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Electronic Nicotine Delivery Systems: A Policy Statement From the Academy of Pediatrics 

October 30, 2015  |  Falmouth Enterprise

Dr. Michael Bihari

The November 5th edition of Pediatrics, the official journal of the American Academy of Pediatrics contains a lengthy policy statement from the Academy about the use of e-cigarettes and similar devices. The article from the Academy’s Section on Tobacco Control provides an in-depth description of these products along with recommended actions for pediatricians and a set of public policy recommendations; all aimed at protecting our children from the health-related dangers of electronic nicotine delivery systems (ENDS).

The following are edited excerpts from the Academy’s ENDS Policy Statement:

Electronic nicotine delivery systems (ENDS) are rapidly growing in popularity among youth. ENDS are handheld devices that produce an aerosolized mixture from a solution typically containing concentrated nicotine and flavoring chemicals to be inhaled by the user. ENDS are sold under a variety of names, most commonly electronic cigarettes and e-cigarettes. 

In 2014, more young Americans reported using ENDS than any other tobacco product. These products pose health risks to both users and nonusers. Nicotine, the major active ingredient in ENDS solutions, is both highly addictive and toxic. In addition to nicotine, other toxins, carcinogens, and metal particles have been detected in solutions and aerosols of ENDS. People who don’t use ENDS may be exposed to the emissions of these devices with secondhand and thirdhand aerosol. (Note: secondhand aerosol are the emissions from electronic nicotine delivery systems that are discharged into the surrounding environment with the use of an ENDS device, both directly from the ENDS and exhaled from the lungs of the user. Thirdhand aerosol are ENDS emissions that remain on surfaces and in dust after ENDS use.)

The concentrated and often flavored nicotine in ENDS solutions poses a poisoning risk for young children. Reports of acute nicotine toxicity from US poison control centers have been increasing. With flavors, design, and marketing that appeal to youth, ENDS threaten to glamorize nicotine and tobacco product use. There is a critical need for ENDS regulation and legislative action to protect youth. ENDS have the potential to addict a new generation of youth to nicotine and reverse more than 50 years of progress in tobacco control.

There are more than 460 different brands of ENDS, which vary considerably in price, quality, and design. ENDS can be purchased in various retail outlets, including vendors that sell tobacco, “vape” shops, mall kiosks, gas stations, convenience stores, grocery stores, and pharmacies, as well as through Internet vendors. Locally, there are dedicated ENDS retail locations in Falmouth and Mashpee.

Youth ENDS Use

ENDS use has increased dramatically among youth. The 2014 Monitoring the Future survey documented for the first time that more teenagers used e-cigarettes in the past 30 days than any other tobacco products, including conventional cigarettes.

The increasing awareness, sales, and use of ENDS is being fueled by the marketing and promotion of ENDS in the media, including television, movies, video games, social media, the Internet, radio and print media, billboards, and point-of-sale advertising, as well as by celebrity role models. ENDS companies have marketed their products with claims of being “healthier” and “safer” than conventional cigarettes; these claims have not been scientifically validated.

More than 7760 unique flavors of ENDS solutions are advertised, the majority of which are confectionary in nature and appealing to children. Popular options include fruit, candy, and dessert flavors such as “Belgian waffle” and chocolate. Because cigarettes with candy and fruit flavoring encourage youth experimentation, regular use, and addiction, flavorings (other than menthol) have been banned in conventional cigarettes since the Family Smoking Prevention and Tobacco Control Act of 2009. Although the flavoring chemicals used in ENDS solutions have been cited as “food grade” and “generally recognized as safe,” under FDA guidelines, this certification relates only to ingestion, not inhalation. 

Nicotine Exposure

Nicotine is the major psychoactive component of an ENDS solution. Nicotine is highly addictive and is the primary psychoactive component causing addiction in tobacco products. Nicotine has neurotoxic effects on the developing brain. In early adolescence, development of executive function and learning processes in the brain have not fully matured. Teens are more likely to engage in experimentation with substances such as cigarettes, and they are also more vulnerable to addiction. Particularly in adolescence, nicotine also has an effect on the brain as a “gateway” drug for cocaine and other illicit drugs.

Use of ENDS for Smoking Cessation

ENDS products have been promoted by some manufacturers as a smoking cessation aid, although they are not approved by the FDA as a smoking cessation product. And, there is insufficient evidence to recommend the use of ENDS for smoking cessation. 

Although federal regulations ban the sale of conventional cigarettes to youth aged 18 years, there are no current federal age restrictions for purchasing ENDS products. The American Academy of Pediatrics recommends 21 years as the minimum age of purchase for all tobacco products. In April 2014, the FDA issued a draft regulation that would extend the agency’s tobacco authority to cover the sale and distribution of ENDS and other tobacco products similar to conventional cigarettes. Final action on this regulation is pending. Federal regulations on the content, labeling, and packaging of ENDS and ENDS solutions also do not exist.

The majority of states have enacted laws prohibiting ENDS sales to minors, and a few states have enacted comprehensive laws that prohibit ENDS use in private worksites, restaurants, and bars. There is no current federal regulation of Internet ENDS sales. No federal laws prevent ENDS and ENDS solutions from being purchased by anyone over the Internet, regardless of age.

Recommended Actions for Pediatricians

Pediatricians should screen for ENDS use and provide prevention counseling in their clinical practices. Screening for ENDS use and exposure should be incorporated into the screening for tobacco use.

Pediatricians should counsel children and adolescents about the harms of ENDS and the importance of remaining a nonuser of ENDS and all nicotine-containing products. As part of tobacco use prevention counseling, pediatricians should include prevention counseling about the known hazards of ENDS and the importance of not initiating use of any nicotine-containing product.

Pediatricians should not recommend ENDS as a treatment for tobacco dependence. Tobacco-dependent parents, caregivers, and adolescents should be offered behavioral counseling and support and should be educated on, offered, and/or referred to evidence-based, FDA-approved, tobacco dependence treatment medications as appropriate for the individual’s severity of tobacco dependence and readiness to quit. 

Pediatricians should recommend to ENDS users that children should avoid contact with ENDS and ENDS solutions. Although counseling should be targeted to prevention of ENDS use, if there are household users of ENDS, pediatricians should counsel parents and caregivers about child- resistant packaging, handling, and storage. The best protection from exposure to ENDS aerosol is for parents and caregivers to not use ENDS. If that is not possible, pediatricians should recommend ENDS-free policies for their home and car.

Public Policy Recommendations 

Reduce youth access to ENDS. Ban the sale to and use of ENDS for children and youth younger than 21 years. Ban Internet sales of ENDS and ENDS solutions.

Reduce youth demand for ENDS. Ban all flavors in ENDS. Because flavors have been shown to promote tobacco product use among youth, flavoring chemicals, including menthol, should be banned in all ENDS products and solutions.

Ban advertising of ENDS in media that can be viewed by youth. Any promotional activities that can be accessed by children and/or adolescents should be considered advertising to youth.

Restrict depictions of ENDS and ENDS use in movies, television shows, and video games. 

Protect youth from harms of involuntary ENDS, ENDS solution, and ENDS aerosol exposure. Because ENDS secondhand and thirdhand aerosol contains nicotine and other harmful toxicants, ENDS use should be prohibited in all public spaces. ENDS use should also be prohibited in all locations where children and youth are cared for, learn, work, and play, including workplaces, restaurants, health care facilities, child care settings, schools, dormitories, entertainment venues, parks, athletic facilities, shopping malls, restaurants, and leisure facilities. 

School and college campuses should prohibit the sale and use of ENDS. Prohibitions of ENDS should be included as part of tobacco-free and smoke-free laws and policies.

Protect children from unintentional nicotine exposure and poisonings.The size of ENDS concentrated nicotine solution pre-filled cartridges and containers should be limited to amounts that would not be lethal to a young child if ingested. ENDS solutions containing nicotine should be dispensed in child- resistant packaging.

Tax ENDS at the same rate as conventional cigarettes. Smokers, particularly youth, are very price-sensitive; therefore, ENDS and ENDS solutions should be taxed at a rate sufficient to discourage their use among youth and at a level not less than state and federal taxes on conventional cigarettes.

The Policy Statement ends with the following: “The increasing use of ENDS among youth threatens 5 decades of public health gains in successfully deglamorizing, restricting, and decreasing the use of tobacco products. Health claims of ENDS as smoking cessation aids are currently unsupported by scientific evidence. There is a crucial need for effective local, state, and federal regulation to protect children and youth from ENDS use and exposure to ENDS secondhand and thirdhand aerosol and concentrated nicotine solution.”

Read the entire Policy Statement.

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