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AAP policy calls for reforms to combat rise in youth e-cigarette use :

January 28, 2019

E-cigarettes have exploded in popularity among teens over the last decade, making them the most common tobacco product used by youths. According to 2018 data, one in five high school students and one in 20 middle school students use e-cigarettes, a 75% increase from 2017.

As a trusted source of health information, pediatricians can educate patients and parents about the harms of these products to prevent youth initiation and guide treatment options for tobacco users. Implementation of proven population-based strategies, in coordination with Food and Drug Administration (FDA) regulation of tobacco products, is key to reducing all forms of tobacco product use, including e-cigarettes, among U.S. youths.

The updated AAP policy statement E-Cigarettes and Similar Devices summarizes the latest evidence on the health harms of e-cigarettes and supports both clinical interventions by pediatricians and policy strategies to protect youths from the epidemic of e-cigarette use. The policy, from the Section on Tobacco Control, is available at and will be published in the February issue of Pediatrics.

What is known about youths and e-cigarettes 

E-cigarettes encompass a wide variety of devices known as vapes, mods, tanks and pod systems, including popular brands like JUUL. E-cigarettes are marketed to youths by promoting the products’ sweet and fruity flavors via media channels and advertising strategies used successfully by the tobacco industry to market conventional tobacco products to youths. E-cigarette advertising is associated with current e-cigarette use by youths.

E-cigarette solutions contain numerous toxicants and carcinogens. Nicotine, the major psychoactive component of e-cigarette solution, is a highly addictive drug that can damage brain development and has been linked to adverse health outcomes. Adolescents and young adults who use e-cigarettes are at high risk of transitioning to traditional cigarettes. The increasing use of e-cigarettes among youths threatens five decades of public health gains in deglamorizing, restricting and decreasing use of tobacco products.

JUUL is a brand of e-cigarette known as a pod system with solution contained in prefilled pods. JUUL is extremely popular with adolescents and young adults and holds 70% of the market share. Its popularity is thought to be due in part to the discreet design (i.e., looks like a flash drive) and sweet flavors. The nicotine concentration in JUUL is higher than other e-cigarette brands, with each pod containing the same amount of nicotine as a pack of cigarettes.

Protecting youths 

Significant gaps remain in e-cigarette regulation. At press time, federal laws and regulations have not appropriately restricted the advertising of e-cigarettes to youths. Furthermore, child-friendly flavors are available and marketed to youths.

In November 2018, the FDA announced steps to protect young people by restricting the availability of some flavored e-cigarettes in certain locations. This was preceded by a warning letter to JUUL and other e-cigarette manufacturers in September 2018 to voluntarily take actions to curb youth appeal.

The Academy continues to advocate for stronger regulation to protect youths from e-cigarettes. Regulation, legislative action and counter promotion are critically needed to minimize the potential public health harm from e-cigarette use and help youths live tobacco-free lives.

Key actions for pediatricians 

  • Screen for e-cigarette use and exposure and provide prevention counseling in clinical practice.
  • Counsel that e-cigarettes and combustible tobacco products should be banned from homes, cars and places where children and adolescents live, learn, play, work and visit.
  • Do not recommend e-cigarettes to treat tobacco dependence.

Public policy recommendations 

  • Reduce youth access to e-cigarettes:
    • The FDA should act immediately to regulate e-cigarettes like traditional cigarettes to protect public health.
    • Ban the sale of e-cigarettes to individuals younger than 21 years.
    • Ban internet sales of e-cigarettes and e-cigarette solution.
  • Reduce youth demand for e-cigarettes:
    • Ban all flavors, including menthol, in e-cigarettes.
    • Ban all e-cigarette product advertising and promotion that are accessible to children and youths.
    • Tax e-cigarettes at rates comparable to conventional cigarettes.
  • Incorporate e-cigarettes into tobacco-free laws and ordinances where children and adolescents live, learn, play, work and visit.

Drs. Jenssen and Walley are lead authors of the policy statement. Dr. Walley is chair of the AAP Section on Tobacco Control Executive Committee, and Dr. Jenssen is the committee’s policy chair. 

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