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

abstractElectronic cigarettes (e-cigarettes) and vape devices have rapidly become themost common tobacco products used by youth, driven in large part bymarketing and advertising by e-cigarette companies. There is substantialevidence that adolescent e-cigarette use leads to use of combustible tobaccoproducts. E-cigarette companies commonly advertise that e-cigarettes containnicotine, flavoring chemicals, and humectants (propylene glycol and/orvegetable glycerin), but toxicants, ultrafine particles, and carcinogens havealso been found in e-cigarette solutions and emissions, many of which areknown to cause adverse health effects. Most major e-cigarette brands areowned by big tobacco companies that use similar marketing and advertisingstrategies to attract youth users as they did with traditional tobacco products.In this review, we provide an overview of e-cigarettes and vape devices withan emphasis on the impact for the pediatric population. We describe the vastarray of e-cigarette devices and solutions, concern for nicotine addiction, andthe scientific background on the known health harms. There areaccompanying visual depictions to assist in identifying these products,including newer e-cigarette products and JUUL. Because current federalregulations are insufficient to protect youth from e-cigarette use, exposure,and nicotine addiction, there are recommendations for pediatricians andpediatric health care providers to counsel and advocate for a tobacco-freelifestyle for patients and families.

DEFINITIONS

Combustible tobacco product: Atobacco product that involves theburning of the tobacco leaf forinhalation. This includesconventional cigarettes, cigars,cigarillos, hookahs, and pipe tobacco.

Electronic cigarette (e-cigarette)aerosol: Although often referred to asvapor, the emission of an e-cigaretteis more accurately described as anaerosol, a suspension of particlesin gas.

Secondhand aerosol: The emissionsof e-cigarettes that nonusingbystanders are exposed to,mainly from what is exhaledby the user during use of theproduct.

Thirdhand aerosol: The nicotine andtoxicants that are present in theenvironment, mainly on surfaces,from the emissions of an e-cigaretteafter use.

JUUL: A brand name of an e-cigarettethat is shaped like a flash drive, hasprefilled cartridges (“pods”) withsolutions that contain a highconcentration of nicotine, and isavailable in many youth-appearingflavors.

E-cigarettes and vape devices arehandheld devices designed to deliveremissions for inhalation by heatinga solution that commonly containsnicotine, a humectant, and flavoringchemicals. For the purpose of thisreview, the term “e-cigarette” will be

aDivision of Pediatric Hospital Medicine, The University ofAlabama at Birmingham and Children’s of Alabama,Birmingham, Alabama; bDivision of General Pediatrics, IcahnSchool of Medicine at Mount Sinai and Mount Sinai KravisChildren’s Hospital, New York, New York; cDivision of GeneralAcademic Pediatrics, Harvard Medical School andMassachusetts General Hospital, Boston, Massachusetts;and dDivision of Primary Care, College of Medicine, The OhioState University and Nationwide Children’s Hospital,Columbus, Ohio

Dr Walley conceptualized and drafted the initialmanuscript and reviewed the final manuscript; DrsWilson, Winickoff, and Groner assisted inconceptualizing and drafting the initial manuscriptand reviewed the final manuscript; and all authorsapproved the final manuscript as submitted.

DOI: https://doi.org/10.1542/peds.2018-2741

Accepted for publication Jan 7, 2019

Address correspondence to Susan C. Walley, MD,CTTS, The University of Alabama at Birmingham,Children’s of Alabama, 1600 7th Ave South, McWaneSuite 108, Birmingham, AL 35233. E-mail: swalley@peds.uab.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,1098-4275).

Copyright © 2019 by the American Academy ofPediatrics

FINANCIAL DISCLOSURE: The authors have indicatedthey have no financial relationships relevant to thisarticle to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors haveindicated they have no potential conflicts of interestto disclose.

To cite: Walley SC, Wilson KM, Winickoff JP, et al. APublic Health Crisis: Electronic Cigarettes, Vape,and JUUL. Pediatrics. 2019;143(6):e20182741

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used; however, these devices aremore commonly referred to by thepublic and users as vapes, podsystems, mods, and tanks as well asby brand names such as JUUL. In thescientific literature, e-cigarettes arecommonly referred to as electronicnicotine delivery systems. Becausethey commonly contain nicotine,which is derived from the tobaccoplant, e-cigarettes are tobaccoproducts.1

The awareness, marketing,advertising, and use of e-cigaretteshave dramatically increasedsince their introduction intothe US marketplace. The e-cigarettewas introduced into the US marketfrom China around 2006, where itwas patented as an “electronicatomizing cigarette.”2,3 By 2010,there were several brands ofe-cigarettes that were sold in USmarkets.2 In 2011, e-cigarettes wereadded to the National YouthTobacco Survey (NYTS) on tobacco-product use, and since 2014, thee-cigarette has been the mostfrequently used tobacco productby youth.4

E-CIGARETTE DEVICES ANDCONSTITUENTS

Basic Operation

Part of the difficulty in the researchand regulation of e-cigarettes is thediversity and rapid change innomenclature, design, and technology,not only of the devices but also in thee-cigarette solution. Despite thisvariation, the majority of theseproducts have similar designcharacteristics, which include thefollowing components (Fig 1):

1. a mouthpiece;

2. a sensor or user-actuated buttonto activate the heating coil (seen inFig 1);

3. a battery;

4. a heating coil or atomizer; and

5. a reservoir or tank.

When a user inhales from themouthpiece, the heating coil isactivated to aerosolize the e-cigarettesolution to form an emission,which is best described as anaerosol but is commonly calleda vapor. A video clip showing theuse of an e-cigarette can be foundonline.5

There have been substantial changesand evolution of e-cigarettes, andthus e-cigarette devices have oftenbeen described as first-, second-, and

third-generation products to assist indescribing their wide variability(Fig 2). The first-generatione-cigarette products usually have theappearance of a cigarette and arereferred to as “cigalikes.” First-generation e-cigarettes are oftendisposable or have a reloadablecartridge for repeated uses. Second-generation e-cigarettes are known asvapes or vape pens and havea refillable reservoir for the electroniccigarette liquid (e-liquid). Third-generation e-cigarettes are frequentlyreferred to as “mods” or tank systemsbecause the wattage and voltage canbe modified. More recently, there hasbeen a wave of products that bear noresemblance to traditional cigarettesor even previous generations ofe-cigarettes, which, for purposes ofthis review, will be referred to asfourth-generation e-cigarettes.Fourth-generation products aresold under the names JUUL (Fig 3),Suorin, and SMPO.

E-cigarette Solution

E-cigarette solutions, often known ase-juice or e-liquid, are even morediverse than the devices. Thesolutions are commonly advertised ascontaining 3 types of chemicals:a humectant, nicotine, and flavors.2

The 2 humectants used most often

FIGURE 1E-cigarette components. (Adapted from E-Cigarette Use Among Youth and Young Adults: A Report ofthe Surgeon General. US Department of Health and Human Services; Centers for Disease Control andPrevention; National Center for Chronic Disease Prevention and Health Promotion; Office on Smokingand Health. Atlanta, GA: US Department of Health and Human Services; 2016:12.)

FIGURE 2E-cigarette design variability. Seen on the farleft is a conventional cigarette. The earliere-cigarettes (first generation) have a similarshape as a conventional cigarette (second,third, and fourth from the left). The second-generation e-cigarettes (fifth and sixth fromthe left) have refillable clear reservoirs forthe e-liquid and are often known as vapepens. The third-generation e-cigarettes (farright) often have the ability to modify wattageand voltage and are thus known as mods.

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are propylene glycol (PG) andvegetable glycerin; both are generallyrecognized as safe for ingestion,but there is little evidence abouttheir safety for long-term inhalation.The majority of e-cigarette solutionsare advertised as containing nicotine;the nicotine concentration can vary,both in the reported concentrationand in the actual concentration asmeasured by gas chromatography.6

There are also some e-liquidsthat are advertised as 0% nicotine.E-cigarette solutions are oftenlabeled with concentrationsbetween 0 and 24 mg/mL of nicotine,but more recently, the e-cigarettebrand JUUL has an e-cigarettesolution containing benzoic acidand a much higher advertisednicotine concentration of 59 mg/mL.7

Typical nicotine absorption froma conventional cigarette is 1 mg(range 0.3–2 mg), with bloodnicotine levels ranging from anaverage of 15 to 30 ng/mL.8,9

Most brands of e-cigarette solutionsare available in a variety of youth-appealing flavors ranging fromfruits, desserts, candy, and sodato traditional tobacco. Mentholis a common compound found inboth mint- and tobacco-flavorede-cigarette solutions.6 An analysis ofcoffee- and chocolate-flavorede-cigarette solutions revealed that42% of coffee-flavored liquids and50% of chocolate-flavored liquidscontained detectable caffeine levels.10

Glucose, fructose, and sucroselevels were also detected in 22% to53% of a set of e-liquid samples.11

Other substances, such as marijuanaand methamphetamine, can also bevaped from some e-cigarettedevices.12

JUUL and Other Vaping Products

JUUL is a brand of e-cigarettethat has recently received significantmedia attention because of itsrapid uptake by adolescents.13

Part of the appeal of JUUL isthe small sleek shape and theability to use the devicesurreptitiously. The JUUL devicelooks like a flash drive (Fig 3) andis rechargeable via a USB port.7

Educators report that teenagerscovertly use the product duringschool, even in the classroom.13

Rather than vaping, JUUL usersare said to be “JUULing,” andthe Internet is full of videos ofadolescents using JUUL. Thedevice uses prefilled cartridgescalled pods that contain 0.7 mLof solution unique to JUUL.7 Inaddition to PG and glycerol, thepod is advertised to contain benzoicacid (a naturally occurring acidfound in the tobacco plant) andnicotine.7 As of August 2018, JUULadvertises pods with 2 nicotineconcentrations of 5% (59 mg/mL)and 3% (35 mg/mL).7 Each pod ismarketed as equivalent to ∼1 packof cigarettes (ie, 200 puffs), andpods are sold in multiple youth-appealing flavors, including mango,fruit medley, crème (brûlée), mint,and cucumber.

The evidence of JUUL’s recentincrease in popularity isdemonstrated by sales data thatrevealed that in August 2018,JUUL sales were 72.1% of the marketshare of the US e-cigarette market,compared with 13.6% in the firstquarter of 2017.14,15 A JUUL starterkit can be purchased for $49.99,which includes the device witha charging dock and 4 JUUL pods.16

Additional JUUL pods can bepurchased in packs of 4 for$15.99.17The JUUL website reportstheir mission is to "improve the livesof the world's one billion adultsmokers by eliminating cigarettes."18

They state on their Web site that theydo not sell to youth ,21 years of age;however, previous marketingcampaigns were clearly targeted ata youthful demographic, and theflavors are appealing to youth. InDecember 2018, JUUL sold a 35%stake to the tobacco company Altria,formerly known as Philip Morris, for$13 billion, evoking additionalconcerns about the company’sstrategy to address use byteenagers.19

MARKETING, ADVERTISING, AND SALES

The tobacco industry has longbeen known to use deceptivemarketing and advertising totarget certain populations, includingyouth and minorities.20 Althoughproduct marketing refers toa company’s strategy to brandtheir product, the term “promotion”refers to advertising in mainstreammedia, including the Internet,television, magazines, social mediachannels, direct-to-consumermarketing, and point-of-saleadvertisements.2 Point of sale refersto advertisements that are visiblearound the time of purchase andaccounts for the majority of theadvertising dollars tobaccocompanies spend.21 It iswell established that marketingand promotional activities bytobacco companies increaseyouth and young adult tobaccoinitiation and usage.22 Televisionadvertisements for cigaretteswere banned in 1971; however,78% of middle and high schoolstudents in 2016 had seena television advertisement fore-cigarettes.23 Studies have revealedthat youth who are exposed toadvertisements are more likely touse e-cigarettes.24–26

FIGURE 3JUUL and JUUL pods.

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E-cigarettes are sold in multiplevenues, including in vape shops,grocery and convenience stores, gasstations, and on the Internet.1 Themajority of underaged sales oftobacco products occur in the retailenvironment, in which enforcementof age at purchase is largely theresponsibility of the retailer.27,28

Internet sales are also a majorconcern regarding youth access toe-cigarettes because of the difficultywith regulation and the number ofonline retailers.29 In a review ofonline e-cigarette brands, 433 distinctsites were found, 12 of which wereowned by tobacco companies.30

EPIDEMIOLOGY OF E-CIGARETTE USE

The ubiquitous marketing, promotion,and sales of e-cigarettes have been

effective, with dramatic increases inyouth e-cigarette use.1 Between 2011and 2015, the NYTS revealed that UScurrent use among high schoolstudents (use on $1 days during thepast 30 days) increased 966% from1.5% to 16% (Fig 4).4,31 After a 2-year period between 2015 and 2017in which there was an overall declinein youth use, there was a sharp 78%increase in current use among highschool students to 20.8% from 2017to 2018.32 Accounting for a currentuse among middle school students of4.9%, this represents 3.62 millionyouth e-cigarette users.32 Anothernational survey, Monitoring theFuture (MTF) has trended youthsubstance use over the past 44 years,including e-cigarette use since2015.33 The MTF has revealed similartrends in e-cigarette use, including

a sharp increase in 2018, with 25% of12th-graders and 20.3% of 10th-graders using vaped nicotine orflavoring (compared with 15.2% and12%, respectively, in 2017).34 Theincrease in e-cigarette use among10th- and 12th-graders from 2017 to2018 represents the largest increaseof any substance the MTF survey hasrecorded in its 44 years.34 Despitethese dramatic increases, manyexperts express concern thate-cigarette use may beunderestimated because of surveylimitations.

Survey results have also revealed thatmany youth use e-cigarettes withother tobacco products, which isknown as dual use. During the periodof 2015–2017, the NYTS revealed that76.7% of middle and high schoolstudents who used e-cigarettes usedanother tobacco product.35 The YouthRisk Behavior Survey from 2015revealed that whereas 15.8% of highschool students used onlye-cigarettes, 7.5% were dual users ofe-cigarettes and conventionalcigarettes.36

Adult US patterns of e-cigarette andtobacco use are different because theconventional cigarette remains themost common tobacco product usedamong those aged 18 years andolder.37 On the basis of the 2017National Health Interview Survey(NHIS), current adult use ofe-cigarettes is 2.8%, whereas use ofcigarettes is 14%.37 However, thereare statistically higher rates of usedepending on age and other tobaccouse. Among younger age groups in theNHIS, adults aged 18 to 24 years hadthe highest rates of e-cigarette use,with 5.2% reporting “every day” or“some days” use.38 The MTF survey in2017 revealed higher rates of currente-cigarette use at 11.3% amongyounger adults (ages 19–30 years),with use among 19- to 20-year-oldsat 13%.33 However, the highest rates,of adult e-cigarette use are amongcurrent and former working adultcigarette users, with rates of 15.9%

FIGURE 4Percentage of middle and high school students who currently use e-cigarettes and any tobacco-products based on NYTS 2011–2018. (Reprinted from Cullen KA, Ambrose BK, Gentzke AS, ApelbergBJ, Jamal A, King BA. Notes from the field: use of electronic cigarettes and any tobacco productamong middle and high school students - United States, 2011-2018. MMWR Morb Mortal Wkly Rep.2018;67(45):1276.)

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and 22%, respectively, in the NHIS.38,39

The Population Assessment ofTobacco and Health (PATH) studyrevealed that 5.5% of adults werecurrent e-cigarette users in2013–2014, with 70% of e-cigaretteusers reporting dual use withcigarettes.40

HEALTH HARMS OF E-CIGARETTE USE

More than 50 years after the initialSurgeon General landmark report,“Smoking and Health: Report of theAdvisory Committee to the SurgeonGeneral of the Public Health Services,”and 30 years after “The HealthConsequences of InvoluntarySmoking,” there continue to be newdiscoveries on health harms relatedto conventional cigarettes andtraditional tobacco products. Becausee-cigarettes have only been marketedfor ∼10 years and because theproducts are rapidly changing,scientific data are limited and willcontinue to emerge. Becausee-cigarette solutions and emissionshave been shown to contain nicotineand many of the same harmfultoxicants and carcinogens ascigarettes, it is reasonable to assumethat there is the potential for similarhealth effects for e-cigarette use,particularly with emerging data oftobacco toxicant exposure foundamong e-cigarette users. Apopulation-based adult cohort studyrevealed that exclusive e-cigaretteusers had higher urine concentrationsof nicotine, metals, volatile organiccompounds (VOCs), and tobacco-specific nitrosamines compared withnontobacco users.41 In addition, thissame study showed that e-cigaretteusers had concentrations of metalsand VOCs (toluene, benzene, andcarbon disulfide) comparable withthose of cigarette smokers, with dualusers having the highest levels ofnicotine and other tobaccobiomarkers, metals, and VOCs.41

In the National Academy of Sciences,Engineering, and Medicine (NAS)

report “The Public HealthConsequences of E-Cigarettes,” it wasconcluded that there is not adequateresearch to predict long-term healthoutcomes but that there is sufficientevidence that use of e-cigarettes cancause acute endothelial dysfunction,oxidative stress, symptoms ofdependence, and an increase in heartrate and that chemicals in e-cigarettescan cause DNA damage andmutagenesis.3 There is evidence of anincrease in blood pressure (systolicand diastolic) after use of nicotine-containing e-cigarettes.3

In addition, there is also a growingbody of evidence of the respiratoryeffects of e-cigarette use for thee-cigarette user, particularly foradolescents with asthma.42–44 TheNAS reportconcludes that “[t]here ismoderate evidence for increasedcough and wheeze in adolescentswho use e-cigarettes and anassociation with e-cigarette useand an increase in asthmaexacerbations.”3

The comparison, when consideringpotential health effects for youth andadults who do not use tobacco,should always be clean air, notcigarette use. Thus, the guidingprinciple should be that e-cigaretteuse is harmful for the short- and long-term health of youth until provenotherwise. Further studies are neededto better characterize the healtheffects of e-cigarettes on youth andadults.

Nicotine: Health Effects andAddiction Potential

Specific to youth, nicotine addictionand dependence leading to lifelongtobacco use is a major concern whenconsidering e-cigarette use. Ninetypercent of adult cigarette smokersbegan smoking before the age of18 years, and the adolescent brain ismore susceptible to nicotineaddiction even with intermittentexposure.22 Nicotine is an ingredientin most e-cigarette solutions and isthe primary ingredient in tobacco

products that causes addiction.45

Nicotine’s primary psychoactiveactions are related to its binding tothe nicotine cholinergic receptor inthe brain to release dopamine, whichis part of the pathway involved indrug-induced reward.7,46 Nicotineaddiction is an adaption to nicotineexposure over time, and thus the highconcentrations of nicotine ine-cigarettes are of major concern.Studies of e-cigarette use haverevealed that, depending on durationof use and user puffing topography,serum levels of nicotine can be ashigh with e-cigarette use as with useof a conventional cigarette.3 In 1study, the urinary cotinineconcentrations (a biomarker fornicotine exposure) amongadolescents using JUUL was evenhigher than the urinary cotinineconcentrations of those who smokedconventional cigarettes.47 FDA-approved nicotine-replacementtherapy increases serum nicotineconcentrations gradually and at lowerlevels than cigarettes, thus decreasingaddiction potential.48

There are concerns for adversehealth effects of nicotine, althoughthe majority of death and diseasefrom tobacco products are secondaryto toxicants other than nicotine.46,49

Studies support that nicotinedependence affects the areas ofthe brain that control executivefunction, memory, and mood, andnicotine has been shown to haveneurodevelopmental effects inchildren with prenatal cigaretteexposure.49 In the NAS report, itwas concluded that “exposure tonicotine from e-cigarettes likelyelevates the risk in people withpreexisting cardiovasculardisease(s), but the risk in peoplewithout cardiovascular disease(s)is uncertain.”3 It was also concludedthat there is plausibility thatnicotine can act as a tumor promoter,but the evidence suggests it isunlikely to increase the incidence ofcancers.3

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Youth Progression to ConventionalCigarettes, Other Substances ofAbuse, and Risky Behaviors

The Surgeon General estimatesthat 5.6 million of today’s youthwill die prematurely of a smoking-related illness.46 One of the mostconcerning aspects of youth useof e-cigarettes is the well-describedtrajectory to use of conventionalcigarettes. In a meta-analysis of9 studies by Soneji et al,50,51

the authors concluded thatadolescents who use e-cigarettesare 3.5 times more likely toinitiate conventional cigarettesmoking than those who do notuse e-cigarettes. Two additionalstudies published in 2018 fromthe PATH survey revealed thatthe odds of 30-day cigarette use atthe 1-year follow-up was almosttwice as high (odds ratio 1.87)for youth who had “ever used”e-cigarettes at baseline, ande-cigarette use was associated withcurrent established cigarettesmoking.52,53

Multiple studies have revealed anassociation between adolescente-cigarette use and other substanceuse, including alcohol, marijuana,and amphetamines, as well as otherrisky behaviors, which areconsistently greatest among dualusers of e-cigarettes andconventional cigarettes.36,54,55 Riskybehaviors include violent behaviors(fighting and attempting suicide),sexual risk behaviors (current sexualactivity and lifetime partners), andschool-related behaviors (truancyand lower grade point average). ThePATH survey also revealedlongitudinally that e-cigarette usewas associated with subsequentyouth use of other substances ofabuse.56 This association wasstrongest for marijuana andnonprescribed Ritalin and/orAdderall but was noted for alcoholand all other drugs (excludingnonprescribed painkillers and/orsedatives).56

PUBLIC HEALTH IMPLICATIONS

Renormalization of Tobacco-ProductUse

Adult and youth use of tobaccoproducts has gradually decreasedover the past 50 years, in part relatedto a culture that has denormalized theuse of traditional tobacco productssuch as conventional cigarettes. Manyyouth do not recognize thate-cigarettes contain nicotine andtherefore may not understand theaddictive potential of e-cigarettes.57,58

A quick Internet search revealsa myriad of videos demonstrating theways e-cigarettes are used byadolescents and young adults. “Cloudchasing,” “stealth vaping,” and“dripping” are popular terms.Dripping involves dripping thee-cigarette solution directly onto theheating coil to inhale the vapordirectly. One in 4 adolescentsreported using their e-cigarettes fordripping.59

E-cigarette Secondhand andThirdhand Aerosol

The secondhand aerosol emitted bye-cigarettes (known commonly asvapor) into the environment isdifferent from that of conventionalcigarettes because it is directlyinhaled from the device without thegeneration of sidestream smoke.Thus, the aerosol emitted into theenvironment from e-cigarettes isalmost 100% mainstream.Additionally, the composition ofaerosols emitted from combustibleand noncombustible devices differs.Secondhand tobacco smoke containssolid and semisolid materials,whereas e-cigarette aerosol is mostlycomposed of small liquid droplets.3

Secondhand aerosol from e-cigarettescontains significantly different levelsof harmful chemicals depending onthe device and the voltage used aswell as the vaping patterns.60

Thirdhand aerosol is the nicotine andtoxicants that are present in theenvironment and surfaces after thee-cigarette has been used.1

Researchers have disproved claims bye-cigarette manufacturers thate-cigarette aerosols are only watervapor, glycerol, and PG and can beused safely in all environments.Investigators have shown that indoornicotine, fine and ultrafine particulatematter, polycyclic aromatichydrocarbons, metals (aluminum),and some volatile inorganiccompounds rise after vapingoccurs.61–63 Particulate matter atvaping conventions reaches a level12 times higher than that of the USEnvironmental Protection Agency 24-hour standard.64 Airborne articulatematter and nicotine levels at vapingconventions were comparable withthose found at bars and nightclubswhere combustible smoking isallowed. In addition, volatileinorganic compound and carbondioxide levels were markedlyelevated. Thirdhand aerosol exposureto nicotine has also been identifiedafter vaping with the accumulation ofnicotine on surfaces and clothing,measured by wipe sampling after thevaping session. Surface nicotine onclothing was measurable both on theperson who vaped and on nonusersafter the vaping session.63

It is of particular concern that bothfine and ultrafine particulate mattercan be found in indoor air aftera vaping session because theseparticles can be inhaled into thelungs and can enter the systemiccirculation, leading to inflammationand potential cardiovascular disease.However, information on health risksas a result of exposure to e-cigaretteemissions is limited. Using an animalmodel of e-cigarette exposure,McGrath-Morrow et al65

demonstrated that neonatal micethat were exposed to e-cigarettevapor (both PG alone and withnicotine) had impaired growthcompared with control mice.Additionally, mice exposed toe-cigarette vapor showed poor lungdevelopment, with decreaseddevelopment of alveoli.65

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In the NAS report, it was concludedthat “e-cigarettes can contribute tosubstantial air pollution, especially inplaces with large number ofe-cigarette users”; it was additionallystated that “[t]here is conclusiveevidence that e-cigarette useincreases airborne concentrations ofparticulate matter and nicotine inindoor environments compared withbackground levels.”3

Poisonings and Other UnintendedInjuries

Injuries from both unintentionalexposure to e-cigarette solutions aswell as to the e-cigarette device havebeen reported. E-cigarette liquidnicotine exposures, mainly fromingestions, have increased by 1085%from 2012 to 2016, althoughexposures have decreased from theirhighest rate in 2015.66 This decreasemay be, in part, related to educationas well as the Child NicotinePoisoning Prevention Act of 2015,which required that nicotine-containing e-cigarette solutions besold in child-resistant packaging. Thehigh concentrations of nicotine insome e-cigarette solutions can causehealth effects for children at smallvolumes and have resulted in 1 childdeath.1 The lithium batteries used inmany e-cigarette devices can explode,and the explosions have resulted insevere burns and fires.3

E-cigarettes Are Not FDA-Approvedfor Adult Smoking Cessation

As of this publication date, there areno e-cigarette products that are FDA-approved smoking cessationtreatments. A recent meta-analysis of26 studies in real-world settings andclinical trials revealed that adultsmokers who use e-cigarettes forsmoking cessation are 27% less likelyto stop smoking than smokers who donot use e-cigarettes.67 The NASconcluded that there are potentialhealth benefits for conventionalcigarette users who completelyswitch to e-cigarettes and that “thereis limited evidence that e-cigarettes

may be effective aids to promotesmoking cessation.”3 The AmericanAcademy of Pediatrics (AAP) andother medical organizationsrecommend that adults dependent ontobacco use evidence-basedtreatments, which include FDA-approved pharmacotherapy.68

FEDERAL AND STATE REGULATION

In 2016, with its “deeming rule,” theFDA extended its authority toe-cigarettes and other tobaccoproducts, including cigars.69 As of thispublication date, aspects of thedeeming rule that have beenimplemented include prohibitingsales to children ,18 years of ageand adding health warning labels.Implementation of other regulationsunder the deeming rule has beensuspended, including premarketreview of new e-cigarette solutions,and would not take full effect until

2022. The deeming rule does notaddress marketing, flavors, orregulation of the e-cigarette devicesnor regulate e-cigarette batteries.There are an estimated15 000 e-cigarette flavors, includingproducts with labels enticing tochildren and adolescents that imitatecookies, whipped cream, alcoholicbeverages, and other dessert flavors.Products such as One Mad Hit JuiceBox imitate a juice box, with labelsthat contain such statements as “AJuicebox a Day Keeps the DoctorAway,” and the Candy King Batch andCandy King Sour Worms labelimitates that of the popular the SourPatch Kids candy (Fig 5). Flavors intobacco products have been knownfor decades to promote youth use,and thus characterizing flavors (withthe exception of menthol) werebanned from conventional cigarettesin 2009 by the Family SmokingPrevention and Tobacco Control Act.

FIGURE 5FDA warning of e-cigarette products with labels similar to juice and candy. (Adapted from US Foodand Drug Administration. E-liquids misleadingly labeled or advertised as food products. Available at:https://www.fda.gov/TobaccoProducts/NewsEvents/ucm605729.htm. Accessed November 28, 2018.)

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In December 2018, in part becauseof the rapid rise in use from2017 to 2018, the US SurgeonGeneral called youth e-cigaretteuse an epidemic and called foraction to protect child health.This was preceded in 2018 bythe FDA announcing efforts torestrict youth access to e-cigarettesthrough efforts targeted at retailersand online sales of e-cigarettesas well as some restrictions offlavored tobacco products.These actions are being followedclosely by the AAP and otherchild health advocates becausethe rapid rise in youth use hasrevealed that previous policies wereinsufficient. Many states and localgovernments have implementedordinances that include e-cigarettesin comprehensive smoke andtobacco bans. In addition, 6 statesand hundreds of cities at the time ofthis publication have implementedTobacco 21 (T21), which refers toraising the minimum age of sale oftobacco products, includinge-cigarettes, to 21 years of age.70

RECOMMENDATIONS FORPEDIATRICIANS AND PEDIATRIC HEALTHCARE WORKERS

Clinical Recommendations

The AAP policy statement “ElectronicNicotine Delivery Systems”recommends that pediatric healthcare providers screen for e-cigaretteuse when screening for tobacco useand tobacco-smoke exposure.1 Foryouth, prevention is crucial withstrong messages to avoid tobaccouse (including e-cigarettes), andfor youth using tobacco products,clinicians should recommendevidence-based tobacco-usetreatment.68 For parents andcaregivers who use tobacco, the AAPclinical practice policy recommendsthat pediatricians offer tobacco-usetreatment to address tobacco useand eliminate tobacco-smokeexposure.68

Public Policy Recommendations

In this section, we present concreteobjectives for advocacy that may helpto control the e-cigarette publichealth crisis.

Objective 1

Support strong T21 legislation, whichhas the potential to severely limittobacco-product use (includinge-cigarettes) in adolescents becausealmost no high schoolers will be oflegal age. Building partnershipsamong pediatricians, communitymembers, youth leaders, tobacco-control groups, departments of publichealth, and local politicians hasshown promise in building thepolitical will needed to disseminate,improve, and enforce T21 regulations.

Objective 2

Develop free continuing medicaleducation programming for cliniciansto ensure that child health careproviders have the tools andstrategies to inoculate againstcorporate marketing that attractsyouth to use nicotine products asearly as middle school.

Objective 3

Conduct research to track andevaluate e-cigarette use andprevention strategies at the middleschool, high school, and collegecampuses where e-cigarette usepropagates. Conduct research onpolicy and regulatory enforcementstrategies to prevent youth access toe-cigarette products in the retailenvironment.

Objective 4

Research and disseminate effectivetobacco-control messaging andeducational content for parents,teachers, and students. Developtreatment strategies and programsfor the adolescents who are currentusers of e-cigarettes and JUUL-typeproducts. Currently, no evidence-based programs exist to help

adolescents and young adults quite-cigarette addiction.

Objective 5

Increase tobacco retail-licensing feesto help cover the cost of enforcement.Increase taxes on tobacco products;adolescents are more price sensitive,so increasing prices will decreaseadolescent initiation and subsequentaddiction.

Objective 6

Ban all flavored tobacco products,including mint and menthol.

CONCLUSIONS

The e-cigarette is the mostcommon tobacco product used byyouth, exposing users to nicotine,toxicants, and ultrafine particles,which have the potential to lead tonicotine addiction and harmfulhealth effects. In 2018, e-cigaretteswere used by 3.6 million middle andhigh school students, and thepopularity of newer e-cigarettebrands, such as JUUL, with sleekdesigns and higher nicotineconcentrations is a public healthcrisis.

ABBREVIATIONS

AAP: American Academy ofPediatrics

e-cigarette: electronic cigarettee-liquid: electronic cigarette liquidFDA: Food and Drug

AdministrationMTF: Monitoring the FutureNAS: National Academy of

Sciences, Engineering, andMedicine

NHIS: National Health InterviewSurvey

NYTS: National Youth TobaccoSurvey

PATH: Population Assessment ofTobacco and Health

PG: propylene glycolT21: Tobacco 21VOC: volatile organic compound

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