Electronic Cigarettes Are Another Route to Nicotine Addiction for Youth

In this issueof JAMAPediatrics, Primackandcolleagues1 show that adolescents and young adults who smoke electronic cigarettes (e-cigarettes) aremuchmore likely than thosewho had not smoked e-cigarettes to progress to traditional combustible cigarette use. Among 694 youth who were not susceptible to cigaretteuse, after 1 year, 68.8%ofe-cigaretteusers andonly 18.9%of thosewhohadnot smokede-cigarettes had smoked a traditional combustible cigarette. E-cigarettes, also called electronic nicotine delivery systems,personal vaporizers, vapepens, e-cigars, e-hookahs, or vaping devices, produce an aerosolmix of flavored liquids and nicotine that is inhaled by the user. Electronic nicotine delivery systems can resemble traditional cigarettes, cigars, pipes, or common gadgets such as flashlights, flash drives, or pens. E-cigarette use has increased rapidly in the past decade in both adolescents and adults. The Centers for Disease Control and Prevention’s recent report on e-cigarette use rates from the National Youth Tobacco Survey increased from4.5% in 2011 to 13.4% in 2014, affecting more than 2.2 million students.2 The 2009 Family Smoking Prevention and Tobacco Control Act gave the US Food and Drug Administration (FDA) authorityover cigarettes, smokeless tobaccoproducts, and loose tobacco products and authorized the Secretary of Health and HumanServices todeemother tobaccoproducts subject to the FDA’s jurisdiction. Until these products are under the FDA’s jurisdiction, therewill be no federal oversight of e-cigarettes, cigars, or other tobacco products. Most states do not have restrictions in place to protect the public’s health, or the health of children, against these products. Until e-cigarettes, cigars, andother tobacco products are deemed to beunder the FDA’s jurisdiction, the FDA has no authority to address the use of candy and fruit flavors in these products or to require liquid nicotine be packaged in childproof containers. The unnecessarydelay in regulating theseproductshasputchildrenat risk.3 Health claims frome-cigarettes are implied, including that theycanaid in smokingcessationandreduceharmfromsmoking.However, the truthdiffers from these claims.While lower levels of toxins are produced by e-cigarettes compared with traditional combustible cigarettes, both the individuals who smoke e-cigarettes and nonsmokers exposed to e-cigarette vapor are exposed to carcinogens4 aswell as toparticulate toxins, formaldehyde, acetaldehydes, and heavy metals drawn into the lungs.5,6 Animal models show fetal and newborn exposure to e-cigarette vapor results in decreased lung growth and impaired lung function7 and endothelial cell disruption.8 In addition, nicotine is not a benign drug. It is highly addictive, affects the nervous system and the cardiovascular system, and its use leads to significant withdrawal symptoms.9 Many e-cigarette devices mimic conventional cigarettes, use of e-cigarette products in public helps normalize smoking behaviors, and a lack of restrictions on advertising e-cigarettes means that a new generation of smokers is being Related article page 1018 Editorial Opinion