| Introduction After barely a decade on the market, electronic cigarettes have transformed the nation's smoking landscape. Now a $5.6 billion business, the vaping industry has disrupted the tobacco marketplace and reversed years of declining smoking trends, creating what health officials call an epidemic of use among teens. The Food and Drug Administration (FDA) began regulating e-cigarettes as tobacco products in 2016 but delayed full implementation of its rules until at least 2021, allowing sales to continue while awaiting FDA approval. E-cigarettes — which deliver the nicotine smokers crave without the toxins of burning tobacco — have split public health officials. Some consider the devices safer than regular cigarettes and an aid to those trying to quit smoking. Others, noting that e-cigarettes deliver a highly concentrated form of nicotine, say the devices are creating a new generation of nicotine users who may move on to traditional cigarettes. E-cigarettes are not approved as a smoking cessation device, and research remains unclear about their long-term safety. Meanwhile, cannabis vaping is catching on among marijuana users. 
Nick Gregory, 26, uses a Juul vaping device in Lexington, Ky. Public health officials are debating whether e-cigarettes are a useful smoking cessation device but are also creating a new generation of nicotine users who may turn to traditional cigarettes in the future. (Getty Images/Lexington Herald-Leader/Charles Bertram) | Go to top Overview Charlotte started smoking at age 13. By high school, she was looking for a way to quit. That's when she turned to electronic cigarettes — specifically to Juul, a small nicotine-delivery device that resembles a flash drive, which has become so popular among teenagers that federal health officials are investigating the company's marketing practices amid what they call an epidemic of underage e-cigarette use. Once she started using Juul (pronounced “jewel”) about a year ago, Charlotte — not her real name — says she was able to kick traditional cigarettes. “For me, the e-cigarette thing was a huge lifesaver because it's just an awful thing to need to smoke cigarettes everywhere you go,” says Charlotte, 18, who asked that her real name not be used because she is still in high school. Using e-cigarettes, also known as “vaping,” gave her the chance to “be better.” She even works in a local vape shop. 
A vaping shop in Los Angeles displays ads for a panoply of e-cigarettes in September 2018. Federal health officials have warned that the use of the products by teens has reached “epidemic” levels. (AFP/Getty Images/Mark Ralston) | The use of Juul and other e-cigarettes has accelerated rapidly since they entered the U.S. market in 2007, particularly among teens such as Charlotte. While traditional cigarette smoking among American adults is at the lowest level ever recorded, use of e-cigarettes has reversed years of declines in teen smoking and disrupted the market for traditional cigarettes. E-cigarettes pose a conundrum that has bitterly divided the public health community. One side argues that e-cigarettes offer a potential public health benefit because they can help people quit or reduce smoking traditional cigarettes — which remain the country's leading cause of preventable disease and death, killing an estimated 480,000 people and costing more than $300 billion annually in health care expenses and lost productivity, according to the federal Centers for Disease Control and Prevention (CDC). Critics counter that these same devices could create a new generation of nicotine users who may be more likely to use traditional cigarettes in the future. They also express concern over e-cigarette users who continue to smoke; almost six in 10 e-cigarette users were in this category in 2015, the CDC said. “This is literally the perfect definition of a double-edged sword,” says Michael Siegel, a public health researcher at Boston University who previously worked in the CDC's Office of Smoking and Health. Initially skeptical about e-cigarettes, he now sees them as a key tool for reducing cigarette smoking. E-cigarettes heat a liquid form of nicotine to produce a vapor that is inhaled. While researchers have scrambled to study e-cigarettes' long-term health effects, they have said the devices are likely to be far less harmful than conventional cigarettes that burn tobacco. But e-cigarettes are not risk-free. They contain and emit potentially toxic substances, including nicotine itself, which is also highly addictive. And the liquid nicotine often is flavored with added chemicals, which critics contend attracts underage users. Federal law defines e-cigarettes as tobacco products because they are derived from tobacco, and the U.S. Food and Drug Administration (FDA) has been regulating them since 2016. The FDA and other federal health agencies have intensified their scrutiny in the past year, driven largely by concern over the increase in teen use, as well as questions about the long-term effects of vaping and the safety of vaping devices. Several states and hundreds of localities have passed laws to tax and regulate e-cigarettes, including by raising the legal age for purchasing all tobacco products from 18 to 21. Measures to raise the federal tobacco age to 21 are under consideration in Congress. Because e-cigarettes are so new, research into their health effects, general safety and usefulness as a smoking cessation tool is still preliminary. But their use continues to grow — and tobacco companies have invested in the technology to counter declining sales of traditional cigarettes. The FDA initially viewed e-cigarettes as a potential tool to help cigarette smokers quit, like nicotine-replacement options such as patches, gum or lozenges. But last year, a survey revealed a 78 percent increase between 2017 and 2018 in high school students who reported current e-cigarette use. More than 3.6 million middle and high school students reported they had used e-cigarettes in the past 30 days, including 4.9 percent of middle schoolers and 20.8 percent — one in five — of high schoolers, according to the federal government's annual National Youth Tobacco Survey. The share of high school students who used e-cigarettes exceeded 20 percent last year, more than 13 times the level in 2011. The share of middle school users increased eightfold between 2011 and 2018. Source: U.S. Centers for Disease Control and Prevention Data for the graphic are as follows: | Year | Percentage of High School Students Using E-Cigarettes | Percentage of Middle School Using E-Cigarettes | | 2011 | 1.5% | 0.6% | | 2012 | 2.8% | 1.1% | | 2013 | 4.5% | 1.1% | | 2014 | 13.4% | 3.9% | | 2015 | 16% | 5.3% | | 2016 | 11.3% | 4.3% | | 2017 | 11.7% | 3.3% | | 2018 | 20.8% | 4.9% | Those numbers triggered public health officials' declaration that teen use of e-cigarettes had become an epidemic. U.S. Surgeon General Jerome M. Adams issued an advisory in December emphasizing the importance of “protecting children from a lifetime of nicotine addiction and associated health risks by immediately addressing the epidemic of youth e-cigarette use.” The FDA responded by cautioning e-cigarette companies not to market to teens, issuing warning letters and fines to retailers selling to underage buyers, launching a public education campaign and threatening to pull flavored vaping products off the market. The agency took specific aim at Juul, demanding documents about its marketing practices and conducting a surprise inspection at the company's San Francisco headquarters in October to seize material. “These products are on the market today only because the FDA exercised what is called enforcement discretion, thereby allowing them to be sold without official authorization,” wrote Health and Human Services Secretary Alex M. Azar and then-FDA Commissioner Scott Gottlieb. “The agency thought the potential upside of e-cigarettes for adults merited their availability to the public before receiving the required marketing authorization. But the FDA had not accurately anticipated the upsurge in e-cigarette use by the young.” Most of the increase can be attributed to Juul, which began selling its products in 2015. The company's share of the $5.6 billion vaping market exceeds 70 percent, based on the dollar value of sales, far outpacing rivals such as Blu and Vuse, and analysts expect total e-cigarette sales to reach $9 billion this year. In December, the country's biggest tobacco company, Altria Group Inc., whose products include Marlboro cigarettes, spent $12.8 billion for a 35 percent stake in Juul, resulting in a $38 billion valuation for the 3-year-old startup. (See Short Feature.) The Juul device's small size allows adult smokers trying to quit to be discreet, but it also lets underage smokers be surreptitious. Students can easily hide the sleek devices, and the vapor has little smell, which means kids are vaping — or “Juuling” — in restrooms, hallways and classrooms. “It kind of caught us off guard because we weren't necessarily prepared to deal with what was to come,” says Jenny Sexton, a substance abuse counselor in Arlington County, Va., schools, where e-cigarette devices have been banned. She and her colleague Mila Vascones-Gatski first noticed an uptick in use in 2017. “By the end of last year, this had really intensified more significantly than we had anticipated,” says Sexton. It is not unusual for students to consume one or two Juul “pods” — replaceable cartridges of e-liquids — a day, each pod containing about the same amount of nicotine as a pack of 20 traditional cigarettes, says Vascones-Gatski. “So you're talking about a young person — 15, 16 years old — using the amount of nicotine in two packs of cigarettes,” she says. “The addiction is very high. I'm working with kids right now in my high school. They can't stop.” The situation is similar at Charlotte's high school in Prince William County, Va., where she is a senior. “I can go to the bathroom and find someone that's doing it anytime I want,” she says. “I've literally made friends just from people asking me in the bathroom, ‘Hey, is it OK if I hit it? I don't have mine on me.’” But she also thinks Juul's popularity may have peaked. Younger students are attracted to the brand, she says, but older students, including herself, realize it is an expensive habit and switch to cheaper options. The Juul device typically costs about $35, plus about $16 for a four-pack of pods. By comparison, Njoy sells a “starter kit” containing a device and four pods for $17.98. The cost of a pack of 20 traditional cigarettes in March ranged from an average of $5.25 in Missouri and Virginia to $12.85 in New York. E-cigarette devices come in a variety of sizes and types, but all work by heating a liquid — usually containing nicotine, flavorings and other chemicals — to produce an aerosol that users inhale. The devices also can be used to consume marijuana and other drugs. Gregory Conley, president of the American Vaping Association, an industry advocacy group, was a dedicated smoker who had tried to quit with nicotine-replacement products. But nothing worked, he says — until he tried vaping. “I got my first real good e-cigarette in a watermelon flavor,” he says, “and quit smoking immediately.” Conley estimates he is among at least 2.5 million American smokers who have used e-cigarettes to quit traditional cigarettes, based on a study published by the American College of Physicians. Conley says threatening the availability of products that have helped people “is not a rational trade-off” to protect teens who obtain the products illegally. “This is a crisis for adult smokers and adults who have switched to these products,” he says. “Public health is about reducing death and disease. It's not a morality play.” Iowa Attorney General Tom Miller, who worked to reach a 1998 landmark civil settlement between states and tobacco companies, argues that when teens were smoking traditional cigarettes at rates higher than current e-cigarette use, the government did not declare an epidemic, but took steps to lower smoking rates. Miller, who led a panel advising Juul on preventing underage use of its products as part of a $30 million education initiative by the company, thinks a similar approach could work now. “You have 34 million adult smokers, and you have about a million kids that are frequent users, so it's a ratio of 34 to 1,” he says. “And the harm is death for the adults, addiction for the kids. So in any kind of public health analysis, e-cigarettes are potentially and currently a public health plus — and fairly dramatically so.” But others counter that the regulatory balance must tip in favor of young people. “In order to take steps to narrow and close down the ‘on ramp’ for kids when it comes to e-cigarettes, it could come at the price of the access to the ‘off ramp’ for adults,” says Mitch Zeller, director of the FDA's Center for Tobacco Products. As regulators, lawmakers and scientists discuss the pros and cons of e-cigarettes, here are some of the issues they are debating: Are e-cigarettes a safe alternative to regular cigarettes? Although the number of smokers has been dropping in recent years, cigarettes remain the No. 1 cause of preventable death and disease in the United States, according to the CDC, and shave 10 years off a current smoker's average life span, according to one study. Many of the health problems caused by smoking are linked to combustion. The smoke of a burning cigarette contains more than 7,000 chemicals, including at least 250 known to be harmful and 69 that cause cancer. The toxins include hydrogen cyanide, carbon monoxide and ammonia. With that in mind, researchers agree it is not hard for a product to be less harmful than cigarettes on what health officials call “the continuum of risk.” E-cigarettes are safer than traditional cigarettes, says Brian King, deputy director for research translation in the CDC's Office on Smoking and Health, “but that also doesn't mean that they're safe.” For smokers trying to quit traditional cigarettes, the possible benefits of e-cigarettes as a path to stop smoking outweigh their risks. “We have the potential to really change people's lives and do it in a very dramatic way,” says Mark Anton, executive director of the Smoke-Free Alternatives Trade Association, another vaping industry group. But just how safe e-cigarettes are remains unclear. Their primary benefit is that, without the combustion, they do not produce the tar or toxic gases found in cigarette smoke. The fluids that go into the devices, known as e-liquids, consist of nicotine and flavorings dissolved in propylene glycol and glycerol, which are then vaporized so they can be inhaled. Globally, experts hold varying views about e-cigarettes that reflect this uncertainty over their safety. Public Health England, the British government's health information agency, maintains vaping is 95 percent safer than smoking and promotes it as an alternative. But the World Health Organization, a United Nations agency, initially said e-cigarettes should not be touted as a way to quit smoking because there is “no scientific evidence to confirm the product's safety and efficacy.” The group later adopted a report calling for further study that said e-cigarettes “represent an evolving frontier, filled with promise and threat for tobacco control.” A 2018 report from the U.S. National Academies of Sciences, Engineering and Medicine surveyed 800 peer-reviewed scientific studies to provide a comprehensive look at the health effects of e-cigarettes. That report found “conclusive evidence” that most e-cigarette products “contain and emit numerous potentially toxic substances” in addition to nicotine, although at lower exposure levels than with traditional cigarettes. Ultimately, more research is needed, the report concluded. “E-cigarettes cannot be simply categorized as either beneficial or harmful,” said David Eaton, a professor of environmental and occupational health sciences at the University of Washington, Seattle, and one of the editors of the National Academies study. 
E-cigarette pods in fruity flavors are displayed in a Chicago store in September 2018. Critics of e-cigarettes say the fruit flavors are calculated to appeal to underage users. (Getty Images/Scott Olson) | Many studies focus on e-cigarettes' key ingredient, nicotine. While it does not cause cancer as do other components of traditional cigarettes, nicotine is as addictive as heroin or cocaine, and is delivered in concentrated doses via e-cigarettes. It is toxic to developing fetuses and can harm adolescent brain development. Because e-cigarettes are so new, long-term data on their health impact is lacking. But emerging studies have found potential links between e-cigarettes and diseases of the heart and lungs as well as changes in DNA that could lead to cancer. “The more we learn, the worse they look,” says Stanton Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco. “In the end, they're probably going to turn out to be about as bad as the cigarette.” Research has found evidence that e-cigarette vapor may have significant “pulmonary toxicity” — in other words, may cause lung damage. But scientists say more studies are needed about the components of the e-liquids that generate the vapor. There are also concerns about ingredients used in the thousands of flavorings that are added to some e-liquids. While many of these flavorings are approved for use in foods and cosmetics, it is unclear whether they are safe when inhaled. In particular, the chemical diacetyl, used to give microwave popcorn its buttery taste and often added as a flavoring to e-liquids, has been shown when inhaled to cause a bronchial condition known as “popcorn lung.” This causes coughing, wheezing and shortness of breath, similar to the symptoms of chronic obstructive pulmonary disease (COPD). Other research found chemical flavorings can react with e-liquids to create new compounds that could trigger irritation and inflammation when inhaled. “The long-term effects of these chemicals on the airways are unknown,” said Hanno Erythropel, a Yale University research scientist who co-authored one such study. In April, the FDA announced it is investigating nearly three dozen cases of people experiencing seizures after vaping. While a link has not been clearly established, officials said the cases warrant concern. But the officials also said the benefit of e-cigarettes may outweigh the risks for adult cigarette smokers. “While we believe that currently addicted adult smokers who completely switch off of combustible tobacco and onto e-cigarettes have the potential to improve their health, e-cigarettes still pose health risks,” Gottlieb and FDA Principal Deputy Commissioner Amy Abernethy said in a statement. Siegel, the Boston University researcher, goes even further in advocating e-cigarette use to quit smoking. “Based on the scientific evidence, there is no question in my mind that vaping is orders of magnitude safer than smoking,” he says. The mixed messages about the safety of e-cigarettes are affecting public perception. A recent study by researchers at Georgia State University and three other institutions found the proportion of U.S. adults who perceived e-cigarettes as equally or more harmful than traditional cigarettes increased substantially from 2012 to 2017. The study's authors, who worry this perception will keep smokers from switching to e-cigarettes, argued there was a need to differentiate between the “absolute harm” of combustible cigarettes and the “relative harm” of e-cigarettes. In addition to the health concerns, liquid nicotine can cause poisoning. After a spike in calls to poison control centers between 2010 and 2014 linked to e-cigarettes, including at least one child death, Congress passed legislation requiring e-liquids and vaping devices to be sold with child-resistant packaging. The lithium ion batteries used in vaping devices also pose a risk. Although it is uncommon, they can explode or ignite, with “devastating and life-altering” consequences, according to the federal U.S. Fire Administration. Between 2009 and 2016, the agency found 195 media reports of incidents of explosion and fire, most of which occurred when a device was in use or in a pocket. Since then, there have been at least two deaths attributed to e-cigarette explosions. There are currently no federal standards for manufacturing the devices. Are e-cigarettes the most effective way to break smoking addiction? Proponents of e-cigarettes, including former smokers and product manufacturers, contend the devices can help people quit traditional cigarettes. That is exactly what Hon Lik, the Chinese pharmacist who invented the modern version of e-cigarettes, had in mind when he came up with his idea for delivering nicotine without the smoke in the early 2000s. He had started smoking at 18 and wanted to find a way to quit. “I found nicotine patches, and used those for a while, but they were not really helping,” he said. “This was the turning point. I decided to use my knowledge to develop an alternative product.” Hon's device ultimately helped him switch from traditional to electronic cigarettes, and similar anecdotes abound from other former smokers. But scientific research about e-cigarettes' effectiveness as a smoking cessation tool remains less clear. 
Hon Lik, creator of the modern e-cigarette, uses his invention in 2009. Hon created the device to help quit smoking traditional cigarettes. E-cigarettes' effectiveness for smoking cessation is unclear, and the FDA has not approved them for that purpose. (AFP/Getty Images/Frederic J. Brown) | The FDA has not approved e-cigarettes as a method to help stop smoking, but those trying to kick the habit use these products more frequently than cessation aids such as patches, gum and lozenges that do have FDA approval. The U.S. Preventive Services Task Force, a group of health experts that makes recommendations about preventive health care, has concluded that “the current evidence on the use of [e-cigarettes] for conventional smoking cessation is insufficient” to recommend them. The CDC's King echoes that sentiment, saying that the current state of the science is inconclusive on whether e-cigarettes are effective for helping smokers quit. Although e-cigarettes have been commonly used in attempts to stop smoking, research comparing their effectiveness with that of FDA-approved nicotine-replacement products has been limited and the results have been mixed. Some studies have found e-cigarettes made quitting easier; others have found they were not helpful. In January, a British study found e-cigarettes were significantly more effective for smoking cessation than nicotine-replacement therapy when both products were accompanied by behavioral support. After one year, 18 percent of those randomly assigned to use e-cigarettes had abstained from smoking, compared to 10 percent of those assigned other nicotine-replacement products. But there was a caveat. After one year, 80 percent of the e-cigarette users were still using the devices, while only 9 percent of those who had employed the other replacement options were still using them. The study, published in The New England Journal of Medicine, was the first randomized trial to test the effectiveness of modern e-cigarettes vs. nicotine-replacement products. An accompanying editorial recommended using e-cigarettes only when FDA-approved treatments fail. It also called for using the lowest possible dosage of nicotine, which can vary in e-cigarettes, and establishing a timeline for ending use of the devices. Research indicates certain products, such as Juul and similar devices that deliver the nicotine smokers crave more efficiently, may be more effective than others, says the CDC's King. But recommending those products as cessation devices would require balancing the potential benefit for adult smokers with the potential harm for underage vapers. While devices such as Juul may be effective in delivering nicotine to adults for cessation, King says, “that also means that they can be very effective at delivering nicotine to kids and resulting in initiation and subsequent addiction.” While it is possible research could eventually show e-cigarettes to be an effective method for quitting smoking, he says, “in the current environment, we're simply not seeing the potential benefit of cessation outweigh the risks to youth.” King and other researchers also worry about the dual use of e-cigarettes and traditional cigarettes among those who reduce, but do not completely quit, smoking. Those people continue to suffer the proven health damage caused by traditional cigarettes and also expose themselves to the potential health effects of e-cigarettes. “The overall exposure to some of those compounds is higher in dual users than for someone who is only smoking cigarettes,” says the FDA's Zeller. Researchers are trying to understand whether a period of dual use is a transitional interval away from cigarettes — or, says Zeller, “is it what I've been calling the new normal, where they're actually less interested in quitting cigarettes because now they have the best of both worlds. They can light up a cigarette where it's still OK to light up a cigarette, and they can vape where it's not. And along the way have a diminished interest in quitting cigarettes.” Robert K. Jackler, a professor at the Stanford University School of Medicine and an expert in tobacco marketing, says the effect of dual use is insidious: “What that does is keep their nicotine level continuously high and actually deepens their addiction.” Conley, of the American Vaping Association, counters that any reduction in traditional cigarette use is a positive outcome. “There is no silver bullet,” he says. “It's about maximizing the number of adults you can get to quit smoking.” Should e-cigarette advertising be regulated like that of traditional cigarettes? When Juul launched in 2015, the company made a splash with a promotional campaign as stylized as the device itself. With the theme “Vaporized,” Juul ran ads in magazines and on billboards that emulated the tobacco ads of a previous era. The ads featured young, vibrant models wearing bright, fashionable clothes, and were fueled by social media and hashtag campaigns that critics say were aimed at young consumers. The company has since shut down its U.S. Facebook and Instagram pages, and all its U.S. advertising now features adults talking about switching from smoking to vaping. Juul, known for vaping devices that resemble computer flash drives, has enjoyed skyrocketing demand. The company's U.S. sales rose from fewer than 50,000 units in 2015 to almost 14 million in 2018. Source: U.S. Centers for Disease Control and Prevention, based on Nielsen data Data for the graphic are as follows: | Date | Total E-Cigarette Sales | Altria | British American Tobacco | Imperial Tobacco | Japan Tobacco | Juul Labs | Other | | 2013 | 4,482,043 | 16,395 | 86,056 | 1,885,872 | 549,175 | Not Available | 1,944,544 | | 2014 | 6,591,800 | 508,857 | 2,642,316 | 1,285,184 | 635,013 | Not Available | 1,520,430 | | 2015 | 6,622,916 | 490,935 | 3,378,706 | 1,070,616 | 558,361 | 45,318 | 1,078,980 | | 2016 | 8,396,764 | 1,781,273 | 3,470,966 | 1,240,849 | 738,894 | 307,340 | 857,441 | | 2017 | 10,653,871 | 2,233,588 | 3,084,130 | 1,301,782 | 851,863 | 2,275,110 | 907,398 | | 2018 | 23,247,111 | 2,204,106 | 3,101,901 | 2,011,458 | 1,012,589 | 13,970,580 | 946,477 | But the critics contend e-cigarette companies, illustrated most prominently by the Juul ads, are following the same script as Big Tobacco, which spent decades portraying smoking as part of a healthy, fashionable lifestyle. A team from a project founded by Jackler, Stanford Research Into the Impact of Tobacco Advertising, analyzed ads on Juul's website, social media accounts and emails to customers, including many images the company has since removed. “In many senses, in its promotional practices Juul has faithfully recapitulated the playbook of traditional cigarette marketers,” the study concluded about Juul's advertising. “Juul's transition from disruptive upstart into a mainstream tobacco company is increasingly evident.” Juul officials have said their initial campaign was ill advised and short-lived and that they do not want their product in the hands of minors. James Monsees, one of the company's co-founders, said selling Juuls to youths was “antithetical to the company's mission.” The other co-founder, Adam Bowen, said the company had tried to make the devices “as adult-oriented as possible,” purposely eschewing cartoon characters or candy names for its flavors. Last year, amid the increasing government scrutiny, the company overhauled its website, which now features testimonials from adults who used the product to switch from traditional cigarettes. Underage use of Juul “is an issue we desperately want to resolve,” Monsees said last year. “It doesn't do us any favors. Any underage consumers using this product are absolutely a negative for our business. We don't want them. We will never market to them. We never have.” It has been nearly 50 years since the last cigarette ad appeared on U.S. television, in 1971. The Marlboro Man and his cohorts signed off after Congress banned cigarette advertising on radio and television, following a landmark 1964 Surgeon General report linking smoking to cancer. In 1998, new rules increased restrictions on tobacco advertising. They banned ads on transit systems and billboards and prohibited cartoons, paid product placement, sponsorships of sporting events and concerts and marketing practices aimed at anyone under 18. 
A classic Marlboro Man billboard promotes smoking, before such displays were banned in 1998. Cigarette ads once widely touted smoking as part of a healthy, fashionable lifestyle. (Getty Images/Corbis Historical/Robert Landau) | But those regulations do not apply to electronic cigarettes, even though the FDA regulates them as tobacco products. E-cigarette companies have advertised on TV previously, including Blu, which featured celebrity Jenny McCarthy, and Njoy, which ran a Super Bowl ad in 2012 that critics said was glamorizing e-cigarettes. In January, Juul announced plans for a $10 million national television and radio campaign featuring testimonials from former smokers urging others to “make the switch.” As part of its 2015 launch, Juul also distributed free devices at movies and music events, activities off limits to traditional tobacco companies. The company “exploited social media, where American middle and high school kids live,” Jackler said. “That was their innovation.” Pointing to the rise in underage vaping, Federal Communications Commission (FCC) Commissioner Jessica Rosenworcel, a Democrat, has called for oversight, citing the FCC's “long history of regulating the advertising of cigarettes on radio and television.” “When it comes to marketing them, in many ways, it is still the wild, wild West,” she wrote. Rosenworcel also called for the FCC to coordinate with the Federal Trade Commission to assess e-cigarette advertising and whether it is deceptive. “We do not need to sit idly by while the electronic equivalent of the Marlboro Man surfaces in new advertising that introduces the next generation to habit-forming tobacco products,” she said. “Instead, we can refresh the tools that served public health in the past.” FCC Commissioner Brendan Carr, a Republican, has been skeptical about whether there is a role for the FCC to play, saying the agency does not have “a roving mandate to police speech in the name of the ‘public interest.’” “Censoring lawful speech based on its content? I'm with the First Amendment. I'm a no,” Carr tweeted in response to Rosenworcel. Several studies have examined the impact of e-cigarette marketing on minors. They found that an increasing number of middle and high school students have been exposed to e-cigarette ads in stores, online and on television; that teens who are receptive to the ads are more likely to try both e-cigarettes and traditional cigarettes; and that tobacco products are being marketed and sold through unpaid content on Facebook. The effect of advertising on teens is significant because health officials are trying to determine whether e-cigarettes offer underage users a gateway to future use of traditional cigarettes. Research has found some linkage between teen vaping and later cigarette smoking. The report by the National Academies found that among youths — who it found use e-cigarettes at higher rates than the 5 percent of adults who do — “there is substantial evidence that e-cigarette use increases the risk of transitioning to smoking conventional cigarettes.” In contrast to its early advertising, Juul's television ads, expected to air this summer, are 60-second spots featuring former smokers ages 37 to 54 talking about how they switched from cigarettes to Juul. “It's clear that we're focused on the mission of the company to convert people off combustible cigarettes,” said Ann Hoey, Juul's vice president of marketing. This campaign, she added, is “an honest, straight down the middle of the fairway, very clear communication about what we're trying to do as a company.” Go to top Background From Native Americans to Cigarette Production The history of tobacco in the Americas dates to 6000 B.C., when Native Americans began cultivating the plant for use in religious ceremonies and for medicinal purposes. A member of the Nicotiana genus and nightshade family, tobacco has about 70 varieties, with Nicotiana tabacum the most widely cultivated for commercial purposes. Following the arrival of European explorers, tobacco use and cultivation spread worldwide. Jamestown settler John Rolfe, who would marry the Native American Pocahontas, established tobacco as a cash crop crucial to the colony's growing economy. By the 1700s, African slaves were working on tobacco plantations and the first tobacco companies opened in Virginia. In 1880, James Albert Bonsack invented a cigarette-rolling machine, revolutionizing production of cigarettes and leading to their mass marketing. Industrialist James Buchanan Duke licensed the machine's use, and his American Tobacco Co. soon controlled 90 percent of the U.S. tobacco market. In a 1911 antitrust ruling, the U.S. Supreme Court ordered the monopoly to dissolve, splitting it into four companies: R.J. Reynolds, Lorillard, Liggett & Myers and American. Tobacco grew so much in popularity and acceptance that when U.S. soldiers headed off for World Wars I and II, their rations included cigarettes. After World War II, cigarette companies began advertising heavily on television. Ads for major brands routinely included positive, health-related statements; endorsements from physicians, athletes and celebrities; and products aimed at women, minorities and young people. However, health studies as early as 1939 began to link cigarette smoking with cancer and heart disease. By the end of the 1950s, all states had prohibited the sale of cigarettes to minors. “If it has not been proved that tobacco is guilty of causing cancer of the lung, it has certainly been shown to have been on the scene of the crime,” Dr. Charles S. Cameron, medical and scientific director of the American Cancer Society, wrote in the January 1956 issue of The Atlantic. Landmark Surgeon General's Report In the 1960s, smoking remained a widely accepted practice. In a TED Talk in March, the FDA's Zeller recounted how smoking was so normalized that children, including himself, made ashtrays as gifts for their parents. “This was at a time when almost one in two adults in the United States smoked,” he said. 
U.S. Surgeon General Luther Terry holds a copy of his office's landmark 1964 report that definitively linked smoking to lung cancer and heart disease. The report led to warning labels on cigarettes and congressional action to limit cigarette advertising. (Getty Images/Bettmann) | But questions about the safety of cigarettes continued. Zeller cited internal documents from that time showing industry officials were well aware of the addictive and potentially carcinogenic nature of their product. In July 1963, the top lawyer for Brown & Williamson, then the third-largest U.S. cigarette company, wrote in a confidential internal memo: “Nicotine is addictive. We are, then, in the business of selling nicotine, an addictive drug.” Five months after that document was written, on Jan. 11, 1964, U.S. Surgeon General Luther Terry released the report that definitively linked smoking to lung cancer, emphysema, bronchitis and cardiovascular diseases. As a result, Congress passed: The Federal Cigarette Labeling and Advertising Act of 1965, which required the first warning on cigarette packaging: “Caution: Cigarette Smoking May Be Hazardous to Your Health.” The Public Health Cigarette Smoking Act of 1969, which prohibited cigarette advertising on television and radio. The final TV cigarette ad — a Virginia Slims spot aimed at women that proclaimed, “You've come a long way baby” — aired at 11:50 p.m. on Jan. 2, 1971, during “The Tonight Show Starring Johnny Carson,” just before the ban took effect at midnight. Early E-Cigarette Prototypes During this same era, a Pennsylvania man filed for a patent for the first electronic cigarette — in 1963, a year before the Surgeon General's report. Herbert A. Gilbert, a two-pack-a-day smoker, received the patent in 1965 for a “smokeless nontobacco cigarette,” a cylindrical device that closely resembled the modern e-cigarette. In a 2013 interview, he said he had decided that combustion was the problem, so he set out “to find a way to put out the fire.” “I had to find a way to replace burning tobacco and paper with heated, moist, flavored air,” he said. The result was a battery-powered heat source that operated much like contemporary devices. However, it produced tobacco-flavored air, rather than vapor, and contained no nicotine. Gilbert never found a company to manufacture his invention. “I showed it to chemical companies, pharmaceutical companies and tobacco companies, and they did what they did to try to protect their markets,” he said. Throughout the 1970s and '80s, more research was conducted into the health effects of smoking and nicotine. In 1976, British psychiatrist and researcher Michael Russell published a widely cited article about the role of nicotine in cigarette addiction, advocating harm reduction techniques that would allow smokers to rely on alternative forms of nicotine without the damaging effects of burning tobacco. “People smoke for nicotine, but they die from the tar,” Russell wrote. “Their risk of lung cancer and bronchitis might be more quickly and effectively reduced if attention were focused on how to reduce their tar intake, irrespective of nicotine intake.” But it wasn't until 1988, when U.S. Surgeon General C. Everett Koop released his office's 20th report on the effects of smoking on health, that nicotine was designated an addictive substance and tobacco use defined as an addiction. The report concluded that nicotine is as addictive as heroin and cocaine. The FDA approved the first pharmacologic aid for smoking cessation, nicotine gum, in 1984. Since then, additional products have been approved, such as patches and lozenges, which all contain nicotine. Smokeless Cigarette Options During the 1980s, another predecessor to the e-cigarette was marketed by Advanced Tobacco Products of San Antonio, Texas. The smokeless cigarette, known as Favor, was the brainchild of NASA engineer and computer pioneer J. Philip Ray, a three-pack-a-day smoker. Ray and co-founder Gerald R. Mazur positioned Favor as an alternative for smokers to use where they could not light up a traditional cigarette. (As the dangers of secondhand smoke became known, restrictions limiting smoking in public places, government buildings and airplanes had begun in the 1970s.) The Favor looked like a regular cigarette, a plastic tube with a nicotine-soaked plug at the end. It was not electronic, but the nicotine was vaporized as it was inhaled through the tube with no combustion or smoke. Although sold in several states, the product soon ran into trouble. Because the liquid nicotine evaporated quickly and developed a bitter taste, it had a short shelf life. In addition, the FDA considered it an unapproved new drug and threatened to take action against the company. Ultimately, the technology was sold to a Swedish company. However, the developers of the Favor cigarette made a lasting contribution: They were the first to use the terms “vaping” for using their products and “vapers” for the users. In 1988, R.J. Reynolds Tobacco briefly marketed a different type of smokeless cigarette, known as Premier. While it was more like a traditional cigarette than an electronic cigarette, with a small piece of burning carbon at one end, opposition to the product mirrored some of the current concerns about e-cigarettes. The American Medical Association contended it should be considered a “new and hazardous system intended to deliver the drug nicotine,” urging the FDA to regulate it as such. Ultimately, Reynolds pulled the product from the market because consumers did not like it. The arguments within the public health community over how to deal with so-called safer cigarette products such as Premier foreshadowed the current split over e-cigarettes. Columbia University public health researchers summarized the debate: “The issue before us is stark: Will a commitment to limiting the toll exacted by smoking preclude the tolerance of a product that while not safe may possibly be safer?” In 1991, Russell, who first identified nicotine's addictiveness, criticized the “misguided” opposition to Premier cigarettes, noting that Reynolds was still allowed to sell its “more lethal conventional cigarettes” to smokers. “There is only one fight,” he said, “and that is against tobacco and tobacco-related disease.” During the 1990s, the federal government intensified its efforts to regulate the tobacco industry. In a watershed event in 1994, company executives testified before Congress, denying under oath that nicotine was addictive, that smoking caused cancer and that the companies were marketing tobacco products to minors. But shortly after their testimony, whistleblowers began leaking internal documents that showed the companies had known for decades that nicotine was addictive and had purposely marketed cigarettes to minors. The documents also revealed the companies dedicated significant resources toward developing a “safer” cigarette — including research into e-cigarettes. Philip Morris had been working since 1990 on what would become its e-cigarette technology. By 1994, the company had developed an aerosol generator that embodied basic e-cigarette technology, which would be marketed nearly two decades later as the MarkTen e-cigarette. In November 1998, the four largest tobacco companies — Philip Morris, Reynolds, Lorillard and Brown & Williamson — reached the landmark Master Settlement Agreement, the largest civil litigation settlement in U.S. history. It settled cases brought by 46 states, the District of Columbia and five U.S. territories. The agreement required the companies to pay the plaintiffs billions of dollars in perpetuity to offset the cost of tobacco-related health care. It also imposed new restrictions on tobacco advertising, restrictions that do not apply to e-cigarettes. E-Cigarettes Hit the U.S. Market The modern e-cigarette evolved from a bad dream, caused by a continuous stream of nicotine that flowed into Hon Lik after the pharmacist forgot to remove his nicotine patch before bed one night in 2001. The experience helped him realize the patch was inadequate as a smoking cessation measure because its steady stream of nicotine did not provide the rush smokers crave. Both Hon and his father were heavy smokers, so the incident prompted him to experiment with a noncombustible nicotine-delivery method. “I believed that if I could use vapor to simulate cigarette smoke, this could help me,” Hon said. In 2003, Hon patented a device that used a heating element to vaporize liquid nicotine, which was then inhaled. The invention came too late for his father, who died from lung cancer in 2004. That same year, Hon's invention hit the market in China, sold by the company Ruyan, whose name means “like smoke.” In 2005, Ruyan began exporting e-cigarettes. In 2007, Ruyan products entered the U.S. market. Hon now works with the parent company of Blu e-cigarettes and believes his invention can help smokers. “My real passion, like many other inventors, is to leave some trace behind,” he said. In 2009, Congress enacted a measure commonly known as the Tobacco Control Act, which gave the FDA authority to regulate the manufacturing, distribution and marketing of tobacco products. That same year, the FDA seized an imported shipment of e-cigarettes, calling them unapproved drug devices. Two distributors sued, and a federal judge agreed, saying they should be regulated as tobacco products rather than medical devices. Forgoing an appeal, the FDA drafted plans to regulate e-cigarettes under the Tobacco Control Act. The agency announced those regulations in 2016. They restricted e-cigarette sales to those age 18 or over and required a warning label that reads: “This product contains nicotine. Nicotine is an addictive chemical.” The regulations also required manufacturers of tobacco products introduced after Feb. 15, 2007 — including e-cigarettes — to submit applications showing the products meet public health standards to receive FDA marketing authorization. The original deadline for those applications was 2018. The manufacturers of e-cigarette devices and liquids, most of which are small businesses, contended the cost of meeting the regulations would put them out of business. “The only companies that are going to be able to remain are the tobacco companies, ironically, because they're the only ones that have the resources … [to fund] the research that's going to be required to put these applications together,” says Siegel, of Boston University. In July 2017, after Gottlieb had taken the helm, the FDA announced a new comprehensive tobacco plan and postponed implementation of the 2016 regulations, allowing e-cigarettes on the market as of Aug. 8, 2016, to remain on sale while awaiting FDA approval. The deadline for the applications was extended to Aug. 8, 2022. Gottlieb said the delay would help the FDA strike “an appropriate balance between regulation and encouraging development of innovative tobacco products that may be less dangerous than cigarettes.” Vaping industry officials praised the decision for providing the industry more time to meet the new requirements, while anti-smoking advocates criticized the move and ultimately sued the agency, saying the delay puts consumers at risk. Go to top Current Situation FDA Reacts Government officials are moving on several fronts to address the rising rate of teen e-cigarette use. Lawmakers are proposing legislation aimed at reversing this trend, and the FDA is speeding up its review process for e-cigarettes. 
FDA Commissioner Scott Gottlieb talks about teen vaping in March, shortly before he stepped down. During his tenure, Gottlieb sought ways to limit teenagers' growing use of e-cigarettes. (Getty Images/Mark Wilson) | Beginning in 2018, as teen use of e-cigarettes continued to increase, the FDA launched an escalating series of actions, beginning with a crackdown on underage sales of e-cigarettes that the agency said have become “wildly popular with kids.” In April 2018, Gottlieb announced a Youth Tobacco Prevention Plan and said the FDA would conduct undercover sting operations to prevent sales to minors, including warning letters and civil penalties for retailers. The FDA also took the first in a series of actions aimed at Juul, sending a letter demanding the company turn over internal documents about marketing and research. It later sent similar letters to other e-cigarette manufacturers. In September 2018, Gottlieb said youth e-cigarette use had reached “epidemic proportions.” At the time, five brands comprised 97 percent of the U.S. market: Juul Blu, owned by Fontem Ventures, a subsidiary of British-owned Imperial Brands, which also owns Imperial Tobacco Logic, owned by Japan Tobacco Inc. MarkTen, owned by Altria, which also owns Philip Morris USA (MarkTen has since been removed from the market.) (See Short Feature.) Vuse, owned by R.J. Reynolds Vapor Co., whose parent company is owned by British American Tobacco The FDA gave those five companies 60 days to explain how they would address the youth vaping problem, threatening to pull their flavored products from the market if they could not keep their products away from minors. The role of flavors in underage e-cigarette use has been a source of controversy and ongoing research for years. E-liquids come in thousands of flavors, including many fruit and candy varieties, that critics say are aimed at young people. But some adults contend the wide variety of flavors has helped them quit smoking. The FDA also issued more than 1,300 warning letters and fines to retailers that it said illegally sold e-cigarette products to minors during the agency's undercover blitz. It issued additional warnings to retailers that sold or advertised e-liquids in packaging that resembled “kid-friendly food products such as candy and cookies.” And it began an educational campaign, including through social media, aimed at underage users. Later in September came the FDA's seizure of more than 1,000 Juul documents related to the company's sales and marketing practices. The surprise action at Juul's headquarters was necessary, the FDA said, “to understand and address the particular appeal of, and ease of access to, these products among kids.” Kevin Burns, Juul's CEO, issued a statement saying the company had turned over more than 50,000 documents since the April request and was committed to working with the FDA to prevent underage use of its products. Gottlieb also held a series of meetings with leaders of Juul and the other four companies, characterizing it as a “constructive dialogue” in which they acknowledged the public health issues associated with youth vaping and offered a range of proposals to confront it. Juul Responds In November, the FDA and CDC released the survey results showing a “startling rise” in the number of middle and high school students using e-cigarettes. With the FDA planning to unveil new restrictions on sales of flavored e-liquids, Juul beat the agency to the punch by announcing Nov. 13 that it would stop selling several popular flavors — mango, cucumber, creme and fruit — in stores, limiting them to online sales. Juul also said it would shut its U.S.-based social media accounts on Facebook and Instagram and add stricter age-verification tools to its website. “We don't want anyone who doesn't smoke, or already use nicotine, to use Juul products,” Burns said. “We certainly don't want youth using the product. It is bad for public health, and it is bad for our mission.” Two days later, the FDA announced its plan to restrict minors' access to most flavored e-cigarettes, limiting sales of flavored nicotine pods and liquids to websites, vape shops and other retailers that impose age restrictions, but stopping short of banning the products entirely. Notably, the proposal does not restrict mint and menthol flavors, an omission criticized by anti-smoking advocates. In December, Altria announced it would stop selling its e-cigarette brand and was buying a 35 percent stake in Juul. As a result, the top five e-cigarettes are either owned by or affiliated with tobacco companies. In March, the FDA outlined how it would implement and accelerate the review process for e-cigarettes to receive market approval. The agency proposed moving the deadline to submit applications up one year to Aug. 8, 2021. Gottlieb, who made e-cigarettes a defining issue of his tenure, announced in March he would resign as FDA commissioner. On April 5, Norman E. “Ned” Sharpless, former director of the National Cancer Institute, became acting commissioner. In his first comments as FDA head, Sharpless said he would continue working to reverse the “growing epidemic” of youth e-cigarette use and “maintain FDA's current course of action in every area and proceed full speed ahead.” Dave Dobbins, chief operating officer for the tobacco control group Truth Initiative, gives the FDA mixed reviews. “We've loved the vision, and we've loved the fact that people are spending political capital in this area,” he says. “We're dismayed that we haven't moved beyond the proposal stage to actually getting the rules in place.” Senators Urge Swift Action While the FDA has pursued its measures, members of Congress also have called for addressing the issue of underage vaping. In March, Sens. Dick Durbin, D-Ill., and Lisa Murkowski, R-Alaska, reintroduced legislation that would limit the sales of e-liquid flavors unless manufacturers can prove they help adults stop smoking without inducing minors to use their products. The bill has two House co-sponsors, Reps. Diana DeGette, D-Colo., and Jamie Raskin, D-Md. “I'm concerned that powerful e-cigarette companies are winning the war for our children's health and well-being,” said Durbin, who has long been involved in legislative efforts to curtail underage e-cigarette use. In October, the two senators wrote to the FDA, urging it to immediately ban “kid-friendly” e-cigarette flavorings and restrict online sales of nicotine products. Rep. Duncan Hunter, R-Calif., who used vaping devices to quit smoking, takes a different approach. By puffing his e-cigarette during committee hearings to prove a point, he has earned the nickname “the vaping congressman.” Hunter introduced a bill in 2017 to rescind the FDA's authority to regulate e-cigarettes. “The reason I vape is simple: It's so I don't smoke cigarettes,” he wrote. “I vape knowing that I'm not inhaling tobacco. Most importantly, I vape because I believe it could save my life.” The Trump administration's fiscal 2020 budget proposal calls for $100 million in new user fees on manufacturers and importers of e-cigarette devices and liquids. The proposal would ensure that the FDA, whose Center for Tobacco Products is funded entirely by user fees, “has the resources to address today's alarming rise in youth e-cigarette use as well as new public health threats of tomorrow,” the budget plan said. States Enact Regulations With final implementation of FDA's proposed e-cigarette rules years away, state and local lawmakers have stepped in to regulate and tax e-cigarettes. The CDC's King says states and communities play a crucial role in formulating policies that can percolate from the bottom up, ultimately influencing federal regulation. “That's really been the bread and butter of tobacco control for years,” he says. While all states have age restrictions for purchasing e-cigarettes, many are raising the minimum age to buy all tobacco products to 21 — with support from the tobacco and vaping industry. Studies have shown that most smokers started before age 21. Currently, 12 states — Arkansas, California, Delaware, Hawaii, Illinois, Maine, Massachusetts, New Jersey, Oregon, Utah, Washington and Virginia — have raised the tobacco age to 21. In addition, 450 localities have done so, including New York City, Boston, Chicago, Cleveland, San Antonio, Minneapolis and Washington. On Capitol Hill, Senate Majority Leader Mitch McConnell, R-Ky., said he would introduce legislation in May to raise the nationwide minimum age to buy tobacco products from 18 to 21, with an exemption for members of the military. The plan is supported by Altria, Juul and British American Tobacco, maker of Vuse. Altria Chairman Howard A. Willard has called efforts to raise the age to 21 “the most effective action to reverse rising underage e-vapor usage rates and in this we are aligned with public health and tobacco control officials.” Meanwhile, jurisdictions are taking other steps to regulate e-cigarettes, including: Eleven states and the District of Columbia tax vaping products. Six states impose an excise tax on consumers while the other five and D.C. tax wholesalers. Thirteen states, plus the District of Columbia and two territories, include e-cigarettes in their clean air laws, prohibiting use in venues designated as 100 percent smoke-free such as workplaces, restaurants, bars, hotels, and colleges and universities. An additional 14 states and one territory bar them in specific venues, such as schools. In addition, 841 cities and counties restrict e-cigarettes in smoke-free venues. More than 30 states have banned or restricted e-cigarette sales through vending machines or self-service displays. Go to top Outlook New Products Coming As the FDA continues implementing regulations for e-cigarettes, several issues remain on the horizon, including a new category of tobacco products and a proposal for reducing the nicotine content in traditional cigarettes to nonaddictive levels. Later this year, new survey data will be released showing rates of e-cigarette use. If the data show use continuing to rise, the FDA's timetable for regulatory action could be accelerated, Zeller says. “If there is another spike in kids' use of e-cigarettes, then we will have to reconsider our most recent policy proposals to see if other options need to be explored,” he says. Siegel, of Boston University, fears that regulation born of a belief that “nicotine itself should be prohibited, that anything that looks like smoking is bad” could result in the country squandering an opportunity to use the new technology of vaping products “to put the final nail in the coffin” of cigarette smoking. “This is a bellwether,” Siegel says. “This is a critical time.” While e-cigarettes are the current technology, the landscape is evolving. Products that heat rather than burn tobacco are on the verge of entering the U.S. marketplace. This so-called heat-not-burn technology “is distinct from e-cigarettes because it doesn't heat a liquid, it actually heats [the] tobacco plant itself, which many believe will give a harder hit to the user and be more appealing than some of the e-cigarettes that have entered the landscape,” says the CDC's King. King puts these products in the middle of the risk spectrum, less dangerous than traditional cigarettes but more perilous than vapor products. After receiving FDA approval in 2018, R.J. Reynolds plans to test its Eclipse tobacco-heating device among U.S. consumers, planning a full market launch this year. Philip Morris International received FDA approval in April to sell its IQOS tobacco-heating device in the United States. It is currently is available in 44 other countries. It will be distributed by Altria, the parent company of Philip Morris USA, under the Marlboro brand, with sales expected to begin this summer. Zeller said that while the authorization does not mean these new products are safe, the agency considers them “appropriate for the protection of the public health” and that it is likely current smokers would use them to transition away from traditional cigarettes. The agency also attached stringent marketing restrictions to prevent underage use. Market analysts predict the sales of such “reduced risk” products will grow as the technology evolves. “Bottom line, we expect more and more consumers to convert to next generation reduced risk platforms,” said Bonnie Herzog, an analyst for Wells Fargo Securities. Miller, the Iowa attorney general, says he foresees an “enormous transition from combustible to e-cigarettes over the next five years or so, with the possibility of changing very dramatically smoking as we know it in America today and the loss of life that comes with it.” Meanwhile, the FDA is in the process of formulating regulations for a long-term initiative to require traditional cigarette makers to lower the nicotine content in their products to minimally addictive or nonaddictive levels. The idea would be to use nicotine reduction in traditional cigarettes as a way to move smokers from conventional cigarettes to less harmful nicotine-delivery products, such as e-cigarettes or nicotine-replacement therapies. “Smoking rates could drop from the current 15 percent to as low as 1.4 percent,” said Gottlieb, who announced the initiative. “All told, this framework could result in more than 8 million fewer tobacco-caused deaths through the end of the century — an undeniable public health benefit.” Jackler, who has devoted much of his medical career at Stanford to studying tobacco issues, says if such a concept could be implemented, the ramifications “would be transformative, absolutely transformative.” Go to top Pro/Con Pro
Resident Scholar, American Enterprise Institute; Lecturer, Yale University School of Medicine. Written for CQ Researcher, May 2019 | The Food and Drug Administration (FDA) is actually doing too much to regulate e-cigarettes. While concern over youth use is indeed warranted, the agency's overall strategy threatens access to e-cigarettes for adult smokers. E-cigarettes are a great public health advance, intended for smokers who cannot or will not give up nicotine. Vapers inhale nicotine via a propylene glycol-based and/or glycerin-based aerosol estimated to be at least 95 percent less hazardous than conventional cigarettes, which burn tobacco and release carcinogens and carbon monoxide. A recent, rigorous study reported that “vaping” was twice as effective as FDA-approved nicotine replacements (patches, gum, lozenges) in helping smokers quit cigarettes for one year. Unfortunately however, the FDA's premarket regulations are needlessly burdensome. They require every electronic cigarette product on the market (the devices and the liquids that give them taste and vapor) to be accompanied by a separate application to the FDA showing that the product is beneficial to the public's health. To do this successfully, a company must show that its e-cigarette product is safer than regular cigarettes; that it helps smokers to quit; and that the above benefits won't be outweighed by the adoption of the product by nonsmokers, including young people. To satisfy this last requirement alone — the so-called population effects — long-term clinical and epidemiological studies are likely to be required. According to the FDA itself, the cost of processing these applications — dozens to hundreds from each company — will take more than 5,000 hours to complete and cost a minimum of $330,000 per product. This extremely high cost will almost surely limit applicants and thereby protect actual cigarettes upon which the agency, per congressional mandate, can impose no approval requirements. A far better approach would entail product quality standards, reminiscent of the United Kingdom's approach. A compendium of agency-issued rules should establish prudent vapor battery and electrical standards that prevent overheating of the charger, explosion, etc., along with restrictions that ban potentially harmful ingredients. Recently, the FDA has devoted enormous attention to the rise in youth use of Juul, a vaping device. Doubtless, teen use is an unwanted development, but the agency has fomented alarm, absent meaningful evidence of harm to date (including convincing data on a net “gateway-to-smoking” effect or compromised cognitive functioning), regarding the impact of vaping on teens. There is wide agreement that e-cigarettes should not be available to minors who do not smoke and that the government should restrict marketing to them. But the intense focus on teen use has diverted almost all attention from the importance of adult access. Availability and product innovation for adult smokers should be encouraged. The FDA has lost perspective when it comes to the adult side of this policy challenge. | Con
President, Campaign for Tobacco-Free Kids. Written for CQ Researcher, May 2019 | The FDA has rightly called skyrocketing youth use of e-cigarettes an “epidemic” that is addicting a new generation and threatens our decades-long progress in reducing youth tobacco use. However, the FDA's response to date falls short of the forceful action this public health crisis demands. The FDA must do more, starting with a ban on the flavored products that have made e-cigarettes so popular with kids. In 2018 alone, e-cigarette use among high school students jumped by 78 percent, to 20.8 percent of all students, according to the National Youth Tobacco Survey. More than 3.6 million middle and high school students used e-cigarettes — an increase of 1.5 million in just one year. Alarmingly, studies indicate that young people who use e-cigarettes are more likely to become cigarette smokers, many of them youths at low risk who would not have otherwise smoked. The FDA has taken steps to address this crisis, including cracking down on sales to kids and proposing to limit the sale of some flavored e-cigarettes to age-restricted locations. But these efforts do not go far enough. The restriction on flavored products does not apply to menthol and mint flavors despite FDA data showing that more than half of high school e-cigarette users use these flavors. It also does little to limit the availability of the most popular e-cigarette among kids, Juul and the Juul pods (cartridges) that deliver as much nicotine as a pack of 20 cigarettes. To reverse this epidemic, the FDA should prohibit all flavored e-cigarettes that have not been subject to public health review, halt online sales until stronger safeguards are in place to prevent sales to kids, restrict marketing that attracts kids and enforce rules prohibiting the sale of new products without FDA authorization. Scientific evidence shows that flavors play a key role in youth use of e-cigarettes, so it is unacceptable that these products are sold in kid-friendly flavors such as gummy bear, cotton candy and mango. The FDA should also reverse its decision to delay until 2022 a required public health review of e-cigarettes already on the market. Manufacturers should have to demonstrate that their products do not appeal to kids and that they have a public health benefit in order to stay on the market. To date, however, the evidence that e-cigarettes help smokers quit is limited and inconclusive. Even as research continues, the FDA must do more to prevent youth use. Our kids cannot be guinea pigs in a years-long experiment to determine the health risks of e-cigarettes. | Go to top
Chronology
| | | | 1880s–1950s | Tobacco cultivation spreads, smoking gains popularity and tobacco advertising increases. | | 1880 | U.S. inventor James Albert Bonsack patents the cigarette-rolling machine. | | 1911 | U.S. Supreme Court anti-trust ruling breaks American Tobacco Company into four entities: American Tobacco Co., Liggett & Myers Tobacco Co., Lorillard Tobacco Co. and R.J. Reynolds Tobacco Co. | | 1917 | U.S. military begins including cigarettes in soldiers' rations. | | 1940s | After World War II, tobacco companies begin advertising heavily on the new medium of television. | | 1950s | Studies link smoking to cancer and heart disease, and cigarette sales to minors are banned in every state by the end of the decade. | | 1960s–1970s | Surgeon general alerts country to the dangers of smoking, leading to warning labels and ad restrictions. | | 1964 | Landmark surgeon general's report definitively links cigarette smoking to lung cancer and other diseases. | | 1965 | Pennsylvania inventor Herbert A. Gilbert patents the first electronic cigarette but cannot find a company willing to mass-produce the device … Congress passes the Federal Cigarette Labeling and Advertising Act, requiring health warning labels on cigarette packages. | | 1969 | Congress passes the Public Health Cigarette Smoking Act, banning cigarette ads on radio and television. | | 1976 | British researcher Michael Russell identifies nicotine as the addictive component in cigarettes. | | 1980s–2000s | Federal government intensifies regulation of tobacco products, and smoking rates decline. | | 1984 | U.S. Food and Drug Administration (FDA) approves nicotine gum as the first smoking cessation aid…. Advanced Tobacco Products Inc. introduces a smokeless cigarette called Favor, a forerunner of e-cigarettes. | | 1988 | Surgeon general designates nicotine an addictive substance and defines tobacco use as an addiction…. R.J. Reynolds' Premier smokeless cigarette is introduced but proves unpopular with consumers. | | 1994 | Tobacco company executives deny under oath to Congress that nicotine is addictive and that smoking causes cancer. But whistleblowers leak internal documents showing the companies lied for decades about nicotine addiction and smoking's health effects while marketing cigarettes to minors. | | 1998 | An agreement settling lawsuits filed by states against tobacco companies requires the companies to reimburse billions in health care costs and imposes new limits on cigarette marketing. | | 2000s–present | E-cigarettes rapidly gain market share, prompting increased federal regulation. | | 2003 | Chinese pharmacist Hon Lik patents the first commercially successful electronic cigarette. | | 2007 | U.S. distributors begin importing Chinese-made e-cigarettes. | | 2009 | Congress passes the Family Smoking Prevention and Tobacco Control Act authorizing the FDA to regulate tobacco products. | | 2014 | Oxford English Dictionary selects “vape” as its word of the year. | | 2015 | Juul Labs begins selling an e-cigarette resembling a flash drive that quickly dominates the market. | | 2016 | FDA announces plan to regulate e-cigarettes…. Congress passes the Child Nicotine Poisoning Prevention Act, requiring e-liquids and vaping devices to be sold with child-resistant packaging. | | 2017 | FDA delays implementing e-cigarette regulations, allowing products to remain on the market longer without the agency's approval. | | 2018 | Survey shows a 78 percent increase in high school students' use of e-cigarettes, prompting health officials to declare it an epidemic and the FDA to take action to prevent sales to minors…. Altria Group Inc., owner of Philip Morris, invests in Juul, resulting in the top five e-cigarettes being owned by or affiliated with tobacco companies. | | 2019 | FDA outlines plans for regulating e-cigarettes and proposes giving companies until 2021 to seek regulatory approval…. FDA Commissioner Scott Gottlieb resigns; Ned Sharpless becomes acting commissioner…. U.S. e-cigarette sales forecast to reach $9 billion by year's end. | | | | Go to top Short Features Since introducing its electronic cigarette in 2015, Juul Labs has come to dominate the e-cigarette market, gaining more than 70 percent of it in less than four years. But critics contend the popularity of e-cigarettes among underage users has fueled what federal health officials call an “epidemic” in teen vaping. Juul's story dates to 2002, when founders Adam Bowen and James Monsees met as graduate students in product design at Stanford University. They set out to create a product to help smokers like themselves find a socially acceptable alternative that retained the ritual aspects of smoking without the attendant health risks. “Adam and I were interested in working on design for social change, and we acknowledged right away that smoking was probably an easy target,” Monsees said in a recording of their 2005 master's thesis presentation posted on the company's website. What they eventually devised closely resembles a computer flash drive, and its design has drawn comparisons with the iPhone. The company says its goal is to improve the lives of the world's 1 billion adult smokers by eliminating traditional cigarettes. Juul went on the market in June 2015 with a high-octane advertising campaign, largely propelled by social media, which has drawn criticism from public health officials and anti-tobacco advocates for attracting underage users. Since then, sales have skyrocketed. 
Juul's co-founders, Adam Bowen (left) and James Monsees, introduced their e-cigarette in 2015. Juul now controls more than 70 percent of the U.S. market. (AFP/Getty Images/Francois Guillot) | In 2018, the company became the fastest startup to hit a key financial milestone — a valuation exceeding $10 billion — by reaching a $15 billion valuation just seven months after initially seeking investments. That was faster than the growth of high-flying tech ventures such as Facebook, Snapchat and Dropbox. In addition to its streamlined design, Juul was also the first e-cigarette company to combine two naturally occurring elements of the tobacco plant, nicotine salt and benzoic acid. This patented formulation makes the e-liquid more palatable and allows higher concentrations of nicotine, producing the rush that smokers crave. Juul's success has spawned imitators of both the device's design and the e-liquid formulation, some of whom Juul has sued. The result is more products with a higher nicotine content than traditional cigarettes, says Robert K. Jackler, a professor at the Stanford University School of Medicine and expert in tobacco marketing. In a recent study, Jackler called the situation a “nicotine arms race” that threatens to addict a generation of youths. Juul's founders “always claimed they were there to disrupt the evil tobacco industry,” to give smokers a safer product, “which is a noble goal that I fully support,” Jackler says. “But instead, they've actually greatly increased the amount of nicotine addiction amongst teenagers, and that's a huge problem.” (Vaping by high school students rose 78 percent in 2018.) The rising use of e-cigarettes by teens led the U.S. Food and Drug Administration (FDA) to crack down on Juul's products, demanding documents and showing up unannounced to seize them at the company's San Francisco headquarters. In November, Juul responded to the criticism about underage use by shutting down its social media accounts and making some of its flavored products available only online. Then, in December, the company that styles itself as a high-tech startup became a partner with Big Tobacco when Altria Group Inc., the largest U.S. tobacco company, paid $12.8 billion for a 35 percent stake. The deal upped Juul's valuation to $38 billion, making it one of the most highly valued startups in Silicon Valley — outstripping SpaceX, Airbnb and Lyft — and making its two founders billionaires. Bowen and Monsees subsequently landed on Time magazine's list of the 100 most influential people for 2019. Juul and Altria both declined to make officials available for an interview, pointing to comments on their websites. In a statement, Juul CEO Kevin Burns acknowledged the partnership appeared “counterintuitive” but said both companies are committed to helping smokers switch from traditional to electronic cigarettes. “We know we need to earn trust and prove that this partnership may provide the opportunity to improve upon our early successes and better equip us to tackle the opportunities and challenges that lie ahead,” Burns said. For Altria, the relationship with the leader in e-cigarette sales will help counter the declining number of U.S. smokers. “Juul's 2018 growth was quite remarkable,” Howard Willard, Altria's CEO, told investors in January. With net revenues of more than $1 billion in 2018, “Juul overwhelmingly reaccelerated the U.S. e-vapor category.” Altria expects that growth to continue at a compounded annual rate of 15 percent to 20 percent through 2023, he said. But the deal angered FDA officials, who accused the two companies of reneging on promises made just months earlier to keep e-cigarettes away from minors. Former FDA Commissioner Scott Gottlieb went further during his final week in office in April, blaming Juul for fueling the youth vaping epidemic that he called an “addiction crisis.” He threatened that the FDA could still pull products off the market if upcoming surveys show teen e-cigarette use continuing to increase. “If [e-cigarette companies] can't keep these [products] out of the hands of kids to a better degree than they're doing now, these products are no longer going to be marketed,” Gottlieb said. Gottlieb's successor, Norman E. “Ned” Sharpless, said in April that the FDA would “make informed regulatory decisions on electronic cigarette products, so that we can reverse the growing epidemic of youth [e-cigarette] use.” In March, Juul's market share was at 73.9 percent, dwarfing the next biggest product, Vuse, made by R.J. Reynolds Vapor Co., at 13.4 percent. Juul forecasts revenue of $3.4 billion for 2019, almost triple what it generated last year. Juul has reacted to the regulatory scrutiny by taking another page from the tobacco industry playbook: opening a Washington office, hiring lobbyists, starting a political action committee and making campaign contributions. The company increased its lobbying expenditures more than 13-fold in a single year, from $120,000 in 2017 to $1.64 million in 2018. Federal regulators are not alone in taking aim at Juul. Officials in the company's hometown recently proposed legislation to ban the sale of e-cigarettes. A separate measure would prohibit e-cigarette companies such as Juul, whose headquarters are on San Francisco city property, from occupying city-owned space in the future. “We don't want them in our city,” said Shamann Walton, a member of the San Francisco Board of Supervisors whose district includes Juul's offices. Despite the regulatory efforts, market analysts remain bullish on the company, projecting that sales of so-called reduced risk products, including e-cigarettes, will surpass traditional cigarettes by 2025. After meeting with Altria executives in March, Wells Fargo Securities analyst Bonnie Herzog put it this way: “We think Juul could ultimately be the Marlboro of e-vapor.” — Jane Fullerton Lemons
Go to top Alan Amsterdam took a deep hit of cannabis vapor from a slim Juul device as he sat in the back office of Capitol Hemp, his cannabis accessories shop in Washington, D.C. “This has become my preferred method when I am out in the world,” Amsterdam says. “But I still prefer old school, the full plant matter,” he adds, inhaling a second time. Amsterdam was vaping cannabidiol, or CBD, a cannabis product often used to alleviate pain. CBD contains only a minuscule amount — 0.3 percent or less of its total weight — of THC, the chemical that generates most of marijuana's psychological effects. CBD can be consumed legally in any setting in Washington. General use of marijuana is legal in D.C. for those age 21 and older in a private setting, while public consumption is illegal. Amsterdam says that what he calls the “pen revolution” — a reference to one type of small handheld vaping device that can be used for cannabis — started around 2011 or 2012. But cannabis vaping — a subset of the recent boom in the use of vaping devices — has accelerated rapidly in recent years. Vaping devices are also used with cannabis products that have significantly higher amounts of THC than CBD contains. 
Alan Amsterdam, co-owner of Capitol Hemp, a Washington cannabis accessories shop, stands behind the counter. He says the “jury is out” on the effects of cannabis vaping. (SAGE Publications/Natalia Gurevich) | Sales of cannabis vape cartridges of all kinds totaled around $1.31 billion last year, a 53 percent increase from 2017, according to Morgan Fox, media relations director of the National Cannabis Industry Association (NCIA), a trade association in Washington representing cannabis businesses. About 33.4 million cannabis cartridges, costing between $35 and $40 per half a gram on average, were sold that year, up from about 10.5 million in 2017, says Fox. But even as sales rise, there is scant regulation of the substances used for cannabis vaping or the devices themselves; and little research was available on potential negative health consequences from frequent cannabis vaping, according to a 2015 paper by six Swiss researchers. The body of research has grown only slightly in recent years as the health and science community catches up to the industry. Vaping devices come in disposable one-piece designs, or two-piece units that take replaceable cartridges, sometimes called pods. Vape pens are slightly larger and sold in either reusable or disposable forms. Vaping devices for cannabis are popular largely because they are easy to use, says Amsterdam. Users buy disposable devices or pop cartridges containing cannabis oil — sometimes with a cutting agent or additives to enhance flavor or taste — into reusable devices, which heat the cartridges to produce vapor. Vaping also offers stealth, says Amsterdam. Most vapor does not smell like burning marijuana, making it very difficult to know if someone is vaping cannabis or nicotine, especially since most vaping devices can be used for either. There is some overlap between nicotine and cannabis vapers. A 2017 survey by researchers at Oberlin College and Yale University found that nearly 18 percent of e-cigarette users said they had also vaped cannabis at some point in their lives, and 11.5 percent had done so in the previous month. “The easier you make it to do drugs, with less adverse effects, less environmental pollution, and less people complaining about it, the more likely you are to do it more often,” says Alan Budney, a psychiatry professor at Dartmouth's Geisel School of Medicine and a specialist in cannabis use disorders in adults and adolescents. “And more often leads to problems.” People who smoke marijuana cigarettes are inhaling carcinogens, although on a lesser scale than those present in tobacco cigarette smoke, Budney says. Vaping cannabis removes that peril, but frequent users still risk becoming addicted, he says. In a 2015 paper, Budney and two other researchers explored the potential risks associated with cannabis vaping, while acknowledging the lack of research on the subject. The paper concluded that the ease of cannabis vaping could lead to earlier adoption of the practice and more frequent use. And increased use, combined with the higher potency of vaped cannabis, could exacerbate the negative effects of marijuana, such as “increased risk behaviors, poor school or job performance, family and interpersonal problems, accidents, memory and motivational problems, development of addiction,” the paper said. A 2018 study of 17 infrequent cannabis users that compared the effects of smoking to those of vaping marijuana found that vaping produced much stronger highs. One participant vomited and another hallucinated after vaping certain concentrations. Participants who vaped cannabis were more cognitively impaired than those who smoked it. Vapers had higher blood concentrations of THC than those who smoked. The possible ramifications of these findings on cognitive function are especially concerning because cannabis vaping “is prevalent among young adults, particularly among those who use other substances frequently and have more favorable attitudes toward smoking cannabis,” researchers at Arizona State University concluded in 2016. They surveyed 482 college students and found that 29 percent reported vaping cannabis at least once. Amsterdam acknowledges the lack of research available on cannabis vaping. “The jury is out on the negative side effects because we don't have any measured tests,” he says. But he remains skeptical that cannabis vaping will lead to an increase in use. “I think that as with alcohol or anything else, you're going to have people who gravitate towards it and then people who don't want to do it,” he says. A 2015 survey by Dartmouth researchers of 2,910 cannabis users, which used Facebook to recruit respondents, found that 61 percent had vaped cannabis at some point. On average, users tried cannabis for the first time between the ages of 15 and 16, and vaped it for the first time at around age 24. A pen was the most popular vaping device for cannabis consumption, favored by 45 percent of respondents. A study by the federal Centers for Disease Control and Prevention found that one in three high school and middle school students reported using e-cigarettes that contained substances other than nicotine, such as cannabis, in 2015. This kind of early use concerns researchers such as Budney. “We might not know there's a problem until you go and do it [vape cannabis] for 15 years,” he says. — Natalia Gurevich
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Bibliography
Books
Dunn, Craig , The Modern Guide to Vaping: An introduction to electronic cigarettes and the world of vaping, independently published, 2018. A software engineer uses his experiences with e-cigarettes to guide newcomers through various product choices and vaping styles.
Milov, Sarah , The Cigarette: A Political History , Harvard University Press, 2019. An assistant professor of history at the University of Virginia explains that the initial popularity and eventual decline of cigarettes reflected shifting political priorities during the 20th century, particularly the move toward nonsmokers' rights.
Wipfli, Heather , The Global War on Tobacco: Mapping the World's First Public Health Treaty , Johns Hopkins University Press, 2015. An assistant professor of preventive medicine at the University of Southern California recounts her experience participating in creation of the World Health Organization Framework Convention on Tobacco Control, a treaty governing tobacco production and distribution.
Articles
Belluz, Julia , “Everything you need to know about e-cigarettes,” Vox, May 26, 2018, https://tinyurl.com/y3ve24ha. A health journalist summarizes the issues surrounding e-cigarettes, including the debate over whether they are safe and questions about how they should be regulated.
Harris, Ainsley , “How Juul, founded on a life-saving mission, became the most embattled startup of 2018,” Fast Company, Nov. 19, 2018, https://tinyurl.com/y3rud8r5. A technology reporter recounts the rise of e-cigarette company Juul Labs and interviews the company's co-founders.
Hoffman, Jan , “She Couldn't Quit Smoking. Then She Tried Juul,” The New York Times, Nov. 16, 2018, https://tinyurl.com/ycp4wy98. A health reporter uses a smoker's experience to explain how e-cigarettes can be effective in helping some long-time smokers avoid the carcinogens in traditional cigarettes, but that vaping nicotine poses its own potential health risks.
Hoffman, Jan , “The Price of Cool: A Teenager, a Juul and Nicotine Addiction,” The New York Times, Nov. 16, 2018, https://tinyurl.com/yb8trzcz. A health reporter uses a teenager's experience with Juul to describe the challenges facing federal regulators as an increasing number of youths become addicted to nicotine through vaping.
Maloney, Jennifer, and Dana Mattioli , “Why Marlboro Maker Bet on Juul, the Vaping Upstart Aiming to Kill Cigarettes,” The Wall Street Journal, March 23, 2019, https://tinyurl.com/y4py2lk8. Two business reporters explain why the nation's largest tobacco company invested in an e-cigarette company whose mission is to eliminate smoking.
Tolentino, Jia , “Goodbye to Juul Season,” The New Yorker, Nov. 15, 2018, https://tinyurl.com/ycptfp7a. A magazine writer looks at how Juul responded to federal regulators and members of the public who blame the company for rising rates of underage e-cigarette use.
Reports
“E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General,” U.S. Centers for Disease Control and Prevention, 2016, https://tinyurl.com/y2enazjr. The first federal report on e-cigarette use among Americans between the ages of 11 and 25 found that e-cigarettes have become the most commonly used tobacco product among youths.
Cullen, Karen A. , et al., “Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018,” U.S. Centers for Disease Control and Prevention, Nov. 16, 2018, https://tinyurl.com/y57a9xyh. An analysis of federal data shows that e-cigarette use among middle and high school students increased significantly between 2017 and 2018.
Hajek, Peter , et al., “A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy,” The New England Journal of Medicine, Feb. 14, 2019, https://tinyurl.com/ycsn6sxw. Researchers in Britain found that e-cigarettes are more effective than nicotine-replacement therapy for smoking cessation when accompanied by behavioral support.
Stratton, Kathleen, Leslie Y. Kwan and David L. Eaton , eds., “Public Health Consequences of E-Cigarettes,” National Academies of Sciences, Engineering and Medicine, Jan. 23, 2018, https://tinyurl.com/y4qkfskx. A committee of health experts who reviewed research on the health effects of e-cigarettes said vaping poses some health risks but is probably far less harmful than smoking conventional cigarettes.
Go to top The Next Step FDA Response LaVito, Angelica , “Tobacco company Reynolds blames teen vaping crisis on Juul in fighting FDA plan to rein in e-cigarettes,” CNBC, May 2, 2019, https://tinyurl.com/yyymf74v. A subsidiary of British American Tobacco says the Food and Drug Administration's crackdown on the sale of fruity e-cigarette flavors in an effort to curb youth vaping is misguided, and that the agency should instead focus on Juul because of its popularity with teens. Luthra, Shefali , “Local health officials say FDA's moves against teen vaping ‘epidemic’ aren't enough,” Los Angeles Times, April 1, 2019, https://tinyurl.com/y234525s. Some local health officials say federal regulations designed to curb teen vaping take effect too slowly and often are not tough enough. Nedelman, Michael , “FDA investigates reports of seizures after vaping,” CNN, April 3, 2019, https://tinyurl.com/yxajkrs9. Federal officials are looking into 35 cases between 2010 and 2019 in which e-cigarette users, particularly younger ones, suffered seizures after vaping. Marketing Tactics Becker, Rachel , “Why Big Tobacco and Big Vape Love Comparing Nicotine to Caffeine,” The Verge, April 26, 2019, https://tinyurl.com/y568bfpb. Scientists say the e-cigarette industry's efforts to minimize nicotine's health risks by equating it with caffeine ignore significant differences between the two drugs. Belluz, Julia , “The vape company Juul said it doesn't target teens. Its early ads tell a different story,” Vox, Jan. 25, 2019, https://tinyurl.com/y23954dd. Stanford University researchers who analyzed Juul's ads and social media posts concluded that the company's marketing campaign has primarily targeted youths. LaVito, Angelica , “Nearly a dozen Democratic senators to investigate Juul's marketing practices, deal with Altria,” CNBC, April 8, 2019, https://tinyurl.com/yyovr8ou. Eleven Senate Democrats say they will look into whether Altria's purchase of a 35 percent stake in Juul — as well as Juul's marketing practices — violate the e-cigarette company's commitment to address rising youth vaping rates. State Regulation Clukey, Keshia , “New Yorkers to Pay 20 Percent Sales Tax on Vaping Products,” Bloomberg Tax, April 2, 2019, https://tinyurl.com/y42dxbmt. Starting December 1, e-cigarette users in New York state will pay a 20 percent tax on all vaping products, with proceeds going to a state fund that finances health care initiatives. Kaplan, Sheila , “In Washington, Juul Vows to Curb Youth Vaping. Its Lobbying in States Runs Counter to That Pledge,” The New York Times, April 28, 2019, https://tinyurl.com/y4ztt5za. Juul has worked to convince federal regulators it is committed to reducing teen vaping, but its lobbyists are fighting state proposals to ban flavored e-cigarette pods and other steps to discourage youth vaping. Oosting, Jonathan , “Plan to ban e-cigarettes sales to minors reignites Michigan vaping debate,” The Detroit News, April 23, 2019, https://tinyurl.com/y4npew87. Lawmakers in Michigan continue to struggle to reach agreement on legislation that would end Michigan's status as the only state that allows minors to buy e-cigarettes. Youth Habits Ducharme, Jamie , “Teens Are Vaping in Record Numbers. But Fewer Than Ever Are Drinking and Smoking,” Time, Dec. 17, 2018, https://tinyurl.com/y4kh4upd. The novelty of e-cigarettes has helped make them popular with youths, even as alcohol use declines among teens, according to the director of the federal government's National Institute on Drug Abuse. Edney, Anna , “Teens Say They Don't Vape, They Juul, Making E-Cigarette Use Hard to Track,” Bloomberg, April 29, 2019, https://tinyurl.com/yyr597wx. This year's annual government survey of youth tobacco use will for the first time include a question that refers specifically to Juul, a change that responds to teens' adoption of the term “juuling” to refer to vaping. Molina, Brett , “Teens are vaping nicotine and they don't even realize it, study says,” USA Today, April 23, 2019, https://tinyurl.com/y3ru55nk. A recently published survey of 500 young people found that many teen e-cigarette users are unaware that the devices often contain high levels of nicotine. Go to top Contacts American Vaping Association
70 Hemlock St., Stratford, CT 06615
609-947-8059
http://www.vaping.org
Advocacy group that promotes the use of vapor products and electronic cigarettes to help smokers quit. Campaign for Tobacco-Free Kids
1400 I St., N.W., Suite 1200, Washington, DC 20005
202-296-5469
http://www.tobaccofreekids.org
Advocacy group that promotes public policies to discourage youth smoking, help smokers quit and reduce exposure to secondhand smoke. Centers for Disease Control and Prevention
Office on Smoking and Health, 1600 Clifton Road, Atlanta, GA 30333
800-232-4636
http://www.cdc.gov/tobacco
Federal agency within the Department of Health and Human Services that conducts research on tobacco use and provides information to reduce tobacco-related disease and deaths. Food and Drug Administration
Center for Tobacco Products, 10903 New Hampshire Ave., Silver Spring, MD 20993
877-287-1373
http://www.fda.gov/TobaccoProducts
Federal agency within the Department of Health and Human Services that regulates tobacco products, including electronic cigarettes. Juul
560 20th St., San Francisco, CA 94107
415-829-2336
http://www.juul.com/
Largest U.S. electronic cigarette company, with revenue of $3.4 billion projected for 2019. Office of the Surgeon General
200 Independence Ave., S.W., Humphrey Bldg. Suite 701H, Washington, D.C. 20201
202-205-0143
http://www.surgeongeneral.gov/
The federal government's spokesperson on health issues; oversees the U.S. Public Health Service Commissioned Corps. Public Health England
Wellington House, 133-155 Waterloo Road, London SE1 8UG United Kingdom
+44-20-7654-8000
http://www.gov.uk/government/organisations/public-health-england
British government's national public health agency. Smoke Free Alternatives Trade Association
1155 F St., N.W., Suite 1050, Washington, DC 20004
202-251-1661
http://www.sfata.org
Trade association representing the vapor products industry. Truth Initiative
900 G St., N.W., Fourth Floor, Washington, DC 20001
202-454-5555
http://www.truthinitiative.org
Tobacco-control organization that seeks to discourage use by young people; previously known as the American Legacy Foundation, established as part of the Master Settlement Agreement between states and tobacco companies over health care costs and tobacco promotion. World Health Organization
Ave. Appia 20, 1202 Geneva
+41-22-7912111
http://www.who.int
United Nations agency that deals with international public health issues. Go to top
Footnotes
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About the Author
Jane Fullerton Lemons is a freelance writer in Northern Virginia with more than 25 years of journalism experience. A former Washington bureau chief for the Arkansas Democrat-Gazette, she has covered the White House and Congress. She holds a master's degree in creative nonfiction from Goucher College in Towson, Md.
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Document APA Citation
Lemons, J. (2019, May 10). E-cigarette dilemma. CQ researcher, 29, 1-31. http://library.cqpress.com/
Document ID: cqresrre2019051000
Document URL: http://library.cqpress.com/cqresearcher/cqresrre2019051000
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Tobacco Industry: on the Defensive, but Still Strong |
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Tobacco Under Siege |
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Regulation of the Cigarette Industry |
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