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Electronic Cigarettes: A New Nicotine Gateway?

      See Related Article p. 144
      Electronic cigarettes (e-cigarettes) have become increasingly prevalent and widely available since their introduction to the U.S. market in 2007 [
      • Noel J.K.
      • Rees V.W.
      • Connolly G.N.
      Electronic cigarettes: A new ‘tobacco’ industry?.
      ]. E-cigarettes are battery-powered devices that look like cigarettes and deliver a nicotine vapor to the user. They are widely advertised as technologically advanced and healthier alternatives to tobacco cigarettes using youth-relevant appeals such as celebrity endorsements, trendy/fashionable imagery, and fruit, candy, and alcohol flavors [
      • Trtchounian A.
      • Talbot P.
      Electronic nicotine delivery systems: Is there a need for regulation?.
      ,
      • Grana R.A.
      • Glantz S.A.
      • Ling P.M.
      Electronic nicotine delivery systems in the hands of Hollywood.
      ]. E-cigarettes are widely available online and in shopping mall kiosks, which may result in a disproportionate reach to teens, who spend much of their free time online and in shopping malls [
      • Noel J.K.
      • Rees V.W.
      • Connolly G.N.
      Electronic cigarettes: A new ‘tobacco’ industry?.
      ]. In 2012, the e-cigarette brand Blu was purchased by Lorillard Tobacco Company and started airing television commercials featuring celebrities using e-cigarettes [
      BluCigs. Blu Electronic Cigarette TV Commercial. 2012.
      ,
      BluCigs. Rise From Ashes TV Commercial. 2012.
      ]. The limited published research about the safety, efficacy, or public health impact of e-cigarettes raises concerns about the product's lack of regulation, safety/quality assurances, and its appeal to youth or nonsmokers [
      • Noel J.K.
      • Rees V.W.
      • Connolly G.N.
      Electronic cigarettes: A new ‘tobacco’ industry?.
      ,
      • Cobb N.K.
      • Byron M.J.
      • Abrams D.B.
      • Shields P.G.
      Novel nicotine delivery systems and public health: The rise of the “e-cigarette”.
      ].
      In this issue of the Journal of Adolescent Health, Pepper and colleagues present the first study of a national sample of U.S. male adolescents' awareness, use, and susceptibility to using e-cigarettes [
      • Pepper J.K.
      • Reiter P.L.
      • McRee A.-L.
      • Cameron L.D.
      • Gilkey M.B.
      • Brewer N.T.
      Adolescent males' awareness of and willingness to try electronic cigarettes.
      ]. The 228 participants were sons of parents recruited to participate in an online panel. Pepper et al found high awareness of e-cigarettes—67%—but little use; < 1% had tried them. Of even greater importance, 18% of the sample endorsed being susceptible to trying e-cigarettes, and this was much higher (74%) among participants who reported current smoking. To date, only two studies of national data sets have provided a glimpse into awareness and use of e-cigarettes, and both were among adults [
      • Regan A.K.
      • Promoff G.
      • Dube S.R.
      • Arrazola R.
      Electronic nicotine delivery systems: Adult use and awareness of the ‘e-cigarette’ in the USA.
      ,
      • Pearson J.
      • Promoff G.
      • Dube S.R.
      • Arrazola R.
      e-Cigarette (ENDS) awareness, use, and harm perceptions in American adults.
      ]. Pearson et al found that among a large nationally representative sample of U.S. adults, 40% were aware of e-cigarettes [
      • Pearson J.
      • Promoff G.
      • Dube S.R.
      • Arrazola R.
      e-Cigarette (ENDS) awareness, use, and harm perceptions in American adults.
      ]. The higher awareness among adolescents than adults (67% vs. 40%, respectively) calls into question whether these nicotine products are solely being marketed to existing adult tobacco smokers.
      The high rate of awareness among youth is concerning, particularly because the literature raises concerns about e-cigarette products with regard to ingredient and device safety. The Food and Drug Administration found tobacco-specific impurities and contaminants such as diethylene glycol in e-cigarette cartridges [
      ]. The nicotine content in e-cigarette products often does not match the advertised or labeled content, where products labeled no nicotine contained nicotine, or nicotine content amounts were higher or lower than labeled [
      ,
      • Trehy M.L.
      • Ye W.
      • Hadwiger M.E.
      • et al.
      Analysis of electronic cigarette cartridges, refill solutions, and smoke for nicotine and nicotine related impurities.
      ,
      • Goniewicz M.L.
      • Kuma T.
      • Gawron M.
      • Knysak J.
      • Kosmider L.
      Nicotine levels in electronic cigarettes.
      ]. Administration of an addictive drug at levels that are unintended may harm users and possibly encourage addiction. Moreover, there appears to be high variability in the quality of the products, in terms of device functioning, across, and even within, brands [
      • Williams M.
      • Talbot P.
      Variability among electronic cigarettes in the pressure drop, airflow rate, and aerosol production.
      ]. E-cigarette cartridges may leak, creating the potential for dermal nicotine exposure and potential poisoning [
      • Trtchounian A.
      • Talbot P.
      Electronic nicotine delivery systems: Is there a need for regulation?.
      ]. In the only published study examining the toxicology of the exhaled e-cigarette vapor, authors found it to contain volatile organic compounds and fine particulate matter, although at levels below secondhand tobacco cigarette smoke [

      Schripp T, Markewitz D, Uhde E, Salthammer T. Does e-cigarette consumption cause passive vaping? Indoor Air (in press).

      ].
      There are many unanswered questions regarding e-cigarettes and their likely impact on public health. Population benefit or harm depends largely on public's perception of the products and their patterns of use. Increased individual risks and population harm may result if dual use with other tobacco products is prevalent, or cessation is deterred by persons using e-cigarettes to circumvent successful tobacco control efforts, such as taxes and smoke-free laws. Studies conducted with e-cigarette users, mainly recruited through smoking cessation Web sites and e-cigarette enthusiast Web sites, demonstrate that they perceive the products to be less toxic than tobacco cigarettes and have used them as a smoking cessation device or to avoid exposing others to tobacco smoke [
      • Etter J.F.
      Electronic cigarettes: A survey of users.
      ]. However, the research on their efficacy for smoking cessation is in its infancy. The only published study enrolled a small sample of adults (n = 40) and demonstrated modest results: of the 27 subjects who completed the 6-month assessment, nine people had quit using the tobacco cigarettes, 13 reduced tobacco cigarette consumption but were using both e-cigarettes and conventional cigarettes, and five maintained cigarette smoking [
      • Polosa R.F.
      • Caponnetto P.
      • Morjaria J.B.
      • et al.
      Effect of an electronic nicotine delivery device (e-cigarette) on smoking reduction and cessation: A prospective 6-month pilot study.
      ]. The only large nationally representative data published to date found the highest rate of current e-cigarette use in current smokers compared with former smokers and nonsmokers, suggesting that dual use is the most common pattern of e-cigarette use [
      • Pearson J.
      • Promoff G.
      • Dube S.R.
      • Arrazola R.
      e-Cigarette (ENDS) awareness, use, and harm perceptions in American adults.
      ]. Further research on the rates and health effects of dual use is critical for assessing and considering total public health impact of these products, particularly because the dose–response relationship for cardiovascular effects of smoking cigarettes is highly nonlinear, with large effects at low doses [
      • Barnoya J.
      • Glantz S.A.
      Cardiovascular effects of secondhand smoke: Nearly as large as smoking.
      ].
      Given the dearth of empirical research on e-cigarette products and who may be using them, the Pepper et al article makes an important contribution toward understanding how youth are responding to their availability [
      • Pepper J.K.
      • Reiter P.L.
      • McRee A.-L.
      • Cameron L.D.
      • Gilkey M.B.
      • Brewer N.T.
      Adolescent males' awareness of and willingness to try electronic cigarettes.
      ]. In their multivariate analysis, being a current smoker was strongly associated with willingness to try e-cigarettes. When the analysis was limited to nonsmoking participants, holding negative beliefs about the typical smoker was associated with less willingness to try e-cigarettes. These findings suggest that e-cigarettes may be perceived by adolescents as symbolically and functionally similar to tobacco cigarettes. Although these findings are limited by a male-only sample, known predictors of initiation of cigarette smoking, such as sensation seeking and positive smoking expectancies, may be relevant factors to examine in future research investigating e-cigarette use among adolescents.
      What can be done to prevent e-cigarettes from becoming the newest gateway to addiction for millions of youth? Lessons from years of dealing with the tobacco industry and burden of tobacco in our society, especially our youth, should be heeded. A U.S. District Court of Appeals ruled in favor of the e-cigarette companies that e-cigarettes should be considered tobacco products under the law [
      • Deyton L.R.
      • Woodcock J.
      Regulation of e-cigarettes and other tobacco products. 2011.
      ]. Although the Food and Drug Administration has yet to exercise regulatory authority over the products, states and localities have passed laws restricting sales to minors (e.g., New Jersey) and included them in their smoke-free policies (e.g., Boston). Additional action should be taken to ensure e-cigarettes are not sold to youth and their appeal to youth and nonsmokers is minimized, such as enacting restrictions on health claims, explicit celebrity endorsements, and the elimination of the flavors. In addition, addressing smoking (and e-cigarette use) in the movies [
      • Grana R.A.
      • Glantz S.A.
      • Ling P.M.
      Electronic nicotine delivery systems in the hands of Hollywood.
      ] and denormalization of tobacco and the tobacco industry may also have positive effects on preventing adolescent uptake of both tobacco and e-cigarettes.

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