Electronic Cigarettes

The electronic cigarette (e-cigarette) is an increasingly popular, aggressively marketed battery powered nicotine delivery system, which is rapidly increasing its niche among adolescents and youth.1 By 2012, an estimated 1.78 million students had used an e-cigarette and a significant number reported concurrent other tobacco use.2 The most recent Monitoring the Future survey reported that e-cigarette use surpassed the use of tobacco cigarettes for the first time since e-cigarette introduction in 2007.3 A cross-sectional analyses of middle and high school students who completed the National Youth Tobacco Survey found that e-cigarette use was associated with higher odds of cigarette smoking and lower odds of abstinence from conventional cigarettes.4

Youth are being increasingly targeted through advertisements 5 and by specific product design such as flavored e-cigarettes. In addition to marketing, peer modeling, access through acquaintances, and parental use have influenced adolescent e-cigarette use.6

Nicotine exposure during adolescence is associated with behavioral and neurochemical changes along with continued engagement in tobacco and other drug use. Further, it is clear that tobacco-naïve adolescents are initiating nicotine exposure with e-cigarettes. Adult and adolescent tobacco users view these devices as less hazardous than conventional tobacco cigarettes and as a cessation aid; on-line interest in e-cigarettes has surpassed the established and empirically tested tobacco cessation treatments.7,8 In particular, this perception of decreased risk is related to increased use. The World Health Organization has urged e-cigarette manufacturing companies to cease the claims regarding therapeutic benefits as they have not been empirically tested.9 The Food and Drug Administration (FDA) has proposed extending its regulatory authority over these devices which would result in age restrictions and examination of claims of reduced harm.10 Though some states have implemented restrictions on e-cigarette sale to minors, these devices are largely unregulated, easily available over the Internet and increasingly being used to administer other substances.

The consequences of the increasing use and acceptance of e-cigarettes were recently reflected in a concerning Centers for Disease Control and Prevention (CDC) report documenting a considerable number of e-cigarette exposure related telephone calls made to poison centers.11 The e-cigarette exposures were mostly among young children and youth, and were reported as inhalations, eye contact, and skin exposures. The safety of these devices has not been scientifically demonstrated and they have been found to contain respiratory irritants, carcinogens, and other volatile organic substances with unknown chronic exposure outcomes.12,13,14,15 There are no requirements to which the manufacturers of e-cigarettes must adhere and no established consumer safety practices, such as listing ingredients and producing consistent products with uniform concentration and defined maximum doses of nicotine.

The rising popularity, low risk perception, and aggressive marketing of e-cigarettes may have long-lasting implications for adolescent nicotine use and the well-known associated lifelong morbidity and mortality.

As child and adolescent mental health advocates, the American Academy of Child and Adolescent Psychiatry (a) supports FDA regulation of electronic cigarettes; (b) supports utilization of empirically tested and evidence-based treatments to achieve tobacco cessation outcomes; (c) advocates vigorous education regarding adolescent e-cigarette use, including early identification and cessation interventions; and (d) advocates restriction of e-cigarette advertisements on television, print media, and Internet, similar to other tobacco products.

References

  1. Etter JF, Bullen C, Flouris AD, et al. Electronic nicotine delivery systems: a research agenda. Tob Control. 2011; 20(3):243-248.
  2. Centers for Disease Control and Prevention. Notes from the Field: electronic cigarette use among middle and high school students. MMWR Morb Mortal Wkly Rep. 2013 Sep 6; 62(35); 729-730
  3. http://www.monitoringthefuture.org/data/14data.html#2014data-cigs. Accessed February,8,2015.
  4. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among U.S. adolescents: a cross-sectional study. JAMA Pediatr. 2014 Jul;168(7):610-7.
  5. Duke JC, Lee YO, Kim AE, et al. Exposure to electronic cigarette television advertisements among youth and young adults. Pediatrics. 2014 Jul;134(1):e29-36. doi: 10.1542/peds.2014-0269. Epub 2014 Jun 2.
  6. Anand V, McGinty KL, O’Brien K, et al. E-cigarette Use and Beliefs Among Urban Public High School Students in North Carolina. Journal of Adolescent Health (In Press)
  7. Choi K, Forster J. Characteristics associated with awareness, perceptions, and use of electronic nicotine delivery systems among young US Midwestern adults. Am J Public Health. 2013; 103(3):556-561. 
  8. Ayers JW, Ribisi KM, Brownstein JS. Tracking the rise in popularity of electronic nicotine delivery systems (electronic cigarettes) using search query surveillance. Am J Prev Med. 2011; 40(4):448-453.
  9. Cho JH, Shin E, Moon SS. Electronic-cigarette smoking experience among adolescents. J Adolesc Health. 2011; 49(5):542-546.
  10. http://www.fda.gov/downloads/TobaccoProducts/GuidanceComplianceRegulatoryInformation/UCM394914.pdf Published April 25, 2014. Accessed February 8, 2015
  11. Chatham-Stephens K, Law R, Taylor E et al. Centers for Disease Control and Prevention (CDC). Notes from the field: calls to poison centers for exposures to electronic cigarettes--United States, September2010-February2014. MMWR Morb Mortal Wkly Rep. 2014; 63(13):292-293.
  12. http://www.theunion.org/what-we-do/publications/official/body/E cigarette_statement_FULL.pdf Published October, 2013. Accessed December 5, 2014.
  13. https://www.fda.gov/safety/medical-product-safety-information/medwatch-safety-alerts-human-medical-products Published July 22, 2009. Accessed December 5, 2014.
  14. Cobb NK, Byron M J, Abrams D B, Shields P G. Novel nicotine delivery systems and public health: the rise of the "e-cigarette." Am J Public Health.2010; 100(12): 2340-2342
  15. Jensen RP, Luo W, Pankow JF, et al. Hidden formaldehyde in e-cigarette aerosols. N Engl J Med. 2015 Jan 22;372(4):392-4. doi: 10.1056/NEJMc1413069.

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The American Academy of Child and Adolescent Psychiatry promotes the healthy development of children, adolescents, and families through advocacy, education, and research. Child and adolescent psychiatrists are the leading physician authority on children’s mental health.

Approved by Council June 2015