Outrage of the Month: Hooking a New Generation of Young People on Nicotine Via E-Cigarettes
Health Letter, December 2018
By Michael Carome, M.D.
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New data released by the Centers for Disease Control and Prevention (CDC) last month revealed an alarming rise in the use of electronic cigarettes (e-cigarettes) by middle school and high school students in the U.S. since 2011, thus confirming what many parents and teachers already knew: Teen use of these tobacco products has now reached epidemic proportions. The CDC’s disturbing findings herald a dramatic reversal of the progress made in the previous decade in the prevention of tobacco use and nicotine addiction in U.S. teens.
E-cigarettes, which were first marketed in the U.S. in 2007, are handheld, battery-powered devices that deliver nicotine, combined with flavorings and other additives, in the form of an aerosol. Nicotine, a drug found naturally in tobacco, is very addictive. In fact, according to the CDC, more people in the U.S. are addicted to nicotine than to any other drug. Studies have shown that nicotine may be as addictive as heroin, cocaine and alcohol.
Adolescents appear to have an enhanced sensitivity to nicotine’s addictive properties. Even more troubling, nicotine exposure can impair brain development and increase the risk of developing psychiatric disorders and cognitive impairment later in life.
For decades, smoking cigarettes was the most common pathway by which young people in the U.S. became addicted to nicotine. Moreover, nearly 90 percent of adult smokers started smoking by age 18. For these reasons, national, state and local public health agencies have engaged in coordinated campaigns to prevent youth from initiating smoking.
These prevention efforts clearly were paying off: the CDC found that from 2000 to 2011, there were gradual year-to-year declines in the prevalence of smoking, as well as the prevalence of any type of tobacco use, by middle and high school students. Over this 11-year period, the prevalence of current ciga¬rette use (defined as use on at least one day in the last month) declined gradually from 11 percent to 4 percent for middle school students and from 28 percent to 16 percent for high school students.
But the most recent data from the CDC’s annual National Youth Tobacco Survey demonstrate that the marketing of e-cigarettes has undermined the long-standing public health efforts to prevent teens from becoming addicted to nicotine. For example, the CDC found that among high school students, current e-cigarette use increased from approximately 1.5 percent (220,000 students) in 2011 to 21 percent (more than 3 million students) in 2018. From 2017 to 2018, current e-cigarette use by high school students spiked by 78 percent (from 12 percent to 21 percent). Moreover, more than a quarter of current high school e-cigarette users in 2018 reported using the products regularly (on 20 or more days in the past month) and two-thirds reported using flavored products.
Likewise, for middle school students, current e-cigarette use increased from approximately 0.6 percent (60,000 students) in 2011 to nearly 5 percent (570,000 students) in 2018. In addition, from 2017 to 2018, current e-cigarette use by middle school students increased by nearly 50 percent (from 3.3 percent to 4.9 percent).
The explosion of e-cigarette use by teens in the U.S. should not have come as a surprise to the Food and Drug Administration (FDA), the agency that has authority to regulate e-cigarettes and other tobacco products. In April 2015, the CDC had reported that by 2014 e-cigarettes had become the most commonly used tobacco products among U.S middle and high school students. And in 2016, the U.S Surgeon General issued a report concluding, among other things, that “E-cigarettes are marketed by promoting flavors and using a wide variety of media channels and approaches that have been used in the past for marketing conventional tobacco products to youth and young adults.”
The CDC’s newest findings pushed FDA Commissioner Dr. Scott Gottlieb to announce plans for new age-based restrictions on the sale of e-cigarettes and the use of flavoring that make them attractive to teens. But for the millions of young people who now are or soon will be addicted to nicotine because of e-cigarette use, the Commissioner’s proposals are too little and too late.
 Goriounova NA, Mansvelder HD. Short- and long-term consequences of nicotine exposure during adolescence for prefrontal cortex neuronal network function. Cold Spring Harb Perspect Med. 2012;2(12):a012120.