may be implemented at mul- nation of uniform and tiered-tax approaches (Shang et al.
tiple levels of government, from local to federal. Increasing 2015). Tiered-tax approaches, such as those based on nico-
the price of conventional cigarettes, including those tine content, could steer consumers to a less toxic product
increases resulting from excise taxes, significantly prevents or one with lower nicotine (Benowitz 2014). Tiered-tax
and reduces tobacco use, particularly among youth and approaches are more complex to administer and may
young adults (USDHHS 2014), and has potentially more provide greater opportunity for tax evasion as a result of
impact on prevalence of current use in this population than manipulation of the product or its packaging by the man-
on first use (Bader et al. 2011). Similarly, price policies are ufacturer (Shang et al. 2015). In recognition of nicotine’s
likely to reduce the use of e-cigarettes: a 10% increase in toxicity, particularly to youth, several health groups have
the price of e-cigarettes has been estimated to reduce sales endorsed imposing excise taxes on e-cigarettes to dis-
of disposable e-cigarettes by approximately 12% and reus- courage their use by youth (American Thoracic Society
able products by about 19% (Bader et al. 2011; Huang et al. 2013; Association of State and Territorial Health Officials
2014). Data are currently lacking on the potential effects 2014; Bhatnagar et al. 2014; Brandon et al. 2015a; Crowley
that taxing e-cigarettes might have on conventional ciga- and Health Public Policy Committee of the American
rettes. Tobacco products are taxed in two main ways: College of Physicians 2015; National Association of
County and City Health Officials 2014). E-cigarettes are
1. A “specific” excise tax is levied based on the quantity likely less toxic than combustible products (such as con-
of the product sold (e.g., as measured by number of ventional cigarettes), and therefore, some contend should
cigarettes, weight, or volume). This type of mecha- be taxed at a lower rate (Benowitz 2014; Bhatnagar et al.
nism applies the same tax across low-end and pre- 2014). Yet others argue that e-cigarettes should be taxed
mium brands and is generally simple to administer. at the same rate as other tobacco products (Freiberg 2012;
The disadvantages to specific excise taxes are that American Thoracic Society 2013; National Association of
the real value of the tax declines over time with County and City Health Officials April 2014).
inflation, making products more affordable, and As of January 2016, four states (Kansas, Louisiana,
that super-lightweight products—such as snus, Minnesota, and North Carolina) and six localities (Juneau,
orbs, sticks, and dissolvables—are grossly under- Matanuska-Susitna, Petersburg, and Sitka, Alaska;
taxed if the tax is based on weight (Freiberg 2012; Montgomery County, Maryland; and Chicago, Illinois)
Boonn 2013; Shang et al. 2015). had enacted e-cigarette taxation policies. Minnesota’s
ad valorem tobacco tax equates to 95% of the wholesale
2. The second tax mechanism is an ad valorem excise cost of any product containing or derived from tobacco
tax, which is levied on a percentage of the value of (Minnesota Revenue 2014; Tobacco Control Legal
the tobacco product (e.g., the retailer’s, wholesal- Consortium 2015). It taxes e-liquids and e-cigarettes
er’s, or manufacturer’s price). This type of tax keeps sold with nicotine cartridges that cannot be removed
up with inflation and establishes a flat tax rate across (i.e., disposables). In Minnesota, devices without a nico-
all brands, product types, weights, and packaging. tine cartridge are not taxed as a tobacco product. On the
The disadvantages to this kind of tax include the other hand, North Carolina applies a specific excise tax,
potential for tax evasion through predatory (below- taxing e-liquids based on volume at 5 cents per milliliter
cost) or anticompetitive pricing; increasing the (National Conference of State Legislatures 2015).
price differential between products with different The Tobacco Control Legal Consortium, which
pretax prices, leading to greater price variability and is based at William Mitchell College of Law in St. Paul,
more opportunity for tax avoidance; a government- Minnesota, recommends using an ad valorem tax for
provided subsidy for manufacturers’ price cuts; and e-cigarettes applied at the retail level to the “essential”
more expensive brands being subjected to a larger components of these devices. The tax is simple, captures
tax (Freiberg 2012; Boonn 2013; Shang et al. 2015). both disposable and refillable devices, and could exclude
accessories and universal parts sold separately, such
Governments use uniform, tiered, and mixed-tax as batteries or charging cords (Tobacco Control Legal
approaches to implement specific and ad valorem tobacco Consortium 2015).
excise taxes. Uniform systems apply the same tax rate Numerous major health organizations support
across all products; tiered systems levy taxes based on raising the price of e-cigarettes through non-tax options,
such product characteristics as toxicity, nicotine content, such as limiting rebates, discounts, and coupons (Freiberg

204   Chapter 5
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2012; Association of State and Territorial Health Officials federal and Master Settlement Agreement restrictions on
2014; Bhatnagar et al. 2014; Huang et al. 2014; Brandon tobacco advertising. Observations of retailers’ practices,
et al. 2015a). assessments of outdoor advertising, and identification
Finally, Chaloupka and colleagues (2015) have pro- of event sponsorships and promotional activities at bars
posed that differential taxation of tobacco products can and community events are actions that state, local, tribal,
be used to incentivize a move away from combustible and territorial public health agencies have taken related
products to less hazardous noncombustible products, to traditional tobacco products. Many of these actions
including e-cigarettes. They have argued that taxation can be adapted to monitor and document the presence of
could be part of a harm-reduction system. In their view, e-cigarette marketing in communities (Pucci et al. 1998;
future determinations by FDA as to whether a product Feighery et al. 2001; Rigotti et al. 2005; Roeseler et al. 2010;
poses a substantially reduced risk would be one criterion Rose et al. 2014).
in determining the relative rate of taxation. In the absence of legal restrictions on e-cigarette
marketing, and apart from the issue of the previous prom-
ulgation by some companies of unsubstantiated health
Restrictions on Marketing and cessation claims, public health groups can advocate
for television and radio broadcasters, print and outdoor
As described in Chapter 4, the marketing of media companies, the management of event venues and
e-cigarettes drives consumer demand for these prod- sports events, digital media outlets, retailers, and others
ucts. Such marketing also may promote misperceptions to voluntarily refuse to air or place e-cigarette advertising,
about the safety and efficacy of these products for use offer sponsorships, or give out free samples at fairs and fes-
as cessation devices (Choi and Forster 2014; Mark et al. tivals. Although the impact of a voluntary approach may
2015; Pokhrel et al. 2015). For some populations—such be low, such actions raise awareness, build concern, and
as pregnant women, adolescents, former smokers, and help to denormalize the proliferation of e-cigarette mar-
young adults—the adverse health consequences of nico- keting. In California, surveillance plus voluntary efforts
tine intake are substantial. Several groups have supported to promote restrictions on sponsorship of events by the
extending marketing restrictions that apply to conven- tobacco industry facilitated a modest decline in tobacco
tional cigarettes and other tobacco products to e-cigarettes industry-sponsored events and youth-oriented activities
(Association of State and Territorial Health Officials 2014; at those events that promoted the interests of the tobacco
Bam et al. 2014; Bhatnagar et al. 2014; Partnership for companies, and it led to a productive partnership with the
Prevention 2014; Brandon et al. 2015a). Significant bar- tobacco litigation unit of the California attorney gener-
riers still exist to regulating commercial speech, including al’s office that resulted in several settlements with tobacco
the First Amendment rights of the e-cigarette companies companies (Roeseler et al. 2010).
(Laird-Metke 2010). State, local, tribal, and territorial public health
Additionally, for traditional tobacco products, partial agencies may be able to contribute to the stimulation
advertising bans and voluntary agreements have gener- of enforcement and compliance with existing rules that
ally been ineffective in reducing consumption because the constrain marketing. Some states have brought lawsuits
tobacco industry circumvents the restrictions by shifting against e-cigarette companies, alleging that distributors
the marketing platforms used to unregulated platforms of these products violated state law by selling to minors
(National Cancer Institute 2008). This response would or making unsubstantiated health claims; some of those
be expected to be similar with regard to e-cigarettes. lawsuits resulted in financial damages and agreements to
Therefore, despite the numerous barriers, public health stop making claims that e-cigarettes are safer than con-
groups and state, local, tribal, and territorial governments ventional cigarettes unless confirmed by rigorous science
should take steps to stem the proliferation of e-cigarette (Center for Public Health and Tobacco Policy 2013).
marketing likely to appeal to young people by using tools Finally, another area to address is the use of “adver-
designed to curb youth-oriented tobacco marketing and torials” employed by e-cigarette retailers to promote
expanding evidence to inform future restrictions on the cessation and health claims. Advertorials are paid adver-
marketing of e-cigarettes to youth and young adults. tisements designed to look like an independent editorial.
Surveillance of e-cigarette marketing, performing Although there are no specific rules for how a publisher
content analyses of the messages used, and conducting should distinguish actual editorial content from paid edi-
studies to assess the link between exposure to e-cigarette torial content in terms of their appearance, the Federal
marketing and the use of e-cigarette products, particularly Trade Commission (FTC) stated in an advisory opinion
among youth and young adults, will facilitate the develop- that disclosure of the source is necessary when content
ment of an evidence base of the type that informed prior “uses the format and has the general appearance of a news

E-Cigarette Policy and Practice Implications   205


A Report of the Surgeon General

feature and/or article for public information which pur- their patients and their communities, including what are
ports to give an independent, impartial and unbiased view” the risks of using e-cigarettes, how do these risks compare
(Federal Register 1972, p. 154). Additionally, paid adver- with those of cigarettes or other combustible products,
tising must be disclosed clearly and conspicuously in a and is e-cigarette use an effective way to quit smoking?
manner that is understandable to consumers (FTC 1984). Chapter 3 set out the limited evidence base related to
State and local public health agencies can play an impor- these questions. Clinicians need to respond to these ques-
tant role by monitoring and providing substantiation to tions and guide their patients in the context of consider-
their state attorney general or FTC regarding advertising able uncertainty. At this time, practitioners can turn to
that makes improper claims or is not clearly identified as the various statements from medical organizations, which
advertising. generally urge caution regarding e-cigarettes and do not
find the evidence to be supportive of their use for cessa-
tion or for formal harm-reduction strategies (Table 5.3).
Educational Initiatives In fact, any recommendation to use e-cigarettes for the
cessation of smoking is not supported by the bulk of
The extensive data reviewed in Chapter 2 high- the available scientific evidence (Hartmann-Boyce et al.
lighted the limited knowledge that members of the gen- 2016). Both the American Association of Cancer Research
eral public, particularly adolescents and young adults, and the American Society of Clinical Oncology recom-
have about e-cigarettes and their potential for nicotine mend against advising the use of e-cigarettes for cessa-
addiction and other adverse health consequences. FDA tion (Brandon et al. 2015b). The U.S. Preventive Services
has jurisdiction for product warnings that can reach Task Force found that there is insufficient evidence that
users, but that agency, along with other federal entities e-cigarettes are an effective smoking cessation tool in
and state and local governmental and nongovernmental adults, including pregnant women (Agency for Healthcare
organizations, can also carry out educational campaigns Research and Quality 2015).
to enhance such limited knowledge levels. Potentially The clinical care setting is a critical venue for taking
effective initiatives with youth and young adults to prevent evidence-based approaches for enhancing smoking cessa-
smoking were reviewed in the 2012 Surgeon General’s tion and increasing the protection of susceptible groups
report and may be applicable to preventing e-cigarette against exposure to secondhand smoke (USDHHS 2014).
use. That report concluded that sufficient evidence exists However, research on e-cigarettes in relation to this set of
to conclude that mass media campaigns, comprehensive venues is lacking and urgently needed. Regardless, some
community programs, comprehensive statewide tobacco pragmatic approaches have been proposed. For example,
control programs, and school-based programs that have the American Academy of Pediatrics (AAP) gives advice
shown evidence of effectiveness, if they contain specific on how pediatricians can approach questioning about the
components, can produce at least short-term effects and use of e-cigarettes. As of October 2015, the AAP’s position
reduce the prevalence of tobacco use among school-aged on e-cigarettes is that sales to minors should be prohib-
youth (USDHHS 2012). ited; flavors that appeal to youth should be prohibited;
and measures against the use of e-cigarette products need
to be included in requirements for maintaining smoke-
free environments, such as in restaurants and workplaces
Implications for Health Care (AAP 2015a).
Practice
Although the issues are not well documented, health
care practitioners face questions about e-cigarettes from

206   Chapter 5
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Table 5.3 Medical organizations


A. Positions of professional organizations
Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
American — • “Concentrated nicotine solution • “The promotion and sale of electronic nicotine delivery —
Academy of for electronic nicotine delivery systems to youth should be prohibited by federal, state, and
Pediatrics systems should be sold in local regulations.”
(2015b) child-resistant containers with • “Prohibitions on promotion should include all media that can
amounts limited to that which be viewed by youth, including broadcast, print, and electronic
would not be lethal to a young (Web- or Internet-based) media.”
child if ingested.” • “Prohibitions on promotion should include prohibitions
• “Prohibitions on smoking and on sponsorships, such as sports, cultural event, and
use of tobacco products should entertainment sponsorships. Any promotional activities that
include prohibitions on use of can be accessed by children and/or adolescents should be
electronic delivery systems.” considered promoting to children.”
• “Electronic nicotine delivery systems should be subject
to the same restrictions on advertising and promotion at
least as restrictive as that on combustible cigarettes. Until
government agencies institute these prohibitions, media
companies, entertainment companies, sports teams, and
promoters should voluntarily institute these prohibitions.”
• “Celebrities should not use their privileged position to model
tobacco product use, including electronic nicotine delivery
systems and other existing or emerging tobacco products.”

E-Cigarette Policy and Practice Implications   207


A Report of the Surgeon General

Table 5.3 A Continued

Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
American • FDA has not • “The evidence regarding the • “The FDA CTP should regulate all ENDS that meet the • “There are
Association approved e-cigarettes risks and benefits of e-cigarettes statutory definition of tobacco products and their component insufficient data on
for Cancer as smoking cessation is difficult to interpret, and data parts. ENDS delivery systems and e-liquids containing health consequences
Research aids, and current on the long-term consequences tobacco-derived nicotine should be regulated whether they of e-cigarette use,
(AACR) and data are inconclusive of e-cigarette use are not yet are sold together or separately.” their value as tobacco
the American with regard to their available.” • “ENDS manufacturers should be required to register with cessation aids, and
Society of efficacy as quit- • “Chemicals and ultrafine FDA and report all product and ingredient listings, as well as their effects on the
Clinical smoking products. particles known to be toxic the nicotine concentration in the ENDS solution.” use of combustible
Oncology • “Oncologists would and carcinogenic and/or to • “ENDS packaging and advertising should be required to tobacco products
(2015) be wise to refrain cause respiratory and heart carry health warnings and safety labels—including a warning by smokers and
(continues from recommending distress have been identified in regarding nicotine addiction.” nonsmokers.”
on next e-cigarettes to e-cigarettes.” • “Youth-oriented ENDS advertising and marketing should • “Oncologists should
page) patients as a first- • “Studies find the levels of the be prohibited, including: self-service ENDS displays, the advise all smokers
line therapy for toxicants in e-cigarette aerosol provision of gifts and other giveaways with purchase of ENDS, to quit smoking
smoking cessation.” to be significantly lower than in the sale and distribution of items such as hats or t-shirts combustible
cigarette smoke and, in many with ENDS brand logos, brand name sponsorship of social or cigarettes, encourage
cases, comparable with trace cultural events, or of any team entry into those events, and use of FDA-
amounts found in a medicinal youth-oriented advertising of tobacco products.” approved cessation
nicotine inhaler. It is unclear • “Internet and other mail-order sellers of ENDS should be medications, refer
what effects these toxicants required to check the age and identification of customers at patients for smoking
might have on e-cigarette users the point of purchase and delivery; to comply with all laws cessation counseling,
after chronic and frequent use.” in the purchaser’s state or local jurisdiction; and pay all and provide
• “The vast majority of e-cigarette applicable federal, state, and local taxes.” education about
users use products containing • “Childproof caps should be required for all e-liquid the potential risks
nicotine. Nicotine is an addictive containers.” and lack of known
chemical, adversely affects • “ENDS and ENDS liquid containing candy and other youth- benefits of long-term
maternal and fetal health friendly flavors should be banned unless there is evidence e-cigarette use.”
during pregnancy, has adverse demonstrating that these products do not encourage youth
consequences for fetal brain uptake.”
development, and may adversely • “ENDS use should be prohibited in places where combustible
affect the adolescent brain. It tobacco product use is prohibited by federal, state, or local
is unclear what effect nicotine law until the safety of second- and thirdhand aerosol exposure
intake via e-cigarettes has on is established.”
health or on the addictiveness of
these products.”

208   Chapter 5
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Table 5.3 A Continued

Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
(continued — • “Data from the [CDC] showed • “Funding generated through tobacco product taxes, including —
from a significant increase in any potential taxes levied on ENDS, should be used to help
previous e-cigarette-related calls to poison support research on ENDS and other tobacco products, but
page) centers between 2010 and 2014 should not preclude the allocation of federal funding for this
American as a result of accidental ingestion research.”
Association or absorption of e-cigarette • “All data related to ENDS composition, use, and health effects
for Cancer liquid.” should be disclosed for dissemination and independent review
Research • “Secondhand exposure to as well as to enhance policy decisions for ENDS product
(AACR) and toxicants and nicotine from regulation.”
the American e-cigarette aerosol has been • “Tobacco products should be taxed proportionate to their
Society of documented, though there are harm; therefore, ENDS should not be taxed at equal or higher
Clinical not current data suggesting rates than combustible cigarettes.”
Oncology that exposure to the aerosol has • “State and local governments should implement ENDS
(2015) adverse health effects.” regulations within their authorities that are appropriate for
• “There are no published protecting the public health, including restricting the sale,
studies evaluating thirdhand distribution, marketing, and advertising of ENDS to youth.”
(i.e., residue that builds up on • “International cooperation is needed to develop standards
surfaces over time) exposure for the regulation of ENDS, and these regulations should
to e-cigarette aerosol in indoor prioritize protection of the public’s health and draw upon the
environments, although best available scientific evidence whenever possible.”
preliminary data suggest that
nicotine from e-cigarettes can
stick to surfaces.”
American • “Even though the • “There is no evidence as to the — • Date effective: April
Association concept of using amount of nicotine or other 2014
for the e-cigarettes for potentially harmful chemicals • “The [AARC] opposes
Respiratory smoking cessation being inhaled during use or if the use of the
Care (AARC) is attractive, they there are any benefits associated electronic cigarette
(2015) have not been fully with using these products.” (e-cigarette).”
studied and the
use among middle
school children is
increasing year after
year.”

E-Cigarette Policy and Practice Implications   209


A Report of the Surgeon General

Table 5.3 A Continued

Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
American • “ENDS, which • “[There is concern] that the • “The Food and Drug Administration [should] extend its • “The [ACP] supports
College of include electronic health effects of ENDS use are regulatory authority granted through the Family Smoking strong regulations to
Physicians cigarettes, or unknown, that they may appeal Prevention and Tobacco Control Act to cover electronic ensure product safety
(ACP) e-cigarettes, to young people, and that they nicotine delivery systems (ENDS).” and transparency,
(Crowley are growing in may encourage dual use of • “Characterizing flavors should be banned from all tobacco policies that prevent
and Health popularity, but their ENDS and traditional tobacco products, including ENDS.” use among young
Public Policy safety and efficacy as products.” • “The [ACP] supports taxing tobacco products, including people, increased
Committee a smoking cessation ENDS devices and nicotine liquids, to discourage use among research to better
of the ACP aid are not well children and adolescents. Local governments should be determine their
2015) understood.” permitted to establish higher tax rates for ENDS and related health effects, strong
products than state levels.” limits on marketing
• “The [ACP] supports legislative or regulatory efforts to and promotion to
restrict promotion, advertising, and marketing for ENDS discourage interest
products in the same manner as for combustible cigarettes, among young people,
including a prohibition on television advertising.” and application of
• “Youth tobacco prevention efforts, such as antismoking media indoor air laws to
campaigns and school-based interventions, should include protect the health of
information about the potential risks of ENDS use.” bystanders.”
• “The federal, state, and local regulators should take action to • “This paper is not
extend indoor and public place clean air laws that prohibit intended to offer
smoking in public places, places of employment, commercial clinical guidance or
aircraft, and other areas to ENDS products.” serve as an exhaustive
• “The federal government should authorize and appropriate literature review
funding to rigorously research the health effects of ENDS of existing ENDS-
use, chemical content, and toxicity; effects of ENDS vapor related evidence but
exposure; dual-use rates; and effects of ENDS-derived nicotine to help direct the
on human health.” [ACP], policymakers,
and regulators on
how to address these
products.”

210   Chapter 5
E-Cigarette Use Among Youth and Young Adults

Table 5.3 A Continued

Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
American • “The new CDC • “The short- and long-term health • “States should regulate e-cigarettes as tobacco products. • “[E]-cigarettes need
Thoracic data show that Big risks of these nicotine-delivery E-cigarettes should not be sold to those younger than 18, and to be subject to the
Society Tobacco is once devices are largely unknown.” regulations requiring identification and proof of age at the same marketing
(2013, 2015) again peddling a new time of purchase should apply. Internet sales of e-cigarettes and manufacturing
(continues product intended to should be strictly regulated.” restrictions as
on next get youth hooked • “E-cigarettes should be taxed at rates equivalent with tobacco products.”
page) on nicotine, and traditional cigarettes and other tobacco products.” • “For the first time,
that e-cigarettes • “E-cigarettes should be subject to the same restrictions e-cigarette use
are not about regarding public use as combustible tobacco products, and among young people
harm reduction or e-cigarettes should not be used in smoke-free areas.” is higher than for
smoking cessation, • “The FDA should deem regulatory authority over any other tobacco
but about addiction.” e-cigarettes.” product.”
• “Candy and menthol flavored e-cigarettes should be banned.”
• “E-cigarette packaging should include warning labels, similar
in size and scope to those required of combustible tobacco
packaging. Where risks are known, the consumer should be
informed of those risks in clear and direct language. Where
data regarding risk is [sic] unavailable or inconclusive, the
consumer should be informed of the lack of reliable safety
testing data.”
• “The FDA should regulate the form and content of e-cigarette
advertising.”
• “Both direct and implied health and safety claims by
e-cigarette manufacturers should be subject to the same
evidentiary review process currently required for other
products making such claims.”
• “The FDA should require e-cigarette manufacturers to adopt
Good Manufacturing Processes similar to those that exist for
other regulated products, including lot numbers, securing
packaging, etc.”
• “Given that nicotine is an addictive drug, with the dependence
liability related to the pharmacokinetic characteristics of
the delivery device, delivery characteristics of the e-cigarette
should be evaluated and disclosed, and periodically monitored
to ensure consistency of the product’s dependence potential
over time.”

E-Cigarette Policy and Practice Implications   211


A Report of the Surgeon General

Table 5.3 A Continued

Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
(continued — — • “Content of e-cigarette cartridges should be disclosed and —
from regulated.”
previous • “The nicotine content of the e-cigarette cartridge should not
page) exceed that of similar user volume of combustible tobacco.”
American • “Deliverable nicotine levels should be consistent between
Thoracic cartridges.”
Society • “Researchers and clinicians, along with scientific societies
(2013, 2015) and publications, receiving funding from e-cigarette
manufacturers should disclose this relationship and the
potential for conflict of interest in a manner equivalent to
disclosures required for funding from the remainder of the
tobacco industry.”

212   Chapter 5
E-Cigarette Use Among Youth and Young Adults

Table 5.3 A Continued

Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
European • “Electronic • “For ERS, the priority of the • “Mandatory reporting system of ingredients used in tobacco • “ERS supports
Respiratory cigarettes are Revision of the Tobacco Products products.” the European
Society designed for the Directive is to protect children • “Harmonised regulation of the ingredients of tobacco Commission’s
(ERS) (2014) purpose of direct and youth from becoming products.” Proposal for the
nicotine delivery smokers by preventing them • “80% pictorial health warnings, covering the front and back Tobacco Products
to the respiratory from picking up their first of packages. Based on evidence, the larger the pictorial health Directive and
system, and they fall cigarette.” warnings are, the more effective they are.” Rapporteur Linda
into a regulatory gap • “There is no adequate scientific • “Plain/standardised packaging of tobacco products.” McAvan’s efforts to
in most countries, research available on the overall • “Introduction of both visible and invisible security features on improve it.”
escaping regulation health risk or the long-term tobacco packaging and ensuring that the storage and access • “Introduction of
as medicinal effects of electronic cigarette use to such data is [sic] independent from tobacco companies.” standard packs with
products and on humans.” • “Prohibition on the cross-border distance sale of tobacco increased health
avoiding the controls products.” warnings.”
applicable to tobacco • “Strong regulatory framework and independent research for • “Prohibition of
products.” electronic cigarettes. Any regulation of electronic nicotine characterizing
delivery systems should be science based.” flavours.”
• “Ensuring the adoption of delegated acts is not exposed to the • “Strengthening
interests of the tobacco industry, which would jeopardise the of traceability and
achievement of high level of health protection.” security features for
combating illicit
trade.”
• “Prohibiting
misleading features,
including slim
cigarettes.”
• “Approximately
700,000 EU citizens
die prematurely
every year because
of tobacco
consumption.”

E-Cigarette Policy and Practice Implications   213


A Report of the Surgeon General

Table 5.3 A Continued

Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
Forum of • “Studies looking at • “The safety of electronic • “Health and safety claims regarding electronic nicotine • “ENDS should be
International whether electronic cigarettes has not been delivery devices should be subject to evidentiary review.” restricted or banned,
Respiratory cigarettes can adequately demonstrated.” • “If ENDS devices are permitted, they should be regulated as at least until more
Societies aid smoking • “The addictive power of nicotine tobacco products.” information about
(American cessation have had and its untoward effects should • “Research, supported by sources other than the tobacco their safety is
College inconsistent results.” not be under-estimated. or electronic cigarette industry, should be carried out to available.”
of Chest • “Potential benefits to an determine the impact of electronic nicotine delivery devices
Physicians individual smoker should be on health in a wide variety of settings.”
2014; weighed against harm to the • “The use and population effects of END devices should be
Schraufnagel population of increased social monitored.”
et al. 2014) acceptability of smoking and use • “All information derived from this research should be
of nicotine.” conveyed to the public in a clear manner.”
• “Adverse health effects for third
parties exposed to the emissions
of electronic cigarettes cannot be
excluded.”

214   Chapter 5
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Table 5.3 Continued


B. Voluntary health organizations
Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
American • “Because the • “[E]-cigarettes are not labeled • “E-cigarettes need to be researched and regulated.” • “Until electronic
Cancer American Cancer with their ingredients, so the cigarettes are
Society Society doesn’t user doesn’t know what’s in scientifically
(ACS) (2014) yet know whether them.” proven to be safe
e-cigarettes are safe • “Inhaling a substance is not the and effective,
and effective, we same as swallowing it.” ACS will support
cannot recommend • “Studies have shown that the regulation of
them to help people e-cigarettes can cause short-term e-cigarettes and laws
quit smoking.” lung changes that are much that treat them like
• “There are proven like those caused by regular all other tobacco
methods available cigarettes.” products.”
to help people quit,
including pure forms
of inhalable nicotine
as well as nasal
sprays, gums, and
patches.”

E-Cigarette Policy and Practice Implications   215


A Report of the Surgeon General

Table 5.3 B Continued

Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
American • “Current evidence • “Low levels of harmful or • “The regulation should allow for quality-controlled products • “The [AHA] supports
Heart evaluating the potentially harmful metals such for adults who want to transition from conventional cigarettes effective regulation
Association efficacy of these as lead, nickel, and chromium to e-cigarettes or to quit or reduce smoking.” that addresses
(AHA) products as a are listed as having been • “Bottles containing nicotine refill liquids can be toxic if marketing, labeling,
(Bhatnagar cessation aid is detected.” swallowed, so cartridges and bottles should have proper quality control of
et al. 2014) sparse, confined • “Trace levels of tobacco-specific warning labeling and child-proofing packaging.” manufacturing,
(continues to 2 randomized N-nitrosamines, polycyclic • “It is important that the relevant government agency monitor and standards for
on next controlled trials aromatic hydrocarbons, and whether these devices are used for delivery of other drugs and contaminants.”
page) and 1 large cross- volatile organic compounds in medications.” • “[It] also supports
sectional study, the e-liquid and vapor have been • “Companies should not be able to claim that e-cigarettes are including
anecdotal reports, reported.” a cessation aid unless they are approved by the FDA for that e-cigarettes in
and Internet-based • “The FDA has issued warnings purpose.” smoke-free air laws
surveys.” to several e-cigarette companies and prohibiting the
• “[R]eports are for selling e-cartridges with sales of e-cigarettes
confounded by a [diethylene glycol, weight- to youth.”
self-selection bias in loss chemical rimonabant
that the respondents (Zimulti), and the erectile
are often e-cigarette dysfunction medication tadalafil
enthusiasts.” (active ingredient in Cialis)]
• “The AHA maintains contaminants.”
that e-cigarette • “There are no reports of
use should be e-cigarette safety in patients with
part of tobacco known cardiovascular disease.”
screening questions
incorporated into
clinical visits and
worksite/community
health screenings
that are tied into
healthcare delivery.”

216   Chapter 5
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Table 5.3 B Continued

Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
(continued • “Clinicians should — — —
from be educated about
previous e-cigarettes and
page) should be prepared
American to counsel their
Heart patients who are
Association using combustible
(AHA) tobacco products to
(Bhatnagar use e-cigarettes as
et al. 2014) a primary cessation
aid.”
• “For patients
with existing
cardiovascular
disease and stroke,
or at risk of a
cardiovascular
disease event,
intensive cessation
counseling should
be offered as soon as
possible.”

E-Cigarette Policy and Practice Implications   217


A Report of the Surgeon General

Table 5.3 B Continued

Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
American • “Until and unless • “There is currently no scientific • “The FDA has not approved any e-cigarettes as a safe or • “Including
Lung the FDA approves a evidence establishing the safety effective method to help smokers quit.” e-cigarettes in
Association specific e-cigarette of e-cigarettes.” smokefree laws and
(2014, 2015) for use as a tobacco • “FDA found detectable levels of ordinances.”
cessation aid, the toxic cancer-causing chemicals, • “State laws that
American Lung including an ingredient used in would prohibit the
Association does not anti-freeze, in two leading brands sale of any flavored
support any direct of e-cigarettes and 18 various e-cigarette product.”
or implied claims cartridges.” • “Taxing e-cigarettes
that e-cigarettes help • “The lab tests also found that at a rate equivalent
smokers quit.” cartridges labeled as nicotine- with all tobacco
free had traceable levels of products, including
nicotine.” cigarettes.”
• “Nicotine is believed to • “Eliminating
contribute to increased incidence e-cigarette sales to
of premature birth, and low birth youth, otherwise
weight.” restricting youth
• “Research has also shown a access to e-cigarettes
negative impact on pulmonary and requiring
function in newborns.” e-cigarette retailers
to be licensed.”
• “E-cigarettes should
be defined as tobacco
products.”
• “Opposes creating
new definitions for
‘vapor products’
and/or ‘alternative
nicotine products’ in
state laws.”

218   Chapter 5
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Table 5.3 B Continued

Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
Americans • “ESDs are not • “Americans for Nonsmokers’ • “Electronic smoking devices are currently unregulated • “Electronic cigarettes
for proven cessation Rights recommends that products.” are not a safe
Nonsmokers’ devices.” e-cigarettes not be used in areas • “[ANR] . . . encourages municipalities and states to prohibit alternative!”
Rights (ANR) • “Many people where people will be exposed to the use of ESDs in all smokefree venues.”
(n.d.a; n.d.b) become ‘stable the vapors they emit.”
dual-users’ who use • “Electronic smoking device
both cigarettes and aerosol is not water vapor. . . .
ESDs.” The aerosol (incorrectly called
vapor) contains nicotine,
hazardous ultrafine particles that
lodge deeply in the lungs . . . and
toxins known to cause cancer.”

C. World Health Organization


Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
World Health • “Prohibit • “ENDS users should be legally • “Parties should contemplate putting in place an effective • “Overall, in
Organization manufacturers and requested not to use ENDS restriction on ENDS advertising, promotion and sponsorship.” its public
(WHO) (Bates third parties from indoors, especially where smoking • “Protection from vested commercial interests.” communication
2014; WHO making health is banned until exhaled vapour • “Governments are recommended to use or strengthen their WHO portrays
2014b) claims for ENDS, is proven to be not harmful existing tobacco surveillance and monitoring systems to assess e-cigarettes as a
(continues on including that to bystanders and reasonable developments in ENDS and nicotine use by sex and age.” threat to public
next page) ENDS are smoking evidence exists that smoke- health.”
cessation aids.” free policy enforcement is not • “Encourage
• “The regulatory undermined. If smoke-free smoking cessation
standard for legislation is not fully developed and provide a
cessation claims according to Article 8 of the WHO quitline number if
and approval as FCTC and the guidelines for its one exists.”
cessation aids implementation, this should be
should remain an done as soon as possible.”
appropriate body • “Health warnings should be
of evidence, based commensurate with proven health
on well-controlled risks.”
clinical trials.”

E-Cigarette Policy and Practice Implications   219


A Report of the Surgeon General

Table 5.3 C Continued


Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
(continued • “For ENDS — — —
from previous products to be
page) approved for
World Health smoking cessation
Organization by the suitable
(WHO) (Bates regulatory agency,
2014; WHO the appropriate
2014b) balance should
be reached
between providing
accurate scientific
information
to the public
about the risk of
ENDS use and its
potential benefits
as compared with
smoking.”

220   Chapter 5
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Table 5.3 Continued


D. Government health
Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
European — • “Certain additives used to create • “The prohibition of tobacco products with characterizing • New directive: May
Union (EU) the impression that tobacco flavours does not preclude the use of individual additives 2014.
(European products have health benefits, as outright, but it does oblige manufacturers to reduce the • New rules applied:
Parliament well as those with [carcinogenic, additive or the combination of additives.” First half of 2016.
and Council mutagenic, or reprotoxic] • “Electronic cigarettes and refill containers should be • “Aims at ensuring
2014; WHO properties in unburnt form, regulated by this Directive.” equal treatment
Framework should be prohibited in order to • “Where the manufacturer of the relevant product is not across the EU for
Convention ensure uniform rules throughout established in the Union, the importer of that product should nicotine-containing
on Tobacco the Union and a high level of bear the responsibilities relating to the compliance of those e-cigarettes
Control 2014) protection of human health.” products with this Directive.” (products that do
• “Electronic cigarettes and • “Nicotine-containing liquid should only be allowed to be not contain nicotine
refill containers could create a placed on the market, where the nicotine concentration does are not covered by
health risk when in the hands not exceed 20 mg/ml.” the Directive).”
of children—it is necessary to • “Only electronic cigarettes that deliver nicotine doses at • “Electronic
ensure products are child and consistent levels should be allowed to be placed on the cigarettes can
tamperproof.” market.” develop into
• “Nicotine-containing liquid should • “The labeling and packaging of [e-cigarettes] should display a gateway to
only be placed on the market in sufficient and appropriate information on their safe use.” nicotine addiction
electronic cigarettes or in refill and ultimately
containers that meet certain safety traditional tobacco
and quality requirements.” consumption, as
they mimic and
normalize the
action of smoking.
For this reason, it
is appropriate to
adopt a restrictive
approach to
advertising
electronic
cigarettes and refill
containers.”

E-Cigarette Policy and Practice Implications   221


A Report of the Surgeon General

Table 5.3 D Continued


Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
CAP/BCAP — • “Ads cannot convey health benefits • “Ads must not be likely to appeal particularly to people under • Effective date:
(UK) (2014) or claim that they are safer or 18, especially by reflecting or being associated with youth November 10, 2014.
healthier than smoking tobacco.” culture.” • “The rules place an
• “People shown using e-cigarettes or playing a significant role emphasis on the
must neither be, nor seem to be, under 25.” protection of young
• “Ads must not be directed at people under 18 through the people and ads must
selection of media or the context in which they appear.” avoid containing
• “Ads must not encourage nonsmokers or nonnicotine users to anything that
use e-cigarettes.” promotes the use of
• “Ads must make clear that the product is an e-cigarette and a tobacco product
not a tobacco product.” or that shows the
• “Ads on TV and radio will be subject to scheduling restrictions use of a tobacco
to reduce the chance of e-cigarette advertisements being seen product in a positive
or heard by children.” light.”
• CAP: Write and
maintain the UK
advertising codes.
Public Health — — • “Under the terms of the new Tobacco Product Directive • Effective date: 2016.
England (UK) (TPD) . . . advertising of nicotine-containing devices that are • “The UK [Medicines
(Britton and not licensed as medicines will be prohibited, products will be and Healthcare
Bogdanovica required to carry health warnings, meet purity and emission products Regulatory
2014; standards that are yet to be defined.” Agency] announced
CAMQUIT that from 2016, it
n.d.) intended to regulate
electronic cigarettes
and other nicotine-
containing products
as medicines by
function, and
thus require
manufacture to
medicinal purity
and delivery
standards, and
proactive controls
on advertising.”

222   Chapter 5
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Table 5.3 D Continued


Organizational
Organization position on cessation Organizational position on harm Organizational position on regulation General comments
International • “The benefits • “The safety of ECs or ENDS has not • “A range of current and proposed legislative and regulatory • “The Union
Union Against of e-cigarettes been scientifically demonstrated.” options exists.” strongly supports
Tuberculosis have not been • “Adverse health effects for • “Brazil, Norway, and Singapore have banned ECs/ENDS the regulation of
and Lung scientifically [secondhand smoke] cannot completely.” the manufacture,
Cancer (2013) proven.” be excluded because the use of • “ENDS could undermine the implementation of WHO FCTC marketing and
• “Very few studies electronic cigarettes leads to Article 12 (de-normalisation of tobacco use).” sale of Electronic
have assessed ECs/ emission of fine and ultrafine • “Use of ENDS could also hamper the implementation of cigarettes (ECs)
ENDS as a harm inhalable liquid particles, nicotine Article 8 (protection from exposure to tobacco smoke).” or electronic
reduction and and cancer-causing substances into nicotine delivery
cessation aid and indoor air.” systems (ENDS);
with conflicting the preferred option
findings.” is to regulate
ECs or ENDS as
medicines.”
• “The Union is
concerned that
the marketing,
awareness and use
of ECs or ENDS is
growing rapidly.”
Note: AARC = American Association for Respiratory Care; ACP = American College of Physicians; ACS = American Cancer Society; AHA = American Heart Association;
ANR = Americans for Nonsmokers’ Rights; CAP/BCAP = Committees of Advertising Practice/Broadcast Committee of Advertising Practice; CDC = Centers for Disease
Control and Prevention; CTP = Center for Tobacco Products; ECs = electronic cigarettes; ENDS = electronic nicotine delivery systems; ERS = European Respiratory
Society; ESDs = electronic smoking devices; EU = European Union; FCTC = Framework Convention for Tobacco Control; FDA = U.S. Food and Drug Administration;
UK = United Kingdom; WHO = World Health Organization.

E-Cigarette Policy and Practice Implications   223


A Report of the Surgeon General

Case Studies

Case studies in California and North Dakota dem- of how cities, counties, and other states might address
onstrate how e-cigarette policies have been enacted at the e-cigarettes in their jurisdictions.
local and state levels, and they provide potential models

City of Hayward Takes Bold Steps to Address Tobacco Products Aimed


at Kids
In response to the “D” grade that the city of Hayward received in 2011 from the American Lung Association in
California for its efforts to protect youth from tobacco sales, the city council directed its staff to develop regulations
to address the problem of youth tobacco sales. Draft regulations were presented at a city planning meeting in 2012,
followed by a series of community meetings and hearings that culminated in the Hayward city council’s adoption of
a 45-day moratorium to begin in January 2014 on the issuance of business licenses or building permits for any new
tobacco retailers. The following month, the moratorium was extended another 15 months to provide more time to
research and consider the issue (City of Hayward 2014).
On July 1, 2014, the Hayward city council unanimously adopted an ordinance that requires sellers of tobacco
products and “electronic smoking devices” to obtain annually a $400 tobacco retailer license that covers the cost of
an annual inspection for compliance with federal, state, local, tribal, and territorial tobacco control laws. The ordi-
nance allowed the city’s existing 142 tobacco retailers, 8 e-cigarette retailers, and 2 hookah lounges to continue
operating at their current locations; however, new sellers must obtain a conditional use permit, are restricted to spe-
cial commercial zones, and may not locate within 500 feet of residential areas or child-sensitive areas (e.g., schools
and parks) or within 500 feet of an existing tobacco seller. It also prohibits new hookah lounges or vaping lounges
from opening within the city.
The ordinance also contains provisions to prohibit self-service displays of tobacco products and e-cigarettes
and to regulate the sales of cigars, flavored products, and imitation tobacco products. Cigars selling for less than
$5 each are required to be sold in pack sizes of five or more, and the sale of flavored traditional tobacco products,
e-cigarettes, and imitation tobacco products (e.g., candy cigarettes, bubble gum chew) is prohibited within 500 feet
of schools for any business not selling these products before July 1, 2014.
Penalties range from $1,500 for a first violation and possible suspension to a complete revocation of a license
after three violations within a 3-year period (City of Hayward 2014; n.d.a.). Active enforcement of the ordinance
began in April 2015 (City of Hayward n.d.b.).
Throughout the process, Hayward officials and staff relied heavily on materials from the American Lung
Association, the Center for Tobacco Policy and Organizing, and ChangeLab Solutions to provide the public health
and legal rationale for supporting the provisions. Hayward’s tobacco retail licensing effort was also supported by
the tobacco control program of the Alameda County public health department, which used monies from its Master
Settlement Agreement to fund the Hayward police department to conduct youth decoy operations and local commu-
nity and youth organizations to conduct educational outreach (City of Hayward 2014). Collectively, these resources
informed the Hayward city council’s decision-making process.

224   Chapter 5
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North Dakota’s Statewide Clean Indoor Air Law Prohibits Conventional


Tobacco Products and E-Cigarettes
In November 2012, North Dakota achieved a remarkable victory for statewide clean indoor air (BreatheND
n.d.a.) despite major obstacles, including a harsh winter climate, an adult smoking rate of 21.9% (CDC 2013), and
several prior failed legislative attempts to close exemptions in the state’s 2005 clean indoor air law (CDC 2014).
Despite these impediments, two-thirds of the state voted to prohibit both the smoking of conventional tobacco prod-
ucts and use of e-cigarettes in all non-hospitality workplaces; restaurants; bars; hotel guest rooms and communal
areas; health care facilities; assisted living facilities; all licensed child and adult day care facilities; gaming facili-
ties; indoor areas of sports arenas; and within 20 feet of entrances, exits, operable windows, air intakes, and venti-
lation systems of enclosed areas where smoking is not allowed (BreatheND n.d.b.). Additionally, the law provided
no exemptions for tobacco-only retail or “vape shops” (Americans for Nonsmokers’ Rights Foundation 2015, n.d.).
The 2012 ballot initiative on statewide clean indoor air resulted from the lack of progress in working with the
legislature to try to close smoking exemptions in the state law. The initiative’s sponsors, Tobacco Free North Dakota
and the American Lung Association in North Dakota, worked closely with the Tobacco Control Legal Consortium
to draft policy language, which included prohibiting the use of e-cigarettes anywhere smoking was prohibited. The
sponsors approached stakeholders and assessed public support. Little opposition was encountered to prohibiting the
use of e-cigarettes indoors. In addition to the sponsors’ efforts, the North Dakota Center for Tobacco Prevention and
Control Policy conducted a media campaign and worked with local partners to educate their communities, resulting
in 11 smokefree ordinances prior to the issuing of the statewide ballot initiative. The landslide victory (66% vs. 33%)
in favor of clean indoor air, with the initiative successfully carried in every one of North Dakota’s 53 counties, dem-
onstrated widespread public support for clean indoor air (Ballotpedia 2012).
Only a few years later, the law continues to enjoy strong public support from nonsmokers (84.4%) and smokers
(58%) alike. Compliance with the law is comparable to cigarette smoking; just 16.8% of North Dakotans reported
having observed smoking indoors in areas where it was prohibited, and 23.2% reported having seen e-cigarettes
used indoors in such places. Local enforcement personnel confirm a high level of compliance, reporting violations
primarily related to smoking within 20 feet of entrances. To date, the only prosecuted violation of the law involved
the sampling of an e-cigarette product inside a “vape shop” (BreatheND 2014). In hindsight, the decision to include
e-cigarettes in North Dakota’s smokefree law was helpful, given increasing concerns about involuntary exposure to
nicotine and other aerosolized e-cigarette emissions.

Summary and Recommendations

The Surgeon General has long played a leading role and other small commercial locations and on the Internet.
in identifying the harms of tobacco use and documenting Marketing strategies exploit social media, reaching widely
the most effective ways to reduce them. This report comes and with tailored targeting to consumers.
amid the rising use of e-cigarettes among the nation’s The differences notwithstanding, the principles and
youth and young adults. It calls attention to this problem strategies articulated in the 2014 Surgeon General’s report
and the need to implement immediately a comprehensive and prior reports remain relevant to e-cigarettes. The 2014
strategy to minimize any negative public health impact report was written not long after the use of e-cigarettes
now and in the future, giving consideration to the potential began to surge dramatically; that report commented on the
for youth to be harmed from e-cigarettes while, simultane- need for rapid elimination of conventional cigarettes and
ously, acknowledging that gains might be made if the use other combustible tobacco products but did not specify
of combustible tobacco products fell among adult smokers. a role for e-cigarettes or discuss strategies to minimize
Chapters 1–4 documented the particular challenges posed adverse effects among youth and young adults (USDHHS
by the rapid emergence and dynamic nature of e-cigarette 2014). The report’s final chapter, however, set out an evi-
use among youth and young adults. The marketplace is dence-based strategy for the future. The present report
diverse, and although it includes the large tobacco com- builds on this foundation, adding recommendations related
panies, e-cigarettes are sold in thousands of “vape shops” to e-cigarettes.

E-Cigarette Policy and Practice Implications   225


A Report of the Surgeon General

Conclusions

1. The dynamic nature of the e-cigarette landscape 5. Health professionals represent an important
calls for expansion and enhancement of tobacco- channel for education about e-cigarettes, particu-
related surveillance to include (a) tracking patterns larly for youth and young adults.
of use in priority populations; (b) monitoring the
characteristics of the retail market; (c) examining 6. Diverse actions, modeled after evidence-based
policies at the national, state, local, tribal, and ter- tobacco control strategies, can be taken at the
ritorial levels; (d) examining the channels and mes- state, local, tribal, and territorial levels to address
saging for marketing e-cigarettes in order to more e-cigarette use among youth and young adults,
fully understand the impact future regulations including incorporating e-cigarettes into smoke-
could have; and (e) searching for sentinel health free policies; preventing the access of youth to
events in youth and young adult e-cigarette users, e-cigarettes; price and tax policies; retail licensure;
while longer-term health consequences are tracked. regulation of e-cigarette marketing that is likely to
attract youth and young adults, to the extent feasible
2. Strategic, comprehensive research is critical to under the law; and educational initiatives targeting
identify and characterize the potential health risks youth and young adults. Among others, research
from e-cigarette use, particularly among youth and focused on policy, economics, and the e-cigarette
young adults. industry will aid in the development and imple-
mentation of evidence-based strategies and best
3. The adoption of public health strategies that are pre- practices.
cautionary to protect youth and young adults from
adverse effects related to e-cigarettes is justified.

4. A broad program of behavioral, communications,


and educational research is crucial to assess how
youth perceive e-cigarettes and associated mar-
keting messages, and to determine what kinds of
tobacco control communication strategies and
channels are most effective.

226   Chapter 5
E-Cigarette Use Among Youth and Young Adults

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U.S. Army. Army Health Promotion, 1996; <http:// U.S. Navy. Naval Hospital Twentynine Palms Instruction
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E-Cigarette Policy and Practice Implications   233


The Call to Action

The Call to Action on E-Cigarette Use Among Youth and Young Adults 237

Goal 1. First, Do No Harm 237

Goal 2. Provide Information About the Dangers of E-Cigarette Use Among Youth and Young Adults 239

Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to Protect Public Health 241

Goal 4. Programs and Policies to Prevent E-Cigarette Use Among Youth and Young Adults 243
Including E-Cigarettes in Smokefree Indoor Air Policies 243
Restricting Youth Access to E-Cigarettes 244
Licensing Retailers 245
Establishing Specific Packaging Requirements 245

Goal 5. Curb Advertising and Marketing that Encourages Youth and Young Adults to Use E-Cigarettes 246

Goal 6. Expand Surveillance, Research, and Evaluation Related to E-Cigarettes 247

Conclusions 249

References 250

235
236
E-Cigarette Use Among Youth and Young Adults

The Call to Action on E-Cigarette Use Among Youth and


Young Adults

The Surgeon General issues this Call to Action on


e-cigarettes, specifically focusing on youth and young Use of e-cigarettes is increasing rapidly
adults, to accelerate policies and programs that can reduce among young people, even among those
e-cigarette use among young people. This Call to Action who have never smoked cigarettes.
comes amid the dramatic increase in e-cigarette use
among our nation’s youth and young adults. It highlights This Call to Action presents six goals and related
the need to implement proven strategies that will pre- strategies that should guide efforts to reduce e-cigarette
vent potentially harmful effects of e-cigarette use among use among youth and young adults. To achieve these
young people. The previous chapters explained what we goals, we must work together, which means working with
know and do not know about e-cigarettes and reviewed individuals and families; civic and community leaders;
policy options. Gaps in scientific evidence still exist, and public health and health care professionals; e-cigarette
this Call to Action is being issued while these products manufacturers and retailers; voluntary health agencies;
and their patterns of use are changing quickly. However, researchers; and other stakeholders.
policies and strategies are available that can clearly reduce
the public health threat posed by e-cigarette use among
young people.

Stakeholders Who Can Take Action


• Individuals, parents, and families • Federal government
• Teachers, coaches, and other youth influencers • State, local, tribal, and territorial governments
• Civic and community leaders • E-cigarette manufacturers, distributors, and
retailers
• Public health and health care professionals
• Voluntary health agencies, non-governmental
• Researchers
organizations, and other community- and faith-
based organizations

Goal 1. First, Do No Harm

Since 1964, reports from the U.S. Surgeon General


have led the way in identifying the harms of tobacco use
and detailing the most effective ways to reduce the dan-
gerous effects of tobacco use. For example, reports from
1994 and 2012 outlined proven strategies to prevent and
reduce tobacco use among youth and young adults (U.S.
Department of Health and Human Services [USDHHS]
1994, 2012). Building on these and other past reports,
this Call to Action considers the harms of e-cigarette use
among youth and young adults and stresses the impor-
tance of strategies that will protect young people from the
adverse consequences of these new products.

The Call to Action   237


A Report of the Surgeon General

• Implementing the U.S. Food and Drug


Strategy 1A. Administration’s (FDA’s) authority to regulate
tobacco products in order to provide oversight of
Implement a comprehensive strategy to address the manufacturing, distribution, and marketing of
e-cigarettes that will avoid adverse consequences and e-cigarettes, particularly as they relate to youth and
give careful consideration to the risks for youth and young adults;
young adults. This can be done by including e-cigarettes
in policies and programs related to conventional • Funding comprehensive statewide tobacco control
cigarette smoking at the national, state, local, tribal, programs at levels recommended by the Centers for
and territorial levels. Disease Control and Prevention (CDC);

• Implementing comprehensive clean indoor air pol-


We have many effective strategies to prevent tobacco icies that protect people from exposure to second-
use among youth and young adults (USDHHS 2012), and hand tobacco smoke and the aerosol emitted from
many of these strategies can also be applied to e-cigarettes. e-cigarettes;
A strategy to address e-cigarette use among young people
should be precautionary. A precautionary approach urges • Raising and strongly enforcing minimum age-of-sale
action to prevent harm when there is scientific uncer- laws for all tobacco products, including e-cigarettes,
tainty. That is, when there is inadequate or early knowl- to prevent initiation at young ages;
edge, public health decisions should be made on the basis
of precaution to prevent harm, rather than on certain
risk. This approach requires proof that a product is not Use of e-cigarettes can expose young people
harmful—especially for youth—rather than proof that it to nicotine. Nicotine can be highly addictive
is harmful. The burden of proof regarding product safety and can harm brain development. Nicotine
should be placed on those who wish to market and sell use may also lead to the use of other tobacco
such tobacco products, rather than the public health com- or nicotine-containing products.
munity charged with protecting the public’s health. The
harms of nicotine exposure in youth and young adults are • Setting price policies for e-cigarettes, which could
well-documented in this report and warrant this Call to include taxation policies;
Action (see Chapter 3). We must protect the health of our
nation’s young people by assuring that there will be no • Restricting advertising and marketing that encour-
harm to youth from e-cigarettes. The stakeholders iden- ages youth and young adults to use e-cigarettes;
tified on the previous page should work together to pre-
vent and reduce the use of all forms of tobacco products, • Sponsoring high-impact media campaigns to edu-
including e-cigarettes, among our nation’s youth and cate the public using evidence-based information
young adults. A comprehensive strategy includes: about the consequences of e-cigarette use among
youth and young adults, including the harms of nic-
otine on the developing brain; and

• Expanding tobacco control and prevention research


efforts to increase our understanding of the evolving
landscape of e-cigarettes.

These components make up an evidence-based


strategy. However, the e-cigarette marketplace is diverse
and continues to evolve. Thus, ongoing efforts should
rapidly and effectively track and adapt to such changes,
thereby protecting our nation’s young people from the
consequences of e-cigarette use and exposure to second-
hand aerosol.

238   The Call to Action


E-Cigarette Use Among Youth and Young Adults

1988, 2014). Beyond addiction, intake of nicotine by


Strategy 1B. young people can harm brain development (Chapter 3).
Additionally, aerosol from e-cigarettes contains
Provide consistent and evidence-based messages about toxins that can harm the body, and the flavorings used in
the health risks of e-cigarette use and exposure to these products cannot be considered safe for inhalation,
secondhand aerosol from e-cigarettes. either firsthand or secondhand (Chapter 3). For example,
some flavorings have been known to be associated with
pulmonary toxicity (Allen et al. 2016).
Research on e-cigarettes is ongoing, and the Messaging about the potential role of e-cigarettes
e-cigarette marketplace continues to evolve. Even so, a in reducing the burden of tobacco-related diseases should
sufficient body of evidence justifies actions taken now to note that e-cigarette products that deliver nicotine are not
prevent and reduce the use of e-cigarettes and exposure to considered safe, particularly for youth and young adults,
secondhand aerosol from e-cigarettes, particularly among even before researchers fully characterize and quantify
youth and young adults. Most important, many health all of their health risks, including possible permanent
risks are already known, and sufficient information exists changes to the adolescent brain and lungs.
to take action to minimize potential harms. The evidence
is most compelling for nicotine. As part of comprehensive
reviews, previous Surgeon General’s reports have provided The use of any tobacco product, including
causal findings on the development of addiction and other e-cigarettes, among young people is unsafe.
health consequences of exposure to nicotine (USDHHS

Goal 2. Provide Information About the Dangers of E-Cigarette Use


Among Youth and Young Adults

Once youth and young adults start using products


that contain nicotine, including e-cigarettes, they can Strategy 2A.
become addicted. Such addiction has the potential to lead
to long-term use of products that contain nicotine, such Educate parents, teachers, coaches, and other
as cigarettes. Most adolescents who use tobacco already influencers of youth about the risks of e-cigarette use
use more than one nicotine-containing product and are among youth and young adults.
not just using e-cigarettes alone (Chapter 2). The majority
of tobacco users start before they are 18 years of age,
and almost no one starts after age 25 (USDHHS 2012). Parents, guardians, teachers, coaches, health profes-
Therefore, the best way to protect young people from the sionals, faith leaders, and other persons whose advice and
harms of tobacco use, including e-cigarettes, is to prevent behavior influence youth play critical roles in protecting
the use of these products altogether. Prevention should youth and young adults from the harms of e-cigarette use
start with robust public policies that make it easy for and exposure to the secondhand aerosol emitted from
youth not to use tobacco and harder for them to use any these devices. Most adults are familiar with some of the
tobacco products. Parents, teachers, health professionals, dangers of using tobacco products, especially conventional
and other influencers of youth should be educated about cigarettes, and of exposure to secondhand tobacco smoke.
the risks of e-cigarette use. They can then help educate Because of these dangers, many adults have taken steps to
their own children as well as other young people about the keep children safe. However, most adults are not aware of
harms of e-cigarettes and the risk of a potential lifetime of the potential risks of using e-cigarettes and exposure to
nicotine addiction. secondhand aerosol, and e-cigarette marketing often pro-
motes these products as safe alternatives to smoking con-
ventional cigarettes. But messaging about the dangers is
Use of e-cigarettes and exposure to nicotine essential. For example, the use of these products can lead
is particularly dangerous for pregnant to nicotine addiction, harm brain development, and lead
women. Nicotine is toxic to the fetus and to continued tobacco use.
impairs fetal brain and lung development.

The Call to Action   239


A Report of the Surgeon General

• Make homes and cars completely tobacco-free,


including the use of e-cigarettes. This means no
use by family members, friends, or guests. Opening
a window does not fully protect against exposure
to secondhand cigarette smoke or from the sec-
ondhand aerosol from e-cigarettes. For youth and
young adults to be fully protected from indoor expo-
sure, all indoor environments must be 100% free
from tobacco smoke and e-cigarette aerosol.

• Set an example by being tobacco-free.

• Provide positive support and encouragement to


anyone who is trying to quit tobacco.

Parents, teachers, coaches, and others can protect


their children and other young people by educating them E-cigarettes are now the most common form
about e-cigarettes: of tobacco used by young people. High school
students use e-cigarettes more than adults.
• Talk openly about the harms of nicotine and tobacco
use.
Research suggests that youth and young adults are
not as aware of the health consequences of e-cigarette use
• Express firmly the idea that young people should not
as they are with the consequences of cigarette smoking
use any tobacco products, including e-cigarettes.
(Chapter 2) (Pearson et al. 2012; Richardson et al. 2014;
Tan and Bigman 2014). FDA has the authority to require
• Do not let any individuals use e-cigarettes or other
health warnings on tobacco products and tobacco adver-
tobacco products around children.
tising. In addition, FDA and other federal entities, along
with state and local organizations, can carry out educa-
• Ask health care providers, adults, and parents to
tional campaigns to better inform the public, especially
discuss with children the health risks of using
parents, and increase their understanding of the harms of
e-cigarettes, such as nicotine addiction.
e-cigarette use.
• Patronize restaurants and other places that do not
allow the use of e-cigarettes indoors, and let busi-
ness owners that allow e-cigarette use indoors know
that it is not as safe as clean air or even legal in many
places.

• Make sure children’s day care centers, schools, and


universities are completely tobacco-free, including
being free of e-cigarettes. A comprehensive tobacco-
free campus policy prohibits any tobacco use,
including e-cigarettes, on school property by anyone
at any time. These policies should be expanded to
include school events that are held off campus.

• Prohibit tobacco and e-cigarette company spon-


sorship of teams or events, promotional activities,
and offers of educational materials for preventing
tobacco use among youth.

240   The Call to Action


E-Cigarette Use Among Youth and Young Adults

care professionals should warn youth and youth influ-


Strategy 2B. encers, such as parents, about the health risks of using
any product that contains nicotine, including e-cigarettes.
Educate health professionals about the risks of They should also warn youth about the dangers of using
e-cigarette use among youth and young adults. other substances, such as marijuana, in e-cigarette devices
(American Academy of Pediatrics 2015).
The health care setting is an ideal place to educate
people of all ages on the potential risks of e-cigarette use
and exposure to secondhand aerosol from e-cigarettes.
Because e-cigarettes are a relatively new product, health
care professionals frequently face a lot of questions about
them. These often include questions related to the risks
of using e-cigarettes and whether these products can
help people to quit smoking. No e-cigarettes have been
approved as safe and effective cessation aids.
For youth, in particular, sufficient evidence shows
that the use of nicotine is not safe regardless of the
delivery device: combustible, non-combustible, or elec-
tronic (USDHHS 2014; see also Chapter 3). Thus, health

Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to


Protect Public Health

In 2009, the Family Smoking Prevention and Tobacco


Control Act (Tobacco Control Act) provided FDA with Strategy 3A.
authority to regulate tobacco products in a manner that
is “appropriate for the protection of public health” (e.g., Implement FDA regulatory authority over the manufac-
§§ 906(d)(1), 907(a)(3)(A) & (a)(4)(A), and § 910(c)(2)(A) of turing, marketing, and distribution of e-cigarettes.
the Federal Food, Drug, and Cosmetic Act, as amended by
the Tobacco Control Act) (Family Smoking Prevention and
Tobacco Control Act 2009, p. 1786). The Tobacco Control Act A federal appellate court decision titled Sottera,
also requires FDA to consider in regulatory actions the health Inc.  v. Food & Drug Administration (2010) determined
effects at the individual and population levels, including the that FDA can regulate e-cigarettes and other products
impacts on the initiation of measures taken to quit tobacco made or derived from tobacco under the Tobacco Control
use as well as effects on relapse among former tobacco users. Act, and that these products are not drugs or devices under
But FDA is not the only federal agency that can address cer- the Food, Drug, and Cosmetic Act unless marketed as
tain aspects of e-cigarettes (see Chapter 5, Table 5.2). therapeutic or smoking cessation products. In May 2016,
FDA finalized a rule deeming most products meeting the
definition of a tobacco product, including e-cigarettes,
subject to regulation under the Tobacco Control Act. The
regulation went into effect on August 8, 2016 (but is under
litigation) (FDA 2016).
FDA’s rule for e-cigarettes includes several provi-
sions that can help protect youth and young adults from
the harms of e-cigarettes, such as the following:

• Prohibiting the sale of e-cigarettes to youth who are


under 18 years of age (both in person and online);

• Requiring proof of age at the point of purchase;

The Call to Action   241


A Report of the Surgeon General

• Prohibiting vending machine sales in all facilities


where children are allowed to enter;

• Prohibiting the distribution of free samples;

• Requiring health warnings about nicotine on pack-


aging and in advertisements;

• Requiring manufacturers to register their e-cigarette


products with FDA and disclose the ingredients and
levels of harmful and potentially harmful constitu-
ents in those products to that agency;

• Requiring premarket review of new or changed


tobacco products and authorization by FDA before
they can be introduced into the marketplace; and • Regulating packaging, including requiring min-
imum package sizes, mandating child-resistant
• Requiring manufacturers that intend to market packaging, and requiring health warnings; and
e-cigarettes for use to reduce harm or risk of tobacco-
related disease to receive authorization from FDA • Prohibiting self-service displays.
based on scientific evidence that the product is less
harmful or presents less risk to the public. Despite gaining this broad authority, FDA does not
have specific authority for certain regulatory actions. For
This authority allows FDA to undertake future regu- example, FDA generally does not restrict tobacco use in
latory actions, if determined appropriate for the protec- public places, levy taxes on tobacco products, or restrict
tion of public health, including: sales to only certain types of retailers (e.g., pharmacies);
and FDA cannot completely eliminate nicotine in tobacco
• Within constitutional limitations, restricting pro- products, require prescriptions for tobacco products,
motion, marketing, and advertising of e–cigarettes; or raise the minimum age for sale of tobacco products
above 18.
• Restricting Internet sales and requiring age verifica- Other complementary comprehensive tobacco con-
tion on websites and upon delivery; trol strategies at the state, local, tribal, and territorial
levels include:
• Prohibiting characterizing flavors;
• Implementing comprehensive clean indoor air laws;
• Promulgating product standards to reduce the tox-
icity, addictiveness, or appeal of tobacco products; • Prohibiting sales to those under 21 years of age;

• Increasing prices of tobacco products; and

• Developing high-impact countermarketing


campaigns.

Effective action at the state and local levels is crit-


ical to fully protecting young people from the harms of
e-cigarettes.

242   The Call to Action


E-Cigarette Use Among Youth and Young Adults

General Services Administration, National Park Service);


Strategy 3B. and some focus on certain aspects of e-cigarettes (e.g., the
Federal Trade Commission, the U.S. Department of
Reinforce other federal agencies as they implement Transportation, and the U.S. Environmental Protection
programs and policies to address e-cigarettes. Agency). Specific strategies to address e-cigarettes could
include those that protect employees, customers, and vis-
itors from exposure to secondhand aerosol, support and
Of the other federal agencies that play a role in imple- encourage tobacco cessation, and curb youth-targeted or
menting strategies to address e-cigarettes (see Chapter 5, false advertising. For example, the National Park Service
Table 5.2), some target specific populations (e.g.,  the (2015) implemented a policy to protect employees and
U.S. Department of Defense and the U.S. Department visitors from exposure to secondhand aerosol from
of Veterans Affairs); others cover specific areas (e.g.,  the e-cigarettes.

Goal 4. Programs and Policies to Prevent E-Cigarette Use Among


Youth and Young Adults

Subject to certain exceptions, the Tobacco Control


Act does not limit the authority of state, local, tribal,
and territorial governments to enact any tobacco-related
policies related to the sale, distribution, or possession of
tobacco products; exposure to these products; or access
to them. This broad preservation of authority enables
states and localities to adopt many comprehensive tobacco
control strategies that have been proven to prevent and
reduce tobacco use among youth and young adults. That
means that state, local, tribal, and territorial governments
could act first in developing regulations, policies, and pro-
grams that minimize any individual- and population-level
harms of e-cigarettes. The strongest, most innovative
tobacco control policies typically have originated at the
local level before eventually being adopted at the state
level. However, it is important that these strategies are be applied to e-cigarettes. And from this evidence, state,
developed with evaluators and epidemiologists that can local, tribal, and territorial entities can take a variety of
collect robust data to inform the implementation and sus- actions to address e-cigarettes, such as:
tainment of such strategies.
• Including e-cigarettes in smokefree indoor air policies;
Strategy 4A.
• Restricting youth access to e-cigarettes in retail
settings;
State, local, tribal, and territorial governments should
implement population-level strategies to reduce • Licensing retailers; and
e-cigarette use among youth and young adults, such
as including e-cigarettes in smokefree indoor air • Establishing specific package requirements.
policies, restricting youth access to e-cigarettes in retail
settings, licensing retailers, and establishing specific
package requirements. Including E-Cigarettes in Smokefree
Indoor Air Policies
Over 50 years of research offers a strong body of Most smokefree indoor air policies were put in place
evidence on the effectiveness of certain tobacco preven- before the great rise in e-cigarette use. Because of that,
tion and control measures. Much of this evidence can also these policies may not cover e-cigarettes or exposure to

The Call to Action   243


A Report of the Surgeon General

the aerosol they produce. Aerosol from e-cigarettes is Restricting Youth Access to
not harmless (CDC 2014). Smokefree indoor air policies
should be updated to prohibit the use of both conven-
E-Cigarettes
tional cigarettes and e-cigarettes, thereby preserving stan-
When laws prohibiting tobacco sales to youth are
dards for clean indoor air. Efforts to include e-cigarettes
strong and actively enforced with the education of retailers,
in smokefree laws should also uphold or strengthen, not
they successfully reduce tobacco use among youth (Task
weaken, existing protections against exposure to second-
Force on Community Preventive Services 2001; Zaza et al.
hand smoke.
2005). To date, all 50 states and the District of Columbia
Including e-cigarettes in smokefree indoor air poli-
restrict the sale of tobacco products to minors (CDC n.d.).
cies can:
Extending such laws to include e-cigarettes can further
protect youth from exposure to nicotine, which nearly all
• Eliminate health risks from exposure to secondhand
states have done. Specific strategies can be implemented
aerosol from e-cigarettes;
to deter the access of youth to e-cigarettes and their use
in this population:
• Discourage people from using both combustible and
electronic tobacco products (dual use);
• Restricting the sale of e-cigarettes to minors;
• Simplify compliance with and enforcement of
• Placing restrictions on Internet sales of all tobacco
existing smokefree laws;
products and e-cigarettes, including requirements
for verifying age and providing identification at the
• Help to reduce the use of e-cigarettes among youth
time of purchase and upon delivery;
and young adults; and
• Requiring age verification at the point of purchase;
• Maintain tobacco-free norms.
• Displaying clear signage in retail locations about
Aerosol from e-cigarettes is not harmless. required age for sale;

To date, several states and several hundred com- • Prohibiting the sale of e-cigarettes from vending
munities include e-cigarettes in comprehensive smoke- machines;
free laws that prohibit smoking in all indoor areas of
public places, including worksites, restaurants, bars, and • Eliminating self-service displays of e-cigarettes; and
gambling facilities (Americans for Nonsmokers’ Rights
Foundation 2015; CDC n.d.). • Enforcing laws on the retail sale of e-cigarettes to
minors.

Nearly all states prohibit the sale of e-cigarettes to


youth under 18 years of age. Some states have a higher
minimum age for purchase (e.g., 19 or 21 years of age)
(CDC 2014). Some e-cigarette manufacturers have sup-
ported state legislation to prevent minors from pur-
chasing e-cigarettes (Healy 2014). Their actions may,
to some extent, be responsible for why these age-of-sale
laws have been adopted more quickly than laws that pro-
hibit e-cigarette use in public indoor spaces. However,
industry-supported, youth-access bills have contained
provisions that undermine prevention efforts for youth,
including preemption of stricter local policies and
weak requirements for enforcement (USDHHS 2012).
Additionally, laws prohibiting sales to minors are likely

244   The Call to Action


E-Cigarette Use Among Youth and Young Adults

to have limited effectiveness as a prevention strategy if Establishing Specific Packaging


they are not aggressively enforced and are not coupled
with proven interventions, such as comprehensive smoke-
Requirements
free laws, pricing strategies, or public health campaigns
Federal, state, local, tribal, and territorial govern-
(USDHHS 2012, 2014). Ensuring that e-cigarettes are reg-
ments are actively considering the potential harms of
ulated at the state and local levels can facilitate the appli-
e-liquids. Exposure to these liquids may lead to nicotine
cation of additional tobacco control policies regarding
and other types of poisoning. Calls to poison control cen-
e-cigarettes.
ters about e-cigarettes and e-liquids have been on the rise,
and about half of these calls are for incidents involving
Many actions can help to protect young young children (American Association of Poison Control
people from the harms of e-cigarettes, such as Centers 2015). The most common adverse health effects
including e-cigarettes in smokefree indoor air of poisoning are vomiting, nausea, and eye irritation, but
policies, restricting youth access to e-cigarettes some deaths have occurred as well. Developing strategies
in retail settings, licensing retailers, and to monitor and prevent future poisonings is critical.
setting specific package requirements.
Calls to poison control centers about e-cigarettes
Licensing Retailers are on the rise. A large portion of these calls
are for incidents involving young children.
Licensing is
another strategy to con- Enacting laws that require e-liquids to be labeled
trol access to e-cigarettes and sold in childproof packaging is one way to reduce
among youth and young the incidence of poisonings, particularly among chil-
adults. A tobacco-related dren. To date, in addition to the federal Child Nicotine
license can authorize Poisoning Prevention Act of 2015 (2016) enacted in
a business to manu- January 2016, more than a dozen states have enacted
facture, distribute, or laws requiring childproof packaging for e-liquids
sell tobacco products (Tobacco Control Legal Consortium n.d.). Health care
(McLaughlin 2010). providers, the public health community, e-cigarette man-
Licensing require- ufacturers and retailers, and the public should be aware
ments help to prevent that e-liquids pose a serious public health concern, par-
sales to minors, pre- ticularly among young children.
vent evasion of tobacco
excise taxes, ensure that
licensees comply with Strategy 4B.
tobacco-related laws,
and promote safe manu- Coordinate, evaluate, and share best practices from state
facturing practices (ChangeLab Solutions 2012). Businesses and local entities that have implemented programs and
that repeatedly violate these laws can have their right to policies to address e-cigarette use among youth and
engage in commercial activity suspended or their licenses young adults.
permanently removed. The possibility of these out-
comes provides a strong incentive to comply with license Many governments at the national, state, local,
requirements. Licensing may also be used to restrict the tribal, and territorial levels are involved in the regulation
sale of flavored products or to address consumer and of e-cigarettes. To have the biggest impact on reducing the
worker safety issues involved with the mixing of liquids use and exposure of e-cigarettes among youth and young
for e-cigarette products (e-liquids). adults, it is integral for these governments to share best
practices and coordinate and evaluate efforts as part of a
comprehensive tobacco prevention and control strategy.
FDA has asserted regulatory authority over e-cigarettes,
and other agencies and governments, as discussed previ-
ously and in Chapter 5, also have relevant authorities.

The Call to Action   245


A Report of the Surgeon General

Goal 5. Curb Advertising and Marketing that Encourages Youth


and Young Adults to Use E-Cigarettes

Unconstrained marketing of e-cigarettes drives con- rules that limit marketing. For example, they can monitor
sumer demand for these products. E-cigarette manufac- advertising and notify their state’s attorney general or the
turers are using tactics similar to those used to market Federal Trade Commission about improper claims or mar-
conventional cigarettes to youth, including offering candy- keting that is not clearly identified as advertising (Federal
flavored products; employing youth-minded themes, such Register 1972; FTC 1984; Center for Public Health and
as rebellion, glamour, and sex; getting celebrity endorse- Tobacco Policy 2013).
ments; and obtaining sports and music sponsorships
(Chapter 4). Some groups have called for extending to
Strategy 5B.
e-cigarettes the same marketing restrictions that already
apply to conventional cigarettes and other tobacco products
(Association of State and Territorial Health Officials 2014; Urge the e-cigarette companies to stop advertising and
Partnership for Prevention 2014). But regulating commer- marketing that encourages and glamorizes e-cigarette
cial speech is typically met with significant barriers and use among youth and young adults.
complex legal issues (Laird-Metke 2010), and partial adver-
tising bans and voluntary agreements generally have not
been fully effective at reducing consumption because the E-cigarette advertising has increased considerably
tobacco industry adapts by shifting to other types of adver- over the years in multiple venues (Legacy for Health 2014;
tising that are not regulated (National Cancer Institute Ganz et al. 2015; see also Chapter 4), while the advertising
2008). Despite these obstacles, public health organiza- for conventional cigarettes on television has been pro-
tions and state and local governments must take action to hibited in the United States since 1971. But e-cigarettes
control the marketing of e-cigarettes to youth and young are now marketed on television and other mainstream
adults, including (a) seeking legally feasible interventions media channels, such as radio and magazines, which are
that are proven to curb youth-oriented tobacco marketing, main sources of information for youth and young adults.
including removing advertising from television; and Emerging research suggests that exposure to television
(b) continuing to help build an evidence base that informs advertisements for e-cigarettes increases the likelihood
future potential restrictions on e-cigarette marketing. that young people will use e-cigarettes in the future and will
believe that e-cigarettes can be used in places where con-
ventional cigarette smoking is not allowed (Farrelly et al.
Strategy 5A. 2015). This is not surprising because e-cigarette marketing
has previously included unproven claims about safety and
Curb e-cigarette advertising and marketing that are smoking cessation, as well as statements that e-cigarettes
likely to attract youth and young adults. are exempt from clean air policies that restrict smoking
(USDHHS 2014). Visual depictions of e-cigarette use in
advertisements may also serve as smoking cues to both cur-
In the absence or delayed implementation of gov- rent and former smokers, increasing their urges to smoke
ernment restrictions on the marketing of e-cigarettes, and undermining their efforts to quit (Maloney and
media outlets, the management staff of special event and Cappella 2015). Advertising for e-cigarettes that encour-
sports venues, and retailers can voluntarily refuse to air or ages and glamorizes the use of e-cigarettes among youth
place youth- and young adult-oriented e-cigarette adver- and young adults can harm public health by undermining:
tising; avoid sponsorships; and not offer free samples of
these products at fairs, festivals, and other events. • Clean indoor air standards;

• Enforcement of smokefree policies;


E-cigarettes are aggressively marketed
using tactics similar to those proven to lead • Tobacco-free social norms; and
to cigarette smoking among youth.
• Marketing restrictions that prohibit the advertising
Finally, state and local public health agencies can of cigarettes and smokeless tobacco on television
stimulate enforcement of and compliance with existing and radio.

246   The Call to Action


E-Cigarette Use Among Youth and Young Adults

Discontinuing advertising and marketing by and features adults (not young adults), does not depict
e-cigarette companies that intentionally or unintention- active use of e-cigarettes, does not use themes proven to
ally encourages or glamorizes e-cigarette use among youth appeal to youth and young adults, avoids media channels
and young adults is essential. Responsible advertising by with high youth access, and does not undermine cessation
the e-cigarette companies is needed, including adver- efforts involving traditional tobacco products.
tising that focuses directly on established adult smokers

Goal 6. Expand Surveillance, Research, and Evaluation Related to


E-Cigarettes

Tobacco control research focused on e-cigarettes has


grown considerably in the past few years. Certainly, more
detailed information is needed to better understand the use
of e-cigarettes and its relationship to the use of other types of
tobacco products. A comprehensive and evolving approach
to research, surveillance, and evaluation is needed.

Strategy 6A.

Improve the quality, timeliness, and scope of e-cigarette


surveillance, research, and evaluation.

Present surveillance systems show that e-ciga-


rette use is increasing rapidly and that most regular • Assess the short- and medium-term health effects of
e-cigarette users also use conventional tobacco products e-cigarette use by youth and young adults and track
(see Chapter 2). Thus, further study can inform strategies long-term consequences;
that minimize harms and maximize the potential health
benefits of these products at the individual and population • Examine the risk factors and other risk behaviors
levels. Data should be timely and focus on the patterns of that may be associated with using e-cigarettes; and
e-cigarette initiation and use among the general public—
including youth, young adults, and former smokers. • Create a model to develop and track the public
Strategic and comprehensive research and evaluation health impact of e-cigarettes.
must further characterize the health risks of e-cigarette
use. A comprehensive package of surveillance, research,
and evaluation should: The rapidly changing nature of the e-cigarette
landscape calls for a comprehensive and evolving
• Track patterns of e-cigarette use through approach to research, surveillance, and evaluation.
cross-sectional surveys and through panels that
follow the same people, including youth and young For such a package, researchers, the public health
adults, over time; community, and other key stakeholders must work
together to address and overcome many challenges:
• Monitor trends in the e-cigarette retail market by
type of product; • The rapidly changing e-cigarette landscape and
terminology;
• Examine the channels and messaging in the
e-cigarette marketplace to inform proactive coun- • Limited resources for collecting timely information;
termarketing strategies;

The Call to Action   247


A Report of the Surgeon General

• The cross-sectional nature of existing surveys and retail settings, assessed outdoor advertising, and identi-
their limited space for questions; fied sponsorships of events by tobacco companies. These
efforts should be adapted to e-cigarettes.
• The different populations that need to be studied; The health care setting has always been an impor-
tant venue for exchanging information about evidence-
• A lack of validated questions; and based approaches to smoking cessation and for protecting
susceptible groups from exposure to secondhand smoke.
• Different measures and definitions across surveys. More research is needed on the role of e-cigarettes in facil-
itating or hindering cessation of conventional cigarettes
and the potential hazards of exposure to secondhand
Strategy 6B.
aerosol from e-cigarettes so that e-cigarettes can also be
a part of this exchange. But even without this research,
Address surveillance, research, and evaluation gaps there is sufficient evidence about the dangers that nico-
related to e-cigarettes. tine-containing cigarettes pose for youth and young adults
that health care providers and professionals can act now
to prevent the use of such products among their young
Patterns of e-cigarette use are rapidly changing patients.
among youth and young adults, as well as among other Finally, existing research and surveillance efforts
groups in the population. Longitudinal data are not yet should include more detailed measures than just general
available to address some of the most critical issues related use of e-cigarettes, including:
to e-cigarettes. The e-cigarette marketplace is changing so
fast that surveillance data and research on the harms of • Frequency and patterns of e-cigarette use;
e-cigarette use and the impact of these changes on tradi-
tional tobacco products are lagging behind. As they look • Type of e-cigarette and/or other tobacco product
to fill in gaps in scientific research, it is important for used;
researchers to continue to seek more current and complete
answers to many critical questions, such as: • The natural history of e-cigarette use, including
initiation, co-use with other tobacco products, and
• What are the risks of progressing to traditional flavoring;
tobacco use among youth and young adults who
have used e-cigarettes? • Ingredients, such as nicotine and flavors;
• What are the health risks posed by e-cigarettes? • Brand;
• Are e-cigarettes safer and more effective than current • Reasons for using and quitting e-cigarettes;
products at helping smokers with smoking cessation?
• Exposure to e-cigarette advertising;
• What are the health consequences for youth and
young adults of initiation of e-cigarettes and of dual • Methods of obtaining e-cigarettes; and
use (conventional cigarettes plus e-cigarettes) com-
pared with the health benefits of completely quitting • Exposure to secondhand aerosol from e-cigarettes.
smoking (or not starting at all)?
Additionally, evaluation is critical to further assess
• What are the health risks to former smokers who are the impact of policies on e-cigarette initiation, use, and
exposed to nicotine from e-cigarette use? Will these other patterns of tobacco use.
persons be more likely to resume smoking?

Additionally, surveillance of e-cigarette marketing


and the advertising messages and strategies used is crit-
ical, as is the carrying out of more studies assessing the
link between exposure to e-cigarette marketing and use
of these products. With traditional tobacco products,
state and local public health agencies have monitored

248   The Call to Action


E-Cigarette Use Among Youth and Young Adults

Conclusions

E-cigarette use, particularly among youth and we must take a precautionary approach by implementing
young adults, has become a public health concern that these strategies and protecting the health of our nation’s
warrants immediate and coordinated action. The increase young people.
in e-cigarette use among youth and young adults in the We know what works to effectively prevent tobacco use
past few years is cause for great concern. Many questions among young people. Now we must apply these strategies to
remain about e-cigarettes and their long-term impact, e-cigarettes—and continue to apply them to other tobacco
even as evidence on patterns of use and risks to health products. To achieve success, we must work together,
continue to emerge. But we know enough about these aligning and coordinating efforts across a wide range of
health risks to take action now to protect the health of our stakeholders. We must protect our nation’s young people
nation’s young people. We cannot wait. Strategies to pre- from a lifetime of nicotine addiction and associated prob-
vent and control the harms of e-cigarettes among youth lems by immediately addressing e-cigarettes as an urgent
and young adults need to be precautionary. Therefore, public health problem. Now is the time to take action.

The Call to Action   249


A Report of the Surgeon General

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The Call to Action   251


E-Cigarette Use Among Youth and Young Adults

List of Abbreviations

α4β2 alpha 4 beta 2-nicotinic acetylcholine AP acetyl propionyl


receptor subtype APA American Psychiatric Association
α7 alpha 7 nicotinic acetylcholine APV advanced personal vaporizers
receptor subtype
arc activity-regulated cytoskeleton-
α6 alpha 6 nicotinic acetylcholine associated protein
receptor subtype
ATF U.S. Department of Justice, Bureau
µg microgram of Alcohol, Tobacco, Firearms and
5AP tLTP protocol 5 action potential timing-dependent Explosives
long-term potentiation protocol A-V atrial-ventricular
5-CSRTT 5-choice serial reaction time task AVA American Vaping Association
5-HIAA 5-hydroxyindole acetic acid, the BART Balloon Analogue Risk Task
primary metabolite of serotonin
BCAP/CAP Committees of Advertising Practice
5-HT1AR serotonin (5-hydroxytryptamine) (UK)
receptor 1A
BLA basolateral amygdala
5-HT2A/C serotonin (5-hydroxytryptamine)
BNST bed nucleus of the stria terminalis
receptor 2 A/C
BOP Bureau of Prisons
86Rb+ efflux assay measure of nicotinic acetylcholine
receptor function via rubidium-86 BP blood pressure
ion efflux [125-I]a-Btx CAD cinnamaldehyde
binding measurement of binding CAM cell-adhesion molecule
at a7 nAChRs using the antagonist
alpha-bungarotoxin cAMP-PKA cyclic AMP-protein kinase A, signaling
cascade
[125I]α-CtxMII binding measurement of binding at a6
nAChRs using the antagonist alpha- CARDIA Coronary Artery Risk Development in
conotoxin MII Young Adults
[125I]A-85380 binding measurement of binding at a4b2 CASAA Consumer Advocates for Smoke-free
nAChRs using the agonist A-85380 Alternatives Association
A1 primary auditory cortex CCTA Contraband Cigarette Trafficking Act
AAP American Academy of Pediatrics CDC Centers for Disease Control and
ACRIDS Prevention
ACR American Association of Cancer CDER Center for Drug Evaluation and
Research Research
AARC American Association for Respiratory C-DISC-IV Diagnostic Interview for Children−
Care Version 4
ACP American College of Physicians cFos protooncogene and immediate early
gene used as a marker of neuronal
ACS American Cancer Society activity
ADHD attention deficit hyperactivity disorder CFR Code of Federal Regulations
ADI acceptable daily intake CI confidence interval
AEMSA American E-Liquid Manufacturing CMS Centers for Medicare & Medicaid
Standards Association Services
AHA American Heart Association CO2 carbon dioxide
AMPA α-amino-3-hydroxy-5-methyl-4- COMDTINST Commandant Instruction
isoxazolepropionic acid
CPP conditioned place preference
AMPAR AMPA receptor
CPu caudate putamen
ANHCS Annenberg National Health
Communication Survey CREB cAMP response element-binding
protein
ANR Americans for Nonsmokers’ Rights
CRF corticotropin-releasing factor
AOR adjusted odds ratio

List of Abbreviations   253


A Report of the Surgeon General

CRP C-reactive protein FDA U.S. Food and Drug Administration


CSI Child Symptom Inventory FEF forced expiratory flow
CTA conditioned taste aversion FeNO exhaled nitric oxide
CTP Center for Tobacco Products FEV1 forced expiratory volume in 1 second
D1R dopamine D1 receptor fMRI functional magnetic resonance
DA diacetyl imaging
DA dopamine FR fixed ratio
DAT1 dopamine regulation genotype FST forced swim test
DEHP diethylhexyl phthalate FTC U.S. Federal Trade Commission
DEP diethyl phthalate FVC forced vital capacity
DHS U.S. Department of Homeland FY fiscal year
Security G20 gestational day 20 (and similar)
DISC-YC Diagnostic Interview Schedule for g gram
Children-Parent Scale-Young Child GABA gamma-aminobutyric acid
DoD U.S. Department of Defense GABAergic any cell, especially any neuron, that
DOPAC 3,4-dihydroxyphenylacetic acid, releases GABA
metabolite of dopamine GPCR G-protein-coupled-receptor
DOT U.S. Department of Transportation GSA General Services Administration
DSM-III Diagnostic and Statistical Manual of GTP guanosine triphosphate
Mental Disorders, 3rd Edition
GTPase large family of hydrolase enzymes that
DSM-IV Diagnostic and Statistical Manual of can bind and hydrolyze GTP
Mental Disorders, 4th Edition
HONC Hooked on Nicotine Checklist
EC electronic cigarette
HPLC-ECD high-performance liquid
ECIG Inc. Electronic Cigarette Industry Group, chromatography electrochemical
Inc. detection
ECIG Ltd. Electronic Cigarettes International HUD U.S. Department of Housing and
Group, Ltd. Urban Development
ED U.S. Department of Education HVA homovanillic acid
ENDS electronic nicotine delivery systems IARC International Agency for Research on
ENNDS electronic non-nicotine delivery Cancer
systems ICD-10 International Statistical Classification
EOP Executive Office of the President of Diseases and Related Health
EPA U.S. Environmental Protection Agency Problems, 10th revision
ERS European Respiratory Society ICE Bureau of Immigration and Customs
Enforcement
EPSC excitatory postsynaptic current
ICR mice Institute for Cancer Research strain of
EPSDT Early and Periodic Screening,
mice
Diagnosis and Treatment
ICSS intracranial self-stimulation
EPSP excitatory postsynaptic potential
IOM Institute of Medicine
ESD electronic smoking device
i.p. intraperitoneal
EU European Union
IQ intelligence quotient
F1 first filial generation (and similar)
IRC Internal Revenue Code
FAA Federal Aviation Administration
i.v. intravenous
FCC Federal Communications Commission
kg kilogram
FCLAA Federal Cigarette Labeling and
Advertising Act KO knockout
FCTC Framework Convention on Tobacco L liter
Control L&M Liggett & Myers
FD&C Act Federal Food, Drug, and Cosmetic Act LC-MS/MS liquid chromatography-tandem mass
spectrometry

254   List of Abbreviations


E-Cigarette Use Among Youth and Young Adults

LH lateral hypothalamus NYS New York State Follow-Up


M&As mergers, formations of partnerships, NYTS National Youth Tobacco Survey
and acquisitions O2 oxygen
m2 square meter ODD oppositional defiant disorder
m3 cubic meter OMB Office of Management and Budget
MAOA monoamine oxidase A OPM Office of Personnel Management
MAPK mitogen-activated protein kinase OR odds ratio
MCH melanin-concentrating hormone OSH Office on Smoking and Health
mFTQ modified Fagerström Tolerance OSHA U.S. Department of Labor,
Questionnaire Occupational Safety and Health
mg milligram Administration
mGluR2 metabotropic glutamate receptor 2 P3 (and similar) postnatal day number
mL milliliter PACT Prevent All Cigarette Trafficking Act
mPFC medial prefrontal cortex PAH polycyclic aromatic hydrocarbon
mRNA messenger ribonucleic acid PATH Population Assessment of Tobacco and
MSN medium spiny neuron Health
MTF Monitoring the Future PDAY Pathological Determinants of
Atherosclerosis in Youth
NAB N-nitrosoanabasine
PFC prefrontal cortex
N2 nitrogen
PHS Public Health Service
NAc nucleus accumbens
PIH Public and Indian Housing
NACDA National Advisory Council on Drug
Abuse PVN paraventricular nucleus of the
thalamus
nAChR nicotinic acetylcholine receptor
PG propylene glycol
NAc-shell nucleus accumbens shell
PM particulate matter
NAT N-nitrosoanatabine
PM2.5 fine particulate matter
NATS National Adult Tobacco Survey
PNE prenatal nicotine exposure
NCI National Cancer Institute
p.o. per os (by mouth)
NDAA National Defense Authorization Act
Postn periostin, osteoblast-specific factor
NDSS Nicotine Dependence Syndrome Scale
PR progressive ratio
NE norepinephrine
PREP potential reduced-exposure product
ng nanogram
PVN paraventricular nucleus of the
NGFI-B nerve growth factor-induced gene-B
thalamus
NHANES III Third National Health and Nutrition
qRT-PCR quantitative real-time polymerase
Examination Survey
chain reaction
NHSDA National Household Survey on Drug
RCRA Resource Conservation and Recovery
Abuse
Act
NIH National Institutes of Health
SAC saccharin
NMDAR N-methyl-d-aspartate receptor
SAMHSA Substance Abuse and Mental Health
NIDA National Institute on Drug Abuse Services Administration
NIOSH National Institute for Occupational s.c. subcutaneous
Safety
SCAN Screening test for Auditory Processing
NJYTS New Jersey Youth Tobacco Survey Disorders
NLSY National Longitudinal Survey of Youth SD standard deviation
nm nanometer SE standard error
NNN N-nitrosonornicotine sec seconds
NNK 4-(methylnitrosamino)-1-(3-pyridyl)- SEC Securities and Exchange Commission
1-butanone
SES socioeconomic status
NRT nicotine replacement therapy

List of Abbreviations   255


A Report of the Surgeon General

SFATA Smoke Free Alternatives Trade USDA U.S. Department of Agriculture


Association USDHEW U.S. Department of Health, Education,
SIDS sudden infant death syndrome and Welfare
SMC serial multiple choice USDHHS U.S. Department of Health and Human
SNAP Special Supplemental Nutrition Services
Program USP U.S. Pharmacopeia
SNP single-nucleotide polymorphism USTR U.S. Trade Representative
SRITA Stanford Research into the Impact of V voltage
Tobacco Advertising VA U.S. Department of Veterans Affairs
STOP Smuggled Tobacco Prevention Act VG vegetable glycerin
TCR trigeminocardiac reflex VOC volatile organic compound
TEOAEs transient evoked otoacoustic VTA ventral tegmental area
emissions
WHO World Health Organization
TH tyrosine hydroxylase
WIC Women, Infants, and Children
THC tetrahydrocannabinol
Wnt Wingless-Type MMTV Integration
TSNA tobacco-specific nitrosamine Site Family, member 1, intracellular
TTB U.S. Department of Treasury, Alcohol signaling factors
and Tobacco Tax and Trade Bureau WT wild type
TVECA Tobacco Vapor Electronic Cigarette w/v weight/volume
Association
YRBSS Youth Risk Behavior Surveillance
UK United Kingdom System
U.S.C. U.S. Code

256   List of Abbreviations


E-Cigarette Use Among Youth and Young Adults

List of Tables and Figures1

Executive Summary Table 2.1b Percentage of high school students who have
used e-cigarettes, by gender and race/ethnicity;
Figure 1 Trends in ever e-cigarette use among U.S. middle National Youth Tobacco Survey (NYTS)
and high school students; National Youth 2015   30
Tobacco Survey (NYTS) 2011–2015   1 Table 2.2a Percentage of middle school students who used
Figure 2 Trends in past-30-day e-cigarette use among e-cigarettes in the past 30 days, by gender and
U.S. middle and high school students; National race/ethnicity; National Youth Tobacco Survey
Youth Tobacco Survey (NYTS) 2011–2015   2 (NYTS) 2011–2015   31
Figure 3 Percentage of young adults who currently Table 2.2b Percentage of high school students who used
use e-cigarettes and conventional cigarettes; e-cigarettes in the past 30 days, by gender and
National Adult Tobacco Survey (NATS) race/ethnicity; National Youth Tobacco Survey
2013–2014   2 (NYTS) 2011–2015   32
Figure 4 Diversity of e-cigarette products   3 Table 2.3a Percentage of middle school students who
have ever used e-cigarettes, by gender and
Figure 5 Percentage of middle school students, high race/ethnicity; National Youth Tobacco Survey
school students, young adults (18–24 years of (NYTS) 2011–2015   34
age), and adults (≥25 years of age) who currently
use e-cigarettes   6 Table 2.3b Percentage of high school students who have
ever used e-cigarettes, by gender and race/
Figure 6 Percentage of middle school students, high ethnicity; National Youth Tobacco Survey
school students, young adults (18–24 years of (NYTS) 2011–2015   35
age), and adults (≥25 years of age) who have ever
used e-cigarettes   7 Table 2.4a Percentage of young adults (18–24 years of age)
who have used e-cigarettes, by gender, race/
Figure 7 Percentage of students in grades 8, 10, and 12 ethnicity, and education; National Adult Tobacco
who used e-cigarettes and cigarettes in the past Survey (NATS) 2013–2014   38
30 days; Monitoring the Future (MTF) 2015   8
Table 2.4b Percentage of adults (≥25 years of age) who have
used e-cigarettes, by gender, race/ethnicity,
Chapter 1. and education; National Adult Tobacco Survey
Introduction, Conclusions, and Historical Background (NATS) 2013–2014   39
Relative to E-Cigarettes Table 2.5 Percentage of students in grades 8, 10, and 12 who
used e-cigarettes, cigarettes, or both products
Table 1.1 Multinational tobacco companies with e-cigarette in the past 30 days, by sociodemographic
brands   15 characteristics; Monitoring the Future (MTF)
2015   41
Figure 1.1 Diversity of e-cigarette products   3
Table 2.6a Lifetime and past-30-day e-cigarette use among
Figure 1.2 Parts of an e-cigarette device   12
U.S. middle school students, by other tobacco
Figure 1.3 Examples of e-liquid flavors   13 product use; National Youth Tobacco Survey
(NYTS) 2015   44
Figure 1.4 E-liquids being poured into an e-cigarette
device   13 Table 2.6b Lifetime and past-30-day e-cigarette use among
U.S. high school students, by other tobacco
product use; National Youth Tobacco Survey
Chapter 2. (NYTS) 2015   45
Patterns of E-Cigarette Use Among U.S. Youth and
Table 2.7a Percentage of middle school students who have
Young Adults ever used tobacco, by type of product; National
Youth Tobacco Survey (NYTS) 2011–2015   47
Table 2.1a Percentage of middle school students who have
used e-cigarettes, by gender and race/ethnicity; Table 2.7b Percentage of high school students who have
National Youth Tobacco Survey (NYTS) ever used tobacco, by type of product; National
2015   29 Youth Tobacco Survey (NYTS) 2011–2015   49

1The Executive Summary and appendixes are not a part of the main report. Instead, they are available online at
http:/www.surgeongeneral.gov/library/reports/.

List of Tables and Figures   257


A Report of the Surgeon General

Table 2.8a Percentage of young adults (18–24 years of Figure 2.4 Percentage of students in grades 8, 10, and
age) who currently use e-cigarettes, cigarettes, 12 who used e-cigarettes and cigarettes in the
or both products, by gender, race/ethnicity, past 30 days; Monitoring the Future (MTF)
and education: National Adult Tobacco Survey 2015   40
(NATS) 2013–2014   54
Figure 2.5 Past-30-day use of various tobacco products
Table 2.8b Percentage of adults (≥25 years of age) who among U.S. middle and high school students;
currently use e-cigarettes, cigarettes, or National Youth Tobacco Survey (NYTS)
both products, by gender, race/ethnicity, and 2015   46
education: National Adult Tobacco Survey
(NATS) 2013–2014   55 Figure 2.6 Percentage of U.S. middle school students who
have ever used tobacco, by type of product;
Table 2.9 Percentage of youth (middle and high school National Youth Tobacco Survey (NYTS)
students), young adults (18–24 years of age), 2011–2015   51
and adults (≥25 years of age) using tobacco
products who reported using flavored e-cigarette Figure 2.7 Percentage of U.S. high school students who have
products, by gender and race/ethnicity; National ever used tobacco, by type of product; National
Youth Tobacco Survey (NYTS) and National Youth Tobacco Survey (NYTS) 2011–2015   52
Adult Tobacco Survey (NATS)   60 Figure 2.8 Percentage of young adults who currently
Table 2.10 Summary of studies on e-cigarette flavors among use e-cigarettes and conventional cigarettes;
youth and young adults   61 National Adult Tobacco Survey (NATS)
2013–2014   53
Table 2.11 Summary of studies on perceptions of e-cigarette
harm among youth and young adults   65
Appendix 2.1.
Table 2.12a Percentage of middle school and high school Sources of Data
students who reported that using e-cigarettes
on some days but not every day caused no harm,
little/some harm, or a lot of harm, by e-cigarette Table A2.1-1 Sources of national data on e-cigarette use
smoking status; National Youth Tobacco Survey among youth and young adults   A2.1-4
(NYTS) 2015   73
Table 2.12b Percentage of middle school students who Appendix 2.2.
reported that using e-cigarettes on some days Key Measures of Use
but not every day caused no harm, little/some
harm, or a lot of harm, by e-cigarette smoking Table A2.2-1 E-cigarette items from sources of national data
status; National Youth Tobacco Survey (NYTS) on e-cigarette use among youth and young
2015   73 adults   A2.2-5
Table 2.12c Percentage of high school students who Table A2.2-2 E-cigarette items from PATH on e-cigarette use
reported that using e-cigarettes on some days among youth and young adults   A2.2-10
but not every day caused no harm, little/some
harm, or a lot of harm, by e-cigarette smoking
status; National Youth Tobacco Survey (NYTS) Appendix 2.3.
2015   74 Other Supporting Literature
Table 2.12d Percentage of young adults (18–24 years of age)
who reported that e-cigarettes were not at all Table A2.3-1 Summary of studies on patterns of e-cigarette
harmful, moderately harmful, or very harmful, use among youth   A.2.3-6
by e-cigarette smoking status; National Adult Table A2.3-2 Summary of studies on susceptibility and
Tobacco Study (NATS) 2013–2014   74 intentions to use e-cigarettes among youth and
Table 2.13 Summary of studies on reasons for use and young adults   2.3-20
discontinuation of e-cigarettes among youth Table A2.3-3 Summary of studies on patterns of e-cigarette
and young adults   76 use among young adults   2.3-23
Figure 2.1 Trends in ever e-cigarette use among U.S. middle
and high school students; National Youth
Tobacco Survey (NYTS) 2011–2015   33 Chapter 3.
Health Effects of E-Cigarette Use Among U.S. Youth and
Figure 2.2 Trends in past-30-day e-cigarette use among Young Adults
U.S. middle and high school students; National
Youth Tobacco Survey (NYTS) 2011–2015   36
Table 3.1 Relevant conclusions from previous Surgeon
Figure 2.3 Trends in ever e-cigarette use among U.S. adults General’s reports on smoking and health   98
by age group; Styles 2010–2014   40

258   List of Tables and Figures


E-Cigarette Use Among Youth and Young Adults

Figure 3.1 Plasma nicotine concentration from different Figure 4.3 Sales volume and price of disposable e-cigarettes,
human laboratory studies and four different U.S. market, 2010–2014   155
products with blood sampled before and
immediately after a 10-puff bout with the Figure 4.4 Sales volume and price of rechargeable
products   103 e-cigarettes, U.S. market, 2010–2014   156

Figure 3.2 Data showing exponential increase in the Figure 4.5 Quarterly promotional spending for e-cigarettes,
number of cases of human exposure to 2010–2014   158
e-cigarette products and liquid nicotine between Figure 4.6 E-cigarette marketing claims   160
2011 and 2016   121
Figure 3.3 Changes in aerosol particle PM2.5 concentrations
Appendix 4.1.
during experiment of e-cigarette use and
tobacco cigarette smoking in an exposure Major E-Cigarette Manufacturers
chamber   123
Table A4.1-1 Major e-cigarette manufacturers   A4.1-2

Appendix 3.1.
Evidence Tables Appendix 4.2.
E-Cigarette Trade Organizations and Advocacy Groups
Table A3.1-1 Studies on aerosolized nicotine and dependence,
by dependency criteria   A3.1-2 Table A4.2-1 E-cigarette trade organizations and advocacy
groups   A4.2-2
Table A3.1-2 Human studies on the effects of nicotine
exposure on adolescent users   A3.1-8
Appendix 4.3.
Table A3.1-3 Preclinical/animal studies on adolescent
nicotine exposure   A3.1-18 The Rapidly Changing E-Cigarette Marketplace

Table A3.1-4 Human studies on the effects of nicotine Figure A4.3-1 Market share of e-cigarette products   A4.3-3
exposure on fetal brain development   A3.1-33
Table A3.1-5 Preclinical/animal studies on fetal nicotine
Appendix 4.4.
exposure   A3.1-63
Data Points for Figure 4.1

Chapter 4. Table A4.4-1 Data points for Figure 4.1 (e-cigarette sales in
Activities of the E-Cigarette Companies tracked channels by brand, 2010–2014)   A4.4-2

Table 4.1 Estimated e-cigarette market size in 2014


Appendix 4.5.
($ billion)   150
Evolution of Market Share in the E-Cigarette Market
Table 4.2 Estimated e-cigarette market size in 2015
($ billion)   150 Figure A4.5-1 E-cigarette market share in tracked channels by
Table 4.3 Mergers, acquisitions, partnerships, and other brand, 2010–2014   A4.5-3
agreements in the e-cigarette industry   165
Table 4.4 Comparison of website access restrictions, Chapter 5.
online sales, nicotine levels, and flavors E-Cigarette Policy and Practice Implications
among e-cigarette brands with no cigarette
manufacturer affiliation, brands acquired by Table 5.1 Comparative risk assessment: Potential harms
cigarette manufacturers, and brands developed and benefits of e-cigarettes   186
by cigarette manufacturers   166
Table 5.2 Principle federal policies and regulations of
Figure 4.1 E-cigarette sales in tracked channels by brand, tobacco that emphasize e-cigarettes   189
2010–2014   153
Table 5.3 Medical organizations   207
Figure 4.2 E-cigarette sales in tracked channels by product
type, 2010–2014   154 Figure 5.1 Potential patterns of use of combustible
products (CPs) and e-cigarettes (e-cigs)   187

List of Tables and Figures   259


E-Cigarette Use Among Youth and Young Adults

Index1

1964 report. See Smoking and Health: Report of the Advisory survey data sources, A2.1-2 to A2.1-3, A2.2-2
Committee to the Surgeon General of the Public Health Service trends in prevalence of e-cigarette use, 37, 40f
(1964 report) Ad valorem excise tax, on tobacco products, 204
1988 report. See The Health Consequences of Smoking–Nicotine Advance cigarettes, 9
Addiction (1988 report) Advanced personal vaporizers, 150
1994 report. See Preventing Tobacco Use Among Young People Advertising. See also Marketing
(1994 report) behavior, effect on, 170–171
2010 report. See How Tobacco Smoke Causes Disease–The Broadcast Ban, 189t
Biologic and Behavioral Basis for Smoking-Attributable burden of proof regarding safety, 238
Disease (2010 report) cigarettes, 8–9
2012 report. See Preventing Tobacco Use Among Youth and e-cigarette companies, 14–15
Young Adults (2012 report) exposure to, youth and young adults, 169
2014 report. See The Health Consequences of Smoking—50 Years protections for youth, 208t
of Progress (2014 report) receptivity to, youth and young adults, 169–170
restrictions, 238
Surgeon General’s report (2012), 4
A targeting youth and young adults, 246–247
Advertorials, 205
AACR (American Association for Cancer Research), 206, Advocacy groups, e-cigarette industry, 15, A4.2-2 to A42-3t
208–209t USP-grade nicotine, 114
AAP (American Academy of Pediatrics), 206, 207t Aerosol inhalation
AARC (American Association for Respiratory Care), 209t adulterants, 100, 116–117
Accord cigalikes, 9 aerosolized solvents, 115
Acetaldehyde, aerosolized adulterant, 117, 118 cannabis and illicit drugs, 58
Acetone, aerosolized toxicant, 118 e-cigarette devices, 11
Acetyl propionyl, aerosolized flavorant, 116 flavorants, 115–116
Acrolein nicotine-related compounds, 114
aerosolized adulterant, 117, 118 non-nicotine constituents, 114–118
e-cigarette component, 99 Aerosolized nicotine
Addiction cardiovascular function, 101
aerosolized nicotine, 102–104, 103f clean air policies, 188
fetal effects of, A3.1-40 to A3.1-48t dependence, 102–104, 103f, A3.1-2 to A3.1-7t
long-term potential, 11, 239 dose and effects of, 100–101, 103f
smoking behavior changes, with low-nicotine cigarettes, 9 maternal exposure, and prenatal and postnatal health
Surgeon General’s report (1988), 9, 97, 98t outcomes, 108–113
withdrawal symptoms (physical abstinence syndrome), 102, secondhand exposure, 120–123, 123f, 183, 209t, 240
A3.1-3 to A3.1-6t thirdhand exposure, 209t
ADHD. See Attention deficit hyperactivity disorder (ADHD) toxicants in, 208t, 219t, 229
Adolescents. See also Young adults; Youth youth, effects on, 104–107
ages of, 4 Affordable Care Act (2010), 193t
brain development, 99 African Americans. See Race/ethnicity
nicotine and brain development, 5 flavored little cigars and cigarillos, 11
nicotine, increased sensitivity to, 105 retail sales of e-cigarettes, 150
pregnancy, 109 Age-of-sale laws, 208t, 238, 241, 242, 244–245
Adulterants, aerosolized, 100, 116–117 Age, of starting tobacco use, 239, 241
Adults (age ≥25). See also National Adult Tobacco Survey Alameda County, California, public health department, 224
(NATS); Styles Survey Alcohol and Tobacco Tax and Trade Bureau (TTB), 200t
current prevalence of e-cigarette use, 37, 39t Alcohol use
flavors in e-cigarettes, 59, 60t e-cigarette use, with, 57–58
poly-tobacco use, 53, 55t maternal smoking, 111

1Note: “t” following a number refers to a table; “f” following a number refers to a figure; “n” following a number refers to a note; and “A”
preceding a number refers to an appendix.

Index   261
A Report of the Surgeon General

Allergic reactions, e-cigarette aerosol exposure, 123 AVA (American Vaping Association), A4.2-2, A4.3-2
Altered corpus callosum, fetal effects of nicotine exposure, Aversive stimuli, enhanced sensitivity to, 107, A3.1-27t
A3.1-34t
Altria Group, Inc./Nu Mark. See also MarkTen e-cigarettes
acquisition, 165t B
company profile, A4.1-2t
multinational tobacco company, 15t Ballantyne Brands (Mistic). See Mistic e-cigarettes
Aluminum, aerosolized, 119 Batteries for e-cigarettes
American Academy of Pediatrics (AAP), 206, 207t explosions and fires, 14, 119
American Association for Cancer Research (AACR), 206, 208–209t voltage and amount of carbonyl compounds, 117, 118
American Association for Respiratory Care (AARC), 209t Bauway Technology Limited (Shenzhen, China), A4.1-14t
American Association of Poison Control Centers, 14 Behavior, advertising, effect of, 170–171
American Cancer Society (ACS), 215t Behavioral disorders, A3.1-56 to A3.1-62t. See also Attention
American College of Physicians, 210t deficit hyperactivity disorder (ADHD)
American Heart Association, 216–217t Benzene, aerosolized, 118
American Legacy Foundation (Truth Initiative), 158, 159, 163 Blacks. See Race/ethnicity
American Lung Association, 218t, 224, 225 Blu (blu) e-cigarettes
Americans for Nonsmokers’ Rights (ANR), 219t advertising expenditures, 157, 159
American Society of Clinical Oncology, 206, 208–209t e-liquid manufacture, 154
American Thoracic Society, 211–212t magazine advertisement, 160f, 161f
American Tobacco Company, 8 manufacturer of, 15t
American Vaping Association (AVA), A4.2-2, A4.3-2 marketing and promotion, 152, 153f
Amino-tadalafil, aerosolized adulterant, 117 plasma nicotine concentration, 103f
Annenberg National Health Communication Survey, 171 sales (2010–2014), A4.4-2 to A4.4-6t
ANR (Americans for Nonsmokers’ Rights), 219t sponsorship of events, 159, 163
Antiandrogenic activity, DEP and DEHP, 117 website access restrictions, 166t
Anxiety disorders BOP (Bureau of Prisons), 198t
adolescent smoking, 107 Bradycardia, SIDS and maternal smoking, 109
Netherlands Study of Depression and Anxiety Disorders, Brain development and nicotine exposure
A3.1-14t prenatal, 14, 99, 104–105, 109–110, 112–113
Apnea, SIDS and maternal smoking, 109 research needed, 185
Appetitive behaviors, fetal effects studies on, A3.1-54 to A3.1-55t
appetitive behaviors, defined, 110 youth and young adults, 104–106
nicotine dependence, 110–111 Brand preference, development of, 157
other substances use, 111–112, A3.1-48 to A3.1-50t British American Tobacco (BAT), 15t, A4.1-3t
overweight and obesity, 111, A3.1-51 to A3.1-53t Broadcast Ban, 189t
smoking uptake and nicotine dependence, A3.1-40 to 1-48t Bronchiolitis obliterans (popcorn lung disease), 116
Ariva smokeless tobacco product, 9 Brown and Williamson (Advance cigarettes), 9
Arousal deficits, SIDS and maternal smoking, 109 Burden of proof for product safety, 238, 242
Asthma Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), 198t
acrolein, 117 Bureau of Immigration and Customs Enforcement (ICE), 196t
PG inhalation, 115 Bureau of Prisons (BOP), 198t
ATF (Bureau of Alcohol, Tobacco, Firearms and Explosives), Butanol, aerosolized, 118
198t Buttery flavor, aerosolized flavorant in e-liquids, 116
Atherogenesis, 101
Atherosclerosis, 118
Attention and cognition disorders, 106–107, A3.1-56 to 1-62t C
Attention deficit hyperactivity disorder (ADHD)
comorbid substance abuse, 106 CAD (cinnamaldehyde)
nicotine dependence, A3.1-13t aerosolized flavorant, 115
nicotine exposure, A3.1-11t cytotoxicity of, 116
prenatal nicotine exposure, 112, 113, A3.1-14t, A3.1-49t, Cadmium, aerosolized, 119
A3.1-56 to A3.1-59t California
Attitudes, knowledge, and risk perceptions, 171 Alameda County public health department, 224
Auditory processing, deficits in Hayward tobacco products aimed at kids, case study, 224
e-cigarettes use, 7 licensing issues, 203
fetal exposure to nicotine, 7, A3.1-35 to 1-39t Camel cigarettes, 8
maternal cigarette smoking, 109–110 Cannabinoids/cannabis. See Marijuana
Autonomic function and SIDS, 109 Car and Driver magazine, 162f

262   Index
E-Cigarette Use Among Youth and Young Adults

Carbonyls, aerosolized, 117, 118 attention and cognition disorders, 106–107, A3.1-56 to 1-62t
Carcinogens deficits, with maternal smoking, 110
acrolein, 118 prenatal nicotine exposure, 112–113
carbonyls, 117 Combustible tobacco products
DEHP, 117 decline in rates of using, 185
NNN and NNK, 116 e-cigarette use associated with, 6
Cardiovascular function and disease, 101, 117, 118 patterns of use, 187f
Case studies Comprehensive strategy approach, prevention, 238, 244
Hayward, California, tobacco products for kids, 224 Conduct disorders, prenatal nicotine exposure, 112–113
North Dakota, clean indoor air, 225 Consumatory behaviors, maternal smoking, 110–111
CDC. See Centers for Disease Control and Prevention (CDC) Consumer perceptions
Center for Devices and Radiological Health (CDRH), 16 discontinuation, reasons for, 81t, 82t, 86, 87
Center for Drug Evaluation and Research (CDER), 16 e-cigarette use as normative, 15
Center for Tobacco Policy and Organizing, 224 perceived harm of e-cigarettes, 59, 64–71t, 87
Center for Tobacco Products (CTP). See U.S. Food and Drug PREPs, safety of, 10
Administration (FDA) use, reasons for, 75–86, 76–85t, 87
Centers for Disease Control and Prevention (CDC) Contraband Cigarette Trafficking Act, reauthorized 2005
aerosolized flavorants, 115 (CCTA), 198t
e-cigarette use among youth, A2.3-6t, A2.3-7t, A2.3-8t, A2.3-18t Convenience stores, 167
flavors in e-cigarettes, 61t Corpus callosum, alteration of
patterns of e-cigarette use among youth adults, A2.3-27t e-cigarettes, 7
poison centers, increase in e-cigarette-related calls, 209t fetal exposure to nicotine, 7
statewide tobacco control programs, 238 maternal smoking, 109
surveys administered or sponsored by Cotinine salivary levels, secondhand smoke, 108
National Adult Tobacco Survey, A2.1-3 Cotinine serum levels
National Youth Tobacco Survey, A2.1-2 e-cigarettes, 99
Styles, A2.1-3 new e-cigarette users, 102
Centers for Medicare & Medicaid Services (CMS), 193–194t secondhand smoke, 122
ChangeLab Solutions, 224 C-reactive protein (CRP), nicotine exposure, 101
Chemical exposure, e-cigarettes, 7, 208t Cross-sectional studies of poly-tobacco use
Chesterfield cigarettes, 8 adults (age ≥25), 53, 55t
Child Nicotine Poisoning Prevention Act (2015), 14, 120, 245 young adults, 53, 53f, 54t
Child-resistant packaging for e-liquid containers, 14, 120, 208t, 245 youth
China current prevalence, 37, 40f, 41–42t, 43, 44t, 45t, 46f
e-cigarette companies and manufacturers, 14, 152, A4.1-12 to trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53
A4.1-14t Crotonaldehyde, aerosolized toxicant, 118
e-cigarette technology, 10 CRP (C-reactive protein) nicotine exposure, 101
products imported from, 149 CTP (Center for Tobacco Products). See U.S. Food and Drug
CHRNA5-A3-B4 haplotypes, gene cluster in nicotine addiction, 104 Administration (FDA)
Chronic obstructive pulmonary disease, acrolein associated with, 117 Curiosity, as reason for trying e-cigarettes, 75, 87
Cigalikes, term usage, 3
Cigarettes
early efforts to modify, 8 D
exclusive use of, compared to e-cigarettes, 6
filters and tar reduction, 8–9 Data for report, sources for, 27
price of, and use of e-cigarettes, 156 Death, from ingestion of e-liquids, 14
reduced-harm products, 8, 185 Deeming rule
trafficking and smuggling, 198t e-liquids, free samples of, 151
Cinnamaldehyde (CAD) FDA authority over e-cigarettes, 6
aerosolized flavorant, 115 free samples, 163
cytotoxicity of, 116 Internet sales to youth under age 18, 163, 164
Closed-system devices, 151 minimum age requirements in retail environments, 167
Cloud Pen e-cigarettes and devices, magazine advertisement, 161f modified risk claims, prohibiting, 163
CMS (Centers for Medicare & Medicaid Services), 193–194t source and provisions of, 17
Coalition on Smoking OR Health, 9 vape shops, and mixing e-liquids, 169
Cocaine use and prenatal nicotine exposure, 111 DEHP (diethylhexyl phthalate), aerosolized adulterant, 117
Cochrane database, NRT during pregnancy, 109 DEP (diethyl phthalate) aerosolized adulterant, 117
Cognition Dependence on nicotine
adolescent smoking, 106–107 aerosolized nicotine, 102–104, 103f, A3.1-2 to A3.1-7t

Index   263
A Report of the Surgeon General

maternal smoking, 110–111 control measures, 184


Depression, adolescent smoking, 107 educational initiatives, 206
Dermatitis, e-cigarette aerosol exposure, 123 future research, 185–186
Diabetes type 2, fetal effects from nicotine exposure, 111 health care practice, implications for, 203
Diacetyl (2,3-butanedione), aerosolized flavorant, 116 licensing, 203
Diethylhexyl phthalate (DEHP), aerosolized adulterant, 117 marketing restrictions, 205–206
Diethyl phthalate (DEP) aerosolized adulterant, 117 overview, 7
Direct-drip atomizers, carbonyls, greater exposure to, 118 pricing measures, 204–205, 238
Disruptive disorders, adolescent smoking, 107 public policy approaches, 187–188
Distribution channels for e-cigarettes, 149–151 risk tradeoffs, 184–185, 186t
Dopamine system taxation, 204–205, 238
abused drugs, 106 tobacco-free spaces, 240
fetal effects from nicotine exposure, 112, 113 youth access and prevention, 203, 243–245
Dr. Scott’s Electric Cigarettes, 8 E-cigarette-related exposures, 14, 209t, 245
Drugs, illicit E-cigarettes
aerosol inhalation, 58 bridge to greater tobacco product use, 11
e-cigarette products and devices, delivery system for, 6, 13–14 controversy over, 183
Dual use countries that have banned e-cigarettes/ENDS, 223t
advertising and, 170–171 discontinuation, reasons for, 81t, 82t, 86, 87
defined, A2.2-3 disposable, and prices, 3f, 152, 154, 154f, 155, 155f
health consequences, 186 federal regulation of, 15–18, 187–188
policies discouraging practice of, 244 growth in awareness and use, 149
health effects
fetal brain development from nicotine exposure, A3.1-33
E to A3.1-62t
fetal nicotine exposure, preclinical/animal studies, A3.1-63
E-cigarette companies to A3.1-79t
activities of, 7 nicotine exposure effects, human studies, A3.1-8 to A3.1-17t
advertising and marketing, 14–15, 169–171 nicotine exposure effects, on fetal brain development,
brands, categories of, 164–165 A3.1-33 to A3.1-62t
burden of proof regarding safety, 238, 242 nicotine exposure effects, preclinical/animal studies,
China based, A4.1-12 to A4.1-14t, A4.3-2 A3.1-18 to A3.1-32t
consolidation of companies, A4.3-2 overview of, 6–7
distribution and purchase channels, 149–150 historical background, 8–10
e-cigarette market in the U.S., 149–154, 150t, 153f, 154f intentions to use summary data, A2.3-20 to A2.3-22t
e-liquids, production of, 154 invention of, 10–11
FDA registration and disclosures, 242 marketplace changes
independent private companies, A4.1-6 to A4.1-11t, A4.3-2 market share of products, A4.3-3f, A4.5-2, A4.5-3 to A4.5-5f
independent public companies, A4.1-4 to A4.1-6t, A4.3-2 tobacco industry, A4.1-2 to A4.1-3t
marketing expenditures, 157–167, 158f, 160–162f, 165t, 166t tracking of, 238
market share of products, 152 trade organizations and partnerships, A4.3-2
mergers, acquisitions, partnerships, and agreements, 165t names used for, 5, A2.2-2
multinational companies, 15t patterns of use, 6, 186, 187f, A2.3-6 to A2.3-19t, A2.3-23 to
other product-related companies, A4.1-11 to A4.1-12t, A4.3-2 A2.3-37t
packaging, 242, 245 persistent use despite harmful consequences, A3.1-7t
product evolution, 151–152 physiological withdrawal state, A3.1-3t, A3.1-3 to A3.1-6t
product standards, 242 potential harms and benefits, 185–186, 186t
retail outlets, 150t, 152–154, 153f, 154f, 167–169 preoccupation with, A3.1-7t
sales projections, 14 prevalence of use, 204, A2.3-2 to A2.3-3
sales volume and prices, 155–157, 155f, 156f price and sales volume, 7
tobacco industry, A4.1-2 to A4.1-3t products and devices
visitors to websites, recruitment of, 14 additional functions, 152
websites, 165–166, 166f candy and menthol flavored, 211t
E-cigarette policy and practice implications components of, 11, 12f
agencies addressing specific populations, 243 disposable, 3f
case studies, 224–225 dose of inhaled nicotine, 100, 103f
changing landscape, 184 evolution of, 151–152
clean indoor air, 188 illicit drugs, delivery system for, 6, 216t
comprehensive strategy relating to adverse consequences, 238 modification of, 11

264   Index
E-Cigarette Use Among Youth and Young Adults

rechargeable, 3f ENDS (electronic nicotine delivery systems), 27. See also


risks, 13–14 E-cigarettes
substances found in, 216t E-pipes, appearance of, 3f
types of, 3, 3f Esquire magazine, 160f
public health concerns, 183 Estrogenic activity, DEP and DEHP, 117
reasons for using, 6 Ethnicity. See Race/ethnicity
rechargeable, and sales volume and price, 3f, 155–156, 156f European Commission, Tobacco Products Directive, 213t
sales, tracked retail outlets, A4.4-2 to A4.4-6t European Medicines Agency, 117
surveys European Respiratory Society (ERS), 213t
key measures, A2.2-2 to A2.2-4 European Union (EU)
methodologic information, A2.2-2 indoor air quality, 122
sources of data, A2.2-5 to A2.2-15t position on e-cigarettes and ENDS, 221t
susceptibility summary data, A2.3-20 to A2.3-22t Evaluation, policy impacts, 248
susceptibility to use, and advertising, 170 Ever (lifetime) use, defined, A2.2-2. See also High school
tolerance to effects, A3.1-6t students; Middle school students; National Youth Tobacco
use, reasons for, 75–86, 76–85t, 87 Survey (NYTS); Youth
use with other tobacco products (See Poly use) EVIC tank device, 103f
without nicotine, health effects of, 17 Evod heating element, 103f
E-cigars, appearance of, 3f Exalt smokeless tobacco product, 9
E-cigs (brand), 15 Excise tax, on tobacco products, 204
Eclipse cigalikes, 9 Explosions caused by e-cigarette batteries, 14, 119
Educational attainment
adults (age ≥25), 39t
young adults, and e-cigarette use, 37, 38t F
Educational initiatives
e-cigarette policies, 206 Facebook
on ENDS products, 210t advertising, 157
health care professionals, 217t, 226, 241 coupons and discounts, 163
media campaigns, 238 distribution and purchase channels, 150
responsibility for, 239–241 e-cigarettes, 15
United Nations organization on, 183 Family Smoking Prevention and Tobacco Control Act of 2009, iii,
Educational plans of youth, 37, 41t 9, 16, 18, 58, 183, 210t, 241
Electronic Cigarette Industry Group, Inc. (ECIG Inc.), A4.3-2 Favor cigarettes, 10
Electronic cigarettes. See entries beginning with E-cigarette FDA. See U.S. Food and Drug Administration (FDA)
Electronic nicotine delivery systems (ENDS), 27. See also Fear responses, and adolescent smoking, 107
E-cigarettes Federal Communications Commission (FCC), 189t
Alcohol and Tobacco Tax and Trade Bureau, 200t Federal Food, Drug, and Cosmetic Act, 16–17, 183, 241
American Association for Cancer Research, 208–209t Federal regulation of e-cigarettes. See also specific agencies by name
American College of Physicians, 210t approach to, 15–18
Forum of International Respiratory Societies, 214t policies of federal agencies, 189–202t
International Union Against Tuberculosis and Lung Cancer, 223t Tobacco Control Act, 187–188
term usage, 27 Fetal effects of nicotine exposure. See also Pregnancy; Prenatal
World Health Organization, 219–220t nicotine exposure
Elektro e-cigarettes, sales (2010–2014), 153f, A4.4-2 to A4.4-6t altered corpus callosum, 7, A3.1-34t
E-liquids appetitive behaviors, A3.1-40 to 1-55t
adulterants, 100 attention and cognition, behavioral disorders, A3.1-56 to
child-resistant packaging, 14, 208t A3.1-62t
concentration, and dose of inhaled nicotine, 100, 103f attention deficit hyperactivity disorder (ADHD), 112, 113,
devices, filling, 11, 13f A3.1-14t, A3.1-49t, A3.1-56 to A3.1-59t
free samples, 151 auditory processing defects, 7, A3.1-35 to 1-39t
ingestion of or exposure to, and health effects, 7, 119–120, brain development, 14, 99, 104–105, 109–110, 112–113
121f, 184 brain reward systems changes, A3.1-54 to A3.1-55t
nut allergy, and e-cigarette aerosol exposure, 123 cognition disorders, 112–113
production of, 154 conduct disorders, 112–113
refills, sales of, 154, 154f obesity, 7
taxation of, 204 preclinical/animal studies, A3.1-63 to A3.1-79t
vape shops, mixing in, 169 sudden infant death syndrome (SIDS), 7, 109, A3.1-33t
Employers, rewards or penalties for tobacco use, 194t Filters, health, effects on, 8
Ending the Tobacco Problem: A Blueprint for the Nation (IOM), 16

Index   265
A Report of the Surgeon General

FIN e-cigarettes Genetics


magazine advertisement, 162f gene expression alterations with maternal smoking, 109
television advertising, 159 genetically modified nontobacco plants, 17
website access restrictions, 166t genetically sensitive research designs, 112, 112n
Fires caused by e-cigarette batteries, 14, 119 nicotine addiction, 104
Flavors for e-cigarettes Glycidol, e-cigarette aerosol, 99
addiction and use of conventional tobacco products, 11 Glyoxal, aerosolized toxicant, 118
aerosol inhalation, 115–116 Green Smoke e-cigarettes
flavors appealing to minors, California prohibiting, 151 manufacturer, 15t
Internet sales, 164 website information, 166, 166t
licensing requirements, 203
restrictions on, 242
safety of inhaling, 13, 184, 186 H
sales, growth of, 154
studies on, 58–59, 60t, 61–63t Halco, e-cigarettes, A4.1-8t
sweet flavors, 11, 13f, 211t Halo Companies, Inc., A4.1-10t
youth and young adults, 6, 11 Harm
Food and Drug Administration (FDA). See U. S. Food and Drug reduced-harm products, 8, 185
Administration (FDA) reduction with e-cigarettes, and advertising, 171
Food and Nutrition Act (2008), 190t strategies to prevent, 237–238
Formaldehyde Haus e-cigarettes, sales (2010–2014), 153f, A4.4-2 to A4.4-6t
aerosolized adulterant, 117, 118 Health Belief Model, tobacco use, and perception of harm, 64
e-cigarettes, 99 Health care practice, implications for, 203
higher temperature of e-cigarettes, 13 Health care professionals, as education channel, 217t, 226, 241
Forum of International Respiratory Societies, ENDS devices, 214t The Health Consequences of Smoking—50 Years of Progress
4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), (2014 report)
aerosolized adulterant, 116 conceptual modeling, 186
Free samples; restrictions, 242 conclusions from, 97, 99t
Frequent use, defined, A2.2-3. See also High school students; maternal cigarette use and disruptive-behavior disorders, 112, 113
Middle school students; National Youth Tobacco Survey passive use effects for pregnant women, 14
(NYTS); Youth relevance of conclusions to e-cigarettes, 225
FTC. See U.S. Federal Trade Commission (FTC) sensitivity of youth to nicotine effects, 99
Future regulatory actions, 242 The Health Consequences of Smoking–Nicotine Addiction (1988
Future research initiatives, 185–186, 226 report)
conclusions from, 97, 98t
nicotine addiction, 9
G Health effects
e-cigarette potential harms and benefits, 185–186, 186t
Gamucci e-cigarettes e-liquids, ingestion of, 7, 184, 245
company profile, A4.1-8t nicotine and tar reduction, 8–9
market share (2010–2014), A4.5-3f risk tradeoffs and, 184–185
sales (2010–2014), 153f, A4.4-2 to A4.4-6t HealthStyles Survey, A2.1-3, A2.1-4 to A2.1-5t
Gender differences Heat-not-burn products, 15t
e-cigarette use Heavy metals, aerosolized, 119
adults (age ≥25), 39t High school students. See also Youth
high school, 28, 30t, 32t, 33, 35t, 37 current prevalence of e-cigarette use
middle school, 28, 29t, 31t, 33, 34t, 36 ever use, 28, 30t
young adults, 37, 38t frequency of use, 28, 30t
flavors in e-cigarettes, 59, 60t past-30-day use, 28, 32t
myelination gene expression with maternal smoking, 109 susceptibility to use, 28, 30t
poly-tobacco use trends in prevalence of e-cigarette use
adults (age ≥25), 55t ever use, 33, 33f, 35t
young adults, 53, 54t past-30-day use, 32t, 36–37, 36f
youth, 37, 41t, 43 Hill, Sir Austin Bradford, 186
General Services Administration (GSA) Hippocampal function, adolescent smoking, 107
agency description, 190t Hispanic population, retail sales of e-cigarettes, 150, 168
e-cigarette regulations, 188 Hispanics. See Race/ethnicity
smoking regulations, 190t Hon Lik, 10
Hookah bars and lounges, 203

266   Index
E-Cigarette Use Among Youth and Young Adults

How Tobacco Smoke Causes Disease–The Biologic and J


Behavioral Basis for Smoking-Attributable Disease (2010
report) Japan Tobacco International (JTI)
aerosols in e-cigarettes, 99 acquisition and partnership, 165t
conclusions from, 97, 98t company profile, A4.1-3t
Hypotension, SIDS and maternal smoking, 109 multinational tobacco company, 15t
JieShiBo Technology (Shenzhen, China), A4.1-14t
Johnson Creek Vapor Company, 154, A4.1-11t
I Joyetech Co., Ltd. (Shenzhen, China), 152, A4.1-12t

ICE (Bureau of Immigration and Customs Enforcement), 196t


Illicit uses. See also Marijuana K
cocaine use and prenatal nicotine exposure, 111
European regulations, 213t Kantar Media, 157, 159
hashish oil, 14 Knowledge, attitudes, and risk perceptions, 171
methamphetamine, 111 Koop, C. Everett, 97
Imperial Tobacco Group (Fontem Ventures) Korean Youth Risk Behavior Web-Based Survey (2011), A2.3-5
acquisitions, 165t Krave e-cigarettes, sales (2010–2014), 153f, A4.4-2 to A4.4-6t
advertising expenditures for blu, 157
company profile, A4.1-2t
Lorillard, 152 L
multinational tobacco company, 15t
Ruyan e-cigarettes, 10
Labels
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
ingredients, 17, 64, 215
Impulsivity in adulthood, adolescent smoking, 107
warning, 206, 211t, 213t, 216t, 240–241
Indoor air policies, 122, 188, 225, 238, 243–244
Latinos. See Race/ethnicity
Inflammatory mediators, nicotine exposure, 101
Lead, aerosolized, 119
Ingredient disclosures, 17, 64, 215, 242
Legislation to curb tobacco sales
Instagram
Hayward, California, case study, 224
advertising, 157
North Dakota, case study, 225
e-cigarette promotion, 166
Licensing
e-cigarettes, 15
e-cigarette policies, 203
Institute of Medicine (IOM)
retailers, 245
comprehensive tobacco control, 16
Lifetime (ever) use, defined, A2.2-2. See also High school
potentially reduced-exposure products, 9
students; Middle school students; National Youth Tobacco
Insurance coverage, rates for tobacco users, 194t. See also
Survey (NYTS); Youth
Medicaid; Medicare
Liggett & Myers (L&M), 8
International cooperation
Limbic system, long-term changes with nicotine exposure, 106
ENDS products, 209t
Literature search for report, 27
Tobacco Tax and Trade Bureau, 209t
Litigation
International Union Against Tuberculosis and Lung Cancer, 223t
FDA regulation of e-cigarettes, 187–188, 241
International Vapor Group (IVG), A4.1-7t
violations of existing local rules, 205
Internet
Local government, tobacco control, 16, 18. See also State, local,
advertising, 157, 158f
tribal, and territorial governments
age verification, 208t, 242
Logic e-cigarettes
distribution and purchase channels, 150
company profile, A4.1-8t
e-cigarette companies, 14, 15
market share, (2012–2014), A4.5-4 to A4.5-5f
e-cigarette marketing, 10
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
e-cigarette promotion, 163
website information, 166, 166t
websites selling e-cigarettes, 163–164
Longitudinal studies
IOM (Institute of Medicine)
data for report, source for, 27
comprehensive tobacco control, 16
poly-tobacco use, 53, 56–57
potentially reduced-exposure products, 9
Lorillard (Lorillard Vapor Company)
IQOS e-cigarettes, 15t
acquisition, 165t
Iron, aerosolized, 119
advertising expenditures for blu, 157, 159
blu, marketing of, 152, 153f
company profile, A4.1-3t
multinational tobacco company, 15t

Index   267
A Report of the Surgeon General

Lucky Strike cigarettes, 8 prescription drug benefits, 193t


Lung cancer, and acrolein, 117 tobacco screening and cessation, 193–194t
Medical organizations
government health, 221–223t
M professional organizations, 207–214t
voluntary health organizations, 215–219t
Machine testing of tar and nicotine yields, 8, 9 World Health Organization, 219–220t
Magazines/print media, and advertising, 158–159, 158f, 160–162f Medicare, tobacco screening and cessation, 194t
Mail-order sales, age verification, 208t Memory, adolescent smoking, 107. See also Cognition
Manufacturers. See E-cigarette companies Men’s Journal magazine, 160f
Marijuana Metals, found in e-cigarettes, 216t
aerosol inhalation, 58 Methamphetamine use, fetal effects from nicotine exposure, 111
e-cigarette devices used for, 6, 14, 58, 203, 241 Methylglyoxal, aerosolized toxicant, 118
e-cigarette use with, 57–58 Middle school students. See also Youth
open systems, 152 current prevalence of e-cigarette use
Ploom PAX e-cigarettes, 15t ever use, 28, 29t
poly-tobacco use, 57 frequency of use, 28, 29t
tank devices, 14 past-30-day use, 28, 31t
“wax” marijuana resin, 14 susceptibility to use, 28, 29t
Market for e-cigarettes in the U.S. See also Vape shops trends in prevalence of e-cigarette use
distribution and purchase channels, 149–151, 154f ever use, 33, 33f, 34t
e-liquid production, 154 past-30-day use, 31t, 36, 36f
market share, evolution of, 152 Minnesota Adult Tobacco Survey, A2.2-2
product evolution, 151–152 Mistic e-cigarettes
sales in retail outlets, 150t, 152–154, 153f, 154f, 167–169 company profile, A4.1-6t
value of, 149, 150t magazine advertisement, 161f
Marketing. See also Advertising market share, (2012), A4.5-4f
burden of proof regarding safety, 238 sales (2010–2014), 153f, A4.4-2 to A4.4-6t
channels, 7 website access restrictions, 166t
e-cigarette companies, 14–15 “Mods.” See Tank devices (“mods”)
e-cigarettes, 7, 185 Monitoring the Future Survey (MTF)
effect of advertising on behavior, 170–171 data for report, source for, 27
exposure and receptivity to advertising, 169–170 e-cigarette use
Internet, 10, 163 items from sources of national data, A2.2-5 to A2.2-9t
marketing expenditures, 157–167, 158f, 160–162f, 165t, 166t sources of national data, A2.1-4 to A2.1-5t
restriction policies, 205–206, 208t, 238 e-cigarette use, current prevalence, 28
retail environment, 167–169 flavors in e-cigarettes, 59
self-service displays, 17, 203, 224, 242, 244 poly-tobacco use, 37, 40f, 41–42t
Surgeon General’s report (2012), 4 profile of, A2.1-2
targeting youth and young adults, 246–247 Monoamine oxidase A, fetal effects from nicotine exposure, 113
themes, 7 Mood disorders, adolescent smoking, 107. See also Anxiety disorders
MarkTen e-cigarettes. See also Altria Group, Inc./Nu Mark Moratoriums, on vape shops, 203
distribution and purchase channels, 150 MTF. See Monitoring the Future Survey (MTF)
e-liquid manufacturers, 154 Myelination
manufacturer, 15t gene expression alterations with maternal smoking, 109
market share (2014), A4.5-5f nicotine exposure, 104–105
promotion of, 158
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
website information, 165, 166, 166t N
Master Settlement Agreement (1998)
Hayward, California, case study, 224 NAB (N-nitrosoanabasine), aerosolized adulterant, 116
marketing surveillance, 205 NACDA (National Advisory Council on Drug Abuse), 195t
placement of e-cigarette advertisement, 168 NAChRs. See Nicotinic acetylcholine receptors (nAChRs)
point-of-sale advertising, 168 NAT (N-nitrosoanatabine), aerosolized adulterant, 116
tobacco product sponsorship of events, 15, 159, 240 National Adult Tobacco Survey (NATS)
Maternal nicotine consumption. See Prenatal nicotine exposure comparison to 2013–2014 survey, A2.3-3
Maxim magazine, 160f data for report, source for, 27, A2.1-3, A2.1-4 to A2.1-5t
Medicaid e-cigarette use data, A2.2-5 to A2.2-9t
Incentives for Chronic Disease Prevention Program, 193t flavors in e-cigarettes, 59, 60t

268   Index
E-Cigarette Use Among Youth and Young Adults

poly-tobacco use, 53, 53f, 54t, 55t Nicotek e-cigarettes


prevalence of e-cigarette use, 37, 38t, 39t sales (2010–2014), 153f, A4.4-2 to A4.4-6t
young adults website access restrictions, 166t
e-cigarette use, A2.3-3 Nicotek LLC, A4.1-9t
perceived harm of e-cigarettes, 64, 74t, 75 Nicotine
National Center for Health Statistics, 27 addiction and fetal effects, A3.1-40 to A3.1-48t
National Comorbidity Survey—Adolescent dataset, 102 adverse effects during pregnancy, 208t
National Defense Authorization Act (2015), 191t Camel cigarettes, and high nicotine content, 8
National Health Interview Survey (NHIS), A2.1-4 to A2.1-5t, A2.3-3 genetically modified nontobacco plants, 17
National Institute for Occupational Safety (NIOSH), 116 higher temperature of e-cigarettes, 13
National Institute on Drug Abuse (NIDA) poisoning, with ingestion of e-liquids, 119–120, 121f
Monitoring the Future Survey, A2.1-2 reduction of content, health effects of, 8–9
Population Assessment of Tobacco and Health Study, A2.1-3 role of, and nicotine delivery, 9
tobacco industry-supported research and funding, 195t secondhand exposure, and California level standards, 123
National Institutes of Health (NIH) Nicotine-related compounds, aerosol inhalation of, 114
supporting e-cigarette research, 186 Nicotine replacement therapy (NRT)
tobacco-free initiative, 195t cardiovascular risk, 101
National Library of Medicine, 27 Nicorette inhalators, 116
National Park Service pregnancy, 108–109
e-cigarette regulations, 188 Nicotinic acetylcholine receptors (nAChRs)
role in implementing strategies, 243 adolescence, 105
National Tobacco Company, 165t e-cigarette addiction, 102
National Youth Tobacco Survey (NYTS) fetal development, 108, 110
advertising NicSelect, A4.1-11t
effect on behavior, 170 NIDA. See National Institute on Drug Abuse (NIDA)
exposure to e-cigarette, 169 NIH. See National Institutes of Health (NIH)
current e-cigarette use by youth, increase of, 10 NIOSH (National Institute for Occupational Safety), 116
current prevalence of e-cigarette use Nitric oxide, aerosol inhalation, 114
ever use, 28, 29t, 30t NJOY cigalikes
frequency of use, 28, 29t, 30t company profile, A4.1-7t
past-30-day use, 28, 31t, 32t e-liquid manufacture, 154
susceptibility to use, 28, 29t, 30t funding for study on flavors in e-cigarettes, 59
data for report, source for, 27 magazine advertisement, 161f
e-cigarette use data market share (2010–2014), A4.5-2 to A4.5-5f
items from sources of national data, A2.2-5 to A2.2-9t product evolution, 151
measures used, A2.2-4 sales (2010–2014), 153f, A4.4-2 to A4.4-6t
patterns of use, 2015 survey, A2.3-2 television advertising, 159
sources of national data, A2.1-4 to A2.1-5t website access restrictions, 166t
survey description, A2.1-2 N-nitrosoanabasine (NAB), aerosolized adulterant, 116
flavors in e-cigarettes, 59, 60t N-nitrosoanatabine (NAT), aerosolized adulterant, 116
perceived harm of e-cigarettes, 64, 73t, 74t N-nitrosonornicotine (NNN), 116
poly-tobacco use NNK (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone), 116
current prevalence, 43, 44t, 45t, 46f NNN (N-nitrosonornicotine), 116
trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53 Nonusers. See Environmental exposure
survey profile, A2.1-2 North America Tobacco Regulatory Laboratory Network, 200t
trends in prevalence of e-cigarette use North Dakota Center for Tobacco Prevention and Control Policy, 225
ever use, 28, 33, 33f, 34t, 35t NRT (nicotine replacement therapy)
past-30-day use, 31t, 32t, 36–37, 36f cardiovascular risk, 101
NATS. See National Adult Tobacco Survey (NATS) Nicorette inhalators, 116
Netherlands Study of Depression and Anxiety Disorders, A3.1-14t pregnancy, 108–109
Netherlands Twin Registry, 106 NuMark. See Altria Group, Inc./Nu Mark
Neurobehavioral disorders of childhood, A3.1-56 to A3.1-62t Nut allergy, and e-cigarette aerosol exposure, 123
Neurobiological development, 104–106 NYTS. See National Youth Tobacco Survey (NYTS)
Neuroteratogens, 14
New Jersey Youth Tobacco Survey (NJYTS), 33, A2.2-4
NHALE, Inc., A4.1-6t O
Nickel, aerosolized, 119
Nicolites e-cigarettes, 15t Obesity. See Overweight and obesity
Nicorette inhalators, 116 Occupational Safety and Health Administration (OSHA), 199t

Index   269
A Report of the Surgeon General

Ocular irritation, acrolein, 117 Population Assessment of Tobacco and Health (PATH) Study
Office of Management and Budget (OMB), 189t e-cigarette use
Office of Personnel Management (OPM), 190t items from sources of national data, A2.2-2 to A2.2-15t
Old Gold cigarettes, 8 patterns of use, 2013–2014 study, A2.3-2
OMB (Office of Management and Budget), 189t sources of national data, A2.1-4 to A2.1-5t
Omni cigarettes, 9 flavors in e-cigarettes, 59
Open system devices, 151–152 overview, A2.1-2
OPM (Office of Personnel Management), 190t profile of, A2.1-3
Oppositional defiant disorder (ODD), 107 Population-level strategies, 243
OSHA (Occupational Safety and Health Administration), 199t Porter Novelli (public relations firm), A2.1-3
Overweight and obesity Potentially reduced-exposure products (PREPs), 9–10
e-cigarettes, 7 Precautionary approach strategy, 238
fetal effects from nicotine exposure, 7, 111, A3.1-51 to A3.1-53t Precautionary principle
appropriate use of, 183
as guide for decision makers, 188
P as guide to address e-cigarette use, 4
Prefrontal cortex, development of, in adolescents and young
Particulate matter 2.5 (PM2.5), secondhand smoke measure, 122, 123f adults, 105
Past-30-day use, defined, A2.2-2. See also High school students; Pregnancy. See also Fetal effects of nicotine exposure; Prenatal
Middle school students; National Youth Tobacco Survey nicotine exposure
(NYTS); Youth adverse effects of nicotine, 7, 208t, 239
PATH study. See Population Assessment of Tobacco and Health e-cigarettes as tobacco cessation option, 206
(PATH) study nicotine exposure, 14
Patient Protection and Affordable Care Act of 2010 (PPACA), 193t nicotine use, 5, 7, 14
PG. See Propylene glycol (PG) tobacco screening cessation services, 193–194t
Philip Morris International (PMI), 15t, A4.1-2t Premarket reviews, 242
Physical abstinence syndrome (withdrawal symptoms), 102, Premier, smokeless cigarette product, 9
A3.1-3 to A3.1-6t Prenatal nicotine exposure. See also Fetal effects of nicotine
Physiological withdrawal state, electronic cigarettes, A3.1-3t exposure; Pregnancy
Pipeline and Hazardous Materials Safety Administration, 199t appetitive and consumatory behaviors, 110–112
Plasma nicotine concentration, 103f attention and cognition, 112–113
Plasticity of the brain, 104–105, 113 auditory processing deficits, 109–110
Ploom e-cigarettes, 15t cocaine use, 111
Ploom vaporizers, 15t, 165t corpus callosum, altered development of, 109
PM2.5 (particulate matter 2.5), secondhand smoke measure, 122, 123f discordant sibling pair design studies, 111
PMI (Philip Morris International), 15t, A4.1-2t e-cigarettes, 14
Poison control centers, e-cigarette-related exposures, 14, 209t, 245 nicotine, 5, 7
Poly use nicotine concentrations in fetal fluid, 108
adults, cross-sectional studies, 53, 55t prenatal and postnatal outcomes, 108–113
defined, A2.2-3 sudden infant death syndrome (SIDS), 109
educational plans of youth, 37, 41t toxicants and, 108, 109
gender differences PREPs (potentially reduced-exposure products), 9–10
adults (age ≥25), 55t Prevent All Cigarette Trafficking Act (2009), 164
young adults, 53, 54t Preventing Tobacco Use Among Young People (1994 report), 4
youth, 37, 41t, 43 Preventing Tobacco Use Among Youth and Young Adults (2012
longitudinal studies, 56–57 report)
marijuana, 57 conclusions from, 97, 98t
race/ethnicity educational initiatives, 206
adults (age ≥25), 55t marketing influence in tobacco use behaviors, 157
young adults, 53, 54t release of, 4
youth, 37, 41t sensitivity of youth to, 99
young adults, cross-sectional studies, 53, 53f, 54t Pricing of e-cigarettes
youth disposable e-cigarettes, 155, 155f
current prevalence, 37, 40f, 41–42t, 43, 44t, 45t, 46f Internet coupons and discounts, 163
educational plans of, 37, 41t policies, 7, 204–205, 238
trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53 sales, impact on, 155–157, 155f, 156f
Popcorn lung disease (bronchiolitis obliterans), 116 Primacy, defined, A2.2-4
Print media/magazines, and advertising, 158–159, 158f, 160–162f
Processed tobacco, defined, 200t

270   Index
E-Cigarette Use Among Youth and Young Adults

Pro-Children Act of (2001), 192t Retail environment


Product placements, e-cigarettes, 15 e-cigarette sales, 14
Promotion or promotional activities. See Marketing U.S. market, 150t, 152–154, 153f, 154f, 167–169
Propanol, aerosolized toxicant, 118 Revel smokeless tobacco product, 9
Propylene glycol (PG) Reward-seeking behavior
aerosol inhalation, 115 adolescent smoking and long-term changes in reward system, 106
inhalation toxicity, 114 nicotine, increased sensitivity to, in adolescents, 105
secondhand exposure, and California level standards, 123 Reynolds American Inc. (RAI) (R.J. Reynolds Vapor Company)
Pruning of unnecessary synapses, and nicotine exposure, 104–105 American manufacturing, 152
Psychiatric events, and rimonabant, 117 company profile, A4.1-3t
Public and Indian Housing (PIH), 197t multinational tobacco company, 15t
Public health Premier “smokeless cigarette product,” 9
agencies role in assisting state attorney general or FTC, 206 VUSE, 150, 152, 158
e-cigarettes policy, 7 Rimonabant (Zimulti), aerosolized adulterant, 117
e-cigarette use, 10–11 Risk assessments, 186t
FDA regulatory authority, 16 Risk perceptions, knowledge and attitudes, 171
future regulatory options, 17–18 Risk tradeoffs, 184–185
precautionary strategies to protect youth and young adults, 226 Risky behaviors, and e-cigarette use, 57–58
Public Health England (UK), 222t R.J. Reynolds. See Reynolds American Inc. (RAI)
Public policy Rolling Stone magazine, 159, 161f
cigarette restrictions, 149 Ruyan e-cigarettes
e-cigarettes, 7, 187–188, 205 introduction of, 10
magazine advertisement, 161f, 162f manufacturer, 15t
retail sales of e-cigarettes, 168
“Puff topography,” dose and effects of inhaled nicotine, 100–101
Puff volumes, dose and effects of inhaled nicotine, 101 S
Purchase channels for e-cigarettes, 149–151
Safe and Drug-Free Schools and Communities Act (1994), 192t
Safety
R battery explosions and fires, 14, 119
burden of proof, responsibility for, 238, 242
Race/ethnicity cigarette marketing, 8
e-cigarette advertising, exposure to, 169 e-cigarette products and components, 13–14
e-cigarette use SAMHSA (Substance Abuse and Mental Health Services
current prevalence, 28, 29t, 30t, 31t, 32t Administration), 196t
trends in prevalence, 28, 33–37, 34t, 35t Satisficing, defined, A2.2-4
flavored little cigars and cigarillos, 11 Schools, proximity to, and e-cigarette availability, 168
flavors in e-cigarettes, 59, 60t Secondhand exposure
poly-tobacco use aerosolized e-cigarette constituents, 120–123, 123f, 183, 209t, 240
adults (age ≥25), 55t e-cigarettes, 14
young adults, 53, 54t nicotine from e-cigarettes, compared to conventional
youth, 37, 41t cigarettes, 97
retail sales of e-cigarettes, 150, 168 nonusers of nicotine, exposure to, 120
Regulation of e-cigarettes. See also specific agencies by name teratogenic effects, 108
federal Seizures, 117
approach to, 15–18 Sensory deficits, with maternal smoking, 109–110
policies of federal agencies, 189–202t SFATA (Smoke Free Alternatives Trade Association), A4.2-2,
Tobacco Control Act, 187–188 A4.3-2
state, local, tribal, and territorial governments SIDS. See Sudden infant death syndrome (SIDS)
clean air policies, 188 Silicates, aerosolized, 119
control measures, 184 Silver, aerosolized, 119
interventions policies, 188 Smoke Free Alternatives Trade Association (SFATA), A4.2-2, A4.3-2
Tobacco Control Act, 16 Smokefree policies, 188, 243–244
Research Smoker Friendly International, LLC, A4.1-10t
suggestions for future research, 185–186, 226, 247–248 Smoker’s One Choice e-cigarettes
tobacco control and prevention, 238 market share, (2011), A4.5-3f
tobacco industry-supported, 195t sales (2010-2014), 153f, A4.4-2 to A4.4-6t
Respiratory irritation, acrolein, 117

Index   271
A Report of the Surgeon General

Smoking and Health: Report of the Advisory Committee to the e-cigarette use with, 57–58
Surgeon General of the Public Health Service (1964 report) fetal effects from nicotine exposure, 111–112
mortality contribution results, 8 Sudden infant death syndrome (SIDS)
release of, 4 e-cigarettes, 7
Smoking behavior fetal effects of nicotine exposure, A3.1-33t
changes, with low-nicotine cigarettes, 9 fetal exposure to nicotine, 7
dose and effects of inhaled nicotine, 100–101 maternal smoking, 109
Smoking cessation Surgeon General Call to Action
in clinical care setting, 206 curb advertising and marketing, 246–247
e-cigarettes as cessation option, 183, 184, 186, 206 do no harm, 237–239
magazine advertisement, 161f expand surveillance, research and evaluations, 247–248
reason for trying e-cigarettes, 75 prevention programs and policies, 243–245
screening and cessation services, 193–194t provide information about dangers, 239–241
studies showing inconsistent results, 214t regulate e-cigarettes at federal level, 241–243
Smuggled Tobacco Prevention (STOP) Act (proposed), 198t stakeholders, 237
SNAP program, 190t Surgeon General’s reports, health risks outlined in previous
Snus reports, 97–99, 98–99t. See also individual reports by name
cardiovascular risk, 101 Surveillance
modified tobacco product, 9 proposals, 205, 226, 247–248
Soap Opera Digest, 161f studies, 27
Social media. See also Facebook; Twitter; YouTube Surveys. See also specific survey or study by name
advertising, 157 data analysis instruments, A2.2-4
distribution and purchase channels, 150 e-cigarette and other tobacco product use, A2.3-4
e-cigarette marketing, 10, 15 future research, 185–186
e-cigarette promotion, 166–167 measurement factors, special issues, A2.2-4
Social Security Act (2010 amendments to), 193t modeling concepts, 186
Socioeconomic status, and price of e-cigarettes, 157 prevalence estimates, 204, A2.3-2 to A2.3-3
Solvents, and aerosol inhalation, 115 Susceptibility to use
Sottera, Inc. See NJOY advertising and, 170
Sottera, Inc. v. U.S. Food and Drug Administration (2010), 16, current prevalence of high school students, 28, 30t
241, A4.2-2 current prevalence of middle school students, 28, 29t
Spin magazine, 162f defined, A2.2-3
Sponsorship of events by e-cigarette companies, 15, 159, 163, 240 intentions to use, A2.3-20t
Sports Illustrated magazine, 160f survey summary data, A2.3-20 to A2.3-22t
Stanford Research into the Impact of Tobacco Advertising Synar Amendment, 196t, 203
research group, 158
Starfire e-cigarettes, television advertising, 159
State, local, tribal, and territorial governments T
best practices of, 245
e-cigarette taxation policies, 204 Tank devices (“mods”)
ENDS regulations, 209t appearance of, 3f, 11
existing rules that constrain marketing, 205 components of, 12f
licensing, 203 increasing role in e-cigarette market, 150
population-level strategies, 243 plasma nicotine concentration, 103f
Tobacco Control Act, 188 product evolution, 151, 152
tobacco control strategies, 16, 18, 226, 238, 242 Tar reduction, health effects of, 8–9
Stimulus-response-discrimination-learning processes, 107 Taxation
Studies. See Surveys e-cigarette policies, 188, 204–205, 238
Styles (HealthStyles, Summer Styles) Survey ENDS, 209t, 210t
e-cigarette use data Tobacco Tax and Trade Bureau, 200t
items from sources of national data, A2.2-5 to A2.2-9t Television advertising, 157, 158f, 159
sources of national data, A2.1-4 to A2.1-5t Temperature of e-cigarettes
prevalence of e-cigarette use, 37, 40f aerosolized carbonyls, 117, 118
profile of, A2.1-3 higher, and increased nicotine and toxicant release, 13
Styrene, aerosolized, 118 toxicants, 118
Substance Abuse Prevention and Treatment Block Grant, 196t, 203 Tetrahydrocannabinol (THC)
Substance use and abuse aerosol inhalation, 58
adolescent smoking as “gateway” for, 106 tank devices, 14
comorbid, with adolescent smoking, 106 Theory of Reasoned Action, tobacco use, and perception of harm, 64

272   Index
E-Cigarette Use Among Youth and Young Adults

Thermal metered-dose cannabis inhalers for medical applications, 58 U


Third-hand smoke
described, 120, 121 Uniform tax rate systems, 204
exposure, 209t United Nations Educational, Scientific and Cultural Organization
Tiered tax rate systems, 204 (2005), 183
Tin, aerosolized, 119 USA Liquid Nicotine/USA Laboratories, A4.1-12t
Tobacco Control Act (2009) U.S. Coast Guard, 196t
deeming rule, 17 U.S. Department of Agriculture (USDA), 190t
e-cigarette regulation relating to youth and young adults, 18 U.S. Department of Defense (DoD), 188, 191t
federal authority to regulate tobacco products, 9, 15, 16, 183, U.S. Department of Education, 192t
187–188, 241 U.S. Department of Health and Human Services (USDHHS)
flavor ban for cigarettes, 11 National Advisory Council on Drug Abuse, 195t
flavors in cigarettes, 58 National Institute on Drug Abuse, 195t
state, local, tribal, and territorial government authority, 16 National Institutes of Health, 195t
vape shops, mixing e-liquids, 169 preparation of Surgeon General’s report (2016), 4–5
youth tobacco access control regulations, 203 Substance Abuse and Mental Health Services Administration, 196t
Tobacco Control Legal Consortium, 204, 225 tobacco screening and cessation, 193–194t
Tobacco Free North Dakota, 225 U.S. Department of Homeland Security (DHS)
Tobacco-free policies, 240 Bureau of Immigration and Customs Enforcement, 196t
Tobacco industry companies, A4.1-2 to A4.1-3t Coast Guard, 196t
Tobacco industry-supported research and funding, 195t U.S. Department of Housing and Urban Development (HUD), 197t
Tobacco Laboratory Network, 200t U.S. Department of Justice
Tobacco Product Directive (TPD), 222t Bureau of Alcohol, Tobacco, Firearms and Explosives, 198t
Tobacco products. See also Aerosol inhalation; Aerosolized Bureau of Prisons, 198t
nicotine; Cigarettes; E-cigarettes U.S. Department of Labor, 199t
combustible, 6 U.S. Department of Transportation (DOT)
e-cigarettes regulated as, legal basis for, 16–17 e-cigarette regulations, 188
FDA regulation of, 9–10, 15–17 Pipeline and Hazardous Materials Safety Administration, 199t
smokeless, 9 tobacco use on aircraft, 199t
sponsorship of events, 15, 159, 163, 240 U.S. Department of Treasury, 200t
Tobacco Products and Risk Perceptions Survey (2014), A2.3-3 U.S. Department of Veterans Affairs, 188, 201t
Tobacco Products Directive, European Commission, 213t U.S. Environmental Protection Agency (EPA)
Tobacco-specific nitrosamines (TSNAs), 99, 116 e-cigarette regulations, 188, 201t
Toluene, aerosolized, 118–119 formaldehyde as carcinogenic, 117
Toxicants U.S. Federal Trade Commission (FTC)
aerosolization process, 114, 118–119 agency profile and policies, 189t
aerosolized adulterants, 100, 116–117 description and authority of, 201t
fetal development, 108, 109 monitoring advertising, 246
flavorants, 116 public health agency interaction, 206
prenatal exposure, 108, 109 source disclosure of advertorials, 205–206
TPD (Tobacco Product Directive), 222t tar and nicotine content in advertising, 9
Trade organizations and partnerships, e-cigarettes, A4.3-2 U.S. Fire Administration, 119
Trigeminocardiac reflex, SIDS and maternal smoking, 109 U.S. Food and Drug Administration (FDA)
Trinkets & Trash archive, 158 areas not authorized to regulate, 242
TruNic, A4.1-12t authority to regulate tobacco products, 9, 238
Truth Initiative (American Legacy Foundation), 158, 159, 163 Center for Devices and Radiological Health (CDRH), 16
TSNAs (tobacco-specific nitrosamines), 99, 116 Center for Drug Evaluation and Research (CDER), 16
21st Century Smoke e-cigarettes Center for Tobacco Products (CTP), 17, A2.1-3
market share, (2010–2014), A4.5-2 to A4.5-5f deeming rule, 6, 17
sales (2010–2014), 153f, A4.4-2 to A4.4-6t e-cigarette regulation as tobacco products, 16–17
website access restrictions, 166t e-cigarette rules, 241–242
Twitter e-cigarette shipments, denying entry to, 16
advertising, 157 future regulatory options, 17–18
coupons and discounts, 163 litigation against, 187, A4.2-2
distribution and purchase channels, 150 minimum age requirements in retail environments, 167
e-cigarette promotion, 166, 167 nicotine regulation, 9–10, 183, 187–188
e-cigarettes, 15
2-methoxycinnamaldehyde, cytotoxicity of, 116
2,3-butanedione (diacetyl), aerosolized flavorant, 116

Index   273
A Report of the Surgeon General

PATH study. See Population Assessment of Tobacco and X


Health (PATH) study
product warnings, 206, 211t, 213t, 216t, 240–241 Xylenes, aerosolized, 118–119
Sottera, Inc. v. U.S. Food and Drug Administration, 16, 241,
A4.2-2
tobacco product regulation, 9–10, 15–16 Y
U.S. Pharmacopeia (USP), 114
U.S. Preventive Services Task Force, 206
Young adolescents, ages of, 4
U.S. Supreme Court, 9
Young adults. See also Surgeon General Call to Action
U.S. Trade Representative (USTR), 189t
ages of, 4
Us Weekly magazine, 159
awareness of consequences of e-cigarettes, 240
current prevalence of e-cigarette use, 37, 38t
e-cigarette use
V intentions to use summary data, A2.3-20 to A2.3-22t
items from PATH, A2.2-10 to A2.2-15t
V2cigs items from sources of national data, A2.2-5 to A2.2-19t
plasma nicotine concentration, 103f patterns of use summary data, A2.3-5, A2.3-23 to A2.3-37t
sales (2010–2014), 153f, A4.4-2 to A4.4-6t survey data sources, A2.1-4 to A2.1-5t
Vape Holdings, Inc., A4.1-6t surveys, A2.1-3
Vape pens susceptibility summary data, A2.3-20 to A2.3-22t
components of, 12f flavors in e-cigarettes, 59, 60t
term usage, 3 perceived harm of e-cigarettes, 64, 74t, 75
Vape shops poly-tobacco use, 53, 53f, 54t
clean indoor air, legislation, 225 prevalence of e-cigarette use, 204, A2.3-3
e-cigarette sales, 14, 203 Surgeon General’s reports focusing on, 4
e-liquid mixing, 120 trends in prevalence of e-cigarette use, 37, 40f
market for e-cigarettes in the U.S., 149, 150–151, 150t, 168–169 Youth. See also High school students; Surgeon General Call to
Vape tanks, components of, 12f. See also Tank devices (“mods”) Action
Vegetable glycerin (VG) access prevention policies, 203
aerosol inhalation, 115 advertising and marketing restrictions, 208t
nose-only exposure to, 114 ages of, 4
Vending machine sales, regulation, 203, 242 attention and cognition with nicotine exposure, 106
Visual processing, deficits in, with maternal smoking, 110 awareness of consequences of e-cigarettes, 240
Volatile organic compounds (VOCs), 118–119 current e-cigarette use, increase of, 10
VUSE e-cigarettes current prevalence of e-cigarette use
distribution and purchase channels, 150 ever use, 28, 29t, 30t
manufacturer, 15t frequency of use, 28, 29t, 30t
market share (2014), A4.5-5f past-30-day use, 28, 31t, 32t
promotion of, 152, 153f, 158 susceptibility to use, 28, 29t, 30t
website information, 165, 166, 166t e-cigarettes, as most commonly used tobacco product, 5
e-cigarette use
higher than other tobacco products, 211t
W intentions to use summary data, A2.3-20 to A2.3-22t
items from PATH, A2.2-10 to A2.2-15t
Warning labels items from sources of national data, A2.2-5 to A2.2-9t
on e-cigarettes, 206, 211t, 213t nicotine exposure effects, human studies, A3.1-8 to A3.1-17t
on refill bottles, 216t nicotine exposure effects, preclinical/animal studies,
on tobacco products, 240–241 A3.1-18 to A3.1-32t
Whites. See Race/ethnicity patterns of use summary data, A2.3-4, A2.3-6 to A2.3-19t
WIC program, 190t survey data sources, A2.1-4 to A2.1-5t
Withdrawal symptoms (physical abstinence syndrome) survey descriptions, A2.1-2
conventional cigarettes, 102 susceptibility summary data, A2.3-20 to A2.3-22t
e-cigarettes, A3.1-3 to A3.1-6t flavored little cigars and cigarillos, 11
Workplace exposure, e-cigarette aerosol, 123 flavors in e-cigarettes, 59, 60t
World Health Organization (WHO) legislation to curb tobacco sales, 224
indoor air quality, 122 mood disorders with nicotine exposure, 107
position on ENDS, 219–220t nicotine, effects of, 104–107
Tobacco Laboratory Network, 200t perceived harm of e-cigarettes, 64, 73t, 74t

274   Index
E-Cigarette Use Among Youth and Young Adults

poly-tobacco use, cross-sectional studies of Youth Risk Behavior Surveillance System (YRBSS)
current prevalence, 37, 40f, 41–42t, 43, 44t, 45t, 46f overview and methods, A2.1-4 to A2.1-5
trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53 data for report, source for, 27
prevalence of e-cigarette use, 204–205, A2.3-2 to A2.3-3 e-cigarette use
restricting access to e-cigarettes, 244–245 current prevalence, 28
reward-seeking behaviors, 106 patterns of use, 2015 survey, A2.3-2
Surgeon General’s reports focusing on, 4 sources of national data, A2.1-4 to A2.1-5t
tobacco cessation services, 193t YouTube
trends in prevalence of e-cigarette use distribution and purchase channels, 150, 151
ever use, 28, 33, 33f, 34t, 35t e-cigarette promotion, 166–167
past-30-day use, 31t, 32t, 36–37, 36f e-cigarettes, 15

Index   275

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