Advertisement

Current Cardiology Reports

, 21:111 | Cite as

Public Health Policies on E-Cigarettes

  • Aditya Bhalerao
  • Farzane Sivandzade
  • Sabrina Rahman Archie
  • Luca CuculloEmail author
Open Access
Public Health Policy (E Klodas, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Public Health Policy

Abstract

Tobacco continues to kill about 0.48 million Americans per year and there are currently 34.3 million smokers in the USA. As a consequence of the First Surgeon General’s Report on Tobacco in 1964, tobacco control interventions on part of the government led to a significant decline in conventional tobacco product usage over the last few decades. However, more recently, a new entity in the form of electronic cigarettes has risen rapidly and has exposed a younger population to a plethora of dangerous consequences. Looking at e-cigarettes from the perspective of tobacco control however raises a lot of challenges. There is little doubt that existing smokers of combustible cigarettes who switch to e-cigarettes will be switching to a less harmful product. However, if the younger generation begins using e-cigarettes as a result of targeted marketing, appealing flavors and ‘safer alternative’ perception, decades of progress made in conventional tobacco control will be negated. Governments at the federal, state, and local levels have a mandate to once again implement new public health policies to ensure that non-conventional tobacco products like e-cigarettes are available as smoking cessation tools for existing smokers but at the same time do not play a role in ruining the health of future generations through addiction and disease.

Purpose of Review

To review the present scenario of regulations and policies impacting public health with respect to electronic nicotine delivery systems (ENDS) with the objective of providing a meaningful and balanced view of the challenges at hand with plausible recommendations.

Recent Findings

Nicotine in tobacco is known to cause addiction and dependence. It is particularly potent in children and young adults. E-cigarettes can deliver high concentrations of nicotine, and these concentrations can vary depending on the numerous constituents within the e-cigarette which vary greatly from one another. Use of e-cigarettes is implicated as a risk factor for future cigarette use in young adults. Moreover, e-cigarette usage patterns also depend on several sociodemographic factors. Banning tobacco products has shown to reduce smoking risk in youth and as such, strong e-cigarette regulation measures are needed for prevention.

Summary

Effective regulation of ENDS faces a multitude of challenges. One such challenge is to prevent youth and non-smokers from getting habituated to nicotine through e-cigarettes. The intention of tobacco companies to sustain sales through harmful marketing strategies that tone down the risks and highlight e-cigarettes as a “much safer alternative” while promoting flavors appealing to children should be immediately prohibited. Another hazard is the endorsement of ENDS as devices meant for enhancing social interaction which opens a path for youth to make erroneous choices under peer pressure. On the other hand, several studies have reported that e-cigarettes significantly reduce an existing smoker’s risk of being exposed to toxic tobacco smoke constituents that are normally present in cigarette smoke. This leads to the conclusions that e-cigarettes can be a tool for smoking cessation for current smokers. Public policy must take a multi-dimensional approach to balance these two extremes.

Keywords

E-cigarettes Electronic cigarettes Electronic nicotine delivery systems Policy Regulation Public health 

Introduction

Electronic nicotine delivery systems (ENDS) are commonly known as electronic cigarettes or e-cigarettes and vape pens. These devices are meant to deliver nicotine by heating up a vape liquid into an inhalable aerosol. The vape liquid is a solution containing nicotine, flavoring agents, and solvents such as propylene glycol or glycerin [1]. The e-cigarette was first invented by Herbert A Gilbert in 1963, but the subsequent commercially viable design was patented by Hon Lik of China [2]. E-cigarettes entered the US market in 2007 [3] and have gained tremendous popularity since, especially among youth. E-cigarettes were marketed as a safer alternative to conventional combustible cigarettes and therefore were promoted as harm reduction substitutes for current smokers. However, there are contrasting claims associated with e-cigarettes being considered as a safer alternative to conventional cigarettes. The bottom-line according to the Centers for Disease Control and Prevention remains that e-cigarettes are possibly a less harmful alternative for current smokers addicted to combustible cigarettes [4••]. E-cigarettes are not for people who have never smoked in their life, and even establishing their efficacy as a smoking cessation tool needs thorough and long-term research [5]. The dangers of e-cigarette vaping include damage to the developing brain from nicotine [6, 7, 8] and exposure to toxic substances such as heavy metals, volatile organic compounds, and ultrafine particles [9, 10•].

Public Health Consequences

The adverse health consequences of e-cigarette use for both primary smokers and those exposed to secondhand smoke arises from the inhalation of the e-cigarette aerosol and levels of nicotine delivered into the system [11, 12].

Nicotine is known to be acutely toxic at high doses, and cases of nicotine poisonings due to vape liquids have seen a rise in recent years [13]. Nicotine is also a pharmacologically active biomolecule that sustains addiction, changes the way one’s brain functions [14], and is known to have particularly harmful consequences on the growing fetus if exposed to it during pregnancy [15, 16].

The e-cigarette aerosol contains a vast array of chemicals including any number of approximately 7000 flavorings [17], humectants such as Propylene Glycol and Vegetable Glycerin and contaminants such as metals, formaldehyde, acrolein, and tobacco-specific nitrosamines [1, 18] all with the potential to cause a wide variety of negative health effects. A list of these compounds and their physiologic effects are outlined below (Table 1).
Table 1

Constituents of ENDS Aerosol [19]

Serial number

Aerosol component

Health risk

Reference

1.

Ultrafine particles

Asthma, vasoconstriction leading to cardiovascular problems

[20, 21]

2.

Benzene, formaldehyde, acetaldehyde, toluene, cadmium, lead, and nickel

Carcinogen, reproductive toxin

[22, 23]

3.

Propylene glycol

Irritant of the eyes, throat and airways, long-term exposure leads to asthma

[24, 25]

4.

Propylene oxide

Carcinogen

[26]

5.

Diethylene glycol

renal and neurologic toxicity

[27]

6.

Diacetyl and acetyl propionyl (sweet flavorings)

bronchiolitis obliterans

[28, 29]

7.

Carbonyls

Cardiovascular toxicity

[30]

8.

Copper nanoparticles

DNA fragmentation, mitochondrial stress

[31]

Need for Regulation

In the years before the advent of ENDS technology, various public health measures made significant progress in tobacco control yielding a 6.9% reduction in smoking across the US population from 2005 to 2017 [32, 33, 34, 35]. Keeping in mind the economic and social burden exacted by smoking-related diseases, the Federal Government had enacted various laws to make the sale of conventional tobacco products more difficult especially for the younger generation. However, rapid and unchecked increase in e-cigarette use [10•, 36] has once again threatened to endanger the health of our youth through nicotine addiction and vaping related disease [6, 37]. The National Youth Tobacco Survey held jointly by the FDA and the Centers for Disease Control and Prevention shows that around 3.6 million students (both middle and high school) were using e-cigarettes in 2018, up from 2.1 million in 2017 [38, 39]. There is emerging evidence that e-cigarettes can spur future tobacco product use in teens, whereas, on the other hand, banning tobacco products diminishes the smoking risk. Socio-economic background is another factor that also plays a major role in smoking initiation [40, 41, 42].

Another area of concern is the public health consequences of secondhand e-cigarette smoke on bystanders. Though the country has made significant progress in enacting clean air laws in public places including workplaces and indoors, a lot still remains to be done. The use of e-cigarettes in public areas poses a serious health risk considering the various toxic constituents that have been shown to affect both the primary smoker and victims of passive smoking. It is pertinent to note that smoke-free laws in the USA were passed before ENDS entered the market and do not specifically mention the prohibition of e-cigarette smoking in many places. As such, this non-clarity may lead to non-compliance or exploitation of smoke-free rules [43, 44].

Existing Regulation

Federal Regulations

The FDA has been regulating tobacco products since June 2009; a timeline of the most important regulations is furnished in Table 2.
Table 2

Timeline of policies/rules/regulations enforced at the federal level

No.

Date

Name of agency

Regulation particulars

Implication

1.

June, 2009

Food and Drug Administration (FDA) of the Department of Health and Human Services.

Family Smoking Prevention and Tobacco Control Act. [45]

Authorizing FDA to regulate tobacco products including e-cigarettes. It led to the creation of center for tobacco products.

2.

April, 2014

Food and Drug Administration (FDA) of the Department of Health and Human Services.

Proposed Deeming Regulations [46]

Authorized the FDA to put heavy restrictions on most of the existing unregulated e-cigarette manufacturing industry and required premarket tobacco applications (PMTA’s) for new manufacturers

On May 10, 2016, the U.S. Food and Drug Administration (FDA) passed a new rule effective August 08, 2016, deeming that all tobacco products be brought under the purview of Federal Food, Drug, and Cosmetic Act thus authorizing the FDA to regulate all tobacco products including ENDS [46]. Apart from banning the sale of e-cigarettes to those below 18 years of age, the rule also stipulates several manufacturing standards and marketing limitations. The rule focuses on preventing a younger generation from becoming addicted to nicotine through e-cigarettes while taking into account the harm reduction potential of e-cigarettes for existing smokers addicted to nicotine.

More recently, in light of the 2018 National Youth Tobacco Survey, the FDA and Federal Trade Commission (FTC) issued warnings to four e-cigarette manufacturing companies around youth-focused advertisement, sale and distribution of ENDS products, especially on social media platforms [47].

State Regulations of e-Cigarettes

The US state and local governments have played a proactive role in enacting several laws at their level to protect against the misuse of e-cigarettes. In June 2019, San Francisco, California, became the first city in the USA to ban the retail and online sale of e-cigarettes. This move is especially significant as Juul Labs, Inc., the makers of the Juul e-cigarettes variety, which has captured 70% of ENDS market share in recent years, is based out of San Francisco. Another trend is the implementation of Tobacco 21 laws in several states, increasing the minimum age of sale of tobacco products from 18 to 21. As of June 2019, 16 states, Arkansas, California, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, New Jersey, Oregon, Texas, Utah, Vermont, Virginia, and Washington, the District of Columbia and 470 localities had implemented tobacco 21 laws [48].

As of April 2019, 13 states, 2 territories, and 841 municipalities have banned the use of e-cigarettes in 100% smoke-free public places [43]. In addition, regulations defining e-cigarettes, taxation, packaging, access to youth, and licensure of e-cigarette sales have been put into place across several states (Table 3).
Table 3

Law(s) in effect across all States & the District of Columbia in the USA (March 15, 2019) [49]

 

State

Law(s) that define e-cigarettes

Law(s) taxing e-cigarettes

Law(s) on product packaging of e-cigarettes

Law(s) restricting youth access to e-cigarettes

Law(s) requiring licenses for retail sales of e-cigarettes

1

Alabama

   

Yes

 

2

Alaska

   

Yes

Yes

3

Arizona

   

Yes

 

4

Arkansas

  

Yes

Yes

Yes

5

California

Yes

Yes

Yes

Yes

Yes

6

Colorado

Yes

  

Yes

 

7

Connecticut

   

Yes

Yes

8

Delaware

Yes

Yes

 

Yes

Yes (vape liquid)

9

District of Columbia

Yes

Yes

 

Yes

Yes

10

Florida

   

Yes

 

11

Georgia

   

Yes

 

12

Hawaii

Yes

  

Yes

Yes

13

Idaho

   

Yes

 

14

Illinois

  

Yes

Yes

 

15

Indiana

Yes

 

Yes

Yes

Yes

16

Iowa

   

Yes

Yes

17

Kansas

 

Yes

 

Yes

Yes

18

Kentucky

   

Yes

 

19

Louisiana

 

Yes

 

Yes

Yes

20

Maine

Yes

 

Yes

Yes

Yes

21

Maryland

   

Yes

Yes

22

Massachusetts

Yes

 

Yes

Yes

 

23

Michigan

     

24

Minnesota

Yes

Yes

Yes

Yes

Yes

25

Mississippi

   

Yes

 

26

Missouri

  

Yes

Yes

Yes

27

Montana

   

Yes

Yes

28

Nebraska

   

Yes

 

29

Nevada

   

Yes

 

30

New Hampshire

  

Yes

Yes

 

31

New Jersey

Yes

Yes

Yes

Yes

 

32

New Mexico

  

Yes

Yes

 

33

New York

  

Yes

Yes

 

34

North Carolina

Yes

Yes

Yes

Yes

Yes (non-local manufacturers)

35

North Dakota

  

Yes

Yes

 

36

Ohio

  

Yes

Yes

 

37

Oklahoma

   

Yes

 

38

Oregon

  

Yes

Yes

 

39

Pennsylvania

Yes

Yes

Yes

 

Yes

40

Rhode Island

  

Yes

Yes

Yes

41

South Carolina

   

Yes

 

42

South Dakota

Yes

 

Yes

Yes

 

43

Tennessee

  

Yes

Yes

 

44

Texas

  

Yes

Yes

Yes

45

Utah

Yes

 

Yes

Yes

Yes

46

Vermont

  

Yes

Yes

Yes

47

Virginia

  

Yes

Yes

 

48

Washington

  

Yes

Yes

Yes

49

West Virginia

Yes

Yes

 

Yes

 

50

Wisconsin

   

Yes

 

51

Wyoming

Yes

 

Yes

Yes

 

Challenges and Recommendations

A review of the scientific literature shows largely incomplete data around the health effects of e-cigarettes. This translates to policy indecision among the regulatory authorities leading to confusion among the general public. This also causes problems for health care professionals in counseling current smokers looking to switch to e-cigarettes [50, 51, 52]. A long-term comprehensive study involving all major stakeholders is required to address this problem.

A bi-pronged approach could be key in balancing the regulatory aspects of e-cigarettes. It should consist of a prevention strategy in case of youth and a control strategy for current smokers who are looking at reduced harm alternatives for their nicotine fixation [53]. The prevention aspect can include laws that prohibit sale to minors, prevent youth-targeted advertisement campaigns [54, 55] and flavors, child-safe packaging, and campaigns addressing awareness and education. On the other hand, the control aspect can include better manufacturing measures, licensing laws for retail and online sale, selective taxation, and supervised subsidy for verified current smokers.

Conclusions

Every once in a while, a newer technology emerges onto the market and causes a massive shift in the prevailing status quo. E-cigarettes are one such technology that emerged a decade ago and has changed the way tobacco is consumed by the current population. It has brought along with it many dangers but also some promises. The regulatory framework has to tread a narrow path of prevention and control to safeguard future generation against the evils of tobacco as well as other unintended health consequences of using ENDS, but at the same time ensure that the path from combustible cigarettes to e-cigarettes ends with complete smoking cessation.

Notes

Author Contributions

A.B. conceived the study and prepared the drafting of the manuscript. F.S. and S.R.A. also contributed to the manuscript preparation. L.C. assisted with the drafting of the manuscript, oversaw the entire project, and provided funding support. All authors reviewed the manuscript.

Funding Information

This work was supported by the National Institutes of Health/National Institute on Drug Abuse 2R01-DA029121-01A1 and ARDF to Dr. Luca Cucullo.

Compliance with Ethical Standards

Conflict of Interest

Aditya Bhalerao, Farzane Sivandzade, Sabrina Rahman Archie, and Luca Cucullo declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Clapp PW, Jaspers I, Cigarettes E. Their constituents and potential links to asthma. Curr Allergy Asthma Rep. 2017;17(11):79.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Bhatnagar A, Whitsel LP, Ribisl KM, Bullen C, Chaloupka F, Piano MR, et al. Electronic cigarettes: a policy statement from the American Heart Association. Circulation. 2014;130(16):1418–36.PubMedGoogle Scholar
  3. 3.
    Lichtenberg K. E-cigarettes: current evidence and policy. Mo Med. 2017;114(5):335–8.PubMedPubMedCentralGoogle Scholar
  4. 4.
    •• Huang J, et al. Changing perceptions of harm of e-cigarette vs cigarette use among adults in 2 US national surveys from 2012 to 2017. JAMA Netw Open. 2019;2(3):e191047. The authors of this study observed that a huge proportion of adults in the US perceived e-cigarettes as equally or more harmful than conventional cigarettes. PubMedPubMedCentralGoogle Scholar
  5. 5.
    [CDC], T.C.f.D.C.a.P. Smoking & tobacco use about electronic cigarettes (e-cigarettes) quick facts on the risks of e-cigarettes for kids, teens, and young adults. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html, 2019.
  6. 6.
    DeVito EE, Krishnan-Sarin S. E-cigarettes: impact of E-liquid components and device characteristics on nicotine exposure. Curr Neuropharmacol. 2018;16(4):438–59.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Siqueira LM. Nicotine and tobacco as substances of abuse in children and adolescents. Pediatrics. 2017;139(1):e20163436.PubMedGoogle Scholar
  8. 8.
    Glasser AM, Collins L, Pearson JL, Abudayyeh H, Niaura RS, Abrams DB, et al. Overview of electronic nicotine delivery systems: a systematic review. Am J Prev Med. 2017;52(2):e33–66.PubMedGoogle Scholar
  9. 9.
    Collaco JM, Drummond MB, McGrath-Morrow SA. Electronic cigarette use and exposure in the pediatric population. JAMA Pediatr. 2015;169(2):177–82.PubMedPubMedCentralGoogle Scholar
  10. 10.
    • Jenssen BP, Boykan R. Electronic cigarettes and youth in the United States: a call to action (at the Local, National and Global Levels). Children (Basel). 2019;6(2). The authors of this review suggest that there is an increasing popularity of ENDS that may reverse years of progress made in tobacco control. PubMedCentralGoogle Scholar
  11. 11.
    Czogala J, Goniewicz ML, Fidelus B, Zielinska-Danch W, Travers MJ, Sobczak A. Secondhand exposure to vapors from electronic cigarettes. Nicotine Tob Res. 2014;16(6):655–62.PubMedGoogle Scholar
  12. 12.
    Cai H, Wang C. Graphical review: the redox dark side of e-cigarettes; exposure to oxidants and public health concerns. Redox Biol. 2017;13:402–6.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Kim JW, Baum CR. Liquid nicotine toxicity. Pediatr Emerg Care. 2015;31(7):517–21 quiz 522-4.PubMedGoogle Scholar
  14. 14.
    Yuan M, Cross SJ, Loughlin SE, Leslie FM. Nicotine and the adolescent brain. J Physiol. 2015;593(16):3397–412.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Spindel ER, McEvoy CT. The role of nicotine in the effects of maternal smoking during pregnancy on lung development and childhood respiratory disease. Implications for dangers of E-cigarettes. Am J Respir Crit Care Med. 2016;193(5):486–94.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Hagino N, Lee JW. Effect of maternal nicotine on the development of sites for [(3)H]nicotine binding in the fetal brain. Int J Dev Neurosci. 1985;3(5):567–71.PubMedGoogle Scholar
  17. 17.
    Zhu SH, Sun JY, Bonnevie E, Cummins SE, Gamst A, Yin L, et al. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob Control. 2014;23(Suppl 3):iii3–9.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Margham J, McAdam K, Forster M, Liu C, Wright C, Mariner D, et al. Chemical composition of aerosol from an E-cigarette: a quantitative comparison with cigarette smoke. Chem Res Toxicol. 2016;29(10):1662–78.PubMedGoogle Scholar
  19. 19.
    Foundation, A.N.R. Electronic smoking devices and secondhand aerosol. Website, 2019. https://no-smoke.org/electronic-smoking-devices-secondhand-aerosol/.
  20. 20.
    Fuoco FC, Buonanno G, Stabile L, Vigo P. Influential parameters on particle concentration and size distribution in the mainstream of e-cigarettes. Environ Pollut. 2014;184:523–9.PubMedGoogle Scholar
  21. 21.
    Grana R, Benowitz N, Glantz SA. Background paper on E-cigarettes (electronic nicotine delivery systems). Center for Tobacco Control Research and Education University of California, San Francisco WHO Collaborating Center on Tobacco Control, 2013.Google Scholar
  22. 22.
    Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2014;23(2):133–9.PubMedGoogle Scholar
  23. 23.
    Williams M, Villarreal A, Bozhilov K, Lin S, Talbot P. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PLoS One. 2013;8(3):e57987.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Wieslander G, Norback D, Lindgren T. Experimental exposure to propylene glycol mist in aviation emergency training: acute ocular and respiratory effects. Occup Environ Med. 2001;58(10):649–55.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Choi H, Schmidbauer N, Spengler J, Bornehag CG. Sources of propylene glycol and glycol ethers in air at home. Int J Environ Res Public Health. 2010;7(12):4213–37.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Program NT. 14th report on carcinogens. Washington, D.C.: U.S. Department of Health and Human Services; 2016.Google Scholar
  27. 27.
    Schep LJ, Slaughter RJ, Temple WA, Beasley DMG. Diethylene glycol poisoning. Clin Toxicol (Phila). 2009;47(6):525–35.Google Scholar
  28. 28.
    Farsalinos KE, Kistler KA, Gillman G, Voudris V. Evaluation of electronic cigarette liquids and aerosol for the presence of selected inhalation toxins. Nicotine Tob Res. 2015;17(2):168–74.PubMedGoogle Scholar
  29. 29.
    (NIOSH), N.I.f.O.S.a.H. Preventing lung disease in workers who use or make flavorings. Atlanta: Centers for Disease Control and Prevention; 2003.Google Scholar
  30. 30.
    Bhatnagar A. E-cigarettes and cardiovascular disease risk: evaluation of evidence, policy implications, and recommendations. Curr Cardiovasc Risk Rep. 2016;10(24).  https://doi.org/10.1007/s12170-016-0505-6.
  31. 31.
    Lerner CA, Rutagarama P, Ahmad T, Sundar IK, Elder A, Rahman I. Electronic cigarette aerosols and copper nanoparticles induce mitochondrial stress and promote DNA fragmentation in lung fibroblasts. Biochem Biophys Res Commun. 2016;477(4):620–5.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Cummings KM, Proctor RN. The changing public image of smoking in the United States: 1964-2014. Cancer Epidemiol Biomark Prev. 2014;23(1):32–6.Google Scholar
  33. 33.
    Prevention, C.f.D.C.a. Current cigarette smoking among adults in the United States. Smoking & tobacco use, 2017. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm.
  34. 34.
    National Center for Chronic Disease, P., S. Health Promotion Office on, and Health. Reports of the surgeon general. In: The health consequences of smoking-50 years of progress: a report of the surgeon general. Centers for Disease Control and Prevention (US): Atlanta; 2014.Google Scholar
  35. 35.
    Wang TW, Asman K, Gentzke AS, Cullen KA, Holder-Hayes E, Reyes-Guzman C, et al. Tobacco product use among adults - United States, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(44):1225–32.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Jenssen BP, Walley SC, McGrath-Morrow SA. Heat-not-burn tobacco products: tobacco industry claims no substitute for science. Pediatrics. 2018;141(1):e20172383.PubMedGoogle Scholar
  37. 37.
    Nasr SZ, Nasrallah AI, Abdulghani M, Sweet SC. The impact of conventional and nonconventional inhalants on children and adolescents. Pediatr Pulmonol. 2018;53(4):391–9.PubMedGoogle Scholar
  38. 38.
    Gentzke AS, Creamer ML, Cullen KA, Ambrose BK, Willis G, Jamal A, et al. Vital signs: tobacco product use among middle and high school students - United States, 2011-2018. MMWR Morb Mortal Wkly Rep. 2019;68(6):157–64.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Wang TW, Gentzke A, Sharapova S, Cullen KA, Ambrose BK, Jamal A. Tobacco product use among middle and high school students - United States, 2011-2017. MMWR Morb Mortal Wkly Rep. 2018;67(22):629–33.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Soneji S, Barrington-Trimis JL, Wills TA, Leventhal AM, Unger JB, Gibson LA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta-analysis. JAMA Pediatr. 2017;171(8):788–97.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Hartwell G, Thomas S, Egan M, Gilmore A, Petticrew M. E-cigarettes and equity: a systematic review of differences in awareness and use between sociodemographic groups. Tob Control. 2017;26(e2):e85–91.PubMedGoogle Scholar
  42. 42.
    Nuyts PAW, Kuijpers TG, Willemsen MC, Kunst AE. How can a ban on tobacco sales to minors be effective in changing smoking behaviour among youth? - a realist review. Prev Med. 2018;115:61–7.PubMedGoogle Scholar
  43. 43.
    Foundation, A.N.R., Electronic smoking devices (ESDs). Website, 2019. https://no-smoke.org/smokefree-threats/electronic-cigarettes/.
  44. 44.
    Foundation, A.N.R. Electronic smoking devices (ESDs) & smokefree laws. Website, 2019. https://no-smoke.org/wp-content/uploads/pdf/e-cigarette-4-pager.pdf.
  45. 45.
    America, G.o.U.S.o. Family smoking prevention and tobacco control act. 2009.Google Scholar
  46. 46.
    U.S. Food and Drug Administration (FDA), H. Deeming tobacco products to be subject to the federal food, drug, and cosmetic act, as amended by the family smoking prevention and tobacco control act; restrictions on the sale and distribution of tobacco products and required warning statements for tobacco products. Final rule. Fed Regist. 2016;81(90):28973–9106.Google Scholar
  47. 47.
    U.S. Food and Drug Administration (FDA), H. FDA, FTC take action to protect kids by citing four firms that make, sell flavored e-liquids for violations related to online posts by social media influencers on their behalf. 2019 [cited 2019 06/27/2019].Google Scholar
  48. 48.
    Kids, C.f.T.-F. U.S. State and local issues raising the tobacco age to 21. 2019 [cited 2019 06/28/2019].Google Scholar
  49. 49.
    Law, P.H.L.C.a.M.H.S.o. U.S. E-cigarette regulations - 50 state review (2019). 2019 [cited 2019].Google Scholar
  50. 50.
    Levy DT, Cummings KM, Villanti AC, Niaura R, Abrams DB, Fong GT, et al. A framework for evaluating the public health impact of e-cigarettes and other vaporized nicotine products. Addiction. 2017;112(1):8–17.PubMedGoogle Scholar
  51. 51.
    El Dib R, et al. Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis. BMJ Open. 2017;7(2):e012680.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Drope J, Cahn Z, Kennedy R, Liber AC, Stoklosa M, Henson R, et al. Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine. CA Cancer J Clin. 2017;67(6):449–71.PubMedGoogle Scholar
  53. 53.
    Polosa R, Russell C, Nitzkin J, Farsalinos KE. A critique of the US surgeon general’s conclusions regarding e-cigarette use among youth and young adults in the United States of America. Harm Reduct J. 2017;14(1):61.PubMedPubMedCentralGoogle Scholar
  54. 54.
    Kaur J, Rinkoo AV. Getting real with the upcoming challenge of electronic nicotine delivery systems: the way forward for the South-East Asia region. Indian J Public Health. 2017;61(Suppl 1):S7–s11.PubMedGoogle Scholar
  55. 55.
    Stone E, Marshall H. Tobacco and electronic nicotine delivery systems regulation. Transl Lung Cancer Res. 2019;8(Suppl 1):S67–s76.PubMedPubMedCentralGoogle Scholar

Copyright information

© The Author(s) 2019

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • Aditya Bhalerao
    • 1
  • Farzane Sivandzade
    • 1
  • Sabrina Rahman Archie
    • 1
  • Luca Cucullo
    • 1
    • 2
    Email author
  1. 1.Department of Pharmaceutical Sciences, Jerry H. Hodge School of PharmacyTexas Tech University Health Sciences CenterAmarilloUSA
  2. 2.Center for Blood Brain Barrier ResearchTTUHSCAmarilloUSA

Personalised recommendations