E-Cigarette use among children and young people: the need for regulation

Abstract

Electronic cigarettes (e-cigarettes) are devices designed to deliver nicotine to the body via the route of inhalation. The principle of operation is based on heating a nicotine solution in propylene glycol and/or glycerine (e-liquid), turning it into aerosol (commonly called ‘vapour’), which is then inhaled by the user. The scientific evidence on the health consequences of long-term e-cigarette use is sparse and currently inconclusive. Young people are the most vulnerable group to initiate use of e-cigarettes. The novelty of the e-cigarette, perceptions about the harmlessness of the product, a wide variety of flavours (fruit, chocolate, peanut butter, bubble gum, gummy bear, amongst others), and peer-influence are just a few examples of factors contributing to the e-cigarette popularity among youth. The comprehensive e-cigarette regulations need to include rules on marketing, safety of newly introduced products (nicotine dosage, packaging, and labelling), marketing limitations, and banning the sale of e-cigarettes to minors.

Keywords:

• adolescent
• electronic cigarettes
• nicotine
• smoking
• tobacco
• youth

Electronic cigarettes: perils & promise

Electronic cigarettes (e-cigarettes or electronic nicotine delivery systems) are devices designed to deliver nicotine to the body via the route of inhalation. The principle of operation is based on heating a nicotine solution in propylene glycol and/or glycerine (e-liquid), turning it into aerosol (commonly called ‘vapour’), which is then inhaled by the user. Solutions for e-cigarettes are available in many flavours that most often fall in five main categories: tobacco flavours (which are similar to cigarettes), fruit flavours (blueberry, peach, etc.), menthol flavours, sweet flavours (candy, chocolate, etc.), and other flavours (coffee, black tea, wine, etc.). Since e-cigarettes were introduced to the global market in 2006, they have become very popular and are the subject of much controversy. Some users and researchers feel that e-cigarettes are low-risk products that could significantly reduce the harmful effects associated with smoking conventional cigarettes [1]. However, concerns have been raised by public health advocates whether e-cigarette use is as harmless as advertised [2]. There were, and still remain, numerous questions and uncertainties about the efficacy of e-cigarettes as a smoking cessation tool, the health effects of their use, how their sale and marketing should be regulated, and their impact on the adolescent population. A majority of these concerns cannot be yet proven or disproven despite extensive research being currently carried out on e-cigarette safety. It will necessarily take many years before safety or health risk of e-cigarettes will be clearly proven. The impact of e-cigarette use on public health is still dubious. However, current data suggest an urgent need for implementing regulations on their use, sale and marketing to children and young people.

Health hazards of e-cigarettes

The scientific evidence on the health consequences of long-term e-cigarette use is sparse and currently inconclusive [1–3]. Current studies show that aerosol produced by some products contains low levels of harmful substances, such as formaldehyde, acetaldehyde, tobacco-specific nitrosamines, and potential allergens [4]. Some recent studies have found that levels of toxicants such as formaldehyde can be quite high under some circumstances, for example, under higher power conditions available on variable wattage devices [5]. E-Cigarette use is also associated with mild or low-risk acute adverse events from cardiovascular or pulmonary system [2]. Studies also suggest that e-cigarettes may be a source of secondary exposure to nicotine [6,7]. Due to increased popularity of e-cigarettes and lack of product regulation, these devices are prone to misuse. The e-liquids may contain nicotine in high concentrations [8], thus inappropriate handling of the products may result in accidental nicotine poisoning. In the US, calls to poison centres related to e-cigarettes increased from one call in September 2010 to 215 calls in February 2014 [9]. They were most commonly reported as ingestions of the e-liquids, less often as eye or skin exposures. What is certainly alarming is that more than half of the calls involved children aged 5 years old and younger. One must also consider the detrimental influence of nicotine on the developing brain. E-Cigarette use in pregnancy and children’s exposure to nicotine from e-cigarette aerosol may have behavioural or cognitive dysfunction consequences [10].

E-Cigarette marketing to young consumers

Young people are the most vulnerable group to initiate use of e-cigarettes [11]. The novelty of the e-cigarette, perceptions about the harmlessness of the product, a wide variety of flavours (fruit, chocolate, peanut butter, bubble gum, gummy bear, etc.), and peer-influence are just a few examples of factors contributing to the e-cigarette popularity among youth. The most concerning issues related to e-cigarette use by adolescents are mass marketing campaigns and easy access to the product. E-Cigarette companies have significantly increased marketing spending, more than doubling expenditures between 2012 and 2013. In the US, six major e-cigarette companies spent $59.3 million in 2013 to market e-cigarettes [12]. Currently, there is very little restriction on the marketing of e-cigarettes. This allows for companies to utilise similar marketing techniques to those formerly used by tobacco industry to encourage young people to try the product [13]. Specific marketing strategies implemented by e-cigarette companies include television and radio advertisements (often featuring celebrities), introducing flavours that are appealing to children (‘Cherry Crush’, ‘Chocolate Treat’), distributing free samples, or sponsoring youth-oriented events. Other issues are wide availability, easy access to the product, and lack of age restrictions on purchasing the e-cigarettes. Young people can purchase them easily via the Internet due to lack of age-verification implemented by online retailers [14].

E-Cigarette use among children & young people

Marketing strategies have contributed to the significant and rapid increase in e-cigarette use among adolescents. According to the National Youth Tobacco Survey, the number of US middle and high school students using e-cigarettes in the preceding 30 days before the survey was taken increased from 1.5% in 2011 to 13.4% (which amounts to estimated 2.4 million students) in 2014 [15]. Similar occurrence can also be noted outside the US. In Poland, current e-cigarette use among students aged 15–19 increased from 5.5% in 2010–2011 to 29.9% in 2013–2014 [16] and in New Zealand, ever e-cigarette use among 14–15-year olds tripled between 2012 and 2014 (7.9 vs 19.9%) [17]. Similar trends can be noted internationally and should raise a significant concern. E-Cigarettes may harm young users by exposing them to possible direct health harm and also by inducing nicotine addiction. Some evidence suggests that e-cigarette use among youth is associated with intentions to switch to regular tobacco cigarettes later in life [18], however, a reverse association (i.e., quitting tobacco smoking with e-cigarettes) has also been shown among young adults (18–23 years) [19].

The need for e-cigarette regulation

As of 2015, >460 e-cigarette brands and almost 8000 unique flavour names have been introduced to the market [20]. Technical design, construction of the devices, and chemical composition of e-liquids are poorly regulated and most often proper production standards are nonexistent [21]. The labelled nicotine content in some products also has been shown to be inaccurate [8]. E-Cigarette industry has grown extremely rapidly due to high demand for the product. The rapidly changing market challenges timely implementation of product regulation. Also a lack of solid scientific data restricts evidence-based approach to product regulation [21]. However, based on available data, important regulatory measures must be implemented to protect children and adolescent against the potential risk associated with e-cigarettes.

Product

It is crucial to control the safety and production standards of both e-cigarettes and e-liquids. The products should be sold in child-resistant packaging to prevent accidental nicotine intoxication by the youngest. The e-liquid packaging must clearly and accurately state a complete list of ingredients, exact nicotine concentration in the solution (maximum dosage should also be enforced), as well as information about potential health risks.

Marketing

Marketing restrictions should be implemented to avoid direct and indirect advertising and promotion of e-cigarettes to young consumers, especially those who do not currently smoke or are under the legal age for smoking (e.g., banning sponsorship of events concerts and sport events attended by youth).

Sale

The authorities must explicitly ban the sale of e-cigarettes and related products to underage people. Internet sale of e-cigarettes needs to be closely monitored and online shops should implement strict age verification processes. Retail outlets should be required to verify the age of every customer purchasing e-cigarettes. Furthermore, licensing of establishments to carry and sell e-cigarettes should be considered.

Use of e-cigarettes in public places

E-Cigarettes have been shown to be a potential source of secondary and tertiary exposure to nicotine [6,7]. Allowing e-cigarettes usage in public places may lead not only to involuntary exposure to nicotine but also to changes in social norms toward smoking and nicotine product use. E-Cigarette use in public places, including schools, restaurants, shopping, and entertaining venues should be prohibited.

Summary

Although e-cigarettes present a safer alternative to tobacco cigarettes and may be very effective tobacco harm reduction strategy, they also pose a potential harm to public health. The rapid increase in adolescent e-cigarette use should prompt implementation and enforcement of regulations to control their increasing popularity among youth. In 2014, the US FDA proposed a rule, which would effectively treat e-cigarettes like tobacco products. The main elements of the proposed regulation comprise some of the strategies discussed in this editorial but none of them has gone into effect yet [22]. A similar proposal, which is due to be applied in 2016, came from the European Parliament [23]. Both of these planned regulations include rules on marketing, safety of newly introduced products (nicotine dosage, labelling requirements), marketing limitations, and banning the sale of e-cigarettes to minors. It is important for the new rules to be implemented as soon as possible and adjusted properly when the status of e-cigarettes on the market change and the research provides new data. Although both the FDA and European Commission have proposed to regulate the product and its marketing, e-cigarette use in public places needs to be restricted by member states at the local level.

Acknowledgement

The authors would like to thank Craig Steger for editorial help.

Financial & competing interests disclosure

M Goniewicz was awarded the 2011 Global Research Award for Nicotine Dependence paid to his former employer. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.