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,