What’s the best way to curb vaping, especially among adolescents and young adults?
Despite Food and Drug Administration (FDA) regulation, vaping is flourishing, with a steady stream of e-cigarette products finding their way into stores as well as into the hands, lungs, and bloodstreams of America’s youth. Vaping, it seems, is the new smoking for teenagers and young adults.
“E-cigarettes have taken over the youth tobacco use landscape. They are the most commonly used tobacco product,” said Thomas Carr, Director of National Policy at the American Lung Association (ALA), in an exclusive interview.
Although there is not yet data to show whether vaping is as harmful as cigarette smoking, substantial harms have been documented — enough to show that vaping poses a threat to human health, especially to the lungs and the heart.1
Given that February has been designated by the Centers for Disease Control and Prevention (CDC) as heart health month, this report looks at what is being done — and what could be done — to curb youth vaping.
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Taxation has worked well at reducing use in every other tobacco product, especially among youth. I feel pretty confident in saying it will reduce vaping rates.
“The [American Lung] Association is committed to reducing and eliminating use of e-cigarettes among youth users,” noted Carr. Moving forward, he added, the ALA is hoping to see:
- better FDA regulation and enforcement with respect to e-cigarettes;
- high levels of taxation on e-cigarettes;
- an end to the sale of flavored e-cigarettes (a measure that has been taken by only 5 states thus far);
- incorporating vaping into existing state tobacco-control programs;
- more media campaigns against e-cigarette use; and
- community education in schools about the dangers of vaping.
The American Heart Association (AHA) is similarly dedicated to curbing youth vaping, said Rose Marie Robertson, MD, AHA Science and Medical Officer, in an exclusive interview. “A comprehensive approach is needed to help reduce vaping among young people,” she said.
“We have heard from young people who recognize the dangers of vaping and their own addiction to these products, but don’t feel like they know the proper strategies to quit or even how to say no to e-cigarettes and other dangerous products to begin with,” said Robertson. “Therefore, our efforts focus on significant investments in research, youth engagement efforts, and support for schools to choose restorative rather than punitive approaches to students who vape,” she noted.
The AHA and the ALA are also united in their desire for better regulation and enforcement of vaping by the FDA and states.
Statistics on Youth Vaping
Although there has been “some decline since 2019” in the use of e-cigarettes, said Carr, “e-cigarettes remain the most commonly used tobacco product.”
CDC’s 2023 National Youth Tobacco Survey confirms that e-cigarettes are the most commonly used tobacco product by youth in the US. The 2023 survey found that 10% of high school students and 4.6% of middle school students used e-cigarettes. Notably:2
- 25.2% of current youth e-cigarette users used an e-cigarette product every day;
- 34.7% of youth e-cigarette users surveyed reported using e-cigarettes during at least 20 of the previous 30 days;
- 89.4% of youth users used flavored e-cigarettes; fruit flavors were most popular, followed by candy, desserts/other sweets, mint, and menthol;
- 57.9% reported using products with “ice” or “iced” in the branding;
- the most common e-cigarette devices used were disposables (60.7%) followed by prefilled/refillable pods (16.1%); and
- the most popular brands included Elf Bar (56.7%), Esco Bars (21.6%), Vuse (20.7%), JUUL (16.5%), and Mr. Fog (13.6%).
Taxation
One under-utilized strategy that may effectively curb the use of e-cigarettes by both youths and adults is heavy taxation — meaning taxation at the same level as cigarettes, said Carr.
Currently, there is no federal tax on e-cigarettes, and only 31 states and the District of Columbia have enacted excise taxes on vaping products.3 The level of taxation varies widely, with some surcharges hardly noticeable, said Carr.
According to the Tax Foundation, a nonprofit organization that researches tax policy in the US and elsewhere, methods used to tax vaping vary. “Authorities tax based on manufacturer, wholesale, or retail price (ad valorem), volume (specific), or with a bifurcated system that has different rates for open and closed tank systems,” noted a Tax Foundation blog on vaping taxes. “Of those that tax wholesale values, Minnesota levies the heaviest tax at 95 percent, followed closely by Vermont at 92 percent. On the other end of the spectrum, Connecticut levies a 10 percent wholesale tax and Wyoming applies a 15 percent wholesale tax.”
Other states levy a per mL tax. The states with the lowest per milliliter (mL) taxations are Delaware, Kansas, North Carolina, and Wisconsin, with a rate of $0.05 per mL. Louisiana has the highest rate per mL, after tripling this rate to $0.15 per mL in 2023, the blog noted.3
“Taxation has worked well at reducing use in every other tobacco product, especially among youth. I feel pretty confident in saying it will reduce vaping rates,” said Carr. “We’re still sorting through what completely works,” he added.
FDA regulation
The FDA is acutely aware of the dangers that e-cigarettes pose to youth. A focused segment of their Comprehensive Plan for Tobacco and Nicotine Regulation aims to prevent youth from accessing e-cigarettes and other tobacco products. The FDA has claimed that “significant regulatory and research efforts related to access, marketing, and education are already underway.”4
Regulation enforcement for e-cigarettes is a stated FDA priority. As former FDA Commissioner Scott Gottlieb, MD, said in a 2019 press release, “As the number of children using e-cigarettes remains at epidemic levels, our enforcement work has been one cornerstone of our efforts to protect youth from the dangers of tobacco products.” Gottlieb noted that the FDA had been involved in “vigorous enforcement efforts.” These included “a number of actions to combat the illegal sales of e-cigarettes to youth at brick-and-mortar and internet storefronts, as well as steps to target companies engaged in kid-friendly marketing that can increase the appeal of these products to youth,” and other actions “focused on both retailers and manufacturers.”5
In its Guidance for Industry issued in April 2020, the FDA laid out its enforcement priorities, announcing its intent to target any electronic nicotine delivery system (ENDS) product being sold after September 9, 2020, “for which the manufacturer has not submitted a premarket application.”6
FDA’s Guidance for Industry also stated that for products marketed “without FDA authorization, FDA intends to prioritize enforcement against: [1] Any flavored, cartridge-based ENDS product (other than a tobacco- or menthol-flavored ENDS product); [2] All other ENDS products for which the manufacturer has failed to take (or is failing to take) adequate measures to prevent minors’ access; and [3] Any ENDS product that is targeted to minors or whose marketing is likely to promote use of ENDS by minors.”6
ALA, AHA: More Regulation, Better Enforcement Needed
Although the ALA is pleased that the FDA has not approved any flavored tobacco products to date, the FDA hasn’t yet enforced against any of these products, said Carr, who noted that the ALA would like to see a ban on the sale of all flavored tobacco products.7
“The Lung Association has been dismayed at the delay with the FDA, although they have been making more progress recently. In some cases, the companies aren’t following the laws at all and selling products without premarket review. A lot of these products come from overseas so they’re hard to interdict — especially flavored disposable varieties,” said Carr.
Dr Robertson of the AHA echoed this sentiment. “While the FDA has fined retailers for continuing to sell unauthorized tobacco products, the agency must be given the proper resources to not only fund additional research on characterizing flavors, but also strengthen enforcement efforts to remove all illegal e-cigarettes from the marketplace,” she said.
“The [AHA] has continued to urge the Food and Drug Administration to complete its review of all e-cigarette product applications and we are working to ensure that state laws align with the federal minimum age for sale of tobacco products, which is 21,” she added.
E-Cigarette Smuggling
The smuggling of e-cigarettes across the border into the US complicates vaping regulation enforcement.7
“The Lung Association was pleased by the FDA announcement in May 2023 that e-cigarette products from several companies — Elf Bar, Esco Bar and Eon Smoke — were added to an FDA import alert red list with CBP [Customs and Border Protection] in order to be detained at the border without conducting a full inspection at the time of entry. Additional e-cigarette products have been added to the list,” stated the ALA’s State of Tobacco Control 2024 Report.7
“However, Elf Bar, the most popular e-cigarette with kids in 2023, was able to avoid enforcement initially by simply changing the name of its product, a disturbing loophole that needs to be closed. A recent US Department of Health and Human Services Inspector General report looked at FDA enforcement against retailers from 2010 to 2020, and found that FDA did not always follow through with more serious penalties such as civil monetary,” the ALA report continued.7
To date, the FDA and Customs and Border Protection have worked together to seize 1.4 million illegal cigarette products at the border, the report noted.7
The Manufacturers Strike Back
Taking a page from the litigation playbook of big tobacco companies, many e-cigarette manufacturers have filed lawsuits against FDA marketing denial orders for flavored e-cigarettes. The ALA has signed more than 20 amicus briefs with coalition partners in 2022 and 2023 asking courts to uphold these orders. To date, 6 of 8 US circuit courts have upheld these FDA marketing denial orders.7
In addition to leveraging litigation to fight to keep flavored e-cigarettes on retail shelves, manufacturers have kept on top of youth trends and interests when marketing their products to ensure sales. “They have proven expert at getting around regulations whenever they can by innovating their products,” Carr lamented.
Dr Robertson of the AHA agreed. “Big Tobacco and the vaping industry continue to foster addiction in younger generations by developing and marketing new tobacco products that appeal to youth and get them addicted.” This, of course, is nothing new, she added. “For decades, the tobacco industry has modified old products and created new ones to hook new users and keep them addicted, leading to tobacco use as a leading cause of preventable disease and death and a major risk factor in the development of heart disease and stroke.”
Second-Hand Vape
An issue of note that has yet to be talked about is the dangers of second-hand vape, said Carr. “Second-hand aerosol isn’t harmless,” he noted. This problem can be addressed by “adding e-cigarettes to smoke-free workplace laws that exist in a number of states … to prevent vaping in restaurants and other public places.”7
Public and Patient Outreach
Public outreach and education are imperative in the battle against rising rates of e-cigarette use in youth, said Carr. This includes efforts by clinicians, community education in schools, peer education on the dangers of tobacco and smoking, and the use of media campaigns.
One such media campaign is #DoTheVapeTalk.8 The American Lung Association (ALA) recently paired with the nonprofit Ad Council to launch this youth vaping awareness campaign, which involves a public service announcement showing how a dad talks to his teen about the dangers of vaping. #DoTheVapeTalk arms parents with the necessary facts to discuss the dangers of vaping with their kids “while they’re still willing to listen,” according to the ALA State of Tobacco Control 2024 report.7 Unfortunately, there is a paucity of youth-cessation resources like #DoTheVapeTalk, Carr noted.
“It’s vital that the harms and consequences of e-cigarettes and other addictive tobacco products be shared by trusted messengers, such as doctors and other health professionals, teachers, coaches and parents,” said the AHA’s Robertson. “But it is just as important that these influencers in young people’s lives specifically encourage them to quit and refer them to the proper resources and care to do so.”
Carr urged clinicians to take an active role in public and patient outreach. In particular:
- When seeing kids in the office, physicians should ask about tobacco use and vaping, assess their desire to quit, and refer to counseling.
- Pediatric pulmonologists can share stories about patients and vaping in the form of letters to the editor or community outreach.
- Clinicians can support public policy efforts.
This article originally appeared on Pulmonology Advisor
