Vaping and the use of e-cigarettes, especially among teenagers, has been in the news frequently in recent months. But what does the research-based evidence have to say about these new devices? I sat down with Jessica Pepper, PhD, MPH, a top published author in the field of e-cigarette research, to learn more about the prevalence of e-cigarettes, how they are regulated, and what research is available.
For the purpose of this interview, the terms “vaping product” and “e-cigarette” are used interchangeably.
Can you explain how e-cigarettes work?
E-cigarette is a shorthand term for a whole family of electronic vaping products that all basically work a similar way. Vaping products/e-cigarettes all contain a heating element that turns liquid into an aerosol which, depending on the type of vaping product, may or may not be flavored or contain nicotine. In addition, some vaping products allow the liquid to be re-filled by the user and some are a closed system that require a pod or cartridge of liquid. For those that require a pod or cartridge, the user wouldn’t interact with the liquid, they would just replace the pod/cartridge when needed.
What population or populations have the highest use of e-cigarettes?
Youth are the most frequent users of e-cigarettes, and their rates of use jumped dramatically in the past year.
In 2017, the National Youth Tobacco Survey reported 11.7% of high-school students currently use e-cigarettes (which means they used some kind of e-cigarette in the past 30 days), and this almost doubled in 2018 to 20.8%. E-cigarette usage is lower among middle school students, with about 5% reporting current use in 2018.
For adults (18+), the prevalence of e-cigarette usage is also lower. Depending on the source, current e-cigarette usage was about 3% in 2017.
Is “current use of e-cigarettes” defined differently between youth and adults?
Youth are considered a “current user” if they report using e-cigarettes once in the last 30 days. Adults are considered a “current user” if they report e-cigarette use as “every day or some days”. These differ because the definition applied to youth takes into account experimentation. It’s basically a lower bar for youth to be considered current users than it is for adults. We don’t want to miss those youth who have recently tried vaping but haven’t reached the point where they describe themselves as vaping “some days.”
Can you describe current regulations around e-cigarettes?
The FDA is responsible for regulating tobacco products, including e-cigarettes with nicotine, and there are some existing e-cigarette regulations such as not selling to youth, not advertising e-cigarettes as smoking cessation aids, and including a warning about nicotine. Further, in certain states or cities, the minimum age for purchasing tobacco/e-cigarette products has been increased to 21. So federally, the minimum age to purchase tobacco/e-cigarette products is 18, but in some locations, it might be 21.
Are there any upcoming or pending regulations around e-cigarettes?
The FDA recently announced a plan to implement additional regulations focusing on youth. These haven’t been implemented yet, but the potential regulations primarily focus on e-cigarette liquid flavors and age verification. In the past, any types of e-cigarette flavors could be sold to anyone that’s of the appropriate age.
The FDA is concerned sweet and fruity e-cigarette flavors that are easily available are a risk factor for youth vaping. Consequently, the FDA is proposing that only tobacco, menthol, and mint flavors would be easily accessible in stores. If your store wanted to sell flavors like strawberry or chocolate brownie, these need to be located in a restricted area of the store or located in a vape shop (where minors are unable to enter).
The other regulation proposed by the FDA is improved online age verification standards and increasing enforcement of age verification standards in stores. This would involve increasing the frequency of checks to ensure that stores are complying with age verification practices. Stores that aren’t complying would then be penalized if they sold e-cigarettes to an underage person.
Are there any other pending tobacco regulations that also might affect e-cigarettes?
The FDA is currently considering banning menthol cigarettes. However, if you take away menthol cigarettes but leave access to menthol flavored e-cigarettes, will people switch to e-cigarettes or will they quit smoking? The FDA is also considering reducing the amount of nicotine in cigarettes to a level not capable of sustaining addiction. If you do this, what will happen to e-cigarettes? Will people quit smoking, or will they start using e-cigarettes? These are regulations that will could definitely affect traditional tobacco products but might also affect e-cigarettes.
Understanding that youth vaping is a big issue, are there any other prevalent issues we should be aware of around e-cigarettes?
We don’t know if restricting flavors will keep youth from using e-cigarettes, or if it would affect adults. Is it important to have fruit or sweet e-cigarette flavors be available at all? Do adults need to have access to these flavors? The CDC’s website states that e-cigarettes could have potential benefit to smokers if smokers completely switch from smoking to vaping, but still reinforces that they aren’t safe. So, for adults, you don’t want to completely discourage e-cigarette use or totally restrict access to e-cigarettes if it can help them switch from traditional cigarettes or quit smoking. However, we don’t know if e-cigarettes really help adults quit smoking traditional cigarettes. The evidence on this topic is very mixed.
There are also newer products available now (commonly called fourth generation products or pod-mods) that are changing the landscape of how people use e-cigarettes and what type of e-cigarettes they use. These devices have specific characteristics that might make them more appealing and we just don’t know how this will change the overall landscape of vaping.
A type of vaping product in the news recently is Juul. Would Juul be considered an e-cigarette? If so, what’s the difference between Juul and e-cigarettes?
Juul is a type of vaping product/e-cigarette. There are a few distinct characteristics of Juuls, and one concern is that youth users are underreporting their vaping behavior because they don’t consider Juul to be a type of e-cigarette.
Juul has a pod-mod structure with a pre-filled pod of liquid that can be removed or changed as needed. One major difference between Juul and other e-cigarettes is the style of the device. Juul devices are more easily concealable and resemble a USB drive, whereas other e-cigarette devices are usually a little bigger. Another difference is Juul uses a liquid formulation of nicotine salts instead of free-base nicotine, which allows Juul to deliver a really strong hit of nicotine without a harsh taste.
How prevalent is Juul in comparison to other types of e-cigarettes?
This is a hard question, because data on the issue is just starting to become available. Depending on the population, rates of current use can very anywhere from 3% to 20%. We don’t know the prevalence; however, in just a few years, Juul went from not existing to having 78% of the e-cigarette marketplace [PDF]. There are also competitors who have seen how successful Juul is, so they are jumping on the bandwagon to create similar pod-mod devices that are easily refillable and use a nicotine salt liquid formulation.
Can you describe any of your recent research on youth use of e-cigarettes?
We just did a study [PDF] with youth and young adults in Florida, which found Juul use in the past 30 days to be about 13% among youth aged 15-17 and about 11% among young adults aged 18-24. In addition, among people who had never used Juul, 58% of youth and 42% of young adults were susceptible to Juul, meaning they expressed interest in trying Juul or using Juul in the future.
The research also looked at how youth and young adults got their Juul devices and refill pods. In the majority of cases, users obtained their devices and refill pods from sharing with others instead of purchasing. This is concerning, because even if the FDA implements stronger regulation at the point of sale for e-cigarettes, it might not help as much as we’d like with curtailing youth usage that stems from sharing devices.
Is there anything we haven’t already discussed that you wanted to share?
When we’re talking about e-cigarettes and vaping, we’re usually talking about vaping nicotine. There’s also vaping of hash oil and other forms of cannabis. However, there’s only a small amount of data on the prevalence of this, and it’s complicated because it is still illegal in about half of the states.
In addition, FDA can only regulate vaping products with nicotine, because FDA is only allowed to regulate “tobacco products”. Unless something has nicotine, it’s not considered a tobacco product. If you’re only vaping flavored liquid with no nicotine, FDA has no regulation over this. Youth often self-report that they are just vaping flavoring with no nicotine, but there’s mixed evidence about how accurate this is. For instance, Juul pods are only available with nicotine, so if someone is using a Juul pod, they’re using nicotine.
Finally, because the current data for adults isn’t as up-to-date as the data for youth, we don’t know if the spike we’ve seen in e-cigarette use between 2017 and 2018 is also happening for adults.
The author of this post would like to thank Jessica Pepper for taking the time to participate in the interview process.
Alexa Ortiz