Use of e-cigarettes among teens has skyrocketed, alarming health advocates, parents, medical professionals and educators across the state and the nation.

To address this growing crisis, the Coalition for a Smoke-Free Tomorrow hosted a conference in late 2018, titled “Next Generation Tobacco: The Impact of E-Cigarettes on Kentucky’s Future Health.” The conference brought together experts in public health to present the latest research on e-cigarette use, the dangers it presents to teens, and how to prevent another generation from becoming to addicted to nicotine.

Here are five key takeaways from the conference:

1) While e-cigarettes may provide a benefit for traditional smokers who are using the products to quit, this benefit is offset by rising use of e-cigarettes by adolescents.

Studies examining the long-term effectiveness of e-cigarettes as a cessation tool are preliminary due to the products’ recent introduction to the mass public. According to Dr. Brian King, PhD, MPH, the deputy director of the Centers for Disease Control’s Office on Smoking and Health, the CDC has stated that the potential health benefit of using e-cigarettes only applies to established smokers of traditional, combustible cigarettes, and then only if the established smokers make a full and final transition to e-cigarettes. Surveys of adult smokers of e-cigarettes from 2015 indicate that 60 percent of them also continued to smoke combustible cigarettes, resulting in a worse health outcome.

“If you’re going to have a health benefit as an adult smoker, you’ve got to quit (traditional cigarettes) completely, and that’s not necessarily what’s happening,” King said. “Now, it could be a means to an end–it’s possible that these people are using them ultimately for eventual cessation–but right now we know a lot of people are using both.”

Adults who rely on e-cigarettes as the primary method to quit smoking traditional cigarettes also forsake other more established and effective approaches, said Dr. Audrey Darville, PhD, APRN, from the University of Kentucky’s College of Nursing. E-cigarette products also contain varying levels of nicotine, making it hard for a traditional smoker to make the transition. “That’s a big hindrance toward using these products for cessation,” Darville said. “People want that steady state. They don’t want to feel bad when they are using tobacco.”

Any potential health improvements for adult smokers of combustible cigarettes will be determined in the years to come, but, for now, those prospects have become overwhelmed by a significant increase in adolescent use of e-cigarettes. According to a survey cited in the Surgeon General’s Advisory, use of e-cigarettes among U.S. high school students increased from 11.7 percent in 2017 to 20.8 percent in 2018, a 78 percent spike. This is contrasted with adult e-cigarette usage of about 2.8 percent in 2017.

“That’s why the public health community is so justifiably outraged over what we’re seeing,” King says.

2) E-cigarettes do not contain many of the toxic chemical additives of traditional tobacco cigarettes, but e-cigarettes have potentially harmful health effects.

Dr. Aruni Bhatnagar, PhD, FAHA, the Smith and Lucille Gibson Chair in Medicine at the University of Louisville and a professor in the Division of Cardiovascular Medicine, discussed the effects of inhaling e-cigarette aerosol on the cardiovascular system. He said that there is clinical evidence suggesting that exposure to fine particles found in e-cigarette aerosol can have adverse health effects similar to air pollution. He also cited a study showing that habitual users of e-cigarettes had an increase in high blood pressure, although this increase was far lower than the increase occurring with smokers of combustible cigarettes.

While heavily smoking combustible cigarettes–a pack a day versus one or two cigarettes–significantly increases cancer risks, Bhatangar pointed out that the cardiovascular risks of smoking reach a high level (80 percent) after just a few cigarettes and then increase slowly after that. He said that this non-linear health risk aspect means that people who trade in one or two traditional cigarettes per day for a “pod” a day of the popular e-cigarette product Juul (equivalent to 1.5 to two packs of cigarettes) may not realize any cardiovascular health benefit at all from the switch.

Overall, however, Bhatnagar and another presenter, Dr. Scott Weaver, Ph.D., a professor at Georgia State University’s School of Public Health, concluded that research into the health effects of e-cigarettes is still in its very early stages, and their long-term impact is unknown. Weaver cited research into the flavorings of e-cigarettes–one of their main draws, especially to youth–and noted a 2014 study finding that some of the flavorings were found to have volatile components. He also noted that while many flavorings were designated as GRAS (generally recognized as safe) by the Food and Drug Administration, this applies to the flavorings as they exist in food products, not when they are aerosolized and inhaled. More research is needed.

3) Using nicotine is harmful to the developing human brain, and the current lack of regulation on the marketing of e-cigarette products means that companies can target adolescents on their preferred terrain–social media.

According to Dr. Pat Purcell, a Louisville pediatrician, nine out of 10 smokers begin before age 18, and 95 percent before age 21. Nicotine, which releases dopamine in the brain, is highly addictive at any age and particularly so to young people. The human brain is not fully developed until around age 25, Purcell said, and areas in the prefrontal cortex that control judgment and executive action are among the last to reach maturity. Adolescents thus become addicted to nicotine more quickly than adults and through lower levels of use.

Melissa Abadi, Ph.D., a research scientist at the Pacific Institute for Research and Evaluation, and Amy Barkley, director of Mid-Atlantic states for Tobacco-Free Kids, discussed the prevalence and effectiveness of e-cigarette marketing campaigns. Although the FDA limited public sales of e-cigarettes to those age 18 and over in 2016, there are still no federal regulations on advertising. In the past couple of years, e-cigarette manufacturers have directed their efforts to social media channels such as Instagram and Twitter. Abadi cited research from a youth survey in which 37 percent of respondents said they were exposed to e-cigarette marketing via ads on social media, a higher percentage than through any other method.

Barkley said that this social media focus is a new twist on tried and true advertising campaigns developed by the major tobacco companies decades ago that emphasized flavors and promoted a “cool” lifestyle choice. “Even though they are not ‘Big Tobacco,’ they sure have taken a cue from Big Tobacco’s playbook,” Barkley said.

Although some manufacturers voluntarily imposed restrictions on social media marketing late in 2018 (including the popular Juul brand), Abadi and Barkley argued that enacting government regulations similar to those imposed on traditional cigarette companies’ marketing and advertising will be far more effective.

4) If nothing is done to reduce the growing epidemic of e-cigarette use among young people, a new generation of smokers will be created.

According to a 2018 report from the National Academies of Sciences cited by Dr. Pat Purcell, adolescents who use e-cigarettes are more likely to transition to using traditional cigarettes. This report, coupled with the 78 percent rise in e-cigarette use among high school students from 2017-18 cited above, indicates that a public health crisis is forming that could wipe out decades of declining smoking rates in the U.S.

“Nicotine primes the brain for addiction,” Dr. Brian King said. “So if you’re using a product with high amounts of nicotine, it’s no wonder that you would transition to a higher-risk product.”

Juul e-cigarettes, known for their high nicotine content and deceptive packaging in containers resembling flash drives, have exploded in popularity over the last two years. Tobacco company Atria bought 35 percent of the San Francisco startup late in 2018. King said that research shows Juul dominating the American e-cigarette market by the end of 2018, becoming the brand of choice for about 75 percent of users. And King noted that many of the recent surveys of adolescents cited during the conference do not include the word “Juul” in their questionnaires because the product is so new, which means that the  surge in e-cigarette use may actually be understated.

A rapidly growing health crisis requires a comprehensive response, the panelists concluded, one that is based on what has worked before in helping people quit tobacco products but is targeted toward young people existing within a hectic media culture.

“Prevention is key,” King said. “We’ve got to stop those nine out of 10 adults who began smoking as youth from starting altogether.”

5) Attendees at the conference recommended that four policy initiatives should be enacted in Kentucky to stem the rising tide of e-cigarette use among adolescents. They are:

• Include e-cigarettes in local smoke-free ordinances and tobacco-free school policies. Following the conference and during the 2019 Kentucky General Assembly, House Bill 11 was introduced, which prohibits tobacco use on or in property that is operated by local school boards in Kentucky at all times. The bill includes e-cigarettes in the ban and is supported by the Coalition for a Smoke-Free Tomorrow, and as of this writing has passed out of the House Committee on Health and Family Services and is awaiting action by the full House. Whether it will receive a hearing or vote this session is in question. 87% of Kentuckians are in support of tobacco-free schools according to a recent Kentucky Health Issues Poll.
• Enact an excise tax on e-cigarettes that is parallel to the tax on combustible cigarettes. “Research shows that higher taxes on tobacco products actually reduces sales,” said Ben Chandler, CEO of the Foundation for a Healthy Kentucky. Currently, there is no excise tax on e-cigarettes in Kentucky, but a poll conducted in December 2018 by the Foundation for a Healthy Kentucky found that 73 percent of Kentuckians statewide support adding an excise tax to e-cigarettes.
• Prohibit the sale of flavored e-cigarettes. This would follow a ban on flavored cigarettes in 2009 by the FDA based on their enhanced appeal to youth.
• Allow cities and counties to enact stricter tobacco control policies than those currently existing at the state level. Currently, state law pre-empts stricter local controls on tobacco sales.

“Kentucky is already behind most other states in terms of tobacco use,” Chandler said, referring to the state’s 2018 rank of 49^th out of 50 states (24.6 percent of adults smoke). “We encourage leaders at the state and local levels to enact these proven e-cigarette policies so that for once, Kentucky can lead the nation in addressing a serious health issue among our children.”