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Home , Electronic cigarette, Juul, Sidestream smoke

A Crisis: Electronic , Vape, and Susan C. Walley, MD, CTTS,a Karen M. Wilson, MD, MPH,b Jonathan P. Winickoff, MD, MPH,c Judith Groner, MDd

Electronic cigarettes (e-cigarettes) and vape devices have rapidly become the abstract most common products used by youth, driven in large part by marketing and by e- companies. There is substantial evidence that adolescent e-cigarette use leads to use of combustible tobacco products. E-cigarette companies commonly advertise that e-cigarettes contain , flavoring chemicals, and ( and/or vegetable glycerin), but , ultrafine particles, and have also been found in e-cigarette solutions and emissions, many of which are known to cause adverse health effects. Most major e-cigarette brands are owned by companies that use similar marketing and advertising aDivision of Pediatric Hospital Medicine, The University of strategies to attract youth users as they did with traditional tobacco products. Alabama at Birmingham and Children’s of Alabama, Birmingham, Alabama; bDivision of General Pediatrics, Icahn In this review, we provide an overview of e-cigarettes and vape devices with School of Medicine at Mount Sinai and Mount Sinai Kravis an emphasis on the impact for the pediatric population. We describe the vast Children’s Hospital, New York, New York; cDivision of General Academic Pediatrics, Harvard Medical School and array of e-cigarette devices and solutions, concern for nicotine , and General Hospital, Boston, Massachusetts; the scientific background on the known health harms. There are and dDivision of Primary Care, College of Medicine, The Ohio State University and Nationwide Children’s Hospital, accompanying visual depictions to assist in identifying these products, Columbus, Ohio including newer e-cigarette products and JUUL. Because current federal fi Dr Walley conceptualized and drafted the initial regulations are insuf cient to protect youth from e-cigarette use, exposure, manuscript and reviewed the final manuscript; Drs and nicotine addiction, there are recommendations for pediatricians and Wilson, Winickoff, and Groner assisted in pediatric health care providers to counsel and advocate for a tobacco-free conceptualizing and drafting the initial manuscript and reviewed the final manuscript; and all authors lifestyle for patients and families. approved the final manuscript as submitted. DOI: https://doi.org/10.1542/peds.2018-2741 Accepted for publication Jan 7, 2019 DEFINITIONS Thirdhand : The nicotine and Address correspondence to Susan C. Walley, MD, toxicants that are present in the CTTS, The University of Alabama at Birmingham, Combustible tobacco product: A ’ environment, mainly on surfaces, Childrens of Alabama, 1600 7th Ave South, McWane tobacco product that involves the Suite 108, Birmingham, AL 35233. E-mail: swalley@ burning of the tobacco leaf for from the emissions of an e-cigarette peds.uab.edu after use. inhalation. This includes PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, conventional cigarettes, , JUUL: A brand name of an e-cigarette 1098-4275). , , and pipe tobacco. that is shaped like a flash drive, has Copyright © 2019 by the American Academy of (e-cigarette) prefilled cartridges (“pods”) with Pediatrics aerosol: Although often referred to as solutions that contain a high FINANCIAL DISCLOSURE: The authors have indicated vapor, the emission of an e-cigarette concentration of nicotine, and is they have no financial relationships relevant to this is more accurately described as an available in many youth-appearing article to disclose. aerosol, a suspension of particles flavors. FUNDING: No external funding. in gas. E-cigarettes and vape devices are POTENTIAL CONFLICT OF INTEREST: The authors have Secondhand aerosol: The emissions handheld devices designed to deliver indicated they have no potential conflicts of interest of e-cigarettes that nonusing emissions for inhalation by heating to disclose. bystanders are exposed to, a solution that commonly contains mainly from what is exhaled nicotine, a , and flavoring To cite: Walley SC, Wilson KM, Winickoff JP, et al. A by the user during use of the chemicals. For the purpose of this Public Health Crisis: Electronic Cigarettes, Vape, and JUUL. Pediatrics. 2019;143(6):e20182741 product. review, the term “e-cigarette” will be

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 143, number 6, June 2019:e20182741 STATE-OF-THE-ART REVIEW ARTICLE used; however, these devices are more commonly referred to by the public and users as vapes, pod systems, mods, and tanks as well as by brand names such as JUUL. In the scientific literature, e-cigarettes are commonly referred to as electronic nicotine delivery systems. Because they commonly contain nicotine, which is derived from the tobacco plant, e-cigarettes are tobacco products.1

The awareness, marketing, advertising, and use of e-cigarettes FIGURE 1 have dramatically increased E-cigarette components. (Adapted from E-Cigarette Use Among Youth and Young Adults: A Report of since their introduction into the Surgeon General. US Department of Health and Human Services; Centers for Control and Prevention; National Center for Chronic Disease Prevention and Health Promotion; Office on the US marketplace. The e-cigarette and Health. Atlanta, GA: US Department of Health and Human Services; 2016:12.) was introduced into the US market from China around 2006, where it “ waspatentedasan electronic When a user inhales from the third-generation products to assist in ”2,3 atomizing cigarette. By 2010, mouthpiece, the heating coil is describing their wide variability there were several brands of activated to aerosolize the e-cigarette (Fig 2). The first-generation e-cigarettes that were sold in US solution to form an emission, e-cigarette products usually have the 2 markets. In 2011, e-cigarettes were which is best described as an appearance of a cigarette and are added to the National Youth aerosol but is commonly called referred to as “cigalikes.” First- Tobacco Survey (NYTS) on tobacco- a vapor. A video clip showing the generation e-cigarettes are often product use, and since 2014, the use of an e-cigarette can be found disposable or have a reloadable e-cigarette has been the most online.5 cartridge for repeated uses. Second- frequently used tobacco product generation e-cigarettes are known as 4 by youth. There have been substantial changes vapes or vape pens and have and evolution of e-cigarettes, and arefillable reservoir for the electronic thus e-cigarette devices have often cigarette liquid (e-liquid). Third- E-CIGARETTE DEVICES AND been described as first-, second-, and generation e-cigarettes are frequently CONSTITUENTS referred to as “mods” or tank systems Basic Operation because the wattage and voltage can be modified. More recently, there has fi Part of the dif culty in the research been a wave of products that bear no and regulation of e-cigarettes is the resemblance to traditional cigarettes diversity and rapid change in or even previous generations of nomenclature, design, and technology, e-cigarettes, which, for purposes of not only of the devices but also in the this review, will be referred to as e-cigarette solution. Despite this fourth-generation e-cigarettes. variation, the majority of these Fourth-generation products are products have similar design sold under the names JUUL (Fig 3), characteristics, which include the FIGURE 2 Suorin, and SMPO. following components (Fig 1): E-cigarette design variability. Seen on the far 1. a mouthpiece; left is a conventional cigarette. The earlier E-cigarette Solution fi e-cigarettes ( rst generation) have a similar E-cigarette solutions, often known as 2. a sensor or user-actuated button shape as a conventional cigarette (second, to activate the heating coil (seen in third, and fourth from the left). The second- e-juice or e-liquid, are even more Fig 1); generation e-cigarettes (fifthandsixthfrom diverse than the devices. The the left) have refillable clear reservoirs for solutions are commonly advertised as 3. a battery; the e-liquid and are often known as vape containing 3 types of chemicals: pens. The third-generation e-cigarettes (far 4. a heating coil or atomizer; and 2 right) often have the ability to modify wattage a humectant, nicotine, and flavors. 5. a reservoir or tank. and voltage and are thus known as mods. The 2 humectants used most often

Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 WALLEY et al Glucose, fructose, and sucrose Additional JUUL pods can be levels were also detected in 22% to purchased in packs of 4 for 53% of a set of e-liquid samples.11 $15.99.17The JUUL website reports Other substances, such as marijuana their mission is to "improve the lives and methamphetamine, can also be of the world's one billion adult vaped from some e-cigarette smokers by eliminating cigarettes."18 devices.12 They state on their Web site that they do not sell to youth ,21 years of age; JUUL and Other Vaping Products however, previous marketing campaigns were clearly targeted at JUUL is a brand of e-cigarette a youthful demographic, and the that has recently received significant flavors are appealing to youth. In FIGURE 3 media attention because of its December 2018, JUUL sold a 35% JUUL and JUUL pods. rapid uptake by adolescents.13 stake to the tobacco company , Part of the appeal of JUUL is formerly known as Philip Morris, for the small sleek shape and the $13 billion, evoking additional are propylene glycol (PG) and ability to use the device concerns about the company’s vegetable glycerin; both are generally surreptitiously. The JUUL device strategy to address use by recognized as safe for ingestion, looks like a flash drive (Fig 3) and teenagers.19 but there is little evidence about is rechargeable via a USB port.7 their safety for long-term inhalation. Educators report that teenagers The majority of e-cigarette solutions covertly use the product during MARKETING, ADVERTISING, AND SALES are advertised as containing nicotine; school, even in the classroom.13 The has long the nicotine concentration can vary, Rather than vaping, JUUL users been known to use deceptive both in the reported concentration are said to be “JUULing,” and marketing and advertising to and in the actual concentration as the Internet is full of videos of 6 target certain populations, including measured by gas chromatography. adolescents using JUUL. The youth and minorities.20 Although There are also some e-liquids device uses prefilled cartridges product marketing refers to that are advertised as 0% nicotine. called pods that contain 0.7 mL acompany’sstrategytobrand E-cigarette solutions are often of solution unique to JUUL.7 In their product, the term “promotion” labeled with concentrations addition to PG and , the refers to advertising in mainstream between 0 and 24 mg/mL of nicotine, pod is advertised to contain benzoic media, including the Internet, but more recently, the e-cigarette acid (a naturally occurring acid television, magazines, brand JUUL has an e-cigarette found in the tobacco plant) and channels, direct-to-consumer solution containing benzoic acid nicotine.7 As of August 2018, JUUL marketing, and point-of-sale and a much higher advertised advertises pods with 2 nicotine 7 advertisements.2 Point of sale refers nicotine concentration of 59 mg/mL. concentrations of 5% (59 mg/mL) to advertisements that are visible Typical nicotine absorption from and 3% (35 mg/mL).7 Each pod is around the time of purchase and a conventional cigarette is 1 mg marketed as equivalent to ∼1pack – accounts for the majority of the (range 0.3 2 mg), with blood of cigarettes (ie, 200 puffs), and advertising dollars tobacco nicotine levels ranging from an pods are sold in multiple youth- 8,9 companies spend.21 It is average of 15 to 30 ng/mL. appealing flavors, including mango, well established that marketing fruit medley, crème (brûlée), mint, Most brands of e-cigarette solutions and promotional activities by and cucumber. are available in a variety of youth- tobacco companies increase appealing flavors ranging from The evidence of JUUL’s recent youth and young adult tobacco fruits, desserts, candy, and soda increase in popularity is initiation and usage.22 Television to traditional tobacco. Menthol demonstrated by sales data that advertisements for cigarettes is a common compound found in revealed that in August 2018, were banned in 1971; however, both mint- and tobacco-flavored JUUL sales were 72.1% of the market 78% of middle and high school e-cigarette solutions.6 An analysis of share of the US e-cigarette market, students in 2016 had seen coffee- and chocolate-flavored compared with 13.6% in the first a television advertisement for e-cigarette solutions revealed that quarter of 2017.14,15 A JUUL starter e-cigarettes.23 Studies have revealed 42% of coffee-flavored liquids and kit can be purchased for $49.99, that youth who are exposed to 50% of chocolate-flavored liquids which includes the device with advertisements are more likely to contained detectable levels.10 a charging dock and 4 JUUL pods.16 use e-cigarettes.24–26

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 143, number 6, June 2019 3 E-cigarettes are sold in multiple effective, with dramatic increases in a sharp increase in 2018, with 25% of venues, including in vape shops, youth e-cigarette use.1 Between 2011 12th-graders and 20.3% of 10th- grocery and convenience stores, gas and 2015, the NYTS revealed that US graders using vaped nicotine or stations, and on the Internet.1 The current use among high school flavoring (compared with 15.2% and majority of underaged sales of students (use on $1 days during the 12%, respectively, in 2017).34 The tobacco products occur in the retail past 30 days) increased 966% from increase in e-cigarette use among environment, in which enforcement 1.5% to 16% (Fig 4).4,31 After a 2- 10th- and 12th-graders from 2017 to of age at purchase is largely the year period between 2015 and 2017 2018 represents the largest increase responsibility of the retailer.27,28 in which there was an overall decline of any substance the MTF survey has Internet sales are also a major in youth use, there was a sharp 78% recorded in its 44 years.34 Despite concern regarding youth access to increase in current use among high these dramatic increases, many e-cigarettes because of the difficulty school students to 20.8% from 2017 experts express concern that with regulation and the number of to 2018.32 Accounting for a current e-cigarette use may be online retailers.29 In a review of use among middle school students of underestimated because of survey online e-cigarette brands, 433 distinct 4.9%, this represents 3.62 million limitations. sites were found, 12 of which were youth e-cigarette users.32 Another Survey results have also revealed that owned by tobacco companies.30 national survey, Monitoring the many youth use e-cigarettes with Future (MTF) has trended youth other tobacco products, which is substance use over the past 44 years, EPIDEMIOLOGY OF E-CIGARETTE USE known as dual use. During the period including e-cigarette use since – 33 of 2015 2017, the NYTS revealed that The ubiquitous marketing, promotion, 2015. The MTF has revealed similar 76.7% of middle and high school and sales of e-cigarettes have been trends in e-cigarette use, including students who used e-cigarettes used another tobacco product.35 The Youth Risk Behavior Survey from 2015 revealed that whereas 15.8% of high school students used only e-cigarettes, 7.5% were dual users of e-cigarettes and conventional cigarettes.36 Adult US patterns of e-cigarette and tobacco use are different because the conventional cigarette remains the most common tobacco product used among those aged 18 years and older.37 On the basis of the 2017 National Health Interview Survey (NHIS), current adult use of e-cigarettes is 2.8%, whereas use of cigarettes is 14%.37 However, there are statistically higher rates of use depending on age and other tobacco use. Among younger age groups in the NHIS, adults aged 18 to 24 years had the highest rates of e-cigarette use, with 5.2% reporting “every day” or “some days” use.38 The MTF survey in 2017 revealed higher rates of current e-cigarette use at 11.3% among younger adults (ages 19–30 years), FIGURE 4 with use among 19- to 20-year-olds Percentage of middle and high school students who currently use e-cigarettes and any tobacco- at 13%.33 However, the highest rates, – products based on NYTS 2011 2018. (Reprinted from Cullen KA, Ambrose BK, Gentzke AS, Apelberg of adult e-cigarette use are among BJ, Jamal A, King BA. Notes from the field: use of electronic cigarettes and any tobacco product among middle and high school students - , 2011-2018. MMWR Morb Mortal Wkly Rep. current and former working adult 2018;67(45):1276.) cigarette users, with rates of 15.9%

Downloaded from www.aappublications.org/news by guest on September 28, 2021 4 WALLEY et al and 22%, respectively, in the NHIS.38,39 report “The Public Health products that causes addiction.45 The Population Assessment of Consequences of E-Cigarettes,” it was Nicotine’s primary psychoactive Tobacco and Health (PATH) study concluded that there is not adequate actions are related to its binding to revealed that 5.5% of adults were research to predict long-term health the nicotine cholinergic receptor in current e-cigarette users in outcomes but that there is sufficient the brain to release , which 2013–2014, with 70% of e-cigarette evidence that use of e-cigarettes can is part of the pathway involved in users reporting dual use with cause acute endothelial dysfunction, -induced reward.7,46 Nicotine cigarettes.40 , symptoms of addiction is an adaption to , and an increase in heart exposure over time, and thus the high rate and that chemicals in e-cigarettes concentrations of nicotine in HEALTH HARMS OF E-CIGARETTE USE can cause DNA damage and e-cigarettes are of major concern. 3 More than 50 years after the initial mutagenesis. There is evidence of an Studies of e-cigarette use have Surgeon General landmark report, increase in blood pressure (systolic revealed that, depending on duration fi “Smoking and Health: Report of the and diastolic) after use of nicotine- of use and user puf ng topography, 3 Advisory Committee to the Surgeon containing e-cigarettes. serum levels of nicotine can be as high with e-cigarette use as with use General of the Public Health Services,” In addition, there is also a growing of a conventional cigarette.3 In 1 and 30 years after “The Health body of evidence of the respiratory study, the urinary Consequences of Involuntary effects of e-cigarette use for the concentrations (a biomarker for Smoking,” there continue to be new e-cigarette user, particularly for – nicotine exposure) among discoveries on health harms related adolescents with .42 44 The adolescents using JUUL was even to conventional cigarettes and NAS reportconcludes that “[t]here is higher than the urinary cotinine traditional tobacco products. Because moderate evidence for increased concentrations of those who smoked e-cigarettes have only been marketed and in adolescents conventional cigarettes.47 FDA- for ∼10 years and because the who use e-cigarettes and an approved nicotine-replacement products are rapidly changing, association with e-cigarette use therapy increases serum nicotine scientific data are limited and will andanincreaseinasthma 3 concentrations gradually and at lower continue to emerge. Because exacerbations.” e-cigarette solutions and emissions levels than cigarettes, thus decreasing 48 have been shown to contain nicotine The comparison, when considering addiction potential. and many of the same harmful potential health effects for youth and toxicants and carcinogens as adults who do not use tobacco, There are concerns for adverse cigarettes, it is reasonable to assume should always be clean air, not health effects of nicotine, although that there is the potential for similar cigarette use. Thus, the guiding the majority of and disease principle should be that e-cigarette from tobacco products are secondary health effects for e-cigarette use, 46,49 particularly with emerging data of use is harmful for the short- and long- to toxicants other than nicotine. tobacco exposure found term health of youth until proven Studies support that nicotine among e-cigarette users. A otherwise. Further studies are needed dependence affects the areas of population-based adult to better characterize the health the brain that control executive revealed that exclusive e-cigarette effects of e-cigarettes on youth and function, memory, and mood, and users had higher urine concentrations adults. nicotine has been shown to have neurodevelopmental effects in of nicotine, metals, volatile organic Nicotine: Health Effects and compounds (VOCs), and tobacco- children with prenatal cigarette Addiction Potential 49 specific nitrosamines compared with exposure. In the NAS report, it fi “ nontobacco users.41 In addition, this Speci c to youth, nicotine addiction was concluded that exposure to same study showed that e-cigarette and dependence leading to lifelong nicotine from e-cigarettes likely users had concentrations of metals tobacco use is a major concern when elevates the risk in people with and VOCs (, , and considering e-cigarette use. Ninety preexisting cardiovascular carbon disulfide) comparable with percent of adult cigarette smokers disease(s), but the risk in people those of cigarette smokers, with dual began smoking before the age of without (s) ”3 users having the highest levels of 18 years, and the adolescent brain is is uncertain. It was also concluded nicotine and other tobacco more susceptible to nicotine that there is plausibility that biomarkers, metals, and VOCs.41 addiction even with intermittent nicotine can act as a tumor promoter, exposure.22 Nicotine is an ingredient but the evidence suggests it is In the National Academy of Sciences, in most e-cigarette solutions and is unlikely to increase the incidence of Engineering, and Medicine (NAS) the primary ingredient in tobacco cancers.3

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 143, number 6, June 2019 5 Youth Progression to Conventional PUBLIC HEALTH IMPLICATIONS Researchers have disproved claims by Cigarettes, Other Substances of e-cigarette manufacturers that Renormalization of Tobacco-Product Abuse, and Risky Behaviors e-cigarette are only water Use The Surgeon General estimates vapor, glycerol, and PG and can be that 5.6 million of today’syouth Adult and youth use of tobacco used safely in all environments. will die prematurely of a smoking- products has gradually decreased Investigators have shown that indoor related illness.46 One of the most over the past 50 years, in part related nicotine, fine and ultrafine particulate concerning aspects of youth use to a culture that has denormalized the matter, polycyclic aromatic of e-cigarettes is the well-described use of traditional tobacco products hydrocarbons, metals (aluminum), trajectory to use of conventional such as conventional cigarettes. Many and some volatile inorganic cigarettes. In a meta-analysis of youth do not recognize that compounds rise after vaping 61–63 9 studies by Soneji et al,50,51 e-cigarettes contain nicotine and occurs. Particulate matter at the authors concluded that therefore may not understand the vaping conventions reaches a level 57,58 adolescents who use e-cigarettes addictive potential of e-cigarettes. 12 times higher than that of the US are3.5timesmorelikelyto A quick Internet search reveals Environmental Protection Agency 24- 64 initiate conventional cigarette a myriad of videos demonstrating the hour standard. Airborne articulate smoking than those who do not ways e-cigarettes are used by matter and nicotine levels at vaping “ use e-cigarettes. Two additional adolescents and young adults. Cloud conventions were comparable with ”“ ” studies published in 2018 from chasing, stealth vaping, and those found at bars and nightclubs “ ” the PATH survey revealed that dripping are popular terms. where combustible smoking is the odds of 30-day cigarette use at Dripping involves dripping the allowed. In addition, volatile the 1-year follow-up was almost e-cigarette solution directly onto the inorganic compound and carbon twice as high (odds ratio 1.87) heating coil to inhale the vapor dioxide levels were markedly for youth who had “ever used” directly. One in 4 adolescents elevated. Thirdhand aerosol exposure e-cigarettes at baseline, and reported using their e-cigarettes for to nicotine has also been identified 59 e-cigarette use was associated with dripping. after vaping with the accumulation of current established cigarette nicotine on surfaces and clothing, E-cigarette Secondhand and smoking.52,53 measured by wipe sampling after the Thirdhand Aerosol vaping session. Surface nicotine on Multiple studies have revealed an The secondhand aerosol emitted by clothing was measurable both on the association between adolescent e-cigarettes (known commonly as person who vaped and on nonusers e-cigarette use and other substance vapor) into the environment is after the vaping session.63 use, including alcohol, marijuana, different from that of conventional and amphetamines, as well as other cigarettes because it is directly It is of particular concern that both risky behaviors, which are inhaled from the device without the fine and ultrafine particulate matter consistently greatest among dual generation of sidestream . can be found in indoor air after usersofe-cigarettesand Thus, the aerosol emitted into the a vaping session because these conventional cigarettes.36,54,55 Risky environment from e-cigarettes is particles can be inhaled into the behaviors include violent behaviors almost 100% mainstream. lungs and can enter the systemic (fighting and attempting suicide), Additionally, the composition of circulation, leading to inflammation sexual risk behaviors (current sexual aerosols emitted from combustible and potential cardiovascular disease. activity and lifetime partners), and and noncombustible devices differs. However, information on health risks school-related behaviors (truancy Secondhand contains asaresultofexposuretoe-cigarette and lower grade point average). The solid and semisolid materials, emissions is limited. Using an animal PATH survey also revealed whereas e-cigarette aerosol is mostly model of e-cigarette exposure, longitudinally that e-cigarette use composed of small liquid droplets.3 McGrath-Morrow et al65 was associated with subsequent Secondhand aerosol from e-cigarettes demonstrated that neonatal mice youth use of other substances of contains significantly different levels that were exposed to e-cigarette abuse.56 This association was of harmful chemicals depending on vapor (both PG alone and with strongest for marijuana and the device and the voltage used as nicotine) had impaired growth nonprescribed Ritalin and/or well as the vaping patterns.60 compared with control mice. Adderall but was noted for alcohol Thirdhand aerosol is the nicotine and Additionally, mice exposed to and all other (excluding toxicants that are present in the e-cigarette vapor showed poor lung nonprescribed painkillers and/or environment and surfaces after the development, with decreased sedatives).56 e-cigarette has been used.1 development of alveoli.65

Downloaded from www.aappublications.org/news by guest on September 28, 2021 6 WALLEY et al In the NAS report, it was concluded that “e-cigarettes can contribute to substantial air pollution, especially in places with large number of e-cigarette users”; it was additionally stated that “[t]here is conclusive evidence that e-cigarette use increases airborne concentrations of particulate matter and nicotine in indoor environments compared with background levels.”3

Poisonings and Other Unintended Injuries Injuries from both unintentional exposure to e-cigarette solutions as well as to the e-cigarette device have been reported. E-cigarette liquid nicotine exposures, mainly from ingestions, have increased by 1085% from 2012 to 2016, although exposures have decreased from their highest rate in 2015.66 This decrease may be, in part, related to education as well as the Child Prevention Act of 2015, FIGURE 5 which required that nicotine- FDA warning of e-cigarette products with labels similar to juice and candy. (Adapted from US Food and Drug Administration. E-liquids misleadingly labeled or advertised as food products. Available at: containing e-cigarette solutions be https://www.fda.gov/TobaccoProducts/NewsEvents/ucm605729.htm. Accessed November 28, 2018.) sold in child-resistant packaging. The high concentrations of nicotine in some e-cigarette solutions can cause may be effective aids to promote 2022. The deeming rule does not health effects for children at small .”3 The American address marketing, flavors, or volumes and have resulted in 1 child Academy of Pediatrics (AAP) and regulation of the e-cigarette devices death.1 The lithium batteries used in other medical organizations nor regulate e-cigarette batteries. many e-cigarette devices can explode, recommend that adults dependent on There are an estimated and the explosions have resulted in tobacco use evidence-based 15 000 e-cigarette flavors, including severe burns and fires.3 treatments, which include FDA- products with labels enticing to approved pharmacotherapy.68 children and adolescents that imitate E-cigarettes Are Not FDA-Approved cookies, whipped cream, alcoholic for Adult Smoking Cessation beverages, and other dessert flavors. As of this publication date, there are FEDERAL AND STATE REGULATION Products such as One Mad Hit Juice no e-cigarette products that are FDA- In 2016, with its “deeming rule,” the Box imitate a juice box, with labels approved smoking cessation FDA extended its authority to that contain such statements as “A treatments. A recent meta-analysis of e-cigarettes and other tobacco Juicebox a Day Keeps the Doctor 26 studies in real-world settings and products, including cigars.69 As of this Away,” and the Candy King Batch and clinical trials revealed that adult publication date, aspects of the Candy King Sour Worms label smokers who use e-cigarettes for deeming rule that have been imitates that of the popular the Sour smoking cessation are 27% less likely implemented include prohibiting Patch Kids candy (Fig 5). in to stop smoking than smokers who do sales to children ,18 years of age tobacco products have been known not use e-cigarettes.67 The NAS and adding health warning labels. for decades to promote youth use, concluded that there are potential Implementation of other regulations and thus characterizing flavors (with health benefits for conventional under the deeming rule has been the exception of menthol) were cigarette users who completely suspended, including premarket banned from conventional cigarettes switch to e-cigarettes and that “there review of new e-cigarette solutions, in 2009 by the Family Smoking is limited evidence that e-cigarettes and would not take full effect until Prevention and Act.

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 143, number 6, June 2019 7 In December 2018, in part because Public Policy Recommendations adolescents and young adults quit of the rapid rise in use from In this section, we present concrete e-cigarette addiction. 2017 to 2018, the US Surgeon objectives for advocacy that may help Objective 5 General called youth e-cigarette to control the e-cigarette public use an epidemic and called for health crisis. Increase tobacco retail-licensing fees action to protect child health. to help cover the cost of enforcement. This was preceded in 2018 by Objective 1 Increase taxes on tobacco products; the FDA announcing efforts to adolescents are more price sensitive, restrict youth access to e-cigarettes Support strong T21 legislation, which so increasing prices will decrease through efforts targeted at retailers has the potential to severely limit adolescent initiation and subsequent and online sales of e-cigarettes tobacco-product use (including addiction. as well as some restrictions of e-cigarettes) in adolescents because Objective 6 flavored tobacco products. almost no high schoolers will be of These actions are being followed legal age. Building partnerships Ban all flavored tobacco products, closely by the AAP and other among pediatricians, community including mint and menthol. child health advocates because members, youth leaders, tobacco- control groups, departments of public the rapid rise in youth use has CONCLUSIONS revealed that previous policies were health, and local politicians has The e-cigarette is the most insufficient. Many states and local shown promise in building the common tobacco product used by governments have implemented political will needed to disseminate, youth, exposing users to nicotine, ordinances that include e-cigarettes improve, and enforce T21 regulations. toxicants, and ultrafine particles, in comprehensive smoke and which have the potential to lead to tobacco bans. In addition, 6 states Objective 2 nicotine addiction and harmful and hundreds of cities at the time of Develop free continuing medical health effects. In 2018, e-cigarettes this publication have implemented education programming for clinicians were used by 3.6 million middle and (T21), which refers to to ensure that child health care high school students, and the raising the minimum age of sale of providers have the tools and popularity of newer e-cigarette tobacco products, including strategies to inoculate against 70 brands, such as JUUL, with sleek e-cigarettes, to 21 years of age. corporate marketing that attracts designs and higher nicotine youth to use nicotine products as concentrations is a public health early as middle school. crisis. RECOMMENDATIONS FOR PEDIATRICIANS AND PEDIATRIC HEALTH Objective 3 CARE WORKERS Conduct research to track and ABBREVIATIONS Clinical Recommendations evaluate e-cigarette use and AAP: American Academy of prevention strategies at the middle The AAP policy statement “Electronic Pediatrics school, high school, and college Nicotine Delivery Systems” e-cigarette: electronic cigarette campuses where e-cigarette use recommends that pediatric health e-liquid: electronic cigarette liquid propagates. Conduct research on care providers screen for e-cigarette FDA: Food and Drug policy and regulatory enforcement use when screening for tobacco use Administration strategies to prevent youth access to and tobacco-smoke exposure.1 For MTF: Monitoring the Future e-cigarette products in the retail youth, prevention is crucial with NAS: National Academy of environment. strong messages to avoid tobacco Sciences, Engineering, and use (including e-cigarettes), and Medicine Objective 4 for youth using tobacco products, NHIS: National Health Interview clinicians should recommend Research and disseminate effective Survey evidence-based tobacco-use tobacco-control messaging and NYTS: National Youth Tobacco treatment.68 For parents and educational content for parents, Survey caregivers who use tobacco, the AAP teachers, and students. Develop PATH: Population Assessment of clinical practice policy recommends treatment strategies and programs Tobacco and Health that pediatricians offer tobacco-use for the adolescents who are current PG: propylene glycol treatment to address tobacco use users of e-cigarettes and JUUL-type T21: Tobacco 21 and eliminate tobacco-smoke products. Currently, no evidence- VOC: volatile organic compound exposure.68 based programs exist to help

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2019/05/21/peds.2 018-2741 References This article cites 54 articles, 13 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2019/05/21/peds.2 018-2741#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Substance Use http://www.aappublications.org/cgi/collection/substance_abuse_sub Public Health http://www.aappublications.org/cgi/collection/public_health_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 28, 2021 A Public Health Crisis: Electronic Cigarettes, Vape, and JUUL Susan C. Walley, Karen M. Wilson, Jonathan P. Winickoff and Judith Groner Pediatrics originally published online May 23, 2019;

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