On October 12, 2021, the FDA announced that it has authorized the marketing of three electronic nicotine delivery systems (ENDS) through its Premarket Tobacco Product Application (PMTA) pathway. The three products, which are all manufactured by R.J. Reynolds, are: Vuse Solo Power Unit, Vuse Replacement Cartridge Original 4.8% G1, and Vuse Replacement Cartridge Original 4.8% G2. The FDA determined the potential benefit of reducing cigarette use in adults would outweigh the likelihood of use of these three products by youth.

By September 9, 2021, the FDA was required to act on e-cigarettes, now know as “the new American addiction.” However, they have failed to do so. Despite the agencies public commitment to prioritize action against the companies that manufacture and sell e-cigarettes, their failure to take action means that the widely used product JUUL will continue to remain on the market and continue to addict more youth. The FDA needs to take action now. They must follow their mission and protect the public. Organizations such as the American Academy of Pediatrics (AAP) are exploring legal options to ensure that these addictive and dangerous products are removed from the market.

In September 2021, the FDA and the Centers for Disease Control and Prevention (CDC) released the results from the 2021 National Youth Tobacco Survey (NYTS). Due to the pandemic, this year’s data was collected using an online survey to allow all eligible students to participate. In prior years, the survey was conducted in classrooms at school. The survey found that 2.6 million middle and high school students in the US used e-cigarettes in 2021; 25% were daily users and 85% of students used flavored products. Almost 50% of current e-cigarette users in high school reported using the product on >20 days of the past 30 days and more than 25% vaped daily. Both middle and high school students reported that their preferred brand was Puff Bar and 85% of students said they preferred flavored e-cigarettes.

April 4, 2021: US Senate Majority Whip Dick Durbin (D-IL), Senate Finance Committee Chair Ron Wyden (D-OR), US Representative Raja Krishnamoorthi (D-IL), and seven other Senate Democrats introduced A Tobacco Tax Equity Act of 2021 today. The proposed bill is designed to close loopholes in the tax code that have been used by the tobacco industry to avoid regulation and taxes for their products. To date, e-cigarettes have not been subject to federal taxes. The bill would also establish the first federal e-cigarette tax and increase the tobacco tax rate for the first time in 10 years.  Public health experts believe the single most effective way to reduce youth tobacco use is to increase the price of tobacco products, including e-cigarettes. The newly-proposed bill will do just that – increase the price of tobacco products.

A new category of tobacco products has entered the market. Oral nicotine pouches have become increasingly popular among youth because they come in appealing flavors that are not as strictly regulated as flavored e-cigarettes. Sales of nicotine pouches such as Zyn, Velo, and On! increased 470% in the first half of 2020 according to an industry news article. Since these products do not contain leaf tobacco, the FDA does not classify these products as a smokeless tobacco product. Although the manufacturers must submit certain information to the FDA, including use nicotine warning labels, and comply with some marketing restrictions, no regulations prevent or restrict flavored nicotine pouches and the restrictions on marketing these products are not as strict as those placed on e-cigarettes; these factors have led to increased use of these dangerous products among our nations youth.

A June 7, 2021 article in JAMA Network Open published recent data from the 2020 National YouthTobacco Survey (NYTS): a cross-sectional, school-based electronic survey used to generate a nationally representative sample of US students. The results were previously published in the March 2021 issue of the New England Journal of Medicine. These results were based on surveys completed by 14,531 students, including 7,330 self-identified female students and 7,133 self-identified male students. About 60% of students obtained e-cigarettes from a friend and 85% of high school and 74% of middle school students who vaped used flavored e-cigarettes, primarily those that were fruit-flavored. NYTS also found that 3.02 million (19.6%) high school and 550,000 (4.7%) middle school students used an e-cigarette within the last 30 days. The results of the study suggest that even though e-cigarette use has declined during 2019-2020, overall prevalence and use of flavored e-cigarettes was high. These findings highlight the importance of continued education about the dangers of e-cigarettes to reduce and prevent use of these products.

A March 16, 2021 New England Journal of Medicine article published the most recent data from the 2020 National Youth Tobacco Survey (NYTS), which is a cross-sectional, school-based electronic survey used to generate a nationally representative sample of US students. NYTS found that 3.02 million (19.6%) high school and 550,000 (4.7%) middle school students used an e-cigarette within the last 30 days. Although these numbers are less than those reported in 2019, the numbers of children who vape are staggering and present a real public health crisis.

The survey stratified users of e-cigarettes by device type. In 2020, prefilled pods and cartridges were the most commonly used type of device (41.3% of middle school students and 48.5% of high school students). In the same year, disposable e-cigarette devices were used by 15.2% of middle school students and by 26.5% of high school students; these numbers represent a shift in preference towards disposable devices. Manufacturers of disposable e-cigarettes have benefited from loopholes in existing regulations because these products are not subject to the new federal policies regulating flavored e-cigarettes. The existing regulations are for closed-system e-liquid cartridges, not for disposable products. It is possible that the increase in sales of disposable e-cigarettes, along with targeted marketing to youth and use of appealing flavors, is directly related to ease of access to such products.

Puff Bars – One Manufacturers Way of Circumventing Regulations

Despite regulators efforts to curb teen vaping, manufacturers have found loopholes that thwart stopping teen vaping. One such is example is Puff Bar. Puff Bars are just like JUUL and many of the other copycat e-cigarette products out there, but with one major difference: they are disposable and meant for one-time use, which means that they are not subject to the new federal policies regulating flavored e-cigarettes. The existing regulations are for closed-system e-liquid cartridges, not refillable cartridges or disposable products. 

Puff Bars are available in a variety of appealing flavors such as banana ice, strawberry, blueberry ice, and pink lemonade. They are particularly appealing because they are small enough to fit in a pocket, pre-filled, easy to use, and are much cheaper than JUUL pods. Like JUUL and other e-cigarettes, Puff Bars contain high amounts of nicotine (one puff bar has about 300 puffs and contains as much nicotine as 2-3 packs of cigarettes) and are highly addicting. Puff Bars are housed in attractive packages designed to entice youth and the cheaper price point eliminates the cost barrier observed with more expensive products like JUUL. 

On March 1, 2021, the US Federal Trade Commission ordered JUUL Labs, NJOY, R.J. Reynolds Vapor Company, Fontem US, and Logic Technology Development to turn over 2019 and 2020 annual data on sales, advertising, and promotional expenses, including giveaways of e-cigarettes, characteristics of their e-cigarette products such as flavors, and annual spending on advertising and promotion. This request by the FTC is in response to mounting concerns about whether the industry specifically targeted advertisements for e-cigarette products towards young people. The FTC made a similar request in October 2019 for similar marketing data from 2015-2018.

Staying at home during the pandemic offers an opportunity for parents to educate their teens about the dangers of vaping and for teens to seek help for their nicotine addiction. It has also altered the patterns of youth e-cigarette use. A recent survey published on December 3, 2020 in JAMA Network Open of 2,167 e-cigarette users 13-24 years old found that 56.4% of participants reported a change in their e-cigarette use since the beginning of the COVID-19 pandemic. Among the 1197 youth who reported a change in their behavior, one-third quit vaping and another third reduced their e-cigarette use, but the other third vaped more or switched to cannabis products. Reasons cited for quitting vaping were lack of access to e-cigarettes, fear e-cigarettes would weaken lungs, parents were home and would find out, or they could not get to the store during the lockdown. If concerns about the effects of vaping on health are motivating youth to stop smoking, it seems that campaigns designed to reduce youth vaping are working.

Although federal laws have prohibited paid tobacco product advertisements in TV programs and movies since 1998, images of tobacco products are found everywhere: TV, social media sites, video game screens, and billboards. In fact, expansion of social media has allowed for a greater opportunity to advertise tobacco and maybe even normalize it. These advertisements are specifically designed to entice and influence youth. Some of the advertisements have even gone so far as to glamorize smoking. Research has shown that children who are exposed to such advertisements are twice as likely to start smoking. Even though Big Tobacco claims they are part of the solution to end smoking, even though they continue to sell cigarettes, they continue to entice a nation of youth through media campaigns to vape and eventually smoke cigarettes. Is Big Tobacco a wolf in sheep’s clothing? I think so.

The nonprofit Truth Initiative has fact sheets on tobacco use by state. Please visit the link below to learn about use in your state.

2020 state fact sheets

A new study conducted at the Yale School of Public Health found that higher rates of vaping and marijuana use were associated with fewer cases of e-cigarette or vaping product use-associated lung injuries (EVALIs) per capita. The study estimated the relationship between the states’ total reported cases of EVALI per capita as of January 2020. The author of the study states “If e-cigarette or marijuana use per se drove this outbreak, areas with more engagement in those behaviors should show a higher EVALI prevalence.” In fact, the study found that that the high prevalence of EVALI in certain states was related to locally available e-liquids or additives than to products widely used across the country. In February 2020, the CDC concluded that vitamin E acetate, an additive previously linked to EVALI, was the primary cause of EVALI. The EVALI outbreak resulted in many states restricting the sale of e-cigarettes or banning flavored e-cigarettes. The author suggests that restricting the sales of these products did not reduce the risk of EVALI given the negative relationship between the prevalence of EVALI and rates of vaping and marijuana pre-EVALI.

About one-quarter of high school students in the US have used e-cigarettes or similar devices within the past 30 days, and almost 12% reported daily use of such products. Vaping is associated with nicotine dependence, exposure to toxicants, and subsequent use of tobacco cigarettes. In a recent survey published in August 2020 in JAMA Pediatrics, in about 500 high school students who use e-cigarettes, nearly 50% reported that they were seriously interested in quitting, and one-quarter had tried to quit in the past year. These results suggest that many adolescents are interested in quitting and highlight the importance of vaping cessation interventions and the need for widespread dissemination of such interventions. Please visit this website to learn more.

On July 20, 2020, the FDA sent a letter to the maker of Puff Bar e-cigarettes stating that they must remove their products from the market within 15 business days. The FDA stated that the company was selling unauthorized products that illegally targeted children. Puff Bar e-cigarettes are disposable cigarettes that are made for one-time use. Previous regulations only restricted flavors available in closed-system liquid cartridges like Juul; the regulations did not apply to disposable products like Puff Bar e-cigarettes. Puff Bar e-cigarettes are sold in fruity flavors such as mango and strawberry and have increased in popularity among teenagers.  

On June 30, 2020, Hawaii’s Attorney General Clare Connors announced that Hawaii is suing JUUL Labs, Inc. and Altria Group, the parent company of Phillip Morris, for using misleading marketing practices to entice youth customers. They lawsuit claims that the company misrepresented the nicotine content in their products and claimed that the products were healthy alternatives to cigarettes, violating Hawaii’s Unfair and Deceptive Acts and Practices Law. It also claims that JUUL Labs, Inc. downplayed the risks of vaping products. Hawaii has one of the highest vaping rates among middle school and high school students in the U.S. 

According to CNN, in early March of 2020, the Centers for Disease Control (CDC) issued a statement saying that persons who are 65 years of age and older infected with the novel coronavirus (SARS-Co-V2) are at highest risk for severe illness. Shortly after this statement was released, the CDC also said that persons who smoke, vape, or use other substances are at high risk of contracting the virus. Users of these substances are already at risk for acute respiratory distress syndrome and other respiratory illnesses. Vaping and smoking cigarettes can also make one more susceptible to pulmonary complications from COVID-19 infection and make it harder for the body’s defense mechanisms to fight COVID-19.

Several states (North Carolina, California, and New York) have sued the nation’s largest e-cigarette maker, JUUL Labs, Inc. in recent months. The lawsuits claim that the company contributed to the youth vaping epidemic by using deceptive marketing practices on various social media sites to target youth. The lawsuit also claims that the company incorrectly claimed that their product was a safer alternative to traditional cigarettes. 

On January 2, 2020, the FDA issued a policy prioritizing the enforcement against certain unauthorized flavored e-cigarette products that appeal to kids, including fruit and mint flavors. Under this policy, the FDA will seek action against companies who do not stop manufacturing, distributing and selling unauthorized flavored cartridge-based e-cigarettes within 30 days. Tobacco and menthol flavored products are excluded from this policy. The FDA states that banning flavored cartridge-based e-cigarettes that are widely used by children will prevent these products from becoming an “on-ramp” to nicotine addiction, while also allowing adults who are smoking traditional cigarettes the ability to “off-ramp” with tobacco and menthol flavored e-cigarettes. 

In January 2020, the United States Surgeon General Jerome Adams, declared that electronic cigarettes do not help smokers quit, but instead increase the likelihood of non-smokers becoming smokers. 

According to a study published in a January 2020 issue of JAMA Pediatrics, Juul use increased particularly among those who were young, thought it was safe, and whose friends vaped.  

According to USA Today and Market Watch teens are spending about $1000 a year just on electronic cigarette products. Published on Thursday June 26, 2019, both magazines say that Juul pod dealers often buy the pods in stores or online, and then sell the pods for a higher price to teenagers. The Juul pod dealers are earning a profit but now the young users have to pay more money just to get a flavored Juul pod.

On Wednesday June 26 of 2019, San Francisco becomes the first state to ban the sale of electronic cigarettes. This law will be enforced about seven months after the mayor signs off on this ban, says USA Today.

The US Surgeon General officially declared e-cigarette use among youth “an epidemic” on December 18, 2018. Although cigarette use across the country has declined, the rate of vaping among teens has increased dramatically. A recent Monitoring the Future survey (drugabuse.gov) that included more than 40,000 teens nationwide found that 21% of 12th graders vaped during the past 30 days, which was double the rate in 2017. Vaping rates increased similarly in children as young as 6th grade.

On November 15, 2018, the FDA asked companies to remove their products within the next 90 days from stores that children can enter and purchase e-cigarettes and online sites that don’t have adequate age-verification processes. More information can be found on the FDA’s website.

According to the Centers for Disease Control (CDC), e-cigarettes are the tobacco product of choice among middle and high school students in the US. In 2018, more than 3.6 million middle and high school students used e-cigarettes in the past 30 days. That is a lot of adolescents – 20.8% of high school students and 4.9% of middle school students.

E-cigarettes are harmful. They are less harmful than regular cigarettes, but they still contain substances like nicotine, lead, volatile organic compounds, and substances that can cause cancer. Chemicals in the e-cigarette aerosol can reach deep into the lungs when inhaled.

Medical experts believe that e-cigarette use could affect an adolescent’s developing brain and lead to nicotine addiction. It could also lead to abuse of stronger drugs such as opioids. An editorial by JM Drazen et al in the February 14, 2019 issue of The New England Journal of Medicine describes nicotine as a “gateway drug that lowers the threshold for addiction to  other agents” and states that “nicotine is as addictive as heroin, so once hooked, most young e-cigarette users will become long-term users.”

Juul is just one type of an e-cigarette. Examples of other e-cigarettes are: hookah pens, e-hookas, vapes/vape pens. All products, not just juul, that contain nicotine are highly addictive.

E-cigarettes are becoming very popular among teenagers. In fact, the National Institute of Drug Abuse (NIDA) says that 79.7% of teens using e-cigarettes don’t know what they are made of, or think that they are made of just popular and satisfying flavors.