£-Cigarette
Use
Among
Youth
and
Young
Adults
A Report
of
the Surgeon General
U.S. Department
of
Health and
Human
Services
E-Cigarette Use Among Youth
and Young Adults: AReport of
the Surgeon General
2016
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Office of the Surgeon General
Rockville, MD
National Library of Medicine Cataloging-in-Publication Data
Names: United States. Public Health Service. Office of the Surgeon General, issuing body. | National
Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and
Health, issuing body.
Title: E-cigarette use among youth and young adults : a report of the Surgeon General.
Description: 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, 2016. | Includes bibliographical references.
Subjects: MESH: Electronic Cigarettes – utilization. | Smoking – adverse effects. | Electronic Cigarettes –
adverse effects. | Tobacco Industry. | Young Adult. | Adolescent. | United States.
Classification: NLM QV 137
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
For more information
For more information about the Surgeon General’s report, visit www.surgeongeneral.gov.
To download copies of this document, go to www.cdc.gov/tobacco.
To order copies of this document, go to www.cdc.gov/tobacco and click on Publications
Catalog or call 1-800-CDC-INFO (1-800-232-4636); TTY: 1-888-232-6348.
Suggested Citation
U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young
Adults. 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, 2016.
Use of trade names is for identification only and does not constitute endorsement by the
U.S. Department of Health and Human Services.
Message from Sylvia Burwell
Secretary, U.S. Department of Health and Human Services
The mission of the Department of Health and Human Services is to enhance and protect the
health and well-being of all Americans. This report confirms that the use of electronic cigarettes (or
e-cigarettes) is growing rapidly among American youth and young adults. While these products are
novel, we know they contain harmful ingredients that are dangerous to youth. Important strides have
been made over the past several decades in reducing conventional cigarette smoking among youth and
young adults. We must make sure this progress is not compromised by the initiation and use of new
tobacco products, such as e-cigarettes. That work is already underway.
To protect young people from initiating or continuing the use of e-cigarettes, actions must be
taken at the federal, state, and local levels. At the federal level, the U.S. Food and Drug Administration
(FDA)—under authority granted to it by Congress under the Family Smoking Prevention and Tobacco
Control Act of 2009—took a historic step to protect America’s youth from the harmful effects of using
e-cigarettes by extending its regulatory authority over the manufacturing, distribution, and marketing
of e-cigarettes. Through such action, FDA now requires minimum age restrictions to prevent sales
to minors and prohibits sales through vending machines (in any facility that admits youth), and will
require products to carry a nicotine warning.
We have more to do to help protect Americans from the dangers of tobacco and nicotine, espe-
cially our youth. As cigarette smoking among those under 18 has fallen, the use of other nicotine
products, including e-cigarettes, has taken a drastic leap. All of this is creating a new generation of
Americans who are at risk of nicotine addiction.
The findings from this report reinforce the need to support evidence-based programs to prevent
youth and young adults from using tobacco in any form, including e-cigarettes. The health and well-
being of our nation’s young people depend on it.
iii
Foreword
Tobacco use among youth and young adults in any form, including e-cigarettes, is not safe. In
recent years, e-cigarette use by youth and young adults has increased at an alarming rate. E-cigarettes
are now the most commonly used tobacco product among youth in the United States. This timely report
highlights the rapidly changing patterns of e-cigarette use among youth and young adults, assesses
what we know about the health effects of using these products, and describes strategies that tobacco
companies use to recruit our nation’s youth and young adults to try and continue using e-cigarettes.
The report also outlines interventions that can be adopted to minimize the harm these products cause
to our nation’s youth.
E-cigarettes are tobacco products that deliver nicotine. Nicotine is a highly addictive substance,
and many of today’s youth who are using e-cigarettes could become tomorrow’s cigarette smokers.
Nicotine exposure can also harm brain development in ways that may affect the health and mental
health of our kids.
E-cigarette use among youth and young adults is associated with the use of other tobacco prod-
ucts, including conventional cigarettes. Because most tobacco use is established during adolescence,
actions to prevent our nation’s young people from the potential of a lifetime of nicotine addiction are
critical.
E-cigarette companies appear to be using many of the advertising tactics the tobacco industry
used to persuade a new generation of young people to use their products. Companies are promoting
their products through television and radio advertisements that use celebrities, sexual content, and
claims of independence to glamorize these addictive products and make them appealing to young
people.
Comprehensive tobacco control and prevention strategies for youth and young adults should
address all tobacco products, including e-cigarettes. Further reductions in tobacco use and initiation
among youth and young adults are achievable by regulating the manufacturing, distribution, mar-
keting, and sales of all tobacco products—including e-cigarettes, and particularly to children—and
combining those approaches with other proven strategies. These strategies include funding tobacco
control programs at levels recommended by the Centers for Disease Control and Prevention (CDC);
increasing prices of tobacco products; implementing and enforcing comprehensive smokefree laws; and
sustaining hard-hitting media campaigns, such as CDC’s Tips from Former Smokers that encourages
smokers to quit for good, and FDA’s Real Cost that is aimed at preventing youth from trying tobacco and
reducing the number of youth who move from experimenting to regular use. We can implement these
cost-effective, evidence-based, life-saving strategies now. Together with additional effort and support,
we can protect the health of our nation’s young people.
Thomas R. Frieden, M.D., M.P.H.
Director
Centers for Disease Control and Prevention
v
Preface
from the Surgeon General
E-cigarette use among U.S. youth and young adults is now a major public health concern.
E-cigarette use has increased considerably in recent years, growing an astounding 900% among high
school students from 2011 to 2015. These products are now the most commonly used form of tobacco
among youth in the United States, surpassing conventional tobacco products, including cigarettes,
cigars, chewing tobacco, and hookahs. Most e-cigarettes contain nicotine, which can cause addiction
and can harm the developing adolescent brain.
Compared with older adults, the brain of youth and young adults is more vulnerable to the nega-
tive consequences of nicotine exposure. The effects include addiction, priming for use of other addic-
tive substances, reduced impulse control, deficits in attention and cognition, and mood disorders.
Furthermore, fetal exposure to nicotine during pregnancy can result in multiple adverse consequences,
including sudden infant death syndrome, altered corpus callosum, auditory processing deficits, effects
on behaviors and obesity, and deficits in attention and cognition. Ingestion of e-cigarette liquids con-
taining nicotine can also cause acute toxicity and possibly death if the contents of refill cartridges or
bottles containing nicotine are consumed.
This report highlights what we know and do not know about e-cigarettes. Gaps in scientific evi-
dence do exist, and this report is being issued while these products and their patterns of use continue to
change quickly. For example, the health effects and potentially harmful doses of heated and aerosolized
constituents of e-cigarette liquids—including solvents, flavorants, and toxicants—are not completely
understood. However, although e-cigarettes generally emit fewer toxicants than combustible tobacco
products, we know that aerosol from e-cigarettes is not harmless.
Although we continue to learn more about e-cigarettes with each passing day, we currently know
enough to take action to protect our nation’s young people from being harmed by these products.
Previous reports of the Surgeon General have established that nearly all habitual tobacco use begins
during youth and young adulthood. To prevent and reduce the use of e-cigarettes by youth and young
adults, we must work together as a society. We must implement proven prevention and education strat
egies. Health care providers, parents, teachers, and other caregivers should advise youth about the
dangers of nicotine and discourage tobacco use in any form, including e-cigarettes. They can set a posi
tive example by being tobacco-free and encouraging those who already use these products to quit. Free
help is available at 1-800-QUIT-NOW or
-
-
http://www.smokefree.gov. Preventing tobacco use in any form
among youth and young adults is critical to ending the tobacco epidemic in the United States.
Vivek H. Murthy, M.D., M.B.A.
U.S. Surgeon General
vii
ix
E-Cigarette Use Among Youth and Young Adults
Acknowledgments
This report was prepared by the U.S. Department of Health
and Human Services under the general direction of the
Centers for Disease Control and Prevention, National
Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health.
Vice Admiral (VADM) Vivek H. Murthy, M.D., M.B.A.,
Surgeon General, Office of the Surgeon General, Office
of the Secretary, U.S. Department of Health and Human
Services, Washington, D.C.
Thomas R. Frieden, M.D., M.P.H., Director, Centers for
Disease Control and Prevention, Atlanta, Georgia.
Ursula E. Bauer, Ph.D., M.P.H., Director, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.
Dana Shelton, M.P.H., Deputy Director, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.
Peter A. Briss, M.D., M.P.H., Medical Director, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and Prevention,
Atlanta, Georgia.
Rachel Kaufmann, Ph.D., M.P.H., Associate Director for
Science, National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.
Corinne Graffunder, Dr.P.H., M.P.H., Director, Office on
Smoking and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.
Editors of the report were
Cheryl L. Perry, Ph.D., Senior Scientific Editor, Professor
and Regional Dean, The Rockwell Distinguished Chair
in Society and Health, The University of Texas Health
Science Center at Houston (UTHealth) School of Public
Health, Austin, Texas.
Melissa Harrell, Ph.D., M.P.H., Senior Scientific Editor,
Associate Professor, Department of Health Promotion and
Behavioral Sciences and the Michael & Susan Dell Center
for Healthy Living, The University of Texas Health Science
Center at Houston (UTHealth) School of Public Health,
Austin, Texas.
MeLisa R. Creamer, Ph.D., M.P.H., Senior Scientific Editor,
Faculty Associate, Department of Health Promotion and
Behavioral Sciences and the Michael & Susan Dell Center
for Healthy Living, The University of Texas Health Science
Center at Houston (UTHealth) School of Public Health,
Austin, Texas.
Steven Kelder, Ph.D., Senior Scientific Editor, Beth Toby
Grossman Distinguished Professor of Spirituality and
Healing; Associate Regional Dean; Co-Director, Michael &
Susan Dell Center for Healthy Living; Professor, Division
of Epidemiology, Human Genetics, and Environmental
Sciences, The University of Texas Health Science Center
at Houston (UTHealth) School of Public Health, Austin,
Texas.
Brian King, Ph.D., Senior Associate Editor, Deputy
Director for Research Translation, Office on Smoking and
Health, National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.
Leslie A. Norman, M.B.A., Managing Editor, Office on
Smoking and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.
Peter L. Taylor, M.B.A., Technical Editor, Fairfax, Virginia.
Contributing editors were
Thomas Eissenberg, Ph.D., Director, Center for the
Study of Tobacco Products; Professor of Psychology
(Health Program), College of Humanities and Sciences
and Member Scientist, Massey Cancer Center, Virginia
Commonwealth University, Richmond, Virginia.
Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco
Control Research Branch, Behavioral Research Program,
Division of Cancer Control and Population Sciences,
National Cancer Institute, National Institutes of Health,
Rockville, Maryland.
A Report of the Surgeon General
x
Pamela Ling, M.D., M.P.H., Professor, Division of General
Internal Medicine, Department of Medicine, Center for
Tobacco Control Research and Education, University of
California, San Francisco, California.
Mark Parascandola, Ph.D., M.P.H., Epidemiologist,
Tobacco Control Research Branch, Behavioral Research
Program, Division of Cancer Control and Population
Sciences, National Cancer Institute, National Institutes of
Health, Rockville, Maryland.
Jennifer L. Pearson, Ph.D., M.P.H., Research Investigator,
The Schroeder Institute for Tobacco Research and Policy
Studies at Truth Initiative, Washington, D.C.; Adjunct
Assistant Professor, Department of Health, Behavior,
and Society, Bloomberg School of Public Health, Johns
Hopkins University, Baltimore, Maryland.
Jonathan M. Samet, M.D., M.S., Distinguished Professor
and Flora L. Thornton Chair, Department of Preventive
Medicine, Keck School of Medicine; Director, Institute
for Global Health, University of Southern California, Los
Angeles, California.
Andrea C. Villanti, Ph.D., M.P.H., Director for
Regulatory Science and Policy, The Schroeder Institute
for Tobacco Research and Policy Studies at Truth
Initiative, Washington, D.C.; Adjunct Assistant Professor,
Department of Health, Behavior, and Society, Bloomberg
School of Public Health, Johns Hopkins University,
Baltimore, Maryland.
Contributing authors were
Melissa D. Blank, Ph.D., Assistant Professor, Department
of Psychology, West Virginia University, Morgantown,
West Virginia.
Frank J. Chaloupka, Ph.D., Director, Health Policy Center,
Institute for Health Research and Policy, and Distinguished
Professor, Department of Economics, University of Illinois
at Chicago, Chicago, Illinois.
Shari P. Feirman, Ph.D., M.S., Project Director for
Regulatory Science and Policy, The Schroeder Institute for
Tobacco Research and Policy Studies at Truth Initiative,
Washington, D.C.
Jonathan Foulds, Ph.D., Professor, Departments of Public
Health Sciences and Psychiatry, College of Medicine, Penn
State University, Hershey, Pennsylvania.
Allison M. Glasser, M.P.H., Senior Project Manager, The
Schroeder Institute for Tobacco Research and Policy
Studies at Truth Initiative, Washington, D.C.
Maciej L. Goniewicz, Ph.D., Pharm.D., Assistant Professor
of Oncology, Department of Health Behavior, Roswell Park
Cancer Institute, Buffalo, New York.
Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco
Control Research Branch, Behavioral Research Program,
Division of Cancer Control and Population Sciences,
National Cancer Institute, National Institutes of Health,
Rockville, Maryland.
Lisa Henriksen, Ph.D., Senior Research Scientist,
Stanford Prevention Research Center, Department of
Medicine, School of Medicine, Stanford University, Palo
Alto, California.
Jidong Huang, Ph.D., Senior Research Scientist, Institute
for Health Research and Policy, University of Illinois at
Chicago, Chicago, Illinois.
Lauren K. Katz, M.P.H., Research Associate I, The
Schroeder Institute for Tobacco Research and Policy
Studies at Truth Initiative, Washington, D.C.
Frances Leslie, Ph.D., Vice Provost for Graduate Education;
Dean of the Graduate Division;Professor of Pharmacology
and Anatomy and Neurobiology, University of California,
Irvine, California.
M. Jane Lewis, Dr.Ph., Associate Professor, Health
Education and Behavioral Science and Center for Tobacco
Studies, School of Public Health, Rutgers University, New
Brunswick, New Jersey.
Kristy Marynak, M.P.P., Public Health Analyst, Office on
Smoking and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.
Mark Parascandola, Ph.D., M.P.H., Epidemiologist,
Tobacco Control Research Branch, Behavioral Research
Program, Division of Cancer Control and Population
Sciences, National Cancer Institute, National Institutes of
Health, Rockville, Maryland.
Terry F. Pechacek, Ph.D., Professor and Interim Division
Director of Health Management and Policy, School of
Public Health, Georgia State University, Atlanta, Georgia.
xi
E-Cigarette Use Among Youth and Young Adults
Gabbi Promoff, M.A., Associate Director for Policy, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.
Kurt M. Ribisl, Ph.D., Professor, Department of Health
Behavior, University of North Carolina Gillings School
of Global Public Health; Program Leader in Cancer
Prevention and Control, University of North Carolina
Lineberger Comprehensive Cancer Center, Chapel Hill,
North Carolina.
April Roeseler, B.S.N., M.S.P.H., Chief, California Tobacco
Control Program, California Department of Public Health,
Sacramento, California.
Jonathan M. Samet, M.D., M.S., Distinguished Professor
and Flora L. Thornton Chair, Department of Preventive
Medicine, Keck School of Medicine; Director, Institute
for Global Health, University of Southern California, Los
Angeles, California.
Laura R. Stroud, Ph.D., Senior Research Scientist,
Centers for Behavioral and Preventive Medicine, The
Miriam Hospital; Associate Professor, Department of
Psychiatry and Human Behavior, Alpert Medical School,
and Department of Behavioral and Social Sciences, School
of Public Health, Brown University, Providence, Rhode
Island.
Prue Talbot, Ph.D., Director, University of California,
Riverside Stem Cell Center and Core; Professor of Cell
Biology, Department of Cell Biology and Neuroscience,
University of California, Riverside, California.
Mark Travers, Ph.D., M.S., Assistant Professor of Oncology,
Department of Health Behavior and Air Pollution Exposure
Research Laboratory, Roswell Park Cancer Institute,
Buffalo, New York.
Scott Weaver, Ph.D., M.A., Assistant Professor, Division of
Epidemiology and Biostatistics, School of Public Health,
Georgia State University, Atlanta, Georgia.
Reviewers were
David B. Abrams Ph.D., Executive Director, The Schroeder
Institute for Tobacco Research and Policy Studies at Truth
Initiative, Washington, D.C.; Professor, Department of
Health, Behavior, and Society, Bloomberg School of
Public Health, Johns Hopkins University, Baltimore,
Maryland; Professor of Oncology, Georgetown University
Medical Center, Lombardi Comprehensive Cancer Center
(adjunct), Washington, D.C.
Heather Rubino Althouse, Senior Regulatory Counsel,
Office of Compliance and Enforcement, Center for
Tobacco Products, U.S. Food and Drug Administration,
Silver Spring, Maryland.
René A. Arrazola, M.P.H., Epidemiologist, Epidemiology
Branch, Office on Smoking and Health, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.
David L. Ashley, Ph.D., Director, Office of Science, Center
for Tobacco Products, U.S. Food and Drug Administration,
Silver Spring, Maryland.
Cathy L. Backinger, Ph.D., M.P.H., Deputy Director for
Research, Office of Science, Center for Tobacco Products,
U.S. Food and Drug Administration, Silver Spring,
Maryland.
Tracey E. Barnett, Ph.D., Associate Professor, Department
of Epidemiology, College of Public Health and Health
Professions and College of Medicine, University of Florida,
Gainesville, Florida.
Neal L. Benowitz, M.D., Professor of Medicine,
Bioengineering, and Therapeutic Sciences, Chief, Division
of Clinical Pharmacology, University of California, San
Francisco, California.
Jay M. Bernhardt, Ph.D., M.P.H., Interim Dean and
Professor, Moody College of Communication; Founding
Director, Center for Health Communication, The
University of Texas, Austin, Texas.
Nazleen Bharmal, M.D., Ph.D., M.P.P., Director of Science
and Policy, Office of the Surgeon General, U.S. Department
of Health and Human Services, Washington, D.C.
Allan M. Brandt, Ph.D., Amalie Moses Kass Professor of
the History of Medicine, Department of Global Health
and Social Medicine, Harvard University Medical School,
Boston, Massachusetts.
April Brubach, M.A., Director, Division of Public Health
Education, Office of Health Communication and
Education, Center for Tobacco Products, U.S. Food and
Drug Administration, Silver Spring, Maryland.
Priscilla Callahan-Lyon, M.D., Medical Branch Chief,
Division of Individual Health Science, Office of Science,
Center for Tobacco Products, U.S. Food and Drug
Administration, Silver Spring, Maryland.
A Report of the Surgeon General
xii
Frank J. Chaloupka, Ph.D., Director, Health Policy Center,
Institute for Health Research and Policy; Distinguished
Professor, Department of Economics, University of Illinois
at Chicago, Chicago, Illinois.
Ii-Lun Chen, M.D., Director, Division of Individual Health
Science, Office of Science, Center for Tobacco Products, U.S.
Food and Drug Administration, Silver Spring, Maryland.
Beverly Chernaik, J.D., Director, Office of Regulations,
Center for Tobacco Products, U.S. Food and Drug
Administration, Silver Spring, Maryland.
Joanna E. Cohen, Ph.D., Director, Institute for Global
Tobacco Control; Bloomberg Professor of Disease
Prevention, Department of Health, Behavior, and Society,
Bloomberg School of Public Health, Johns Hopkins
University, Baltimore, Maryland.
Catherine G. Corey, M.S.P.H., Epidemiologist, Office of
Science, Center for Tobacco Products, U.S. Food and Drug
Administration, Silver Spring, Maryland.
Kathleen Crosby, Director, Office of Health Communication
and Education, Center for Tobacco Products, U.S. Food
and Drug Administration, Silver Spring, Maryland.
Cristine D. Delnevo, Ph.D., M.P.H., Professor and Director,
Center for Tobacco Studies, Rutgers School of Public
Health, New Brunswick, New Jersey.
Lauren M. Dutra, Sc.D., M.A., Postdoctoral Fellow, Center
for Tobacco Control Research and Education, University of
California, San Francisco, California.
Lucinda J. England, M.D., M.S.P.H., Medical Officer, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.
Michael P. Eriksen, Sc.D., Sc.M., Dean and Regents’ Professor,
Division of Health Management and Policy, School of Public
Health, Georgia State University, Atlanta, Georgia.
Michael C. Fiore, M.D., M.P.H., M.B.A., University of Wisconsin
Hilldale Professor of Medicine; Director, Center for Tobacco
Research and Intervention, University of Wisconsin School of
Medicine and Public Health, Madison, Wisconsin.
Neal D. Freedman, Ph.D., M.P.H., Senior Investigator,
Metabolic Epidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute,
National Institutes of Health, Rockville, Maryland.
Elizabeth M. Ginexi, Ph.D., Program Director, Tobacco
Control Research Branch, Division of Cancer Control and
Population Sciences, National Cancer Institute, National
Institutes of Health, Rockville, Maryland.
Gary A. Giovino, Ph.D., M.S., Professor and Chair,
Department of Community Health and Health Behavior,
School of Public Health and Health Professions, University
at Buffalo, The State University of New York, Buffalo, New
York.
Stanton A. Glantz, Ph.D., Professor of Medicine and
American Legacy Foundation Distinguished Professor in
Tobacco Control; Director, Center for Tobacco Control
Research and Education, University of California, San
Francisco, California.
Maciej L. Goniewicz, Ph.D., Pharm.D., Assistant Professor
of Oncology, Department of Health Behavior, Roswell Park
Cancer Institute, Buffalo, New York.
Rachel A. Grana, Ph.D., M.P.H., Program Director, Tobacco
Control Research Branch, Behavioral Research Program,
Division of Cancer Control and Population Sciences,
National Cancer Institute, National Institutes of Health,
Rockville, Maryland.
Bonnie Halpern-Felsher, Ph.D., FSAHM, Director of
Research, Professor, Division of Adolescent Medicine,
Stanford University, Palo Alto, California.
Dorothy K. Hatsukami, Ph.D., Forster Family Professor in
Cancer Prevention,Masonic Cancer Center, University of
Minnesota, Minneapolis, Minnesota.
Corinne Husten, M.D., M.P.H., Senior Medical Advisor,
Center for Tobacco Products, U.S. Food and Drug
Administration, Silver Spring, Maryland.
Frances Jensen, M.D., F.A.C.P., Professor and Chair,
Neurology Department, Perelman School of Medicine,
University of Pennsylvania, Philadelphia, Pennsylvania.
Ronald L. Johnson, Ph.D., Program Director, DNA and
Chromosome Aberrations Branch, Division of Cancer
Biology, National Cancer Institute, National Institutes of
Health, Bethesda, Maryland.
Sarah E. Johnson, Ph.D., Social Scientist, Office of
Science, Center for Tobacco Products, U.S. Food and Drug
Administration, Silver Spring, Maryland.
xiii
E-Cigarette Use Among Youth and Young Adults
Annette R. Kaufman, Ph.D., M.P.H., Health Scientist and
Program Director, Tobacco Control Research Branch,
Behavioral Research Program, Division of Cancer Control
and Population Sciences, National Cancer Institute,
National Institutes of Health, Rockville, Maryland.
Ryan David Kennedy, Ph.D., Assistant Professor, Institute
for Global Tobacco Control, Department of Health,
Behavior, and Society, Bloomberg School of Public Health,
Johns Hopkins University, Baltimore, Maryland.
Jonathan D. Klein, M.D., M.P.H., F.A.A.P., Associate
Executive Director; Director, Julius B. Richmond Center,
American Academy of Pediatrics, Elk Grove Village,
Illinois.
Suchitra Krishnan-Sarin, Ph.D., Professor, Department
of Psychiatry, School of Medicine, Yale University, New
Haven, Connecticut.
Lauren K. Lempert, J.D., M.P.H., Associate Specialist,
Center for Tobacco Control Research and Education,
University of California, San Francisco, California.
Maggie Mahoney, J.D., Executive Director, Tobacco
Control Legal Consortium at the Public Health Law
Center, St. Paul, Minnesota.
Tim McAfee, M.D., Medical Officer, Office on Smoking and
Health, National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.
Daniel McGoldrick, M.A., Vice President, Global Health
Advocacy Incubator, Campaign for Tobacco-Free Kids,
Washington, D.C.
Cindy Miner, Ph.D., Associate Director for Scientific
Communication, Office of Science, Center for Tobacco
Products, U.S. Food and Drug Administration, Silver
Spring, Maryland.
Matthew L. Myers, J.D., President, Campaign for Tobacco-
Free Kids, Washington, D.C.
Linda J. Neff, Ph.D., Senior Epidemiologist, Epidemiology
Branch, Office on Smoking and Health, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.
Richard J. O’Connor, Ph.D., Member and Professor of
Oncology, Department of Health Behavior, Division of
Cancer Prevention and Population Sciences, Roswell Park
Cancer Institute, Buffalo, New York.
Mark Parascandola, Ph.D., M.P.H., Epidemiologist,
Tobacco Control Research Branch, Behavioral Research
Program, Division of Cancer Control and Population
Sciences, National Cancer Institute, National Institutes of
Health, Rockville, Maryland.
Terry F. Pechacek, Ph.D., Professor and Interim Division
Director of Health Management and Policy, School of
Public Health, Georgia State University, Atlanta, Georgia.
Alexander Persoskie, Ph.D., Social Scientist, Center for
Tobacco Products, U.S. Food and Drug Administration,
Silver Spring, Maryland.
John P. Pierce, Ph.D., Professor Emeritus, Department of
Family Medicine and Public Health and the Moores Cancer
Center, University of California, San Diego, La Jolla,
California.
David W. Racine, M.S., Senior Program Management
Officer, Office of Compliance and Enforcement, Center for
Tobacco Products, U.S. Food and Drug Administration,
Silver Spring, Maryland.
Chad J. Reissig, Ph.D., Addiction Branch Chief, Office of
Science, Center for Tobacco Products, U.S. Food and Drug
Administration, Silver Spring, Maryland.
Joelle Robinson, M.P.H., Social Scientist, Office of
Science, Center for Tobacco Products, U.S. Food and Drug
Administration, Silver Spring, Maryland.
Jonathan M. Samet, M.D., M.S., Distinguished Professor
and Flora L. Thornton Chair, Department of Preventive
Medicine, Keck School of Medicine; Director, Institute
for Global Health, University of Southern California, Los
Angeles, California.
Peter G. Shields, M.D., Deputy Director, Comprehensive
Cancer Center, James Cancer Hospital; Professor, College
of Medicine, The Ohio State University, Columbus, Ohio.
Ann Simoneau, J.D., M.B.A., Director, Office of Compliance
and Enforcement, Center for Tobacco Products, U.S. Food
and Drug Administration, Silver Spring, Maryland.
A Report of the Surgeon General
Theodore A. Slotkin, Ph.D., Professor, Department of
Pharmacology and Cancer Biology, Duke University
Medical Center, Durham, North Carolina.
Anne Sowell, Ph.D., Health Scientist, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.
Erin L. Sutfin, Ph.D., Associate Professor and Vice Chair,
Department of Social Sciences and Health Policy, Division
of Public Health Sciences, Wake Forest School of Medicine,
Wake Forest University, Winston-Salem, North Carolina.
Robert E. Vollinger, Jr., M.S.P.H., (Dr.P.H. Candidate),
Program Director and Public Health Advisor, Tobacco
Control Research Branch, Behavioral Research Program,
Division of Cancer Control and Population Sciences,
National Cancer Institute, National Institutes of Health,
Rockville, Maryland.
Kenneth E. Warner, Ph.D., Avedis Donabedian
Distinguished University Professor of Public Health,
Department of Health Management and Policy, University
of Michigan School of Public Health, Ann Arbor,
Michigan.
Geoffrey Ferris Wayne, M.A., Research Consultant,
Sebastopol, California.
Deborah M. Winn, Ph.D., Deputy Director, Division
of Cancer Control and Population Sciences, National
Cancer Institute, National Institutes of Health, Rockville,
Maryland.
Mitchell Zeller, J.D., Director, Center for Tobacco
Products, U.S. Food and Drug Administration, Silver
Spring, Maryland.
Other contributors were
Katherine J. Asman, M.S.P.H., Statistician, Biostatistics
and Epidemiology Division, RTI International, Atlanta,
Georgia.
Adam J. Burke, M.A., Research Associate Lead, The
Monitoring the Future Study, University of Michigan, Ann
Arbor, Michigan.
Dayana Chanson, M.P.H., Research Associate to Jonathan
M. Samet, M.D., M.S., Department of Preventive Medicine,
Keck School of Medicine, University of Southern
California, Los Angeles, California.
Tara Christine Chu, M.P.H., Research Associate to
Jonathan M. Samet, M.D., M.S., Department of Preventive
Medicine, Keck School of Medicine, University of Southern
California, Los Angeles, California.
Stephanie L. Clendennen, M.P.H., Predoctoral Fellow,
Tobacco Center of Regulatory Science on Youth and
Young Adults, The University of Texas Health Science
Center at Houston (UTHealth) School of Public Health,
Austin, Texas.
Sarah J. Cross, Graduate Student Researcher, Department
of Anatomy and Neurobiology, University of California,
Irvine, California.
Nicholas J. Felicione, Graduate Research Assistant,
Department of Psychology, West Virginia University,
Morgantown, West Virginia.
Kyle R. Gregory, J.D., M.S.H.A., Postdoctoral Research
Associate, Tobacco Center of Regulatory Science, School of
Public Health, Georgia State University, Atlanta, Georgia.
Emily T. Hébert, M.P.H., Doctoral Student, Michael &
Susan Dell Center for Healthy Living, The University
of Texas Health Science Center at Houston (UTHealth)
School of Public Health, Austin, Texas.
Erin O’Connor Landau, M.S., Data Analyst, DB Consulting
Group (Contractor), Office on Smoking and Health,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.
Pamela Lemos, M.S., Public Health Analyst, Office on
Smoking and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.
Gerald V. [Simon] McNabb, Lead Public Health Analyst,
Office on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Washington, D.C.
Ronald L. Johnson, Ph.D., Program Director, DNA and
Chromosome Aberrations Branch, Division of Cancer
Biology, National Cancer Institute, National Institutes of
Health, Bethesda, Maryland.
Hoda S. Magid, M.H.S., Center for Tobacco Control
Research and Education, University of California,
SanFrancisco, California.
xiv
xv
E-Cigarette Use Among Youth and Young Adults
Dale Mantey, M.P.A., Predoctoral Fellow, Tobacco Center
of Regulatory Science on Youth and Young Adults, The
University of Texas Health Science Center at Houston
(UTHealth) School of Public Health, Austin, Texas.
Mandie Mills, Photographer, Office of the Associate
Director for Communication, Centers for Disease Control
and Prevention, Atlanta, Georgia.
Richard Miech, Ph.D., Professor, Institute for Social
Research, University of Michigan, Ann Arbor, Michigan.
Luz M. Moncayo, Executive Assistant to Jonathan M.
Samet, M.D., M.S., Department of Preventive Medicine,
Keck School of Medicine, Institute for Global Health,
University of Southern California, Los Angeles, California.
Maureen O’Brien, J.D., Staff Attorney, Tobacco Control
Legal Consortium at the Public Health Law Center,
St.Paul, Minnesota.
Patrick M. O’Malley, Ph.D., Research Professor, Survey
Research Center, Institute for Social Research, University
of Michigan, Ann Arbor, Michigan.
Gabriela V. Portillo, Masters Student, Michael & Susan
Dell Center for Healthy Living, The University of Texas
Health Science Center at Houston (UTHealth) School of
Public Health, Austin, Texas.
Anna Teplinskaya, M.D., M.P.H., Public Health Analyst,
Epidemiology Branch, Office on Smoking and Health,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.
Tenecia Smith, M.P.H., Data Analyst, DB Consulting Group
(Contractor), Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and Prevention,
Atlanta, Georgia.
Kathryn E. Szynal, Editorial Assistant, McNeal
Professional Services (Contractor), Office on Smoking and
Health, National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.
Teresa Wang, Ph.D., M.S., Epidemic Intelligence Service
Officer, Lieutenant, U.S. Public Health Service, Office on
Smoking and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.
Jennifer Whitmill, M.P.H., Data Analyst, DB Consulting
Group (Contractor), Office on Smoking and Health,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia
E-Cigarette Use Among Youth and Young Adults
Chapter 1 Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 1
Introduction 3
Major Conclusions 5
Chapter Conclusions 6
Historical Background 8
The E-Cigarette 10
E-Cigarette Companies 14
Federal Regulation of E-Cigarettes 15
Summary 18
References 19
Chapter 2 Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 25
Introduction 27
Key Findings 28
Evidence Summary 86
Conclusions 88
References 89
Chapter 3 Health Effects of E-Cigarette Use Among U.S.Youth and Young Adults 95
Introduction 97
Conclusions from Previous Surgeon General’s Reports 97
Health Effects of E-Cigarette Use 100
Evidence Summary 124
Conclusions 125
References 126
Chapter 4 Activities of the E-Cigarette Companies 147
Introduction 149
Manufacturing and Price 149
Marketing and Promotion of E-Cigarettes 157
Evidence Summary 172
Conclusions 172
References 173
Chapter 5 E-Cigarette Policy and Practice Implications 181
Introduction 183
Critical Issues Related to Policies on E-Cigarettes in 2016 184
Potential Public Policy Approaches 187
Case Studies 224
Summary and Recommendations 225
Conclusions 226
References 227
xvii
The Call to Action 235
The Call to Action on E-Cigarette Use Among Youth and Young Adults 237
Goal 2. Provide Information About the Dangers of E-Cigarette Use Among Youth
Goal 5. Curb Advertising and Marketing that Encourages Youth and Young Adults
Goal 1. First, Do No Harm 237
and Young Adults 239
Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to Protect Public Health 241
Goal 4. Programs and Policies to Prevent E-Cigarette Use Among Youth and Young Adults 243
to Use E-Cigarettes 246
Goal 6. Expand Surveillance, Research, and Evaluation Related to E-Cigarettes 247
Conclusions 249
References 250
List of Abbreviations 253
List of Tables and Figures 257
Index 261
xviii
1
Introduction 3
Organization of the Report 4
Preparation of this Report 4
Scientific Basis of the Report 5
Major Conclusions 5
Chapter Conclusions 6
Chapter 1. Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 6
Chapter 2. Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 6
Chapter 3. Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 6
Chapter 4. Activities of the E-Cigarette Companies 7
Chapter 5. E-Cigarette Policy and Practice Implications 7
Historical Background 8
Early Efforts to Modify Cigarettes 8
Filters, Tar Reduction, and Light and Low-Tar Cigarettes 8
The Role of Nicotine and Nicotine Delivery 9
FDA and Nicotine Regulation 9
The E-Cigarette 10
Invention of the E-Cigarette 10
E-Cigarette Products 11
Components and Devices 11
Flavors and E-Cigarettes 11
E-Cigarette Devices 11
E-Cigarette Product Components and Risks 13
E-Cigarette Companies 14
Federal Regulation of E-Cigarettes 15
A “Two-Pronged” Approach to Comprehensive Tobacco Control 15
Legal Basis for Regulating E-Cigarettes as Tobacco Products 16
Deeming Rule 17
Future Regulatory Options 17
Summary 18
References 19
Chapter 1
Introduction, Conclusions, and Historical Background
Relative to E-Cigarettes
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 3
E-Cigarette Use Among Youth and Young Adults
Introduction
Although conventional cigarette smoking has
declined markedly over the past several decades among
youth and young adults in the United States (U.S.
Department of Health and Human Services [USDHHS]
2012), there have been substantial increases in the use of
emerging tobacco products among these populations in
recent years (Centers for Disease Control and Prevention
[CDC] 2015c). Among these increases has been a dramatic
rise in electronic cigarette (e-cigarette) use among youth
and young adults. It is crucial that the progress made
in reducing cigarette smoking among youth and young
adults not be compromised by the initiation and use of
e-cigarettes. This Surgeon General’s report focuses on the
history, epidemiology, and health effects of e-cigarette use
among youth and young adults; the companies involved
with marketing and promoting these products; and
existing and proposed public health policies regarding the
use of these products by youth and young adults.
E-cigarettes include a diverse group of devices that
allow users to inhale an aerosol, which typically contains
nicotine, flavorings, and other additives. E-cigarettes vary
widely in design and appearance, but generally operate in
a similar manner and are composed of similar components
(Figure 1.1). A key challenge for surveillance of the prod-
ucts and understanding their patterns of use is the diverse
and nonstandard nomenclature for the devices (Alexander
et al. 2016). These devices are referred to, by the companies
themselves, and by consumers, as “e-cigarettes,” “e-cigs,”
“cigalikes,” “e-hookahs,” “mods,” “vape pens,” “vapes,”
and “tank systems.” In this report, the term “e-cigarette”
is used to represent all of the various products in this rap-
idly diversifying product category. The terms may differ
by geographic region or simply by the prevailing prefer-
ences among young users. For example, some refer to all
cigarette-shaped products as “e-cigarettes” or as “cigalikes,”
and some may refer to the pen-style e-cigarettes as “hookah
pens” or “vape pens” (Richtel 2014; Lempert et al. 2016).
Figure 1.1 Diversity of e-cigarette products
Source: Photo by Mandie Mills, CDC.
A Report of the Surgeon General
4 Chapter 1
This report focuses on research conducted among
youth and young adults because of the implications of
e-cigarette use in this population, particularly the poten-
tial for future public health problems. Understanding
e-cigarette use among young persons is critical because
previous research suggests that about 9 in 10 adult
smokers first try conventional cigarettes during adoles-
cence (USDHHS 2012). Similarly, youth e-cigarette exper-
imentation and use could also extend into adulthood;
however, e-cigarette use in this population has not been
examined in previous reports of the Surgeon General.
The first Surgeon General’s report on the health conse-
quences of smoking was published in 1964; of the subse-
quent reports, those published in 1994 and 2012 focused
solely on youth and young adults (USDHHS 1994, 2012).
More recently, the 2012 report documented the evidence
regarding tobacco use among youth and young adults,
concluding that declines in cigarette smoking had slowed
and that decreases in the use of smokeless tobacco had
stalled. That report also found that the tobacco industry’s
advertising and promotional activities are causal to the
onset of smoking in youth and young adults and the con-
tinuation of such use as adults (USDHHS 2012). However,
the 2012 report was prepared before e-cigarettes were as
widely promoted and used in the United States as they are
now. Therefore, this 2016 report documents the scientific
literature on these new products and their marketing,
within the context of youth and young adults. This report
also looks to the future by examining the potential impact
of e-cigarette use among youth and young adults, while
also summarizing the research on current use, health
consequences, and marketing as it applies to youth and
young adults.
Evidence for this report was gathered from studies
that included one or more of three age groups. We defined
these age groups to be young adolescents (11–13 years of
age), adolescents (14–17 years of age), and young adults
(18–24 years of age). Some studies refer to the younger
groups more generally as youth. Despite important issues
related to e-cigarette use in adult populations, clinical and
otherwise (e.g., their potential for use in conventional
smoking cessation), that literature will generally not be
included in this report unless it also discusses youth and
young adults (Farsalinos and Polosa 2014; Franck et al.
2014; Grana et al. 2014).
Given the recency of the research that pertains to
e-cigarettes, compared with the decades of research on
cigarette smoking, the “precautionary principle” is used
to guide actions to address e-cigarette use among youth
and young adults. This principle supports intervention
to avoid possible health risks when the potential risks
remain uncertain and have been as yet partially undefined
(Bialous and Sarma 2014; Saitta et al. 2014; Hagopian et al.
2015). Still, the report underscores and draws its conclu-
sions from the known health risks of e-cigarette use in
this age group.
Organization of the Report
This chapter presents a brief introduction to this
report and includes its major conclusions followed by the
conclusions of the chapters, the historical background of
e-cigarettes, descriptions of the products, a review of the
marketing and promotional activities of e-cigarette compa-
nies, and the current status of regulations from the U.S.
Food and Drug Administration (FDA). Chapter2 (“Patterns
of E-Cigarette Use Among U.S. Youth and Young Adults”)
describes the epidemiology of e-cigarette use, including cur-
rent use (i.e., past 30 day); ever use; co-occurrence of using
e-cigarettes with other tobacco products, like cigarettes;
and psychosocial factors associated with using e-cigarettes,
relying on data from the most recent nationally representa-
tive studies available at the time this report was prepared.
Chapter 3 (“Health Effects of E-Cigarette Use Among U.S.
Youth and Young Adults”) documents the evidence related
to the health effects of e-cigarette use, including those that
are associated with direct aerosol inhalation by users, the
indirect health effects of e-cigarette use, other non-aerosol
health effects of e-cigarette use, and secondhand exposure
to constituents of the aerosol. Chapter 4 (“Activities of the
E-Cigarette Companies”) describes e-cigarette companies’
influences on e-cigarette use and considers manufacturing
and price; the impact of price on sales and use; the rapid
changes in the industry, particularly the e-cigarette com-
panies; and the marketing and promotion of e-cigarettes.
Chapter 5 (“E-Cigarette Policy and Practice Implications”)
discusses the implications for policy and practice at the
national, state, and local levels. The report ends with a Call
to Action to stakeholders—including policymakers, public
health practitioners and clinicians, researchers, and the
public—to work to prevent harms from e-cigarette use
and secondhand aerosol exposure among youth and young
adults.
Preparation of this Report
This Surgeon General’s report was prepared by
the Office on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion, CDC,
which is part of USDHHS. The initial drafts of the chap-
ters were written by 27 experts who were selected for their
knowledge of the topics addressed. These contributions
are summarized in five chapters that were evaluated by
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 5
E-Cigarette Use Among Youth and Young Adults
approximately 30 peer reviewers. After peer review, the
entire manuscript was sent to more than 20 scientists
and other experts, who examined it for its scientific integ-
rity. After each review cycle, the drafts were revised by the
report’s scientific editors on the basis of reviewers’ com-
ments. Subsequently, the report was reviewed by various
institutes and agencies within USDHHS.
Scientific Basis of the Report
The statements and conclusions throughout this
report are documented by the citation of studies published
in the scientific literature. Publication lags have pre-
vented an up-to-the-minute inclusion of all recently pub-
lished articles and data. This overall report primarily cites
peer-reviewed journal articles, including reviews that inte-
grate findings from numerous studies and books that were
published through December 2015. However, selected
studies from 2016 have been added during the review pro-
cess that provide further support for the conclusions in
this report. When a cited study has been accepted for pub-
lication, but the publication has not yet occurred because
of the delay between acceptance and final publication, the
study is referred to as “in press.” This report also refers, on
occasion, to unpublished research, such as presentations
at a professional meeting, personal communications from
a researcher, or information available in various media.
These references are employed when acknowledged by
the editors and reviewers as being from reliable sources,
which add to the emerging literature on a topic.
Major Conclusions
1. E-cigarettes are a rapidly emerging and diversified
product class. These devices typically deliver nico-
tine, flavorings, and other additives to users via an
inhaled aerosol. These devices are referred to by a
variety of names, including “e-cigs,” “e-hookahs,”
“mods,” “vape pens,” “vapes,” and “tank systems.”
2. E-cigarette use among youth and young adults has
become a public health concern. In 2014, current
use of e-cigarettes by young adults 18–24 years of
age surpassed that of adults 25 years of age and older.
3. E-cigarettes are now the most commonly used
tobacco product among youth, surpassing conven-
tional cigarettes in 2014. E-cigarette use is strongly
associated with the use of other tobacco products
among youth and young adults, including combus-
tible tobacco products.
4. The use of products containing nicotine poses dan-
gers to youth, pregnant women, and fetuses. The use
of products containing nicotine in any form among
youth, including in e-cigarettes, is unsafe.
5. E-cigarette aerosol is not harmless. It can con-
tain harmful and potentially harmful constituents,
including nicotine. Nicotine exposure during ado-
lescence can cause addiction and can harm the
developing adolescent brain.
6. E-cigarettes are marketed by promoting flavors
and using a wide variety of media channels and
approaches that have been used in the past for mar-
keting conventional tobacco products to youth and
young adults.
7. Action can be taken at the national, state, local, tribal,
and territorial levels to address e-cigarette use among
youth and young adults. Actions could include
incorporating e-cigarettes into smokefree policies,
preventing access to e-cigarettes by youth, price and
tax policies, retail licensure, regulation of e-cigarette
marketing likely to attract youth, and educational ini-
tiatives targeting youth and young adults.
A Report of the Surgeon General
6 Chapter 1
Chapter Conclusions
Chapter 1. Introduction,
Conclusions, and Historical
Background Relative to
E-Cigarettes
1. E-cigarettes are devices that typically deliver nico-
tine, flavorings, and other additives to users via an
inhaled aerosol. These devices are referred to by a
variety of names, including “e-cigs,” “e-hookahs,”
“mods,” “vape pens,” “vapes,” and “tank systems.”
2. E-cigarettes represent an evolution in a long history
of tobacco products in the United States, including
conventional cigarettes.
3. In May 2016, the Food and Drug Administration
issued the deeming rule, exercising its regulatory
authority over e-cigarettes as a tobacco product.
Chapter 2. Patterns of E-Cigarette
Use Among U.S. Youth and Young
Adults
1. Among middle and high school students, both ever
and past-30-day e-cigarette use have more than tri-
pled since 2011. Among young adults 18–24 years
of age, ever e-cigarette use more than doubled from
2013 to 2014 following a period of relative stability
from 2011 to 2013.
2. The most recent data available show that the prev-
alence of past-30-day use of e-cigarettes is similar
among high school students (16% in 2015, 13.4% in
2014) and young adults 18–24 years of age (13.6%
in 2013–2014) compared to middle school students
(5.3% in 2015, 3.9% in 2014) and adults 25 years of
age and older (5.7% in 2013–2014).
3. Exclusive, past-30-day use of e-cigarettes among
8th-, 10th-, and 12th-grade students (6.8%, 10.4%,
and 10.4%, respectively) exceeded exclusive,
past-30-day use of conventional cigarettes in 2015
(1.4%, 2.2%, and 5.3%, respectively). In contrast—
in 2013–2014 among young adults 18–24 years of
age—exclusive, past-30-day use of conventional cig-
arettes (9.6%) exceeded exclusive, past-30-day use of
e-cigarettes (6.1%). For both age groups, dual use of
these products is common.
4. E-cigarette use is strongly associated with the use
of other tobacco products among youth and young
adults, particularly the use of combustible tobacco
products. For example, in 2015, 58.8% of high
school students who were current users of combus-
tible tobacco products were also current users of
e-cigarettes.
5. Among youth—older students, Hispanics, and
Whites are more likely to use e-cigarettes than
younger students and Blacks. Among young
adults—males, Hispanics, Whites, and those with
lower levels of education are more likely to use
e-cigarettes than females, Blacks, and those with
higher levels of education.
6. The most commonly cited reasons for using
e-cigarettes among both youth and young adults are
curiosity, flavoring/taste, and low perceived harm
compared to other tobacco products. The use of
e-cigarettes as an aid to quit conventional cigarettes
is not reported as a primary reason for use among
youth and young adults.
7. Flavored e-cigarette use among young adult current
users (18–24 years of age) exceeds that of older adult
current users (25 years of age and older). Moreover,
among youth who have ever tried an e-cigarette, a
majority used a flavored product the first time they
tried an e-cigarette.
8. E-cigarette products can be used as a delivery
system for cannabinoids and potentially for other
illicit drugs. More specific surveillance measures are
needed to assess the use of drugs other than nicotine
in e-cigarettes.
Chapter 3. Health Effects of
E-Cigarette Use Among U.S. Youth
and Young Adults
1. Nicotine exposure during adolescence can cause addic-
tion and can harm the developing adolescent brain.
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 7
E-Cigarette Use Among Youth and Young Adults
2. Nicotine can cross the placenta and has known effects
on fetal and postnatal development. Therefore, nico-
tine delivered by e-cigarettes during pregnancy can
result in multiple adverse consequences, including
sudden infant death syndrome, and could result in
altered corpus callosum, deficits in auditory pro-
cessing, and obesity.
3. E-cigarettes can expose users to several chemicals,
including nicotine, carbonyl compounds, and vol-
atile organic compounds, known to have adverse
health effects. The health effects and potentially
harmful doses of heated and aerosolized constituents
of e-cigarette liquids, including solvents, flavorants,
and toxicants, are not completely understood.
4. E-cigarette aerosol is not harmless “water vapor,”
although it generally contains fewer toxicants than
combustible tobacco products.
5. Ingestion of e-cigarette liquids containing nicotine
can cause acute toxicity and possibly death if the
contents of refill cartridges or bottles containing
nicotine are consumed.
Chapter 4. Activities of the
E-Cigarette Companies
1. The e-cigarette market has grown and changed
rapidly, with notable increases in total sales of
e-cigarette products, types of products, consolida-
tion of companies, marketing expenses, and sales
channels.
2. Prices of e-cigarette products are inversely related
to sales volume: as prices have declined, sales have
sharply increased.
3. E-cigarette products are marketed in a wide variety
of channels that have broad reach among youth and
young adults, including television, point-of-sale,
magazines, promotional activities, radio, and the
Internet.
4. Themes in e-cigarette marketing, including sexual
content and customer satisfaction, are parallel to
themes and techniques that have been found to be
appealing to youth and young adults in conventional
cigarette advertising and promotion.
Chapter 5. E-Cigarette Policy and
Practice Implications
1. The dynamic nature of the e-cigarette landscape
calls for expansion and enhancement of tobacco-
related surveillance to include (a) tracking patterns
of use in priority populations; (b) monitoring the
characteristics of the retail market; (c) examining
policies at the national, state, local, tribal, and ter-
ritorial levels; (d)examining the channels and mes-
saging for marketing e-cigarettes in order to more
fully understand the impact future regulations
could have; and (e) searching for sentinel health
events in youth and young adult e-cigarette users,
while longer-term health consequences are tracked.
2. Strategic, comprehensive research is critical to
identify and characterize the potential health risks
from e-cigarette use, particularly among youth and
young adults.
3. The adoption of public health strategies that are pre-
cautionary to protect youth and young adults from
adverse effects related to e-cigarettes is justified.
4. A broad program of behavioral, communications,
and educational research is crucial to assess how
youth perceive e-cigarettes and associated mar-
keting messages, and to determine what kinds of
tobacco control communication strategies and
channels are most effective.
5. Health professionals represent an important
channel for education about e-cigarettes, particu-
larly for youth and young adults.
6. Diverse actions, modeled after evidence-based
tobacco control strategies, can be taken at the
state, local, tribal, and territorial levels to address
e-cigarette use among youth and young adults,
including incorporating e-cigarettes into smoke-
free policies; preventing the access of youth to
e-cigarettes; price and tax policies; retail licensure;
regulation of e-cigarette marketing that is likely to
attract youth and young adults, to the extent feasible
under the law; and educational initiatives targeting
youth and young adults. Among others, research
focused on policy, economics, and the e-cigarette
industry will aid in the development and imple-
mentation of evidence-based strategies and best
practices.
A Report of the Surgeon General
8 Chapter 1
Historical Background
Understanding the role of e-cigarettes requires
understanding the long history of tobacco use in the United
States, including the role of nicotine delivery, the mul-
tiple examples of “reduced-harm” products and associated
health claims, and the impact of using tobacco products on
the public’s health. Since the late nineteenth century, when
the “modern” cigarette came into use, scientists and public
health officials have linked cigarette smoking to a remark-
able number of adverse effects, and it is now recognized as
the primary cause of premature death in the United States
(USDHHS 2014). Correspondingly, for a century, manufac-
turers, scientists, entrepreneurs, and public health leaders
have promoted or recommended product changes that
might remove some of the harmful elements in cigarette
smoke. E-cigarettes are among the latest products.
E-cigarettes are designed for users to inhale nico-
tine, flavorings, and other additives through an aerosol.
The claims and marketing strategies employed by the
e-cigarette companies, and the efforts made by others to
develop scientific and regulatory tools to deal with these
new products, both contribute to the current discourse
on e-cigarettes. Many lessons for assessing the poten-
tial (and future) consequences of these products can be
learned from examining the relevant experiences of the
past century, especially the introduction of novel prod-
ucts (including e-cigarettes as well as other tobacco and
nicotine products) and the claims of reduced exposure to
toxins made by the industry and elsewhere.
Early Efforts to Modify Cigarettes
In the 1880s and 1890s, entrepreneurs promoted
novel products that allegedly blocked nicotine and other
constituents of conventional cigarettes believed to be
poisonous. Dr. Scott’s Electric Cigarettes, advertised
in Harper’s Weekly, claimed not only to light without
matches but also to contain a cotton filter that “strains
and eliminates the injurious qualities from the smoke,”
including nicotine (Harper’s Weekly 1887). Nicotine
delivery was essential to the development of the modern
cigarette in the twentieth century; early on, this substance
was thought to be addicting and thus vital to retaining
customers. In 1913, the Camel brand was a new kind of
cigarette that introduced high-nicotine content by using
burley tobacco, which was generally too harsh to inhale
into the lungs, but was made more inhalable through the
addition of casings (e.g., sugars, licorice) (Tindall 1992;
Proctor 2011). In 1916, American Tobacco introduced
its Lucky Strike blended cigarette, and in 1918 Liggett &
Myers (L&M) reformulated its Chesterfield brand to make
it more palatable to users. As the market grew, advertise-
ments for major brands routinely included health-related
statements and testimonials from physicians. During
the 1930s and 1940s, prominent advertising campaigns
included claims like “Not a cough in a carload” (Old Gold)
(Federal Trade Commission [FTC] 1964, p. LBA-5); “We
removed from the tobacco harmful corrosive ACRIDS
(pungent irritants) present in cigarettes manufactured
in the old-fashioned way” (Lucky Strike) (FTC 1964,
p. LBA-2); and “Smoking Camels stimulates the natural
flow of digestive fluids … increases alkalinity” (Camel)
(FTC 1964, p. LBA-1a). Thus, early modifications to the
cigarette were made so that it was more palatable, had a
higher nicotine delivery and uptake, and could be mar-
keted as “safe” (FTC 1964; Calfee 1985).
Filters, Tar Reduction, and Light and
Low-Tar Cigarettes
The landmark 1964 Surgeon General’s report on
smoking and health concluded that cigarette smoking
contributed substantially to mortality from certain spe-
cific diseases, including lung cancer (U.S. Department of
Health, Education, and Welfare 1964). Although the 1964
report considered the topic, it found the evidence insuffi-
cient to assess the potential health benefits of cigarette fil-
ters. Cigarettes with filters became the norm by the 1960s,
and marketing them with an overt message about harm
reduction became the standard (National Cancer Institute
[NCI] 1996). However, the Surgeon General convened
another group of experts on June 1, 1966, to review the
evidence on the role played by the tar and nicotine con-
tent in health. The group concluded that “[t]he prepon-
derance of scientific evidence strongly suggests that the
lower the ‘tar’ and nicotine content of cigarette smoke,
the less harmful are the effects” (Horn 1966, p. 16,168).
Subsequent studies have repeatedly failed to demonstrate
health benefits of smoking light and low-tar cigarettes
versus full-flavor cigarettes (Herning et al. 1981; Russell
et al. 1982; Benowitz et al. 1983, NCI 2001).
Over the years, the tobacco industry used multiple
methods to reduce the machine-tested yields of tar and
nicotine in cigarettes as a way to claim “healthier” ciga-
rettes. Beginning in the 1970s, tobacco companies adver-
tised the tar and nicotine levels for their cigarettes, which
encouraged smokers to believe, without substantiation,
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 9
E-Cigarette Use Among Youth and Young Adults
they could reduce their risk of exposure to these constitu-
ents (Cummings et al. 2002; Pollay and Dewhirst 2002).
In 1996, the FTC issued a statement that it would allow
cigarette companies to include statements about tar and
nicotine content in their advertising as long as they used a
standardized machine-testing method (Peeler 1996).
The Role of Nicotine and Nicotine
Delivery
Although the public health community under-
stood early on that nicotine was the primary psycho-
active ingredient in cigarette smoke, before the 1980s,
little was known about the importance of nicotine in the
addiction process beyond what the cigarette manufac-
turers had learned from their own research. Some scien-
tists warned that due to nicotine addiction, a reduction
in nicotine yields, along with decreases in tar, could lead
smokers to change their smoking behavior, such as by
smoking a greater number of cigarettes to maintain their
nicotine intake or changing their behavior in more subtle
ways, such as varying the depth of inhalation or smoking
more of the cigarette (Jarvis et al. 2001; National Cancer
Institute 2001; Thun and Burns 2001). Not until the 1970s
and 1980s, as researchers studying other forms of drug
abuse began to apply their research methods to cigarette
smoking, did it become apparent that nicotine was similar
in its addictive capability to other drugs of abuse, such as
heroin and cocaine (USDHHS 1981, 1988). As described
in the 1988 Surgeon General’s report and in subsequent
research, symptoms associated with nicotine addiction
include craving, withdrawal, and unconscious behaviors
to ensure consistent intake of nicotine (USDHHS 1988;
al’Absi et al. 2002; Hughes 2007).
Although the tobacco industry has long understood
the importance of nicotine to maintain long-term ciga-
rette smokers through addiction, public health officials
did not fully appreciate this in a broad sense until the
1988 Surgeon General’s report, The Health Consequences
of Smoking: Nicotine Addiction (USDHHS 1988).
FDA and Nicotine Regulation
In 1988 (and again in 1994), the Coalition on
Smoking OR Health and other public-interest organi-
zations petitioned FDA to classify low-tar and nicotine
products as drugs and to classify Premier, the short-
lived “smokeless cigarette product” from R.J. Reynolds,
as an alternative nicotine-delivery system (Stratton et al.
2001). The Coalition on Smoking OR Health cited indirect
claims made through advertising and marketing as evi-
dence of R. J. Reynolds’s intent to have the product used
for the mitigation or prevention of disease (Slade and
Ballin 1993). Meanwhile, FDA launched an investigation
into the practices of the tobacco industry, including the
manipulation of nicotine delivery. FDA asserted its juris-
diction over cigarettes and smokeless tobacco and issued
certain rules governing access to and promotion of these
products (Federal Register 1996). On March 21, 2000, the
U.S. Supreme Court ruled 5-4 that Congress had not yet
given FDA the necessary statutory authority to issue any
rules pertaining to tobacco products (Gottleib 2000; FDA
v. Brown & Williamson Tobacco Corp. 2000). The subse-
quent debate over control of nicotine products, including
their potential impact on youth, ultimately led to the pas-
sage of the 2009 Family Smoking Prevention and Tobacco
Control Act, which gave FDA authority to regulate tobacco
products. Thus, discussions about the introduction of
novel nicotine-containing tobacco products in the market
during the 1980s and 1990s helped shape the current reg-
ulation of tobacco and nicotine products.
New products introduced in the 1990s or later
included modified tobacco cigarettes (e.g., Advance,
Omni); cigarette-like products, also called cigalikes
(e.g., Eclipse, Accord); and smokeless tobacco products
(e.g., Ariva, Exalt, Revel, snus). Advance, made by Brown
and Williamson, was test-marketed with the slogan “All
of the taste … Less of the toxins.” Vector launched a
national advertising campaign for its Omni cigarette
with the slogan “Reduced carcinogens. Premium taste.”
In addition to the question of whether the claims were
supported by sufficient evidence, scientists and tobacco
control leaders raised concerns about the potential for
adverse consequences associated with novel nicotine and
tobacco products marketed for harm reduction, such as a
reduction in cessation rates or increased experimentation
by children (Warner and Martin 2003; Joseph et al. 2004;
Caraballo etal. 2006). Studies have shown that smokers
are interested in trying novel “reduced-exposure” products
and perceive them to have lower health risks, even when
advertising messages do not make explicit health claims
(Hamilton et al. 2004; O’Connor et al. 2005; Caraballo
etal. 2006; Choi et al. 2012; Pearson et al. 2012).
At FDA’s request, the Institute of Medicine (IOM
[now the National Academy of Medicine]) convened a
committee of experts to formulate scientific methods and
standards by which potentially reduced-exposure products
(PREPs), whether the purported reduction was pharma-
ceutical or tobacco related, could be assessed. The com-
mittee concluded that “[f]or many diseases attributable to
tobacco use, reducing risk of disease by reducing expo-
sure to tobacco toxicants is feasible” (Stratton et al. 2001,
p. 232). However, it also cautioned that “PREPs have not
A Report of the Surgeon General
10 Chapter 1
yet been evaluated comprehensively enough (including to less harm reduction for a population (as well as less risk
for a sufficient time) to provide a scientific basis for con- reduction for that individual) than would occur without
cluding that they are associated with a reduced risk of dis- the PREP, and possibly to an adverse effect on the popula-
ease compared to conventional tobacco use” (Stratton et al. tion” (Stratton et al. 2001, p. 235). Subsequently, in 2006,
2001, p. 232). The committee added that “the major con- Judge Kessler cited these findings in her decision which
cern for public health is that tobacco users who might demanded the removal of light and low-tar labeling due
otherwise quit will use PREPs instead, or others may ini- to the misleading nature of these claims (United States v.
tiate smoking, feeling that PREPs are safe. That will lead Philip Morris 2006).
The E-Cigarette
Invention of the E-Cigarette
An early approximation of the current e-cigarette
appeared in a U.S. patent application submitted in 1963 by
Herbert A. Gilbert and was patented in August 1965 (U.S.
Patent No. 3,200,819) (Gilbert 1965). The application was
for a “smokeless nontobacco cigarette,” with the aim of
providing “a safe and harmless means for and method of
smoking” by replacing burning tobacco and paper with
heated, moist, flavored air. A battery-powered heating ele-
ment would heat the flavor elements without combustion
(Gilbert 1965). The Favor cigarette, introduced in 1986,
was another early noncombustible product promoted
as an alternative nicotine-containing tobacco product
(United Press International 1986; Ling and Glantz 2005).
The first device in the recent innovation in
e-cigarettes was developed in 2003 by the Chinese pharma-
cist Hon Lik, a former deputy director of the Institute of
Chinese Medicine in Liaoning Province. Lik’s patent appli-
cation described a kind of electronic atomizing cigarette
(Hon 2013). With support from Chinese investors, in 2004
the product was introduced on the Chinese market under
the company name Ruyan (Sanford and Goebel 2014). The
product gained some attention among Chinese smokers
early on as a potential cessation device or an alternative
cigarette product.
The e-cigarette was part of the U.S. market by the
mid-2000s, and by 2010 additional brands started to
appear in the nation’s marketplace, including Ruyan and
Janty (Regan et al. 2013). Ruyan gained a U.S. patent for
its product with the application stating that the product
is “an electronic atomization cigarette that functions as
substitutes (sic) for quitting smoking and cigarette sub-
stitutes.” (U.S. Patent No. 8,490,628 B2, 2013). In August
2013, Imperial Tobacco Group purchased the intellectual
property behind the Ruyan e-cigarette for $75 million.
As of 2014 an estimated 90% of the world’s production
of e-cigarette technology and products came from main-
land China, mainly Guangdong Province and Zhejiang
Province (Barboza 2014).
Sales of e-cigarettes in the United States have risen
rapidly since 2007. Widespread advertising via television
commercials and through print advertisements for pop-
ular brands, often featuring celebrities, has contributed
to a large increase in e-cigarette use by both adults and
youth since 2010 (Felberbaum 2013; King et al. 2013;
Regan et al. 2013). Additionally, marketing through social
media, as well as other forms of Internet marketing, has
been employed to market these devices (Huang et al. 2014;
Kim et al. 2014).
In 2013, an estimated 13.1 million middle school
and high school students were aware of e-cigarettes
(Wang et al. 2014). According to data from the National
Youth Tobacco Survey, in 2011 the prevalence of current
e-cigarette use (defined as use during at least 1 day in
the past 30 days) among high school students was 1.5%;
prevalence increased dramatically, however, to 16% by
2015, surpassing the rate of conventional-cigarette use
among high school students (CDC 2016b; see Chapter
2). This equates to 2.4 million high school students and
620,000 middle school students having used an e-cigarette
at least one time in the past 30 days in 2015 (CDC 2016b).
These trends have led to substantial concern and
discussion within public health communities, including
state and national public health agencies, professional
organizations, and school administrators and teachers.
A primary concern is the potential for nicotine addiction
among nonsmokers, especially youth and young adults,
and that this exposure to nicotine among youth and young
adults is harmful. The diversity and novelty of e-cigarette
products on the market and ongoing product innova-
tions make assessments of the biological effects of current
e-cigarettes under actual conditions of use—such as their
long-term harmfulness—difficult to measure. Unanswered
questions remain about the risk profile of these devices,
their potential use by young people as a first step to other
nicotine products, and their total impact on public health.
There are diverging opinions about the potential public
health impact of these new products. Some public health
scientists have highlighted the potential for alternative
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 11
E-Cigarette Use Among Youth and Young Adults
nicotine products to serve as a substitute for conventional
cigarettes and thus a harm reduction tool (Henningfield
et al. 2003; Abrams 2014). Others have cautioned that
the use of alternative nicotine products might become
a bridge that may lead to greater tobacco product use—
including dual- or multiple-product use—or initiate nico-
tine addiction among nonsmokers, especially youth (Cobb
et al. 2010; Wagener et al. 2012; Benowitz and Goniewicz
2013; Britton 2013; Chapman 2013; Etter 2013; USDHHS
2014). Current evidence is insufficient to reject either of
these hypotheses.
E-Cigarette Products
Components and Devices
E-cigarette devices are composed of a battery, a res-
ervoir for holding a solution that typically contains nico-
tine, a heating element or an atomizer, and a mouthpiece
through which the user puffs (Figure 1.2). The device
heats a liquid solution (often called e-liquid or e-juice)
into an aerosol that is inhaled by the user. E-liquid typi-
cally uses propylene glycol and/or glycerin as a solvent for
the nicotine and flavoring chemicals
Flavors and E-Cigarettes
The e-liquids in e-cigarettes are most often flavored;
a study estimated that 7,700 unique flavors exist (Zhu
etal. 2014) and that most of them are fruit or candy fla-
vors (Figure 1.3). A content analysis of the products avail-
able via online retail websites documented that tobacco,
mint, coffee, and fruit flavors were most common, fol-
lowed by candy (e.g., bubble gum), unique flavors (e.g.,
Belgian waffle), and alcoholic drink flavors (e.g., straw-
berry daiquiri) (Grana and Ling 2014). Some retail stores
are also manufacturers that create custom flavors, which
increases the variety of flavors available.
The widespread availability and popularity of fla-
vored e-cigarettes is a key concern regarding the potential
public health implications of the products. The con-
cern, among youth, is that the availability of e-cigarettes
with sweet flavors will facilitate nicotine addiction and
simulated smoking behavior—which will lead to the
use of conventional tobacco products (Kong et al. 2015;
Krishnan-Sarin et al. 2015). Flavors have been used for
decades to attract youth to tobacco products and to mask
the flavor and harshness of tobacco (USDHHS 2012).
Industry documents show that tobacco companies mar-
keted flavored little cigars and cigarillos to youth and to
African Americans to facilitate their uptake of cigarettes
(Kostygina et al. 2014). Companies also intended flavored
smokeless tobacco products to facilitate “graduation” to
unflavored products that more easily deliver more nico-
tine to the user (USDHHS 2012). Various studies have
shown that youth are more likely than adults to choose
flavored cigarettes and cigars (CDC 2015b). Concern over
these findings led Congress to include a ban on character-
izing flavors for cigarettes, other than tobacco or menthol,
in the Tobacco Control Act. A similar concern exists about
e-cigarettes, and this concern is supported by studies indi-
cating that youth and young adults who have ever used
e-cigarettes begin their use with sweet flavors rather than
tobacco flavors (Kong et al. 2015; Krishnan-Sarin et al.
2015). Notably, 81.5% of current youth e-cigarette users
said they used e-cigarettes “because they come in flavors I
like” (Ambrose et al. 2015).
E-Cigarette Devices
First-generation e-cigarettes were often similar in
size and shape to conventional cigarettes, with a design
that also simulated a traditional cigarette in terms of the
colors used (e.g., a white body with tan mouthpiece).
These devices were often called cigalikes, but there were
other products designed to simulate a cigar or pipe. Other
cigalikes were slightly longer or narrower than a cigarette;
they may combine white with tan or may be black or col-
ored brightly. These newer models use a cartridge design
for the part of the device that holds the e-liquid, which is
either prefilled with the liquid or empty and ready to be
filled. The user then squeezes drops of the e-liquid onto a
wick (or bit of cotton or polyfil) connected to the heating
element and atomizer (Figure 1.4). As e-cigarettes have
become more popular, their designs have become more
diverse, as have the types of venues where they are sold
(Noel et al. 2011; Zhu et al. 2014).
Second-generation devices include products that
are shaped like pens, are comparatively larger and cylin-
drical, and are often referred to as “tank systems” in a nod
to the transparent reservoir that holds larger amounts
of e-liquid than previous cartridge-containing models.
Third- and fourth-generation devices represent a diverse
set of products and, aesthetically, constitute the greatest
departure from the traditional cigarette shape, as many
are square or rectangular and feature customizable and
rebuildable atomizers and batteries. In addition, since the
beginning of the availability of e-cigarettes and their com-
ponent parts, users have been modifying the devices or
building their own devices, which are often referred to
as “mods.” The differences in design and engineering of
the products are key factors in the size, distribution, and
amount of aerosol particles and the variability in levels of
chemicals and nicotine present in the e-liquid/aerosol and
delivered to the user (Brown and Cheng 2014).
A Report of the Surgeon General
12 Chapter 1
Figure 1.2 Parts of an e-cigarette device
Source: Photo by Mandie Mills, CDC.
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 13
E-Cigarette Use Among Youth and Young Adults
Figure 1.3 Examples of e-liquid flavors
Source: Photo by Mandie Mills, CDC.
Figure 1.4 E-liquids being poured into an e-cigarette device
Source: Photo by Mandie Mills, CDC.
E-Cigarette Product Components
and Risks
One of the primary features of the more recent gener-
ation of devices is that they contain larger batteries and are
capable of heating the liquid to a higher temperature, poten-
tially releasing more nicotine, forming additional toxicants,
and creating larger clouds of particulate matter (Bhatnagar
et al. 2014; Kosmider et al. 2014). For instance, one study
demonstrated that, at high temperatures (150°C), exceed-
ingly high levels of formaldehyde—a carcinogen (found to
be 10 times higher than at ambient temperatures)—are
present that are formed through the heating of the e-liquid
solvents (propylene glycol and glycerin), although the level
of tolerance of actual users to the taste of the aerosol heated
to this temperature is debated (Kosmider et al. 2014; CDC
2015a; Flavor and Extract Manufacturers Association of
the United States 2015; Pankow et al. 2015). There is also
concern regarding the safety of inhaling e-cigarette flavor-
ings. Although some manufacturers have claimed their
flavorants are generally recognized as safe for food addi-
tives (i.e., to be used in preparing foods for eating), little is
known about the long-term health effects of inhaling these
substances into the lungs (CDC 2015a).
Many devices can be readily customized by their
users, which is also leading to the concern that these
devices are often being used to deliver drugs other than
nicotine (Brown and Cheng 2014). Most commonly
reported in the news media, on blogs, and by user anecdote
A Report of the Surgeon General
14 Chapter 1
is the use of certain types of e-cigarette-related products
for delivering different forms of marijuana (Morean et al.
2015; Schauer et al. 2016). The tank systems, for example,
have been used with liquid tetrahydrocannabinol (THC)
or hash oil. Some personal vaporizer devices can be used
with marijuana plant material or a concentrated resin
form of marijuana called “wax.” One study describes the
use, in Europe, of e-cigarette devices to smoke marijuana
(Etter 2015).
The various e-cigarette products, viewed as a group,
lack standardization in terms of design, capacity for safely
holding e-liquid, packaging of the e-liquid, and features
designed to minimize hazards with use (Yang etal. 2014).
All of these design features may have implications for the
health impact of e-cigarette use. Notably, from 2010 to
2014, calls to poison control centers in the United States
about exposures related to e-cigarettes increased dramati-
cally. According to the American Association of Poison
Control Centers (2015), 271 cases were reported in 2011,
but 3,783 calls were reported in 2014. Among all calls,
51% involved exposure among children younger than
5years of age (CDC 2014). Most poisonings appear to have
been caused by exposure to nicotine-containing liquid
(CDC 2014). The lack of a requirement for child-resistant
packaging for e-liquid containers may have contrib-
uted to these poisonings. Since these data were released,
one death in the United States has been confirmed in a
child who drank e-liquid containing nicotine (Mohney
2014). Additionally, serious adverse reactions, including
at least two deaths, have been reported to FDA in cases
that could be attributed to the use of e-cigarettes (FDA
2013). This increase in poisonings prompted the Child
Nicotine Poisoning Prevention Act of 2015 (2016), which
was enacted in January 2016. This law requires any con-
tainer of liquid nicotine that is sold, manufactured, dis-
tributed, or imported into the United States to be placed
in packaging that is difficult to open by children under
5years of age.
Secondary risks are also of concern regarding
e-cigarettes, including passive exposure to nicotine and
other chemicals, and adverse events due to device mal-
function. Nicotine is a neuroteratogen, and its use by
pregnant women exposes a developing fetus to risks that
are well documented in the 50th-anniversary Surgeon
General’s report on smoking (USDHHS 2014) and include
impaired brain development (England et al. 2015) and
other serious consequences. Finally, another consequence
of the lack of device regulation is the occurrence of battery
failures and subsequent explosions. Explosions have typi-
cally occurred during charging, resulting in house and car
fires, and sometimes causing injuries to those involved.
From 2009 to late 2014, 25 incidents of explosions and
fires involving e-cigarettes occurred in the United States
(Chen 2013; U.S. Fire Administration 2014; FDA 2013).
E-Cigarette Companies
E-cigarette companies include manufacturers,
wholesalers, importers, retailers, distributors, and some
other groups that overlap with these entities (Barboza 2014;
Whelan 2015). Currently, most of the products are manu-
factured in Shenzhen, Guangdong Province, China (Cobb
et al. 2010; Grana et al. 2014; Zhu et al. 2014). One study
placed the number of brands at 466 in January 2014 and
found a net increase of 10.5 brands per month (Zhu etal.
2014). All the major tobacco companies (e.g., Reynolds
American, Altria; Table 1.1) and many smaller, indepen-
dent companies are now in the business. When e-cigarettes
first entered the U.S. market, they were sold primarily by
independent companies via the Internet and in shopping
malls at kiosks where those interested could sample the
products. A unique feature of the e-cigarette industry,
compared to other tobacco and nicotine products, is the
recruitment of visitors to their websites as “affiliates” or
distributors to help market the products and, in turn,
receive commissions on sales (Grana and Ling 2014; Cobb
et al. 2015). For example, some companies offer a way for
users to earn a commission by advertising the products
(e.g., a banner ad is placed on one’s website, and when
someone clicks on the link and subsequently purchases
a product, the website owner gets a percentage commis-
sion). Some companies also offer rewards programs for
recruiting new customers or for brand loyalty, with web-
site users earning points for free or reduced-price prod-
ucts (Richardson et al. 2015).
E-cigarettes are now in widespread national distribu-
tion through convenience stores, tobacco stores, pharma-
cies, “big box” retail chains such as Costco, online retailers,
and shops devoted to e-cigarette products (often called
“vape shops”) (Giovenco et al. 2015; Public Health Law
Center 2015). The “vape shops” offer a place to buy custom-
izable devices and e-liquid solutions in many flavors and
sometimes include a café or other elements that promote
socializing, essentially making such places like a lounge.
With the rapid increase in distribution and marketing in
the industry, sales have increased rapidly and were pro-
jected to reach $2.5billion in 2014 and $3.5 billion in 2015,
including projections for retail and online channels, as well
as “vape shops” (Wells Fargo Securities 2015).
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 15
E-Cigarette Use Among Youth and Young Adults
Table 1.1 Multinational tobacco companies with e-cigarette brands
Company E-cigarette brand
Altria (NuMark) MarkTen, Green Smoke
Philip Morris International Heat-not-burn, IQOS brand (Vape Ranks 2014)
E-cigs, Nicolites by Nicocigs (Philip Morris International 2014)
Reynolds (Reynolds Vapor Company) VUSE
Lorillard (Lorillard Vapor Company) blu (until 2015)
Imperial Tobacco (Fontem Ventures) Puritane (formerly Ruyan)
blu (acquired in 2015)
British American Tobacco Vype
Swisher E-swisher
Japan Tobacco International (JTI) E-Lites, offered in the United Kingdom by Zandera Ltd., which
was acquired by Japan Tobacco Inc. in 2014 (Japan Tobacco Inc.
2014)
Ploom (tobacco pods in heat-not-burn) and Ploom PAX (used for
vaporizing marijuana) (Japan Tobacco Inc. 2015)
The advertising and marketing of e-cigarette prod-
ucts has engendered skepticism among public health
professionals and legislators, who have noted many similar-
ities to the advertising claims and promotional tactics used
for decades by the tobacco industry to sell conventional
tobacco products (Campaign for Tobacco-Free Kids 2013;
CDC 2016a). Indeed, several of the e-cigarette marketing
themes have been reprised from the most memorable cig-
arette advertising, including those focused on freedom,
rebellion, and glamor (Grana and Ling 2014). E-cigarette
products are marketed with a variety of unsubstantiated
health and cessation messages, with some websites fea-
turing videos of endorsements by physicians (another
reprisal of old tobacco industry advertising) (Grana and
Ling 2014; Zhu et al. 2014). Unlike conventional cigarettes,
for which advertising has been prohibited from radio and
television since 1971, e-cigarette products are advertised on
both radio and television, with many ads featuring celeb-
rities. E-cigarettes also are promoted through sports and
music festival sponsorships, in contrast to conventional
cigarettes and smokeless tobacco products, which have
been prohibited from such sponsorships since the Master
Settlement Agreement in 1998. E-cigarettes also appear as
product placements in television shows and movies (Grana
et al. 2011; Grana and Ling 2014).
Another key avenue for e-cigarette promotion
is social media, such as Twitter, Facebook, YouTube,
and Instagram. As is true in the tobacco industry, the
e-cigarette industry organizes users through advocacy
groups (Noel et al. 2011; Harris et al. 2014; Saitta et al.
2014; Caponnetto et al. 2015). The extensive marketing
and advocacy through various channels broadens expo-
sure to e-cigarette marketing messages and products;
such activity may encourage nonsmokers, particularly
youth and young adults, to perceive e-cigarette use as
socially normative. The plethora of unregulated adver-
tising is of particular concern, as exposure to advertising
for tobacco products among youth is associated with ciga-
rette smoking in a dose-response fashion (USDHHS 2012).
Federal Regulation of E-Cigarettes
A “Two-Pronged” Approach to
Comprehensive Tobacco Control
Since the passage of the Tobacco Control Act in
2009, FDA has had the authority to regulate the manufac-
turing, distribution, and marketing of tobacco products
sold in the United States. FDA had immediate jurisdic-
tion over cigarettes, roll-your-own cigarette tobacco, and
smokeless tobacco. In May 2016, FDA asserted jurisdic-
tion over products that meet the statutory definition of
a tobacco product, including e-cigarettes, except accesso-
ries of these products (Federal Register 2016). That regu-
lation is currently under litigation.
A Report of the Surgeon General
16 Chapter 1
The IOM’s 2007 report, Ending the Tobacco Problem:
A Blueprint for the Nation, established a “two-pronged”
strategy for comprehensive tobacco control: (1)full imple-
mentation of proven, traditional tobacco control measures
such as clean indoor air laws, taxation, and countermar-
keting campaigns; and (2) “strong federal regulation of
tobacco products and their marketing and distribution”
(Bonnie et al. 2007, p. 1).
Included in FDA’s broad authority are the restric-
tion of marketing and sales to youth, requiring disclo-
sure of ingredients and harmful and potentially harmful
constituents, setting product standards (e.g., requiring
the reduction or elimination of ingredients or constitu-
ents), requiring premarket approval of new tobacco prod-
ucts and review of modified-risk tobacco products, and
requiring health warnings. The standard for FDA to use
many of its regulatory authorities is whether such an
action is appropriate for the protection of public health
(Federal Food, Drug, and Cosmetic Act, § 907(a)(3)(A)).
The public health standard in the Tobacco Control Act
also requires FDA to consider the health impact of certain
regulatory actions at both the individual and population
levels, including their impact on nonusers, and on initia-
tion and cessation (Federal Food, Drug, and Cosmetic Act,
§ 907(a)(3)(B)).
Importantly, the Tobacco Control Act preserves the
authority of state, local, tribal, and territorial govern-
ments to enact any policy “in addition to, or more strin-
gent than” requirements established under the Tobacco
Control Act “relating to or prohibiting the sale, distri-
bution, possession, exposure to, access to, advertising
and promotion of, or use of tobacco products by individ-
uals of any age” (Federal Food, Drug, and Cosmetic Act,
§ 916(a)(1)). This preservation of state and local authority
ensures the continuation of more local-level, compre-
hensive tobacco control. However, the statute expressly
preempts states and localities from establishing or con-
tinuing requirements that are different from or in addi-
tion to FDA requirements regarding standards for tobacco
products, premarket review, adulteration, misbranding,
labeling, registration, good manufacturing practices, or
modified-risk tobacco products (Federal Food, Drug, and
Cosmetic Act, § 916(a)(2)(A)). But this express preemp-
tion provision does not apply to state and local authority
to impose requirements relating to the “sale, distribution,
possession, information reporting to the State, exposure
to, access to, the advertising and promotion of, or use of,
tobacco products by individuals of any age . . .” (Federal
Food, Drug, and Cosmetic Act, § 916(a)(2)(b)). The inter-
action of these complex provisions related to federal pre-
emption of state law has been the subject of challenges
by the tobacco industry to state and local laws. Thus far,
courts have upheld certain local ordinances restricting the
sale of flavored tobacco products (National Association
of Tobacco Outlets, Inc. v. City of Providence 2013; U.S.
Smokeless Tobacco Manufacturing Co. v. City of New
York 2013).
Legal Basis for Regulating
E-Cigarettes as Tobacco Products
In the United States, e-cigarettes can be regulated
either as products marketed for therapeutic purposes or
as tobacco products. Since the advent of e-cigarettes in the
United States around 2007, manufacturers have had the
option to apply to FDA’s Center for Drug Evaluation and
Research (CDER) or Center for Devices and Radiological
Health (CDRH) for approval to market e-cigarettes for ther-
apeutic purposes; as of August 2016, no e-cigarette manu-
facturers have received approval through this avenue.
In 2008 and early 2009, FDA detained multiple ship-
ments of e-cigarettes from overseas manufacturers and
denied them entry into the United States on the grounds
that e-cigarettes were unapproved drug-device combina-
tion products (FDA 2011). Sottera, Inc., which now does
business as NJOY, challenged that determination (Smoking
Everywhere, Inc. and Sottera, Inc., d/b/a NJOY v. U.S. Food
and Drug Administration, et al. 2010; Bloomberg Business
2015). Between the filing of the lawsuit and a decision on
the motion for preliminary injunction, Congress passed
the Tobacco Control Act and the President signed it into
law. The Tobacco Control Act defines the term “tobacco
product,” in part, as any product, including component
parts or accessories, “made or derived from tobacco” that is
not a “drug,” “device,” or “combination product” as defined
by the Federal Food, Drug, and Cosmetic Act (21 U.S.C.
321(rr)) (Family Smoking Prevention and Tobacco Control
Act 2009, § 101(a)). The District Court subsequently
granted a preliminary injunction relying on the Supreme
Court’s decision in Brown and Williamson (1996) and the
recently enacted Tobacco Control Act. FDA appealed the
decision and the U.S. Court of Appeals for the D.C. Circuit
held that e-cigarettes and, therefore, other products “made
or derived from tobacco” are not drug/device combinations
unless they are marketed for therapeutic purposes, but can
be regulated by FDA as tobacco products under the Tobacco
Control Act (Sottera, Inc. v. Food & Drug Administration
2010).
On September 25, 2015, FDA proposed regulations
to describe the circumstances in which a product made
or derived from tobacco that is intended for human con-
sumption will be subject to regulation as a drug, device, or
a combination product. The comment period for this pro-
posed regulation closed on November 24, 2015.
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 17
E-Cigarette Use Among Youth and Young Adults
Most e-cigarettes marketed and sold in the United
States today contain nicotine made or derived from
tobacco. Although some e-cigarettes claim that they
contain nicotine not derived from tobacco, or that they
contain no nicotine at all (Lempert et al. 2016), there may
be reason to doubt some of these claims. Currently, syn-
thetic nicotine and nicotine derived from genetically mod-
ified, nontobacco plants are cost-prohibitive for e-cigarette
manufacturers, although technological advances could
eventually increase the cost-effectiveness of using nicotine
that was not derived from tobacco (Lempert et al. 2016).
The health effects of passive exposure to e-cigarettes with
no nicotine, as well as their actual use and the extent of
exposure to these products, have just begun to be studied
(Hall et al. 2014; Marini et al. 2014; Schweitzer et al. 2015)
and some states and localities are taking steps to regu-
late e-cigarettes that do not contain nicotine or tobacco
(Lempert et al. 2016).
Deeming Rule
The Tobacco Control Act added a new chapter to
the Federal Food, Drug, and Cosmetic Act, which pro-
vides FDA with authority over tobacco products. The new
chapter applied immediately to all cigarettes, cigarette
tobacco, roll-your-own tobacco, and smokeless tobacco;
and the law included “any other tobacco products that
the Secretary of Health and Human Services by regula-
tion deems to be subject to this chapter” (Federal Food,
Drug, and Cosmetic Act, §901 (b)). Therefore, to regu-
late e-cigarettes as tobacco products, FDA was required to
undertake a rulemaking process to extend its regulatory
authority to include e-cigarettes.
Consequently, in May 2016, through its Center
for Tobacco Products (CTP), FDA issued a rule—often
referred to as the “deeming rule”—to extend its authority
over all products meeting the definition of a tobacco
product, except accessories of the newly deemed products.
This rule extended FDA’s tobacco product authorities to
include e-cigarettes and their components and parts (e.g.,
nicotine cartridges), but also to such products as cigars,
pipe tobacco, nicotine gels, waterpipe/hookah tobacco,
and dissolvables not already regulated as smokeless
tobacco products (Federal Register 2016). This regulation
is currently under litigation. The deeming rule subjects
e-cigarettes to Tobacco Control Act provisions, including:
• Prohibitions on adulterated and misbranded
products;
• Required disclosure of existing health information,
including lists of ingredients and documents on
health effects;
• Required registration of manufacturers;
• Required disclosure of a list of all tobacco prod-
ucts, including information related to labeling and
advertising;
• Premarket review of new tobacco products
(i.e.,those not on the market on February 15, 2007);
• Restrictions on products marketed with claims
about modified risk.
In addition to the aforementioned Tobacco Control
Act provisions applicable to all deemed tobacco products,
the Tobacco Control Act grants FDA authority to under-
take a broad range of other actions on specific classes
of products. In its deeming rule, FDA included the fol-
lowing additional actions for tobacco products, including
e-cigarettes:
• Minimum age restrictions to prevent sales to minors;
• Requirements to include a nicotine warning; and
• Prohibitions on vending machine sales, unless in a
facility that never admits youth.
Future Regulatory Options
E-cigarette manufacturers have the option to apply
to FDA to authorize the marketing of their products or
to be able to manufacture and sell tobacco products mar-
keted with modified-risk claims, in addition to the existing
option to apply to FDA’s CDER or CDRH for approval to
market their products for therapeutic purposes. FDA also
has authority to undertake a number of actions if the
Secretary of USDHHS finds such actions to be appropriate
for the protection of public health, including:
• Product standards, including restrictions on flavors;
• Restrictions on promotion, marketing, and adver-
tising, and prohibitions on brand-name sponsorship
of events;
• Minimum package sizes;
• Prohibitions on self-service displays;
A Report of the Surgeon General
18 Chapter 1
• Child-resistant packaging and the inclusion of
health warnings; and
• Regulation of nicotine levels in products.
Despite this broad authority, FDA is prohibited from
certain regulatory actions, even if those actions may be
appropriate for the protection of public health. Specifically,
FDA generally cannot restrict tobacco use in public places,
levy taxes on tobacco products, prohibit sales by a specific
category of retail outlet (e.g., pharmacies), completely elim-
inate nicotine in tobacco products, require prescriptions
for tobacco products unless it is marketed for therapeutic
purposes, or establish a federal minimum age of sale for
tobacco products above 18 years of age. Thus, even if FDA
fully exercises all of its existing authority over e-cigarettes,
regulation will still need to be complemented at the state
and local levels, including efforts previously shown to be
effective for conventional tobacco products, such as compre-
hensive smokefree laws at the state and local levels, pricing
strategies, raising the minimum age of sales to minors to
21, and high-impact countermarketing campaigns. In the
current context of rising rates of use by youth, localities
and states can also implement policies and programs that
minimize the individual- and population-level harms of
e-cigarettes (see Chapter 5).
Summary
This chapter presents the major conclusions of
this Surgeon General’s report and the conclusions of
each chapter. E-cigarettes are presented within their his-
torical context, with an overview of the components of
these devices and the types of products. In 2016, FDA
announced its final rule to regulate e-cigarettes under the
Family Smoking Prevention and Tobacco Control Act. The
chapter outlines options for the regulation of e-cigarettes,
particularly as they relate to youth and young adults,
based on successful smoking policies. The need to protect
youth and young adults from initiating or continuing the
use of nicotine-containing products forms a strong basis
for the need to regulate e-cigarettes at the local, state, and
national levels in the future.
Introduction, Conclusions, and Historical Background Relative to E-Cigarettes 19
E-Cigarette Use Among Youth and Young Adults
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25
Chapter 2
Patterns of E-Cigarette Use Among U.S. Youth and
Young Adults
Introduction 27
Sources of Data 27
Other Literature 27
Key Findings 28
Youth 28
Current Prevalence 28
Trends in Prevalence 28
Young Adults 37
Current Prevalence 37
Trends in Prevalence 37
E-Cigarette Use and Use of Other Tobacco Products 37
Cross-Sectional Studies 37
Longitudinal Studies 53
E-Cigarette Use and Other Substance Use 57
E-Cigarettes and Marijuana 58
Use of Flavored E-Cigarettes 58
Consumer Perceptions of E-Cigarettes 59
Perceived Harm of E-Cigarettes 59
Reasons for Use and Discontinuation 75
Evidence Summary 86
Conclusions 88
References 89
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 27
E-Cigarette Use Among Youth and Young Adults
Introduction
This chapter documents patterns and trends in
awareness of electronic cigarettes (e-cigarettes), their
use, and perceptions about these devices among youth
and young adults in the United States. Both the aware-
ness of e-cigarettes and levels of their use have increased
rapidly throughout the U.S. population. Understanding
young people’s patterns of e-cigarette use is essential
to determining the scope of potential benefits or harms
that these products may have from a public health per-
spective. This chapter summarizes the patterns of use of
e-cigarettes, identifies subgroups at higher risk for using
them, highlights the ways in which e-cigarettes are used
with other tobacco products, and identifies correlates of
e-cigarette use, including knowledge, attitudes, beliefs,
and sociodemographic characteristics. In most cases, the
term “e-cigarette(s)” is used, but when needed to accord
with usage in the cited literature, the acronym “ENDS”
(electronic nicotine delivery systems) is employed.
Sources of Data
Data summarized in this chapter come from nation-
ally representative datasets that were federally funded and
peer-reviewed literature of subnational and international
surveillance studies of e-cigarette use that were mostly
cross-sectional in design. Appendix 2.1. and Table A2.1-1
in that appendix
1
1
All appendixes and appendix tables that are cross-referenced in this chapter are available only online at http://www.surgeongeneral.gov/
library/reports/
describe all the years of data available
for these data sources, but only selected years are used for
this report. For youth, this report relies on data from the
National Youth Tobacco Survey (NYTS) and the Monitoring
the Future Study (MTF), as measures of e-cigarette
use were available for at least two or more time points.
For this reason, the report also relies on data from the
National Adult Tobacco Survey (NATS) for young adults.
More recently, the Youth Risk Behavior Surveillance
System and other surveys from the National Center for
Health Statistics have added measures of e-cigarette use
to their surveys, but only one data point was available at
the time this report was prepared. Only five longitudinal
studies were available on this topic at the time this report
was prepared (Leventhal et al. 2015; Primack et al. 2015;
Barrington-Trimis et al. 2016; Unger et al. 2016; Wills
etal. 2016). Because e-cigarettes only became prevalent
in the tobacco product marketplace in recent years, min-
imal data are available on their use before 2011. Given the
paucity of surveillance information on e-cigarettes and the
low prevalence of their use in the early years of their avail-
ability in the United States, peer-reviewed studies with
smaller subnational samples are used in this chapter to
complement national surveillance data. Surveillance of
e-cigarette use presents a unique set of challenges, given
the emerging and dynamic market specific to these prod-
ucts (see Chapter 4 for more on the latter topic). Appendix
2.1 and Tables A2.2-1 and A2.2-2 in Appendix 2.2 summa-
rize the key terms and measures used in this chapter.
Other Literature
This chapter also summarizes findings from peer-
reviewed literature on e-cigarettes that were identified
through a systematic review of studies of these products
from the United States and abroad. A literature search was
conducted in April 2015 (Glasser et al. 2015) using the
National Library of Medicine’s PubMed database and the
following keywords: “e-cigarette*” OR “electronic ciga-
rette” OR “electronic cigarettes” OR “electronic nicotine
delivery” OR “vape” OR “vaping.” Articles were excluded
from this review for any of five reasons: (1) the article was
not available in English; (2) the article was not relevant
to e-cigarettes; (3) the study included nonhuman sub-
jects; (4)the study did not include original data; or (5)the
study did not include findings specific to adolescents or
young adults. More details about this review’s method-
ology are available in Glasser and colleagues’ (2015) report.
The search was subsequently updated in November 2015,
January 2016, and March 2016 during continued devel-
opment of the report. For consistency, the same search
strategy and databases were employed at all times. Studies
on patterns of e-cigarette use behaviors for both youth and
young adults are reviewed in the text and tables that follow.
All other studies not explicitly described in the text are sum-
marized in Appendix 2.3 and Tables A2.3-1 through A2.3-3.
A Report of the Surgeon General
28 Chapter 2
Key Findings
Youth
Current Prevalence
Ever Use
According to the 2015 National Youth Tobacco Survey
(NYTS), an estimated 27.1% of U.S. adolescents, repre-
senting approximately 7,260,500 persons, had ever tried
e-cigarettes (Centers for Disease Control and Prevention
[CDC], unpublished data [NYTS 2015]). This included
13.5% of middle school students and 37.7% of high school
students (Tables 2.1a and 2.1b). Among middle school stu-
dents, use was comparable between boys and girls, but it
was higher among Hispanics compared with other racial/
ethnic groups (Table 2.1a). For high school students, use
was also comparable between boys and girls, but higher
among both White and Hispanic youth compared with
Black youth (Table 2.1b). According to data from the 2015
Youth Risk Behavior Survey (YRBS), a larger percentage
of high school students (44.9%) had ever used e-cigarettes
(Kann et al. 2016), while the Monitoring the Future (MTF)
survey does not collect data on ever use of e-cigarettes
(Johnston et al. 2016).
Past-30-Day Use
According to the 2015 NYTS, an estimated 620,000
middle school students and 2,390,000 high school students
had used e-cigarettes at least once in the past 30days (CDC
2016). This was an increase from the 2014 NYTS, which
reported 450,000 middle school students and 2,010,000 high
school students had used e-cigarettes in the past 30 days
(CDC 2015c). Levels of past-30-day use were 5.3% for
middle school students and 16% for high school students in
2015 (Tables 2.2a and 2.2b), compared with 3.9% for middle
school students and 13.4% for high school students in 2014.
Sociodemographic differences in past-30-day use for middle
and high school students had the same patterns as those for
ever use (Tables2.2a and 2.2b). In 2015, according to the
YRBS, 24.1% of high school students had used e-cigarettes
at least once in the past 30 days (Kann et al. 2016). The 2015
MTF shows past-30-day prevalence of e-cigarette use among
adolescents was 9.5% among 8th graders, 14% among
10thgraders, and 16% among 12th graders (Johnston etal.
2016). Notably, data from NYTS, YRBS, and MTF show that
in 2014 exclusive past-30-day use of e-cigarettes exceeded
exclusive past-30-day use of conventional cigarettes for the
first time since these types of data were collected (University
of Michigan 2014; CDC 2015c).
Frequency of Use
Among middle school students, according to the
2015 NYTS, 5.3% were current users of e-cigarettes,
and 0.6% used e-cigarettes frequently (defined as using
an e-cigarette 20 or more days in the past 30 days pre-
ceding the survey) (Table 2.1a). Among high school stu-
dents, these estimates were 15.5% and 2.5%, respectively
(Table 2.1b). Due to smaller sample sizes, confidence
intervals were too wide to determine sociodemographic
differences in these measures. These estimates are consis-
tent with a report by CDC (2015b).
A recent analysis of 2014 MTF data, specific to high
school seniors, showed the frequency of e-cigarette use
(defined as the number of days in the past 30 days a student
used an e-cigarette) increases with ever cigarette smoking
(Warner et al. 2016). Among high school seniors who used
at least 1 e-cigarette in the past 30 days, the frequency
of e-cigarette use was almost twice as high (10.2 days)
among those who regularly smoke conventional ciga-
rettes, compared to those who had never smoked a con-
ventional cigarette (5.8 days). However, the frequency of
e-cigarette use did not vary substantially among current
cigarette smokers. Among high school seniors who used
at least 1 e-cigarette in the past 30 days, the frequency
of e-cigarette use averaged 8–10 days for “heavy cigarette
smokers” (those who smoked more than a half pack of
cigarettes per day), “light cigarette smokers” (those who
smoked 1–5 cigarettes per day), and “very light cigarette
smokers” (those who smoked fewer than 1 cigarette per
day) (Warner et al. 2016).
Susceptibility to Use
Among those who had never used an e-cigarette,
32.1% of middle school students and 38.4% of high school
students were susceptible to using e-cigarettes in the
future. That is, these students did not have a firm resolve
not to use e-cigarettes in the future. This is according to the
2015 NYTS (Tables 2.1a and 2.1b). No differences in suscep-
tibility to use e-cigarettes were observed by gender or race/
ethnicity for either middle school or high school students.
Trends in Prevalence
Ever Use
Overall, according to the NYTS, ever use of
e-cigarettes among students in grades 6–12 increased
from 3.3% in 2011, to 6.8% in 2012, to 8.1% in 2013, to
19.8% in 2014, and then to 27% in 2015 (Figure 2.1). As
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 29
Table 2.1a Percentage of middle school students who have used e-cigarettes, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS)
2015
Ever use
a
Current use
b
Frequent use
c
:
Among current
users
Frequent use
c
:
Among all students
Susceptibility to
use
d
: Among never
users
Susceptibility to
use
d
: Among all
students
Characteristic
% (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 13.5 (11.8–15.5) 0.9 5.3 (4.6–6.2) 0.4 11.7 (8.6–15.8) 1.8 0.6 (0.4–0.9) 0.1 32.1 (29.7–34.7) 1.3 41.4 (38.3–44.5) 1.5
Gender
Female 12.2 (10.5–14.1) 0.9 4.8 (4.0–5.6) 0.4 11.0 (6.9–17.0) 2.5 0.5 (0.3–0.8) 0.1 33.1 (30.2–36.2) 1.5 41.4 (38.0–44.8) 1.7
Male 14.9 (12.9–17.2) 1.1 5.9 (4.7–7.2) 0.6 11.8 (8.3–16.5) 2.0 0.7 (0.5–1.0) 0.1 31.3 (28.2–34.6) 1.6 41.6 (37.9–45.4) 1.9
Race/ethnicity
White 12.2 (10.1–14.5) 1.1 4.4 (3.6–5.5) 0.5 10.8 (6.5–17.5) 2.7 0.5 (0.3–0.8) 0.1 29.7 (26.1–33.6) 1.9 38.0 (33.7–42.5) 2.2
Black or
African
American
11.7 (9.5–14.3) 1.2 4.1 (3.1–5.3) 0.6 14.0 (5.9–29.6) 5.7 — — 34.7 (30.7–39.0) 2.1 42.5 (39.0–46.2)
1.8
Hispanic or
Latino
18.6 (15.9–21.5) 1.4 8.3 (6.8–10.0) 0.8 12.1 (7.5–18.9) 2.8 1.0 (0.6–1.6) 0.2 38.0 (35.2–40.8) 1.4 49.8 (46.9–52.7) 1.5
Other
e
11.9 (8.2–17.1) 2.2 4.6 (2.7–7.7) 1.2 — — — — 30.4 (24.7–36.8) 3.1 39.5 (33.2–46.2) 3.3
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%.
a
Includes those who reported using an e-cigarette, even once or twice.
b
Includes those who reported using e-cigarettes on 1 or more days in the past 30 days.
c
Includes those who responded “≥20 days” to the following question: “During the past 30 days, on how many days did you use electronic cigarettes or e-cigarettes?”
See CDC (2015b).
d
Includes those who failed to respond “denitely not” to any of the following questions: (a) “Do you think that you will try an electronic cigarette or e-cigarette soon?”;
(b) “If one of your best friends were to offer you an electronic cigarette or e-cigarette, would you use it?”; or (c) “Have you ever been curious about using an electronic
cigarette or e-cigarette, even once or twice?”
e
Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacic Islander, and non-Hispanic American Indian/Alaska Native.
A Report of the Surgeon General
30 Chapter 2
Table 2.1b Percentage of high school students who have used e-cigarettes, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS) 2015
Ever use
a
Current use
b
Frequent use
c
:
Among current
users
Frequent use
c
:
Among all students
Susceptibility to
use
d
: Among never
users
Susceptibility to
use
d
: Among all
students
Characteristic
% (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 37.7 (35.3–40.2) 1.2 16 .0 (14.1–18.0) 1.0 15.5 (12.9–18.4) 1.4 2.5 (1.9–3.2) 0.3 38.4 (36.5–40.4) 1.0 61.1 (59.0–63.2) 1.0
Gender
Female 34.6 (31.9–37.3) 1.4 12.8 (11.0–15.0) 1.0 10.1 (7.2–14.0) 1.7 1.3 (0.9–1.8) 0.2 39.8 (37.4–42.2) 1.2 60.3 (58.1–62.5) 1.1
Male 40.7 (37.7–43.7) 1.5 19.0 (16.5–21.7) 1.3 19.1 (15.6–23.1) 1.9 3.6 (2.7–4.8) 0.5 36.9 (34.3–39.5) 1.3 61.8 (59.2–64.4) 1.3
Race/ethnicity
White 38.0 (35.1–41.0) 1.5 17.2 (14.7–19.9) 1.3 16.8 (13.4–20.8) 1.9 2.9 (2.1–3.9) 0.4 36.3 (33.4–39.4) 1.5 60.1 (57.4–62.7) 1.3
Black or
African
American
28.5 (25.5–31.8) 1.6 8.9 (7.4–10.8) 0.8 8.5 (3.9–17.4) 3.2 0.8 (0.3–1.7) 0.3 37.2 (32.2–42.5) 2.6 54.5 (51.0–57.9) 1.7
Hispanic or
Latino
43.0 (38.9–47.2) 2.1 16.4 (14.1–19.0) 1.2 12.8 (9.3–17.3) 2.0 2.1 (1.4–3.1) 0.4
44.6 (41.2–48.0) 1.7 67.8 (64.3–71.1) 1.7
Other
e
37.4 (24.8–52.1) 7.0 18.9 (10.3–32.2) 5.5 18.2 (11.2–28.2) 4.3 3.4 (2.1–5.7) 0.9 41.2 (35.4–47.3) 3.0 62.6 (54.0–70.5) 4.2
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Note: CI = confidence interval; SE = standard error.
a
Includes those who reported using an e-cigarette, even once or twice.
b
Includes those who reported using e-cigarettes on 1 or more days in the past 30 days.
c
Includes those who responded “≥20 days” to the following question: “During the past 30 days, on how many days did you use electronic cigarettes or e-cigarettes?”
See CDC (2015b).
d
Includes those who failed to respond “denitely not” to any of the following questions: (a) “Do you think that you will try an electronic cigarette or e-cigarette soon?”;
(b) “If one of your best friends were to offer you an electronic cigarette or e-cigarette, would you use it?”; or (c) “Have you ever been curious about using an electronic
cigarette or e-cigarette, even once or twice?”
e
Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacic Islander, and non-Hispanic American Indian/Alaska Native.
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 31
Table 2.2a Percentage of middle school students who used e-cigarettes in the past 30 days
a
, by gender and race/ethnicity; National Youth Tobacco
Survey (NYTS) 2011–2015
2011 2012 2013 2014 2015
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 0.6 (0.4–0.9) 0.1 1.1 (0.9–1.5) 0.1 1.1 (0.8–1.5) 0.2 3.9 (3.0–5.0) 0.5 5.3 (4.6–6.2) 0.4
Gender
Female 0.4 (0.2–0.7) 0.1 0.8 (0.5–1.1) 0.1 0.9 (0.6–1.4) 0.2 3.3 (2.5–4.3) 0.5 4.8 (4.0–5.6) 0.4
Male 0.7 (0.4–1.3) 0.2 1.5 (1.1–2.1) 0.3 1.4 (0.9–1.9) 0.2 4.5 (3.4–5.9) 0.6 5.9 (4.7–7.2) 0.6
Race/ethnicity
White 0.6 (0.3–1.0) 0.2 0.9 (0.6–1.3) 0.2 0.9 (0.6–1.4) 0.2 3.1 (2.2–4.2) 0.5 4.4 (3.6–5.5) 0.5
Black or African
American
— — 1.1 (0.6–2.2) 0.4 1.4 (0.7–2.5) 0.4 3.8 (2.5–5.6) 0.7 4.1 (3.1–5.3) 0.6
Hispanic or
Latino
0.6 (0.4–1.1) 0.2 2.0 (1.4–2.9) 0.4 1.8 (1.1–2.7) 0.4 6.2 (4.8–7.9) 0.8 8.3 (6.8–10.0) 0.8
Other
b
— — — — — — 3.2 (1.6–6.3) 1.1 4.6 (2.7–7.7) 1.2
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: CI = condence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of
questions used to measure e-cigarette use varied from 2011 to 2015.
a
Includes those who reported using e-cigarettes on 1 or more of the past 30 days. This is also considered “current use” in this survey.
b
Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacic Islander, and non-Hispanic American Indian/Alaska Native.
A Report of the Surgeon General
32 Chapter 2
Table 2.2b Percentage of high school students who used e-cigarettes in the past 30 days
a
, by gender and race/ethnicity; National Youth Tobacco Survey
(NYTS) 2011–2015
2011 2012 2013 2014 2015
Characteristic % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 1.5 (1.2–2.0) 0.2 2.8 (2.3–3.5) 0.3 4.5 (3.8–5.3) 0.4 13.4 (11.2–16.1) 1.2 16.0 (14.1–18.0) 1.0
Gender
Female 0.7 (0.5–1.0) 0.1 1.9 (1.5–2.4) 0.2 3.5 (2.8–4.3) 0.4 11.9 (9.7–14.5) 1.2 12.8 (11.0–15.0) 1.0
Male 2.3 (1.7–3.2) 0.4 3.7 (2.9–4.8) 0.5 5.5 (4.5–6.8) 0.6 15.0 (12.4–18.2) 1.4 19.0 (16.5–21.7) 1.3
Race/ethnicity
White 1.8 (1.3–2.4) 0.3 3.4 (2.7–4.2) 0.4 4.8 (3.8–6.1) 0.6 15.3 (12.4–18.8) 1.6 17.2 (14.7–19.9) 1.3
Black or African
American
— — 1.1 (0.7–1.9) 0.3 2.7 (1.9–3.9) 0.5 5.6 (3.7–8.5) 1.2 8.9 (7.4–10.8) 0.8
Hispanic or
Latino
1.3 (0.8–2.1) 0.3 2.7 (1.9–3.8) 0.5 5.3 (4.2–6.6) 0.6 15.3 (11.8–19.5) 1.9 16.4 (14.1–19.0) 1.2
Other
b
— — — — 4.0 (2.3–6.9) 1.1 9.4 (6.8–12.9) 1.5 18.9 (10.3–32.2) 5.5
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: CI = condence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of
questions used to measure e-cigarette use varied from 2011 to 2015.
a
Includes those who reported using e-cigarettes on 1 or more of the past 30 days. This is also considered “current use” in this survey.
b
Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacic Islander, and non-Hispanic American Indian/Alaska Native.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 33
E-Cigarette Use Among Youth and Young Adults
(Continued from last paragraph on page 28.)
discussed in Appendix 2.2 (see NYTS Measures—Special
Issues), measures of e-cigarette use were changed for
the 2014 NYTS, as signaled by the dotted line in the
figure. Research conducted using the New Jersey Youth
Tobacco Survey suggests that the NYTS measures used
in 2011–2013 may potentially underestimate use, com-
pared with the 2014 measure (Delnevo et al. 2016). For
the 2011−2015 period, use of e-cigarettes was higher in
each year among high school students than among middle
school students (Tables 2.3a and 2.3b).
Figure 2.1 Trends in ever e-cigarette use
a
among U.S. middle and high school students; National Youth Tobacco
Survey (NYTS) 2011–2015
Source: Centers for Disease Control and Prevention 2013a, 2014b; unpublished data (data: NYTS 2015).
Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of this
estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent these differences.
a
Includes those who responded “1 or more” to the following question: During the last 30 days, on how many days did you use
electronic cigarettes or e-cigarettes?
Middle school students. Trends in ever use of
e-cigarettes among U.S. middle school students are pre-
sented in Table 2.3a and Figure 2.1, using data from the
2011–2015 NYTS. The prevalence of ever use increased
from 1.4% in 2011 to 2.7% in 2012, to 3.0% in 2013, to
10.1% in 2014, and then to 13.5% in 2015. The jump in
prevalence between 2013 and 2014 may be an artifact of a
change in how the use item was asked (see Appendix2.2.
Key Measures of Use). Nonetheless, prevalence of use would
be expected to be minimal prior to 2011, suggesting that a
considerable increase in use was still observed during this
relatively short 4-year period. In 2015, among middle school
students, an estimated 1,595,481 had ever tried e-cigarettes
(CDC, unpublished data [NYTS 2015]). From 2011 to 2013,
the prevalence of ever use did not differ significantly by
gender or race/ethnicity. There remained no significant dif-
ference in ever use by gender in the 2014 or 2015 NYTS, but
by 2014 and still in 2015, a greater percentage of Hispanic
middle school students (18.6%) had tried e-cigarettes than
White (12.2%) or Black (11.7%) students or students of
other races/ethnicities (11.9%) (Table 2.3a).
High school students. Trends in ever use of
e-cigarettes among U.S. high school students are pre-
sented in Tables 2.3b and Figure 2.1, using data from the
2011–2015 NYTS. The prevalence of ever use increased
from 4.7% in 2011 to 10% in 2012, to 11.9% in 2013,
to 27.3% in 2014, and then to 37.7% in 2015. In that year,
an estimated 5,624,876 high school students had ever
used e-cigarettes (CDC, unpublished data [NYTS 2015]).
In 2011–2013, male high school students had a higher
rate of ever use each year compared with female students,
but in 2014 the genders did not differ significantly in their
rates. From 2011 to 2015, White and Hispanic high school
students were more likely each year to be ever users than
were Black students: In 2015, these figures were 38% and
43%, respectively, for White and Hispanic students com-
pared with 28.5% for Black students.
A Report of the Surgeon General
34 Chapter 2
Table 2.3a Percentage of middle school students who have ever used e-cigarettes
a
, by gender and race/ethnicity; National Youth Tobacco Survey
(NYTS) 2011–2015
2011 2012 2013 2014 2015
Characteristic
% (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 1.4 (1.0–2.0) 0.2 2.7 (2.2–3.2) 0.2 3.0 (2.5–3.5) 0.2 10.1 (8.5–11.9) 0.8 13.5 (11.8–15.5) 0.9
Gender
Female 1.2 (0.8–1.6) 0.2 2.4 (1.9–3.0) 0.3 2.8 (2.3–3.5) 0.3 9.9 (7.8–12.6) 1.2 12.2 (10.5–14.1) 0.9
Male 1.7 (1.1–2.7) 0.4 3.0 (2.4–3.6) 0.3 3.1 (2.5–3.9) 0.3 10.3 (8.6–12.3) 0.9 14.9 (12.9–17.2) 1.1
Race/ethnicity
White 1.5 (0.9–2.3) 0.3 2.6 (2.1–3.3) 0.3 3.0 (2.4–3.7) 0.3 8.9 (7.2–11.1) 1.0 12.2 (10.1–14.5) 1.1
Black or African
American
1.2 (0.7–2.0) 0.3 2.3 (1.3–4.2) 0.7 2.7 (1.9–3.7) 0.5 9.7 (7.9–11.9) 1.0 11.7 (9.5–14.3) 1.2
Hispanic or Latino 1.6 (1.1–2.3) 0.3 3.3 (2.3–4.6) 0.6 3.9 (2.9–5.2) 0.6 14.6 (12.2–17.4) 1.3 18.6 (15.9–21.5) 1.4
Other
b
— — 1.0 (0.5–2.2) 0.4 — — 6.5 (3.9–10.9) 1.7 11.9 (8.2–17.1) 2.2
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%. Wording of
questions used to measure e-cigarette use varied from 2011 to 2015.
a
Includes those who reported ever trying e-cigarettes.
b
Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacic Islander, and non-Hispanic American Indian/Alaska Native.
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 35
Table 2.3b Percentage of high school students who have ever used e-cigarettes
a
, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS)
2011–2015
2011 2012 2013 2014 2015
Characteristic
% (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 4.7 (3.8–5.7) 0.5 10.0 (8.6–11.6) 0.7 11.9 (10.5–13.5) 0.8 27.3 (24.4–30.5) 1.5 37.7 (35.3–40.2) 1.2
Gender
Female 3.5 (2.7–4.4) 0.4 8.0 (6.7–9.5) 0.7 9.9 (8.3–11.7) 0.8 24.5 (21.4–27.9) 1.6 34.6 (31.9–37.3) 1.4
Male 5.9 (4.7–7.3) 0.7 12.0 (10.2–14.1) 1.0 13.8 (12.1–15.8) 0.9 30.1 (27.2–33.3) 1.5 40.7 (37.7–43.7) 1.5
Race/ethnicity
White 5.8 (4.6–7.4) 0.7 12.3 (10.5–14.4) 1.0 14.7 (12.8–16.9) 1.0 29.7 (26.2–33.4) 1.8 38.0 (35.1–41.0) 1.5
Black or African
American
1.5 (0.9–2.4) 0.4 4.0 (3.1–5.1) 0.5 4.9 (3.6–6.6) 0.7 17.6 (14.1–21.8) 1.9 28.5 (25.5–31.8) 1.6
Hispanic or
Latino
3.7 (2.5–5.5) 0.7 8.5 (6.6–10.8) 1.0 10.4 (8.6–12.5) 1.0 29.9 (25.4–34.9) 2.4 43.0 (38.9–47.2) 2.1
Other
b
2.8 (1.7–4.6) 0.7 6.0 (3.3–10.8) 1.8 8.3 (5.3–12.8) 1.8 18.7 (14–24.5) 2.6 37.4 (24.8–52.1) 7.0
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: CI = confidence interval; SE = standard error. Wording of questions used to measure e-cigarette use varied from 2011 to 2015.
a
Includes those who reported ever trying e-cigarettes.
b
Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacic Islander, and non-Hispanic American Indian/Alaska Native.
A Report of the Surgeon General
36 Chapter 2
Past-30-Day Use
According to the NYTS, past-30-day use of
e-cigarettes among students in grades 6−12 in the
United States increased from 1.1% in 2011 to 2.1% in
2012, to 3.1% in 2013, to 9.3% in 2014, and then 11.3%
in 2015 (CDC 2013b; Ambrose et al. 2014; Lippert 2015;
CDC, unpublished data) (Figure 2.2). In 2015, approxi-
mately 3,038,000 middle and high school students were
past-30-day users of e-cigarettes (CDC, unpublished
data [NYTS 2015]). Across all years, past-30-day use of
e-cigarettes was higher among high school students than
middle school students (Figure 2.2; Tables 2.2a and 2.2b).
In the MTF, estimates were stable from 2014 to 2015;
among 8th, 10th, and 12th graders, past-30-day use went
from 8.7% to 9.5%, 16.2% to 14%, and 17.1% to 16.2%,
respectively (University of Michigan, Institute for Social
Research, unpublished data). Differences in trends in past-
30-day use between the NYTS and MTF may be due to dif-
ferences in age groups (e.g., the NYTS includes all grades
in middle school and all grades in high schools) and the
way in which these measures were asked on the instru-
ments (see Table A2.2-1 in Appendix 2.2).
Figure 2.2 Trends in past-30-day e-cigarette use
a
among U.S. middle and high school students; National Youth
Tobacco Survey (NYTS) 2011–2015
Source: Centers for Disease Control and Prevention 2013a, 2014b; unpublished data (data: NYTS 2015).
Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of this
estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent these differences.
a
Includes those who responded “1 or more” for the following question: “During the last 30 days, on how many days did you use
electronic cigarettes or e-cigarettes?”
Middle school students. Trends in past-30-day use of
e-cigarettes among middle school students in the United
States are presented in Table 2.2a and Figure 2.2, again
using data from the 2011–2015 NYTS. The prevalence of
such use in this population increased from 0.6% in 2011
to 1.1% in 2012 and 2013, to 3.9% in 2014, and then to
5.3% in 2015 (Table 2.2a) (CDC 2016). Between 2011 and
2015, there were no significant differences in prevalence
by gender; unstable estimates (see notes to the table)
precluded an examination of differences in past-30-day
e-cigarette use by race/ethnicity for 2011–2013. In 2014,
the prevalence of past-30-day use was higher among
Hispanics (6.2%) than Whites (3.1%), a trend that was also
seen in 2015 with 8.3%of Hispanics and 4.4% of Whites
reporting past-30-day use. From 2011 to 2015, increases
were seen among females (0.4% to 4.8%), males (0.7% to
5.9%), Whites (0.6% to 4.4%), Hispanics (0.6% to 8.3%),
and Blacks (1.1% in 2012 to 4.1%) (Table2.2a) (CDC2013b;
CDC 2015c; CDC 2016).
High school students. Trends in past-30-day use
of e-cigarettes among high school students are also pre-
sented in Table 2.2b and Figure 2.2, again using data from
the 2011−2015 NYTS. The prevalence of such use in this
population increased from 1.5% in 2011 to 2.8%in 2012,
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 37
E-Cigarette Use Among Youth and Young Adults
to 4.5% in 2013, to 13.4% in 2014, and then to 16% in
2015. From 2011 to 2013 and in 2015, males were signifi-
cantly more likely each year to be past-30-day users than
were females, but this difference was not significant in
2014 (Table 2.2b). From 2012 to 2015, Black high school
students were less likely each year to be past-30-day
users than were White or Hispanic high school stu-
dents (Table 2.2b). During 2011–2015, large increases
in past-30-day use were seen among females (0.7% to
12.8%), males (2.3% to 19%), Whites (1.8% to 17.2%),
and Hispanics (1.3% to 16.4%) (Table 2.2b) (CDC 2013b,
2015c, 2016).
Young Adults
Current Prevalence
According to the 2013–2014 National Adult Tobacco
Survey (NATS), among young U.S. adults aged 18–24 years,
the prevalence of ever use and current use of e-cigarettes
was 35.8% and 13.6%, respectively (Table 2.4a). These
percentages were significantly higher than for the same
measures among adults aged 25 years or over (16.4%and
5.7%, respectively) (Table 2.4b). Among young adults,
ever and current use were both higher among males than
females and for Whites than in other racial/ethnic groups
(Table 2.4a). By educational attainment, among young
adults, both ever and current use were lowest among
those with a college degree (Table 2.4a). Among all young
adults, 2%reported using e-cigarettes “every day”; while
among current users in this age group, 15% reported this
frequency (Table 2.4a). Use of e-cigarettes “every day”
among older adults (≥25 years of age) was 1.3% overall
and 22%among current users (Table 2.4b). Among young
adults, sociodemographic differences in frequent use fol-
lowed the same pattern as those for ever and current use
(Table 2.4a).
Trends in Prevalence
According to the Styles (also known as HealthStyles
or Summer Styles) survey, the prevalence of ever use of
e-cigarettes among young adults aged 18–24 years was
6.9% in 2011, 4.1% in 2012, 7.8% in 2013, and 14.3%in
2014, a year that saw the addition of other products to
this measure, including e-hookahs and e-pipes or e-cigars
(Figure 2.3). Although the prevalence of ever use of
e-cigarettes among young adults remained consistent
from 2010 to 2013, it doubled from 2013 to 2014, pre-
sumably reflecting in part the addition of new products
to the definition of e-cigarettes. In 2010, young adults
(18–24 years) were more likely than older adults (25–44
and 45–64 years of age) to be ever users of e-cigarettes
(King et al. 2015). In 2014, ever use of e-cigarettes or sim-
ilar products was statistically equivalent between young
adults (18–24 years old) at 14.3%, adults 25–44 years old
at 15%, and adults 45–64 years old at 11.9% (p >0.05)
(CDC, unpublished data [Styles 2014]).
E-Cigarette Use and Use of Other
Tobacco Products
Evidence from both national and regional studies
suggests that e-cigarette use is strongly associated with
other tobacco use, especially the use of combustible prod-
ucts (including conventional cigarettes, cigar products,
and hookahs). However, many youth and young adults
use e-cigarettes exclusively, too. Estimates from cross-
sectional surveys such as the NYTS, MTF, and NATS are
presented below for youth and young adults, followed by
longitudinal studies that examine whether e-cigarette use
precedes the use of other tobacco products (Leventhal
etal. 2015; Primack et al. 2015; Barrington-Trimis et al.
2016; Unger et al. 2016; Wills et al. 2016).
Cross-Sectional Studies
Youth
Current prevalence. Using data from the 2015 MTF
survey, Figure 2.4 and Table 2.5 show past-30-day use of
e-cigarettes and conventional cigarettes, including both
exclusive and combined use of these products, among
8th-, 10th-, and 12th-grade students. In the 2015 MTF
survey, 10.4% of 12th graders used e-cigarettes only,
5.3% used conventional cigarettes only, and 5.8% used
both e-cigarettes and conventional cigarettes at least once
in the past 30 days (Table 2.5) (MTF 2015a,b). For all grade
levels, exclusive use of e-cigarettes was more prevalent
(6.8%, 10.4%, and 10.4% of 8th, 10th, and 12th graders,
respectively) than exclusive use of conventional cigarettes
alone (1.4%, 2.2%, 5.3%, respectively). In the 8th and
10th grades, the combined or dual use of e-cigarettes and
conventional cigarettes was also more prevalent than the
use of conventional cigarettes alone (2.4% vs. 1.4%, and
3.5%vs. 2.2% for 8th and 10th
graders, respectively); while
in the 12th grade, the prevalence in the two categories was
nearly identical (5.8% vs. 5.3%). As grade level increases,
the ratio of any e-cigarette use to any conventional ciga-
rette use decreases. Among 12th
graders, dual use of these
products was higher among boys than girls and among
Whites than Blacks. In all grade levels, dual use was much
higher among students who planned to attend fewer
than 4 years of college compared to those who planned
to attend 4 years of college. No other sociodemographic
A Report of the Surgeon General
38 Chapter 2
Table 2.4a Percentage of young adults (18–24 years of age) who have used e-cigarettes, by gender, race/ethnicity, and education; National Adult
Tobacco Survey (NATS) 2013–2014
Ever use
a
Current use
b
Frequent use
c
: Among
current users
Frequent use
c
:
Among all young adults
Characteristic
% (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall
35.8 (34.1–37.6) 0.9
13.6 (12.5–14.8)
0.6
15.0 (12.1–18.5) 1.6 2.0 (1.6–2.6) 0.2
Gender
Female
28.4 (26.1–30.8) 1.2
9.8 (8.3–11.5)
0.8
10.0 (6.5–15.1) 2.2 1.0 (0.6–1.5) 0.2
Male
42.9 (40.4–45.3) 1.2
17.1 (15.4–19.0)
0.9
17.8 (13.9–22.5) 2.2 3.0 (2.3–4.0) 0.4
Race/ethnicity
White
39.7 (37.4–41.9) 1.2
16.1 (14.5–17.8)
0.9
15.3 (11.7–19.7) 2.0 2.5 (1.9–3.2) 0.4
Black or African
American
23.1 (19.0–27.8) 2.3
5.4 (3.7–7.9)
1.1
— — — —
Hispanic or Latino
36.6 (32.6–40.7) 2.1
13.4 (10.9–16.4)
1.4
12.0 (6.8–20.2) 3.3 1.6 (0.9–2.8) 0.5
Other
d
30.8 (25.8–36.3) 2.7
10.8 (8.1–14.2)
1.6
21.5 (11.6–36.4) 6.3
2.3 (1.2–4.4) 0.8
Education
< High school
44.8 (38.9–50.9) 3.1
15.2 (11.5–19.7)
2.1
9.8 (4.8–18.8)
3.4 1.5 (0.7–3.0) 0.5
High school
39.4 (36.7–42.2) 1.4
14.9 (13.1–17.0)
1.0
17.6 (13.0–23.4) 2.6 2.6 (1.9–3.6) 0.4
Some college
e
34.3 (31.6–37.0) 1.4
14.7 (12.8–16.8)
1.0
14.8 (10.2–21.0) 2.7 2.2 (1.5–3.2) 0.4
College degree
f
16.9 (14.2–20.0) 1.5
4.5 (3.1–6.4)
0.8
— — — —
Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
Notes: CI = confidence interval; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard error >40%.
a
Includes those who reported they had heard of e-cigarettes and tried e-cigarettes.
b
Includes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.
c
Includes those who reported they had heard of e-cigarettes, tried e-cigarettes, and reported using e-cigarettes every day at the time of the interview.
d
Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacic Islander, non-Hispanic American Indian/Alaska Native, and multiracial.
e
Includes some college, no degree; associate’s degree, academic program; associate’s degree, unspecied; certicate; diploma; or associate’s degree.
f
Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 39
Table 2.4b Percentage of adults (≥25 years of age) who have used e-cigarettes, by gender, race/ethnicity, and education; National Adult Tobacco Survey
(NATS) 2013–2014
Ever use
a
Current use
b
Frequent use
c
: Among
current users
Frequent use
c
:
Among all adults
Characteristic
% (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 16.4 (15.9–16.8)
0.2 5.7 (5.5–6.0) 0.1
22.0 (20.1–24.0) 1.0 1.3 (1.1–1.4) 0.1
Gender
Female
14.7 (14.2–15.3)
0.3 5.0 (4.7–5.4) 0.2
20.6 (18.1–23.3) 1.3 1.0 (0.9–1.2) 0.1
Male
18.3 (17.6–18.9)
0.3 6.6 (6.1–7.0) 0.2
23.0 (20.2–25.9) 1.5 1.5 (1.3–1.7) 0.1
Race/ethnicity
White
16.2 (15.8–16.7)
0.2 6.0 (5.7–6.4) 0.2
23.9 (21.7–26.3) 1.2 1.4 (1.3–1.6) 0.1
Black or African
American
15.1 (13.9–16.5)
0.7 3.8 (3.2–4.5) 0.3 15.2 (10.2–22.2) 3.0 0.6 (0.4–0.9) 0.1
Hispanic or Latino 15.6 (14.3–17.0)
0.7 4.9 (4.1–5.8) 0.4
15.8 (10.4–23.4) 3.3 0.8 (0.5–1.2) 0.2
Other
d
21.0 (19.2–22.9)
0.9 8.0 (6.7–9.4) 0.7
19.4 (14.0–26.2) 3.1 1.5 (1.1–2.1) 0.3
Education
<High school
18.2 (16.8–19.7)
0.8 5.2 (4.4–6.1) 0.4
20.8 (15.2–27.7) 3.2 1.1 (0.8–1.5) 0.2
High school
20.6 (19.7–21.6)
0.5 7.6 (7.0–8.3) 0.3
19.2 (16.1–22.7) 1.7 1.5 (1.2–1.8) 0.1
Some college
e
19.7 (18.9–20.5)
0.4 7.4 (6.8–7.9) 0.3
24.5 (21.4–27.8) 1.6 1.8 (1.6–2.1) 0.1
College degree
f
8.7 (8.2–9.1)
0.2 2.8 (2.5–3.1) 0.1
22.0 (18.1–26.4) 2.1 0.6 (0.5–0.8) 0.1
Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
Note: CI = confidence interval; SE = standard error.
a
Includes those who reported they had heard of and tried e-cigarettes.
b
Includes those who reported they had heard, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.
c
Includes those who reported they had heard of, tried, and reported using e-cigarettes every day at the time of the interview.
d
Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic American Indian/Alaska Native, and multiracial.
e
Includes some college, no degree; associate’s degree, academic program; associate’s degree, unspecified; certificate; diploma; or associate’s degree.
f
Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
A Report of the Surgeon General
40 Chapter 2
Figure 2.3 Trends in ever e-cigarette use
a
among U.S. adults by age group; Styles 2010–2014
Source: King et al. (2015) (data: HealthStyles 2010–2013); Centers for Disease Control and Prevention, unpublished data (data:
HealthStyles 2014).
Note: In 2014, modifications were made to the e-cigarette measure to enhance its accuracy, which may limit the comparability of
this estimate to those collected in previous years. The dotted lines from 2013 to 2014 represent these differences.
a
Includes those who responded “electronic cigarettes or e-cigarettes” to the following question, “Have you ever tried any of the
following products, even just one time? Electronic cigarettes or e-cigarettes, such as Ruyan or NJOY?”
Figure 2.4 Percentage of students in grades 8, 10, and 12 who used e-cigarettes and cigarettes in the past 30 days;
Monitoring the Future (MTF) 2015
Source: University of Michigan, Institute for Social Research, unpublished data (data: MTF 2015).
Note: Questions on e-cigarette use were asked on four of six questionnaire forms. Data presented here are based on those four
forms only.
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 41
Table 2.5 Percentage of students in grades 8, 10, and 12 who used e-cigarettes, cigarettes, or both products in the past 30 days, by sociodemographic characteristics;
Monitoring the Future (MTF) 2015
8th grade 10th grade 12th grade
Neither: %
(95% CI)
E-cigarettes
only: %
(95%CI)
Cigarettes
only: %
(95%CI)
Both: %
(95% CI)
Neither: %
(95% CI)
E-cigarettes
only: %
(95%CI)
Cigarettes
only: %
(95%CI)
Both: %
(95% CI)
Neither: %
(95% CI)
E-cigarettes
only: %
(95% CI)
Cigarettes
only: %
(95%CI)
Both: %
(95%CI)
Overall 89.4
(88.4–90.5)
6.8
(5.8–7.8)
1.4
(0.9–1.8)
2.4
(1.9–2.9)
83.9
(81.9–85.9)
10.4
(9.0–11.8)
2.2
(1.7–2.7)
3.5
(2.8–4.3)
78.5
(76.7–80.3)
10.4
(9.1–11.8)
5.3
(4.6–6.0)
5.8
(5.0–6.6)
Gender
Female 90.2
(88.7–91.7)
6.2
(4.9–7.5)
1.4
(0.7–2.0)
2.2
(1.6–2.9)
85.6
(83.6–87.6)
8.6
(7.2–10.1)
2.4
(1.6–3.1)
3.4
(2.5–4.3)
84.4
(82.8–86.0)
7.1
(6.2–8.0)
4.7
(3.6–5.7)
3.8
(3.1–4.6)
Male 88.9
(87.3–90.4)
7.2
(6.0–8.5)
1.4
(0.7–2.0)
2.5
(1.7–3.3)
82.2
(79.6–84.7)
12.2
(10.2–14.2)
2.0
(1.3–2.7)
3.6
(2.6–4.7)
72.9
(70.2–75.6)
14.1
(11.8–16.3)
5.6
(4.6–6.6)
7.5
(6.1–8.9)
Race/
ethnicity
White 90.1
(88.6–91.6)
6.2
(4.9–7.4)
1.2
(0.6–1.8)
2.6
(1.7–3.4)
82.1
(79.5–84.7)
11.2
(9.2–13.2)
2.3
(1.6–2.9)
4.4
(3.4–5.4)
75.2
(72.7–77.7)
12.0
(10.4–13.6)
5.8
(4.7–6.9)
7.1
(5.9–8.3)
African
American
91.2
(88.2–94.1)
5.3
(2.7–7.8)
2.1
(0.6–3.7)
1.5
(0.0–2.9)
89.9
(85.7–94.1)
6.6
(3.6–9.5)
1.8
(0.4–3.1)
1.7
(0.4–3.1)
87.7
(85.1–90.3)
5.2
(3.8–6.6)
5.1
(3.3–6.8)
2.0
(1.1–3.0)
Hispanic 88.7
(85.8–91.5)
8.2
(6.1–10.4)
0.9
(0.2–1.6)
2.2
(1.2–3.2)
84.6
(81.5–87.6)
10.5
(7.6–13.4)
2.4
(0.9–4.0)
2.5
(0.8–4.2)
80.9
(78.0–83.7)
10.3
(8.0–12.5)
4.4
(3.2–5.5)
4.5
(3.1–6.0)
College
plans
None or
<4years
76.8
(71.0–82.5)
10.1
(6.1–14.0)
4.9
(1.7–8.1)
8.3
(4.8–11.8)
66.3
(61.1–71.5)
15.4
(11.3–19.4)
7.0
(3.8–10.2)
11.3
(7.6–15.1)
65.1
(61.2–68.9)
13.0
(9.7–16.3)
10.2
(8.2–12.3)
11.7
(9.5–13.9)
Complete
4years
90.5
(89.4–91.5)
6.5
(5.5–7.4)
1.1
(0.7–1.5)
2.0
(1.5–2.5)
85.7
(83.6–87.7)
9.8
(8.3–11.4)
1.7
(1.3–2.2)
2.8
(2.1–3.5)
81.6
(79.9–83.2)
9.9
(8.6–11.1)
4.1
(3.4–4.8)
4.5
(3.8–5.2)
A Report of the Surgeon General
42 Chapter 2
8th grade 10th grade 12th grade
Neither: %
(95% CI)
E-cigarettes
only: %
(95%CI)
Cigarettes
only: %
(95%CI)
Both: %
(95% CI)
Neither: %
(95% CI)
E-cigarettes
only: %
(95%CI)
Cigarettes
only: %
(95%CI)
Both: %
(95% CI)
Neither: %
(95% CI)
E-cigarettes
only: %
(95% CI)
Cigarettes
only: %
(95%CI)
Both: %
(95%CI)
Parental
education
a
1–2 (Low) 88.1
(83.9–92.2)
5.9
(3.3–8.4)
1.8
(0.3–3.2)
4.3
(2.1–6.6)
77.2
(72.0–82.4)
12.6
(9.0–16.2)
4.8
(1.5–8.0)
5.4
(3.1–7.8)
77.3
(73.4–81.2)
10.1
(7.3–13.0)
7.9
(5.4–10.4)
4.7
(3.1–6.3)
2.5–3 86.2
(83.3–89.1)
9.4
(6.7–12.1)
1.8
(0.6–3.1)
2.6
(1.2–3.9)
81.7
(78.3–85.2)
10.6
(8.1–13.0)
2.5
(1.3–3.7)
5.2
(3.2–7.1)
75.2
(72.4–78.1)
11.1
(9.0–13.3)
7.2
(5.5–8.8)
6.5
(5.0–7.9)
3.5–4 89.6
(87.5–91.8)
7.3
(5.5–9.2)
1.3
(0.3–2.3)
0.8
(1.7–2.7)
83.5
(80.3–86.7)
10.0
(7.7–12.3)
2.8
(1.7–3.9)
3.7
(2.5–5.0)
78.7
(75.9–81.5)
9.9
(7.9–11.8)
4.6
(3.6–5.6)
6.8
(5.3–8.4)
4.5–5 91.0
(89.1–92.8)
6.2
(4.5–7.9)
1.3
(0.4–2.1)
1.5
(0.6–2.5)
86.1
(83.5–88.8)
9.7
(7.5–11.8)
1.4
(0.7–2.0)
2.9
(1.7–4.1)
78.6
(75.7–81.5)
11.2
(9.1–13.2)
4.4
(3.3–5.5)
5.8
(4.4–7.2)
5.5–6
(High)
91.9
(89.4–94.5)
5.2
(3.3–7.0)
1.0
(0.0–2.1)
1.9
(0.4–3.4)
87.6
(83.6–91.6)
9.2
(6.3–12.2)
1.0
(0.2–1.8)
2.2
(0.7–3.7)
82.7
(79.7–85.7)
10.4
(8.1–12.7)
3.2
(2.1–4.3)
3.7
(2.2–5.2)
Source: University of Michigan, Institute for Social Research, unpublished data (data: MTF 2015).
Notes: Questions on e-cigarette use were asked on four of six questionnaire forms. Data presented here are based on those four forms only.
a
Parental education is an average score of mother’s education and father’s education.
Table 2.5 Continued
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 43
E-Cigarette Use Among Youth and Young Adults
(Continued from last paragraph on page 37.)
differences were observed among dual users (Table 2.5).
For 10th and 12th graders, exclusive use of e-cigarettes
was higher among boys than girls.
Tables 2.6a and 2.6b present data from the 2015 NYTS
for middle and high school students. These data represent
the percentages of tobacco users who were either lifetime
or past-30-day users of e-cigarettes, by tobacco-use cat-
egory (e.g., cigarettes only, other combustibles only). In
these data, a correlation among the increasing levels of
tobacco use, increasing complexity of poly-tobacco use, and
e-cigarette use is apparent, with ever use and past-30-day
use of e-cigarettes emerging as least prevalent among never
tobacco users and most prevalent among the highest cat-
egory of poly-tobacco users (conventional cigarettes plus
other combustibles and noncombustibles) for both age
groups. As an example, past-30-day e-cigarette use was
rare (2.8%) among middle school students who did not
use other tobacco products in that time period. However,
using the standard of past-30-day-use for each category, the
level of such use grew from 44.9% among those who had
used cigarettes only; to 61.3% among those who had used
cigarettes and other combustibles only; to 74.6% among
those who had used cigarettes, other combustibles, and
other noncombustibles only (Table 2.6a). These data are
consistent with results from the 2013–2014 PATH study
(n = 13,651 youth, 12–17 years old), which showed that
52.6% of past-30-day tobacco users also used e-cigarettes
(Kasza et al. 2016).
According to the 2015 NYTS, among high school stu-
dents, past-30-day use of e-cigarettes was also rare (3.4%)
among never users of other tobacco products (Table 2.6b).
In contrast, 18.4% of ever smokers of cigarettes only;
36.3% of ever smokers of cigarettes and other combustible
products only; and 55% of ever users of cigarettes, other
combustibles, and other noncombustible products only
had used e-cigarettes in the past 30 days. Although the
survey found that just 7.3% of high school students were
past-30-day exclusive users of e-cigarettes, many types of
tobacco product users in the past 30 days were found to
have used e-cigarettes in that period: 41.1% of cigarette-
only smokers; 58.8% of cigarette smokers and smokers of
other combustible tobacco products only; and 77% of cig-
arette, other combustible, and noncombustible product
users only. Similarly, 27.4% of high school students who
had not used tobacco products in the past 30 days had ever
tried e-cigarettes, as had 80.8% of past-30-day cigarette-
only smokers and 95.5% of those who had used cigarettes,
other combustible, and other noncombustible tobacco
products only (Table 2.6b).
Figure 2.5 presents data from the 2015 NYTS on the
prevalence of past-30-day use of various tobacco products
among middle and high school students. Although the
overall level of tobacco use was lower in middle school,
the patterns of poly-tobacco use were similar between the
two groups, albeit with a larger proportion of poly-tobacco
use in high school. An estimated 6.6% of high school stu-
dents and 1.8% of middle school students were dual users
of combustible tobacco products and e-cigarettes in 2015.
Combined use of combustible tobacco, noncombustible
tobacco, and e-cigarettes in the past 30 days was rare,
with this pattern found for just 0.7% of middle school
and 2.6% of high school students in 2015 (Figure 2.5).
Longitudinal data are needed to follow individuals over
time, ideally for several years, to more precisely examine
both the trajectories into and out of cigarette and
e-cigarette use and to determine if dual use is a steady state
or a pathway-to-persistent-use-of-combustible-tobacco
state (Cobb et al. 2015). The small number of such studies
that currently exist are discussed below.
Trends in prevalence. Tables 2.7a and 2.7b and
Figures 2.6 and 2.7 present patterns of ever e-cigarette
and poly-tobacco use over time, using the NYTS data
from 2011 to 2015. Among both middle school and high
school students, the exclusive use of combustible prod-
ucts declined over time, while both the exclusive use of
e-cigarettes and the dual use of e-cigarettes with combus-
tible products increased, especially from 2013 to 2015.
Middle school students. In 2011, an estimated
21%of middle school students had ever used some form
of tobacco in their lifetimes, compared to just 1.4% of
middle school students who had ever used e-cigarettes
(Table 2.7a). By 2015, 13.5% of middle school students
had ever tried a tobacco product, while 3.5% had tried
e-cigarettes. In that year, 4.5% of middle school students
were ever users of e-cigarettes only; 6.2% were ever users
of e-cigarettes and combustible products only; and 2.2%
were ever users of combustible products, noncombustible
products, and e-cigarettes. This means that 70% of middle
school students who had ever used e-cigarettes had
also experimented with a combustible tobacco product,
although which came first is unknown. In 2015, for
past-30-day use, exclusive e-cigarette use was 2.6% and
exclusive combustible tobacco use was 1.2%. Also in 2015,
the prevalence of past-30-day dual use of e-cigarettes and
any other combustible or noncombustible product was
similar to those estimates, at 2.7% (1.8% for e-cigarettes
plus combustibles only, 0.2% for noncombustibles and
e-cigarettes only, and 0.7% for e-cigarettes plus combusti-
bles and noncombustibles only). In 2015, ever use of ciga-
rettes in combination with combustibles (6.2%) was equal
to or higher than ever use of e-cigarettes only (4.5%) or
combustibles only (4.4%) (Table 2.7a).
High school students. In 2011, an estimated 47.2%of
high school students had ever used other tobacco prod-
ucts in their lifetimes, compared to 4.7% who had ever
used e-cigarettes (Table 2.7b). By 2015, 50.4% of high
A Report of the Surgeon General
44 Chapter 2
Table 2.6a Lifetime and past-30-day e-cigarette use among U.S. middle school students, by other tobacco product
use; National Youth Tobacco Survey (NYTS) 2015
Lifetime e-cigarette use
a
Past-30-day
e-cigarette use
b
N
c
% (95% CI) SE % (95% CI) SE
Ever other tobacco use
d
(n=1,757) 8,162
Never 6,942 5.3 (4.5–6.2) 0.4 1.6 (1.3–2.0) 0.2
Cigarettes only 343 54.3 (46.7–61.7) 3.8 20.8 (15.7–27.0) 2.8
Other combustibles only 261 59.0 (51.5–66.1) 3.7 24.8 (19.0–31.7) 3.2
Noncombustibles only 89 30.7 (23.2–39.3) 4.1 — —
Cigarettes + other combustibles only 300 70.6 (62.9–77.3) 3.6 35.0 (27.5–43.3) 4.0
Cigarettes + noncombustibles only 67 69.5 (54.5–81.3) 6.9 21.7 (12.7–34.6) 5.5
Other combustibles + noncombustibles only 27 80.3 (56.1–92.9) 9.2 39.4 (20.3–62.3) 11.2
Cigarettes + other combustibles + noncombustibles
only
133 84.1 (73.3–91.1) 4.4 45.0 (34.7–55.7) 5.3
Past-30-day other tobacco use
e
(n=417) 8,145
No 7,728 10.5 (9.1–12.0) 0.7 2.8 (2.3–3.4) 0.3
Cigarettes only 70 80.6 (68.3–89.0) 5.2 44.9 (32.0–58.6) 6.8
Other combustibles only 153 82.8 (74.0–89.1) 3.8 69.2 (59.1–77.8) 4.7
Noncombustibles only 50 49.0 (34.9–63.3) 7.3 23.1 (12.7–38.2) 6.4
Cigarettes + other combustibles only 63 77.3 (58.8–89.0) 7.6 61.3 (43.9–76.2) 8.4
Cigarettes + noncombustibles only 18 87.2 (65.2–96.1) 7.2 67.8 (40.0–87.0) 12.6
Other combustibles + noncombustibles only 20 87.5 (63.2–96.6) 7.7 64.8 (42.2–82.3) 10.6
Cigarettes + other combustibles + noncombustibles
only
43 85.8 (67.5–94.6) 6.5 74.6 (43.4–91.8) 12.7
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = condence interval; SE = standard error. Cigarettes Only includes those who reported trying cigarettes but not any other
tobacco product. Other combustibles includes cigars, pipes, and hookah or bidis. Noncombustibles includes smokeless tobacco, dissolv-
ables, or snus. Other Combustibles Only includes those who reported trying other combustibles but not cigarettes nor noncombustibles.
Noncombustibles Only includes those who reported trying noncombustibles but not cigarettes nor other combustibles. Cigarettes and
Other Combustibles Only includes those who reported trying cigarettes and other combustibles but not noncombustibles. Cigarettes
and Noncombustibles Only includes those who reported trying cigarettes and noncombustibles but not other combustibles. Other
Combustibles and Noncombustibles Only includes those who reported trying other combustibles and noncombustibles but not cigarettes.
Cigarettes, Other Combustibles, and Noncombustibles includes those who reported trying a product from each group.
a
Includes those who responded “yes” to the following question, “Have you ever used an electronic cigarette or e-cigarette, even once
or twice?”
b
Includes those who responded “1 or more days” to the following question, “During the past 30 days, on how many days did you use
electronic cigarettes or e-cigarettes?”
c
Includes all respondents categorized into each group. It does not exclude those missing for e-cigarette status.
d
Includes those who reported trying at least one of the following products (e-cigarettes not included in the denitions): Cigarettes Only;
Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and Noncombustibles Only;
Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.
e
Includes those who reported using at least one of the following products on 1 of the past 30 days (e-cigarettes were not included in the
denitions): Cigarettes Only; Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and
Noncombustibles Only; Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 45
E-Cigarette Use Among Youth and Young Adults
Table 2.6b Lifetime and past-30-day e-cigarette use among U.S. high school students, by other tobacco product use;
National Youth Tobacco Survey (NYTS) 2015
Lifetime e-cigarette use
a
Past-30-day
e-cigarette use
b
N
c
% (95% CI) SE % (95% CI) SE
Ever other tobacco use
d
(n=5,094) 9,422
Never 5,326 13.1 (11.7–14.8) 0.8 3.4 (2.5–4.4) 0.5
Cigarettes only 675 54.7 (48.5–60.6) 3.0 18.4 (13.7–24.4) 2.7
Other combustibles only 947 60.0 (54.4–65.3) 2.7 21.7 (18.0–25.9) 2.0
Noncombustibles only 137 39.8 (30.8–49.6) 4.7 20.2 (12.5–31.0) 4.6
Cigarettes + other combustibles only 1,307 79.6 (74.7–83.8) 2.3 36.3 (31.5–41.3) 2.5
Cigarettes + noncombustibles only 131 61.5 (48.7–72.9) 6.2 25.5 (18.5–34.0) 3.9
Other combustibles + noncombustibles only 171 69.5 (57.1–79.6) 5.7 35.3 (26.1–45.8) 5.0
Cigarettes + other combustibles + noncombustibles
only
728 89.2 (82.6–93.5) 2.7 55.0 (47.5–62.4) 3.8
Past-30-day other tobacco use
e
(n=2,389) 9,416
No 7,542 27.4 (25.2–29.7) 1.1 7.3 (6.1–8.8) 0.7
Cigarettes only 288 80.8 (74.2–86.0) 2.9 41.1 (32.2–50.6) 4.7
Other combustibles only 701 77.2 (71.2–82.3) 2.8 50.4 (45.0–55.8) 2.7
Noncombustibles only 192 69.6 (54.6–81.4) 6.8 31.2 (23.0–40.9) 4.5
Cigarettes + other combustibles only 353 87.1 (77.5–93.0) 3.8 58.8 (49.1–67.8) 4.7
Cigarettes + noncombustibles only 62 76.9 (59.8–88.2) 7.2 50.8 (27.9–73.5) 12.3
Other combustibles + noncombustibles only 108 88.7 (78.8–94.3) 3.8 74.1 (61.3–83.9) 5.7
Cigarettes + other combustibles + noncombustibles
only
170 95.9 (87.2–98.8) 2.4 77.0 (66.6–84.8) 4.6
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = condence interval; SE = standard error. Cigarettes Only includes those who reported trying cigarettes but not any other
tobacco product. Other combustibles includes cigars, pipes, and hookah or bidis. Noncombustibles includes smokeless tobacco, dissolv-
ables, or snus. Other Combustibles Only includes those who reported trying other combustibles but not cigarettes nor noncombustibles.
Noncombustibles Only includes those who reported trying noncombustibles but not cigarettes nor other combustibles. Cigarettes and
Other Combustibles Only includes those who reported trying cigarettes and other combustibles but not noncombustibles. Cigarettes
and Noncombustibles Only includes those who reported trying cigarettes and noncombustibles but not other combustibles. Other
Combustibles and Noncombustibles Only includes those who reported trying other combustibles and noncombustibles but not cigarettes.
Cigarettes, Other Combustibles, and Noncombustibles includes those who reported trying a product from each group.
a
Includes those who responded “yes” to the following question, “Have you ever used an electronic cigarette or e-cigarette, even once
or twice?”
b
Includes those who responded “1 or more days” to the following question, “During the past 30 days, on how many days did you use
electronic cigarettes or e-cigarettes?”
c
Includes all respondents categorized into each group. It does not exclude those missing for e-cigarette status.
d
Includes those who reported trying at least one of the following products (e-cigarettes not included in the denitions): Cigarettes Only;
Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and Noncombustibles Only;
Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.
e
Includes those who reported using at least one of the following products on 1 of the past 30 days (e-cigarettes were not included in the
denitions): Cigarettes Only; Other Combustibles Only; Noncombustibles Only; Cigarettes and Other Combustibles Only; Cigarettes and
Noncombustibles Only; Other Combustibles and Noncombustibles Only; and Cigarettes, Other Combustibles, and Noncombustibles.
A Report of the Surgeon General
46 Chapter 2
Figure 2.5 Past-30-day use of various tobacco products among U.S. middle and high school students; National
Youth Tobacco Survey (NYTS) 2015
Source: Centers for Disease Control and Prevention 2015b; unpublished data (data: NYTS 2015).
a
Includes exclusive use of e-cigarettes. It does not include use of any other product.
b
Includes exclusive use of smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products or
e-cigarettes.
c
Includes the use of cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It includes participants who reported use of combustible
and noncombustible products but not e-cigarettes.
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 47
Table 2.7a Percentage of middle school students who have ever used tobacco, by type of product; National Youth Tobacco Survey (NYTS) 2011–2015
2011 2012 2013 2014 2015
Characteristic
% (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Any lifetime
a
tobacco use 21.0 (19.2–22.9) 0.9 17.9 (15.9–20.0) 1.0 17.6 (15.6–19.9) 1.1 19.1 (16.7–21.8) 1.3 19.4 (17.0–22.0) 1.2
Any lifetime e-cigarette use
b
1.4 (1.0–2.0) 0.2 2.7 (2.2–3.2) 0.2 3.0 (2.5–3.5) 0.2 10.1 (8.5–11.9) 0.8 13.5 (11.8–15.5) 0.9
Ever tobacco use
c
E-cigarettes only 0.3 (0.2–0.6) 0.1 0.4 (0.3–0.5) 0.1 0.5 (0.3–0.9) 0.1 2.9 (2.3–3.5) 0.3 4.5 (3.9–5.2) 0.3
Combustibles and e-cigarettes only 0.4 (0.3–0.6) 0.1 1.1 (0.9–1.4) 0.1 1.5 (1.1–1.9) 0.2 4.5 (3.9–5.3) 0.4 6.2 (5.4–7.2) 0.5
Noncombustibles and e-cigarettes only ND ND — — — — 0.3 (0.1–0.6) 0.1 0.4 (0.2–0.7) 0.1
Combustibles, noncombustibles, and
e-cigarettes
0.5 (0.3–0.9) 0.1 1.1 (0.8–1.4) 0.1 0.8 (0.6–1.2) 0.1 2.2 (1.45–3.2) 0.4 2.2 (1.7–2.9) 0.3
Combustibles only 13.9 (12.5–15.4) 0.7 10.7 (9.5–12.1) 0.7 11.6 (10.1–13.3) 0.8 6.9 (5.6–8.4) 0.7 4.4 (3.7–5.2) 0.4
Noncombustibles only 1.5 (1.1–1.9) 0.2 1.2 (0.9–1.6) 0.2 0.8 (0.6–1.1) 0.1 0.8 (0.5–1.2) 0.2 1.0 (0.7–1.4) 0.2
Combustibles and noncombustibles
only
4.3 (3.5–5.1) 0.4 3.4 (2.8–4.0) 0.3 2.4 (1.8–3.2) 0.3 1.5 (1.1–2.1) 0.2 0.7 (0.4–1.1) 0.2
Any past-30-day tobacco use
d
7.5 (6.4–8.8) 0.6 6.7 (5.8–7.7) 0.5 6.5 (5.43–7.8) 0.6 7.7 (6.7–8.9) 0.6 7.4 (6.3–8.7) 0.6
Any past-30-day e-cigarette use
e
0.6 (0.4–0.9) 0.1 1.1 (0.9–1.5) 0.1 1.1 (0.8–1.5) 0.2 3.9 (3.0–5.0) 0.5 5.3 (4.6–6.2) 0.4
Past-30-day tobacco use
E-cigarettes only
f
0.2 (0.1–0.4) 0.1 0.3 (0.2–0.4) 0.1 0.4 (0.2–0.8) 0.1 1.9 (1.4–2.5) 0.3 2.6 (2.2–3.2) 0.3
Combustibles and e-cigarettes only 0.1 (0.1–0.3) 0.0 0.5 (0.3–0.7) 0.1 0.4 (0.3–0.6) 0.1 1.3 (1.0–1.7) 0.2 1.8 (1.4–2.2) 0.2
Noncombustibles and e-cigarettes only — — — — — — 0.1 (0.1–0.2) 0.0 0.2 (0.1–0.3) 0.0
Combustibles, noncombustibles, and
e-cigarettes
0.2 (0.1–0.3) 0.1 0.4 (0.2–0.5) 0.1 0.2 (0.1–0.4) 0.1 0.6 (0.4–0.8) 0.1 0.7 (0.4–1.1) 0.1
Combustibles only 4.5 (3.7–5.5) 0.4 3.7 (3.2–4.3) 0.3 4.0 (3.3–4.9) 0.4 2.7 (2.1–3.3) 0.3 1.2 (0.9–1.6) 0.2
Noncombustibles only 0.9 (0.6–1.3) 0.2 0.7 (0.5–1.0) 0.1 0.6 (0.3–0.9) 0.2 0.7 (0.4–1.2) 0.2 0.6 (0.3–1.2) 0.2
Combustibles and noncombustibles
only
1.6 (1.3–2.0) 0.2 1.2 (0.9–1.5) 0.2 0.8 (0.5–1.1) 0.1 0.5 (0.4–0.8) 0.1 0.3 (0.1–0.6) 0.1
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: CI = confidence interval; ND = no data for this cell; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard
error >40%. Wording of questions used to measure e-cigarette use varied from 2011 to 2015. Cigarettes were not included in this analysis. Combustibles includes cigars, pipes,
hookahs, or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Combustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and
combustibles but not noncombustibles. Noncombustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and noncombustibles but not combustibles.
A Report of the Surgeon General
48 Chapter 2
Combustibles, Noncombustibles, and E-Cigarettes includes those who reported trying e-cigarettes, noncombustibles, and combustibles. Combustibles Only includes those
who reported trying combustibles but not noncombustibles or e-cigarettes. Noncombustibles Only includes those who reported trying noncombustibles but not combustibles or
e-cigarettes. Combustibles and Noncombustibles Only includes those who reported trying noncombustibles and combustibles but not e-cigarettes.
a
Includes those who reported having tried at least one tobacco product in their lives (e-cigarettes, combustibles, and noncombustibles).
b
Includes those who reported having tried e-cigarettes in their lives.
c
Includes those who reported having tried at least one tobacco product in their lives.
d
Includes those who reported using at least one other tobacco product on at least 1 of the past 30 days.
e
Includes those who reported using e-cigarettes on at least 1 of the past 30 days.
f
Includes those who reported using e-cigarettes only on at least 1 of the past 30 days.
Table 2.7a Continued
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 49
Table 2.7b Percentage of high school students who have ever used tobacco, by type of product; National Youth Tobacco Survey (NYTS) 2011–2015
2011 2012 2013 2014 2015
Characteristic
% (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Any lifetime
a
tobacco use 47.2 (44.0–50.4) 1.6 45.7 (43.0–48.5) 1.4 46.0 (43.3–48.7) 1.4 47.1 (44.5–49.8) 1.3 50.4 (47.9–52.9) 1.3
Any lifetime e-cigarette use
b
4.7 (3.8–5.7) 0.5 10.0 (8.6–11.6) 0.7 11.9 (10.5–13.5) 0.8 27.3 (24.4–30.5) 1.5 37.7 (35.3–40.2) 1.2
Ever tobacco use
c
E-cigarettes only 0.1 (0.1–0.2) 0.0 0.2 (0.2–0.4) 0.0 0.3 (0.2–0.6) 0.1 3.7 (2.9–4.8) 0.5 7.4 (6.6–8.4) 0.5
Combustibles and e-cigarettes
only
1.6 (1.3–2.0) 0.2 4.2 (3.5–5.0) 0.4 6.0 (5.2–6.9) 0.4 14.5 (13.2–16.0) 0.7 20.0 (18.6–21.6) 0.8
Noncombustibles and e-cigarettes
only
— — — — — — 0.3 (0.1–0.4) 0.1 0.6 (0.4–0.8) 0.1
Combustibles, noncombustibles,
and e-cigarettes
2.8 (2.2–3.6) 0.4 5.2 (4.3–6.2) 0.5 5.2 (4.2–6.3) 0.5 8.3 (7.0–9.7) 0.7 9.1 (7.6–10.9) 0.8
Combustibles only 29.1 (27.3–30.9) 0.9 25.1 (23.1–27.1) 1.0 25.2 (22.7–27.8) 1.3 15.8 (14.3–17.5) 0.8 10.2 (8.8–11.8) 0.8
Noncombustibles only 1.8 (1.3–2.4) 0.3 1.3 (1.0–1.8) 0.2 1.5 (1.1–1.9) 0.2 1.2 (0.9–1.7) 0.2 0.9 (0.7–1.2) 0.1
Combustibles and
noncombustibles only
11.8 (9.8–13.9) 1.1 9.7 (8.6–10.9) 0.6 7.8 (6.6–9.3) 0.7 3.3 (2.6–4.2) 0.4 2.2 (1.6–3.0) 0.4
Any past-30-day tobacco use
d
24.0 (22.0–26.5) 1.2 23 (21.5–25.2) 0.9 22.9 (21.1–24.9) 0.9 24.6 (22.6–26.7) 1.0 25.3 (23.1–27.6) 1.1
Any past-30-day e-cigarette use
e
1.5 (1.2–2.0)
0.2
2.8 (2.3–3.5)
0.3
4.5 (3.8–5.3)
0.4
13.4 (11.2–16.1)
1.2
16.0 (14.1–18.0) 1.0
Past-30-day tobacco use
E-cigarettes only
f
0.1 (0.1–0.2) 0.0 0.3 (0.2–0.4) 0.1 0.7 (0.5–0.9) 0.1 4.4 (3.4–5.7) 0.6 5.9 (4.9–7.0) 0.5
Combustibles and e-cigarettes
only
0.7 (0.5–0.9) 0.1 1.4 (1.1–1.8) 0.2 2.6 (2.1–3.2) 0.3 5.8 (4.9–6.8) 0.5 6.6 (5.7–7.7) 0.5
Noncombustibles and
e-cigarettes only
ND ND — — — — 0.6 (0.4–0.8) 0.1 0.7 (0.5–0.9) 0.1
Combustibles, noncombustibles,
and e-cigarettes
0.6 (0.4–0.9) 0.1 1.1 (0.8–1.4) 0.1 1.1 (0.8–1.4) 0.1 2.5 (2.0–3.2) 0.3 2.6 (2.1–3.3) 0.3
Combustibles only 15.6 (14.5–16.8) 0.6 14.4 (13.2–15.6) 0.6 13.5 (12.4–14.8) 0.6 8.1 (7.2–9.2) 0.5 6.8 (5.9–7.8) 0.5
Noncombustibles only 2.3 (1.7–3.0) 0.3 1.9 (1.4–2.4) 0.2 1.6 (1.2–2.2) 0.3 1.5 (1.1–2.0) 0.2 1.5 (1.0–2.2) 0.3
Combustibles and
noncombustibles only
4.9 (4.0–6.1) 0.5 4.3 (3.7–5.2) 0.4 3.4 (2.7–4.3) 0.4 1.6 (1.2–2.2) 0.2 1.1 (0.7–1.8) 0.2
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
A Report of the Surgeon General
50 Chapter 2
Notes: CI = confidence interval; ND = no data for this cell; SE = standard error. An em dash (—) indicates that data are statistically unstable because of a relative standard
error >40%. Wording of questions used to measure e-cigarette use varied from 2011 to 2015. Cigarettes were not included in this analysis. Combustibles includes cigars, pipes,
hookahs, or bidis. Noncombustibles includes smokeless tobacco, dissolvables, or snus. Combustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and
combustibles but not noncombustibles. Noncombustibles and E-Cigarettes Only includes those who reported trying e-cigarettes and noncombustibles but not combustibles.
Combustibles, Noncombustibles, and E-Cigarettes includes those who reported trying e-cigarettes, noncombustibles, and combustibles. Combustibles Only includes those
who reported trying combustibles but not noncombustibles or e-cigarettes. Noncombustibles Only includes those who reported trying noncombustibles but not combustibles or
e-cigarettes. Combustibles and Noncombustibles Only includes those who reported trying noncombustibles and combustibles but not e-cigarettes.
a
Includes those who reported having tried at least one tobacco product in their lives (e-cigarettes, combustibles, and noncombustibles).
b
Includes those who reported having tried e-cigarettes in their lives.
c
Includes those who reported having tried at least one tobacco product in their lives.
d
Includes those who reported using at least one other tobacco product on at least 1 of the past 30 days.
e
Includes those who reported using e-cigarettes on at least 1 of the past 30 days.
f
Includes those who reported using e-cigarettes only on at least 1 of the past 30 days.
Table 2.7b Continued
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 51
E-Cigarette Use Among Youth and Young Adults
Figure 2.6 Percentage of U.S. middle school students who have ever used tobacco
a
, by type of product; National
Youth Tobacco Survey (NYTS) 2011–2015
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: For more information see Table 2.10a. In 2014, modifications were made to the e-cigarette measure to enhance its accuracy,
which may limit the comparability of this estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent
these differences.
a
Includes those who reported having tried at least one other tobacco product in their lives.
b
Includes exclusive use of only e-cigarettes. It does not include use of any other product. Ever e-cigarette use includes those who
responded “electronic cigarettes or e-cigarettes, such as Ruyan or NJOY” to the following question: “Which of the following tobacco
products have you ever tried, even just one time?”
c
Includes exclusive use of only cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It does not include use of noncombustible
products or e-cigarettes. They were defined using the following questions: Conventional cigarettes: “Have you ever tried cigarette
smoking, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigarettes?”; cigars: “Have you
ever tried smoking cigars, cigarillos, or little cigars, such as Black and Milds, Swisher Sweets, Dutch Masters, White Owl, or Phillies
Blunts, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?”;
pipes: “Have you ever tried smoking tobacco in a pipe, even one or two puffs?” and “During the past 30 days, on how many days did
you smoke tobacco in a pipe?”; and hookahs, kreteks, and bidis: “Which of the following tobacco products have you ever tried, even
just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the following products have you used on at
least 1 day? (CHOOSE ALL THAT APPLY).”
d
Includes exclusive use of only smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products
or e-cigarettes. They were defined using the following questions: Smokeless tobacco: “Have you ever used chewing tobacco, snuff,
or dip, such as Red Man, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen, even just a small amount?” and “During the
past 30 days, on how many days did you use chewing tobacco, snuff, or dip?”; and dissolvables and snus: “Which of the following
tobacco products have you ever tried, even just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the
following products have you used on at least 1 day? (CHOOSE ALL THAT APPLY).”
A Report of the Surgeon General
52 Chapter 2
Figure 2.7 Percentage of U.S. high school students who have ever used tobacco
a
, by type of product; National Youth
Tobacco Survey (NYTS) 2011–2015
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2011–2015).
Notes: For more information see Table 2.10b. In 2014, modifications were made to the e-cigarette measure to enhance its accuracy,
which may limit the comparability of this estimate to those collected in previous years. The dotted lines from 2013 to 2015 represent
these differences.
a
Includes those who reported having tried at least one other tobacco product in their lives.
b
Includes exclusive use of only e-cigarettes. It does not include use of any other product. Ever e-cigarette use includes those who
selected “electronic cigarettes or e-cigarettes, such as Ruyan or NJOY” for the following question: “Which of the following tobacco
products have you ever tried, even just one time?”
c
Includes exclusive use of only cigarettes, cigars, pipes, bidis, kreteks, and/or hookahs. It does not include use of noncombustible
products or e-cigarettes. They were defined using the following questions: Conventional cigarettes: “Have you ever tried cigarette
smoking, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigarettes?”; cigars: “Have you
ever tried smoking cigars, cigarillos, or little cigars, such as Black and Milds, Swisher Sweets, Dutch Masters, White Owl, or Phillies
Blunts, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?”;
pipes: “Have you ever tried smoking tobacco in a pipe, even one or two puffs?” and “During the past 30 days, on how many days did
you smoke tobacco in a pipe?”; and hookahs, kreteks, and bidis: “Which of the following tobacco products have you ever tried, even
just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the following products have you used on at
least 1 day? (CHOOSE ALL THAT APPLY).”
d
Includes exclusive use of only smokeless tobacco, snus, and/or dissolvable tobacco. It does not include use of combustible products
or e-cigarettes. They were defined using the following questions: Smokeless tobacco: “Have you ever used chewing tobacco, snuff,
or dip, such as Red Man, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen, even just a small amount?” and “During the
past 30 days, on how many days did you use chewing tobacco, snuff, or dip?”; and dissolvables and snus: “Which of the following
tobacco products have you ever tried, even just one time? (CHOOSE ALL THAT APPLY)” and “During the past 30 days, which of the
following products have you used on at least 1 day? (CHOOSE ALL THAT APPLY).”
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 53
E-Cigarette Use Among Youth and Young Adults
(Continued from last paragraph on page 43.)
school students had ever tried a tobacco product, and
37.7% had ever used an e-cigarette. In 2015, 7.4% of high
school students had ever used e-cigarettes exclusively;
20% were ever dual users of e-cigarettes and combustible
products; 0.6% were ever dual users of noncombustible
products and e-cigarettes only; and 9.1% were ever poly
users of combustibles, noncombustibles, and e-cigarettes.
However, the order of the use (i.e., which product came
first) remains unknown. In 2015, 5.9% of high school stu-
dents were exclusive past-30-day users of e-cigarettes; 6.6%
were past-30-day dual users of e-cigarettes and combus-
tible tobacco products; 0.7% were past-30-day dual users
of e-cigarettes and noncombustible tobacco products only;
and 2.6% were past-30-day poly users of e-cigarettes, com-
bustible, and noncombustible tobacco products. Exclusive
use of combustible products (6.8%) remained as prevalent
as past-30-day dual use of e-cigarettes and combustible
products (6.6%) among high school students (Table 2.7b).
Young Adults
2
2
As opposed to the situation in youth, cigarettes are the most commonly used tobacco product among young adults. Therefore, this
chapter does not assess co-use of e-cigarettes and other tobacco products among young adults.
Current prevalence. Using data from the 2013–2014
NATS, current exclusive and combined use of e-cigarettes
and cigarettes are presented in Figure 2.8 and Table 2.8a
for young adults (18–24 years old), and in Figure 2.8 and
Table 2.8b for adults 25 years of age and older. For both
age groups, exclusive use of regular cigarettes was the
most prevalent pattern of behavior (9.6%, young adults;
13%, adults), followed by dual use of cigarettes and
e-cigarettes (7.5%, young adults; 4.2%, adults), and exclu-
sive use of e-cigarettes (6.1%, young adults; 1.6%, adults).
Among young adults, combined use of the two products
and exclusive use of e-cigarettes were both higher among
males than females; combined use was higher among
Whites than in Hispanics or Blacks; and both combined
use of the two products and exclusive use of e-cigarettes
were lowest among those with a college degree.
Figure 2.8 Percentage of young adults who currently use e-cigarettes
a
and conventional cigarettes; National Adult
Tobacco Survey (NATS) 2013–2014
Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
a
Current e-cigarette use was defined as those who reported they had heard of e-cigarettes and had tried e-cigarettes, and reported
using e-cigarettes every day, some days, or rarely at the time of the interview.
Longitudinal Studies
Understanding the role that e-cigarettes play in
the initiation of tobacco product use, especially conven-
tional cigarettes and other combustible tobacco prod-
ucts, such as cigars and hookahs, is extremely important
for informing public health policy, planning, and prac-
tice. It is unclear what impact e-cigarette use will have
on the overall toll of tobacco use on public health (Cobb
et al. 2015). Some researchers and policymakers are con-
cerned about the order in which the initiation of tobacco
products takes place, positing that the use of e-cigarettes
A Report of the Surgeon General
54 Chapter 2
Table 2.8a Percentage of young adults (18–24 years of age) who currently use e-cigarettes
a
, cigarettes
b
, or both
c
products, by gender, race/ethnicity,
and education: National Adult Tobacco Survey (NATS) 2013–2014
Neither
d
E-cigarettes only
e
Cigarettes only
f
Both
c
Characteristic
% (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall
76.8 (75.3–78.3) 0.8 6.1 (5.3–7.0) 0.4
9.6 (8.6–10.7)
0.5
7.5 (6.6–8.4)
0.5
Gender
Female
81.8 (79.7–83.7) 1.0 4.0 (3.1–5.2) 0.5
8.4 (7.1–9.9)
0.7
5.8 (4.7–7.2)
0.6
Male
72.3 (70.1–74.4) 1.1 8.1 (6.9–9.4) 0.6
10.6 (9.2–12.2)
0.8
9.0 (7.7–10.4)
0.7
Race/ethnicity
White
72.8 (70.7–74.8) 1.1 6.3 (5.3–7.5) 0.6
11.2 (9.8–12.8)
0.8
9.7 (8.4–11.2)
0.7
Black or African American
84.8 (80.8–88.2) 1.9 2.9 (1.7–4.9) 0.8
9.8 (7.0–13.5)
1.6
2.5 (1.4–4.4)
0.7
Hispanic or Latino
80.5 (77.0–83.6) 1.7 7.5 (5.7–9.7) 1.0
6.1 (4.3–8.5)
1.1
5.9 (4.2–8.3)
1.1
Other
g
79.8 (75.5–83.5) 2.1 5.7 (3.8–8.6) 1.2
9.4 (6.9–12.5)
1.4
5.1 (3.4–7.6)
1.0
Education
<High school
67.4 (61.7–72.6) 2.8 5.8 (3.7–9.1) 1.3
17.3 (13.4–22.1)
2.2
9.4 (6.6–13.3)
1.7
High school
74.4 (71.9–76.7) 1.2 6.5 (5.3–7.8) 0.6
10.7 (9.2–12.5)
0.8
8.5 (7.0–10.1)
0.8
Some college
h
78.2 (75.8–80.4) 1.2 7.3 (5.9–9.0) 0.8
7.2 (5.9–8.7)
0.7
7.3 (6.1–8.8)
0.7
College degree
i
92.5 (90.2–94.4) 1.1 2.3 (1.4–3.9) 0.6
3.1 (2.0–4.7)
0.7
2.1 (1.2–3.5)
0.6
Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
Note: CI = confidence interval; SE = standard error.
a
Includes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.
b
Includes those who smoked at least 100 cigarettes and reported using cigarettes every day or some days at the time of the interview.
c
Includes those who reported currently using both e-cigarettes and conventional cigarettes.
d
Includes those who reported currently using neither conventional cigarettes nor e-cigarettes.
e
Includes those who reported currently using e-cigarettes but not conventional cigarettes.
f
Includes those who reported currently using conventional cigarettes but not electronic e-cigarettes.
g
Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacic Islander, non-Hispanic American Indian/Alaska Native, and multiracial.
h
Includes some college, no degree; associate’s degree, academic program; associate’s degree, unspecied; certicate; diploma; or associate’s degree.
i
Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 55
Table 2.8b Percentage of adults (≥25 years of age) who currently use e-cigarettes
a
, cigarettes
b
, or both
c
products, by gender, race/ethnicity, and
education: National Adult Tobacco Survey (NATS) 2013–2014
Neither
d
E-cigarettes only
e
Cigarettes only
f
Both
c
Characteristic
% (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 81.3 (80.8–81.7) 0.2 1.6 (1.5–1.7) 0.1 13.0 (12.6–13.4) 0.2 4.2 (3.9–4.4) 0.1
Gender
Female 83.4 (82.8–84.0) 0.3 1.3 (1.1–1.4) 0.1 11.5 (11.0–12.0) 0.3 3.8 (3.5–4.1) 0.2
Male 78.8 (78.1–79.5) 0.4 2.0 (1.7–2.2) 0.1 14.6 (14.0–15.3) 0.3 4.6 (4.2–5.0) 0.2
Race/ethnicity
White 82.1 (81.6–82.6) 0.3 1.6 (1.5–1.8) 0.1 11.9 (11.5–12.3) 0.2 4.4 (4.1–4.7) 0.1
Black or African American 76.2 (74.6–77.7) 0.8 0.9 (0.7–1.3) 0.2 20.0 (18.6–21.5) 0.7 2.9 (2.4–3.5) 0.3
Hispanic or Latino 83.2 (81.6–84.6) 0.8 1.5 (1.1–2.0) 0.2 12.0 (10.7–13.3) 0.7 3.4 (2.7–4.2) 0.4
Other
g
77.5 (75.6–79.4)
1.0
2.5 (1.9–3.3) 0.4 14.5 (13.0–16.1) 0.8 5.5 (4.4–6.7) 0.6
Education
<High school 71.3 (69.5–73.1) 0.9 1.0 (0.7–1.4) 0.2 23.5 (21.8–25.2) 0.9 4.2 (3.5–5.1) 0.4
High school 75.4 (74.4–76.4) 0.5 1.8 (1.5–2.2) 0.2 16.9 (16.1–17.8) 0.4 5.9 (5.3–6.5) 0.3
Some college
h
79.2 (78.4–80.0) 0.4 2.0 (1.8–2.3) 0.1 13.4 (12.7–14.1) 0.3 5.3 (4.9–5.8) 0.2
College degree
i
92.5 (92.1–93.0) 0.2 1.2 (1.0–1.4) 0.1 4.7 (4.3–5.0) 0.2 1.6 (1.4–1.8) 0.1
Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
Note: CI = confidence interval; SE = standard error.
a
Includes those who reported they had heard of, tried, and used e-cigarettes every day, some days, or rarely at the time of the interview.
b
Includes those who smoked at least 100 cigarettes and reported using cigarettes every day or some days at the time of the interview.
c
Includes those who reported currently using both e-cigarettes and conventional cigarettes.
d
Includes those who reported currently using neither conventional cigarettes nor e-cigarettes.
e
Includes those who reported currently using e-cigarettes but not conventional cigarettes.
f
Includes those who reported currently using conventional cigarettes but not e-cigarettes.
g
Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacic Islander, non-Hispanic American Indian/Alaska Native, and multiracial.
h
Includes some college, no degree; associate’s degree: academic program; associate’s degree, unspecied; certicate; diploma; or associate’s degree.
i
Includes bachelor’s degree, master’s/professional school degree, or doctoral degree.
A Report of the Surgeon General
(Continued from last paragraph on page 53.)
could increase the likelihood that adolescents and young
adults who have never used any tobacco products, but ini-
tiate e-cigarettes, will become lifetime users of conven-
tional cigarettes or other tobacco products in sufficiently
large numbers, resulting in a net harm to public health
(USDHHS 2012). Other researchers suggest that the order
of product initiation for tobacco products is unimportant
and that experimentation with a variety of substances may
be a marker of acommon vulnerability to tobacco, alcohol,
marijuana, and other substance-use behaviors (Vanyukov
et al. 2012). Regardless, both of these perspectives on the
effect of e-cigarette use on youth and young adults require
longitudinal data to understand how current behaviors
may affect health outcomes.
Five longitudinal studies to date suggest that
e-cigarette use among youth (Leventhal et al. 2015;
Barrington-Trimis et al. 2016; Wills et al. 2016) and youth
and young adults (Primack et al. 2015; Unger et al. 2016)
might lead to initiation of the use of combustible tobacco
products in the future. The first study to appear was by
Leventhal and colleagues (2015). In this study, a cohort of
9thgraders
in Los Angeles, California, was followed up at
both 6 and 12 months, into 10th grade. Those who at base-
line had never used combustible tobacco, but were ever
users of an e-cigarette, were more likely to use combus-
tible tobacco products at both follow-up points (odds ratio
[OR] = 4.27, 95% confidence interval [CI], 3.19–5.71).
Product-specific analyses showed that e-cigarette use in
9th grade was associated with the use of cigars (OR=4.85,
95% CI, 3.38–6.96), hookahs (OR = 3.25, 95% CI,
2.29–4.62), and cigarettes (OR=2.65, 95% CI, 1.73–4.05)
in 10th grade. It was also associated with the number
of different combustible products used in 10th grade
(OR = 4.26, 95% CI, 3.16–5.74) (all ORs presented here
were averaged across the two time points). In these
analyses, Leventhal and colleagues (2015) adjusted for
demographic characteristics (age, gender, race/ethnicity,
highest parental education), social factors (peer smoking,
parental smoking), and intrapersonal factors (depression,
impulsivity, delinquent behaviors) linked with cigarette
smoking in previous research.
Primack and colleagues (2015), in a national cohort
study, followed youth and young adults, 16–26 years of age,
for 1 year. At baseline, only 16 participants (2.3%) had ever
used e-cigarettes. In adjusted models that included only
those who did not use conventional cigarettes at base-
line and adjusted for gender, age, race/ethnicity, maternal
educational level, sensation seeking, parental cigarette
smoking, and peer cigarette smoking, baseline e-cigarette
use was independently associated with progression to cig-
arette smoking (OR = 8.3, 95% CI, 1.2–58.6) and suscep-
tibility to cigarette smoking (OR = 8.5, 95% CI, 1.3–57.2).
Susceptibility was defined as a lack of a firm commitment
56 Chapter 2
not to smoke using established measures of this construct
(Evans et al. 1995; Pierce et al. 1996).
Wills and colleagues (2016) followed a cohort of
2,338 students in grades 9 and 10 in Hawaii for 1 year. At
baseline, 31% of the sample had ever used an e-cigarette,
and 15% had ever used a conventional cigarette. One
year later, these increased to 38% and 21%, respectively.
Of those who had not used either of these products at
baseline, 10% initiated exclusive e-cigarette use 1 year
later; 2% initiated exclusive conventional cigarette use;
and 4% initiated use of both products. Students who
had never smoked a conventional cigarette at baseline
but had used an e-cigarette at baseline were three times
more likely to smoke conventional cigarettes 1 year later
(adjusted OR = 2.87, p <0.001). By comparison, among
those who smoked conventional cigarettes at baseline,
use of e-cigarettes at that same point in time was not
related to any reduction in the use of conventional cig-
arettes 1 year later (p >0.05). Moreover, students were
more likely to transition from never use to dual use of
both products 1year later if they were older, Caucasian
or Native Hawaiian (compared with Asian-American),
more rebellious, and perceived e-cigarettes as healthier
(adjusted OR= 2.05, 2.15, 3.10, 3.32, 2.59, respectively,
all p<0.001).
Barrington-Trimis and colleagues (2016) followed a
cohort of 11th and 12th grade students in California for
more than 1 year (median 15.6 months). In this cohort,
at baseline, 146 were ever e-cigarette users and 152 were
never e-cigarette users; none had ever smoked a cigarette.
Among never e-cigarette users at baseline, 16 participants
(10.5%) reported using cigarettes at follow-up; among
ever e-cigarette users at baseline, 59 participants (40.4%)
reported the same (OR = 6.17; 95% CI, 3.30–11.60).
After adjusting for cigar, pipe, or hookah use at baseline,
the relationship attenuated only somewhat (OR = 5.48;
95%CI, 2.69–11.20). When stratified by susceptibility to
cigarette smoking at baseline (defined, like Primack and
colleagues [2015], as the lack of a firm commitment not
to smoke using established measures of this construct
[Evans et al. 1995; Pierce et al. 1996]), the relationship
was actually stronger among those who were not suscep-
tible (OR = 9.69; 95% CI, 4.02–23.40) compared to those
who were susceptible (OR = 2.12; 95% CI, 0.79–5.74). The
latter relationship was not statistically significant. In addi-
tional analyses that were restricted to those who reported
no use of any combustible tobacco product at baseline,
e-cigarette users were more likely to initiate use of any
combustible tobacco product at follow-up (OR = 4.98;
95% CI, 2.37–10.4), including the use of cigarettes
(OR = 4.29; 95% CI; 1.84–10.0), hookahs (OR = 2.86;
95%CI, 1.21–6.78), cigars (OR = 4.39; 95% CI, 1.72–11.2),
and pipes (OR=8.21; 95% CI, 1.20–56.2). The models used
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 57
E-Cigarette Use Among Youth and Young Adults
by Barrington-Trimis and colleagues (2016) adjusted for
a variety of demographic characteristics (grade, gender,
race/ethnicity, highest parental education) and social fac-
tors (peer and parental smoking). Additionally, gender,
race/ethnicity (Hispanic White, non-Hispanic White,
other), grade (11th or 12th), and ever use of hookahs were
tested as potential effect modifiers of these associations,
but no evidence was found for the same.
Unger and colleagues (2016) followed a cohort of
1,332 Hispanic young adults in California who provided
survey data in 2014 and 2015. At baseline, these par-
ticipants were an average of 22.7 years old. E-cigarette
use at baseline was significantly associated with ciga-
rette smoking (OR = 3.32; 95% CI, 1.55–7.10, among
non-cigarette smokers at baseline) and marijuana use
(OR = 1.97; 95% CI, 1.01–3.86, among non-marijuana
users at baseline) at follow-up. Among those who did not
smoke cigarettes at baseline (n = 1,056), 42 reported past
month e-cigarette use in 2014; 26% of those who smoked
e-cigarettes at baseline became cigarette smokers in 2015,
compared to 7% of those who did not smoke e-cigarettes.
Further, among those who did not smoke marijuana at
baseline (n = 1,028), 68 reported past month e-cigarette
use in 2014; 24% of those who smoked e-cigarettes at
baseline became marijuana smokers in 2015, compared to
12% of those who did not smoke e-cigarettes. Moreover,
in this study, e-cigarette use at baseline was not associ-
ated with cessation of cigarette smoking (OR = 1.31;
95% CI, 0.73– 2.36) or marijuana use (OR = 1.05; 95%
CI. 0.54–2.01) at follow-up. Among those who did smoke
cigarettes at baseline (n = 276), 76% reported past month
e-cigarette use in 2014; and 63% of those who smoked
e-cigarettes at baseline were still smoking cigarettes at
follow-up, compared to 58% of those who did not smoke
e-cigarettes. Covariates in these regression models
included age, gender, past month use of alcohol, and past
month use of other tobacco products (hookah, cigars,
little cigars, smokeless tobacco).
Despite the several strengths of these studies,
including their longitudinal nature, they had weaknesses
as well. Rigotti (2015) notes, for example, that the study
by Leventhal and colleagues (2015) could not distin-
guish between those who merely began experimenting
with a combustible product and those who became reg-
ular smokers at follow-up. The same could be said for
the studies by Barrington-Trimis and colleagues (2016),
Primack and colleagues (2015), and Wills and colleagues
(2016). Similarly, the single exposure measure of the
independent variable (i.e., any e-cigarette use) in these
studies did not allow the authors to assess whether there
was a dose–response relationship between the extent of
prior e-cigarette use and subsequent use of combustible
tobacco products. In addition, the studies by Primack and
colleagues (2015) and Wills and colleagues (2016) did not
assess prior use at baseline of other tobacco products,
marijuana, or alcohol. Though it is not highlighted prom-
inently in their article, Leventhal and colleagues (2015)
showed a bidirectional relationship between e-cigarette
use and other combustible tobacco product use in their
study: Use of other combustible tobacco products at
baseline was significantly associated with the onset of
e-cigarette use in two follow-ups. This hypothesis was not
tested by Barrington-Trimis and colleagues (2016), Wills
and colleagues (2016), or Primack and colleagues (2015).
However, at the 1-year follow-up, Wills and colleagues
(2016) did consider other demographics, personality, and
psychosocial predictors of exclusive e-cigarette use and
dual use of conventional cigarettes and e-cigarettes.
Concerns about the samples for the two studies
can be raised as well. The samples in the studies by
Barrington-Trimis and colleagues (2016) and Leventhal
and colleagues (2015) were limited to youth in California;
the study by Primack and colleagues (2015) suffered
from a small sample size, with only 16 e-cigarette users
at baseline (Leventhal et al. 2015; Primack et al. 2015);
and the study by Wills and colleagues (2016) was limited
to 9th- and 10th-grade students in Hawaii. Additional
studies are still needed in the future to further elucidate
any causal relationship in either direction between the use
of e-cigarettes and other types of tobacco products, such
as combustibles.
E-Cigarette Use and Other
Substance Use
Few studies have investigated the co-occurrence
of e-cigarette use and other risk behaviors in adoles-
cents and young adults. The available evidence suggests
that e-cigarette use is associated not only with the use of
other tobacco products, but also with alcohol and other
substance use, such as marijuana. This is consistent with
the common liability model for substance use and other
risky behaviors (Vanyukov et al. 2012). Because nearly all
currently available studies on this topic focus on regional,
international, and at-risk samples, the conclusions from
most studies cannot be generalized to the U.S. population
as a whole, however.
In the only nationally representative study exam-
ining the associations between e-cigarettes, alcohol, and
other drug use in young adults 18–24 years of age, the
odds of alcohol use were nine times as high and the odds
of everyday/some-day marijuana use were three-and-a-half
times as high among past-30-day e-cigarette users as
they were for those who had not used these products in
A Report of the Surgeon General
58 Chapter 2
that period (Cohn et al. 2015). Elsewhere, in a nonprob-
ability sample of college students 17–25 years of age,
66% of current e-cigarette users and 67% of current dual
users were heavy drinkers, defined as consuming at least
once, five or more drinks (men) or four or more drinks
(women) in a single sitting during the course of 1 month
(Littlefield et al. 2015). In another study, this one of col-
lege students in New York, past-30-day use of e-cigarettes
was positively associated with current binge drinking and
tobacco product use, and it was less common among those
20–23 years of age (versus those 18 years of age), females,
non-Hispanic non-Whites (compared with non-Hispanic
Whites), and those reporting better-than-average school
performance (Saddleson et al. 2015).
Data from a longitudinal cohort study of children
with alcoholic parents found that adolescents (both middle
and late adolescence) who used cigarettes, marijuana, or
alcohol were significantly more likely to have ever used
e-cigarettes. Among those who had used marijuana,
e-cigarette use was associated with greater use of mari-
juana during the previous 30 days (Lessard etal. 2014).
In a cross-sectional pilot study of seventh-grade students
in Southern California, ever use of e-cigarettes was 11%,
compared to 6.8% for cigarettes, 38.1% for alcohol, and
39% for cigarettes or alcohol. In this study, 80% of ever
users of e-cigarettes had used alcohol, and 42.2% had used
conventional cigarettes (Pentz et al. 2015).
In a 2013 sample of students (n = 2,002) in two states
in the southeastern United States, 53.4% of e-cigarette
users also used marijuana (Berg et al. 2015). Elsewhere,
in a sample of young adults (18–23 years of age) at col-
leges and universities that was taken in 2013 in upstate
New York (n = 1,437), 54.2% of past-30-day marijuana
users, 23.9% of past-30-day alcohol users, and 40.3% of
past-30-day binge drinkers had ever used e-cigarettes
(Saddleson et al. 2015). In Switzerland, among a sample
of eighth graders, nearly 60% of regular e-cigarette users
“had been drunk” at least once in the past 30 days (defined
as an affirmative response to the question, “have you been
drunk in the previous 30 days”), and 44.8% had used mari-
juana at least once during that period (Suris et al. 2015).
There are several limitations to these observational
studies. For example, when considering the associations
derived from these observational studies, the order of ini-
tiation of the products of interest cannot be inferred. In
addition, some biases cannot be ruled out because of the
nature of the samples, and patterns of associations may
reflect an underlying common liability to use substances
and take part in other risky behaviors. Some studies
adjusted for risk taking, sensation seeking, and impul-
sivity, while others did not.
E-Cigarettes and Marijuana
Because of their design, e-cigarettes may facilitate
drug use among youth and young adults, as these prod-
ucts can be used as a delivery system for cannabinoids
and other illicit drugs (Giroud et al. 2015; Morean et al.
2015; Schauer et al. 2016). The aerosolization of cannabis
is a relatively new technology used to deliver inhaled tet-
rahydrocannabinol (THC) and other cannabinoids while
reducing the toxic byproducts of smoked cannabis, which
are primarily caused by combustion (Abrams et al. 2007).
Laboratory studies of prototype aerosolizers have
demonstrated that they can provide a relatively effective
mode of delivering THC, with plasma THC concentrations
similar to those obtained from smoking a standard mari-
juana cigarette (Abrams et al. 2007; Giroud et al. 2015).
In addition, thermal metered-dose cannabis inhalers
have been developed for medical applications; their tech-
nology is similar to that of e-cigarettes (Eisenberg et al.
2014). While the first generation of cannabis aerosolizers
was developed to aerosolize dry cannabis, the widespread
availability of e-cigarettes and rapid advances in their
technology have led to the development ofliquid/oil forms
of cannabis/THC that can be used with e-cigarettes in a
fashion similar to that employed when they are filled with
nicotine (Giroud et al. 2015). Articles explaining how to
acquire and use THC-containing liquid using e-cigarette
technology are accessible on the Internet and are strongly
suggestive of relatively widespread awareness and use
(Gray 2013).
The actual prevalence of users of marijuana aero-
solizers and their experiences remain unclear and under-
studied (Van Dam and Earleywine 2010; Malouff et al.
2014). In one of the few published studies on this issue
specific to youth, Morean and colleagues (2015) found
that, among high school students in Connecticut, vapor-
izing cannabis was common among ever e-cigarette users
(18%), ever cannabis users (18.4%), and ever dual users
(26.5%). This finding suggests a need for more specific
surveillance measures that take into account the use of
drugs other than nicotine in e-cigarettes.
Use of Flavored E-Cigarettes
The liquid that is vaporized in an e-cigarette is avail-
able to consumers in a wide variety of flavors, including
tobacco, mint/menthol, and fruit flavors. Although char-
acterizing “flavors” are prohibited in cigarettes (with the
exception of menthol and tobacco) by the Family Smoking
Prevention and Tobacco Control Act of 2009, this prac-
tice is not currently prohibited in other tobacco prod-
ucts, like e-cigarettes. Retail sales data suggest that the
59
consumption of flavored e-cigarettes and tobacco prod-
ucts, such as flavored cigars, has increased in recent years
(Delnevo et al. 2015; Giovenco et al. 2015), and recent
studies show that youth and young adults may find these
flavored products more appealing than their unflavored
counterparts (Table 2.9) (Ambrose et al. 2015; Krishnan-
Sarin et al. 2015; McDonald and Ling 2015).
Data on the use of flavored e-cigarettes among
youth and young adults is presented in Table 2.9. In the
2015 NYTS, participants were asked about any current use
of e-cigarettes that were “flavored to taste like menthol
(mint), alcohol (wine, cognac), candy, fruit, chocolate, or
other sweets” (CDC 2015a, 1066). Among middle and high
school students who were past-30-day users of e-cigarettes,
1.26 million, or 44.6%, had used a flavored e-cigarette in
that timeframe (CDC, unpublished data [NYTS 2015]);
this included 42.6% of middle school students and 45.1%
of high school students (Table 2.9) (CDC 2015a). The use
of flavored e-cigarettes did not differ by gender and was
lowest among Blacks (Table 2.9) (CDC 2015a). The use
of flavored e-cigarettes was highest among young adults,
according to the 2013–2014 NATS (Table 2.9): among
those who reported using e-cigarettes every day or some
days, 91.6% of young adults (18–24 years old) reported
using an e-cigarette flavored to taste like menthol, mint,
clover, spice, candy, fruit, chocolate, or other sweets.
On the other hand, 66.6% of adults (≥25 years of age)
who reported using e-cigarettes every day or some days
had used flavored e-cigarettes. No gender differences were
noted for young adults, but Blacks, as with middle and
high school students, reported the lowest rate of using fla-
vored e-cigarette products.
Data from the 2013–2014 wave of the PATH
study revealed that a majority of adolescents who used
e-cigarettes use flavors. Of those who had ever tried
e-cigarettes, 81%used flavors the first time they tried an
e-cigarette; of past-30-day users, 85.3% regularly used
flavored e-cigarettes (Ambrose et al. 2015). Ambrose and
colleagues (2015) also reported that 81.5% of respon-
dents aged 12–17 reported that they used e-cigarettes
because “they come in flavors I like.” Elsewhere, among
8th, 10th, and 12th graders in the 2015 MTF study, about
40% said that the primary reason they used e-cigarettes
was “because they tasted good.” In contrast, about 10%
said they used e-cigarettes to quit smoking conventional
cigarettes (University of Michigan 2015). In the 2015 MTF
study, about two-thirds of 8th-, 10th-, and 12th-grade
students said that they used “just flavouring” in their
vaporizer when they “last used” a vaporizer, while only
20% reported that they used nicotine (Miech et al. 2016).
While the findings specific to nicotine are unexpected, it
is important to note that these data are self-reported. It
is questionable whether youth know what nicotine is, let
alone whether it is contained in the e-cigarette products
that they are using. Moreover, even if youth were accu-
rately reporting nicotine strength according to the label
on the package, a study by Buettner-Schmidt and col-
leagues (2016) found that more than half of the labels on
assessed e-cigarette products did not accurately reflect
actual nicotine content in the product. Therefore, further
research on nicotine content using objective measures
(e.g., retail sales data) is warranted. Both the PATH and
MTF studies, however, reinforce that flavorings may play
an important role in the initiation of e-cigarette use.
Other regional studies have reinforced the popu-
larity of flavored e-cigarette use among youth. Table 2.10
summarizes these data on the use of flavored e-cigarettes
among youth and young adults. Krishnan-Sarin and col-
leagues (2015), for example, found that sweet-flavored
e-cigarettes were popular among middle and high school
students. In another study, which examined nonsmoking
middle and high school students and college-aged adults
in New Haven County, Connecticut, Kong and colleagues
(2015) found that “appealing flavors” was the second most
common reason cited for experimenting with e-cigarettes,
and in a qualitative study of young adults living in New
York City, flavors were identified as an attractive aspect of
e-cigarettes (McDonald and Ling 2015). In a study exam-
ining nonsmoking teens and adult smokers, the e-cigarette
flavors tested appealed more to adults than to teens; non-
smoking teens demonstrated equally low levels of interest
in tobacco, fruit, and candy flavors (Shiffman etal. 2015).
It should be noted, however, that this study was funded by
NJOY, an e-cigarette company and, therefore, may have
suffered from commercial bias. Additional concerns about
this study concerning selection bias, validity of the survey
measures, and reliability of the findings have been raised
(Glantz 2015).
Consumer Perceptions of
E-Cigarettes
Perceived Harm of E-Cigarettes
In the general population of U.S. adults, e-cigarettes
have been perceived to be generally less harmful (Pearson
et al. 2012; Czoli et al. 2014; Gallus et al. 2014; Richardson
et al. 2014; Berg et al. 2015; Pokhrel et al. 2015) and less
addictive (Dockrell et al. 2013; Li et al. 2013; Brown et al.
2014; Farsalinos et al. 2015; Harrell et al. 2015; Hendricks
et al. 2015; Kadimpati et al. 2015; Wackowski and Delnevo
2015) than conventional cigarettes. The perceived harm
of e-cigarettes relative to conventional cigarettes was
lowest among those who were current smokers, followed
by former smokers and then nonsmokers (Pearson et al.
A Report of the Surgeon General
60 Chapter 2
Table 2.9 Percentage of youth (middle and high school students), young adults (18–24 years of age), and adults (≥25 years of age) using tobacco
products who reported using flavored e-cigarette products, by gender and race/ethnicity; National Youth Tobacco Survey (NYTS)
a
and
National Adult Tobacco Survey (NATS)
b
NYTS 2015
a
(youth):
Middle school students
NYTS 2015
a
(youth): High
school students
NATS 2013–2014
b
(young
adults): 18–24 years of age
NATS 2013–2014
b
(adults): ≥25 years of age
Characteristic
% (95% CI) SE % (95% CI) SE % (95% CI) SE % (95% CI) SE
Overall 42.6 (36.1–49.3) 3.3 45.1 (40.4–49.9) 2.4 91.6 (87.0–94.6) 1.9 66.6 (63.4–69.5) 1.6
Gender
Female 45.5 (36.2–55.2) 4.8 46.8 (40.5–53.2) 3.2 90.1 (78.6–95.7) 4.1 68.2 (63.7–72.3) 2.2
Male 40.2 (32.2–48.7) 4.2 44.0 (39.3–48.8) 2.4 92.2 (87.0–95.4) 2.1 65.2 (60.7–69.4) 2.2
Race/ethnicity
White 52.5 (42.0–62.8) 5.3 51.4 (45.7–57.0) 2.9 90.9 (84.7–94.7) 2.5 61.2 (57.5–64.8) 1.9
Black or African American 32.9 (18.5–51.6) 8.6 20.4 (12.8–31.0) 4.5 100 (100–100)
c
0.0
c
92.0 (82.1–96.6) 3.5
Hispanic or Latino 28.5 (20.5–38.1) 4.4 38.8 (32.7–45.3) 3.2 89.8 (75.3–96.2)
c
5.0
c
85.9 (76.6–91.9) 3.8
Other
d
57.3 (39.4–73.5) 8.9 34.1 (24.8–44.9) 5.1 94.4 (82.1–98.4)
c
3.5
c
67.4 (57.0–76.3) 5.0
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015; NATS 2013–2014).
Note: CI = confidence interval; SE = standard error.
a
Flavored e-cigarette product use in NYTS was determined by the response to the question, “Which of the following tobacco products that you used in the past 30 days
were flavored to taste like menthol (mint), alcohol (wine, cognac), candy, fruit, chocolate, or other sweets?” Participants could select from a list of options to designate the
flavored tobacco product(s) they used. (Among those who reported any use of e-cigarettes in the preceding 30 days.) Those who selected e-cigarettes were coded as “yes”
for flavored e-cigarettes. Those who did not select e-cigarettes were categorized as “no” for flavored e-cigarettes. Excludes 82 current e-cigarette users whose answers were
missing for all flavored tobacco response options.
b
Flavored e-cigarette product use in NATS was determined by the response to the question, “Were any of the electronic cigarettes that you used in the past 30 days avored
to taste like menthol, mint, clover, spice, candy, fruit, chocolate, or other sweets?” (Among those who reported using e-cigarettes every day or some days.) Those who selected
“yes” were categorized as “yes” for flavored e-cigarettes. Those who selected “no” were categorized as “no” for flavored e-cigarettes. Excludes five every-day or some-day
users who reported not using any noncigarette tobacco product in the past 30 days.
c
Sample size <50. No estimates had a relative SE >.40.
d
Includes non-Hispanic Asian, non-Hispanic Native Hawaiian/Other Pacic Islander, and non-Hispanic American Indian/Alaska Native. For young adults and adults, this group
also includes multiracial.
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 61
Table 2.10 Summary of studies on e-cigarette flavors among youth and young adults
Study Design/population Measures Outcomes/findings
Ambrose et al. (2015)
• Cross-sectional
• Wave 1 of PATH study
• Household-based, nationally representative survey
of 13,651 youth 12–17 years of age
• For each product ever used, youth
were asked if it was flavored to
taste like menthol, mint, clove,
spice, candy, fruit, chocolate,
alcohol (such as wine or cognac),
or other sweets
• 81% of e-cigarette ever users used a
flavored product at first use
• 85.3% of past-30-day e-cigarette users
used a flavored product
• 81.5% of past-30-day users cited “because
they come in flavors I like” as a reason for
using e-cigarettes
Berg et al. (2015)
• Cross-sectional
• Recruitment through Facebook targeting of
tobacco and marijuana users and nonusers
• 2014
• 1,567 participants, 18–34 years of age, living in the
United States
• E-cigarette use (ever tried,
number of days in past 30 days)
• Flavors used or of interest
• Most commonly used flavor was fruit
flavors (67%), which was most commonly
reported by never cigarette smokers.
• Current smokers were most likely to
report using tobacco flavors, but least
likely to report using caramel, vanilla,
chocolate, cream, or candy flavors.
CDC (2015a)
• Cross-sectional
• 2014 NYTS data
• Three-stage cluster sampling procedure
• Nationally representative sample of 22,007 U.S.
middle and high school students
• Participants were asked about any
current use of tobacco products
that were “flavored to taste like
menthol (mint), alcohol (wine,
cognac), candy, fruit, chocolate, or
other sweets”
• Participants could select from a
list of options
• Among current e-cigarette users,
63.3%used a flavored product
Kong et al. (2015) • Cross-sectional
• 18 focus groups, schoolwide survey
• Recruitment by flyers and active recruitment
sessions
• Years sample drawn: 2012–2013
• New Haven County, Connecticut
• Youth: Middle and high school students; focus
group n = 127 (youth); survey n = 4,780
• Young adults: New Haven County, Connecticut,
college students; focus group n = 127
(young adults); survey n = 625
• Why did you try an e-cigarette? • 43.8% of e-cigarette ever users
experimented with e-cigarettes for the
availability of appealing flavors
• School-level differences:
χ
2
(2, N = 1,157) = 18.63, p ≤0.001
• Compared with college students, high
school students were more likely to
experiment with e-cigarettes because of
flavors (47% vs. 32.8%):
χ
2
(1, N = 1,116) = 13.61, p ≤0.001
A Report of the Surgeon General
62 Chapter 2
Study Design/population Measures Outcomes/findings
Krishnan-Sarin et al. (2015) • Cross-sectional
• School-based survey
• Recruitment by selected district reference groups
• Year sample drawn: 2013
• Youth: Connecticut middle (n = 1,166) and high
school (n = 3,614) students
• Young adults: n/a
• Which of the following flavors of
e-cigarettes have you tried?
• Most e-cigarette ever users preferred
sweet flavors:
– Sweet flavors: 56.8%
– Menthol: 8.7%
– Combos: 7.7%
– Tobacco: 3%
– Other: 2.8%
• Menthol and tobacco flavors used mostly
by e-cigarette users who were also
cigarette smokers.
– Menthol preference:
3.5% (never smokers)
5.5% (ever smokers)
18.6 (current smokers)
– Tobacco preference:
0.5% (never smokers)
2.4% (ever smokers)
7.1% (current smokers)
McDonald and Ling (2015) • Focus groups and semistructured interviews
• Recruitment from bars through screener surveys
• Years sample drawn: 2012–2013
• Youth: n/a
• Young adults: 87 young adults, 18–27 years of
age, in the boroughs of Manhattan, Brooklyn, and
Queens in New York City
• Attraction to flavors • Flavors were an attractive e-cigarette
characteristic
Shiffman et al. (2015) • Cross-sectional
• Participants drawn from online research panel
• Year sample drawn: 2014
• Youth: Nonsmoking teenagers, 13–17 years of age
• Young adults: n/a
• Interest in e-cigarettes paired with
various flavor descriptors
• Nonsmoking teens’ interest in
e-cigarettes was very low
(mean=0.41 ± 0.14 [SE] on 0–10 scale).
• Teen interest did not vary by flavor
(p= .75)
Table 2.10 Continued
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 63
Study Design/population Measures Outcomes/findings
Ford et al. (2016) • Cross-sectional in-home survey
• Wave 7 of the Youth Tobacco Policy Survey (YTPS)
• Random location quota sampling
• 1,205 youth, 11–16 years of age, in the United
Kingdom
• Awareness of e-cigarettes
• E-cigarette use
• E-cigarette flavor awareness
• Perceptions of harm
• 12% had tried e-cigarettes
• 2% were regular users (confined to
adolescents who had also smoked
tobacco)
• 82% were aware of at least one
promotional channel (82%)
• 69% were aware that e-cigarettes came in
different flavours
• Brand awareness was low
• E-cigarettes were perceived as harmful
(mean=3.54, SD=1.19)
Vasiljevic et al. (2016) • Randomized controlled trial
• Participants exposed to advertisements of candy-
like flavored e-cigarettes, non-flavoured cigarettes,
or control
• Youth: 598 English children, 11–16 years of age
• Appeal of using e-cigarettes
• Appeal of e-cigarette ads
• Interest in buying and trying
e-cigarettes following ad exposure
• Exposure to e-cigarette ads did not seem
to increase the appeal of tobacco smoking
in children.
• Exposure to flavoured e-cigarette ads
(compared with non-flavoured ads)
increased the appeal and interest in
buying and trying e-cigarettes in children.
Note: NYTS = National Youth Tobacco Survey; PATH = Population Assessment of Tobacco and Health Study; SD = standard deviation; SE = standard error.
Table 2.10 Continued
A Report of the Surgeon General
64 Chapter 2
(Continued from last paragraph on page 59.)
2012; Richardson et al. 2014). In a nationally representa-
tive sample of U.S. adults, young adults 18–34 years of age
were more likely than their older counterparts to perceive
e-cigarettes as being less harmful than conventional ciga-
rettes (Tan and Bigman 2014).
Common theories of health behavior, such as
the Theory of Reasoned Action and the Health Belief
Model, posit that perceptions of harm influence tobacco-
use behavior, with lower perceived harm encouraging
higher levels of experimentation and current tobacco
use (Primack et al. 2008). Monitoring both absolute per-
ceived harm and perceived harm relative to conventional
cigarettes could be an indicator of later product adop-
tion. Table 2.11 presents studies of the perceived harm of
e-cigarettes among adolescents and young adults that are
included in this chapter.
Youth
Table 2.12a presents NYTS data from middle
school and high school students on the perceived harm
of using e-cigarettes on some days but not every day.
In 2015, 61.9% of these students, overall, believed that
e-cigarettes caused “little or some harm” under such con-
ditions; 14.5%, “no harm”; and 23.6%, “a lot of harm.”
However, when these data are stratified by students’ his-
tory of e-cigarette use, important differences become
clear. Notably, 34.2% of past-30-day e-cigarette users
believed e-cigarettes cause “no harm,” compared with
22.4% of ever e-cigarette users and only 9.5% of never
e-cigarette users. Conversely, 29.4%of never e-cigarette
users believed that e-cigarettes cause “a lot of harm,”
compared with 8.3% of ever e-cigarette users and 6.8% of
past-30-day e-cigarette users. These important differences
by e-cigarette use status, which suggest perceptions of no
harm related to e-cigarette use, were consistent for both
middle school students and high school students (Tables
2.12b and 2.12c).
Three studies that used data from the 2012 NYTS
examined the correlates of U.S. adolescents’ opinions about
the perceived harm of e-cigarettes relative to the harm of
conventional cigarettes. Non-Hispanic Whites, students
who lived with a smoker (Cardenas et al. 2015) or had
afamily member who used tobacco (Amrock et al. 2015),
and past-30-day users of tobacco products other than cig-
arettes were more likely to believe that e-cigarettes were
safer than conventional cigarettes (Amrock et al. 2015).
Conversely, girls and students 17 years of age or older
were more likely to believe that e-cigarettes were more
harmful than regular cigarettes (Amrock et al. 2015). The
perceived harm of e-cigarettes decreased with increasing
levels of cigarette smoking, such that in 2012, 25% of ado-
lescent never smokers, 41.3% of adolescent ever smokers,
and 54.2% of adolescent past-30-day smokers believed that
e-cigarettes were less harmful than cigarettes (Ambrose
etal. 2014). Prior use of e-cigarettes was also associated
with perceived harm of that product. Among students
who had ever tried e-cigarettes in 2012, 71.8% believed
that they were less harmful than cigarettes, 12.1% equally
harmful, and 5% more harmful. These estimates were
similar to those for students who had used e-cigarettes in
the past 30 days (Amrock et al. 2015). In addition, sus-
ceptibility to cigarette smoking among never smokers was
associated with perceptions of low harm for e-cigarettes
(Ambrose et al. 2014).
Although not all studies reviewed in this section
included “don’t know” as a response option for ques-
tions on the harms of e-cigarettes, those that did, found
that a large number of students were unsure of the rel-
ative harmfulness of e-cigarettes compared to conven-
tional cigarettes (Ambrose et al. 2014; Amrock et al.
2015). In fact, among U.S. adolescents responding to the
2012 NYTS, “don’t know” was the most common response
(41.1–53.3%) across all the demographic subgroups
examined (gender, age, and race/ethnicity) (Amrock et al.
2015). In this sample, more never smokers (57.4%) than
ever smokers (37.5%) or past-30-day smokers (24%) had
not heard of or did not know enough about e-cigarettes to
make a judgment of harm (Ambrose et al. 2014). Future
studies will benefit from examining the effect of harm per-
ception on the use of e-cigarettes and other tobacco-use
behaviors among adolescents.
Young Adults
Table 2.12d presents data from the 2013−2014
NATS on beliefs about harm from e-cigarettes among
young adults (18–24 years old). Just over half (53.8%) of
young adults believed that e-cigarettes were “moderately
harmful,” 26.8% believed they were “very harmful,” and
19.4%believed they caused “no harm.” Levels of belief in
moderate harm were quite similar by type of e-cigarette
use: 52.8% of never users, 56.8% of ever (but not cur-
rent) users, and 53.6% of current users. Ever and current
users were more likely than never users to report that
e-cigarettes were “not at all harmful,” while never users
were more likely than the other two groups to report that
e-cigarettes were “very harmful.”
Published studies on perceived harm of e-cigarettes
from regional samples, primarily of college and univer-
sity students, are presented in Table 2.11. A large survey
(n = 4,444) of college students in North Carolina conducted
in 2009 found that, as with adolescents, perceived harm
of e-cigarettes, compared with conventional cigarettes,
was lower among college students who had ever used
e-cigarettes(45%) than among those who had never used
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 65
Table 2.11 Summary of studies on perceptions of e-cigarette harm among youth and young adults
Study Design/population Measures Outcomes/findings Comments
Choi et al. (2012) • Focus groups
• Recruitment by (1) online
advertisements, (2) flyers on one
4-year and two 2-year college
campuses, (3)announcements in
student life newsletter at a 2-year
college, and (4) recruitment booth on
a 2-year college campus
• Year sample drawn: 2010
• Youth: n/a
• Young adults: Individuals in
Minneapolis-St. Paul, MN, enrolled
in or who had graduated from
4-year colleges, or those who were
enrolled in or had graduated from
2-year colleges, or those who had not
enrolled in postsecondary education;
N = 66
• Perceived harmfulness relative
to cigarettes
• No consensus among participants
• Lack of information on
(1) ingredients, (2) health impact,
and (3)mechanism used to vaporize
nicotine
• Some noted e-cigarettes to be as
harmful as cigarettes (“all one
product, in different forms”)
• Generalizability
• Limited sample size
Adkison et al. (2013) • Parallel prospective cohort
• Telephone interview and web-based
surveys
• Probability sampling methods
(random-digit dialing)
• Years sample drawn: 2010–2011
(Wave8), 2008–2009 (Wave 7, where
available)
• Youth: n/a
• Young adults: current smokers,
≥18 years of age; N = 5,939 (Canada:
n = 1,581; United States: n = 1,520;
United Kingdom: n = 1,325;
Australia: n = 1,513)
• Are electronic cigarettes more
harmful than, less harmful
than, or equally harmful as
regular cigarettes to one’s
health?
• Not explicitly reported for young
adults
• Inclusion of only
current and former
cigarette smokers
• Limited set of
questions
A Report of the Surgeon General
66 Chapter 2
Study Design/population Measures Outcomes/findings Comments
Faletau et al. (2013) • Qualitative exploratory
• Structured focus groups and
individual interviews
• Recruited from two low
socioeconomic primary schools
in East and South Auckland, New
Zealand
• Year sample drawn: 2011
• Youth: Maori, Tongan, Samoan,
Cook Island, and Niuean children,
6–10years of age; N = 20
• Young adults: n/a
• Viewed tobacco cigarette and
electronic cigarette videos
• Still allows smokers to smoke,
despite its function as a cessation aid
• Generalizability
• Unknown if
saturation was
reached in
children between
focus groups
and individual
interviews
Sutfin et al. (2013)
• Cross-sectional
• Web-based survey (part of a
randomized group trial)
• Stratified random sample
• Year sample drawn: 2009
• Youth: n/a
• Young adults: undergraduate students
attending eight universities in North
Carolina; N = 4,857 (completers of
e-cigarette question, n = 4,444).
• Compared with a regular
cigarette, how harmful do you
think e-cigarettes are?
– Less harmful
– As harmful
– More harmful
– Do not know
• Among the overall sample:
– 17% indicated “as harmful”
– 23% indicated “less harmful”
– 2% indicated “more harmful”
– 50% indicated “do not know”
• Among ever e-cigarette users:
– 17% indicated “as harmful”
– 45% indicated “less harmful”
– 3% indicated “more harmful”
– 23% indicated “do not know”
• Among never e-cigarette users:
– 16% indicated “as harmful”
– 22% indicated “less harmful”
– 2% indicated “more harmful”
– 51% indicated “do not know”
• Ever e-cigarette use significantly
associated with harm perceptions
(p <0.001)
• Low response rate
• Generalizability
• Inability to
differentiate former
smokers from
experimenters
• Cross-sectional
analysis
Table 2.11 Continued
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 67
Study Design/population Measures Outcomes/findings Comments
Ambrose et al. (2014) • NYTS
• Cross-sectional
• School-based survey
• Three-stage cluster sampling
• Year sample drawn: 2012
• Youth: U.S. middle and high school
students (grades 6–12); N = 24,658
• Young adults: n/a
• Do you believe that electronic
cigarettes or e-cigarettes, such
as Ruyan or NJOY, are less
harmful, equally harmful, or
more harmful than regular
cigarettes?
• 30.6% (CI, 29.3–31.9%)
of respondents believed
e-cigarettes are less harmful
than cigarettes: never smokers:
25%(CI, 23.9–26.2%); ever smokers:
41.3% (CI, 39.1–43.6%); current
smokers: 54.2%(CI, 51.0–57.4%)
• Female and Hispanics were less
likely to perceive e-cigarettes as less
harmful than cigarettes compared
with males and Whites, across all
smoking statuses
• Current smokers that had ever used
e-cigarettes were more than twice as
likely to perceive e-cigarettes as less
harmful, compared with smokers
who had never used e-cigarettes
(AOR = 2.48; CI, 1.87–3.29)
• Never smokers who had ever used
e-cigarettes were almost six times
as likely to perceive e-cigarettes
as less harmful, compared with
never smokers who had never used
e-cigarettes (AOR = 5.88;
CI, 3.07–11.25)
• Perceived graduated
risk
• Self-reported items
• Social desirability
bias
• Generalizability
Table 2.11 Continued
A Report of the Surgeon General
68 Chapter 2
Study Design/population Measures Outcomes/findings Comments
Czoli et al. (2014) • Cross-sectional
• Survey
• Recruitment through online panel
of commercial market research
company
• Year sample drawn: 2012
• Youth: Canadian youth recruited
from online panel, 16–30 years of age;
n=1,188
• Young adults: Canadian young adults
recruited from same online panel (see
above)
• Is this product harmful to your
health?
• Have you ever experienced
any side-effects or adverse
outcome(s) while using
e-cigarettes?
• Mean score for agreement with
e-cigarettes as harmful to your
health (higher score indicates greater
agreement):
– Among cigarette nonsmokers:
5.5 (e-cigarette nonuser) vs. 4.4
(e-cigarette ever user)
– Among former smokers: 5.2
(e-cigarette nonuser) vs. 3.6
(e-cigarette ever user)
– Among current smokers: 2.6
(e-cigarette nonuser) vs. 3.5
(e-cigarette ever user)
• Cross-sectional
analysis
• Generalizability
Gallus et al. (2014) • Cross-sectional
• In-person survey
• Representative multistage sampling
• Year sample drawn: 2013
• Youth: n/a
• Young adults: Italians ≥15 years of
age; N = 3,000
• Indicate your opinion (true/
false) concerning e-cigarettes
on the following:
– (1) Are not harmful for health
– (2) Are less harmful than
traditional cigarettes because
they do not contain nicotine
– (3) Are less harmful
because there is no tobacco
combustion
– (4) Are less harmful because
they contain only nicotine
– (5) Are more harmful than
traditional cigarettes
– (6) Are an efficient tool to
quit smoking
– (7) Allow smoking even
where it is forbidden
• Findings not explicitly reported for
young adults
• Unstable estimates
due to small sample
of e-cigarette users
• Unvalidated survey
Table 2.11 Continued
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 69
Study Design/population Measures Outcomes/findings Comments
Tan and Bigman (2014) • Cross-sectional
• Health Information National Trends
Survey 4 Cycle 2
• Collected between October 2012 and
January 2013
• U.S. adults ≥18 years of age
• N=3,630, 29.8% 18–34 years of age
• Compared to smoking
cigarettes, would you say that
electronic cigarettes are:
– Much less harmful
– Less harmful
– Just as harmful
– More harmful
– Much more harmful
– I’ve never heard of electronic
cigarettes
• Compared with younger respondents
(18–34 years of age), older
respondents had 38%–72% lower
odds of believing that e-cigarettes are
less harmful than regular cigarettes
—
Tucker et al. (2014)
• Cross-sectional
• Paper-based survey
• Probability-based sampling
• Year sample drawn: not reported
• Youth: n/a
• Young adults: homeless young adults,
17–25 years of age; N = 292 (subset of
lifetime e-cigarette users, n = 83)
• Rate whether they perceive
e-cigarettes to be less harmful,
more harmful, or just as
harmful as smoking cigarettes
• 44.9% viewed e-cigarettes as less
harmful than conventional cigarettes
• 26.6% viewed e-cigarettes as just as
harmful as conventional cigarettes
• 3.7% viewed e-cigarettes as more
harmful than conventional cigarettes
• 24.8% did not know the relative
harm
• Did not collect
information on
youth’s attitudes
about alternate
tobacco products
besides e-cigarettes
• Did not collect
information on the
conditions under
which they used
various products
Amrock et al. (2015)
• NYTS
• Cross-sectional
• School-based survey
• Three-stage cluster sampling
• Year sample drawn: 2012
• Youth: U.S. middle and high school
students (grades 6–12); N = 24,658
• Young adults: n/a
• Do you believe that electronic
cigarettes or e-cigarettes, such
as Ruyan or NJOY, are less
harmful, equally harmful, or
more harmful than regular
cigarettes?
• 34.2% (CI, 32.8–35.6%) of
adolescents considered e-cigarettes
to be less harmful than cigarettes
• Females were less likely than males
to perceive e-cigarettes as less
harmful than cigarettes
• Lifetime e-cigarette users were more
likely than never users to report
e-cigarettes as less harmful than
cigarettes (71.8% vs. 31%)
• Past-30-day e-cigarette users were
more likely than nonrecent users to
report e-cigarettes as less harmful
than cigarettes (73.8% vs. 33.1%)
• Missingness
• Perceived graduated
risk
• Self-reported items
• Social desirability
bias
• Generalizability
Table 2.11 Continued
A Report of the Surgeon General
70 Chapter 2
Study Design/population Measures Outcomes/findings Comments
Berg et al. (2015) • Cross-sectional
• Online-based survey
• Recruitment by random selection
• Year sample drawn: 2013
• Youth: n/a
• Young adults: U.S. university
students; n=2,002
• How harmful to your health do
you think electronic cigarettes
are?
• How addictive do you think
electronic cigarettes are?
• How socially acceptable among
your peers do you think
electronic cigarettes are?
• Respondents considered e-cigarettes
among the least harmful
(4.26 ±1.95), addictive
(4.29 ± 2.08), and socially acceptable
(4.12 ± 2.03) of the products
considered
• Electronic cigarettes were among the
most positively perceived products
(11.56 ± 4.22)
• Predictors of more favorable
perceptions included:
– Being male (p = 0.03)
– Parental tobacco smoking
(p = 0.02)
– More friends who smoke cigarettes
(p <0.001)
– More friends who use hookah
(p<0.001)
– More friends who use electronic
cigarettes (p = 0.04)
• Recent cigarette smoking (p <0.001).
• Generalizability
• Responder bias
• Cross-sectional
analysis
Camenga et al. (2015) • Focus groups
• Purposive sampling
• Years sample drawn: 2012–2013
• Youth: middle and high school
students in Connecticut; n = 68
• Young adults: college students in
Connecticut; n = 59
• Discuss the comparison
between e-cigarettes and
cigarettes.
• Compared with nonsmokers, college
and high school smokers were
more likely to believe the use of
e-cigarettes could lead to a persistent
“craving” that would prevent
successful smoking cessation
• Compared with nonsmokers, college
and high school smokers were more
likely to believe that e-cigarette use
would maintain nicotine addiction
• Transferability
• Generalizability
• Limited definition
of e-cigarettes
Table 2.11 Continued
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 71
Study Design/population Measures Outcomes/findings Comments
Cardenas et al. (2015) • Cross-sectional
• School-based survey
• Three-stage cluster sampling
• Year sample drawn: 2012
• Youth: U.S. middle and high school
students; full sample size not
reported; subsample of children who
never tried smoking cigarettes,
n = 14,861
• Young adults: n/a
• Do you believe that electronic
cigarettes or e-cigarettes, such
as Ruyan or NJOY, are less
harmful, equally harmful, or
more harmful than regular
cigarettes?
• Participants who lived with a
smoker were more likely to report
e-cigarettes are less harmful than
regular cigarettes (16.2% vs. 24.8%)
• E-cigarette users were more likely to
believe e-cigarettes are less harmful
than regular cigarettes
(70.9% vs. 27.5%)
• No limitations
reported
Chaffee et al. (2015)
• Cross-sectional
• Year sample drawn: 2014
• Youth: male high school students
from San Francisco; n=104
• Participants were asked to
estimate the probability
(0–100%) that specific health
or social outcomes would
happen to them as a result
of e-cigarette use (e.g., heart
attack, lung cancer, get into
trouble, upset family, etc.)
• Ever use of electronic cigarettes
was associated with lower perceived
probabilities that unfavorable
outcomes would happen
—
Lotrean (2015)
• Cross-sectional
• 2013
• Students 19–24 years of age from
Cluj-Napoca, Romania; n = 480
• Belief that e-cigarettes are less
dangerous than cigarettes:
agree, partially agree, disagree,
partially disagree, don’t know
• 55.9% of the total sample agreed
or partially agreed that e-cigarettes
are less dangerous, 35.8% did not
know, and 8.3% disagreed or partially
disagreed
• More smokers than nonsmokers or
ex-smokers agreed or partially agreed
that e-cigarettes are less dangerous
(62.3% vs. 58.7% and 33.3%,
respectively)
• Very small sample
• Measures not clearly
defined
Table 2.11 Continued
A Report of the Surgeon General
72 Chapter 2
Study Design/population Measures Outcomes/findings Comments
McDonald and Ling
(2015)
• Focus groups and semistructured
interviews
• Recruitment from bars through
screener surveys
• Years sample drawn: 2012–2013
• Youth: n/a
• Young adults: young adults in the
boroughs of Manhattan, Brooklyn,
and Queens in New York City,
18–27years of age; N = 87
• Perceived risks • Little knowledge of the devices
• Belief that e-cigarettes contain
harmless “water vapor” rather than
smoke
• Belief that “water vapor” is less
harmful or even “good” for users
• No limitations
reported
Roditis and Halpern-
Felsher (2015)
• Focus groups
• Recruitment from after-school
programs in urban Northern
California
• 2–6 participants in each group
• 24 adolescents: 9 female, 15 male
• Perceived risks and benefits
associated with conventional
cigarettes versus e-cigarettes
• Little knowledge of risks of
e-cigarette use
• Belief that e-cigarettes have no
nicotine
—
Cooper et al. (2016) • Cross-sectional
• Drawn from 2014 Texas Youth
Tobacco Survey, a school-based
survey
• Youth: students in grades 6–12 from
27 counties in Texas; N = 13,602
• “How dangerous do you think it
is for a person your age to use
electronic cigarettes?”
• Those in the e-cigarette-only group
viewed conventional cigarettes as
more harmful than did those in the
dual user group
• No differences in how harmful those
in the e-cigarette-only group and the
dual user group rated e-cigarettes
• Those in the cigarette-only group
rated e-cigarettes as more harmful
than did those in the dual user group
—
Note: Studies in this table are sorted by year of publication and then alphabetically.
AOR = adjusted odds ratio; CI = condence interval; NYTS = National Youth Tobacco Survey.
Table 2.11 Continued
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 73
E-Cigarette Use Among Youth and Young Adults
Table 2.12a Percentage of middle school and high school students who reported that using e-cigarettes on some days
but not every day caused no harm, little/some harm, or a lot of harm
a
, by e-cigarette smoking status;
National Youth Tobacco Survey (NYTS) 2015
No harm Little/some harm A lot of harm
Characteristic
n % (95% CI) n % (95% CI) n % (95% CI)
Overall 2,511 14.5 (13.4–15.8) 10,471 61.9 (60.3–63.5) 4,070 23.6 (22.2–25.0)
E-cigarette use
Never
b
1,200 9.5 (8.4–10.8) 7,528 61.0 (59.4–62.6) 3,653 29.4 (28.0–30.9)
Ever, but not past 30 days
c
601 22.4 (20.3–24.6) 1,748 69.3 (66.4–72.1) 249 8.3 (7.0–9.9)
Past 30 days
d
641 34.2 (31.2–37.3) 1,089 59.0 (55.9–62.0) 126 6.8 (5.4–8.7)
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = condence interval. There were 325 youth excluded due to missing responses for e-cigarette use.
a
Includes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not
every day?” Responses for “little harm” and “some harm” were combined.
b
Includes those who reported never trying e-cigarettes.
c
Includes those who reported trying e-cigarettes but not using e-cigarettes on 1 or more days in the past 30 days.
d
Includes those who reported using e-cigarettes on 1 or more days in the past 30 days.
Table 2.12b Percentage of middle school students who reported that using e-cigarettes on some days but not every
day caused no harm, little/some harm, or a lot of harm
a
, by e-cigarette smoking status; National Youth
Tobacco Survey (NYTS) 2015
No harm Little/some harm A lot of harm
Characteristic
n % (95% CI) n % (95% CI) n % (95% CI)
Overall 1,089 13.5 (11.9–15.4) 4,579 57.6 (56.1–59.2) 2,260 28.8 (27.1–30.6)
E-cigarette use
Never
b
658 9.9 (8.3–11.6) 3,927 58.0 (56.5–59.4) 2,141 32.2 (30.5–33.9)
Ever, but not past 30 days
c
211 31.9 (27.7–36.3) 383 60.6 (55.7–65.4) 60 7.5 (5.4–10.4)
Past 30 days
d
193 41.5 (35.6–47.6) 220 50.0 (44.3–55.7) 38 8.5 (6.0–12.0)
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = condence interval. There were 132 middle students excluded due to missing responses for e-cigarette use.
a
Includes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not
every day?” Responses for “little harm” and “some harm” were combined.
b
Includes those who reported never trying e-cigarettes.
c
Includes those who reported trying e-cigarettes but not using e-cigarettes on 1 or more days in the past 30 days.
d
Includes those who reported using e-cigarettes, on 1 or more days in the past 30 days.
A Report of the Surgeon General
74 Chapter 2
Table 2.12c Percentage of high school students who reported that using e-cigarettes on some days but not every
day caused no harm, little/some harm, or a lot of harm
a
, by e-cigarette smoking status; National Youth
Tobacco Survey (NYTS) 2015
No harm Little/some harm A lot of harm
Characteristic
n % (95% CI) n % (95% CI) n % (95% CI)
Overall 1,422 15.3 (14.0–16.7) 5,892 65.3 (63.2–67.3) 1,810 19.4 (18.0–20.9)
E-cigarette use
Never
b
542 9.2 (7.8–10.9) 3,601 64.3 (62.0–66.7) 1,512 26.4 (24.6–28.3)
Ever, but not past 30 days
c
390 19.5 (17.5–21.8) 1,365 71.9 (68.6–74.9) 189 8.6 (6.9–10.6)
Past 30 days
d
448 32.3 (28.8–35.9) 869 61.3 (57.8–64.8) 88 6.4 (4.8–8.4)
Source: Centers for Disease Control and Prevention, unpublished data (data: NYTS 2015).
Notes: CI = condence interval. There were 166 high school students excluded due to missing responses for e-cigarette use.
a
Includes responses to the question, “How much do you think people harm themselves when they use e-cigarettes some days but not
every day?” Responses for “little harm” and “some harm” were combined.
b
Includes those who reported never trying e-cigarettes.
c
Includes those who reported trying e-cigarettes but not using electronic cigarettes on 1 or more days in the past 30 days.
d
Includes those who reported using e-cigarettes, on 1 or more days in the past 30 days.
Table 2.12d Percentage of young adults (18–24 years of age) who reported that e-cigarettes were not at all harmful,
moderately harmful, or very harmful
a
, by e-cigarette smoking status; National Adult Tobacco Study
(NATS) 2013–2014
Not at all harmful Moderately harmful Very harmful
Characteristic
n % (95% CI) n % (95% CI) n % (95% CI)
Overall 796 19.4 (17.9–20.9) 2,260 53.8 (51.9–55.7) 1,053 26.8 (25.1–28.6)
E-cigarette use
Never
b
359 14.3 (12.7–16.2) 1,423 52.8 (50.4–55.2) 814 32.9 (30.6–35.2)
Ever, but not current
c
210 22.9 (19.7–26.4) 520 56.8 (52.7–60.8) 186 20.3 (17.2–23.8)
Current
d
227 36.4 (31.8–41.2) 317 53.6 (48.6–58.5) 53 10.0 (7.2–13.9)
Source: Centers for Disease Control and Prevention, unpublished data (data: NATS 2013–2014).
Notes: CI = condence interval. There were three young adults who were excluded because of missing responses for both ECIGEVER
and ECIGNOW.
a
Includes responses to the question, “How harmful do you think using e-cigarettes are to a person’s health?”
b
Includes those who reported having never tried e-cigarettes or having never heard of them.
c
Includes those who reported having heard of e-cigarettes and tried e-cigarettes but reported using them “not at all” at the time of
the interview.
d
Includes those who reported having heard of e-cigarettes, tried e-cigarettes, and using e-cigarettes some days, every day, or rarely at
the time of the interview.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 75
E-Cigarette Use Among Youth and Young Adults
(Continued from last paragraph on page 64.)
e-cigarettes (22%) (Sutfin et al. 2013). Just over half of the
participants in this study who had never tried e-cigarettes,
however, said that they did not know enough to judge the
relative harm of e-cigarettes compared to conventional
cigarettes. In this study and another study, lack of knowl-
edge about the perceived harm of e-cigarettes relative to
conventional cigarettes was associated with lower odds of
using e-cigarettes (Sutfin et al. 2013; Choi and Forster
2014b). In the study by Choi and Forster (2014b), lower
perceived harm of e-cigarettes and the belief at baseline
that e-cigarettes can help people quit smoking were both
associated at follow-up with a higher likelihood of having
tried e-cigarettes.
Reasons for Use and Discontinuation
Reasons for Use
Table 2.13 summarizes studies of reasons for using
and discontinuing e-cigarettes. The most commonly cited
reasons for use by adolescent and young adult e-cigarette
users included curiosity (Schmidt et al. 2014; Biener and
Hargraves 2015; Biener et al. 2015; Kong et al. 2015;
McDonald and Ling 2015; Suris et al. 2015; Sutfin et al.
2015), flavorings/taste (Ambrose et al. 2015; University of
Michigan 2015), use as a less harmful/less toxic alternative
to conventional cigarettes (Peters et al. 2013; Tucker et al.
2014; Ambrose et al. 2015; Kong et al. 2015; McDonald
and Ling 2015; Sutfin et al. 2015), and avoidance of indoor
smoking restrictions or disturbing people with second-
hand smoke from conventional cigarettes (Tucker et al.
2014; Ambrose et al. 2015; Kong et al. 2015; McDonald
and Ling 2015; Suris et al. 2015; Sutfin et al. 2015). Other
reasons youth and young adults reported trying or using
e-cigarettes included affordability and lower cost than
conventional cigarettes (Tucker et al. 2014; Ambrose etal.
2015); accessibility and convenience (Choi et al. 2012;
Kong et al. 2015); social approval and/or offer from a
family member or friend (Peters et al. 2013; Kong et al.
2015; Suris et al. 2015; Sutfin et al. 2015); perception
that e-cigarettes are “cool,” “modern,” or “high-tech”
(Choi etal. 2012; Kong et al. 2015); avoidance of smelling
cigarette smoke (Peters et al. 2013; Tucker et al. 2014;
Ambrose et al. 2015; Kong et al. 2015; Sutfin et al. 2015);
ease of keeping hidden from parents/teachers (Peters et al.
2013; Kong et al. 2015); and weight control (Tucker et al.
2014). Young adults also perceived that e-cigarettes were
more socially acceptable than smoking conventional ciga-
rettes in public (Trumbo and Harper 2013).
Some youth and young adults also reported using
e-cigarettes as an aid to reducing and/or quitting their use of
conventional cigarettes (Li et al. 2013; Schmidt etal. 2014;
Tucker et al. 2014; Suris et al. 2015; Sutfin etal. 2015; Bold
et al. 2016). Data from the 2012 NYTS, however, suggest
that while e-cigarette use among U.S. youth may be associ-
ated with intentions to smoke conventional cigarettes, it is
not associated with intentions to quit conventional ciga-
rette smoking (Park et al. 2016). This is further reinforced
by a study of young adults from Switzerland, which found
that after 15 months of follow-up, e-cigarette use was not
associated with either cessation or reduction in the use of
conventional cigarettes (Gmel et al. 2016). There is some
evidence to suggest that curiosity was a stronger driver of
an e-cigarette trial among young adults than smoking ces-
sation, and that smoking cessation was a stronger driver
of such a trial among older adults (Schmidt etal. 2014).
Other evidence suggests that reasons for use were driven
by tobacco-use status, with regular adolescent e-cigarette
users much more likely than adolescents who had used
e-cigarettes just once to give the reason for use as smoking
cessation, smoking reduction, or avoidance of smoke-free
air regulations (Suris et al. 2015). Nationwide, according
to the 2015 MTF (University of Michigan 2015), “because
they tasted good” was cited as a reason to use e-cigarettes
among 40% of 8th-, 10th-, and 12th-grade users, versus
just 10% who reported they used them in an attempt to
quit smoking conventional cigarettes. In a New Zealand
study, interest in using e-cigarettes to quit using conven-
tional cigarettes was higher among young adults than
older adults (Li et al. 2013). Finally, another study, this
one conducted among high school, middle school, and
college students in Connecticut in 2012–2013, found that
although the students were aware that e-cigarettes could
be used to aid in smoking cessation, they thought that few
smokers had successfully used e-cigarettes to quit smoking
(Camenga et al. 2015). However, in an article published
by this group (Bold et al. 2016), trying e-cigarettes to
quit smoking was the most robust predictor of continued
e-cigarette use 6months later, using a multivariable model
that included all reasons simultaneously, though this
reason was only endorsed at baseline by 5.9% of youth. Low
cost was the most robust predictor of more frequent use
6months later, though only 10% of students endorsed this
reason at baseline (Bold et al. 2016). Therefore, the reasons
to experiment with e-cigarettes are likely different from the
reasons to continue using them, over time.
No randomized controlled trials specific to the effi-
cacy of using e-cigarettes for quitting conventional ciga-
rette smoking for young adults have been conducted to
date. Although use of e-cigarettes as a potential cessation
device for conventional cigarette smoking among adults is
important to examine (e.g., McRobbie et al. 2014; McNeill
et al. 2015), none of this evidence is included here, as it
does not directly discuss youth and young adults. Three
observational studies specific to this issue, however, have
been conducted among young adults to date. Data from
A Report of the Surgeon General
76 Chapter 2
Table 2.13 Summary of studies on reasons for use and discontinuation of e-cigarettes among youth and young adults
Study Design/population Measures Outcomes/findings
Adkison et
al. (2013)
• Parallel prospective cohort
• Telephone interview and web-based
surveys
• Probability sampling methods (random-
digit dialing)
• Years sample drawn: 2010–2011 (Wave
8), 2008–2009 (Wave 7; where available)
• Youth: n/a
• Young adults: current smokers,
≥18 years of age; N = 5,939
(Canada, n = 1,581; U.S., n = 1,520;
United Kingdom, n = 1,325;
Australia, n=1,513)
• Four questions were asked regarding
reasons for use (yes/no):
1. Electronic cigarettes may not be as bad as
cigarettes for your health
2. Easier to cut down on the number of
cigarettes you smoke
3. Can smoke in places where smoking
conventional cigarettes is prohibited
4. Might help you quit
• Not explicitly reported for young adults
Choi et al.
(2012)
• Focus groups
• Recruitment by (1) online
advertisements, (2) flyers on one
4-year and two 2-year college campuses,
(3) announcements in student life
newsletter at a 2-year college, and
(4) recruitment booth on a 2-year
college campus
• Year sample drawn: 2010
• Youth: n/a
• Young adults: Individuals in
Minneapolis-St. Paul, MN, enrolled in or
who had graduated from
4-year colleges, or those who were
enrolled in or had graduated from
2-year colleges, or those who had not
enrolled in postsecondary education;
N = 66
• Potential as quit aids • Ineffective as quit aids because:
– Contain nicotine
– Potential to be addicted to e-cigarettes
– Eliminate social interaction aspect
• Potential to help quit smoking because:
– Potential for gradual reduction in nicotine
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 77
Study Design/population Measures Outcomes/findings
Choi and
Forster
(2013)
• Population-based prospective cohort
study
• Interview
• Cluster random sampling
• Years sample drawn: 2010–2011
• Youth: n/a
• Young adults: U.S. midwestern adults,
20–28 years of age; n = 2,624 (sample
from Minnesota)
• Indicate your level of agreement:
1. E-cigarettes can help people quit smoking
2. E-cigarettes are less harmful than
cigarettes
3. E-cigarettes are less addictive than
cigarettes
• 44.5% agreed e-cigarettes can help quit smoking;
associated with the following characteristics:
– Not being non-Hispanic White (AOR = 0.60;
CI, 0.44–0.84)
– Enrolled/graduated from 2-year college (AOR = 1.47;
CI, 1.09–1.98)
– Current smoker (AOR = 1.35; CI, 1.05–1.73)
– At least one close friend who smokes (AOR = 1.27;
CI,1.03–1.57)
• 52.9% agreed e-cigarettes are less harmful than cigarettes;
associated with the following characteristics:
– Not being non-Hispanic White (AOR = 0.73;
CI, 0.53–0.99)
– Male (AOR = 1.39; CI, 1.15–1.67)
– Current smoker (AOR = 1.42; CI, 1.11–1.83)
• 26.4% agreed e-cigarettes are less addictive than cigarettes;
associated with the following characteristics:
– Current smoker (AOR = 1.51; CI, 1.15–1.99)
– Former smoker (AOR = 1.64; CI, 1.19–2.25)
– At least one close friend who smokes (AOR = 1.28;
CI,1.00–1.63)
Faletau et
al. (2013)
• Qualitative exploratory
• Structured focus groups and individual
interviews
• Recruited from two low socioeconomic
primary schools in East and South
Auckland, New Zealand
• Year sample drawn: 2011
• Youth: Maori, Tongan, Samoan, Cook
Island, and Niuean children, 6–10 years
of age; N = 20
• Young adults: n/a
• Viewed tobacco cigarette and electronic
cigarette videos
• Stops people from smoking
• People won’t die
• Protects those around e-cigarette users from sickness
Table 2.13 Continued
A Report of the Surgeon General
78 Chapter 2
Study Design/population Measures Outcomes/findings
Li et al.
(2013)
• Cross-sectional
• Telephone-based survey
• Random-digit-dial sampling
• Years sample drawn: 2011–2012
• Youth: n/a
• Young adults: current smokers and
recent quitters, ≥18 years of age, in New
Zealand; N = 840
• Indicate your level of agreement:
1. E-cigarettes are safer to use than tobacco
cigarettes (n = 317)
2. E-cigarettes can help people quit smoking
tobacco (n = 313)
• OR = 1.81 (.78–4.18) among participants 18–24 years of
age for perceived safety of e-cigarettes compared with
participants ≥45 years of age
• OR = 0.50 (0.21–1.17) among participants 18–24 years of
age for perceived efficacy of e-cigarettes compared with
participants ≥45 years of age
Pepper et
al. (2013)
• Cross-sectional
• Web-based survey
• Recruited through parents who were
members of an online panel assembled
by random-digit dialing and address-
based sampling.
• Year sample drawn: 2011
• Youth: U.S. males, 11–17 years of age;
N=228
• Young adults: n/a
• If one of your best friends were to offer you
an e-cigarette, would you try it?
• If one of your best friends were to offer you a
flavored e-cigarette (chocolate, mint, apple,
etc.), would you try it?
• Overall, 18% were willing to try an e-cigarette if offered by
a best friend:
– 13% willing to try a plain e-cigarette
– 5% willing to try flavored e-cigarettes or both kinds
• Willingness to try e-cigarettes by age:
– 11–13: 11%
– 14–16: 15%
– 17–19: 29%
• OR = 3.26 (CI, 1.27–8.35) among those 17–19 years of age
for willingness to try an e-cigarette, compared with those
11–13 years of age
• Willingness to try e-cigarettes by smoking status:
– Nonsmoker: 13%
– Smoker: 74%
• OR = 18.67 (6.22–55.98) among smokers for willingness to
try an e-cigarette, compared with nonsmokers
Peters et
al. (2013)
• Focus groups
• Recruitment through large, diverse high
school in southwestern United States
• Year sample drawn: 2012
• Youth: U.S. teenage boys; N=47
• Young adults: n/a
• Why do youth use electronic cigarettes?
• What do your friends think about electronic
cigarettes?
• Why are electronic cigarettes so popular?
• Reported reasons for use among youth:
– Expeditious consumption and concealment: 40%
– High school approval: 26%
– Healthier than cigarettes: 19%
– Odorless: 15%
• Reported perceptions of friends:
– High school approval: 49%
– Healthier than cigarettes: 36%
– Safe high: 15%
• Reported reasons for popularity:
– Accessibility: 43%
– Healthier than cigarettes: 30%
– Aesthetics: 23%
• Don’t know: 4%
Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 79
Study Design/population Measures Outcomes/findings
Trumbo
and
Harper
(2013)
• Cross-sectional
• Web-based survey
• Recruitment by offer of extra credit to
students in a 100-level course
• Year sample drawn: 2011
• Youth: n/a
• Young adults: freshmen and sophomores
in a 100-level mass media in society
course; n = 244
• Indicate your level of agreement with
relative advantage:
1. I think e-cigarettes are safer in terms of
“secondhand” smoke compared to tobacco
cigarettes
2. I think e-cigarettes are not as harmful to
users as tobacco cigarettes
• Indicate your level of agreement with
compatibility:
1. I think e-cigarette users can easily make
use of existing smoking areas
2. I believe using e-cigarettes would fit in
well with the lifestyle of most smokers
• Indicate your level of agreement with
complexity:
1. I believe it will not be difficult for smokers
to learn how to use e-cigarettes
2. Overall, e-cigarettes are no more
complicated to use than ordinary tobacco
cigarettes
• Indicate your level of agreement with
“trialability”:
1. I think it will be easy for people to
purchase e-cigarettes
2. Smokers could easily give e-cigarettes a
try to see if they like them better than
tobacco
• Mean score (SD) of innovation items: 36.0 (4.7)
Zhu et al.
(2013)
• Population
• Online-based surveys
• National probability sample
• Year sample drawn: 2012
• Youth: n/a
• Young adults: U.S. adults,
>18 years of age; N = 10,041
• Why did you use e-cigarettes (yes/no)?
1. Safer than cigarettes
2. Cheaper than cigarettes
3. Easy to use when I can’t smoke
4. To try to quit smoking cigarettes
5. Just because
• Not explicitly reported for young adults
Table 2.13 Continued
A Report of the Surgeon General
80 Chapter 2
Study Design/population Measures Outcomes/findings
Choi and
Forster
(2014b)
• Population-based prospective cohort
study
• Survey
• Cluster random sampling
• Years sample drawn: 2011–2012
• Youth: n/a
• Young adults: participants in Minnesota
Adolescent Community Cohort;
n = 1,379
• Indicate your level of agreement with the
following:
1. Using e-cigarettes can help people quit
smoking
2. Using e-cigarettes is less harmful to
health of the user than smoking cigarettes
3. E-cigarettes are less addictive than
cigarettes
• 10% agreed that e-cigarettes can help people quit smoking;
associated with e-cigarette experimentation at follow-up
(AOR = 1.98; CI, 1.29–3.04)
• 10.1% agreed that e-cigarettes are less harmful than
cigarettes; associated with e-cigarette experimentation at
follow-up (AOR = 2.34; CI, 1.49–3.69)
• 9.3% agreed that e-cigarettes are less addictive than
cigarettes
Czoli et al.
(2014)
• Cross-sectional
• Survey
• Recruitment through online panel of
commercial market research company
• Year sample drawn: 2012
• Youth: Canadian youth recruited
from online panel, 16–30 years of age;
n = 1,188
• Young adults: Canadian young adults
recruited from same online panel
• Indicate your agreement with the following
reasons for trying e-cigarettes:
1. In places where you can’t smoke
cigarettes
2. For times when you don’t want to smoke
around others
3. To help you cut back on the amount you
smoke
4. To help you while you are trying to quit
smoking
5. As a long-term replacement for cigarettes
6. As a cheaper alternative to cigarettes
• Reasons for trying e-cigarettes among current cigarette
smokers:
– To help cut back on the amount they smoked (77.7%)
– As a long-term replacement for cigarettes (77.8%)
– For the times when they don’t want to smoke around
others (78.8%)
– To help them while they are trying to quit smoking
(80.4%)
– As a cheaper alternative to cigarettes (80.7%)
– In places where they can’t smoke cigarettes (80.9%)
Li et al.
(2014)
• Cross-sectional
• Telephone-based survey
• Recruitment by telephone-based
omnibus survey and quitline client
database
• Year sample drawn: 2013
• Youth: n/a
• Young adults: current smokers and
recent quitters, ≥18 years of age, in New
Zealand; N = 267
• Indicate your level of agreement:
1. Electronic cigarettes are for people who
want to stop smoking completely
2. Electronic cigarettes are for people who
want to cut down on their smoking
3. Electronic cigarettes are for people who
want to still smoke in restricted public
places such as inside a cafe, restaurant,
or pub
• OR = 1.99 (CI, 0.99–3.97) among those 18–34 years of
age for agreeing that “electronic cigarettes are for people
who want to stop smoking completely,” compared with
individuals ≥35 years of age
• OR = 0.72 (CI, 0.24–2.21) among those 18–34 years of
age for agreeing that “electronic cigarettes are for people
who want to cut down on their smoking,” compared with
individuals ≥35 years of age
• OR = 0.93 (0.47–1.85) among those 18–34 years of age for
agreeing that “electronic cigarettes are for people who want
to still smoke in restricted public places such as inside a
cafe, restaurant or pub,” compared with individuals ≥35
years of age
Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 81
Study Design/population Measures Outcomes/findings
Schmidt et
al. (2014)
• Cross-sectional
• Telephone-based survey
• Random-digit-dial sampling
• Year sample drawn: 2013
• Youth: n/a
• Young adults: noninstitutionalized
adults in Montana; n = 5,000
• Select all of the reasons you initiated use of
e-cigarettes:
1. To quit smoking cigarettes
2. To reduce cigarette consumption
3. To try something new (curiosity)
4. To not disturb other people with smoke
5. To smoke in a place where cigarette
smoking is prohibited
6. To save money
7. E-cigarettes might be less harmful than
cigarettes
8. E-cigarettes taste better
9. Other
• Among those 18–34 years of age, approximately
50%reported trying e-cigarettes to quit or reduce
cigaretteuse
• Among those 18–34 years of age, approximately
70%reported trying e-cigarettes to try something
new(curiosity)
Tucker et
al. (2014)
• Cross-sectional
• Paper-based survey
• Probability-based sampling
• Year sample drawn: not reported
• Youth: n/a
• Young adults: homeless young adults,
17–25 years of age; N = 292 (subset of
lifetime e-cigarette users, n = 83)
• 18-item measure of reasons for using
e-cigarettes, rating each reason on a 4-point
scale (1 = not at all true, 4 = very true)
• Most common reasons for use included:
– Not having to go outside to smoke cigarettes (38%)
– To deal with situations or places where they cannot
smoke (36%)
– To avoid bothering other people with tobacco smoke
(31%)
• Less common to report using e-cigarettes was to quit
smoking (17–18%)
Ambrose
et al.
(2015)
• Cross-sectional
• Wave 1 of PATH study
• Household-based, nationally
representative survey
• Youth: 12–17 years of age; n = 13,651
• Young adults: n/a
• Past 30-day e-cigarette users were asked to
report reasons for product use, including “it
comes in flavors I like”
• 81.5% of past-30-day users cited “because they come in
flavors I like” as a reason for using e-cigarettes
• Other common reasons for use were “they might be less
harmful to me than cigarettes” (79.1%); “they might be
less harmful to people around me than cigarettes” (78.1%);
and “I can smoke/use them at times when or in places
where smoking cigarettes isn’t allowed” (58.9%)
Biener et
al. (2015)
• Cross-sectional
• Population-based mail survey
• Dual-frame sample
• Youth: n/a
• Young adults: 18–25 years of age;
n=4,740
• Reasons for trying: curiosity, use by friends,
health risks relative to cigarettes, absence of
smell, for use where smoking is prohibited,
and to quit or cut down on smoking
• Reasons for stopping e-cigarette use: health
concerns, negative reactions to taste and
feeling sick, inferiority to other forms of
tobacco, expense, lack of availability, and
social disapproval
• Most common reason cited was curiosity, with never
smokers more likely to cite this (77.3%) than former or
current cigarette smokers (59% and 61%)
Table 2.13 Continued
A Report of the Surgeon General
82 Chapter 2
Study Design/population Measures Outcomes/findings
Camenga
et al.
(2015)
• Focus groups
• Purposive sampling
• Years sample drawn:
2012–2013
• Youth: middle and high school students
in Connecticut; n = 68
• Young adults: college students in
Connecticut; n = 59
• Discuss your motivations to use e-cigarettes • Maintain smoking actions while allowing individuals to use
a “healthier” nicotine product
• Maintain tactile sensations to help with conditioned-
smoking cues
• College students believed e-cigarettes to be healthier than
cigarettes
Kong et al.
(2015)
• Cross-sectional
• Focus groups, schoolwide survey
• Recruitment by flyers and active
recruitment sessions
• Years sample drawn: 2012–2013
• Youth: New Haven County, Connecticut,
middle and high school students; focus
group n = 127 (youth and young adults);
survey n=4,780
• Young adults: New Haven County,
Connecticut, college students; focus
group n=127 (youth and young adults);
survey n=625
• Focus group:
– Why do you think people your age would
use e-cigarettes?
• Survey:
– Why did you try an e-cigarette?
– If you tried an e-cigarette but stopped
using it, why did you stop?
• Focus group responses:
– Reasons for use:
Influence of family and friends
To be “cool”
Curiosity
Readily available
Flavors
– Comparison to cigarettes:
Healthier
Less harsh
Cheaper
Smells better
More convenient
Can hide it
Use it indoors
– Reasons for discontinuation:
Losing interest
Negative physical effects (e.g., light-headed)
Bad taste
High cost
Less satisfying than cigarettes
• Survey responses:
– Reasons for experimentation (among lifetime e-cigarette
users):
Curiosity (54.4%)
Friends’ influence (31.6%)
– Reasons for discontinuation:
Uncool (16.3%)
Health risks (12.1%)
Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 83
Study Design/population Measures Outcomes/findings
Li et al.
(2015)
• Cross-sectional
• 2014
• Nationwide, in-home survey in New
Zealand
• Multistage, stratified, clustered, and
random probability sampling method
(oversampling of Maori and Pacific
peoples)
• Participants ≥15 years of age; n = 2,594:
– Youth: 15–17 years of age, 3.8% of
sample
– Young adults: 18–24 years of age,
13.4%of sample
• Why did you try using an electronic
cigarette? (Multiple responses allowed—
wanted to quit smoking cigarettes
completely/wanted to replace smoking
cigarettes some of the time/wanted to smoke
in places where cigarette smoking is not
allowed/cheaper than tobacco cigarettes/
safer than tobacco cigarettes/curiosity/
recommendation/other)
• 57.1% of ever users cited curiosity as a reason for first
trying, followed by 31.3% of ever users who cited wanting
to quit smoking completely
• Current e-cigarette users were more likely than noncurrent
users to report wanting to quit smoking completely as a
reason for using e-cigarettes
McDonald
and Ling
(2015)
• Focus groups and semistructured
interviews
• Recruitment from bars through screener
surveys
• Years sample drawn: 2012–2013
• Youth: n/a
• Young adults: young adults in the
boroughs of Manhattan, Brooklyn, and
Queens in New York City, 18–27 years of
age; N=87
• Bodily sensations
• Use in response to clean air laws
• Vapor described as “harsh” or “burning”
• Discontinued use because believed it would cause one to
smoke more
• Discontinued use due to fear of nicotine hangover
• Use to smoke in places where conventional smoking is not
allowed
Pokhrel et
al. (2015)
• Cross-sectional
• Web-based survey
• Recruitment by flyers across
three college campuses
• Year sample drawn: 2013
• Youth: n/a
• Young adults: U.S. students from
a 4-year university and two 2-year
community colleges in Oahu, Hawaii;
n = 307
• Fourteen items, scored on a scale of 1 (do not
agree) to 7 (agree), address three main
beliefs. E-cigarettes:
– Are less harmful than cigarettes
– Improve the health of current smokers
– May be used to quit smoking
• Participants generally scored harm-reduction items higher
• Among health benefit items, “e-cigarettes improve
breathing and reduce coughing” received the highest
average score: mean (SD) = 3.9 (1.6)
• Among smoking-cessation items, “e-cigarettes are a good
compromise for people trying to quit smoking” received
the highest average score: mean (SD) = 4.6 (1.8)
• Across all items, “e-cigarettes cut down on the harmful
effects of secondhand smoke” was scored the highest: mean
(SD) = 5.3 (1.7)
• 69% of participants agreed with the above item
Table 2.13 Continued
A Report of the Surgeon General
84 Chapter 2
Study Design/population Measures Outcomes/findings
Suris
(2015)
• Cross-sectional
• Data drawn from spring 2014 wave of
ado @ internet.ch, a longitudinal study
on Internet use
• Representative sample of students in
French-speaking part of Switzerland
• Sample of 621 students included
never e-cigarette users (n = 353),
experimenters (n = 120), and users
(n=148); mean age = 16.2 years
• Reason for having used e-cigarettes?
– Curiosity
– To smoke where it is forbidden
– To reduce smoking
– To do like my friends
– To quit smoking
– Other
• Experimenters were significantly more likely to have used
e-cigarettes for curiosity while users were more likely to
use them where it is forbidden to smoke (p<.01)
Sutn
(2015)
• Longitudinal cohort study
• Data from the Smokeless Tobacco Use
in College Students Study
• College students from North Carolina
and Virginia
• Reasons for e-cigarette use were
evaluated at Wave 6 of the study, n = 271
• Why did you try e-cigarettes? (check all
that apply):
– “I was curious about the product”
– “It might be better for my health than
smoking cigarettes”
– “My friends use e-cigarettes”
– “I can use it in places where cigarette
smoking is not allowed”
– “To help me quit smoking”
– “To cut down on smoking”
– “It doesn’t smell bad”
• The majority (91.6%) reported curiosity as a reason for
trying e-cigarettes
• More than 70% tried e-cigarettes because their friends
used them
• About 70% tried e-cigarettes because they believed them
to be better for their health than cigarettes
• Fifty percent cited, “It doesn’t smell bad,” and “I can use
it where cigarette smoking is not allowed”
• About 31% said that they used e-cigarettes to cut down
on smoking
• Twenty percent said that they tried e-cigarettes to help
them quit smoking
University
of
Michigan
(2015)
• Cross-sectional
• Data from the Monitoring the Future
Study
• School-based, self-administered, paper-
and-pencil questionnaire with cross-
sectional and longitudinal components
• Students from 8th, 10th, and 12th grades
• Weighted sample of students responding
to the “reasons for use of electronic
vaporizer” question: 603 (8th grade), 846
(10th grade), and 1,449 (12th grade)
• “What have been the most important reasons
for your using an electronic vaporizer, such
as an e-cigarette?”
– To help me quit regular cigarettes
– Because regular cigarette use is not
permitted
– To experiment to see what it’s like
– To relax or relieve tension
– To feel good or get high
– Because it looks cool
– To have a good time with my friends
– Because of boredom—nothing else to do
– Because it tastes good
– Because I am “hooked”—I have to have it
• More than half of all students in 8th, 10th, and 12th grades
reported that curiosity to see what they were like was a
primary reason for use
• Forty percent said that they used e-cigarettes because they
tasted good
• About 10% said they used them in an attempt to quit
smoking regular cigarettes
Table 2.13 Continued
E-Cigarette Use Among Youth and Young Adults
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 85
Study Design/population Measures Outcomes/findings
Berg
(2016)
• Cross-sectional
• Recruitment through Facebook
targeting of tobacco and marijuana users
and nonusers
• 2014
• Youth: n/a
• Young adults: 18–34 years of age, living
in the United States; N = 1,567
• Reasons for use: For what reasons do you/
might you use e-cigarettes?
• Reasons for discontinued use: Why have you
not used recently?
• Reasons for use among current e-cigarette users:
– ‘‘They might be less harmful than cigarettes’’ (77%)
– ‘‘They do not smell’’ (77%)
– ‘‘They help people quit smoking’’ (66%)
– ‘‘They cost less than other forms of tobacco’’ (62%)
• Reasons for use among nonusers:
– “They might be less harmful than cigarettes” (41%)
– “They don’t smell” (34%)
• Reasons for discontinuation:
– ‘‘Using other tobacco products instead’’ (43%)
– ‘‘They are too expensive’’ (35%)
– ‘‘I just don’t think about it’’ (31%)
Bold
(2016)
• Longitudinal
• Youth: New Haven County, Connecticut,
middle and high school students
• 2013–2014
• 340 e-cigarette users at baseline
• Reasons for first trying e-cigarettes:
– Curiosity
– It is cool
– Good flavors
– Does not smell bad
– Can hide it from adults
– Low cost
– My friends use it
– My parents/family use it
– Can use it anywhere
– To quit smoking regular cigarettes
– It is healthier than regular cigarettes
• In multivariable model, including all reasons
simultaneously, trying e-cigarettes to quit smoking was
the most robust predictor of current (i.e., past 30 days)
e-cigarette use 6 months later; however, this reason was
endorsed by very few youth (5.9%)
• In multivariable model, including all reasons
simultaneously, trying e-cigarettes because of low cost was
the most robust predictor of more frequent e-cigarette use
(i.e., more days/month) 6 months later; this reason was
endorsed by few youth (10%)
Note: Studies in this table are sorted by year of publication and then alphabetically. AOR = adjusted odds ratio; OR = odds ratio; PATH = Population Assessment of Tobacco
and Health Study; SD = standard deviation.
Table 2.13 Continued
A Report of the Surgeon General
86 Chapter 2
(Continued from last paragraph on page 75.)
a population-based cohort study of U.S. young adults
in the Midwest suggest that e-cigarettes are not effec-
tive as a technique for quitting the use of conventional
cigarettes. In that study, 11% of cigarette smokers who
had used e-cigarettes in the past 30 days at baseline quit
smoking at the 1-year follow-up, compared with 17%of
cigarette smokers who had never used e-cigarettes
(OR=0.93, p=0.93) (Choi and Forster 2014a). Another
cohort study of Swiss young adult men concluded that
there were no beneficial effects of vaping for conventional
cigarette smoking cessation or smoking reduction (Gmel
et al. 2016). In this study, e-cigarette users reported lower
cigarette smoking cessation rates at follow-up among
those who were occasional cigarette smokers at baseline
(OR = 0.43; 95%CI, 0.19–0.96). No differences between
e-cigarette users and nonusers were noted among those
who were daily cigarette smokers at baseline (OR = 0.42;
95% CI, 0.15–1.18). No differential changes between
e-cigarette users and nonusers in the number of conven-
tional cigarettes smoked per week were noted at follow-
up, either (Gmel et al. 2016). In a study by Unger and col-
leagues (2016), which focused on Hispanic young adults
in California, e-cigarette use at baseline (2014) was not
associated with cessation of cigarette smoking (OR = 1.31;
95% CI, 0.73–2.36) or marijuana use (OR = 1.05; 95% CI,
0.54–2.01) at follow-up (2015), though e-cigarette use
at baseline did increase the likelihood of transitioning
from nonuser to user of cigarettes (OR = 3.32; 95% CI,
1.55–7.10) and marijuana (OR=1.97; 95% CI, 1.01–3.86)
(Unger et al. 2016). Additional research is required to
determine any potential efficacy of e-cigarette use for con-
ventional cigarette smoking cessation in young adults.
Reason for Discontinuation
In the small number of published studies on reasons
for discontinuation of e-cigarette use in young users, ado-
lescent and young adult smokers have cited lack of satis-
faction and e-cigarettes’ poor taste and cost (Kong et al.
2015) as reasons for discontinuing. Additional reasons
have included negative physical effects (e.g., feeling light-
headed) (Kong et al. 2015) and loss of interest. In one study
of young adults aged 18–35, former and never smokers of
conventional cigarettes also cited the idea that e-cigarettes
were “bad for their health” as a reason for discontinuation
(Biener and Hargraves 2015; Biener et al. 2015).
Evidence Summary
The most recent estimates available show that
13.5% of middle school students (2015), 37.7% of high
school students (2015), and 35.8% of young adults
(2013–2014) had ever used an e-cigarette (Tables 2.1a, 2.1b,
and 2.4a). The most recent data also show that past-30-day
use of e-cigarettes is higher among high school students
(16% in 2015) and young adults (13.6% in 2013–2014)
than among middle school students (5.3% in 2015) and
adults (25 years of age and older) (5.7% in 2013–2014)
(Tables 2.1b, 2.4a, and 2.4b). Among youth and young
adults, rates of ever and past-30-day use of e-cigarettes
have increased greatly since the earliest e-cigarette surveil-
lance efforts began in 2011. The increases among adults
25 years of age and older, by comparison, have been less
steep. Among middle school and high school students, both
ever use and past-30-day use of e-cigarettes more than tri-
pled from 2011 to 2015 (NYTS 2011–2015; Figures2.1 and
2.2) (CDC 2013a; Ambrose et al. 2014; Lippert 2015), and
among young adults (18–24years of age), the prevalence
of ever use more than doubled from 2013 to 2014 (Styles
2013–2014; Figure 2.3).
Among youth, past-30-day exclusive use of
e-cigarettes among 8th, 10th, and 12 graders (6.8%, 10.4%,
and 10.4%, respectively) was more common than exclusive
use of conventional cigarettes (1.4%, 2.2%, and 5.3% in
those grades) or dual use of e-cigarettes and conventional
cigarettes (2.4%, 3.5%, and 5.8% in those grades) (Table2.5;
Figure 2.4). However, among young adults 18–24 years of
age, the patterns were different. In that group, exclusive
use of conventional cigarettes surpassed exclusive use of
e-cigarettes and use of both types of products (Figure2.8).
For example, in 2013–2014, 9.6% of young adults smoked
conventional cigarettes exclusively, 6.1% were current
users of e-cigarettes, and 7.5% currently used both. The
use of e-cigarettes and other tobacco products, such as
combustibles, appeared to co-vary among youth and young
adults (Figures 2.6, 2.7, and 2.8). Although five longitu-
dinal studies suggest that e-cigarette use is related to the
onset of other tobacco product and marijuana use among
youth and young adults (Leventhal et al. 2015; Primack
et al. 2015; Barrington-Trimis et al. 2016; Unger et al.
2016; Wills et al. 2016), some studies had limitations in
their ability to distinguish experimental smokers from reg-
ular smokers at follow-up (Leventhal etal. 2015; Primack
et al. 2015; Barrington-Trimis etal. 2016; Wills et al. 2016).
Therefore, more studies are needed to elucidate the nature
of any true causal relationship between e-cigarette use and
combustible tobacco products. Investigation of whether
e-cigarette use is related to other types of substance abuse
(e.g.,marijuana, alcohol) might help distinguish the extent
to which e-cigarette use may precede or follow other forms
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 87
E-Cigarette Use Among Youth and Young Adults
of substance use in the context of the common liability/
vulnerability model (Vanyukov et al. 2012).
Although use of other tobacco products has been the
strongest correlate of ever and past-30-day e-cigarette use
among youth and young adults, sociodemographic char-
acteristics have also been associated with the use of these
products. Across both ever use and past-30-day use mea-
sures, e-cigarette use has been more common among high
school than middle school students, a pattern similar to
trends seen in other categories of tobacco products (CDC
2015c). Among middle school students in 2014 and 2015
(CDC 2016), ever e-cigarette use was highest for Hispanics
(Table 2.1a); among high school students, ever use was
highest among Hispanics and Whites (Table 2.1b). No differ-
ences between boys and girls were observed among middle
school students in 2015 (Tables 2.1a, 2.1b). However, in
2015 male high school students were significantly more
likely to report past-30-day use than their female counter-
parts (Table 2.2b) (CDC 2016). For young adults, ever and
past-30-day use of e-cigarettes were significantly higher
among males than females (Table 2.4a). Current e-cigarette
use was significantly lower among Blacks than in other
racial/ethnic groups (Table 2.4a). Ever and past-30-day
e-cigarette use was also significantly lower among those
with a college education. Continued research is warranted
to monitor patterns of e-cigarette use across population
groups by gender, age, race/ethnicity, and education, as well
as by sociodemographic characteristics for which dispari-
ties in tobacco use have been noted. Availability of data on
e-cigarette use among youth and young adults is currently
limited, including geography (e.g., subnational data at the
state or local levels), sexual orientation and gender iden-
tity (e.g., lesbian, gay, bisexual, transgender), and socioeco-
nomic status (e.g., household income, poverty status) (CDC
2014a; Johnson et al. 2016).
Research on youth and young adults’
e-cigarette-related knowledge, attitudes, and beliefs is
still developing and remains relatively sparse. Perceived
harm is the most developed area of research. Most youth
and young adults believe e-cigarettes are “less harmful”
than conventional cigarettes (Table 2.11). However, up to
50%of respondents in some of these studies felt they did
not know enough about the potential dangers associated
with e-cigarettes to answer questions about perceived harm
(Ambrose et al. 2014; Amrock et al. 2015). Although rela-
tive harm compared with cigarettes is important to assess,
equally important is determining young people’s percep-
tion of the absolute harm from e-cigarettes. National data
show that only 23.6% of middle and high school students
combined believed that e-cigarettes cause “a lot of harm”
(Table 2.12a), and only 26.8% of young adults believed
e-cigarettes are “very harmful” (Table2.12d). However, sig-
nificant differences emerge in these perceptions of harm
when examined by whether or not youth and young adults
use e-cigarettes. Among both middle and high school stu-
dents and young adults, perceptions of “no harm” were
much more prevalent among those with prior experience
with e-cigarettes (Tables 2.12b–2.12d). Current e-ciga-
rette users were two to three times more likely to report
that e-cigarettes convey “no harm” compared to never
e-cigarette users, for both age groups (Tables 2.12a and
2.12d).
The most commonly cited reasons that youth and
young adults reported using e-cigarettes included curi-
osity (Schmidt et al. 2014; Biener and Hargraves 2015;
Biener etal. 2015; Kong et al. 2015; McDonald and Ling
2015; Suris et al. 2015; Sutfin et al. 2015), flavorings/taste
(Ambrose et al. 2015; University of Michigan 2015), use as
a less harmful/less toxic alternative to conventional ciga-
rettes (Peters et al. 2013; Tucker et al. 2014; Ambrose etal.
2015; Kong et al. 2015; McDonald and Ling 2015; Sutfin
et al. 2015), and avoidance of indoor smoking restrictions
or disturbing people with secondhand smoke from conven-
tional cigarettes (Tucker et al. 2014; Ambrose etal. 2015;
Kong et al. 2015; McDonald and Ling 2015; Suris etal. 2015;
Sutfin et al. 2015). Using e-cigarettes as an aid to conven-
tional cigarette smoking reduction/cessation (Li etal. 2013;
Schmidt et al. 2014; Tucker et al. 2014) was not a primary
motivator among youth and young adults. Youth and young
adult smokers cited lack of satisfaction, poor taste, and cost
(Kong et al. 2015) as reasons for discontinuing e-cigarette
use. Additional research is needed to examine how reasons
for use, including the appeal of flavored e-cigarettes, are
causally related to the onset and progression of e-cigarette
use among youth and young adults. Data from the first
wave of the PATH study suggest that flavors may play an
important role in the initiation of e-cigarette use among
youth (Ambrose et al. 2015), while data from the 2014
NYTS (Corey et al. 2015) and 2013–2014 NATS (Table2.9)
underscore that use of flavored e-cigarettes remains prev-
alent among youth and young adults who currently use
e-cigarettes.
A Report of the Surgeon General
88 Chapter 2
Conclusions
1. Among middle and high school students, both ever
and past-30-day e-cigarette use have more than tri-
pled since 2011. Among young adults 18–24years
of age, ever e-cigarette use more than doubled from
2013 to 2014 following a period of relative stability
from 2011 to 2013.
2. The most recent data available show that the preva-
lence of past-30-day use of e-cigarettes is similar
among high school students (16% in 2015, 13.4% in
2014) and young adults 18–24years of age (13.6%in
2013–2014) compared to middle school students
(5.3%in 2015, 3.9% in 2014) and adults 25 years of
age and older (5.7% in 2013–2014).
3. Exclusive, past-30-day use of e-cigarettes among
8th-, 10th-, and 12th-grade students (6.8%, 10.4%,
and 10.4%, respectively) exceeded exclusive,
past-30-day use of conventional cigarettes in 2015
(1.4%, 2.2%, and 5.3%, respectively). In contrast—
in 2013–2014 among young adults 18–24 years of
age—exclusive, past-30-day use of conventional cig-
arettes (9.6%) exceeded exclusive, past-30-day use of
e-cigarettes (6.1%). For both age groups, dual use of
these products is common.
4. E-cigarette use is strongly associated with the
use of other tobacco products among youth and
young adults, particularly the use of combustible
tobacco products. For example, in 2015, 58.8% of
high school students who were current users of
combustible tobacco products were also current
users of e-cigarettes.
5. Among youth—older students, Hispanics, and
Whites are more likely to use e-cigarettes than
younger students and Blacks. Among young
adults—males, Hispanics, Whites, and those with
lower levels of education are more likely to use
e-cigarettes than females, Blacks, and those with
higher levels of education.
6. The most commonly cited reasons for using
e-cigarettes among both youth and young adults are
curiosity, flavoring/taste, and low perceived harm
compared to other tobacco products. The use of
e-cigarettes as an aid to quit conventional cigarettes
is not reported as a primary reason for use among
youth and young adults.
7. Flavored e-cigarette use among young adult current
users (18–24 years of age) exceeds that of older adult
current users (25 years of age and older). Moreover,
among youth who have ever tried an e-cigarette, a
majority used a flavored product the first time they
tried an e-cigarette.
8. E-cigarette products can be used as a delivery
system for cannabinoids and potentially for other
illicit drugs. More specific surveillance measures are
needed to assess the use of drugs other than nicotine
in e-cigarettes.
Patterns of E-Cigarette Use Among U.S. Youth and Young Adults 89
E-Cigarette Use Among Youth and Young Adults
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95
Chapter 3
Health Effects of E‑Cigarette Use Among U.S.Youth and
Young Adults
Introduction 97
Conclusions from Previous Surgeon General’s Reports 97
Health Effects of E‑Cigarette Use 100
Effects of Aerosol Inhalation by the E‑Cigarette User 100
Dose and Effects of Inhaling Aerosolized Nicotine 100
Aerosolized Nicotine and Cardiovascular Function 101
Aerosolized Nicotine and Dependence 102
Effects of Nicotine in Youth Users 104
Nicotine Exposure from Maternal Nicotine Consumption: Prenatal and Postnatal Health Outcomes 108
Summary 113
Effects of the Inhalation of Aerosol Constituents Other than Nicotine 114
Aerosolized Nicotine‑Related Compounds 114
Aerosolized Solvents 115
Aerosolized Flavorants 115
Aerosolized Adulterants 116
Summary 117
Effects of Toxicants Produced During Aerosolization 118
Summary 119
Effects Not Involving Inhalation of Aerosol by the E‑Cigarette User 119
Health Effects Attributable to Explosions and Fires Caused by E‑Cigarettes 119
Health Effects Caused by Ingestion of E‑Cigarette Liquids 119
Secondhand Exposure to the Constituents of E‑Cigarette Aerosol 120
Exposure to Nonusers 120
Movement of E‑Cigarette Aerosol 121
Exposure to E‑Cigarette Aerosol and Considerations of Dose 121
Health Effects of Secondhand Exposure to E‑Cigarette Aerosols 122
Evidence Summary 124
Conclusions 125
References 126
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 97
E-Cigarette Use Among Youth and Young Adults
Introduction
This chapter focuses on the short‑term and poten‑ regarding harmful consequences of close contact with
tial long‑term health effects related to the incidence and malfunctioning e‑cigarette devices and ingestion of the
continued use of electronic cigarettes (e‑cigarettes) by nicotine‑containing liquids (e‑liquids) are also explored.
youth and young adults. The sharp increase in the preva‑ This chapter examines available data on e‑cigarettes and
lence of e‑cigarette use among youth and young adults, youth, reviews established human and animal data on
especially from 2011 to 2015 (Centers for Disease Control harmful developmental effects of nicotine (prenatal and
and Prevention [CDC] 2015, 2016), highlights the com‑ adolescent), and reviews data on e‑cigarettes among adults
pelling need to learn more about this evolving class of when data on youth are not available. Of note, given the
products. This chapter highlights the scientific litera‑ relatively recent emergence of e‑cigarettes, data are not
ture that addresses potential adverse health effects caused yet available that address the long‑term health effects of
by direct exposure to aerosolized nicotine, flavorants, use or exposure over several years compared with nonuse
chemicals, and other particulates of e‑cigarettes; sec‑ or exposure to air free from secondhand tobacco smoke
ondhand exposure to e‑cigarette aerosol; and exposure to and aerosol from e‑cigarettes; thus, the discussion is lim‑
the surface‑deposited aerosol contaminants. Literature ited in that regard.
Conclusions from Previous Surgeon General’s Reports
This chapter comprehensively reviews a new and
emerging body of scientific evidence related to the use
of e‑cigarettes by youth and young adults. The enormous
knowledge base on tobacco smoking and human health
is also relevant to this discussion. That literature, which
has been accumulating for more than 50 years, provides
incontrovertible evidence that smoking is a cause of dis‑
ease in almost every organ of the body (U.S. Department
of Health and Human Services [USDHHS] 2004, 2014).
Laboratory research has characterized the components
of tobacco smoke and probed the mechanisms by which
these constituents cause addiction and injury to cells, tis‑
sues, organs, and the developing fetus.
The evidence on the harmful consequences of nic‑
otine exposure in conventional cigarettes, including
addiction, and other adverse effects, is particularly rel‑
evant to e‑cigarettes. Nicotine doses from e‑cigarettes
vary tremendously depending on characteristics of the
user (experience with smoking conventional cigarettes
or e‑cigarettes), technical aspects of the e‑cigarette, and
levels of nicotine in the e‑liquid. Although studies of nico‑
tine doses in youth and young adults are lacking, studies
of adults have found delivery of nicotine from e‑cigarettes
in doses ranging from negligible to as large as (Lopez
et al. 2016; Vansickel and Eissenberg 2013; Spindle et al.
2015; St. Helen et al. 2016) or larger than (Ramôa et al.
2016) conventional cigarettes. Similarly, passive exposure
to secondhand nicotine from e‑cigarettes is just as large
(Flouris et al. 2013) or lower than (Czogala et al. 2014)
conventional cigarettes.
The findings of scientific research on smoking
and involuntary exposure to tobacco smoke have been
reviewed thoroughly in the 32 reports on smoking and
health produced by the Surgeon General to date (there is
one report on smokeless tobacco) (Table 3.1). The land‑
mark first report was published in 1964 (U.S. Department
of Health, Education, and Welfare [USDHEW] 1964), and
the 50th‑anniversary report, released in January 2014,
comprehensively covered multiple aspects of cigarette
smoking and health and lengthened the list of diseases
caused by smoking and involuntary exposure to tobacco
smoke (USDHHS 2014). Other Surgeon General’s reports
that are particularly relevant to the present report include
reports on the health consequences of smoking and
involuntary exposure to tobacco smoke (USDHHS 2004,
2006), on the mechanisms by which smoking causes dis‑
ease (USDHHS 2010), and on the health consequences
of smoking on youth and young adults (USDHHS 1994,
2012). The Surgeon General’s reports on smoking and
health have provided powerful conclusions on the dangers
of nicotine. The 1988 report, released by Surgeon General
C. Everett Koop, was the first to characterize smoking
as addictive, and it identified nicotine as “…the drug in
tobacco that causes addiction” (Appendix 3.1)
1
1
All appendixes and appendix tables that are cross‑referenced in this chapter are available only online at http://www.surgeongeneral.gov/
library/reports/
(USDHHS
1988, p. 9).
A Report of the Surgeon General
98 Chapter 3
Table 3.1 Relevant conclusions from previous Surgeon General’s reports on smoking and health
Report Year Conclusions
The Health
Consequences of
Smoking: Nicotine
Addiction (USDHHS
1988, p. 9)
1988 Major Conclusions
1. Cigarettes and other forms of tobacco are addicting.
2. Nicotine is the drug in tobacco that causes addiction.
3. The pharmacologic and behavioral processes that determine tobacco addiction are similar
to those that determine addiction to drugs such as heroin and cocaine.
How Tobacco Smoke
Causes Disease: The
Biology and Behavioral
Basis for Smoking-
Attributable Disease
(USDHHS 2010, p. 183)
2010 Chapter 4. Nicotine Addiction: Past and Present
1. Nicotine is the key chemical compound that causes and sustains the powerful addicting
effects of commercial tobacco products.
2. The powerful addicting effects of commercial tobacco products are mediated by diverse
actions of nicotine at multiple types of nicotinic receptors in the brain.
3. Evidence is suggestive that there may be psychosocial, biologic, and genetic determinants
associated with different trajectories observed among population subgroups as they move
from experimentation to heavy smoking.
4. Inherited genetic variation in genes such as CYP2A6 contributes to the differing patterns of
smoking behavior and smoking cessation.
5. Evidence is consistent that individual differences in smoking histories and severity of
withdrawal symptoms are related to successful recovery from nicotine addiction.
Preventing Tobacco
Use Among Youth and
Young Adults (USDHHS
2012, pp. 8, 460)
2012 Major Conclusions
1. Cigarette smoking by youth and young adults has immediate adverse health consequences,
including addiction, and accelerates the development of chronic diseases across the full life
course.
2. Prevention efforts must focus on both adolescents and young adults because among adults
who become daily smokers, nearly all first use of cigarettes occurs by 18 years of age
(88%), with 99% of first use by 26 years of age.
3. Advertising and promotional activities by tobacco companies have been shown to cause the
onset and continuation of smoking among adolescents and young adults.
4. After years of steady progress, declines in the use of tobacco by youth and young adults
have slowed for cigarette smoking and stalled for smokeless tobacco use.
5. Coordinated, multicomponent interventions that combine mass media campaigns,
price increases including those that result from tax increases, school‑based policies and
programs, and statewide or community‑wide changes in smokefree policies and norms are
effective in reducing the initiation, prevalence, and intensity of smoking among youth and
young adults.
Chapter 4. Social, Environmental, Cognitive, and Genetic Influences on the Use of Tobacco
Among Youth
1. Given their developmental stage, adolescents and young adults are uniquely susceptible to
social and environmental influences to use tobacco.
2. Socioeconomic factors and educational attainment influence the development of youth
smoking behavior. The adolescents most likely to begin to use tobacco and progress to
regular use are those who have lower academic achievement.
3. The evidence is sufficient to conclude that there is a causal relationship between peer
group social influences and the initiation and maintenance of smoking behaviors during
adolescence.
4. Affective processes play an important role in youth smoking behavior, with a strong
association between youth smoking and negative affect.
5. The evidence is suggestive that tobacco use is a heritable trait, more so for regular use
than for onset. The expression of genetic risk for smoking among young people may be
moderated by small‑group and larger social‑environmental factors.
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 99
E-Cigarette Use Among Youth and Young Adults
Report Year Conclusions
The Health
Consequences of
Smoking—50 Years
of Progress (USDHHS
2014, p.126)
2014 Chapter 5: Nicotine
1. The evidence is sufficient to infer that at high‑enough doses nicotine has acute toxicity.
2. The evidence is sufficient to infer that nicotine activates multiple biological pathways
through which smoking increases risk for disease.
3. The evidence is sufficient to infer that nicotine exposure during fetal development,
a critical window for brain development, has lasting adverse consequences for brain
development.
4. The evidence is sufficient to infer that nicotine adversely affects maternal and fetal health
during pregnancy, contributing to multiple adverse outcomes such as preterm delivery and
stillbirth.
5. The evidence is suggestive that nicotine exposure during adolescence, a critical window for
brain development, may have lasting adverse consequences for brain development.
6. The evidence is inadequate to infer the presence or absence of a causal relationship
between exposure to nicotine and risk for cancer.
Note: USDHHS = U.S. Department of Health and Human Services.
Table 3.1 Continued
Subsequent reports expanded on the conclusions
in the 1988 report related to nicotine—reaffirming that
nicotine causes addiction, describing nicotine’s effects on
key brain receptors (USDHHS 2010), and emphasizing
that youth are more sensitive to nicotine than adults
and can become dependent to nicotine much faster than
adults (USDHHS 2012). This is of particular concern in
the context of e‑cigarettes because blood nicotine levels
in e‑cigarette users have been reported as being compa‑
rable to or higher than levels in smokers of conventional
cigarettes (Lopez et al. 2016; Spindle et al. 2015), and
serum cotinine (a nicotine metabolite) levels have been
reported as being equal to that found in conventional ciga‑
rette users (Etter 2016; Marsot and Simon 2016). Because
of their sensitivity to nicotine and subsequent addiction,
about 3 out of 14 young smokers end up smoking into
adulthood, even if they intend to quit after a few years;
among youth who continue to smoke as adults, one‑
half will die prematurely from smoking (Peto et al. 1994;
CDC 1996; Hahn et al. 2002; Doll et al. 2004). Surgeon
General’s reports have also emphasized the critical role
of environmental determinants of tobacco use, including
the causal roles of the tobacco industry’s advertising and
promotional activities and of the peer social environment
(USDHHS 2012).
The review documented the broad biological activity of
nicotine, which can activate multiple biological path‑
ways, and the adverse effects of nicotine exposure during
pregnancy on fetal development and during adolescence
on brain development. Of concern with regard to cur‑
rent trends in e‑cigarette use among youth and young
adults, the evidence suggests that exposure to nicotine
during this period of life may have lasting deleterious con‑
sequences for brain development, including detrimental
effects on cognition (USDHHS 2014).
The 2014 Surgeon General’s report included a
chapter that addressed the numerous adverse conse‑
quences of nicotine other than addiction (USDHHS 2014).
Finally, the aerosol from e‑cigarettes may include
other components that have been addressed in previous
Surgeon General’s reports, such as tobacco‑specific nitro‑
samines (TSNAs), acrolein, and formaldehyde (USDHEW
1979; USDHHS 2010). Aerosols generated with vapor‑
izers contain up to 31 compounds, including nicotine,
nicotyrine, formaldehyde, acetaldehyde glycidol, acro‑
lein, acetol, and diacetyl (Sleiman et al. 2016). Glycidol
is a probable carcinogen not previously identified in the
vapor, and acrolein is a powerful irritant (Sleiman et al.
2016). Although these constituents have been identified in
e‑cigarette aerosol, current evidence is unclear on whether
typical user dosages achieve levels as high as conventional
cigarettes, or at harmful or potentially harmful levels.
More information will be available in the coming years
as e‑cigarette manufacturers begin reporting harmful or
potential harmful constituents in compliance with the
Tobacco Control Act.
A Report of the Surgeon General
100 Chapter 3
Health Effects of E‑Cigarette Use
The potential adverse health effects for youth who
inhale e‑cigarette aerosol include those on the body from
acute administration of nicotine, flavorants, chemicals,
other particulates, and additional effects, such as (1)nico‑
tine addiction; (2) developmental effects on the brain from
nicotine exposure, which may have implications for cog‑
nition, attention, and mood; (3) e‑cigarette influence ini‑
tiating or supporting the use of conventional cigarettes
and dual use of conventional cigarettes and e‑cigarettes;
(4) e‑cigarette influence on subsequent illicit drug use;
(5) e‑cigarette effects on psychosocial health, particularly
among youth with one or more comorbid mental health
disorders; and (6) battery explosion and accidental overdose
of nicotine.
Effects of Aerosol Inhalation by the
E‑Cigarette User
Determining the potential health effects of inhaling
e‑cigarette aerosol is challenging due to the number of pos‑
sible combinations of customizable options (Seidenberg
et al. 2016), including battery power, nicotine concentra‑
tion, e‑liquids (Goniewicz et al. 2015; Buettner‑Schmidt
et al. 2016), and use behaviors and puff topography (Dawkins
et al. 2016; Lopez et al. 2016). The amount of nicotine, fla‑
vorants, and other e‑liquid constituents in e‑cigarettes
available for consumers to purchase varies widely, and the
aerosolized constituents delivered vary by the type and
voltage of the e‑cigarette device being used (Cobb et al.
2015). Studies of commercial products have shown that
e‑liquids can contain as little as 0 milligrams/milliliter
(mg/mL) to as much as 36.6 mg/mL of nicotine (Goniewicz
et al. 2015); can be mislabeled (Peace et al. 2016); can vary
by propylene glycol (PG)/vegetable glycerin (VG) ratio; and
can contain one or more of several thousand available fla‑
vorants (Zhu et al. 2014b). Some liquids intended for use in
e‑cigarettes contain adulterants not named on ingredient
lists (Varlet et al. 2015), and under at least some user con‑
ditions, the aerosolization process, which involves heating,
produces additional toxicants that may present health risks
(Talih et al. 2015). The sections that follow comprehen‑
sively cover the effects of inhaling aerosolized nicotine and
then consider what is known about solvents (i.e., PG and
VG, flavorants, and other chemicals) added to e‑cigarettes,
adulterants in e‑liquids formed in the nicotine extraction
process (e.g., N‑nitrosonornicotine), and toxicants formed
during the heating and aerosolization process (e.g., acro‑
lein and formaldehyde) (Sleiman et al. 2016).
Dose and Effects of Inhaling Aerosolized Nicotine
Nicotine addiction via e‑cigarette use is a primary
public health concern due to the exponential growth in
e‑cigarette use among youth. The potential for widespread
nicotine addiction among youth is high, as are the harmful
consequences of nicotine on fetal development and the
developing adolescent brain (USDHHS 2014). Nicotine, a
psychomotor stimulant drug, is the primary psychoactive
and addictive constituent in the smoke of conventional
cigarettes and an important determinant in maintaining
smoking dependence (e.g., USDHHS 2014). E‑liquids
typically contain nicotine, although in more widely vari‑
able concentrations than those found in conventional
cigarettes (Trehy et al. 2011; Cameron et al. 2014; Cheng
2014; Goniewicz et al. 2015; Marsot and Simon 2016). The
concentration of liquid nicotine is only one factor that
influences the amount of aerosolized nicotine available
for inhalation (Lopez et al. 2016); other factors include
the power of the device being used (e.g., battery voltage,
heater resistance) and user behavior (e.g., puff duration,
interpuff interval) (Shihadeh and Eissenberg 2015; Talih
et al. 2016; Etter 2016). The interplay of these factors may
help to explain the variability in plasma nicotine concen‑
tration when adults use e‑cigarettes under controlled con‑
ditions which can be higher (Ramôa et al. 2016), lower
(Bullen et al. 2010; Vansickel et al. 2010, 2012; Farsalinos
et al. 2014b; Nides et al. 2014; Oncken et al. 2015; Yan
and D’Ruiz 2015), or similar to those obtained by smoking
conventional cigarettes (Vansickel and Eissenberg 2013;
Spindle et al. 2015; St. Helen et al. 2016; see Figure 3.1).
Generalization across studies is difficult due to variations
in devices, e‑liquids, and e‑cigarette use behavior within
the study sample. As demonstrated in Figure 3.1, in studies
where a variety of products were used under similar labo‑
ratory conditions (i.e., blood sampling before and imme‑
diately after a 10‑puff episode), there was wide variability
in nicotine delivery between devices, with “cigalike” prod‑
ucts (cigarette‑like products) delivering less nicotine than
“tank” products (Farsalinos et al. 2014b; Yan and D’Ruiz
2015), and low‑resistance, dual‑coil “cartomizer” prod‑
ucts having the capacity to deliver less or more nicotine
than a conventional cigarette, depending on the concen‑
tration of liquid nicotine (Ramôa et al. 2016).
When the device type and liquid dose were held con‑
stant in a controlled session in one study, plasma nico‑
tine concentrations (in this case in nanograms [ng]/mL)
varied considerably across participants (0.8 to 8.5 ng/mL)
(Nides et al. 2014). This variation was likely attributable
to the manner in which the users puffed when using
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 101
E-Cigarette Use Among Youth and Young Adults
e‑cigarettes, or that person’s “puff topography,” which
includes the number of puffs, the intake volume and dura‑
tion, the interpuff interval, and the flow rate (Zacny and
Stitzer 1988; Blank etal. 2009).
Available data suggest that puff durations among
adult cigarette smokers who are new e‑cigarette users
are comparable to those observed with conventional cig‑
arettes (at least about 2 seconds [sec]) (Farsalinos etal.
2013b; Hua et al. 2013; Norton et al. 2014). However,
puff durations during e‑cigarette use among experienced
e‑cigarette users may be twice as long (~4 sec) (Farsalinos
etal. 2013b; Hua etal. 2013; Spindle etal. 2015) as puff
duration during conventional cigarette use. Puff duration
is directly related to the nicotine content of the e‑cigarette
aerosol (i.e., the yield or dose) (Talih et al. 2016), sug‑
gesting that smokers of conventional cigarettes who switch
to e‑cigarettes may increase the duration of their puffs
when using the new product in an attempt to extract more
nicotine. Research also suggests that cigarette smokers
may learn to alter other aspects of their puffing behavior
when using an e‑cigarette (Spindle etal. 2015). Relative
to smokers of conventional cigarettes (Kleykamp et al.
2008), experienced e‑cigarette users were found to have
puff volumes that were significantly higher (101.4mL vs.
51.3 mL) and puff flow rates that were significantly lower
(24.2 mL/sec vs. 37.9 mL/sec) (Spindle etal. 2015). In a
different study, adult cigarette smokers who had never
used e‑cigarettes but switched to e‑cigarettes showed sig‑
nificantly increased puff durations and decreased puff flow
rates within 1 week (Lee etal. 2015). Elsewhere, adult cig‑
arette smokers given an e‑cigarette appeared to show an
enhanced ability to extract nicotine from their device after
4 weeks of use (Hajek etal. 2015). Thus, the health effects
of aerosolized nicotine in e‑cigarette users may depend on
a variety of factors, including the e‑liquid used, the user’s
behavior, and the user’s experience with the product.
Aerosolized Nicotine and Cardiovascular Function
Smoking is a major cause of death from cardiovas‑
cular disease (USDHHS 2014), and exposure to nicotine
has been identified as a potential initiating factor in the
atherogenic process (Lee etal. 2011; Santanam etal. 2012;
Benowitz and Burbank 2016). Acute administration of
nicotine causes a variety of well‑characterized, dose‑ and
route‑dependent effects in adults, including cardiovascular
effects, such as increases in heart rate and blood pressure
(BP) and greater cardiac output, leading to an increase
in myocardial oxygen demand (Rosenberg et al. 1980;
USDHHS 2014). Reports from cell biology and animal
studies have established biologic plausibility between nic‑
otine alone and negative cardiovascular effects (Hanna
2006; Santanam et al. 2012). These studies have shown
that nicotine induces the production of various inflam‑
matory mediators involved with atherosclerotic patho‑
genesis (Lau and Baldus 2006), and that at the cellular
level, nicotine induces C‑reactive protein (CRP) expres‑
sion in macrophages that contribute pro‑inflammatory
and pro‑atherosclerotic effects (Mao etal. 2012).
Long‑term studies on the safety of nicotine‑only
exposure (e.g., as with using e‑cigarettes rather than
smoking conventional cigarettes) among youth have not
been conducted, and little is known about the cardiovas‑
cular effects of e‑cigarette use among adults. However,
when e‑cigarettes are accompanied by a measurable
increase in plasma nicotine concentration, it increases
heart rate (Vansickel etal. 2012; Vansickel and Eissenberg
2013; Nides etal. 2014; Yan and D’Ruiz 2015), and dia‑
stolic BP rises.
Given the paucity of long‑term data on the impact of
e‑cigarette smoking in relation to cardiovascular disease,
other nicotine products offer a useful analogy. A meta‑
analysis reported that replacing the consumption of con‑
ventional cigarettes with nicotine replacement therapy
(NRT) reduces cardiovascular risk among former smokers
without significant adverse consequences (compared with
current smokers) (Greenland et al. 1998; Moore et al.
2009). However, most NRT use is temporary (<26 months),
and the adverse consequences of longer term NRT therapy
are unknown.
Elsewhere, investigators examined the relationship
between the use of Swedish‑type moist snuff (or “snus”),
which contains high levels of nicotine and low levels of
TSNAs, and the incidence of acute myocardial infarction
among men with a mean age of 35 years who had never
smoked cigarettes. The researchers, who pooled data from
eight prospective cohort studies, found no support for
any association between the use of snus and the develop‑
ment of acute myocardial infarction (Hansson etal. 2012),
regardless of timing, intensity, duration, or period of use
among the men who were followed for 4–29 years.
In summary, despite overwhelming epidemiologic
evidence linking the use of conventional cigarettes with
cardiovascular disease, the precise components of cig‑
arette smoke responsible for this relationship and the
mechanisms by which they exert their effects have not yet
been fully explained (Hanna 2006). For e‑cigarettes, bio‑
logical data support a potential association with cardio‑
vascular disease, and short‑term use of these products is
accompanied by a measurable increase in plasma nicotine
concentrations in adults as well as increases in heart rate
and blood pressure. Much more research is needed, but the
limited data available suggest the typical cardiovascular
effects exerted by nicotine are also exerted by e‑cigarettes
(Benowitz and Burbank 2016; Bhatnagar 2016).
A Report of the Surgeon General
102 Chapter 3
Aerosolized Nicotine and Dependence
Although a great deal is known about self‑
administration of nicotine and the development of nicotine
dependence among adults (USDHHS 2014) and youth (Colby
et al. 2000; USDHHS 2012; O’Loughlin et al. 2014; Yuan et al.
2015), more research is needed on nicotine dependence in
youth and young adults as a result of using e‑cigarettes.
Nicotine dependence, also referred to as nicotine addic‑
tion (USDHHS 2010) or tobacco use disorder (American
Psychiatric Association [APA] 2013), is defined as a neu‑
robiological adaptation to repeated drug exposure that is
manifested behaviorally by highly controlled or compulsive
use; psychoactive effects such as tolerance, physical depen‑
dence, and pleasant effect; and nicotine‑reinforced behavior,
including an inability to quit despite harmful effects, a
desire to quit, and repeated cessation attempts (USDHHS
1988; APA 2013). In tobacco‑dependent users of conven‑
tional cigarettes, a predictable consequence of short‑term
abstinence (e.g., for more than a few hours) is the onset
of withdrawal symptoms indicated by self‑reported behav‑
ioral, cognitive, and physiological symptoms and by clinical
signs (USDHHS 2010). Subjective withdrawal symptoms
are manifested by affective disturbance, including irrita‑
bility and anger, anxiety, and depressed mood. The behav‑
ioral symptoms include restlessness, sleep disturbance, and
increased appetite. Cognitive disturbances usually center
on difficulty in concentrating (USDHHS 2010).
Early studies of conventional cigarette smokers
using e‑cigarettes reported poor nicotine delivery with
little to no increase in blood nicotine levels after puffing
(Eissenberg 2010; Vansickel et al. 2010). Later studies
reported that the effect on serum cotinine levels among
new e‑cigarette users can be similar to that generated by
conventional cigarettes (Flouris et al. 2013; Lopez et al.
2016). Studies examining this discrepancy found that
e‑cigarette users require longer puffs to deliver equivalent
nicotine doses (Lee et al. 2015), and within a week, inex‑
perienced e‑cigarette users adjust their puffing patterns
after switching (Hua et al. 2013b; Lee et al. 2015; Talih
et al. 2015).
In more experienced e‑cigarette users, blood nico‑
tine levels appear to be influenced by puffing patterns,
such as puff length. Volume and frequency and plasma
nicotine levels ranging from 2.50 to 13.4 ng/mL have
been observed after 10 puffs of an e‑cigarette (Dawkins
and Corcoran 2014). Dawkins and colleagues (2016) used
24 mg/mL nicotine strength liquid and observed high
blood nicotine levels that were achieved very quickly,
matching and even exceeding those reported in conven‑
tional cigarette smokers. St. Helen and colleagues (2016)
conducted a similar study and reported that e‑cigarettes
can deliver levels of nicotine that are comparable to or
higher than conventional cigarettes. Finally, Etter (2016)
reported cotinine levels among experienced e‑cigarette
users similar to levels usually observed in conven‑
tional cigarette smokers. Figure 3.1 and Table A3.1‑1 in
Appendix 3.1 summarize studies on aerosolized nico‑
tine from e‑cigarettes and dependence using dependency
criteria.
The ability of e‑cigarettes to deliver comparable or
higher amounts of nicotine compared to conventional
cigarettes raises concerns about e‑cigarette use gener‑
ating nicotine dependence among young people (Dawkins
et al. 2016; Etter 2016; St. Helen et al. 2016). The reported
blood levels of nicotine, or cotinine, in e‑cigarette users
is likely to cause physiological changes in nicotinic ace‑
tylcholine receptors in the brain that would sustain nico‑
tine addiction (Kandel and Kandel 2014; Yuan et al. 2015).
This is particularly concerning for adolescents and young
adults, given that early exposure to nicotine increases the
severity of future nicotine dependence (St. Helen et al.
2016; USDHHS 2014).
Symptoms of nicotine dependence can occur soon
after the initiation of conventional smoking, and even
before established use, among adolescents and young
adults (DiFranza et al. 2002; O’Loughlin et al. 2003;
Dierker et al. 2007; Ramôa et al. 2016). Furthermore,
some adolescents have reported nicotine dependence
symptoms while using tobacco as little as 1–3 days per
month (Rose et al. 2010). Using the National Comorbidity
Survey‑Adolescent dataset, Dierker and colleagues (2012)
reported that nicotine dependence in adolescents was
likely to occur within 1 year of the initiation of weekly or
daily smoking, regardless of sociodemographic variables.
Importantly, when smoking onset began at a younger
age, the transition to weekly and daily smoking was more
rapid, indicating a youthful neurobiological sensitivity to
nicotine (Dierker et al. 2012). Zhan and colleagues (2012)
found that symptoms of nicotine dependence could be
detected among teenagers before they had smoked even
100 cigarettes.
Because few validated measures exist for assessing
dependence on e‑cigarette use, some researchers have
adapted those originally developed to measure dependence
in smokers of conventional cigarettes. Among adults,
scores on these measures have been consistently lower
in e‑cigarette users than in smokers of conventional ciga‑
rettes (Farsalinos etal. 2013a; Etter and Eissenberg 2015;
Foulds etal. 2015). Still, scores for e‑cigarette dependence
among former cigarette smokers were positively associ‑
ated with the nicotine concentration of the e‑cigarette
liquid and the type of device used (Etter 2015; Etter and
Eissenberg 2015; Foulds et al. 2015). Research in this
area is challenging to interpret because measurement of
youth e‑cigarette dependence has not been standardized
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 103
E-Cigarette Use Among Youth and Young Adults
Figure 3.1 Plasma nicotine concentration from different human laboratory studies and four different products with
blood sampled before and immediately after a 10‑puff bout with the products
Source: Vansickel et al. (2010); Farsalinos et al. (2014b); Yan and D’Ruiz (2015); and Ramôa et al. (2016).
Notes: Data for conventional cigarettes are from 32 tobacco cigarette smokers using their usual brand of cigarette (Vansickel et al. 2010).
E‑cigarette A is a cigalike called “blu” loaded with two different concentrations of liquid nicotine (16or 24 mg/mL, both containing 20%
propylene glycol and 50% vegetable glycerin). Data are from 23 smokers of tobacco cigarettes with 7 days of experience with the e‑cigarette
product (Yan and D’Ruiz 2015). E‑cigarette B is a cigalike called “V2cigs”, and E‑cigarette C is a “tank” product called “EVIC” with an “Evod”
heating element; both were loaded with an 18 mg/mL liquid containing 34% propylene glycol and 66% vegetable glycerin. Data are from 23
experienced users of e‑cigarettes (Farsalinos et al. 2014b). E‑cigarette D uses a 3.3‑volt “Ego” battery fitted with a 1.5‑Ohm dual coil carto‑
mizer (“Smoktech”) and filled with ~1 mL of a 70% propylene glycol, 30%vegetable glycerin liquid that varied by liquid nicotine concentra‑
tion (0, 8, 18, or 36 mg/mL). Data are from 16 experienced users of e‑cigarettes (Ramôa et al. 2016).
A Report of the Surgeon General
104 Chapter 3
(Continued from last paragraph on page 102.)
and there is a wide variation in device/e‑liquid combina‑
tions, which allow for adjustable nicotine delivery among
study participants. Regardless, among 766 adults, who
were daily users of e‑cigarettes (with nicotine) and who
were either former cigarette smokers (83%) or current
cigarette smokers (17%), 30.7% indicated that they would
likely be unable to stop using e‑cigarettes, 28.2%that they
would find it “very difficult” or “impossible” to stop using
e‑cigarettes, and 27.5% that they were unable to stop
e‑cigarette use (Etter and Eissenberg 2015). However, it
is important to note that e‑cigarettes were less addictive
than conventional cigarettes in this sample (Etter and
Eissenberg 2015).
In summary, the addictive liability of e‑cigarettes
has the potential to be at least equivalent to that of con‑
ventional cigarettes, given nicotine dose levels produced
by these products, particularly among experienced users
operating new‑generation devices (Ramôa et al. 2016).
More generally, the delivery of nicotine in sufficient doses
and blood concentration would be expected to produce
and maintain dependence in e‑cigarette users. Further
work would be useful to determine the natural course
and history of e‑cigarette use among smokers of conven‑
tional cigarettes, former smokers, and never smokers and
to more accurately determine the nicotine addiction lia‑
bility of e‑cigarette use. Unfortunately, these issues have
not been explored in adolescents, although the prevalence
of e‑cigarette use has increased considerably in that popu‑
lation since 2011 (see Chapter 2).
Effects of Nicotine in Youth Users
Nicotine is the prime psychoactive substance in con‑
ventional cigarettes (Yuan etal. 2015), and given that the
developing adolescent brain is immature and vulnerable
to neurobiological insults (Bernheim et al. 2013; Lydon
etal. 2014), it is important to understand how nicotine
delivered by e‑cigarette use affects adolescent brain devel‑
opment and how responses to nicotine in adolescents
differ from those seen in adults. Substantial evidence sug‑
gests that nicotine can negatively influence both adoles‑
cent and prenatal brain development (USDHHS 2014).
For example, Weiss and colleagues (2008) reported a
strong mechanistic link among early nicotine exposure
(younger than 16 years of age), common genes related to
the severity of nicotine addiction (CHRNA5‑A3‑B4 hap‑
lotypes), and adult nicotine addiction in three indepen‑
dent populations of European origins. Although much of
the literature on nicotine addiction arises from studies
of nicotine exposure among adults, and with combus‑
tible tobacco products (see Table A3.1‑2 in Appendix 3.1),
there is a growing body of biological mechanistic litera‑
ture from animal studies that model the effects of nicotine
in doses equivalent to those for humans (see Table A3.1‑3
in Appendix 3.1). These animal and human studies, taken
together with studies of rising e‑cigarette prevalence in
youth (see Chapter 2), point to an age‑dependent suscep‑
tibility to nicotine as a neurobiological insult.
Limited direct human experimental data exist on
the effects of nicotine exposure from e‑cigarettes on the
developing adolescent brain, but experimental laboratory
data have been found to be relevant in animal models to
contextualize effects in humans (Stevens and Vaccarino
2015). Even if the full complexity of human brain develop‑
ment and behavioral function during adolescence cannot
be completely modeled in other species, the similarities
across adolescents of different species support the use of
animal models of adolescence when examining neural and
environmental contributors to adolescent‑characteristic
functioning (Spear 2010).
Animal studies provide an effective method to
examine the persistent effects of prenatal, child, and ado‑
lescent nicotine exposure, in addition to human epide‑
miologic data. When considering an epidemiologic causal
argument of exposure (risk factor) to health outcome (dis‑
ease), one should note that animal models lend biolog‑
ical plausibility when experimentation with humans is not
possible (or ethical) (Rothman etal. 2008). Furthermore,
animal studies offer significant advantages compared to
human studies—with the ability to control for many con‑
founding factors, to limit nicotine exposure to differing
levels of physical and neural development—and are piv‑
otal for understanding the neural substrates associated
with adolescence. The validity of any causal argument
when examining animal models requires careful consider‑
ation, and yet in combination with epidemiologic data—
such as prevalence, incidence, and strength of association
between exposure and outcome—a causal argument can
be constructed with literature from animal models rep‑
resenting biologic plausibility. Using a variety of study
designs and research paradigms including humans and
animals, research in this area provides evidence for neu‑
roteratogenic and neurotoxic effects on the developing
adolescent brain (Lydon etal. 2014; England etal. 2015).
The brain undergoes significant neurobiological
development during adolescence and young adulthood,
which are critical periods of sensitivity to neurobiolog‑
ical insults (such as nicotine) and experience‑induced
plasticity (Spear 2000; Dahl 2004; Gulley and Juraska
2013). Although maturation occurs in different regions of
the brain at different rates, a similar progression occurs
in all areas characterized by a rapid formation of syn‑
aptic connections in early childhood, followed by a loss
of redundant or unnecessary synapses (called pruning)
and the formation of myelin. Myelination is the process
by which a fatty layer, called myelin, accumulates around
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 105
E-Cigarette Use Among Youth and Young Adults
nerve cells (neurons). Because of myelin, nerve cells can
transmit information faster, allowing for more complex
brain processes. Pruning allows for more focused con‑
centration, and myelination allows for faster electrical
and neural signaling; both allow for more efficient cog‑
nitive processing. During adolescence and into young
adulthood, myelination occurs rapidly in the frontal lobe,
a place in the brain that controls executive functioning,
reasoning, decision‑making skills, self‑discipline, and
impulse control. Plasticity refers to the current under‑
standing that the brain continues to change throughout
life, not only because of normal, maturational neural
growth and development but also because of changes in
environmental neurobiological exposures (such as nico‑
tine), injuries, behaviors, thinking, and emotions (Mills
and Tamnes 2014).
Across species, and in humans, adolescence is a key
period of increased plasticity and rapid growth of brain
circuits that regulate social, emotional, and motivational
processes and decision making (Spear 2000, 2011; Nelson
etal. 2005; Ernst and Fudge 2009; Counotte etal. 2011).
The prefrontal cortex, which is involved in higher level
regulatory control of complex behaviors (such as plan‑
ning, impulse control, and working memory), continues
normal structural and functional development into young
adulthood, to about 25 years of age (Giedd and Rapoport
2010; Somerville and Casey 2010). Because of the immatu‑
rity and rapid growth of the prefrontal cortex, adolescents
and young adults normally exhibit moody, risk‑taking,
and unpredictable impulsive behaviors. The combina‑
tion of delayed maturation of frontal cognitive control
and increased reactivity of subcortical reward‑related
and emotion‑processing systems may lead to increased
risk‑taking behavior and a greater susceptibility to initi‑
ating substance use and the development of dependence
(Steinberg 2008; Ernst and Fudge 2009; Counotte etal.
2011; Spear 2011). Thus, myelination is vitally important
to the healthy functioning of the central nervous system,
and any exposure that significantly interferes with the
myelination process can cause mild‑to‑severe cognitive
and learning problems (Brady etal. 2012).
Brain development in juvenile rodents has been
reported to display patterns that resemble those of human
beings, suggesting that the rodent model might be rel‑
evant to studying the neurobiological underpinnings
of brain maturation in teenagers (Spear 2000). Studies
across species have revealed unique characteristics of
adolescent nonhuman brain structure, mechanisms, and
function that provide biological plausibility to the hypoth‑
esis that human adolescents are particularly vulnerable to
nicotine uptake (O’Loughlin etal. 2015; Yuan etal. 2015).
There is evidence for rapid growth of gray matter, fol‑
lowed by activity‑dependent synaptic pruning (the process
of synapse elimination that occurs between early child‑
hood and the onset of puberty) and increasing myelina‑
tion throughout the brain (Casey etal. 2005; Lenroot and
Giedd 2006; Giedd and Rapoport 2010; Counotte et al.
2011).
Nicotine has more significant and durable damaging
effects on adolescent brains compared to adult brains,
the former suffering more harmful effects. Preclinical
animal studies have shown that in rodent models, nico‑
tinic acetylcholine receptor (nAChR) signaling is still
actively changing during adolescence, with higher expres‑
sion and functional activity of nAChRs in the forebrain
of adolescent rodents compared to their adult counter‑
parts (Britton etal. 2007; Kota et al. 2007; Doura et al.
2008). Furthermore, in rodent models, nicotine actu‑
ally enhances neuronal activity in several reward‑related
regions and does so more robustly in adolescents than in
adults (Schochet etal. 2005; Shram etal. 2007; Dao etal.
2011). This increased sensitivity to nicotine in the reward
pathways of adolescent rats is associated with enhanced
behavioral responses, such as strengthening the stimulus‑
response reward for administration of nicotine. In condi‑
tioned place‑preference tests—where reward is measured
by the amount of time animals spend in an environment
where they receive nicotine compared to an environment
where nicotine is not administered—adolescent rodents
have shown an increased sensitivity to the rewarding
effects of nicotine at very low doses (0.03 mg/kg) (Vastola
et al. 2002; Belluzzi et al. 2004; Brielmaier et al. 2007;
Kota et al. 2007; Natarajan et al. 2011) and exhib‑
ited a unique vulnerability to oral self‑administration
during the early‑adolescent period (Adriani etal. 2002).
Adolescent rodents also have shown higher levels of nic‑
otine self‑administration than adults (Levin et al. 2003;
Chen etal. 2007; Natividad etal. 2013), decreased sensi‑
tivity to the aversive effects of nicotine (Adriani etal. 2002;
Shram etal. 2006; Torres etal. 2008), and less prominent
withdrawal symptoms following chronic nicotine expo‑
sure (O’Dell et al. 2006). This characteristic in rodent
models of increased positive and decreased negative short‑
term effects of nicotine during adolescence (versus adult‑
hood) highlights the possibility that human adolescents
might be particularly vulnerable to developing depen‑
dency to and continuing to use e‑cigarettes. These bio‑
logical mechanisms are of great public health importance
as exposure to nicotine grows among nonsmoking youth
through the increasing prevalence of e‑cigarette use.
Beyond their unique vulnerability to nicotine use,
and thus smoking uptake, human adolescents may be par‑
ticularly vulnerable to the detrimental consequences of
nicotine exposure, including an increase in drug‑seeking
behaviors (Kandel and Kandel 2014), deficits in attention
and cognition, and mood disorders (Yuan et al. 2015). In
A Report of the Surgeon General
106 Chapter 3
animal models, chronic nicotine exposure during adoles‑
cence has been shown to produce long‑lasting, unique
effects that are not observed in mature adult animals.
Moreover, animal models have provided substantial evi‑
dence that the limbic system—which controls cognition,
emotion, and drug‑reward—is actively maturing during
adolescence and during this age is vulnerable to long‑
term modification by nicotine.
Reward‑Seeking Behaviors. A very strong argument
can be made about the association between adolescent expo‑
sure to nicotine by smoking conventional cigarettes and
the subsequent onset of using other dependence‑producing
substances. Strong, temporal, and dose‑dependent associa‑
tions have been reported (Isensee et al. 2003; John et al.
2004b; Bronisch et al. 2008; Kandel and Kandel 2015), and
a plausible biological mechanism (via rodent and human
modeling) suggests that long‑term changes in the neural
reward system take place as a result of adolescent smoking
(Lewinsohn et al. 1999; Huang et al. 2013; Kandel and
Kandel 2014). Adolescent smokers of conventional ciga‑
rettes have disproportionately high rates of comorbid sub‑
stance abuse (Kandel et al. 1992; Lai et al. 2000; Hanna et al.
2001), and longitudinal studies have suggested that early
adolescent smoking may be a starting point or “gateway” for
substance abuse later in life (Kandel et al. 1992; Lewinsohn
et al. 1999; Wagner and Anthony 2002; Brook et al. 2007),
with this effect more likely for persons with attention
deficit hyperactivity disorder (ADHD) (Biederman et al.
2006; Wilens et al. 2008). Although factors such as genetic
comorbidity, innate propensity for risk taking, and social
influences may underlie these findings (Lindsay and Rainey
1997; Smith et al. 2015), both human neuroimaging and
animal studies suggest a neurobiological mechanism also
plays a role. In addition, behavioral studies in adolescent
and young adult smokers have revealed an increased pro‑
pensity for risk taking, both generally and in the presence of
peers, and neuroimaging studies have shown altered frontal
neural activation during a risk‑taking task as compared
with nonsmokers (Lejuez et al. 2005; Cavalca et al. 2013;
Galvan et al. 2013). Rubinstein and colleagues (2011b) used
neuroimaging to show decreased brain response to a nat‑
ural reinforcer (pleasurable food cues) in adolescent light
smokers (1–5 cigarettes per day), with their results high‑
lighting the possibility of neural alterations consistent with
nicotine dependence and altered brain response to reward
even in adolescent low‑level smokers.
Nicotine exposure in rodents at an age of physical
development corresponding to human adolescence has
been found to increase the reinforcing effects of other
drugs of abuse, including cocaine, methamphetamine,
and alcohol, without having a major impact on responding
for other rewards, thus providing further evidence in sup‑
port of nicotine as an initiation toward other substance
use and abuse (McQuown et al. 2007; Dao et al. 2011;
Dickson et al. 2014; Pipkin et al. 2014; Kandel and Kandel
2014). In several rodent studies, treatment with very low
doses of nicotine for a few days during early adolescence,
but not in late adolescence or adulthood, produced lasting
changes in D2 and D3 dopamine receptors and in the self‑
administration of other abused drugs (McQuown et al.
2007; Dao et al. 2011; Mojica et al. 2014). Nicotine expo‑
sure in adolescent rats also induced rapid and long‑lasting
dendritic remodeling in the nucleus accumbens shell, a
critical component of reward learning and addiction, via
a D1 dopamine receptor‑mediated mechanism (Ehlinger
etal. 2016). This persistent form of nicotine‑induced neu‑
roplasticity has the potential to alter synaptic connectivity
within reward‑processing centers and enhance the addic‑
tive effects of drugs of abuse.
Attention and Cognition. Both cognitive improve‑
ments (Jasinska et al. 2014) and cognitive deficits (Hall
et al. 2014) have been reported after nicotine exposure
in healthy human adults, while smoking during adoles‑
cence impairs cognition and attention processes. Results
of a genetically sensitive, longitudinal “concordant”
and “discordant” twin study from the Netherlands Twin
Registry indicated a larger increase in attention prob‑
lems from adolescence to adulthood in twins who smoked
than in their never‑smoking co‑twins (Treur etal. 2015).
In another study, adolescent smokers were found to have
chronic impairments in the accuracy of their working
memory (e.g., in processing information from two sensory
modalities simultaneously), which were more severe with
an earlier age of onset of smoking (Jacobsen etal. 2005).
Functional imaging studies have shown that 24‑hour
smoking abstinence in adolescent smokers causes acute
impairments of verbal memory and working memory,
along with chronic decrements in cognitive performance
(Jacobsen etal. 2007a). In another study, adolescent users
of conventional cigarettes showed decreased prefrontal
cortex activation (versus never smokers) during attention
tasks, and duration of smoking (in years) was directly cor‑
related with the extent of reduction in prefrontal cortical
activity (Musso etal. 2007).
Thus, longitudinal and imaging studies in humans
provide support for the hypothesis that adolescent use of con‑
ventional cigarettes has both acute and long‑term effects on
attention and memory. Although nicotine exposure cannot
be cited as the sole cause of cognitive defects (or even one
of several combined effects in humans), other studies have
shown that adolescent nicotine exposure in rats induces
lasting synaptic changes in the prefrontal cortical regions
critical for normal attention, memory, and cognition that
likely underlie observed impairments in attentional and
cognitive function (Bergstrom et al. 2008). Adolescent
nicotine exposure in rats has induced impairments in
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 107
E-Cigarette Use Among Youth and Young Adults
stimulus‑response‑discrimination‑learning processes but
not in abstract rule‑learning processes, which are dependent
on dissociable cognitive systems, thus showing the selective
effects of nicotine (Pickens etal. 2013). In addition, adoles‑
cent, but not postadolescent, treatment of rats with nico‑
tine resulted in diminished attention span and enhanced
impulsivity in adulthood (Counotte etal. 2009, 2011). The
biological causes of these cognitive disturbances (reduced
attention span and impulse control) were associated with
reduced regulation of prefrontal cortex excitatory synapses
function in metabotropic glutamate receptor 2 (mGluR2)
(Counotte etal. 2011; Goriounova and Mansvelder 2012).
In addition, hippocampal function, which is critical for
memory, was altered in adult mice by nicotine exposure
during adolescence. Contextual fear conditioning—a
hippocampus‑dependent task in which animals learn and
remember to associate a fearful stimulus (e.g., a foot shock)
with a particular context—was disrupted in adult mice that
had been treated during adolescence with chronic nicotine
but not following chronic treatment with nicotine in adult‑
hood (Portugal etal. 2012). Rodent studies have implica‑
tions for human adolescents, suggesting that exposure to
tobacco during youth may lead to long‑lasting changes in
behavioral and neuronal plasticity into adulthood.
Mood Disorders. Adolescents with symptoms of
mental health disorders (e.g., anxiety, aggressive and dis‑
ruptive behaviors, mood disorders) are at increased risk
for initiation of conventional cigarette use and long‑
term nicotine dependence compared with those without
such disorders (Gehricke etal. 2007; Morris etal. 2011).
Although this risk may reflect a common genetic predis‑
position, or the use of nicotine to self‑medicate in the
hope of improving mental health symptoms, the question
arises of whether the smoking of conventional cigarettes
by adolescents contributes to the development of mood
disorders. A meta‑analysis of existing studies showed con‑
sistent evidence that both tobacco use and dependence
on tobacco products among adolescents indeed increased
their risk of anxiety disorders (Moylan etal. 2012). Other
studies have shown that an early onset of smoking is asso‑
ciated with a shorter time to first onset of an anxiety dis‑
order (Jamal etal. 2011), and there is a positive association
between adolescent smoking, particularly through a nico‑
tine pathway, and anxiety in early adulthood (Moylan etal.
2013). Bidirectional relationships between adolescent
smoking and disruptive disorders (e.g., ADHD; opposi‑
tional defiant disorder [ODD] [Griesler etal. 2011]) as well
as depression (Tjora etal. 2014) also have been reported,
while a longitudinal birth cohort found evidence to sup‑
port a causal relationship between teen smoking and onset
of depression (Boden etal. 2010). Although these findings
are complex and warrant further study using comparisons
of genetic polymorphisms associated with smoking or
twin and sibling discordant/concordant studies (Munafo
and Araya 2010; Leventhal and Zvolensky 2015), they do
suggest that nicotine exposure during adolescence could
contribute to long‑term mental health disorders.
Findings of animal studies support the theory that
adolescent nicotine exposure results in long‑term alter‑
ations in emotional response, specifically enhanced anx‑
iety and fear (Slawecki etal. 2003; Smith etal. 2006), and
in persistent alterations in serotonin systems involved in
mediating mood disorders by reprogramming the future
response of 5‑HT systems to nicotine (Slotkin and Seidler
2009). Even a single day of nicotine treatment in adoles‑
cent rats can enhance sensitivity to aversive stimuli later
in life and result in a depression‑like state in adulthood
that is normalized by treatment with nicotine or antide‑
pressants (Iniguez etal. 2009).
In summary, given the existing evidence from
human and animal studies of the detrimental impact of
nicotine exposure on adolescent brain development, the
use of e‑cigarettes by youth should be avoided and actively
discouraged. Both preadolescence and adolescence are
developmental periods associated with increased vulner‑
ability to nicotine addiction, and exposure to nicotine
during these periods may lead to long‑lasting changes in
behavioral and neuronal plasticity. Studies reveal that for
most tobacco users, initial use begins before 18 years of
age. Moreover, in some adolescents, symptoms of nico‑
tine dependence can develop after exposure to very low
levels of nicotine—less than 100 cigarettes. Cross‑species
studies have identified characteristics of the adolescent
brain that may render it vulnerable at this age to nicotine
uptake in the form of equivalent doses via nonsmoking
administration mechanisms. In addition, animal models
of nicotine exposure in adolescence reveal neural and
behavioral alterations consistent with an increased like‑
lihood of future nicotine use, increased activation of
reward pathways and, unlike in adult animals, decreased
aversive effects. Regarding e‑cigarettes, data demonstrate
adolescent use of these devices is associated with use of
tobacco, alcohol, and other drugs (Dutra and Glantz 2014;
Kristjansson et al. 2015; Wills et al. 2015a, b; Schneider
and Diehl 2016). Finally, animal and human studies sug‑
gest a bidirectional relationship between the smoking of
conventional cigarettes and exposure to nicotine during
adolescence and factors related to disruptive disorders,
such as ADHD and ODD that impair academic perfor‑
mance, as well as to depression. Because the adolescent
brain is still developing, nicotine use during adolescence
can disrupt the formation of brain circuits that con‑
trol attention, learning, and susceptibility to addiction.
Further research is warranted to more fully understand
the effects of e‑cigarette use on youth.
A Report of the Surgeon General
108 Chapter 3
Nicotine Exposure from Maternal Nicotine
Consumption: Prenatal and Postnatal Health
Outcomes
Prenatal nicotine exposure through maternal ciga‑
rette use during pregnancy is one of the most widespread
perinatal insults in the world (Levin and Slotkin 1998; Xiao
etal. 2008; USDHHS 2014). Despite medical and societal
sanctions and ongoing public health campaigns, the prev‑
alence of maternal cigarette use during pregnancy in the
United States was estimated to be 11–15% in 2013 (Tong
etal. 2013). Smoking rates were even higher among women
who were poor, young, or less educated, with rates as high
as 25–30%, indicating that infants born to mothers who are
poor have disproportionately higher exposure to nicotine
(Dietz etal. 2011; Hamilton etal. 2012; Tong etal. 2013).
Despite these adverse consequences, an estimated one‑half
of pregnant smokers continue to smoke into the third tri‑
mester (Osterman etal. 2013; Tong etal. 2013).
Because adults who use e‑cigarettes can achieve
plasma nicotine concentrations similar to those found
among smokers of equivalent amounts of conventional
cigarettes (Vansickel et al. 2010; Lopez et al. 2016;
St.Helen etal. 2016), it is important that research con‑
tinues in this area. Nicotine has been shown to cross the
placenta and has been found in placental tissue as early
as 7 weeks of embryonic gestation, and nicotine concen‑
trations are higher in fetal fluids than in maternal fluids
(Luck et al. 1985; Jauniaux et al. 1999). nAChRs are
widely distributed in the fetal brain. As has been clearly
demonstrated in animal models, acetylcholine acts on
nAChRs to modulate functional connections during crit‑
ical periods of development when regions are most sen‑
sitive to environmental input (Dwyer etal. 2008). When
nicotine in the maternal bloodstream crosses the pla‑
cental barrier, it binds to these receptors (Pentel et al.
2006; Wong etal. 2015), and in rodents this can result
in long‑term changes in neural structure and function.
Results from animal studies show consistent associations
between prenatal nicotine exposure and upregulation of
nAChRs associated with disruption of fetal brain cell rep‑
lication and differentiation (Slotkin 1998). Highlighting
the role of nicotine in the effects of maternal smoking
during pregnancy, nAChRs have been shown to be present
in the human embryonic brain from 5 weeks of gesta‑
tion (Hellstrom‑Lindahl et al. 1998), and their normal
maturation is altered in a region‑ and receptor subtype‑
dependent fashion by maternal cigarette smoking during
pregnancy (Falk etal. 2005; Duncan etal. 2008). In those
brainstem nuclei important for arousal, prenatal nicotine
exposure decreases [
3
H]‑nicotine binding (Duncan etal.
2008) and prevents normal age‑related increases in α4
and α7 mRNA (Falk etal. 2005).
Prenatal nicotine exposure also has been associated
with dysregulation of catecholaminergic, serotonergic,
and other neurotransmitter systems. In addition, animal
work suggests significant adverse effects of nicotine alone
at levels commensurate with exposure to secondhand
smoke (10‑fold below those seen in active smokers), and
that the non‑nicotine components of tobacco smoke can
exacerbate nicotine’s teratogenic effects (Slotkin et al.
2015). Offermann (2015) concluded that e‑cigarettes
emit many harmful chemicals into the air and that indi‑
rect exposure to nicotine exceeded exposure‑level stan‑
dards for noncarcinogenic health effects established by
the California Environmental Protection Agency. No safe
level of prenatal nicotine exposure has been established
(England etal. 2015).
Airborne nicotine exposure through secondhand
aerosol from e‑cigarettes has been observed, as has sali‑
vary cotinine concentrations of nonsmokers in the homes
of e‑cigarette users (Ballbe et al. 2014; Czogala et al.
2014). Ballbe and colleagues (2014) reported the geo‑
metric means of airborne nicotine were 0.74 μg/m3 in the
homes of smokers, 0.13 μg/m3 in the homes of e‑cigarette
users, and 0.02 μg/m3 in the homes of nonsmoking con‑
trols. While airborne nicotine exposure from combustible
cigarette smoke was 5.7 (Ballbe et al. 2014) to 10 times
higher (Czogala et al. 2014) than e‑cigarette aerosol, one
study reported only a twofold increase in salivary cotinine
(0.38 ng/ml in the homes of smokers versus 0.19 ng/ml in
the homes of e‑cigarette users) (Ballbe et al. 2014), and
another study found that exposure to cigarette smoke and
exposure to e‑cigarette aerosol had similar effects on the
serum cotinine levels of bystanders (Flouris et al. 2013).
Thus, the passive exposure to nicotine from e‑cigarette
smoking has been reported to be just as large (Flouris
et al. 2013; Grana et al. 2013) or lower than (Czogala et al.
2014) conventional cigarettes, but exposure to nicotine
from e‑cigarette smoking is not negligible and is higher
than in nonsmoking environments. This evidence sug‑
gests the importance of avoiding secondhand exposure
of e‑cigarette vapor and secondhand smoke during preg‑
nancy (Flouris et al. 2013; Grana et al. 2013; Czogala et al.
2014).
Of the components of tobacco smoke, nicotine
has been cited as the most important toxicant in terms
of interfering with fetal development. Because of the
health risks to the developing fetus associated with nico‑
tine exposure during pregnancy, the U.S. Food and Drug
Administration (FDA) (2015) recommends that pregnant
women seek medical approval before using NRT, and the
American College of Obstetricians and Gynecologists
(2011) recommends consideration of NRT only if a woman
fails behavioral interventions to quit smoking conven‑
tional cigarettes and has discussed the potential harms
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 109
E-Cigarette Use Among Youth and Young Adults
and benefits of NRT with her physician.
NRT is most often
used during pregnancy as a last resort to avoid exposing
the fetus to the other toxic ingredients found in con‑
ventional tobacco smoke (Fiore etal. 2008). A Cochrane
Database systematic review concluded that both the effec‑
tiveness and safety of NRT during pregnancy are unclear
(Coleman etal. 2012). Table A3.1‑4 in Appendix 3.1 pres‑
ents a summary of studies in humans on the effects of
tobacco exposure on fetal brain development.
Even with a firm understanding of the negative
health consequences of nicotine on the developing fetus
(Fiore et al. 2008; USDHHS 2014; Ekblad et al. 2015),
little is known about the prevalence of e‑cigarette use
among pregnant women or the direct harmful effects
on their fetus by other toxicants delivered by the aerosol
from e‑cigarettes (England etal. 2015; Suter etal. 2015).
In one of the few studies identified, a survey of 316 preg‑
nant women in a Maryland clinic found that the majority
had heard of e‑cigarettes, 13% had ever used them, and
0.6%were current daily users (Mark et al. 2015). These
findings are of concern because the dose of nicotine
delivered by e‑cigarettes can be as high or higher than
that delivered by conventional cigarettes. Therefore,
plasma nicotine concentrations delivered while using
e‑cigarettes have the potential to harm the developing
fetus. Furthermore, in 2013 in the United States, there
were 26.5 births for every 1,000 adolescent females
(15–19 years of age), or 273,105 babies born to females
in this age group (Hamilton etal. 2013). Currently, the
rate of e‑cigarette use among pregnant adolescents is
unknown, but the effects of nicotine and the potential for
harm by other e‑cigarette toxicants indicate that the use
of e‑cigarettes is a fetal risk factor among pregnant ado‑
lescent girls.
As outlined below, the specific effects of nicotine
on prenatal development and postnatal outcomes include
sudden infant death syndrome (SIDS) and may include
altered development of the corpus callosum, deficits in
auditory processing, and alterations in appetitive behavior,
attention, and cognition.
SIDS. SIDS is the sudden and unexplained death of
an infant younger than 1 year of age (Krous 2014). Maternal
smoking and infant exposure to secondhand smoke have
been causally associated with SIDS, with 20–29% of deaths
from SIDS attributable to maternal smoking of conven‑
tional cigarettes during pregnancy (Dietz et al. 2010;
Zhang and Wang 2013; USDHHS 2014). Prenatal exposure
to cigarettes and to smokeless tobacco have been associ‑
ated with increased risk for apnea events, which have been
linked to increased risk for SIDS (Gunnerbeck etal. 2011;
Zhang and Wang 2013; Inamdar etal. 2015).
Although the mechanistic pathways underlying
SIDS remain largely unknown, nicotine has effects on
pathways that could be related to SIDS and is related
to known risk factors, particularly lung and respira‑
tory development (England et al. 2015; Holbrook 2016;
Spindel and McEvoy 2016). Evidence from animal models
supports the hypothesis that prenatal nicotine exposure
alters both fetal autonomic function and arousal, which
could increase the risk of SIDS (Slotkin 1998; Task Force
on Sudden Infant Death Syndrome and Moon 2011). In
humans, a dose–response relationship between cotinine
(the major nicotine metabolite) and altered arousal pat‑
terns has been shown in preterm infants (Richardson
et al. 2009), and this relationship is suggestive of nico‑
tine’s role in arousal deficits that could be linked to SIDS.
There is widespread distribution of nAChRs in the brain‑
stem nuclei in both humans and animals that control car‑
diopulmonary integration and arousal in the newborn
(Dwyer et al. 2008). In some animal studies, prenatal
exposure to nicotine has increased mortality in newborns
that were exposed to reduced oxygen (Slotkin etal. 1995;
Fewell and Smith 1998). Prenatal exposure to nicotine
is also associated with altered serotonin signaling in the
brainstem in the rat model, leading to an exaggerated tri‑
geminocardiac reflex and resulting in bradycardia, hypo‑
tension, and apnea (Gorini etal. 2013).
Altered Development of the Corpus Callosum. The
corpus callosum, the largest white matter structure in
the brain, facilitates communication between the left and
right cerebral hemispheres. Several human studies have
revealed alterations in the structure of the corpus callosum
in offspring following their exposure to maternal cigarette
use during pregnancy (Jacobsen etal. 2007b; Paus etal.
2008). In animal models, prenatal exposure to nicotine
has been shown to result in widespread alterations in gene
expression in the brains of adolescent offspring (Cao etal.
2011, 2013; Wei etal. 2011). In particular, the expression
of a number of genes involved in myelination—the forma‑
tion of white matter via the addition of protective myelin
sheaths to axons—is altered in a sex‑dependent manner,
with upregulation in males and downregulation in females
(Cao etal. 2013). Such changes in the expression profiles
of myelin‑related genes may influence the structure and
function of white matter, and both hypermyelination and
hypomyelination have been associated with cognitive defi‑
cits (Quaranta etal. 2002; Sokolov 2007).
Deficits in Auditory Processing. A number of
human studies, using a variety of methods, have inves‑
tigated the effects of maternal cigarette smoking during
pregnancy on auditory processing from the fetal period
through childhood (Jacobson and Morehouse 1984;
Kristjansson et al. 1989; McCartney et al. 1994; Franco
etal. 1999; Leech etal. 1999; Cowperthwaite etal. 2007).
Deficits in auditory processing in fetuses are of concern
because they affect later language development (Kisilevsky
A Report of the Surgeon General
110 Chapter 3
and Davies 2007; Kisilevsky etal. 2014). Various studies in
infants have investigated the brain’s physiological activity
response to auditory stimuli (the cochlea translates sound
into nerve impulses to be sent to the brain), neuroelectric
activity of the auditory nerve, and cochlear response (Key
etal. 2007; Korres etal. 2007; Kable etal. 2009; Peck etal.
2010; Katbamna etal. 2013). Key and colleagues (2007)
reported prenatal exposure to cigarette use (compared
with nonexposed infants) to be associated with alterations
in hemispheric asymmetry and suboptimal brain activity
related to speech processing in otherwise healthy new‑
borns at least 2 days of age. Korres and associates (2007)
found altered cochlear responses to auditory stimuli
in newborns that were exposed to maternal cigarette
smoking (n = 200) compared with those that were unex‑
posed (n = 200), regardless of degree of cigarette exposure.
Similar findings were reported by Durante and colleagues
(2011) in two case‑control studies.
Two additional studies investigated effects of
maternal cigarette use during pregnancy on auditory
brainstem responses in newborns (≤2 days old) (Peck etal.
2010) and infants (6 months old) (Kable etal. 2009). Both
studies found greater neuroelectric response to sound
stimuli, a phenomenon that may disrupt an infant’s ability
to encode auditory information, potentially leading to def‑
icits in language development. Furthermore, both studies
demonstrated dose–response relationships between
altered auditory processing and maternal cotinine levels.
Finally, in a study of a small sample of newborns that
sought to understand the direct biological pathway,
maternal smoking during pregnancy produced changes in
newborn cochlear and auditory brainstem functions and
changes in placental gene expression in genes that appear
to modulate the motility of cochlear hair cells (Katbamna
etal. 2013). Thus, all three studies indicate effects based
on consumption of conventional cigarettes, and they high‑
light the possibility of a mediating role of maternal nico‑
tine use in altered infant auditory processing, although
further work must rule out confounding effects and effect
modification by other constituents (e.g., arsenic, benzene,
and cadmium).
A study using functional magnetic resonance
imaging (fMRI) in older offspring exposed to tobacco
in utero assessed response to auditory and visual atten‑
tion tasks in adolescent smokers (Jacobsen etal. 2007a).
Teens whose mothers smoked during pregnancy exhibited
decreased accuracy in the tasks, with greater activation
of both the temporal lobe and the occipital lobe, regions
of the brain that are critical for auditory and visual pro‑
cessing. Additive effects of maternal cigarette use during
pregnancy and of adolescent smoking on activation of the
temporal and occipital lobes also emerged, indicative of
reduced coordination among brain regions during audi‑
tory attention tasks.
Animal studies have shown that nAChRs play a
critical developmental role in establishing synaptic con‑
nections between sensory thalamic afferents and those
cortical targets that are necessary for normal sensory
processing (Table A3.1‑5 in Appendix 3.1). Brief nicotine
exposure during this critical postnatal period of sensory
cortex development disrupts glutamate transmission
(Aramakis etal. 2000) and eliminates nAChR regulation of
signal processing in the adult auditory cortex, inhibiting
normal auditory learning (Liang et al. 2006). Animals
that are prenatally exposed to nicotine also exhibit defi‑
cits in cognitive processing in response to an auditory cue,
which appears to be mediated by a loss of function of the
nAChR β2 subunit (Liang etal. 2006; Horst etal. 2012).
Appetitive and Consummatory Behaviors. Clinical
studies and animal studies have linked prenatal exposure
to nicotine to subsequent appetitive behaviors (an active
searching process that is performed consciously) and con‑
summatory behaviors (such as ingestion of food or drugs)
in offspring. Associations have been demonstrated in
humans between maternal cigarette use during pregnancy
and risk to the child of smoking uptake/nicotine depen‑
dence, drug abuse, and obesity; parallel relationships have
been shown in animal models between prenatal exposure
to nicotine and similar appetitive behaviors of offspring.
Parental use of tobacco is one of many well‑known
risk factors for offspring initiation of tobacco, progres‑
sion to heavy use, and nicotine dependence. Tobacco use
by parents influences their children through social, envi‑
ronmental, cognitive, and genetic mechanisms (USDHHS
2012). As a subset of these influences, mothers’ use of
tobacco during pregnancy has been studied as an inde‑
pendent risk factor and has been associated with offspring
susceptibility, initiation, regular use, and dependence
(Kandel etal. 1994; Griesler etal. 1998; Kandel and Udry
1999; Buka et al. 2003; Lieb et al. 2003; Oncken et al.
2004; Al Mamun et al. 2006; O’Callaghan et al. 2009;
Tehranifar et al. 2009; Agrawal et al. 2010; Rydell et al.
2012; Weden and Miles 2012; Stroud etal. 2014; Shenassa
etal. 2015). Wakschlag and colleagues (2010, 2011) sug‑
gest that maternal smoking during pregnancy has a ter‑
atologic effect with abnormalities stemming from the in
utero environment which disrupt neural (Kandel et al.
1994; Jacobsen et al. 2006) and dopamine systems that
promote sensitivity to nicotine dependence (Kandel etal.
1994; Selya etal. 2013). For example, nicotinic receptors
of laboratory animals exposed to nicotine in utero are
upregulated, suggesting a latent vulnerability to nicotine
dependence among animals exposed to nicotine in utero
(Slotkin etal. 2006, 2015).
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 111
E-Cigarette Use Among Youth and Young Adults
At issue with all human studies investigating
maternal use of tobacco during pregnancy and offspring
use of tobacco is isolating the independent effect on the
fetus in relation to the other social, environmental, and
cognitive factors that also predict offspring tobacco use.
After controlling for maternal smoking during the off‑
spring’s childhood, several studies have reported that
maternal smoking during pregnancy is associated with
higher nicotine dependence in offspring (Kardia et al.
2003; Lieb etal. 2003; Selya et al. 2013; Shenassa etal.
2015), increased or earlier smoking initiation, and heavier
smoking among adolescent girls and adult offspring
(Kandel etal. 1994; Cornelius etal. 2005). However, the
association was attenuated and nonsignificant among sev‑
eral studies that controlled for a variety of environmental,
social, and cognitive confounders between maternal cig‑
arette use during pregnancy and initiation of offspring
smoking (but not nicotine dependence) (Cornelius etal.
2005; Roberts etal. 2005; Munafo etal. 2006; Kandel etal.
2007; D’Onofrio etal. 2012; Rydell etal. 2014; Taylor etal.
2014), leaving speculation for the independent effect. In
summary, evidence from animal models offers a biologic
mechanism for, and human evidence is suggestive of, an
association between maternal tobacco use during preg‑
nancy with offspring smoking and nicotine dependence,
but is insufficient to infer causation. Further research and
longitudinal studies that examine these outcomes while
assessing the full spectrum of environmental, social, and
cognitive mediating pathways are needed to disentangle
these issues.
A smaller set of literature has documented associa‑
tions between maternal cigarette smoking during preg‑
nancy and use of other substances by the child (Fergusson
etal. 1998; Weissman etal. 1999; Porath and Fried 2005;
Nomura etal. 2011). In utero exposure to nicotine also
affects behavioral responses for drug rewards in both ado‑
lescent and adult experimental animals. Prenatal expo‑
sure to nicotine increases the preference of adolescents
for a saccharin solution containing nicotine compared
with saccharin alone (Klein etal. 2003), and it results in
self‑administration of nicotine either during acquisition
of the task (Chistyakov etal. 2010) or after forced absti‑
nence (Levin etal. 2006). Prenatal exposure to nicotine
also increases subsequent oral intake of alcohol (Chang
etal. 2013), and intravenous self‑administration of both
cocaine and methamphetamine is enhanced in a dose‑
dependent manner in adolescent rats (Franke etal. 2008)
and adult rats (Lacy etal. 2014).
In contrast, in a study that used a discordant sib‑
ling pair design to reduce confounding by genetic and
environmental factors, initial associations between pre‑
natal smoking and alcohol use disorder were attenuated
and were no longer statistically significant (D’Onofrio
et al. 2012). In a large longitudinal study that spanned
40years, Shenassa and colleagues (2015) found evidence
to support effects on nicotine dependence among chil‑
dren of mothers who smoked during pregnancy, but no
effects on their progression to marijuana dependence
were observed. A possible explanation for these discordant
findings is suggested by a study that found significant
effects from prenatal smoking of conventional cigarettes
on drug use among adolescents, but showed that these
effects were restricted to a genetic subpopulation of car‑
riers of a specific α6 nAChR gene (rs2304297) polymor‑
phism (Lotfipour etal. 2010). In sum, a number of studies
have documented associations between cigarette use by
the mother during pregnancy and smoking initiation,
heavy use, and nicotine dependence among her children,
although control of confounding reduces this associa‑
tion. In addition, the literature is sparse and inconsistent
regarding a connection between maternal cigarette use
during pregnancy and the use of nontobacco substances
by the child.
A large body of literature has demonstrated effects
of maternal cigarette use during pregnancy on weight
levels and obesity in childhood. For example, three meta‑
analytic reviews found a 47–64% increased risk of obe‑
sity in children following exposure to maternal cigarette
smoking during pregnancy (Oken etal. 2008; Ino 2010;
Weng et al. 2012; Behl et al. 2013). Additional system‑
atic reviews (Bruin etal. 2010) and other studies (Harrod
etal. 2015; La Merrill etal. 2015; Mourtakos etal. 2015;
Bao et al. 2016) have all concluded that prenatal expo‑
sure to nicotine likely acts as a developmental obesogen
in humans. However, unmeasured residual confounding
or confounding by familial factors, which have not been
fully explored, could attenuate the observed associations
(Gilman etal. 2008; Iliadou et al. 2010). Animal studies
support the epidemiologic literature suggesting a poten‑
tially causal relationship here by defining biologic path‑
ways (Wong etal. 2015). Fetal and neonatal exposure to
nicotine in rodents has resulted in neurochemical, neu‑
robehavioral, and metabolic changes in the children that
are consistent with obesity and type 2 diabetes (Williams
and Kanagasabai 1984; Newman etal. 1999; Grove etal.
2001; Chen and Kelly 2005; Gao et al. 2005; Holloway
etal. 2005).
In humans, studies involving structural MRI and
fMRI have shown alterations in the size and sensitivity of
brain reward centers in the teenage offspring of maternal
smokers. Several of these studies revealed a thinning of
the orbitofrontal cortex among persons who were prena‑
tally exposed to maternal cigarette smoking, a thinning
that was associated with drug use and experimentation
during adolescence (Toro et al. 2008; Lotfipour et al.
2009); decreased amygdalar volume, which is associated
A Report of the Surgeon General
112 Chapter 3
with increased fat intake (Haghighi et al. 2013); and
altered response to reward anticipation in the ventral stri‑
atum, an area associated with risk taking and drug use
(Muller etal. 2013). In addition, highlighting the role of
altered nicotinic pathways in the disruption of neural cir‑
cuits from prenatal tobacco exposure, changes in striatal
volume, and a propensity for drug use in adolescent off‑
spring have been linked to interactions between prenatal
exposure to cigarette smoking and a polymorphism in
the gene encoding the α6 nAChR (Lotfipour etal. 2010).
Structural alterations in the orbital frontal cortex have
also been shown to result from interactions between
maternal cigarette smoking during pregnancy and poly‑
morphisms of brain‑derived neurotrophic factor, a growth
factor that regulates growth and differentiation of new
neurons and supports existing neurons (Lotfipour etal.
2009). Although these clinical findings are specific to con‑
ventional cigarettes, they converge with results of animal
studies of the effects of prenatal nicotine on brain reward
centers and thus highlight the potential pernicious effects
of e‑cigarettes in pregnant women.
Animal studies have shown that the dopamine
system, which is critically involved in satisfaction‑seeking
or appetitive behaviors, is modulated by nAChRs from the
fetal period to adulthood (Azam etal. 2007). Prenatal nico‑
tine exposure alters dopamine’s content, turnover, release,
and receptor expression in forebrain regions, which are
important for motor and cognitive functions (Navarro
etal. 1988; Richardson and Tizabi 1994; Muneoka etal.
1999; Zhu etal. 2012) and for assigning motivational value
to natural and drug rewards (Kohlmeier 2015; McNair and
Kohlmeier 2015). Prenatal exposure to nicotine also mod‑
ifies the structure of dendritic targets of dopamine inner‑
vations in the nucleus accumbens (a critical component
of reward learning and addiction) (Mychasiuk etal. 2013)
and alters neuronal signaling that affects dopamine func‑
tion (Chang etal. 2013; Morgan etal. 2013).
Prenatal exposure to nicotine has been shown in
a variety of animal studies to induce complex effects on
behavioral response to natural rewards. Although adoles‑
cent offspring of nicotine‑exposed mothers show an ini‑
tial decrease in motivation to work for sucrose reward
(Franke etal. 2008), they exhibit enhanced sensitivity to
the rewarding effects as the task becomes harder (Lacy
et al. 2012). Prenatal exposure to nicotine also results
in enhanced intake of fatty foods, with no change in the
intake of normal chow (Chang etal. 2013).
Attention and Cognition. Numerous human
studies have investigated the effects of maternal cigarette
use during pregnancy on disruptive behavior and atten‑
tion deficits in the child. The 2014 Surgeon General’s
report included results of a systematic review of effects
of maternal cigarette use during pregnancy on disrup‑
tive‑behavior disorders—including ADHD, conduct dis‑
order, and ODD—in offspring (USDHHS 2014). The
evidence for effects of maternal cigarette use during
pregnancy on disruptive‑behavior disorders, and ADHD
in particular, was suggestive but not sufficient to infer
a causal relationship. Several systematic reviews using
meta‑analyses have found evidence for associations
between exposure to maternal cigarette use during preg‑
nancy and ADHD in offspring, including dose–response
relationships between number of cigarettes smoked per
day and ADHD symptoms (Linnet et al. 2003; Langley
et al. 2005; Latimer et al. 2012; Massey et al. 2016).
However, similar to effects on nicotine dependence and
obesity in offspring, the possibility of unmeasured con‑
founding remains (D’Onofrio et al. 2008; Thapar et al.
2009; Langley et al. 2012). Evidence for associations
with maternal cigarette use during pregnancy is perhaps
more consistent for offspring conduct disorders than it
is for ADHD. In particular, although some studies that
used a gene–environment interaction design or a pro‑
pensity score‑matching approach to exposure to control
for confounding, they found no effect of maternal cig‑
arette smoking during pregnancy on conduct disorders
(D’Onofrio etal. 2008; Gilman etal. 2008; Boutwell and
Beaver 2010; Lavigne etal. 2011). However, several other
studies—including a meta‑analytic review across three
studies using “genetically sensitive”
2
2
Genetically sensitive designs typically include monozygotic and dizygotic twins and a broader inclusion of sibling pairs, mother–child
pairs, and grandparent–grandchild pairs. Genetically sensitive multigroup designs allow for simultaneous testing of additive and nonad-
ditive genetic, common, and specic environmental effects, including cultural transmission and twin-specic environmental inuences.
research designs—
have suggested a direct causal relationship between
maternal smoking during pregnancy and conduct disor‑
ders in offspring (McCrory and Layte 2012; Gaysina etal.
2013; Kuja‑Halkola et al. 2014; Estabrook et al. 2015;
Paus and Pausova 2015).
To explore the potential role of nicotine exposure in
these associations, a small number of studies have included
a prospective measure of confirmed tobacco exposure,
maternal cotinine levels, in addition to maternal report
of smoking, to study relationships with disruptive behav‑
iors among offspring (Wakschlag etal. 2011; O’Brien etal.
2013; Massey etal. 2016). Wakschlag and colleagues (2011)
found associations between maternal cigarette smoking
and aggression and noncompliance among offspring.
Studies have also shown alterations in the structure and
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 113
E-Cigarette Use Among Youth and Young Adults
function of the orbital frontal cortex, a region impor‑
tant for emotional regulation and cognition, in relation
to maternal cigarette smoking during pregnancy (Toro
etal. 2008; Bennett etal. 2009). Consistent with animal
models of altered dopamine regulation, two studies have
shown interactions of maternal cigarette smoking during
pregnancy with dopamine regulation genotype (DAT1) in
influencing disruptive‑behavior phenotypes in offspring
(Wakschlag etal. 2011; O’Brien et al. 2013). In another
study, Wakschlag and colleagues (2010) demonstrated a
sex‑dependent interaction of maternal smoking during
pregnancy with monoamine oxidase A (MAOA) geno‑
type, which is associated with the development of anti‑
social behavior. In this study, maternal smoking during
pregnancy further increased the risk for conduct disorder.
In sum, although issues of confounding remain, much
evidence from human studies is suggestive of a causal
association between maternal cigarette smoking during
pregnancy and disruptive behaviors among offspring.
This was confirmed by the 2014 Surgeon General’s report
on tobacco (USDHHS 2014). Since then, newer studies,
controlling for personal and genetic confounders, have
reported significant associations as well as nonsignificant,
attenuated associations. Biologic evidence of nicotine‑
induced alterations in dopamine regulation also provides
a possible mechanism for the role of nicotine in these
outcomes.
Animal studies have shown that cholinergic modu‑
lation of prefrontal cortex function, via nAChRs, is essen‑
tial for attention and cognition (Poorthuis and Mansvelder
2013; Proulx et al. 2014). Prenatal exposure to nicotine
alters the morphology and nAChR functional response of
prefrontal cortical neurons (Mychasiuk etal. 2013; Bailey
etal. 2014). When tested as adolescents, animals that were
exposed prenatally to nicotine show some behaviors char‑
acteristic of ADHD. For example, exposed offspring were
found in two studies to show less impulse control and/or
slower learning acquisition on two cognitive tests that tax
attentional processes (Sorenson et al. 1991; Schneider
etal. 2012). In addition, some studies have found hyper‑
activity in exposed offspring (Pauly etal. 2004; Schneider
etal. 2012; Zhu etal. 2012), which was found in another
study to be transmitted via maternal lineage from one
generation to the next and to be ameliorated by methyl‑
phenidate treatment across all generations, showcasing
the long‑term impact of prenatal nicotine exposure (Zhu
etal. 2014a). This transgenerational transmission of pre‑
natal nicotine‑induced hyperactivity must reflect long‑
term changes to the epigenome (Leslie 2013). Finally,
emerging animal studies suggest that prenatal exposure
to nicotine affects the proliferation and maturation of
progenitor cells to glutamatergic neurons during neu‑
rodevelopment in the medial prefrontal cortex, resulting
in behavioral impairments in attentional function and
behavioral flexibility in adulthood (Aoyama et al. 2016;
Poon and Leibowitz 2016; Powell etal. 2016).
Summary
Because of the rising prevalence of e‑cigarette use,
there is potential for widespread nicotine exposure to
youth and young adults, resulting in nicotine addiction
and related harmful consequences associated with expo‑
sure to nicotine. During pregnancy, there is neural sensi‑
tivity to the number and volume of substances, including
nicotine, transported through the placenta. From pre‑
natal development through adolescence and early adult‑
hood, exposure to nicotine poses a serious threat, because
these are critical times for brain development and brain
plasticity. Furthermore, youth and young adults are more
vulnerable than adults to the long‑term consequences
of nicotine exposure, including susceptibility to nicotine
addiction and potentially reduced impulse control, deficits
in attention and cognition, and mood disorders. An addi‑
tional public health concern is exposure to e‑cigarettes
among persons who have never used conventional tobacco
products. If the prevalence of e‑cigarette use continues to
rise among those who do not use conventional tobacco
products, the harmful consequences of exposure to nico‑
tine will rise accordingly.
The 2014 Surgeon General’s report (USDHHS 2014)
states there is sufficient evidence to infer that: (a) nicotine
activates multiple biological pathways through which
smoking increases risk for disease; (b) nicotine expo‑
sure during fetal development, a critical window for brain
development, has lasting adverse consequences for brain
development; (c) nicotine adversely affects maternal and
fetal health during pregnancy, contributing to multiple
adverse outcomes such as preterm delivery and stillbirth;
and (d) nicotine exposure during adolescence, a critical
window for brain development, may have lasting adverse
consequences for brain development and cognition. The
literature presented in this section attempts to differen‑
tiate the risks to fetal and child health associated with nic‑
otine in tobacco versus nicotine alone or in e‑cigarettes.
Evidence is sufficient to conclude tobacco use increases
the risk of SIDS (USDHHS 2014), but further research
is necessary with regard to nicotine alone or nicotine in
e‑cigarettes. The review finds evidence that tobacco is
associated with structural brain changes and alterations
in cognition, attention, and appetitive behaviors in human
offspring. Less well known is the role that nicotine plays
in mediating these associations, although animal models
provide support for a role for nicotine in these outcomes.
nAChRs, the chief receptor targets for nicotine, are widely
expressed in the fetal brain, and their normal functioning
A Report of the Surgeon General
114 Chapter 3
is negatively affected by smoking and, in animals, by pre‑
natal exposure to nicotine through experimental treat‑
ment. Furthermore, both human genetic studies and
animal studies implicate a neurotoxic effect of fetal nic‑
otine exposure. Pregnant women and women intending
to become pregnant should be cautioned against using
e‑cigarettes to avoid unnecessary nicotine exposure to
their baby.
Effects of the Inhalation of Aerosol
Constituents Other than Nicotine
The scientific literature on the health effects of expo‑
sure to constituents other than nicotine in the e‑cigarette
aerosol is still developing. One study found that after
5minutes of ad lib e‑cigarette use, healthy adult cigarette
smokers showed an increase in airway resistance, but
no effect on other spirometry parameters such as forced
vital capacity (FVC), forced expiratory volume in 1 second
FEV1, and ratios of these values (FEV1/FVC) (Vardavas
etal. 2012).
A noninvasive marker of airway inflammation is
the fraction of exhaled nitric oxide (FeNO) (Taylor etal.
2006; Munakata 2012). NO is a gaseous molecule that pro‑
duces vasodilation and bronchodilation (decreasing resis‑
tance in the respiratory airway and increasing airflow to
the lungs). FeNO is reduced by acute and chronic ciga‑
rette smoking (resulting in poorer vasodilation and bron‑
chodilation) and is increased among smokers following
cessation (see Vleeming etal. 2002 for a review). Studies
examining current adult cigarette smokers revealed a
reduction in FeNO after use of an e‑cigarette with and
without nicotine (Vardavas etal. 2012; Marini etal. 2014;
Ferrari etal. 2015). One study found that these reductions
did not differ significantly between e‑cigarettes containing
nicotine and those without nicotine (Marini etal. 2014),
suggesting non‑nicotine factors mediated the effect.
However, a study of occasional smokers (<10 cig‑
arettes per week), but non‑e‑cigarette users, found an
increase in FeNO after use of an e‑cigarette containing
nicotine (Schober et al. 2014). Furthermore, this study
found no statistical difference in FeNO after use of an
e‑cigarette not containing nicotine. This variation in
findings suggests the impact of e‑cigarette use on FeNO
may vary based on smoking history, nicotine content of
e‑liquid, or other environmental or biological factors.
Limited studies have examined chronic exposure
on the potential inhalation toxicity of PG and VG. Prior
to e‑cigarettes, consumer products containing these
chemicals were almost exclusively liquids or creams, or
the substance was contained in a matrix. Animal models
have shown few toxicological effects resulting from nose‑
only exposure to VG aerosol, with the exception of min‑
imal or mild squamous metaplasia in rats exposed to the
highest concentration (0.662 mg glycerol) for 13 weeks
(Anderson et al. 1950; Renne et al. 1992). Other inhala‑
tion studies testing PG in rats and monkeys did not observe
treatment‑related effects on respiratory physiology, clin‑
ical chemistry, hematology, gross pathology, or respiratory
tract histology (Robertson et al. 1947). However, neither
of these studies examined potential inhalation toxicity of
PG and VG in humans using e‑cigarette devices. In sum‑
mary, other than nicotine, very little is known from human
studies about the long‑term health effects of inhaling PG
and VG from e‑cigarette aerosol, although adverse effects
have been detected in animal models. Further investigation
would improve our understanding of the effects of nicotine‑
related compounds, aerosolized solvents (PG and VG), aero‑
solized flavorants, aerosolized adulterants in e‑liquids, and
toxicants produced during the aerosolization process—or a
combination of these chemicals.
Aerosolized Nicotine‑Related Compounds
The nicotine used in e‑liquids is extracted from
tobacco. The extraction process may produce some poten‑
tially harmful tobacco‑specific impurities, including
minor alkaloids like nornicotine, anatabine, anabasine,
myosmine, cotinine, nicotine‑N‑oxides (cis and trans iso‑
mers), β‑nicotyrine, and β‑nornicotyrine (Etter etal. 2013;
Farsalinos etal. 2015a; Lisko etal. 2015; Oh and Shin 2015).
The correlation between nicotine and the concentrations of
minor alkaloids is much stronger in conventional tobacco
products (Jacob etal. 1999) than in e‑cigarettes (Lisko etal.
2015). While the cause of these differing concentrations of
minor alkaloids is unknown, Lisko and colleagues (2015)
speculated potential reasons may derive from the e‑liquid
extraction process (i.e., purification and manufacturing)
used to obtain nicotine from tobacco, as well as poor quality
control of e‑liquid products.
The American E‑Liquid Manufacturing Standards
Association (2014), an industry group with no regula‑
tory authority, has called for the use of U.S. Pharmacopeia
(USP)‑grade nicotine in its e‑cigarette products. USP
specifications for nicotine allow for a maximum of
0.5%(5 mg/g) of a single impurity and 1% (10 mg/g) of
total impurities (U.S. Pharmacopeia n.d.). Although the
health implications of nicotine‑related impurities are not
known, toxicology studies are needed to demonstrate the
effects of high levels of these products.
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 115
E-Cigarette Use Among Youth and Young Adults
Aerosolized Solvents
Although e‑cigarettes produce PG aerosols at levels
known to cause eye and respiratory irritation to both
users and nonusers (Offermann 2015), only mild effects
(e.g., upper respiratory irritation) have been described
in humans exposed to PG mist for 1 minute (Wieslander
etal. 2001), and little is known about long‑term effects.
Inhaling PG can increase the risk of developing asthma
(Choi etal. 2010). Animal studies of PG and VG aerosol‑
izing agents not produced by e‑cigarettes concluded that
these substances are relatively safe when inhaled by ani‑
mals for up to 28 days (Werley etal. 2011) or 18 months
(Robertson etal. 1947).
Particles emitted from e‑cigarettes are assumed
to be formed from supersaturated PG (i.e., concentra‑
tion beyond the point of saturation) in e‑liquids (Schripp
etal. 2013). Several studies designed to characterize the
aerosol generated by e‑cigarettes examined the chemical
composition of the particles and their concentrations as
measured by their number and distribution by size (Trehy
etal. 2011; Ingebrethsen etal. 2012; Schripp etal. 2013;
Zhang etal. 2013; Fuoco etal. 2014; Ruprecht etal. 2014;
Saffari et al. 2014 ; Mikheev et al. 2016). E‑cigarettes
are recognized as a new source of submicron‑sized par‑
ticles, leading to possible high exposure to these parti‑
cles in users. Concentrations in the range of 10
9
particles
× cm
‑3
were measured in the mainstream of e‑cigarette
and colleagues (2013) found that under the conditions
of a single‑puff experiment, an e‑cigarette generated an
aerosol having particle sizes in the range of 100–600 nm
(nanometers), similar to that of conventional cigarettes.
Mikheev and colleagues (2016) reported that the size dis‑
tribution of e‑cigarette aerosol differs from that of com‑
bustible tobacco smoke and that e‑cigarettes normally
exhibit a bimodal particle size distribution: nanoparti‑
cles (11–25 nm count median diameter) and submicron
particles (96–175 nm count median diameter). Each
mode has comparable number concentrations
aerosols (Fuoco etal. 2014). An in vitro study by Zhang
(10
7
–10
8
particles/cm
3
). Goel and colleagues (2015) detected radi‑
cals in aerosols from all e‑cigarettes and e‑liquids tested
(2.5−10.3 x10
13
radicals per puff at 3.3V [voltage]), from
e‑liquid solvents PG and VG, and from “dry puffing” (over‑
heating of e‑liquid) (Farsalinos etal. 2015c).
Because the aerosols deriving from e‑liquids are
mainly made of droplets that are expected to dissolve as
they reach the lung’s epithelium, not only the number but
also the volume (size) of particles needs to be considered.
Manigrasso and colleagues (2015) found that e‑cigarettes
are a source of extremely high doses of particles in the
human respiratory system. On average, 6.25 ×10
10
par‑
ticles were deposited in the respiratory tree after a single
2‑second puff, an estimated 30% of the daily doses of par‑
ticles for a nonsmoking person. After 10 puffs, the relevant
mean‑layer thickness of the e‑liquid on the lung epithe‑
lium was comparable to the thickness of surfactant layer
covering the alveolar and bronchial regions, suggesting
a higher susceptibility to irritant endpoints (Manigrasso
etal. 2015). These results demonstrate that e‑cigarettes
produce submicron‑sized particles and highly oxidizing
free radicals that may present a potential toxicologic risk
to e‑cigarette users.
Aerosolized Flavorants
Little is known about the flavorants used in
e‑cigarettes, and more than 7,700 unique flavors are on
the market (Zhu etal. 2014b). Flavored e‑cigarette prod‑
ucts are popular with adult users, and sweet and candy‑
like flavors may make these products attractive to children
and adolescents (Villanti et al. 2013; Farley et al. 2014;
King etal. 2014). Many of the chemicals used in e‑liquid
flavorings are “generally recognized as safe” for ingesting
(e.g.,in food). However, these substances have not been
tested adequately for safety when heated at various tem‑
peratures when inhaled in aerosolized form (Barrington‑
Trimis etal. 2014). The Flavor and Extract Manufacturers
Association of the United States (2015), in an official state‑
ment, notes that ingredients in flavors are evaluated for
exposure through ingestion only; thus, any results cannot
be extrapolated to use through inhalation. Further, fla‑
voring compounds often remain undeclared on e‑cigarette
and e‑liquid packaging (Tierney etal. 2016).
CDC tested 36 e‑cigarette products for 10 flavor
compounds commonly used as additives in tobacco prod‑
ucts (Lisko etal. 2015). Measurable levels of eucalyptol and
pulegone were found in the menthol‑flavored varieties for
all manufacturers. Menthol concentrations ranged from
3,700 to 12,000 μg/g in flavored e‑liquids, levels similar
to those found in the filler of conventional cigarettes.
Interestingly, menthol was found at low concentrations in
40% of the tobacco‑flavored nonmenthol products tested.
Other flavor compounds found were camphor, methyl,
salicylate, pulegone, cinnamaldehyde (CAD), and eugenol
(Lisko etal. 2015).
Tierney and colleagues (2016) analyzed 30e‑cigarette
products on the U.S. market and found 13products con‑
tained more than 1% flavor chemicals by weight. Among
the chemicals identified were aldehydes (e.g., benzalde‑
hyde and vanillin), which are categorized as primary irri‑
tants of the respiratory tract (Roberts etal. 2015). Tierney
and colleagues (2016) also found that tobacco‑flavored
e‑liquids were derived from confection‑flavored chemicals
(e.g., bubble gum and cotton candy flavoring) rather than
tobacco extract.
A Report of the Surgeon General
116 Chapter 3
Some chemicals in e‑cigarettes, although approved
for ingestion, have established adverse health effects when
inhaled. In vitro studies of cytotoxicity suggest that dif‑
ferent flavored e‑cigarette products may vary in their
potential to adversely affect health. Bahl and colleagues
(2012) reported cytotoxic effects of the solutions used in
e‑cigarettes that were not attributable to the nicotine but
to the concentration of chemicals employed as flavors.
These effects were most pronounced on mouse neural
stem cells and human embryonic stem cells compared to
human pulmonary fibroblast (Bahl etal. 2012).
Similar findings were reported by Behar and col‑
leagues (2014) who found a greater cytotoxic effect
of flavored e‑liquid solutions on human embryonic
stem cells compared to human pulmonary fibroblast.
Further, two cinnamon‑related chemicals, CAD and
2‑methoxycinnamaldehyde, were particularly cytotoxic at
doses found in the refill liquids (Behar etal. 2014). CAD,
which is derived from the essential oil of cinnamon bark, is
a highly bioactive compound (Jayaprakasha and Rao 2011).
It has been used as an anticancer agent (Nagle etal. 2012),
an insecticide (Cheng etal. 2009), and a bactericide (Nostro
etal. 2012), and it is employed commercially as an additive
in many foods and fragrances (Cocchiara etal. 2005).
Farsalinos and colleagues (2014a) analyzed
159 e‑liquids obtained from a variety of manufacturers and
retailers in Europe and the United States for the presence
of two flavorings: diacetyl (DA) and acetyl propionyl (AP).
The study revealed that these substances were present in
the majority of the samples tested, with a significant pro‑
portion containing both chemicals. Furthermore, Allen and
colleagues (2016) detected DA above the laboratory limit
of detection in 39 of 51 flavors tested. DA, also known as
2, 3‑butanedione, is a member of a general class of organic
compounds referred to as diketones, α‑diketones, or
α‑dicarbonyls. It provides a characteristic buttery flavor,
is naturally found in various foods, and is used as a syn‑
thetic flavoring agent in food products such as butter, car‑
amel, cocoa, coffee, dairy products, and alcoholic beverages.
Although it is generally recognized as safe when ingested,
it has been associated with a decline in respiratory func‑
tion in persons exposed to it through inhalation (Egilman
etal. 2011; Clark and Winter 2015). Inhaling DA and arti‑
ficial butter‑flavored powders and aerosols can cause fixed
obstructive lung disease in exposed workers (Chaisson etal.
2010). In addition, it has been implicated in the develop‑
ment of bronchiolitis obliterans, an irreversible respiratory
disease also called “popcorn lung disease” (Harber et al.
2006). AP, also called 2, 3‑pentanedione, is a α‑diketone
that is chemically and structurally similar to DA. Although
it has become a popular replacement for DA, acute inhala‑
tion exposure to AP has been shown to cause airway epithe‑
lial damage similar to DA (Hubbs etal. 2012).
The analysis by Farsalinos and colleagues (2014a)
found that 74.2% of the sample contained one or both
of these chemicals, with 69.2% of the sample containing
DA. Both DA and AP were found in 28.3% of the sample
e‑liquids. These chemicals were detected even in samples
coming from manufacturers that stated these flavorings
were not present in their products. However, exposure
to DA and AP was 100 and 10 times lower, respectively,
than exposure to these chemicals from cigarette smoking.
Few studies have examined safe levels of DA and AP via
tobacco product; however, 47.3% of DA‑ and 41.5% of
AP‑containing samples exposed consumers to levels higher
than the safety limits outlined by the National Institute
for Occupational Safety (NIOSH) for occupational expo‑
sure. This exposure threshold outlined by NIOSH is not
intended to suggest exposure at or below that limit should
be considered sufficiently safe (Hubbs et al. 2015).
Aerosolized Adulterants
TSNAs, potent carcinogens identified in tobacco
and tobacco smoke, include N‑nitrosonornicotine (NNN),
4‑(methylnitrosamino)‑1‑(3‑pyridyl)‑1‑butanone (NNK),
N‑nitrosoanabasine (NAB), and N‑nitrosoanatabine
(NAT) (Hecht 1998, 1999; USDHHS 2010, 2014). NNN
and NNK are classified by the International Agency for
Research on Cancer (IARC) as Group 1 human carcino‑
gens (IARC 2004). Their presence in e‑liquids is mostly
attributable to the processes used in extracting nicotine
from tobacco leaves or the addition of tobacco flavorings
(Kim and Shin 2013; Cheng 2014). These compounds are
formed from their alkaloid precursors and from nitrite or
nitrate, predominantly during tobacco curing, fermen‑
tation, and aging. NNN, NAB, and NAT are formed pri‑
marily from their corresponding secondary amines (nor‑
nicotine, anatabine, and anabasine) in the early stages of
tobacco curing and processing, while the majority of NNK
is formed from the tertiary amine nicotine at the later
stages of tobacco curing and fermentation (Hecht 1998).
Nitrosation reactions of corresponding amines can occur
in e‑liquids, especially during inadequate storage or man‑
ufacturing processes; inadequate storage is believed to
increase the levels of NNN as a consequence of the nitro‑
sation of nornicotine converted from nicotine in liquids
(Kim and Shin 2013).
Some studies have identified traces of TSNAs in
e‑liquids, but at levels far below those seen in combustible
tobacco (Trehy etal. 2011; Farsalinos etal. 2015a). Further,
Goniewicz and colleagues (2014b) found that the aerosol of
some e‑cigarettes contains traces of the carcinogenic nitro‑
samines NNN and NNK, but neither was detected in aerosol
from the Nicorette inhalator (an NRT product).
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 117
E-Cigarette Use Among Youth and Young Adults
Several studies have reported the presence of other
hazardous compounds in e‑liquids or in the aerosol pro‑
duced by e‑cigarettes (Exponent Inc. 2009; Hadwiger etal.
2010; Lim and Shin 2013; Uchiyama etal. 2013; Williams
et al. 2013; Bekki et al. 2014; Goniewicz et al. 2014a,b;
Kosmider etal. 2014; Jensen etal. 2015; Kavvalakis etal.
2015; Laugesen 2015; Oh and Shin 2015; Varlet etal. 2015;
Khlystov and Samburova 2016). For example, an FDA study
detected the presence of amino‑tadalafil and rimonabant in
e‑liquids (Hadwiger etal. 2010); amino‑tadalafil is a struc‑
tural analogue of tadalafil, the active pharmaceutical ingre‑
dient in Cialis, aprescription drug approved in the United
States for treatment of erectile dysfunction. Rimonabant
(trade name Zimulti) was approved in Europe for the treat‑
ment of obesity, but its marketing authorization was with‑
drawn by the European Medicines Agency in 2009. FDA
approval of this drug has been withheld because of unre‑
solved issues involving rimonabant therapy and increased
frequencies of psychiatric adverse events, including suicide
and an ill‑defined constellation of neurologic symptoms
and seizures (FDA 2007). The presence of unapproved active
pharmaceutical ingredients suggests that some e‑cigarettes
may expose users to pharmacologically active substances
with undocumented and unknown effects.
Oh and Shin (2015) conducted a study to identify
and quantify the presence of diethyl phthalate (DEP) and
diethylhexyl phthalate (DEHP) in e‑liquids. DEP is used
as a solvent to bind cosmetics and fragrances and in var‑
ious industrial applications, including plasticizers, deter‑
gent bases, and aerosol sprays. DEHP is used widely as a
plasticizer in the manufacture of articles made of poly‑
vinylchloride. DEP and DEHP were detected in 47.6%and
79.1% of e‑liquids, respectively, with concentration
ranges of 0.01–1745.20 mg/L and 0.06–81.89 mg/L (Oh
and Shin 2015). Both DEP and DEHP have estrogenic
and antiandrogenic activity that cause premature breast
development in girls. DEHP is classified by IARC as a pos‑
sible carcinogen in humans (IARC 2000). Although the
amounts of the two phthalates detected in this study were
lower than the safety levels, the source of these toxicants
is unknown, perhaps coming from packaging materials
and the production procedure.
Carbonyls are present in e‑cigarettes, and levels
increase with device voltage (Kosmider et al. 2014;
Jensen et al. 2015). Long‑term exposure to carbonyl
compounds, such as formaldehyde, acetaldehyde, and
acrolein, increases the risk of cancer. IARC and the U.S.
Environmental Protection Agency (EPA) have classified
formaldehyde as “carcinogenic to humans” (USDHHS
1999; IARC 2009). EPA has set the acceptable daily intake
(ADI) of formaldehyde as 0.2 mg/kg (kilograms) body
weight and has warned of the potential adverse health
effects of exceeding ADI. Acetaldehyde is also toxic, an
irritant, and a probable carcinogen (USDHHS 1999).
Acrolein is toxic through all routes of administration and
may cause respiratory and ocular irritation (Faroon etal.
2008; Bein and Leikauf 2011). Acrolein in cigarette smoke
has been linked to several pulmonary diseases, including
increased risk of lung cancer (Feng et al. 2006), as well
as asthma and chronic obstructive pulmonary disease
(Bein and Leikauf 2011). One study found an association
between acrolein exposure and risk of cardiovascular dis‑
ease (DeJarnett et al. 2014).
Lim and Shin (2013) detected formaldehyde and
acetaldehyde in 225 replacement liquids for e‑cigarettes
purchased in Korea, with ranges of 0.02–10.09 mg/L (mean
2.16 mg/L) and 0.10–15.63 mg/L (mean = 4.98 mg/L).
Although the amounts of formaldehyde and acetalde‑
hyde detected in replacement liquids for e‑cigarettes are
relatively low compared to conventional cigarettes, they
should be controlled to the lowest possible concentrations
in raw materials, as they may be formed when e‑liquids
are heated. Furthermore, as larger capacity batteries
and heating mechanisms are developed (Farsalinos etal.
2014b; Sleiman et al. 2016), users will be exposed to higher
concentrations of formaldehyde, acetaldehyde, acro‑
lein, and other carbonyls (Kosmider etal. 2014). Jensen
and colleagues (2015) reported formaldehyde concentra‑
tions higher than conventional cigarettes in high‑voltage
e‑cigarettes. Havel and colleagues (2016) reported acetal‑
dehyde, acrolein, and formaldehyde generation increased
markedly at voltages at or above 5 volts. Geiss and col‑
leagues (2016) reported that formaldehyde exceeded safety
levels at the lowest wattage (5 watts), which is the wattage
applied in most second generation e‑cigarettes.
Summary
Although some typical constituents of the e‑cigarette
aerosol have been identified, the potential short‑ and long‑
term health consequences of inhalation of the heated and
aerosolized constituents of the e‑liquids, including solvents,
flavorants, and toxicants, still require further investigation
to quantify health effects. Commercial and custom‑mixed
e‑liquids are produced with undisclosed manufacturing
procedures, packaging materials, and purity standards for
their constituents, increasing the risks of potential health
consequences. E‑cigarettes are a source of extremely high
doses of fine particles (e.g., aerosol) in the human respira‑
tory system. Fine particles are emitted when the solvents
PG and VG are aerosolized, and mild respiratory effects have
been documented, but adequate assessments are lacking.
An additional concern is the aerosolization and inhalation
of flavor additives in e‑liquids. While some of the chemicals
used may be generally recognized as safe for use in foods,
they have not been thoroughly tested for their potential
A Report of the Surgeon General
118 Chapter 3
sensitizing, toxic, or irritating characteristics when inhaled.
Further, given the extent of possible variations in the ratio
of flavor additives, with up to 7,700 unique e‑liquid vari‑
eties available (Zhu et al. 2014b), these chemicals may be
toxic in the concentrations present in manufactured or
do‑it‑yourself e‑liquids. Finally, other hazardous com‑
pounds and carcinogens have been detected in e‑liquids, or
in the heated aerosol produced by e‑cigarettes, including
formaldehyde, acetaldehyde, and acrolein.
Effects of Toxicants Produced
During Aerosolization
A primary reason for investigating the health effects
of heated and aerosolized e‑liquids is that, under such con‑
ditions, chemical reactions may result in the formation of
new compounds (Sleiman et al. 2016). In some devices,
the temperature in the center of a heating coil can exceed
350°C, causing changes in the chemical components of
the e‑liquid. When carbonyl compounds are present in the
refill liquids, heating can enhance their concentrations in
the aerosol (Talih etal. 2015). Carbonyl compounds result
from dehydration and fragmentation of VG and PG, which
can be oxidized to formaldehyde and acetaldehyde during
heating. Hutzler and colleagues (2014) applied headspace
gas chromatography‑mass spectrometry to enable incuba‑
tion of liquids at various temperatures. At 150°C, the levels
of acetaldehyde and formaldehyde were found to be up to
10‑fold higher than they were at ambient temperatures for
samples in which PG was a main component. The gen‑
eration of carbonyl compounds seems to increase when
liquids touch the heating element inside an e‑cigarette,
which is indicated by a color change around the wire, as
has been reported in some devices (Uchiyama etal. 2013).
Evidence suggests when e‑liquid touches the heating ele‑
ment (heated nichrome wire), it is oxidized to formalde‑
hyde, acetaldehyde, acrolein, glyoxal, and methylglyoxal
in the presence of oxygen (Bekki etal. 2014; Goniewicz
etal. 2014b; Kosmider etal. 2014).
Several studies have reported that short‑chain alde‑
hydes, such as formaldehyde, acetaldehyde, or acrolein, are
produced during heating. Uchiyama and colleagues (2013)
measured carbonyl compounds in e‑cigarette aerosols
generated according to the Canadian “intense regimen”
(55mL puff volume, 2‑second puff duration, 30 seconds
between puffs, and a total of 10 puffs). Thirteen brands of
e‑cigarettes were assessed, and investigators detected sev‑
eral carbonyl compounds, such as formaldehyde, acetal‑
dehyde, acetone, acrolein, propanol, crotonaldehyde, and
butanol. They also detected two other harmful carbonyl
compounds that had not been detected in the mainstream
smoke from conventional cigarettes: glyoxal and methyl‑
glyoxal. Jensen and colleagues (2015) observed that form‑
aldehyde‑containing hemiacetals can be formed during
the aerosolization process. These molecules are known to
release formaldehyde and are used as industrial biocides,
but it is not currently known how formaldehyde‑releasing
agents affect the respiratory tract.
The amount of carbonyl compounds in e‑cigarette
aerosols varies substantially, not only among different
brands but also among different samples of the same prod‑
ucts (Ohta etal. 2011; Bekki etal. 2014; Kosmider etal.
2014; Jensen etal. 2015), from 100‑fold less than tobacco
to nearly equivalent values. Notably, the amount of voltage
the battery puts out affects the concentration of the car‑
bonyl compounds in the emission. Some e‑cigarettes allow
users to increase aerosol production and nicotine delivery
by raising the battery’s output voltage. In addition, some
users elect to directly drip e‑liquid onto an exposed heater
coil, reportedly for greater aerosol production and “throat
hit.” Talih and colleagues (2015) showed that use of such
direct‑drip atomizers may involve greater exposure to
toxic carbonyls, including formaldehyde, because of the
potentially higher temperatures reached by the coil. The
adverse effects of acrolein (2‑propenal), an unsaturated
aldehyde, depend on dose and cell type and are influenced
by experimental conditions (Bein and Leikauf 2011). In
vitro studies found that acrolein inhibits DNA repair and
forms acrolein‑deoxyguanosine DNA adducts that are
mutagenic (Wang et al. 2009, 2012; Tang et al. 2011).
Despite the known DNA‑damaging effects of acrolein, its
mutagenicity in mammalian cells remains uncertain, and
according to an evaluation by the IARC, there is inade‑
quate evidence for carcinogenicity in humans or animals
(IARC 1995). Because of its extreme toxicity, acrolein has
been difficult to characterize in standard animal carcino‑
genicity tests. Animal experiments showed that acrolein
can have a range of adverse effects, including a role in car‑
cinogenesis (Cohen etal. 1992); excessive mucus produc‑
tion and macrophage and neutrophil accumulation with
consequent production of proinflammatory cytokines and
proteases (Moretto et al. 2012); damage to neurons and
myelin disruption (Shi etal. 2011); and it may play a role
in the progression of atherosclerosis and cardiovascular
disease (Park and Taniguchi 2008; DeJarnett etal. 2014).
Other volatile organic compounds (VOCs) found
in e‑cigarette aerosol include a variety of chemicals
(e.g., aliphatic and aromatic hydrocarbons), some of
which may have short‑ or long‑term adverse health
effects. Benzene (classified as group 1 by IARC) and other
solvents (toluene, xylenes, and styrene) could be present
in e‑cigarettes because of their use in the extraction of
nicotine from tobacco leaves. Goniewicz and colleagues
(2014b) detected both toluene and m‑ and p‑xylene in
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 119
E-Cigarette Use Among Youth and Young Adults
e‑cigarette aerosols. A wide variety of other VOCs in
e‑cigarette liquids produce aromas and flavor through
heating (Tierney etal. 2016).
Heavy metals such as tin, lead, and nickel were dis‑
covered by Williams and colleagues (2013) in a brand of
e‑liquids and the resulting aerosols. Those researchers
analyzed the contents of e‑cigarette cartomizers (a poly‑
fill wrapped heating coil capable of longer puff durations
than an atomizer) and the aerosols by using light and elec‑
tron microscopy, x‑ray microanalysis, particle counting,
and inductively coupled plasma optical emission spec‑
trometry. The aerosol contained particles >1 µm that were
composed of tin, silver, iron, nickel, aluminum, and sili‑
cate, and nanoparticles (<100 nm) of tin, chromium, and
nickel. Small particles composed of various elements (tin,
other metals, semimetals, and silicates) passed through
the cartomizer fibers and were present in aerosols.
These particles likely originated from parts of the device
(i.e.,atomizer/cartomizer) (Williams etal. 2013).
Concentrations of 9 of the 11 elements in e‑cigarette
aerosol identified by Williams and colleagues (2013)
were higher than or equal to concentrations in conven‑
tional cigarette smoke. Many of the metals identified in
e‑cigarette aerosol, such as lead and cadmium (Farsalinos
etal. 2015b), are known to cause respiratory distress and
disease (Zalups and Ahmad 2003). These metals are pro‑
duced by the aerosolization of e‑liquids (Farsalinos etal.
2015b) and by flaws in e‑cigarette heating mechanisms
and poor quality control (Williams etal. 2013; Farsalinos
etal. 2015b; Mikheev et al. 2016). While these initial anal‑
yses indicate potential exposures, additional measures are
needed because of challenges in measuring trace levels of
metals.
Summary
E‑liquids produce chemical reactions that may result
in the formation of new, harmful compounds. Carcinogens
(e.g., formaldehyde, acetaldehyde, and acrolein) and toxic
heavy metals (e.g., lead and cadmium) have been found
in e‑cigarette aerosols in laboratory tests conducted at
temperatures within the range of most e‑cigarette prod‑
ucts. These chemicals and metals have been detected in
e‑liquids and e‑cigarette aerosols, signifying the need for
further study on the potential short‑ and long‑term health
ramifications.
A limitation to understanding the health impact
of chemical reactions is the heterogeneity of e‑cigarette
devices (e.g., voltage), e‑liquids (e.g., quality, content),
and use behaviors (e.g., puff duration), as emissions
may be altered by any combination of these mechanical
and behavioral differences. Further, it is difficult to fully
contextualize the carcinogenic emissions of e‑cigarette
aerosol given the diversity of products currently available,
as well as those that may become available as the devices
continue to evolve (Farsalinos etal. 2014b).
Effects Not Involving Inhalation of
Aerosol by the E‑Cigarette User
Health effects not attributable to direct inhalation
of e‑cigarette aerosol include explosion or fire associ‑
ated with malfunctioned devices, poisoning through con‑
tact exposure or intentional or unintentional ingestion
of e‑liquid, and exposure to secondhand aerosol or its
condensate.
Health Effects Attributable to Explosions and
Fires Caused by E‑Cigarettes
Most reports of explosions and fires caused by
e‑cigarettes have appeared in print and online media and
on televised programs. From August 2009 to March 2014, a
search of U.S. media by the U.S. Fire Administration (2014)
found 25 reports of e‑cigarette explosions or fires. These
data suggest that the number of such events is small when
compared with the number of e‑cigarette users. Of the
25incidents found in the search, 2 caused serious harm,
and there were no deaths attributable to explosions. In most
cases, the resulting fires did not spread far from the site of
the explosion. However, in one case an entire bedroom was
lost to fire (U.S. Fire Administration 2014). As for explo‑
sions, several have occurred during an e‑cigarette’s use,
causing severe facial damage or injuries to bodies and hands
(Brennan 2015; Corona and Marcus 2015; Duranty 2015;
Fox 5 Digital Team 2015; Goff and Schwartz 2015; Jablow
and Sexton 2015; Shastry and Langdorf 2016), but most
occurred while the device’s batteries were being charged.
Overcharging lithium batteries can lead to thermal run‑
away, causing the e‑cigarette battery or container to be
propelled, often with portions catching fire (U.S. Fire
Administration 2014; Bohr et al. in press).
Health Effects Caused by Ingestion of E‑Cigarette
Liquids
The liquids in both e‑cigarettes and the con‑
tainers used to refill them can cause nicotine poisoning.
Consequences of nicotine intoxication in the e‑liquid
include nausea, vomiting, headaches, dizziness, and diar‑
rhea at low doses; seizures; tachycardia; abdominal pain;
confusion; and even death (Cervellin et al. 2013). The
amount of nicotine needed to cause death in humans is
uncertain and, according to a reevaluation, may be higher
than previously thought (Mayer 2014). The total amount
A Report of the Surgeon General
120 Chapter 3
of nicotine in refill liquids varies and can be as high as
1,000 mg/10 mL in do‑it‑yourself bottles (Davis et al.
2015), which could be lethal if consumed (Mayer 2014).
The increase in poisonings prompted enactment of
the Child Nicotine Poisoning Prevention Act of 2015 (2016)
in January 2016. This law requires any container of liquid
nicotine sold, manufactured, distributed, or imported
into the United States be placed in special packaging
that is difficult to open by children under 5 years of age.
Although labels may indicate the concentrations of nico‑
tine, such labels can be incomplete, confusing, or inaccu‑
rate (Trtchounian and Talbot 2011; Cameron etal. 2014),
and some bottles have not been labeled at all (Davis etal.
2015). Of most concern, some bottles of e‑cigarette refill
liquids labeled “no nicotine” have been found to contain
significant amounts of that substance (e.g., 25.6 mg/mL;
Trehy etal. 2011). Regardless, many e‑cigarette users may
not be aware of the toxic effects of nicotine and may not
know that refill liquids should be kept away from toddlers
and children. These liquids are often sold in colorful bot‑
tles with flavors that are attractive to children (Bahl etal.
2012). The liquids usually come in small dropper bottles
that can be mistaken for bottles containing food dye or eye
drops. Finally, many refill liquids are made in local “vape
shops,” which have only recently come under FDA regu‑
lation (Federal Register 2016), with no uniform training
process for mixers, a lack of standards and protections,
and unknown concentrations of nicotine.
The rapid growth in popularity of e‑cigarettes and
the ease with which refill liquids can be purchased have
made e‑cigarettes an increasingly common item in many
households, thereby elevating the possibility of accidental
nicotine poisoning. Instances of related case reports, often
involving children or infants, are increasing. For example,
an 18‑month‑old girl was treated at an emergency room
for hypertension and tachycardia after drinking about
2mL of refill liquid from a bottle on a nightstand (Shawn
and Nelson 2013). Unintentional exposure to nicotine
can occur through ingestion, absorption through the
skin, inhalation, or dropping refill liquids into one’s eyes
(Cantrell 2014).
Figure 3.2 shows data from 2011 to 2016 on expo‑
sures to e‑cigarettes or liquid nicotine (i.e., any con‑
tact with e‑cigarettes or liquid nicotine, not necessarily
resulting in any health effects) (American Association of
Poison Control Centers 2016). These data show a dramatic
increase in exposures through 2014 with a slight reduc‑
tion of exposures in 2015. Fifty‑one percent of the calls to
poison control centers regarding exposures to e‑cigarettes
involved children 5 years of age or younger (CDC 2014).
Increased e‑cigarette exposures have also been reported by
state and local poison centers (Banerji etal. 2014; Cantrell
2014; Guttenburg etal. 2014; Lee etal. 2014; California
Department of Public Health 2015).
Secondhand Exposure to the
Constituents of E‑Cigarette Aerosol
Exposure to secondhand smoke from combustible
tobacco products is a known cause of morbidity and mor‑
tality (USDHHS 2006). Secondhand smoke, a mixture of
the sidestream smoke from a smoldering cigarette and the
mainstream smoke exhaled by a smoker, is known to con‑
taminate both indoor and outdoor environments. In addi‑
tion, when the constituents of smoke deposit on surfaces,
nonsmokers can be exposed to them via touch, ingestion,
or inhalation. These deposited constituents of combustible
smoke are known as “thirdhand smoke” (Matt etal. 2011;
Protano and Vitali 2011). E‑cigarettes represent another
potential source of exposure to toxicants for nonusers, via
secondhand or thirdhand exposure to aerosol.
Exposure to Nonusers
In contrast to combustible tobacco products,
e‑cigarettes do not produce sidestream emissions; aerosol
is produced during activation of the device. Some of this
aerosol is subsequently exhaled into the environment
where nonusers may be exposed through inhalation, inges‑
tion, or dermal contact. As previously described in this
chapter, constituents of the emissions may include nico‑
tine, carbonyl compounds, VOCs, polyaromatic hydro‑
carbons, TSNAs, heavy metals, and glycols. It is not clear
how much of inhaled e‑cigarette aerosol is exhaled into
the environment where nonusers can be exposed. Some
studies have used machines to produce e‑cigarette aero‑
sols and measured the pollutants emitted (McAuley etal.
2012; Czogala et al. 2014; Geiss et al. 2015); others have
involved the use by one or more persons of an e‑cigarette
and measured the change in pollutants in either a room
or a test chamber after use (Schripp etal. 2013; Schober
etal. 2014). One study measured airborne nicotine in the
homes of e‑cigarette users (Ballbe etal. 2014). The concen‑
tration of e‑cigarette aerosol in a given microenvironment
depends primarily on the strength of the source or the
number of e‑cigarettes used and the emission rate of the
aerosol for that device. E‑cigarettes, however, are heteroge‑
neous in their design and in the liquids used, and the spe‑
cific product combination significantly affects the second‑
hand emissions (Kosmider etal. 2014; Geiss et al. 2015).
The number of puffs and depth of inhalation may be partic‑
ularly relevant to the amount exhaled by the user and may
also affect e‑cigarette emissions (Talih etal. 2016).
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 121
E-Cigarette Use Among Youth and Young Adults
Figure 3.2 Data showing exponential increase in the number of cases of human exposure to e‑cigarette products and
liquid nicotine between 2011 and 2016
Source: American Association of Poison Control Centers (2016).
Note: These numbers reflect the closed human exposures to e‑cigarettes and liquid nicotine reported to poison centers as of July 31,
2016. The numbers may change as cases are closed and additional information is received.
Movement of E‑Cigarette Aerosol
Similar to the case with secondhand tobacco smoke,
e‑cigarette aerosol is an inherently dynamic mixture that
changes over time in terms of constituents and concen‑
trations. Czogala and colleagues (2014) demonstrated a
significant signal from a laser photometer indicating the
presence of ambient aerosol in a room after e‑cigarette
use. However, this aerosol disappeared in just seconds
to a few minutes as it either evaporated to the gas phase
or deposited on surfaces in the room. In contrast, in the
same study, secondhand cigarette smoke exhibited a par‑
ticulate phase that stayed suspended in the room at high
concentrations for more than 30 minutes. For the VOCs
in e‑cigarette aerosol, such as formaldehyde, acrolein, and
acetaldehyde, the source strength and ventilation rate will
largely determine their concentration in indoor air. Semi‑
VOCs, such as nicotine and TSNAs, are also largely affected
by sorption on and subsequent desorption from surfaces
and dust in a room (Singer etal. 2002, 2003; Goniewicz
and Lee 2015). The extent of this type of thirdhand con‑
tamination from e‑cigarettes in real‑world settings has
not been established but would be of particular concern
for children living in homes of e‑cigarette users, as they
spend more time indoors, are in proximity to and engage
in greater activity in areas where dust collects and may be
resuspended (e.g., carpets on the floor), and insert non‑
food items in their mouths more frequently (EPA 2008;
Matt etal. 2011).
Exposure to E‑Cigarette Aerosol and
Considerations of Dose
A large body of studies has measured exposure to
secondhand and thirdhand smoke from conventional
cigarettes using personal or area air monitoring, sur‑
face testing, and dust testing. Studies of the exposure
of e‑cigarette aerosol to nonusers, however, are limited.
Schripp and colleagues (2013) observed small increases of
fine and ultrafine particles and some VOCs, including PG,
A Report of the Surgeon General
122 Chapter 3
flavoring substances, and nicotine, indicating passive inha‑
lation of e‑cigarette aerosols by nonusers in the presence
of e‑cigarette users. Those authors demonstrated that the
distribution in the sizes of the aerosol’s component par‑
ticles changes in the lungs and results in the exhalation of
smaller particles, likely caused by the evaporation of the
liquid particles in the lungs and in the environment after
exhalation. Schober and colleagues (2014) found substan‑
tially higher amounts of PG, VG, particulate matter (PM),
and nicotine in a 45‑m
3
chamber during e‑cigarette use
sessions with volunteers compared to controlled sessions.
They also found a 20% increase in the level of polycyclic
aromatic hydrocarbons (PAHs) and a 2.4‑fold increase in
aluminum concentrations.
Williams and colleagues (2013) demonstrated con‑
tamination by metal and silicate particles in e‑liquid
and its aerosol using scanning electron microscopy. In
a different study measuring machine‑generated second‑
hand e‑cigarette aerosol in an emission chamber, Geiss
and colleagues (2015) found significant levels of PG, VG,
and nicotine in the chamber’s air. Carbonyl compounds
of concern (e.g., formaldehyde, acetaldehyde, acrolein,
and acetone) were below the limits of detection in this
study. O’Connell and colleagues (2015), who assessed
secondhand e‑cigarette emissions in a small meeting
room (12.8 m
2
) with three e‑cigarette users during a
165‑minute session, found a significant increase in PG but
did not see the expected increase in VG or nicotine. This
study reported no increase in PAHs, trace metals, TSNAs,
or acrolein, but did find an increase in total VOCs, formal‑
dehyde, and acetaldehyde. However, the compounds were
found at levels below guidelines for the quality of indoor
air from the World Health Organization or European
Union. Ruprecht and colleagues (2014) found signifi‑
cantly lower concentrations and counts for particles from
an e‑cigarette used in a 50‑m
3
room compared with con‑
ventional cigarettes. Interestingly, they also found that
nicotine‑free e‑cigarettes produced higher particle levels
than e‑cigarettes containing nicotine. Saffari and col‑
leagues (2014) found that total particulate exposure was
10‑fold lower in e‑cigarettes than it was in conventional
cigarettes. Emissions of heavy metals from e‑cigarettes
were also dramatically less, with the exception of nickel,
zinc sulfide, and silver, which showed higher emission
rates from e‑cigarettes. PAH levels were not elevated by
e‑cigarette use in this study.
Concentrations of PM, especially PM
2.5
, which is
fine PM, and nicotine are the two most common markers
used to measure exposure to secondhand smoke (Avila‑
Tang etal. 2010; Apelberg etal. 2013). Indirect measures
of the mass concentration of PM from secondhand smoke
using real‑time particle monitors are well validated in
terms of the accuracy of these measurements in relation
to other constituents of secondhand smoke and to health
effects (Hyland et al. 2008; Apelberg et al. 2013). These
same types of particle monitors are often used in studies
of e‑cigarette aerosol to compare PM levels from conven‑
tional cigarettes with those from e‑cigarettes, though PM
findings may not directly relate to the short‑ and long‑
term health effects of each product (Czogala etal. 2014;
Schober etal. 2014).
Caution is warranted when interpreting the results
of PM measurements comparing e‑cigarettes with conven‑
tional cigarettes. The aerosols produced are fundamentally
different, with the former resulting from aerosolization of
liquid and the latter resulting from combustion of organic
matter. The true PM
2.5
mass concentration of e‑cigarette
aerosol from commonly used light‑scattering instruments
(Czogala etal. 2014) cannot be determined without cali‑
brating the device to a reference standard for the aerosol
in question. Even this calibration would be questionable
given the highly volatile nature of e‑cigarette aerosol,
making it difficult to capture and accurately determine
the mass. Real‑time PM
2.5
measurements such as this are
useful, however, to determine the presence of an aerosol
and to see the relative changes in this aerosol over time
and under various conditions, such as changing source
strength. Figure 3.3 shows the significant increase in
aerosol concentration from e‑cigarettes after about 1hour
and the subsequent rapid decline, presumably from initial
aerosolization and deposition of this aerosol. There may
still be significant amounts of this e‑cigarette aerosol in
the environment, but the particle monitor can no longer
measure it, as it is either in the aerosol phase or deposited
on surfaces. For these reasons, it is important not to rely
solely on PM mass concentrations for determining expo‑
sure to e‑cigarette aerosol and for making comparisons
with conventional cigarettes. Measurement of the indi‑
vidual toxicants of concern in the aerosol phase and on
surfaces is warranted.
Health Effects of Secondhand Exposure to
E‑Cigarette Aerosols
Flouris and colleagues (2012, 2013) conducted two
clinical studies of the health effects of secondhand exposure
to e‑cigarette aerosol. The researchers found no short‑term
change in markers of complete blood count after 1 hour
of exposure to e‑cigarette aerosol in a group of 15 non‑
smokers (Flouris etal. 2012). Similarly, the same exposure
caused no significant change in short‑term lung function,
although the results were of borderline statistical signifi‑
cance (Flouris et al. 2013). However, these studies dem‑
onstrated that passive exposure to e‑cigarettes causes an
increase in serum cotinine that is similar to that from pas‑
sive exposure to cigarette smoke, suggesting the need to
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 123
E-Cigarette Use Among Youth and Young Adults
examine the impact of passive aerosolized nicotine inha‑
lation on long‑term lung function. Furthermore, limited
effects would likely occur in the short exposure observed
through the methodologies used by Flouris and colleagues
(2012, 2013), as these studies did not account for prolonged
and persistent passive exposure to e‑cigarette aerosols.
Figure 3.3 Changes in aerosol particle PM
2.5
concentrations during experiment of e‑cigarette use and tobacco
cigarette smoking in an exposure chamber
Source: Czogala et al. (2014).
Note: PM = particulate matter.
Several researchers have modeled the health risks
of passive exposure to e‑cigarettes (Colard etal. 2015) on
the basis of the limited exposure data available and have
come to various conclusions. Offermann (2015) concluded
that, for indirect exposure, two chemicals—nicotine and
PG—exceeded California EPA exposure level standards for
noncarcinogenic health effects. Burstyn (2014), who com‑
pared e‑cigarette aerosol exposure to workplace exposure
standards, concluded that only PG and VG warrant atten‑
tion in e‑cigarette users while, for bystanders, none of the
constituents of e‑cigarette aerosol pose apparent concern. It
is important to note that standards for workplace exposure
are typically not appropriate to apply to the population as a
whole, as they are intended for a healthy working popula‑
tion during a typical work day, not accounting for the risks
to children, pregnant women, or those with preexisting
health conditions. Further, standards for workplace expo‑
sure are very different in concentration and duration than
what is to be expected from e‑cigarette use.
An additional consideration for regulating e‑cigarettes
in indoor environments is the potential for allergic reactions
in nonusers. Dermal and oral PG exposures are known causes
of dermatitis and allergic sensitization (Warshaw etal. 2009;
Al Jasser et al. 2011). Several e‑liquids contain flavorants
derived from nuts and in fact have labels cautioning persons
who have nut allergies not to use these products. Research
has not evaluated whether nonusers can have allergic reac‑
tions from these potential allergens in e‑cigarette aerosol,
but this is a risk that should be explored as 8% of U.S. chil‑
dren have food allergies (Gupta etal. 2011).
A Report of the Surgeon General
124 Chapter 3
Evidence Summary
E‑cigarette use among youth and young adults in the
United States has increased considerably in recent years (see
Chapter 2). There is little doubt that the use of e‑cigarettes
by youth and young adults represents self‑administration
of the drug nicotine, and this self‑administration of nic‑
otine puts youth at risk for addiction and many related
harmful consequences. Animal research indicates adoles‑
cent brains are particularly sensitive to nicotine’s effects,
such that subsequent self‑administration is more likely,
and that same literature indicates that this age group is
at risk for a constellation of nicotine‑induced neural and
behavioral alterations. Studies of the effects of maternal
smoking of conventional cigarettes during pregnancy,
coupled with preclinical literature examining the effects
of maternal self‑administration of nicotine during preg‑
nancy, suggest that e‑cigarette use by mothers during
pregnancy presents a wide variety of risks to fetal, infant,
and child brain development.
Users of e‑cigarettes risk respiratory exposure to a
variety of aerosolized chemicals, including solvents and fla‑
vorants added intentionally to e‑liquids, adulterants added
unintentionally, and other toxicants produced during the
heating/aerosolization process. The health impacts of fre‑
quent exposure to the toxicants in e‑cigarette aerosol
are not well understood, though several are known car‑
cinogens. As highlighted previously in this chapter, the
detection and level of these carcinogens depend on several
factors, including the concentration of the e‑liquid and the
strength of the heating device. Although e‑cigarettes have
been used as a cessation device, the evidence supporting the
effectiveness of e‑cigarettes as an aid for quitting conven‑
tional cigarettes remains extremely weak for adults (Bullen
et al. 2013; Caponnetto et al. 2013; Grana et al. 2014;
Kalkhoran and Glantz 2016) and untested and nonexistent
among youth.
Further research is warranted to focus on the
characteristics of e‑cigarette devices, the constituents
of e‑liquids, and the user behaviors that can influence
the yield of nicotine and other toxicants (Shihadeh and
Eissenberg 2015). This close focus includes providing
details of devices (e.g.,voltage of the power supply, heating
element resistance) and components of e‑liquids (e.g.,pro‑
pylene glycol, vegetable glycerin, other additives), and
measuring user puff topography. Standardization of pro‑
cedures for producing and delivering the aerosol is likely a
necessary component of at least some in vivo and in vitro
work. Preclinical work examining the effects of e‑cigarette
aerosols is a clear research need and, again, the standard‑
ization of procedures for production and delivery of the
aerosol is necessary. To enhance relevance, the parameters
of aerosol production should span the range of those seen
with humans (Shihadeh and Eissenberg 2011).
The huge variety of products of different origin and
design, the rapid emergence of new products, and the
varied ways in which consumers use these products make
the development of standard measurement conditions
challenging (Famele etal. 2015). Accordingly, research is
needed to understand how different design features relate
to potential toxicity—for example, if the compounds in
e‑cigarettes are affected by heating, changes in chemical
composition, or pH; if these compounds are absorbed into
the bloodstream; and how additives to the e‑liquid affect
the bioavailability of these compounds, among other con‑
siderations. Research is also needed to understand whether
potential health risks may be ameliorated by changes in
product engineering.
Health Effects of E-Cigarette Use Among U.S. Youth and Young Adults 125
E-Cigarette Use Among Youth and Young Adults
Conclusions
1. Nicotine exposure during adolescence can cause addic‑
tion and can harm the developing adolescent brain.
2. Nicotine can cross the placenta and has known effects
on fetal and postnatal development. Therefore, nico‑
tine delivered by e‑cigarettes during pregnancy can
result in multiple adverse consequences, including
sudden infant death syndrome, and could result in
altered corpus callosum, deficits in auditory pro‑
cessing, and obesity.
3. E‑cigarettes can expose users to several chemicals,
including nicotine, carbonyl compounds, and vol‑
atile organic compounds, known to have adverse
health effects. The health effects and potentially
harmful doses of heated and aerosolized constituents
of e‑cigarette liquids, including solvents, flavorants,
and toxicants, are not completely understood.
4. E‑cigarette aerosol is not harmless “water vapor,”
although it generally contains fewer toxicants than
combustible tobacco products.
5. Ingestion of e‑cigarette liquids containing nicotine
can cause acute toxicity and possibly death if the
contents of refill cartridges or bottles containing
nicotine are consumed.
A Report of the Surgeon General
126 Chapter 3
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147
Chapter 4
Activities of the E-Cigarette Companies
Introduction 149
Manufacturing and Price 149
Overview of the E-Cigarette Market in the United States 149
Distribution and Purchase Channels 149
Product Evolution 151
Evolution of Market Share in the E-Cigarette Market 152
E-Cigarette Sales in Tracked Retail Outlets 152
Production of E-Liquids 154
Impact of E-Cigarette Price on Sales and Use of These Products 155
Trends in E-Cigarette Prices over Time 155
Impact of E-Cigarette Prices on E-Cigarette Sales 156
Marketing and Promotion of E-Cigarettes 157
Marketing Expenditures 157
Magazine and Print Advertising 158
Television Advertising to Youth and Young Adults 159
Sponsorships 159
Digital Landscape for E-Cigarettes 163
E-Cigarettes in the Retail Environment 167
Conventional Tobacco Retailers (Convenience Stores, Pharmacies, Tobacco Shops) 167
“Vape Shops” 168
Exposure and Receptivity to Advertising for E-Cigarettes 169
Exposure 169
Receptivity to Advertising 169
Effect of E-Cigarette Advertising on Behavior 170
Associations with E-Cigarette Use and Intentions to Use 170
Associations with Knowledge, Risk Perceptions, and Other Attitudes 171
Evidence Summary 172
Conclusions 172
References 173
Activities of the E-Cigarette Companies 149
E-Cigarette Use Among Youth and Young Adults
Introduction
This chapter focuses on the companies that
are active in the production, distribution, or marketing
of e-cigarettes in the United States and examines the
potential influence of these companies on the use of
e-cigarettes, particularly among youth and young adults.
The e-cigarette marketplace is complicated by the fact that
some brands and devices are owned by tobacco companies,
while others are independently owned. This chapter will
refer to the e-cigarette companies as a whole but, when
necessary, will distinguish between the e-cigarette brands
that are owned by tobacco companies and others that are
independently owned. The chapter covers manufacturing
and price, marketing and promotional activities, the retail
environments for e-cigarette products, exposure to mar-
keting and receptivity to such activity, and the effects of
e-cigarette marketing activities on consumer behavior.
Manufacturing and Price
As discussed in Chapter 1, although the concept
of e-cigarettes was initially introduced in the 1960s, the
first-generation version of e-cigarettes was not devel-
oped and commercialized until the mid-2000s (Grana
and Ling 2014). In the short period since the first appear-
ance of e-cigarettes, the exponential growth in awareness
and use of these products (Centers for Disease Control
and Prevention [CDC] 2015), the rapid product develop-
ment (Zhu et al. 2014), and the rapid evolution of both
the e-cigarette market and the industry itself (Huang
and Chaloupka in press) have been unprecedented.
E-cigarettes were recently named a “disruptive innova-
tion” that may change the existing tobacco market and
displace conventional (combustible) cigarettes in a fore-
seeable timeframe (Spielman and Azer 2013).
Consumer demand for a less harmful alternative to
conventional cigarettes and the implementation of macro
policies, such as those that restrict cigarette use or man-
date clean indoor air, may influence the use of e-cigarettes
(Pepper et al. 2014b; Rose et al. 2014). However, e-cigarette
companies may play a critical role in shaping the market,
affecting everything from the development and innovation
of new products and brands to the manufacture, distribu-
tion, marketing, promotion, and pricing of the product—
activities that parallel those in the cigarette industry.
This section describes and summarizes both the
rapidly changing e-cigarette market and the activities
of e-cigarette companies in the United States, providing
abroad overview of the major players. These participants
include the major tobacco companies and other manu-
facturers. The chapter also addresses how the companies
influence the e-cigarette market in the United States,
focusing on the impact of product development and inno-
vation, distribution channels, product availability, and
pricing strategies, as well as the role of e-cigarette trade
organizations and partnerships.
Overview of the E-Cigarette Market
in the United States
For 2014, the value of the e-cigarette market in the
United States was estimated at $2.5 billion: 40% ($1.0 bil-
lion) was for cigarette-like e-cigarettes (cigalikes), and
60% ($1.5 billion) was for tank-style e-cigarettes, mods,
and other types of “vaporizers” (Wells Fargo Securities
2015a) (Table 4.1). The market was projected to grow
to $3.5 billion, a rise of 40%, in 2015 (Rose et al. 2014)
(Table4.2). Total sales of e-cigarettes in convenience, food,
drug, and big-box stores (such as Walmart), which are
tracked by commercial market research companies (such
as Nielsen), were estimated to be $900 million in 2014.
There was an additional estimated $500 million in online
sales, and $1.1 billion in sales in “vape shops” and other
channels, which are not currently tracked by commer-
cial market research companies (Table 4.1) (Wells Fargo
Securities 2015b).
Distribution and Purchase Channels
E-cigarettes entered the U.S. market around
2006–2007, and since that time the distribution and pur-
chase channels for these products have evolved greatly.
Initially they were sold exclusively by Internet retailers,
but then selling activity expanded to shopping mall kiosks
and conventional retail outlets and, more recently, to
“vape shops” and some pharmacies (Rose et al. 2014; Lee
and Kim 2015).
Some companies operating in the U.S. market have
their own manufacturing facilities in this country, but
companies generally import parts or even complete prod-
ucts from abroad, almost exclusively from China (Barboza
2014). Manufacturers and importers distribute their prod-
ucts via a wide number of channels, such as the companies’
A Report of the Surgeon General
150 Chapter 4
own e-commerce websites and/or retail outlets. In 2010,
the most popular channels for selling e-cigarettes and
their accessories directly to consumers were websites and
third parties, such as retail outlets (Linarch Information
Solutions 2012). Many e-cigarette manufacturers and
importers, including the big-brand companies and those
supplying products to “vape shops,” rely on distributors
and retailers to deliver the products to the consumer
(Linarch Information Solutions 2012).
Table 4.1 Estimated e-cigarette market size in 2014 ($ billion)
Convenience, food, drug,
and big-box stores Online
Other channels (“vape shops” and
other untracked retail channels) Total
E-cigarettes 0.6 0.2 0.2 1.0
Vapors/tanks/mods 0.3 0.3 0.9 1.5
Total 0.9 0.5 1.1 2.5
Source: Wells Fargo Securities (2015a).
Table 4.2 Estimated e-cigarette market size in 2015 ($ billion)
Convenience, food, drug,
and big-box stores Online
Other channels (“vape shops” and
other untracked retail channels) Total
E-cigarettes 0.7 0.4 0.4 1.5
Vapors/tanks/mods 0.4 0.4 1.2 2.0
Total 1.1 0.8 1.6 3.5
Source: Wells Fargo Securities (2015a).
The emergence of e-cigarette devices and products
resulted from the endeavors of a few entrepreneurs and
widespread Internet and television advertising (Grana etal.
2013; Rose et al. 2014). It is noteworthy that the product
class took hold when e-commerce was rapidly expanding
in the United States, and major social media platforms—
such as Facebook (founded in 2004), YouTube (2005), and
Twitter (2006)—were emerging. In such an environment,
information about a new product like e-cigarettes could be
rapidly disseminated across geographic boundaries, and
new products and technologies could be speedily adopted.
This process is partly reflected by the Google search
volume of queries related to e-cigarettes; the volume of
queries surpassed those for nicotine replacement therapy
products and snus by 2008 (Ayers et al. 2011).
Manufacturers noticed the fast rise in consumer
interest in e-cigarettes, so they quickly pushed to expand
the sale of their products to brick-and-mortar retail stores.
Sales of cigalikes and related products were first observed
in Nielsen’s store-scanner database in 2007, and between
2009 and 2012, retail sales of e-cigarettes expanded to all
major markets in the United States (Huang and Chaloupka
in press). This growth coincided with a surge in mar-
keting expenditures by the e-cigarette companies across
all media platforms (Kim et al. 2014; Kornfield et al.
2015). The products sold in these conventional channels
were predominantly disposable and rechargeable cigalikes
(Giovenco et al. 2015; Huang and Chaloupka in press), but
retail stores started to carry tank-style e-cigarette devices
as well (CSP Daily News 2014; Giovenco et al. 2015).
Today, e-cigarette brands, such as MarkTen (manu-
factured by Altria) and VUSE (manufactured by Reynolds
American Inc.), are available in more than 70,000 retail
stores across the country, and their availability is expanding
rapidly (Wells Fargo Securities 2014b). E-cigarettes were
more likely to be available in retail locations in neigh-
borhoods with a higher median household income and
alower percentage of African American and Hispanic res-
idents; these sales patterns are consistent with patterns
of use of these products observed among youth, young
adults, and adults more generally (see Chapter 2). Notably,
the price of conventional cigarettes and the existence of
comprehensive smokefree laws were inversely associated
with the availability of e-cigarettes (Rose et al. 2014).
Through growth in their sales, tank-style e-cigarettes
(also known as mods) and advanced personal vaporizers
(APVs) have begun to play an increasingly important role
in the e-cigarette market (Wells Fargo Securities 2015a).
“Vape shops,” which provide arange of e-cigarette devices
and products, have emerged as the primary retail channel
for consumers seeking such products (Lee and Kim 2015).
Unlike conventional retail outlets, “vape shops” sell a wide
range of more complex and powerful tank-style e-cigarettes
Activities of the E-Cigarette Companies 151
E-Cigarette Use Among Youth and Young Adults
and many different types of liquids for e-cigarette devices
(e-liquids or e-juices) (Sussman et al. 2016).
The rise of “vape shops” can be attributed to a number
of factors. First, in the past, most of these establishments
offered a wide range of e-cigarettes and e-liquids, allowed
users to sample different types of flavored e-liquids at
no cost, and permitted the trial use of various types of
e-cigarettes. Most of these establishments sell products
made by independent companies, as opposed to products
manufactured by the major conventional tobacco compa-
nies (Kamerow 2014; Sussman et al. 2016). As a result,
“vape shops” can serve as an information hub where con-
sumers can easily obtain knowledge about (and gain
experience with) a wide range of e-cigarettes and related
products (Sussman et al. 2016). However, the information
provided may be misleading or misinterpreted (Cheney
etal. 2016). Second, unlike traditional retail outlets, “vape
shops” are usually equipped to provide consumers with
individualized information about how e-cigarette prod-
ucts can be used to best satisfy the user’s preferences;
this capability may be important as e-cigarette products
become more diversified and sophisticated. Because of
the diversity of these products, some of these establish-
ments provided free samples of different flavored e-liquids
and allowed trial use of different e-cigarettes before actual
purchase in an attempt to compete with traditional retail
outlets. Under the deeming rule published in May 2016,
free samples of e-liquids containing nicotine were banned
(Federal Register 2016). Third, “vape shops” serve as a
place for e-cigarette users to socialize.
Some “vape shops” also host various events,
including competitions (also known as cloud chasing),
that build loyal customer bases by creating a sense of com-
munity and camaraderie among customers (Sussman et al.
2014; Cheney et al. 2015; Lee and Kim 2015). Additionally,
a2015 study of “vape shop” owners found that customers
view the owners as important sources of health informa-
tion, which could include information related to cessa-
tion (Cheney et al. 2016). However, the owners reported
(a) obtaining their information from YouTube or industry
sources but finding the research hard to understand and
(b) looking for government sources but not finding them.
Estimates of the number of “vape shops” in the
United States have varied greatly due to the lack of a clear
definition of what constitutes such an establishment.
The low end of these estimates puts the number around
3,500 (Klein 2013; Lee and Kim 2015), while interme-
diate estimates indicate that there are about 6,000–15,000
“vape shops” in this country (Bour 2015; Wells Fargo
Securities 2015b). One high estimate is that in 2014 there
were as many as 35,000 such shops in the United States
(Kamerow2014).
Product Evolution
E-cigarette products have evolved and diversified
rapidly since they entered the U.S. market (see Chapter 1).
Detailed information about different types of e-cigarette
products has been presented elsewhere (Grana et al.
2014). Over time, with consolidation of e-cigarette com-
panies and technological improvements, the manufac-
turing process has become more standardized, enabling
the production of e-cigarette products with a more effec-
tive and more consistent dose and delivery of nicotine and
flavorings, and a more consistent generation of aerosol
(Goniewicz et al. 2013a,b; Farsalinos and Polosa 2014;
Saitta etal. 2014).
Many e-cigarette manufacturers make multiple
types of e-cigarette products. For example, the NJOY brand
has not only disposable and rechargeable cigalikes but also
tank-style e-cigarette devices, which are larger than ciga-
likes and include options for refills and batteries. In addi-
tion, NJOY sells a variety of flavored e-liquids, although
in California, flavors appealing to minors (e.g.,strawberry
and cookies and cream) are prohibited (State of California
v. Sottera, Inc. 2010). Within each product type, there
are many different brands, albeit the brands are often
very similar. For example, NJOY, blu, Logic, Mistic, and
many other brands of rechargeable e-cigarettes differ very
little from each other with regard to the flavors and types
of products offered (e.g., cigalike, tank style) (Zhu et al.
2014). A study examining the growth of brands and flavors
between 2012 and 2014 found that older brands were more
likely to involve cigalikes, while newer brands were more
likely to offer tank-style devices and mods (Zhu etal. 2014).
As tank systems and mods become more popular, the
distinction between a closed system and an open system
becomes more important. In a closed system, components
cannot be customized. In this case, the e-liquid is “locked
in”; the amounts of e-liquid, level of nicotine, and flavors
are dictated by the manufacturer. Because users cannot mix
their own e-liquids or refill the cartridges or tanks, there
is less risk of spillage, nicotine overdose, and accidental
ingestion. In addition, users cannot change the power
source, adjust the voltage, or customize the atomizers.
Many brands offer only closed-system devices (e.g.,Vype,
Vapestick, and FIN). Most cigalikes are closed systems, sold
primarily online or in conventional retail outlets, and are
favored by the larger e-cigarette companies, likely because
of the high profit margins from the e-liquid refill cartridges
and the nature of the distribution paths.
Open systems, in contrast, allow for personaliza-
tion and customization: Users can mix their own e-liquid,
choosing different e-liquid bases, flavors, and nicotine
concentration levels. Users can also adjust the voltage,
customize the atomizers, and/or modify the aesthetics and
A Report of the Surgeon General
152 Chapter 4
shapes/sizes of their devices (Popken 2014; Richtel 2014c;
Lee and Kim 2015). Tanks and mods/APVs are open systems
sold primarily in “vape shops” or online. While research
has demonstrated that more-experienced e-cigarette users
prefer open system mods (Farsalinos etal. 2014), one ana-
lyst has suggested that closed systems may better facilitate
consistent and enforceable product and manufacturing
standards (Wells Fargo Securities 2014a).
Beyond the increased variety over time of products,
their components, and related products (including acces-
sories such as carriers, lanyards, stickers, and sleeves),
the products continue to appeal to consumers through
the incorporation of increasingly complex technologies—
including location tracking; Bluetooth connectivity;
social networking functions and integration with users’
social media accounts; and entertainment functions, such
as playing music and videos (Bauld et al. 2014; Brown and
Cheng 2014; Honig 2014).
The terminology for e-cigarettes has also expanded.
Terms such as e-cigars, e-hookahs, vaping pens, hookah
pens, and personal vaporizers are used interchange-
ably (or preferentially) by some users (Richtel 2014b).
In addition, the spectrum of use has broadened, as some
e-cigarettes that involve open systems are also used for the
aerosolization of marijuana and cannabis oil (Bryan 2014;
Morean et al. 2015) and could be adapted for other illicit
substances (see Chapter 2).
Worldwide, more than 95% of e-cigarettes sold are
thought to have been manufactured in China (Jourdan
2014), most in one city—Shenzhen (Barboza 2014). Afew
large manufacturers (e.g., Joyetech, Kimree, and First
Union) dominate the market (see Appendix 4.1 for descrip-
tions of the major e-cigarette manufacturers).
1
1
All appendixes and appendix tables that are cross-referenced in this chapter are available only online at http://www.surgeongeneral.gov/
library/reports/.
Most of
these manufacturers provide supplies to many different
e-cigarette companies, including American companies
marketing conventional cigarettes, as well as independent
e-cigarette companies. Some companies (e.g., Gamucci)
have an exclusive manufacturer in Shenzhen.
Some e-cigarette companies have begun to locate
their manufacturing base in the United States. Reynolds
American, for example, has a factory in Tobaccoville,
North Carolina, to manufacture its VUSE brand and
strongly emphasizes this location as part of its marketing
strategy (CSP Daily News 2015). White Cloud, another
U.S.-based company, moved its cartridge-filling produc-
tion from China to Tarpon Springs, Florida, in May 2014
(McConnell 2014), and the U.S.-based brand Mistic has
announced plans to move its manufacturing from China
to Greenville, North Carolina (Bettis 2014).
Evolution of Market Share in the E-Cigarette
Market
Although the e-cigarette market in the United States
has changed significantly since its emergence, these
changes have not been studied extensively. This section
documents market share by brand for e-cigarette sales
in retail outlets tracked by Nielsen, using data from the
forthcoming study by Huang and Chaloupka (in press)
and supplemented with data from industry reports issued
by a number of investment banks. These data, available
in Appendix 4.5, clearly show the dynamic changes in the
e-cigarette market, and these changes are important to
understand in terms of access to and marketing of these
products to youth and young adults.
E-Cigarette Sales in Tracked Retail Outlets
Total sales of e-cigarettes in tracked retail channels
have surged exponentially since 2010, increasing from
only a few million dollars per quarter in 2010 to more
than $170 million in the last quarter of 2014 (Figure4.1).
Although Reynolds American’s VUSE brand did not
enter the market until late 2013, its sales climbed rap-
idly in 2014 because of heavy promotion and price dis-
counts. At the end of 2014, VUSE had become the market
leader with the highest quarterly sales at $56 million. Blu
(owned by Lorillard and thus now by Imperial Tobacco)
was the market leader for most of 2013 and 2014, with an
average $60 million in quarterly sales. During this time
the number of its distribution points rose from 60,000 to
more than 150,000 because of its acquisition by Lorillard
and subsequent marketing and promotion efforts.
After doubling every year between 2010 and 2013
(Figure 4.2) in the tracked retail channels, rates of
increase in the sales of e-cigarettes decelerated signifi-
cantly, with total sales actually declining in the second
quarter of 2014. The deceleration may reflect, in part, the
shift away from cigalikes to tank-style devices, mods, and
other e-cigarette products among users; the sales of these
devices are not tracked as well, which makes it difficult to
know the true trends in sales (see Tables 4.1 and 4.2).
Figure 4.2 presents sales data by product type. Sales
of disposable e-cigarettes trended upward from 2010
to 2013, increasing from a minimal amount in 2010 to
almost $100 million in the second quarter of 2013, but
2014 showed a substantial decline, with the value only
about $50 million for the final quarter of that year. The
figure shows a clear pattern of seasonality in sales for
disposables: sales usually rose in the first quarter of the
Activities of the E-Cigarette Companies 153
E-Cigarette Use Among Youth and Young Adults
Figure 4.1 E-cigarette sales in tracked channels by brand, 2010–2014
Source: Huang and Chaloupka (in press).
Note: Data points for this figure are shown in Table A4.4-1 in Appendix 4.4.
A Report of the Surgeon General
154 Chapter 4
year—potentially reflecting the effect of New Year’s res-
olutions among smokers who seek to use rechargeable
e-cigarettes as a way to quit conventional cigarettes—
but had subsequently declined during the rest of the year.
Sales of e-liquid refills increased steadily over the 4-year
period between 2010 and 2014 and reached $80 million in
the final quarter of 2014, representing approximately half
of the total e-cigarette sales in the tracked retail channels.
Figure 4.2 E-cigarette sales in tracked channels by product type, 2010–2014
Source: Huang and Chaloupka (in press).
In 2014, more than 85% of e-cigarette sales occurred
in the tracked retail and online channels, including cer-
tain convenience stores and food, drug, and big-box stores
(Wells Fargo Securities 2015a; see Table 4.1). It was
estimated that 20% of all e-cigarette sales (including
e-cigarettes and tanks/mods) in 2014 occurred online,
while 44% of all e-cigarette sales occurred in “vape
shops” and other untracked retail channels (Wells Fargo
Securities 2015a; see Table 4.1).
Another important trend in e-cigarette sales is the
growth of flavored products. Although some brands, such
as NJOY, initially did not sell flavored e-cigarette products,
most companies now offer some form of flavored varieties.
Giovenco and colleagues (2015) found that sales of men-
thol-flavored e-cigarettes in traditional U.S. retail chan-
nels (e.g., convenience stores, grocery stores, pharmacies,
and mass merchandisers) more than doubled between
2012 and 2013, increasing from $96.4 million in 2012 to
$215.7 million in 2013. Sales of fruit-flavored e-cigarettes
more than tripled during the same period, from $4.9 mil-
lion to $16.7 million.
Sales of different types and brands of e-cigarettes
likely differ by demographic group. For example, anec-
dotal evidence suggests that youth and young adults prefer
pen-style devices, those that come in various shapes and
styles, and devices that may be used interchangeably with
e-hookahs (Richtel 2014b). Research also suggests that
users may eventually graduate to more complex systems;
more specifically, experienced users may be more likely to
use tanks and mods (Farsalinos et al. 2014). Unfortunately,
sales data by demographics are very limited, and studies
have not yet examined how sales of e-cigarette products
differ by demographic classification.
Production of E-Liquids
E-liquids used in closed-system devices usually are
produced in the United States and then shipped to China
to be included in the assembly process. For example,
MarkTen, blu, and NJOY manufacture their own e-liquids
in the United States, which then are sent to China before
the final product is assembled there.
In the United States, one of the biggest players in
the premixed e-liquid market for refillable e-cigarettes is
Johnson Creek Vapor Company (2011), which claims to
be the world’s leading manufacturer of e-liquid and the
first company to produce and manufacture e-liquid in the
United States. Johnson Creek has not disclosed the sup-
pliers of its nicotine solution.
Activities of the E-Cigarette Companies 155
E-Cigarette Use Among Youth and Young Adults
Impact of E-Cigarette Price on Sales
and Use of These Products
This section summarizes the limited evidence on
the impact of e-cigarette prices on the sales and consump-
tion of these products. The sizable body of research exam-
ining the effects of taxes and prices on the sale and use
of conventional cigarettes (Chaloupka and Tauras 2011;
International Agency for Research on Cancer 2011) leads
to the conclusion that price increases resulting from
higher excise taxes are effective tools for reducing ciga-
rette consumption, especially among youth.
Trends in E-Cigarette Prices over Time
A study by Huang and Chaloupka (in press) docu-
mented and analyzed the relationship between real price
and sales volume for both disposable and rechargeable
e-cigarettes by using Nielsen data, which reflected the
e-cigarette (predominantly cigalikes) sales and prices in
retail stores tracked by Nielsen.
Figure 4.3 presents U.S. data on real price (deter-
mined by adjusting the prices to the value of the U.S.dollar
in the fourth quarter of 2014) and sales volume for dispos-
able e-cigarettes between 2010 and 2014 based on data from
Huang and Chaloupka (in press). The average price for a
single disposable e-cigarette declined from approximately
$17 in the first quarter of 2010 to less than $9 in 2014.
In terms of volume, the estimate for disposables increased
from far below 100,000 in the first quarter of 2010 to
almost 11 million in the first quarter of 2014, before drop-
ping to about 6.3 million in the final quarter of 2014. This
graph reveals an association between real price and the
sales volume for disposable e-cigarettes from 2010 to the
second quarter of 2013: As real price declined over time,
sales volume increased. Looking back, the rapid decline in
the price of disposable e-cigarettes between 2007 and 2011
(Huang and Chaloupka in press) may have occurred because
of improvements in product technology and industry pro-
motion, which significantly cut the costs of producing such
products (Bhatnagar et al. 2014; Wells Fargo Securities
2015c). The rather modest declines in prices since 2011
may reflect the fact that further technological improve-
ments became less feasible (Wells Fargo Securities 2015c).
Figure 4.3 Sales volume and price of disposable e-cigarettes, U.S. market, 2010–2014
Source: Huang and Chaloupka (in press).
In terms of volume, the substantial decrease in 2014
may be partly attributable to consumers shifting away
from cigalikes to tanks, mods, and other more powerful
devices, for which sales were not tracked well.
An inverse relationship is also evident between
real price and sales volume for rechargeable e-cigarettes.
Figure 4.4 demonstrates that when the real price went
down, the sales volume increased, particularly after
2012. Between 2010 and 2014, the average unit price for
rechargeables decreased markedly, dropping from $37
in the first quarter of 2010 to $12 at the end of 2014.
However, there were more price fluctuations than were
found for disposable e-cigarettes (Figure 4.3). The price
fluctuations for rechargeables were likely because of the
A Report of the Surgeon General
156 Chapter 4
change in product mix and the influx of various new types
and brands of these devices during this period (Bhatnagar
et al. 2014; Wells Fargo Securities 2015c). Sales volume
increased dramatically between 2010 and 2014, rising
from a minimal amount at the beginning of 2010 to about
3 million units in the last quarter of 2014.
Figure 4.4 Sales volume and price of rechargeable e-cigarettes, U.S. market, 2010–2014
Source: Huang and Chaloupka (in press).
Impact of E-Cigarette Prices on E-Cigarette Sales
In one of the first studies to explore the effects of
e-cigarette prices on the sales of these products, Huang
and colleagues (2014b) estimated, from Nielsen data,
both the own-price elasticity and the cross-price elasticity
of demand for e-cigarettes (disposable or rechargeable)
and studied the impact of conventional cigarette prices
and smokefree policies on e-cigarette sales. Own-price
elasticity is a measure showing how much demand for a
product will change given a change in its price, while cross-
price elasticity is a measure showing how much demand
for a product will change given a change in another prod-
uct’s price. Using data from Nielsen’s commercial retail
store scanning service, this study employed fixed-effects
models to estimate elasticity of demand and associa-
tions between e-cigarette sales and either the prices of
conventional cigarettes or smokefree policies from 2009
to 2012. Results demonstrated (a) that e-cigarette sales
were quite responsive to own-price changes (estimated
own-price elasticities for disposable e-cigarettes centered
around −1.2 [a 10% increase in price would decrease
sales by 12%], while those for rechargeable e-cigarettes
were approximately −1.9 [a 10% increase in price would
decrease sales by 19%]) and (b) that disposable e-cigarettes
appeared to be emerging as substitutes for recharge-
ables (a 10% increase in rechargeable e-cigarette prices
increased sales of disposable e-cigarettes by about 5%).
This study concluded that policies increasing the retail
prices of e-cigarettes—such as imposing taxes or lim-
iting rebates, coupons, and discounts—could potentially
lead to significant reductions in e-cigarette sales and that
variations in tax policy by product type could lead to sub-
stitution between product categories. It is important to
note that “vape shops” were not included in these data, as
Nielsen collects data only from convenience, food, drug,
and big-box stores.
Although these results provide evidence that
changing the price of e-cigarettes affects the number
sold, the potential effects of the price of conventional
cigarettes on the purchase of e-cigarettes are less clear.
Huang and colleagues (2014b) found no consistent or
statistically significant relationship between the price of
conventional cigarettes and the sale of e-cigarettes. In
contrast, Grace and colleagues (2015), who measured the
cross-price elasticity of e-cigarettes and conventional cig-
arettes using simulated demand for the latter in a sample
of New Zealand smokers, found that the cross-price elas-
ticity of e-cigarettes was significantly positive, suggesting
that e-cigarettes may be partially substitutable for con-
ventional cigarettes. Thus, the use of e-cigarettes may
increase as the price of conventional cigarettes increases.
Activities of the E-Cigarette Companies 157
E-Cigarette Use Among Youth and Young Adults
Other evidence suggests that the potential impact
of price changes on the use of e-cigarettes may differ by
demographic characteristics. Relationships between the
smoking of conventional cigarettes and socioeconomic
status (SES) are well documented in the literature, and
additional evidence has demonstrated that youth and
young adults, and those with low SES, tend to exhibit
higher sensitivity to changes in the price of conventional
cigarettes (International Agency for Research on Cancer
2011; U.S. Department of Health and Human Services
[USDHHS] 2012). Therefore, youth and young adults, as
well as low-SES persons, may be more price-sensitive in
the purchase of e-cigarette products, and thus they may
be more likely to stop using e-cigarettes as their price
increases. These potential connections between the price
of e-cigarettes and their use should be examined carefully
as more data become available.
Marketing and Promotion of E-Cigarettes
Marketing is an important tool for industries to use
in influencing consumer preferences, and the potential
for marketing to influence smoking behaviors has been
asource of public health concern for many years (DiFranza
et al. 1991; USDHHS 2000, 2012; National Cancer Institute
[NCI] 2008). Research has demonstrated a causal relation-
ship between tobacco marketing and smoking, with the
majority of research focusing on the impact of tobacco
marketing on the initiation of smoking by youth (Biener
and Siegel 2000; USDHHS 2012). For adolescents, studies
have found cross-sectional and longitudinal associations
between the intensity of cigarette marketing and initiation
of smoking, brand awareness, brand preferences, attitudes
toward smoking, susceptibility to smoking, and smoking
behaviors (O’Connell etal. 1981; Chapman and Fitzgerald
1982; McNeill etal. 1985; Charlton 1986; Potts etal. 1986;
Aitken etal. 1987; Goldstein etal. 1987; Aitken and Eadie
1990; Botvin etal. 1991; DiFranza etal. 1991; Klitzner etal.
1991; Pierce etal. 1991; Botvin etal. 1993; Hastings etal.
1994; Pierce etal. 1994; Coeytaux etal. 1995; Evans etal.
1995; Pierce and Gilpin 1995; Richards et al. 1995; Slade
etal. 1995; Unger etal. 1995; Pollay etal. 1996; Schooler
etal. 1996; Gilpin and Pierce 1997; Lam etal. 1998; Feighery
etal. 2006). A review of these and other studies led the 2012
Surgeon General’s report to conclude that exposure to adver-
tising causes the initiation of smoking (USDHHS 2012).
In general, product marketing is designed to
inform people about the products being offered (and thus
develop brand “awareness”) and to persuade people to
buy particular brands (i.e., develop brand “preference”).
Branding is particularly important for products consid-
ered to be “commodities,” such as conventional ciga-
rettes and e-cigarettes, where the offerings are similar
and branding differentiates the products (Rossiter and
Bellman 2005; NCI 2008). Marketing is particularly crit-
ical for e-cigarettes, as new products must be introduced
to potential users (Sethuraman et al. 2011).
Like marketers of conventional cigarettes, mar-
keters of e-cigarettes use a number of channels and tactics
to advertise and promote their products. These chan-
nels have included extensive marketing on the Internet
and advertising in mainstream media, including popular
magazines, retailer point-of-sale ads, product placement
on popular media, and even television commercials—
an advertising option unavailable to cigarette manufac-
turers because of regulatory policies (Legacy for Health
2014; Ganz et al. 2015). E-cigarette brands also use web-
sites to interact directly with their customers through
direct-to-consumer marketing (e.g., direct mail and direct
e-mail) and social media channels, such as Facebook,
Twitter, and Instagram (Huang et al. 2014a; Richardson
etal. 2014; Ganz et al. 2015).
Marketing Expenditures
E-cigarette manufacturers currently are not
required to report marketing expenditures to any regu-
latory agency (Boxer et al. 2013; Federal Register 2015).
Using proprietary data from Kantar Media, however,
Kornfield and colleagues (2015) tracked marketing expen-
ditures (television, print, radio, and Internet) back to 2008
for approximately 130 e-cigarette brands (note that many
e-cigarette products are not branded, and thus these data
are not complete). Kornfield and colleagues (2015) found
minimal spending through 2010, followed by an accelera-
tion in spending from $12 million in 2011 to $125 mil-
lion in 2014 (Figure 4.5). Not shown in the figure is that
in 2012, more than 60% of advertising expenditures were
for blu (then owned by Lorillard, now Imperial Tobacco),
which was the market leader (Kornfield et al. 2015). The
trajectory for spending was consistent with the pattern for
product sales, particularly for the most dominant brands
(Figures 4.1 and 4.5).
Annual marketing expenditures for conventional
cigarettes ($9.2 billion in 2012) dwarf the $125 million in
2014 for e-cigarettes (Federal Trade Commission 2015a,b;
A Report of the Surgeon General
158 Chapter 4
Kornfield et al. 2015). However, the available data about
e-cigarette marketing also underestimate total mar-
keting expenditures. Not included are expenditures for
retail marketing, social media, and sponsored events, all
of which are essential components of the industry’s inte-
grated marketing strategy. In the absence of regulation,
television advertising for e-cigarettes will continue, as
the two largest tobacco companies moved promotions of
MarkTen (Altria) and VUSE (Reynolds American) from test
markets to national distribution in 2014 (Kornfield et al.
2015; Truth Initiative 2015; Cantrell et al. 2016).
Tobacco marketing and surveillance systems—
including the Trinkets & Trash archive maintained by
the Rutgers University School of Public Health and the
Stanford Research into the Impact of Tobacco Advertising
(SRITA) research group—collect examples of e-cigarette
advertising and promotions and make these available to
users through image-rich websites (see Trinkets & Trash
[http://www.trinketsandtrash.org] and Stanford Research
into the Impact of Tobacco Advertising [http://tobacco.
stanford.edu/tobacco_main/index.php]).
Magazine and Print Advertising
Print has been the dominant channel for tracked
expenditures of traditional e-cigarette advertising, rep-
resenting 84% of annual expenditures in 2014 (Kornfield
et al. 2015; Figure 4.5). A study by Richardson and col-
leagues (2014) collected U.S. advertisements for all
noncombustible tobacco products (i.e., e-cigarettes, snus,
dissolvables, and chew/dip/snuff) for a 3-month period in
2012 through Mintel, which tracks direct mail and opt-in
e-mail ads, and Competitrack, which monitors 21other
media sources. Metadata for identified ads showed adver-
tising for e-cigarettes in print, television, radio, online,
direct mail, and e-mail. The three most common media
were print, television, and e-mail, and spending was
highest for print ads (Richardson et al. 2014). An anal-
ysis of industry marketing data by the American Legacy
Foundation (now called Truth Initiative) reported that
47% of U.S. teens (12–17 years of age) and 82% of young
adults (18–21 years of age) were exposed to magazine
advertising for e-cigarettes in 2014; popular venues
Figure 4.5 Quarterly promotional spending for e-cigarettes, 2010–2014
Source: Data for 2010–2013 (Q2) from Kornfield and colleagues (2015, p. 110) and adapted with permission from BMJ Publishing
Group Limited. Data for 2013 (Q3)–2014 from Kantar Media (unpublished data).
Activities of the E-Cigarette Companies 159
E-Cigarette Use Among Youth and Young Adults
included tabloids, entertainment weeklies, and men’s life-
style magazines (Truth Initiative 2015).
Research indicates that e-cigarette advertising
in magazines with high teen readership is on the rise
(U.S. Congress 2014). From 2012 to 2013, the number
of e-cigarette advertisements in magazines with high
youth readership was four times the number in magazines
with high adult readership (U.S. Congress 2014). Recent
studies using data from Kantar Media and GfK MRI (the
latter measures media audiences and consumer insights;
see http://www.mri.gfk.com) on e-cigarette advertise-
ments show that blu led all e-cigarette brands in magazine
advertising and that respondents had the highest recall of
blu advertisements (Legacy for Health 2014).
A content analysis by Banerjee and colleagues (2015)
of print magazine tobacco ads for 2012–2013, using data
collected from Kantar Media, identified 171 e-cigarette
ads over this period, 27 of which were unique. Ads were
found in 24 magazines, 11 of which had been identified in
prior studies as having youth and young adult readerships
greater than 2 million per year or for which the teen por-
tion of the audience was more than 10%. By number, ads for
e-cigarettes were second only to those for conventional cig-
arettes and higher than the numbers for moist snuff, cigars,
and snus. Eighty-five percent of the content in e-cigarette
ads focused more on a theme of logos (i.e.,logic or facts to
support a position) than on a theme of emotional appeal.
In examining persuasive themes, the study found
that ads used several approaches, including highlighting
the conventional advantages of the product—such as
a focus on customer satisfaction—and emphasizing the
quality of the product or price (85.2%) (Banerjee et al.
2015). The ads also used the comparative approach, such as
portraying the product as being different from other prod-
ucts, being smokefree, or being exempt from use in areas
where conventional cigarettes are prohibited. Figure4.6
shows examples of the claims in e-cigarette marketing.
In terms of images, 100% of the ads included the brand
name and an image of the product. In addition, ads were
most frequently full-page advertisements (89.9%), usu-
ally placed the product in a way that drew attention to it
(92.6%), and most often used six or more colors (85.2%),
which the authors noted increases the attention-grabbing
ability of the ads (Banerjee et al. 2015).
A different content analysis of magazine ads for
e-cigarettes, this one for a 3-month period in 2012
(Richardson et al. 2014), found health-related themes and
non-health-related attributes—such as romantic, sexual,
or sociability content, with the highlighting of taste as the
most frequent selling proposition (see Figure 4.6, parts
B–D for examples). All ads in this analysis were found
to contain links to a product’s website. When examined
by readership, e-cigarette ads were found to have run in
magazines with mostly White-male readers and, to a lesser
extent, magazines targeting White women. The analysis
noted that ads were targeted to a magazine’s readership,
with different ads shown in the White, male-oriented
Rolling Stone publication as compared with the female-
dominated Us Weekly.
Television Advertising to Youth and Young Adults
The increasing frequency and reach of advertising
on television raises concerns about the potential impact of
promoting nicotine products and renormalizing smoking
through that medium, particularly for youth (Hodge Jr
2013; Duke et al. 2014; Grana and Ling 2014). At least
40unique advertisements for e-cigarettes appeared on U.S.
television in 2013 and early 2014 (Farrelly et al. 2015). For
example, e-cigarette ads were featured in the Super Bowl
broadcast, which reached an estimated audience of more
than 100 million persons in 2012 (Deans 2012). The Truth
Initiative (formerly the American Legacy Foundation)
found that in 2014, television advertising reached sim-
ilar proportions of youth (62% of 12- to 17-year-olds) and
young adults (64% of 18- to 24-year-olds) (Truth Initiative
2015). Using proprietary data from Nielsen, Duke and
colleagues (2014) estimated that 50% of U.S. youth
were exposed to e-cigarette ads on television in 2013
and that 80% of this advertising was for blu (Lorillard,
now Reynolds American). On average, those exposed
saw 21ads between October 2012 and September 2013.
Between 2011 and 2013, exposure to e-cigarette adver-
tising on television increased dramatically, by 321% for
young adults (18–24years of age) and 256% for adoles-
cents (12–17 years of age) (Duke etal. 2014).
The same study (Duke et al. 2014) found that
more than 75% of the exposure of youth to e-cigarette
ads occurred on cable networks. The study found televi-
sion ads for several different brands—including blu, FIN,
Starfire, and NJOY—during a 9-month period in 2013.
The most widely aired ad was for blu, featuring a celeb-
rity and closing with the tagline “we’re all adults here. It’s
time to take back your freedom” (Duke et al. 2014, p. 6).
Sponsorships
After the Master Settlement Agreement in 1998,
sponsorship of events with a significant youth audi-
ence, such as concerts and athletic events, was banned
for conventional cigarettes. However, e-cigarettes do not
fall under these parameters, and recalling the early mar-
keting of conventional cigarettes, e-cigarette brands have
used sponsorships to increase the awareness and appeal
of their label and product. For example, in 2011 blu spon-
sored a NASCAR driver and had its own car in some races
(PRNewswire 2011). Additionally, blu has handed out free
A Report of the Surgeon General
160 Chapter 4
Figure 4.6 E-cigarette marketing claims
A. Freedom
Source: Esquire (2014).
B. Health
Source: Stanford Research into the Impact of
Tobacco Advertising (n.d.b.).
C. Romance, sexuality, or sociability
Source: (Left) Maxim (2012), (middle) Men’s Journal (2014), and (right) Sports Illustrated (2014).
Activities of the E-Cigarette Companies 161
E-Cigarette Use Among Youth and Young Adults
Figure 4.6 Continued
D. Taste
Source: Soap Opera Digest (2013).
E. Smoking cessation
Source: Rolling Stone (2013).
F. Use in smokefree environments
Source: Rolling Stone (2012).
G. Product engineering
Source: Rolling Stone (2015).
A Report of the Surgeon General
162 Chapter 4
Figure 4.6 Continued
H. Cleaner than cigarettes
Source: Car and Driver (2014).
I. Save money
Source: FIN Electronic Cigarettes (n.d.).
J. Circumvent smokefree policies
Source: Spin (2012).
Activities of the E-Cigarette Companies 163
E-Cigarette Use Among Youth and Young Adults
samples during large events and has even sponsored events
at music festivals (PRNewswire 2013; blu eCigs 2014).
Further, conservative estimates indicate that in 2012 and
2013, free samples were provided by six companies at
348 events, most of these events having high participa-
tion by youth (Durbin et al. 2014). Under the deeming rule
published in May 2016 (currently under litigation), free
samples were banned (Federal Register 2016).
Digital Landscape for E-Cigarettes
The Internet has been widely used to promote cig-
arettes, cigars, and smokeless products (Ribisl 2003;
Freeman and Chapman 2007; USDHHS 2012). This
medium—through websites, message forums, and social
media—has been heavily used to sell and glamorize
e-cigarettes and their use. Nearly all teens 13–17 years
of age (92%) use the Internet daily, and 73% of teens
access the Internet via smartphones (Lenhart 2015). In
2015, a study conducted by the Truth Initiative indicated
that 40%of youth (13–17 years of age) and 57% of young
adults (18–21 years of age) had seen e-cigarette adver-
tising online (Truth Initiative 2015).
Price promotions are not just involved in sales at
brick-and-mortar stores; they are also offered by online
stores and through social media. Grana and Ling (2014)
found that 80% of websites indicated a sale price or dis-
count, while Huang and colleagues (2014a) found that
34% of commercial tweets mentioned the words “price” or
“discount.” Both Facebook and Twitter provide opportuni-
ties for brands and companies to offer online coupons and
discounts (Discount Coupons for blu n.d.; Vapor4Life n.d.).
In a study of online e-cigarette retailers, 28% of the web-
sites offered a promotion, such as a discount, other free
items, or a loyalty program (Williams et al. in press).
Without age restrictions or age verification, youth can
access these websites easily and thus obtain the discount
or coupon (Williams et al. in press). However, under the
deeming rule, websites cannot sell e-cigarettes to youth
under the age of 18, so access will likely be curtailed as
a result (Federal Register 2016). The following sections
review three basic categories of online e-cigarette content:
websites that sell e-cigarettes, manufacturer-sponsored
brand name websites, and e-cigarette promotions on
social media websites (including Facebook, Twitter, and
YouTube).
Websites Selling E-Cigarettes
Tobacco industry analysts estimate that online sales
accounted for approximately 30% of e-cigarette sales
volume in the first quarter of 2015 (Wells Fargo Securities
2015a). Some Internet vendors sell their own brands
exclusively (e.g., Mistic, Green Smoke), while a large
number are online stores that sell many brands and vari-
eties of products (Zhu et al. 2014; Williams et al. in press).
Although the marketers of e-cigarettes have made
claims that differ from those made for conventional ciga-
rettes (such as use for smoking cessation, which is illegal
without being an approved cessation drug or device),
a content analysis of e-cigarette marketing (Grana and
Ling 2014) and the observations of tobacco marketing sur-
veillance systems point to several similarities, including
the use of young, attractive models; lifestyle claims; and
celebrities. Other claims made in e-cigarette advertising
have been used in the past by conventional cigarette
brands (such as having fewer carcinogens, lower risk of
tobacco-related disease) or by smokeless tobacco products
(such as the ability to use them where smoking is prohib-
ited) (Grana and Ling 2014). However, under the deeming
rule that was published in May 2016, after August8, 2016,
e-cigarette manufacturers cannot make modified risk
claims (Federal Register 2016) (although this provision
has been challenged in pending lawsuits).
Formal analyses of marketing claims of branded
e-cigarette sites that both promote and sell e-cigarettes
provide details on the types of claims made in these chan-
nels. The study by Grana and Ling (2014) analyzed claims
from 59 English-language websites over a 2-month period
in 2011 and found four major thematic content areas:
health- and cessation-related benefits, avoiding smokefree
policies, lifestyle benefits, and product-engineering claims.
Ninety-five percent of websites made explicit or implicit
health-related claims, and 64% made claims related to
cessation, often through the use of testimonials. Almost
all (98%) included a comparison of the risks and benefits
of e-cigarettes and conventional cigarettes; 95%included
claims that e-cigarettes are cleaner; and 93% said they
were cheaper. Claims regarding where e-cigarettes
could be used were also common—with 88% claiming
e-cigarettes can be used anywhere, and 71%pointing to
e-cigarette use as a means of circumventing clean air poli-
cies. Figure4.6 shows advertising that exemplifies these
marketing claims for e-cigarettes.
Grana and Ling’s (2014) analysis also points to the
common use of lifestyle-related claims, a hallmark of tra-
ditional tobacco marketing: 73% of websites contained
images or claims of being modern or glamorous. Websites
also pointed to social advantages for users of their par-
ticular brand: 44% of claims pointed to increased social
status and 32% to enhanced social activity, 31% suggested
romantic advantages, and 22% used celebrities. Claims
of increased social status, opportunity, and romance as
well as the use of celebrities may resonate especially with
youth and young adults (Grana et al. 2011).
A different content analysis, this one of the mar-
keting messages of English-language branded e-cigarette
A Report of the Surgeon General
164 Chapter 4
retail sites, examined and compared websites for two dif-
ferent time periods (May–August 2012 and December
2013–January 2014) and found differences in claims between
the two timeframes (Zhu et al. 2014). In comparing claims
for brands available during both time periods with those
that were newly available in 2013–2014, the authors found
that products and advertising messages varied between the
two samples. Brands analyzed from 2012 were significantly
more likely than those in the later period to (a) claim that
their products were healthier and less expensive than con-
ventional cigarettes and could be used where smoking is
prohibited and (b) indirectly claim their products were
effective for smoking cessation through testimonials and
other methods (Zhu et al. 2014). The study also found an
increase from one period to the next in the number of
branded retail websites and the number of flavors per brand
advertised on a website, as well as the likelihood of a web-
site offering e-cigarette hardware and such other products
as e-liquids and e-hookahs or other products that did not
resemble cigalikes (Zhu etal. 2014). The study’s findings
suggested that the emphasis for newer brands had shifted
from comparing them with conventional cigarettes to a
focus on their role as new nicotine delivery systems.
Williams and colleagues (in press) used a stan-
dardized search strategy employed in their earlier study
of websites selling cigarettes (Ribisl 2003) to identify
995 English-language websites selling e-cigarettes in
2014. The authors performed a content analysis on the
281most popular websites, as judged by data on traffic.
Most of the websites were based in the United States
(71.9%), the United Kingdom (16.7%), and China (5.3%),
and they offered a variety of products, but more sold
e-cigarette starter kits (92.5%) than disposables (55.2%).
Most offered flavors, with the most popular being fruit
(79.4%), candy (75.2%), coffee (68.0%), and alcohol
(45.6%). Although 71.5% featured some type of health
warning, 69.4% claimed health advantages over other
tobacco products, and 32.7% claimed that the product
helped people to quit smoking conventional cigarettes.
The sites also featured endorsements or mentions of
celebrities using the products (Stanford Research into
the Impact of Tobacco Advertising n.d.a.). Physicians and
other health professionals provided endorsements as well.
Elsewhere, Cobb and colleagues (2015) conducted a
forensic analysis of websites that sold e-cigarettes and par-
ticipated in affiliate advertising on the Internet. In addi-
tion to identifying multiple layers of redirection between
online advertising by affiliates and websites selling
e-cigarettes, the authors found that online advertisements
and affiliate websites included cessation claims.
Research suggests Internet e-cigarette vendors have
not routinely verified the age and identity of website visi-
tors or blocked sales to minors. However, after August8,
2016, due to the deeming rule, it has become illegal for
online retailers to sell e-cigarettes to those under 18
(Federal Register 2016). In a survey of purchasing by
youth, Williams and colleagues (2015) identified 98web-
sites selling e-cigarettes on which youth, 14–17 years of
age, made purchase attempts using prepaid credit cards.
In all, 18 (of 98) order attempts failed because of technical
problems with the website or the payment system, all of
which were unrelated to age verification. Of the remaining
80 orders, 75 (93.8%) were filled. Five vendors claimed to
use a service offered by shipping companies to verify age
at delivery, but none actually did. Although data are not
available on the proportion of youth who purchase their
e-cigarettes online versus buying them at retail outlets,
this study suggests that youth would have ready access if
they tried to purchase e-cigarettes online. The Prevent All
Cigarette Trafficking Act of 2009 requires Internet sellers
of cigarettes and smokeless tobacco to, among other provi-
sions, verify age of customers at the time of purchase and
ensure that the deliverer checks identification at the time
of delivery; stop Internet sales to minors; and pay applicable
local, state, federal, and territorial taxes to reduce the price
advantage of online sales. FDA regulation now prohibits
the Internet sales of e-cigarettes to minors. However, there
are currently no federal requirements for Internet vendors
of e-cigarettes to check identification upon delivery or pay
applicable taxes (Campaign for Tobacco Free Kids 2016).
The marketing of candy and fruit flavors may be one
of the reasons that e-cigarettes appeal to youth (Grana
and Ling 2014; Richtel 2014a; Zhu et al. 2014). Young
adults (18–24 years of age) are more likely to use flavored
tobacco products than are adults in the next age group
(25–34 years of age) (Villanti et al. 2013). Zhu and col-
leagues (2014), who used three search engines (Google,
Yahoo!, and Bing) and various keywords from May 2012
to January 2014 to identify a wide variety of e-cigarette
brands and flavors, found 466 brands and 7,764 unique fla-
vors, with 242 new flavors appearing each month. Other
than tobacco flavor, the most popular flavors were menthol
(92.1%), fruit (84.2%), dessert/candy (79.9%), and alcohol/
drinks (77.5%). Additionally, in their content analysis of
e-cigarette retail websites, Grana and Ling (2014) found
that such flavors as coffee, fruit, and candy were offered on
most sites. Further, flavors were being sold under brand
names similar to cereal and candy products that appeal to
youth, such as Wrigley’s Big Red Gum (Daniels 2015).
Tobacco Industry Corporate and Brand
Websites
Three categories of e-cigarette brands have emerged
within the U.S. market: brands developed by cigarette
manufacturers (i.e., MarkTen, VUSE), brands acquired
Activities of the E-Cigarette Companies 165
E-Cigarette Use Among Youth and Young Adults
by cigarette manufacturers (i.e., blu, Green Smoke)
(Table4.3), and brands that have no affiliation with a ciga-
rette manufacturer (e.g., NJOY, FIN). A content analysis
of websites for these three types of brands suggested that
those developed by cigarette manufacturers may be mar-
keted more cautiously than brands acquired by cigarette
manufacturers or brands that have no affiliation with a
cigarette manufacturer (Seidenberg et al. 2016).
Table 4.3 Mergers, acquisitions, partnerships, and other agreements in the e-cigarette industry
Date Purchaser Acquisition target
Partnerships and
other agreements Deal size
a
Geography
b
December 2011 Japan Tobacco — Ploom (partnership) Not disclosed United States
December 2012 BAT CN Creative — £40 million United Kingdom
April 2012 Lorillard blu — $135 million United States
April 2013 National Tobacco — V2 Cigs
(partnership)
Not disclosed United States
August 2013 Imperial Dragonite — $75 million China
October 2013 Lorillard SKYCIG — £60 million United Kingdom
January 2014 ECIG VAPESTICK — $70 million United Kingdom
January 2014 Gilla Drinan — Not disclosed Ireland
February 2014 Altria Green Smoke — $110 million United States
March 2014 ECIG FIN — $170 million United States
April 2014 ECIG VIP — $58 million United Kingdom
June 2014 ECIG Ten Motives — $104 million United Kingdom
June 2014 PMI Nicocigs — Not disclosed United Kingdom
July 2014 ECIG Hardwire — $30 million Internet
November 2014 Japan Tobacco E-Lites — Not disclosed United Kingdom
January 2015 BreatheEcigs/DNA Breathe LLC — Not disclosed United States
February 2015 Japan Tobacco — Ploom (purchased
the intellectual
rights to some
Ploom technology)
Not disclosed United States
March 2015 Gilla An undisclosed
Florida e-liquid
company
— $1.5 million United States
April 2015 Japan Tobacco Logic — Not disclosed United States
June 2015 Imperial blu — $7.1 billion
United States and
United Kingdom
December 2015 Gilla The Mad Alchemist — $500,000 United States,
Canada, Europe,
and United Arab
Emirates
Source: Various news sources and companies’ websites, SEC (Securities and Exchange Commission) reports, and press releases as of
January 25, 2016.
a
Deal size refers to prices at the time of the announcement, not necessarily the final transaction price.
b
Geography refers to the country in which the acquisition target was registered.
Table4.4
compares and contrasts some key features of the web-
sites by manufacturer affiliation. It shows, for example,
that access to websites of brands developed by cigarette
manufacturers (or a subsidiary) was restricted to users
21 years of age and older (MarkTen), and user registra-
tion was required (i.e., the user needed to input personal
information such as name, address, and birthdate) for
VUSE. In contrast, websites for brands with no affiliation
A Report of the Surgeon General
166 Chapter 4
with a cigarette manufacturer and those acquired by ciga-
rette manufacturers were accessible to users 18years of
age and older via self-reporting of age, with the exception
of 21st Century Smoke. In addition, VUSE e-cigarettes
were not sold online (they were sold only in retail out-
lets), and they were available in a single nicotine level
with limited flavor options (except for forthcoming tank
versions), while MarkTen could be purchased online. The
websites for both MarkTen and VUSE mentioned selling
flavored e-cigarettes. As far as e-cigarette brands not
having an affiliation with a cigarette manufacturer or
that were acquired by a cigarette manufacturer, all brands
except Logic offered fruit, candy, or other flavors. Further,
all of the unaffiliated brand websites sold e-cigarettes
online and offered multiple nicotine levels. Most websites
offered nicotine-free options and flavored e-cigarettes as
well (Seidenberg et al. 2016). The Green Smoke website
even provided a link to guide customers in finding the
proper nicotine level for their cartridges (Green Smoke
E-Vapor n.d.).
Table 4.4 Comparison of website access restrictions, online sales, nicotine levels, and flavors among e-cigarette
brands with no cigarette manufacturer affiliation, brands acquired by cigarette manufacturers, and brands
developed by cigarette manufacturers
E-cigarette brands (10)
Not affiliated with a cigarette
manufacturer: NJOY, Logic,
21st Century Smoke, FIN,
Nicotek, and Mistic (6)
Acquired by a cigarette
manufacturer: blu and Green
Smoke (2)
Developed by a cigarette manufacturer
(or subsidiary): MarkTen and
VUSE(2)
Website access All websites (except 21st
Century Smoke) have one-click
access
a
or age verification to
restrict initial access to people
18 years of age and older; 21st
Century Smoke does not have
any website restrictions for
initial access.
Both sites have one-click
access or age verification to
restrict initial access to people
18 years of age and older (blu)
and 21years of age and older
(Green Smoke).
MarkTen has age verication to restrict
initial access to people 21 years of age
and older. Before initial access, VUSE
requires people 21 years of age and
older to register rst with the website.
Online sales All brands can be purchased
online.
Both brands can be purchased
online.
MarkTen can be purchased online;
VUSE cannot.
Multiple levels of
nicotine
Among all brands, the level
of nicotine varies by product.
Some (e.g., blu, Logic Zero,
21st Century Smoke, Nicotek)
offer products with 0% nicotine
(by volume).
Among both brands, the level of
nicotine varies by product.
For MarkTen, the level of nicotine
varies by product. VUSE e-cigarettes
contain 4.8% nicotine (by weight).
VUSE tanks, set to come out in
February 2016, will have different
levels of nicotine (Kress 2015).
Flavors (other than
tobacco and/or
menthol)
All brands offer a variety of
flavors, such as fruit and candy.
Both brands offer a variety of
flavors.
MarkTen offers two flavors: fusion and
wintermint. VUSE offers four flavors:
crema, chai, berry, and mint (Kress
2015).
Source: Unless cited otherwise, information was obtained from the companies’ websites (January 2016): https://www.njoy.com/;
http://store.logicecig.com/; https://www.21stcenturysmoke.com/; https://www.fincigs.com/; http://www.nicotekecigs.com/;
http://www.misticecigs.com/; http://www.blucigs.com/; https://www.greensmoke.com/; https://www.markten.com/; and
https://vusevapor.com/.
a
With “one-click access,” visitors to a website self-report on their age by identifying their age from a clickable pop-up box. For
example, persons 18 years of age and older can browse the website, but those younger than 18 cannot.
Social Media Promoting E-cigarettes
E-cigarettes have been widely promoted on social
media platforms such as YouTube, Twitter, Instagram, and
Facebook; most of these social media sites do not require
age verification. YouTube is the most popular video-
sharing website globally and features many e-cigarette
videos. Luo and colleagues (2014) used various search
terms to identify 196 unique videos in February 2013
that were portraying e-cigarettes and found that 94%of
the videos were “pro” e-cigarettes, 4% were neutral, and
Activities of the E-Cigarette Companies 167
E-Cigarette Use Among Youth and Young Adults
2% were “anti” e-cigarettes. Those authors found that
the three most common genres were advertising of prod-
ucts, user sharing, and product reviews. Of the “pro”
e-cigarette videos, 84.3% featured links to websites selling
e-cigarettes, and 71.4% claimed that e-cigarettes were a
healthier alternative to conventional cigarettes. Finally,
the “pro” videos received more visits and were rated more
favorably than were the small number of “anti” videos.
The authors of another study, this one a content
analysis of 365 e-cigarette videos on YouTube that ran at
some time from June 2007 to June 2011, estimated that
more than 1.2 million youth and a total of 15.5 million
people worldwide were exposed to these videos (Paek
etal. 2014). In addition to looking at viewership, the con-
tent analysis examined the type, sponsorship, and health
claims of the videos. Just 16% of the videos were formal
advertisements or news clips, and 79.2% of the content
was coded as appearing to have been generated by users.
Videos emphasized economic, psychological, and social
benefits, and health claims included e-cigarettes being
less harmful than conventional cigarettes, healthy, and
providing help in quitting smoking. Most (85.2%) videos
in the sample were sponsored by e-cigarette companies
or their associates, with an additional 10% coming from
individuals who did not mention a specific website or
company. Interestingly, videos sponsored by marketers
contained a significantly lower level of health claims than
did those from laypeople (users) and, not surprisingly,
contained a higher level of information cues (e.g., product
contents, price, distribution channel).
A cross-sectional study of Twitter, a microblogging
platform, that examined more than 74,000 tweets accessed
through a licensed Twitter data provider over a 2-month
period in 2012, found extensive marketing of e-cigarettes
(Huang et al. 2014a). The majority of e-cigarette con-
tent during this period was advertising and promotion.
In fact, 89.6% of the tweets contained commercial con-
tent (e.g., presence of branded promotional messages or
hyperlinks to commercial websites), and only 11% iden-
tified as being non-sponsored or independent, reflecting
individual opinions or experiences, or being linked to non-
promotional content. Commercial tweets most commonly
contained price promotions and discounts (34.3%), with
cessation-related claims included in 10.8% and lower per-
centages for health or safety (Huang et al. 2014a).
Jo and colleagues (2016), in a study of 2,847 tobacco-
related tweets about price promotions and coupons, found
that e-cigarettes, not conventional cigarettes, were the
most frequently mentioned product (90.1%), and about
one-third of all e-cigarette-related tweets included a dis-
count code. The tweets also touted the relatively low price
of e-cigarettes and made comparative claims about the
health risks of the product.
Sponsored Online and Video Advertising
The study by Richardson and colleagues (2015)
used information from the monitoring service
Competitrack to analyze the volume and characteristics of
industry-sponsored tobacco and e-cigarette online banner/
video advertisements in the United States and Canada in
2012–2013. This study found that online banner/video
advertising—which embeds an ad or video on a web-
site—was more commonly used for e-cigarettes than
for conventional cigarettes. E-cigarette ads were often
placed on music or entertainment (39.1%) sites, which
the authors noted attract a sizeable number of youth and
young adults. The most frequent theme for the 24 online
banner or video e-cigarette ads (promoting five e-cigarette
brands) analyzed was that the product was more “green”
or environmentally friendly than conventional cigarettes
(54.2%), followed by less harmful than cigarettes (37.5%),
and being an alternative to conventional cigarettes when
someone could not smoke (33.3%).
E-Cigarettes in the Retail
Environment
Conventional Tobacco Retailers (Convenience
Stores, Pharmacies, Tobacco Shops)
As of December 2015, 48 of the 50 states prohibited
sales of e-cigarettes to minors (National Conference of
State Legislatures 2015), but compliance of retailers with
youth-access laws has not yet been studied. FDA is actively
enforcing the federal minimum age requirements. As of
August 8, 2016, the federal deeming rule bans the sale of
e-cigarettes to minors under the age of 18 and requires
photo identification for those under age 27 (Federal
Register 2016). In the past few years, brick-and-mortar
retailers have surpassed the Internet as the dominant
distribution channel for e-cigarettes. For example, after
Lorillard acquired blu in 2012, the number of retailers
selling this brand increased from 13,000 to 127,000 in
just 1 year (Esterl 2012; Bannon 2013). In California,
the proportion of licensed tobacco retailers that sold
e-cigarettes increased from 12% in 2011 to 67% in 2014
(Chapman2015).
E-cigarettes are widely available in convenience
stores, a type of establishment that 4.1 million U.S.
teenagers visit at least once per week (Rose et al. 2014;
Sanders-Jackson et al. 2015a). According to a 2013 state-
sponsored survey that included a sample of approximately
7,300 licensed tobacco retailers in California, e-cigarettes
were sold in more than half of convenience stores, phar-
macies, and liquor stores and in nearly all tobacco shops
A Report of the Surgeon General
168 Chapter 4
(California Department of Public Health and California
Tobacco Control Program 2014).
Only three studies have examined the retail avail-
ability of e-cigarettes near schools. In a 2012 nationally
representative sample of tobacco retailers, the presence of
a public school within 1,000 feet was not related to the
availability of e-cigarettes (Rose et al. 2014). In a study
that examined a much larger buffer zone in Kentucky,
88% of schools in two counties were located within 1 mile
of a retailer that sold e-cigarettes (Hahn et al. 2015). As
for colleges, disposable and/or rechargeable e-cigarettes
were available at 60% of tobacco retailers near campuses
in North Carolina and Virginia in 2013, a more than two-
fold increase from the previous year (Wagoner et al. 2014).
A pilot study examining tobacco point-of-sale adver-
tising and promotion in the central Harlem neighborhood
of New York City found that 26% of stores had e-cigarette
advertising on the building’s exterior (Ganz et al. 2015).
External ads included those located less than 3 feet above
the ground at the eye level of children—a placement that
was outlawed for conventional cigarettes by the Master
Settlement Agreement—and featured flavored products
(Ganz et al. 2015).
Unlike conventional cigarettes, e-cigarettes appear
to be relatively less prevalent at stores in economically
disadvantaged communities. In an analysis that examined
data from two studies that had used representative sam-
ples of U.S. tobacco retailers, e-cigarettes were less likely
to be sold than conventional cigarettes at stores located in
economically disadvantaged neighborhoods and in neigh-
borhoods with a higher proportion of African American
residents (Rose et al. 2014). These patterns are consistent
with evidence that e-cigarette marketing in other channels
targets higher income non-Hispanic White males (Emery
et al. 2014). However, the retail availability of e-cigarettes
has changed at different rates in different neighborhoods.
In a study of U.S. food stores, only 3% of stores located
in non-Hispanic White and Hispanic neighborhoods sold
e-cigarettes in 2010; none of the stores in predominantly
African American neighborhoods sold them (Khan et al.
2014). Three years later, the figures were 36% in pre-
dominantly non-Hispanic White neighborhoods, 18% in
Hispanic-majority neighborhoods, and 19% in African
American-majority neighborhoods. Notably, these data
were collected before the two largest U.S. tobacco com-
panies launched MarkTen (Altria) and VUSE (Reynolds
American) in late 2013. Thus, the industry’s current
influence on disparities in the retail availability and mar-
keting of e-cigarettes cannot be readily estimated from the
studies reviewed.
Two studies examined retail data about e-cigarettes
as a function of state and/or county smokefree air laws
(Huang et al. 2014b; Rose et al. 2014). In one of the
studies, which used data collected in two studies that used
independent samples of U.S. tobacco retailers, the odds
of selling e-cigarettes were greater for retailers in states
with weaker smokefree air policies, even after control-
ling for store type, price of conventional cigarettes, and
neighborhood demographics (Rose et al. 2014). A similar
inverse relationship was found between sales of dispos-
able e-cigarettes (as measured by retail scanner data in
52U.S. markets from 2009 to 2012) and the proportion
of the population protected by 100% smokefree policies
covering all indoor areas of bars, restaurants, and work-
places (Huang et al. 2014b). Taken together, these results
suggest that e-cigarettes are, at least initially, more likely
to be sold in communities with weaker smokefree policies.
Few retail surveillance studies have characterized
promotion, placement, or price for e-cigarettes (Hsu et al.
2013; Wagoner et al. 2014; Ganz et al. 2015). In a study
of licensed tobacco retailers in Florida, advertising for
e-cigarettes was more prevalent on the exterior than the
interior (50% vs. 11%) (Kim et al. 2015). In the study by
Wagoner and colleagues (2014), the presence of e-cigarette
advertising near college campuses in North Carolina and
Virginia tripled on store exteriors and quadrupled in store
interiors in just 1 year. Although the price of recharge-
able units decreased significantly, there was little evidence
of price discounting for any e-cigarettes (Wagoner et al.
2014). The low visibility of price discounts at the point
of sale suggests that marketing for e-cigarettes favors a
“pull” strategy, relying on direct mail and e-mail coupons
and special offers to entice customers to retail locations.
“Vape Shops”
“Vape shops” specialize in the sale of refillable devices
and tank systems, typically offer a tasting menu of flavors,
and sometimes feature a lounge area where customers can
“vape” while socializing (Lee and Kim 2015; Sussman et al.
2016). “Vape shops” have been excluded from most studies
about the retail marketing of e-cigarettes, in part because
the environment is so different from that of conventional
tobacco retailers (Lee and Kim 2015) and because so few
states require these establishments to obtain a tobacco
retailer license, effectively keeping them out of the sam-
pling frame for many studies and making the monitoring
and enforcement of laws difficult (Lee etal. 2014).
Anecdotal evidence suggests that “vape shops” cur-
rently do not have readily visible branded signs and displays
that characterize the retail marketing of other tobacco
products. Even though the relationship between the “vape
shop” industry and the tobacco industry can be adversarial
(Sussman et al. 2016), one study found that the marketing
practices of these establishments closely resemble the cur-
rent and former strategies that tobacco companies have
Activities of the E-Cigarette Companies 169
E-Cigarette Use Among Youth and Young Adults
used to market other tobacco products (Cheney et al. 2015).
According to this study, “vape shop” owners and managers
in Oklahoma used free samples, loyalty programs, spon-
sored events, direct mail, advertising through social media,
and price promotions targeted at particular consumers,
such as college students (Cheney et al. 2015). No other
study about marketing by “vape shops” has been published.
Numerous gaps exist in research about “vape shops,”
including information on consumer behavior, the use of
tracking systems for sales data, marketing surveillance,
purchases by youth, and the opinions of retailers and
the general public about regulations. Spatial analyses
are needed to determine whether “vape shops” are clus-
tered near schools or college campuses, whether other
neighborhood demographics are correlated with the loca-
tion of these establishments, and how such associations,
if present, have changed over time and in response to state
and local policy interventions. The proportion of “vape
shops” where workers mix solutions of liquid nicotine on
site is not known, and the absence of uniform safety pre-
cautions regarding handling and spills poses additional
concern for regulation (ChangeLab Solutions 2014). Under
the deeming rule that was published in May 2016, “vape
shops” that mix and sell e-liquids are both retailers and
manufacturers and, therefore, are subject to the provisions
in the deeming rule and the Tobacco Control Act that apply
to both (Federal Register 2016).
Exposure and Receptivity to
Advertising for E-Cigarettes
Exposure
Given industry data about increasing expenditures
for e-cigarette advertising and extending its reach, the
high levels of advertising awareness reported in studies of
youth and/or young adults are not surprising. An online
panel of U.S. youth (13–17 years of age) and young adults
(18–21 years of age) conducted in February 2014 found
that awareness of e-cigarette advertising was greatest for
retail advertising, followed by awareness of advertising
on television and online (Truth Initiative 2015). In this
study, and compared with the entire population, aware-
ness among current smokers of e-cigarette advertising
was higher across all channels and higher for online ads
than for television ads (Legacy for Health 2014).
In school-based surveys of middle and high school
students in Connecticut, gas stations and television were
the dominant channels in which students reported recently
seeing e-cigarettes advertised or sold (Krishnan-Sarin et al.
2015). A different pattern was observed in a convenience
sample of college students in Hawaii, where the figures for
seeing ads were 59%, online; 58%, television; 71%, malls;
41%, gas stations; and 47%, convenience stores (Pokhrel
et al. 2015). Elsewhere, in an online experiment, 56%
of adolescents (13–17 years of age) who had never used
e-cigarettes reported seeing at least one televised advertise-
ment previously, and there were modest, but statistically
insignificant differences in exposure by smoking status and
race/ethnicity (p<.10) (Farrelly et al. 2015).
The National Youth Tobacco Survey reported that in
2014, 18.3 million middle and high school students were
exposed to e-cigarette advertising from at least one source
(CDC 2016b). In this nationally representative sample of
U.S. middle and high school students, nearly 7 out of 10
reported seeing an e-cigarette advertisement in that year.
The most common places for exposure among middle
school students were retail stores (52.8%), the Internet
(35.8%), television and movies (34.1%), and newspapers
and magazines (25.0%). Similarly, high school students
reported the highest exposure at retail stores (56.3%) and
then the Internet (42.9%), television and movies (38.4%),
and newspapers and magazines (34.6%). Among both
middle school and high school students, exposure through
retail stores was higher among non-Hispanic Whites than
non-Hispanic Blacks. However, non-Hispanic Blacks had
higher exposure to e-cigarette advertisements on televi-
sion and in movies than non-Hispanic Whites. Females
had higher exposure than males to advertisements on the
Internet and in newspapers and magazines.
Receptivity to Advertising
Receptivity to tobacco marketing is a well-established
risk factor for tobacco use by adolescents and young adults
(NCI 2008; USDHHS 2012), and two studies adapted mea-
sures of receptivity to the marketing of tobacco in research
on e-cigarettes. In one study, college students from
asouthwestern state who watched three advertisements
for different brands of e-cigarettes in an online survey
used a 7-point scale to rate how enjoyable, likable, and
appealing the ads were; results suggested moderate recep-
tivity (mean of 51 on a scale ranging from 7 to 126) and
significant differences between brands (Trumbo and Kim
2015). In the other study, Pokhrel and colleagues (2015),
using a sample of college students from Hawaii, adapted
a multi-item scale of liking advertisements from studies
about alcohol (Unger et al. 2003) and two items from the
most commonly used measure of receptivity to tobacco
marketing (Pierce et al. 1998). This study observed low
levels of liking advertisements (all below the scale mid-
point) (Pokhrel et al. 2015). The extent to which youth
and young adults who are receptive to e-cigarette mar-
keting are also receptive to tobacco marketing has not
been studied. However, the extent to which advertising
A Report of the Surgeon General
170 Chapter 4
strategies for e-cigarettes mimic strategies used by tobacco
companies suggests that the two measures of receptivity
could be highly correlated.
Effect of E-Cigarette Advertising on
Behavior
Associations with E-Cigarette Use and Intentions
to Use
Evidence that advertising for conventional ciga-
rettes increases product initiation among never users,
discourages quit attempts in current users, and encour-
ages relapse in those trying to quit is well established (NCI
2008; USDHHS 2012). However, while fewer studies have
focused on e-cigarette advertising in particular, the avail-
able evidence suggests that e-cigarette advertising has
similar effects, although additional research is recom-
mended. A search for studies of youth or adults that either
(a)manipulated exposure to e-cigarette advertising or mea-
sured self-reported recall of advertisements, (b) assessed
the frequency of exposure to advertising in one or more
channels, or (c)measured receptivity to e-cigarette adver-
tising yielded 10 studies that addressed the impact of
advertising on the use of or intentions to use e-cigarettes.
One experiment tested whether seeing television
advertising for e-cigarettes predisposed adolescents to try
these products (Farrelly et al. 2015). Among adolescents
(13–17 years of age) who had never used e-cigarettes,
asingle exposure to a set of four televised advertisements
for popular brands resulted in significantly greater inten-
tion to try e-cigarettes—more than 50% higher in the
treatment group than the control group (Farrelly et al.
2015). Another study examined responses to e-cigarette
advertisements among young adults (Trumbo and Kim
2015); among a convenience sample of college students
who watched three television ads for e-cigarettes, greater
receptivity to e-cigarette advertising was associated with
significantly higher odds of intending to use e-cigarettes
in the future, but the analysis did not adjust for prior use
or individual demographics (Trumbo and Kim 2015).
Very few cross-sectional or longitudinal surveys have
examined associations between adolescents’ exposure to
e-cigarette advertising and either trial or regular use of
such products. An analysis of the 2011 National Youth
Tobacco Survey found that adolescents who reported fre-
quent exposure to protobacco advertising at the point
of sale and on the Internet (e.g., seeing ads most of the
time or always) had significantly higher odds of ever using
e-cigarettes, and there was a dose-response association
between the number of marketing channels to which they
were exposed and ever use (Agaku and Ayo-Yusuf 2014).
Surveillance research that differentiates exposure to
advertising for e-cigarettes from exposure to ads for con-
ventional tobacco products would be useful to establish
whether exposure to e-cigarette advertising is correlated
with product use and contributes to product initiation and
product use among young people who were not tobacco
users to start. It bears mentioning here that a genera-
tion of U.S. youth has grown up without any television or
billboard ads for conventional cigarettes. In this context,
research is needed to understand at what age young people
understand that e-cigarette advertising depicts the use of
e-cigarettes rather than the smoking of conventional ciga-
rettes and to examine whether there are spillover effects
of marketing for e-cigarettes on the use of conventional
tobacco products.
In the study from Hawaii (Pokhrel et al. 2015),
researchers examined the association between exposure
to e-cigarette advertising and product use using a conve-
nience sample of approximately 300 college students in
that state. The study found that more frequent exposure
to e-cigarette advertising—as measured by exposure in
any of multiple channels (e.g., newspapers, magazines,
Internet, television billboards, sporting/cultural events,
convenience stores, gas stations, grocery stores, and
malls)—was associated with significantly higher odds
of ever using e-cigarettes, and receptivity to e-cigarette
advertising was associated with higher odds of past-month
use, even after adjustments for smoking status and indi-
vidual demographics.
Two studies strongly support the association between
exposure to e-cigarette advertising and youth suscepti-
bility to and use of e-cigarettes (CDC 2016a; Mantey et al.
2016). Both studies examined data from the 2014 National
Youth Tobacco Survey, a survey of more than 20,000 U.S.
middle and high school students. The studies assessed
self-reported levels of exposure to e-cigarette ads on the
Internet, in newspapers and magazines, at retail stores,
and on television or in movies, and used multivariate
logistic regression models to examine the relationships
between marketing exposure and e-cigarette susceptibility
and use. Exposure to each type of e-cigarette marketing
was significantly associated with increased likelihood of
ever having used and current use of e-cigarettes among
middle and high school students (CDC 2016a; Mantey et
al. 2016). Exposure was also associated with susceptibility
to use e-cigarettes among current nonusers. In multi-
variate models, as the number of channels of e-cigarette
marketing exposure increased, the likelihood of use and
susceptibility also increased (Mantey et al. 2016).
One concern is that e-cigarette advertising may
perpetuate dual use of conventional cigarettes and
e-cigarettes, a concern that comes from the visual depic-
tions of e-cigarette use that may serve as smoking cues
Activities of the E-Cigarette Companies 171
E-Cigarette Use Among Youth and Young Adults
to current and former smokers of conventional ciga-
rettes, increasing the urge to smoke and decreasing inten-
tions and efficacy to quit or abstain from smoking (Glynn
2014; Grana and Ling 2014; Maloney and Cappella 2016).
Consistent with cue-reactivity studies about conventional
cigarettes, exposure to e-cigarette use in a laboratory was
associated with increased urge to smoke conventional cig-
arettes among smokers and an urge to use e-cigarettes
among users of that product (King et al. 2015). Whether
exposure to depictions in advertising of the use of
e-cigarettes triggers urges to begin or continue to smoke
conventional cigarettes or weakens users’ resolve to quit
has received little attention. This is particularly important
because rates of cigarette smoking among youth in the
United States are at an historic low (CDC 2014).
Associations with Knowledge, Risk Perceptions,
and Other Attitudes
Advertising is an important source of information
about e-cigarettes for youth and adults (de Andrade et al.
2013; Pepper et al. 2014a), and there is emerging evidence
about how unregulated advertising for e-cigarettes may
influence consumer perceptions about product safety.
One study of adolescents (Farrelly et al. 2015) and three
studies of adults (Pokhrel et al. 2015; Sanders-Jackson
et al. 2015b; Tan et al. 2015a) examined the associations
between exposure to e-cigarette advertising and knowl-
edge or perceptions of these products.
Among U.S. adolescents (13–17 years of age) who
had never used e-cigarettes, a single exposure to a set of
four televised advertisements was associated with signifi-
cantly higher odds of agreeing that the products can be
used without affecting those around you and with lower
odds of agreeing that the products are harmful (Farrelly
et al. 2015). Compared with the control group, the treat-
ment group reported significantly more positive attitudes
about the benefits of using e-cigarettes. Elsewhere, in an
online survey representative of U.S. households, 57% of
young adults (18–34 years of age) were aware that some
e-cigarettes contain nicotine, but more frequent expo-
sure to e-cigarette advertising at point of sale, in mass
media, and in social media (the three variables combined)
was associated with a significantly higher likelihood of
answering this question incorrectly (Sanders-Jackson
etal. 2015b).
In the previously cited study of college students
in Hawaii (Pokhrel et al. 2015), greater receptivity to
e-cigarette marketing—but not more frequent exposure
to the advertising of these products—was associated with
significantly greater endorsement of beliefs about harm
reduction for e-cigarettes (e.g., safer, improves health,
helps to quit). A different study referred to an online
survey of U.S. adults (the Annenberg National Health
Communication Survey [ANHCS]) in which surveyors
measured the frequency of exposure to e-cigarette adver-
tising (point of sale, mass media, and social media) and
the degree to which participants perceived those mes-
sages as negative or positive (Tan et al. 2015a). Compared
with those who reported no exposure to advertising,
those who held negative perceptions of these messages
reported significantly greater perceptions of harm from
breathing e-cigarette vapor. Taken together, the available
evidence suggests that continued exposure to unregulated
advertising likely promotes reduced perceptions of harm
and toxicity and increased perceptions of the efficacy of
e-cigarettes for quitting conventional cigarettes.
Whether the increasing amount of advertising and
promotional activities for e-cigarettes serves to renor-
malize the smoking of conventional cigarettes—that
is, to shift public norms back to acceptance of cigarette
smoking—is also not known. In focus groups of adult
smokers 45 years of age and older, participants expressed
almost unanimous agreement, after seeing selected ads,
that e-cigarette advertisements promote smoking as
a socially desirable behavior (Cataldo et al. 2015). The
analysis by Farrelly and colleagues (2015) also looked at
outcomes for conventional cigarettes. After exposure to
e-cigarette advertising, there were no significant differ-
ences between the treatment and control groups on inten-
tions to smoke conventional cigarettes, attitudes toward
those products, or perceived harm from cigarettes (even
though there were differences between groups on their
perceptions of e-cigarettes, as noted previously).
The study that used data from the ANHCS also tested
the hypothesis that greater exposure to e-cigarette adver-
tising was associated with weaker support for restricting
cigarette smoking in public spaces (Tan et al. 2015b). Both
more frequent exposure to e-cigarette advertising and the
degree to which participants perceived those messages as
positive correlated negatively with support for smoking
restrictions. However, in models adjusted for demographic
variables, neither measure predicted support for restricting
smoking. Further research is needed to address whether
the large amount of advertising for e-cigarettes weakens
support for smokefree air laws and other tobacco control
policies or supports other potential indicators of renormal-
izing smoking, particularly those indicators that are known
risk factors for tobacco use by adolescents and young
adults, such as descriptive norms (e.g., perceived preva-
lence), injunctive norms (e.g., peer acceptance or social
acceptability), outcome expectations (e.g., perceived bene-
fits), and attitudes toward the tobacco industry. Additional
research is also needed to assess whether e-cigarette adver-
tising that draws comparisons to conventional cigarettes
could serve to undermine antismoking messages.
A Report of the Surgeon General
172 Chapter 4
Evidence Summary
Although the e-cigarette marketplace is complicated
by the differences in brands that are owned by tobacco
companies versus independent brands, e-cigarette com-
panies continue to change and to influence the manufac-
turing, price, marketing and promotion, and distribution
of e-cigarette products and accessories. The e-cigarette
market continues to grow, with projected sales of $3.5bil-
lion in 2015. Consolidation of e-cigarette companies has
been rapid, with the first major merger taking place in
2012. These mergers and acquisitions are likely to con-
tinue, but the rate of consolidation may slow down as sales
of cigalikes decelerate, and “vape shops” could have the
potential to influence the e-cigarette marketplace based
on the current structure of the marketplace and a regula-
tory landscape where federal regulation is just beginning
to be implemented. All of these factors create additional
uncertainties and risks for both the existing independent
e-cigarette companies and the large cigarette companies.
This chapter has shown that many of the marketing tech-
niques used by e-cigarette companies are similar to those
used by the tobacco industry for conventional cigarettes,
and that awareness by youth and young adults of this mar-
keting, and their levels of exposure to it, is high. Further,
tracking marketing expenditures and product sales is dif-
ficult because of the rapidly changing venues, including
“vape shops,” use of social media, and online advertising.
Conclusions
1. The e-cigarette market has grown and changed
rapidly, with notable increases in total sales of
e-cigarette products, types of products, consolida-
tion of companies, marketing expenses, and sales
channels.
2. Prices of e-cigarette products are inversely related
to sales volume: as prices have declined, sales have
sharply increased.
3. E-cigarette products are marketed in a wide variety
of channels that have broad reach among youth and
young adults, including television, point-of-sale,
magazines, promotional activities, radio, and the
Internet.
4. Themes in e-cigarette marketing, including sexual
content and customer satisfaction, are parallel to
themes and techniques that have been found to be
appealing to youth and young adults in conventional
cigarette advertising and promotion.
Activities of the E-Cigarette Companies 173
E-Cigarette Use Among Youth and Young Adults
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181
Chapter 5
E-Cigarette Policy and Practice Implications
Introduction 183
Critical Issues Related to Policies on E-Cigarettes in 2016 184
The E-Cigarette Landscape Is Dynamic and Evolving 184
Risk Tradeoffs Are Inherent for E-Cigarettes 184
Additional Evidence Suggested for Future Research 185
Potential Public Policy Approaches 187
Clean Indoor Air Policies 188
Prevent Youth Access 203
Licensing 203
Taxation and Other Price Policies 204
Restrictions on Marketing 205
Educational Initiatives 206
Implications for Health Care Practice 206
Case Studies 224
Summary and Recommendations 225
Conclusions 226
References 227
E-Cigarette Policy and Practice Implications 183
E-Cigarette Use Among Youth and Young Adults
Introduction
The previous chapters have set out what is currently
known and not known about e-cigarettes. Despite the
identified gaps in evidence and the dynamic, evolving pat-
terns of the use of e-cigarettes, policy options are needed.
These policy options are particularly important as they
affect the use of e-cigarettes by youth and young adults.
As this report has demonstrated, e-cigarettes are widely
used by youth and young adults and are particularly risky
for these age groups, and efforts to prevent their use by
young people are needed. This chapter explores the policy
landscape of e-cigarettes and sets forth recommendations
that should protect the public’s health, particularly as
these policies relate to the short- and long-term health of
youth and young adults.
The Family Smoking Prevention and Tobacco
Control Act of 2009 (or Tobacco Control Act) (2009) is
meant to protect the health of the public, including young
people. As previously discussed, on May 10, 2016, FDA
published a final rule which deemed all other products,
including e-cigarettes, meeting the definition of a tobacco
product, except accessories of such products, to be sub-
ject to the Federal Food, Drug, and Cosmetic Act. This
rule went into effect on August 8, 2016 (Federal Register
2016). Under the Tobacco Control Act, FDA likely will be
required to consider the consequences of e-cigarette use
for those who do not use tobacco products (as well as for
those who do).
It can be stated that public health will be harmed if
the availability of e-cigarettes:
• Increases exposure to nicotine among youth and
young adults;
• Leads to the initiation of combustible tobacco
smoking;
• Slows or prevents cessation of combustible products
by nicotine-addicted smokers; or
• Increases the likelihood that former smokers will
again become addicted to nicotineand/or use com-
bustible products after being reintroduced to nico-
tine by e-cigarettes.
Potential harm also comes from secondhand expo-
sure to the vapor or aerosol expelled from e-cigarette
users. Secondhand exposure comes from inhaling the
aerosol or contacting vapor-contaminated surfaces. Each
of the potential negative consequences of the availability
of e-cigarettes could lead to additional disease and prema-
ture mortality (Chapter 3).
Relative to efforts in cigarette and smokeless tobacco
use prevention and control, a polarized debate has been in
progress for several years over the role of e-cigarettes. There
is general agreement that exclusive use of e-cigarettes poses
a lower health risk to the individual than the extremely high
health risks of using conventional, combustible tobacco
products (Farsalinos and Polosa 2014; Grana et al. 2014a,b),
although more research is needed on this as more becomes
known about the harmful constituents of e-cigarettes
(Sleiman et al. 2016). The controversy reflects the relative
degree of emphasis given to the potential harm to adoles-
cents and young adults from using e-cigarettes at one pole
compared with the potential for reduced risk for estab-
lished adult users of conventional cigarettes at the other (if
they transition completely to e-cigarettes). Although this
characterization does not reflect the complexity of the sit-
uation, it is useful in defining the potential tradeoffs that
are implicit: increased numbers of young people who are
exposed to nicotine (and who may go on to conventional
tobacco products) versus reduced health risks to individ-
uals who completely switch from conventional, combus-
tible tobacco products with their extremely high health
risks. The discussion has become increasingly complicated
as e-cigarette use has increased, and still-incomplete evi-
dence potentially supports the views of those holding to
both poles of the argument about reducing harm for the
overall population. However, the majority of currently
available scientific evidence does not support the recom-
mendation to use e-cigarettes for the cessation of ciga-
rette smoking (Hartmann-Boyce et al. 2016). Additionally,
the use of e-cigarettes does not pose benefits to youth and
young adults, and some data suggest that use of e-cigarettes
could lead to the more harmful use of conventional ciga-
rettes. In the context of young people, the precautionary
principle should apply. The precautionary principle is
defined by the United Nations Educational, Scientific and
Cultural Organization (2005) as appropriate “when human
activities may lead to morally unacceptable harm that is sci-
entifically plausible but uncertain, actions shall be taken to
avoid or diminish that harm” (p.14).
A Report of the Surgeon General
184 Chapter 5
Critical Issues Related to Policies on E-Cigarettes in 2016
The E-Cigarette Landscape Is
Dynamic and Evolving
Considerations of policy approaches to e-cigarettes
offered in this report are made in the context of a rap-
idly changing marketplace for nicotine-containing prod-
ucts that now includes primarily conventional cig-
arettes, cigars, smokeless products, hookahs, and
e-cigarettes (see Chapter 2). The manufacture and sales
of nicotine-containing products, once dominated by a few
large companies selling conventional cigarettes, have been
transformed and now include many smaller companies
that manufacture and sell through stores and “vape shops.”
E-cigarettes are also sold through websites and in places
where conventional cigarettes have long been available—
convenience stores, pharmacies, gas stations, and grocery
stores. Currently, hundreds of different e-cigarette products
are on the market: designs are evolving rapidly, and major
tobacco companies have their own lines of e-cigarette prod-
ucts. However, unlike the situation in the past in which the
marketing of conventional tobacco products changed rela-
tively slowly and there were limited media outlets, informa-
tion about e-cigarettes is now promoted quickly through
new media, as well as television, in part to reach key target
groups, including youth and young adults.
As documented in Chapter 2, patterns of use are rap-
idly changing among adolescents and young adults, and
likely among other groups within the population. For some
of the most critical issues related to e-cigarettes, longitu-
dinal data are not yet available because the use of these
products is recent and constantly changing, and whether
and when the patterns of use will stabilize is uncertain.
Additionally, surveillance data and research on the wide-
ranging consequences of e-cigarette use, including such
key issues as the likelihood of addiction and other health
problems for users and those passively exposed, are lag-
ging behind the highly dynamic changes in the nicotine-
product marketplace and the impact of these changes on
the use of tobacco products, including e-cigarettes.
With regard to the potential health consequences of
using e-cigarettes, estimates can be made based on knowl-
edge of the characteristics and components of the aerosols
that are then inhaled. Unfortunately, evidence on short-
term risks is limited, and long-term risks have not yet been
identified because this would require monitoring users for
years. For example, the impact of long-term inhalation of
flavorings is not yet known. While some of the flavorings
used in e-cigarettes are generally recognized as safe for
ingestion as food, the health effects of their inhalation are
generally unknown, and some flavorings have been shown
to cause a serious lung disease, bronchiolitis obliterans,
when inhaled (Kreiss et al. 2002; Barrington-Trimis et al.
2014). Whether the risk of lung disease or other disorders
is truly substantial will require longer term epidemiologic
and other research (Allen et al. 2016).
Thus, policy approaches must support control mea-
sures that (a) are as dynamic as the rapidly changing mar-
ketplace for e-cigarettes; (b) are supported by surveillance
data; and (c) document in timely fashion the current status
of the use of multiple types of tobacco products (including
e-cigarettes); the emergence of state, local, tribal, and terri-
torial policies; and the strategies being used to market these
products.
Risk Tradeoffs Are Inherent for
E-Cigarettes
Policy discussions about e-cigarettes have highlighted
the potential tradeoffs in risk that could occur, particularly
if e-cigarettes are positioned as a harm-reducing alterna-
tive to combustible tobacco products. Some have charac-
terized these products as new technologies that might lead
to a dramatic decline in the use of more dangerous forms
of nicotine delivery, particularly conventional cigarettes
and other combustible tobacco products (Abrams 2014;
Cobb and Abrams 2014; Fagerström and Bridgman 2014;
Grana et al. 2014a; Hajek et al. 2014; Henningfield 2014;
Schraufnagel et al. 2014; West and Brown 2014; Lindblom
2015). Correspondingly, e-cigarettes have been proposed by
some as a harm-reduction strategy and as a tool for smoking
cessation, but the data to date do not support e-cigarettes
for harm reduction or cessation (Siegel et al. 2011; Abrams
2014). By contrast, others are concerned that the avail-
ability of these new products will expand the number of
youth and young adults who are exposed to nicotine and
will eventually lead to exclusive use of other conventional
tobacco products or dual use of both (e-cigarettes and con-
ventional cigarettes) (Leventhal et al. 2015; Primack et al.
2015). Early longitudinal evidence provides some support
for these concerns, although further research on this issue
is still warranted.
As reviewed in Chapter 3, uncertainty remains
about the health effects of e-cigarettes, particularly in the
long term. Such effects will remain unknown until suffi-
cient observations can be made over time. However, cur-
rent knowledge of the characteristics of the inhaled aerosol
from e-cigarettes suggests that if a current adult smoker of
E-Cigarette Policy and Practice Implications 185
E-Cigarette Use Among Youth and Young Adults
conventional cigarettes or other combustible tobacco prod-
ucts would use e-cigarettes exclusively instead of combusti-
bles as a substitute nicotine delivery system, either en route
to quitting tobacco completely or even as a long-term
alternative, the risks of tobacco-related diseases would be
reduced substantially compared with the risk imparted by
continued smoking of conventional cigarettes (Fiore et al.
2014; USDHHS 2014; McNeill et al. 2015).
Still, as documented in Chapter 3, immediate and
future health risks for youth and young adults who use
e-cigarettes can be anticipated from exposure to nicotine,
including addiction and harmful effects on brain develop-
ment. Research must continue to characterize and quan-
tify the full spectrum of potential health risks. Thus, in
formulating policies related to the role of e-cigarettes
in tobacco control and reducing the burden of tobacco-
related disease, particularly among youth and young
adults, e-cigarette products that deliver nicotine cannot
be considered a risk-free alternative to conventional ciga-
rettes or other combustible tobacco products.
Any analysis of the potential increased risks and
reduced harms of e-cigarette use also needs to consider
data on the actual patterns of use because more of the
risks affect youth and young adults and most of the poten-
tial benefits from reduced risk to health largely accrue
to older cigarette smokers (Chapter 2). However, the
reports of the tobacco industry to investors indicate the
industry’s interest in maintaining a broad pattern of use
of nicotine-containing products, including conventional
cigarettes, for decades to come (Calantzopoulos 2015).
When considered in the context of the tobacco industry’s
past changes to product design (e.g., the creation of so-
called “low-tar” cigarettes), the broader array of tobacco
products now being discussed within the tobacco indus-
try’s plans (e.g., “Heat-Not-Burn” products) could slow
cessation (because smokers have historically been drawn
to reduced-harm products) and thus the overall decline of
tobacco-related diseases (USDHHS 2014).
The dynamic balancing between risks and potential
benefits of e-cigarette use will be swayed by the impact of
such use on the use of other tobacco products by youth
and young adults over time. The availability of e-cigarettes
could adversely affect the use of tobacco products in
this group by slowing the decline of smoking because
this population will be exposed to nicotine and possibly
become addicted to that substance. Indeed, data reviewed
in Chapter 2 show evidence of such trends. Although
the decline in rates of smoking conventional cigarettes
and other combustible tobacco products is viewed uni-
versally as positive, the increasing number of youth and
young adults who use e-cigarettes is a serious concern for
all the reasons cited above. West and Brown (2014) and
McNeill and colleagues (2015) suggest that the limited
evidence from the United Kingdom does not support the
concern that using e-cigarettes leads to the use of other
tobacco products, and they maintain that the new adoles-
cent users of these e-cigarette products include very few
never smokers. However, the marketing of e-cigarettes is
quite different between the United Kingom and the United
States, and the patterns of use, particularly among youth,
are also quite different (European Parliament and Council
2014; England et al. 2015; Klein 2015; Leventhal et al.
2015; Primack et al. 2015; Barrington-Trimis et al. 2016;
Wills et at. 2016; Institute for Global Tobacco Control
n.d.). This pattern is also evident in some U.S. survey
data from early in the era of e-cigarette use (as reviewed
in Chapter 2), but not in more recent data, which indi-
cate that e-cigarette products may contribute to nicotine
addiction in a new generation of young people and thereby
lead to increased use of a variety of nicotine delivery prod-
ucts, including combustible tobacco (Bauld et al. 2016;
CDC 2016).
Fundamentally, the public health challenge and the
charge to policy development can be framed as balancing
the potential use of e-cigarettes as a new technology to
reduce the use of combustible tobacco products against
the possibility of expanding tobacco use among non-using
youth and young adults, long-term former smokers, and
other vulnerable populations (e.g., women of reproduc-
tive age and individuals with significant comorbidities,
including those with mental health problems). Already, the
e-cigarette companies are increasing the appeal of their
offerings by enhancing the efficiency of nicotine delivery
and using flavorings while they continue to advertise and
promote their products aggressively.
Additional Evidence Suggested for
Future Research
To characterize the critical balance for public health
between the harms and potential benefits of e-cigarettes,
more evidence on each of the elements that determine
that balance would be useful (Table 5.1). The needed
data would come from surveillance of patterns of adop-
tion of e-cigarettes and their use among the popula-
tion generally, and particularly among the most critical
populations for uptake: youth and young adults, former
smokers, smokers, and other populations that are particu-
larly at risk for adverse outcomes. Few studies have been
done on the health risks posed by e-cigarettes and their
potential effectiveness for smoking cessation (Hartmann-
Boyce et al. 2016). However, as discussed in Chapter 2,
there are still no standardized questions for research on
A Report of the Surgeon General
186 Chapter 5
e-cigarettes, and there is a need for further testing and
development of e-cigarette questions and measurements.
Table 5.1 Comparative risk assessment: Potential harms and benefits of e-cigarettes
Harms Benefits
Increased youth exposure to nicotine and potentially greater
initiation of conventional cigarettes
Reduced disease risk for current smokers who completely switch
to e-cigarettes
Slowing cessation by smokers due to nicotine addiction Reduced disease morbidity for smokers with existing heart or
lung disease who switch to e-cigarettes
Nicotine addiction in former smokers who begin to use
e-cigarettes and possibly transition back to smoking
Potential for cessation of combustible products
Renormalization of nicotine use and smoking as acceptable Fewer users of combustible products in the entire population
Future disease risks for youth who are exposed to nicotine
Increasing the dual use of e-cigarettes with combustible
products
Serving as a “gateway” to the initiation of tobacco smoking
Increased disease risk vs. complete cessation among those who
use both e-cigarettes and combustible products
Exposure to secondhand aerosol and lack of clean air
To characterize the harms and benefits of e-cigarettes
to public health, models are used to project their overall
impact on public health (Levy et al. 2016). The use of mod-
eling was described in detail in the 2014 Surgeon General’s
report (USDHHS 2014). Conceptual models are needed to
define the potential scenarios of changes in patterns of use
among youth, young adults, adult smokers, former smokers,
and other significant vulnerable populations. Figure 5.1 dis-
plays the range of patterns that are emerging with the wider
adoption of e-cigarettes (Cobb et al. 2015; Vugrin et al. 2015).
Researchers and public health officials can use dynamic
population models (Mejia et al. 2010; Kalkhoran and Glantz
2015; Vugrin et al. 2015; Levy et al. 2016) to analyze the
potential impact on population health of the relative prob-
abilities of these various paths. Initial modeling has shown
that the potential population health benefits are very sensi-
tive to several factors: the levels of product risk, particularly
those of e-cigarettes; patterns of initiation and switching; and
the extent of dual use (Mejia et al. 2010; Cobb et al. 2015;
Kalkhoran and Glantz 2015; Vugrin et al. 2015). The ben-
efits of smoking cessation, particularly as early in life as pos-
sible, are well documented, but the epidemiologic evidence
that reducing (but not quitting) cigarette consumption can
lower the risk of all-cause mortality, or mortality from car-
diovascular diseases, remains inconclusive (USDHHS 2014).
Thus, more research is needed to better characterize the
health consequences of dual use, in particular, in compar-
ison to the recognized health benefits of complete smoking
cessation (or potentially only e-cigarette use). Similarly, the
health risks to former smokers who become exposed again
to nicotine through e-cigarettes are uncertain. Data are still
limited on the risk of starting (or not starting) to smoke con-
ventional cigarettes again (after successful cessation) fol-
lowing exposure to nicotine via e-cigarettes.
As reviewed in Chapter 3, the long-term health risks
of e-cigarettes will not be known for decades, although evi-
dence to date suggests that they are generally less harmful
than combustible products. However, less harmful is not
the same as harmless. A substantial amount of evidence
is available on some components of the aerosols inhaled
by e-cigarette users. For many people, exposure to aerosol
could occur across much of the life span, beginning in
adolescence and even in childhood, when the lungs and
brain are still developing. Flavorings are of particular con-
cern with regard to pulmonary toxicity, as are the various
effects of nicotine on the brain. Although the National
Institutes of Health is now supporting a growing program
of research on e-cigarettes, critical questions have not yet
been answered. Given experiences with conventional ciga-
rettes, long-term studies will be needed to identify the full
health consequences of using e-cigarettes.
Thus, policies related to e-cigarettes will necessarily
be made in the context of accumulating but incomplete
evidence. The landscape is changing rapidly and, inevi-
tably, research cannot keep pace. Quoting Sir Austin
Bradford Hill’s landmark paper on environment and dis-
ease: “All scientific work is incomplete—whether it be
observational or experimental. All scientific work is liable
to be upset or modified by advancing knowledge. That
does not confer on us a freedom to ignore the knowledge
we already have, or to postpone the action that it appears
to demand at a given time” (Hill 1965, p. 300).
E-Cigarette Policy and Practice Implications 187
E-Cigarette Use Among Youth and Young Adults
Figure 5.1 Potential patterns of use of combustible products (CPs) and e-cigarettes (e-cigs)
Source: USDHHS (2014). Adapted for this report.
Potential Public Policy Approaches
In formulating public policies related to e-cigarettes,
the context and possibilities vary across the national,
state, local, tribal, and territorial governments and public
entities. At the national level, progressive steps are being
taken by FDA under the Tobacco Control Act. In 2010,
the U.S. Court of Appeals for the D.C. Circuit determined
that e-cigarettes and other products made or derived from
tobacco may be regulated by FDA as tobacco products
under the Tobacco Control Act and are not drugs or devices
unless marketed for therapeutic purposes, such as being
an aid to smoking cessation (Sottera, Inc. v. Food and
Drug Administration 2010). In May 2016, FDA released
its deeming rule to regulate the sale and distribution of
e-cigarettes as a tobacco product (see Chapter 1) (Federal
Register 2016). The rule is currently under litigation. The
rule restricts the age of sale to those 18 years of age and
older and requires retailers to check the age identification
of young people under age 27, restricts vending machines
to adult-only facilities, prohibits free samples, requires a
health-warning statement about nicotine on packaging
and in advertisements, requires domestic manufacturers
to register their products and disclose the ingredients
of their products, requires the reporting of the levels of
harmful and potentially harmful constituents to FDA,
allows FDA to review any new or changed products before
being sold, and requires manufacturers to show scientific
evidence that demonstrates the overall public health ben-
efit of any product before it can be marketed as a modified
risk tobacco product (Federal Register 2016). The Tobacco
Control Act does not provide FDA with authority to impose
taxes on tobacco products (Bhatnagar et al. 2014; Huang
et al. 2014; Tobacco Control Legal Consortium 2015) or
A Report of the Surgeon General
188 Chapter 5
regulate indoor air quality (Schripp et al. 2013; Bam et al.
2014; Bhatnagar et al. 2014; Brandon et al. 2015a), occu-
pational health and safety (USDHHS 2015; Whitsel et al.
2015), or hazardous waste disposal (Chang 2014; Krause
and Townsend 2015).
FDA is not the only federal agency with potential
jurisdiction over some aspect of e-cigarettes (Table 5.2).
For example, the U.S. Department of Defense and U.S.
Department of Veterans Affairs relate to specific popula-
tions, and other agencies relate to regulatory activities, such
as the U.S. Federal Trade Commission, U.S. Department
of Transportation, and the U.S. Environmental Protection
Agency. Some agencies have coverage over specific areas,
such as the General Services Administration and the
National Park Service.
State, local, tribal, and territorial governments, as well
as private entities, may also address these and other mat-
ters that are covered by the Tobacco Control Act (Freiberg
2012), and since 2010 many actions have been taken at
the nonfederal level. State and local governments may uti-
lize effective interventions that would also be expected to
apply to e-cigarettes: increasing the price of tobacco prod-
ucts through taxation (Community Preventive Services
Task Force 2012); creating and enforcing clean air policies
(Hopkins et al. 2010); and passing comprehensive laws pro-
hibiting sales to minors, combined with active enforcement
(Community Preventive Services Task Force 2001). In addi-
tion, based on evidence that new e-cigarette products may
addict a generation of young people to nicotine (Bunnell
et al. 2015; CDC 2015b) and on mounting indications about
potential harm from the use of these products in this popu-
lation (Flouris et al. 2013; Barrington-Trimis et al. 2014;
Goniewicz et al. 2014; Grana et al. 2014a; Pisinger and
Dossing 2014; Goniewicz and Lee 2015), numerous health
organizations have called for the extension of smoking-
related policies to e-cigarettes (Association of State and
Territorial Health Officials 2014; Bam et al. 2014; Bhatnagar
et al. 2014; Offermann 2014; Schraufnagel et al. 2014; World
Health Organization 2014a; Brandon et al. 2015a; USDHHS
2015). In the absence of causal findings that have guided
evidence-based tobacco control for decades, the “precau-
tionary principle” is relevant to decision makers as a guide
to action to address e-cigarettes among youth and young
adults. This principle supports intervention to avoid pos-
sible health risks when the potential risks remain uncertain
and have been as yet partially undefined (Bialous and Sarma
2014; Saitta et al. 2014; Hagopian et al. 2015). However, the
interventions should be appropriate to the currently per-
ceived risk for future health consequences, in this case
from e-cigarette use by youth, young adults, and pregnant
women, as well as from the secondhand exposure of non-
users to e-cigarette vapor.
Clean Indoor Air Policies
Clean indoor air or smokefree policies prohibit
the use of conventional tobacco products in indoor
public places, such as worksites, restaurants, bars, and
casinos. Because most of these policies predate the rise
of e-cigarettes, their language does not necessarily
cover emissions from these products. To protect the
public from both secondhand smoke and secondhand
aerosol, smokefree air policies should be modernized
to include e-cigarettes. Such policies will maintain cur-
rent standards for clean indoor air, reduce the potential
for renormalization of tobacco product use, and prevent
involuntary exposure to nicotine and other aerosolized
emissions from e-cigarettes (Ingebrethsen et al. 2012;
Schripp et al. 2013; Goniewicz et al. 2014; Offermann
2014; Schober et al. 2014). Updating existing policies to
cover e-cigarettes (and all electronic nicotine delivery sys-
tems) will eliminate the introduction of airborne toxins
into enclosed spaces and establish a uniform standard for
preventing the use of both combustible and electronic
tobacco products in public and private spaces, including
schools, offices, restaurants, bars, casinos, and airplanes.
Prohibiting the use of e-cigarettes in enclosed
spaces eliminates potential health risks to nonusers and
ensures their right to clean air; may discourage the dual
use of electronic and combustible tobacco products; sim-
plifies public compliance with and enforcement of existing
clean indoor air laws; facilitates reduced consumption of
these products; and maintains clear, comprehensive non-
smoking norms (Richardson et al. 2014; World Health
Organization 2014a). As of January 1, 2016, six states
(Delaware, Hawaii, New Jersey, North Dakota, Oregon,
and Utah) had passed comprehensive smokefree indoor
air laws that include e-cigarettes (CDC 2015a). These laws
prohibit smoking and the use of e-cigarettes in indoor
areas of private worksites, restaurants, and bars. Sixteen
additional states had prohibited the use of e-cigarettes on
some or all state property, and 475 local laws restricted
e-cigarette use in 100% smokefree venues (Americans for
Nonsmokers’ Rights Foundation 2015). Nationwide, more
than 400 local jurisdictions prohibit e-cigarette use in
100%-smokefree workplaces (Americans for Nonsmokers’
Rights Foundation 2015). Major cities that have addressed
e-cigarettes include Austin, Boston, El Paso, Chicago, Los
Angeles, Minneapolis, San Francisco, and New York City.
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 189
Table 5.2 Principle federal policies and regulations of tobacco that emphasize e-cigarettes
Agency
Authority and
description Current Potential
Executive Office
of the President
(EOP) and Office
of Management
and Budget
(OMB)
— Executive Order 13058, issued on August 9, 1997 (EOP 1997), generally prohibits
the smoking of tobacco products in all interior space owned, rented, or leased by
the executive branch of the federal government, and in any outdoor areas under
executive branch control in front of air intake ducts. The Executive Order carves
out an exception to its smoking prohibition for any residential accommodation for
persons voluntarily or involuntarily residing, on a temporary or long-term basis,
in a building owned, leased, or rented by the federal government.
—
Executive Office
of the President
(EOP) and Office
of the U.S. Trade
Representative
(USTR)
— Executive Order 13193, issued January 18, 2001 (EOP 2001), prohibits all U.S.
executive branch agencies from promoting the sale or export of tobacco. It also
prohibits using U.S. trade initiatives to restrict tobacco marketing and advertising
regulations in other countries, unless those regulations discriminate against U.S.
tobacco products in favor of that country’s domestic tobacco products.
—
Federal
Communications
Commission
(FCC)
Has broad
regulatory power
over commercial
communication,
including television,
radio, and the
Internet.
15 U.S.C. § 1335 (the “Broadcast Ban”), 15 U.S.C. § 4402(f): Prohibits advertising
for cigarettes, little cigars, smokeless tobacco, and chewing tobacco on radio, TV,
or any other medium of electronic communication under FCC’s jurisdiction.
Prohibit the advertising of smoking
accessories, cigars, pipes, pipe tobacco, or
cigarette-making machines on television;
prohibit the advertising of e-cigarettes on
television; and regulate the advertising of
tobacco products on the Internet.
Federal Trade
Commission
(FTC)
Publishes annual
report on tobacco
products.
Reviews tobacco
manufacturer-
proposed schedules
to rotate mandatory
package warnings.
Protects consumers.
Enforces antitrust
laws.
15 U.S.C. § 46 authorizes FTC to require entities to file special reports. On an
annual basis, FTC collects and publishes information on the practices of the
largest manufacturers of cigarettes and smokeless tobacco in the United States.
Among other things, the information collected includes sales and, in several
categories, expenditures for marketing.
15 U.S.C. § 45: FTC has broad authority to prevent “unfair or deceptive”
business practices. It is an unfair and deceptive act or practice for a firm to make
unsubstantiated claims, express or implied, about such matters as a product’s
efficacy, safety, or health benefits (FTC 1983).
FTC is broadly authorized to prevent companies from using “unfair methods of
competition” that affect commerce. FTC uses its antitrust authority to review and
impose conditions on those proposed mergers of tobacco companies that raise
anticompetitive concerns.
Collect sales, advertising, and information
on promotion expenditures from
e-cigarette companies and issue reports
on same.
Take enforcement action against unfair or
deceptive advertising of tobacco products
or e-cigarettes.
A Report of the Surgeon General
190 Chapter 5
Agency
Authority and
description Current Potential
General Services
Administration
(GSA)
In its role as an
independent agency,
GSA manages and
maintains more
than 1,550 federally
owned buildings
and leases space
in an additional
7,100buildings in
the United States.
GSA manages
the federal
government’s
automobile fleet and
is the acquisition
arm of the federal
government.
GSA Order ADM, 5800. 1C: Smoking in GSA-occupied space and government-
owned or -leased vehicles assigned to GSA is prohibited “to protect GSA
employees, GSA contractors, and the visiting public from exposure to tobacco
smoke in the Federal workplace.” The Order prohibits smoking in or on all
“interior GSA-occupied space, exterior GSA-occupied space, including courtyards,
garages, loading docks, stairwells, rooftops and balconies, and other outdoor areas
under GSA control within 25 feet of doorways and building air intake ducts; and
government-owned or leased vehicles assigned to GSA” (U.S. General Services
Administration 2009).
Clarify that existing policies include
e-cigarettes.
Implement a tobacco-free campus policy
in GSA-occupied space.
Office of
Personnel
Management
(OPM)
— While not regulatory in nature, OPM and GSA coordinate standard responses to
frequently asked questions about the use of e-cigarettes in government facilities.
—
U.S. Department
of Agriculture
(USDA)
Commodity and
inspection standards
for agricultural
products.
Administers SNAP
and WIC programs.
7 U.S.C. § 30: USDA provides commodity standards for tobacco.
7 U.S.C. § 2012: Under the Food and Nutrition Act of 2008, tobacco products
cannot be purchased with SNAP benefits. ENDS are included in the policy because
the USDA interprets ENDS to be tobacco products.
7 CFR 246.10: USDA identifies requirements for WIC-eligible foods.
—
Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 191
Agency
Authority and
description Current Potential
U.S. Department
of Defense (DoD)
May issue general
instructions and
restrictions in
regulating the
sale and/or use of
tobacco products.
Individual service
branches may
expand these
regulations.
Individual bases
may also draft
regulations.
These typically
are based on DoD
instructions,
directives, or service
policies. DoD has
authority over
TRICARE.
DoD follows the smoking policy in federal facilities covered in 41 CFR 102-74.315,
which states, “pursuant to Executive Order 13058, ‘Protecting Federal Employees
and the Public From Exposure to Tobacco Smoke in the Federal Workplace’ it
is the policy of the Executive Branch to establish a smokefree environment for
federal employees and members of the public visiting or using federal facilities.
The smoking of tobacco products is prohibited in all interior space owned, rented
or leased by the Executive Branch of the federal government” (Federal Register
2008, p. 77518).
Each of the armed services has issued statements clarifying that the prohibition on
smoking tobacco products extends to the use of e-cigarettes.
The 2015 NDAA directs the sale of cigarettes, cigars, and chewing tobacco at
military commissaries. These items cannot be sold on military bases at prices
lower than the most competitive prices in the local community. The NDAA
replaced Directive 1330.09 (U.S. Department of Defense 2005), which established
that tobacco prices on U.S. military bases should be no lower than 5% below the
most competitive commercial price in the local community.
Branches of the armed services have tobacco policies:
• U.S. Navy and Marines, Instruction 5100.13E (U.S. Navy 2002)
• U.S. Army, Army Health Promotion Policy Regulation 600–63 (U.S. Army 1996)
• U.S. Air Force, Instruction 40-102, Air Force Tobacco Policy (U.S. Air Force
2013)
TRICARE covers limited tobacco cessation counseling from any TRICARE-
authorized provider in the United States. This coverage includes up to
18counseling sessions per quit attempt, with up to 4 individual counseling
sessions per quit attempt. Two quit attempts per fiscal year are automatically
covered, with coverage extending to a third with a doctor’s justification and
pre-authorization. TRICARE also covers tobacco cessation products, including
prescriptions and over-the-counter products, with 120days’ use of a tobacco
cessation product per quit attempt.
DoD-unified regulations on tobacco use in
common housing.
Increased restrictions on commissary
sales.
Table 5.2 Continued
A Report of the Surgeon General
192 Chapter 5
Agency
Authority and
description Current Potential
U.S. Department
of Education
(ED)
Funding for tobacco
control programs
In FY 2014, pursuant to 20 U.S.C. § 7131, Safe and Drug-Free Schools and
Communities Act, ED awarded the first round of 5-year grant awards under
the School Climate Transformation Grant—Local Educational Agency Grants
program. These FY 2014, Year 1 grant awards provided more than $35.8 million
to 71 school districts in 23 states; Washington, DC; and the U.S.Virgin Islands.
The funds should be used to develop, enhance, or expand systems of support for
implementing evidence-based, multitiered behavioral frameworks for improving
behavioral outcomes and learning conditions among students. The goals of the
program are to connect children, youth, and families to appropriate services and
supports; improve conditions for learning and behavioral outcomes for school-
aged youth; and increase awareness of mental health issues and the ability to
respond to such issues among school-aged youth. School districts can also use
the funds to implement models for reform and evidence-based practices. Drug
prevention, including preventing tobacco use by youth, is an allowable activity.
Grantees are encouraged, as part of their local needs assessment, to measure
drug use among students along with other relevant issues and problems. This
assessment of local needs will also be used by grantees to help identify and
select the most appropriate evidence-based programs and practices. If the needs
assessment indicates that drug abuse is an issue for students, prevention of drug
abuse should be addressed by a multitiered behavioral framework.
—
U.S. Department
of Education
(ED)
Restrictions on
tobacco use
20 U.S.C. § 7181: The Pro-Children Act of 2001 prohibits smoking in any indoor
facility that provides routine or regular kindergarten, elementary, or secondary
education and library, health, or day care services to children, if such services
and/or facilities are funded by the federal government, whether directly or through
state or local governments, by federal grant, loan, loan guarantee, or contract
programs.
—
Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 193
Agency
Authority and
description Current Potential
U.S. Department
of Health
and Human
Services, Centers
for Medicare
& Medicaid
Services (CMS)
(continues on
next page)
Sets policies
regarding Medicaid
coverage for tobacco
cessation products
and counseling.
42 U.S.C. § 1396r–8(d)(7): Tobacco cessation medications cannot be excluded from
coverage under Medicaid prescription drug benefits. Section 2502 of the Affordable
Care Act amends section 1927(d)(2) of the Social Security Act by removing
barbiturates, benzodiazepines, and agents used to promote smoking cessation
from the list of drugs that a state Medicaid program may exclude from coverage or
otherwise restrict.
42 U.S.C. §§ 18021(a)(1)(B), 18022(b)(1): Tobacco use screening and cessation
must be provided at no cost as an essential health benefit and a preventive benefit.
This includes Medicaid expansion plans, plans sold on insurance exchanges, and
private plans.
For youth: Tobacco cessation services are coverable as part of EPSDT, the Medicaid
benefit for children and adolescents. EPSDT provides a comprehensive array of
prevention, diagnostic, and treatment services for low-income infants, children,
and adolescents under age 21, as specified in Section 1905I of the Social Security
Act.
For pregnant women: Section 4107 of the Affordable Care Act amends
section 1905 of the Social Security Act to require coverage of counseling and
pharmacotherapy for cessation of tobacco use by pregnant women. Section
1905(bb)(2) of the Social Security Act defines the new tobacco cessation coverage
services for pregnant women as services recommended in the 2008 PHS Guideline,
or any subsequent modification of this Guideline, and such other services that
the Secretary recognizes to be effective for cessation of tobacco use by pregnant
women.
Affordable Care Act, Section 4108, Medicaid Incentives for Chronic Disease
Prevention Program: This is a grant program in which states apply for funds to
incentivize Medicaid recipients to prevent chronic disease, including through
tobacco cessation.
—
Table 5.2 Continued
A Report of the Surgeon General
194 Chapter 5
Agency
Authority and
description Current Potential
(continued from
previous page)
U.S. Department
of Health
and Human
Services, Centers
for Medicare
& Medicaid
Services (CMS)
— 42 U.S.C. § 1395x (ddd): Medicare covers tobacco cessation programs (Centers
for Medicare & Medicaid Services 2010): Effective for claims with dates of service
on or after August 25, 2010, CMS will cover tobacco cessation counseling for
outpatient and hospitalized Medicare beneficiaries:
• Who use tobacco, regardless of whether they have signs or symptoms of
tobacco-related disease;
• Who are competent and alert at the time that counseling is provided; and
• Whose counseling is furnished by a qualified physician or other Medicare-
recognized practitioner.
Intermediate and intensive tobacco cessation counseling services are covered
under Medicare Parts A and B when the above conditions of coverage are met,
subject to frequency and other limitations. Medicare covers two individual
tobacco cessation counseling attempts per 12-month period. Each attempt may
include a maximum of four intermediate or intensive sessions, with a total benefit
covering up to eight sessions per 12-month period per Medicare beneficiary who
uses tobacco. The practitioner and patient have the flexibility to choose between
intermediate (more than 3 minutes, up to 10 minutes) and intensive (more than
10 minutes) cessation counseling sessions for each attempt. Medicare beneficiaries
also have access to smoking cessation prescription medication through Medicare
Part D.
—
U.S. Department
of Health
and Human
Services, Centers
for Medicare
& Medicaid
Services (CMS)
Sets policies
regarding private
and marketplace
health plan
coverage of tobacco
cessation products
and counseling.
42 U.S.C. §§ 18021(a)(1)(B), 18022(b)(1): Tobacco cessation must be provided at
no cost as an essential health benefit. This includes Medicaid expansion plans,
plans sold on insurance exchanges, and private plans.
42 U.S.C. § 300gg-6 (Public Law 114-38): Tobacco cessation must be covered
in employer plans. Plans should cover two cessation attempts per year,
including (1)all FDA-approved cessation medications (both prescription and
over-the-counter) and (2)four tobacco cessation counseling sessions, including
telephone, group, and individual counseling.
42 U.S.C. § 300gg(a)(1(iv)): Tobacco users may be charged 50% more for
insurance than nonusers of tobacco.
42 U.S.C. § 300gg–4(j)-(k): Employers may reward or penalize employees by up to
50% of the cost of health care coverage based on their tobacco use, if the employer
offers a health-contingent wellness program designed to prevent or reduce tobacco
use.
—
Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 195
Agency
Authority and
description Current Potential
U.S. Department
of Health and
Human Services,
National
Institutes of
Health (NIH)
NIH is a tobacco-
free campus.
NIH’s policy specifically includes e-cigarettes. In accordance with the tobacco-free
initiative from HHS, the use of cigarettes, e-cigarettes, cigars, pipes, smokeless
tobacco (“snuff”), and any other tobacco product is prohibited on the NIH campus
in Bethesda, MD (NIH 2016).
—
U.S. Department
of Health and
Human Services,
National
Institutes of
Health, National
Institute on
Drug Abuse
(NIDA), National
Advisory Council
on Drug Abuse
(NACDA)
The mission
of NIDA is to
advance science
on the causes and
consequences
of drug use and
addiction and
to apply that
knowledge to
improve individual
and public health.
NACDA serves
crucial roles in
advising NIDA on
research priorities
and policy and
in providing a
secondary level
of review for
applications under
consideration for
federal funding.
NIDA (2016) urges grantees to recognize that:
• Receiving funding from the tobacco industry may compromise the perceived
objectivity of their research results, which in turn could impact the overall
credibility of their research findings, including its interpretation, acceptance,
and implementation;
• Acceptance of tobacco industry funds is viewed by many as contributing directly
or indirectly to the industry’s interests, and thus harmful to the public health;
and
• Any connection between tobacco industry-supported research (or tobacco
industry scientists) and NIDA could negatively impact NIDA’s credibility and the
public’s trust in NIDA-funded research.
—
Table 5.2 Continued
A Report of the Surgeon General
196 Chapter 5
Agency
Authority and
description Current Potential
U.S. Department
of Health and
Human Services,
Substance Abuse
and Mental
Health Services
Administration
(SAMHSA)
Implements the
Synar Amendment,
which requires
states, in order to
receive their full
Substance Abuse
Prevention and
Treatment Block
Grant awards,
to enact and
enforce laws that
prohibit the sale
or distribution of
tobacco products to
individuals under
the age of 18.
More information about the Synar Program is available online: http://www.
samhsa.gov/synar/about
SAMHSA is exploring opportunities to
align the Synar regulation with the federal
statutory definition of tobacco products,
which includes e-cigarettes.
U.S. Department
of Homeland
Security (DHS)
Sales and use
restrictions for the
U.S. Coast Guard.
DHS Management
Directorate-
Directive No. 06603
Smoking Policy.
COMDTINST M6200.1B limits smoking to designated outdoor areas, prohibits use
of tobacco by recruits, and prohibits tobacco use in any Coast Guard-controlled
living quarters, including common areas. This policy includes extensive sales and
advertising restrictions, but it does not consider NRT to be a tobacco product.
Implement a policy to enforce a ban on
e-cigarette use on federal property.
U.S. Department
of Homeland
Security (DHS),
Bureau of
Immigration
and Customs
Enforcement
(ICE)
Issues standards for
facilities housing
immigration
detainees
Detainee smoking is prohibited in all buildings, including detainee-housing units.
If smoking is permitted at a particular facility, the only designated smoking areas
are outside of all buildings (Immigration and Naturalization Service 2000).
—
Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 197
Agency
Authority and
description Current Potential
U.S. Department
of Housing
and Urban
Development
(HUD)
Resident health in
assisted housing
Public and Indian Housing (PIH) Notice 2009-21 strongly encourages HUD-funded
public housing agencies to adopt smokefree policies in some or all of their public
housing units.
Housing Notice 2010-21 encourages owners and management agents of HUD-
assisted multifamily housing to implement smokefree housing policies in one or
all of the properties they own or manage.
Both notices focus on cigarettes that “burn” as their mechanism for generating
smoke, and so their applicability to e-cigarettes is uncertain.
Regarding its Weaver Building headquarters (the only building for which GSA has
designated HUD as the facility management authority), HUD follows GSA Order
ADM5800.1C, GSA’s smoking policy for federal offices (U.S. General Services
Administration 2009). This GSA policy permits smoking in exterior space under
GSA control that is beyond “25 feet of doorways and building air intake ducts,”
except for “courtyards, garages, loading docks, stairwells, rooftops, and balconies.”
The management of HUD’s other facilities, federally owned or leased, is not
delegated to the Department, and so GSA makes the decision on smoking policy
for those campuses.
HUD’s Office of PIH published its
proposed rule on Instituting Smoke-
Free Public Housing (80 FR 71762) on
November 17, 2015, accepting comments
through January 19, 2016 (Federal
Register 2015). In addition to inviting
comments on all aspects of the proposed
rule, the notice specifically solicited public
comments on nine questions (e.g., should
the policy extend to electronic nicotine
delivery systems, such as e-cigarettes,
and/or to waterpipe tobacco smoking?).
Based on responses to HUD’s Request for
Information on Adopting Smoke-Free
Policies in PHAs and Multifamily Housing
(77 FR 60712) (Federal Register 2012),
HUD may consider drafting a regulation
or notice that could prohibit smoking
in some or all HUD-assisted multifamily
housing. Such a proposal could cover
e-cigarettes.
HUD is beginning to prepare for the
adoption and implementation of a
campus-wide tobacco-free policy, which
would include e-cigarette use,
at the Weaver Building headquarters by
January 1, 2017.
Table 5.2 Continued
A Report of the Surgeon General
198 Chapter 5
Agency
Authority and
description Current Potential
U.S. Department
of Justice,
Bureau of
Alcohol,
Tobacco,
Firearms and
Explosives (ATF)
ATF is given
primary jurisdiction
to combat cigarette
trafficking and
administration
(via the CCTA) and
to stop tobacco
diversion (via the
PACT).
18 U.S.C. § 2342: Under the CCTA, it is illegal to possess more than 10,000
unstamped cigarettes in a state that requires a tax stamp.
18 U.S.C. § 2343: Any person who distributes more than 10,000 cigarettes must
keep accurate records pertaining to the shipment, receipt, sale, and distribution of
cigarettes.
18 U.S.C § 2320: Trafficking in counterfeit cigarettes.
15 U.S.C. § 375: It is illegal to ship cigarettes to a non-licensee in a state without
notifying the state taxation authority.
15 U.S.C. § 375–377: Requires online retailers to check the identification of
customers at purchase and delivery: section 375 covers definitions; section
376covers reports to state tobacco administrators; and section 377 covers
penalties.
The Smuggled Tobacco Prevention (STOP) Act amends the IRC to restrict the sale,
lease, export or import, or delivery of tobacco production machines to persons
lawfully engaged in (1) the sale, lease, export or import, or delivery of such
machines; (2)the manufacture or packaging of tobacco products or processed
tobacco; or (3)the application of unique identification markings onto tobacco
products or processed tobacco packages.
—
U.S. Department
of Justice,
Bureau of
Prisons (BOP)
BOP has authority
to govern the
control and
management
of federal penal
and correctional
institutions.
28 C.F.R. § 551.162: Smoking is generally prohibited in and on the grounds of
BOP institutions and offices, with exceptions for smoking as part of an authorized
inmate religious activity, and for smoking only in smoking areas designated by the
warden, for BOP staff and official visitors.
28 C.F.R. § 551.163: Possession of smoking apparatus and tobacco in any form is
prohibited for inmates, unless as part of an authorized inmate religious activity.
BOP Operations Memorandum 006-
2015 (BOP 2015) sets out guidelines
for e-cigarette use. Guidelines state
that e-cigarette use is to be limited
to designated outdoor areas that are
reasonably accessible to employees and
provide a measure of protection from the
elements. These areas may only be used by
employees, but must be separate from the
areas presently designated as “smoking
areas” for use of tobacco products. Indoor
use of e-cigarettes shall not be permitted
in BOP facilities, except in perimeter
towers and perimeter patrol vehicles when
occupied by one person.
Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 199
Agency
Authority and
description Current Potential
U.S. Department
of Labor,
Occupational
Safety and
Health
Administration
(OSHA)
Sets standards for
indoor air quality.
29 CFR 1910.1000, Air Contaminants: This policy restricts employee exposure to
several of the main chemical components found in tobacco smoke. OSHA rules
apply to tobacco smoke only in rare and extreme circumstances, such as when
contaminants created by a manufacturing process combine with tobacco smoke
to create a dangerous air supply that fails OSHA standards for the workplace. In
normal situations, exposures would not exceed permissible exposure limits and, as
a matter of prosecutorial discretion, OSHA will not apply the General Duty Clause
to environmental tobacco smoke.
Have smokefree workplaces. In the
1990s, OSHA proposed a regulation
setting indoor air quality standards for
environmental tobacco smoke, but this
rulemaking was terminated (Federal
Register 2001).
U.S. Department
of Transportation
(DOT)
Sets restrictions
on tobacco use on
commercial and
personal aircraft.
49 U.S.C. § 41706: Prohibits smoking on passenger flights.
14 CFR Part 252: DOT rule implementing 49 U.S.C. § 41706, and prohibiting
smoking on most passenger flights. DOT interprets current Part 252 to include
e-cigarettes in smokefree policies.
Note: FAA regulations also prohibit smoking on most aircraft from an aircraft
safety perspective, not from a health perspective (see notes to 14 CFR Part 252).
In early 2016, DOT issued a final rule
(RIN 2105-AE06). In keeping with
section 41706, the rule amends Part 252
to prohibit smoking on charter flights
where a flight attendant is a required crew
member. The rule also makes explicit the
determination that the use of e-cigarettes
falls within the definition of smoking.
DOT’s Pipeline and Hazardous Materials
Safety Administration has proposed a rule
to prohibit the charging of e-cigarettes in
an aircraft cabin, and to prohibit stowage
of e-cigarettes in the cargo hold of an
aircraft (this is a hazardous material/safety
rule, not a health/tobacco rule).
Table 5.2 Continued
A Report of the Surgeon General
200 Chapter 5
Agency
Authority and
description Current Potential
U.S. Department
of Treasury,
Alcohol and
Tobacco Tax and
Trade Bureau
(TTB)
TTB administers the
provisions of the
Internal Revenue
Code (IRC) of 1986,
as amended, that
impose federal
excise taxes on
tobacco products
and cigarette
papers and tubes,
and it establishes
a comprehensive
civil and criminal
framework to
protect the revenue.
Among other issues,
TTB investigates
illegal production,
underreporting
of production,
smuggling
or unlawful
importation,
and diversion of
domestic tobacco
products intended
for export.
26 U.S.C. 26 § 5701–5763, Tobacco Products and Cigarette Papers and Tubes:
Under the IRC, the tobacco products that are subject to tax and TTB regulation
are cigars, cigarettes, smokeless tobacco (chewing tobacco and snuff), pipe
tobacco, and roll-your-own tobacco. Each of these tobacco products is defined with
reference to “tobacco.” TTB also has regulatory authority over processed tobacco,
which is not subject to tax. TTB regulations define processed tobacco to mean
any tobacco that has undergone processing but that does not include tobacco
products. The processing of tobacco includes, but is not limited to, stemming
(i.e., removing the stem from the tobacco leaf); fermenting, threshing, cutting,
or flavoring the tobacco; or otherwise combining the tobacco with nontobacco
ingredients.
To protect revenue, the IRC and its implementing regulations establish
qualification criteria to engage in businesses related to manufacturing, importing,
or exporting tobacco products or in manufacturing or importing processed
tobacco, and they require that persons obtain permits to engage in these activities.
Under the IRC, manufacturers of tobacco products and export warehouse
proprietors must file a bond that relates to the tax liability for the tobacco
products on the premises covered by the permit. The IRC and implementing
regulations also include recordkeeping and reporting requirements designed to
ensure that TTB can verify that the tax on tobacco products is paid or determined
or that adequate documentation exists to confirm that a tax exemption applies.
The IRC also provides TTB with certain enforced-collection options (e.g., liens and
levies), civil and criminal penalties, permit suspension and revocation procedures,
and forfeiture provisions to ensure that the tax is collected.
ENDS that do not contain nicotine derived from tobacco are not tobacco products
under the IRC and are not subject to taxation or TTB regulation. ENDS containing
nicotine derived from tobacco may meet the definition of a tobacco product under
the IRC, in which case they would be regulated by TTB and taxed accordingly.
TTB will collaborate with foreign-
counterpart tax administrators to share
information and best practices in the
administration of tobacco excise taxes
and their enforcement. Areas of possible
technical assistance include setting up an
auditing system and permitting regimen
and conducting investigations.
TTB’s tobacco laboratory provides
technical assistance to TTB program
offices on tobacco products for regulatory
compliance and enforcement purposes.
TTB’s tobacco laboratory develops and
validates analytical methods and protocols
on tobacco products. It also collaborates
with national and international tobacco
regulatory federal agencies and has
established a collaborative partnership
with the World Health Organization’s
Tobacco Laboratory Network and the
North America Tobacco Regulatory
Laboratory Network.
Table 5.2 Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 201
Agency
Authority and
description Current Potential
U.S. Department
of Veterans
Affairs (VA)
Can restrict the
use of e-cigarettes
and combustible
cigarettes on facility
grounds of the
Veterans Health
Administration to
designated outdoor
smoking areas only.
Public Law 102-585: Requires medical centers, nursing homes, and domiciliary
care facilities of the Veterans Health Administration to establish smoking areas for
patients and residents in a way that is consistent with medical requirements and
limitations.
Include language about restrictions on the
use of e-cigarettes in local and national
guidance regarding smokefree policies.
U.S. Department
of Veterans
Affairs (VA)
Provides evidence-
based tobacco
cessation treatment
to veterans
receiving care in
the VA health care
system.
38 CFR Part 17: Eliminated in 2006 the copayment for smoking cessation
counseling for veterans in care facilities of the Veterans Health Administration
(Federal Register 2006).
Continue to provide clinical guidance
for the health care professionals and
patients in facilities of the Veterans Health
Administration on the evidence base of
(a)potential health effects of e-cigarettes
and (b)comparisons to FDA-approved
NRT for cessation treatment.
U.S.
Environmental
Protection
Agency (EPA)
Sets policies
regarding the
hazardous
waste status of
e-cigarettes under
the RCRA.
Nicotine is a commercial chemical product listed in 40 CFR 261.33(e) and is an
acute hazardous waste (EPA waste code P075) when disposed. EPA has concluded
that nicotine is the sole active ingredient of the e-liquid in e-cigarettes and thus
a commercial chemical product, that e-cigarettes are not manufactured articles,
and that e-cigarette cartridges are considered containers of nicotine. Therefore,
e-cigarettes may be regulated as acute hazardous waste code P075 when disposed.
If the nicotine e-liquid is legitimately recycled, it is not considered a solid
waste under 261.2 because it is considered a commercial chemical product, and
therefore it is not subject to hazardous waste regulation. E-cigarettes that are
disposed of by consumers at their residences are considered exempt household
hazardous waste under 261.4(b)(1) and are not subject to regulation as hazardous
waste under the federal RCRA regulations.
• Regulatory Citation(s): 261.2, 261.4(b)(1), 261.33.
• Statutory Citation(s): 3006 Read U.S. Code 42, Chapter 82.
—
Note: ATF=Bureau of Alcohol, Tobacco, Firearms and Explosives; BOP = Bureau of Prisons; CCTA = Contraband Cigarette Trafficking Act; CFR = Code of Federal
Regulations; CMS = Centers for Medicare & Medicaid Services; DHS = U.S. Department of Homeland Security; DoD = U.S. Department of Defense; DOT = U.S. Department
of Transportation; ED = U.S. Department of Education; ENDS = electronic nicotine delivery systems; EOP = Executive Office of the President; EPA = U.S. Environmental
Protection Agency; EPSDT = Early and Periodic Screening, Diagnosis and Treatment; FAA = Federal Aviation Administration; FCC = Federal Communications
Table 5.2 Continued
A Report of the Surgeon General
202 Chapter 5
Commission; FDA = Food and Drug Administration; FTC = U.S. Federal Trade Commission; FY = fiscal year; GSA = General Services Administration;
HUD = U.S. Department of Housing and Urban Development; ICE = Bureau of Immigration and Customs Enforcement; IRC = Internal Revenue Code; NACDA = National
Advisory Council on Drug Abuse; NDAA = National Defense Authorization Act; NIDA = National Institute on Drug Abuse; NIH = National Institutes of Health;
NRT = nicotine replacement therapy; OMB = Office of Management and Budget; OPM = Office of Personnel Management; OSHA = Occupational Safety and Health
Administration; PACT = Prevent All Cigarette Trafficking Act; PHS = Public Health Service; PIH = Public and Indian Housing; RCRA = Resource Conservation and
Recovery Act; SAMHSA = Substance Abuse and Mental Health Services Administration; SNAP = Special Supplemental Nutrition Program; TTB = Alcohol and Tobacco Tax
and Trade Bureau; U.S.C. = United States Code; USDA = U.S. Department of Agriculture; USTR = U.S. Trade Representative; VA = U.S. Department of Veterans Affairs;
WIC = Women, Infants, and Children.
Table 5.2 Continued
E-Cigarette Policy and Practice Implications 203
E-Cigarette Use Among Youth and Young Adults
Prevent Youth Access
Ensuring that laws on youth access include
e-cigarettes is intended to protect youth from exposure
to nicotine, which can lead to addiction and other health
problems. Additionally, ensuring that these laws include
e-cigarettes helps to capture the full diversity of the
tobacco product landscape, including combustible, non-
combustible, and electronic tobacco products. Effective
strategies to deter access to e-cigarettes by youth and the
use of these products in this population include restricting
sales of e-cigarettes to minors, requiring verification of
age, mandating clear signage about minimum age where
sales take place, prohibiting the sale of e-cigarettes from
vending machines, eliminating self-service displays of
e-cigarettes, and actively enforcing existing laws with a
focus on retailers. Compliance with laws that regulate
the sale and distribution of e-cigarettes is facilitated by
requiring retailers to be licensed. To date, 46states have
prohibited the sale of e-cigarettes to minors younger than
a specified age (National Conference of State Legislatures
2015; The Council of State Governments 2015). Federally,
aligning youth tobacco access control regulations with
the statutory definition of tobacco products in the Tobacco
Control Act, which includes e-cigarettes, could provide
consistent framework to help ensure that restrictions on
youth access to e-cigarettes are prioritized and enforced
(Federal Register 2016). This could include modifications
to the Synar regulation, which requires states, U.S. ter-
ritories, and jurisdictions to enact and enforce laws pro-
hibiting the sale or distribution of tobacco products to
youth. Substance Abuse Prevention and Treatment Block
Grant recipients must comply with the Synar amendment
and implement regulations in order to receive their full
awards (U.S. Food and Drug Administration, Center for
Tobacco Products n.d.).
Licensing
Licensing is used to regulate professional practice
and business operations and represents one strategy to con-
trol the rising use of e-cigarettes among youth. In general,
in the case of tobacco-related licensing, a business is autho-
rized to manufacture, distribute, or sell tobacco products
as long as it complies with all relevant laws (McLaughlin
2010). Typically, tobacco-related licensing requirements
for retailers and/or manufacturers help to prevent evasion
of excise taxes, ensure that licensees comply with tobacco-
related laws, and promote safe manufacturing practices
(ChangeLab Solutions 2012). Repeat violators of relevant
laws may be subject to suspension or permanent revocation
of their license, an outcome that provides a strong incentive
to comply with existing requirements. As in the conven-
tional cigarette industry, licensing of e-cigarette retailers
and manufacturers is designed in part to prevent the use
of these products by youth and to facilitate safe manufac-
turing practices. Unlike traditional tobacco products, for
which retailers sell prepackaged products and the number
of manufacturers is limited, a growing number of busi-
nesses engage in both the retail sale and manufacturing of
devices and liquids used in the devices (e-liquids). Stores
devoted exclusively to the sale of e-cigarettes are known as
“vape shops.” These shops frequently offer a social environ-
ment for using products, and they may also sell food and
beverages (Sussman et al. 2014).
As of April 2015, 99 cities and counties in California
required a retailer to obtain a license to sell e-cigarettes.
The majority of these jurisdictions did so by broadening
the definition of tobacco products to include “electronic
smoking devices” (ChangeLab Solutions 2015a). The
definition was purposely broadened to include prod-
ucts that do not include nicotine to decrease the com-
plexity of enforcement and in recognition of the fact
that e-cigarette devices are sometimes used with liquids
that do not contain nicotine but may contain marijuana
oil (The Center for Tobacco Policy & Organizing 2015a).
Licensing requirements also may be used to restrict the
sale of flavored products or to address issues of consumer
and worker safety relative to the mixing of e-liquids.
Imposing a moratorium is another potential
approach that has been used in some communities to stop
new “vape shops” from entering the market while a more
comprehensive approach was being considered. A morato-
rium is a land-use law that takes effect immediately to stop
temporarily the issuance of a business license, building
permit, or use permit. Typically, a moratorium is enacted
to provide a jurisdiction with time to research and study
how to regulate a type of business (ChangeLab Solutions
2015b). In California, several communities enacted mor-
atoria that are initially 45 days but can be extended for
up to 2 years (ChangeLab Solutions 2014, 2015b). Afour-
fifths vote, however, is required to establish a moratorium
in California. Hayward and Union City, California, are
examples of cities that have enacted moratoria and later
adopted both retail licensing requirements for existing
e-cigarette retailers and zoning restrictions to prohibit
new vapor and hookah bars and lounges from opening
within city limits (ChangeLab Solutions 2014; The Center
for Tobacco Policy & Organizing 2015b).
A Report of the Surgeon General
204 Chapter 5
Taxation and Other Price Policies
Taxation and other price policies directed at making
e-cigarettes more expensive may be implemented at mul-
tiple levels of government, from local to federal. Increasing
the price of conventional cigarettes, including those
increases resulting from excise taxes, significantly prevents
and reduces tobacco use, particularly among youth and
young adults (USDHHS 2014), and has potentially more
impact on prevalence of current use in this population than
on first use (Bader et al. 2011). Similarly, price policies are
likely to reduce the use of e-cigarettes: a 10%increase in
the price of e-cigarettes has been estimated to reduce sales
of disposable e-cigarettes by approximately 12% and reus-
able products by about 19% (Bader et al. 2011; Huang et al.
2014). Data are currently lacking on the potential effects
that taxing e-cigarettes might have on conventional ciga-
rettes. Tobacco products are taxed in two main ways:
1. A “specific” excise tax is levied based on the quantity
of the product sold (e.g., as measured by number of
cigarettes, weight, or volume). This type of mecha-
nism applies the same tax across low-end and pre-
mium brands and is generally simple to administer.
The disadvantages to specific excise taxes are that
the real value of the tax declines over time with
inflation, making products more affordable, and
that super-lightweight products—such as snus,
orbs, sticks, and dissolvables—are grossly under-
taxed if the tax is based on weight (Freiberg 2012;
Boonn 2013; Shang et al. 2015).
2. The second tax mechanism is an ad valorem excise
tax, which is levied on a percentage of the value of
the tobacco product (e.g., the retailer’s, wholesal-
er’s, or manufacturer’s price). This type of tax keeps
up with inflation and establishes a flat tax rate across
all brands, product types, weights, and packaging.
The disadvantages to this kind of tax include the
potential for tax evasion through predatory (below-
cost) or anticompetitive pricing; increasing the
price differential between products with different
pretax prices, leading to greater price variability and
more opportunity for tax avoidance; a government-
provided subsidy for manufacturers’ price cuts; and
more expensive brands being subjected to a larger
tax (Freiberg 2012; Boonn 2013; Shang et al. 2015).
Governments use uniform, tiered, and mixed-tax
approaches to implement specific and ad valorem tobacco
excise taxes. Uniform systems apply the same tax rate
across all products; tiered systems levy taxes based on
such product characteristics as toxicity, nicotine content,
type of production (handmade versus machine made),
sales volume, packaging, or whether the products are
domestic or imported; and mixed systems use a combi-
nation of uniform and tiered-tax approaches (Shang etal.
2015). Tiered-tax approaches, such as those based on nico-
tine content, could steer consumers to a less toxic product
or one with lower nicotine (Benowitz 2014). Tiered-tax
approaches are more complex to administer and may
provide greater opportunity for tax evasion as a result of
manipulation of the product or its packaging by the man-
ufacturer (Shang et al. 2015). In recognition of nicotine’s
toxicity, particularly to youth, several health groups have
endorsed imposing excise taxes on e-cigarettes to dis-
courage their use by youth (American Thoracic Society
2013; Association of State and Territorial Health Officials
2014; Bhatnagar et al. 2014; Brandon et al. 2015a; Crowley
and Health Public Policy Committee of the American
College of Physicians 2015; National Association of
County and City Health Officials 2014). E-cigarettes are
likely less toxic than combustible products (such as con-
ventional cigarettes), and therefore, some contend should
be taxed at a lower rate (Benowitz 2014; Bhatnagar et al.
2014). Yet others argue that e-cigarettes should be taxed
at the same rate as other tobacco products (Freiberg 2012;
American Thoracic Society 2013; National Association of
County and City Health Officials April 2014).
As of January 2016, four states (Kansas, Louisiana,
Minnesota, and North Carolina) and six localities (Juneau,
Matanuska-Susitna, Petersburg, and Sitka, Alaska;
Montgomery County, Maryland; and Chicago, Illinois)
had enacted e-cigarette taxation policies. Minnesota’s
ad valorem tobacco tax equates to 95% of the wholesale
cost of any product containing or derived from tobacco
(Minnesota Revenue 2014; Tobacco Control Legal
Consortium 2015). It taxes e-liquids and e-cigarettes
sold with nicotine cartridges that cannot be removed
(i.e., disposables). In Minnesota, devices without a nico-
tine cartridge are not taxed as a tobacco product. On the
other hand, North Carolina applies a specific excise tax,
taxing e-liquids based on volume at 5 cents per milliliter
(National Conference of State Legislatures 2015).
The Tobacco Control Legal Consortium, which
is based at William Mitchell College of Law in St. Paul,
Minnesota, recommends using an ad valorem tax for
e-cigarettes applied at the retail level to the “essential”
components of these devices. The tax is simple, captures
both disposable and refillable devices, and could exclude
accessories and universal parts sold separately, such
as batteries or charging cords (Tobacco Control Legal
Consortium 2015).
Numerous major health organizations support
raising the price of e-cigarettes through non-tax options,
such as limiting rebates, discounts, and coupons (Freiberg
E-Cigarette Policy and Practice Implications 205
E-Cigarette Use Among Youth and Young Adults
2012; Association of State and Territorial Health Officials
2014; Bhatnagar et al. 2014; Huang et al. 2014; Brandon
et al. 2015a).
Finally, Chaloupka and colleagues (2015) have pro-
posed that differential taxation of tobacco products can
be used to incentivize a move away from combustible
products to less hazardous noncombustible products,
including e-cigarettes. They have argued that taxation
could be part of a harm-reduction system. In their view,
future determinations by FDA as to whether a product
poses a substantially reduced risk would be one criterion
in determining the relative rate of taxation.
Restrictions on Marketing
As described in Chapter 4, the marketing of
e-cigarettes drives consumer demand for these prod-
ucts. Such marketing also may promote misperceptions
about the safety and efficacy of these products for use
as cessation devices (Choi and Forster 2014; Mark et al.
2015; Pokhrel et al. 2015). For some populations—such
as pregnant women, adolescents, former smokers, and
young adults—the adverse health consequences of nico-
tine intake are substantial. Several groups have supported
extending marketing restrictions that apply to conven-
tional cigarettes and other tobacco products to e-cigarettes
(Association of State and Territorial Health Officials 2014;
Bam et al. 2014; Bhatnagar et al. 2014; Partnership for
Prevention 2014; Brandon et al. 2015a). Significant bar-
riers still exist to regulating commercial speech, including
the First Amendment rights of the e-cigarette companies
(Laird-Metke 2010).
Additionally, for traditional tobacco products, partial
advertising bans and voluntary agreements have gener-
ally been ineffective in reducing consumption because the
tobacco industry circumvents the restrictions by shifting
the marketing platforms used to unregulated platforms
(National Cancer Institute 2008). This response would
be expected to be similar with regard to e-cigarettes.
Therefore, despite the numerous barriers, public health
groups and state, local, tribal, and territorial governments
should take steps to stem the proliferation of e-cigarette
marketing likely to appeal to young people by using tools
designed to curb youth-oriented tobacco marketing and
expanding evidence to inform future restrictions on the
marketing of e-cigarettes to youth and young adults.
Surveillance of e-cigarette marketing, performing
content analyses of the messages used, and conducting
studies to assess the link between exposure to e-cigarette
marketing and the use of e-cigarette products, particularly
among youth and young adults, will facilitate the develop-
ment of an evidence base of the type that informed prior
federal and Master Settlement Agreement restrictions on
tobacco advertising. Observations of retailers’ practices,
assessments of outdoor advertising, and identification
of event sponsorships and promotional activities at bars
and community events are actions that state, local, tribal,
and territorial public health agencies have taken related
to traditional tobacco products. Many of these actions
can be adapted to monitor and document the presence of
e-cigarette marketing in communities (Pucci et al. 1998;
Feighery et al. 2001; Rigotti et al. 2005; Roeseler et al. 2010;
Rose et al. 2014).
In the absence of legal restrictions on e-cigarette
marketing, and apart from the issue of the previous prom-
ulgation by some companies of unsubstantiated health
and cessation claims, public health groups can advocate
for television and radio broadcasters, print and outdoor
media companies, the management of event venues and
sports events, digital media outlets, retailers, and others
to voluntarily refuse to air or place e-cigarette advertising,
offer sponsorships, or give out free samples at fairs and fes-
tivals. Although the impact of a voluntary approach may
be low, such actions raise awareness, build concern, and
help to denormalize the proliferation of e-cigarette mar-
keting. In California, surveillance plus voluntary efforts
to promote restrictions on sponsorship of events by the
tobacco industry facilitated a modest decline in tobacco
industry-sponsored events and youth-oriented activities
at those events that promoted the interests of the tobacco
companies, and it led to a productive partnership with the
tobacco litigation unit of the California attorney gener-
al’s office that resulted in several settlements with tobacco
companies (Roeseler et al. 2010).
State, local, tribal, and territorial public health
agencies may be able to contribute to the stimulation
of enforcement and compliance with existing rules that
constrain marketing. Some states have brought lawsuits
against e-cigarette companies, alleging that distributors
of these products violated state law by selling to minors
or making unsubstantiated health claims; some of those
lawsuits resulted in financial damages and agreements to
stop making claims that e-cigarettes are safer than con-
ventional cigarettes unless confirmed by rigorous science
(Center for Public Health and Tobacco Policy 2013).
Finally, another area to address is the use of “adver-
torials” employed by e-cigarette retailers to promote
cessation and health claims. Advertorials are paid adver-
tisements designed to look like an independent editorial.
Although there are no specific rules for how a publisher
should distinguish actual editorial content from paid edi-
torial content in terms of their appearance, the Federal
Trade Commission (FTC) stated in an advisory opinion
that disclosure of the source is necessary when content
“uses the format and has the general appearance of a news
A Report of the Surgeon General
206 Chapter 5
feature and/or article for public information which pur-
ports to give an independent, impartial and unbiased view”
(Federal Register 1972, p. 154). Additionally, paid adver-
tising must be disclosed clearly and conspicuously in a
manner that is understandable to consumers (FTC 1984).
State and local public health agencies can play an impor-
tant role by monitoring and providing substantiation to
their state attorney general or FTC regarding advertising
that makes improper claims or is not clearly identified as
advertising.
Educational Initiatives
The extensive data reviewed in Chapter 2 high-
lighted the limited knowledge that members of the gen-
eral public, particularly adolescents and young adults,
have about e-cigarettes and their potential for nicotine
addiction and other adverse health consequences. FDA
has jurisdiction for product warnings that can reach
users, but that agency, along with other federal entities
and state and local governmental and nongovernmental
organizations, can also carry out educational campaigns
to enhance such limited knowledge levels. Potentially
effective initiatives with youth and young adults to prevent
smoking were reviewed in the 2012 Surgeon General’s
report and may be applicable to preventing e-cigarette
use. That report concluded that sufficient evidence exists
to conclude that mass media campaigns, comprehensive
community programs, comprehensive statewide tobacco
control programs, and school-based programs that have
shown evidence of effectiveness, if they contain specific
components, can produce at least short-term effects and
reduce the prevalence of tobacco use among school-aged
youth (USDHHS 2012).
Implications for Health Care
Practice
Although the issues are not well documented, health
care practitioners face questions about e-cigarettes from
their patients and their communities, including what are
the risks of using e-cigarettes, how do these risks compare
with those of cigarettes or other combustible products,
and is e-cigarette use an effective way to quit smoking?
Chapter 3 set out the limited evidence base related to
these questions. Clinicians need to respond to these ques-
tions and guide their patients in the context of consider-
able uncertainty. At this time, practitioners can turn to
the various statements from medical organizations, which
generally urge caution regarding e-cigarettes and do not
find the evidence to be supportive of their use for cessa-
tion or for formal harm-reduction strategies (Table5.3).
In fact, any recommendation to use e-cigarettes for the
cessation of smoking is not supported by the bulk of
the available scientific evidence (Hartmann-Boyce et al.
2016). Both the American Association of Cancer Research
and the American Society of Clinical Oncology recom-
mend against advising the use of e-cigarettes for cessa-
tion (Brandon et al. 2015b). The U.S. Preventive Services
Task Force found that there is insufficient evidence that
e-cigarettes are an effective smoking cessation tool in
adults, including pregnant women (Agency for Healthcare
Research and Quality 2015).
The clinical care setting is a critical venue for taking
evidence-based approaches for enhancing smoking cessa-
tion and increasing the protection of susceptible groups
against exposure to secondhand smoke (USDHHS 2014).
However, research on e-cigarettes in relation to this set of
venues is lacking and urgently needed. Regardless, some
pragmatic approaches have been proposed. For example,
the American Academy of Pediatrics (AAP) gives advice
on how pediatricians can approach questioning about the
use of e-cigarettes. As of October 2015, the AAP’s position
on e-cigarettes is that sales to minors should be prohib-
ited; flavors that appeal to youth should be prohibited;
and measures against the use of e-cigarette products need
to be included in requirements for maintaining smoke-
free environments, such as in restaurants and workplaces
(AAP 2015a).
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 207
Table 5.3 Medical organizations
A. Positions of professional organizations
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
American
Academy of
Pediatrics
(2015b)
—
• “Concentrated nicotine solution
for electronic nicotine delivery
systems should be sold in
child-resistant containers with
amounts limited to that which
would not be lethal to a young
child if ingested.”
• “Prohibitions on smoking and
use of tobacco products should
include prohibitions on use of
electronic delivery systems.”
• “The promotion and sale of electronic nicotine delivery
systems to youth should be prohibited by federal, state, and
local regulations.”
• “Prohibitions on promotion should include all media that can
be viewed by youth, including broadcast, print, and electronic
(Web- or Internet-based) media.”
• “Prohibitions on promotion should include prohibitions
on sponsorships, such as sports, cultural event, and
entertainment sponsorships. Any promotional activities that
can be accessed by children and/or adolescents should be
considered promoting to children.”
• “Electronic nicotine delivery systems should be subject
to the same restrictions on advertising and promotion at
least as restrictive as that on combustible cigarettes. Until
government agencies institute these prohibitions, media
companies, entertainment companies, sports teams, and
promoters should voluntarily institute these prohibitions.”
• “Celebrities should not use their privileged position to model
tobacco product use, including electronic nicotine delivery
systems and other existing or emerging tobacco products.”
—
A Report of the Surgeon General
208 Chapter 5
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
American
Association
for Cancer
Research
(AACR) and
the American
Society of
Clinical
Oncology
(2015)
(continues
on next
page)
• FDA has not
approved e-cigarettes
as smoking cessation
aids, and current
data are inconclusive
with regard to their
efficacy as quit-
smoking products.
• “Oncologists would
be wise to refrain
from recommending
e-cigarettes to
patients as a first-
line therapy for
smoking cessation.”
• “The evidence regarding the
risks and benefits of e-cigarettes
is difficult to interpret, and data
on the long-term consequences
of e-cigarette use are not yet
available.”
• “Chemicals and ultrafine
particles known to be toxic
and carcinogenic and/or to
cause respiratory and heart
distress have been identified in
e-cigarettes.”
• “Studies find the levels of the
toxicants in e-cigarette aerosol
to be significantly lower than in
cigarette smoke and, in many
cases, comparable with trace
amounts found in a medicinal
nicotine inhaler. It is unclear
what effects these toxicants
might have on e-cigarette users
after chronic and frequent use.”
• “The vast majority of e-cigarette
users use products containing
nicotine. Nicotine is an addictive
chemical, adversely affects
maternal and fetal health
during pregnancy, has adverse
consequences for fetal brain
development, and may adversely
affect the adolescent brain. It
is unclear what effect nicotine
intake via e-cigarettes has on
health or on the addictiveness of
these products.”
• “The FDA CTP should regulate all ENDS that meet the
statutory definition of tobacco products and their component
parts. ENDS delivery systems and e-liquids containing
tobacco-derived nicotine should be regulated whether they
are sold together or separately.”
• “ENDS manufacturers should be required to register with
FDA and report all product and ingredient listings, as well as
the nicotine concentration in the ENDS solution.”
• “ENDS packaging and advertising should be required to
carry health warnings and safety labels—including a warning
regarding nicotine addiction.”
• “Youth-oriented ENDS advertising and marketing should
be prohibited, including: self-service ENDS displays, the
provision of gifts and other giveaways with purchase of ENDS,
the sale and distribution of items such as hats or t-shirts
with ENDS brand logos, brand name sponsorship of social or
cultural events, or of any team entry into those events, and
youth-oriented advertising of tobacco products.”
• “Internet and other mail-order sellers of ENDS should be
required to check the age and identification of customers at
the point of purchase and delivery; to comply with all laws
in the purchaser’s state or local jurisdiction; and pay all
applicable federal, state, and local taxes.”
• “Childproof caps should be required for all e-liquid
containers.”
• “ENDS and ENDS liquid containing candy and other youth-
friendly flavors should be banned unless there is evidence
demonstrating that these products do not encourage youth
uptake.”
• “ENDS use should be prohibited in places where combustible
tobacco product use is prohibited by federal, state, or local
law until the safety of second- and thirdhand aerosol exposure
is established.”
• “There are
insufficient data on
health consequences
of e-cigarette use,
their value as tobacco
cessation aids, and
their effects on the
use of combustible
tobacco products
by smokers and
nonsmokers.”
• “Oncologists should
advise all smokers
to quit smoking
combustible
cigarettes, encourage
use of FDA-
approved cessation
medications, refer
patients for smoking
cessation counseling,
and provide
education about
the potential risks
and lack of known
benefits of long-term
e-cigarette use.”
Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 209
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
(continued
from
previous
page)
American
Association
for Cancer
Research
(AACR) and
the American
Society of
Clinical
Oncology
(2015)
—
• “Data from the [CDC] showed
a significant increase in
e-cigarette-related calls to poison
centers between 2010 and 2014
as a result of accidental ingestion
or absorption of e-cigarette
liquid.”
• “Secondhand exposure to
toxicants and nicotine from
e-cigarette aerosol has been
documented, though there are
not current data suggesting
that exposure to the aerosol has
adverse health effects.”
• “There are no published
studies evaluating thirdhand
(i.e., residue that builds up on
surfaces over time) exposure
to e-cigarette aerosol in indoor
environments, although
preliminary data suggest that
nicotine from e-cigarettes can
stick to surfaces.”
• “Funding generated through tobacco product taxes, including
any potential taxes levied on ENDS, should be used to help
support research on ENDS and other tobacco products, but
should not preclude the allocation of federal funding for this
research.”
• “All data related to ENDS composition, use, and health effects
should be disclosed for dissemination and independent review
as well as to enhance policy decisions for ENDS product
regulation.”
• “Tobacco products should be taxed proportionate to their
harm; therefore, ENDS should not be taxed at equal or higher
rates than combustible cigarettes.”
• “State and local governments should implement ENDS
regulations within their authorities that are appropriate for
protecting the public health, including restricting the sale,
distribution, marketing, and advertising of ENDS to youth.”
• “International cooperation is needed to develop standards
for the regulation of ENDS, and these regulations should
prioritize protection of the public’s health and draw upon the
best available scientific evidence whenever possible.”
—
American
Association
for
Respiratory
Care (AARC)
(2015)
• “Even though the
concept of using
the e-cigarettes for
smoking cessation
is attractive, they
have not been fully
studied and the
use among middle
school children is
increasing year after
year.”
• “There is no evidence as to the
amount of nicotine or other
potentially harmful chemicals
being inhaled during use or if
there are any benefits associated
with using these products.”
—
• Date effective: April
2014
• “The [AARC] opposes
the use of the
electronic cigarette
(e-cigarette).”
Table 5.3 A Continued
A Report of the Surgeon General
210 Chapter 5
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
American
College of
Physicians
(ACP)
(Crowley
and Health
Public Policy
Committee
of the ACP
2015)
• “ENDS, which
include electronic
cigarettes, or
e-cigarettes,
are growing in
popularity, but their
safety and efficacy as
a smoking cessation
aid are not well
understood.”
• “[There is concern] that the
health effects of ENDS use are
unknown, that they may appeal
to young people, and that they
may encourage dual use of
ENDS and traditional tobacco
products.”
• “The Food and Drug Administration [should] extend its
regulatory authority granted through the Family Smoking
Prevention and Tobacco Control Act to cover electronic
nicotine delivery systems (ENDS).”
• “Characterizing flavors should be banned from all tobacco
products, including ENDS.”
• “The [ACP] supports taxing tobacco products, including
ENDS devices and nicotine liquids, to discourage use among
children and adolescents. Local governments should be
permitted to establish higher tax rates for ENDS and related
products than state levels.”
• “The [ACP] supports legislative or regulatory efforts to
restrict promotion, advertising, and marketing for ENDS
products in the same manner as for combustible cigarettes,
including a prohibition on television advertising.”
• “Youth tobacco prevention efforts, such as antismoking media
campaigns and school-based interventions, should include
information about the potential risks of ENDS use.”
• “The federal, state, and local regulators should take action to
extend indoor and public place clean air laws that prohibit
smoking in public places, places of employment, commercial
aircraft, and other areas to ENDS products.”
• “The federal government should authorize and appropriate
funding to rigorously research the health effects of ENDS
use, chemical content, and toxicity; effects of ENDS vapor
exposure; dual-use rates; and effects of ENDS-derived nicotine
on human health.”
• “The [ACP] supports
strong regulations to
ensure product safety
and transparency,
policies that prevent
use among young
people, increased
research to better
determine their
health effects, strong
limits on marketing
and promotion to
discourage interest
among young people,
and application of
indoor air laws to
protect the health of
bystanders.”
• “This paper is not
intended to offer
clinical guidance or
serve as an exhaustive
literature review
of existing ENDS-
related evidence but
to help direct the
[ACP], policymakers,
and regulators on
how to address these
products.”
Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 211
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
American
Thoracic
Society
(2013, 2015)
(continues
on next
page)
• “The new CDC
data show that Big
Tobacco is once
again peddling a new
product intended to
get youth hooked
on nicotine, and
that e-cigarettes
are not about
harm reduction or
smoking cessation,
but about addiction.”
• “The short- and long-term health
risks of these nicotine-delivery
devices are largely unknown.”
• “States should regulate e-cigarettes as tobacco products.
E-cigarettes should not be sold to those younger than 18, and
regulations requiring identification and proof of age at the
time of purchase should apply. Internet sales of e-cigarettes
should be strictly regulated.”
• “E-cigarettes should be taxed at rates equivalent with
traditional cigarettes and other tobacco products.”
• “E-cigarettes should be subject to the same restrictions
regarding public use as combustible tobacco products, and
e-cigarettes should not be used in smoke-free areas.”
• “The FDA should deem regulatory authority over
e-cigarettes.”
• “Candy and menthol flavored e-cigarettes should be banned.”
• “E-cigarette packaging should include warning labels, similar
in size and scope to those required of combustible tobacco
packaging. Where risks are known, the consumer should be
informed of those risks in clear and direct language. Where
data regarding risk is [sic] unavailable or inconclusive, the
consumer should be informed of the lack of reliable safety
testing data.”
• “The FDA should regulate the form and content of e-cigarette
advertising.”
• “Both direct and implied health and safety claims by
e-cigarette manufacturers should be subject to the same
evidentiary review process currently required for other
products making such claims.”
• “The FDA should require e-cigarette manufacturers to adopt
Good Manufacturing Processes similar to those that exist for
other regulated products, including lot numbers, securing
packaging, etc.”
• “Given that nicotine is an addictive drug, with the dependence
liability related to the pharmacokinetic characteristics of
the delivery device, delivery characteristics of the e-cigarette
should be evaluated and disclosed, and periodically monitored
to ensure consistency of the product’s dependence potential
over time.”
• “[E]-cigarettes need
to be subject to the
same marketing
and manufacturing
restrictions as
tobacco products.”
• “For the first time,
e-cigarette use
among young people
is higher than for
any other tobacco
product.”
Table 5.3 A Continued
A Report of the Surgeon General
212 Chapter 5
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
(continued
from
previous
page)
American
Thoracic
Society
(2013, 2015)
— —
• “Content of e-cigarette cartridges should be disclosed and
regulated.”
• “The nicotine content of the e-cigarette cartridge should not
exceed that of similar user volume of combustible tobacco.”
• “Deliverable nicotine levels should be consistent between
cartridges.”
• “Researchers and clinicians, along with scientific societies
and publications, receiving funding from e-cigarette
manufacturers should disclose this relationship and the
potential for conflict of interest in a manner equivalent to
disclosures required for funding from the remainder of the
tobacco industry.”
—
Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 213
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
European
Respiratory
Society
(ERS) (2014)
• “Electronic
cigarettes are
designed for the
purpose of direct
nicotine delivery
to the respiratory
system, and they fall
into a regulatory gap
in most countries,
escaping regulation
as medicinal
products and
avoiding the controls
applicable to tobacco
products.”
• “For ERS, the priority of the
Revision of the Tobacco Products
Directive is to protect children
and youth from becoming
smokers by preventing them
from picking up their first
cigarette.”
• “There is no adequate scientific
research available on the overall
health risk or the long-term
effects of electronic cigarette use
on humans.”
• “Mandatory reporting system of ingredients used in tobacco
products.”
• “Harmonised regulation of the ingredients of tobacco
products.”
• “80% pictorial health warnings, covering the front and back
of packages. Based on evidence, the larger the pictorial health
warnings are, the more effective they are.”
• “Plain/standardised packaging of tobacco products.”
• “Introduction of both visible and invisible security features on
tobacco packaging and ensuring that the storage and access
to such data is [sic] independent from tobacco companies.”
• “Prohibition on the cross-border distance sale of tobacco
products.”
• “Strong regulatory framework and independent research for
electronic cigarettes. Any regulation of electronic nicotine
delivery systems should be science based.”
• “Ensuring the adoption of delegated acts is not exposed to the
interests of the tobacco industry, which would jeopardise the
achievement of high level of health protection.”
• “ERS supports
the European
Commission’s
Proposal for the
Tobacco Products
Directive and
Rapporteur Linda
McAvan’s efforts to
improve it.”
• “Introduction of
standard packs with
increased health
warnings.”
• “Prohibition of
characterizing
flavours.”
• “Strengthening
of traceability and
security features for
combating illicit
trade.”
• “Prohibiting
misleading features,
including slim
cigarettes.”
• “Approximately
700,000 EU citizens
die prematurely
every year because
of tobacco
consumption.”
Table 5.3 A Continued
A Report of the Surgeon General
214 Chapter 5
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
Forum of
International
Respiratory
Societies
(American
College
of Chest
Physicians
2014;
Schraufnagel
etal. 2014)
• “Studies looking at
whether electronic
cigarettes can
aid smoking
cessation have had
inconsistent results.”
• “The safety of electronic
cigarettes has not been
adequately demonstrated.”
• “The addictive power of nicotine
and its untoward effects should
not be under-estimated.
• “Potential benefits to an
individual smoker should be
weighed against harm to the
population of increased social
acceptability of smoking and use
of nicotine.”
• “Adverse health effects for third
parties exposed to the emissions
of electronic cigarettes cannot be
excluded.”
• “Health and safety claims regarding electronic nicotine
delivery devices should be subject to evidentiary review.”
• “If ENDS devices are permitted, they should be regulated as
tobacco products.”
• “Research, supported by sources other than the tobacco
or electronic cigarette industry, should be carried out to
determine the impact of electronic nicotine delivery devices
on health in a wide variety of settings.”
• “The use and population effects of END devices should be
monitored.”
• “All information derived from this research should be
conveyed to the public in a clear manner.”
• “ENDS should be
restricted or banned,
at least until more
information about
their safety is
available.”
Table 5.3 A Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 215
B. Voluntary health organizations
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
American
Cancer
Society
(ACS) (2014)
• “Because the
American Cancer
Society doesn’t
yet know whether
e-cigarettes are safe
and effective, we
cannot recommend
them to help people
quit smoking.”
• “There are proven
methods available
to help people quit,
including pure forms
of inhalable nicotine
as well as nasal
sprays, gums, and
patches.”
• “[E]-cigarettes are not labeled
with their ingredients, so the
user doesn’t know what’s in
them.”
• “Inhaling a substance is not the
same as swallowing it.”
• “Studies have shown that
e-cigarettes can cause short-term
lung changes that are much
like those caused by regular
cigarettes.”
• “E-cigarettes need to be researched and regulated.” • “Until electronic
cigarettes are
scientifically
proven to be safe
and effective,
ACS will support
the regulation of
e-cigarettes and laws
that treat them like
all other tobacco
products.”
Table 5.3 Continued
A Report of the Surgeon General
216 Chapter 5
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
American
Heart
Association
(AHA)
(Bhatnagar
et al. 2014)
(continues
on next
page)
• “Current evidence
evaluating the
efficacy of these
products as a
cessation aid is
sparse, confined
to 2 randomized
controlled trials
and 1 large cross-
sectional study,
anecdotal reports,
and Internet-based
surveys.”
• “[R]eports are
confounded by a
self-selection bias in
that the respondents
are often e-cigarette
enthusiasts.”
• “The AHA maintains
that e-cigarette
use should be
part of tobacco
screening questions
incorporated into
clinical visits and
worksite/community
health screenings
that are tied into
healthcare delivery.”
• “Low levels of harmful or
potentially harmful metals such
as lead, nickel, and chromium
are listed as having been
detected.”
• “Trace levels of tobacco-specific
N-nitrosamines, polycyclic
aromatic hydrocarbons, and
volatile organic compounds in
the e-liquid and vapor have been
reported.”
• “The FDA has issued warnings
to several e-cigarette companies
for selling e-cartridges with
[diethylene glycol, weight-
loss chemical rimonabant
(Zimulti), and the erectile
dysfunction medication tadalafil
(active ingredient in Cialis)]
contaminants.”
• “There are no reports of
e-cigarette safety in patients with
known cardiovascular disease.”
• “The regulation should allow for quality-controlled products
for adults who want to transition from conventional cigarettes
to e-cigarettes or to quit or reduce smoking.”
• “Bottles containing nicotine refill liquids can be toxic if
swallowed, so cartridges and bottles should have proper
warning labeling and child-proofing packaging.”
• “It is important that the relevant government agency monitor
whether these devices are used for delivery of other drugs and
medications.”
• “Companies should not be able to claim that e-cigarettes are
a cessation aid unless they are approved by the FDA for that
purpose.”
• “The [AHA] supports
effective regulation
that addresses
marketing, labeling,
quality control of
manufacturing,
and standards for
contaminants.”
• “[It] also supports
including
e-cigarettes in
smoke-free air laws
and prohibiting the
sales of e-cigarettes
to youth.”
Table 5.3 B Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 217
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
(continued
from
previous
page)
American
Heart
Association
(AHA)
(Bhatnagar
et al. 2014)
• “Clinicians should
be educated about
e-cigarettes and
should be prepared
to counsel their
patients who are
using combustible
tobacco products to
use e-cigarettes as
a primary cessation
aid.”
• “For patients
with existing
cardiovascular
disease and stroke,
or at risk of a
cardiovascular
disease event,
intensive cessation
counseling should
be offered as soon as
possible.”
— — —
Table 5.3 B Continued
A Report of the Surgeon General
218 Chapter 5
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
American
Lung
Association
(2014, 2015)
• “Until and unless
the FDA approves a
specific e-cigarette
for use as a tobacco
cessation aid, the
American Lung
Association does not
support any direct
or implied claims
that e-cigarettes help
smokers quit.”
• “There is currently no scientific
evidence establishing the safety
of e-cigarettes.”
• “FDA found detectable levels of
toxic cancer-causing chemicals,
including an ingredient used in
anti-freeze, in two leading brands
of e-cigarettes and 18various
cartridges.”
• “The lab tests also found that
cartridges labeled as nicotine-
free had traceable levels of
nicotine.”
• “Nicotine is believed to
contribute to increased incidence
of premature birth, and low birth
weight.”
• “Research has also shown a
negative impact on pulmonary
function in newborns.”
• “The FDA has not approved any e-cigarettes as a safe or
effective method to help smokers quit.”
• “Including
e-cigarettes in
smokefree laws and
ordinances.”
• “State laws that
would prohibit the
sale of any flavored
e-cigarette product.”
• “Taxing e-cigarettes
at a rate equivalent
with all tobacco
products, including
cigarettes.”
• “Eliminating
e-cigarette sales to
youth, otherwise
restricting youth
access to e-cigarettes
and requiring
e-cigarette retailers
to be licensed.”
• “E-cigarettes should
be defined as tobacco
products.”
• “Opposes creating
new definitions for
‘vapor products’
and/or ‘alternative
nicotine products’ in
state laws.”
Table 5.3 B Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 219
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
Americans
for
Nonsmokers’
Rights (ANR)
(n.d.a; n.d.b)
• “ESDs are not
proven cessation
devices.”
• “Many people
become ‘stable
dual-users’ who use
both cigarettes and
ESDs.”
• “Americans for Nonsmokers’
Rights recommends that
e-cigarettes not be used in areas
where people will be exposed to
the vapors they emit.”
• “Electronic smoking device
aerosol is not water vapor. . . .
The aerosol (incorrectly called
vapor) contains nicotine,
hazardous ultrafine particles that
lodge deeply in the lungs . . . and
toxins known to cause cancer.”
• “Electronic smoking devices are currently unregulated
products.”
• “[ANR] . . . encourages municipalities and states to prohibit
the use of ESDs in all smokefree venues.”
• “Electronic cigarettes
are not a safe
alternative!”
C. World Health Organization
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
World Health
Organization
(WHO) (Bates
2014; WHO
2014b)
(continues on
next page)
• “Prohibit
manufacturers and
third parties from
making health
claims for ENDS,
including that
ENDS are smoking
cessation aids.”
• “The regulatory
standard for
cessation claims
and approval as
cessation aids
should remain an
appropriate body
of evidence, based
on well-controlled
clinical trials.”
• “ENDS users should be legally
requested not to use ENDS
indoors, especially where smoking
is banned until exhaled vapour
is proven to be not harmful
to bystanders and reasonable
evidence exists that smoke-
free policy enforcement is not
undermined. If smoke-free
legislation is not fully developed
according to Article 8 of the WHO
FCTC and the guidelines for its
implementation, this should be
done as soon as possible.”
• “Health warnings should be
commensurate with proven health
risks.”
• “Parties should contemplate putting in place an effective
restriction on ENDS advertising, promotion and sponsorship.”
• “Protection from vested commercial interests.”
• “Governments are recommended to use or strengthen their
existing tobacco surveillance and monitoring systems to assess
developments in ENDS and nicotine use by sex and age.”
• “Overall, in
its public
communication
WHO portrays
e-cigarettes as a
threat to public
health.”
• “Encourage
smoking cessation
and provide a
quitline number if
one exists.”
Table 5.3 B Continued
A Report of the Surgeon General
220 Chapter 5
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
(continued
from previous
page)
World Health
Organization
(WHO) (Bates
2014; WHO
2014b)
• “For ENDS
products to be
approved for
smoking cessation
by the suitable
regulatory agency,
the appropriate
balance should
be reached
between providing
accurate scientific
information
to the public
about the risk of
ENDS use and its
potential benefits
as compared with
smoking.”
— — —
Table 5.3 C Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 221
Table 5.3 Continued
D. Government health
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
European
Union (EU)
(European
Parliament
and Council
2014; WHO
Framework
Convention
on Tobacco
Control 2014)
—
• “Certain additives used to create
the impression that tobacco
products have health benefits, as
well as those with [carcinogenic,
mutagenic, or reprotoxic]
properties in unburnt form,
should be prohibited in order to
ensure uniform rules throughout
the Union and a high level of
protection of human health.”
• “Electronic cigarettes and
refill containers could create a
health risk when in the hands
of children—it is necessary to
ensure products are child and
tamperproof.”
• “Nicotine-containing liquid should
only be placed on the market in
electronic cigarettes or in refill
containers that meet certain safety
and quality requirements.”
• “The prohibition of tobacco products with characterizing
flavours does not preclude the use of individual additives
outright, but it does oblige manufacturers to reduce the
additive or the combination of additives.”
• “Electronic cigarettes and refill containers should be
regulated by this Directive.”
• “Where the manufacturer of the relevant product is not
established in the Union, the importer of that product should
bear the responsibilities relating to the compliance of those
products with this Directive.”
• “Nicotine-containing liquid should only be allowed to be
placed on the market, where the nicotine concentration does
not exceed 20 mg/ml.”
• “Only electronic cigarettes that deliver nicotine doses at
consistent levels should be allowed to be placed on the
market.”
• “The labeling and packaging of [e-cigarettes] should display
sufficient and appropriate information on their safe use.”
• New directive: May
2014.
• New rules applied:
First half of 2016.
• “Aims at ensuring
equal treatment
across the EU for
nicotine-containing
e-cigarettes
(products that do
not contain nicotine
are not covered by
the Directive).”
• “Electronic
cigarettes can
develop into
a gateway to
nicotine addiction
and ultimately
traditional tobacco
consumption, as
they mimic and
normalize the
action of smoking.
For this reason, it
is appropriate to
adopt a restrictive
approach to
advertising
electronic
cigarettes and refill
containers.”
A Report of the Surgeon General
222 Chapter 5
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
CAP/BCAP
(UK) (2014)
— • “Ads cannot convey health benefits
or claim that they are safer or
healthier than smoking tobacco.”
• “Ads must not be likely to appeal particularly to people under
18, especially by reflecting or being associated with youth
culture.”
• “People shown using e-cigarettes or playing a significant role
must neither be, nor seem to be, under 25.”
• “Ads must not be directed at people under 18 through the
selection of media or the context in which they appear.”
• “Ads must not encourage nonsmokers or nonnicotine users to
use e-cigarettes.”
• “Ads must make clear that the product is an e-cigarette and
not a tobacco product.”
• “Ads on TV and radio will be subject to scheduling restrictions
to reduce the chance of e-cigarette advertisements being seen
or heard by children.”
• Effective date:
November 10, 2014.
• “The rules place an
emphasis on the
protection of young
people and ads must
avoid containing
anything that
promotes the use of
a tobacco product
or that shows the
use of a tobacco
product in a positive
light.”
• CAP: Write and
maintain the UK
advertising codes.
Public Health
England (UK)
(Britton and
Bogdanovica
2014;
CAMQUIT
n.d.)
— —
• “Under the terms of the new Tobacco Product Directive
(TPD) . . . advertising of nicotine-containing devices that are
not licensed as medicines will be prohibited, products will be
required to carry health warnings, meet purity and emission
standards that are yet to be defined.”
• Effective date: 2016.
• “The UK [Medicines
and Healthcare
products Regulatory
Agency] announced
that from 2016, it
intended to regulate
electronic cigarettes
and other nicotine-
containing products
as medicines by
function, and
thus require
manufacture to
medicinal purity
and delivery
standards, and
proactive controls
on advertising.”
Table 5.3 D Continued
E-Cigarette Use Among Youth and Young Adults
E-Cigarette Policy and Practice Implications 223
Organization
Organizational
position on cessation Organizational position on harm Organizational position on regulation General comments
International
Union Against
Tuberculosis
and Lung
Cancer (2013)
• “The benefits
of e-cigarettes
have not been
scientifically
proven.”
• “Very few studies
have assessed ECs/
ENDS as a harm
reduction and
cessation aid and
with conflicting
findings.”
• “The safety of ECs or ENDS has not
been scientifically demonstrated.”
• “Adverse health effects for
[secondhand smoke] cannot
be excluded because the use of
electronic cigarettes leads to
emission of fine and ultrafine
inhalable liquid particles, nicotine
and cancer-causing substances into
indoor air.”
• “A range of current and proposed legislative and regulatory
options exists.”
• “Brazil, Norway, and Singapore have banned ECs/ENDS
completely.”
• “ENDS could undermine the implementation of WHO FCTC
Article 12 (de-normalisation of tobacco use).”
• “Use of ENDS could also hamper the implementation of
Article 8 (protection from exposure to tobacco smoke).”
• “The Union
strongly supports
the regulation of
the manufacture,
marketing and
sale of Electronic
cigarettes (ECs)
or electronic
nicotine delivery
systems (ENDS);
the preferred option
is to regulate
ECs or ENDS as
medicines.”
• “The Union is
concerned that
the marketing,
awareness and use
of ECs or ENDS is
growing rapidly.”
Note: AARC=American Association for Respiratory Care; ACP=American College of Physicians; ACS=American Cancer Society; AHA=American Heart Association;
ANR = Americans for Nonsmokers’ Rights; CAP/BCAP=Committees of Advertising Practice/Broadcast Committee of Advertising Practice; CDC = Centers for Disease
Control and Prevention; CTP = Center for Tobacco Products; ECs=electronic cigarettes; ENDS=electronic nicotine delivery systems; ERS=European Respiratory
Society; ESDs=electronic smoking devices; EU=European Union; FCTC = Framework Convention for Tobacco Control; FDA = U.S. Food and Drug Administration;
UK=United Kingdom; WHO=World Health Organization.
Table 5.3 D Continued
A Report of the Surgeon General
224 Chapter 5
Case Studies
Case studies in California and North Dakota dem-
onstrate how e-cigarette policies have been enacted at the
local and state levels, and they provide potential models
of how cities, counties, and other states might address
e-cigarettes in their jurisdictions.
City of Hayward Takes Bold Steps to Address Tobacco Products Aimed
at Kids
In response to the “D” grade that the city of Hayward received in 2011 from the American Lung Association in
California for its efforts to protect youth from tobacco sales, the city council directed its staff to develop regulations
to address the problem of youth tobacco sales. Draft regulations were presented at a city planning meeting in 2012,
followed by a series of community meetings and hearings that culminated in the Hayward city council’s adoption of
a 45-day moratorium to begin in January 2014 on the issuance of business licenses or building permits for any new
tobacco retailers. The following month, the moratorium was extended another 15 months to provide more time to
research and consider the issue (City of Hayward 2014).
On July 1, 2014, the Hayward city council unanimously adopted an ordinance that requires sellers of tobacco
products and “electronic smoking devices” to obtain annually a $400 tobacco retailer license that covers the cost of
an annual inspection for compliance with federal, state, local, tribal, and territorial tobacco control laws. The ordi-
nance allowed the city’s existing 142 tobacco retailers, 8 e-cigarette retailers, and 2 hookah lounges to continue
operating at their current locations; however, new sellers must obtain a conditional use permit, are restricted to spe-
cial commercial zones, and may not locate within 500 feet of residential areas or child-sensitive areas (e.g., schools
and parks) or within 500 feet of an existing tobacco seller. It also prohibits new hookah lounges or vaping lounges
from opening within the city.
The ordinance also contains provisions to prohibit self-service displays of tobacco products and e-cigarettes
and to regulate the sales of cigars, flavored products, and imitation tobacco products. Cigars selling for less than
$5 each are required to be sold in pack sizes of five or more, and the sale of flavored traditional tobacco products,
e-cigarettes, and imitation tobacco products (e.g., candy cigarettes, bubble gum chew) is prohibited within 500 feet
of schools for any business not selling these products before July 1, 2014.
Penalties range from $1,500 for a first violation and possible suspension to a complete revocation of a license
after three violations within a 3-year period (City of Hayward 2014; n.d.a.). Active enforcement of the ordinance
began in April 2015 (City of Hayward n.d.b.).
Throughout the process, Hayward officials and staff relied heavily on materials from the American Lung
Association, the Center for Tobacco Policy and Organizing, and ChangeLab Solutions to provide the public health
and legal rationale for supporting the provisions. Hayward’s tobacco retail licensing effort was also supported by
the tobacco control program of the Alameda County public health department, which used monies from its Master
Settlement Agreement to fund the Hayward police department to conduct youth decoy operations and local commu-
nity and youth organizations to conduct educational outreach (City of Hayward 2014). Collectively, these resources
informed the Hayward city council’s decision-making process.
E-Cigarette Policy and Practice Implications 225
E-Cigarette Use Among Youth and Young Adults
North Dakota’s Statewide Clean Indoor Air Law Prohibits Conventional
Tobacco Products and E-Cigarettes
In November 2012, North Dakota achieved a remarkable victory for statewide clean indoor air (BreatheND
n.d.a.) despite major obstacles, including a harsh winter climate, an adult smoking rate of 21.9% (CDC 2013), and
several prior failed legislative attempts to close exemptions in the state’s 2005 clean indoor air law (CDC 2014).
Despite these impediments, two-thirds of the state voted to prohibit both the smoking of conventional tobacco prod-
ucts and use of e-cigarettes in all non-hospitality workplaces; restaurants; bars; hotel guest rooms and communal
areas; health care facilities; assisted living facilities; all licensed child and adult day care facilities; gaming facili-
ties; indoor areas of sports arenas; and within 20 feet of entrances, exits, operable windows, air intakes, and venti-
lation systems of enclosed areas where smoking is not allowed (BreatheND n.d.b.). Additionally, the law provided
no exemptions for tobacco-only retail or “vape shops” (Americans for Nonsmokers’ Rights Foundation 2015, n.d.).
The 2012 ballot initiative on statewide clean indoor air resulted from the lack of progress in working with the
legislature to try to close smoking exemptions in the state law. The initiative’s sponsors, Tobacco Free North Dakota
and the American Lung Association in North Dakota, worked closely with the Tobacco Control Legal Consortium
to draft policy language, which included prohibiting the use of e-cigarettes anywhere smoking was prohibited. The
sponsors approached stakeholders and assessed public support. Little opposition was encountered to prohibiting the
use of e-cigarettes indoors. In addition to the sponsors’ efforts, the North Dakota Center for Tobacco Prevention and
Control Policy conducted a media campaign and worked with local partners to educate their communities, resulting
in 11smokefree ordinances prior to the issuing of the statewide ballot initiative. The landslide victory (66% vs. 33%)
in favor of clean indoor air, with the initiative successfully carried in every one of North Dakota’s 53 counties, dem-
onstrated widespread public support for clean indoor air (Ballotpedia 2012).
Only a few years later, the law continues to enjoy strong public support from nonsmokers (84.4%) and smokers
(58%) alike. Compliance with the law is comparable to cigarette smoking; just 16.8% of North Dakotans reported
having observed smoking indoors in areas where it was prohibited, and 23.2% reported having seen e-cigarettes
used indoors in such places. Local enforcement personnel confirm a high level of compliance, reporting violations
primarily related to smoking within 20 feet of entrances. To date, the only prosecuted violation of the law involved
the sampling of an e-cigarette product inside a “vape shop” (BreatheND 2014). In hindsight, the decision to include
e-cigarettes in North Dakota’s smokefree law was helpful, given increasing concerns about involuntary exposure to
nicotine and other aerosolized e-cigarette emissions.
Summary and Recommendations
The Surgeon General has long played a leading role
in identifying the harms of tobacco use and documenting
the most effective ways to reduce them. This report comes
amid the rising use of e-cigarettes among the nation’s
youth and young adults. It calls attention to this problem
and the need to implement immediately a comprehensive
strategy to minimize any negative public health impact
now and in the future, giving consideration to the potential
for youth to be harmed from e-cigarettes while, simultane-
ously, acknowledging that gains might be made if the use
of combustible tobacco products fell among adult smokers.
Chapters 1–4 documented the particular challenges posed
by the rapid emergence and dynamic nature of e-cigarette
use among youth and young adults. The marketplace is
diverse, and although it includes the large tobacco com-
panies, e-cigarettes are sold in thousands of “vape shops”
and other small commercial locations and on the Internet.
Marketing strategies exploit social media, reaching widely
and with tailored targeting to consumers.
The differences notwithstanding, the principles and
strategies articulated in the 2014 Surgeon General’s report
and prior reports remain relevant to e-cigarettes. The 2014
report was written not long after the use of e-cigarettes
began to surge dramatically; that report commented on the
need for rapid elimination of conventional cigarettes and
other combustible tobacco products but did not specify
a role for e-cigarettes or discuss strategies to minimize
adverse effects among youth and young adults (USDHHS
2014). The report’s final chapter, however, set out an evi-
dence-based strategy for the future. The present report
builds on this foundation, adding recommendations related
to e-cigarettes.
A Report of the Surgeon General
226 Chapter 5
Conclusions
1. The dynamic nature of the e-cigarette landscape
calls for expansion and enhancement of tobacco-
related surveillance to include (a) tracking patterns
of use in priority populations; (b) monitoring the
characteristics of the retail market; (c) examining
policies at the national, state, local, tribal, and ter-
ritorial levels; (d) examining the channels and mes-
saging for marketing e-cigarettes in order to more
fully understand the impact future regulations
could have; and (e) searching for sentinel health
events in youth and young adult e-cigarette users,
while longer-term health consequences are tracked.
2. Strategic, comprehensive research is critical to
identify and characterize the potential health risks
from e-cigarette use, particularly among youth and
young adults.
3. The adoption of public health strategies that are pre-
cautionary to protect youth and young adults from
adverse effects related to e-cigarettes is justified.
4. A broad program of behavioral, communications,
and educational research is crucial to assess how
youth perceive e-cigarettes and associated mar-
keting messages, and to determine what kinds of
tobacco control communication strategies and
channels are most effective.
5. Health professionals represent an important
channel for education about e-cigarettes, particu-
larly for youth and young adults.
6. Diverse actions, modeled after evidence-based
tobacco control strategies, can be taken at the
state, local, tribal, and territorial levels to address
e-cigarette use among youth and young adults,
including incorporating e-cigarettes into smoke-
free policies; preventing the access of youth to
e-cigarettes; price and tax policies; retail licensure;
regulation of e-cigarette marketing that is likely to
attract youth and young adults, to the extent feasible
under the law; and educational initiatives targeting
youth and young adults. Among others, research
focused on policy, economics, and the e-cigarette
industry will aid in the development and imple-
mentation of evidence-based strategies and best
practices.
E-Cigarette Policy and Practice Implications 227
E-Cigarette Use Among Youth and Young Adults
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The Call to Action
The Call to Action on E-Cigarette Use Among Youth and Young Adults 237
Goal 1. First, Do No Harm 237
Goal 2. Provide Information About the Dangers of E-Cigarette Use Among Youth and Young Adults 239
Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to Protect Public Health 241
Goal 4. Programs and Policies to Prevent E-Cigarette Use Among Youth and Young Adults 243
Including E-Cigarettes in Smokefree Indoor Air Policies 243
Restricting Youth Access to E-Cigarettes 244
Licensing Retailers 245
Establishing Specific Packaging Requirements 245
Goal 5. Curb Advertising and Marketing that Encourages Youth and Young Adults to Use E-Cigarettes 246
Goal 6. Expand Surveillance, Research, and Evaluation Related to E-Cigarettes 247
Conclusions 249
References 250
235
236
The Call to Action 237
E-Cigarette Use Among Youth and Young Adults
The Call to Action on E-Cigarette Use Among Youth and
Young Adults
The Surgeon General issues this Call to Action on
e-cigarettes, specifically focusing on youth and young
adults, to accelerate policies and programs that can reduce
e-cigarette use among young people. This Call to Action
comes amid the dramatic increase in e-cigarette use
among our nation’s youth and young adults. It highlights
the need to implement proven strategies that will pre-
vent potentially harmful effects of e-cigarette use among
young people. The previous chapters explained what we
know and do not know about e-cigarettes and reviewed
policy options. Gaps in scientific evidence still exist, and
this Call to Action is being issued while these products
and their patterns of use are changing quickly. However,
policies and strategies are available that can clearly reduce
the public health threat posed by e-cigarette use among
young people.
Use of e-cigarettes is increasing rapidly
among young people, even among those
who have never smoked cigarettes.
This Call to Action presents six goals and related
strategies that should guide efforts to reduce e-cigarette
use among youth and young adults. To achieve these
goals, we must work together, which means working with
individuals and families; civic and community leaders;
public health and health care professionals; e-cigarette
manufacturers and retailers; voluntary health agencies;
researchers; and other stakeholders.
Stakeholders Who Can Take Action
• Individuals, parents, and families
• Teachers, coaches, and other youth influencers
• Civic and community leaders
• Public health and health care professionals
• Researchers
• Federal government
• State, local, tribal, and territorial governments
• E-cigarette manufacturers, distributors, and
retailers
• Voluntary health agencies, non-governmental
organizations, and other community- and faith-
based organizations
Goal 1. First, Do No Harm
Since 1964, reports from the U.S. Surgeon General
have led the way in identifying the harms of tobacco use
and detailing the most effective ways to reduce the dan-
gerous effects of tobacco use. For example, reports from
1994 and 2012 outlined proven strategies to prevent and
reduce tobacco use among youth and young adults (U.S.
Department of Health and Human Services [USDHHS]
1994, 2012). Building on these and other past reports,
this Call to Action considers the harms of e-cigarette use
among youth and young adults and stresses the impor-
tance of strategies that will protect young people from the
adverse consequences of these new products.
A Report of the Surgeon General
Strategy 1A.
Implement a comprehensive strategy to address
e-cigarettes that will avoid adverse consequences and
give careful consideration to the risks for youth and
young adults. This can be done by including e-cigarettes
in policies and programs related to conventional
cigarette smoking at the national, state, local, tribal,
and territorial levels.
We have many effective strategies to prevent tobacco
use among youth and young adults (USDHHS 2012), and
many of these strategies can also be applied to e-cigarettes.
A strategy to address e-cigarette use among young people
should be precautionary. A precautionary approach urges
action to prevent harm when there is scientific uncer-
tainty. That is, when there is inadequate or early knowl-
edge, public health decisions should be made on the basis
of precaution to prevent harm, rather than on certain
risk. This approach requires proof that a product is not
harmful—especially for youth—rather than proof that it
is harmful. The burden of proof regarding product safety
should be placed on those who wish to market and sell
such tobacco products, rather than the public health com-
munity charged with protecting the public’s health. The
harms of nicotine exposure in youth and young adults are
well-documented in this report and warrant this Call to
Action (see Chapter 3). We must protect the health of our
nation’s young people by assuring that there will be no
harm to youth from e-cigarettes. The stakeholders iden-
tified on the previous page should work together to pre-
vent and reduce the use of all forms of tobacco products,
including e-cigarettes, among our nation’s youth and
young adults. A comprehensive strategy includes:
• Implementing the U.S. Food and Drug
Administration’s (FDA’s) authority to regulate
tobacco products in order to provide oversight of
the manufacturing, distribution, and marketing of
e-cigarettes, particularly as they relate to youth and
young adults;
• Funding comprehensive statewide tobacco control
programs at levels recommended by the Centers for
Disease Control and Prevention (CDC);
• Implementing comprehensive clean indoor air pol-
icies that protect people from exposure to second-
hand tobacco smoke and the aerosol emitted from
e-cigarettes;
• Raising and strongly enforcing minimum age-of-sale
laws for all tobacco products, including e-cigarettes,
to prevent initiation at young ages;
Use of e-cigarettes can expose young people
to nicotine. Nicotine can be highly addictive
and can harm brain development. Nicotine
use may also lead to the use of other tobacco
or nicotine-containing products.
• Setting price policies for e-cigarettes, which could
include taxation policies;
• Restricting advertising and marketing that encour-
ages youth and young adults to use e-cigarettes;
• Sponsoring high-impact media campaigns to edu-
cate the public using evidence-based information
about the consequences of e-cigarette use among
youth and young adults, including the harms of nic-
otine on the developing brain; and
• Expanding tobacco control and prevention research
efforts to increase our understanding of the evolving
landscape of e-cigarettes.
These components make up an evidence-based
strategy. However, the e-cigarette marketplace is diverse
and continues to evolve. Thus, ongoing efforts should
rapidly and effectively track and adapt to such changes,
thereby protecting our nation’s young people from the
consequences of e-cigarette use and exposure to second-
hand aerosol.
238 The Call to Action
The Call to Action 239
E-Cigarette Use Among Youth and Young Adults
Strategy 1B.
Provide consistent and evidence-based messages about
the health risks of e-cigarette use and exposure to
secondhand aerosol from e-cigarettes.
Research on e-cigarettes is ongoing, and the
e-cigarette marketplace continues to evolve. Even so, a
sufficient body of evidence justifies actions taken now to
prevent and reduce the use of e-cigarettes and exposure to
secondhand aerosol from e-cigarettes, particularly among
youth and young adults. Most important, many health
risks are already known, and sufficient information exists
to take action to minimize potential harms. The evidence
is most compelling for nicotine. As part of comprehensive
reviews, previous Surgeon General’s reports have provided
causal findings on the development of addiction and other
health consequences of exposure to nicotine (USDHHS
1988, 2014). Beyond addiction, intake of nicotine by
young people can harm brain development (Chapter 3).
Additionally, aerosol from e-cigarettes contains
toxins that can harm the body, and the flavorings used in
these products cannot be considered safe for inhalation,
either firsthand or secondhand (Chapter 3). For example,
some flavorings have been known to be associated with
pulmonary toxicity (Allen et al. 2016).
Messaging about the potential role of e-cigarettes
in reducing the burden of tobacco-related diseases should
note that e-cigarette products that deliver nicotine are not
considered safe, particularly for youth and young adults,
even before researchers fully characterize and quantify
all of their health risks, including possible permanent
changes to the adolescent brain and lungs.
The use of any tobacco product, including
e-cigarettes, among young people is unsafe.
Goal 2. Provide Information About the Dangers of E-Cigarette Use
Among Youth and Young Adults
Once youth and young adults start using products
that contain nicotine, including e-cigarettes, they can
become addicted. Such addiction has the potential to lead
to long-term use of products that contain nicotine, such
as cigarettes. Most adolescents who use tobacco already
use more than one nicotine-containing product and are
not just using e-cigarettes alone (Chapter 2). The majority
of tobacco users start before they are 18 years of age,
and almost no one starts after age 25 (USDHHS 2012).
Therefore, the best way to protect young people from the
harms of tobacco use, including e-cigarettes, is to prevent
the use of these products altogether. Prevention should
start with robust public policies that make it easy for
youth not to use tobacco and harder for them to use any
tobacco products. Parents, teachers, health professionals,
and other influencers of youth should be educated about
the risks of e-cigarette use. They can then help educate
their own children as well as other young people about the
harms of e-cigarettes and the risk of a potential lifetime of
nicotine addiction.
Use of e-cigarettes and exposure to nicotine
is particularly dangerous for pregnant
women. Nicotine is toxic to the fetus and
impairs fetal brain and lung development.
Strategy 2A.
Educate parents, teachers, coaches, and other
influencers of youth about the risks of e-cigarette use
among youth and young adults.
Parents, guardians, teachers, coaches, health profes-
sionals, faith leaders, and other persons whose advice and
behavior influence youth play critical roles in protecting
youth and young adults from the harms of e-cigarette use
and exposure to the secondhand aerosol emitted from
these devices. Most adults are familiar with some of the
dangers of using tobacco products, especially conventional
cigarettes, and of exposure to secondhand tobacco smoke.
Because of these dangers, many adults have taken steps to
keep children safe. However, most adults are not aware of
the potential risks of using e-cigarettes and exposure to
secondhand aerosol, and e-cigarette marketing often pro-
motes these products as safe alternatives to smoking con-
ventional cigarettes. But messaging about the dangers is
essential. For example, the use of these products can lead
to nicotine addiction, harm brain development, and lead
to continued tobacco use.
A Report of the Surgeon General
Parents, teachers, coaches, and others can protect
their children and other young people by educating them
about e-cigarettes:
• Talk openly about the harms of nicotine and tobacco
use.
• Express firmly the idea that young people should not
use any tobacco products, including e-cigarettes.
• Do not let any individuals use e-cigarettes or other
tobacco products around children.
• Ask health care providers, adults, and parents to
discuss with children the health risks of using
e-cigarettes, such as nicotine addiction.
• Patronize restaurants and other places that do not
allow the use of e-cigarettes indoors, and let busi-
ness owners that allow e-cigarette use indoors know
that it is not as safe as clean air or even legal in many
places.
• Make sure children’s day care centers, schools, and
universities are completely tobacco-free, including
being free of e-cigarettes. A comprehensive tobacco-
free campus policy prohibits any tobacco use,
including e-cigarettes, on school property by anyone
at any time. These policies should be expanded to
include school events that are held off campus.
• Prohibit tobacco and e-cigarette company spon-
sorship of teams or events, promotional activities,
and offers of educational materials for preventing
tobacco use among youth.
• Make homes and cars completely tobacco-free,
including the use of e-cigarettes. This means no
use by family members, friends, or guests. Opening
a window does not fully protect against exposure
to secondhand cigarette smoke or from the sec-
ondhand aerosol from e-cigarettes. For youth and
young adults to be fully protected from indoor expo-
sure, all indoor environments must be 100% free
from tobacco smoke and e-cigarette aerosol.
• Set an example by being tobacco-free.
• Provide positive support and encouragement to
anyone who is trying to quit tobacco.
E-cigarettes are now the most common form
of tobacco used by young people. High school
students use e-cigarettes more than adults.
Research suggests that youth and young adults are
not as aware of the health consequences of e-cigarette use
as they are with the consequences of cigarette smoking
(Chapter2) (Pearson et al. 2012; Richardson et al. 2014;
Tan and Bigman 2014). FDA has the authority to require
health warnings on tobacco products and tobacco adver-
tising. In addition, FDA and other federal entities, along
with state and local organizations, can carry out educa-
tional campaigns to better inform the public, especially
parents, and increase their understanding of the harms of
e-cigarette use.
240 The Call to Action
The Call to Action 241
E-Cigarette Use Among Youth and Young Adults
Strategy 2B.
Educate health professionals about the risks of
e-cigarette use among youth and young adults.
The health care setting is an ideal place to educate
people of all ages on the potential risks of e-cigarette use
and exposure to secondhand aerosol from e-cigarettes.
Because e-cigarettes are a relatively new product, health
care professionals frequently face a lot of questions about
them. These often include questions related to the risks
of using e-cigarettes and whether these products can
help people to quit smoking. No e-cigarettes have been
approved as safe and effective cessation aids.
For youth, in particular, sufficient evidence shows
that the use of nicotine is not safe regardless of the
delivery device: combustible, non-combustible, or elec-
tronic (USDHHS 2014; see also Chapter 3). Thus, health
care professionals should warn youth and youth influ-
encers, such as parents, about the health risks of using
any product that contains nicotine, including e-cigarettes.
They should also warn youth about the dangers of using
other substances, such as marijuana, in e-cigarette devices
(American Academy of Pediatrics 2015).
Goal 3. Continue to Regulate E-Cigarettes at the Federal Level to
Protect Public Health
In 2009, the Family Smoking Prevention and Tobacco
Control Act (Tobacco Control Act) provided FDA with
authority to regulate tobacco products in a manner that
is “appropriate for the protection of public health” (e.g.,
§§ 906(d)(1), 907(a)(3)(A) & (a)(4)(A), and § 910(c)(2)(A) of
the Federal Food, Drug, and Cosmetic Act, as amended by
the Tobacco Control Act) (Family Smoking Prevention and
Tobacco Control Act 2009, p. 1786). The Tobacco Control Act
also requires FDA to consider in regulatory actions the health
effects at the individual and population levels, including the
impacts on the initiation of measures taken to quit tobacco
use as well as effects on relapse among former tobacco users.
But FDA is not the only federal agency that can address cer-
tain aspects of e-cigarettes (see Chapter 5, Table5.2).
Strategy 3A.
Implement FDA regulatory authority over the manufac-
turing, marketing, and distribution of e-cigarettes.
A federal appellate court decision titled Sottera,
Inc. v. Food & Drug Administration (2010) determined
that FDA can regulate e-cigarettes and other products
made or derived from tobacco under the Tobacco Control
Act, and that these products are not drugs or devices under
the Food, Drug, and Cosmetic Act unless marketed as
therapeutic or smoking cessation products. In May 2016,
FDA finalized a rule deeming most products meeting the
definition of a tobacco product, including e-cigarettes,
subject to regulation under the Tobacco Control Act. The
regulation went into effect on August 8, 2016 (but is under
litigation) (FDA 2016).
FDA’s rule for e-cigarettes includes several provi-
sions that can help protect youth and young adults from
the harms of e-cigarettes, such as the following:
• Prohibiting the sale of e-cigarettes to youth who are
under 18 years of age (both in person and online);
• Requiring proof of age at the point of purchase;
A Report of the Surgeon General
• Prohibiting vending machine sales in all facilities
where children are allowed to enter;
• Prohibiting the distribution of free samples;
• Requiring health warnings about nicotine on pack-
aging and in advertisements;
• Requiring manufacturers to register their e-cigarette
products with FDA and disclose the ingredients and
levels of harmful and potentially harmful constitu-
ents in those products to that agency;
• Requiring premarket review of new or changed
tobacco products and authorization by FDA before
they can be introduced into the marketplace; and
• Requiring manufacturers that intend to market
e-cigarettes for use to reduce harm or risk of tobacco-
related disease to receive authorization from FDA
based on scientific evidence that the product is less
harmful or presents less risk to the public.
This authority allows FDA to undertake future regu-
latory actions, if determined appropriate for the protec-
tion of public health, including:
• Within constitutional limitations, restricting pro-
motion, marketing, and advertising of e–cigarettes;
• Restricting Internet sales and requiring age verifica-
tion on websites and upon delivery;
• Prohibiting characterizing flavors;
• Promulgating product standards to reduce the tox-
icity, addictiveness, or appeal of tobacco products;
• Regulating packaging, including requiring min-
imum package sizes, mandating child-resistant
packaging, and requiring health warnings; and
• Prohibiting self-service displays.
Despite gaining this broad authority, FDA does not
have specific authority for certain regulatory actions. For
example, FDA generally does not restrict tobacco use in
public places, levy taxes on tobacco products, or restrict
sales to only certain types of retailers (e.g., pharmacies);
and FDA cannot completely eliminate nicotine in tobacco
products, require prescriptions for tobacco products,
or raise the minimum age for sale of tobacco products
above18.
Other complementary comprehensive tobacco con-
trol strategies at the state, local, tribal, and territorial
levels include:
• Implementing comprehensive clean indoor air laws;
• Prohibiting sales to those under 21 years of age;
• Increasing prices of tobacco products; and
• Developing high-impact countermarketing
campaigns.
Effective action at the state and local levels is crit-
ical to fully protecting young people from the harms of
e-cigarettes.
242 The Call to Action
The Call to Action 243
E-Cigarette Use Among Youth and Young Adults
Strategy 3B.
Reinforce other federal agencies as they implement
programs and policies to address e-cigarettes.
Of the other federal agencies that play a role in imple-
menting strategies to address e-cigarettes (see Chapter5,
Table 5.2), some target specific populations (e.g., the
U.S. Department of Defense and the U.S. Department
of Veterans Affairs); others cover specific areas (e.g.,the
General Services Administration, National Park Service);
and some focus on certain aspects of e-cigarettes (e.g.,the
Federal Trade Commission, the U.S. Department of
Transportation, and the U.S. Environmental Protection
Agency). Specific strategies to address e-cigarettes could
include those that protect employees, customers, and vis-
itors from exposure to secondhand aerosol, support and
encourage tobacco cessation, and curb youth-targeted or
false advertising. For example, the National Park Service
(2015) implemented a policy to protect employees and
visitors from exposure to secondhand aerosol from
e-cigarettes.
Goal 4. Programs and Policies to Prevent E-Cigarette Use Among
Youth and Young Adults
Subject to certain exceptions, the Tobacco Control
Act does not limit the authority of state, local, tribal,
and territorial governments to enact any tobacco-related
policies related to the sale, distribution, or possession of
tobacco products; exposure to these products; or access
to them. This broad preservation of authority enables
states and localities to adopt many comprehensive tobacco
control strategies that have been proven to prevent and
reduce tobacco use among youth and young adults. That
means that state, local, tribal, and territorial governments
could act first in developing regulations, policies, and pro-
grams that minimize any individual- and population-level
harms of e-cigarettes. The strongest, most innovative
tobacco control policies typically have originated at the
local level before eventually being adopted at the state
level. However, it is important that these strategies are
developed with evaluators and epidemiologists that can
collect robust data to inform the implementation and sus-
tainment of such strategies.
Strategy 4A.
State, local, tribal, and territorial governments should
implement population-level strategies to reduce
e-cigarette use among youth and young adults, such
as including e-cigarettes in smokefree indoor air
policies, restricting youth access to e-cigarettes in retail
settings, licensing retailers, and establishing specific
package requirements.
Over 50 years of research offers a strong body of
evidence on the effectiveness of certain tobacco preven-
tion and control measures. Much of this evidence can also
be applied to e-cigarettes. And from this evidence, state,
local, tribal, and territorial entities can take a variety of
actions to address e-cigarettes, such as:
• Including e-cigarettes in smokefree indoor air policies;
• Restricting youth access to e-cigarettes in retail
settings;
• Licensing retailers; and
• Establishing specific package requirements.
Including E-Cigarettes in Smokefree
Indoor Air Policies
Most smokefree indoor air policies were put in place
before the great rise in e-cigarette use. Because of that,
these policies may not cover e-cigarettes or exposure to
A Report of the Surgeon General
the aerosol they produce. Aerosol from e-cigarettes is
not harmless (CDC 2014). Smokefree indoor air policies
should be updated to prohibit the use of both conven-
tional cigarettes and e-cigarettes, thereby preserving stan-
dards for clean indoor air. Efforts to include e-cigarettes
in smokefree laws should also uphold or strengthen, not
weaken, existing protections against exposure to second-
hand smoke.
Including e-cigarettes in smokefree indoor air poli-
cies can:
• Eliminate health risks from exposure to secondhand
aerosol from e-cigarettes;
• Discourage people from using both combustible and
electronic tobacco products (dual use);
• Simplify compliance with and enforcement of
existing smokefree laws;
• Help to reduce the use of e-cigarettes among youth
and young adults; and
• Maintain tobacco-free norms.
Aerosol from e-cigarettes is not harmless.
To date, several states and several hundred com-
munities include e-cigarettes in comprehensive smoke-
free laws that prohibit smoking in all indoor areas of
public places, including worksites, restaurants, bars, and
gambling facilities (Americans for Nonsmokers’ Rights
Foundation 2015; CDC n.d.).
Restricting Youth Access to
E-Cigarettes
When laws prohibiting tobacco sales to youth are
strong and actively enforced with the education of retailers,
they successfully reduce tobacco use among youth (Task
Force on Community Preventive Services 2001; Zaza et al.
2005). To date, all 50 states and the District of Columbia
restrict the sale of tobacco products to minors (CDC n.d.).
Extending such laws to include e-cigarettes can further
protect youth from exposure to nicotine, which nearly all
states have done. Specific strategies can be implemented
to deter the access of youth to e-cigarettes and their use
in this population:
• Restricting the sale of e-cigarettes to minors;
• Placing restrictions on Internet sales of all tobacco
products and e-cigarettes, including requirements
for verifying age and providing identification at the
time of purchase and upon delivery;
• Requiring age verification at the point of purchase;
• Displaying clear signage in retail locations about
required age for sale;
• Prohibiting the sale of e-cigarettes from vending
machines;
• Eliminating self-service displays of e-cigarettes; and
• Enforcing laws on the retail sale of e-cigarettes to
minors.
Nearly all states prohibit the sale of e-cigarettes to
youth under 18 years of age. Some states have a higher
minimum age for purchase (e.g., 19 or 21 years of age)
(CDC 2014). Some e-cigarette manufacturers have sup-
ported state legislation to prevent minors from pur-
chasing e-cigarettes (Healy 2014). Their actions may,
to some extent, be responsible for why these age-of-sale
laws have been adopted more quickly than laws that pro-
hibit e-cigarette use in public indoor spaces. However,
industry-supported, youth-access bills have contained
provisions that undermine prevention efforts for youth,
including preemption of stricter local policies and
weak requirements for enforcement (USDHHS 2012).
Additionally, laws prohibiting sales to minors are likely
244 The Call to Action
The Call to Action 245
E-Cigarette Use Among Youth and Young Adults
to have limited effectiveness as a prevention strategy if
they are not aggressively enforced and are not coupled
with proven interventions, such as comprehensive smoke-
free laws, pricing strategies, or public health campaigns
(USDHHS 2012, 2014). Ensuring that e-cigarettes are reg-
ulated at the state and local levels can facilitate the appli-
cation of additional tobacco control policies regarding
e-cigarettes.
Many actions can help to protect young
people from the harms of e-cigarettes, such as
including e-cigarettes in smokefree indoor air
policies, restricting youth access to e-cigarettes
in retail settings, licensing retailers, and
setting specific package requirements.
Licensing Retailers
Licensing is
another strategy to con-
trol access to e-cigarettes
among youth and young
adults. A tobacco-related
license can authorize
a business to manu-
facture, distribute, or
sell tobacco products
(McLaughlin 2010).
Licensing require-
ments help to prevent
sales to minors, pre-
vent evasion of tobacco
excise taxes, ensure that
licensees comply with
tobacco-related laws,
and promote safe manu-
facturing practices (ChangeLab Solutions 2012). Businesses
that repeatedly violate these laws can have their right to
engage in commercial activity suspended or their licenses
permanently removed. The possibility of these out-
comes provides a strong incentive to comply with license
requirements. Licensing may also be used to restrict the
sale of flavored products or to address consumer and
worker safety issues involved with the mixing of liquids
for e-cigarette products (e-liquids).
Establishing Specific Packaging
Requirements
Federal, state, local, tribal, and territorial govern-
ments are actively considering the potential harms of
e-liquids. Exposure to these liquids may lead to nicotine
and other types of poisoning. Calls to poison control cen-
ters about e-cigarettes and e-liquids have been on the rise,
and about half of these calls are for incidents involving
young children (American Association of Poison Control
Centers 2015). The most common adverse health effects
of poisoning are vomiting, nausea, and eye irritation, but
some deaths have occurred as well. Developing strategies
to monitor and prevent future poisonings is critical.
Calls to poison control centers about e-cigarettes
are on the rise. A large portion of these calls
are for incidents involving young children.
Enacting laws that require e-liquids to be labeled
and sold in childproof packaging is one way to reduce
the incidence of poisonings, particularly among chil-
dren. To date, in addition to the federal Child Nicotine
Poisoning Prevention Act of 2015 (2016) enacted in
January 2016, more than a dozen states have enacted
laws requiring childproof packaging for e-liquids
(Tobacco Control Legal Consortium n.d.). Health care
providers, the public health community, e-cigarette man-
ufacturers and retailers, and the public should be aware
that e-liquids pose a serious public health concern, par-
ticularly among young children.
Strategy 4B.
Coordinate, evaluate, and share best practices from state
and local entities that have implemented programs and
policies to address e-cigarette use among youth and
young adults.
Many governments at the national, state, local,
tribal, and territorial levels are involved in the regulation
of e-cigarettes. To have the biggest impact on reducing the
use and exposure of e-cigarettes among youth and young
adults, it is integral for these governments to share best
practices and coordinate and evaluate efforts as part of a
comprehensive tobacco prevention and control strategy.
FDA has asserted regulatory authority over e-cigarettes,
and other agencies and governments, as discussed previ-
ously and in Chapter5, also have relevant authorities.
A Report of the Surgeon General
Goal 5. Curb Advertising and Marketing that Encourages Youth
and Young Adults to Use E-Cigarettes
Unconstrained marketing of e-cigarettes drives con-
sumer demand for these products. E-cigarette manufac-
turers are using tactics similar to those used to market
conventional cigarettes to youth, including offering candy-
flavored products; employing youth-minded themes, such
as rebellion, glamour, and sex; getting celebrity endorse-
ments; and obtaining sports and music sponsorships
(Chapter 4). Some groups have called for extending to
e-cigarettes the same marketing restrictions that already
apply to conventional cigarettes and other tobacco products
(Association of State and Territorial Health Officials 2014;
Partnership for Prevention 2014). But regulating commer-
cial speech is typically met with significant barriers and
complex legal issues (Laird-Metke 2010), and partial adver-
tising bans and voluntary agreements generally have not
been fully effective at reducing consumption because the
tobacco industry adapts by shifting to other types of adver-
tising that are not regulated (National Cancer Institute
2008). Despite these obstacles, public health organiza-
tions and state and local governments must take action to
control the marketing of e-cigarettes to youth and young
adults, including (a)seeking legally feasible interventions
that are proven to curb youth-oriented tobacco marketing,
including removing advertising from television; and
(b)continuing to help build an evidence base that informs
future potential restrictions on e-cigarette marketing.
Strategy 5A.
Curb e-cigarette advertising and marketing that are
likely to attract youth and young adults.
In the absence or delayed implementation of gov-
ernment restrictions on the marketing of e-cigarettes,
media outlets, the management staff of special event and
sports venues, and retailers can voluntarily refuse to air or
place youth- and young adult-oriented e-cigarette adver-
tising; avoid sponsorships; and not offer free samples of
these products at fairs, festivals, and other events.
E-cigarettes are aggressively marketed
using tactics similar to those proven to lead
to cigarette smoking among youth.
Finally, state and local public health agencies can
stimulate enforcement of and compliance with existing
rules that limit marketing. For example, they can monitor
advertising and notify their state’s attorney general or the
Federal Trade Commission about improper claims or mar-
keting that is not clearly identified as advertising (Federal
Register 1972; FTC 1984; Center for Public Health and
Tobacco Policy 2013).
Strategy 5B.
Urge the e-cigarette companies to stop advertising and
marketing that encourages and glamorizes e-cigarette
use among youth and young adults.
E-cigarette advertising has increased considerably
over the years in multiple venues (Legacy for Health 2014;
Ganz et al. 2015; see also Chapter 4), while the advertising
for conventional cigarettes on television has been pro-
hibited in the United States since 1971. But e-cigarettes
are now marketed on television and other mainstream
media channels, such as radio and magazines, which are
main sources of information for youth and young adults.
Emerging research suggests that exposure to television
advertisements for e-cigarettes increases the likelihood
that young people will use e-cigarettes in the future and will
believe that e-cigarettes can be used in places where con-
ventional cigarette smoking is not allowed (Farrelly etal.
2015). This is not surprising because e-cigarette marketing
has previously included unproven claims about safety and
smoking cessation, as well as statements that e-cigarettes
are exempt from clean air policies that restrict smoking
(USDHHS 2014). Visual depictions of e-cigarette use in
advertisements may also serve as smoking cues to both cur-
rent and former smokers, increasing their urges to smoke
and undermining their efforts to quit (Maloney and
Cappella 2015). Advertising for e-cigarettes that encour-
ages and glamorizes the use of e-cigarettes among youth
and young adults can harm public health by undermining:
• Clean indoor air standards;
• Enforcement of smokefree policies;
• Tobacco-free social norms; and
• Marketing restrictions that prohibit the advertising
of cigarettes and smokeless tobacco on television
and radio.
246 The Call to Action
The Call to Action 247
E-Cigarette Use Among Youth and Young Adults
Discontinuing advertising and marketing by and features adults (not young adults), does not depict
e-cigarette companies that intentionally or unintention- active use of e-cigarettes, does not use themes proven to
ally encourages or glamorizes e-cigarette use among youth appeal to youth and young adults, avoids media channels
and young adults is essential. Responsible advertising by with high youth access, and does not undermine cessation
the e-cigarette companies is needed, including adver- efforts involving traditional tobacco products.
tising that focuses directly on established adult smokers
Goal 6. Expand Surveillance, Research, and Evaluation Related to
E-Cigarettes
Tobacco control research focused on e-cigarettes has
grown considerably in the past few years. Certainly, more
detailed information is needed to better understand the use
of e-cigarettes and its relationship to the use of other types of
tobacco products. A comprehensive and evolving approach
to research, surveillance, and evaluation is needed.
Strategy 6A.
Improve the quality, timeliness, and scope of e-cigarette
surveillance, research, and evaluation.
Present surveillance systems show that e-ciga-
rette use is increasing rapidly and that most regular
e-cigarette users also use conventional tobacco products
(see Chapter2). Thus, further study can inform strategies
that minimize harms and maximize the potential health
benefits of these products at the individual and population
levels. Data should be timely and focus on the patterns of
e-cigarette initiation and use among the general public—
including youth, young adults, and former smokers.
Strategic and comprehensive research and evaluation
must further characterize the health risks of e-cigarette
use. A comprehensive package of surveillance, research,
and evaluation should:
• Track patterns of e-cigarette use through
cross-sectional surveys and through panels that
follow the same people, including youth and young
adults, over time;
• Monitor trends in the e-cigarette retail market by
type of product;
• Examine the channels and messaging in the
e-cigarette marketplace to inform proactive coun-
termarketing strategies;
• Assess the short- and medium-term health effects of
e-cigarette use by youth and young adults and track
long-term consequences;
• Examine the risk factors and other risk behaviors
that may be associated with using e-cigarettes; and
• Create a model to develop and track the public
health impact of e-cigarettes.
The rapidly changing nature of the e-cigarette
landscape calls for a comprehensive and evolving
approach to research, surveillance, and evaluation.
For such a package, researchers, the public health
community, and other key stakeholders must work
together to address and overcome many challenges:
• The rapidly changing e-cigarette landscape and
terminology;
• Limited resources for collecting timely information;
A Report of the Surgeon General
• The cross-sectional nature of existing surveys and
their limited space for questions;
• The different populations that need to be studied;
• A lack of validated questions; and
• Different measures and definitions across surveys.
Strategy 6B.
Address surveillance, research, and evaluation gaps
related to e-cigarettes.
Patterns of e-cigarette use are rapidly changing
among youth and young adults, as well as among other
groups in the population. Longitudinal data are not yet
available to address some of the most critical issues related
to e-cigarettes. The e-cigarette marketplace is changing so
fast that surveillance data and research on the harms of
e-cigarette use and the impact of these changes on tradi-
tional tobacco products are lagging behind. As they look
to fill in gaps in scientific research, it is important for
researchers to continue to seek more current and complete
answers to many critical questions, such as:
• What are the risks of progressing to traditional
tobacco use among youth and young adults who
have used e-cigarettes?
• What are the health risks posed by e-cigarettes?
• Are e-cigarettes safer and more effective than current
products at helping smokers with smoking cessation?
• What are the health consequences for youth and
young adults of initiation of e-cigarettes and of dual
use (conventional cigarettes plus e-cigarettes) com-
pared with the health benefits of completely quitting
smoking (or not starting at all)?
• What are the health risks to former smokers who are
exposed to nicotine from e-cigarette use? Will these
persons be more likely to resume smoking?
Additionally, surveillance of e-cigarette marketing
and the advertising messages and strategies used is crit-
ical, as is the carrying out of more studies assessing the
link between exposure to e-cigarette marketing and use
of these products. With traditional tobacco products,
state and local public health agencies have monitored
retail settings, assessed outdoor advertising, and identi-
fied sponsorships of events by tobacco companies. These
efforts should be adapted to e-cigarettes.
The health care setting has always been an impor-
tant venue for exchanging information about evidence-
based approaches to smoking cessation and for protecting
susceptible groups from exposure to secondhand smoke.
More research is needed on the role of e-cigarettes in facil-
itating or hindering cessation of conventional cigarettes
and the potential hazards of exposure to secondhand
aerosol from e-cigarettes so that e-cigarettes can also be
a part of this exchange. But even without this research,
there is sufficient evidence about the dangers that nico-
tine-containing cigarettes pose for youth and young adults
that health care providers and professionals can act now
to prevent the use of such products among their young
patients.
Finally, existing research and surveillance efforts
should include more detailed measures than just general
use of e-cigarettes, including:
• Frequency and patterns of e-cigarette use;
• Type of e-cigarette and/or other tobacco product
used;
• The natural history of e-cigarette use, including
initiation, co-use with other tobacco products, and
flavoring;
• Ingredients, such as nicotine and flavors;
• Brand;
• Reasons for using and quitting e-cigarettes;
• Exposure to e-cigarette advertising;
• Methods of obtaining e-cigarettes; and
• Exposure to secondhand aerosol from e-cigarettes.
Additionally, evaluation is critical to further assess
the impact of policies on e-cigarette initiation, use, and
other patterns of tobacco use.
248 The Call to Action
The Call to Action 249
E-Cigarette Use Among Youth and Young Adults
Conclusions
E-cigarette use, particularly among youth and
young adults, has become a public health concern that
warrants immediate and coordinated action. The increase
in e-cigarette use among youth and young adults in the
past few years is cause for great concern. Many questions
remain about e-cigarettes and their long-term impact,
even as evidence on patterns of use and risks to health
continue to emerge. But we know enough about these
health risks to take action now to protect the health of our
nation’s young people. We cannot wait. Strategies to pre-
vent and control the harms of e-cigarettes among youth
and young adults need to be precautionary. Therefore,
we must take a precautionary approach by implementing
these strategies and protecting the health of our nation’s
young people.
We know what works to effectively prevent tobacco use
among young people. Now we must apply these strategies to
e-cigarettes—and continue to apply them to other tobacco
products. To achieve success, we must work together,
aligning and coordinating efforts across a wide range of
stakeholders. We must protect our nation’s young people
from a lifetime of nicotine addiction and associated prob-
lems by immediately addressing e-cigarettes as an urgent
public health problem. Now is the time to take action.
A Report of the Surgeon General
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E-Cigarette Use Among Youth and Young Adults
List of Abbreviations 253
List of Abbreviations
α4β2 alpha 4 beta 2-nicotinic acetylcholine
receptor subtype
α7 alpha 7 nicotinic acetylcholine
receptor subtype
α6 alpha 6 nicotinic acetylcholine
receptor subtype
µg microgram
5AP tLTP protocol 5 action potential timing-dependent
long-term potentiation protocol
5-CSRTT 5-choice serial reaction time task
5-HIAA 5-hydroxyindole acetic acid, the
primary metabolite of serotonin
5-HT
1AR
serotonin (5-hydroxytryptamine)
receptor 1A
5-HT
2A/C
serotonin (5-hydroxytryptamine)
receptor 2 A/C
86Rb+ efflux assay measure of nicotinic acetylcholine
receptor function via rubidium-86
ion efflux [125-I]a-Btx binding
measurement of binding at a7
nAChRs using the antagonist alpha-
bungarotoxin
[
125
I]α-CtxMII binding measurement of binding at a6
nAChRs using the antagonist alpha-
conotoxin MII
[
125
I]A-85380 binding measurement of binding at a4b2
nAChRs using the agonist A-85380
A1
primary auditory cortex
AAP
American Academy of Pediatrics
ACR
American Association of Cancer
Research
AARC
American Association for Respiratory
Care
ACP
American College of Physicians
ACS
American Cancer Society
ADHD
attention deficit hyperactivity disorder
ADI
acceptable daily intake
AEMSA
American E-Liquid Manufacturing
Standards Association
AHA
American Heart Association
AMPA
a-amino-3-hydroxy-5-methyl-4-
isoxazolepropionic acid
AMPAR
AMPA receptor
ANHCS
Annenberg National Health
Communication Survey
ANR
Americans for Nonsmokers’ Rights
AOR
adjusted odds ratio
AP acetyl propionyl
APA American Psychiatric Association
APV advanced personal vaporizers
arc activity-regulated cytoskeleton-
associated protein
ATF U.S. Department of Justice, Bureau
of Alcohol, Tobacco, Firearms and
Explosives
A-V atrial-ventricular
AVA American Vaping Association
BART Balloon Analogue Risk Task
BCAP/CAP Committees of Advertising Practice
(UK)
BLA basolateral amygdala
BNST bed nucleus of the stria terminalis
BOP Bureau of Prisons
BP blood pressure
CAD cinnamaldehyde
CAM cell-adhesion molecule
cAMP-PKA cyclic AMP-protein kinase A, signaling
cascade
CARDIA Coronary Artery Risk Development in
Young Adults
CASAA Consumer Advocates for Smoke-free
Alternatives Association
CCTA Contraband Cigarette Trafficking Act
CDC Centers for Disease Control and
Prevention
CDER Center for Drug Evaluation and
Research
C-DISC-IV Diagnostic Interview for Children−
Version4
cFos protooncogene and immediate early
gene used as a marker of neuronal
activity
CFR Code of Federal Regulations
CI confidence interval
CMS Centers for Medicare & Medicaid
Services
CO
2
carbon dioxide
COMDTINST Commandant Instruction
CPP conditioned place preference
CPu caudate putamen
CREB cAMP response element-binding
protein
CRF corticotropin-releasing factor
A Report of the Surgeon General
254 List of Abbreviations
CRP C-reactive protein
CSI Child Symptom Inventory
CTA conditioned taste aversion
CTP Center for Tobacco Products
D1R dopamine D1 receptor
DA diacetyl
DA dopamine
DAT1 dopamine regulation genotype
DEHP diethylhexyl phthalate
DEP diethyl phthalate
DHS U.S. Department of Homeland
Security
DISC-YC Diagnostic Interview Schedule for
Children-Parent Scale-Young Child
DoD U.S. Department of Defense
DOPAC 3,4-dihydroxyphenylacetic acid,
metabolite of dopamine
DOT U.S. Department of Transportation
DSM-III Diagnostic and Statistical Manual of
Mental Disorders, 3rd Edition
DSM-IV Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition
EC electronic cigarette
ECIG Inc. Electronic Cigarette Industry Group,
Inc.
ECIG Ltd. Electronic Cigarettes International
Group, Ltd.
ED U.S. Department of Education
ENDS electronic nicotine delivery systems
ENNDS electronic non-nicotine delivery
systems
EOP Executive Office of the President
EPA U.S. Environmental Protection Agency
ERS European Respiratory Society
EPSC excitatory postsynaptic current
EPSDT Early and Periodic Screening,
Diagnosis and Treatment
EPSP excitatory postsynaptic potential
ESD electronic smoking device
EU European Union
F1 first filial generation (and similar)
FAA Federal Aviation Administration
FCC Federal Communications Commission
FCLAA Federal Cigarette Labeling and
Advertising Act
FCTC Framework Convention on Tobacco
Control
FD&C Act Federal Food, Drug, and Cosmetic Act
FDA U.S. Food and Drug Administration
FEF forced expiratory flow
FeNO exhaled nitric oxide
FEV
1
forced expiratory volume in 1 second
fMRI functional magnetic resonance
imaging
FR fixed ratio
FST forced swim test
FTC U.S. Federal Trade Commission
FVC forced vital capacity
FY fiscal year
G20 gestational day 20 (and similar)
g gram
GABA gamma-aminobutyric acid
GABAergic any cell, especially any neuron, that
releases GABA
GPCR G-protein-coupled-receptor
GSA General Services Administration
GTP guanosine triphosphate
GTPase large family of hydrolase enzymes that
can bind and hydrolyze GTP
HONC Hooked on Nicotine Checklist
HPLC-ECD high-performance liquid
chromatography electrochemical
detection
HUD U.S. Department of Housing and
Urban Development
HVA homovanillic acid
IARC International Agency for Research on
Cancer
ICD-10 International Statistical Classification
of Diseases and Related Health
Problems, 10th revision
ICE Bureau of Immigration and Customs
Enforcement
ICR mice Institute for Cancer Research strain of
mice
ICSS intracranial self-stimulation
IOM Institute of Medicine
i.p. intraperitoneal
IQ intelligence quotient
IRC Internal Revenue Code
i.v. intravenous
kg kilogram
KO knockout
L liter
L&M Liggett & Myers
LC-MS/MS liquid chromatography-tandem mass
spectrometry
E-Cigarette Use Among Youth and Young Adults
List of Abbreviations 255
LH lateral hypothalamus
M&As mergers, formations of partnerships,
and acquisitions
m
2
square meter
m
3
cubic meter
MAOA monoamine oxidase A
MAPK mitogen-activated protein kinase
MCH melanin-concentrating hormone
mFTQ modified Fagerström Tolerance
Questionnaire
mg milligram
mGluR2 metabotropic glutamate receptor 2
mL milliliter
mPFC medial prefrontal cortex
mRNA messenger ribonucleic acid
MSN medium spiny neuron
MTF Monitoring the Future
NAB N-nitrosoanabasine
N
2
nitrogen
NAc nucleus accumbens
NACDA National Advisory Council on Drug
Abuse
nAChR nicotinic acetylcholine receptor
NAc-shell nucleus accumbens shell
NAT N-nitrosoanatabine
NATS National Adult Tobacco Survey
NCI National Cancer Institute
NDAA National Defense Authorization Act
NDSS Nicotine Dependence Syndrome Scale
NE norepinephrine
ng nanogram
NGFI-B nerve growth factor-induced gene-B
NHANES III Third National Health and Nutrition
Examination Survey
NHSDA National Household Survey on Drug
Abuse
NIH National Institutes of Health
NMDAR N-methyl-
d-aspartate receptor
NIDA National Institute on Drug Abuse
NIOSH National Institute for Occupational
Safety
NJYTS New Jersey Youth Tobacco Survey
NLSY National Longitudinal Survey of Youth
nm nanometer
NNN N-nitrosonornicotine
NNK 4-(methylnitrosamino)-1-(3-pyridyl)-
1-butanone
NRT nicotine replacement therapy
NYS New York State Follow-Up
NYTS National Youth Tobacco Survey
O
2
oxygen
ODD oppositional defiant disorder
OMB Office of Management and Budget
OPM Office of Personnel Management
OR odds ratio
OSH Office on Smoking and Health
OSHA U.S. Department of Labor,
Occupational Safety and Health
Administration
P3 (and similar) postnatal day number
PACT Prevent All Cigarette Trafficking Act
PAH polycyclic aromatic hydrocarbon
PATH Population Assessment of Tobacco and
Health
PDAY Pathological Determinants of
Atherosclerosis in Youth
PFC prefrontal cortex
PHS Public Health Service
PIH Public and Indian Housing
PVN paraventricular nucleus of the
thalamus
PG propylene glycol
PM particulate matter
PM
2.5
fine particulate matter
PNE prenatal nicotine exposure
p.o. per os (by mouth)
Postn periostin, osteoblast-specific factor
PR progressive ratio
PREP potential reduced-exposure product
PVN paraventricular nucleus of the
thalamus
qRT-PCR quantitative real-time polymerase
chain reaction
RCRA Resource Conservation and Recovery
Act
SAC saccharin
SAMHSA Substance Abuse and Mental Health
Services Administration
s.c. subcutaneous
SCAN Screening test for Auditory Processing
Disorders
SD standard deviation
SE standard error
sec seconds
SEC Securities and Exchange Commission
SES socioeconomic status
A Report of the Surgeon General
256 List of Abbreviations
SFATA Smoke Free Alternatives Trade
Association
SIDS sudden infant death syndrome
SMC serial multiple choice
SNAP Special Supplemental Nutrition
Program
SNP single-nucleotide polymorphism
SRITA Stanford Research into the Impact of
Tobacco Advertising
STOP Smuggled Tobacco Prevention Act
TCR trigeminocardiac reflex
TEOAEs transient evoked otoacoustic
emissions
TH tyrosine hydroxylase
THC tetrahydrocannabinol
TSNA tobacco-specific nitrosamine
TTB U.S. Department of Treasury, Alcohol
and Tobacco Tax and Trade Bureau
TVECA Tobacco Vapor Electronic Cigarette
Association
UK United Kingdom
U.S.C. U.S. Code
USDA U.S. Department of Agriculture
USDHEW U.S. Department of Health, Education,
and Welfare
USDHHS U.S. Department of Health and Human
Services
USP U.S. Pharmacopeia
USTR U.S. Trade Representative
V voltage
VA U.S. Department of Veterans Affairs
VG vegetable glycerin
VOC volatile organic compound
VTA ventral tegmental area
WHO World Health Organization
WIC Women, Infants, and Children
Wnt Wingless-Type MMTV Integration
Site Family, member 1, intracellular
signaling factors
WT wild type
w/v weight/volume
YRBSS Youth Risk Behavior Surveillance
System
E-Cigarette Use Among Youth and Young Adults
List of Tables and Figures 257
List of Tables and Figures
1
1
The Executive Summary and appendixes are not a part of the main report. Instead, they are available online at
http:/www.surgeongeneral.gov/library/reports/.
Executive Summary
Figure 1 Trends in ever e-cigarette use among U.S.middle
and high school students; National Youth
Tobacco Survey (NYTS) 2011–2015 1
Figure 2 Trends in past-30-day e-cigarette use among
U.S. middle and high school students; National
Youth Tobacco Survey (NYTS) 2011–2015
2
Figure 3 Percentage of young adults who currently
use e-cigarettes and conventional cigarettes;
National Adult Tobacco Survey (NATS)
2013–2014 2
Figure 4 Diversity of e-cigarette products 3
Figure 5 Percentage of middle school students, high
school students, young adults (18–24 years of
age), and adults (≥25 years of age) who currently
use e-cigarettes 6
Figure 6 Percentage of middle school students, high
school students, young adults (18–24 years of
age), and adults (≥25 years of age) who have ever
used e-cigarettes 7
Figure 7 Percentage of students in grades 8, 10, and 12
who used e-cigarettes and cigarettes in the past
30 days; Monitoring the Future (MTF) 2015 8
Chapter 1.
Introduction, Conclusions, and Historical Background
Relative to E-Cigarettes
Table 1.1 Multinational tobacco companies with e-cigarette
brands 15
Figure 1.1 Diversity of e-cigarette products 3
Figure 1.2 Parts of an e-cigarette device 12
Figure 1.3 Examples of e-liquid flavors 13
Figure 1.4 E-liquids being poured into an e-cigarette
device 13
Chapter 2.
Patterns of E-Cigarette Use Among U.S. Youth and
Young Adults
Table 2.1a Percentage of middle school students who have
used e-cigarettes, by gender and race/ethnicity;
National Youth Tobacco Survey (NYTS)
2015 29
Table 2.1b Percentage of high school students who have
used e-cigarettes, by gender and race/ethnicity;
National Youth Tobacco Survey (NYTS)
2015 30
Table 2.2a Percentage of middle school students who used
e-cigarettes in the past 30 days, by gender and
race/ethnicity; National Youth Tobacco Survey
(NYTS) 2011–2015 31
Table 2.2b Percentage of high school students who used
e-cigarettes in the past 30 days, by gender and
race/ethnicity; National Youth Tobacco Survey
(NYTS) 2011–2015 32
Table 2.3a Percentage of middle school students who
have ever used e-cigarettes, by gender and
race/ethnicity; National Youth Tobacco Survey
(NYTS) 2011–2015 34
Table 2.3b Percentage of high school students who have
ever used e-cigarettes, by gender and race/
ethnicity; National Youth Tobacco Survey
(NYTS) 2011–2015 35
Table 2.4a Percentage of young adults (18–24 years of age)
who have used e-cigarettes, by gender, race/
ethnicity, and education; National Adult Tobacco
Survey (NATS) 2013–2014 38
Table 2.4b Percentage of adults (≥25 years of age) who have
used e-cigarettes, by gender, race/ethnicity,
and education; National Adult Tobacco Survey
(NATS) 2013–2014 39
Table 2.5 Percentage of students in grades 8, 10, and 12 who
used e-cigarettes, cigarettes, or both products
in the past 30 days, by sociodemographic
characteristics; Monitoring the Future (MTF)
2015 41
Table 2.6a Lifetime and past-30-day e-cigarette use among
U.S. middle school students, by other tobacco
product use; National Youth Tobacco Survey
(NYTS) 2015 44
Table 2.6b Lifetime and past-30-day e-cigarette use among
U.S. high school students, by other tobacco
product use; National Youth Tobacco Survey
(NYTS) 2015 45
Table 2.7a Percentage of middle school students who have
ever used tobacco, by type of product; National
Youth Tobacco Survey (NYTS) 2011–2015 47
Table 2.7b Percentage of high school students who have
ever used tobacco, by type of product; National
Youth Tobacco Survey (NYTS) 2011–2015 49
A Report of the Surgeon General
258 List of Tables and Figures
Table 2.8a Percentage of young adults (18–24 years of
age) who currently use e-cigarettes, cigarettes,
or both products, by gender, race/ethnicity,
and education: National Adult Tobacco Survey
(NATS) 2013–2014 54
Table 2.8b Percentage of adults (≥25 years of age) who
currently use e-cigarettes, cigarettes, or
both products, by gender, race/ethnicity, and
education: National Adult Tobacco Survey
(NATS) 2013–2014 55
Table 2.9 Percentage of youth (middle and high school
students), young adults (18–24 years of age),
and adults (≥25 years of age) using tobacco
products who reported using flavored e-cigarette
products, by gender and race/ethnicity; National
Youth Tobacco Survey (NYTS) and National
Adult Tobacco Survey (NATS) 60
Table 2.10 Summary of studies on e-cigarette flavors among
youth and young adults 61
Table 2.11 Summary of studies on perceptions of e-cigarette
harm among youth and young adults 65
Table 2.12a Percentage of middle school and high school
students who reported that using e-cigarettes
on some days but not every day caused no harm,
little/some harm, or a lot of harm, by e-cigarette
smoking status; National Youth Tobacco Survey
(NYTS) 2015 73
Table 2.12b Percentage of middle school students who
reported that using e-cigarettes on some days
but not every day caused no harm, little/some
harm, or a lot of harm, by e-cigarette smoking
status; National Youth Tobacco Survey (NYTS)
2015 73
Table 2.12c Percentage of high school students who
reported that using e-cigarettes on some days
but not every day caused no harm, little/some
harm, or a lot of harm, by e-cigarette smoking
status; National Youth Tobacco Survey (NYTS)
2015 74
Table 2.12d Percentage of young adults (18–24 years of age)
who reported that e-cigarettes were not at all
harmful, moderately harmful, or very harmful,
by e-cigarette smoking status; National Adult
Tobacco Study (NATS) 2013–2014 74
Table 2.13 Summary of studies on reasons for use and
discontinuation of e-cigarettes among youth
and young adults 76
Figure 2.1 Trends in ever e-cigarette use among U.S.middle
and high school students; National Youth
Tobacco Survey (NYTS) 2011–2015 33
Figure 2.2 Trends in past-30-day e-cigarette use among
U.S. middle and high school students; National
Youth Tobacco Survey (NYTS) 2011–2015 36
Figure 2.3 Trends in ever e-cigarette use among U.S. adults
by age group; Styles 2010–2014 40
Figure 2.4 Percentage of students in grades 8, 10, and
12 who used e-cigarettes and cigarettes in the
past 30 days; Monitoring the Future (MTF)
2015 40
Figure 2.5 Past-30-day use of various tobacco products
among U.S. middle and high school students;
National Youth Tobacco Survey (NYTS)
2015 46
Figure 2.6 Percentage of U.S. middle school students who
have ever used tobacco, by type of product;
National Youth Tobacco Survey (NYTS)
2011–2015 51
Figure 2.7 Percentage of U.S. high school students who have
ever used tobacco, by type of product; National
Youth Tobacco Survey (NYTS) 2011–2015 52
Figure 2.8 Percentage of young adults who currently
use e-cigarettes and conventional cigarettes;
National Adult Tobacco Survey (NATS)
2013–2014 53
Appendix 2.1.
Sources of Data
Table A2.1-1 Sources of national data on e-cigarette use
among youth and young adults A2.1-4
Appendix 2.2.
Key Measures of Use
Table A2.2-1 E-cigarette items from sources of national data
on e-cigarette use among youth and young
adults A2.2-5
Table A2.2-2 E-cigarette items from PATH on e-cigarette use
among youth and young adults A2.2-10
Appendix 2.3.
Other Supporting Literature
Table A2.3-1 Summary of studies on patterns of e-cigarette
use among youth A.2.3-6
Table A2.3-2 Summary of studies on susceptibility and
intentions to use e-cigarettes among youth and
young adults 2.3-20
Table A2.3-3 Summary of studies on patterns of e-cigarette
use among young adults 2.3-23
Chapter 3.
Health Effects of E-Cigarette Use Among U.S. Youth and
Young Adults
Table 3.1 Relevant conclusions from previous Surgeon
General’s reports on smoking and health 98
E-Cigarette Use Among Youth and Young Adults
List of Tables and Figures 259
Figure 3.1 Plasma nicotine concentration from different
human laboratory studies and four different
products with blood sampled before and
immediately after a 10-puff bout with the
products 103
Figure 3.2 Data showing exponential increase in the
number of cases of human exposure to
e-cigarette products and liquid nicotine between
2011 and 2016 121
Figure 3.3 Changes in aerosol particle PM
2.5
concentrations
during experiment of e-cigarette use and
tobacco cigarette smoking in an exposure
chamber 123
Appendix 3.1.
Evidence Tables
Table A3.1-1 Studies on aerosolized nicotine and dependence,
by dependency criteria A3.1-2
Table A3.1-2 Human studies on the effects of nicotine
exposure on adolescent users A3.1-8
Table A3.1-3 Preclinical/animal studies on adolescent
nicotine exposure A3.1-18
Table A3.1-4 Human studies on the effects of nicotine
exposure on fetal brain development A3.1-33
Table A3.1-5 Preclinical/animal studies on fetal nicotine
exposure A3.1-63
Chapter 4.
Activities of the E-Cigarette Companies
Table 4.1 Estimated e-cigarette market size in 2014
($billion) 150
Table 4.2 Estimated e-cigarette market size in 2015
($billion) 150
Table 4.3 Mergers, acquisitions, partnerships, and other
agreements in the e-cigarette industry 165
Table 4.4 Comparison of website access restrictions,
online sales, nicotine levels, and flavors
among e-cigarette brands with no cigarette
manufacturer affiliation, brands acquired by
cigarette manufacturers, and brands developed
by cigarette manufacturers 166
Figure 4.1 E-cigarette sales in tracked channels by brand,
2010–2014 153
Figure 4.2 E-cigarette sales in tracked channels by product
type, 2010–2014 154
Figure 4.3 Sales volume and price of disposable e-cigarettes,
U.S. market, 2010–2014 155
Figure 4.4 Sales volume and price of rechargeable
e-cigarettes, U.S. market, 2010–2014 156
Figure 4.5 Quarterly promotional spending for e-cigarettes,
2010–2014 158
Figure 4.6 E-cigarette marketing claims 160
Appendix 4.1.
Major E-Cigarette Manufacturers
Table A4.1-1 Major e-cigarette manufacturers A4.1-2
Appendix 4.2.
E-Cigarette Trade Organizations and Advocacy Groups
Table A4.2-1 E-cigarette trade organizations and advocacy
groups A4.2-2
Appendix 4.3.
The Rapidly Changing E-Cigarette Marketplace
Figure A4.3-1 Market share of e-cigarette products A4.3-3
Appendix 4.4.
Data Points for Figure 4.1
Table A4.4-1 Data points for Figure 4.1 (e-cigarette sales in
tracked channels by brand, 2010–2014) A4.4-2
Appendix 4.5.
Evolution of Market Share in the E-Cigarette Market
Figure A4.5-1 E-cigarette market share in tracked channels by
brand, 2010–2014 A4.5-3
Chapter 5.
E-Cigarette Policy and Practice Implications
Table 5.1 Comparative risk assessment: Potential harms
and benefits of e-cigarettes 186
Table 5.2 Principle federal policies and regulations of
tobacco that emphasize e-cigarettes 189
Table 5.3 Medical organizations 207
Figure 5.1 Potential patterns of use of combustible
products (CPs) and e-cigarettes (e-cigs) 187
E-Cigarette Use Among Youth and Young Adults
Index 261
Index
1
1
Note: “t” following a number refers to a table; “f” following a number refers to a figure; “n” following a number refers to a note; and “A”
preceding a number refers to an appendix.
1964 report. See Smoking and Health: Report of the Advisory
Committee to the Surgeon General of the Public Health Service
(1964 report)
1988 report. See The Health Consequences of Smoking–Nicotine
Addiction (1988 report)
1994 report. See Pr
eventing Tobacco Use Among Young People
(1994 report)
2010 report. See How Tobacco Smoke Causes Disease–The
Biologic and Behavioral Basis for Smoking-Attributable
Disease (2010 report)
2012 report. See Preventing Tobacco Use Among Youth and
Young Adults (2012 report)
2014 report. See The Health Consequences of Smoking—50 Years
of Progress (2014 report)
A
AACR (American Association for Cancer Research), 206,
208–209t
AAP (American Academy of Pediatrics), 206, 207t
AARC (American Association for Respiratory Care), 209t
Accord cigalikes, 9
Acetaldehyde, aerosolized adulterant, 117, 118
Acetone, aerosolized toxicant, 118
Acetyl propionyl, aerosolized avorant, 116
Acrolein
aerosolized adulterant, 117, 118
e-cigarette component, 99
Addiction
aerosolized nicotine, 102–104, 103f
fetal effects of, A3.1-40 to A3.1-48t
long-term potential, 11, 239
smoking behavior changes, with low-nicotine cigarettes, 9
Surgeon General’s report (1988), 9, 97, 98t
withdrawal symptoms (physical abstinence syndrome), 102,
A3.1-3 to A3.1-6t
ADHD. See Attention decit hyperactivity disorder (ADHD)
Adolescents. See also Young adults; Youth
ages of, 4
brain development, 99
nicotine and brain development, 5
nicotine, increased sensitivity to, 105
pregnancy, 109
Adulterants, aerosolized, 100, 116–117
Adults (age ≥25). See also National Adult Tobacco Survey
(NATS); Styles Survey
current prevalence of e-cigarette use, 37, 39t
avors in e-cigarettes, 59, 60t
poly-tobacco use, 53, 55t
survey data sources, A2.1-2 to A2.1-3, A2.2-2
trends in prevalence of e-cigarette use, 37, 40f
Ad valorem excise tax, on tobacco products, 204
Advance cigarettes, 9
Advanced personal vaporizers, 150
Advertising. See also Marketing
behavior, effect on, 170–171
Broadcast Ban, 189t
burden of proof regarding safety, 238
cigarettes, 8–9
e-cigarette companies, 14–15
exposure to, youth and young adults, 169
protections for youth, 208t
receptivity to, youth and young adults, 169–170
restrictions, 238
Surgeon General’s report (2012), 4
targeting youth and young adults, 246–247
Advertorials, 205
Advocacy groups, e-cigarette industry, 15, A4.2-2 to A42-3t
USP-grade nicotine, 114
Aerosol inhalation
adulterants, 100, 116–117
aerosolized solvents, 115
cannabis and illicit drugs, 58
e-cigarette devices, 11
avorants, 115–116
nicotine-related compounds, 114
non-nicotine constituents, 114–118
Aerosolized nicotine
cardiovascular function, 101
clean air policies, 188
dependence, 102–104, 103f, A3.1-2 to A3.1-7t
dose and effects of, 100–101, 103f
maternal exposure, and prenatal and postnatal health
outcomes, 108–113
secondhand exposure, 120–123, 123f, 183, 209t, 240
thirdhand exposure, 209t
toxicants in, 208t, 219t, 229
youth, effects on, 104–107
Affordable Care Act (2010), 193t
African Americans. See Race/ethnicity
avored little cigars and cigarillos, 11
retail sales of e-cigarettes, 150
Age-of-sale laws, 208t, 238, 241, 242, 244–245
Age, of starting tobacco use, 239, 241
Alameda County, California, public health department, 224
Alcohol and Tobacco Tax and Trade Bureau (TTB), 200t
Alcohol use
e-cigarette use, with, 57–58
maternal smoking, 111
A Report of the Surgeon General
262 Index
Allergic reactions, e-cigarette aerosol exposure, 123
Altered corpus callosum, fetal effects of nicotine exposure,
A3.1-34t
Altria Group, Inc./Nu Mark. See also MarkTen e-cigarettes
acquisition, 165t
company prole, A4.1-2t
multinational tobacco company, 15t
Aluminum, aerosolized, 119
American Academy of Pediatrics (AAP), 206, 207t
American Association for Cancer Research (AACR), 206, 208–209t
American Association for Respiratory Care (AARC), 209t
American Association of Poison Control Centers, 14
American Cancer Society (ACS), 215t
American College of Physicians, 210t
American Heart Association, 216–217t
American Legacy Foundation (Truth Initiative), 158, 159, 163
American Lung Association, 218t, 224, 225
Americans for Nonsmokers’ Rights (ANR), 219t
American Society of Clinical Oncology, 206, 208–209t
American Thoracic Society, 211–212t
American Tobacco Company, 8
American Vaping Association (AVA), A4.2-2, A4.3-2
Amino-tadalal, aerosolized adulterant, 117
Annenberg National Health Communication Survey, 171
ANR (Americans for Nonsmokers’ Rights), 219t
Antiandrogenic activity, DEP and DEHP, 117
Anxiety disorders
adolescent smoking, 107
Netherlands Study of Depression and Anxiety Disorders,
A3.1-14t
Apnea, SIDS and maternal smoking, 109
Appetitive behaviors, fetal effects
appetitive behaviors, dened, 110
nicotine dependence, 110–111
other substances use, 111–112, A3.1-48 to A3.1-50t
overweight and obesity, 111, A3.1-51 to A3.1-53t
smoking uptake and nicotine dependence, A3.1-40 to 1-48t
Ariva smokeless tobacco product, 9
Arousal decits, SIDS and maternal smoking, 109
Asthma
acrolein, 117
PG inhalation, 115
ATF (Bureau of Alcohol, Tobacco, Firearms and Explosives),
198t
Atherogenesis, 101
Atherosclerosis, 118
Attention and cognition disorders, 106–107, A3.1-56 to 1-62t
Attention decit hyperactivity disorder (ADHD)
comorbid substance abuse, 106
nicotine dependence, A3.1-13t
nicotine exposure, A3.1-11t
prenatal nicotine exposure, 112, 113, A3.1-14t, A3.1-49t,
A3.1-56 to A3.1-59t
Attitudes, knowledge, and risk perceptions, 171
Auditory processing, decits in
e-cigarettes use, 7
fetal exposure to nicotine, 7, A3.1-35 to 1-39t
maternal cigarette smoking, 109–110
Autonomic function and SIDS, 109
AVA (American Vaping Association), A4.2-2, A4.3-2
Aversive stimuli, enhanced sensitivity to, 107, A3.1-27t
B
Ballantyne Brands (Mistic). See Mistic e-cigarettes
Batteries for e-cigarettes
explosions and res, 14, 119
voltage and amount of carbonyl compounds, 117, 118
Bauway Technology Limited (Shenzhen, China), A4.1-14t
Behavior, advertising, effect of, 170–171
Behavioral disorders, A3.1-56 to A3.1-62t. See also Attention
decit hyperactivity disorder (ADHD)
Benzene, aerosolized, 118
Blacks. See Race/ethnicity
Blu (blu) e-cigarettes
advertising expenditures, 157, 159
e-liquid manufacture, 154
magazine advertisement, 160f, 161f
manufacturer of, 15t
marketing and promotion, 152, 153f
plasma nicotine concentration, 103f
sales (2010–2014), A4.4-2 to A4.4-6t
sponsorship of events, 159, 163
website access restrictions, 166t
BOP (Bureau of Prisons), 198t
Bradycardia, SIDS and maternal smoking, 109
Brain development and nicotine exposure
prenatal, 14, 99, 104–105, 109–110, 112–113
research needed, 185
studies on, A3.1-54 to A3.1-55t
youth and young adults, 104–106
Brand preference, development of, 157
British American Tobacco (BAT), 15t, A4.1-3t
Broadcast Ban, 189t
Bronchiolitis obliterans (popcorn lung disease), 116
Brown and Williamson (Advance cigarettes), 9
Burden of proof for product safety, 238, 242
Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), 198t
Bureau of Immigration and Customs Enforcement (ICE), 196t
Bureau of Prisons (BOP), 198t
Butanol, aerosolized, 118
Buttery avor, aerosolized avorant in e-liquids, 116
C
CAD (cinnamaldehyde)
aerosolized avorant, 115
cytotoxicity of, 116
Cadmium, aerosolized, 119
California
Alameda County public health department, 224
Hayward tobacco products aimed at kids, case study, 224
licensing issues, 203
Camel cigarettes, 8
Cannabinoids/cannabis. See Marijuana
Car and Driver magazine, 162f
E-Cigarette Use Among Youth and Young Adults
Index 263
Carbonyls, aerosolized, 117, 118
Carcinogens
acrolein, 118
carbonyls, 117
DEHP, 117
NNN and NNK, 116
Cardiovascular function and disease, 101, 117, 118
Case studies
Hayward, California, tobacco products for kids, 224
North Dakota, clean indoor air, 225
CDC. See Centers for Disease Control and Prevention (CDC)
Center for Devices and Radiological Health (CDRH), 16
Center for Drug Evaluation and Research (CDER), 16
Center for Tobacco Policy and Organizing, 224
Center for Tobacco Products (CTP). See U.S. Food and Drug
Administration (FDA)
Centers for Disease Control and Prevention (CDC)
aerosolized avorants, 115
e-cigarette use among youth, A2.3-6t, A2.3-7t, A2.3-8t, A2.3-18t
avors in e-cigarettes, 61t
patterns of e-cigarette use among youth adults, A2.3-27t
poison centers, increase in e-cigarette-related calls, 209t
statewide tobacco control programs, 238
surveys administered or sponsored by
National Adult Tobacco Survey, A2.1-3
National Youth Tobacco Survey, A2.1-2
Styles, A2.1-3
Centers for Medicare & Medicaid Services (CMS), 193–194t
ChangeLab Solutions, 224
Chemical exposure, e-cigarettes, 7, 208t
Chestereld cigarettes, 8
Child Nicotine Poisoning Prevention Act (2015), 14, 120, 245
Child-resistant packaging for e-liquid containers, 14, 120, 208t, 245
China
e-cigarette companies and manufacturers, 14, 152, A4.1-12 to
A4.1-14t
e-cigarette technology, 10
products imported from, 149
CHRNA5-A3-B4 haplotypes, gene cluster in nicotine addiction, 104
Chronic obstructive pulmonary disease, acrolein associated with, 117
Cigalikes, term usage, 3
Cigarettes
early efforts to modify, 8
exclusive use of, compared to e-cigarettes, 6
lters and tar reduction, 8–9
price of, and use of e-cigarettes, 156
reduced-harm products, 8, 185
trafcking and smuggling, 198t
Cinnamaldehyde (CAD)
aerosolized avorant, 115
cytotoxicity of, 116
Closed-system devices, 151
Cloud Pen e-cigarettes and devices, magazine advertisement, 161f
CMS (Centers for Medicare & Medicaid Services), 193–194t
Coalition on Smoking OR Health, 9
Cocaine use and prenatal nicotine exposure, 111
Cochrane database, NRT during pregnancy, 109
Cognition
adolescent smoking, 106–107
attention and cognition disorders, 106–107, A3.1-56 to 1-62t
decits, with maternal smoking, 110
prenatal nicotine exposure, 112–113
Combustible tobacco products
decline in rates of using, 185
e-cigarette use associated with, 6
patterns of use, 187f
Comprehensive strategy approach, prevention, 238, 244
Conduct disorders, prenatal nicotine exposure, 112–113
Consumatory behaviors, maternal smoking, 110–111
Consumer perceptions
discontinuation, reasons for, 81t, 82t, 86, 87
e-cigarette use as normative, 15
perceived harm of e-cigarettes, 59, 64–71t, 87
PREPs, safety of, 10
use, reasons for, 75–86, 76–85t, 87
Contraband Cigarette Trafcking Act, reauthorized 2005
(CCTA), 198t
Convenience stores, 167
Corpus callosum, alteration of
e-cigarettes, 7
fetal exposure to nicotine, 7
maternal smoking, 109
Cotinine salivary levels, secondhand smoke, 108
Cotinine serum levels
e-cigarettes, 99
new e-cigarette users, 102
secondhand smoke, 122
C-reactive protein (CRP), nicotine exposure, 101
Cross-sectional studies of poly-tobacco use
adults (age ≥25), 53, 55t
young adults, 53, 53f, 54t
youth
current prevalence, 37, 40f, 41–42t, 43, 44t, 45t, 46f
trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53
Crotonaldehyde, aerosolized toxicant, 118
CRP (C-reactive protein) nicotine exposure, 101
CTP (Center for Tobacco Products). See U.S. Food and Drug
Administration (FDA)
Curiosity, as reason for trying e-cigarettes, 75, 87
D
Data for report, sources for, 27
Death, from ingestion of e-liquids, 14
Deeming rule
e-liquids, free samples of, 151
FDA authority over e-cigarettes, 6
free samples, 163
Internet sales to youth under age 18, 163, 164
minimum age requirements in retail environments, 167
modied risk claims, prohibiting, 163
source and provisions of, 17
vape shops, and mixing e-liquids, 169
DEHP (diethylhexyl phthalate), aerosolized adulterant, 117
DEP (diethyl phthalate) aerosolized adulterant, 117
Dependence on nicotine
aerosolized nicotine, 102–104, 103f, A3.1-2 to A3.1-7t
A Report of the Surgeon General
264 Index
maternal smoking, 110–111
Depression, adolescent smoking, 107
Dermatitis, e-cigarette aerosol exposure, 123
Diabetes type 2, fetal effects from nicotine exposure, 111
Diacetyl (2,3-butanedione), aerosolized avorant, 116
Diethylhexyl phthalate (DEHP), aerosolized adulterant, 117
Diethyl phthalate (DEP) aerosolized adulterant, 117
Direct-drip atomizers, carbonyls, greater exposure to, 118
Disruptive disorders, adolescent smoking, 107
Distribution channels for e-cigarettes, 149–151
Dopamine system
abused drugs, 106
fetal effects from nicotine exposure, 112, 113
Dr. Scott’s Electric Cigarettes, 8
Drugs, illicit
aerosol inhalation, 58
e-cigarette products and devices, delivery system for, 6, 13–14
Dual use
advertising and, 170–171
dened, A2.2-3
health consequences, 186
policies discouraging practice of, 244
E
E-cigarette companies
activities of, 7
advertising and marketing, 14–15, 169–171
brands, categories of, 164–165
burden of proof regarding safety, 238, 242
China based, A4.1-12 to A4.1-14t, A4.3-2
consolidation of companies, A4.3-2
distribution and purchase channels, 149–150
e-cigarette market in the U.S., 149–154, 150t, 153f, 154f
e-liquids, production of, 154
FDA registration and disclosures, 242
independent private companies, A4.1-6 to A4.1-11t, A4.3-2
independent public companies, A4.1-4 to A4.1-6t, A4.3-2
marketing expenditures, 157–167, 158f, 160–162f, 165t, 166t
market share of products, 152
mergers, acquisitions, partnerships, and agreements, 165t
multinational companies, 15t
other product-related companies, A4.1-11 to A4.1-12t, A4.3-2
packaging, 242, 245
product evolution, 151–152
product standards, 242
retail outlets, 150t, 152–154, 153f, 154f, 167–169
sales projections, 14
sales volume and prices, 155–157, 155f, 156f
tobacco industry, A4.1-2 to A4.1-3t
visitors to websites, recruitment of, 14
websites, 165–166, 166f
E-cigarette policy and practice implications
agencies addressing specic populations, 243
case studies, 224–225
changing landscape, 184
clean indoor air, 188
comprehensive strategy relating to adverse consequences, 238
control measures, 184
educational initiatives, 206
future research, 185–186
health care practice, implications for, 203
licensing, 203
marketing restrictions, 205–206
overview, 7
pricing measures, 204–205, 238
public policy approaches, 187–188
risk tradeoffs, 184–185, 186t
taxation, 204–205, 238
tobacco-free spaces, 240
youth access and prevention, 203, 243–245
E-cigarette-related exposures, 14, 209t, 245
E-cigarettes
bridge to greater tobacco product use, 11
controversy over, 183
countries that have banned e-cigarettes/ENDS, 223t
discontinuation, reasons for, 81t, 82t, 86, 87
disposable, and prices, 3f, 152, 154, 154f, 155, 155f
federal regulation of, 15–18, 187–188
growth in awareness and use, 149
health effects
fetal brain development from nicotine exposure, A3.1-33
to A3.1-62t
fetal nicotine exposure, preclinical/animal studies, A3.1-63
to A3.1-79t
nicotine exposure effects, human studies, A3.1-8 to A3.1-17t
nicotine exposure effects, on fetal brain development,
A3.1-33 to A3.1-62t
nicotine exposure effects, preclinical/animal studies,
A3.1-18 to A3.1-32t
overview of, 6–7
historical background, 8–10
intentions to use summary data, A2.3-20 to A2.3-22t
invention of, 10–11
marketplace changes
market share of products, A4.3-3f, A4.5-2, A4.5-3 to A4.5-5f
tobacco industry, A4.1-2 to A4.1-3t
tracking of, 238
trade organizations and partnerships, A4.3-2
names used for, 5, A2.2-2
patterns of use, 6, 186, 187f, A2.3-6 to A2.3-19t, A2.3-23 to
A2.3-37t
persistent use despite harmful consequences, A3.1-7t
physiological withdrawal state, A3.1-3t, A3.1-3 to A3.1-6t
potential harms and benets, 185–186, 186t
preoccupation with, A3.1-7t
prevalence of use, 204, A2.3-2 to A2.3-3
price and sales volume, 7
products and devices
additional functions, 152
candy and menthol avored, 211t
components of, 11, 12f
disposable, 3f
dose of inhaled nicotine, 100, 103f
evolution of, 151–152
illicit drugs, delivery system for, 6, 216t
modication of, 11
E-Cigarette Use Among Youth and Young Adults
Index 265
rechargeable, 3f
risks, 13–14
substances found in, 216t
types of, 3, 3f
public health concerns, 183
reasons for using, 6
rechargeable, and sales volume and price, 3f, 155–156, 156f
sales, tracked retail outlets, A4.4-2 to A4.4-6t
surveys
key measures, A2.2-2 to A2.2-4
methodologic information, A2.2-2
sources of data, A2.2-5 to A2.2-15t
susceptibility summary data, A2.3-20 to A2.3-22t
susceptibility to use, and advertising, 170
tolerance to effects, A3.1-6t
use, reasons for, 75–86, 76–85t, 87
use with other tobacco products (See Poly use)
without nicotine, health effects of, 17
E-cigars, appearance of, 3f
E-cigs (brand), 15
Eclipse cigalikes, 9
Educational attainment
adults (age ≥25), 39t
young adults, and e-cigarette use, 37, 38t
Educational initiatives
e-cigarette policies, 206
on ENDS products, 210t
health care professionals, 217t, 226, 241
media campaigns, 238
responsibility for, 239–241
United Nations organization on, 183
Educational plans of youth, 37, 41t
Electronic Cigarette Industry Group, Inc. (ECIG Inc.), A4.3-2
Electronic cigarettes. See entries beginning with E-cigarette
Electronic nicotine delivery systems (ENDS), 27. See also
E-cigarettes
Alcohol and Tobacco Tax and Trade Bureau, 200t
American Association for Cancer Research, 208–209t
American College of Physicians, 210t
Forum of International Respiratory Societies, 214t
International Union Against Tuberculosis and Lung Cancer, 223t
term usage, 27
World Health Organization, 219–220t
Elektro e-cigarettes, sales (2010–2014), 153f, A4.4-2 to A4.4-6t
E-liquids
adulterants, 100
child-resistant packaging, 14, 208t
concentration, and dose of inhaled nicotine, 100, 103f
devices, lling, 11, 13f
free samples, 151
ingestion of or exposure to, and health effects, 7, 119–120,
121f, 184
nut allergy, and e-cigarette aerosol exposure, 123
production of, 154
rells, sales of, 154, 154f
taxation of, 204
vape shops, mixing in, 169
Employers, rewards or penalties for tobacco use, 194t
Ending the Tobacco Problem: A Blueprint for the Nation (IOM), 16
ENDS (electronic nicotine delivery systems), 27. See also
E-cigarettes
E-pipes, appearance of, 3f
Esquire magazine, 160f
Estrogenic activity, DEP and DEHP, 117
Ethnicity. See Race/ethnicity
European Commission, Tobacco Products Directive, 213t
European Medicines Agency, 117
European Respiratory Society (ERS), 213t
European Union (EU)
indoor air quality, 122
position on e-cigarettes and ENDS, 221t
Evaluation, policy impacts, 248
Ever (lifetime) use, dened, A2.2-2. See also High school
students; Middle school students; National Youth Tobacco
Survey (NYTS); Youth
EVIC tank device, 103f
Evod heating element, 103f
Exalt smokeless tobacco product, 9
Excise tax, on tobacco products, 204
Explosions caused by e-cigarette batteries, 14, 119
F
Facebook
advertising, 157
coupons and discounts, 163
distribution and purchase channels, 150
e-cigarettes, 15
Family Smoking Prevention and Tobacco Control Act of 2009, iii,
9, 16, 18, 58, 183, 210t, 241
Favor cigarettes, 10
FDA. See U.S. Food and Drug Administration (FDA)
Fear responses, and adolescent smoking, 107
Federal Communications Commission (FCC), 189t
Federal Food, Drug, and Cosmetic Act, 16–17, 183, 241
Federal regulation of e-cigarettes. See also specic agencies by name
approach to, 15–18
policies of federal agencies, 189–202t
Tobacco Control Act, 187–188
Fetal effects of nicotine exposure. See also Pregnancy; Prenatal
nicotine exposure
altered corpus callosum, 7, A3.1-34t
appetitive behaviors, A3.1-40 to 1-55t
attention and cognition, behavioral disorders, A3.1-56 to
A3.1-62t
attention decit hyperactivity disorder (ADHD), 112, 113,
A3.1-14t, A3.1-49t, A3.1-56 to A3.1-59t
auditory processing defects, 7, A3.1-35 to 1-39t
brain development, 14, 99, 104–105, 109–110, 112–113
brain reward systems changes, A3.1-54 to A3.1-55t
cognition disorders, 112–113
conduct disorders, 112–113
obesity, 7
preclinical/animal studies, A3.1-63 to A3.1-79t
sudden infant death syndrome (SIDS), 7, 109, A3.1-33t
Filters, health, effects on, 8
A Report of the Surgeon General
266 Index
FIN e-cigarettes
magazine advertisement, 162f
television advertising, 159
website access restrictions, 166t
Fires caused by e-cigarette batteries, 14, 119
Flavors for e-cigarettes
addiction and use of conventional tobacco products, 11
aerosol inhalation, 115–116
avors appealing to minors, California prohibiting, 151
Internet sales, 164
licensing requirements, 203
restrictions on, 242
safety of inhaling, 13, 184, 186
sales, growth of, 154
studies on, 58–59, 60t, 61–63t
sweet avors, 11, 13f, 211t
youth and young adults, 6, 11
Food and Drug Administration (FDA). See U. S. Food and Drug
Administration (FDA)
Food and Nutrition Act (2008), 190t
Formaldehyde
aerosolized adulterant, 117, 118
e-cigarettes, 99
higher temperature of e-cigarettes, 13
Forum of International Respiratory Societies, ENDS devices, 214t
4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK),
aerosolized adulterant, 116
Free samples; restrictions, 242
Frequent use, dened, A2.2-3. See also High school students;
Middle school students; National Youth Tobacco Survey
(NYTS); Youth
FTC. See U.S. Federal Trade Commission (FTC)
Future regulatory actions, 242
Future research initiatives, 185–186, 226
G
Gamucci e-cigarettes
company prole, A4.1-8t
market share (2010–2014), A4.5-3f
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
Gender differences
e-cigarette use
adults (age ≥25), 39t
high school, 28, 30t, 32t, 33, 35t, 37
middle school, 28, 29t, 31t, 33, 34t, 36
young adults, 37, 38t
avors in e-cigarettes, 59, 60t
myelination gene expression with maternal smoking, 109
poly-tobacco use
adults (age ≥25), 55t
young adults, 53, 54t
youth, 37, 41t, 43
General Services Administration (GSA)
agency description, 190t
e-cigarette regulations, 188
smoking regulations, 190t
Genetics
gene expression alterations with maternal smoking, 109
genetically modied nontobacco plants, 17
genetically sensitive research designs, 112, 112n
nicotine addiction, 104
Glycidol, e-cigarette aerosol, 99
Glyoxal, aerosolized toxicant, 118
Green Smoke e-cigarettes
manufacturer, 15t
website information, 166, 166t
H
Halco, e-cigarettes, A4.1-8t
Halo Companies, Inc., A4.1-10t
Harm
reduced-harm products, 8, 185
reduction with e-cigarettes, and advertising, 171
strategies to prevent, 237–238
Haus e-cigarettes, sales (2010–2014), 153f, A4.4-2 to A4.4-6t
Health Belief Model, tobacco use, and perception of harm, 64
Health care practice, implications for, 203
Health care professionals, as education channel, 217t, 226, 241
The Health Consequences of Smoking—50 Years of Progress
(2014 report)
conceptual modeling, 186
conclusions from, 97, 99t
maternal cigarette use and disruptive-behavior disorders, 112, 113
passive use effects for pregnant women, 14
relevance of conclusions to e-cigarettes, 225
sensitivity of youth to nicotine effects, 99
The Health Consequences of Smoking–Nicotine Addiction (1988
report)
conclusions from, 97, 98t
nicotine addiction, 9
Health effects
e-cigarette potential harms and benets, 185–186, 186t
e-liquids, ingestion of, 7, 184, 245
nicotine and tar reduction, 8–9
risk tradeoffs and, 184–185
HealthStyles Survey, A2.1-3, A2.1-4 to A2.1-5t
Heat-not-burn products, 15t
Heavy metals, aerosolized, 119
High school students. See also Youth
current prevalence of e-cigarette use
ever use, 28, 30t
frequency of use, 28, 30t
past-30-day use, 28, 32t
susceptibility to use, 28, 30t
trends in prevalence of e-cigarette use
ever use, 33, 33f, 35t
past-30-day use, 32t, 36–37, 36f
Hill, Sir Austin Bradford, 186
Hippocampal function, adolescent smoking, 107
Hispanic population, retail sales of e-cigarettes, 150, 168
Hispanics. See Race/ethnicity
Hon Lik, 10
Hookah bars and lounges, 203
E-Cigarette Use Among Youth and Young Adults
Index 267
How Tobacco Smoke Causes Disease–The Biologic and
Behavioral Basis for Smoking-Attributable Disease (2010
report)
aerosols in e-cigarettes, 99
conclusions from, 97, 98t
Hypotension, SIDS and maternal smoking, 109
I
ICE (Bureau of Immigration and Customs Enforcement), 196t
Illicit uses. See also Marijuana
cocaine use and prenatal nicotine exposure, 111
European regulations, 213t
hashish oil, 14
methamphetamine, 111
Imperial Tobacco Group (Fontem Ventures)
acquisitions, 165t
advertising expenditures for blu, 157
company prole, A4.1-2t
Lorillard, 152
multinational tobacco company, 15t
Ruyan e-cigarettes, 10
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
Impulsivity in adulthood, adolescent smoking, 107
Indoor air policies, 122, 188, 225, 238, 243–244
Inammatory mediators, nicotine exposure, 101
Ingredient disclosures, 17, 64, 215, 242
Instagram
advertising, 157
e-cigarette promotion, 166
e-cigarettes, 15
Institute of Medicine (IOM)
comprehensive tobacco control, 16
potentially reduced-exposure products, 9
Insurance coverage, rates for tobacco users, 194t. See also
Medicaid; Medicare
International cooperation
ENDS products, 209t
Tobacco Tax and Trade Bureau, 209t
International Union Against Tuberculosis and Lung Cancer, 223t
International Vapor Group (IVG), A4.1-7t
Internet
advertising, 157, 158f
age verication, 208t, 242
distribution and purchase channels, 150
e-cigarette companies, 14, 15
e-cigarette marketing, 10
e-cigarette promotion, 163
websites selling e-cigarettes, 163–164
IOM (Institute of Medicine)
comprehensive tobacco control, 16
potentially reduced-exposure products, 9
IQOS e-cigarettes, 15t
Iron, aerosolized, 119
J
Japan Tobacco International (JTI)
acquisition and partnership, 165t
company prole, A4.1-3t
multinational tobacco company, 15t
JieShiBo Technology (Shenzhen, China), A4.1-14t
Johnson Creek Vapor Company, 154, A4.1-11t
Joyetech Co., Ltd. (Shenzhen, China), 152, A4.1-12t
K
Kantar Media, 157, 159
Knowledge, attitudes, and risk perceptions, 171
Koop, C. Everett, 97
Korean Youth Risk Behavior Web-Based Survey (2011), A2.3-5
Krave e-cigarettes, sales (2010–2014), 153f, A4.4-2 to A4.4-6t
L
Labels
ingredients, 17, 64, 215
warning, 206, 211t, 213t, 216t, 240–241
Latinos. See Race/ethnicity
Lead, aerosolized, 119
Legislation to curb tobacco sales
Hayward, California, case study, 224
North Dakota, case study, 225
Licensing
e-cigarette policies, 203
retailers, 245
Lifetime (ever) use, dened, A2.2-2. See also High school
students; Middle school students; National Youth Tobacco
Survey (NYTS); Youth
Liggett & Myers (L&M), 8
Limbic system, long-term changes with nicotine exposure, 106
Literature search for report, 27
Litigation
FDA regulation of e-cigarettes, 187–188, 241
violations of existing local rules, 205
Local government, tobacco control, 16, 18. See also State, local,
tribal, and territorial governments
Logic e-cigarettes
company prole, A4.1-8t
market share, (2012–2014), A4.5-4 to A4.5-5f
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
website information, 166, 166t
Longitudinal studies
data for report, source for, 27
poly-tobacco use, 53, 56–57
Lorillard (Lorillard Vapor Company)
acquisition, 165t
advertising expenditures for blu, 157, 159
blu, marketing of, 152, 153f
company prole, A4.1-3t
multinational tobacco company, 15t
A Report of the Surgeon General
268 Index
Lucky Strike cigarettes, 8
Lung cancer, and acrolein, 117
M
Machine testing of tar and nicotine yields, 8, 9
Magazines/print media, and advertising, 158–159, 158f, 160–162f
Mail-order sales, age verication, 208t
Manufacturers. See E-cigarette companies
Marijuana
aerosol inhalation, 58
e-cigarette devices used for, 6, 14, 58, 203, 241
e-cigarette use with, 57–58
open systems, 152
Ploom PAX e-cigarettes, 15t
poly-tobacco use, 57
tank devices, 14
“wax” marijuana resin, 14
Market for e-cigarettes in the U.S. See also Vape shops
distribution and purchase channels, 149–151, 154f
e-liquid production, 154
market share, evolution of, 152
product evolution, 151–152
sales in retail outlets, 150t, 152–154, 153f, 154f, 167–169
value of, 149, 150t
Marketing. See also Advertising
burden of proof regarding safety, 238
channels, 7
e-cigarette companies, 14–15
e-cigarettes, 7, 185
effect of advertising on behavior, 170–171
exposure and receptivity to advertising, 169–170
Internet, 10, 163
marketing expenditures, 157–167, 158f, 160–162f, 165t, 166t
restriction policies, 205–206, 208t, 238
retail environment, 167–169
self-service displays, 17, 203, 224, 242, 244
Surgeon General’s report (2012), 4
targeting youth and young adults, 246–247
themes, 7
MarkTen e-cigarettes. See also Altria Group, Inc./Nu Mark
distribution and purchase channels, 150
e-liquid manufacturers, 154
manufacturer, 15t
market share (2014), A4.5-5f
promotion of, 158
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
website information, 165, 166, 166t
Master Settlement Agreement (1998)
Hayward, California, case study, 224
marketing surveillance, 205
placement of e-cigarette advertisement, 168
point-of-sale advertising, 168
tobacco product sponsorship of events, 15, 159, 240
Maternal nicotine consumption. See Prenatal nicotine exposure
Maxim magazine, 160f
Medicaid
Incentives for Chronic Disease Prevention Program, 193t
prescription drug benets, 193t
tobacco screening and cessation, 193–194t
Medical organizations
government health, 221–223t
professional organizations, 207–214t
voluntary health organizations, 215–219t
World Health Organization, 219–220t
Medicare, tobacco screening and cessation, 194t
Memory, adolescent smoking, 107. See also Cognition
Men’s Journal magazine, 160f
Metals, found in e-cigarettes, 216t
Methamphetamine use, fetal effects from nicotine exposure, 111
Methylglyoxal, aerosolized toxicant, 118
Middle school students. See also Youth
current prevalence of e-cigarette use
ever use, 28, 29t
frequency of use, 28, 29t
past-30-day use, 28, 31t
susceptibility to use, 28, 29t
trends in prevalence of e-cigarette use
ever use, 33, 33f, 34t
past-30-day use, 31t, 36, 36f
Minnesota Adult Tobacco Survey, A2.2-2
Mistic e-cigarettes
company prole, A4.1-6t
magazine advertisement, 161f
market share, (2012), A4.5-4f
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
website access restrictions, 166t
“Mods.” See Tank devices (“mods”)
Monitoring the Future Survey (MTF)
data for report, source for, 27
e-cigarette use
items from sources of national data, A2.2-5 to A2.2-9t
sources of national data, A2.1-4 to A2.1-5t
e-cigarette use, current prevalence, 28
avors in e-cigarettes, 59
poly-tobacco use, 37, 40f, 41–42t
prole of, A2.1-2
Monoamine oxidase A, fetal effects from nicotine exposure, 113
Mood disorders, adolescent smoking, 107. See also Anxiety disorders
Moratoriums, on vape shops, 203
MTF. See Monitoring the Future Survey (MTF)
Myelination
gene expression alterations with maternal smoking, 109
nicotine exposure, 104–105
N
NAB (N-nitrosoanabasine), aerosolized adulterant, 116
NACDA (National Advisory Council on Drug Abuse), 195t
NAChRs. See Nicotinic acetylcholine receptors (nAChRs)
NAT (N-nitrosoanatabine), aerosolized adulterant, 116
National Adult Tobacco Survey (NATS)
comparison to 2013–2014 survey, A2.3-3
data for report, source for, 27, A2.1-3, A2.1-4 to A2.1-5t
e-cigarette use data, A2.2-5 to A2.2-9t
avors in e-cigarettes, 59, 60t
E-Cigarette Use Among Youth and Young Adults
Index 269
poly-tobacco use, 53, 53f, 54t, 55t
prevalence of e-cigarette use, 37, 38t, 39t
young adults
e-cigarette use, A2.3-3
perceived harm of e-cigarettes, 64, 74t, 75
National Center for Health Statistics, 27
National Comorbidity Survey—Adolescent dataset, 102
National Defense Authorization Act (2015), 191t
National Health Interview Survey (NHIS), A2.1-4 to A2.1-5t, A2.3-3
National Institute for Occupational Safety (NIOSH), 116
National Institute on Drug Abuse (NIDA)
Monitoring the Future Survey, A2.1-2
Population Assessment of Tobacco and Health Study, A2.1-3
tobacco industry-supported research and funding, 195t
National Institutes of Health (NIH)
supporting e-cigarette research, 186
tobacco-free initiative, 195t
National Library of Medicine, 27
National Park Service
e-cigarette regulations, 188
role in implementing strategies, 243
National Tobacco Company, 165t
National Youth Tobacco Survey (NYTS)
advertising
effect on behavior, 170
exposure to e-cigarette, 169
current e-cigarette use by youth, increase of, 10
current prevalence of e-cigarette use
ever use, 28, 29t, 30t
frequency of use, 28, 29t, 30t
past-30-day use, 28, 31t, 32t
susceptibility to use, 28, 29t, 30t
data for report, source for, 27
e-cigarette use data
items from sources of national data, A2.2-5 to A2.2-9t
measures used, A2.2-4
patterns of use, 2015 survey, A2.3-2
sources of national data, A2.1-4 to A2.1-5t
survey description, A2.1-2
avors in e-cigarettes, 59, 60t
perceived harm of e-cigarettes, 64, 73t, 74t
poly-tobacco use
current prevalence, 43, 44t, 45t, 46f
trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53
survey prole, A2.1-2
trends in prevalence of e-cigarette use
ever use, 28, 33, 33f, 34t, 35t
past-30-day use, 31t, 32t, 36–37, 36f
NATS. See National Adult Tobacco Survey (NATS)
Netherlands Study of Depression and Anxiety Disorders, A3.1-14t
Netherlands Twin Registry, 106
Neurobehavioral disorders of childhood, A3.1-56 to A3.1-62t
Neurobiological development, 104–106
Neuroteratogens, 14
New Jersey Youth Tobacco Survey (NJYTS), 33, A2.2-4
NHALE, Inc., A4.1-6t
Nickel, aerosolized, 119
Nicolites e-cigarettes, 15t
Nicorette inhalators, 116
Nicotek e-cigarettes
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
website access restrictions, 166t
Nicotek LLC, A4.1-9t
Nicotine
addiction and fetal effects, A3.1-40 to A3.1-48t
adverse effects during pregnancy, 208t
Camel cigarettes, and high nicotine content, 8
genetically modied nontobacco plants, 17
higher temperature of e-cigarettes, 13
poisoning, with ingestion of e-liquids, 119–120, 121f
reduction of content, health effects of, 8–9
role of, and nicotine delivery, 9
secondhand exposure, and California level standards, 123
Nicotine-related compounds, aerosol inhalation of, 114
Nicotine replacement therapy (NRT)
cardiovascular risk, 101
Nicorette inhalators, 116
pregnancy, 108–109
Nicotinic acetylcholine receptors (nAChRs)
adolescence, 105
e-cigarette addiction, 102
fetal development, 108, 110
NicSelect, A4.1-11t
NIDA. See National Institute on Drug Abuse (NIDA)
NIH. See National Institutes of Health (NIH)
NIOSH (National Institute for Occupational Safety), 116
Nitric oxide, aerosol inhalation, 114
NJOY cigalikes
company prole, A4.1-7t
e-liquid manufacture, 154
funding for study on avors in e-cigarettes, 59
magazine advertisement, 161f
market share (2010–2014), A4.5-2 to A4.5-5f
product evolution, 151
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
television advertising, 159
website access restrictions, 166t
N-nitrosoanabasine (NAB), aerosolized adulterant, 116
N-nitrosoanatabine (NAT), aerosolized adulterant, 116
N-nitrosonornicotine (NNN), 116
NNK (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone), 116
NNN (N-nitrosonornicotine), 116
Nonusers. See Environmental exposure
North America Tobacco Regulatory Laboratory Network, 200t
North Dakota Center for Tobacco Prevention and Control Policy, 225
NRT (nicotine replacement therapy)
cardiovascular risk, 101
Nicorette inhalators, 116
pregnancy, 108–109
NuMark. See Altria Group, Inc./Nu Mark
Nut allergy, and e-cigarette aerosol exposure, 123
NYTS. See National Youth Tobacco Survey (NYTS)
O
Obesity. See Overweight and obesity
Occupational Safety and Health Administration (OSHA), 199t
A Report of the Surgeon General
270 Index
Ocular irritation, acrolein, 117
Ofce of Management and Budget (OMB), 189t
Ofce of Personnel Management (OPM), 190t
Old Gold cigarettes, 8
OMB (Ofce of Management and Budget), 189t
Omni cigarettes, 9
Open system devices, 151–152
OPM (Ofce of Personnel Management), 190t
Oppositional deant disorder (ODD), 107
OSHA (Occupational Safety and Health Administration), 199t
Overweight and obesity
e-cigarettes, 7
fetal effects from nicotine exposure, 7, 111, A3.1-51 to A3.1-53t
P
Particulate matter 2.5 (PM
2.5
), secondhand smoke measure, 122, 123f
Past-30-day use, dened, A2.2-2. See also High school students;
Middle school students; National Youth Tobacco Survey
(NYTS); Youth
PATH study. See Population Assessment of Tobacco and Health
(PATH) study
Patient Protection and Affordable Care Act of 2010 (PPACA), 193t
PG. See Propylene glycol (PG)
Philip Morris International (PMI), 15t, A4.1-2t
Physical abstinence syndrome (withdrawal symptoms), 102,
A3.1-3 to A3.1-6t
Physiological withdrawal state, electronic cigarettes, A3.1-3t
Pipeline and Hazardous Materials Safety Administration, 199t
Plasma nicotine concentration, 103f
Plasticity of the brain, 104–105, 113
Ploom e-cigarettes, 15t
Ploom vaporizers, 15t, 165t
PM
2.5
(particulate matter 2.5), secondhand smoke measure, 122, 123f
PMI (Philip Morris International), 15t, A4.1-2t
Poison control centers, e-cigarette-related exposures, 14, 209t, 245
Poly use
adults, cross-sectional studies, 53, 55t
dened, A2.2-3
educational plans of youth, 37, 41t
gender differences
adults (age ≥25), 55t
young adults, 53, 54t
youth, 37, 41t, 43
longitudinal studies, 56–57
marijuana, 57
race/ethnicity
adults (age ≥25), 55t
young adults, 53, 54t
youth, 37, 41t
young adults, cross-sectional studies, 53, 53f, 54t
youth
current prevalence, 37, 40f, 41–42t, 43, 44t, 45t, 46f
educational plans of, 37, 41t
trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53
Popcorn lung disease (bronchiolitis obliterans), 116
Population Assessment of Tobacco and Health (PATH) Study
e-cigarette use
items from sources of national data, A2.2-2 to A2.2-15t
patterns of use, 2013–2014 study, A2.3-2
sources of national data, A2.1-4 to A2.1-5t
avors in e-cigarettes, 59
overview, A2.1-2
prole of, A2.1-3
Population-level strategies, 243
Porter Novelli (public relations rm), A2.1-3
Potentially reduced-exposure products (PREPs), 9–10
Precautionary approach strategy, 238
Precautionary principle
appropriate use of, 183
as guide for decision makers, 188
as guide to address e-cigarette use, 4
Prefrontal cortex, development of, in adolescents and young
adults, 105
Pregnancy. See also Fetal effects of nicotine exposure; Prenatal
nicotine exposure
adverse effects of nicotine, 7, 208t, 239
e-cigarettes as tobacco cessation option, 206
nicotine exposure, 14
nicotine use, 5, 7, 14
tobacco screening cessation services, 193–194t
Premarket reviews, 242
Premier, smokeless cigarette product, 9
Prenatal nicotine exposure. See also Fetal effects of nicotine
exposure; Pregnancy
appetitive and consumatory behaviors, 110–112
attention and cognition, 112–113
auditory processing decits, 109–110
cocaine use, 111
corpus callosum, altered development of, 109
discordant sibling pair design studies, 111
e-cigarettes, 14
nicotine, 5, 7
nicotine concentrations in fetal uid, 108
prenatal and postnatal outcomes, 108–113
sudden infant death syndrome (SIDS), 109
toxicants and, 108, 109
PREPs (potentially reduced-exposure products), 9–10
Prevent All Cigarette Trafcking Act (2009), 164
Preventing Tobacco Use Among Young People (1994 report), 4
Preventing Tobacco Use Among Youth and Young Adults (2012
report)
conclusions from, 97, 98t
educational initiatives, 206
marketing inuence in tobacco use behaviors, 157
release of, 4
sensitivity of youth to, 99
Pricing of e-cigarettes
disposable e-cigarettes, 155, 155f
Internet coupons and discounts, 163
policies, 7, 204–205, 238
sales, impact on, 155–157, 155f, 156f
Primacy, dened, A2.2-4
Print media/magazines, and advertising, 158–159, 158f, 160–162f
Processed tobacco, dened, 200t
E-Cigarette Use Among Youth and Young Adults
Index 271
Pro-Children Act of (2001), 192t
Product placements, e-cigarettes, 15
Promotion or promotional activities. See Marketing
Propanol, aerosolized toxicant, 118
Propylene glycol (PG)
aerosol inhalation, 115
inhalation toxicity, 114
secondhand exposure, and California level standards, 123
Pruning of unnecessary synapses, and nicotine exposure, 104–105
Psychiatric events, and rimonabant, 117
Public and Indian Housing (PIH), 197t
Public health
agencies role in assisting state attorney general or FTC, 206
e-cigarettes policy, 7
e-cigarette use, 10–11
FDA regulatory authority, 16
future regulatory options, 17–18
precautionary strategies to protect youth and young adults, 226
Public Health England (UK), 222t
Public policy
cigarette restrictions, 149
e-cigarettes, 7, 187–188, 205
magazine advertisement, 161f, 162f
retail sales of e-cigarettes, 168
“Puff topography,” dose and effects of inhaled nicotine, 100–101
Puff volumes, dose and effects of inhaled nicotine, 101
Purchase channels for e-cigarettes, 149–151
R
Race/ethnicity
e-cigarette advertising, exposure to, 169
e-cigarette use
current prevalence, 28, 29t, 30t, 31t, 32t
trends in prevalence, 28, 33–37, 34t, 35t
avored little cigars and cigarillos, 11
avors in e-cigarettes, 59, 60t
poly-tobacco use
adults (age ≥25), 55t
young adults, 53, 54t
youth, 37, 41t
retail sales of e-cigarettes, 150, 168
Regulation of e-cigarettes. See also specic agencies by name
federal
approach to, 15–18
policies of federal agencies, 189–202t
Tobacco Control Act, 187–188
state, local, tribal, and territorial governments
clean air policies, 188
control measures, 184
interventions policies, 188
Tobacco Control Act, 16
Research
suggestions for future research, 185–186, 226, 247–248
tobacco control and prevention, 238
tobacco industry-supported, 195t
Respiratory irritation, acrolein, 117
Retail environment
e-cigarette sales, 14
U.S. market, 150t, 152–154, 153f, 154f, 167–169
Revel smokeless tobacco product, 9
Reward-seeking behavior
adolescent smoking and long-term changes in reward system, 106
nicotine, increased sensitivity to, in adolescents, 105
Reynolds American Inc. (RAI) (R.J. Reynolds Vapor Company)
American manufacturing, 152
company prole, A4.1-3t
multinational tobacco company, 15t
Premier “smokeless cigarette product,” 9
VUSE, 150, 152, 158
Rimonabant (Zimulti), aerosolized adulterant, 117
Risk assessments, 186t
Risk perceptions, knowledge and attitudes, 171
Risk tradeoffs, 184–185
Risky behaviors, and e-cigarette use, 57–58
R.J. Reynolds. See Reynolds American Inc. (RAI)
Rolling Stone magazine, 159, 161f
Ruyan e-cigarettes
introduction of, 10
manufacturer, 15t
S
Safe and Drug-Free Schools and Communities Act (1994), 192t
Safety
battery explosions and res, 14, 119
burden of proof, responsibility for, 238, 242
cigarette marketing, 8
e-cigarette products and components, 13–14
SAMHSA (Substance Abuse and Mental Health Services
Administration), 196t
Satiscing, dened, A2.2-4
Schools, proximity to, and e-cigarette availability, 168
Secondhand exposure
aerosolized e-cigarette constituents, 120–123, 123f, 183, 209t, 240
e-cigarettes, 14
nicotine from e-cigarettes, compared to conventional
cigarettes, 97
nonusers of nicotine, exposure to, 120
teratogenic effects, 108
Seizures, 117
Sensory decits, with maternal smoking, 109–110
SFATA (Smoke Free Alternatives Trade Association), A4.2-2,
A4.3-2
SIDS. See Sudden infant death syndrome (SIDS)
Silicates, aerosolized, 119
Silver, aerosolized, 119
Smoke Free Alternatives Trade Association (SFATA), A4.2-2, A4.3-2
Smokefree policies, 188, 243–244
Smoker Friendly International, LLC, A4.1-10t
Smoker’s One Choice e-cigarettes
market share, (2011), A4.5-3f
sales (2010-2014), 153f, A4.4-2 to A4.4-6t
A Report of the Surgeon General
272 Index
Smoking and Health: Report of the Advisory Committee to the
Surgeon General of the Public Health Service (1964 report)
mortality contribution results, 8
release of, 4
Smoking behavior
changes, with low-nicotine cigarettes, 9
dose and effects of inhaled nicotine, 100–101
Smoking cessation
in clinical care setting, 206
e-cigarettes as cessation option, 183, 184, 186, 206
magazine advertisement, 161f
reason for trying e-cigarettes, 75
screening and cessation services, 193–194t
studies showing inconsistent results, 214t
Smuggled Tobacco Prevention (STOP) Act (proposed), 198t
SNAP program, 190t
Snus
cardiovascular risk, 101
modied tobacco product, 9
Soap Opera Digest, 161f
Social media. See also Facebook; Twitter; YouTube
advertising, 157
distribution and purchase channels, 150
e-cigarette marketing, 10, 15
e-cigarette promotion, 166–167
Social Security Act (2010 amendments to), 193t
Socioeconomic status, and price of e-cigarettes, 157
Solvents, and aerosol inhalation, 115
Sottera, Inc. See NJOY
Sottera, Inc. v. U.S. Food and Drug Administration (2010), 16,
241, A4.2-2
Spin magazine, 162f
Sponsorship of events by e-cigarette companies, 15, 159, 163, 240
Sports Illustrated magazine, 160f
Stanford Research into the Impact of Tobacco Advertising
research group, 158
Starre e-cigarettes, television advertising, 159
State, local, tribal, and territorial governments
best practices of, 245
e-cigarette taxation policies, 204
ENDS regulations, 209t
existing rules that constrain marketing, 205
licensing, 203
population-level strategies, 243
Tobacco Control Act, 188
tobacco control strategies, 16, 18, 226, 238, 242
Stimulus-response-discrimination-learning processes, 107
Studies. See Surveys
Styles (HealthStyles, Summer Styles) Survey
e-cigarette use data
items from sources of national data, A2.2-5 to A2.2-9t
sources of national data, A2.1-4 to A2.1-5t
prevalence of e-cigarette use, 37, 40f
prole of, A2.1-3
Styrene, aerosolized, 118
Substance Abuse Prevention and Treatment Block Grant, 196t, 203
Substance use and abuse
adolescent smoking as “gateway” for, 106
comorbid, with adolescent smoking, 106
e-cigarette use with, 57–58
fetal effects from nicotine exposure, 111–112
Sudden infant death syndrome (SIDS)
e-cigarettes, 7
fetal effects of nicotine exposure, A3.1-33t
fetal exposure to nicotine, 7
maternal smoking, 109
Surgeon General Call to Action
curb advertising and marketing, 246–247
do no harm, 237–239
expand surveillance, research and evaluations, 247–248
prevention programs and policies, 243–245
provide information about dangers, 239–241
regulate e-cigarettes at federal level, 241–243
stakeholders, 237
Surgeon General’s reports, health risks outlined in previous
reports, 97–99, 98–99t. See also individual reports by name
Surveillance
proposals, 205, 226, 247–248
studies, 27
Surveys. See also specic survey or study by name
data analysis instruments, A2.2-4
e-cigarette and other tobacco product use, A2.3-4
future research, 185–186
measurement factors, special issues, A2.2-4
modeling concepts, 186
prevalence estimates, 204, A2.3-2 to A2.3-3
Susceptibility to use
advertising and, 170
current prevalence of high school students, 28, 30t
current prevalence of middle school students, 28, 29t
dened, A2.2-3
intentions to use, A2.3-20t
survey summary data, A2.3-20 to A2.3-22t
Synar Amendment, 196t, 203
T
Tank devices (“mods”)
appearance of, 3f, 11
components of, 12f
increasing role in e-cigarette market, 150
plasma nicotine concentration, 103f
product evolution, 151, 152
Tar reduction, health effects of, 8–9
Taxation
e-cigarette policies, 188, 204–205, 238
ENDS, 209t, 210t
Tobacco Tax and Trade Bureau, 200t
Television advertising, 157, 158f, 159
Temperature of e-cigarettes
aerosolized carbonyls, 117, 118
higher, and increased nicotine and toxicant release, 13
toxicants, 118
Tetrahydrocannabinol (THC)
aerosol inhalation, 58
tank devices, 14
Theory of Reasoned Action, tobacco use, and perception of harm, 64
E-Cigarette Use Among Youth and Young Adults
Index 273
Thermal metered-dose cannabis inhalers for medical applications, 58
Third-hand smoke
described, 120, 121
exposure, 209t
Tiered tax rate systems, 204
Tin, aerosolized, 119
Tobacco Control Act (2009)
deeming rule, 17
e-cigarette regulation relating to youth and young adults, 18
federal authority to regulate tobacco products, 9, 15, 16, 183,
187–188, 241
avor ban for cigarettes, 11
avors in cigarettes, 58
state, local, tribal, and territorial government authority, 16
vape shops, mixing e-liquids, 169
youth tobacco access control regulations, 203
Tobacco Control Legal Consortium, 204, 225
Tobacco Free North Dakota, 225
Tobacco-free policies, 240
Tobacco industry companies, A4.1-2 to A4.1-3t
Tobacco industry-supported research and funding, 195t
Tobacco Laboratory Network, 200t
Tobacco Product Directive (TPD), 222t
Tobacco products. See also Aerosol inhalation; Aerosolized
nicotine; Cigarettes; E-cigarettes
combustible, 6
e-cigarettes regulated as, legal basis for, 16–17
FDA regulation of, 9–10, 15–17
smokeless, 9
sponsorship of events, 15, 159, 163, 240
Tobacco Products and Risk Perceptions Survey (2014), A2.3-3
Tobacco Products Directive, European Commission, 213t
Tobacco-specic nitrosamines (TSNAs), 99, 116
Toluene, aerosolized, 118–119
Toxicants
aerosolization process, 114, 118–119
aerosolized adulterants, 100, 116–117
fetal development, 108, 109
avorants, 116
prenatal exposure, 108, 109
TPD (Tobacco Product Directive), 222t
Trade organizations and partnerships, e-cigarettes, A4.3-2
Trigeminocardiac reex, SIDS and maternal smoking, 109
Trinkets & Trash archive, 158
TruNic, A4.1-12t
Truth Initiative (American Legacy Foundation), 158, 159, 163
TSNAs (tobacco-specic nitrosamines), 99, 116
21st Century Smoke e-cigarettes
market share, (2010–2014), A4.5-2 to A4.5-5f
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
website access restrictions, 166t
Twitter
advertising, 157
coupons and discounts, 163
distribution and purchase channels, 150
e-cigarette promotion, 166, 167
e-cigarettes, 15
2-methoxycinnamaldehyde, cytotoxicity of, 116
2,3-butanedione (diacetyl), aerosolized avorant, 116
U
Uniform tax rate systems, 204
United Nations Educational, Scientic and Cultural Organization
(2005), 183
USA Liquid Nicotine/USA Laboratories, A4.1-12t
U.S. Coast Guard, 196t
U.S. Department of Agriculture (USDA), 190t
U.S. Department of Defense (DoD), 188, 191t
U.S. Department of Education, 192t
U.S. Department of Health and Human Services (USDHHS)
National Advisory Council on Drug Abuse, 195t
National Institute on Drug Abuse, 195t
National Institutes of Health, 195t
preparation of Surgeon General’s report (2016), 4–5
Substance Abuse and Mental Health Services Administration, 196t
tobacco screening and cessation, 193–194t
U.S. Department of Homeland Security (DHS)
Bureau of Immigration and Customs Enforcement, 196t
Coast Guard, 196t
U.S. Department of Housing and Urban Development (HUD), 197t
U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives, 198t
Bureau of Prisons, 198t
U.S. Department of Labor, 199t
U.S. Department of Transportation (DOT)
e-cigarette regulations, 188
Pipeline and Hazardous Materials Safety Administration, 199t
tobacco use on aircraft, 199t
U.S. Department of Treasury, 200t
U.S. Department of Veterans Affairs, 188, 201t
U.S. Environmental Protection Agency (EPA)
e-cigarette regulations, 188, 201t
formaldehyde as carcinogenic, 117
U.S. Federal Trade Commission (FTC)
agency prole and policies, 189t
description and authority of, 201t
monitoring advertising, 246
public health agency interaction, 206
source disclosure of advertorials, 205–206
tar and nicotine content in advertising, 9
U.S. Fire Administration, 119
U.S. Food and Drug Administration (FDA)
areas not authorized to regulate, 242
authority to regulate tobacco products, 9, 238
Center for Devices and Radiological Health (CDRH), 16
Center for Drug Evaluation and Research (CDER), 16
Center for Tobacco Products (CTP), 17, A2.1-3
deeming rule, 6, 17
e-cigarette regulation as tobacco products, 16–17
e-cigarette rules, 241–242
e-cigarette shipments, denying entry to, 16
future regulatory options, 17–18
litigation against, 187, A4.2-2
minimum age requirements in retail environments, 167
nicotine regulation, 9–10, 183, 187–188
A Report of the Surgeon General
274 Index
PATH study. See Population Assessment of Tobacco and
Health (PATH) study
product warnings, 206, 211t, 213t, 216t, 240–241
Sottera, Inc. v. U.S. Food and Drug Administration, 16, 241,
A4.2-2
tobacco product regulation, 9–10, 15–16
U.S. Pharmacopeia (USP), 114
U.S. Preventive Services Task Force, 206
U.S. Supreme Court, 9
U.S. Trade Representative (USTR), 189t
Us Weekly magazine, 159
V
V2cigs
plasma nicotine concentration, 103f
sales (2010–2014), 153f, A4.4-2 to A4.4-6t
Vape Holdings, Inc., A4.1-6t
Vape pens
components of, 12f
term usage, 3
Vape shops
clean indoor air, legislation, 225
e-cigarette sales, 14, 203
e-liquid mixing, 120
market for e-cigarettes in the U.S., 149, 150–151, 150t, 168–169
Vape tanks, components of, 12f. See also Tank devices (“mods”)
Vegetable glycerin (VG)
aerosol inhalation, 115
nose-only exposure to, 114
Vending machine sales, regulation, 203, 242
Visual processing, decits in, with maternal smoking, 110
Volatile organic compounds (VOCs), 118–119
VUSE e-cigarettes
distribution and purchase channels, 150
manufacturer, 15t
market share (2014), A4.5-5f
promotion of, 152, 153f, 158
website information, 165, 166, 166t
W
Warning labels
on e-cigarettes, 206, 211t, 213t
on rell bottles, 216t
on tobacco products, 240–241
Whites. See Race/ethnicity
WIC program, 190t
Withdrawal symptoms (physical abstinence syndrome)
conventional cigarettes, 102
e-cigarettes, A3.1-3 to A3.1-6t
Workplace exposure, e-cigarette aerosol, 123
World Health Organization (WHO)
indoor air quality, 122
position on ENDS, 219–220t
Tobacco Laboratory Network, 200t
X
Xylenes, aerosolized, 118–119
Y
Young adolescents, ages of, 4
Young adults. See also Surgeon General Call to Action
ages of, 4
awareness of consequences of e-cigarettes, 240
current prevalence of e-cigarette use, 37, 38t
e-cigarette use
intentions to use summary data, A2.3-20 to A2.3-22t
items from PATH, A2.2-10 to A2.2-15t
items from sources of national data, A2.2-5 to A2.2-19t
patterns of use summary data, A2.3-5, A2.3-23 to A2.3-37t
survey data sources, A2.1-4 to A2.1-5t
surveys, A2.1-3
susceptibility summary data, A2.3-20 to A2.3-22t
avors in e-cigarettes, 59, 60t
perceived harm of e-cigarettes, 64, 74t, 75
poly-tobacco use, 53, 53f, 54t
prevalence of e-cigarette use, 204, A2.3-3
Surgeon General’s reports focusing on, 4
trends in prevalence of e-cigarette use, 37, 40f
Youth. See also High school students; Surgeon General Call to
Action
access prevention policies, 203
advertising and marketing restrictions, 208t
ages of, 4
attention and cognition with nicotine exposure, 106
awareness of consequences of e-cigarettes, 240
current e-cigarette use, increase of, 10
current prevalence of e-cigarette use
ever use, 28, 29t, 30t
frequency of use, 28, 29t, 30t
past-30-day use, 28, 31t, 32t
susceptibility to use, 28, 29t, 30t
e-cigarettes, as most commonly used tobacco product, 5
e-cigarette use
higher than other tobacco products, 211t
intentions to use summary data, A2.3-20 to A2.3-22t
items from PATH, A2.2-10 to A2.2-15t
items from sources of national data, A2.2-5 to A2.2-9t
nicotine exposure effects, human studies, A3.1-8 to A3.1-17t
nicotine exposure effects, preclinical/animal studies,
A3.1-18 to A3.1-32t
patterns of use summary data, A2.3-4, A2.3-6 to A2.3-19t
survey data sources, A2.1-4 to A2.1-5t
survey descriptions, A2.1-2
susceptibility summary data, A2.3-20 to A2.3-22t
avored little cigars and cigarillos, 11
avors in e-cigarettes, 59, 60t
legislation to curb tobacco sales, 224
mood disorders with nicotine exposure, 107
nicotine, effects of, 104–107
perceived harm of e-cigarettes, 64, 73t, 74t
E-Cigarette Use Among Youth and Young Adults
Index 275
poly-tobacco use, cross-sectional studies of
current prevalence, 37, 40f, 41–42t, 43, 44t, 45t, 46f
trends in prevalence, 43, 47–48t, 49–50t, 51f, 52f, 53
prevalence of e-cigarette use, 204–205, A2.3-2 to A2.3-3
restricting access to e-cigarettes, 244–245
reward-seeking behaviors, 106
Surgeon General’s reports focusing on, 4
tobacco cessation services, 193t
trends in prevalence of e-cigarette use
ever use, 28, 33, 33f, 34t, 35t
past-30-day use, 31t, 32t, 36–37, 36f
Youth Risk Behavior Surveillance System (YRBSS)
overview and methods, A2.1-4 to A2.1-5
data for report, source for, 27
e-cigarette use
current prevalence, 28
patterns of use, 2015 survey, A2.3-2
sources of national data, A2.1-4 to A2.1-5t
YouTube
distribution and purchase channels, 150, 151
e-cigarette promotion, 166–167
e-cigarettes, 15
