Tallahassee, Fla. – In April 2014, the U.S. Food and Drug Administration (FDA) publicly released a draft of its proposed rule – commonly called a “deeming document” – seeking to regulate electronic cigarettes and other electronic nicotine delivery systems. The Florida Department of Health is pleased with the release of the long-overdue proposed rule regarding e-cigarettes, and we remain mindful of the ongoing discussion regarding e-cigarettes in the Florida legislature. The Bureau of Tobacco Free Florida looks forward to additional clarity on the marketing, manufacturing and sale of these products.

The emergence of e-cigarettes (also known as vapors, vaporizers, vape pens, hookah pens, electronic hookahs, e-hookahs, vape pipes, and electronic cigars) has triggered a flood of questions and considerable discussion regarding the risks they pose to children and teens. Until e-cigarettes are deemed safe and of acceptable quality by a competent national regulatory body, the Bureau of Tobacco Free Florida advises consumers not to use these products. Even then, youth should never use these products as nicotine in any form, including e-cigarettes, is unsafe for anyone under age 18.[1],[2] Parents must be vigilant about e-cigarette use by their children, and need to protect young children from exposure to all forms of nicotine.

In addition to their potentially harmful effects, Tobacco Free Florida is concerned that e-cigarettes may become a tool to hook youth and young adults on nicotine, a highly addictive chemical.[3],[4],[5] Youth in the state are increasingly using e-cigarettes at an alarming rate.[6] Among Florida high school students, one in five has tried e-cigarettes and current e-cigarette use has doubled – from 5.4 percent in 2013 to 10.8 percent in 2014.[7] Current use is described as using e-cigarettes at least once during the past 30 days.[8]

Nicotine exposure at a young age may cause lasting harm to brain development, promote addiction, and lead to sustained tobacco use.[9] Nicotine is highly addictive.[10] Adolescents are more sensitive to nicotine and more easily addicted than adults.[11] Because the adolescent brain is still developing, nicotine use during adolescence can disrupt the formation of brain circuits that control attention, learning and susceptibility to addiction.[12]

E-cigarette companies are using the same strategies previously employed by the tobacco industry to effectively market cigarettes to youth. Many e-cigarette brands offer products in fruit and candy flavors – such as cotton candy and gummy bear – that are especially enticing to youth. It is illegal to sell e-cigarettes to Florida minors (under age 18), yet many of these products are available online, at mall kiosks or at local retailers, making them easily accessible to youth. While most tobacco products have faced marketing restrictions for decades, there has been a notable increase in the marketing of e-cigarettes, from TV commercials to billboards and music festival sponsorships.

The e-cigarette industry is unregulated; therefore, there are no product standards or laws requiring child-resistant packaging on bottles and cartridges of liquid nicotine. As a result, the number of calls to poison centers involving e-cigarette liquids containing nicotine rose from one per month in September 2010 to 215 per month in February 2014, according to a CDC study published April 3, 2014.[13] The number of calls per month involving conventional cigarettes did not show a similar increase during the same time period. More than half of the calls to poison centers due to e-cigarettes involved young children under age 5.[14] Exposure to nicotine by swallowing or contact with the skin can result in nausea and vomiting, as well as respiratory arrest, seizures or even death.[15] One teaspoon of liquid nicotine could be lethal to a child, and smaller amounts can cause severe illness, often requiring trips to the emergency room, according to the American Association of Poison Control Centers.[16] Less than a tablespoon, at high concentrations, can kill an adult.[17]

There are additional important questions about e-cigarettes that remain unanswered, such as:

  • Are e-cigarettes attracting youth that would not have otherwise used a tobacco product?
  • Are e-cigarettes a youth gateway to nicotine addiction and use of other tobacco products?
  • Does the alarming increase in e-cigarette use among youth and their accessibility have the potential to renormalize smoking?
  • What is the health impact of young people ingesting large amounts of nicotine via these products?
  • What are the effects of exposure to vapor by non-e-cigarette users, especially youth?
  • What is the potential impact for using these devices for other chemicals, especially illicit drugs?

E-cigarette advocates believe it is better for youth to use e-cigarettes instead of conventional cigarettes. Tobacco Free Florida considers this claim highly dangerous and poor public health policy, as youth should not be using any products that contain nicotine.[18],[19]

What the Public Health Community Has Said About Electronic Cigarettes

“We want parents to know that nicotine is dangerous for kids at any age whether it’s an e-cigarette, hookah, cigarette or cigar. Adolescence is a critical time for brain development.”[20]
– Tom Frieden, Director of the Centers for Disease Control and Prevention (CDC)

“Because liquid nicotine comes in a variety of bright colors and in flavors like cotton candy and gummy bear, it is no surprise that it has found its way into the hands of children, with tragic results; late last year, a one-year-old boy died after accidentally swallowing the highly toxic substance. Liquid nicotine poisoning is a public health crisis that is preventable, and warrants immediate action from our federal government.”[21]
– Sandra G Hassink, MD, FAAP, president, American Academy of Pediatrics

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References

[1] U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014

[2] England, L. et al. Nicotine and the Developing Human: A Neglected Element of the E -cigarette Debate. Am J Prev Med. 2015 Mar 7. [Epub ahead of print].

[3] U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014

[4] U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010

[5] National Institute on Drug Abuse. Research Report Series: Tobacco Addiction. Bethesda (MD): National Institutes of Health, National Institute on Drug Abuse, 2009

[6] Florida Youth Tobacco Survey (FYTS), Florida Department of Health, Bureau of Epidemiology, 2014

[7] Florida Youth Tobacco Survey (FYTS), Florida Department of Health, Bureau of Epidemiology, 2014

[8] Florida Youth Tobacco Survey (FYTS), Florida Department of Health, Bureau of Epidemiology, 2014

[9] “E-cigarette Use Triples among Middle and High School Students in Just One Year.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 16 Apr. 2015. Web. 18 July 2015.

[10] USDHHS. The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

[11] U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.

[12] England, L. et al. Nicotine and the Developing Human: A Neglected Element of the E -cigarette Debate. Am J Prev Med. 2015 Mar 7. [Epub ahead of print].

[13] U.S. Centers for Disease Control and Prevention (CDC). Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes — United States, September 2010–February 2014. MMWR 2014; 3(13);292-293. <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm> [accessed 2014 Apr 24].

[14] U.S. Centers for Disease Control and Prevention (CDC). Notes from the Field: Calls to Poison Centers for Exposures to Electronic Cigarettes — United States, September 2010–February 2014. MMWR 2014; 3(13);292-293. <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm> [accessed 2014 Apr 24].

[15] Stanton Glantz, Child Resistant Packaging of Electronic Cigarette Devices and Refill Liquid to Prevent Child Poisoning, Center for Tobacco Control Research & Education (July 8, 2014), http://tobacco.ucsf.edu/child-resistant-packaging-electronic-cigarette-devices-and-refill-liquid-containerscontaining-nicot.

[16] American Association of Poison Control Centers (AAPCC). “American Association of Poison Control Centers Urges Government Liquid Nicotine Regulation in Wake of Child Death.” 12 Dec. 2014. Press Release. Last Accessed 24 July 2015. http://www.aapcc.org/press/37/

[17] The New York Times Editorial Board. “Lethal Liquid Nicotine,” The New York Times. 24 March 2014. Web. Last Accessed 24 July 2015. http://www.nytimes.com/2014/03/25/opinion/lethal-liquid-nicotine.html

[18] U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014

[19] England, L. et al. Nicotine and the Developing Human: A Neglected Element of the E -cigarette Debate. Am J Prev Med. 2015 Mar 7. [Epub ahead of print].

[20] “E-cigarette Use Triples among Middle and High School Students in Just One Year.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 16 Apr. 2015. Web. 18 July 2015.

[21] American Academy of Pediatrics (AAP). AAP Statement on FDA’s Announcement on Protecting children from Liquid Nicotine. 30 Jun 2015. https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Statement-on-FDA%E2%80%99s-Announcement-on-Protecting-Children-from-Liquid-Nicotine.aspx