Considerable declines in cigarette smoking have occurred among US high school students over the past two decades: smoking declined from 30% in 2000 to 6% in 2019.1 However, e-cigarette use has increased substantially over the past decade, with current use among high school students increasing from about 1% in 2011 to nearly 28% in 2019.1 This increase was of greater magnitude in recent years, which coincided with the growing popularity of cartridge-based e-cigarettes known as “pod mods,” including those made by Juul, the market leader since 2017.2 These newer products use nicotine salts, which allow higher levels of nicotine to be inhaled more easily and with less irritation than the free-base nicotine used in earlier e-cigarettes. Nicotine is an addictive drug that can harm adolescent brain development and prime the brain for addiction to other drugs.3

The increase in youth e-cigarette use has been driven by multiple factors, including advertising, high nicotine content, and the availability of flavors that appeal to youths.3 Youths report that flavors are a primary reason they use e-cigarettes, and most youth e-cigarette users first initiate use with flavored products.4 Among youth e-cigarette users in 2019, 70% reported using flavored varieties, making e-cigarettes the most common flavored tobacco product used among youths.1

Under authority from the 2009 Family Smoking Prevention and Tobacco Control Act (FSPTCA), the Food and Drug Administration issued a policy in January 2020 that prioritized enforcement against certain unauthorized cartridge-based e-cigarette flavors that appeal to youths, including fruit and mint. The policy was informed by available data, including from (1) a study of high school students that found the most commonly reported flavors used by current exclusive e-cigarette users were fruit (66%) and menthol or mint (57%),5 and (2) a study that assessed mint and menthol separately that found that among current Juul users in 8th, 10th, and 12th grades, the self-reported use of mint-, mango-, and other fruit–flavored e-cigarettes was greater than the use of tobacco- or menthol-flavored e-cigarettes.6 The FSPTCA does not preempt states and localities from adopting more restrictive regulations than the federal standard in some instances. Accordingly, several communities have restricted flavored e-cigarette sales, including menthol; additionally, Massachusetts and New Jersey have enacted legislation prohibiting all flavored e-cigarette sales, and beginning in late 2019, seven other states issued executive or emergency actions to temporarily prohibit flavored e-cigarette sales, some of which were overturned after legal challenges (www.tobaccofreekids.org/assets/factsheets/0398.pdf).

Evaluation of these policies is critical to ascertain their impact on youth e-cigarette use. Such studies will also be important to identify any potential unintended consequences, including transitions to other tobacco products, e-cigarette types, or flavors excluded from some policies. In addition to annual self-reported surveys of youths, subannual assessments—including retail sales data from commercial databases and self-reported data from existing or newly developed Web panels—can quickly inform policy refinements that may be warranted to best protect public health.

We are at the precipice of a critical period in the history of tobacco control. Cigarette smoking has declined, but this progress has been offset by increased youth e-cigarette use.1 The situation has been compounded by the recent outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI), which has mostly affected young adults and is strongly linked to vitamin E acetate in tetrahydrocannabinol-containing products from informal sources.7 Although both the EVALI and youths’ use epidemics have warranted urgent public health action, efforts to address each must focus on their drivers.7 To effectively combat the youth e-cigarette epidemic, efforts at the national, state, and local levels are critical to make flavored e-cigarettes less acceptable, accessible, and appealing to youths.3 It is important that such efforts are part of a comprehensive approach alongside other evidence-based population-level strategies.3

See also Dasgupta and Fiala, p. 759, and the AJPH After FDA Vaping Guidance section, pp. 771789.

CONFLICTS OF INTEREST

The author has no conflicts of interest to declare.

References

1. Centers for Disease Control and Prevention. Tobacco product use and associated factors among middle and high school students—United States, 2019. MMWR Surveill Summ. 2019;68(12):122. CrossrefGoogle Scholar
2. King BA, Gammon DG, Marynak KL, Rogers T. Electronic cigarette sales in the United States, 2013–2017. JAMA. 2018;320(13):13791380. Crossref, MedlineGoogle Scholar
3. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services; 2016. Google Scholar
4. Ambrose BK, Day HR, Rostron B, et al. Flavored tobacco product use among US youth aged 12–17 years, 2013–2014. JAMA. 2015;314(17):18711873. Crossref, MedlineGoogle Scholar
5. Cullen KA, Gentzke AS, Sawdey MD, et al. E-cigarette use among youth in the United States, 2019. JAMA. 2019;322(21):20952103. CrossrefGoogle Scholar
6. Leventhal AM, Miech R, Barrington-Trimis J, Johnston LD, O’Malley PM, Patrick ME. Flavors of e-cigarettes used by youths in the United States. JAMA. 2019;322(21):21322134. CrossrefGoogle Scholar
7. King BA, Jones CM, Baldwin GT, Briss PA. The EVALI and youth vaping epidemics—implications for public health. N Engl J Med. 2020;382(8):689691. Crossref, MedlineGoogle Scholar

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Brian A. King, PhD, MPHBrian A. King is with the Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta, GA. “Flavors Are a Major Driver of the Youth E-Cigarette Epidemic”, American Journal of Public Health 110, no. 6 (June 1, 2020): pp. 773-774.

https://doi.org/10.2105/AJPH.2020.305670

PMID: 32374696