POLICY STATEMENT

Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

Brian P. Jenssen, MD, MSHP, FAAP,​a Susan C. Walley, MD, FAAP,​b SECTION ON TOBACCO CONTROL E-Cigarettes and Similar Devices

Electronic cigarettes (e-cigarettes) are the most commonly used abstract tobacco product among youth. The 2016 US Surgeon General’s Report on e-cigarette use among youth and young adults concluded that aDepartment of Pediatrics, Perelman School of Medicine, University of e-cigarettes are unsafe for children and adolescents. Furthermore, Pennsylvania and PolicyLab, Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and strong and consistent evidence finds that children and adolescents bDepartment of Pediatrics, The University of Alabama at Birmingham who use e-cigarettes are significantly more likely to go on to use and Children’s of Alabama, Birmingham, Alabama traditional cigarettes—a product that kills half its long-term users. Drs Jenssen and Walley conceptualized the manuscript, drafted the initial manuscript, reviewed the final manuscript, and note substantial E-cigarette manufacturers target children with enticing candy and involvement and contribution to the manuscript; the members fruit flavors and use marketing strategies that have been previously of the Section on Tobacco Control Executive Committee reviewed the manuscript, provided critical appraisal, and note substantial successful with traditional cigarettes to attract youth to these products. involvement and contribution to the manuscript; and all authors Numerous toxicants and carcinogens have been found in e-cigarette approved the final manuscript as submitted. solutions. Nonusers are involuntarily exposed to the emissions of these This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have devices with secondhand and thirdhand aerosol. To prevent children, filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process adolescents, and young adults from transitioning from e-cigarettes to approved by the Board of Directors. The American Academy of traditional cigarettes and minimize the potential public health harm Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. from e-cigarette use, there is a critical need for e-cigarette regulation, Policy statements from the American Academy of Pediatrics benefit legislative action, and counterpromotion to protect youth. from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course DEFINITIONS of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. •• All policy statements from the American Academy of Pediatrics Electronic cigarette (e-cigarette): handheld devices that automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. produce an aerosol from a solution typically containing nicotine, “ flavoring chemicals, and other additives for inhalation through DOI: https://​doi.​org/​10.​1542/​peds.​2018-​3652 ” “ ” a mouthpiece by the user (alternative names include e-cigs,​ Address correspondence to Brian P. Jenssen, MD, MSHP, FAAP. E-mail: “ ” electronic cigars [or e-cigars ], electronic nicotine delivery [email protected] systems, electronic hookah [or e-hookah ], hookah sticks, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

personal vaporizers, mechanical mods, vape pens, pod systems, Copyright © 2019 by the American Academy of Pediatrics •• and vaping devices); secondhand aerosol: e-cigarette emissions that are discharged into the To cite: Jenssen BP, Walley SC, AAP SECTION ON TOBACCO surrounding environment with e-cigarette use both directly from the CONTROL. E-Cigarettes and Similar Devices. Pediatrics. •• e-cigarette and exhaled from the lungs of the user; and 2019;143(2):e20183652 thirdhand aerosol: e-cigarette emissions that remain on surfaces and in dust after e-cigarette use. Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 143, number 2, February 2019:e20183652 FROM THE AMERICAN ACADEMY OF PEDIATRICS BACKGROUND

making them the most common shops, mall kiosks, gas stations, tobacco product used among youth. convenience stores, grocery stores, E-cigarettes are handheld devices Because of the shifting landscape and pharmacies as well as through that produce an aerosol from in e-cigarette product design online/Internet vendors. E-cigarette a solution typically containing and terminology, combined with companies market their products nicotine, flavoring chemicals, and different survey definitions, various to children and adolescents by other additives for inhalation sources are used to capture data promoting flavors and using a through a mouthpiece by the 1 on e-cigarette use. Similar trends wide variety of media channels, user. There is wide variability in have been observed across 3 cross- approaches used by the tobacco e-cigarette terminology, product sectional surveys with data on youth industry to successfully market design, engineering, and solution use: the National Youth Tobacco conventional1 tobacco products components2 (ie, electronic liquid Survey, Monitoring– the Future, and to youth. E-cigarette companies, [e-liquid]). For the purposes of “ ” 3 the Youth Risk Behavior Surveillance many of which are owned by major this Policy Statement update,​ the 7 9 System. ‍‍ For the latest data as of tobacco companies, use promotional term e-cigarettes encompasses the “ ” 2018, the National Youth Tobacco tactics including television wide variety of devices that are Survey reported 20.8% of high school advertisements targeted to known as vapes, mods,​ tanks, and 12 students and 4.9% of middle school stations with clear youth appeal ; pod systems, including currently 4 students currently used e-cigarettes advertisements at the point of sale popular brands, such as JUUL. 13 (defined as use of an e-cigarette at at retail stores ; product Web E-cigarettes were introduced to 10 14 least 1 day in the past 30 days) ; for sites and social media ; targeted the US market in the mid-2000s, 2017, Monitoring the Future reported advertisements through search and the design of these products 17% of 12th graders, 13% of 10th engines and Web sites that are has evolved over time, varying graders, and 7% of eighth graders focused on music, entertainment, considerably in price, quality, and 8 15 2,4,​ 5​ currently used e-cigarettes ; while and sports ; celebrity design. ‍ ‍ Early products initially the Youth Risk Behavior Surveillance endorsements; and sponsorships resembled conventional cigarettes, System reported 13.2% of high school and free samples at youth-oriented with prefilled cartridges of e-liquid, 9 1 students currently used e-cigarettes. events. Many of these e-cigarette but quickly developed into tank- Current e-cigarette use increased methods of advertising are illegal style systems, with large refillable considerably among middle and high for conventional cigarettes precisely cartridges, adding variability in school students during 2017-2018 because such tactics promote the amount and composition of the 1,2​ (increasing by 78% from 11.7% to youth initiation and progression to e-liquid and potential additives. ‍ 10 16,17​ 20.8% among high school students),​ traditional tobacco product use. ‍ More recent e-cigarette products increasing overall– tobacco use and are more diverse in their design, reversing a decline observed in E-cigarette advertising has sometimes resembling common 7 9 recent years. ‍ More than 3 million effectively reached youth and young items such as a pen, flashlight, or high school students and 570000 adults and is associated with current computer flash drive. In addition to “ ” middle school students currently e-cigarette use. In 2016, 78.2% of product manufacturers referring to 10 “ ” use e-cigarettes. E-cigarette use middle and high school students the product as vaping devices,​ they has been documented as highest (20.5 million youth) were exposed are often known as mods because 1,2​ among boys, non-Hispanic white to e-cigarette advertisements from of the ability to modify the devices. ‍ 7,11​ 18 youth, and Hispanic youth. ‍ at least 1 source. Exposure to Although commonly referred to as E-cigarette use is generally greatest these advertisements increases a vapor, the emission from among adolescents and young intention to use e-cigarettes e-cigarettes is most accurately 19 adults and decreases with age in among adolescent nonusers. It is classified as an aerosol, which is adults. Adult e-cigarette users tend associated with current e-cigarette a suspension of fine particles in 20 6 to be previous users of combustible use,​ with increasing exposure a gas. Nonusers can be exposed tobacco products, such as traditional being associated with increased involuntarily to the emissions from 2 21,22​ 1 cigarettes. odds of use. The increased use of the exhaled aerosol. E-CIGARETTE MARKETING, and exposure to e-cigarettes among EPIDEMIOLOGY OF YOUTH E-CIGARETTE ADVERTISING, AND SALES youth, combined with dramatic23 USE increases in advertising,​ have serious potential to undermine E-cigarettes can be purchased in successful efforts to deglamorize, Use of e-cigarettes increased various retail outlets, including restrict, and decrease the use of dramatically over the past decade, vendors that sell tobacco, vape tobacco products. Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS E-CIGARETTE SOLUTION AND HEALTH EFFECTS smokers initiated31 tobacco use by 18 secondhand and thirdhand years of age. aerosol in a manner similar to that of secondhand and thirdhand E-cigarette solutions are often Components of e-cigarette solutions cigarette smoke. Known harmful flavored, with thousands of unique generally include nicotine, flavoring 36,37​ toxicants and carcinogens have been flavors advertised. ‍ Popular 1,2​ chemicals, and other additives found in e-cigarette emissions. ‍ options include fruit, candy, and (including those unknown and/or These include polycyclic aromatic 1 dessert flavors and are appealing to 46 unadvertised to the user). Currently, 36,37​ hydrocarbons as well as nicotine, children and youth. ‍ Availability there are no federal quality standards volatile organic compounds, and fine of flavors is among the most 47,48​ to ensure the accuracy of e-cigarette – and ultrafine particles. Metal and prominently cited reasons for constituents as advertised or labeled. 38 40 silicate particles, some of which are youth e-cigarette use. ‍ ‍ Studies Refillable cartridges allow the at higher levels than in conventional reveal that candy- or fruit-flavored user to deliver other psychoactive cigarettes, have been detected in 24 e-cigarettes are more appealing substances, including marijuana. e-cigarette aerosol, resulting from than tobacco flavors to adolescents Numerous toxicants and carcinogens 41,42​ degradation of the metal coil used to and young adults. ‍ Furthermore, 49 have been found in e-cigarette heat the solution. There are limited adolescents perceive that e-cigarettes solutions, including aldehydes, data on the human health effects of with flavors are less harmful tobacco-specific nitrosamines, 41 e-cigarette emissions. Studies suggest than those with tobacco flavors,​ metals, tobacco alkaloids, and adolescent e-cigarette users are at 25,26​ creating a potential misperception polycyclic aromatic hydrocarbons. ‍ increased risk of cough, wheeze, and that e-cigarettes with flavors do 2 E-cigarette solution has also been 8 asthma exacerbations. not contain nicotine. Many of shown to be cytotoxic to human POISONINGS AND INJURIES 27 the flavoring chemicals contain embryonic stem cells. aldehydes, known respiratory irritants, in sufficient concentrations Nicotine is the major psychoactive 37 1 to be of toxicologic concern. Unintentional exposure to and component of e-cigarette solution. Flavorings (other than menthol) poisoning from e-cigarette solutions There are often wide discrepancies have been banned in conventional containing nicotine have increased between the labeled amount and cigarettes since the Family Smoking dramatically in the United States actual nicotine content within 2 Prevention and Tobacco Control Act since 2011. Although symptoms of the solution. Reported nicotine of 2009 because flavoring encourages acute nicotine toxicity are generally concentration in e-cigarette solution 28,29​ youth experimentation and regular mild and resolve within 12 hours ranges widely ‍ and, depending 16,43,​ 44​ use and results in addiction. ‍ with no treatment,50 large exposure on how the product is used, can be can be fatal. One child death caused Carrier solvents, such as propylene comparable to or exceed the amount by ingestion of liquid nicotine has 51 glycol or vegetable glycerin of nicotine30 in a single conventional been reported in the United States. cigarette. Nicotine is a highly (glycerol), are used in e-cigarette The Child Nicotine Poisoning addictive drug that can have lasting solutions to produce an aerosol that, Prevention Act of 2015, which was damaging effects on adolescent brain when heated, simulates1 conventional enacted nationally in January 2016, development and has been linked to cigarette smoke. Although these requires containers of liquid nicotine carrier solvents are used in other a variety of adverse health outcomes,30,31​ to be in child-resistant packaging; especially for the developing fetus. ‍ settings, there are insufficient data nonetheless, there continue to be on the health effects of repeated Nicotine has neurotoxic32,33​ effects on thousands of reports of exposure to long-term inhalation and exposure to the developing brain. ‍ In early 45 e-cigarette liquid nicotine yearly 52to adolescence, executive function and these solvents. the National Poison Data System. neurocognitive processes in the brain HEALTH EFFECTS OF E-CIGARETTE In addition, the lithium-ion batteries AEROSOL have not fully developed or matured. used in e-cigarettes have exploded,2 Adolescents are more likely to engage leading to burns and fires. in experimentation with substances E-CIGARETTE USE AND PROGRESSION such as cigarettes, and they are also The aerosol generated by e-cigarettes TO TRADITIONAL CIGARETTE USE physiologically34 more vulnerable to is inhaled and then exhaled by the addiction. The earlier in childhood user, and some of the generated an individual uses nicotine- aerosol may be discharged directly Studies of US youth who use containing products, the stronger the into the surrounding environment e-cigarettes identify remarkably addiction35 and the more difficult it is and deposited on surface areas. consistent findings: adolescents and to quit. The vast majority of adult Bystanders are exposed to this young adults who use e-cigarettes, Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 143, number 2, February 2019 3 compared with those who do not, behavioral counseling,63 and additional on the market without66 premarket are at higher risk of transitioning2,53​ to pharmacotherapy. review until 2022. traditional cigarettes. ‍ This finding Although only the federal is based on substantial evidence For established smokers, e-cigarettes – government can regulate the from several separate, well-designed, may reduce health risks for the 54– 61 manufacture of tobacco products, longitudinal studies. ‍ Adolescents individual user compared with states have the ability to regulate and young adults (14 30 years of the risk of continued combustible 2 how tobacco products are sold and age) who have used e-cigarettes are tobacco use. However, the nuance used. Many states and localities have 3.6 times more likely to report using in this finding must be placed in a enacted e-cigarette regulations, traditional cigarettes at follow-up larger public health context. Tobacco, including applying excise taxes to compared with those who had not, when used as intended, causes – 53 31 the purchase price, incorporating according to a recent meta-analysis. disease, disability, and death. e-cigarettes in smoke-free air In addition, adolescents who use Operationally, even if e-cigarettes laws, implementing point-of-sale e-cigarettes appear to have fewer themselves pose less risk to the user restrictions, and raising the minimum social and behavioral risk factors than other tobacco products, they 67 – purchasing age to 21 years. The than conventional cigarette still represent a significant public 56 58,60​ State Tobacco Activities Tracking users. ‍‍ These findings raise health burden in need of further and Evaluation system of the Centers significant concern that e-cigarettes regulation, particularly if they cause for Disease Control and Prevention have the potential to addict a new more adolescents and adults to begin tracks individual state laws related to generation to nicotine and tobacco, harmful combustible tobacco use or 68 e-cigarettes. slowing or reversing the decline in prevent fewer2 people from quitting adolescent cigarette smoking that has tobacco use. Significant gaps remain in e-cigarette occurred over the past 20 years. FEDERAL, STATE, AND LOCAL regulation. As of this publication date, federal laws and regulations ROLE IN SMOKING CESSATION AMONG E-CIGARETTE REGULATION ESTABLISHED SMOKERS do not appropriately restrict the advertising of e-cigarettes to youth. Furthermore, with no restrictions The federal government first on flavored e-cigarettes in general, Health claims that e-cigarettes are regulated e-cigarettes in 2016 child-friendly flavors are still effective smoking cessation aids with the Child Nicotine Poisoning available and marketed to youth. In are not currently supported by Prevention Act and the FDA addition, the delayed implementation scientific evidence. According to Deeming Rule, which extended FDA of the FDA Deeming Rule allows the National Academies of Sciences, regulatory authority to all tobacco64 all e-cigarettes currently on the Engineering, and Medicine, there is products, including e-cigarettes. market to continue to be marketed limited evidence regarding the ability FDA regulations of e-cigarettes now and sold to consumers without FDA of e-cigarettes2 to promote smoking include banning sales to people review through 2022. In 2018, the cessation. In particular, with a younger than 18 years, requiring American Academy of Pediatrics limited number of small, randomized- photo identification verification (AAP) and 6 other health groups ’ 69 controlled trials, there is insufficient from consumers younger than filed a lawsuit against the FDA,​ evidence on the effectiveness of 27 years, banning free samples noting that the agency s decision e-cigarettes as a cessation aid and vending machine sales, and to delay product reviews leaves compared with no treatment or including a warning statement on youth vulnerable to the use of these – Food and Drug Administration e-cigarette packaging and advertising products and deprives the public

(FDA) approved2 smoking-cessation explaining that nicotine is addictive. of critical health information about treatments. Studies in real-world Following the FDA Deeming Rule, e-cigarettes that are already on the “ “ clinical settings of smokers interested e-cigarette manufacturers will be market. In 2018, the FDA publicly ” ” in quitting reveal that e-cigarette required to submit a premarket acknowledged the epidemic of users have lower rates of successful review application,​ which will e-cigarette use among teenagers70 quitting compared with 62those who enable the FDA to assess the public and proposed regulatory action in never used e-cigarettes. Given the health impact of these products response to data demonstrating10 rapid current state of the science, smokers to determine if they can continue65 acceleration in use. As these usage interested in quitting should seek and to sell them to consumers. trends continue, with the rapid rise in be referred to evidence-based, safe, However, in 2017, the FDA delayed popularity among youth of71 the latest and effective treatments, including implementation of the Deeming generation of e-cigarettes,​ the need nicotine replacement therapy, Rule, allowing e-cigarettes to remain for federal regulation becomes even Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS more evident. As of this publication and adolescents live, learn, play, For additional AAP clinical and policy date, the FDA is considering policy work, and visit should have recommendations to protect children “ actions that could protect youth from comprehensive tobacco-free from the harms of tobacco, see e-cigarettes, including newer systems bans that include e-cigarettes Clinical Practice Policy to Protect 72 ” like JUUL. as well as combustible tobacco Children From Tobacco, Nicotine, and ONGOING RESEARCH products. Tobacco Smoke (http://​pediatrics.​ aappublications.​org/​content/​early/​ III. Do not recommend e-cigarettes “ 2015/10/​ ​21/​peds.2015-​ 3108),​ and as a tobacco-dependence Public Policy to Protect Children As the e-cigarette market grows, treatment product. ” From Tobacco, Nicotine, and there is continued need for research PUBLIC POLICY RECOMMENDATIONS to inform regulatory standards Tobacco Smoke (http://​pediatrics.​ aappublications.​org/​content/​136/​ and understand the effects of use 2 and exposure across the life span. 5/​998). Additional research is needed to I. Reduce youth access to CONCLUSIONS understand the trajectory of addiction e-cigarettes. among youth and the progression1 a. The FDA should act immediately to combustible tobacco products. to regulate e-cigarettes similar E-cigarettes are the most common Studies are needed to determine to how traditional cigarettes tobacco product used among youth. if and how e-cigarettes may be are regulated to protect public E-cigarettes are marketed and effective for smoking cessation; these health. advertised by promoting flavors and trials must be carefully designed 2 b. Ban the sale of e-cigarettes to using a wide variety of media channels and adequately powered. Finally, children and youth younger than and approaches previously used with research is needed to evaluate 21 years. success by the tobacco industry to effective countermessaging and market conventional tobacco products public health interventions. c. Ban Internet sales of e-cigarettes to youth. E-cigarette advertising has Despite the need for ongoing and e-cigarette solution. effectively reached youth and young research, the evidence base is II. Reduce youth demand for adults and is associated with current sufficient to support immediate e-cigarettes. e-cigarette use. Numerous toxicants regulatory and public health actions. and carcinogens have been found in a. Ban all characterizing Lessons learned from tobacco control e-cigarette solutions. Adolescents and flavors, including menthol, in of combustible cigarettes along young adults who use e-cigarettes e-cigarettes. with available e-cigarette research are at high risk of transitioning to can be used to build science-based b. Ban all e-cigarette product traditional cigarettes. The increasing regulations and interventions, advertising and promotion in use of e-cigarettes among youth including preventing youth access, threatens 5 decades of public health – forms that are accessible to banning flavors, incorporating children and youth. gains in successfully deglamorizing, e-cigarettes into smoke-free air restricting, and decreasing the use of c. Tax e-cigarettes at comparable laws, regulating marketing practices, tobacco products. To prevent children, rates to those of conventional and implementing public education adolescents, and young adults from 1 cigarettes. programs. It is critical that pediatric transitioning from e-cigarettes to health care providers; local, state, and III. Incorporate e-cigarettes into traditional cigarettes and to minimize federal governments; and the public current tobacco-free laws and the potential public health harm from health community act immediately to ordinances where children and e-cigarette use, there is a critical need protect youth from these products. adolescents live, learn, play, for e-cigarette regulation, legislative RECOMMENDED ACTIONS FOR THE work, and visit. action, and counterpromotion to help PEDIATRICIAN youth live tobacco-free lives. For more information, including an e-cigarette fact sheet, please ACKNOWLEDGMENT refer to the AAP Julius B. Richmond I. Screen for e-cigarette use Center of Excellence e-cigarette and exposure and provide Web page (https://​www.​aap.​org/​ The Section on Tobacco Control prevention counseling in en-​us/​advocacy-​and-​policy/aap-​ ​ acknowledges Julie Gorzkowski, clinical practice. health-​initiatives/​Richmond-​Center/​ Director of the AAP Division of II. Provide counseling that homes, Pages/​Electronic-​Nicotine-Delivery-​ ​ Tobacco Control, for her expertise and cars, and places where children Systems.​aspx). important contributions to this article. Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 143, number 2, February 2019 5 LEAD AUTHORS Rachel Boykan, MD, FAAP Bryan Mih, MD, FAAP ABBREVIATIONS Brian P. Jenssen, MD, FAAP Jyothi N. Marbin, MD, FAAP Susan C. Walley, MD, FAAP Alice Little Caldwell, MD, FAAP SECTION ON TOBACCO CONTROL, STAFF AAP: American Academy of 2018–2019 Julie Gorzkowski, MSW Pediatrics Judith A. Groner, MD, FAAP Nana Ama Bullock, MPH e-cigarette: electronic cigarette Maria Rahmandar, MD, FAAP Colleen Spatz, MSBA e-liquid: electronic liquid FDA: Food and Drug Administration

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES 1. US Department of Health and Human Survey Results on Drug Use: 1975-2017: on Twitter. Tob Control. 2014;23(suppl Services. E-Cigarette Use Among Overview, Key Findings on Adolescent 3):iii26–iii30 Youth and Young Adults. A Report of Drug Use. Ann Arbor, MI: Institute 15. Richardson A, Ganz O, Vallone D. the Surgeon General. Atlanta, GA: US for Social Research, University of Tobacco on the web: surveillance and Department of Health and Human Michigan; 2018 characterisation of online tobacco and Services, Centers for Disease Control e-cigarette advertising. Tob Control. and Prevention, National Center for 9. Kann L, McManus T, Harris WA, et al. 2015;24(4):341–347 Chronic Disease Prevention and Health Youth risk behavior surveillance - Promotion, Office on Smoking and United States, 2017. MMWR Surveill 16. National Center for Chronic Disease Health; 2016 Summ. 2018;67(8):1–114 Prevention and Health Promotion, Office on Smoking and Health. Preventing 2. National Academies of Sciences, 10. Cullen KA, Ambrose BK, Gentzke AS, Tobacco Use Among Youth and Young Engineering, and Medicine. Public Apelberg BJ, Jamal A, King BA. Notes Adults: A Report of the Surgeon General. Health Consequences of E-Cigarettes. from the Field: Use of Electronic Atlanta, GA: Centers for Disease Control Washington, DC: The National Cigarettes and Any Tobacco Product and Prevention; 2012 Academies Press; 2018 Among Middle and High School Students -- United States, 2011- 17. US Department of Health and Human 3. Walley SC, Jenssen BP; Section on 2018. MMWR Morb Mortal Wkly Rep. Services. Preventing Tobacco Use Tobacco Control. Electronic nicotine 2018;67(45):1276–1277 Among Youth and Young Adults: A delivery systems. Pediatrics. Report of the Surgeon General. Atlanta, 2015;136(5):1018–1026 11. Arrazola RA, Neff LJ, Kennedy SM, GA: US Department of Health and 4. Barrington-T rimis JL, Leventhal Holder-Hayes E, Jones CD; Centers Human Services, Centers for Disease AM. Adolescents' Use of "Pod Mod" for Disease Control and Prevention Control and Prevention, Office on E-Cigarettes -- Urgent Concerns. N Engl (CDC). Tobacco use among middle and Smoking and Health; 2012 high school students United States, J Med. 2018;379(12):1099–1102 – 18. Marynak K, Gentzke A, Wang TW, Neff 2013. MMWR Morb Mortal Wkly Rep. 5. Hsu G, Sun JY, Zhu SH. Evolution of L, King BA. Exposure to electronic 2014;63(45):1021–1026 electronic cigarette brands from cigarette advertising among middle 2013-2014 to 2016-2017: analysis of 12. Duke JC, Lee YO, Kim AE, et al. and high school students - United brand websites. J Med Internet Res. Exposure to electronic cigarette States, 2014-2016. MMWR Morb Mortal 2018;20(3):e80 television advertisements among Wkly Rep. 2018;67(10):294–299 6. Cheng T. Chemical evaluation of youth and young adults. Pediatrics. 19. Farrelly MC, Duke JC, Crankshaw EC, electronic cigarettes. Tob Control. 2014;134(1). Available at: www.​ et al. A randomized trial of the effect pediatrics.​org/​cgi/​content/​full/​134/​ 2014;23(suppl 2):ii11–ii17 of e-cigarette TV advertisements on 1/​e29 intentions to use e-cigarettes. Am J 7. Wang TW, Gentzke A, Sharapova S, Prev Med. 2015;49(5):686 693 Cullen KA, Ambrose BK, Jamal A. 13. Giovenco DP, Hammond D, Corey CG, – Tobacco product use among middle Ambrose BK, Delnevo CD. E-cigarette 20. Hammig B, Daniel-Dobbs P, Blunt- and high school students - United market trends in traditional U.S. retail Vinti H. Electronic cigarette initiation States, 2011-2017. MMWR Morb Mortal channels, 2012-2013. Nicotine Tob Res. among minority youth in the United Wkly Rep. 2018;67(22):629–633 2015;17(10):1279–1283 States. Am J Drug Alcohol Abuse. 2017;43(3):306–310 8. Johnston LD, Miech RA, O’Malley PM, 14. Huang J, Kornfield R, Szczypka G, Emery Bachman JG, Schulenberg JE, Patrick SL. A cross-sectional examination of 21. Singh T, Agaku IT, Arrazola RA, et al. ME. Monitoring the Future National marketing of electronic cigarettes Exposure to advertisements and

Downloaded from www.aappublications.org/news by guest on September 24, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS electronic cigarette use among US Available at: www.​surgeongeneral.​gov/​ and adult users. Prev Med Rep. middle and high school students. library/​reports/​50-​years-​of-​progress/​. 2016;5:33–40 Pediatrics. 2016;137(5):e20154155 Accessed February 11, 2016 43. Deyton L, Sharfstein J, Hamburg 22. Mantey DS, Cooper MR, Clendennen 32. Dwyer JB, McQuown SC, Leslie FM. M. Tobacco product regulation–a SL, Pasch KE, Perry CL. E-cigarette The dynamic effects of nicotine on the public health approach. N Engl J Med. marketing exposure is associated with developing brain. Pharmacol Ther. 2010;362(19):1753–1756 2009;122(2):125 139 e-cigarette use among US youth. – 44. Cour temanche CJ, Palmer MK, Pesko J Adolesc Health. 2016;58(6):686–690 33. Schraufnagel DE. Electronic cigarettes: MF. Influence of the flavored cigarette 23. Cantrell J, Emelle B, Ganz O, Hair EC, vulnerability of youth. Pediatr Allergy ban on adolescent tobacco use. Am J Vallone D. Rapid increase in e-cigarette Immunol Pulmonol. 2015;28(1):2–6 Prev Med. 2017;52(5):e139–e146 advertising spending as Altria’s 34. Pentz MA, Shin H, Riggs N, Unger JB, 45. Callahan-Lyon P. Electronic cigarettes: MarkTen enters the marketplace. Collison KL, Chou CP. Parent, peer, human health effects. Tob Control. Tob Control. 2016;25(e1):e16 e18 – and executive function relationships 2014;23(suppl 2):ii36–ii40 to early adolescent e-cigarette use: a 24. Grana R, Benowitz N, Glantz SA. 46. Schober W, Szendrei K, Matzen W, substance use pathway? Addict Behav. E-cigarettes: a scientific review. et al. Use of electronic cigarettes 2015;42:73 78 Circulation. 2014;129(19):1972–1986 – (e-cigarettes) impairs indoor air 25. Goniewicz ML, Knysak J, Gawron M, 35. Siqueira LM; Committee on Substance quality and increases FeNO levels et al. Levels of selected carcinogens Use and Prevention. Nicotine and of e-cigarette consumers. Int J Hyg and toxicants in vapour from tobacco as substances of abuse in Environ Health. 2014;217(6):628–637 children and adolescents. Pediatrics. electronic cigarettes. Tob Control. 47. Schripp T, Markewitz D, Uhde E, 2017;139(1):e20163436 2014;23(2):133–139 Salthammer T. Does e-cigarette 36. Zhu SH, Sun JY, Bonnevie E, et al. consumption cause passive vaping? 26. Jensen RP, Luo W, Pankow JF, Strongin Four hundred and sixty brands of Indoor Air. 2013;23(1):25 31 RM, Peyton DH. Hidden formaldehyde – e-cigarettes and counting: implications in e-cigarette aerosols. N Engl J Med. 48. Czogala J, Goniewicz ML, Fidelus B, for product regulation. Tob Control. 2015;372(4):392 394 Zielinska-Danch W, Travers MJ, Sobczak – 2014;23(suppl 3):iii3 iii9 – A. Secondhand exposure to vapors 27. Bahl V, Lin S, Xu N, Davis B, Wang YH, 37. Tierney PA, Karpinski CD, Brown JE, from electronic cigarettes. Nicotine Talbot P. Comparison of electronic Luo W, Pankow JF. Flavour chemicals in Tob Res. 2014;16(6):655 662 cigarette refill fluid cytotoxicity using – electronic cigarette fluids. Tob Control. embryonic and adult models. Reprod 49. Williams M, Villarreal A, Bozhilov K, 2016;25(e1):e10–e15 Toxicol. 2012;34(4):529–537 Lin S, Talbot P. Metal and silicate 38. Ambrose BK, Day HR, Rostron B, et al. particles including nanoparticles 28. Collaco JM, Drummond MB, Flavored tobacco product use among are present in electronic cigarette McGrath-Morrow SA. Electronic US youth aged 12-17 years, 2013-2014. cartomizer fluid and aerosol. PLoS One. cigarette use and exposure in the JAMA. 2015;314(17):1871 1873 2013;8(3):e57987 pediatric population. JAMA Pediatr. – 2015;169(2):177–182 39. Patrick ME, Miech RA, Carlier C, 50. Mayer B. How much nicotine kills a O Malley PM, Johnston LD, Schulenberg human? Tracing back the generally 29. Grana RA, Ling PM. Smoking ’ “ JE. Self-reported reasons for vaping accepted lethal dose to dubious self- revolution : a content analysis of ” among 8th, 10th, and 12th graders experiments in the nineteenth century. electronic cigarette retail websites. in the US: nationally-representative Arch Toxicol. 2014;88(1):5 7 Am J Prev Med. 2014;46(4):395 403 – – results. Drug Alcohol Depend. 51. Eggleston W, Nacca N, Stork CM, 30. Soghoian S. Nicotine. In: Hoffman 2016;165:275 278 – Marraffa JM. Pediatric death after RS, Howland MA, Lewin NA, Nelson 40. Tsai J, Walton K, Coleman BN, et al. unintentional exposure to liquid LS, Goldfrank LR, eds. Goldfrank s ’ Reasons for electronic cigarette nicotine for an electronic cigarette. Toxicologic Emergencies, 10th ed. use among middle and high Clin Toxicol (Phila). 2016;54(9): New York, NY: McGraw-Hill Education; school students - National Youth 890–891 2015:1138 1143 – Tobacco Survey, United States, 52. Govindarajan P, Spiller HA, Casavant 31. US Department of Health and Human 2016. MMWR Morb Mortal Wkly Rep. MJ, Chounthirath T, Smith GA. Services. The Health Consequences 2018;67(6):196 200 – E-cigarette and liquid nicotine of Smoking—50 Years of Progress: 41. Pepper JK, Ribisl KM, Brewer NT. exposures among young children. A Report of the Surgeon General. Adolescents interest in trying Pediatrics. 2018;141(5):e20173361 Atlanta, GA: US Department of Health ’ flavoured e-cigarettes. Tob Control. and Human Services, Centers for 53. Soneji S, Barrington-Trimis JL, Wills 2016;25(suppl 2):ii62 ii66 Disease Control and Prevention, – TA, et al. Association between initial National Center for Chronic Disease 42. Harrell MB, Weaver SR, Loukas use of e-cigarettes and subsequent Prevention and Health Promotion, A, et al. Flavored e-cigarette use: cigarette smoking among adolescents Office on Smoking and Health; 2014. characterizing youth, young adult, and young adults: a systematic review

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 143, number 2, February 2019 7 and meta-analysis. JAMA Pediatr. 61. Chaffee BW, Watkins SL, Glantz electronic cigarettes - U.S. states, 2017;171(8):788–797 SA. Electronic cigarette use and Guam, Puerto Rico, and U.S. Virgin 54. Primack BA, Soneji S, Stoolmiller M, progression from experimentation Islands, September 30, 2017. Fine MJ, Sargent JD. Progression to to established smoking. Pediatrics. MMWR Morb Mortal Wkly Rep. traditional cigarette smoking after 2018;141(4):e20173594 2017;66(49):1341–1346 electronic cigarette use among US 62. Kalkhoran S, Glantz SA. E-cigarettes 68. Centers for Disease Control adolescents and young adults. JAMA and smoking cessation in real-world and Prevention. State Tobacco Pediatr. 2015;169(11):1018–1023 and clinical settings: a systematic Activities Tracking and Evaluation review and meta-analysis. Lancet 55. Miech R, Patrick ME, O’Malley PM, (STATE) System. 2018. Available at: Johnston LD. E-cigarette use as a Respir Med. 2016;4(2):116–128 https://​www.​cdc.​gov/​statesystem/​ index.​html. Accessed April 4, predictor of cigarette smoking: results 63. Fiore MC, Jaén CR, Baker TB, et from a 1-year follow-up of a national al. Treating Tobacco Use and 2018 sample of 12th grade students. Tob Dependence: 2008 Update. Clinical 69. McGinley L. FDA sued for delaying Control. 2017;26(e2):e106–e111 Practice Guideline. Rockville, MD: US e-cigarette, cigar regulations. 56. Barrington-T rimis JL, Urman R, Department of Health and Human Washington Post. March 27, Berhane K, et al. E-cigarettes and Services. Public Health Service; 2008 2018. Available at: https://www​ .​ future cigarette use. Pediatrics. 64. US Food and Drug Administration. washingtonpost.​com/​news/​to-​your-​ 2016;138(1):e20160379 FDA takes significant steps to protect health/​wp/​2018/​03/​27/​fda-​sued-​for-​ delaying-​e-​cigarette-​cigar-​regulations/​. 57. Leventhal AM, Strong DR, Kirkpatrick Americans from dangers of tobacco Accessed April 4, 2018 MG, et al. Association of electronic through new regulation. Available at: cigarette use with initiation of www.​fda.​gov/​NewsEvents/​Newsroom/​ 70. US Food and Drug Administration. combustible tobacco product PressAnnouncement​s/​ucm499234.​htm. Statement from FDA commissioner smoking in early adolescence. JAMA. Accessed September 9, 2016 Scott Gottlieb, MD, on new steps to 2015;314(7):700–707 65. US Food and Drug Administration. The address epidemic of youth e-cigarette 58. Wills TA, Knight R, Sargent JD, Gibbons facts on the FDA’s new tobacco rule. use. 2018. Available at: https://​www.​ FX, Pagano I, Williams RJ. Longitudinal Available at: https://​www.​fda.​gov/​ fda.​gov/​NewsEvents/​Newsroom/​ study of e-cigarette use and onset ForConsumers/​ConsumerUpdates/​ PressAnnouncement​s/​ucm620185.​htm. of cigarette smoking among high ucm506676.htm.​ Accessed April 3, 2018 Accessed October 30, 2018 school students in Hawaii. Tob Control. 66. US Food and Drug Administration. 71. King BA, Gammon DG, Marynak KL, 2017;26(1):34–39 Statement from FDA commissioner Rogers T. Electronic Cigarette Sales 59. Bold KW, Kong G, Camenga DR, Scott Gottlieb, M.D., on pivotal public in the United States, 2013-2017. JAMA. et al. Trajectories of e-cigarette health step to dramatically reduce 2018;320(13):1379–1380 smoking rates by lowering nicotine in and conventional cigarette 72. Office of the Commissioner C for TP. combustible cigarettes to minimally use among youth. Pediatrics. Press Announcements - Statement or non-addictive levels. Available at: 2018;141(1):e20171832 from FDA Commissioner Scott Gottlieb, https://​www.​fda.​gov/​NewsEvents/​ 60. Watkins SL, Glantz SA, Chaffee BW. M.D., on proposed new steps to protect Newsroom/​PressAnnouncement​s/​ Association of noncigarette tobacco youth by preventing access to flavored ucm601039.htm.​ Accessed April 4, 2018 product use with future cigarette tobacco products and banning menthol smoking among youth in the 67. Marynak K, Kenemer B, King BA, in cigarettes. 2018. Available at: https://​ population assessment of tobacco and Tynan MA, MacNeil A, Reimels E. www.​fda.​gov/​NewsEvents/​Newsroom/​ health (PATH) study, 2013-2015. JAMA State laws regarding indoor public PressAnnouncement​s/​ucm625884.​htm. Pediatr. 2018;172(2):181–187 use, retail sales, and prices of Accessed November 28, 2018

Downloaded from www.aappublications.org/news by guest on September 24, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS E-Cigarettes and Similar Devices Brian P. Jenssen, Susan C. Walley and SECTION ON TOBACCO CONTROL Pediatrics originally published online January 28, 2019;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2019/01/24/peds.2 018-3652 References This article cites 57 articles, 20 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2019/01/24/peds.2 018-3652#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Current Policy http://www.aappublications.org/cgi/collection/current_policy Substance Use http://www.aappublications.org/cgi/collection/substance_abuse_sub Smoking http://www.aappublications.org/cgi/collection/smoking_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 24, 2021 E-Cigarettes and Similar Devices Brian P. Jenssen, Susan C. Walley and SECTION ON TOBACCO CONTROL Pediatrics originally published online January 28, 2019;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2019/01/24/peds.2018-3652

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on September 24, 2021