The continuing investigation into the world of e-cigarettes
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Last Thursday, U.S. Surgeon General Dr. Vivek Murthy released a comprehensive report on e-cigarettes, identifying youth use of these products as “a major public health concern.” While there are still many unknowns about the long-term health risks of e-cigarette use, the surgeon general’s report lays out a compelling case for taking action now.

In short, youth e-cigarette use is increasing at an alarming rate, and we already know that exposing developing brains to nicotine from e-cigarettes can cause serious neurological harm including, but not limited to, lifelong addiction 

Despite the health risks from nicotine, heavy metals and other toxins that can pervade e-cigarette vapor, U.S. Food and Drug Administration (FDA) oversight only started to go into effect this August. The FDA announced its intent to regulate e-cigarettes in 2011, but it did not finalize a rule to extend its authority to e-cigarettes until more than five years later – and some of the major provisions in the FDA’s “deeming” rule do not take effect for another couple of years.  

Just this past week, the FDA postponed a requirement that e-cigarette companies register their products with the agency – meaning that it will be until at least mid-2017 before the FDA even knows what e-cigarette products are being sold. This pattern of delay has put a large number of young people at increased risk. 

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The Surgeon General's report must be heeded as a call to action—at the federal, state and local levels—to ensure e-cigarettes do not become the means for addicting a new generation of youth.

E-cigarettes, youth, and public health

The most popular way of consuming tobacco – smoking – is also the most deadly.  Most lung cancer cases—as many as 90 percent—are linked to cigarettes. Cardiovascular disease, respiratory disease, birth defects, and more than a dozen other cancers are all tied conclusively to smoking. In total, smoking causes nearly one in five U.S. deaths every year.

Less harmful alternatives to smoking are needed and welcome.  But the history of tobacco teaches these alternatives much be approached with caution.  (The example of so-called “light” cigarettes provides a cautionary tale.) 

Nicotine, though extremely addictive, is not the most harmful component of smoking.  Thus, delivering “clean” nicotine in a way that is more effective than existing nicotine gums and patches could help current smokers to quit more easily.  However, nicotine has a powerful ability to alter the developing mind, and is therefore particularly dangerous for youth. In addition to deepening addiction, an emerging body of research suggests that early nicotine exposure may predispose youth to several mental disorders or illnesses including depression, anxiety, and schizophrenia. Moreover, several recent studies suggest that adolescents are transitioning from e-cigarettes to more harmful combustible cigarettes once addicted to nicotine. 

Thus, it matters how e-cigarettes are sold and who is using them.  When e-cigarettes first appeared in the United States a decade or so ago, they were sold in mall kiosks and often cost more than $100 for a device and rechargeable battery.  At that point, youth use was not much of a concern.  But today, e-cigarettes are sold in nearly every convenience store, in addition to thousands of vape shops, and disposable e-cigarettes can be cheaper than a pack of cigarettes.  E-cigarettes today are much easier to use, and they are available in thousands of kid-friendly flavors (like “banana cream pie” and “cinnamon bun”).  And, in recent years, the major tobacco companies have put their marketing muscle behind e-cigarette brands.  It is no wonder then that the percentage of high school students that used e-cigarettes in the past month skyrocketed from 1.5 percent in 2011 to 16 percent in 2015. 

History repeating itself?

By the time Americans realized there was a health problem with cigarette smoking, the industry was fantastically wealthy, had effective marketing in place and was able to mount a comprehensive public relations strategy. The Surgeon General’s landmark 1964 report on smoking and health received only cautious support from President Lyndon Johnson, who was concerned about the political fallout from taking on Big Tobacco. And it was not until 45 years later that Congress finally granted the FDA authority to regulate tobacco.

Although the FDA can now regulate tobacco, it is extremely challenging for it to do so effectively.  Beyond the political obstacles, there is simply no easy way to reduce the use of a product that is heavily addictive and is regularly used by more than 35 million people.

One lesson from this experience is that is far easier to set clear rules to protect public health before an addictive product is in wide circulation. That is what has made the FDA’s delay in regulating e-cigarettes so frustrating.

Already, some in Congress are seeking to weaken or eliminate the FDA’s nascent regulation of e-cigarettes.  That would be an unfortunate step backwards.  As the surgeon general said in a public service announcement released alongside the report, “Your kids are not an experiment.”  Eliminating FDA oversight would leave our kids as the unwitting subjects of a wide-scale, unregulated experiment in the long-term effects of adolescent e-cigarette use. My colleagues at The Ohio State University Comprehensive Cancer Center and numerous colleges across the broader university are working diligently to study e-cigarette use and its effects, specifically in youth.  But given what we already know about nicotine and brain development, why would we ignore this “major public health concern”? 

Lessons learned?

There is still time to learn from past mistakes and chart a new path forward.  Recently, with co-author Y. Tony Yang of George Mason University, I published an article in JAMA Pediatrics that calls on the FDA to take further steps to regulate e-cigarettes before more damage is done. Specifically, there must be a concerted effort to address the flavors and marketing that appeal to children and teens. With a new administration arriving in January, leadership at FDA will likely change — but these measures should remain a priority.

It is also imperative that states and local jurisdictions take on greater responsibility counter e-cigarette use by minors and young adults. One immediate step that state and local governments can take is limiting the sale of tobacco products, including e-cigarettes, to adults over the age of 21, as more than 200 communities around the country have already done.  Because in most places e-cigarettes are available to anyone 18 or older, even high school seniors can purchase them, simplifying wide distribution to teens.  Raising the age to 21 makes it much more difficult to for teens to obtain e-cigarettes, and we know if that use can be delayed beyond the high school years, it is far less likely to occur.

Today, my home city of Columbus, Ohio intends to pass its own law prohibiting the sale of all tobacco products, including e-cigarettes, to people under the age of 21. I'm hopeful it will have broad impact in our state and inspire others. E-cigarette risks may be new, but as the surgeon general’s report makes clear, we now know enough to take action.

Micah Berman is a member of The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute’s Cancer Control Research Program. He holds a joint appointment with The Ohio State University Moritz College of Law and the College of Public Health. His research explores the intersection between public health research and legal doctrine, with a focus on tobacco policy. 

The views expressed by contributors are their own and not the views of The Hill.