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National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General [Internet]. Atlanta (GA): Centers for Disease Control and Prevention (US); 2016.

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E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General [Internet].

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Chapter 5E-Cigarette Policy and Practice Implications

Introduction

The previous chapters have set out what is currently known and not known about e-cigarettes. Despite the identified gaps in evidence and the dynamic, evolving patterns of the use of e-cigarettes, policy options are needed. These policy options are particularly important as they affect the use of e-cigarettes by youth and young adults. As this report has demonstrated, e-cigarettes are widely used by youth and young adults and are particularly risky for these age groups, and efforts to prevent their use by young people are needed. This chapter explores the policy landscape of e-cigarettes and sets forth recommendations that should protect the public’s health, particularly as these policies relate to the short- and long-term health of youth and young adults.

The Family Smoking Prevention and Tobacco Control Act of 2009 (or Tobacco Control Act) (2009) is meant to protect the health of the public, including young people. As previously discussed, on May 10, 2016, FDA published a final rule which deemed all other products, including e-cigarettes, meeting the definition of a tobacco product, except accessories of such products, to be subject to the Federal Food, Drug, and Cosmetic Act. This rule went into effect on August 8, 2016 (Federal Register 2016). Under the Tobacco Control Act, FDA likely will be required to consider the consequences of e-cigarette use for those who do not use tobacco products (as well as for those who do).

It can be stated that public health will be harmed if the availability of e-cigarettes:

  • Increases exposure to nicotine among youth and young adults;
  • Leads to the initiation of combustible tobacco smoking;
  • Slows or prevents cessation of combustible products by nicotine-addicted smokers; or
  • Increases the likelihood that former smokers will again become addicted to nicotine and/or use combustible products after being reintroduced to nicotine by e-cigarettes.

Potential harm also comes from secondhand exposure to the vapor or aerosol expelled from e-cigarette users. Secondhand exposure comes from inhaling the aerosol or contacting vapor-contaminated surfaces. Each of the potential negative consequences of the availability of e-cigarettes could lead to additional disease and premature mortality (Chapter 3).

Relative to efforts in cigarette and smokeless tobacco use prevention and control, a polarized debate has been in progress for several years over the role of e-cigarettes. There is general agreement that exclusive use of e-cigarettes poses a lower health risk to the individual than the extremely high health risks of using conventional, combustible tobacco products (Farsalinos and Polosa 2014; Grana et al. 2014a,b), although more research is needed on this as more becomes known about the harmful constituents of e-cigarettes (Sleiman et al. 2016). The controversy reflects the relative degree of emphasis given to the potential harm to adolescents and young adults from using e-cigarettes at one pole compared with the potential for reduced risk for established adult users of conventional cigarettes at the other (if they transition completely to e-cigarettes). Although this characterization does not reflect the complexity of the situation, it is useful in defining the potential tradeoffs that are implicit: increased numbers of young people who are exposed to nicotine (and who may go on to conventional tobacco products) versus reduced health risks to individuals who completely switch from conventional, combustible tobacco products with their extremely high health risks. The discussion has become increasingly complicated as e-cigarette use has increased, and still-incomplete evidence potentially supports the views of those holding to both poles of the argument about reducing harm for the overall population. However, the majority of currently available scientific evidence does not support the recommendation to use e-cigarettes for the cessation of cigarette smoking (Hartmann-Boyce et al. 2016). Additionally, the use of e-cigarettes does not pose benefits to youth and young adults, and some data suggest that use of e-cigarettes could lead to the more harmful use of conventional cigarettes. In the context of young people, the precautionary principle should apply. The precautionary principle is defined by the United Nations Educational, Scientific and Cultural Organization (2005) as appropriate “when human activities may lead to morally unacceptable harm that is scientifically plausible but uncertain, actions shall be taken to avoid or diminish that harm” (p.14).

Critical Issues Related to Policies on E-Cigarettes in 2016

The E-Cigarette Landscape Is Dynamic and Evolving

Considerations of policy approaches to e-cigarettes offered in this report are made in the context of a rapidly changing marketplace for nicotine-containing products that now includes primarily conventional cigarettes, cigars, smokeless products, hookahs, and e-cigarettes (see Chapter 2). The manufacture and sales of nicotine-containing products, once dominated by a few large companies selling conventional cigarettes, have been transformed and now include many smaller companies that manufacture and sell through stores and “vape shops.” 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 are on the market: designs are evolving rapidly, and major tobacco companies have their own lines of e-cigarette products. However, unlike the situation in the past in which the marketing of conventional tobacco products changed relatively slowly and there were limited media outlets, information about e-cigarettes is now promoted quickly through new media, as well as television, in part to reach key target groups, including youth and young adults.

As documented in Chapter 2, patterns of use are rapidly changing among adolescents and young adults, and likely among other groups within the population. For some of the most critical issues related to e-cigarettes, longitudinal data are not yet available because the use of these products is recent and constantly changing, and whether and when the patterns of use will stabilize is uncertain. Additionally, surveillance data and research on the wide-ranging consequences of e-cigarette use, including such key issues as the likelihood of addiction and other health problems for users and those passively exposed, are lagging behind the highly dynamic changes in the nicotine-product marketplace and the impact of these changes on the use of tobacco products, including e-cigarettes.

With regard to the potential health consequences of using e-cigarettes, estimates can be made based on knowledge of the characteristics and components of the aerosols that are then inhaled. Unfortunately, evidence on short-term risks is limited, and long-term risks have not yet been identified because this would require monitoring users for years. For example, the impact of long-term inhalation of flavorings is not yet known. While some of the flavorings used in e-cigarettes are generally recognized as safe for ingestion as food, the health effects of their inhalation are generally unknown, and some flavorings have been shown to cause a serious lung disease, bronchiolitis obliterans, when inhaled (Kreiss et al. 2002; Barrington-Trimis et al. 2014). Whether the risk of lung disease or other disorders is truly substantial will require longer term epidemiologic and other research (Allen et al. 2016).

Thus, policy approaches must support control measures that (a) are as dynamic as the rapidly changing marketplace for e-cigarettes; (b) are supported by surveillance data; and (c) document in timely fashion the current status of the use of multiple types of tobacco products (including e-cigarettes); the emergence of state, local, tribal, and territorial policies; and the strategies being used to market these products.

Risk Tradeoffs Are Inherent for E-Cigarettes

Policy discussions about e-cigarettes have highlighted the potential tradeoffs in risk that could occur, particularly if e-cigarettes are positioned as a harm-reducing alternative to combustible tobacco products. Some have characterized these products as new technologies that might lead to a dramatic decline in the use of more dangerous forms of nicotine delivery, particularly conventional cigarettes and other combustible tobacco products (Abrams 2014; Cobb and Abrams 2014; Fagerström and Bridgman 2014; Grana et al. 2014a; Hajek et al. 2014; Henningfield 2014; Schraufnagel et al. 2014; West and Brown 2014; Lindblom 2015). Correspondingly, e-cigarettes have been proposed by some as a harm-reduction strategy and as a tool for smoking cessation, but the data to date do not support e-cigarettes for harm reduction or cessation (Siegel et al. 2011; Abrams 2014). By contrast, others are concerned that the availability of these new products will expand the number of youth and young adults who are exposed to nicotine and will eventually lead to exclusive use of other conventional tobacco products or dual use of both (e-cigarettes and conventional cigarettes) (Leventhal et al. 2015; Primack et al. 2015). Early longitudinal evidence provides some support for these concerns, although further research on this issue is still warranted.

As reviewed in Chapter 3, uncertainty remains about the health effects of e-cigarettes, particularly in the long term. Such effects will remain unknown until sufficient observations can be made over time. However, current knowledge of the characteristics of the inhaled aerosol from e-cigarettes suggests that if a current adult smoker of conventional cigarettes or other combustible tobacco products would use e-cigarettes exclusively instead of combustibles as a substitute nicotine delivery system, either en route to quitting tobacco completely or even as a long-term alternative, the risks of tobacco-related diseases would be reduced substantially compared with the risk imparted by continued smoking of conventional cigarettes (Fiore et al. 2014; USDHHS 2014; McNeill et al. 2015).

Still, as documented in Chapter 3, immediate and future health risks for youth and young adults who use e-cigarettes can be anticipated from exposure to nicotine, including addiction and harmful effects on brain development. Research must continue to characterize and quantify the full spectrum of potential health risks. Thus, in formulating policies related to the role of e-cigarettes in tobacco control and reducing the burden of tobacco-related disease, particularly among youth and young adults, e-cigarette products that deliver nicotine cannot be considered a risk-free alternative to conventional cigarettes or other combustible tobacco products.

Any analysis of the potential increased risks and reduced harms of e-cigarette use also needs to consider data on the actual patterns of use because more of the risks affect youth and young adults and most of the potential benefits from reduced risk to health largely accrue to older cigarette smokers (Chapter 2). However, the reports of the tobacco industry to investors indicate the industry’s interest in maintaining a broad pattern of use of nicotine-containing products, including conventional cigarettes, for decades to come (Calantzopoulos 2015). When considered in the context of the tobacco industry’s past changes to product design (e.g., the creation of so-called “low-tar” cigarettes), the broader array of tobacco products now being discussed within the tobacco industry’s plans (e.g., “Heat-Not-Burn” products) could slow cessation (because smokers have historically been drawn to reduced-harm products) and thus the overall decline of tobacco-related diseases (USDHHS 2014).

The dynamic balancing between risks and potential benefits of e-cigarette use will be swayed by the impact of such use on the use of other tobacco products by youth and young adults over time. The availability of e-cigarettes could adversely affect the use of tobacco products in this group by slowing the decline of smoking because this population will be exposed to nicotine and possibly become addicted to that substance. Indeed, data reviewed in Chapter 2 show evidence of such trends. Although the decline in rates of smoking conventional cigarettes and other combustible tobacco products is viewed universally as positive, the increasing number of youth and young adults who use e-cigarettes is a serious concern for all the reasons cited above. West and Brown (2014) and McNeill and colleagues (2015) suggest that the limited evidence from the United Kingdom does not support the concern that using e-cigarettes leads to the use of other tobacco products, and they maintain that the new adolescent users of these e-cigarette products include very few never smokers. However, the marketing of e-cigarettes is quite different between the United Kingom and the United States, and the patterns of use, particularly among youth, are also quite different (European Parliament and Council 2014; England et al. 2015; Klein 2015; Leventhal et al. 2015; Primack et al. 2015; Barrington-Trimis et al. 2016; Wills et at. 2016; Institute for Global Tobacco Control n.d.). This pattern is also evident in some U.S. survey data from early in the era of e-cigarette use (as reviewed in Chapter 2), but not in more recent data, which indicate that e-cigarette products may contribute to nicotine addiction in a new generation of young people and thereby lead to increased use of a variety of nicotine delivery products, including combustible tobacco (Bauld et al. 2016; CDC 2016).

Fundamentally, the public health challenge and the charge to policy development can be framed as balancing the potential use of e-cigarettes as a new technology to reduce the use of combustible tobacco products against the possibility of expanding tobacco use among non-using youth and young adults, long-term former smokers, and other vulnerable populations (e.g., women of reproductive age and individuals with significant comorbidities, including those with mental health problems). Already, the e-cigarette companies are increasing the appeal of their offerings by enhancing the efficiency of nicotine delivery and using flavorings while they continue to advertise and promote their products aggressively.

Additional Evidence Suggested for Future Research

To characterize the critical balance for public health between the harms and potential benefits of e-cigarettes, more evidence on each of the elements that determine that balance would be useful (Table 5.1). The needed data would come from surveillance of patterns of adoption of e-cigarettes and their use among the population generally, and particularly among the most critical populations for uptake: youth and young adults, former smokers, smokers, and other populations that are particularly at risk for adverse outcomes. Few studies have been done on the health risks posed by e-cigarettes and their potential effectiveness for smoking cessation (Hartmann-Boyce et al. 2016). However, as discussed in Chapter 2, there are still no standardized questions for research on e-cigarettes, and there is a need for further testing and development of e-cigarette questions and measurements.

Table 5.1. Comparative risk assessment: Potential harms and benefits of e-cigarettes.

Table 5.1

Comparative risk assessment: Potential harms and benefits of e-cigarettes.

To characterize the harms and benefits of e-cigarettes to public health, models are used to project their overall impact on public health (Levy et al. 2016). The use of modeling was described in detail in the 2014 Surgeon General’s report (USDHHS 2014). Conceptual models are needed to define the potential scenarios of changes in patterns of use among youth, young adults, adult smokers, former smokers, and other significant vulnerable populations. Figure 5.1 displays the range of patterns that are emerging with the wider adoption of e-cigarettes (Cobb et al. 2015; Vugrin et al. 2015). Researchers and public health officials can use dynamic population models (Mejia et al. 2010; Kalkhoran and Glantz 2015; Vugrin et al. 2015; Levy et al. 2016) to analyze the potential impact on population health of the relative probabilities of these various paths. Initial modeling has shown that the potential population health benefits are very sensitive to several factors: the levels of product risk, particularly those of e-cigarettes; patterns of initiation and switching; and the extent of dual use (Mejia et al. 2010; Cobb et al. 2015; Kalkhoran and Glantz 2015; Vugrin et al. 2015). The benefits of smoking cessation, particularly as early in life as possible, are well documented, but the epidemiologic evidence that reducing (but not quitting) cigarette consumption can lower the risk of all-cause mortality, or mortality from cardiovascular diseases, remains inconclusive (USDHHS 2014). Thus, more research is needed to better characterize the health consequences of dual use, in particular, in comparison to the recognized health benefits of complete smoking cessation (or potentially only e-cigarette use). Similarly, the health risks to former smokers who become exposed again to nicotine through e-cigarettes are uncertain. Data are still limited on the risk of starting (or not starting) to smoke conventional cigarettes again (after successful cessation) following exposure to nicotine via e-cigarettes.

Potential patterns among never users include (1) progressing from combustible products to either (a) only combustible product use or (b) only e-cigarette use or (c) dual use of combustible products and e-cigarettes; or (2) progressing from e-cigarettes to either (a) only e-cigarettes or (b) dual use of combustible products and e-cigarettes. Patterns among former users include (a) staying quit or (b) using only combustible product or (c) using only e-cigarettes or (d) dual use of combustible products and e-cigarettes. Patterns among current users of only combustible products include (a) continued use of only combustible products or (b) use of only e-cigarettes or (c) dual use of combustible products and e-cigarettes or (d) quitting. Patterns among current users of only e-cigarettes include (a) continued use of only e-cigarettes or (b) use of only combustible products or (c) dual use of combustible products and e-cigarettes or (d) quitting. Patterns among current users of both combustible products and e-cigarettes include (a) continued use of both products or (b) use of only combustible products or (c) use of only e-cigarettes or (d) quitting.

Figure 5.1

Potential patterns of use of combustible products (CPs) and e-cigarettes (e-cigs). Source: USDHHS (2014). Adapted for this report.

As reviewed in Chapter 3, the long-term health risks of e-cigarettes will not be known for decades, although evidence to date suggests that they are generally less harmful than combustible products. However, less harmful is not the same as harmless. A substantial amount of evidence is available on some components of the aerosols inhaled by e-cigarette users. For many people, exposure to aerosol could occur across much of the life span, beginning in adolescence and even in childhood, when the lungs and brain are still developing. Flavorings are of particular concern with regard to pulmonary toxicity, as are the various effects of nicotine on the brain. Although the National Institutes of Health is now supporting a growing program of research on e-cigarettes, critical questions have not yet been answered. Given experiences with conventional cigarettes, long-term studies will be needed to identify the full health consequences of using e-cigarettes.

Thus, policies related to e-cigarettes will necessarily be made in the context of accumulating but incomplete evidence. The landscape is changing rapidly and, inevitably, research cannot keep pace. Quoting Sir Austin Bradford Hill’s landmark paper on environment and disease: “All scientific work is incomplete—whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer on us a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time” (Hill 1965, p. 300).

Potential Public Policy Approaches

In formulating public policies related to e-cigarettes, the context and possibilities vary across the national, state, local, tribal, and territorial governments and public entities. At the national level, progressive steps are being taken by FDA under the Tobacco Control Act. In 2010, the U.S. Court of Appeals for the D.C. Circuit determined that e-cigarettes and other products made or derived from tobacco may be regulated by FDA as tobacco products under the Tobacco Control Act and are not drugs or devices unless marketed for therapeutic purposes, such as being an aid to smoking cessation (Sottera, Inc. v. Food and Drug Administration 2010). In May 2016, FDA released its deeming rule to regulate the sale and distribution of e-cigarettes as a tobacco product (see Chapter 1) (Federal Register 2016). The rule is currently under litigation. The rule restricts the age of sale to those 18 years of age and older and requires retailers to check the age identification of young people under age 27, restricts vending machines to adult-only facilities, prohibits free samples, requires a health-warning statement about nicotine on packaging and in advertisements, requires domestic manufacturers to register their products and disclose the ingredients of their products, requires the reporting of the levels of harmful and potentially harmful constituents to FDA, allows FDA to review any new or changed products before being sold, and requires manufacturers to show scientific evidence that demonstrates the overall public health benefit of any product before it can be marketed as a modified risk tobacco product (Federal Register 2016). The Tobacco Control Act does not provide FDA with authority to impose taxes on tobacco products (Bhatnagar et al. 2014; Huang et al. 2014; Tobacco Control Legal Consortium 2015) or regulate indoor air quality (Schripp et al. 2013; Bam et al. 2014; Bhatnagar et al. 2014; Brandon et al. 2015a), occupational health and safety (USDHHS 2015; Whitsel et al. 2015), or hazardous waste disposal (Chang 2014; Krause and Townsend 2015).

FDA is not the only federal agency with potential jurisdiction over some aspect of e-cigarettes (Table 5.2). For example, the U.S. Department of Defense and U.S. Department of Veterans Affairs relate to specific populations, and other agencies relate to regulatory activities, such as the U.S. Federal Trade Commission, U.S. Department of Transportation, and the U.S. Environmental Protection Agency. Some agencies have coverage over specific areas, such as the General Services Administration and the National Park Service.

Table 5.2. Principle federal policies and regulations of tobacco that emphasize e-cigarettes.

Table 5.2

Principle federal policies and regulations of tobacco that emphasize e-cigarettes.

State, local, tribal, and territorial governments, as well as private entities, may also address these and other matters that are covered by the Tobacco Control Act (Freiberg 2012), and since 2010 many actions have been taken at the nonfederal level. State and local governments may utilize effective interventions that would also be expected to apply to e-cigarettes: increasing the price of tobacco products through taxation (Community Preventive Services Task Force 2012); creating and enforcing clean air policies (Hopkins et al. 2010); and passing comprehensive laws prohibiting sales to minors, combined with active enforcement (Community Preventive Services Task Force 2001). In addition, based on evidence that new e-cigarette products may addict a generation of young people to nicotine (Bunnell et al. 2015; CDC 2015b) and on mounting indications about potential harm from the use of these products in this population (Flouris et al. 2013; Barrington-Trimis et al. 2014; Goniewicz et al. 2014; Grana et al. 2014a; Pisinger and Dossing 2014; Goniewicz and Lee 2015), numerous health organizations have called for the extension of smoking-related policies to e-cigarettes (Association of State and Territorial Health Officials 2014; Bam et al. 2014; Bhatnagar et al. 2014; Offermann 2014; Schraufnagel et al. 2014; World Health Organization 2014a; Brandon et al. 2015a; USDHHS 2015). In the absence of causal findings that have guided evidence-based tobacco control for decades, the “precautionary principle” is relevant to decision makers as a guide to action to address e-cigarettes among youth and young adults. This principle supports intervention to avoid possible health risks when the potential risks remain uncertain and have been as yet partially undefined (Bialous and Sarma 2014; Saitta et al. 2014; Hagopian et al. 2015). However, the interventions should be appropriate to the currently perceived risk for future health consequences, in this case from e-cigarette use by youth, young adults, and pregnant women, as well as from the secondhand exposure of non-users to e-cigarette vapor.

Clean Indoor Air Policies

Clean indoor air or smokefree policies prohibit the use of conventional tobacco products in indoor public places, such as worksites, restaurants, bars, and casinos. Because most of these policies predate the rise of e-cigarettes, their language does not necessarily cover emissions from these products. To protect the public from both secondhand smoke and secondhand aerosol, smokefree air policies should be modernized to include e-cigarettes. Such policies will maintain current standards for clean indoor air, reduce the potential for renormalization of tobacco product use, and prevent involuntary exposure to nicotine and other aerosolized emissions from e-cigarettes (Ingebrethsen et al. 2012; Schripp et al. 2013; Goniewicz et al. 2014; Offermann 2014; Schober et al. 2014). Updating existing policies to cover e-cigarettes (and all electronic nicotine delivery systems) will eliminate the introduction of airborne toxins into enclosed spaces and establish a uniform standard for preventing the use of both combustible and electronic tobacco products in public and private spaces, including schools, offices, restaurants, bars, casinos, and airplanes.

Prohibiting the use of e-cigarettes in enclosed spaces eliminates potential health risks to nonusers and ensures their right to clean air; may discourage the dual use of electronic and combustible tobacco products; simplifies public compliance with and enforcement of existing clean indoor air laws; facilitates reduced consumption of these products; and maintains clear, comprehensive non-smoking norms (Richardson et al. 2014; World Health Organization 2014a). As of January 1, 2016, six states (Delaware, Hawaii, New Jersey, North Dakota, Oregon, and Utah) had passed comprehensive smokefree indoor air laws that include e-cigarettes (CDC 2015a). These laws prohibit smoking and the use of e-cigarettes in indoor areas of private worksites, restaurants, and bars. Sixteen additional states had prohibited the use of e-cigarettes on some or all state property, and 475 local laws restricted e-cigarette use in 100% smokefree venues (Americans for Nonsmokers’ Rights Foundation 2015). Nationwide, more than 400 local jurisdictions prohibit e-cigarette use in 100%-smokefree workplaces (Americans for Nonsmokers’ Rights Foundation 2015). Major cities that have addressed e-cigarettes include Austin, Boston, El Paso, Chicago, Los Angeles, Minneapolis, San Francisco, and New York City.

Prevent Youth Access

Ensuring that laws on youth access include e-cigarettes is intended to protect youth from exposure to nicotine, which can lead to addiction and other health problems. Additionally, ensuring that these laws include e-cigarettes helps to capture the full diversity of the tobacco product landscape, including combustible, non-combustible, and electronic tobacco products. Effective strategies to deter access to e-cigarettes by youth and the use of these products in this population include restricting sales of e-cigarettes to minors, requiring verification of age, mandating clear signage about minimum age where sales take place, prohibiting the sale of e-cigarettes from vending machines, eliminating self-service displays of e-cigarettes, and actively enforcing existing laws with a focus on retailers. Compliance with laws that regulate the sale and distribution of e-cigarettes is facilitated by requiring retailers to be licensed. To date, 46 states have prohibited the sale of e-cigarettes to minors younger than a specified age (National Conference of State Legislatures 2015; The Council of State Governments 2015). Federally, aligning youth tobacco access control regulations with the statutory definition of tobacco products in the Tobacco Control Act, which includes e-cigarettes, could provide consistent framework to help ensure that restrictions on youth access to e-cigarettes are prioritized and enforced (Federal Register 2016). This could include modifications to the Synar regulation, which requires states, U.S. territories, and jurisdictions to enact and enforce laws prohibiting the sale or distribution of tobacco products to youth. Substance Abuse Prevention and Treatment Block Grant recipients must comply with the Synar amendment and implement regulations in order to receive their full awards (U.S. Food and Drug Administration, Center for Tobacco Products n.d.).

Licensing

Licensing is used to regulate professional practice and business operations and represents one strategy to control the rising use of e-cigarettes among youth. In general, in the case of tobacco-related licensing, a business is authorized to manufacture, distribute, or sell tobacco products as long as it complies with all relevant laws (McLaughlin 2010). Typically, tobacco-related licensing requirements for retailers and/or manufacturers help to prevent evasion of excise taxes, ensure that licensees comply with tobacco-related laws, and promote safe manufacturing practices (ChangeLab Solutions 2012). Repeat violators of relevant laws may be subject to suspension or permanent revocation of their license, an outcome that provides a strong incentive to comply with existing requirements. As in the conventional cigarette industry, licensing of e-cigarette retailers and manufacturers is designed in part to prevent the use of these products by youth and to facilitate safe manufacturing practices. Unlike traditional tobacco products, for which retailers sell prepackaged products and the number of manufacturers is limited, a growing number of businesses engage in both the retail sale and manufacturing of devices and liquids used in the devices (e-liquids). Stores devoted exclusively to the sale of e-cigarettes are known as “vape shops.” These shops frequently offer a social environment for using products, and they may also sell food and beverages (Sussman et al. 2014).

As of April 2015, 99 cities and counties in California required a retailer to obtain a license to sell e-cigarettes. The majority of these jurisdictions did so by broadening the definition of tobacco products to include “electronic smoking devices” (ChangeLab Solutions 2015a). The definition was purposely broadened to include products that do not include nicotine to decrease the complexity of enforcement and in recognition of the fact that e-cigarette devices are sometimes used with liquids that do not contain nicotine but may contain marijuana oil (The Center for Tobacco Policy & Organizing 2015a). Licensing requirements also may be used to restrict the sale of flavored products or to address issues of consumer and worker safety relative to the mixing of e-liquids.

Imposing a moratorium is another potential approach that has been used in some communities to stop new “vape shops” from entering the market while a more comprehensive approach was being considered. A moratorium is a land-use law that takes effect immediately to stop 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 2015b). In California, several communities enacted moratoria that are initially 45 days but can be extended for up to 2 years (ChangeLab Solutions 2014, 2015b). A four-fifths vote, however, is required to establish a moratorium in California. Hayward and Union City, California, are examples of cities that have enacted moratoria and later adopted both retail licensing requirements for existing e-cigarette retailers and zoning restrictions to prohibit new vapor and hookah bars and lounges from opening within city limits (ChangeLab Solutions 2014; The Center for Tobacco Policy & Organizing 2015b).

Taxation and Other Price Policies

Taxation and other price policies directed at making e-cigarettes more expensive may be implemented at multiple levels of government, from local to federal. Increasing the price of conventional cigarettes, including those increases resulting from excise taxes, significantly prevents and reduces tobacco use, particularly among youth and young adults (USDHHS 2014), and has potentially more impact on prevalence of current use in this population than on first use (Bader et al. 2011). Similarly, price policies are likely to reduce the use of e-cigarettes: a 10% increase in the price of e-cigarettes has been estimated to reduce sales of disposable e-cigarettes by approximately 12% and reusable products by about 19% (Bader et al. 2011; Huang et al. 2014). Data are currently lacking on the potential effects that taxing e-cigarettes might have on conventional cigarettes. Tobacco products are taxed in two main ways:

  1. A “specific” excise tax is levied based on the quantity of the product sold (e.g., as measured by number of cigarettes, weight, or volume). This type of mechanism applies the same tax across low-end and premium brands and is generally simple to administer. The disadvantages to specific excise taxes are that the real value of the tax declines over time with inflation, making products more affordable, and that super-lightweight products—such as snus, orbs, sticks, and dissolvables—are grossly under-taxed if the tax is based on weight (Freiberg 2012; Boonn 2013; Shang et al. 2015).
  2. The second tax mechanism is an ad valorem excise tax, which is levied on a percentage of the value of the tobacco product (e.g., the retailer’s, wholesaler’s, or manufacturer’s price). This type of tax keeps up with inflation and establishes a flat tax rate across all brands, product types, weights, and packaging. The disadvantages to this kind of tax include the potential for tax evasion through predatory (below-cost) or anticompetitive pricing; increasing the price differential between products with different pretax prices, leading to greater price variability and more opportunity for tax avoidance; a government-provided subsidy for manufacturers’ price cuts; and more expensive brands being subjected to a larger tax (Freiberg 2012; Boonn 2013; Shang et al. 2015).

Governments use uniform, tiered, and mixed-tax approaches to implement specific and ad valorem tobacco excise taxes. Uniform systems apply the same tax rate across all products; tiered systems levy taxes based on such product characteristics as toxicity, nicotine content, type of production (handmade versus machine made), sales volume, packaging, or whether the products are domestic or imported; and mixed systems use a combination of uniform and tiered-tax approaches (Shang et al. 2015). Tiered-tax approaches, such as those based on nicotine content, could steer consumers to a less toxic product or one with lower nicotine (Benowitz 2014). Tiered-tax approaches are more complex to administer and may provide greater opportunity for tax evasion as a result of manipulation of the product or its packaging by the manufacturer (Shang et al. 2015). In recognition of nicotine’s toxicity, particularly to youth, several health groups have endorsed imposing excise taxes on e-cigarettes to discourage their use by youth (American Thoracic Society 2013; Association of State and Territorial Health Officials 2014; Bhatnagar et al. 2014; Brandon et al. 2015a; Crowley and Health Public Policy Committee of the American College of Physicians 2015; National Association of County and City Health Officials 2014). E-cigarettes are likely less toxic than combustible products (such as conventional cigarettes), and therefore, some contend should be taxed at a lower rate (Benowitz 2014; Bhatnagar et al. 2014). Yet others argue that e-cigarettes should be taxed at the same rate as other tobacco products (Freiberg 2012; American Thoracic Society 2013; National Association of County and City Health Officials April 2014).

As of January 2016, four states (Kansas, Louisiana, Minnesota, and North Carolina) and six localities (Juneau, Matanuska-Susitna, Petersburg, and Sitka, Alaska; Montgomery County, Maryland; and Chicago, Illinois) had enacted e-cigarette taxation policies. Minnesota’s ad valorem tobacco tax equates to 95% of the wholesale cost of any product containing or derived from tobacco (Minnesota Revenue 2014; Tobacco Control Legal Consortium 2015). It taxes e-liquids and e-cigarettes sold with nicotine cartridges that cannot be removed (i.e., disposables). In Minnesota, devices without a nicotine cartridge are not taxed as a tobacco product. On the other hand, North Carolina applies a specific excise tax, taxing e-liquids based on volume at 5 cents per milliliter (National Conference of State Legislatures 2015).

The Tobacco Control Legal Consortium, which is based at William Mitchell College of Law in St. Paul, Minnesota, recommends using an ad valorem tax for e-cigarettes applied at the retail level to the “essential” components of these devices. The tax is simple, captures both disposable and refillable devices, and could exclude accessories and universal parts sold separately, such as batteries or charging cords (Tobacco Control Legal Consortium 2015).

Numerous major health organizations support raising the price of e-cigarettes through non-tax options, such as limiting rebates, discounts, and coupons (Freiberg 2012; Association of State and Territorial Health Officials 2014; Bhatnagar et al. 2014; Huang et al. 2014; Brandon et al. 2015a).

Finally, Chaloupka and colleagues (2015) have proposed that differential taxation of tobacco products can be used to incentivize a move away from combustible products to less hazardous noncombustible products, including e-cigarettes. They have argued that taxation could be part of a harm-reduction system. In their view, future determinations by FDA as to whether a product poses a substantially reduced risk would be one criterion in determining the relative rate of taxation.

Restrictions on Marketing

As described in Chapter 4, the marketing of e-cigarettes drives consumer demand for these products. Such marketing also may promote misperceptions about the safety and efficacy of these products for use as cessation devices (Choi and Forster 2014; Mark et al. 2015; Pokhrel et al. 2015). For some populations—such as pregnant women, adolescents, former smokers, and young adults—the adverse health consequences of nicotine intake are substantial. Several groups have supported extending marketing restrictions that apply to conventional cigarettes and other tobacco products to e-cigarettes (Association of State and Territorial Health Officials 2014; Bam et al. 2014; Bhatnagar et al. 2014; Partnership for Prevention 2014; Brandon et al. 2015a). Significant barriers still exist to regulating commercial speech, including the First Amendment rights of the e-cigarette companies (Laird-Metke 2010).

Additionally, for traditional tobacco products, partial advertising bans and voluntary agreements have generally been ineffective in reducing consumption because the tobacco industry circumvents the restrictions by shifting the marketing platforms used to unregulated platforms (National Cancer Institute 2008). This response would be expected to be similar with regard to e-cigarettes. Therefore, despite the numerous barriers, public health groups and state, local, tribal, and territorial governments should take steps to stem the proliferation of e-cigarette marketing likely to appeal to young people by using tools designed to curb youth-oriented tobacco marketing and expanding evidence to inform future restrictions on the marketing of e-cigarettes to youth and young adults.

Surveillance of e-cigarette marketing, performing content analyses of the messages used, and conducting studies to assess the link between exposure to e-cigarette marketing and the use of e-cigarette products, particularly among youth and young adults, will facilitate the development of an evidence base of the type that informed prior federal and Master Settlement Agreement restrictions on tobacco advertising. Observations of retailers’ practices, assessments of outdoor advertising, and identification of event sponsorships and promotional activities at bars and community events are actions that state, local, tribal, and territorial public health agencies have taken related to traditional tobacco products. Many of these actions can be adapted to monitor and document the presence of e-cigarette marketing in communities (Pucci et al. 1998; Feighery et al. 2001; Rigotti et al. 2005; Roeseler et al. 2010; Rose et al. 2014).

In the absence of legal restrictions on e-cigarette marketing, and apart from the issue of the previous promulgation by some companies of unsubstantiated health and cessation claims, public health groups can advocate for television and radio broadcasters, print and outdoor media companies, the management of event venues and sports events, digital media outlets, retailers, and others to voluntarily refuse to air or place e-cigarette advertising, offer sponsorships, or give out free samples at fairs and festivals. Although the impact of a voluntary approach may be low, such actions raise awareness, build concern, and help to denormalize the proliferation of e-cigarette marketing. In California, surveillance plus voluntary efforts to promote restrictions on sponsorship of events by the tobacco industry facilitated a modest decline in tobacco industry-sponsored events and youth-oriented activities at those events that promoted the interests of the tobacco companies, and it led to a productive partnership with the tobacco litigation unit of the California attorney general’s office that resulted in several settlements with tobacco companies (Roeseler et al. 2010).

State, local, tribal, and territorial public health agencies may be able to contribute to the stimulation of enforcement and compliance with existing rules that constrain marketing. Some states have brought lawsuits against e-cigarette companies, alleging that distributors of these products violated state law by selling to minors or making unsubstantiated health claims; some of those lawsuits resulted in financial damages and agreements to stop making claims that e-cigarettes are safer than conventional cigarettes unless confirmed by rigorous science (Center for Public Health and Tobacco Policy 2013).

Finally, another area to address is the use of “advertorials” employed by e-cigarette retailers to promote cessation and health claims. Advertorials are paid advertisements designed to look like an independent editorial. Although there are no specific rules for how a publisher should distinguish actual editorial content from paid editorial content in terms of their appearance, the Federal Trade Commission (FTC) stated in an advisory opinion that disclosure of the source is necessary when content “uses the format and has the general appearance of a news feature and/or article for public information which purports to give an independent, impartial and unbiased view” (Federal Register 1972, p. 154). Additionally, paid advertising must be disclosed clearly and conspicuously in a manner that is understandable to consumers (FTC 1984). State and local public health agencies can play an important role by monitoring and providing substantiation to their state attorney general or FTC regarding advertising that makes improper claims or is not clearly identified as advertising.

Educational Initiatives

The extensive data reviewed in Chapter 2 highlighted the limited knowledge that members of the general public, particularly adolescents and young adults, have about e-cigarettes and their potential for nicotine addiction and other adverse health consequences. FDA has jurisdiction for product warnings that can reach users, but that agency, along with other federal entities and state and local governmental and nongovernmental organizations, can also carry out educational campaigns to enhance such limited knowledge levels. Potentially effective initiatives with youth and young adults to prevent smoking were reviewed in the 2012 Surgeon General’s report and may be applicable to preventing e-cigarette use. That report concluded that sufficient evidence exists to conclude that mass media campaigns, comprehensive community programs, comprehensive statewide tobacco control programs, and school-based programs that have shown evidence of effectiveness, if they contain specific components, can produce at least short-term effects and reduce the prevalence of tobacco use among school-aged youth (USDHHS 2012).

Implications for Health Care Practice

Although the issues are not well documented, health care practitioners face questions about e-cigarettes from their patients and their communities, including what are the risks of using e-cigarettes, how do these risks compare with those of cigarettes or other combustible products, and is e-cigarette use an effective way to quit smoking? Chapter 3 set out the limited evidence base related to these questions. Clinicians need to respond to these questions and guide their patients in the context of considerable uncertainty. At this time, practitioners can turn to the various statements from medical organizations, which generally urge caution regarding e-cigarettes and do not find the evidence to be supportive of their use for cessation or for formal harm-reduction strategies (Table 5.3). In fact, any recommendation to use e-cigarettes for the cessation of smoking is not supported by the bulk of the available scientific evidence (Hartmann-Boyce et al. 2016). Both the American Association of Cancer Research and the American Society of Clinical Oncology recommend against advising the use of e-cigarettes for cessation (Brandon et al. 2015b). The U.S. Preventive Services Task Force found that there is insufficient evidence that e-cigarettes are an effective smoking cessation tool in adults, including pregnant women (Agency for Healthcare Research and Quality 2015).

The clinical care setting is a critical venue for taking evidence-based approaches for enhancing smoking cessation and increasing the protection of susceptible groups against exposure to secondhand smoke (USDHHS 2014). However, research on e-cigarettes in relation to this set of venues is lacking and urgently needed. Regardless, some pragmatic approaches have been proposed. For example, the American Academy of Pediatrics (AAP) gives advice on how pediatricians can approach questioning about the use of e-cigarettes. As of October 2015, the AAP’s position on e-cigarettes is that sales to minors should be prohibited; 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 (AAP 2015a).

Table 5.3. Medical organizations.

Table 5.3

Medical organizations.

Case Studies

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

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City of Hayward Takes Bold Steps to Address Tobacco Products Aimed at Kids.

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North Dakota’s Statewide Clean Indoor Air Law Prohibits Conventional Tobacco Products and E-Cigarettes.

Summary and Recommendations

The Surgeon General has long played a leading role in identifying the harms of tobacco use and documenting the most effective ways to reduce them. This report comes amid the rising use of e-cigarettes among the nation’s youth and young adults. It calls attention to this problem and the need to implement immediately a comprehensive strategy to minimize any negative public health impact now and in the future, giving consideration to the potential for youth to be harmed from e-cigarettes while, simultaneously, acknowledging that gains might be made if the use of combustible tobacco products fell among adult smokers. Chapters 14 documented the particular challenges posed by the rapid emergence and dynamic nature of e-cigarette use among youth and young adults. The marketplace is diverse, and although it includes the large tobacco companies, e-cigarettes are sold in thousands of “vape shops” and other small commercial locations and on the Internet. Marketing strategies exploit social media, reaching widely and with tailored targeting to consumers.

The differences notwithstanding, the principles and strategies articulated in the 2014 Surgeon General’s report and prior reports remain relevant to e-cigarettes. The 2014 report was written not long after the use of e-cigarettes began to surge dramatically; that report commented on the need for rapid elimination of conventional cigarettes and other combustible tobacco products but did not specify a role for e-cigarettes or discuss strategies to minimize adverse effects among youth and young adults (USDHHS 2014). The report’s final chapter, however, set out an evidence-based strategy for the future. The present report builds on this foundation, adding recommendations related to e-cigarettes.

Conclusions

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

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