Vapes and E-Cigarettes

There is no shortage of research highlighting the health risks associated with vaping -- especially when looking at the additives that are particularly popular among younger consumers. 

A new study conducted by researchers from the University of South Florida has explored the flavor additives even further, and it found that these chemicals can increase the risk of lasting heart damage.

“The flavored electronic nicotine delivery systems widely popular among teens and young adults are not harm-free,” said researcher Sami Noujaim, PhD. “Altogether, our findings in the cells and mice indicate that vaping does interfere with the normal functioning of the heart and can potentially lead to cardiac rhythm disturbances.”

Compromising heart health

The researchers conducted experiments on both young mice and human cardiac cells to better understand how flavor additives in e-cigarettes can compromise heart health. In all of the trials, both the mice and the human cells were exposed to several different flavor additives, as well as e-vapors that didn’t contain flavorings, to understand how the health risks change. 

While e-cigarettes pose a threat to consumers’ health without adding flavors, the researchers learned that the flavor additives only exacerbated those health risks in both mice and human cells. 

For the mice, the researchers observed several changes to their normal heart functioning. The primary disturbance was heart rate, as the mice exposed to e-cigarette flavor additives were more likely to develop ventricular tachycardia, which speeds up the natural heart rate. However, other mice were also more susceptible to a slowed heart rate variability, which means the time between heartbeats is slower; this typically happens when the body is under stress, and it can increase the risk for heart disease over time. 

The researchers noted similar effects to the human cardiac cells. Even before exposing the cells to the flavor additives, the e-cigarette vapor alone affected how fast the cells were able to beat. As the researchers added both nicotine and flavoring, the cells became even more compromised, though the worst outcomes came from the addition of the flavoring.  

“This experiment told us that the flavoring chemicals added to vaping devices can increase harm beyond what the nicotine alone can do,” Dr. Noujaim said. 

Tightening restrictions

Despite efforts to regulate e-cigarettes -- especially in recent months as experts warned about the risks associated with the COVID-19 pandemic -- many young people continue to seek out flavored vaping options. The researchers hope that these findings can help cut down on the use of e-cigarettes among this demographic.

“Our research matters because regulation of the vaping industry is a work in progress,” said Dr. Noujaim. “The FDA needs input from the scientific community about all the possible risks of vaping in order to effectively regulate electronic nicotine delivery systems and protect the public’s health. At USF Health, in particular, we will continue to examine how vaping may adversely affect cardiac health.”

Youth vaping rates plunged during the COVID-19 lockdown period, according to a new survey published Thursday in JAMA Network Online. 

Roughly two-thirds (35 percent) of teen and young adult e-cigarette users said they reduced their use of the products or stopped using them altogether (32 percent). The survey found that concerns about lung health were a key factor for 1 in 4 respondents who said they either cut back or quit. 

Concerns about COVID-19 (which affects the lungs) have combined with concerns stemming from last year’s nationwide outbreak of a condition dubbed “EVALI,” short for “e-cigarette- or vaping-associated lung injury.” 

"One of the main reasons they quit is that they were worried about lung health, and we think that's important, that they thought they could hurt their lungs," said lead researcher Bonnie Halpern-Felsher, a developmental psychologist and professor of pediatrics at Stanford University in California.

Kids adhered to stay-at-home orders were 50 percent more likely to quit or reduce their vaping, researchers found. However, only 15 percent of respondents said they were motivated to quit for fear of their parents finding out about their vaping.  

Emphasizing adverse health effects

Doctors and health officials say the study results suggest that emphasizing the health risks of vaping is an effective way to get younger users to stop using the products. Although teen vaping has become less of a concern in light of the COVID-19 pandemic, experts say it’s still a major problem. 

“Vaping is still an important issue just as I think smoking is still an important issue … We've sort of forgotten about it because we've had a bigger health concern to worry about,” Dr. Nancy Rigotti, director of the Tobacco Research and Treatment Center at Massachusetts General Hospital in Boston, told TODAY.

Experts say vaping use among teens could rise again after the pandemic is over and normal social events are cleared to resume. Halpern-Felsher said e-cigarette use among minors is largely socially driven, so the problem could resurface once kids can congregate safely.

"The concern is that as soon as youth are not having sheltering in place and they're all back in school, whether we're going to see more social use again and the uptick will happen," she said.

Highlighting research showing the health effects of vaping can be an effective way to get e-cigarette users to re-think their decision to start using the products in the first place. 

"If we can emphasize that vaping is not healthy and make it appear unattractive, we will win over this generation of e-cigarette users. We'll get them to stop,” said Dr. Panagis Galiatsatos, director of the Johns Hopkins Tobacco Treatment Clinic in Baltimore.

Signs of lung damage are common among people who vape, according to a new study. 

Researchers have found that one out of every three e-cigarette users (33 percent) reported having one or more of the following symptoms: cough, shortness of breath, nausea, stomach pain, and chest pain. 

All five of these symptoms are on the list of symptoms that the CDC has said are associated with e-cigarette- or vaping-associated lung injury -- a condition known as “EVALI.”

The symptoms were less prevalent among people who used disposable e-cigarettes, said lead researcher Dr. Thanh-Huyen Vu, a research associate professor of epidemiology at Northwestern University Feinberg School of Medicine in Chicago. 

That finding suggests that experimenting with unregulated ingredients and untested devices is “risky,” Vu said. The symptoms were 40 percent more common among vapers who mixed their own e-liquids and 71 percent more common among those who used flavored e-cigarettes. 

"We did not anticipate seeing such strong and consistent relationships between the users' product modifications and the use of flavored products with clinical symptoms, including EVALI-like symptoms," Vu said. "Clinical symptoms are common in [e-cigarette] users, and they are especially prevalent for users who modify products or consume flavored products."

Health concerns

Fifty-five percent of the more than 1,400 people involved in the study said they had one or more of the systems listed above. One third (33 percent) reported having one or more of the five e-cigarette- or vaping-associated lung injury (EVALI)-like symptoms. Cough and nausea were the most common.

People who reported EVALI-like symptoms were more likely to be younger than age 45, Hispanic, current cigarette smokers, or current users of other tobacco products such as pipes or smokeless tobacco.

"Our results indicate that e-cigarette- or vaping-associated lung injury symptoms were not an oddity, a brief occurrence or solely related to the use of THC (the psychoactive component of cannabis) or vitamin E acetate, both of which were pegged as possible contributors to EVALI outbreaks in the past year or so," Vu said. 

Vu and her team said the study suggests the need for health care professionals to “assist patients in better understanding the full risks and potential harms of using e-cigarettes and related products." 

People who do vape should be careful with the products they use and “not self-modify those products,” Vu said. Better yet, she says they should not vape at all. 

"Although further research is needed on the association of vaping with EVALI and the association of lung injury with COVID-19, the existing evidence indicates that there should be concern, and it is worth avoiding this risk by not vaping," Vu said.

With more and more consumers affected by vaping-related lung illness -- otherwise known as EVALI -- experts continue to look for risk factors associated with smoking e-cigarettes. While recent studies have pointed to both vitamin E and THC as the primary sources of EVALI, a new study found that the vaping devices themselves could be to blame. 

According to researchers from the University of California at Irvine, the results from the earliest stages of a new study found that the heating source on vaping devices has been linked with an increased risk of lung damage. 

“While further research is needed, these results indicate specific devices and power settings may play a key role in the development of EVALI as much as the additives do,” said researcher Dr. Robert A. Kloner. “The harms associated with e-cigarettes and vaping simply cannot be overstated.” 

Analyzing vaping devices

The researchers didn’t set out to uncover this link between vaping devices’ heating sources and subsequent lung damage; they were initially studying the effect of vaping on consumers’ heart health. However, after the e-cigarette they had been using in their study was discontinued and participants were forced to use a different model, they observed some key differences. 

While the new vaping device was essentially the same as the first one, the heating element was different. The first device used stainless steel as the heating source, and the second device used a nickel-chromium alloy as the heating source. Though that change may not seem like it would make a massive difference, the researchers observed drastic changes to the participants’ health in a short amount of time. 

“Within an hour of beginning an experiment, we observed evidence of severe respiratory distress, including labored breathing, wheezing, and panting,” said researcher Michael Kleinman, PhD. “After analyzing lung tissue from subjects in the study, we found them to be severely compromised and observed other serious changes such as lung lesions, red blood cell congestion, obliteration of alveolar spaces, and pneumonitis in some cases.”  

Despite several studies that have pointed to the additives in e-cigarettes as the primary source of lung damage, the researchers explained that the devices they used contained no nicotine, vitamin E, or THC. The participants had been involved in the study for more than a year when they received the new vaping devices, and none of them had shown any signs of lung illness or similar health concerns up to that point. 

The researchers plan to do more work in this area to better understand how the heating element on vaping devices can be a risk to consumers’ health. However, they hope that consumers take these findings seriously and take steps to prevent severe health concerns. 

“The results were so impactful, we felt it imperative to release the initial findings early so that electronic cigarette users could be cautioned sooner, especially considering e-cigarette users are at an increased risk of COVID-19,” said Dr. Kloner. 

The number of children and teenagers who use e-cigarettes is slightly down this year, but not enough for health officials to stop calling it an “epidemic.” 

The Centers for Disease Control and Prevention (CDC) said in a release that 3.6 million youths have used e-cigarettes this year. That’s down from 5.4 million in 2019. 

"Although the decline in e-cigarette use among our nation's youth is a notable public health achievement, our work is far from over," said CDC director Dr. Robert Redfield. "Youth e-cigarette use remains an epidemic, and [the] CDC is committed to supporting efforts to protect youth from this preventable health risk."

Vaping still common among youth

The CDC, which drew its findings from the National Youth Tobacco Survey, found that 8 in 10 middle and high school students who currently vape said they use flavored e-cigarettes. The use of mint and menthol flavored vaping products was also common among the demographic.

Health officials have been attempting to curb the rise in teen vaping for several years now. Efforts to drive down the rate of vaping among youth have focused on cracking down on sales of flavored products, which have been found to appeal to minors. 

Unfortunately, researchers have found that teenagers who use e-cigarettes may be more likely to continue vaping. 

“While many children try e-cigarettes, not all become regular users,” said researcher Adam Leventhal, who worked on a 2019 study out of the University of Southern California “Teens who use e-cigarettes may be more inclined to continue vaping rather than just temporarily experiment with e-cigs.” 

“The longer and more frequently you vape, the more you’re exposing yourself to toxins in e-cigarette aerosol and put yourself at risk of nicotine addiction,” Leventhal said. 

Working to drive down the numbers

In the latest analysis of data, the CDC found that 19.6 percent of high school students and 4.7 percent of middle school students used e-cigarettes in 2020 -- down from about 27 percent and 10 percent, respectively, in 2019.

"These findings reinforce the importance of continuing to focus on the strategies that work to reduce youth tobacco product use while keeping pace with emerging trends in tobacco products," said Dr. Karen Hacker, director of CDC's National Center for Chronic Disease Prevention and Health Promotion. "Implementing these strategies at the national, state and local levels is integral to preventing and reducing youth tobacco product use, including e-cigarettes.”

In a statement, FDA Commissioner Dr. Stephen Hahn said the agency “remains very concerned about the 3.6 million U.S. youth who currently use e-cigarettes” and that it “will do everything possible” to stop the health crisis. 

"The findings come as we mark today's premarket review submission deadline, a milestone for ensuring new tobacco products, including many already on the market, undergo a robust scientific evaluation by the FDA,” Hahn said. “Scientific review of new products is a critical part of how we carry out our mission to protect the public -- especially kids -- from the harms associated with tobacco use.”

On Monday, a flavored tobacco product ban (SB 793) was unanimously approved by the California Assembly. 

SB 793 will prohibit the retail sale of flavored tobacco products, flavored e-cigarettes, and flavored vaping products in the state. The legislation is part of a larger effort to curb rates of flavored tobacco use among children, to whom the products tend to appeal.

Supporters of the legislation said it would help reduce rates of smoking and vaping among children and teenagers who use them specifically because they come in flavors like menthol, cotton candy, and gummy bears. 

Health experts have raised concerns that the high rate of flavored tobacco use among minors threatens to derail progress in curbing overall smoking rates. 

“These flavors are marketed to kids and people of color to ensure tobacco companies have a clientele on the hook for life,” said Assembly Speaker Anthony Rendon (D-Lakewood).

Exemption for some products 

During the legislative process, the bill was modified to include an exemption for some premium cigars. The bill defines “premium” as “any cigar that is handmade, is not mass produced by use of mechanization, has a wrapper that is made entirely from whole tobacco leaf, and has a wholesale price of no less than twelve dollars ($12). A premium cigar does not have a filter, tip, or non-tobacco mouthpiece and is capped by hand.”

“It’s the most deadly consumer product ever created,” Assemblyman Jim Wood (D-Healdsburg) said during Monday’s floor debate. “In a perfect world, there would be no exemptions to this bill, but we all know we don’t live in a perfect world.”

Assemblyman Heath Flora (R-Ripon) said exempting cigars, hookah products, and cannabis threatens to leave open a loophole that could put kids at risk. 

“If we actually cared about the kids, we would deal with some of the other industries as well,” he said.

The measure -- which is supported by the American Lung Association in California, American Heart Association, and American Cancer Society -- now faces one more vote in the Senate before heading to Gov. Gavin Newsom’s desk. 

Earlier this year, U.S. lawmakers crafted and passed a new policy that banned certain e-cigarette products that were popular with America’s youth. Now, regulators are asking for more e-cigarette products to be taken off the market -- but for a very different reason. 

Rep. Raja Krishnamoorthi (D-IL) sent a letter to FDA Commissioner Dr. Stephen M. Hahn this week to request that e-cigarette products be pulled from circulation due to additional risks they create in connection with the coronavirus. In the letter, Krishnamoorthi cites studies that suggest COVID-19 is even more dangerous for e-cigarette smokers.

“Today, we have the evidence that the FDA was waiting for, and it can no longer deny the danger e-cigarettes pose during the coronavirus crisis. The science is now in: e-cigarette users are much likelier to be diagnosed with COVID-19 and to experience symptoms,” Krishnamoorthi stated. 

Increased risk of infection

The evidence that the letter refers to is from a study conducted at Stanford University that gauged the risk of contracting COVID-19 in young e-cigarette smokers aged 13 to 24. The results suggest that this demographic is up to five times more likely to contract COVID-19 than those who don’t vape e-cigarette products. 

The statistics are even worse for those who vape e-cigarettes and smoke traditional cigarettes. These dual users were almost seven times more likely to be diagnosed with COVID-19 and nearly five times more likely to experience symptoms of the virus. Krishnamoorthi says that these numbers are putting a considerable burden on the nation’s COVID-19 testing system and leading to increased waiting times for results. 

“If we reduce the number of vapers in America, we will reduce the unnecessary stress we are putting on our testing system. People should not have to wait weeks for COVID-19 test results -- removing the risk posed by vaping will help,” he said.

The letter asks the FDA to confirm in writing within the next week whether or not will take e-cigarettes off the market. If the agency chooses to do so, it is also tasked with providing a description of its action plan. 

Several recent studies have highlighted the serious health risks associated with vaping. Because of how many young people have taken up the habit, lawmakers have worked to make it harder for minors to purchase e-cigarettes. 

Now, researchers from the European Society of Cardiology are focusing on how consumers’ heart health can be at risk due to vaping. The researchers are still citing large numbers of young people using e-cigarettes, and the habit has been linked with an increased risk of blood clots, high blood pressure, and heart attacks, among other risks. 

“Vaping is marketed towards teenagers and the tobacco industry uses celebrities to promote it as being healthier than smoking,” said researcher Maja-Lisa Løchen. “Action is urgently needed to halt the growing use in young people. The World Health Organization (WHO) states that e-cigarettes are harmful to health.” 

Risks to heart health

Though the risks associated with vaping continue to be documented by experts, the researchers focused specifically on cardiovascular health for this report. Because so many young people are using e-cigarettes, the long-term effects of vaping are cause for concern. The researchers analyzed several recent studies to explore how vaping is negatively affecting consumers’ heart health. 

While many were under the impression that vaping was healthier than traditional cigarettes, the researchers want to emphasize that this is not the case. Vaping can complicate heart health in countless ways. Ultimately, the consistent use of e-cigarettes can increase the risk of heart attack because vaping can lead to permanent damage to consumers’ blood vessels and arteries. The researchers say the habit can also increase the risk for blood clots. 

However, the risks don’t always start out so drastic. Oftentimes, consumers first experience changes to heart rate or blood pressure, which can lead to other, more serious, complications over time. Recent studies have also highlighted the stress vaping can put on the lungs and the harm caused by the chemicals used in e-cigarettes. 

Protecting consumers’ health

Moving forward, the researchers hope that future messaging about vaping is clear and that lawmakers do their part to enact measures that make it more difficult for young people to have access to e-cigarettes. 

“E-cigarettes are a relatively new product and the long-term health effects are unknown,” said Løchen. “Now is the time for politicians and regulators to act -- with public health campaigns to increase awareness and legislation to halt uptake in young people.” 

The U.S. Food and Drug Administration (FDA) is clamping down on a company selling a kind of fruity disposable e-cigarette product called Puff Bar e-cigarettes, which are popular among teenagers.

In warning letters to the manufacturer of Puff Bar vapes and nine other companies, the FDA said Puff Bar e-cigarettes -- which come in “youth-appealing” flavors like mango, pink lemonade, and strawberry -- must be pulled from the market within 15 business days. 

The FDA said the companies never received permission to sell the products in the United States. 

"We are concerned about the popularity of these products among youth and want to make clear to all tobacco product manufacturers and retailers that, even during the ongoing pandemic, the FDA is keeping a close watch on the marketplace and will hold companies accountable," FDA Commissioner Stephen Hahn said in a statement. 

Similar to Juul products

The agency added that it’s continuing to take action against companies selling unauthorized e-cigarette products, even in the midst of the pandemic. 

“These warning letters are the result of ongoing internet monitoring for violations of tobacco laws and regulations,” said Mitch Zeller, J.D., director of the FDA’s Center for Tobacco Products. 

The FDA’s action closes a loophole it left earlier this year when it cracked down on flavored e-cigarettes. Disposable vaping products like Puff Bar are similar to Juul products, but Puff Bar vaping products somehow evaded the FDA’s ban. 

The agency warned the companies that received letters that failure to correct violations could result in further action, such as civil money penalties, seizure, or injunction.

Juul, the maker of a popular e-cigarette product, has reportedly told federal regulators that it is willing to redesign its vaporizer so that it unlocks only for people 21 years of age or older.

The Wall Street Journal quotes people “familiar with the matter” as saying that the company is willing to make this accommodation in order to keep its products legal in the United States.

The Food and Drug Administration (FDA) has the authority to regulate e-cigarette products, as well as all tobacco products. For manufacturers of e-cigarettes, the companies must demonstrate that their products present a “net benefit to public health.” 

That’s widely interpreted as meaning the products help adult smokers kick their cigarette habit by switching to e-cigarettes, which deliver nicotine in vapor form. While that’s a noble objective, public health officials have sounded the alarm over a huge increase in young people getting hooked on nicotine through “vaping.”

Former Food and Drug Administration (FDA) Commissioner Dr, Scott Gottlieb has accused Juul, in particular, of luring young people into the nicotine habit through vaping.

Juul proclaims its innocence 

Juul, in which tobacco company Altria is a stakeholder, has professed its innocence. It says it intends to provide the FDA with more than 250,000 pages of scientific research and marketing materials, as well as an update on its efforts to curb illegal sales to minors, to prove that it has not been marketing to young people. 

Juul also says it plans to submit additional paperwork over the next three to five years, including an application to market its products as less harmful than cigarettes, to show that its mission has been to help smokers kick their smoking habit.

The company has reportedly submitted an application to the FDA that says its product can combat underage use of e-cigarettes by locking the cartridge where the vaping liquid is stored. That would prevent a user from replacing the liquid with one that is more desirable.

Juul has been working on this solution for some time. It has introduced products in the U.K. and Canada that allow the cartridge to be locked or unlocked using a Bluetooth connection to a mobile app. 

Users must submit a photo of themselves and government identification. The app also allows users to monitor their nicotine consumption.

The change addresses a new U.S. law that bans sweet and fruity e-cigarette cartridges because underage users tend to favor these flavors rather than the tobacco flavored liquids that are used to wean smokers away from cigarettes.

There has been no shortage of e-cigarette news as of late. Many experts say that the popular devices could be just as detrimental to consumers’ health as traditional cigarettes. 

While e-cigarettes contain a number of harmful chemicals, researchers from the University of California Riverside have now found that they also have harmful levels of metals. The researchers are most concerned about the levels of zinc, as exposure to the metal in these quantities can lead to several health concerns, including damage to consumers’ DNA. 

“Our study found that e-cigarette users are exposed to increased concentrations of potentially harmful levels of metals -- especially zinc -- that are correlated to oxidative DNA damage,” said researcher Prue Talbot. 

Harm to the body

To understand what effect these high levels of zinc can have on the body, the researchers analyzed how e-cigarettes affected 50 participants. The group was made up of cigarette smokers, e-cigarette smokers, and non-smokers so the researchers could best assess how e-cigarettes affect consumers with different smoking habits. 

The researchers tested the participants for certain biomarkers that are genetic indicators of disease or environmental exposures. They collected urine samples from all of the participants and evaluated their DNA responses. 

E-cigarette smokers were more likely than participants from the other two groups to present with genetic concerns related to metal exposure. The researchers found that e-cigarette smokers had higher levels of three biomarkers due to unsafe exposure to metals; each biomarker was related to oxidative damage to DNA. 

This is cause for concern, as damage to DNA can worsen if consumers use e-cigarettes over longer periods of time. This can increase their risk for any number of serious health conditions. According to researcher Shane Sakamaki-Ching, “prolonged use [of e-cigarettes] may lead to disease progression.” 

The researchers hope that consumers are mindful of these findings and that they understand the risks related to using e-cigarettes. 

“Given the recent deaths and pulmonary illnesses related to e-cigarette usage, everyone should be made aware of the potential health risks linked to e-cigarette usage,” said Talbot. 

Massachusetts’ Attorney General (AG) Maura Healey has filed a lawsuit against the e-cigarette company JUUL for its role in creating what she calls a “youth vaping epidemic,” and for its marketing ploys intended to lure youth to e-smoking.

The lawsuit demands that JUUL pay for all costs associated with Massachusetts's efforts in  countering the “public health crisis” that’s touched more than half of the state’s adolescents.

“JUUL, more than any other company, bears responsibility for the fact that millions of young people nationwide are now addicted to e-cigarettes, reversing decades of progress in combating underage tobacco and nicotine use and addiction,” Healey wrote in the complaint.

Going for the “cool crowd”

The new lawsuit is an interesting window into JUUL’s marketing plan. The strategy appears to be built around building awareness by targeting the “cool crowd” -- young people who are considered “fashionable, urban with a vibrant life,” and “enjoy[ed] going out to shows and events.” That includes a crowd, the AG points out, that’s not even of legal age to buy e-cigarettes. 

The complaint goes on to point out that JUUL paid little or no attention to how old the people it was marketing to actually were. Specifically, JUUL...

• Sold the under-18 market its product “even when (the youth) supplied dates of birth to JUUL that established they were younger than the local minimum legal sales age.” 

• Ignored the age verification tools it put in place when distributing marketing materials, according to the attorney general’s allegations. 

“Approximately 40,000 email addresses on JUUL’s email marketing list were associated with records of individuals who had ‘failed’ JUUL’s own age verification process,” read the complaint. On top of that, 83 percent of the estimated 420,000 email addresses on JUUL’s marketing list weren’t able to be matched with the record of someone at least 18 years old.

Advertising on youth networks

The lawsuit brings to light an onslaught of JUUL marketing on websites and TV networks that are “highly attractive to children, adolescents in middle school and high school, and underage college students.”

JUUL was found to have advertised on child favorites, such as Nickelodeon's Nick.com and NickJr.com. But the company didn’t stop there; it also bought ads on the Cartoon Network’s website and other websites generally designed for children such as allfreekidscrafts.com, hellokids.com, and kidsgameheroes.com. 

JUUL also reportedly purchased advertising on sites that younger girls favor such as dailydressupgames.com, didigames.com, forhergames.com, games2girls.com, girlgames.com, and girlsgogames.com. 

While most of what happens in Washington, D.C. happens at a snail’s pace, it was only a matter of months after the Trump administration called for a ban on e-cigarettes that it was put to work. Effective Thursday, that plan went into effect.

The ABC’s of the policy

The essential things consumers need to know about the policy are pretty straightforward:

• While it’s called a “ban,” it’s not a law and it’s not binding -- at least not at the moment.

• What’s covered is the manufacturing, distribution, and sale of flavored (e.g. fruit and mint) vaping cartridges or pods. An example of those would be what Juul was offering prior to the ban.

• Disposable vapes that use an open-tank system, and their respective flavored e-liquids, are not banned.

• Flavored “e-liquid” that’s not packaged in a cartridge is not banned, either.

If you happen to see an e-cigarette on the market, it’s there illegally. The Food and Drug Administration (FDA) has not given any e-cigarette manufacturer “premarket authorization” and it continues to put violators in its crosshairs. 

“Our review of premarket product applications will help evaluate the public health benefits and harms of a tobacco product to ensure that those authorized for marketing are appropriate for the protection of public health,” said Acting FDA Commissioner Ned Sharpless, M.D. 

“This will include understanding the likelihood that those who do not use tobacco products – such as kids – will start using them, as well as the likelihood that tobacco users will stop.” The FDA’s intention is to prioritize the shutdown of flavor cartridge-based vaping products. Menthol and tobacco flavors are not included in the policy.

Teens continue to be the focus

The number one goal of both the FDA and the U.S. Department of Health and Human Services (HHS) is keeping teens from falling into the e-cig trap. 

“The United States has never seen an epidemic of substance use arise as quickly as our current epidemic of youth use of e-cigarettes,” said HHS Secretary Alex Azar. “HHS is taking a comprehensive, aggressive approach to enforcing the law passed by Congress, under which no e-cigarettes are currently on the market legally.”

To that end, the FDA just rolled out “The Real Cost,” a video campaign featuring teenagers sharing cautionary tales about their e-cigarette addiction. In one of the series, called “My Vaping Mistake,” teenagers get personal about the physical and emotional effects vaping addiction had on their lives. 

“We will not stand idly by as this crisis among America’s youth grows and evolves, and we will continue monitoring the situation and take further actions as necessary,” Azar said.

Getting around the ban

Agencies behind the ban have their work cut out for them. The New York Times reported just last week that teens have already found a loophole in the ban and are working it to their advantage.

The wrinkle in the ban? Disposable vapes.

“Students were telling me that everybody had gone to Puff Bars, which are disposable,” Lauren W. Williams, a teacher at McCracken County High School in Kentucky told the Times. “The one we confiscated here this week is Banana Ice. Students are not using Juuls anymore because no one wants menthol or tobacco.”

Possible exceptions

It’s important to note that individual states may have their own vaping bans. Two examples are North Carolina and Missouri. According to Bloomberg Government, law-enforcement agencies in two states have told stores that sell cigarettes that state enforcement of tobacco rules isn’t changing yet, even though federal law prohibits the sale of e-cigarettes and vaping devices to minors. 

The reason isn’t a lack of desire. It has more to do with the layers and layers of getting statewide regulations into play. 

“You can’t just turn a battleship around on a dime,” Mike O’Connell, communications director for the Missouri Department of Public Safety, told Bloomberg.

The Centers for Disease Control and Prevention (CDC) is continuing to update consumers on the number of lung illness (EVALI) cases that are connected to vaping. In its latest advisory, the agency points to new evidence that devices containing THC are part of the problem. 

THC, or tetrahydrocannabinol, is the chemical in marijuana that produces a psychological “high.” The agency says that e-cigarette devices that contain THC were linked to 82 percent of EVALI cases as of January 14. Overall, 33 percent of consumers who developed EVALI reported that they only used a THC-containing device before becoming ill. 

With those numbers in mind, the CDC has adjusted its advisory to focus more on warning consumers to avoid THC-containing e-cigarettes.

“The EVALI outbreak primarily affects young adults, is driven by use of THC-containing products from informal sources and is strongly linked to vitamin E acetate,” the agency stated. “CDC and FDA recommend that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, or family, or in-person or online dealers.”

“THC use has been associated with a wide range of health effects, particularly with prolonged frequent use. The best way to avoid potentially harmful effects is to not use THC-containing e-cigarette, or vaping, products.”

Cases continue to decline

While the CDC continues to narrow down the factors related to these lung illnesses, the number of EVALI cases continues to decline. 

As of January 14, 2,668 consumers had been hospitalized nationwide due to lung illnesses linked to e-cigarette use. There have also been 60 reported deaths from 27 states and the District of Columbia, and officials say these cases are still under investigation. 

Consumers in Illinois and Texas have been hit hardest by this outbreak of illnesses, with each state experiencing between 200-249 hospitalizations. Cases of EVALI peaked last September but have slowed to a trickle in 2020. 

For more information, consumers can visit the CDC’s website here.

As e-cigarette-related deaths and illnesses affected dozens of consumers at the end of 2019, lawmakers tried doing their part to ensure that young people couldn’t continue the life-threatening habit. 

However, a new study conducted by researchers from the University of California at San Francisco found that products made by Juul have more nicotine than any other e-cigarette brand or even traditional cigarettes. 

“The comparison of cardiovascular health effects of Juul use with those of previous generation e-cigs and combusted cigarettes is an important issue for policymakers, including the FDA and comparable bodies outside the United States,” said researcher Matthew Springer, PhD. “Our findings show that the adverse effects of cigarettes on vascular endothelial function, which has been a known consequence of cigarette smoking since the 1990s, is not prevented using Juul.” 

Evaluating health effects

To see how Juul stacks up against other e-cigarette and regular cigarette brands, the researchers tested the vitals of rats after exposure to various kinds of nicotine. 

The researchers divided the rats into four testing groups and exposed them to vapor from e-cigarettes produced by Juul, traditional cigarette smoke, vapor from an e-cigarette with freebase nicotine, or clean air. The rats inhaled their substance 10 times over the course of five minutes, with each inhalation lasting two seconds. 

Following the trials, the researchers tested the rats’ blood vessel function and also collected blood samples to determine how their health was compromised, if at all, by their chosen supplement. 

The study revealed that inhaling Juul vapor was the most dangerous for the rats, as they were exposed to far more nicotine in that brand than in either the traditional cigarette or the other e-cigarette brand that was tested. 

Juul had five times more nicotine than a traditional cigarette and eight times as much nicotine as the other e-cigarette that was tested. 

The researchers explained that because of the varying nicotine levels in cigarettes and e-cigs, smokers who are new to e-cigarettes could try to keep their nicotine consumption the same on the device. However, this could become problematic for younger smokers who are new to the habit. The researchers urge consumers to understand how this could be detrimental to young people’s health. 

“...Adolescent non-smokers who are not familiar with the effects of nicotine may be more likely to chase higher levels of the drug’s effects,” said Dr. Springer. “The ease of over-consuming nicotine with Juul makes this likely, especially in light of reports of teenagers binging on Juul to the point of rapid addiction and behavioral consequences.” 

Reports in recent weeks have suggested that the Food and Drug Administration (FDA) was getting ready to ban a litany of flavored cartridge-based e-cigarettes. On Thursday, those speculations became reality as the agency finalized its enforcement policy on the issue.

In a press release, the agency said its decision is motivated by the desire to stem the tide of youth vaping in the U.S., which has been called an “epidemic” by officials.

“The United States has never seen an epidemic of substance use arise as quickly as our current epidemic of youth use of e-cigarettes,” said Health and Human Services (HHS) Secretary Alex Azar. 

“By prioritizing enforcement against the products that are most widely used by children, our action today seeks to strike the right public health balance by maintaining e-cigarettes as a potential off-ramp for adults using combustible tobacco while ensuring these products don’t provide an on-ramp to nicotine addiction for our youth.”

Policy takes place within 30 days

The FDA says that the new policy will be enforced within 30 days after it has been submitted to the Federal Register for publication. After that time, the agency says that it will begin enforcement actions against illegal electronic nicotine delivery systems (ENDS) that fit the following description:

• Any flavored, cartridge-based ENDS product (other than tobacco- or menthol-flavored ENDS product);

• All other ENDS products for which the manufacturer has failed to take (or is failing to take) adequate measures to prevent minors’ access; and 

• Any ENDS product that is targeted to minors or likely to promote use of ENDS to minors.

In other words, the agency will aggressively pursue legal action against companies who sell e-cigarettes or e-liquids that have flavors other than tobacco and menthol, and it will be paying special attention to how products are marketed to young people.

“Coupled with the recently signed legislation increasing the minimum age of sale of tobacco to 21, we believe this policy balances the urgency with which we must address the public health threat of youth use of e-cigarette products with the potential role that e-cigarettes may play in helping adult smokers transition completely away from combustible tobacco to a potentially less risky form of nicotine delivery,” said FDA Commissioner Dr. Stephen M. Hahn.

The Food and Drug Administration (FDA) spent the better part of 2019 stepping up the pressure on e-cigarettes. This year, the FDA may move from pressure to outright bans of certain types of “vaping” devices.

The Wall Street Journal cites “people familiar with the matter” as saying the agency will move within days to ban fruit-flavored cartridge e-cigarettes because they are believed to be most appealing to children and young adults. The move would allow the continued sale of tobacco and menthol-flavored tank system devices.

According to the Journal report, the FDA, which has expressed increasing concern about teen use of vaping devices, had to compromise with other elements of the Trump administration because of political concerns.

Political non-starter

An outright ban on e-cigarettes that some favored was seen as a political non-starter because it would cause too much discontent during an election year. An outright ban was also seen as a potential economic blow to small businesses.

Since the objective is to discourage teen vaping, the compromise was viewed as workable because teens prefer the flavored cartridge systems like Juu. Open tank devices are typically favored by older adults who are using e-cigarettes in an attempt to quit smoking.

The report says the FDA could announce the ban within days. It would follow a move by Congress two weeks ago to raise the legal age for purchasing both tobacco and e-cigarettes from 18 to 21.

Former commissioner began the campaign

The FDA’s campaign against e-cigarettes began under former FDA Commissioner Scott Gottlieb, who resigned in early March. At the beginning of last year, Gottlieb called the growing teen use of e-cigarettes “an epidemic” and first raised the possibility of an outright ban if surging teen use continued.

“I still believe e-cigs offer an opportunity for currently addicted adult smokers to transition off cigarettes and onto products that may not have the same level of risks,” Gottlieb wrote in a tweet last January. “But if youth use continues to rise, the entire category faces an existential threat.”

Gottlieb singled out Juul for special criticism as he left office in April, saying there is no question the company bears some responsibility for the surging levels of teen vaping. 

Gottlieb cited research showing that an estimated 37 percent of high school seniors have tried e-cigarettes. A quarter of youth users told researchers they didn’t realize the products contain nicotine.

In November, Juul voluntarily stopped selling mint-flavored products. Previously, it halted sales of its mango, creme, and cucumber flavors. With mint dropped from its offerings, Juul now only offers tobacco and menthol flavors. 

In the last few months of 2019, record numbers of vaping-related illnesses and deaths were plaguing consumers, and researchers ultimately made a connection between these incidents and the chemical vitamin E acetate. 

Now, researchers from Ohio State University Wexner Medical Center found that the connection between vitamin E acetate and vaping-related deaths could be stronger than initially anticipated. 

The role that vitamin E acetate plays

Experts have dubbed vaping-related illnesses EVALI. To better understand how vitamin E acetate contributes to the condition, the researchers tested lung fluid in participants. Having fluid in the lungs is typically associated with lung disease, so this process would give the researchers a clear picture of how consumers are affected by vaping and vitamin E acetate. 

The researchers worked hand-in-hand with the Centers for Disease Control and Prevention (CDC) to get these fluid samples from public health facilities, comparing nearly 100 patients with no history of EVALI with 51 patients who had been diagnosed with the condition. 

Based on the test results, the researchers discovered that all but three of the EVALI patients tested positive for fluid in their lungs, whereas those who didn’t vape and had no connection to EVALI were free of any lung fluid. 

Making change

As the vaping death toll continued to rise at the end of 2019, policymakers began getting involved in an effort to regulate the vaping industry. Moving forward, the researchers hope that these findings can help propel that momentum even further and ensure that the source of such health concerns can be targeted appropriately. 

“These findings support the conclusion that vitamin E acetate is a potential causative agent of EVALI, and that it is an important discovery as decisions are made about how to best regulate the rapidly evolving e-cig industry,” said researcher Dr. Peter Shields. 

The Centers for Disease Control and Prevention (CDC) released an update today on the number of hospitalizations and deaths associated with EVALI.

EVALI -- or “E-cigarettes or Vaping product use Associated Lung Injury” -- was a condition coined by the agency earlier this year after a rash of mysterious hospitalizations and deaths that were linked to vaping. After extensive investigations into the issue, the CDC connected these illnesses with the presence of Vitamin E acetate in certain e-cigarette products.

As of December 17, the agency says that there have been 2,506 hospitalizations in all 50 states and the District of Columbia that are linked to EVALI. The agency has also confirmed 54 deaths to these illnesses in 27 states and the District of Columbia.

“Adults who continue to use e-cigarette, or vaping, products, should carefully monitor themselves for symptoms and see a healthcare provider immediately if they develop symptoms like those reported in this outbreak,” the CDC stated.

Increasing legal age to buy

The number of deaths and illnesses brought on by EVALI may have been a huge part of the decision by lawmakers this week to increase the minimum age for buying tobacco and e-cigarette products to 21. 

The move was broadly supported by both Republicans and Democrats in the Senate and House of Representatives, and it is expected to be passed into law by the President’s signature in the near future. Lawmakers say passage of the bill will have important health implications for consumers of all ages in the U.S.

“By raising the age to buy tobacco products nationwide, we can save 223,000 lives and reduce youth tobacco use,” said Senator Tim Kaine (D-Va.), who was one of the bill’s co-sponsors.

Juul, the grand potentate of e-cigarettes, has taken another punch in the gut. 

In a study just released by Portland State University (Oregon), researchers found that the formula Juul uses for its e-cigarettes is almost a dead-ringer for both the addictive composition and the flavor of Marlboro cigarettes. Or, in their own words, Juul is nothing more than an “analog” version of Marlboro.

Déjà vu?

Previous research showed that the nicotine levels in tobacco-based cigarette smoke is “much higher than those in early e-liquids.”If this sounds familiar to the nicotine controversy of the ‘90s, there are some similarities. 

“The distribution of nicotine ... has been manipulated in tobacco smoke and now in electronic cigarettes by the use of acids to de-freebase nicotine and form ‘nicotine salts’” wrote the researchers. “The design evolution for e-cigarettes has made them more effective as substitutes to get smokers off combustibles. However, this evolution has likely made e-cigarette products vastly more addictive for never-smokers.”

“It becomes obvious why novice users, people who’ve never smoked before, find it easy to try Juul,” researcher David Peyton told Reuters. “And once you try it, you’re getting dosed with a high concentration of nicotine.”

The Goldilocks Principle

Maybe Marlboro didn’t want to see its $12.8 billion investment in Juul go up in smoke, but it had to know that this vaping thing could turn out bad for everyone involved.

“For Marlboro, by using additives and/or blend manipulation … [it accomplished] a Goldilocks principle solution (ie, not too harsh, not too mild),” the researchers wrote, further noting the “human affinity for the sensory bite” similar to carbonated beverages.

One of the key reasons why teens and young adults are drawn to e-cigarettes like Juul is the flavor. In a parallel study that was just released, researchers found that the “smoothness” of e-cigarettes is a “cross-cutting mediator” when compared to the bitter taste of tobacco. 

“Sweetness may also mediate appeal-enhancing effects of fruit and appeal-reducing effects of nicotine. Non-tobacco flavours may suppress appeal-reducing effects of nicotine in e-cigarettes through attenuation of nicotine’s aversive taste attributes,” the researchers concluded.

Where does Juul go from here?

Maybe it’s time for Juul to cut bait and go home. It was recenlty forced to give up its popular mint-flavored pods, and the FDA has repeatedly called the company out for playing a large role in the teen vaping crisis. Its CEO even apologized to the parents of teens hooked on its product.

Where the company is going is anyone’s guess, but it’s possible Juul can find a way out of the woods of woe it keeps walking into, primarily the one where all its teen consumers are.

“Youth use of vapor products is detrimental to our mission, and to our business,” the company recently wrote on its website. “Our target market is the one billion adult smokers globally, more than 70 percent of whom want to quit using combustible cigarettes (per CDC). Offering these adult smokers a real alternative to cigarettes is a public health and commercial opportunity of historic proportions, with over 7 million preventable deaths per year caused by cigarettes. Youth use puts this all at risk.”

“Through shared effort, we can significantly reduce youth access to, and usage of, all vapor products, including JUUL, while at the same time ensuring that adult smokers can access a product that is helping millions of them switch from combustible cigarettes – a goal we all share.”

Consumers who use e-cigarettes in hopes of quitting smoking may not be helping their cause. In fact, a recent study suggests that it could be raising their risk for respiratory disease.

While the products were originally created and marketed as an alternative to traditional cigarettes, study findings show that many consumers are using them in addition to traditional cigarettes. That, the research team says, demonstrates that the products should not be used as a stop-gap for consumers looking to quit smoking completely.

“Although switching from combustible tobacco, including cigarettes, to e-cigarettes theoretically could reduce the risk of developing respiratory disease, current evidence indicates high prevalence of dual use, which is associated with increased risk beyond combustible tobacco use,” the researchers concluded. 

“For most smokers, using an e-cigarette is associated with lower odds of successfully quitting smoking. E-cigarettes should not be recommended.”

Dangerous dual use

To come to their conclusions, researchers from the Center for Tobacco Control Research and Education collected data on e-cigarette use over a three-year period from consumers who used the devices. Participants, ranging in age from 18 to 74, answered questions about their e-cigarette use and health.

While the findings showed that participants who switched from using traditional cigarettes to exclusively using e-cigarettes could lower their risk for respiratory disease, the researchers say that less than one percent of participants at two checkpoints in the study were able to completely make that switch. Instead, they said the vast majority continued to use both traditional cigarettes and e-cigarettes after beginning to use the latter. 

To make matters worse, findings showed that consumers who used both e-cigarettes and traditional cigarettes were 3.3 times more likely to develop respiratory disease when compared to participants who had never used either product.

“Dual use of e-cigarettes and combustible tobacco (including cigarettes) is more dangerous than using either product alone,” the team concluded. 

Deaths and hospitalizations continue to rise

The findings come in the wake of a stark update from the Centers for Disease Control and Prevention (CDC). As of December 10, the agency estimates that over 2,400 hospitalizations linked to vaping and e-cigarette use had occurred in the U.S. Fifty-two deaths in 26 states have also been tied to the devices.

Unfortunately, the number of deaths and injuries have not stopped young people from using the devices. A report published earlier this month showed that over 6.2 million middle and high school students used tobacco within the previous 30 days, with much of that number being attributed to e-cigarette use. 

“Youth use of any tobacco product, including e-cigarettes, is unsafe. It is incumbent upon public health and healthcare professionals to educate Americans about the risks resulting from this epidemic among our youth,” said CDC Director Robert R. Redfield.

Around 6.2 million middle and high school students used tobacco in the past 30 days, according to data released Thursday in the 2019 National Youth Tobacco Survey from the CDC. The latest figures are up 3.6 million from last year and represent the highest level since 2000. 

CDC officials attributed the spike in tobacco use among teenagers to e-cigarettes. For the sixth consecutive year, e-cigarettes were the most commonly used tobacco product among teenagers, the survey found. 

More than half of students (55 percent) who took the survey reported using e-cigarettes only. Other tobacco products used by adolescents included cigars, cigarettes, smokeless tobacco, hookahs, and pipe tobacco. Around 31 percent of high schoolers and 12 percent of middle school students said they had used some type of tobacco product within the past 30 days. 

“Given the evolving variety and availability of tobacco products, surveillance for all forms of youth tobacco product use and associated factors is important to inform action at the national, state, and community levels,” the CDC said in a statement.

Increases in youth tobacco use

The CDC said curiosity and misperceptions of health risks have played a role in the growing popularity of e-cigarettes among adolescents. To counter their rise in use among teens, CDC Director Robert R. Redfield said it’s “incumbent” to increase education surrounding the health risks of the products.  

“Our Nation’s youth are becoming increasingly exposed to nicotine, a drug that is highly addictive and can harm brain development,” he said in a statement. “Youth use of any tobacco product, including e-cigarettes, is unsafe. It is incumbent upon public health and healthcare professionals to educate Americans about the risks resulting from this epidemic among our youth.”

E-cigarettes come in flavors that have been found to appeal to youth users. Nearly a quarter (22 percent) of middle and high school students who participated in the 2019 poll said they used e-cigarettes because “they are available in flavors, such as mint, candy, fruit, or chocolate.” 

The products have also been marketed in a way that health officials have deemed problematic, as it appeared to speak directly to youth users. Nearly 9 in 10 students reported having been exposed to tobacco product advertisements from at least one source.

Juul recently agreed to stop marketing its products altogether in an effort to minimize its appeal to teen users. Lawmakers are also considering banning flavored products and raising the minimum age to buy the products.  

In September, President Trump said the FDA would soon release some "very strong recommendations" regarding the sale of flavored e-cigarettes. An official policy has yet to be announced. 

The New York City Council has voted 42-2 to ban all non-tobacco flavored e-cigarettes. Mayor Bill de Blasio is set to sign the bill or allow its passage into law, according to his deputy press secretary. 

The bill was introduced in an effort to combat a surge in teen vaping. Federal health officials and regulators have expressed concern about the rise in teen vaping and have attributed it to the growing popularity of these products and the availability of fruity and minty flavors. 

“This bill would ban the sale of flavored electronic cigarettes and flavored e-liquids in New York City, including mint, menthol and wintergreen electronic cigarettes and e-liquids,” the ordinance states. 

Flavored products popular among teens

Studies have found that teenagers tend to prefer fruit, mint, and candy-flavored e-cigarette products. A National Institutes of Health-funded study published earlier this month found that less than two percent of teenagers who vape said their favorite flavor was tobacco. 

"New York City is finally addressing a public health crisis which has been mounting for years while state and local governments across the nation did next to nothing. We are finally taking action to address the resurgence of youth nicotine addiction caused by e-cigarette usage," Mark Levine, who introduced the legislation and is chair of the council's health committee, said in a statement to CNBC. 

"With this vote, the City Council is moving to ban the fruity, minty, candy-like flavors of e-cigarettes which were clearly designed to appeal to young people in the first place.”

Health concerns

The move to combat the rise in teen vaping comes amid growing concern about the health effects of the products. In recent months, a lung illness associated with vaping claimed 42 lives and sickened at least 2,100 people. 

The Trump administration is currently mulling whether or not to ban flavored vape pods or raise the minimum e-cigarette age to “21 or so” to reduce teen vaping numbers.

Attorneys general in New York, California, and Washington, D.C. have filed lawsuits claiming e-cigarette maker Juul used deceptive and illegal marketing practices to target young users. 

Juul has maintained that it’s committed to minimizing its appeal to youth users and “earning the trust of society by working cooperatively with attorneys general, regulators, public health officials, and other stakeholders to combat underage use and convert adult smokers from combustible cigarettes.” 

The company recently stopped sales of fruit and mint-flavored vape products and suspended all broadcast, print, and digital product advertising in the U.S.

New York is following the lead of other states, counties, and school districts in suing Juul for allegedly marketing to teenagers through the use of a “deceptive and illegal” campaign. 

The state’s Attorney General, Letitia James, announced the lawsuit on Tuesday and said she has no doubt that the company’s actions caused minors to become addicted to its products. In the complaint, James accuses Juul of marketing directly to teens by advertising its fruit flavored products on social media and downplaying the fact that the products contain nicotine. 

"Juul is putting countless New Yorkers at risk and compromising the health of millions of young people," James said at a press conference. "There is no doubt that Juul ... has caused this addiction."

Rise in teen vaping

Lawmakers have previously said they believe e-cigarette manufacturers like Juul must be held accountable for their role in creating and fueling the youth vaping epidemic. 

Meanwhile, Juul has said it’s just as concerned as regulators that its products are falling into the hands of underage users instead of its target demographic, “the world's 1 billion adult smokers.” James claims in the lawsuit that Juul “took a page from Big Tobacco’s playbook” when it allowed young consumers to purchase its products.

“JUUL’s advertising and social media posts misled consumers about the content of its products by failing to warn that they contain nicotine, a highly addictive chemical that is particularly dangerous for adolescents,” the complaint alleges.

Similar lawsuits

Earlier this week, California filed a similar lawsuit against Juul. The state’s Attorney General, Xavier Becerra, accused the e-cigarette maker of targeting minors through its marketing tactics and product design. 

The suit also accuses the company of using a “flawed” age-verification process for online sales and failing to properly warn consumers of the fact that they would be exposed to chemicals associated with cancer and birth defects.

“We’ve worked too hard, committed our hard-earned money for too long combatting harmful tobacco use to stand idly by as we now lose Californians to vaping and nicotine addiction,” Becerra said in a statement.

In May, North Carolina also filed a lawsuit against Juul, accusing the company of employing “deceptive and unfair” marketing practices to drive sales to minors.

In an effort to appease regulators and minimize its appeal to youth users, Juul recently stopped sales of fruit and mint-flavored vape products and suspended all broadcast, print, and digital product advertising in the U.S. 

Juul says it’s committed to “earning the trust of society by working cooperatively with attorneys general, regulators, public health officials, and other stakeholders to combat underage use and convert adult smokers from combustible cigarettes.” 

California has filed a lawsuit accusing Juul of deliberately targeting minors through its marketing tactics and product design. 

The complaint accuses the e-cigarette maker of failing to adequately warn consumers of the fact that they would be exposed to chemicals associated with cancer and birth defects. Additionally, Juul is accused of using a “flawed” age-verification process for online sales.

“We’ve worked too hard, committed our hard-earned money for too long combatting harmful tobacco use to stand idly by as we now lose Californians to vaping and nicotine addiction,” California’s Attorney General Xavier Becerra said in a statement.

“JUUL adopted the tobacco industry’s infamous playbook, employing advertisements that had no regard for public health and searching out vulnerable targets. Today we take legal action against the deceptive practices that JUUL and the e-cigarette industry employ to lure our kids into their vaping web. We will hold JUUL and any other company that fuels a public health crisis accountable.”

Teen vaping crisis 

The suit comes as lawmakers attempt to combat a surge in teen vaping. The Trump administration has proposed banning flavored e-cigarette products and/or bumping the minimum vaping age to “21 or so.”

Becerra noted that the number of high school students vaping in 2019 is 27.5 percent, up from 11.7 percent in 2017. He attributed the rise in teen vaping to the array of fruit-flavored products that were created. 

“JUUL has systematically targeted the teen market with everything from the design of their products to their advertisements,” said Supervisor Hahn. “With this lawsuit we are going to hold JUUL accountable for their hand in this public health crisis and do what we can to stop this company from creating a new generation of nicotine addicts.”

Juul has previously said it shares regulators’ concerns about its products getting into the hands of minors. In a statement, the company said it hasn’t yet reviewed the latest complaint but remains “focused on resetting the vapor category in the U.S. and earning the trust of society by working cooperatively with attorneys general, regulators, public health officials, and other stakeholders to combat underage use and convert adult smokers from combustible cigarettes.” 

Juul noted that it recently stopped sales of fruit and mint-flavored vape products and suspended all broadcast, print, and digital product advertising in the U.S. in an effort to minimize its appeal to youth users. 

“Our customer base is the world's 1 billion adult smokers and we do not intend to attract underage users,” Juul said. 

The lawsuit, which was announced on Monday, seeks monetary damages based on violations of California laws related to false advertising and unfair competition.

Apple has pulled all vaping-related apps from its App Store amid widespread concern over the health impact of the products. 

In a statement to Axios, the company said its App Store guidelines have been updated to prohibit software that encourages or facilitates vaping. 

"Experts ranging from the CDC to the American Heart Association have attributed a variety of lung injuries and fatalities to e-cigarette and vaping products, going so far as to call the spread of these devices a public health crisis and a youth epidemic," an Apple spokesperson said. "We agree, and we've updated our App Store Review Guidelines to reflect that apps encouraging or facilitating the use of these products are not permitted."

iPhone users who have already downloaded a vaping app will be able to continue using them, the company said. 

Vaping illnesses on the rise

The number of vaping-related lung illnesses has risen sharply in recent months, and investigators from the CDC, FDA, and elsewhere are still trying to figure out what exactly is causing the illnesses. 

To date, there have been 2,172 illnesses and 42 deaths tied to vaping. Health officials reported last week that vitamin E acetate has emerged as the likely culprit causing the lung illnesses, but investigations are ongoing. 

"Vitamin E acetate is used as an additive in the production of e-cigarette, or vaping, products," the CDC said in a report. "This is the first time that we have detected a potential chemical of concern in biologic samples from patients with these lung injuries."

CDC officials continue to recommend that consumers avoid any e-cigarette or vaping product that contains THC, “particularly from informal sources like friends or family, online dealers or the illicit market.” 

President Trump says the White House will soon unveil new minimum age requirements for vaping products in an effort to combat teen use. Speaking to reporters on Friday, Trump said his administration plans to implement a new policy that will raise the age limit for e-cigarettes from 18 to “21 or so.” 

“We’re going to be coming out with a very important position on vaping. We have to take care of our kids, most importantly, so we're going to have an age limit of 21 or so, but we'll be coming out with something next week very important on vaping," he said.

The Trump administration initially proposed banning all non-tobacco flavored pods back in September, saying the move would help reduce youth use of the products since flavored pods tend to appeal to teenage users. 

Critics of the plan have argued that the flavors on the market should remain because they help adult smokers quit. Government officials are now considering raising the minimum age requirement to counter rising levels of teen use. 

"We have a lot of people to look at, including jobs, quite frankly," Trump said. "Because, you know, it's become a pretty big industry."

He added that details on the potential minimum vaping age increase will be coming next week. CNBC points out that the FDA doesn’t have the authority to raise the smoking age, so it’s “unclear” how the Trump administration plans to go about implementing and enforcing a new minimum vaping age. 

Addressing health concerns

Word of the expected policy change comes as health officials continue to investigate an uptick in vaping-related lung injuries. Just a few days ago, the CDC said recent research appears to indicate that vitamin E acetate — which is present in many cannabis vaping products — is a likely culprit. 

Market leader Juul has been called out for its role in fueling what regulators have called a teen vaping “epidemic.” The e-cigarette maker has been a vocal supporter of bumping the minimum age of vaping to 21. 

In March, Juul said “raising the legal age to purchase tobacco products to 21 is not the only strategy for reducing underage use, we believe it is critical because it will prevent high-school seniors and recent high-school graduates from purchasing tobacco products and sharing them with underage users.” 

Several states have already enacted state-level regulations to counter teen use. Lawmakers have also pushed to limit the concentration of nicotine in e-cigarettes as a way to address concerns about the health effects of the products. 

Health officials have identified vitamin E acetate as the cause of a mysterious lung illness linked to vaping that has sickened more than 2,000 people over the past several months. 

In an advisory published Friday, the Centers for Disease Control and Prevention (CDC) announced that a majority of the lung fluid samples of 29 patients from 10 different states tested positive for the presence of the substance. 

"Vitamin E acetate is used as an additive in the production of e-cigarette, or vaping, products," the CDC noted in its report. "This is the first time that we have detected a potential chemical of concern in biologic samples from patients with these lung injuries."

The agency added that it continues to recommend that people refrain from using e-cigarettes or vaping products that contain THC, “particularly from informal sources like friends, or family, or in-person or online dealers.” 

“We will continue to provide updates as more data become available,” the CDC said. 

‘Strong culprit’

The FDA initially raised suspicion that the vitamin supplement was causing a surge in lung illnesses back in September, saying it had found it in cannabis products used by many people who had gotten sick over the summer. 

At the time, federal health officials stopped short of naming the substance as the definitive cause of the lung injuries. CDC officials say that the latest findings are a huge step toward finding the primary cause of the illness, although more tests are still needed for confirmation. 

“These new findings are significant," Dr. Anne Schuchat, the principal deputy director of the CDC, said during a press briefing on Friday. "We have a strong culprit."

The CDC said it hasn’t ruled out the possibility that other ingredients have caused the illness. However, the fact that 23 of the 29 lung fluid samples of people with the illness had vitamin E acetate in them is “noteworthy.” 

In total, the vaping-related lung illness — which was recently named “EVALI” -- has sickened 2,051 people and been tied to 39 deaths. The illness has been reported in every state except Alaska, as well as in Washington, D.C. and one U.S. territory.

Ahead of an expected announcement about the government’s plan to restrict e-cigarette flavors in an effort to reduce youth use, e-cigarette market leader Juul has announced that it has stopped selling mint-flavored pods. 

The action follows the release of a new study showing that mint flavors appeal to teenagers. Close to half of high school seniors polled by University of Southern California researchers said they almost always opt for mint Juul products. 

"These results are unacceptable," K.C. Crosthwaite, CEO of Juul Labs, said in a statement. "That is why we must reset the vapor category in the U.S. and earn the trust of society by working cooperatively with regulators, Attorneys General, public health officials, and other stakeholders to combat underage use."

Menthol still available

Juul has already halted sales of its mango, creme, and cucumber flavors. With mint dropped from its offerings, Juul now only offers tobacco and menthol flavors. Experts say allowing menthol to remain on the e-cigarette market could still leave a crack in the door to addiction for youth users, since menthol isn’t markedly different from mint. 

"It's just semantics," Bonnie Halpern-Felsher, a professor and expert in teen vaping at Stanford University told NBC News. "Young people are going to switch to menthol. It's really easy for companies to slightly change the formula or just re-name everything and kids won't know the difference."

The USC study, however, found that fewer than 6 percent of teenagers across all grades preferred menthol. Department of Health and Human Services (HHS) Secretary Alex Azar previously suggested that the expected federal ban on e-cigarettes would include mint, menthol, and all flavors except tobacco. 

“These products are still getting to kids and we cannot let a whole generation get addicted to them through mint and menthol and other flavors,” Azar said when the ban was initially proposed in September.

Vaping illnesses on the rise

The Centers for Disease Control and Prevention (CDC) reported on Thursday that the number of vaping-related lung injuries is up to 2,051. At least 39 deaths associated with the products have been confirmed, and additional deaths are under investigation.

Vaping or e-cigarette use has so far been “the only commonality among all cases” of the lung injuries, the CDC said. The current outbreak of lung illnesses tied to vaping hasn’t been linked to Juul specifically. 

Health officials are still trying to figure out what is causing the lung illnesses; no single product or ingredient has so far been linked to all the lung injuries.  

Federal regulators are expected to unveil new restrictions on e-cigarettes in an effort to reduce youth use of the products. However, vape shops could be exempted from those restrictions, Bloomberg reports. 

Speaking at the White House on Wednesday, presidential adviser Kellyanne Conway noted that teenagers like vaping mint and fruit-flavored products, but tobacco and menthol flavored products remain unpopular among youth users — a claim supported by a National Institutes of Health-funded study published Tuesday. 

“Kids report they use mint, and other flavors like mango, bubble gum, tutti frutti, unicorn milk -- pretty remarkable -- and that they don’t care for menthol,” Conway said Wednesday. 

That said, the Trump Administration may not include menthol in the flavored e-cigarette ban it proposed in September. Conway noted that the Department of Health and Human Services (HHS) has jurisdiction over e-cigarettes but not over vaping and vape shops. 

“This is a burgeoning health crisis; the difference is between kids and adults,” Conway said, according to Bloomberg. “So HHS and FDA have jurisdiction over cigarettes and e-cigarettes under the Tobacco Control Act. They do not have jurisdiction over vaping and vape shops, for example. So, if we’re talking about e-cigarettes, the president, yes, he’s been discussing this with his team and he will, or HHS, will make an announcement soon.”

Addressing teen use

HHS Secretary Alex Azar suggested last month that the soon-to-be-announced ban on e-cigarettes would include mint, menthol, and all flavors except tobacco. 

“These products are still getting to kids and we cannot let a whole generation get addicted to them through mint and menthol and other flavors,” Azar said when the ban was initially proposed.

Conway’s comments on Wednesday “indicate there may also be some kind of a reprieve for vape shops, who’ve mounted widespread pushback to a ban and warned it could cost both jobs and votes in 2020,” Bloomberg said. 

An announcement about the plan to restrict e-cigarette flavors to drive down youth use will be made by either the HHS or President Trump soon, Conway said. 

As the vaping death toll continues to rise among younger consumers, it may come as a surprise to many that the younger demographic has lessened its cannabis use. 

Researchers from the Columbia University Mailman School of Public Health found that the number of teens and young adults affected by cannabis use disorder declined between 2002 and 2016. 

“Contrary to expectations, the frequency of cannabis use disorder among people reporting daily/almost daily use decreased significantly between 2002 and 2016,” said researcher Dr. Silvia Martins. “The findings contradict the predominating hypothesis that the prevalence of DSM-IV CUD would be stable, or increase, among those using with regularity.” 

Lower rates of cannabis use

The researchers analyzed over 22,000 responses to the National Survey on Drug Use and Health to better understand the cannabis habits of those in three age groups: 12-17 years old, 18-25 years old, and over 26 years old. 

For the purposes of the study, the researchers used the DSM-IV definition for cannabis use disorder. While there are several factors that come into play, cannabis use becomes cause for concern when a person becomes dependent on the drug or uses it in a way that’s harmful to the body. 

The survey responses showed that every age bracket they observed had lowered their rates cannabis use disorder. Those 26 and older used the substance less than any others, dropping nearly 40 percent over the span of the study. 

Across the board, the motivation to quit wasn’t associated with any physical or mental health concerns. Those who dropped the habit said they didn’t do so out of necessity, and their health wasn’t compromised in any way. 

While the researchers noted that social and societal changes may have made an impact on some young people’s decision to stop using the drug, it is interesting to know that young people’s health -- either mental or physical -- was not on the line and didn’t affect their decision. 

“First, the new national cannabis policy environment, with 33 states legalizing medical use and 10 states allowing recreational use of cannabis may have played a role in reducing stigma and perceptions of risk associated with cannabis use,” said Dr. Martins. “Secondly, increasing legalization may be associated with changes in social attitudes resulting in fewer conflicts with relatives and friends around cannabis use.”

Vaping is a stark contrast

While the social aspect associated with cannabis use may be behind the sharp decline in use among young people, these findings do come in stark contrast to teens’ e-cigarette use, which has become problematic. 

Despite several warnings about health-related concerns, teens have not altered their vaping habits. One recent study found that flavored e-cigarettes, which have been under fire recently, are associated with higher teen use of vaping devices.

“While many children try e-cigarettes, not all become regular users,” said researcher Adam Leventhal. “Teens who use e-cigarettes may be more inclined to continue vaping rather than just temporarily experiment with e-cigs. Whether or not children continue vaping is important -- the longer and more frequently you vape, the more you’re exposing yourself to toxins in e-cigarette aerosol and put yourself at risk of nicotine addiction.”

The Federal Trade Commission (FTC) has launched an investigation into Altria and its role, if any, in the resignation of the CEO of Juul, its e-cigarette subsidiary that has come under close regulatory scrutiny in recent months.

According to a Securities and Exchange Commission (SEC) filing, Altria has received a demand from regulators seeking information about any role Atria played in the resignation of Juul’s CEO. At the end of September, Juul announced it was replacing its CEO Kevin Burns with Altria executive K.C. Crosthwaite.

Regulators are interested because within days of taking the top job, Crosthwaite hired Altria colleague Joe Murillo as Juul’s chief regulatory officer. 

Juul has been at the center of controversy over its marketing efforts and whether it targeted underage consumers with its vaping products. The company has also been in the crosshairs of the government’s efforts to stop underage use of vaping products.

In April, former Food and Drug Administration (FDA) Commissioner Scott Gottlieb accused Juul of being largely responsible for the spike in teen vaping. The FDA has cited research that shows an estimated 37 percent of high school seniors have tried e-cigarettes. A quarter of youth users told researchers they didn’t realize the products contain nicotine.

Attractive to minors

The agency has said products manufactured by Juul have been shown to be especially attractive to minors because they come in fruity flavors such as mango, mint, and fruit and creme. In January, Gottlieb warned that e-cigarettes could be taken off the market unless marketers made efforts to stop sales to minors.

Since then, Juul and its products have come under increasing scrutiny. In September, an official art the Centers for Disease Control and Prevention (CDC) called out Juul for allegedly using dangerous salts in its products.

In its SEC filing, Altria disclosed that the agency is conducting an antitrust review of Altria’s investment in the e-cigarette maker. Specifically, the agency is seeking information about any Altria role in the resignation of Juul’s CEO and his replacement with a long-time Altria executive.

In its filing, Altria also disclosed that the FTC and possibly other regulatory agencies are investigating Juul’s marketing practices. The company has been accused of targeting underage consumers -- something Juul vigorously denies.

In a lawsuit filed Tuesday, a former Juul executive accuses the e-cigarette maker of shipping a million contaminated pods earlier this year and not issuing a recall, according to BuzzFeed News.

The suit was filed by Siddharth Breja, Juul’s former senior vice president of global finance. Breja said he attended an executive meeting back in March, during which it came to his attention that Juul had shipped approximately 250,000 Juul “mint refills kits” (the equivalent of one million pods). 

The former executive claims that he pushed Juul to issue a product recall or public safety notice, but Juul allegedly dismissed the idea since doing so would cost it billions of dollars. Breja claims he was fired a week after expressing concern about the contaminated pods.

According to the lawsuit, former CEO Kevin Burns -- who was replaced by former Altria executive K.C. Crosthwaite in September -- responded to Breja’s concerns by saying: "Half our customers are drunk and vaping like mo-fo's, who the f*** is going to notice the quality of our pods?"

In a statement to BuzzFeed News, Breja's lawyer Harmeet Dhillon said that his client "became aware of very concerning actions at the company, and he performed his duty to shareholders and to the board by reporting these issues internally.” 

“In exchange for doing that, he was inappropriately terminated,” Dhillon continued. “This is very concerning, particularly since some of the issues he raised concerned matters of public safety."

Juul responds

Juul called Breja’s claims “baseless” and refuted the claim that he was fired after voicing concerns about the contaminated pods. 

“He was terminated in March 2019 because he failed to demonstrate the leadership qualities needed in his role,” a company spokesperson said in a statement issued to various media outlets. “The allegations concerning safety issues with Juul products are equally meritless, and we already investigated the underlying manufacturing issue and determined the product met all applicable specifications.” 

Juul added that it intends to “vigorously defend this lawsuit."

Juul has been singled out for fueling the current vaping epidemic, as its flavored products have been found to appeal to younger users. At this point, however, the current outbreak of lung illnesses tied to vaping hasn’t been linked to Juul specifically. Health officials say a majority of the more than 1,600 people who have gotten sick reported using THC-containing products.

The vaping industry itself is still under intense scrutiny as investigators seek to uncover a more specific cause behind the sudden rise in vaping-related lung illnesses and deaths. 

E-cigarettes have dominated the headlines recently, as more and more consumers are being diagnosed with vaping-related illnesses that healthcare professionals have been struggling to get to the root of. 

Health experts have pointed to additives in electronic cigarettes that can cause any number of health issues, and the sale of flavored e-cigarettes has been halted. However, the vaping death toll only continues to rise, and many young consumers continue to use e-cigarette devices.

Now, a new study conducted by researchers from the University of Southern California discovered that teens are more likely to stick to their vaping habits because of flavored e-cigarettes. 

“While many children try e-cigarettes, not all become regular users,” said researcher Adam Leventhal. “Teens who use e-cigarettes may be more inclined to continue vaping rather than just temporarily experiment with e-cigs. Whether or not children continue vaping is important -- the longer and more frequently you vape, the more you’re exposing yourself to toxins in e-cigarette aerosol and put yourself at risk of nicotine addiction.” 

How flavors play a role

The researchers created a survey to gauge teens’ vaping habits. They surveyed nearly 500 tenth graders every six months through their senior years of high school to see what changes -- if any -- took place over that time span. 

While a large majority of the students reported vaping at some point over the course of the study, the fruity or candy flavored e-cigarettes proved to be more popular and were often successful at getting students to stick with the habit long-term. While under 43 percent of students who vaped with the regular tobacco flavor continued the habit for an additional six months, over 64 percent of vapers who opted for sweeter flavors did the same. 

Overall, the researchers learned that 90 percent of the students had taken advantage of the wide variety of flavors available for e-cigarettes, and doing so often upped their typical day-to-day vaping habits. 

Federal regulation needed

As e-cigarettes remain unregulated by the government, the researchers are calling for federal intervention in an effort to keep young people healthy and reduce overall e-cigarette usage. 

“Regulations that reduce youth exposure to flavored e-cigarettes may aid in preventing young people who try e-cigarettes from becoming long-term e-cig users, and also from inhaling more aerosol into their lungs,” said Leventhal. “Regulations like these could also encourage the millions of U.S. adolescents who already use e-cigarettes to quit vaping, especially if they can no longer access e-cigs in the flavors they like.” 

The number of deaths attributed to the vaping-related illness recently named “EVALI” (short for “e-cigarette or vaping product use associated lung injury”) has risen to 34 people, the Centers for Disease Control and Prevention (CDC) reported Thursday. 

More than a hundred new cases of the illness have been reported over the past week, bringing the total number of cases to 1,604. The deaths and illnesses are spread across 49 states, as well as the District of Columbia and the Virgin Islands. 

While the severe lung illness responsible for these deaths and illnesses seems to have a clear link to vaping, health officials are still trying to find out exactly what is it to manifest. No one product or ingredient has so far been involved in all of the cases. However, a majority of patients have reported vaping THC.

“The latest national and state findings suggest products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak,” the CDC said. 

Though most people reported using a THC-containing product prior to getting sick, 10 percent of patients said they only used nicotine-containing products. Health officials still haven’t identified what in the products is making people sick.

“At this time, FDA and CDC have not identified the cause or causes of the lung injuries in these cases, and the only commonality among all cases is that patients report the use of e-cigarette, or vaping, products,” the CDC said. 

Testing for EVALI 

Symptoms of the lung injury connected to vaping include chest pain, shortness of breath, and vomiting. Last week, the CDC released guidance for clinicians on the diagnosis, management, and follow-up of the illness.

In the guidance, the CDC recommended that doctors consider testing all patients with symptoms of EVALI for influenza and other respiratory illnesses. 

“It is unknown if patients with a history of EVALI are at higher risk for severe complications of influenza or other respiratory viral infections if they are infected simultaneously or after recovering from lung injury,” the guidance says.

While state and federal health officials continue to investigate the illness, the CDC has urged people not to use e-cigarette or vaping products that contain THC.

Juul has ceased sales of its flavored nicotine products in the U.S. ahead of an expected order for it to do so from the U.S. Food and Drug Administration (FDA). 

The e-cigarette maker had previously pulled its flavored products from retail outlets, but its fruit-flavored e-cigarettes were still available online. Juul has now stopped selling flavored products, including mango, creme, fruit, and cucumber. The company is still selling tobacco, mint, and menthol flavored products.

The move comes as federal regulators seek to combat the rise in teen use of the products, which have been linked to severe lung illnesses and deaths. 

Cooperating with regulators 

Earlier this week, a parent whose son died after becoming “intensely addicted” to Juul’s products filed a wrongful death lawsuit against the company. Juul has previously been accused of targeting youth users through its marketing campaign and faces a number of similar lawsuits over its role in the vaping crisis. 

Juul announced last month that it would stop advertising its products in the U.S. and also stop fighting regulators over President Trump’s decision to remove all e-cigarette flavors from the market.

Going forward, Juul says it will continue to try to get its flavored products back on the market as an alternative to smoking for adults. The company said it’s also working on coming up with ways to prevent underage use of its products. 

“We must reset the vapor category by earning the trust of society and working cooperatively with regulators, policymakers, and stakeholders to combat underage use while providing an alternative to adult smokers,” Juul CEO K.C. Crosthwaite said in a statement.

Juul has been hit with a wrongful death suit following the death of a teenager who “became intensely addicted” to the e-cigarette maker’s nicotine products. 

The complaint, filed by the mother of 18-year-old Florida resident Daniel David Wakefield, accuses Juul of causing the teen’s death through its marketing campaign. The company has faced significant criticism over its marketing campaign, which lawmakers and health officials claim deliberately targeted youth users.

Juul recently agreed to stop advertising its products altogether in the U.S. while cases of a mysterious lung illness linked to vaping are being investigated. 

Years of Juul use

In the wrongful death suit filed on Tuesday, Wakefield’s mother claims her son’s behavior changed “dramatically” after being exposed to Juul advertising in 2015. She claims he gradually became “intensely addicted” to the company’s products. 

Within a year of starting to vape, the teen ended up hospitalized for three days. In August 2018, he was found in an unresponsive state by his father. The previously healthy teenager’s death was ultimately pinned on “breathing complications.” The complaint notes that the death occurred after a day that included moving boxes. 

The suit accuses Juul of “wrongful conduct in marketing, promoting, manufacturing, designing, and selling JUUL.” The plaintiff is seeking compensatory, punitive, and other damages related to Wakefield’s death, which Juul is accused of “substantially” contributing to.  

Lung illnesses under investigation

The CDC said last week that the vaping-related death toll in the U.S. had increased to 26, and the number of illnesses had been raised to 1,299. Health authorities are currently trying to find a specific cause of the illnesses, but vaping has so far been a common thread among all of the illnesses and deaths. 

Most of the confirmed cases of lung injuries have involved patients who reported using THC-containing products. However, some reported using only nicotine vaping products. 

Lawmakers and health officials are particularly concerned about the rise in youth use of the products over the past few years. Around 15 percent of those who either got sick or died are under the age of 18, and 21 percent are 18 to 20 years old, according to the CDC. 

Reacting to a finding drawn from a recent study involving mice, former FDA Commissioner Scott Gottlieb said he’s “skeptical that nicotine causes cancer.” 

“It might be a tumor promoter, [researchers] have said that there’s a potential that nicotine is a tumor promoter, but it doesn’t cause cancer,” Gottlieb said Monday on CNBC’s “Squawk Box.” 

Though skeptical of the claim that nicotine is carcinogenic, Gottlieb -- who stepped down from his position as FDA Commissioner in April -- said he did believe inhaling e-cigarette vapor would likely cause damage to the lungs.

“We had a signal when I was at the FDA of damage that vaping was causing to the lungs in an animal study,” Gottlieb told CNBC, adding that the results of the FDA study should be released soon. “You can’t inhale something into the lungs that way on a repeated basis and not cause some damage to the lung.”

Dangers of vaping

Last week, a New York University study found that e-cigarette vapor containing nicotine causes lung cancer and precancerous lesions on the bladder of mice. Researchers said 22 percent of the 40 mice involved in the study developed lung cancer. 

In light of the study’s findings, the researchers asserted that vaping is likely harmful to humans as well. Gottlieb, however, pointed out that the study was small and “isolated the effects of nicotine,” according to CNBC. 

The health impact of vaping is currently being studied extensively as health officials continue to report more cases of a lung illness linked to vaping. 

Last week, the CDC updated the official toll of lung illnesses and deaths linked to e-cigarette use. The death toll had risen to 26, and the number of vaping-related lung illnesses had been raised to 1,299.

The Centers for Disease Control and Prevention (CDC) has updated the official toll of lung illnesses and deaths linked to e-cigarette use. The death toll has increased to 26, and the number of illnesses has been raised to 1,299.

Health agencies across the U.S. have focused more intently in recent weeks on patients complaining of lung illnesses to determine if there could be a connection with vaping. Officials at the CDC say an alarming number of these illnesses and deaths have e-cigarette use in common.

Perhaps more alarming is the fact that many of the victims are young. According to CDC data, 15 percent of those who either got sick or died are under the age of 18, and 21 percent are 18 to 20 years old.

THC plays a role

The CDC said most patients reported a history of vaping THC products derived from cannabis. Approximately 70 percent of the patients are males, and the overwhelming majority are under the age of 35.

The health agency says there is still a lot that health authorities don’t know. For example, it isn’t known what chemical or combination of chemicals in the vapor is actually causing the illnesses. It says no single product or substance has been linked to all lung injury cases.

“The outbreak is occurring in the context of a dynamic marketplace for e-cigarette, or vaping, products, which may have a mix of ingredients, complex packaging and supply chains, and include potentially illicit substances,” the CDC said.

Because of the proliferation of illicit vaping products, the CDC says consumers may have no way of knowing what’s in them. Many of the products can be modified by users, which could also make them more dangerous.

More information needed

The CDC says more information is needed to know whether one or more e-cigarette or vaping products, substances, or brands caused the outbreak. The FDA recently launched a criminal investigation into vaping that will focus on uncovering the cause of the illnesses by looking at the chemical makeup of the products and how people use them. 

“We are in desperate need of facts," Mitch Zeller, the agency’s tobacco director, said in a statement last week. “The focus of their work is to identify what is making people sick, as well as a focus on the supply chain.”

The CDC continues to advise consumers to consider not using e-cigarette products. It says those who use the products should monitor themselves for symptoms such as shortness of breath, chest pain, nausea, vomiting, and cough. If any of these symptoms are present, regulators urge consumers to seek medical attention. 

A study published Monday is the first to connect e-cigarette vapor with several types of cancer in mice. Researchers say the results of the study suggest that vaping is also harmful to humans. 

Understanding the carcinogenic effect of e-cigarettes on humans could take another ten years, the study authors said. However, the latest research appears to strongly suggest that the products pose health risks that warrant further examination.

"Tobacco smoke is among the most dangerous environmental agents to which humans are routinely exposed, but the potential of E-cig smoke as a threat to human health is not yet fully understood," said Moon-Shong Tang, the study’s lead researcher, in a statement.

“Our study results in mice were not meant to be compared to human disease, but instead argue that E-cig smoke must be more thoroughly studied before it is deemed safe or marketed that way."

More research needed

Published Monday in The Proceedings of the National Academy of Sciences and funded by the National Institutes of Health, the study found that 22 percent of mice exposed to e-cigarette smoke with nicotine for 54 weeks developed lung cancer. 

By contrast, none of the 20 mice that were exposed to the same e-cigarette smoke without nicotine developed cancer -- a “statistically significant” figure, Tang said. The researcher and his team also found that 23 of 40 mice exposed to e-cigarette smoke developed precancerous lesions on the bladder and genetic changes that make cells more likely to multiply. 

The study authors estimated that the amount of smoke the mice were exposed to was equivalent to what a human would inhale in three to six years’ worth of regular vaping. 

The results of the study highlight the need for more research on the health effects of e-cigarettes. In the meantime, the researchers said the findings suggest that e-cigarette makers should refrain from marketing the products as safer than combustible cigarettes.

"Our results support the argument that the nicotine-derived DNA adducts are likely the main causes for carcinogenesis in mice exposed to E-cig smoke," said study author Dr. Herbert Lepor. "Our next step in this line of work will be to expand the number of mice studied, to shorten and prolong E-cigarette exposure time, and to further investigate the genetic changes caused by E-cigarette smoke."

The study comes as federal health officials continue to investigate a rise in lung illnesses linked to e-cigarette use. As of last week, the CDC said there were 805 confirmed and probable cases of lung injury associated with e-cigarette use in 46 states and the U.S. Virgin Islands. At least sixteen deaths have now been linked to e-cigarette use.

Congressman Raja Krishnamoorthi (D-Ill.) has unveiled a bill that would limit the amount of nicotine in e-cigarettes to no more than 20 milligrams per milliliter. 

The introduction of the “Ending Nicotine Dependence from Electronic Nicotine Delivery Systems Act” (or END ENDS Act) comes in the midst of ongoing concern about the health effects of e-cigarettes and a surge in teen use of the products.

Public health officials are continuing to investigate what’s behind the recent rise in vaping-related lung illnesses. As of last week, there were 805 confirmed and probable cases of lung injury associated with e-cigarette use in 46 states and the U.S. Virgin Islands. At least sixteen deaths have been linked to e-cigarette use.

Regulators have described the dramatic rise in teen vaping over the last few years as an “epidemic.” Krishnamoorthi, who himself is the parent of a teenager, said the issue is “deeply personal” to him.  

“More than 1 in four high school students are vaping, and as a concerned parent I am always working to do what’s best for my kids and future generations,” he wrote on Twitter. 

Creating less addictive products

If passed, the bill would require the amount of nicotine in e-cigarettes to be capped at about a third of the 59 milligrams per milliliter contained in standard Juul pods. Under the law, the FDA would be allowed to further lower the cap to make e-cigarettes minimally addictive or not addictive at all. 

“Capping the concentration of nicotine in e-cigarettes is integral to ending the youth vaping epidemic by making these products less addictive, less appealing to youth, and less harmful to public health,” Krishnamoorthi said in a statement. “After all, while flavors hook kids, it’s nicotine that nets them and pulls them on the boat into a lifelong vaping habit and addiction.”

Lawmakers on both sides of the aisle argue that e-cigarette manufacturers like Juul must be held accountable for their role in creating and fueling the youth vaping epidemic.

“We commend lawmakers for uniting on a bipartisan and bicameral basis to create the Congressional Caucus to End the Youth Vaping Epidemic,” Nancy Brown, CEO of the American Heart Association, said in a statement. “It is no secret that the tobacco industry has long preyed on young people with viral marketing and flavors intended to entice and addict a new generation to nicotine.” 

“Now we are in the midst of a public health crisis, and we need bold action from our nation’s leaders to keep e-cigarettes out of the hands of our youth. Together we can protect the health and safety of youth across the country and combat the mounting threat e-cigarettes pose to our population.”

The Food and Drug Administration (FDA) is stepping up its warnings to consumers about using e-cigarettes to “vape” THC products derived from cannabis.

The FDA is partnering with the Centers for Disease Control and Prevention (CDC) to investigate a growing number of lung illnesses -- including deaths -- that appear to be linked to vaping certain products. 

“We're strengthening our message to the public in an updated consumer alert stating that they should not use vaping products containing tetrahydrocannabinol (THC), the primary psychoactive component of the cannabis plant,” said Acting FDA Commissioner Ned Sharpless. 

“Additionally, consumers who choose to use any vaping products should not modify or add any substances such as THC or other oils to products purchased in stores and should not purchase any vaping products, including those containing THC, off the street or from other illicit channels.”

Last week, health officials in Virginia and New Jersey reported additional lung illness deaths that appear to be related to vaping. The deaths are part of hundreds of illnesses that have sent other consumers to the hospital.

E-cigarettes a common factor

The CDC said it knows for a fact that all patients used e-cigarettes or vaping devices prior to becoming ill; however, the exact cause of the illnesses is still under investigation.

“The specific chemical exposure(s) causing lung injuries associated with e-cigarette product use, or vaping, remains unknown at this time,” the CDC said in a statement late last week. “No single product or substance has been linked to all lung injury cases.” 

Sharpless said the lung ailments are at the center of what he called a complex, ongoing, and evolving investigation. The FDA is conducting its own analyses while also reviewing published literature of third-party analyses of samples and data.

“At this time, the FDA does not have enough data to identify the cause, or causes, of the lung injuries in these cases,” Sharpless said. “Additionally, while no one compound or ingredient has emerged as a singular culprit, we do know that THC is present in most of the samples being tested.”

Stop now

The amount of uncertainty linked to these illnesses is largely why the health agency has asked consumers to immediately stop using vaping products that contain THC or that have had any substances added to them, including those purchased from retail establishments. 

“Simply put, inhaling harmful contaminants in the lungs could put a patient's health at risk and should be avoided,” Sharpless said. 

Last month, the FDA said it suspected a chemical present in many varieties of marijuana liquid vaping products may be the underlying cause of some of the lung illnesses. Most patients reported vaping THC before becoming ill. At present, no single vaping product or ingredient has been found to have been involved in all of the cases. 

“For those who choose to continue the use of vaping products, particularly those containing THC, we urge you to monitor for symptoms and promptly seek medical attention if you have concerns about your health,” Sharpless said.

The Federal Trade Commission (FTC) has ordered six e-cigarette companies to submit documents containing their sales and advertising data, suggesting the federal agency could be close to launching a probe into their marketing practices. 

The orders were sent to Juul, Reynolds Vapor Company, Fontem US, Logic Technology Development, Nu Mark, and NJOY. The agency said its request is intended to help it gather information about e-cigarette sales, advertising, and promotional practices in the U.S. for the years 2015 through 2018. 

“The goal is to assist the Commission, policy makers, and the public to better understand the rapidly growing e-cigarette market,” the agency said in a statement on Thursday. 

An FTC official said the agency is seeking “annual data on the sales and give-aways of e-cigarette products; information about the characteristics of the companies’ e-cigarette products, such as product flavors; annual amounts the companies spent on advertising and promoting e-cigarette products; and information about e-cigarette product placement, the websites and social media accounts used to advertise or sell e-cigarettes, affiliate programs, influencer marketing, and college campus programs.” 

Rise in vaping-related deaths

According to the most recent data from the Centers for Disease Control and Prevention (CDC), 1,080 people in the U.S. are now affected by vaping-related lung illnesses, with 18 people having died as a result of their symptoms.

Regulators are actively seeking more information on e-cigarettes in an effort to uncover a more specific cause of the illnesses. 

At this time, health authorities suspect a chemical present in many varieties of marijuana liquid vaping products may be the underlying cause of some of the lung illnesses. Most patients reported using a THC-containing product before becoming ill. However, no single vaping product or ingredient has yet been linked to all of the cases. 

Juul, which previously sold flavored products that tended to entice youth users, recently agreed to stop advertising its products in the U.S. The Trump administration said it’s moving toward a ban on all flavored e-cigarette products in the U.S. 

While investigations into the matter are ongoing, the CDC has advised consumers to avoid using e-cigarettes or vaping products. 

The number of vaping-related deaths nationwide has now climbed to 16 following two additional death confirmations from health officials in Virginia and New Jersey. 

"I am deeply saddened to announce the first death of a Virginia resident related to this outbreak," Virginia's state health commissioner, Dr. M. Norman Oliver, said in a statement on Tuesday.

Officials from the New Jersey Department of Health said the tragedy in their state “underscores the potential dangers associated with vaping.”

E-cigarette use has been linked to fourteen other deaths in recent months, and the number of lung illnesses associated with vaping has grown by hundreds just within the past few weeks. 

Last week, the Centers for Disease Control and Prevention (CDC) announced that there are now 805 confirmed and probable cases of lung injury associated with e-cigarette use in 46 states and the U.S. Virgin Islands. 

Exact cause still unknown

The CDC said it knows for a fact that all patients used e-cigarettes or vaping devices prior to becoming ill; however, the exact cause of the illnesses is still under investigation.

“The specific chemical exposure(s) causing lung injuries associated with e-cigarette product use, or vaping, remains unknown at this time,” the CDC said. “No single product or substance has been linked to all lung injury cases.” 

Researchers currently suspect a chemical derived from vitamin E, which is present in many different types of marijuana liquid vaping products, may be behind some of the lung illnesses. A majority of patients have said they used THC-containing products. 

The FDA recently launched a criminal investigation into vaping that will focus on uncovering the cause of the illnesses by looking at the chemical makeup of the products and how people use them. 

“We are in desperate need of facts," Mitch Zeller, the agency’s tobacco director, said in a statement. “The focus of their work is to identify what is making people sick, as well as a focus on the supply chain.”

While health officials work to uncover a more precise cause of the illnesses, the CDC has advised consumers to consider not using e-cigarette products. Those who use the products should monitor themselves for symptoms such as shortness of breath, chest pain, nausea, vomiting, and cough. If any of these symptoms are present, regulators urge consumers to seek medical attention. 

Amid escalating concern over the health risks of e-cigarettes, Juul has announced that it will suspend all TV, print, and digital product advertising in the U.S. 

The e-cigarette maker also said it would stop fighting the Trump administration on its plan to remove flavored e-cigarettes from the market until they have received approval from federal regulators. Juul said it would fully support and comply with any new federal policy related to vaping policy when effective. 

The Trump Administration is currently finalizing a ban on all flavored e-cigarette products, including mint and menthol flavors. 

Juul CEO resigns

Wednesday’s announcement also included news that Juul’s CEO Kevin Burns is stepping down immediately and will be replaced by K. C. Crosthwaite. Crosthwaite previously held the title of Chief Growth Officer at tobacco giant Altria, which owns a 35 percent stake in Juul. 

“I have long believed in a future where adult smokers overwhelmingly choose alternative products like JUUL,” Crosthwaite said in the announcement. “That has been this company’s mission since it was founded, and it has taken great strides in that direction.” 

“Unfortunately, today that future is at risk due to unacceptable levels of youth usage and eroding public confidence in our industry,” he continued. “Against that backdrop, we must strive to work with regulators, policymakers and other stakeholders, and earn the trust of the societies in which we operate. That includes inviting an open dialogue, listening to others and being responsive to their concerns.”

Talks of a merger of Philip Morris and Altria have been called off. Both companies said Wednesday that they will remain separate entities. 

Health concerns under investigation

Last week, health officials said the number of illnesses associated with vaping has now climbed to 530. Since August, at least nine people in the U.S. have died following e-cigarette use. The CDC has not identified any one company or vaping product as responsible for all of the illnesses and fatalities.

Juul has been singled out for its role in the youth e-cigarette epidemic, as its flavored products have been shown to be particularly appealing to teens. Juul currently faces numerous lawsuits accusing it of deliberately targeting young consumers with its flavored nicotine products.

The FDA is considering banning all flavored e-cigarettes in an effort to curb use by teens while the health effects of the products are still being investigated.

At an emergency hearing regarding the recent surge in vaping-related lung illnesses, a CDC official said that Juul -- the manufacturer of an e-cigarette product that is especially popular among teens -- uses potentially dangerous salts in its vaping devices. 

“Juul products use nicotine salts, which can lead to much more available nicotine,” CDC Principal Deputy Director Dr. Anne Schuchat told the House Oversight and Reform Committee’s panel on consumer products on Tuesday.

She added that doctors believe the salts allow nicotine to “cross the blood brain barrier and lead to potentially more effect on the developing brain in adolescents.” 

High nicotine delivery

Last week, health officials said the number of illnesses associated with vaping has now climbed to 530. Since August, at least nine people in the U.S. have died following e-cigarette use. 

Amid escalating concern over the health impacts of the products, Juul has maintained that its sole mission is to serve as an “off-ramp” from smoking combustible cigarettes. 

Juul claims its nicotine salt formulation increases the rate and amount of nicotine delivered into the blood compared with other formulations. The formulation is intended to give users an experience similar to traditional cigarettes, which may help them quit. 

However, Schuchat said the nicotine salts could lead to higher quantities of nicotine being delivered. When used by teens, Juul’s devices could give way to a unique set of problems.

“The devices are very easy to conceal, between the high levels of nicotine and discreet use, we think that the use among teens is particularly concerning,” Schuchat said. She added that flavored e-cigarettes have been shown to appeal to youth users, which health officials and lawmakers have expressed concern about. 

“We really want to avoid another generation being addicted to nicotine so addressing flavors directly is a good idea,” she said. 

Avoiding e-cigarette use recommended

Schuchat echoed the CDC’s recent recommendation that consumers “consider not using e-cigarette products” while the investigation into the illnesses is ongoing. 

“We do not yet know the specific cause of these lung injuries,” the CDC said in a recent advisory. “The investigation has not identified any specific e-cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases.” 

Separately, the FDA is conducting an analysis of more than 150 vaping product samples in an effort to find a common thread behind the illnesses. 

“We are in desperate need of facts," Mitch Zeller, the agency’s tobacco director said in a statement. Zeller said the focus of the investigation is to “identify what is making people sick, as well as a focus on the supply chain.”

A Kansas man over 50 years old with preexisting health conditions died Monday from causes believed to be linked to vaping, bringing the total number of vaping-related deaths in the U.S. to nine.

The patient who died had begun using e-cigarettes just before his symptoms set in and hospitalization became necessary. Kansas health officials said they don’t know which type of e-cigarette product, device, and substances he used. 

In a press release announcing the latest fatality, officials from the state noted that the number of illnesses associated with vaping has now surpassed 500. Federal and state health officials are still investigating the cause of an outbreak of lung illnesses. 

“E-cigarettes are unregulated, which means that we don’t know what’s in them,” said Kansas Department of Health and Environment Secretary Dr. Lee Norman. “And, of great concern to me, is that in the midst of all these illnesses being reported, the amount of young people using them is significant.”

Cause of lung illnesses still under investigation

At this time, researchers suspect a chemical derived from vitamin E may be the underlying cause of some of the lung illnesses. 

“We know that in vaping solutions, there’s oils like Vitamin E acetate which is the one that’s thought to be probably contributing, there’s heavy metals, there’s poisons,” Dr. Norman said. “And we know that it looks like an oil infused into the lungs that is causing this, but the compound has not been 100% identified.”

The FDA recently launched a criminal investigation into vaping that will focus on uncovering the cause of the illnesses by looking at the chemical makeup of the products and how people use them. Researchers will conduct a forensic analysis of more than 150 vaping product samples to look for the presence of nicotine, THC, and other cannabinoids, opioids, cutting agents, additives, pesticides, poisons, toxins and any other substances.

“We are in desperate need of facts," Mitch Zeller, the agency’s tobacco director, said in a statement. “The focus of their work is to identify what is making people sick, as well as a focus on the supply chain.”

Avoiding use of e-cigarettes recommended

While the investigation into the illnesses is ongoing, the Centers for Disease Control and Prevention (CDC) has advised people to consider not using e-cigarette products. Those who use the products should monitor themselves for symptoms such as shortness of breath, chest pain, nausea, vomiting, and cough and seek medical attention for any health concerns. 

“We do not yet know the specific cause of these lung injuries,” the CDC said in an advisory. “The investigation has not identified any specific e-cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases.” 

The House Oversight and Reform Committee’s panel on consumer products is set to meet Tuesday for a hearing on the surge in illnesses tied to vaping.

The anti-vaping drumbeat is getting louder in Washington, as four members of the U.S. Senate have asked the Food and Drug Administration (FDA) to immediately ban the most popular kind of e-cigarette products from the market.

The senators -- Dick Durbin (D-IL), Lisa Murkowski (R-AK), Jeff Merkley (D-OR), and Richard Blumenthal (D-CT) -- cite the mysterious lung ailments that have been linked to e-cigarette use. In a letter to Acting FDA Commissioner Dr. Ned Sharpless, the lawmakers call for the immediate removal of all pod- and cartridge-based e-cigarettes from the market, unless or until they can prove that they benefit the public health.

The proposal is a sharp escalation of the steps currently under consideration. The FDA last week launched a criminal investigation into the 530 cases of lung illnesses, including eight deaths. The Trump administration is also reportedly considering a ban on flavored e-cigarette products.

Lawmakers fault the FDA

In their letter, the senators denounce what they say has been a lack of action from the FDA when it comes to e-cigarette products. 

“The proliferation of cartridge-based e-cigarettes—and their ever-increasing popularity with children—is primarily due to the FDA’s years-long refusal to regulate any e-cigarette devices or impose common-sense design standards preventing against adulteration, despite having the authority to do so,” they said. “Make no mistake: none of the e-cigarettes, including cartridge-based e-cigarettes, currently on the market have gone through the FDA approval process.  They have not demonstrated that they are safe and effective for helping adults quit smoking cigarettes.”

The lawmakers point to reports of the increasing use of e-cigarettes by people under the age of 18. They contend that five million children are now vaping, including one in four high school students.

In a recent one-year period, 2017 to 2018, the lawmakers say America saw a 78 percent increase in the number of high school students using e-cigarettes and a 48 percent increase in the number of middle school children using the products. 

The senators draw a distinction between cartridge-based systems and the open tank e-cigarettes that are typically sold in vape shops. They say cartridge-based products are often sold in convenience stores and other outlets where under-age consumers have freer access.

Walmart has announced that it will stop selling e-cigarettes and all related devices and accessories at its U.S. locations. 

The retailer said Friday that its decision to pull the products was made in response to “growing federal, state and local regulatory complexity and uncertainty” around e-cigarettes. Walmart said it will no longer stock the products once its current inventory is gone. 

Health officials said last week that more than 530 cases of a mysterious lung illnesses linked to vaping have now been reported. Since August, at least eight people who reported using e-cigarettes have died. 

“Given the growing federal, state and local regulatory complexity and uncertainty regarding e-cigarettes, we plan to discontinue the sale of electronic nicotine delivery products at all Walmart and Sam’s Club U.S. locations,” the company said in a memo to local managers, according to CNBC. “We will complete our exit after selling through current inventory.”

Health risks in question

Last week, the Trump administration announced that it’s moving toward a federal ban on all non-tobacco flavored e-cigarette products in response to mounting health concerns related to the products. The same week, New York announced that it would ban the sale of flavored e-cigarettes and other vaping products in an effort to address the same concerns.

The Food and Drug Administration (FDA) disclosed late last week that it has opened a criminal investigation into vaping and the illnesses it appears to have caused. The agency’s tobacco director, Mitch Zeller, said the probe is focused on uncovering the cause of the illnesses by examining the chemical makeup of the products and how people use them. 

“We are in desperate need of facts," Zeller said. “The focus of their work is to identify what is making people sick, as well as a focus on the supply chain.”

Walmart’s decision to stop selling e-cigarettes came several months after it ceased sales of fruit- and dessert-flavored e-cigarettes and raised the minimum age for tobacco purchases to 21.

Leaders in the vaping industry continue to assert that the products are less harmful than traditional cigarettes. Tony Abboud, executive director of the Vapor Technology Association, called Walmart’s decision to reduce adult smokers’ access to regulated vaping products “irresponsible.” 

"This will drive former adult smokers to purchase more cigarettes,” Abboud said in a statement.

The Food and Drug Administration (FDA) has launched a criminal probe into vaping as the number of lung illnesses and deaths linked to the products continues to climb. 

Health officials say more than 530 people have now been affected by the mysterious vaping-related lung illness, which has claimed eight lives. All patients have reported using either an electronic cigarette or vaping device prior to getting sick. 

The FDA’s tobacco director, Mitch Zeller, said the investigation is focused specifically on uncovering the cause of the illnesses by examining the chemical components of the products as it relates to how people use them. Zeller noted that the agency isn’t looking to prosecute people for their use of controlled substances through the probe. 

“We are in desperate need of facts," Zeller said. “The focus of their work is to identify what is making people sick, as well as a focus on the supply chain.”

Nationwide investigation

Health authorities suspect a chemical present in many varieties of marijuana liquid vaping products may be the underlying cause of some of the lung illnesses. Most patients reported vaping THC before becoming ill. At present, no single vaping product or ingredient has been found to have been involved in all of the cases. 

The FDA’s investigation will involve the forensic analysis of more than 150 vaping product samples, according to USA Today. Investigators will look for the presence of nicotine, THC, and other cannabinoids, opioids, cutting agents, additives, pesticides, poisons, toxin and any other substances in the samples.

“We are leaving no stones unturned," Zeller said.

Last week, the Trump administration announced that it’s moving toward a federal ban on all non-tobacco flavored e-cigarette products in an effort to address the rising tide of health concerns. New York announced earlier this week that it would implement an emergency ban on the sale of flavored e-cigarettes and other vaping products. 

Health officials in California have confirmed a seventh death connected to a vaping-related lung illness. 

The first death linked to vaping was confirmed in August in California and others were gradually reported in Kansas, Illinois, Indiana, Minnesota, and Oregon. Close to 400 cases of vaping-related lung illnesses have now been reported in 36 states. 

The man in California was reportedly sick for several weeks before dying of "severe pulmonary injury associated with vaping," said Karen Haught, the Tulare County public health officer, in a statement.

"Long-term effects of vaping on health are unknown. Anyone considering vaping should be aware of the serious potential risk associated with vaping,” Haught said. 

In the wake of the most recent death, the Centers for Disease Control and Prevention (CDC) activated its emergency operations center to help it respond to the health threat more effectively.

“CDC has made it a priority to find out what is causing this outbreak of e-cigarette or vaping-related injuries and deaths,” said CDC Director Robert Redfield, M.D. in a statement. “Activation of CDC’s Emergency Operations Center allows us to enhance operations and provide additional support to CDC staff working to protect our Nation from this serious health threat.”

Health effects in question

Lawmakers are currently lobbying to have flavored e-cigarettes banned, at least while investigations into the health effects of the products are ongoing. Last week, the Trump administration announced that it’s moving toward a federal ban on flavored vaping products amid persistent concerns over the “epidemic” of youth e-cigarette use.

Earlier this week, Governor Andrew Cuomo announced an emergency order to ban flavored e-cigarette products in New York. Sen. Richard Blumenthal (D-CT) also said this week that he wants flavored e-cigarettes to be banned in his state. Additionally, Blumenthal is pushing for a bill that would invest $500 million over the next 10 years to address e-cigarette use among teens.

"They should know these products are not harmless, they are not hip and cool, they can be severely damaging because of these compounds found in them," Blumenthal said on Monday.

The CDC recently recommended that young adults, pregnant women, and non-smokers avoid using e-cigarettes and vaping products while the agency investigates the outbreak of illnesses. 

"It is time to stop vaping," Kansas Department of Health and Environment Secretary Dr. Lee Norman said. "If you or a loved one is vaping, please stop. The recent deaths across our country, combined with hundreds of reported lung injury cases continue to intensify."

Over the weekend, New York Governor Andrew Cuomo announced he would issue an emergency order to ban flavored e-cigarette products. 

The announcement comes just a few days after the Centers for Disease Control and Prevention (CDC) said it had identified nearly 400 cases of lung disease associated with e-cigarettes. As of last week, six deaths have now been linked to vaping. 

Health officials have expressed deep concern over the “epidemic” of youth e-cigarette use that has unfolded over the past few years. Last week, the Trump administration announced that it’s moving toward a federal ban on flavored vaping products in an effort to reverse the trend. 

In a statement, Cuomo said New York is “confronting this crisis head-on” and taking a “nation-leading step to combat a public health emergency.”

"Vaping is dangerous. At a minimum, it is addicting young people to nicotine at a very early age,” Cuomo said on Sunday. 

‘Targeting young people’

Cuomo noted that there has been a 160 percent increase from 2014 on e-cigarette flavors such as bubble gum, cotton candy, and "Captain Crunch."

"Manufacturers of fruit and candy-flavored e-cigarettes are intentionally and recklessly targeting young people, and today we're taking action to put an end to it,” he said. 

Tobacco and menthol e-cigarette flavors wouldn’t be pulled from the market under the order, since these products can serve as a tool for adult smokers looking to discontinue their use of traditional cigarettes. However, "that could change in the future," Cuomo said.

Cuomo has also signed an order that would put educational awareness programs on vaping into school systems. In July, the Democratic governor announced that New York would also be raising the minimum age to purchase tobacco to 21 beginning in November. 

The Trump administration is reportedly gearing up to impose a ban on flavored e-cigarettes. 

The move comes as health officials continue to express concern over the number of teens who have picked up vaping in recent years. It also comes amid an ongoing national investigation into a surge in “severe” lung illnesses among e-cigarette users that has claimed six lives.

U.S. Health and Human Services Secretary Alex Azar said in a statement on Wednesday that the administration is “making it clear that we intend to clear the market of flavored e-cigarettes to reverse the deeply concerning epidemic of youth e-cigarette use that is impacting children, families, schools and communities.” 

“We will not stand idly by as these products become an on-ramp to combustible cigarettes or nicotine addiction for a generation of youth,” Azar continued. 

He said the Trump Administration wants to pull the products from the market entirely, at least until the FDA can thoroughly review their safety. 

Late last week, health officials reported that e-cigarette use is likely behind more than 450 cases of lung illnesses affecting users in 33 states. As of Tuesday, six people have died from causes believed to be linked to the use of e-cigarettes and other devices. 

FDA guidance coming soon

President Trump said on Wednesday that the FDA would be issuing "some very strong recommendations" regarding the use of flavored e-cigarettes in "a couple of weeks,” according to CNN.

The policy expected to be unveiled in the coming weeks would require manufacturers of flavored e-cigarette products to remove their products from the market within 30 days.

"It'll take several weeks for us to put out the final guidance that will announce all the parameters around the enforcement policy, and then there will likely be about a 30-day delay to effective date, as is customary," Azar said. “At that point all flavored e-cigarettes other than tobacco flavor would have to be removed from the market."

Applications seeking FDA approval to reenter the market could be submitted at a later date. 

“We strongly agree with the need for aggressive category-wide action on flavored products,” a Juul spokesman told CNBC. “We will fully comply with the final FDA policy when effective.”

The Centers for Disease Control and Prevention recently recommended that young adults, pregnant women, and non-smokers avoid using e-cigarettes and vaping products while the agency investigates the outbreak of lung illnesses. Those who use e-cigarette products are urged not to buy them off the street, modify them, or add any substances to the products that are not intended by the manufacturer. 

A sixth person has died from the mysterious vaping-related illness that is currently the subject of a national investigation.

Kansas health officials said on Tuesday that a woman over 50 with pre-existing health problems died after her symptoms were exacerbated by vaping. The woman died of acute respiratory distress syndrome less than a week after she began using e-cigarettes. 

Just a few days ago, health authorities announced that the number of vaping-related lung illnesses has increased to over 450. The CDC said those affected by the “outbreak of severe pulmonary disease” are spread across 33 states.  

The number of recent deaths believed to be linked to vaping has now risen to six. The other five vaping-related deaths were reported in Illinois, Indiana, Oregon, Minnesota, and California.

"It's time to stop vaping," Dr. Lee Norman, secretary for the Kansas Department of Health and Environment, wrote in a news release. "If you or a loved one is vaping, please stop."

Officials recommend avoiding use

On Friday, officials said they suspect a chemical derived from vitamin E may be the underlying cause of the lung illnesses. The chemical is present in many different types of marijuana liquid vaping products, which many patients reported using. 

While the investigation is ongoing, health officials have recommended that young adults, pregnant women, and non-smokers avoid using e-cigarettes and vaping products. Those who use e-cigarette products are urged not to buy them off the street, modify them, or add any substances to the products that are not intended by the manufacturer. 

“The severity of illness people are experiencing is alarming and we must get the word out that using e-cigarettes and vaping can be dangerous,” said Ngozi Ezike, director of the Illinois Department of Public Health, in an August statement. 

On Monday, the Food and Drug Administration (FDA) charged vaping industry leader Juul with illegally marketing its nicotine pods as “safe.” In a letter to the company’s CEO Kevin Burns, the FDA demanded that Juul change its marketing practices or risk being hit with a hefty fine or having its products seized. 

The letter was sent two days after the FDA reviewed testimony from a congressional hearing on Juul, which took place in July. The FDA said it found that Juul illegally sold or distributed its products as “modified risk tobacco products without an FDA order in effect that permits such sale or distribution.”

The agency stressed that regulatory approval is required before a company can market a specific product as being safer than traditional cigarettes. 

Federal regulators said Juul shirked that law by touting its products as carrying "a lower risk of tobacco-related disease” and being “less harmful than one or more other commercially marketed tobacco products.” Juul has never submitted its vaping devices for FDA review. 

“The law is clear that, before marketing tobacco products for reduced risk, companies must demonstrate with scientific evidence that their specific product does in fact pose less risk or is less harmful," acting FDA Commissioner Ned Sharpless said in a statement. "JUUL has ignored the law, and very concerningly, has made some of these statements in school to our nation's youth."

Health concerns raised

The FDA has given Juul 15 days to respond to the letter with a plan for maintaining compliance with the U.S. Federal Food, Drug, and Cosmetic Act. 

Alternatively, Juul may provide “reasoning and provide any and all scientific evidence and data, if any, that support that your statements and representations do not explicitly or implicitly convey that JUUL products pose less risk, are less harmful, present reduced exposure, or are safer than other tobacco products.”

A spokesperson for Juul said the company intends to “fully cooperate” with regulators.

Juul’s legal troubles come amid growing concern over the health risks of vaping products. On Friday, the Centers for Disease Protection and Control and Prevention (CDC) announced that it’s investigating hundreds of lung illness cases and five deaths that could be linked to chemical exposure while vaping.

While the investigation is ongoing, health officials have recommended that young adults, pregnant women, and non-smokers avoid using e-cigarettes and vaping products. Those who use e-cigarette products are urged not to buy them off the street, modify them, or add any substances to the products that are not intended by the manufacturer. 

On the heels of three more deaths believed to be associated with electronic cigarettes, federal health officials have issued a warning urging consumers to avoid using the products while they conduct an investigation into the matter. 

The Centers for Disease Control and Prevention (CDC) said on Friday that over 450 users of these devices have now reported symptoms of severe pulmonary disease.  

"CDC, US Food and Drug Administration (FDA), state and local health departments, and other clinical and public health partners are investigating a multistate outbreak of severe pulmonary disease associated with e-cigarette product (devices, liquids, refill pods, and/or cartridges) use,” the CDC said. 

“This investigation is ongoing and has not identified a cause, but all reported cases have a history of using e-cigarette products," the agency noted.

The illnesses have been reported from 33 states. With the addition of the three recent deaths, the number of deaths potentially linked with vaping has now risen to five. 

Chemical link suspected

Towards the end of August, the CDC announced that it was launching an investigation in response to “a cluster of pulmonary illnesses” in multiple states. Patients who had confirmed that they used e-cigarettes reported symptoms such as chest pain, fatigue, shortness of breath, and vomiting. 

The agency said there is no evidence that an infectious disease is causing the illnesses, which has led officials to believe the illnesses may be associated with chemical exposure. On Friday, health officials suggested that the lung illnesses were linked to a chemical derived from vitamin E that is present in many different types of marijuana liquid vaping products. 

All of the patients who have gotten sick have reported using e-cigarettes, but no specific substance or product was found to be linked to all the cases. However, many patients reported using e-cigarette products with liquids that contain cannabinoid products (such as THC), the CDC said. 

“These investigations are ongoing,” the agency wrote. “CDC will provide updates when more information is available.” 

In the meantime, health officials have recommended that young adults, pregnant women, and non-smokers avoid using e-cigarettes and vaping products. Those who use e-cigarette products are urged not to buy them off the street, modify them, or add any substances to the products that are not intended by the manufacturer. 

Federal health officials are making a case that a recent outbreak of lung illnesses may be linked to a chemical derived from vitamin E that is present in many different types of marijuana liquid vaping products.

The Washington Post reports information about the possible link was revealed this week in a conference call by the Food and Drug Administration (FDA) and health officials from various states.

Previously, the lung illnesses were linked to the vaping of a wide-ranging assortment of marijuana products. The chemical showed up in most of the cannabis samples from patients who got sick over the summer.

Vitamin E is harmless enough and millions of consumers take it daily in the form of a supplement. It’s also found naturally in certain food oils.

When ingested as a food, it’s not known to cause any problems -- but inhaling it may be another matter. Scientists say vitamin E’s molecular structure could cause problems if it is inhaled as a vapor.

The issue first came to light at least a year ago when health researchers claimed that vaping can damage important cells in the immune system and cause inflammation of the lungs. The researchers, writing in the journal Thorax, said that they "caution against the widely held opinion that e-cigarettes are safe.”

Official vaping death

Last month, the Centers for Disease Control and Prevention (CDC) for the first time officially attributed a death to vaping. Previously, some 200 cases of severe lung illnesses had been flagged as being potentially linked with vaping

In August, the agency said one adult patient in Illinois died over the summer after symptoms from an existing pulmonary illness were exacerbated or caused by e-cigarette use. 

Bureaucratic irregularities may make it harder for health officials to pin down the exact cause of these mystery lung ailments. At present, states don’t have to report suspected cases of vaping-related illnesses. Even if they did it might be difficult to pin down the ingredient in the many types of vaping liquids that is causing the problem.

Meanwhile, as of last week, state health department had reported 215 possible cases of vaping-related illnesses in 25 states.

A published report claims the Federal Trade Commission (FTC) is investigating Juul, the manufacturer of a popular e-cigarette product, to determine whether it has aimed its marketing efforts at minors.

The Wall Street Journal reports the regulator’s wide-ranging investigation is also focused on the company’s past use of paid influencers to help promote the product.

The Journal quotes a company spokesman as saying Juul used paid influencers in a “small, short-lived pilot” program that ended last year. Juul says it paid influencers less than $10,000 to post positive reviews about the e-cigarettes.

Juul is also under investigation by the Food and Drug Administration (FDA). A year ago the FDA seized more than a thousand pages of documents from Juul during an unannounced inspection of the company’s headquarters in San Francisco.

Then-FDA Commissioner Scott Gottlieb called the growing use of e-cigarettes among teens an “epidemic” and said easy access to the products was only fueling the trend.

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens," Gottlieb said last year. "The FDA won't tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products."

At the time, the FDA expressed concern that e-cigarette manufacturers, including Juul. were offering flavored products that appealed to teens. Since then, manufacturers have taken steps to discourage the use of their products by under-age consumers.

Smokers only

Juul has said that its products are for use by cigarette smokers to help them stop smoking. In an interview with CBS News Juul CEO Kevin Burns said people who don’t have a pre-existing  relationship with nicotine should not use his company’s products.

“Don't vape. Don't use Juul," Juul CEO Kevin Burns told the network. "Don't start using nicotine if you don't have a preexisting relationship with nicotine. Don't use the product. You're not our target consumer."

While Juul appears to be a favorite product of teens, the company says it never wanted to tap into that market. It recently introduced a bluetooth-enabled e-cigarette that requires consumers to submit a photo ID before the product can be used.

Juul Labs, which has been accused of fueling the teen vaping epidemic through its marketing campaign, has announced a new POS age-verification system that it hopes will reduce youth use of its products. 

“Today, we are implementing a series of new measures to combat the serious problem of youth access, appeal, and use of vapor products,” Juul said in a statement.

Juul says it’s partnering with retailers to implement the Retail Access Control Standards program (or RACS) -- “the strictest age-verification system ever required for age-restricted products,” said CEO Kevin Burns.

Under the new set of guidelines: 

• ID scanning to verify age is required

• Bulk purchasing is blocked to prevent social sourcing 

• Clerks can’t override the system manually 

Retailers who sell Juul must implement the new system by May 2021. More than 50 chains (totaling about 40,000 stores) have pledged to make the switch so far, and more than half of those outlets say they will comply with the system before the end of this year. 

Taking steps to curb youth use

Juul’s new plan to prevent youth use of its products comes about a month after CEO Kevin Burns apologized to parents whose children are addicted to the company’s e-cigarettes. 

“First of all, I’d tell them that I’m sorry that their child’s using the product,” Burns said in a documentary called “Vaporized: America’s E-cigarette Addiction.” 

“It’s not intended for them. I hope there was nothing that we did that made it appealing to them. As a parent of a 16-year-old, I’m sorry for them, and I have empathy for them, in terms of what the challenges they’re going through,” Burns said. 

In the RACS release, Juul said it’s aware that youth vaping in the U.S. has become a “serious and urgent problem” over the past few years. “At JUUL Labs, we have no higher priority than combating youth use,” the company said. 

The Centers for Disease Control and Prevention (CDC) has announced that it has recorded the first death believed to be linked to vaping. 

Nationwide, nearly 200 cases of severe lung illnesses have been flagged as being potentially linked with vaping, according to the CDC’s most recent figures. The agency said one adult patient in Illinois died over the summer after symptoms from an existing pulmonary illness were exacerbated or caused by vaping or e-cigarette use. 

The CDC said “severe unexplained respiratory symptoms” have been reported after vaping or e-cigarette use. Symptoms reported by patients have included breathing difficulties, vomiting, nausea, chest pain, and fatigue. 

Health officials have determined that an infectious disease isn’t causing the illnesses, but they have stopped short of naming vaping as the definitive cause. 

“While some cases in each of the states are similar and appear to be linked to e-cigarette product use, more information is needed to determine what is causing the illnesses,” CDC official Ileana Arias said in a statement. 

‘Alarming’ rise in illnesses

Last week, the CDC announced that it was investigating “a cluster of pulmonary illnesses” in five states (California, Illinois, Indiana, Minnesota and Wisconsin) that appeared to be linked with the use of e-cigarettes and other vaping devices. 

The agency said at the time that 94 cases of lung illnesses associated with e-cigarette use had been reported. Over the last week, the number of individuals who reported similar symptoms between June 28 and today increased to 193. 

Illinois has a particularly high concentration of the unknown lung illnesses among e-cigarette users. As of Friday, 22 people in the state have been hospitalized and 12 more cases are being reviewed. 

“The severity of illness people are experiencing is alarming and we must get the word out that using e-cigarettes and vaping can be dangerous,” said Ngozi Ezike, director of the Illinois Department of Public Health, in a statement.

The CDC said it’s working on developing a system to “collect, aggregate, and analyze data at the national level to better characterize this illness.”

​The Centers for Disease Control and Prevention (CDC) has announced that it’s looking into a possible link between severe lung diseases and e-cigarette use. 

The agency launched its probe in response to “a cluster of pulmonary illnesses” in five states -- California, Illinois, Indiana, Minnesota and Wisconsin -- that appear to be linked with the use of e-cigarettes and other vaping devices. 

The illnesses were mostly reported among adolescents and young adults, the CDC said. 

“Additional states have alerted CDC to possible (not confirmed) cases and investigations into these cases are ongoing,” the agency stated over the weekend. “There is no conclusive evidence that an infectious disease is causing the illnesses. While some cases in each of the states are similar and appear to be linked to e-cigarette product use, more information is needed to determine what is causing the illnesses.” 

Patients reported symptoms such as chest pain, fatigue, shortness of breath, and vomiting. Health officials said patients who experienced these problems were hospitalized after their symptoms worsened.

“All patients were hospitalized, with some needing assistance to breathe. While patients have improved with treatment, it is unknown whether there will be long-term health effects,” the Utah Department of Health said in a statement.

Nearly 94 cases of “severe” illnesses associated with e-cigarette use have so far been reported across 14 states since June 28, according to the CDC. 

Teen vaping raises alarm

Use of e-cigarettes among teenagers has skyrocketed in recent years, prompting both the FDA’s former chief and the Surgeon General of the United States to describe the issue as an “epidemic.” 

Studies have found that e-cigarette use among high schoolers grew by 78 percent between 2017 and 2018, and Juul has been singled out for its role in creating the problem. 

“The rise in e-cigarette use during 2017–2018 is likely because of the recent popularity of e-cigarettes shaped like a USB flash drive, such as JUUL,” the CDC said. “These products can be used discreetly, have a high nicotine content, and come in flavors that appeal to youths.”

In addition to carrying possible health risks, health officials have expressed concern that the recent surge in e-cigarette use among teens may lead to an increase in the use of combustible cigarettes. 

In a statement published in February, CDC Director Robert Redfield said the rise in teen vaping “threatens to erase progress made in reducing youth tobacco use and is “putting a new generation at risk for nicotine addiction.” 

The Vapor Technology Association, an industry group representing 800 vaping companies, has filed a lawsuit seeking to delay the FDA’s upcoming review of e-cigarettes.

The FDA originally set a 2022 deadline for submitting applications for e-cigarette approval, but it advanced it to May 2020 in response to a dramatic rise in teen vaping and pressure from anti-tobacco groups. In June, a judge ruled in favor of the new 2020 deadline, which prompted the vaping group to sue.

The lawsuit filed Wednesday claims the FDA’s new deadline will put many smaller vaping companies out of business. 

“It is time for FDA to stop moving the goalposts and changing the rules in the middle of the game to the detriment of our manufacturers and small businesses,” VTA executive director Tony Abboud said in a statement.

Health concerns

E-cigarette manufacturers have stressed that their products are intended to help adult smokers quit, but teens have gravitated toward them at a rate that has generated concern among health officials. 

Last month, the CEO of Juul -- which is among the members of the vaping association seeking to delay the government’s review of e-cigarettes -- issued a public apology to parents of children addicted to vaping products. 

“It’s not intended for them,” said Juul CEO Kevin Burns. “I hope there was nothing that we did that made it appealing to them. As a parent of a 16-year-old, I’m sorry for them, and I have empathy for them, in terms of what the challenges they’re going through.”

Researchers are still trying to get a clear picture of the health effects associated with e-cigarettes. The FDA is currently investigating nearly 130 reports of seizures in e-cigarette users, and regulators have expressed concern that the rise in e-cigarette threatens undo progress in reducing rates of tobacco use among minors.

The U.S. Food and Drug Administration (FDA) has sent warning letters to four companies to demand that they stop selling certain flavored e-cigarette and hookah products.

The agency says that a combined 44 products distributed by the four companies -- Mighty Vapors LLC, Liquid Labs USA LLC, V8P Juice International LLC, and Hookah Imports Inc. -- were not authorized to be legally sold in the U.S. The move comes shortly after a rule took effect that placed tobacco products under the jurisdiction of the FDA. 

“Today’s actions make clear that we will continue to keep a close watch on whether companies are breaking the law and will take swift steps when violations are found. Our work in this area has already resulted in a number of companies removing products from the market,” said Dr. Ned Sharpless, the FDA’s acting commissioner. 

The companies will have 15 days to respond to the FDA’s warning. If they fail to do so, the agency says it may have to take further action.

Addressing the youth vaping epidemic

The FDA’s decision follows several months in which regulators have sought to address the teen vaping crisis. Reports indicate that millions of teens currently use e-cigarettes, and regulators believe those high numbers may translate to future tobacco use. 

“The marketing of illegal tobacco products is particularly concerning given the epidemic of youth vaping that we’re facing, which we know has resulted in part from irresponsible practices from manufacturers importers and retailers who have targeted kids in their marketing of these products,” said Sharpless. 

“It is critical that we remain vigilant in our efforts to stem the increase in use and nicotine addiction in children driven by e-cigarettes, which threatens to erase the years of progress we’ve made combatting tobacco use among kids.”

In addition to its legal efforts, the FDA has launched its Youth Tobacco Prevention Plan to counter the teen vaping threat. It has also launched a new TV ad campaign designed to educate young people on the dangers of vaping.

What’s the “real cost” of vaping? The Food and Drug Administration (FDA) hopes to make it abundantly clear with a new television ad campaign aimed at the underage use of e-cigarettes.

It’s a dramatic expansion of the agency’s ”The Real Cost” Youth E-Cigarette Prevention Campaign launched in 2018 amid alarming statistics which showed large increases in teens’ use of e-cigarettes. Federal data showed e-cigarette use among high school students rose by 77 percent that year.

The initial campaign used hard-hitting advertising on digital and social media sites, as well as posters with e-cigarette prevention messages displayed in high schools across the nation. The new TV ads are intended to drive home public health messages about the risks of e-cigarette use.

Supposed to help smokers quit

E-cigarettes were initially introduced as a substitute for tobacco cigarettes. They produce a vapor from liquid that can be inhaled much like a cigarette. Because the liquid contains nicotine, the product is supposed to give a smoker the pleasures of smoking without using tobacco.

Many public health experts charge e-cigarette marketers of expanding their target beyond smokers who are trying to quit to teens who have never smoked. Former FDA Commissioner Scott Gottlieb, who resigned in April, was a particularly harsh critic of e-cigarette marketers.

“We don’t yet fully understand why these products are so popular among youth,” Gottlieb said in April 2018. “But it’s imperative that we figure it out, and fast.”

‘Troubling epidemic’

The FDA said the ad campaign has taken on heightened importance in light of what it says is an “emerging science” which suggests that teens who vape are more likely to start smoking cigarettes. The concern is that teens who get hooked on nicotine by using e-cigarettes will eventually graduate to tobacco in order to get a stronger dose.

“The troubling epidemic of youth vaping threatens to erase the years of progress we’ve made combating tobacco use among kids, and it’s imperative that our work to tackle this immensely concerning trend continues to include efforts to educate our nation’s youth about the dangers of these products,”  said Acting FDA Commissioner Ned Sharpless.

The new ads feature street magician Julius Dein, a YouTube star with 113 videos and nearly 800,000 subscribers. In the ads, the social media personality takes a young person’s e-cigarette  and transforms it into a cigarette in front of their eyes. The illusion is supposed to drive home the idea that teens who vape are more likely to start smoking cigarettes. 

The FDA says the new ads will run on TeenNick, CW, ESPN, and MTV, as well as on music streaming sites, social media networks, and other teen-focused media channels.

During an interview with CNBC’s Carl Quintanilla, Juul CEO Kevin Burns said he would apologize to parents whose children are addicted to Juul e-cigarettes. 

“First of all, I’d tell them that I’m sorry that their child’s using the product,” Burns said in a documentary called “Vaporized: America’s E-cigarette Addiction,” which is set to premiere Monday at 10 p.m. ET.

“It’s not intended for them,” he added. “I hope there was nothing that we did that made it appealing to them. As a parent of a 16-year-old, I’m sorry for them, and I have empathy for them, in terms of what the challenges they’re going through.”

Campaign for Tobacco-Free Kids President Matthew Myers called the apology “a deceptive, self-serving gesture by Juul given their complete refusal to take responsibility for creating the youth e-cigarette epidemic.”

“It is a blatant attempt to deflect attention from the company’s wrongdoing while it opposes meaningful government regulation to prevent it from continuing to addict kids,” Myers said in a statement on Monday, according to CNBC.

Juul’s role in the teen vaping ‘epidemic’

From 2017 to 2018, the number of youth e-cigarette users grew by 1.5 million, according to a survey conducted earlier this year by the Centers for Disease Control and Prevention (CDC).

In April, former FDA Commissioner Scott Gottlieb called out Juul -- a dominating force in the e-cigarette industry -- for fueling what they have called a teen vaping epidemic. Vaping products manufactured by Juul have been shown to be especially popular among teen users since they come in fruity flavors like fruit, creme, and mango. 

“I hope they recognize the problem that’s been created has been created largely by their product,” Gottlieb told Vox.

Juul has maintained that its intent was never to pull in youth users. To address the issue, the company has taken several actions to curb teen use of its products, including shuttering its social media accounts and eliminating its flavored products.

Controversial marketing campaign

Federal regulators have set out to reduce youth use of e-cigarettes in recent years, but critics say the damage caused by Juul may already have been done. Gottlieb noted that Juul’s early marketing campaigns appeared to speak directly to young people. 

“If you go back and look at their marketing campaigns from 2015 and 16, it’s hard not to look at that marketing and conclude that it's not going to be appealing to a youth, to a teenager,” Gottlieb said earlier this year. “It certainly in my view had some impact on creating the problem we have now.”

In the upcoming documentary, Burns refutes the claim that Juul’s initial marketing marketing campaign had any significant impact on sales. 

“When we launched Juul, we had a campaign that was arguably too kind of lifestyle-oriented, too flashy,” Burns said. “It lasted less than six months. It was in the early days of the product introduction. We think it had no impact on sales.”

Health impact in question

E-cigarette manufacturers have stressed that their products are intended to help adult smokers quit. However, teens have gravitated toward them at a rate that has sparked concern among health officials, who aren’t yet sure of the adverse health effects the products could cause down the line.

“Frankly, we don’t know [the impact of chronic vaping] today,” Burns said. “We have not done the long-term, longitudinal, clinical testing that we need to do.”

Additionally, regulators have expressed concern that the rise in e-cigarette could undo progress in reducing rates of tobacco use among minors.

"The skyrocketing growth of young people's e-cigarette use over the past year threatens to erase progress made in reducing youth tobacco use. It's putting a new generation at risk for nicotine addiction," CDC Director Robert Redfield said in a statement published in February.

Juul has said it supports the initiative to raise the minimum smoking age to 21 to prevent minors from buying its products.

On Tuesday, San Francisco became the first U.S. city to ban e-cigarettes when city officials passed an ordinance prohibits selling nicotine “pods” -- cartridges that contain nicotine and used in a vaporizer -- or electronic smoking devices that haven’t been approved by the Food and Drug Administration (FDA).

“There is so much we don’t know about the health impacts of these products, but we do know that e-cigarette companies are targeting our kids in their advertising and getting them hooked on addictive nicotine products,” San Francisco mayor London Breed said in a statement.

Who’ll be the next to step up?

It’ll be interesting to see if San Francisco’s ban catches fire and moves to other cities. Two other cities in the Bay Area --  the cities of Richmond and Livermore -- have already announced that they may follow in San Francisco’s footsteps.

On a state level, 48 states have laws in place prohibiting access to e-cigarettes for people up to 18 years old or older. 

On the federal level, the initiative has great support from the FDA. Last year, the agency carried out the largest coordinated enforcement effort in the FDA’s history when it issued more than 1,300 warning letters and fines to businesses that illegally sold e-cigarette products to minors.

Manufacturers say they’re on board, at least with teen use

Teens are the primary consumer target for e-cig companies. Close to 21 percent of U.S. high school students and 5 percent of middle schoolers say they’ve used electronic cigarettes in the past 30 days. Adding to that concern is an estimate that some addicted minors spend as much as $1,500 per year feeding their e-cig habit.

Juul -- the largest e-cig manufacturer, one owned in part by Altria, the parent company of Philip Morris -- has its white hat on and says it’s behind the prohibition to minors all the way. In its “commitment to youth prevention,” Juul promises it will:

• Suspend the distribution of non-tobacco and non-menthol-based flavored JUUL products to retail outlets;

• Enhance its e-commerce platform to ensure purchasers are 21+ and to prevent bulk purchases;

• Promote retailer compliance to ensure retail stores do not sell JUUL products to those underage;

• Exit its U.S. Facebook and Instagram accounts; and

• Develop technology-based solutions to prevent youth use.

Finding out the full impact will take time

It’s too early to predict the long-term effects of e-cigarette smoking. With tobacco, there were decades of use and diseases to draw from. But researchers are already seeing some similarity in how genes and proteins are affected. 

“While many of the chemicals found in e-liquids are FDA approved, they are approved for ingestion, not inhalation,” said UNC School of Medicine toxicologist Ilona Jaspers. “When you switch the route of exposure (inhaling instead on ingesting), and go through the lung, the lung is really not a good organ to metabolize foreign compounds.”

City supervisors in San Francisco are set to make the city the first in the country to prohibit all sales of e-cigarettes. The move comes as federal regulators continue to formulate ways to combat the alarming surge in teen vaping rates.

In addition to banning e-cigarette distribution and sales, city supervisors are expected to vote to impose a ban on manufacturing e-cigarettes on city property. The measures, which will receive a final vote next week, are each intended to prevent e-cigarettes from taking the place of traditional cigarettes.

Though vaping is considered to be less harmful than smoking cigarettes, researchers say the health risks of e-cigarettes may be more extensive than consumers may have been led to believe.

“This is about thinking about the next generation of users and thinking about protecting the overall health and sending a message to the rest of the state and the country: Follow our lead,” Supervisor Ahsha Safaí said in a statement to the media.

Addressing the rise in teen vaping

While vaping may be a useful tool in helping some smokers quit, former FDA Commissioner Scott Gottlieb has said that the agency “will not allow that opportunity to come at the expense of addicting a whole new generation of kids to nicotine.”

Just recently, the FDA reprimanded four vaping companies for failing to ensure that content posted by social media influencers contained the statement, “WARNING: This product contains nicotine. Nicotine is an addictive chemical.”

“Given the significant risk of addiction, the failure to disclose the presence of and risks associated with nicotine raises concerns that the social media postings could be unfair or likely to mislead consumers,” federal regulators said in letters sent to the four companies.

Juul, the leader in the e-cigarette industry, wasn’t among the companies that received a letter. However, the manufacturer was accused of reneging on its promise to serve only as an “off-ramp” for smokers to quit when it accepted a $12.8 billion investment from tobacco giant Altria.

The upcoming vote in San Francisco could have a big impact on Juul, which is headquartered in the city. Juul is currently backing a signature-collecting initiative for a November vote to overrule the measure.

Banning vaping products for all adults in San Francisco “will not effectively address underage use and will leave cigarettes on shelves as the only choice for adult smokers, even though they kill 40,000 Californians every year,” a spokesman for Juul told the Associated Press.

If imposed as expected, the ban would go into effect in around seven months.

A federal judge ruled Wednesday that the Food and Drug Administration (FDA) must speed up its review of the health impact of electronic cigarettes.

The ruling represents a victory for public health groups, who last year sued the agency after its delay in regulating e-cigarette products gave way to a rise in vaping among teens.

The groups that filed the lawsuit included the American Academy of Pediatrics, the Campaign for Tobacco-Free Kids, the American Cancer Society Cancer Action Network, and the heart and lung associations.  

Lack of regulation in the industry

In the complaint, the groups expressed deep concern that the FDA’s lack of written rules and product standards in the e-cigarette industry could threaten to get a new generation of Americans addicted to nicotine.

"It is now the FDA's responsibility to take immediate action to protect our kids and require manufacturers to apply to the FDA if they want to keep their products on the market," the groups said in a statement.

The lawsuit centers around the fact that the FDA postponed its review of the impact of e-cigarettes by several years -- a move that Maryland U.S. District Judge Paul Grimm, who issued the ruling, called “so extreme as to amount to an abdication of its statutory responsibilities.”

For its part, the agency has argued that both its staff and manufacturers need more time to prepare for regulation. Grimm has ordered the FDA to submit plans for speeding up the review process within two weeks.

E-cigarettes remain controversial within the Food and Drug Administration, which has expressed alarm at what it calls an epidemic of teen use of the nicotine-delivery device.

But the agency has flashed a green light for a new tobacco product that some critics argue is very similar to electronic cigarettes. The FDA has authorized the marketing of a new Phillip Morris product called a “tobacco heating system.” It consists of an electronic device that heats tobacco-filled sticks wrapped in paper to generate a nicotine-containing aerosol.

At the same time, the FDA said it is placing strict marketing restrictions on the products in an effort to prevent youth access and exposure.

The FDA said it is approving the product because, in the long run, it may be beneficial to public health by encouraging more cigarette smokers to quit. Following a review, it was determined that the new product produces lower levels of some toxins than regular cigarettes.

Marlboro brand

The FDA has cleared the way for marketing of the product, known as an IQOS device, sold under the brand names Marlboro Heatsticks, Marlboro Smooth Menthol Heatsticks, and Marlboro Fresh Menthol Heatsticks.

The agency makes clear that while it is approving the sale of this type of product in the U.S., it in no way is declaring it safe or ”FDA approved.”

“Ensuring new tobacco products undergo a robust premarket evaluation by the FDA is a critical part of our mission to protect the public, particularly youth, and to reduce tobacco-related disease and death,” said Mitch Zeller, J.D., director of the FDA’s Center for Tobacco Products.

May help smokers quit

Zeller said the agency paid particular attention to how the product may affect the use of nicotine and tobacco, a concern that has increased in recent years as young people who have never smoked have taken up “vaping,” inhaling nicotine vapor. In the end, the agency decided that with stringent controls to keep the new product away from teens it had potential to move smokers away from cigarettes.

“Importantly, the FDA is putting in place postmarket requirements aimed at, among other things, monitoring market dynamics such as potential youth uptake,” Zeller said. “We’ll be keeping a close watch on the marketplace, including how the company is marketing these products, and will take action as necessary to ensure the continued sale of these products in the U.S. remains appropriate and make certain that the company complies with the agency’s marketing restrictions to prevent youth access and exposure.”

Underscoring its concern, the FDA said all tobacco products are potentially harmful and addictive and those who do not use tobacco products shouldn’t start.

As he left office, Food and Drug Administration Commissioner Scott Gottlieb was highly critical of e-cigarette maker JUUL, charging the company has had a role in the increase of teen “vaping.”

But concern about the company is a bipartisan issue, with 11 Democratic members of the U.S. Senate now voicing their concern. In a letter to the company, the lawmakers asked for answers to questions about JUUL’s marketing practices.

The Democrats told JUUL they will not only look at how the company markets its product but also investigate its sale of a portion of the firm to Altria, a tobacco company.

“While JUUL has promised to address youth vaping through its modest voluntary efforts, by accepting $12.8 billion from Altria—a tobacco giant with such a disturbing record of deceptive marketing to hook children onto cigarettes—JUUL has lost what little remaining credibility the company had when it claimed to care about the public health.,” the senators wrote. “While you and your investors may be perfectly content with hooking an entire new generation of children on your tobacco products in order to increase your profit margins, we will not rest until your dangerous products are out of the hands of our nation’s children.”

Following FDA commissioner’s lead

On his way out the door, Gottlieb took another shot at JUUL, a company he has repeatedly pressed to limit access by underage consumers to their product.

“I hope they recognize the problem that’s been created has been created largely by their product,” Gottlieb said in an interview with Vox.

During his nearly two years as FDA head, Gottlieb made combating the rise in underage use of e-cigarettes one of the agency’s highest priorities. He’s previously called out JUUL for its role in creating what he’s called a public health crisis, which he’s previously described as an “epidemic.”

‘Public health epidemic’

Sen. Dick Durbin (D-Ill.), one of the senators signing the letter, noted that both the U.S. Surgeon General and the Food and Drug Administration (FDA) Commissioner have called youth use of e-cigarettes a “public health epidemic.”

Durbin cites data from the National Youth Tobacco Survey (NYTS) showing 20.8 percent of high-school students and 4.9 percent of middle-school students—more than 3.6 million children—currently use e-cigarettes. Durbin says in the last year children’s use of e-cigarettes has increased by 78 percent.

JUUL has defended itself from criticism by saying it makes its product for smokers who are trying to break their addiction to cigarettes. It said it agreed to the investment by Altria because the money it received allows the company to reach more smokers who are trying to quit.

FDA Commissioner Scott Gottlieb, who last month announced that he would be resigning from his position to spend more time with his family, said in an interview with Vox during his final week that e-cigarette manufacturer Juul is largely to blame for the “dramatic spike of youth [vaping].”

“I hope they recognize the problem that’s been created has been created largely by their product,” Gottlieb told Vox.

During his nearly two years as FDA head, Gottlieb has made combating the rise in underage use of e-cigarettes one of the agency’s highest priorities. He’s previously called out Juul for its role in creating the public health crisis, which he’s previously described as an “epidemic.”

Appeals to minors

The FDA has cited research that shows an estimated 37 percent of high school seniors have tried e-cigarettes. A quarter of youth users told researchers they didn’t realize the products contain nicotine.

The agency has said products manufactured by Juul have been shown to be especially attractive to minors because they come in fruity flavors such as mango, mint, and fruit and creme. In January, Gottlieb warned that e-cigarettes could be taken off the market unless marketers made efforts to stop sales to minors.

Gottlieb said in his interview with Vox this week that there’s “no question” that Juul -- which markets a device that looks like a USB drive -- “drove a lot of the youth use.”

“I’m not willing to concede the point that the Juul product was responsible — at least in part — for the sharp uptick in youth use,” he said.

Controversial marketing strategies

For its part, Juul has maintained that it’s dedicated to helping adult smokers quit by serving as an “off-ramp” for users of traditional cigarettes. However, Juul’s early marketing campaign often appeared to speak directly to young people.

“If you go back and look at their marketing campaigns from 2015 and 16, it’s hard not to look at that marketing and conclude that it's not going to be appealing to a youth, to a teenager,” Gottlieb said. “It certainly in my view had some impact on creating the problem we have now.”

Next steps

After Gottlieb steps down from his post, Ned Sharpless -- the current director of the National Cancer Institute -- will replace him as interim FDA commissioner.

Gottlieb says the surge in adolescent vaping has now reached the level of an “addiction crisis” which will “take time to reverse.” He said concerns about youth vaping should take priority over concerns about smokers if teen vaping rates continue to rise.

Gottlieb’s past moves to curb youth use of e-cigarettes have included restricting the sale of flavored e-cigarette products to young people and asking companies to take voluntary steps to withdraw them.

The Food and Drug Administration (FDA) is investigating dozens of reports that consumers using e-cigarettes have suffered seizures.

The agency said a search of its files revealed 35 reports of seizures, occurring between 2011 and 2019. In most instances, the victims were teens and young adults. In a joint statement, FDA Commissioner Scott Gottlieb and Deputy Commissioner Amy Abernathy said it’s another reason to be concerned about the growing vaping trend among young people.

“We know that nicotine isn't a harmless substance, especially in the developing brains of our youth,” the two officials said. “We know that initiation to, and addiction to nicotine by never-smokers – predominantly youth and young adults – raises public health concerns. These risks are among the many reasons why we so strongly believe that no child should be using any tobacco product.”

No established pattern

The FDA says the investigation has just begun and that so far, there doesn’t appear to be a pattern to the cases. In fact, Gottlieb and Abernathy say there isn’t proof of a direct connection, but the possibility of one requires the agency to investigate.

In some of the cases, the victims were vaping for the first time. In others, the victims were regular users. A few had a history of seizures and a few others had a history of drug use.

“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,” Gottliieb and Abernathy said. “These include the possible release of some chemicals at higher levels than conventional cigarettes.”

They said there is also data to indicate there may be other potential health concerns with the product, especially since some e-cigarettes deliver a higher concentration of nicotine.

Other dangers

E-cigarettes use a small battery to heat nicotine-laced liquid into a vapor, which is inhaled much like a conventional cigarette. Some smokers have been able to give up cigarettes by vaping, but the FDA has expressed concern that many non-smoking teens have begun using e-cigarettes.

In addition to concerns about possible health risks, there are documented cases in which the products have caused serious injury when they exploded. A report last fall from researchers at George Mason University suggested the number of these cases has been underreported.

Analyzing data from the Consumer Product Safety Commission the researchers reported that approximately 2,035 people ended up in the emergency room due to e-cigarette burns or explosions between 2015 and 2017.

San Francisco city officials have introduced a measure to ban the sale of e-cigarettes within the city until the Food and Drug Administration (FDA) can rule on their safety.

It’s the first U.S. city to consider outlawing the sale of the electronic nicotine-delivery devices, which have come under fire because of their growing popularity among teens. The city has already outlawed the sale of flavored e-cigarettes because they are believed to be more popular with young people.

If the proposed ordinance is adopted in San Francisco, it would prohibit the sale of e-cigarettes within the city limits, either in retail stores or online. The measure was announced Tuesday by the city attorney, Dennis Herrera, and Supervisor Shamann Walton.

“San Francisco has never been afraid to lead and we’re certainly not afraid to do so when the health and lives of our children are at stake,” Herrera said.  E-cigarettes have wiped out the hard-fought gains we have made in curbing youth tobacco use. Today we are taking action to protect our kids.”

Would require FDA review

Herrera said the law requires a new tobacco product, before it goes on sale, to be reviewed by the FDA for its impact on health.

“Inexplicably, the FDA has failed to do its job when it comes to e-cigarettes,” Herrera said. “Until the FDA does so, San Francisco has to step up. These products should not be on our shelves until the FDA has reviewed the threat they pose to public health.”

Walton singled out Juul, an e-cigarette maker owned by Altria but based in San Francisco,  claiming it is contributing to increased numbers of people addicted to nicotine.

“Banning vaping products that target young people and push them towards addiction to nicotine and tobacco is the only way to ensure the safety of our youth,” he said.

‘Modern day prohibition’

In an interview with USA Today, Gregory Conley, president of the American Vaping Association, pointed out that actual tobacco products, such as cigars and cigarettes, are still legally sold in the California city.

"No youth should vape, but no politician should try to enact modern-day prohibition," Conley told the newspaper. "It is hard for San Francisco to get even more absurd, but this proposal and the rhetoric around it is absolutely insane."

If the San Francisco action weren’t bad enough for Juul and its parent company Altria, FDA Commissioner Scott Gottlieb disclosed that his meeting last week with Altria officials to discuss its e-cigarette business was “difficult.”

Gottlieb said the meeting left the firm impression with him that Altria’s decision to invest in the e-cigarette maker last year was purely a business decision and not an effort to offer a tobacco substitute.

The U.S. Food and Drug Administration (FDA) has proposed a new set of rules that would restrict sales of flavored e-cigarette products as part of its larger goal to counter the rise in teen vaping.

As flavored e-cigs have been shown to appeal to youth, the FDA has proposed prioritizing enforcement on sales of flavored products (other than tobacco-, mint-, and menthol-flavored).

“For instance, we’ll consider whether the products are sold under circumstances, whether at retail or online, without heightened age verification,” outgoing Commissioner Scott Gottlieb wrote in a statement.

In its draft guidance, the FDA also said it would be moving up the deadline to submit market applications to August 8, 2021.

“This is an important change in our expectations and enforcement priorities,” Gottlieb wrote of the new deadline, which is a year earlier than stated in a previous proposal.

“For all flavored ENDS [electronic nicotine delivery system] products, including any that continue to be offered for sale under circumstances involving heightened age verification, the FDA expects manufacturers to prepare and submit applications that demonstrate these products meet the public health standard by Aug. 8, 2021.”

Gottlieb, who announced recently that he plans to step down next month, has previously singled out Juul for offering fruity flavors that tend to appeal to underage users and contributing to “epidemic” levels of teen use.

He said the agency would consider taking further action if youth demand for “plain” e-cigarettes rises following the adoption of stricter rules for flavored products.

The proposal is open for public comment for the next 30 days.

In case you had any optism left that vaping could be a healthy alternative to smoking, a new study of nearly 100,000 Americans adds to the growing pile of evidence that e-cigarettes hurt smokers more than they help.

The new research, set to be presented next week at the American College of Cardiology's 68th Annual Scientific Session, is based on data about 96,467 people that was collected by the National Health Interview Survey, a federal government program that falls under the Centers for Disease Control and Prevention (CDC).

According to the findings, Americans who reported smoking e-cigarettes in the survey were 56 percent more likely to have a heart attack, 30 percent more likely to suffer a stroke, 10 percent more likely to suffer from coronary artery disease, and twice as likely to report depression or anxiety.

"These data are a real wake-up call and should prompt more action and awareness about the dangers of e-cigarettes," author Dr. Mohinder Vindhyal, a professor at the University of Kansas School of Medicine Wichita, told Environmental Health News in a statement.

“When the risk of heart attack increases by as much as 55 percent among e-cigarettes users compared to nonsmokers, I wouldn't want any of my patients nor my family members to vape," he added.

Mounting evidence

Experts say that the synthetic chemicals that create the seemingly harmless “puff” of fake smoke are the likely culprit.

The study follows three others published in recent years suggesting a link between e-cigs and cardiovascular problems and strokes. This particular report is significant because it also detected a link between e-cigs and circulatory problems, according to Dr. Stanton Glantz, a University of California, San Francisco researcher who has studied the dangers of smoking regular old cigarettes for decades, as well as e-cigarettes more recently.

On his website, Glantz writes that e-cigarettes are also harmful because they don’t actually encourage people to quit their cigarette addictions.

“Of course, most smokers who use e-cigs continue to be dual users, he writes, (i.e., continue using both products at the same time),” he writes, “which is substantially more dangerous than using either product alone.”

Citing thousands of tobacco-related violations, Food and Drug Administration (FDA) Commissioner Scott Gottlieb on Monday requested a meeting with Walgreens corporate leadership as part of the agency's ongoing crackdown on e-cigarette sales to minors.

E-cigarettes, like other tobacco products, can only be sold to people 18 and older under federal law. But in practice, critics and researchers say that the e-cig industry is intentionally marketing and selling their products to teens.

An estimated 37 percent of high school seniors have tried e-cigarettes. A quarter of those who did said they didn’t realize the products contain nicotine, according to a study published in December.  

Gas chains violate the law

The FDA says that convenience stores and other chains are also complicit in the e-cigarette epidemic among teens. Walgreens, in particular, has racked up more tobacco-related violations than any other chain, the agency says.

“Since the FDA began its retailer inspection program in 2010, FDA inspectors have found nearly 1,800 instances in which Walgreens stores failed to follow the law,” the agency wrote in a letter to Walgreens President Richard Ashworth on Monday.

“Among pharmacy chains that sell tobacco products, Walgreens is the top violator, with 22 percent of the stores inspected having illegally sold tobacco products to minors. These illegal sales must stop,” Gottlieb added.

In an accompanying press release, the agency says that Walgreens “isn’t alone” in the violations. Circle-K, 7-Eleven, and nearly every major gas station chain are also named by the agency as violating federal tobacco laws.

“We plan to similarly hold them accountable,” the FDA says.  “Ignoring the law and then paying associated fines and penalties should not simply be viewed as a cost of doing business.”

Electronic cigarettes have been dominating headlines recently, as experts continue to go back and forth on the risks associated with the devices.

Amidst countless headlines touting negative health effects, researchers from the University of Rochester Medical Center suggest that adults who are experiencing wheezing and other respiratory issues should look to their electronic cigarettes.

“The take-home message is that electronic cigarettes are not safe when it comes to lung health,” said researcher Deborah J. Ossip, PhD. “The changes we’re seeing with vaping, both in laboratory experiments and studies of people who vape, are consistent with early signs of lung damage, which is very worrisome.”

Discovering more dangers

To see the effect that e-cigarettes have on wheezing, the researchers evaluated responses from over 28,000 adults involved in the Population Assessment of Tobacco and Health (PATH) study.

While the PATH study relies on participants to report on their own behaviors, and doesn’t include information about the participants’ physical activity levels or eating habits, the researchers did find a correlation between adults who vape and those who experience wheezing.

Based on the responses, those who vape were nearly two times more likely to experience respiratory issues. The finding is significant because wheezing -- and difficulty breathing -- can lead to more serious health complications. While the researchers couldn’t prove a causal relationship between vaping and wheezing, they say the two are linked.

Teens at risk

As teens and young adults continue to be the primary users of electronic cigarettes, lawmakers have been working to make it harder for them to access the devices in an effort to eliminate any negative health effects.

The Food and Drug Administration (FDA) was working to ban online e-cigarette sales, as FDA Commissioner Scott Gottlieb called vaping an “epidemic” among teens. In late January, Gottlieb suggested that e-cigarettes could be taken off the market completely should use among teens continue to rise.

“I still believe e-cigs offer an opportunity for currently addicted adult smokers to transition off cigarettes and onto products that may not have the same level of risks. But if youth use continues to rise, the entire category faces an existential threat,” Gottlieb tweeted.

Food and Drug Administration Commissioner Scott Gottlieb has reportedly questioned whether or not Juul and Marlboro-maker Altria are truly committed to combating the rise in teen vaping. Gottlieb has asked to talk with the CEOs of these companies about "public statements that seem inconsistent" with the vows they made last year to curb youth use of e-cigarettes.

Gottlieb once again threatened to remove e-cigarettes from the market entirely if youth use continues to rise.

The FDA has previously called the alarming surge in teen vaping an “epidemic.” From 2017 to 2018, there was a 78 percent increase in current e-cigarette use among high school students and a 48 percent increase among middle school students, according to the 2018 National Youth Tobacco Survey.

“If youth use goes up 40 percent or 50 percent this year, we’re going to be having a very different discussion come this summer or fall,” Gottlieb said in an interview with Bloomberg.

Accused of backing off plan

In September, Gottlieb ordered the five largest e-cigarette manufacturers to submit their proposed plans for reducing use of e-cigarettes among minors.

Altria, Juul Labs, and other e-cigarette makers have all maintained that they fully support efforts to reduce youth access to e-cigarettes. In November, Juul said that it would halt sales of many of its flavored e-cig pods in retail stores, as fruity flavors have been shown to appeal to underage users.

Not long after these promises were made, Juul announced that it made a $12.8 billion deal with Altria, the parent company of Philip Morris USA and makers of Marlboro cigarettes. Altria said it planned to use its distribution experience to get Juul into more stores.

Questioning commitments

In an interview with CNBC on Thursday, Gottlieb stated that he’s "concerned."

"Did something change? Do they have new data? Do they have a new understanding? Because they just made a very big commitment to support the expansion of pod-based products, which they said contributes to the youth epidemic."

Altria said it still shares Gottlieb’s belief that "underage vaping has to be addressed” and that it’s still "committed to being part of the solution.”

"We look forward to meeting with the commissioner," Altria spokesman Steve Callahan told CNBC.

In December, Gottlieb expressed similar concerns over the lack of action from e-cig makers to curb teen use of their products. Gottlieb said he would be contacting e-cigarette makers “to meet to discuss commitments they made last month, and why some are changing course.”

“There’s no reason manufacturers must wait for [FDA] to more forcefully address the epidemic. Yet some already appear to back away from commitments made to FDA and the public,” Gottlieb tweeted.

The American Academy of Pediatrics (AAP) has called for the creation and implementation of new federal regulations that could help lower the rate of vaping among minors.

Citing its own data, the AAP pointed out that e-cigarette use among teens has jumped 75 percent since 2017. The group said that 20 percent of high school students and 5 percent of middle school students used e-cigarettes last year.  

“E-cigarettes are marketed to youths by promoting the products’ sweet and fruity flavors via media channels and advertising strategies used successfully by the tobacco industry to market conventional tobacco products to youths,” the AAP said in a new policy statement.

Combating the rise in teen vaping

To address what the FDA has declared an “epidemic” affecting young people, the AAP called for action on the part of federal regulators. On Monday, the organization called for new federal regulations, including:

• Setting a minimum age of 21 to buy the products;

• Banning online sales and youth-targeted marketing; and

• Stopping production of certain flavored e-cigarette products.

"Nicotine is highly addictive, and we know that the earlier that someone uses nicotine products in childhood, the more difficult it is to quit later," said Dr. Brian Jenssen, lead author of the new policy statement.

Earlier this month, FDA Commissioner Scott Gottlieb expressed similar concerns regarding the rise in teen vaping. Gottlieb warned that if e-cigarette makers fail to take sufficient measures to counter the teen vaping epidemic, e-cigarette products could be wiped from the market entirely.

“I still believe e-cigs offer an opportunity for currently addicted adult smokers to transition off cigarettes and onto products that may not have the same level of risks,” Gottlieb said. “But if youth use continues to rise, the entire category faces an existential threat.”

The AAP warned in its latest policy statement that the increasing use of e-cigarettes among minors “threatens five decades of public health gains.”

The Food and Drug Administration (FDA) is continuing to voice its concern on the alarming rise in e-cigarette use among teens.

Over the weekend, Commissioner Scott Gottlieb -- who has repeatedly called the surge in teen vaping “an epidemic” -- said that all e-cigarette makers face an “existential threat” if they fail to take sufficient measures to combat youth vaping.

“I still believe e-cigs offer an opportunity for currently addicted adult smokers to transition off cigarettes and onto products that may not have the same level of risks. But if youth use continues to rise, the entire category faces an existential threat,” Gottlieb tweeted on Saturday.

“I believe if every currently addicted adult smoker switched completely to e-cigs it would provide a tremendous public health gain. But that opportunity is in significant risk if kids use continues to rise,” he said.

Need for intervention by manufacturers

During a Friday public hearing on “Eliminating Youth Use of Electronic Cigarette and Other Tobacco Product Use,” Gottlieb noted that the number of teens using e-cigarettes (especially flavored e-cigarettes) has risen dramatically since 2017.

From 2017 to 2018, there was a 78 percent increase in current e-cigarette use among high school students and a 48 percent increase among middle school students, according to the 2018 National Youth Tobacco Survey.

Gottlieb emphasized that there’s a need for makers of e-cigarette products to take measures to mitigate the issue. If companies don’t stop marketing vaping products to youth, Gottlieb said the products could end up being removed from store shelves altogether.

“[I]f the epidemic continues to mount, I’m sure that the debate will change to one of whether these products should continue to be marketed at all without authorized pre-market tobacco applications,” Gottlieb said.

“It could be ‘game over’ for some these products until they can successfully traverse the regulatory process. I think the stakes are that high. And would be a blow for all of the currently addicted adult smokers who, I believe, could potentially benefit from these products,” he said.

Juul reacts

The FDA has previously singled out Juul for its significant role in the teen vaping epidemic, since underage users tend to gravitate toward flavored products such as those marketed by Juul. However, the company has maintained that it’s doing everything in its power to curb youth use of e-cigarettes.

“Underage use of JUUL and any other vaping products is completely unacceptable to us and is directly opposed to our mission of eliminating cigarettes by offering existing adult smokers a true alternative to combustible cigarettes," said Ted Kwong, a Juul Labs spokesperson.

"We are moving full steam ahead on implementing our action plan to limit youth usage, and this is unchanged since we announced our plan in November," he added. "We will be a transparent, engaged, and committed partner with FDA, state Attorneys General, local municipalities, and community organizations in the effort to combat underage use.”

Juul announced in November that it planned to pull some of its flavored pods from retail stores, shutter several of its social media accounts, and introduce stricter age-verification tools on its website as part of its effort to reduce youth use of its products.

The U.S. Food and Drug Administration (FDA) is planning to meet with the heads of e-cigarette companies to discuss ways to combat the alarming rise in teen vaping.

FDA Commissioner Scott Gottlieb, who has said previously that youth use of e-cigarettes has reached an “epidemic” proportion, said Thursday that he’s contacting e-cigarette makers “to meet to discuss commitments they made last month, and why some are changing course.”

“There’s no reason manufacturers must wait for [FDA] to more forcefully address the epidemic. Yet some already appear to back away from commitments made to FDA and the public,” Gottlieb tweeted.

“The vaping community that supports harm reduction for adults should also focus more of their efforts on select manufacturers that are primarily responsible for the youth epidemic if, like [FDA], they seek to preserve these opportunities as a way to transition adult smokers,” he said.

Last month, the FDA said it planned to roll out new restrictions on flavored e-cigarette products. The new restrictions included a ban on the sale of fruit and candy flavored e-cigarettes at convenience stores and gas stations, as well as stricter age verification rules for online sales of the products.

Efforts to limit youth access

Tobacco giant Altria, Juul Labs, and other e-cigarette makers have all said that they support efforts to reduce youth access to e-cigarettes. Juul said in November that it would no longer sell many of its flavored e-cig pods in retail stores, as these products have been shown to appeal to youth users.

The e-cigarette company also shuttered many of its social media accounts over concerns that teens were spreading and retweeting the company’s messages on platforms like Twitter.

Last week, the U.S. Surgeon General Jerome Adams issued a warning about e-cigarette use among teens, in which he urged aggressive steps to combat the “epidemic” of teen use. Adams specifically singled out Juul in the advisory when he said that it’s critical that strategies to curb tobacco use be applied to products “including USB flash drive-shaped products, such as Juul.”

In response to the advisory, Juul’s Senior Director of Communications Victoria Davis said in a statement that the company was “committed to preventing youth access of JUUL products.”

“We stopped the distribution of certain flavored JUULpods to retail stores as of November 17, 2018, strengthened the age verification of our industry leading site, eliminated our Facebook and Instagram accounts, and are developing new technology to further limit youth access and use,” Davis said.

“We are committed to working with the Surgeon General, FDA, state Attorneys General, local municipalities, and community organizations as a transparent and responsible partner in this effort,” she said.

Earlier this month, Juul Labs announced that it made a $12.8 billion deal with Altria, the parent company of Philip Morris USA and makers of Marlboro cigarettes. The deal brought Juul’s valuation to an estimated $38 billion.

Today, Juul Labs announced that it has made a deal with Altria Group, the parent company of Philip Morris USA and makers of Marlboro cigarettes.

The deal values Juul at $38 billion and “will put its products next to Marlboro cigarettes on American retail shelves,” according to Bloomberg. Under the deal, Altria will invest $12.8 billion in Juul in exchange for a 35 percent stake in Juul Labs.

“We understand the controversy and skepticism that comes with an affiliation and partnership with the largest tobacco company in the US. We were skeptical as well,” Juul Labs CEO Kevin Burns said in a statement. “But over the course of the last several months we were convinced by actions, not words, that in fact this partnership could help accelerate our success switching adult smokers. We understand the doubt. We doubted as well.”

Prior to the announcement, the deal had been rumored to be on the horizon. Altria announced earlier this month that it would be discontinuing MarkTen and Green Smoke, their two lines of e-cigarette brands. In their place, Altria will be buying a stake in Juul.

Anticipating change in tobacco industry

The deal comes after a year of Juul claiming that it’s taking steps to combat the alarming rise in the number of teenagers using its products.

In November, FDA Commissioner Scott Gottlieb announced a new plan of action for the e-cigarette industry intended to keep the products from being used by teens. One measure seeks to ban the sale of flavored e-cigarette products.

Juul has maintained that its primary goal is serve as an off-ramp for smokers to quit by providing an alternative to traditional cigarettes. Altria has reportedly agreed to several measures that would get information about Juul into the hands of adult cigarette smokers.

Altria said in a statement that the investment is largely rooted in the fact that the company understands that change is coming to the tobacco industry.

“We are taking significant action to prepare for a future where adult smokers overwhelmingly choose non-combustible products over cigarettes by investing $12.8 billion in JUUL, a world leader in switching adult smokers,” said Howard Willard, Altria’s Chairman and Chief Executive Officer.

“We have long said that providing adult smokers with superior, satisfying products with the potential to reduce harm is the best way to achieve tobacco harm reduction. Through JUUL,  we are making the biggest investment in our history to achieve that goal. We strongly believe that working with JUUL to accelerate its mission will have long-term benefits for adult smokers and our shareholders.”

The federal government is stepping up its war against e-cigarettes, used by some smokers to wean themselves off cigarettes but feared by public health professionals because they are exposing teens to nicotine.

U.S. Surgeon General Jerome Adams has issued a public health warning, saying he is concerned that there has been a large increase in teenagers using the products. E-cigarettes create vapor from liquid that contains nicotine, the addictive substance in cigarettes.

Public health officials are concerned that young people who get hooked on nicotine from their use of e-cigarettes will eventually begin smoking. They also worry about other chemicals in the vapor they say is harmful.

In his advisory, Adams said he is concerned about the increase in teen “vaping” because it isn’t clear what nicotine will do to a developing adolescent brain.

“Brain development begins during the growth of the fetus in the womb and continues through childhood and to about age 25,” Adams warned. “Nicotine exposure during adolescence and young adulthood can cause addiction and harm the developing brain.”

Rapid growth in use by teens

Adams said he is concerned that e-cigarette use has become popular among young people, noting its use has become exponentially widespread over the last five years. Adams says the use of e-cigarettes is higher among high school students than adults and that more young people use e-cigarettes than smoke cigarettes.

Adams singled out the e-cigarette product Juul for special condemnation because it appears to be highly popular with teenagers. In his advisory, Adams said Juul’s sleek design is easy to conceal and doesn’t emit much of an odor. Adams says parents should be vigilant and look for signs that teens are using e-cigarettes.

In October, the Centers for Disease Control and Prevention (CDC) documented a huge increase in sales of Juul products, noting that sales increased from 2.2 million devices sold in 2016 to 16.2 million devices sold in 2017. The study found that Juul was found to contain more nicotine than any other brand of e-cigarette.

‘No redeeming benefits’

“There are no redeeming benefits of e-cigarettes for young people,” Corinne Graffunder, director of the CDC’s Office on Smoking and Health, said at the time. “The use of certain USB-shaped e-cigarettes is especially dangerous among youth because these products contain extremely high levels of nicotine, which can harm the developing adolescent brain.”

Last month, the Food and Drug Administration (FDA) announced plans to restrict the sale of fruit and candy-flavored e-cigarettes at convenience stores and gas stations. FDA Commissioner Scott Gottlieb said expressed alarm at what he called the “disturbing and accelerating trajectory of use we’re seeing in youth and the resulting path to addiction.”

When the Food and Drug Administration (FDA) announced last month that it would crack down on e-cigarette companies that sell their products online or in convenience stores, citing research that e-cigs were getting teens and other non-smokers hooked, Juul steadfastly denied that its products were intended for anyone other than consumers trying to quit cigarette addictions.

That already questionable assurance from Juul just became a little more difficult to believe. Altria, the parent company of tobacco giant Philip Morris, has announced that it is discontinuing MarkTen and Green Smoke, their two lines of e-cigarette brands. In place of those, Altria is instead reportedly planning to buy a stake in Juul, sources familiar with the deal told CNBC.

Juul has yet to officially confirm the news. But it wouldn’t be the brand’s first partnership with a tobacco company. The e-cigarette brand, valued at $16 billion, partnered with Japan Tobacco International back in 2011.

The news comes as some consumers’ rosey views of legal cannabis also appears poised to get corrupted by tobacco interests. Altria is reportedly investing $1.8 billion in Cronos, a Canadian cannabis firm that is taking off with legalization up north.

"Investing in Cronos Group as our exclusive partner in the emerging global cannabis category represents an exciting new growth opportunity for Altria," Howard Willard, Altria's CEO, said in an announcement.  

A popular talking point for the e-cigarette industry is that vaping helps cigarette addicts quit smoking. But that doesn’t appear to be what e-cigarettes are actually designed to do.

The Food and Drug Administration (FDA) announced today that its own research found that vaping has increased by 80 percent in high schoolers and by 50 percent in middle schoolers, suggesting once again that non-smokers are an important target market to the vaping industry.

Those teens are then more likely to turn to traditional cigarettes -- some of which are sold by the same business interests that have entered the vaping market.

“The data show that kids using e-cigarettes are going to be more likely to try combustible cigarettes later,” FDA Commissioner Scott Gottlieb said in a lengthy statement Thursday about his agency’s plans for an industry-wide crackdown. “This is a large pool of future risk.”

While some proponents have claimed that cracking down on vaping will be a boon to Big Tobacco, the cigarette industry has actually invested heavily in e-cigarettes. Philip Morris is currently aggressively lobbying Australian regulators to overturn a country-wide ban on vaping.

The United States approach to regulating vaping would be less stringent.

Banning flavors

To combat what they say is an “astonishing” rise in teen vaping, the FDA is pursuing a ban on selling flavored e-cigarettes at any stores where people under the age of 18 are allowed.

Such a policy would ban flavored products from convenience stores and gas stations, though tobacco and vape shops would still be able to sell flavored pods.

The FDA will also make an exception to those rules for mint, menthol, and tobacco flavors because they say that people trying to quit traditional cigarettes have found those flavors helpful.

The agency is, however, following through on plans to crackdown on menthol cigarettes and flavored cigars.

Juul, a vaping brand that has gained a cult-like following among teens, said it has agreed to stop selling its Mango, Fruit, Cream, and Cucumber flavored pods at 90,000 retail stores, though the company claims it was never trying to get kids hooked.

“We launched flavors like Mango, Fruit, Creme, and Cucumber as effective tools to help adult smokers switch from combustible cigarettes, and we do not sell flavors like Gummy Bear or Cotton Candy, which are clearly targeted to kids,” the company said online.

Industry panic

But research has suggested otherwise. In 2016, researchers at the UCSF School of Medicine found that vaping actually made people 28 percent less likely to quit cigarettes. Experts say that cigarette addicts should stick to e-cigarettes with large cartridges if they are vaping to quit.

The FDA’s announcement appears to be sending chills through the vaping industry.

The Smoke Free Alternatives Trade Association, one of the vaping industry lobbying groups, is planning a meeting in December with other vaping trade groups to organize against “the many issues facing the vaping industry at the Federal level.”

“It's time for us all to stop viewing each other as the enemy and start working together -- or we will face dire consequences as an industry,” the group’s Executive Director Mark Anton wrote today on Facebook.

Juul has announced that it will temporarily halt sales of most of its flavored nicotine pods in over 90,000 brick-and-mortar stores. The move comes as the FDA is trying to reduce “epidemic” levels of teen use.

Juul said on Tuesday that it stopped taking retail orders for its mango, fruit, creme, and cucumber pods at convenience stores, vape shops, and other retailers that sell them. Sales of all of the company’s flavors will continue on its website, and sales of its four tobacco and menthol-flavored pods will continue in retail stores.

“We don’t want anyone who doesn’t smoke, or already use nicotine, to use JUUL products. We certainly don’t want youth using the product. It is bad for public health, and it is bad for our mission. JUUL Labs and FDA share a common goal – preventing youth from initiating on nicotine,” CEO Kevin Burns said in a blog post on the company’s website.

“To paraphrase Commissioner Gottlieb, we want to be the off-ramp for adult smokers to switch from cigarettes, not an on-ramp for America’s youth to initiate on nicotine. We won’t be successful in our mission to serve adult smokers if we don’t narrow the on-ramp,” Burns continued.

Suspending promotional activity on social media

As part of its effort to comply with regulators seeking to curb youth use of e-cigarettes, Juul will also shut down its Facebook and Instagram accounts and end promotional activity on Twitter.

A recent study found that a significant percentage of the company’s Twitter followers are teens, many of whom regularly spread the brand’s messages. Critics have said the advertising tactics of e-cigarette makers make the products seem glamorous.

Toward that end, Juul says it will use its Twitter account for “non-promotional communications only” going forward.

In September, FDA Commissioner Scott Gottlieb ordered Juul and four other e-cigarette producers to announce their proposed plans to reduce what he called "epidemic" levels of teen e-cigarette use.

Gottlieb said preliminary federal data showed a more than 75 percent surge in high school students using e-cigarettes. Juul’s product was the number one e-cigarette in the United States as of December 2017. Sales increased from 2.2 million devices sold in 2016 to 16.2 million devices sold in 2017.

Earlier this month, reports surfaced that the FDA is planning to issue a ban on the sale of fruit and candy flavored e-cigarettes at convenience stores and gas stations. The agency is also expected to introduce stricter age-verification requirements for online sales of e-cigarettes.

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens,” FDA Gottlieb said in September. “The disturbing and accelerating trajectory of use we’re seeing in youth, and the resulting path to addiction, must end. It’s simply not tolerable.”

To combat the “epidemic” of teen electronic cigarette use, the U.S. Food and Drug Administration (FDA) plans to issue a ban on the sale of fruit and candy flavored e-cigarettes at convenience stores and gas stations, The Washington Post reports.

The ban -- which is expected to be announced by FDA Commissioner Scott Gottlieb as soon as next week -- could hit Juul Labs the hardest, since it will mean that only tobacco, mint, and menthol flavors will be permitted to be sold at these stores.

In addition to restricting e-cigarette flavors, the FDA will introduce stricter age-verification requirements for online sales of e-cigarettes. The upcoming restrictions on flavors will not apply to vape shops or other specialty retail stores, officials said.

Surge in teen use

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens,” FDA Commissioner Scott Gottlieb said in September. “The disturbing and accelerating trajectory of use we’re seeing in youth, and the resulting path to addiction, must end. It’s simply not tolerable.”

The agency’s move to restrict e-cigarette flavors follows its warning to Juul and other top e-cigarette manufacturers to disclose their proposed steps to curb use among youth within 60 days.

Sales of Juul vaping devices surged from 2.2 million in 2016 to 16.2 million last year, according to the CDC. The products are especially attractive to minors because they come in flavors such as mango, mint, and fruit and creme (previously called creme brulee).

A recent study found that Juul’s Twitter account has amassed a large number of teen followers, many of whom regularly spread the brand’s messages.

Gottlieb has said that protecting children from tobacco-related disease is his first priority, and addressing the surge in underage e-cigarette use is crucial to achieving that goal. Research has shown that many e-cigarette users go on to become addicted to nicotine and will likely end up using regular cigarettes. Additionally, the health risks of e-cigarettes are still being studied.

“In order to firmly confront and reverse these trends – and fulfill the central premise of our public health mandate – we may need to take actions that might narrow the off-ramp from smoking for adults in order to close the on-ramp to nicotine addiction to kids,” Gottlieb said last month.

The U.S. Food and Drug Administration (FDA) has had “constructive” meetings with several e-cigarette manufacturers, Commissioner Scott Gottlieb said on Wednesday.

In recent months, the agency has called electronic cigarette use among youth an “epidemic” and has set out to address the dangerous trend. Gottlieb said he’s met with five companies over the past few weeks: Altria Group, JUUL Labs, Reynolds American, Fontem Ventures, and Japan Tobacco International USA.

“The companies acknowledged the serious public health consequences associated with youth use of tobacco products,” Gottlieb said. “They presented thoughtful proposals, consisting not only of what steps they would take themselves to restrict youth access to and appeal of these products, but also steps that they think the FDA and other policy-makers can take to reverse the trends in youth use of e-cigarettes.”

“Some stated explicitly that preventing youth use must be a priority, and that any potential benefits of e-cigarettes for adult smokers cannot justify significant increases in youth use and addiction,” he said.

Restricting youth access

E-cigarette use among high school students has risen by 77 percent this year, according to preliminary federal data.

“In order to firmly confront and reverse these trends – and fulfill the central premise of our public health mandate – we may need to take actions that might narrow the off-ramp from smoking for adults in order to close the on-ramp to nicotine addiction to kids,” Gottlieb said.

In meetings with manufacturers that collectively represent 97 percent of the market, Gottlieb said the companies “acknowledged the role that flavored e-cigarette products play in appealing to kids, as well as the role that flavored e-cigarettes can also play in helping adult smokers quit”

The companies offered several proposals for mitigating this problem. These include:

• That the FDA restrict distribution of certain flavored products to channels with enhanced age verification processes; and

• That the agency require certain products that are more appealing to kids -- such as those with fruity flavors -- to come off the market until these products receive premarket authorization from the FDA.

In a statement, Gottlieb said the FDA welcomes any voluntary steps the companies may take to address teen use.

Last month, the FDA ordered five e-cigarette manufacturers to submit plans to curb teen use of their products within 60 days.

Nearly a quarter of users who follow the electronic cigarette brand Juul on Twitter are under 18, according to a study published recently in the Journal of Adolescent Health.

The latest findings are raising concern not only because the products aren’t intended for underage use, but because many of these youth followers are retweeting the company’s messages.

For the study, researchers from the University of Pittsburgh School of Medicine and the University of Southern California analyzed users who engaged with the 3,239 tweets sent by @JUULvapor between February 2017 and January 2018. The team found that roughly 1 in 4 users spreading the brand’s messages are younger than 18.

Growing number of youth users

The study comes a month after Juul was called out by health officials for appealing to teens through its marketing. The FDA seized thousands of pages of documents following a surprise inspection of Juul’s headquarters as part of its investigation into whether the company is intentionally marketing to teens.

The FDA has previously described the explosion of e-cigarette use among teens as an “epidemic.” The authors of the latest study share the FDA’s concern over who Juul is actually appealing to through its advertising.

"Juul representatives have said the company is not trying to target adolescents with their advertising or sales, but our research clearly indicates that a sizable proportion of their Twitter audience is exactly this population," said study author Kar-Hai Chu, an assistant professor of medicine at Pitt's Center for Research on Media, Technology and Health.

"This is highly concerning because adolescents exposed to e-cigarette marketing are more likely to use e-cigarettes and, in turn, young adults who use e-cigarettes are four times as likely as their non-vaping peers to transition to smoking traditional tobacco cigarettes," Chu said in a statement.

Juul says it’s taking action

Juul says it’s aware of the problem and is taking steps to mitigate it. The company said it "has aggressively worked with social media platforms to remove posts and accounts that portray our product in unauthorized and youth-oriented manners. In just six months this year, we helped remove over 8,000 listings, 450 accounts, and 18,000 online marketplace listings."

Getting initiated with e-cigarettes at a young age can increase a teens’ risk of becoming an actual smoker, experts say. Additionally, most e-cigarettes contain nicotine, which can harm brain development in adolescents.

The authors of the study said the fact that Juul’s official Twitter account is being followed by such a large number of adolescents “presents a major public health concern because e-cig marketing exposure increases the adolescent risk of ever use of e-cigs.”

“In particular, adolescents exposed to e-cig messages online are more likely to initiate tobacco use later in life,” the authors said.

E-cigarettes have certainly been dominating the news cycle recently. Though a popular alternative -- particularly among youth -- to traditional cigarettes, the device comes with a rather long list of dangerous side effects and health risks for users.

Because e-cigarettes aren’t regulated, how the devices will impact users’ health later in life is still unknown. However, a team of researchers was interested in studying how the chemicals in e-cigarettes’ refillable cartridges affect users’ health.  

A new study examined the harmful effects found in the flavorings and additives that are used in e-cigarettes, as the researchers found they can alter lung function, cause inflammation throughout the body, and increase mucus production.

Negative effects similar to cigarettes

According to the Centers for Disease Control and Prevention (CDC), the aerosol found in e-cigarettes contains nicotine, cancer-causing chemicals, heavy metals, ultrafine particles, volatile organic compounds, and flavorings.

To test the effects of these chemicals, the researchers exposed mice to several different chemical combinations four times each day, with 30-minutes in between each exposure of smoke-free air.

Some of the mice were exposed for longer periods of time -- up to four weeks -- while others were removed after three days. The groups exposed to the chemicals were compared against another group of mice that were exposed to smoke-free air.

The different chemical combinations included:

• E-cigarette vapor that had propylene glycol (an additive found in pharmaceuticals, foods, and drinks) and vegetable glycerol (a liquid that comes from plants)

• Cigarette smoke

• Nicotine, tobacco flavoring, and propylene glycol

• Nicotine and propylene glycol

Because many people turn to e-cigarettes either to quit smoking or as a healthier alternative than regular cigarettes, the researchers were interested in comparing the results between the mice exposed to the cigarette smoke and those exposed to the e-cigarettes. The results proved to be surprising to them, as they found that the e-cigarette group experienced oxidative stress -- the state of oxidative damage in a cell -- at a rate either higher or equal to the cigarette group.

The researchers also found that in the mice exposed to the e-cigarette flavorings showed more adverse side effects in the short-term that appeared to go away over time. For example, the mice exposed to the e-cigarette vapors after just three days had impaired lung function, an increase in mucus production, and signs of inflammation. However, over the long-term, the e-cigarette group showed fewer negative side effects.

The researchers believe that further research is necessary in this area to really see how e-cigarettes are affecting people.

Dangerous side effects

A recent study done by George Mason University found that not only do many e-cigarettes cause severe burns, but some have lithium-ion batteries that have been known to explode or catch fire, leaving users with third-degree burns, loss of tongue, teeth or eyes, and some have led to death.

The researchers were particularly concerned because many people aren’t reporting these injuries and incidents. E-cigarettes aren’t regulated or monitored in any way nationally, and because of this, the researchers have reason to believe more injuries are occurring because of e-cigarettes.

Additionally, in late September, the Food and Drug Administration (FDA) was discussing banning the sale of e-cigarettes online. Commissioner Scott Gottlieb believes e-cigarettes have caused a “epidemic” among teens, and is looking to reduce the number of young people using e-cigarettes.

The Centers for Disease Control and Prevention (CDC) published a study in JAMA earlier this week detailing the sales of JUUL electronic cigarettes from 2013 through 2017, and the findings show a rapid increase in sales in just the last year.

While all e-cigarettes contain nicotine, JUUL was found to contain the most nicotine of any e-cigarette, though that didn’t stop teens from purchasing them. The USB-shaped e-cigarette was the number one e-cigarette in the United States by December 2017, and sales increased from 2.2 million devices sold in 2016 to 16.2 million devices sold in 2017.

“There are no redeeming benefits of e-cigarettes for young people,” said Corinne Graffunder, DrPH, director of the CDC’s Office on Smoking and Health. “The use of certain USB-shaped e-cigarettes is especially dangerous among youth because these products contain extremely high levels of nicotine, which can harm the developing adolescent brain.”

A market geared towards young people

Many people -- particularly young people -- turn to e-cigarettes because they perceive them to be a healthier alternative to traditional cigarettes. However, in addition to the countless chemicals found in e-cigarettes, the CDC warns against several other health risks that are associated with them.

Additionally, much of the marketing for e-cigarettes seems aimed directly at the younger generation, as the companies look to focus their attention on their prime audience. However, as the Food and Drug Administration (FDA) pushes its Youth Tobacco Prevention Plan, the agency is working to change the nature of these ads.

The FDA has also set its sights on over one thousand stores, as many retailers have been selling JUULs and other e-cigarettes to underage teenagers. The agency is looking for accountability from these establishments, and in addition to sending warning letters to known retailers selling to minors, has demanded answers about how these stores plan to combat this issue in future marketing materials.

“The popularity of JUUL among kids threatens our progress in reducing e-cigarette use,” said Robert Redfield, M.D., director of the CDC. “We are alarmed that these new high nicotine content e-cigarettes, marketed and sold in kid-friendly flavors, are so appealing to our nation’s young people.”

Recent concerns

JUUL hasn’t been able to escape the news cycle as of late.

Earlier this week, the FDA seized over one thousand pages of documents from the e-cigarette company as part of an unannounced inspection of the company’s headquarters in San Francisco.

The FDA reported that the investigation was an attempt to seek “further documentation related to Juul’s sales and marketing practices, among other things,” according to a statement. The investigation came shortly after the FDA announced it was looking to ban the sale of e-cigarettes online.

FDA Commissioner Scott Gottlieb said that the ease with which teens can access e-cigarettes has caused an “epidemic,” and the agency is working to minimize the use of tobacco by underage teens.

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens," Gottlieb said in a statement. "The FDA won't tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products."

Electronic cigarettes (or e-cigarettes) have become increasingly popular in recent years -- particularly in the younger demographic. Consumers have switched from the more traditional form of smoking to the small, battery-operated device, with many under the assumption that it’s a healthier and safer alternative to regular cigarettes.

However, not only does data from the Centers for Disease Control and Prevention (CDC) tell a different story, but a new report recently published in Tobacco Control found that federal agencies have been underestimating the number of burns and explosions caused by e-cigarettes.

Dangers of e-cigarettes

Though many perceive e-cigarettes to be a healthier and safer option, or even a method to quit smoking, the CDC warns against the potential dangers of the smoking alternative.

“E-cigarettes produce an aerosol by heating a liquid that usually contains nicotine -- the addictive drug in regular cigarettes, cigars, and other tobacco products -- flavorings, and other chemicals that help to make the aerosol,” the CDC says.

Along with health issues, consumers should also be warned of the other dangers associated with e-cigarettes.

Some lithium-ion batteries found in e-cigarettes can be defective and have been known to explode or catch fire, and in doing so they can cause third-degree burns; loss of tongue, teeth, or eyes; lacerations; and death.

Reporting injuries

This new report from George Mason University utilizes data from the United States Consumer Product Safety Commission, which shows approximately 2,035 people ended up in the emergency room due to e-cigarette burns or explosions between 2015 and 2017.

However, due to a lack of national monitoring of e-cigarettes, and keeping in mind that not everyone reports an injury, the researchers -- led by Dr. Matthew Rossheim -- believe that figure has been underestimated and that more people are harmed in some way by an e-cigarette.

The researchers are calling for stricter regulations for e-cigarettes in an effort to prevent future injuries, and they say that it’s important that consumers are aware of what the devices are capable of.

The U.S. Food and Drug Administration (FDA) announced on Tuesday that it seized more than a thousand pages of documents from e-cigarette maker Juul during an unannounced inspection of the company’s headquarters in San Francisco on Friday.

The news comes a week after the agency announced that it was considering a ban on the online sale of e-cigarettes, which would primarily be an effort to drive down the number of minors who are able to acquire and use the products.

Commissioner Scott Gottlieb called the widespread use of e-cigarettes among teens an “epidemic” and said easy access to the products is only fueling the trend.

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens," Gottlieb said in a statement. "The FDA won't tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products."

Scrutiny of marketing practices

The agency has requested that e-cigarette manufacturers, including Juul, submit plans to curb youth use of their products within 60 days.

Last week, the FDA said it was looking into how e-cigarette manufacturers market their products -- especially flavored products, which tend to appeal to kids. Gottlieb said at an event hosted by Axios that the FDA will be releasing data in November that shows a “disturbingly sharp rise” in the number of teens using e-cigarettes.

That announcement came a month after the agency revealed that it had sent more than 1,300 warning letters to retailers who were found to have illegally sold Juul and other e-cigarette products to minors during “an undercover blitz" of both brick-and-mortar and online stores that occurred over the summer.

Friday’s surprise investigation was an attempt to seek “further documentation related to Juul's sales and marketing practices, among other things," the FDA said in a statement. The investigation “resulted in the collection of over a thousand pages of documents," the agency said.

The U.S. Food and Drug Administration (FDA) is reportedly mulling a ban on online sales of e-cigarettes.

During a panel discussion on vaping hosted by Axios earlier this week, Commissioner Scott Gottlieb said the move is “on the table” and is “very clearly something we are now looking at,” CNBC reports.

Gottlieb said easy access to vaping products has resulted in an “epidemic” of use among teens. The FDA says it will announce its next steps to combat underage use of e-cigarettes in November, when the agency will reveal data on teen vaping and invite public and corporate feedback.

Trend among youth

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens," Gottlieb said in a statement earlier this month. "The FDA won't tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products."

Gottlieb said the FDA is also weighing a ban on flavored e-cigarettes, which he says tend to entice youth.

"One factor we're closely evaluating is the availability of characterizing flavors. We know that the flavors play an important role in driving the youth appeal. And in view of the trends underway, we may take steps to curtail the marketing and selling of flavored products," he said.

In May, the FDA (joined by the FTC) sent 13 warning letters to companies that advertise e-cigarettes in a way that causes them to “resemble kid-friendly food products, such as juice boxes, candy or cookies."

This month, the agency sent more than 1,300 warning letters to retailers who were found to have illegally sold JUUL and other e-cigarette products to minors during “an undercover blitz" of both brick-and-mortar and online stores that occurred over the summer.

"We're in possession of data that shows a disturbingly sharp rise in the number of teens using e-cigarettes in just the last year," Gottlieb said in a statement last week.

“The numbers of kids now using these products is unacceptable,” he said. “We can’t allow these trends to continue.”

Regulators and advocates have long spoken out against the use of e-cigarettes by young teens in middle school and high school. Now, a study conducted by the Centers for Disease Control and Prevention (CDC) shows that the problem may be worse than many may have thought.

The National Youth Tobacco Survey, which surveys young students in the U.S. in grades 6 through 12, shows that over 2 million young people have used e-cigarettes to vape marijuana. In all, the researchers say that one out of every eleven students have engaged in this activity across the country.

The CDC researchers say that the findings are dismaying because marijuana use has been associated with negative health effects in young people.

“The National Academies of Sciences has found cannabis use among youth can adversely affect learning and memory and may impair later academic achievement and education,” they said. “Strategies to reduce cannabis use in e-cigarettes are critical for protecting young people from these potential health risks.”

Stopping the e-cigarette youth epidemic

The findings, which were published in JAMA Pediatrics, come shortly after regulators announced a crackdown on selling e-cigarette devices to underage consumers.

Last week, the Food and Drug Administration announced that it would be taking action against over 1,300 retailers and five major manufacturers for their roles in making e-cigarettes available to young people. FDA Commissioner Scott Gottlieb went so far as to say that youth access to electronic cigarettes had reached “epidemic” levels.

“We must adjust certain aspects of our comprehensive strategy to stem this clear and present danger. This starts with the actions we’re taking today to crack down on retail sales of e-cigarettes to minors,” he said.

“While we remain committed to advancing policies that promote the potential of e-cigarettes to help adult smokers move away from combustible cigarettes, that work can’t come at the expense of kids. We cannot allow a whole new generation to become addicted to nicotine,” he concluded.

The Food and Drug Administration (FDA) has taken the epidemic of youth e-cigarette use by the horns, issuing a historic action against more than 1,300 retailers and 5 major manufacturers for their roles in leveraging youth access to the tobacco alternative.

It’s clear the FDA has done its homework on the matter. In serving its warning, the agency detailed specific dates and times minors were allowed to buy e-liquid products and that the agency will be watching offending retailers like a hawk.

“We will periodically inspect your establishment and review your promotional activities (e.g., website(s) related to FDA-regulated tobacco products to assess your compliance with all applicable laws and regulations, including access, marketing, labeling, and advertising restrictions,” wrote the FDA in its warning letter, which also gave the e-product vendors 15 days to let the agency know how they will address the violations and comply going forward.

The FDA’s commitment

“We’re committed to the comprehensive approach to address addiction to nicotine that we announced last year,” said FDA Commissioner Scott Gottlieb.

“But at the same time, we see clear signs that youth use of electronic cigarettes has reached an epidemic proportion, and we must adjust certain aspects of our comprehensive strategy to stem this clear and present danger. This starts with the actions we’re taking today to crack down on retail sales of e-cigarettes to minors. We will also revisit our compliance policy that extended the dates for manufacturers of certain flavored e-cigarettes to submit applications for premarket authorization.”

It’s been reported that nearly 12 percent of middle and high school students -- more than 12 million -- have used e-cigarettes, and Gottlieb believes that one of the chief lures for youth are the different flavors of e-vapor.

“While we remain committed to advancing policies that promote the potential of e-cigarettes to help adult smokers move away from combustible cigarettes, that work can’t come at the expense of kids. We cannot allow a whole new generation to become addicted to nicotine.”

Whether a user calls their vaping a harmless activity or an addiction, the notion is a front-burner health issue.

Researchers from the University of California say the use of e-cigarettes every day can nearly double the odds of a heart attack, according to a new analysis of a survey of nearly 70,000 people. The research also found that dual use of e-cigarettes and conventional cigarettes -- the most common use pattern among e-cigarette users -- appears to be more dangerous than using either product alone.

“Given the emerging data showing that e-cigarette use increased exposure to metal and other toxicants, FDA initiatives to reduce e-cigarette use among youth are urgently needed,” said Columbia University’s Mailman School environmental health scientist Ana Navas-Acien in a previous statement.

The warning signs are clear

The larger question of vaping is the possible connection between e-cigarettes and tobacco use. A report by the National Academies of Science, Engineering, and Medicine produces evidence that both teens and young adults who use e-cigarettes are at increased risk for trying cigarettes. As for adults, the report finds e-cigarettes can help them break a tobacco habit.

“You need a device that is sufficiently satisfying for those who want to quit,” says Navas-Acien, “but at the same time, one that doesn’t increase the risk of long-term addiction.”

Who’s in charge?

While federal law bans minors from purchasing e-cigarettes, state laws vary widely.

For example, how states define e-cigarettes runs the gamut. According to the Public Health Law Center, Indiana’s law on electronic delivery devices includes expected substances such as nicotine but throws in lobelia, a tropical or subtropical plant of the bellflower family, into the mix as well. In Rhode Island, the state included electronic hookahs into its definition, and some states -- including Michigan and Missouri -- have no anti-vaping laws in place at all.

But, it appears that the FDA’s proactive move into the vaping regulation arena signals that the agency is taking charge. “There is a clear need for strong federal enforcement of youth access restrictions,” said the FDA’s Gottlieb, “and the FDA will continue to hold retailers accountable by vigorously enforcing the law with the help of the agency’s state partners.

As millions of people have turned to electronic cigarettes in recent years, the only thing that researchers and the industry have agreed upon is that smoking vaporized nicotine is at least safer than smoking a normal cigarette.  

But whether that’s a good enough reason to allow e-cig makers to market their products to the general population remains an open question.  

A new peer-reviewed study claims that vaping can damage important cells in the immune system and cause inflammation of the lungs. The researchers, writing in the journal Thorax, say that they "caution against the widely held opinion that e-cigarettes are safe.”

Vaping and lung damage

Using lung tissue samples in a laboratory, the researchers said they found evidence that the vapors, when inhaled, can damage the immune system cells that protect lungs from bacteria, allergens, dust, and other irritants.

While the researchers acknowledge that vaping is clearly less carcinogenic than smoking cigarettes, they say they are worried that vaping may still cause lung disease.

"I don't believe e-cigarettes are more harmful than ordinary cigarettes -- but we should have a cautious scepticism that they are as safe as we are being led to believe,” lead author Dr. David Thickett, a professor at the University of Birmingham in England, told the BBC.

"They are safer in terms of cancer risk -- but if you vape for 20 or 30 years and this can cause COPD [chronic obstructive pulmonary disease], then that's something we need to know about,” he added.

Hooking new users?

For people struggling to quit their cigarette addictions or bystanders who otherwise would breathe in secondhand smoke, researchers widely agree that e-cigarettes are a better choice.

But the impression that vaping is harmless may also be getting people who otherwise wouldn’t smoke hooked on the devices. Previous studies  show that only 52 percent of e-cigarette users are former smokers  

Experts say that smokers using e-cigarettes to quit should choose devices with larger cartridges, because e-cigs that deliver more nicotine are the only ones proven to work as a cessation aid. Researchers also advise consumers to avoid any brands that have ties to the tobacco industry.

Sales of e-cigarettes and similar vaping products have skyrocketed over the past five years as their prices decreased substantially, according to a new study from the Centers for Disease Control and Prevention (CDC).

Sales rose 132 percent while their prices dropped between 2012 and 2016, especially prices for rechargeable devices. Taxes helped keep sales down, federal health officials noted in the report.

“Overall, U.S. e-cigarette unit sales generally increased as product prices decreased,” wrote the team, led by Teresa Wang of the CDC.

Lower prices promote sales among young adults

“By state, average monthly sales significantly increased for at least one of four e-cigarette products in all 48 states and Washington, D.C.,” the researchers added.

On average in 2016, 766 pre-filled cartridges were sold per 100,000 people each month, according to the CDC. The cartridges, also called pods, sold for an average of $14.36 per five-pack.

"We certainly see that these re-chargeable devices, including USB shaped devices like Juul, are certainly the next wave of popularity when it comes to e-cigarettes in the United States,” said Brain King, senior author of the study and a deputy director in the CDC's Office on Smoking and Health.

As prices have tumbled in recent years, it’s become easier for teens to get the devices. Research has shown that young adults are more likely to use the products than adults. Between 2011 and 2015, e-cigarette use among high schoolers rose 900 percent. The CDC study noted that devices are now more popular among teenagers than traditional cigarettes.

Not considered safe

King says e-cigarettes are not considered safe. In addition to nicotine, they can contain potentially harmful ingredients, including ultrafine particles that can be inhaled into the lungs and flavorants such as diacetyl (a chemical linked to lung disease).

“When it comes to e-cigarettes, they're still a tobacco product, so regardless of whether you're talking about a conventional cigarette or an e-cigarette, youth use of tobacco is unsafe," King said. "So the same strategies…are ultimately going to help prevent youth initiation of these products."

The researchers said their findings can help inform state and federal decision makers, who are trying to determine what impact e-cigarettes have on health in order to figure out how to regulate them.

The study has been published in the journal Preventing Chronic Disease.

Early this week, San Francisco residents voted to ban the sale of flavored tobacco products, including menthol cigarettes and flavored vaping liquids. With 99 percent of precincts reporting on the vote, 68 percent voted in favor of the ban and 31 percent voted against it.

This has been a longstanding -- and expensive -- issue for the city of San Francisco in recent years, as tobacco company R.J. Reynolds contributed nearly $12 million against the proposition. Former New York City Mayor Michael Bloomberg also contributed more than $3 million in support of it.

“People really have a big dislike and big distrust for Big Tobacco companies and are not fooled by propaganda and tactics,” said Gil Duran, the spokesman for Campaign Yes on Proposition E.

A look into the debate

The legislation was largely supported by public health advocates who believe that flavored tobacco products are appealing to younger generations and could begin encouraging them to use tobacco. A number of public health organizations, including the American Association, American Cancer Society, and American Lung Association, supported the ban, citing their dedication toward protecting the health of the next generation.

“San Francisco’s youth are routinely bombarded with advertising for flavored tobacco and e-cigarettes every time they walk into a neighborhood convenience store,” the American Lung Association said in a statement. “It’s clear that these products with candy themes and colorful packaging are geared towards teens.”

“No amount of deceptive advertising will distract from the fact that candy flavors target kids,” echoed Melissa Welch, a spokesperson for the American Heart Association. “We believe the success of Proposition E will encourage other cities to follow suit and end the sale of candy-flavored tobacco before nicotine addiction claims a new generation of young people.”

However, not all of San Francisco’s residents were happy about the vote. Opponents fear the proposition could take business away from local convenience stores and could potentially become more wide-reaching than just San Francisco.

“Telling adults what they can and can’t do isn’t effective,” opponents stated in an argument to voters before the election, noting that California recently just raised the age to buy tobacco to 21.

“Big tobacco sees vaping as their future,” said Patrick Reynolds, executive director of the Foundation for a Smokefree America. “They are very afraid this is going to pass and if the voters make an informed decision to side with the health community, it will lead to hopefully a tidal wave of cities doing what SF did because the FDA did nothing. We will start to turn the tide against vaping.”

A wave of change

While the San Francisco vote is considered a win by many, the battle over e-cigarettes -- and the ban of flavored tobacco -- certainly isn’t a new one.

City Council members in nearby Oakland, CA decided to ban the sale of flavored tobacco products late last year, with the ban becoming effective mid-2018. Other Bay Area cities passed similar legislation, including Berkeley, Los Gatos, Palo Alto, and Santa Clara County.

Moreover, a recent study by researchers from six continents asked legislators to ban flavored versions of e-cigarettes, as well as corresponding advertisements. The group cited growing concerns over teen addiction and future health problems as the primary reasons for proposing legislation.

“Until recently, the risks of e-cigarettes and their rising popularity with children and adolescents were under-recognized or ignored,” said Dr. Thomas Ferkol, a professor at Washington State University. “Some people truly believe e-cigarettes could be used as a smoking cessation technique, but these products also are an entry to nicotine addiction and tobacco use in young people.”

Doctors, researchers, and health advocates across the globe have gone back and forth on the supposed health benefits of e-cigarettes. Now, a coalition of researchers from six continents have spoken out and asked regulators to ban flavored versions of the product and certain types of advertisements.

The group alleges that e-cigarettes cause extensive damage to users’ health – a prospect that is worrying given their rising popularity with teens.

"Until recently, the risks of e-cigarettes and their rising popularity with children and adolescents were under-recognised or ignored. We wrote this statement to address growing public health concerns over e-cigarette use among youths,” said Dr. Thomas Ferkol, a professor at Washington State University and co-author of a paper published by the coalition.

“Some people truly believe e-cigarettes could be used as a smoking cessation technique, but these products also are an entry to nicotine addiction and tobacco use in young people.”

Harmful to young people

The group explains that young people are especially susceptible to nicotine addiction, and that the increasing acceptance of e-cigarette products from a safety standpoint detracts from the harm they can do.

The group states further that the assertion that e-cigarettes are less harmful than cigarettes does not mean that they are an acceptable substitute.

"Although exposure to potentially harmful ingredients from electronic cigarettes may be lower than traditional cigarettes, this does not mean that e-cigarettes are harmless,” said Charlotta Pisinger, a professor and clinician at the University of Copenhagen.

“When we are talking about children and adolescents who are trying e-cigarettes for the first time, we should not be comparing their use to traditional cigarettes. We should be comparing them to no tobacco use.”

Banning flavorings and advertisements

In their paper, the researchers make several recommendations about how e-cigarettes should be regulated. They believe that the products should be subject to the same rules that other tobacco products must follow.

Specifically, they call for policymakers to ban sales to younger people, discontinue flavored products to make e-cigarettes less appealing to this group, and stop advertisements that spin the products as a safer alternative.

“E-cigarettes are largely unregulated, particularly in low and middle-income countries. They are marketed as a smoking cessation tool and a safer alternative to tobacco cigarettes. However, there is growing evidence that nicotine has many acute and long-term adverse effects, including addiction. Young people are at particular risk for this,” said Dr. Aneesa Vanker, a specialist in pediatric pulmonology at the University of Cape Town in South Africa.

"We want local, national, and regional decision-makers to recognise the growing public health threat that e-cigarettes pose to children and adolescents. Inhaling something other than air is never good for a child's lungs."

The group’s full statement has been published in the European Respiratory Journal.

A new long-term study suggests electronic cigarettes, or e-cigarettes, have no negative health outcomes when used daily by young adults who have never smoked.

After tracking nine e-cigarette users with no history of smoking and twelve lifetime non-smokers and non-vapers over several years, researchers from the University of Catania concluded that vaping had “no impact” on participants’ health.

“In spite of previous health scares, our study shows for the first time no risk in long-term vapers who have never smoked in their life,” said lead author Dr. Riccardo Polosa.

No long-term health consequences

A growing body of research has attempted to answer the question of whether or not e-cigarettes are safe to use. Detractors have pointed out that heavy e-cigarette use, or vaping, can lead to increased frequency of smoking and heavier smoking overall, especially among teens.

The safety of these products has also been called into question by researchers who say that e-cigarette liquid contains high levels of toxic metals and other dangerous chemicals.

But despite these findings, Polosa and his colleagues say that relatively few long-term studies have investigated how safe e-cigarettes are for humans. Their study found that young people who had never smoked showed no marked difference in blood pressure, heart rate, lung function, or other health metrics after using the products for three and a half years.

While two years of cigarette usage was enough to fuel changes in spirometry and CT scans in young people, the CT scans of vapers did not reveal any signs of lung damage, lipoid pneumonia, or popcorn lung. The researchers say this finding held true even among participants with the highest consumption of e-liquid.

More research needed

Despite the positive findings, the researchers noted that even longer-term research is needed to rule out any possible negative impacts of vaping. However, they argue that the results of the study suggest fears about the impact of vaping on nonsmokers may be unwarranted.

In an interview with ConsumerAffairs, pulmonary specialist Dr. Mario F. Perez said he believes it’s too early for researchers to say that vaping is a “safe” alternative to smoking.

“I think more research is necessary in order to answer this question and that is something that we are currently doing,” he said.

“I believe that we are still discussing their safety both in the general population and in those who currently use conventional cigarettes and are attempting to quit through electronic cigarettes, but the current data does not allow us to really recommend these products quite yet for that purpose.”

Americans are smoking fewer cigarettes and health researchers at the University of California San Diego School of Medicine and Moores Cancer Center think e-cigarettes might have something to do with it.

Introduced about a decade ago, e-cigarettes provide some of the same effects as smoking a cigarette. They are in the shape of a cigarette and deliver a water vapor containing nicotine instead of smoke.

Anti-smoking advocates have never liked the devices and have worried that they will hook a generation of non-smokers on nicotine.

But the California researchers analyzed smoking surveys conducted in the U.S. between 2001 and 2015 and found that the number of smokers who quit rose for the first time in 15 years. They conclude that e-cigarettes are helping smokers kick the habit.

A higher quit rate

“Our analysis of the population survey data indicated that smokers who also used e-cigarettes were more likely to attempt to quit smoking, and more likely to succeed,” said Shu-Hong Zhu, a UC San Diego professor. “Use of e-cigarettes was associated both with a higher quit rate for individuals as well as at the population level; driving an increase in the overall number of people quitting.”

The researchers say they were impressed that the rate of smokers who quit stayed fairly stable at 4.5% for years. Then in 2014 to 2015, it rose to 5.6%.

That's significant, they say. The 1.1% increase represents about 350,000 smokers who quit in a single year.

The survey provided additional evidence that e-cigarettes may have played a role in the reduced smoking rate. It asked smokers whether they used the devices. Sixty-five percent of smokers who used e-cigarettes within the previous 12 months had tried to stop smoking. Only 40% of smokers who did not use e-cigarettes attempted to quit.

E-cigarette users more likely to quit smoking

When measuring success, the researchers found 8.2% of smokers who also used e-cigarettes were able to stop smoking, while 4.8% of those who didn't use e-cigarettes were able to quit.

“The cessation rate among those who did not use e-cigarettes remained the same compared to previous years,” said Zhu. “These data suggest that e-cigarettes play the role of a cessation tool.”

But the researchers are not ready to give e-cigarettes an unqualified endorsement as a smoking cessation tool. They say it is possible that smokers who used e-cigarettes were more serious and motivated to quit smoking, and were therefore more likely to succeed than smokers who did not use the device.

The study also did not investigate whether using e-cigarettes makes a non-smoker more likely to start using tobacco. However, they point to research conducted by the Centers for Disease Control and Prevention (CDC) which shows e-cigarette use among young people is rising but smoking rates are not.

When electronic cigarettes (e-cigarettes) appeared in the marketplace a few years ago, it caught anti-smoking advocates by surprise.

Cigarette smoking was on the decline. Now there was another product that looked like a cigarette, delivered nicotine, but contained no tobacco. Was it safe? Would it lead to a resurgence of smoking?

Since then, opposition to e-cigarettes among these groups has hardened. The devices are said to deliver harmful chemicals and serve as a gateway to cigarettes, hooking young people on nicotine.

Questioning conventional wisdom

While the health effects of e-cigarettes are still being studied, new research calls into question the contention that they are a gateway to tobacco. Researchers from the University at Buffalo (UB) and University of Michigan flatly assert the evidence isn't there.

“The national trends in vaping and cigarette smoking do not support the argument that vaping is leading to smoking,” said Lynn Kozlowski, the paper’s lead author and a professor at UB.

Kozlowski says that existing research shows that as use of e-cigarettes has increased, overall smoking rates in the U.S. have declined. Kozlowski says the research team looked for the link between e-cigarettes and tobacco but didn't find it.

Questioning previous research

But what about previous studies that contend there is a link? Kozlowski and his colleagues say these studies have flaws. In particular, he says these studies don't clearly define what "smoking" is.

“Measures of ‘at least one puff in the past six months’ can mean little more than the experimenting vaper was curious how cigarettes compared,” Kozlowski said.

Kozlowski says the study only looked at the risks associated with moving from vaping on an e-cigarette to becoming a regular cigarette smoker. Critics of e-cigarettes, meanwhile, have worried that young people are increasingly vaping, and will develop a nicotine dependency that will eventually only be satisfied with tobacco.

Different ideas across the Atlantic

As we noted in 2015, the UK and U.S. have different ideas about e-cigarettes. Public health officials in the UK had just released a report saying e-cigarettes were 95% less harmful than cigarettes.

"My reading of the evidence is that smokers who switch to vaping remove almost all the risks smoking poses to their health," said Professor Peter Hajek of Queen Mary University, a co-author of the report.

The report also concluded there was no evidence that people who used e-cigarettes later took up smoking. Kozlowski says efforts in the U.S. should focus more on product safety.

“The public deserves accurate information on the health risks of e-cigarettes versus cigarettes,” Kozlowski said. “From the best evidence to date, e-cigarettes are much less dangerous than cigarettes. The public has become confused about this.”

The U.S. Surgeon General recently warned that American teens are risking their health with their increasing use of cigarettes.

Now, researchers at Texas A&M University are echoing that concern after drilling deeper into the Surgeon General's report.

They point to the very rapid growth in e-cigarette use between 2010 and 2015. By last year, surveys showed that 40% of high school students had tried an e-cigarette at least once and 16% had used one in the past 30 days.

The only saving grace, says Amy Fairchild, associate dean of academic affairs at the Texas A&M School of Public Health, is teens appear to be smoking fewer cigarettes. The Centers for Disease Control and Prevention (CDC) reported in November 2015 that teen use of cigarettes had hit an all-time low.

“The consequences of combustible tobacco use are well known and serious, while e-cigarettes—while not risk free—represent a far lesser harm,” she said.

Where are teens getting e-cigarettes?

A concern, however, is the easy access teens appear to have to e-cigarettes. When they first hit the market a few years ago, they were completely unregulated. Now, the Food and Drug Administration (FDA) has authority to regulate them and has set age limits on their purchase.

The FDA has set the age limit at 18, while a few states, such as California, have set higher age limits on sales. But researchers say that doesn't seem to be stopping very young teens – those in middle school – from obtaining the devices.

Fairchild suggests increasing the tax on e-cigarettes – making them more expensive – as a way to deter use by young people.

“Kids are extremely price sensitive,” she said. “There is evidence to suggest that you can tax e-cigarettes and other less risky smokeless products out of their hands. At the same time, if the tax is lower than for combustible cigarettes, current smokers aren’t also stripped of a financial incentive to switch to reduced risk products.”

While e-cigarettes have fewer toxic chemicals than tobacco, but they do contain chemicals, and Fairchild says there is concern that we don't have a complete picture of the potential harm they could do.

But the effects of the nicotine these devices contain is pretty well known. Fairchild says nicotine can harm brains that are still developing, meaning anyone under age 25 should steer clear of it.

Back in 1964, the U.S. Surgeon General, Dr. Luther Terry, released a report that documented in exhaustive detail the health risks of cigarette smoking, something that had been considered benign and even healthy just a few years before.

Now another report from the U.S. Surgeon General is raising concerns about e-cigarette use among U.S. youth and young adults, now estimated to amount to 1 in 6 high school students.

“All Americans need to know that e-cigarettes are dangerous to youth and young adults,” said U.S. Surgeon General Dr. Vivek H. Murthy, in releasing the report. “Any tobacco use, including e-cigarettes, is a health threat, particularly to young people.”

The report finds that, while nicotine is a highly addictive drug at any age, youth and young adults are uniquely vulnerable to the long-term consequences of exposing the brain to nicotine, and concludes that using nicotine in any form is dangerous to young people.

The report also finds that secondhand aerosol that is exhaled into the air by e-cigarette users can expose others to potentially harmful chemicals.

"First comprehensive review"

Today’s report, which was written and reviewed by more than 150 experts, is the first comprehensive federal review of the public health impact of e-cigarettes on U.S. youth and young adults. After years of study, the Food and Drug Administration in May set the legal age for using tobacco and e-cigarettes at 18 after finding that the rate of teen "vaping" was increasing markedly. 

“We have more to do to help protect Americans from the dangers of tobacco and nicotine, especially our youth. As cigarette smoking among those under 18 has fallen, the use of other nicotine products, including e-cigarettes, has taken a drastic leap. All of this is creating a new generation of Americans who are at risk of addiction,” said HHS Secretary Sylvia Burwell at the time the age limit was announced. 

There have been numerous, conflicting studies about the health effects of e-cigarettes and other electronic nicotine delivery systems. Some countries, most notably Britain, have concluded that e-cigs are less harmful than regular tobacco products. In 1995, Public Health England (PHE) -- roughly equivalent to the U.S. FDA -- said it had found e-cigs about 95% less harmful than smoking.

"My reading of the evidence is that smokers who switch to vaping remove almost all the risks smoking poses to their health," said Professor Peter Hajek of Queen Mary University. Hajek co-authored the report with Professor Ann McNeill of King's College London

Perhaps, but in November, a University of Southern California study suggested that the health of young users may be at serious risk in the short- and long-term. The reason, the authors say, is that e-cigarette use and vaping can be associated with an increased frequency of smoking and heavier smoking habits overall.

Recommendations

The latest Surgeon General's report includes a series of recommendations to reduce vaping and smoking by young people, including:

• continuing to regulate e-cigarettes at the federal level;
• raising and strongly enforcing minimum age-of-sale laws for all tobacco products, including e-cigarettes;
• incorporating e-cigarettes into smoke-free policies;
• regulating e-cigarette marketing;
• sponsoring high-impact media campaigns to educate the public on the harms of e-cigarettes among young people; and
• expanding research efforts related to e-cigarettes.

“Protecting our nation’s youth from the harms of tobacco and nicotine is a top priority for HHS and this Administration. And this report, outlining the harms of e-cigs and providing clear steps to reduce their impact on our kids, is an important step in our fight,” said Secretary of Health and Human Services Sylvia Burwell. “We cannot let the enormous progress we’ve made toward a tobacco-free generation be undermined by e-cigarettes and other emerging tobacco products.”

“We need parents, teachers, health care providers, and other influencers to help make it clear that e-cigarettes contain harmful chemicals and are not okay for kids to use” Dr. Murthy said. “Today’s report gives them the facts about how these products can be harmful to young people’s health.”

A new interactive website containing key information from the report, written especially for parents and adult influencers of youth, is available at E-cigarettes.SurgeonGeneral.gov.

Electronic cigarettes are growing in popularity as current smokers find they can get their nicotine fix by inhaling the vapor produced by these devices.

More concerning to health officials is the growing use of e-cigarettes by teens and young adults. Not only do health officials worry e-cigarettes could eventually lead to smoking, they are increasingly focusing on the chemicals that are present in e-cigarette vapor.

Researchers writing in the American Chemical Society (ACS) journal Environmental Science & Technology looked at what happens to e-liquid flavorings when they're heated up. Their study reports some flavorings, when vaporized, break down into toxic compounds. These compounds, they say, tend to exceed occupational safety standards.

Heat can alter chemistry

The researchers say knowing what compounds are present in e-cigarettes isn't enough. They say there needs to be more information about how these chemicals change once heated to the point of becoming water vapor.

The study cites previous research that has shown that subjecting e-cigarette chemicals to heat produces aldehydes and other toxic compounds. In this study, the researchers wanted to focus on what happens when flavoring agents are heated up.

They tested a wide range of e-cigarettes, some with flavorings and some without. They found the amount of potentially harmful compounds produced by heat varied widely across the different products tested.

In general, however, the researchers concluded that just a single puff of flavored vapor contained levels of aldehydes exceeding the safe thresholds for occupational exposure by factors of 1.5 to 270. Unflavored e-cigarettes produced significantly lower levels of aldehydes.

7,700 different flavors

According to the American Lung Association, there are 500 brands of e-cigarettes on the market with 7,700 different flavors. While e-cigarettes now fall under Food and Drug Administration (FDA) regulation, the association says it could be another two years before the FDA has a full grasp on the chemicals present in these products.

“We don't presently know what is in e-cigarettes,” the Lung Association says on its website. “However, in initial lab tests conducted in 2009 the FDA found detectable levels of toxic cancer-causing chemicals, including an ingredient used in anti-freeze, in two leading brands of e-cigarettes and 18 various cartridges.”

The Lung Association also has raised concerns about flavorings used in e-cigarettes, saying just because they have been safe to consume in food does not mean they are also safe to inhale.

Health officials have always been worried about teen smoking. Getting hooked on nicotine early in life makes it harder to quit later on and can lead to health problems down the road.

When e-cigarettes were introduced to the marketplace, they drew the same kind of concern, as statistics showed teens were among the early adopters. While there is no tobacco in an e-cigarette, there is nicotine, and health activists worried that teens who used the devices would gravitate to cigarettes later on.

The National Institute on Drug Abuse recently reported that teens are more likely to use e-cigarettes than smoke tobacco. By eighth grade, it says only 3.6% had started smoking but 9.5% were using e-cigarettes. By 12th grade, it found more than 16% were using e-cigarettes.

But being a gateway to tobacco is not the only concern about these nicotine delivery systems. New research suggests even those who don't later start lighting up can be damaging their health by inhaling the nicotine-laden vapor.

Persistent cough and bronchitis

Researchers at the University of Southern California (USC) say they have found an association between e-cigarettes and development of a persistent cough, bronchitis, and congestion or phlegm in the young people who use them.

“E-cigarettes are known to deliver chemicals toxic to the lungs, including oxidant metals, glycerol vapor, diketone flavoring compounds and nicotine,” said lead author Dr. Rob McConnell. “However, there has been little study of the chronic health effects of e-cigarettes.”

The study compared kids who had used e-cigarettes to those who had never tried “vaping.” It found that young people who had used e-cigarettes in the past were 85% more likely to exhibit respiratory symptoms. Current users were twice as likely.

“The Food and Drug Administration recently banned the sale of e-cigarettes to children under 18 years of age, and California just prohibited sale to young adults under 21,” McConnell said. “Our results suggest that these regulations and an environment that discourages the initiation of any tobacco product may reduce the burden of chronic respiratory symptoms in youth.

But because e-cigarettes are relatively new, McConnell said he believes they need additional study so doctors can better understand their long-term effects.

The popularity of e-cigarettes continues to rise for teens across the U.S. Middle and high school students are glorifying habits like vaping, and many still believe that the products don’t pose much of an immediate threat to their health.

While different studies have disagreed over that fact, new findings from the University of Southern California suggest that the health of young users may be at serious risk in the short- and long-term. The reason, the authors say, is that e-cigarette use and vaping can be associated with an increased frequency of smoking and heavier smoking habits overall.

Heavier smoking patterns

Dr. Adam M. Leventhal and his colleagues came to their conclusions after analyzing surveys given to 10^th grade students in ten public high schools in Los Angeles County between 2014 and 2015. Questions focused on the frequency and heaviness of e-cigarette and cigarette use, as well as vaping habits. A follow-up survey was given six months later to gauge any changes.

The analysis found that students that smoked or vaped at the time when they took the first survey were more likely to increase their e-cigarette smoking frequency by the time the second survey was taken. Similarly, the researchers found that adolescents who smoked cigarettes were more likely to increase their smoking frequency and heaviness if they also vaped; this was especially true for infrequent smokers.

The researchers believe these findings speak to the need for stronger tobacco control policies, though they admit that more research will need to be conducted to verify the results. The full study has been published in JAMA. 

When e-cigarettes were introduced a few years ago, they were presented as a safer alternative to cigarettes. They delivered the same nicotine but not the tars and some other contaminants present in tobacco.

What might have gotten lost in the discussion, however, is another safety issue. Users are putting an electronic device in their mouths. And just as we have seen with other electronic devices, like smartphones, they sometimes explode.

Researchers at the University of North Carolina's (UNC) Tobacco Prevention and Evaluation Program decided to focus solely on e-cigarette safety rather than any other adverse health effects they might have.

They said that in the first half of this year, doctors at the North Carolina Jaycee Burn Center at UNC Hospitals treated 10 inpatients with severe burns and facial fractures. The injuries, they say, all came from e-cigarette explosions.

Serious injury

According to their study, most of the injuries required surgery, and one patient lost his eye when an e-cigarette exploded while he puffed on it.

Clare Meernik, lead author of an editorial published in the British Medical Journal (BMJ), says the UNC burn center's experience is not an outlier.

“We think these explosions are happening to a greater extent than the current medical literature suggests,” she said.

Other safety officials have recognized a threat. E-cigarettes have been banned from airline luggage, for fear they could ignite a fire while the plane is airborne.

The BMJ editorial says there should be better monitoring of e-cigarette-related injuries, as well as better oversight of the manufacturing process.

Dr. Felicia Williams, of the UNC School of Medicine, says victims of an exploding e-cigarette suffer from flame burns, but also from exposure to chemicals. She's concerned most emergency rooms, where victims tend to first be treated, are unaware of the severe nature of the burns.

No way to track

Currently, the researchers say there isn't a system in the U.S. health care system to track these injuries. Most cases are gleaned from media reports. They point to a 2015 Centers for Disease Control and Prevention (CDC) report that more than nine million people in the U.S. are using e-cigarettes as a reason to increase the focus on safety.

“We believe the FDA should immediately develop safety standards that all manufacturers must comply with, Williams said. We know that some explosions are related to battery issues, but other mechanisms may also be involved.”

Improved safety standards, she says, would reduce the number of severe burns and other injuries. Since the FDA now has the authority to regulate e-cigarettes, the researchers say that authority should extend to the design and manufacture of these devices.

Recent trends among teens seem to favor vaping with e-cigarettes, with many high- and middle school students saying that they’ve tried it. While many fear that this habit could lead to nicotine and smoking dependence, a new study suggests that the problem may not be that worrisome.

Researchers have found that many teens that vape don’t do so for the nicotine; instead, many teens say that the flavors offered by e-cigarette products are the drawing point. This throws into question the supposition that teens are vaping nicotine in the first place and that there is a “nicotine epidemic” amongst this age group.

Vaping for flavor

The researchers came to their conclusions after analyzing the results of the 2015 Monitoring the Future Survey, wherein teens were asked about their vaping experiences. The survey was a nationally representative study of 8th, 10th, and 12th grade students.

Out of 15,000 students who took part in the survey, nearly 4,000 admitted to having vaped at some point. Narrowing the numbers further, the researchers found that 1,701 had done so at least once, 1,085 had done it up to five times, and 616 had done it at least half a dozen times.

When asked what they had vaped most recently, two-thirds of respondents gave the answer “just flavoring.” Vaping nicotine came in second by a large margin, with only 13% of 8th graders, 20% of 10th graders, and 22% of 12th graders giving that answer. Vaping marijuana was even less pervasive, with only 14% of 12th graders, and 6% and 7% of 8th and 10th graders giving that answer, respectively.

Targeted interventions

These findings indicate that vaping nicotine is not nearly as big of a problem as many experts have stated in the past. This is good news, say the researchers, because interventions to stop vaping can be modified to be more specific and effective.  

“Because many US youth who use vaporisers do not vape nicotine, they are candidates for primary interventions, which are particularly strategic to combat nicotine use, because they take place before the need to address nicotine’s addictive properties,” they said.

Additionally, the researchers say that designating e-cigarettes as Electronic Nicotine Delivery Systems (ENDS) may be unfair since most teens do not use them for that purpose, although they do say that vaporiser use does increase tobacco and nicotine prevalence.

The full study has been published in Tobacco Control. 

A study by researchers at the Lawrence Berkeley National Laboratory (Berkeley Lab) has found that emissions from e-cigarettes are not consistent, affected by things like temperature, type, and age of the device.

The say their discovery may prove helpful to both manufacturers and regulators, working to minimize negative health effects from “vaping.”

The Berkeley Lab study found that the thermal breakdown of propylene glycol and glycerin, two solvents found in most “e-liquids,” can be unstable and lead to emissions containing toxic chemicals, including formaldehyde.

“Advocates of e-cigarettes say emissions are much lower than from conventional cigarettes, so you’re better off using e-cigarettes,” said Berkeley Lab researcher and the study’s corresponding author Hugo Destaillats.

The researchers say that might be true in the case of heavy smokers who have not been successful in their attempts to quit. But they say e-cigarettes are still unhealthy, even though cigarettes are worse.

Label discrepancy

Meanwhile, researchers at North Dakota State University (NDSU) conducted a study of the nicotine levels found in e-cigarettes liquid nicotine containers, comparing that amount to what was listed on the label. They say they found 51% of labels don't accurately reflect the amount of nicotine they contain.

For the project, the researchers purchased liquid nicotine at random at 16 North Dakota stores. In one case they said the actual amount of nicotine was 172% higher than the amount listed on the label. As an added concern, the researchers said the majority of containers did not come in child-resistant packaging.

“Mislabeling of nicotine in e-liquids exposes the user to the harmful effects of nicotine,” said study author Kelly Buettner-Schmidt, associate professor of nursing at NDSU. “In areas without child-resistant packaging requirements, children may be exposed to harmful nicotine.”

Danger to children

Ingestion of nicotine by a child is hazardous, with the level of severity depending on the size of the child and the amount ingested. The result can be nicotine toxicity, accidental poisoning, or death.

Last August, North Dakota outlawed the sale of e-cigarettes and tobacco to those under 18. The law also mandates child-resistant e-liquid containers, although the amount of nicotine content remains unregulated.

This August, the U.S. Food and Drug Administration (FDA) is expected to issue final regulations that prohibit the sale of e-cigarette products to anyone under 18. The proposed rule would also outlaw free samples, false or misleading advertising of e-cigarette products.

The exploding cigar was a mainstay of slapstick humor back in the day. But there's nothing funny about an exploding e-cigarette, according to those who've had the experience.

Dozens of lawsuits have been filed by consumers who say their e-cigs blew up, causing serious and expensive injuries. The Food and Drug Administration has found 134 reports of overheating, fires, and explosions of the devices in the U.S. between 2009 and January 2016, the Wall Street Journal reports. The FDA is phasing in rules covering the devices, which will eventually require government approval before they can be marketed. 

Most of the lawsuits allege that the explosions and injuries were caused by the lithium-ion batteries used in the devices, which are mostly made by Chinese companies. The industry argues that the number of explosions and fires is small considering how many of the devices are in use and says many of the mishaps are the result of user error.

Severe burns

A jury in Riverside, Calif., recently awarded $1.9 million in damages to a woman who suffered severe burns when her e-cigarette exploded while hooked up to a car charger. Like most such suits, hers named the retailer, distributor, and wholesaler rather than the manufacturer, since it's difficult to sue an overseas company.

The Journal article notes another case, that of Rachel Berven of Modesto, Calif. She had been using her vaping device -- as the e-cigs are called -- for about a year. One day she inserted a new battery and when she fired the device up, it exploded, ripping a hole in her mouth and spewing acid across her body, leaving her with three cracked teeth and scars on her legs and elsewhere.

In another gruesome case, a school counselor in California alleges that his e-cig exploded and tore through his eye, smashing two cheekbones and starting a fire.

Joseph Cavins said he was working at his computer on April 15 when his e-cig "suddenly exploded, striking Joseph in the left eye, continuing past his head, hitting the ceiling, ricocheting off the wall and landing on top of the computer station, where it started a fire," according to his complaint in Orange County Court, Courthouse News Service reported. He has sued four distributors and retailers. 

Cavins said the explosion smashed his orbital and sinus bones, "left several pieces of shrapnel inside the eyeball itself," causing doctors to remove the eyeball. He will need more surgery to fix his broken bones, reconstructive surgery on his sinus cavity, and he and his wife have both missed work. He sued four distributors and retailers.

The vaping industry contends that many of the incidents are the result of consumers using the wrong chargers. Others involve the more complex "mechanical mods," which are more customizable than the smaller, cigarette-like e-cigs. 

“When used and charged properly, vapor products pose no more of a fire risk than any other product that is powered by lithium-ion batteries, like cellphones or laptops,” Gregory Conley of the American Vaping Association told the Journal.

Traditional cigarettes are really bad for you, but at least they don't blow up in your face, as e-cigarettes have been doing lately. In one of the most recent cases, an Albany, N.Y., man said his e-cig blew up and knocked him to the ground.

“Like a M80 bomb went off in my mouth,” Kenneth Barbaro said. “When I hit the button, I saw a huge yellow light. The next thing I know, I’m on the floor and my arms are paralyzed.”

Barbaro was hospitalized with burns to his hands, knocked-out teeth, and a splt tongue, he said in a televised report.

“When it blows up in your face, you’re not having a good time,” he said in a televised news report.

More serious

In an even more serious case, an e-cig exploded on April 15, tearing through a man's eye, smashing two cheekbones, and starting a fire. Joseph Cavins, now blind in one eye, has filed a lawsuit against vaping retailers and distributors, Courthouse News Service reported.

He said he was working at his computer when his vaping device exploded, hitting him in the eye, then hitting the ceiling, and finally landing on top of the computer, where it started a fire.

Cavins, a public school counselor, underwent seven hours of surgery. Doctors removed his left eye and performed surgery to fix broken bones in his face and to repair his sinus cavity.

The problem, according to Cavins' lawsuit, is that the batteries in vaping devices have "an inherent risk of fire and explosion," exacerbated by what it says is the cheap construction and poor design of many of the devices. 

If the temperature inside the lithium-ion battery builds up high enough, it can cause an explosion that propels the battery "like a bullet or rocket," Cavins' suit says. 

Several similar cases have been reported in recent months. 

Recent reports have indicated that e-cigarette use amongst teens is rising, but how much of it is attributed to the way these products are advertised? According to a study from The University of Texas Health Science Center in Houston, quite a lot.

Researchers have found a significant association between marketing for e-cigarettes and product use among middle and high school students. The teens report seeing advertisements for these products in many different places – a marketing tactic that closely resembles those used by the tobacco industry.

“E-cigarette companies are following what cigarette companies did. There are no restrictions on the messaging they can use, and health warnings do not appear on e-cigarettes like they do on cigarette packages. Flavored e-cigarettes are widely available and appeal to youth,” said Dr. Maria Cooper, co-author of the study.

Pervasive advertising

The study utilized data from the 2014 National Youth Tobacco Survey, which asked young people about their exposure to tobacco products. The researchers found that out of over 22,000 middle and high school students, 20% had tried e-cigarettes before and 9% were currently using them.

The researchers found that those who had tried e-cigarettes before were 16% more likely than their peers to have seen an advertisement for the products in print, online, in a retail setting, or in a movie or television show. Current users were 22% more likely to have seen these ads.

While teens reported seeing ads the most in retail settings or online, the researchers point out that the products are becoming more and more widespread.

“You go to a convenience store and the entire wall behind the cashier is tobacco advertising. We’re seeing e-cigarettes are following that trend. The internet and social media are also a concern because e-cigarette companies have a big online presence,” said Dale Mantey, lead author of the study.

Increased spending

The increase in advertising is no accident either. The researchers state in their paper that marketing for e-cigarette products nearly tripled from 2011 to 2012 – from $6.4 million to $18.3 million.

That trend would continue into subsequent years; expenditures for e-cigarette ads in the second quarter of 2013 eclipsed all of the spending for 2012. The Centers for Disease Control and Prevention (CDC) estimates that spending increased to $115 million in 2014.

While more research must be done to prove a definitive link between e-cigarette advertising and its use, the researchers believe that their study has laid some of the groundwork for future studies.

The full study has been published in the Journal of Adolescent Health.

A New Zealand study finds that smokers who used a nicotine inhaler were twice as likely to quit smoking as smokers using a placebo inhaler. The study also found that adding a nicotine inhaler to a nicotine patch doubled the chances of quitting over using a nicotine patch alone.

"There is considerable debate about whether inhaled nicotine is helpful for people who wish to stop smoking," said Julian Crane, a professor at the University of Otago, Wellington. "This is the first study to show that inhaled nicotine from a metered dose inhaler in the context of a smoker wanting to stop doubles their chances of quitting."

Crane says the findings are the first evidence that inhaled nicotine from a simple inhaler is highly effective and substantially increases a smoker's chances of quitting compared to the best current nicotine replacement treatment.

"Currently most smokers use nicotine patches to help them stop smoking. This study shows that if you add a nicotine inhaler to a nicotine patch, it doubles the chances of quitting over a nicotine patch alone," Crane said.

Inappropriate use less likely

The results of the New Zealand study funded by the Health Research Council appear in the journal Nicotine and Tobacco Research.

Crane said an advantage of the nicotine inhaler is that, unlike electronic cigarettes, it has no physical associations with the act of smoking.

"It also has benefits in that it is much less likely to be used inappropriately to administer other drugs given that it is a completely sealed unit," notes Crane.

The researchers are currently looking at how to make the inhaler available to all smokers who would like to use it.

The Transportation Department has issued a final rule banning battery-powered electronic smoking devices – primarily e-cigarettes – from checked bags aboard commercial aircraft.

The government said it is taking the action as a safety precaution.

“Fire hazards in flight are particularly dangerous, and a number of recent incidents have shown that e-cigarettes in checked bags can catch fire during transport,” said U.S. Transportation Secretary Anthony Foxx, who called the ban a “prudent and important safety measure.”

The move was not unexpected. Back in October the agency issued an interim rule to the same effect, opening it to an extended comment period.

The final rule does allow passengers to carry e-cigarettes in the cabin of the aircraft, but it does not allow them to charge the devices during a flight.

Lithium ion batteries

Batteries, as a rule, make aviation officials nervous. There have been instances of lithium ion batteries in laptop computers and smartphones overheating, with some catching fire. Officials have long worried what would happen if a computer, packed in a suitcase and stowed in the body of a jetliner, caught fire.

In 2014 a plane in Tel Aviv had to be evacuated after the lithium-ion battery powering a passenger's iPhone 5 caught on fire, filling the cabin with smoke. A decade earlier a California teenager suffered second-degree burns when her cell phone caught fire without warning, with investigators pinning the blame on the lithium ion battery.

Granted, the batteries powering e-cigarettes are much smaller, but officials say it only takes a tiny spark to create a catastrophe.

“This final rule is the next step in hazardous materials safety standards following our interim final rule issued last October,” Marie Therese Dominguez, a Transportation Department officials, said. “The rule addresses the risk of fire brought about by carrying these electronic devices in checked baggage or charging them on board aircraft.”

The rule, however, does not stop people from carrying other devices powered by lithium ion batteries -- like computers, phones, and cameras -- in checked bags. It also does not stop a passenger from carrying battery-powered devices in carry-on luggage.

A new study disputes claims that e-cigarettes are a "disruptive technology" that can help smokers quit by replacing their traditional cigarettes. The study follows last week's action by the U.S. Food and Drug Administration to regulate e-cigs and restrict their sale to anyone under 18.

The study by researchers at the Tobacco Center of Regulatory Science (TCORS) at Georgia State University found that most smokers who have tried electronic cigarettes have rejected them as less satisfying than regular cigarettes, thus reducing their potential as a quit-smoking device.

E-cigs "need to improve as a satisfying alternative or the attractiveness and appeal of regular cigarette must be degraded to increase the potential of replacing regular cigarettes," according to lead author Dr. Terry F. Pechacek, professor of Health Management and Policy.

"It can be argued that efforts are needed by the public health community to reduce the appeal and attractiveness of the cigarette and other combusted tobacco products, namely, decreasing the product, promotion, placement and price advantage of these more lethal combusted tobacco products," the researchers wrote.

The findings are published in Nicotine & Tobacco Research.

Survey details

The researchers surveyed 5,717 U.S. adults in 2014, asking questions about their awareness of e-cigarettes, use of their products, and reasons for using traditional and novel tobacco products.

Among the 144 former cigarette smokers who had tried e-cigarettes, nearly 30 percent (or 43 people) continued to use them as a satisfying alternative to regular cigarettes.

But among the 585 smokers in the study, nearly 58 percent (or 337 people) reported they found e-cigarettes unsatisfying and stopped using them. 

The e-cigarette industry has been taking a lot of flak recently in the U.S. Earlier this month, we reported on a study that showed that the products actually make consumers less likely to quit smoking – a major discrepancy in claims that many companies in the industry had made. Perhaps even more worrying is that the products are becoming more and more popular amongst middle and high school-aged children.

Now, a new study is backing up a previous study that the flavoring compounds used in many e-cigarettes pose major health hazards. Researchers at the Roswell Park Cancer Institute (RPCI) have completed an analysis of nearly 150 e-cigarette flavoring products and found that many contain a potentially harmful chemical.

May cause throat irritation

The research team, led by Doctor Maciej Goniewicz, found that one chemical, benzaldehyde, was particularly potent in some e-cigarette flavoring compounds. Benzaldehyde is not particularly dangerous under normal circumstances – in fact, it is used in many different foods and cosmetic products. However, that fact changes under certain conditions.

It has been shown that benzaldehyde can cause airway irritation when it is heated up and inhaled, much like it would be when smoking or “vaping” it. Out of 145 e-cigarette products that were tested, researchers found that benzaldehyde was found in 108 of them. One flavor, though, stood out from the rest. The research team found that benzaldehyde levels were 43 times higher in cherry-flavored e-cigarette products than any other type.

While the research does show that there may be signs for concern, Dr. Goniewicz remained non-committal, stating that more research would need to be done before any solid conclusions could be drawn on the products.

“This analysis reveals some very important implications. .  . Health care professionals should be asking patients not just whether they smoke tobacco cigarettes but also whether they vape e-cigarettes, and whether they are using flavored products,” he said. “For e-cigarette users, it’s important that they pay attention to how the products are affecting them. If they notice irritation, maybe a cough or sore throat, when they use e-cigarettes, they might want to consider switching to a different flavoring.”

The team has published a research letter on their work in the journal Thorax. 

The Food and Drug Administration (FDA) is in the process of finalizing rules to regulate e-cigarettes, and just about everyone who has been following the process assumes the rules will ban sales to people under 18.

When that happens, the focus will next shift to whether e-cigarette marketing is targeting young people who aren't allowed to buy the product. In fact, it already has.

You may recall that tobacco companies were accused of using youth-oriented marketing gimmicks during the 1980s and 90s. A new report suggests e-cigarette marketers are turning to social media to reach their most lucrative market.

Unfortunately for health officials, researchers at Drexel University and the University of Southern California suggest it is next to impossible to contain social media marketing.

Influential tweets

"As public health researchers our job is to figure out whether people are seeing messages that might lead them to make unhealthy decisions," Kar-Hai Chu, the study's author, said in a release. "If an e-cigarette tweet reaches underage users and makes them curious about trying e-cigarettes, that is something we would want to know. The results of the study could help provide guidelines and advice for many potential regulations."

Social media has changed the game for all marketers, not just those selling e-cigarettes. Companies can easily used social media platforms to extend the reach of their advertising. Not only that, they can more narrowly target their message to a specific audience and track its reception.

The problem the study authors see is that once an ad message goes beyond its primary target and is picked up by social media, anyone can see it, regardless off their age. It doesn't have to “go viral” to have major impact. Policymakers, the study says, need to understand that before finalizing regulations governing advertising.

Internet a major advertising medium

The Centers for Disease Control and Prevention (CDC) has noted that 39.8 percent of teens who are exposed to e-cigarette advertising see it on the internet, especially on social media sites like Twitter.

"We chose Twitter because hundreds of millions of people all over the world use it to express their opinions about important topics, so it's a huge source of information and a quick and efficient way for researchers to learn about those opinions," Chu said. "A fascinating thing about Twitter is that users choose which messages they think are important to pass on to their friends. From a marketing perspective, companies and brands are very active on Twitter, including Blu, the brand we chose for this study."

The study followed three months of Twitter traffic, originating with tweets from the Blu e-cigarette company's official handle "@blucigs." As researchers expected, followers of @bluecigs spread the messages to others within their networks through retweets.

"The retweet network in our data demonstrated how rapidly and widely messages diffused--reaching an exponential number of users," said Christopher Yang, a professor in Drexel's College of Computing & Informatics, who was a co-author of the paper.

More important, he said, by the second level of followers, researchers saw a big shift in the types of users who were seeing the messages. After three months, a single tweet that originally went out to just 214 followers ended up through retweets reaching 2,600 unique users.

When electronic cigarettes, or e-cigarettes, first arrived on the scene, they were touted as a way to help smokers kick the habit. A new study suggests, however, that's not how they're being used.

Researchers at the University of California (UC) San Francisco say they discovered that adult smokers who use e-cigarettes are actually 28% less likely to give up cigarettes.

The study appears in The Lancet Respiratory Medicine, a journal detailing information about respiratory medicine and critical care.

“As currently being used, e-cigarettes are associated with significantly less quitting among smokers,” concluded first author Sara Kalkhoran, MD, in the article.

Kalkhoran was a clinical fellow at the UCSF School of Medicine when the research was conducted but is now at Massachusetts General Hospital and Harvard Medical School. She believes the jury is still out on the effectiveness of e-cigarettes as a smoking cessation tool.

Shouldn't be recommended

“E-cigarettes should not be recommended as effective smoking cessation aids until there is evidence that, as promoted and used, they assist smoking cessation,” she writes.

E-cigarettes are long and thin like a tobacco cigarette but are reusable devices that use an electric charge to create water vapor filled with nicotine. The user gets the nicotine rush without the tobacco smoke.

Health officials are still studying the safety of this inhaled vapor but have expressed strong reservations so far.

While it is true that many smokers have tried them, health officials worry that young adults – many of whom have never smoked – are trying them as well. Aside from the unknown health effects, they worry their use can create a nicotine dependency where none existed before.

The California researchers say they reviewed 38 studies that traced the association between e-cigarette use and kicking the cigarette habit among adult smokers. After combining the results of 20 studies they concluded that the odds of quitting smoking were 28 percent lower in smokers who used e-cigarettes compared to those who did not.

In other words, using e-cigarettes made it less likely to stop smoking.

Not marketed in the U.S. as anti-smoking tool

It should be pointed out that e-cigarettes are not specifically marketed as a way to stop smoking. It would require Food and Drug Administration approval to do so, since it would then be considered a medical device.

In the UK, they take a different view. The British National Health Service lists e-cigarettes as an accepted form of nicotine replacement therapy.

In August, a British report suggested e-cigarettes were about 95% less harmful than smoking.

"My reading of the evidence is that smokers who switch to vaping remove almost all the risks smoking poses to their health," Professor Peter Hajek of Queen Mary University wrote in the report.  

Electronic cigarettes, or e-cigarettes, are an object of intense focus by health researchers who worry that not enough is known about their health effects.

But what is known is worrisome enough. They might – might, because the research isn't there yet – be less harmful than cigarettes, and help heavy smokers ween themselves off tobacco.

On the other hand, they are nicotine delivery systems. If you aren't already hooked on nicotine through cigarettes, why in the world would you start using e-cigarettes and develop a dependence or addiction?

Researchers at the University at Buffalo asked that very question to a group of college-aged young adults, one of the product's biggest markets.

30% have tried it

More than 1,400 college students from four upstate New York universities were in the study group. Of that sample, 429 students -- about 30% – had tried e-cigarettes at least once.

Of those young adults, about 79% said they used e-cigarettes to “try something new,” and nearly 58% reported using them for enjoyment.

“Our findings suggest that college students and young adults may be more interested in using e-cigarettes for affective reasons, such as enjoyment or the pleasure they get from using these products, compared with use for cognitive reasons such as quitting smoking or because they perceive e-cigarettes to be a safer alternative to cigarette smoking,” said Megan Saddleson, PhD, who led the study.

Vaping for enjoyment

A small number of people – 15 students – reported “vaping,” the practice of inhaling nicotine vapor from an e-cigarette, daily. All daily vapers said they use e-cigarettes because they enjoy the product.

“The availability of flavors could be related to the enjoyment factor of e-cigarettes, especially among young people,” Saddleson said.

But 77% of the participants said they used e-cigarettes as a substitute for cigarettes, believing the vapor is less harmful than tobacco.

“Using e-cigs because they are less toxic could appeal to users and make the product more enjoyable for the user,” Saddleson said.

At the moment, e-cigarettes are not regulated at the federal level, though that is likely to change later this year. The Food and Drug Administration is in the final phase of readying regulations.

Companies that make and sell e-cigarettes are quick to point out how they are different from tobacco cigarettes.

For starters, they contain no tobacco. They deliver flavored nicotine in vapor form.

But the Centers for Disease Control and Prevention (CDC) says these nicotine delivery devices have one big thing in common with cigarettes – the way in which they are marketed.

In its most recent Vital Signs report, the CDC notes e-cigarette ads use many of the same themes – independence, rebellion, and sex – used to sell cigarettes and other conventional tobacco products.

That's of concern, the CDC says, because it has found that about seven out of 10 middle and high school students – more than 18 million young people – see e-cigarette advertising in stores, online, in newspapers and magazines, or on television and in movies.

No marketing restrictions

Currently e-cigarette marketing faces none of the restrictions imposed on tobacco. Health officials are worried that will translate into a surge of young people being hooked on nicotine.

“The same advertising tactics the tobacco industry used years ago to get kids addicted to nicotine are now being used to entice a new generation of young people to use e-cigarettes,” said CDC Director Tom Frieden. “I hope all can agree that kids should not use e-cigarettes.”

The CDC is concerned about the health effects of nicotine on young, developing bodies. In 2014, e-cigarettes became the most commonly used tobacco product among youths, surpassing conventional cigarettes.

From 2011 to 2014, the CDC said e-cigarette use among high school students soared from 1.5% to 13.4%, and among middle school students from 0.6% to 3.9%.

Spending on e-cigarette advertising rose from $6.4 million in 2011 to an estimated $115 million in 2014, the CDC said.

Regulations still in the works

The Food and Drug Administration (FDA) has the authority to regulate e-cigarettes, but is still in the final stages of that process. The FDA's official position is that many of the potential risks are unknown. It also says it is unknown whether the products have any potential benefit.

However, the BBC reported Monday that health authorities in the UK have approved a brand of e-cigarette as an aid to help people stop smoking. That means Britons could get a prescription for e-cigarettes through the government-run National Health Service.

Public Health England says e-cigarettes are far less harmful than tobacco and help smokers quit.

Much of the controversy over electronic cigarettes has centered around their nicotine content, but a study by Harvard researchers has found a chemical linked to severe respiratory disease in more than 75% of flavored e-cigarettes.

Diacetyl is a flavoring chemical that can cause bronchiolitis obliterans, commonly known as "popcorn lung" because it first appeared in workers who inhaled artificial butter flavor in microwave popcorn plants.

The Harvard T.H. Chan School of Public Health researchers found diacetyl and two other potentially harmful compounds in many flavored e-cigs, including those targeted to young people with flavors such as cotton candy, “Fruit Squirts,” and cupcake.

“Recognition of the hazards associated with inhaling flavoring chemicals started with ‘popcorn lung’ over a decade ago. However, diacetyl and other related flavoring chemicals are used in many other flavors beyond butter-flavored popcorn, including fruit flavors, alcohol flavors, and, we learned in our study, candy-flavored e-cigarettes,” said lead author Joseph Allen, assistant professor of exposure assessment sciences.

Dangers are well-known

The dangers of inhaling diacetyl are well-known and the Occupational Safety and Health Administration (OSHA) warns employers about the risks posed to workers exposed to the chemical.

The study, published today in Environmental Health Perspectives, notes that there are currently more than 7,000 varieties of flavored e-cigarettes and e-juice (nicotine-containing liquid that is used in refillable devices) on the market.

E-cigarettes are not currently regulated, although the U.S. Food and Drug Administration (FDA) has issued a proposed rule to include e-cigarettes under its authority to regulate certain tobacco and nicotine-containing products.

In the study, Allen and colleagues tested 51 types of flavored e-cigarettes and liquids for the presence of diacetyl, acetoin, and 2,3-pentanedione, two related flavoring compounds that the Flavor and Extract Manufacturers Association lists as “high priority,” meaning they may pose a respiratory hazard in the workplace.

At least one of the three chemicals was detected in 47 of the 51 flavors tested. Diacetyl was detected above the laboratory limit of detection in 39 of the flavors tested. Acetoin and 2,3-pentanedione were detected in 46 and 23 and of the flavors, respectively.

“Since most of the health concerns about e-cigarettes have focused on nicotine, there is still much we do not know about e-cigarettes. In addition to containing varying levels of the addictive substance nicotine, they also contain other cancer-causing chemicals, such as formaldehyde, and as our study shows, flavoring chemicals that can cause lung damage,” said study co-author David Christiani, Elkan Blout Professor of Environmental Genetics.

A non-profit group has filed lawsuits against e-cigarette manufacturers, claiming they failed to warn consumers about two cancer-causing chemicals and the health effects of nicotine.

The Center for Environmental Health (CEH) said it purchased e-cigarettes, e-liquids, and other vaping products from major retailers including RiteAid and 7-Eleven between February and October 2015 and found that 90% contained formaldehyde or acetaldehyde or both.

A test on one e-cigarette found the level of formaldehyde was more than 470 times higher than the California safety standard.

Testing for formaldehyde and acetaldehyde was conducted by an independent lab accredited by the American Association for Laboratory Accreditation. The two chemicals are known to cause cancer and are also linked to genetic damage, birth defects, and reduced fertility, the lawsuits argue. Under California’s Prop 65 consumer protection law, companies must warn consumers when their products expose users to chemicals that can cause cancer and/or birth defects.

Those named in the lawsuits include RJ Reynolds (Vuse brand), Fontem/Imperial Tobacco (blu brand), and NJOY.

In all, the nonprofit has launched legal actions against more than 60 companies for failing to warn consumers about exposure from e-cigarettes to nicotine and/or one or both of the two cancer-causing chemicals, formaldehyde and acetaldehyde, as required by California law.

Teen usage growing

The organization charged that teen use of e-cigarettes is skyrocketing: among 8th and 10th graders, twice as many say they use e-cigarettes as compared to those who smoke traditional cigarettes, with 17% of high school seniors nationally saying they smoke e-cigarettes.

“The tobacco industry is banned from targeting teens in cigarette ads, but they and the rest of the e-cigarette industry use all of the banned tactics in marketing e-cigarettes,” said Michael Green, Executive Director of CEH. “Parents should know that vaping presents real risks to young people. It’s long past time for this industry to end its predatory and deceptive marketing.”

In February, CEH sued 19 e-cigarette companies for failing to warn consumers about the reproductive health threats from nicotine in their products. In one settlement reached in those cases, the e-cigarette company Sapphire Vapor agreed to legally binding restrictions on sales and marketing to teens and prohibited the use of unverified health claims.

The Federal Trade Commission is planning to study the marketing of e-cigarettes, the first step in a process that could eventually lead to tougher regulation of sales and advertising practices for the fast-growing industry.

The agency will first send information requests to e-cigarette marketers and will use the information as a basis for a report on the sales, marketing activities, and expenditures in this new and complex industry.

Since the mid-2000s, the sale of battery-powered e-cigarettes has grown rapidly in the United States. Rather than burning tobacco, e-cigarettes heat liquid containing flavorings and chemicals (usually including nicotine) to produce an aerosol that the user inhales. E-cigarettes are sold both online and in conventional brick-and-mortar stores, are available in both disposable and refillable models, and come in a range of different flavors and nicotine levels.

The FTC is seeking clearance from the Office of Management and Budget to collect information from the e-cigarette marketers, which is the first step toward conducting the study. It will publish a Federal Register notice seeking public comment on the proposed collection of information from approximately five large and ten smaller e-cigarette marketers.

If you've flown lately, you may have noticed airline crews warning that e-cigarettes are not allowed in checked baggage. The U.S. Department of Transportation has now made that ban official.

“We know from recent incidents that e-cigarettes in checked bags can catch fire during transport,” said Transportation Secretary Anthony Foxx. “Fire hazards in flight are particularly dangerous.  Banning e-cigarettes from checked bags is a prudent safety measure.” 

In January, the department alerted airliners to the hazard and airlines began alerting passengers then. 

It can become quite a hassle for passengers who can't find room for their carry-on bags in the overhead bins. They're required to open their bags and remove the e-cigs before the bag is gate-checked.

Using or charging e-cigs is also prohibited.

The new rule does not prohibit a passenger from carrying other devices containing batteries for personal use (such as laptop computers, cell phones, cameras, etc.) in checked or carry-on baggage, nor does it restrict a passenger from transporting batteries for personal use in carry-on baggage, the department said.

It's easy to purchase e-cigarettes on the Internet, researchers say. Too easy.

A study by the University of California, San Diego School of Medicine says e-cigarette markets who sell their products online are aggressive in their marketing and make purchasing e-cigarettes easy for all ages.

E-cigarettes are a relatively recent invention. Only around since 2007, they have sold millions because users inhale nicotine vapor, not tobacco smoke.

“We found e-cigarette vendors were highly engaged in promoting the culture of ‘vaping’ online, including posting images to Instagram, a social media site used by 52% of teens,” said Tim K. Mackey, first author of the study. “Despite the fact that 47 states prohibit the sale of e-cigarettes to minors, the results highlight the potential of the Internet to encourage e-cigarette initiation and underage purchasing. This is particularly concerning given that the FDA does not have specific proposed regulations for online e-cigarette sales."

E-cigarettes contain no tobacco but the courts have ruled that they are tobacco products. As such, they come under the regulatory control of the FDA, which has yet to enact regulations. Proposed regulations were issued last year and are currently being reviewed.

Increasing use by young people

While most states have moved into the vacuum to impose some regulations, such as setting age limits on who can purchase the products, e-cigarettes are finding their way to plenty of underage consumers.

The researchers point to data from the 2014 National Youth Tobacco Survey showing e-cigarette use tripled among middle and high school students from 2013 to 2014.

While the jury is still out on potential harm, e-cigarettes are growing in popularity, in part because these battery-operated devices that look and feel like a tobacco cigarette come in all sorts of flavors, like bubble gum and peach fuzz.

The researchers say people who use these devices exhale a mixture of volatile organic compounds, heavy metals, and ultrafine particles that usually contain aerosolized nicotine in a cloud of vapor.

The study looked at 57 online vendors and found that 68% of them displayed one or more health warnings about the devices on their website. But the authors said the notices were usually written in smaller fonts or placed discretely in the terms and conditions section of a website.

Hard to prove age

More disturbing, one-third of the vendors had no detectable way to determine the age of who was buying the e-cigarettes. Most required only a simple click to say the buyer was within the legal age limit.

“The study found that online e-cigarette vendors use a variety of sophisticated and aggressive marketing practices, including promotional offers and high social media engagement to promote the sale of their products,” said Mackey.

As a result, sales are booming. Industry analysts estimate that online sales make up 25% to 30% of the $2 billion annual e-cigarette market, which may account for a high presence of vendors on social media.

The researchers said the findings could impact the U.S. Food and Drug Administration’s 2014 proposed regulations of e-cigarette use, sale, marketing, and manufacturing to include online monitoring of the laws.

Attorneys general from 33 states have signed off on comments stepping up pressure on the U.S. Food and Drug Administration (FDA) to strengthen proposed regulations of e-cigarettes, citing concerns that children and young adults may become hooked on nicotine.

E-cigarettes have been marketed as tobacco-free substitutes for the real thing. They deliver nicotine in a vapor and, because they don't produce smoke, are often used in public spaces where smoking isn't allowed.

In comments to the FDA, the attorneys general want proposed regulations to go a step farther than what is currently being discussed, requiring appropriate warning labels and child-resistant packaging to help protect youth from nicotine exposure.

Liquid nicotine concerns

The state officials also want the FDA to require liquid nicotine, nicotine-containing e-liquids and novel tobacco products, such as dissolvables, lotions, gels, and drinks, to carry warning labels regarding nicotine exposure that are similar to the labels on other tobacco products.

Illinois Attorney General Lisa Madigan said she is concerned that liquid nicotine is particularly toxic to children and can be ingested or absorbed through the skin. That's why she and others are advocating child-resistant packaging.

There's currently a patchwork of state regulations in place. Seventeen states have already enacted laws requiring such packaging, but no federal standards currently exist. The attorneys general are also recommending flow restrictors for liquid nicotine and nicotine containing e-liquids to further protect children from exposure in the event that closures are not fully secured.

Youthful appeal

Madigan is concerned that e-cigarettes are being made to appear attractive to young consumers.

“With a variety of sweet, candy and fruity flavors, and marketing campaigns that feature themes from popular children’s movies, it is no surprise that the numbers of young people using e-cigarettes is rising,” said Madigan. “Nicotine is harmful no matter how it is consumed, and e-cigarettes should come with warnings about its dangers.”

Madigan cites statistics from the U.S. Centers for Disease Control and Prevention (CDC), showing the percentage of high school students using e-cigarettes had more than tripled in one year – from 4.5 percent in 2013 to 13.4 percent in 2014, or approximately 2 million students.

“As more and more Americans – especially young people – take up e-cigarettes, it is more important than ever that the FDA ensures our children are protected from the dangers of liquid nicotine,” said New York Attorney General Eric Schneiderman. “Child-resistant packaging and health warnings are an essential step to keeping these potentially lethal toxins out of the hands of our children. The FDA must step up and regulate the sale and packaging of these dangerous products before any more kids are harmed.”

The FDA has only begun using its recently granted authority to regulate tobacco products, which include e-cigarettes. The agency says these products have not been fully studied, so consumers currently don’t know the potential risks, how much nicotine or other potentially harmful chemicals are being inhaled during use, or whether there are any benefits associated with using these products.

The agency's Center for Tobacco Products held three public workshops earlier this year to obtain information on electronic cigarettes and the public health.  

Great Britain and the United States haven't always seen eye-to-eye. The latest example: e-cigarettes. Politicians and public health authorities in the U.S. continue to view e-cigs with caution while England has taken a more positive view -- most notably a new report from Public Health England (PHE) that finds e-cigs about 95% less harmful than smoking.

"My reading of the evidence is that smokers who switch to vaping remove almost all the risks smoking poses to their health," said Professor Peter Hajek of Queen Mary University. Hajek co-authored the report with Professor Ann McNeill of King's College London.

The expert independent evidence review also finds "no evidence so far that e-cigarettes are acting as a route into smoking for children or non-smokers." That contradicts a study by the University of California last year that found that adolescents who used the devices were more likely to smoke cigarettes and less likely to quit smoking. 

Falling smoking rates

The review, commissioned by Public Health England (PHE) -- an arm of the British Department of Health -- goes further and suggests that e-cigarettes may be contributing to falling smoking rates among adults and young people. 

The review found that almost all of the 2.6 million adults using e-cigarettes in Great Britain are current or ex-smokers, most of whom are using the devices to help them quit smoking or to prevent them going back to cigarettes.

It also provides reassurance that very few adults and young people who have never smoked are becoming regular e-cigarette users (less than 1% in each group).

Emerging evidence suggests some of the highest successful quit rates are now seen among smokers who use an e-cigarette and also receive additional support from their local stop smoking services.

Time to reconsider?

The report drew the expected response from the American Vaping Association, which represents manufacturers of the electronic nicotine delivery devices. It called for U.S. organizations and government agencies like the American Cancer Society, American Lung Association, Campaign for Tobacco-Free Kids, and Centers for Disease Control & Prevention (CDC) to reassess their views on vaping. 

Attitude gap

Nothing better illustrates the attitude gap between the U.S. and Britain than the concern expressed by U.K. health officials that too many people think e-cigs are just as harmful as traditional cigarettes. 

"The problem is people increasingly think they are at least as harmful and this may be keeping millions of smokers from quitting. Local stop smoking services should look to support e-cigarette users in their journey to quitting completely," said Professor Kevin Fenton, Director of Health and Wellbeing at Public Health England. "E-cigarettes are not completely risk free but when compared to smoking, evidence shows they carry just a fraction of the harm." 

Ann McNeill, co-author of the review, agreed:

There is no evidence that e-cigarettes are undermining England’s falling smoking rates. Instead the evidence consistently finds that e-cigarettes are another tool for stopping smoking and in my view smokers should try vaping and vapers should stop smoking entirely.

E-cigarettes could be a game changer in public health in particular by reducing the enormous health inequalities caused by smoking.

Electronic cigarettes or "e-cigs" have been touted as a safer tool smokers can use to wean themselves off of traditional cigarettes. But is that really true? After all, e-cig liquid contains nicotine and emits carcinogens, just like tobaco-based cigarettes.

A research team reports in the ACS journal Chemical Research in Toxicology that much of the nicotine in e-cigarettes is the addictive form of the compound.

Although e-cigs don't burn tobacco, they heat and vaporize a liquid that contains nicotine, flavorings and other substances. 

Some experts say the nicotine content in e-cigs could lead users to become addicted to e-cigs, or that it could even serve as a gateway to conventional cigarettes and other drugs. But not all nicotine is created equal, and studies had yet to investigate what kind of nicotine was in the liquids.

Out of three forms, scientists believe "free-base" nicotine is the only one that gets absorbed by the body, making it the most addictive kind. Najat Saliba and colleagues wanted to find out which nicotine forms are in e-cigs.

The researchers tested commercial samples of liquids made for the devices and found that, by and large, the nicotine was in the most addictive form. They also determined that the concentration of nicotine varied and often didn't match the concentrations the labels claimed.

Funding for the study came from the National Institute on Drug Abuse and the U.S. FDA's Center for Tobacco Products.

Federal health officials lit a match today that ignited a firestorm on both sides of the vaping divide, reporting that current e-cigarette use among middle and high school students tripled from 2013 to 2014.

Sen. Barbara Boxer (D-Calif.) called the report from the Centers for Disease Control and Prevention and the U.S. Food and Drug Administration "a wake-up call to all of us that more and more of our kids are becoming addicted to e-cigarettes.

"If e-cigarette companies are serious about helping people quit smoking, they must stop targeting our kids with their products and pull their advertisements from television," Boxer said.

The American Vaping Association -- an industry group -- in effect labeled the report a smokescreen and interpreted the numbers to indicate that "as youth experimentation with vaping has grown, teen smoking has declined at a rate faster than ever before."

The annual study found that current e-cigarette use (use on at least 1 day in the past 30 days) among high school students increased from 4.5% in 2013 to 13.4% in 2014, rising from approximately 660,000 to 2 million students. Among middle school students, current e-cigarette use more than tripled from 1.1% in 2013 to 3.9% in 2014 — an increase from approximately 120,000 to 450,000 students.

E-cigs now top tobacco product

This is the first time since the survey started collecting data on e-cigarettes in 2011 that current e-cigarette use has surpassed current use of every other tobacco product overall, including conventional cigarettes, the CDC said.

“We want parents to know that nicotine is dangerous for kids at any age, whether it’s an e-cigarette, hookah, cigarette or cigar,” said CDC Director Tom Frieden, M.D., M.P.H. “Adolescence is a critical time for brain development. Nicotine exposure at a young age may cause lasting harm to brain development, promote addiction, and lead to sustained tobacco use.”

Hookah smoking roughly doubled for middle and high school students in the study, while cigarette use declined among high school students and remained unchanged for middle school students. Among high school students, current hookah use rose from 5.2% in 2013 (about 770,000 students) to 9.4% in 2014 (about 1.3 million students). 

The increases in e-cigarette and hookah use offset declines in use of more traditional products such as cigarettes and cigars. There was no decline in overall tobacco use between 2011 and 2014. Overall rates of any tobacco product use were 24.6 % for high school students and 7.7 % for middle school students in 2014.

Staggering increases

“In today’s rapidly evolving tobacco marketplace, the surge in youth use of novel products like e-cigarettes forces us to confront the reality that the progress we have made in reducing youth cigarette smoking rates is being threatened,” said Mitch Zeller, J.D., director of FDA’s Center for Tobacco Products. “These staggering increases in such a short time underscore why FDA intends to regulate these additional products to protect public health.”

Cigarettes, cigarette tobacco, roll-your-own tobacco and smokeless tobacco are currently subject to FDA’s tobacco control authority. The agency currently is finalizing the rule to bring additional tobacco products such as e-cigarettes, hookahs and some or all cigars under that same authority.

Sen. Boxer would like to see things move along a bit faster. In March, she sent a letter to Food and Drug Administration (FDA) Commissioner Margaret A. Hamburg along with a petition urging the agency to finalize a rule to regulate e-cigarettes and protect public health.

Yesterday, she wrote to the executives of five of the largest e-cigarette manufacturers urging them to refrain from advertising e-cigarettes on television, citing the effects of e-cigarette advertising on young people.

The Vaping Association, meanwhile, claimed the CDC's figures -- showing a huge increase in vaping and a decline in smoking by high school students -- amounted to evidence that vaping was helping students resist the urge to smoke cigarettes.

"While no vaping or smoking by teens is obviously the ideal, we do not live in a perfect world. There remains no evidence that e-cigarettes are acting as gateway products for youth. In fact, this study and others suggest that the availability of vapor products has acted as a deterrent for many teenagers and potentially kept them away from traditional cigarettes," said Gregory Conley, the group's president.

Congresswoman Jackie Speier (D-Calif.) and five co-sponsors today introduced a measure that would ban companies from selling and marketing e-cigarettes to children. It would also direct the FDA to establish regulations for their safe packaging, doses, and labeling.

“E-cigarette makers think they can take us back to the days of Joe Camel,” said Speier. “They are selling nicotine to children in flavors like gummy bear, cotton candy, and chocolate cake. Something is gravely wrong with that picture. The SMOKE Act (Stop Selling and Marketing to Our Kids E-Cigarettes) would establish that e-cigarettes are for adults, not minors, and it would ensure they are safely regulated and packaged so that they can’t harm children.

The SMOKE Act would direct the Federal Trade Commission (FTC) to prohibit e-cigarette advertising that increases usage of the products by children. It would designate such advertising as an unfair or deceptive practice and vest the FTC and state attorneys-general with authority to prosecute violators and subject them to penalties.

More authority

The act would also give the FDA authority to ban e-cigarette sales to minors. It would require the FDA to establish childproof packaging standards, dosage limits, maximum levels of nicotine concentration, and nicotine concentration labeling requirements.

The bill would mandate a study on the impact that e-cigarette flavorings have on children’s use and smoking cessation, requiring the FDA to consider banning or restricting flavorings based on those findings.

The Centers for Disease Control and Prevention (CDC) has found that e-cigarette use by middle and high school students more than tripled from 2011 to 2013. Lack of child proof packaging has led to an escalating number of e-cigarette-related calls to Poison Control Centers, 51.1 percent of which involved young children, Speier noted.

E-cigarettes contain poisonous and addictive chemicals including nicotine and 5 to 15 times the level of formaldehyde present in regular cigarettes, she said.

The bill is supported by American Association of Cancer Research (AACR).

A tobacco control expert says there's plenty of evidence to justify regulating e-cigarettes immediately. Meanwhile, a new study says that e-cigarette advertising makes consumers crave -- guess what? -- tobacco. 

Writing in the March issue of Food and Drug Law Journal, Georgetown Law Professor Eric N. Lindblom says enough is already known about e-cigarettes to regulate them effectively without any further research or delay. 

"We already know that using e-cigarettes is less harmful than smoking, but more harmful than not using any tobacco or nicotine at all, and that's enough to figure out how to regulate them both to protect and promote the public health," says Lindblom, the former director of the Office of Policy at the Center for Tobacco Products at the U.S. Food and Drug Administration (FDA).

He says his approach would minimize the threats e-cigarettes pose to public health while still enabling them to potentially help reduce smoking.

"This approach could help to heal the current split in the public health community over e-cigarettes by addressing the concerns of both sides," Lindblom says.

"Because e-cigarette use, by itself, is neither beneficial nor benign to users and nonusers, the only public health justification for allowing their marketing would be if doing so would help smokers quit completely or provide them with a less harmful way to obtain the nicotine they crave, without causing any offsetting public health harms," Lindblom wrote.

Based on that observation, Lindblom suggests that an effective regulatory scheme would

1) make e-cigarettes less harmful to users and non-users;

2) increase their use as a cessation aid and as a less harmful alternative for smokers who would not otherwise quit; and

3) minimize e-cigarette use among everyone else.

Lindblom notes that the proposal faces challenges in the United States, primarily from First Amendment constraints on government action to regulate e-cigarette advertising. His paper suggests, however, that "some helpful text and established procedures in the Tobacco Control Act reduce those constraints in this context, providing the FDA with a tremendous opportunity to place the kinds of careful restrictions and requirements on e-cigarette advertising necessary to minimize their harmful aspects and maximize their potential to produce substantial net public health gains."

Advertising what?

As Lindblom notes, e-cigarette advertising is not currently regulated the way tobacco advertising is, and a new study by University of Pennsylvania researchers finds that TV advertisements for e-cigarettes may be enticing current and even former tobacco smokers to reach for another cigarette.

The researchers studied more than 800 daily, intermittent, and former smokers who watched e-cigarette advertising, and who then took a survey to determine smoking urges, intentions, and behaviors.

Using a standard test to measure the urge to smoke a cigarette, people who smoke tobacco cigarettes daily and who watched e-cigarette advertisements with someone inhaling or holding an e-cigarette ("vaping") showed a greater urge to smoke than regular smokers who did not see the vaping, as reported in the journal Health Communication.

Former smokers who watched e-cigarette advertisements with vaping had less confidence that they could refrain from smoking tobacco cigarettes than former smokers seeing e-cigarette ads without vaping.

The findings are significant, considering that tobacco advertising on television went up in smoke over four decades ago by way of a federal ban. Moreover, e-cigarette advertising is stoked by big tobacco companies. Estimates peg e-cigarette ad spending at more than $1 billion this year. That number is expected to grow at a 50 percent rate over the next four years.

"We know that exposure to smoking cues such as visual depictions of cigarettes, ashtrays, matches, lighters, and smoke heightens smokers' urge to smoke a cigarette, and decreases former smokers' confidence in their ability to refrain from smoking a cigarette," said Erin K. Maloney, Ph.D., one of the lead researchers.

Maloney and Joseph N. Cappella, Ph.D., pulled together more than a dozen e-cigarette advertisements via searches of Google, YouTube, and e-cigarette web sites. 

Maloney and Cappella observed a trend that more daily smokers who viewed ads with vaping smoked a tobacco cigarette during the experiment than daily smokers who viewed ads without vaping and daily smokers who did not view ads.

Over 35 percent of the daily smokers in the condition that showed vaping reported having a tobacco cigarette during the study versus 22 percent of daily smokers who saw ads without vaping, and about 23 percent of daily smokers who did not see any advertising.

"Given the sophistication of cigarette marketing in the past and the exponential increase in advertising dollars allotted to e-cigarette promotion in the past year, it should be expected that advertisements for these products created by big tobacco companies will maximize smoking cues in their advertisements, and if not regulated, individuals will be exposed to much more e-cigarette advertising on a daily basis," Maloney and Cappella wrote.

Liquid nicotine sold in New York must be packaged in childproof containers under terms of a new law signed by Gov. Andrew Cuomo yesterday. The measure also bans the sale of liquid nicotine to those under 21 in New York City and under 18 in the rest of the state.

New York banned the sale of electronic cigarettes to minors in 2010, but did not explicitly ban the sale of the liquid nicotine, according to a news release from the governor's office.

"This action will help combat nicotine addiction by keeping it out of the hands of minors, as well as prevent a heartbreaking accident that can occur if a child is exposed to this potentially dangerous substance,” Cuomo said. "I am proud to sign this legislation into law and thank the sponsors for their work on this much-needed initiative.” 

The measure follows the death of a one-year-old Fort Plain, N.Y., toddler who died after swallowing liquid nicotine. 

Assemblywoman Linda B. Rosenthal (D-Manhattan), who sponsored the bill, cited the boy's death as a reason why the law was needed.

"The accidental death of the one-year-old boy from Fort Plain, N.Y. as a result of liquid nicotine poisoning, the first of its kind in the nation, makes clear the need for this kind of common-sense legislation," Rosenthal said in a statement.

Highly toxic

Liquid nicotine, often known as electronic liquid or e-liquid, is a composite of nicotine and other chemicals. Concentrated liquid nicotine is highly toxic, even in small doses, and if ingested, liquid nicotine may cause tremors, vomiting, seizures, and potentially, death. For infants and children, ingesting liquid nicotine is particularly lethal.

According to a 2014 Centers for Disease Control Report, the number of calls to poison control centers involving liquid nicotine rose from one per month in September 2010 to 215 per month in February 2014. More than half of the calls (51.1%) involved children under age 5. 

When electronic cigarettes arrived on the scene they were billed as a safer alternative to cigarettes and a nicotine alternative that could help some smokers quit.

They may be that, though the jury is still out. But anti-smoking activists worried that these devices, which deliver nicotine through water vapor instead of smoke, would eventually be adopted by teens, hooking them on nicotine. Sooner or later, the activists said, these young people would graduate to cigarettes.

Cancer researchers in Hawaii say they are seeing evidence teens are, in fact, gravitating to e-cigarettes. Their data, published in the journal Pediatrics, found that nearly 30% of the more than 1,900 teens surveyed in Hawaii had tried e-cigarettes. Of those, 17% were regularly using e-cigarettes, a practice known as “vaping.”

Three times greater

Those numbers are about 3 time greater than previously reported in earlier research. In fact, very few adolescents in the national studies were just using e-cigarettes.

The Hawaii survey, which questioned 14- and 15-year-olds, measured responses to a broad range of substances – e-cigarettes, cigarettes, alcohol and marijuana. Researchers said teens who only used e-cigarettes were found to be intermediate in levels of risk and protective factors between nonusers and those who used both cigarettes and e-cigarettes.

“This raises a question about whether e-cigarettes are recruiting low-risk youth, who would otherwise not try smoking, to tobacco product use,” the authors wrote.

Dr. Thomas Wills, of the University of Hawaii Cancer Center's Prevention and Control Program, said researchers aren't sure why the rate of e-cigarette use is so high among teens in Hawaii. He thinks one reason may be that young people underestimate the difficulty of abstaining from nicotine once you become addicted. But there could be other reasons.

Aggressive marketing

"The marketing is very aggressive here," he said, noting that manufacturers place ads at venues such as movie theaters that are accessible to teenagers.

They also make flavored liquids in varieties such as mango and pineapple. Other reasons could include the high tax rate on cigarettes in Hawaii, which makes alternatives such as e-cigarettes more attractive from a cost perspective.

The Food and Drug Administration has been studying these issues for more than a year, with the expectation the agency will issue e-cigarette regulations. Some manufacturers have supported regulations that would bar e-cigarette sales to minors.

Fuel for debate

The Hawaii study may add fuel to the debate over e-cigarettes, and whether these devices are a gateway to tobacco. Researchers at the University at Buffalo say it may be hard to determine that, since the data we have on teen smoking is not that accurate.

Their study says many public health agencies rely too heavily on reports of monthly cigarette use, a broad statistic that makes it difficult to draw conclusions about current habits and historical changes in behavior.

“We need information on smoking intensity to assess health risk, because heavy smoking causes more disease and death than light smoking,” said study co-author Lynn Kozlowski. “Also, non-daily smokers often represent lower-level exposure to carcinogens and can be more likely to quit.”

Not only should there be more accurate ways to assess cigarette smoking, Kozlowski says health researchers need much better data on who is using e-cigarettes and how they're using them.

“Given the increasing popularity of vaping, there needs to be more regular and diligent reporting of frequency and intensity of the use both of cigarettes and tobacco/nicotine products like e-cigarettes to insure accurate conclusions about the trends in teen tobacco use,” Kozlowski said.

A toddler in New York is the latest apparent victim of a new household hazard -- liquid nicotine refills for e-cigarettes. Police in Fort Plain, N.Y., said they answered a call concerning an unresponsive child. The child was taken to a local hospital and died a short time later.

Sgt. Austin Ryan of the Fort Plain police said investigators were told the child drank from a bottle containing liquid refills for e-cigarettes.

Though shocking, such accidents are becoming increasingly common. Earlier this year, it was reported that a CDC study published in the agency's Morbidity and Mortality Weekly Report found that calls to poison control centers for nicotine ingestion by children shot up from 1 per month in September 2010 to 215 per month this past February. And, the report says, the number of calls per month involving conventional cigarettes did not show a similar increase during the same time period.

The New York General Assembly recently passed a measure requiring child-resistant containers on e-cigarette refills, which are often flavored with fruit and other sweet substances attractive to children.

The CDC report said that more than half (51.1%) of the calls to poison centers due to e-cigarettes involved young children 5 years and under, and about 42% of the poison calls involved people age 20 and older.

The analysis, which compared total monthly poison center calls involving e-cigarettes and conventional cigarettes, found the proportion of e-cigarette calls jumped from 0.3% in September 2010 to 41.7% in February 2014.

Poisoning from conventional cigarettes is generally due to young children eating them. Poisoning related to e-cigarettes involves the liquid containing nicotine used in the devices and can occur in three ways: by ingestion, inhalation or absorption through the skin or eyes.

Red flag

“This report raises another red flag about e-cigarettes -- the liquid nicotine used in e-cigarettes can be hazardous,” said CDC Director Tom Frieden, M.D., M.P.H. “Use of these products is skyrocketing and these poisonings will continue. E-cigarette liquids as currently sold are a threat to small children because they are not required to be childproof, and they come in candy and fruit flavors that are appealing to children.”

"One teaspoon of liquid nicotine could be lethal to a child, and smaller amounts can cause severe illness, often requiring trips to the emergency department," the American Association of Poison Control (AAPC) centers said recently.

Adults should use care to protect their skin when handling the products, and they should be out of sight and out of the reach of children, AAPC said. Additionally, those using these products should dispose of them properly to prevent exposure to pets and children from the residue or liquid left in the container.  

The American Association of Poison Control Centers recommends the following steps:

• Protect your skin when handling the products.
• Always keep e-cigarettes and liquid nicotine locked up and out of the reach of children.
• Follow the specific disposal instructions on the label.
• If you think someone has been exposed to an e-cigarette or liquid nicotine, call your local poison center at 1-800-222-1222 immediately.

A group of Democratic U.S. Senators are calling on the Food and Drug Administration (FDA) today to adopt stronger warning labels for e-cigarettes, charging that big tobacco companies are not telling the whole story.

"Media reports have recently highlighted that in the absence of a clear federal standard, e-cigarette manufacturers owned by big tobacco companies are beginning to concoct their own health warnings about their products that lack uniformity and are not comprehensive in listing all of the health threats the products pose," the Senators wrote in today's letter to the FDA.

They said inadequate health warnings on e-cigarettes reinforce the need for the FDA to quickly finalize proposed deeming regulations that would expand the agency's regulatory authority over the nicotine-based products.

A recent New York Times story noted the inconsistent standard that currently exists in the unregulated e-cigarette industry, with manufacturers including warning labels on their products that fail to fully advise consumers of the well-established consequences of nicotine use.

"In FDA's proposed 'deeming regulation,' the agency includes a warning label for e-cigarettes that does not adequately warn consumers on the known dangers of nicotine use. The proposed label reads 'WARNING: This product contains nicotine derived from tobacco. Nicotine is an addictive chemical.' We support requiring a label on nicotine's addictive properties, but we ask the FDA pursue requirements for more extensive warnings that address health risks that e-cigarettes pose," the Senators continued.

Signing the letter were Senators Barbara Boxer (D-CA), Dick Durbin (D-IL), Richard Blumenthal (D-CT), Jack Reed (D-RI), Sherrod Brown (D-OH), and Edward Markey (D-MA).

In August, thirteen Members of Congress - including Boxer, Durbin, Blumenthal, Reed, Brown, and Markey - asked the FDA to move quickly to finalize a proposed rule on e-cigarettes within one year, and to include provisions that would limit youth access to the addictive products.

In February, Senator Boxer and her colleagues introduced the Protecting Children from Electronic Cigarette Advertising Act, a bill that would prohibit the marketing of electronic cigarettes to children and teens. The measure would permit the Federal Trade Commission (FTC) to determine what constitutes marketing e-cigarettes to children and would allow the FTC to work with states attorneys general to enforce the ban.

The World Health Organization (WHO) is weighing in on electronic cigarettes, declaring that they represent an “evolving frontier filled with promise and threat for tobacco control.” 

In a report prepared for an upcoming conference in Moscow, WHO questions whether e-cigs actually help smokers quit the habit, calls for bans on advertising and restrictions on using the devices indoors. It also suggests regulations are needed to:

• Impede e-cigarette promotion to non-smokers and young people;
• Minimize potential health risks to e-cigarette users and nonusers;
• Prohibit unproven health claims about e-cigarettes; and
• Protect existing tobacco control efforts from commercial and other vested interests of the tobacco industry.

The suggested regulations outlined in the report include a ban on e-cigarettes with fruit, candy-like and alcohol-drink flavours until it can be proved they are not attractive to children and adolescents.

E-cigarettes have been marketed in almost 8,000 different flavours, and there is concern they will serve as a gateway to nicotine addiction and, ultimately, smoking, particularly for young people, the report warns.

Experimentation with e-cigarettes is increasing rapidly among adolescents, with e-cigarette use in this group doubling from 2008 to 2012, the report says.

Everybody knows that smoking is bad. Vaping? It's worse than not smoking at all but the American Heart Association says it may be worthwhile as a last-chance effort for smokers who have tried everything to quit smoking and failed.

In a policy statement released today, the AHA said physicians shouldn’t routinely discourage e-cigarette use as a last resort to stop smoking.

“If someone refuses to quit, we’re not opposed to them switching from conventional to e-cigarettes,” said Aruni Bhatnagar, lead writer of the policy statement from the Dallas-based nonprofit group and a professor of medicine at the University of Louisville in Kentucky.

“Don’t use them indefinitely. Set a quit date for quitting conventional, e-cigarettes and everything else. We don’t think that will be the long-term or useful way to look at it because e-cigarettes may continue and fuel nicotine addiction. Nicotine is not innocuous — it’s known to be harmful and have cardiovascular effects,” Bhatnagar said.

Studies show that nicotine causes a short-term increase in blood pressure, heart rate and blood flow from the heart. It also causes the arteries to narrow.

“We consider exposure to nicotine as part of smoking. We don’t want separate definitions for combustible and e-cigarettes,” he said.

"Re-normalize tobacco use"

Despite the concession that e-cigarettes may be worth trying when all else fails, the AHA made it clear it is steadfastly opposed to letting the devices sneak in under the wire. 

E-cigarettes are dangerous because they target young people, can keep people hooked on nicotine, and threaten to “re-normalize” tobacco use, the AHA said, insisting that e-cigs are tobacco products and should be subject to all laws that apply to these products.

The association also calls for strong new regulations to prevent access, sales and marketing of e-cigarettes to youth, and for more research into the product’s health impact.

“Over the last 50 years, 20 million Americans died because of tobacco. We are fiercely committed to preventing the tobacco industry from addicting another generation of smokers,” said Nancy Brown, CEO of the American Heart Association. “Recent studies raise concerns that e-cigarettes may be a gateway to traditional tobacco products for the nation’s youth, and could renormalize smoking in our society.”

While the Food and Drug Administration (FDA) mulls new regulations of electronic cigarettes, the attorneys general of 29 states are urging the agency to adopt even tougher rules than it has already proposed.

“E-cigarettes have all the addictive qualities of regular, combustible cigarettes, yet they are completely unregulated by the FDA,” said New York Attorney General Eric T. Schneiderman, one of the author of a letter to the FDA signed by the 29 AGs. “While we applaud the FDA’s proposal to start regulating these tobacco products, it falls far short of what is needed to protect our youth.

Among other recommendations, the attorneys general pressed the FDA to prohibit flavors in e-cigarettes, and to restrict advertising and marketing for e-cigarettes in the same manner as for cigarettes.

"Each year, electronic cigarette companies spend millions of dollars advertising their product – often on prime-time television -- glamorizing smoking in the same way combustible cigarettes did before those commercials were banned. And each year, more and more youth try electronic cigarettes, exposing themselves to the proven dangers of nicotine,” the AGs argue.

While some claim that e-cigarettes may have the potential to help smokers quit using combustible cigarettes, the FDA has not approved them as smoking cessation devices, the AGs note, and they say they're concerned that e-cigs will cause teens to become addicted to nicotine and ultimately to start using cancer-causing combustible products that do contain tobacco.

In 2013, e-cigarette advertisements on television reached over 14 million teens, and magazine advertisements reached 9.5 million teens. In just one year, the five largest e-cigarette companies increased their marketing expenditures by 164%.

Over 35 years ago, tobacco companies recognized that flavored cigarettes were attractive to younger smokers, leading the FDA to ban flavored cigarettes.

“Today, we urge the FDA to do the right thing and protect our youth from yet another tobacco epidemic,” the letter continues. “We don’t need these e-cigarettes aimed at our youth. What we need are strong FDA regulations that protect the public health and protect our youth from a lifetime of nicotine addiction. The FDA should ban all flavored electronic cigarettes and should prohibit e-cigarette advertising on television, radio and youth-oriented magazines.”

E-cigarette manufacturers are free to use just about any medium they want to market their products. Unlike tobacco cigarettes, e-cigarette commercials may be broadcast on radio and TV and displayed online.

But the marketing medium of choice, it appears, is social media. A study in Tobacco Control may have implications for future Food and Drug Administration (FDA) regulations on the marketing of e-cigarettes and related products, according to researchers at the University of Illinois at Chicago (UIC).

“There’s this whole wild west of social media platforms – Facebook, Twitter and Instagram – and the FDA has no way to track what’s happening in those platforms,” said Jidong Huang, senior research scientist at UIC’s Institute for Health Research and Policy and lead author of the study.

The researchers collected tweets and metadata that mentioned e-cigarettes during a two month period in 2012. They captured more than 70,000 tweets related to the cigarette substitutes.

Most of the 70,000 tweets, it turns out, were commercials for brands of e-cigarettes. Only 10% were “organic,” or legitimate consumer opinions.

Links to products

The researchers found that 94% of the commercial tweets included a website link while only 11% of the organic tweets did.

E-cigarettes deliver nicotine in water vapor, often accompanied by flavorings, and simulate the physical act of smoking. Many of the users are former smokers and people trying to quit, who say e-cigarettes keep them from using the real thing.

Public health advocates worry that e-cigarettes will hook young people, who don't currently smoke, on nicotine. The FDA is in the process of drawing up regulations that will bar sales to minors.

The UIC researchers say that of the commercial tweets they monitored, only 11% mentioned quitting smoking. More than one-third directed viewers to a place where they could download coupons or get discounts to purchase e-cigarette products.

Twitter is the second-largest search engine after Google and that gives the UIC researchers pause.

“If kids or youth search for ‘vaping pen’ or ‘e-cig’ on Twitter, they will get links to commercial sites where they can purchase these items,” said Huang.

Unlike Facebook and some other platforms where one can set privacy controls, all information on Twitter is accessible to anyone.

Jury still out

So far the jury is out on whether e-cigarettes are a good way to help people stop smoking, as the industry claims, or a gateway to eventual tobacco use, as the industry's public health critics claim.

Previous research has shown rapid growth in both use and awareness of e-cigarettes among adults and young people in the last couple of years. However, there is limited evidence that can settle the argument about the product's merits or threat.

“We know very little about what these products are made of and what kind of chemicals are in the e-juice,” Huang said.

In an unrelated study, researchers at the University of California, San Diego School of Medicine also conclude the FDA will have its hands full trying to draw up and implement e-cigarette regulations.

The study found that an average 10 new e-cigarette brands entered the Internet marketplace every month from 2012 to 2014. At present online consumers can choose from 466 e-cigarette brands.

Advice for the FDA

The researchers urged the FDA to tread carefully in drawing up regulations, warning against unintended consequences. Overly-stringent regulations, they say, would likely favor brands with strong financial backing and most of these would be owned by tobacco companies.

“Obviously, tobacco companies would be more concerned with protecting cigarette market share than smaller e-cigarette companies,” said lead author Shu-Hong Zhu.

In other words, put too many regulations in place and you run the risk of changing only the market share of different e-cigarette brands rather than reducing the prevalence of smoking.

The most important goal in e-cigarette regulation, says Zhu, is to reduce the number of people smoking cigarettes.

The makers of e-cigarettes take great pains to point out their products should not be sold to minors. That said, plenty of young people are exposed to television advertising for e-cigarettes, which deliver nicotine through water vapor instead of smoke.

Because the products have only begun to be regulated, manufacturers are free to market them on TV, which has been off-limits for cigarette ads since 1971.

Researchers at RTI International and the Florida Department of Health have measured e-cigarette advertising on TV and say the number of youth and young adults exposed to these ads has more than doubled in the past 2 years.

Specifically, it found youth exposure to e-cigarette advertisements increased by 256% from 2011 to 2013 and young adult exposure jumped 321% in the same time period.

Absence of public health messages

“If the current trends continue, awareness and use of e-cigarettes will increase among youth and young adults,” said Jennifer Duke, senior research public health analyst and co-author of the study. “And unfortunately, in the absence of evidence-based public health messages regarding the health risks of e-cigarettes, television advertising is promoting beliefs and behaviors that pose harm to youth and young adults and raise public health concerns.”

The study, published in Pediatrics, looked at media industry data for ads promoting e-cigarettes across cable networks, where most of the ads run. They then calculated exposure for viewers ages 12 to 17 and 18 to 24.

The study determined that more than 75% of youth ad exposure occurred on cable networks like AMC, Country Music Television, Comedy Central, WGN America, TV Land, and VH1.

Further, the researchers say they discovered that e-cigarette ads appeared on programs like The Bachelor, Big Brother, and Survivor that were among the 100 most-watched programs by youth during the 2012-2013 TV season.

Heavy Internet advertising too

Another study earlier this year found a large increase in e-cigarette ads on the Internet. The public health foundation Legacy looked at how tobacco companies spent their advertising dollars and found an every-expanding percentage now goes to e-cigarettes.

With ever-tighter regulations on the sale of cigarettes, many U.S. tobacco companies have enthusiastically embraced e-cigarette products. More than 80% of the ads logged by RTI researchers in 2013 were for a single brand, blu eCigs, which is owned by Lorillard, a tobacco company.

“E-cigarette companies advertise to a broad TV audience that includes 24 million youth,” Duke said. “Given the potential harm of e-cigarettes to youth and their potential as a gateway to using cigarettes and other tobacco products, the FDA needs to regulate the positive images of e cigarettes on television and other venues where youth view advertising and marketing like they do for traditional cigarettes.”

Modest regulations

Food and Drug Administration (FDA) regulations are in the works. Last month the FDA proposed regulations that would ban e-cigarette sales to minors. However, it stopped short of regulating how the products are advertised on TV.

One reason may be a rather fierce debate about how harmful the product really is. A number of public health researchers have suggested the jury is still out.

In fact, the FDA's chief tobacco regulator testified before Congress, saying there is little doubt e-cigarettes are healthier than cigarettes.

“If we could get all of those people who smoke to completely switch all of their cigarettes to noncombustible cigarettes, it would be good for public health,” Mitch Zeller, director of the FDA Center for Tobacco Products, told the lawmakers.

E-cigarettes have captured the interest of smokers, and they've also captured the interest of researchers, who are turning out a flurry of studies of the risks and rewards of the nicotine burners.

One of the latest is an article in the June issue of Annals of Allergy, Asthma & Immunology, the scientific journal of the American College of Allergy, Asthma and Immunology (ACAAI). It examines the risks associated with e-cigarettes, including the ongoing dependence on nicotine and the dual use of e-cigarettes and regular cigarettes.

The conclusion: caveat emptor – "buyer beware."

The article notes that while e-cigs are frequently promoted as helping smokers cut back, that theory hasn't been proven, and there's little evidence to support the claims.

"Despite the apparent optimism surrounding e-cigarettes and their purported therapeutic role in smoking cessation, there just simply is not enough evidence to suggest that consumers should use e-cigarettes for this purpose." said allergist Andrew Nickels, MD, Mayo Clinic Division of Allergy and Immunology, the lead author of the study.

Recently, however, a large survey of smokers in England found that people who use e-cigs to help them stop smoking are 60% more likely to succeed than those who use other over-the-counter therapies such as nicotine patches or gum.

The study, conducted by University College London and published in Addiction, surveyed 5,863 smokers between 2009 and 2014 who had attempted to quit smoking without the aid of prescription medication or professional support; 20% of people trying to quit with the aid of e-cigarettes reported having stopped smoking conventional cigarettes at the time of the survey.

Another cause for concern, the ACAAI report said, is that when people use e-cigarettes in public and still smoke regular cigarettes at home, they continue to expose children and asthma sufferers in the household to dangerous second hand smoke, the article cautions.

"Dual use of both e-cigarettes and regular cigarettes carries the risk of secondhand smoke exposure, causing worsening respiratory effects on children and asthma sufferers. It also promotes ongoing nicotine dependence," said Chitra Dinakar, MD, Professor of Pediatrics, Children's Mercy Hospitals.

Long-term complications

Because e-cigarettes are fairly new, there could be other long-term health complications that have yet to be discovered. Results of long-term exposure to such substances are unknown. Due to the lack of production oversight, most consumers don't know what's in the e-cigarettes they buy, the article says.

Organizations like ACAAI are calling for enhanced scrutiny and regulation by the FDA. The ACAAI's position statement on e-cigarettes recognizes that nicotine delivered by any mechanism represents a drug exposure, and that vaporization instruments are a drug delivery system, both of which are within the FDA's scope of regulation.

Inhaling irritants such as smoke and vapors has an impact on the lungs, whether it is mild or severe and could cause asthma attacks in some individuals. These attacks are responsible for some of the 4,000 asthma-related deaths per year.

E-cigarettes have taken something of a beating recently, as numerous studies have identified negative health consequences from using the nicotine burners while others have challenged the claim that e-cigs can help people stop smoking.

But now a large survey of smokers in England finds that people who use e-cigs to help them stop smoking are 60% more likely to succeed than those who use other over-the-counter therapies such as nicotine patches or gum.

The study, conducted by University College London and published in Addiction, surveyed 5,863 smokers between 2009 and 2014 who had attempted to quit smoking without the aid of prescription medication or professional support; 20% of people trying to quit with the aid of e-cigarettes reported having stopped smoking conventional cigarettes at the time of the survey.

The research, chiefly funded by Cancer Research UK, suggests that e-cigarettes could play a positive role in reducing smoking rates.

"E-cigarettes could substantially improve public health because of their widespread appeal and the huge health gains associated with stopping smoking," says Prof. Robert West of UCL's Department of Epidemiology & Public Health, senior author of the study.

Even better with professional help

West said, however, that the success rate for those using Britain's National Health Service stop-smoking program was even better -- nearly three times better than do-it-yourself smoking cessation programs.

The researchers noted that, while some use e-cigs to stop smoking, others may want to continue using them indefinitely.

"It is not clear whether long-term use of e-cigarettes carries health risks but from what is known about the contents of the vapour these will be much less than from smoking," West said. 

West also said he sees no sign that e-cigarettes are leading to a resurgence of smoking in the UK.

"Some public health experts have expressed concern that widespread use of e-cigarettes could "re-normalise" smoking. However, we are tracking this very closely and see no evidence of it. Smoking rates in England are declining, quitting rates are increasing and regular e-cigarette use among never smokers is negligible." 

E-cigarettes have been losing much of their initial luster as a safer alternative to tobacco as one study after another finds some new problem with the electronic nicotine burners. 

The latest is something of a shocker: researchers say e-cigarettes appear to increase the virulence of drug- resistant and potentially life-threatening bacteria, while decreasing the ability of human cells to kill these bacteria.

"As health care professionals, we are always being asked by patients, "Would this be better for me?" lead investigator Laura E. Crotty Alexander, M.D., said. "In the case of smoking e-cigarettes, I hated not having an answer. While the answer isn't black and white, our study suggests a response: even if e-cigarettes may not be as bad as tobacco, they still have measurable detrimental effects on health."

Crotty Alexander and other researchers at the VA San Diego Healthcare System (VASDHS) and the University of California, San Diego (UCSD), tested the effects of e-cigarette vapor on live methicillin-resistant Staphylococcus aureus (MRSA) and human epithelial cells.

MRSA commonly colonizes the region of the nasal passage where the bacteria and the cells that line the passage are exposed constantly to inhaled substances such as e-cigarette vapor and cigarette smoke.

"The virulence of MRSA is increased by e-cigarette vapor," Crotty Alexander said. Exposure to e-cigarette vapor increased the virulence of the bacteria. However, she added, the vapor did not make the bacteria as aggressive as cigarette smoke exposure did in parallel studies her group conducted.

Early warnings, not much action

Scientists have been warning of potential health hazards in e-cigs for years but the popularity of the devices has continued to grow amid light regulation.

In 2010, researchers at UC-Riverside concluded that e-cigarettes are potentially harmful and urged regulators to consider removing e-cigarettes from the market until their safety is adequately evaluated.

Last month, a CDC study reported that calls to poison control centers shot up from 1 per month in September 2010 to 215 per month in February 2014. The number of calls per month involving conventional cigarettes did not show a similar increase during the same time period.

Also in April, a study published in the academic journal Clinical Cancer Research finds that the vapor from e-cigarettes damages human cells in much the same way as the smoke from traditional cigarettes. Scientists at Boston University grew a batch of human bronchial cells in the presence of e-cig vapor and another batch in the presence of tobacco smoke. The result: the two batches of cells showed similar patterns of gene expression, which can cause the mutations that lead to cancer.

In March, a University of California San Francisco study found that e-cigs may be a new route to conventional smoking and nicotine addiction. UCSF researchers found that adolescents who used the devices were more likely to smoke cigarettes and less likely to quit smoking. 

Study details

To conduct the e-cigarette vapor experiment, the researchers grew MRSA in culture with vapor concentrations similar to inhalers on the market. They tested first for biochemical changes in the culture known to promote pathogen virulence and then introduced epithelial cell- and alveolar macrophage-killing assays.

The researchers looked at five factors that contribute to MRSA virulence: growth rate, susceptibility to reactive oxygen species (ROS), surface charge, hydrophobicity and biofilm formation. In particular, e-cigarette vapor led to alterations in surface charge and biofilm formation, which conferred greater resistance to killing by human cells and antibiotics.

Crotty Alexander said that one possible contribution to the increased virulence of MRSA was the rapid change in pH induced by e-cigarette vapor. Exposure changed the pH from 7.4 up to 8.4, making the environment very alkalotic for both bacterial and mammalian cells. This alkalosis stresses the cells, giving them a danger signal, leading to activation of defense mechanisms. The bacteria make their surface more positively charged, to avoid binding by the lethal antimicrobial peptides produced by human innate immune cells. The bacteria also form thicker biofilms, increasing their stickiness and making MRSA less vulnerable to attack.

These changes make MRSA more virulent. However, when MRSA is exposed to regular cigarette smoke, their virulence is even greater.

Cigarette smoke induces surface charge changes 10-fold greater than that of e-cigarette exposure, alters hydrophobicity and decreases sensitivity to reactive oxygen species and antimicrobial peptides.

In a mouse model of pneumonia, cigarette smoke exposed MRSA had four-times greater survival in the lungs, and killed 30% more mice than control MRSA. E-cigarette vapor exposed MRSA were also more virulent in mice, with a three-fold higher survival.

Unfortunately, while e-cigarette vapor is increasing bacterial virulence, Crotty Alexander has found that the vapor is also decreasing the ability of human epithelial cells to kill pathogens.

The study was presented at the 2014 American Thoracic Society International Conference.

E-cigarettes are gaining mainstream attention as a competitor to traditional cigarettes, but a new study finds that smokers are less inclined to consider them safer than cigarettes.

Researchers from the University of Pennsylvania and the University of Illinois at Urbana-Champaign found that in 2010, 84.7% of smokers surveyed believed e-cigarettes were less harmful than traditional cigarettes, but according to this new study in 2013, that number dropped to just 65%.

The study also looked at the perceived harmfulness of e-cigarettes among current smokers. In 2010, 84.7% of smokers surveyed believed e-cigarettes were less harmful than traditional cigarettes, but according to this new study in 2013, that number dropped to just 65%.

"This apparent decline in smokers' beliefs about reduced harm of e-cigarettes compared with regular cigarettes is perplexing against the background of advertising and media messages touting e-cigarettes as safer alternatives and cessation aids," said co-investigator Cabral Bigman, PhD, College of Liberal Arts & Sciences, University of Illinois at Urbana-Champaign.

"One possible explanation is that the increased media attention over the lack of FDA approval and regulation of this emerging tobacco product, injuries arising from e-cigarette-induced fires, and health concerns from toxic chemicals in e-cigarettes in recent years may have conveyed conflicting information about the relative safety of e-cigarette use," Bigman said.

Low usage levels

While levels of awareness have increased rapidly, use percentage is still very low with only 6% of U.S. adults reporting ever using e-cigarettes. This small number means that e-cigarettes may not yet be a threat to tobacco control programs, but at the same time, means any claim that e-cigarettes are helping to reduce the harm done by regular cigarettes is probably premature.

"There is an ongoing debate within the public health community about whether e-cigarettes are a viable alternative for harm reduction and whether smokers are merely supplementing or truly replacing their smoking with e-cigarettes and achieving smoking cessation," said co-investigator Andy Tan, MBBS, MPH, MBA, PhD, Center of Excellence in Cancer Communication Research, Annenberg School for Communication, University of Pennsylvania.

"It is uncertain whether increased population e-cigarette awareness and perceptions about reduced harm might play a role in encouraging smoking-cessation behaviors. However, public health professionals should systematically scrutinize the nature of marketing activities and media coverage of e-cigarettes, their impact on population awareness and perceptions of e-cigarettes, and how these factors may influence e-cigarette use and smoking prevalence in the U.S. population."

A new study finds that people suffering from mental health disorders are three times more likely than others to be current e-cigarette users.  

Researchers at University of California, San Diego School of Medicine also found that people living with depression, anxiety or other mental health conditions are twice as likely to have tried e-cigarettes.

They are also more susceptible to trying e-cigarettes in the future in the belief that doing so will help them quit smoking traditional cigarettes, even though the FDA has not approved e-cigarettes as a smoking cessation aid, the scientists said.

"The faces of smokers in America in the 1960s were the 'Mad Men' in business suits," said lead author Sharon Cummins, PhD, assistant professor in the Department of Family and Preventive Medicine. "They were fashionable and had disposable income. Those with a smoking habit today are poorer, have less education, and, as this study shows, have higher rates of mental health conditions."

By some estimates, people with psychiatric disorders consume approximately 30% to 50% of all cigarettes sold annually in the U.S.

"Since the safety of e-cigarettes is still unknown, their use by nonsmokers could put them at risk," Cummins said. Another concern is that the widespread use of e-cigarettes could reverse the social norms that have made smoking largely socially unacceptable.

The study shows that smokers, regardless of their mental health condition, are the primary consumers of the nicotine delivery technology. People with mental health disorders also appear to be using e-cigarettes for the same reasons as other smokers – to reduce potential harm to their health and to help them break the habit.

"So far, nonsmokers with mental health disorders are not picking up e-cigarettes as a gateway to smoking," Cummins said.

"People with mental health conditions have largely been forgotten in the war on smoking," Cummins said. "But because they are high consumers of cigarettes, they have the most to gain or lose from the e-cigarette phenomenon. Which way it goes will depend on what product regulations are put into effect and whether e-cigarettes ultimately prove to be useful in helping smokers quit."

Study details

The study is based on a survey of Americans' smoking history, efforts to quit and their use and perceptions about e-cigarettes. People were also asked whether they had ever been diagnosed with an anxiety disorder, depression or other mental health condition.

Among the 10,041 people who responded to the survey, 27.8% of current smokers had self-reported mental health conditions, compared with 13.4% of non-smokers; 14.8% of individuals with mental health conditions had tried e-cigarettes, and 3.1% were currently using them, compared with 6.6% and 1.1% without mental health conditions, respectively.

In addition, 60.5% of smokers with mental health conditions indicated that they were somewhat likely or very likely to try e-cigarettes in the future, compared with 45.3% of smokers without mental health conditions.

The study will be published in the May 13 online issue of Tobacco Control.

After years of delay, the U.S. Food and Drug Administration today issued proposed new regulations for e-cigarettes, nicotine gels and and products that aren't currently regulated.

The new rules fall short of existing regulations governing traditional cigarettes, however, and are unlikely to satisfy anti-smoking advocates who had hoped for more stringent measures. They won't outlaw advertising or Internet sales and won't ban flavors, which critics say attract younger users.

However, manufacturers will have to disclose the chemicals used in their e-cigarettes, which will be required to carry health warnings.

“This proposed rule is the latest step in our efforts to make the next generation tobacco-free,” said HHS Secretary Kathleen Sebelius.

Sen. Barbara Boxer (D-Calif.) said the proposed rule is a good start but goesn't go far enough.

"Stopping the sales of these products to minors is a critical step that will help protect our children from a lifetime of nicotine addiction," Boxer said. "The FDA was also right to propose barring e-cigarette companies from making unproven health claims and requiring them to disclose the harmful ingredients in their products."

"Now it is time for the Administration to take the next important step by banning the outrageous marketing of e-cigarettes to our kids, including the use of candy flavors and cartoon advertisements that are shamelessly designed to lure and addict them," she said. 

In February, introduced legislation to prohibit the marketing of e-cigarettes to children and teens. Earlier this month, she and several other senators urged the Federal Trade Commission (FTC) and the FDA to take enforcement action against e-cigarette manufacturers who make unsubstantiated or false claims in their advertising, including unproven assertions that their products help smokers of conventional cigarettes quit.

Products covered

Products that would fall under FDA regulation for the first time include e-cigarettes, cigars, pipe tobacco, nicotine gels, waterpipe (or hookah) tobacco, and dissolvables.

Manufacturers would be required to:

• Register with the FDA and report product and ingredient listings;
• Only market new tobacco products after FDA review;
• Only make direct and implied claims of reduced risk if the FDA confirms that scientific evidence supports the claim and that marketing the product will benefit public health as a whole; and
• Not distribute free samples.

In addition, the newly regulated products would have to meet these provisions:

• Minimum age and identification restrictions to prevent sales to underage youth;
• Requirements to include health warnings; and
• Prohibition of vending machine sales, unless in a facility that never admits youth.

Death and disease

“Tobacco remains the leading cause of death and disease in this country. This is an important moment for consumer protection and a significant proposal that if finalized as written would bring FDA oversight to many new tobacco products,” said FDA Commissioner Margaret A. Hamburg, M.D. “Science-based product regulation is a powerful form of consumer protection that can help reduce the public health burden of tobacco use on the American public, including youth.”

The proposed rule will be available for public comment for 75 days. 

Tobacco companies face tough restrictions when it comes to marketing cigarettes. Advertising for e-cigarettes, on the other hand, faces no such regulations. At least not yet.

Not surprisingly, e-cigarette advertising spending in the U.S. tripled in one year, according to a study by RTI International. The researchers found ad spending went from $6.4 million in 2011 to $18.3 million in 2012.

“E-cigarette advertising expenditures are focusing heavily on national markets and TV ads, which will likely increase consumer awareness and use of e-cigarettes,” said Annice Kim, Ph.D., senior social scientist at RTI and co-author of the study.

Most of the ad spending was for television and magazines. Newspapers and the Internet received the lowest share.

Gray area

At the moment, e-cigarettes fall into a regulatory gray area. A federal court has ruled that they are tobacco products, even though they contain no tobacco.

But while cigarettes are barred from television and radio advertising, and face other restrictions, e-cigarettes remain unregulated, even though the Federal Trade Commission (FTC) is reportedly drafting proposed rules.

Many former smokers praise e-cigarettes as a means to quit. They say e-cigarettes provide many of the pleasures of smoking, with nicotine delivered through water vapor that can be inhaled.

While e-cigarettes lack many of the toxins found in tobacco smoke, some health advocates worry that e-cigarettes could have some negative health effects that aren't yet known. Meanwhile, they are being heavily advertised.

“Our results suggest that federal-level efforts are needed to track e-cigarette advertising, as the U.S. Federal Trade Commission (FTC) does not currently require companies to report e-cigarette ad expenditures,” Kim said. “Tobacco companies are required to report their ad expenditures annually to the FTC, but there are no comparable reporting requirements for e-cigarette companies because e-cigarettes are not regulated by the U.S. Food and Drug Administration.”

Congressional push

Eleven members of Congress released their own report this week, not only showing a spike in e-cigarette advertising but claiming the marketing efforts are aimed at young people.

“For years, federal regulations prohibiting tobacco companies from targeting young people have helped to protect a new generation of smokers from getting hooked on nicotine,” said Sen. Richard Durbin (D-IL). “Now, we must close this new gateway to addiction to protect our children.”

Rep. Henry Waxman (D-CA), said he sees parallels between past cigarette marketing and e-cigarette marketing.

“E-cigarette makers are starting to prey on kids, just like the big tobacco companies,” Waxman said. “With over a million youth now using e-cigarettes, FDA needs to act without further delay to stop the companies from marketing their addictive products to children.”

States taking action

Some states have not waited for the federal government to draft rules governing e-cigarettes. Kentucky Gov. Steve Beshear this week signed legislation that outlaws the sale of e-cigarettes to minors.

The law addresses concerns that young people will be lured into using e-cigarettes and, as a result, will become addicted to nicotine. E-cigarette makers, meanwhile, are trying not to be seen as promoting use by young consumers.

One of the main cheerleaders for the new Kentucky law was Lorrilard, a major tobacco firm and parent company of the Blu e-cigarette brand.

"Legislation that prevents the sale or distribution of electronic cigarettes to minors is the right thing to do," said Murray Kessler, Lorillard's chairman and CEO, who attended the bill signing.

Kessler said Lorillard has actively supported age of purchase legislation in other states and encourages states that have not passed similar legislation to do so.

Concerns about cigarette marketing

A new study by Dartmouth researchers, meanwhile, raises new concerns about young people's exposure to advertising for traditional cigarettes. This exposure, the study argues, leads to increased use of tobacco.

“For several years, the emphasis in the tobacco industry has been on direct marketing, especially to young people who are highly price sensitive and who may find coupons, samples, and promotions appealing,” said Samir Soneji, a Dartmouth professor and lead author of the study.

The research team said it found exposure to tobacco coupons and websites increased the chances that a young person would start to smoke. Direct marketing includes coupons and ads sent through the mail or posted on the web, as well as in-store displays and signs.

In 2010, the tobacco industry spent $236 million in cigarette coupons and $22 million in Internet marketing, the study found.

Internet marketing proved particularly effective as some of it made its way to social media, widely used by teens and young adults.

Promoters of electronic cigarettes have been claiming that inhaling the vapor from e-cigs is less harmful than smoking traditional cigarettes made from tobacco.

It sounds good but is it true? Maybe not.

A new study published in the academic journal Clinical Cancer Research finds that the vapor from e-cigarettes damages human cells in much the same way as the smoke from traditional cigarettes.

Scientists at Boston University grew a batch of human bronchial cells in the presence of e-cig vapor and another batch in the presence of tobacco smoke. The result: the two batches of cells showed similar patterns of gene expression, which can cause the mutations that lead to cancer.

Lead researcher Avrum Spira, M.D., said that while e-cigs may be safer than tobacco, "our preliminary studies suggest that they may not be benign." He said more research is needed.

"New route to ... addiction"

It's hardly the study to find potential problems with e-cigs. In March, a University of California San Francisco study found that e-cigs may be a new route to conventional smoking and nicotine addiction.

UCSF researchers found that adolescents who used the devices were more likely to smoke cigarettes and less likely to quit smoking. The study of nearly 40,000 youth around the country also found that e-cigarette use among middle and high school students doubled between 2011 and 2012, from 3.1 percent to 6.5 percent.

"Despite claims that e-cigarettes are helping people quit smoking, we found that e-cigarettes were associated with more, not less, cigarette smoking among adolescents,” said lead author Lauren Dutra, a postdoctoral fellow at the UCSF Center for Tobacco Control Research and Education.

“E-cigarettes are likely to be gateway devices for nicotine addiction among youth, opening up a whole new market for tobacco,” she said.

Poison control

Earlier this month, the Centers for Disease Control and Prevention (CDC) report finding a huge increase in the number of calls to poison centers involving e-cigarette liquids containing nicotine.

A CDC study published in the agency's Morbidity and Mortality Weekly Report says calls shot up from 1 per month in September 2010 to 215 per month this past February. And, the report says, the number of calls per month involving conventional cigarettes did not show a similar increase during the same time period.

Sen. Barbara Boxer (D-Calif.) called the increase in poisoning cases "alarming" and said the report "should serve as a wake-up call to the American people that it is time for the FTC and the FDA to regulate these products to help prevent more tragedies."

"I am particularly concerned that many e-cigarettes are packaged in bright colors and flavored to smell like candy or fruit, which puts children at higher risk of poisoning," Boxer said.

There's been a huge increase in the last few years in the number of calls to poison centers involving e-cigarette liquids containing nicotine.

A CDC study published in the agency's Morbidity and Mortality Weekly Report says calls shot up from 1 per month in September 2010 to 215 per month this past February. And, the report says, the number of calls per month involving conventional cigarettes did not show a similar increase during the same time period.

Sen. Barbara Boxer (D-Calif.) called the increase in poisoning cases "alarming" and said the report "should serve as a wake-up call to the American people that it is time for the FTC and the FDA to regulate these products to help prevent more tragedies."

"I am particularly concerned that many e-cigarettes are packaged in bright colors and flavored to smell like candy or fruit, which puts children at higher risk of poisoning," Boxer said.

In February, Boxer introduced the Protecting Children from Electronic Cigarette Advertising Act to prohibit the marketing of e-cigarettes to children and teens. 

The trade group for e-cigarette manufacturers, the Smoke Free Alternatives Trade Association (SFATA), said it supports stronger safety measures. In a statement, executive director Cynthia Cabrera said the manufacturers "support federal age restrictions on the purchase of vapor products, childproof caps and proper labeling to safeguard against accidental ingestion of e-liquid by minors or adults."

Kids at risk

More than half (51.1%) of the calls to poison centers due to e-cigarettes involved young children 5 years and under, and about 42% of the poison calls involved people age 20 and older.

The analysis, which compared total monthly poison center calls involving e-cigarettes and conventional cigarettes, found the proportion of e-cigarette calls jumped from 0.3% in September 2010 to 41.7% in February 2014.

Poisoning from conventional cigarettes is generally due to young children eating them. Poisoning related to e-cigarettes involves the liquid containing nicotine used in the devices and can occur in three ways: by ingestion, inhalation or absorption through the skin or eyes.

“This report raises another red flag about e-cigarettes -- the liquid nicotine used in e-cigarettes can be hazardous,” said CDC Director Tom Frieden, M.D., M.P.H. “Use of these products is skyrocketing and these poisonings will continue. E-cigarette liquids as currently sold are a threat to small children because they are not required to be childproof, and they come in candy and fruit flavors that are appealing to children.”

A sweeping study

Data for this study came from the poison centers that serve the 50 states, the District of Columbia, and U.S. Territories. The study examined all calls reporting exposure to conventional cigarettes, e-cigarettes, or nicotine liquid used in e-cigarettes.

Poison centers reported 2,405 e-cigarette and 16,248 cigarette exposure calls from September 2010 to February 2014. The total number of poisoning cases is likely higher than reflected in this study, CDC says, because not all exposures might have been reported to poison centers.

“The most recent National Youth Tobacco Survey showed e-cigarette use is growing fast, and now this report shows e-cigarette related poisonings are also increasing rapidly,” said Tim McAfee, M.D., M.P.H., Director of CDC’s Office on Smoking and Health. “Health care providers, e-cigarette companies and distributors, and the general public need to be aware of this potential health risk from e-cigarettes.”

The report shows that e-cigarette liquids containing nicotine have the potential to cause immediate adverse health effects and represent an emerging public health concern. That, according to CDC, makes developing strategies to monitor and prevent future poisonings critical.

Here's the latest chapter in the continuing debate over whether e-cigarettes are a cure or an affliction: a study from the University of California San Francisco that finds e-cigs may in fact be a new route to conventional smoking and nicotine addiction.

In what is said to be the first analysis of the relationship between e-cigarette use and smoking among adolescents in the United States, UCSF researchers found that adolescents who used the devices were more likely to smoke cigarettes and less likely to quit smoking. The study of nearly 40,000 youth around the country also found that e-cigarette use among middle and high school students doubled between 2011 and 2012, from 3.1 percent to 6.5 percent.

“Despite claims that e-cigarettes are helping people quit smoking, we found that e-cigarettes were associated with more, not less, cigarette smoking among adolescents,” said lead author Lauren Dutra, a postdoctoral fellow at the UCSF Center for Tobacco Control Research and Education.

“E-cigarettes are likely to be gateway devices for nicotine addiction among youth, opening up a whole new market for tobacco,” she said. The study was published online on March 6 in JAMA Pediatrics.

A trade group took issue with the study, saying it "is implying conclusions that simply aren't borne out by the data."

In a prepared statement, Cynthia Cabrera, Executive Director, Smoke Free Alternatives Trade Association (SFATA), said: "As the survey summary itself states, it wasn't designed to derive any insight about motivation or a possible causal relationship between use of e-cigarettes and combustible cigarettes. What the survey data does show is that cigarette smoking among teens has decreased." 

FDA action expected

The U.S. Food and Drug Administration (FDA) has been considering regulations that could restrict advertising and sales of the popular battery-powered devices, which look like cigarettes and deliver an aerosol of nicotine and other chemicals.

Several states and cities, including New York and Los Angeles, have banned the use of e-cigs, generally treating them as though they were tobacco products. 

In Congress, five U.S. Senators introduced the "Protecting Children from Electronic Cigarette Advertising Act" last month. It would  prohibit the marketing of e-cigs to children and teens.

“We cannot risk undoing decades of progress in reducing youth smoking by allowing e-cigarette makers to target our kids,” Sen. Barbara Boxer (D-Calif.) said. “This bill will help protect our children from an industry that profits from addiction.”

Manufacturers promote the devices as safer alternatives to cigarettes and as smoking cessation aids. They are sold in flavors such as chocolate and strawberry that are banned in conventional cigarettes because of their appeal to youth.

Cabrera denied that the e-cig industry is targeting children.

"Our industry does not sell or market to minors, and it is our view that no one under 18 should use electronic cigarettes. Electronic cigarettes and vaping products are intended strictly for adults who smoke cigarettes. We fully support limitations on the sale of these products to youth at retail to further reduce access to anyone under 18," she said.

Students studied

In the new UCSF study, the researchers examined survey data from middle and high school students who completed the National Youth Tobacco Survey in 2011 and 2012.

The authors found that the devices were associated with higher odds of progression from experimenting with cigarettes to becoming established cigarette smokers. Additionally, adolescents who smoked both conventional cigarettes and e-cigarettes smoked more cigarettes per day than non-e-cigarette users.

“It looks to me like the wild west marketing of e-cigarettes is not only encouraging youth to smoke them, but also it is promoting regular cigarette smoking among youth,” said senior author Stanton A. Glantz, PhD, UCSF professor of medicine and director of the Center for Tobacco Control Research and Education.

Contrary to advertiser claims that e-cigarettes can help consumers stop smoking conventional cigarettes, teenagers who used e-cigarettes and conventional cigarettes were much less likely to have abstained from cigarettes in the past 30 days, 6 months, or year. At the same time, they were more likely to be planning to quit smoking in the next year than smokers who did not use e-cigarettes.

The new results are consistent with a similar study of 75,000 Korean adolescents published last year by UCSF researchers, which also found that adolescents who used e-cigarettes were less likely to have stopped smoking conventional cigarettes.

In combination, the two studies suggest that “e-cigarettes may contribute to nicotine addiction and are unlikely to discourage conventional cigarette smoking among youths,” said the scientists.

The federal Centers for Disease Control and Prevention reported last year that the majority of adolescents who have ever smoked e-cigarettes also have smoked regular cigarettes. An estimated 1.78 million U.S. students have used the devices as of 2012, the CDC reported.

For years, the U.S. Food and Drug Administration (FDA) has been trying to decide what to do about e-cigarettes -- the electronic gadgets that vaporize nicotine, a process promoters say produces a healthier way of ingesting nicotine.

Apparently tired of waiting on the FDA, five U.S. Senators today introduced the "Protecting Children from Electronic Cigarette Advertising Act" to prohibit the marketing of e-cigs to children and teens.

“We cannot risk undoing decades of progress in reducing youth smoking by allowing e-cigarette makers to target our kids,” Senator Barbara Boxer (D-Calif.) said. “This bill will help protect our children from an industry that profits from addiction.”

State and local jusidictions have also been stepping into the void left by the lack of action by the FDA. Earlier this week, a committee of the Los Angeles city council passed a measure that would treat e-cigs like tobacco cigarettes and subject them to the same restrictions. Before leaving office last year, ex-New York City Mayor Michael Bloomberg signed a bill outlawing e-cigs and plastic plates. 

Mass marketing techniques

Sen. Dick Durbin (D-Ill.), another sponsor of the Senate measure, said e-cig makers are increasingly adopting mass marketing techniques previously used by tobacco companies to target children and teens.

"With fruit and candy flavors and glossy celebrity ads, e-cigarettes makers are undeniably targeting young people. Unfortunately, it’s working. We must take action now to prevent a new generation from walking down the dangerous path towards nicotine addiction,” Durbin said.

“When it comes to the marketing of e-cigarettes to children and teens, it’s ‘Joe Camel’ all over again," said Sen. Tom Harkin (D-Iowa), chairman of the Senate Health, Education, Labor, and Pensions Committee. "It is troubling that manufacturers of e-cigarettes – some of whom also make traditional cigarettes – are attempting to establish a new generation of nicotine addicts through aggressive marketing that often uses cartoons and sponsorship of music festivals and sporting events.” 

The other senators sponsoring the bill are Tom Harkin (D-Iowa), Richard Blumenthal (D-Conn.), and Edward J. Markey (D-Mass.).

The Protecting Children from Electronic Cigarette Advertising Act would permit the Federal Trade Commission (FTC) to determine what constitutes marketing to children, and would authorize the FTC to work with state attorneys general to enforce the ban.

The health implications of using electronic cigarettes are not yet clear, and the FDA has warned that consumers of e-cigarette products “currently have no way of knowing” if e-cigarettes are safe for their intended use, or how much nicotine or other potentially harmful chemicals are being inhaled during use.

Gateway to tobacco

“E-cigarettes are a gateway to tobacco use by children and teens and should not be marketed to youth, period,” Sen. Markey said. “We’ve made great strides educating young people about the dangers of smoking, and we cannot allow e-cigarettes to snuff out the progress we’ve made preventing nicotine addiction and its deadly consequences."

According to the National Youth Tobacco Survey, 1.8 million middle and high school students said they tried e-cigarettes in 2012, and a study released by the Centers for Disease Control and Prevention (CDC) found that the percentage of high school students who had tried them had more than doubled in just one year – indicating that e-cigarette companies could be targeting youth through advertisements.

More than 76 percent of those users said they also smoked conventional cigarettes, suggesting that for many young people, e-cigarettes could be a gateway to nicotine addiction and smoking of conventional cigarettes, the senators noted.

The bill has been endorsed by the American Academy of Pediatrics, the American Heart Association, the American Lung Association, the American Cancer Society Cancer Action Network and Campaign for Tobacco-Free Kids.

In December, Senators Boxer, Blumenthal, Durbin, Harkin, Markey, and Sherrod Brown (D-Ohio) sent a letter urging the FTC to investigate the marketing practices of e-cigarette manufacturers.

A California man named Eric McGovern is attempting to bring a class action suit against e-cig maker Njoy, on the grounds that e-cigs are allegedly not as harmless as they claim to be, and also that it is inconsistent regarding whether it does or does not help smokers give up the habit.

Courthouse News Service reports that McGovern's suit claims that e-cig vapor contains the “same impurities and the same cancer-causing agents as traditional cigarettes” (though the levels of such substances in tobacco smoke vs. e-cig vapor are not specified).

E-cigs are marketed as the less-harmful alternative to cigarette smoking, though this has not prevented criticism from those opposed to any use of nicotine, regardless of form. For example: last November, researchers at UC San Francisco released a report criticizing e-cigs for being “the new phase of the nicotine epidemic” and claiming that, instead of reducing the number of nicotine addicts (read: smokers of tobacco) in the world, e-cigs actually increase the number of nicotine addicts (read: inhalers of e-cig vapor).

However, traditional opposition to tobacco smoking was based not on opposition to nicotine use per se, but to the very real health risks that come from regularly inhaling pure tobacco smoke into your lungs. So the debate on whether e-cigs are good, bad or neutral could also be reframed as a debate over what, exactly, is bad about traditional cigarette smoking: is it bad only because of the harmfulness of the smoke? Or should we assume any use of nicotine is bad, even if smoke damage is removed from the equation?

The Courthouse News article about McGovern's lawsuit also reports this apparent non-sequitur:

Njoy touts e-cigarettes as a safe alternative by implying that its product is as safe as vegetables and plants that contain nicotine, McGovern says.

"In reality, a typical consumer would need to ingest, as an example, 244 grams of tomatoes to equal the amount of nicotine a passive smoker would absorb in about three hours in a room with a minimal amount of tobacco smoke," the 25-page lawsuit states.

Assuming this is accurate, it still conflates two different things: the question of whether nicotine-containing plants can safely be ingested is entirely different from the question of how many plants one must ingest specifically to get a certain dose of nicotine. (If cigarette addicts jonesing for a nicotine fix are in the habit of eating tomatoes instead, this trend has not yet received mainstream media coverage.)

And, of course, neither question addresses how much nicotine one might expect from a typical e-cig dose, let alone how much if any nicotine passive non-e-cig users could expect if they sat in a room with an e-cig user.

McGovern is being represented by Brian Chase, a personal injury lawyer out of Newport Beach.

There doesn't seem to be much middle ground on electronic cigarettes; people either love them or hate them. And those who hate them tend to be in positions of power.

The Los Angeles city council is the latest to consider outlawing the gadgets. A pending ordinance would basically treat e-cigs as though they were traditional, tobacco-burning cigarettes, outlawing them in public places.

The proposed ordinance made it through a committee on Monday and is now headed to the full city council. The committee acted after hearing from Los Angeles County's public health director, Jonathan Fielding, who said the e-cigs tend to make smoking socially acceptable, encouraging young people to take up smoking.

"We don't want to risk e-cigarettes undermining a half century of successful tobacco control," he said, according to the Los Angeles Times.

Opponents of the measure say it would simply drive smokers back to tobacco.

Promoters of e-cigs argue that they are much safer than traditional cigarettes, which release nicotine as a byproduct of burning tobacco, a process that releases deadly tars into the lungs of smokers and those nearby. 

E-cigarettes electrically heat nicotine, releasing it as vapor, giving users their nicotine fix without the dangerous tars and minus the fire hazards of traditional cigarettes.

But a study released late last year disputed the contention that e-cigs are an effective way to keep teens from taking up the smoking habit.

UC San Francisco researchers said last November that the youths they studied using e-cigarettes were more likely to be trying to quit, but also were less likely to have stopped smoking and were smoking more, not less.

"We are witnessing the beginning of a new phase of the nicotine epidemic and a new route to nicotine addiction for kids," according to senior author Stanton A. Glantz, PhD, UCSF professor of medicine and director of the Center for Tobacco Control Research and Education at UCSF.

The Centers for Disease Control and Prevention recently reported that the majority of adolescent e-cigarette users also smoke regular cigarettes, and that the percentage of middle and high school students who use e-cigarettes more than doubled from 2011 to 2012. An estimated 1.78 million U.S. students had used the devices as of 2012, said the CDC.

Tobacco giant Altria Group, Inc., is buying the e-cigarette business of Green Smoke, Inc., for about $110 million, the latest in a series of moves by big tobacco companies to stake a claim in the electronic cigarette business.

It also is the latest example of Big Tobacco's strategy to re-christen e-cigs as "e-vapor" products, in an effort to escape some of the stigma associated with cigarettes. The corporatespeak apparatchiks also prefer the verb "vaping" as opposed to "smoking." 

“Nu Mark’s entry into the e-vapor category with its MarkTen product was an important development in Altria’s innovation strategy. Adding Green Smoke’s significant e-vapor expertise and experience, along with its supply chain, product lines and customer service, will complement Nu Mark’s capabilities and enhance its competitive position,” said Marty Barrington, Altria’s Chairman and CEO. 

Green Smoke was founded in 2008 and has operations in the United States and Israel. Green Smoke has sold e-cigs since 2009, mostly in the U.S. Green Smoke's product lines, which are sold under the Green Smoke e-vapor brand, include both rechargeable and disposable versions.

Up in smoke

Tobacco companies have faced declining sales in the U.S. for years although sales remain strong in some international markets. Altria, based in Richmond, Va., has increased market share for Marlboro and some of its other brands through aggressive pricing.

Altria said last year that it would seek an entry into the e-cigarette business was it became clear that the electroinc devices were beginning to erode sales of traditional cigarettes.

Other major tobacco companies have also gotten into the e-vapor business. Lorillard, which makes Newport cigarettes, bought the blu e-cig brand in 2012. It is currently the top e-cig seller in the U.S.  Reynolds, which makes Camels, launched its Vuse brand last year.

E-cigs work by heating nicotine-laced liquir into vapor. Their adherents say they are more healthful than tobacco products and can be an aid to those trying to quit smoking. Critics say they encourage smoking and charge that their health effects are unknown.

The Food and Drug Administration (FDA) has for years been saying that it is about to issue regulations for e-cigarettes but has not yet done so, leaving them unregulated except in a few cities where their public use has been outlawed.

Back in the day, people might try to bum a cigarette off you, which was basically no big deal. But with today's electronic cigarettes, it's a different story.

While some e-cigs are disposable, the high-end models can get fairly pricey, so it's something you want to nail down if at all possible.

Vapor Corp. introduced its solution to the problem at the Consumer Electronics Show yesterday -- the Vapor X personalized vaporizer.

The Vapor X, with patent-pending fingerprint lock technology, will incorporate biometric technologies to keep the device locked and turned off unless the authorized user is present.

When first purchased, Vapor X will require an authorized user to be assigned through a fingerprint scan. Once assigned, that user is the only person who can activate the device and start vaping away. This will not only protect against minors being able to turn on the device, but it will render the device useless in the case of theft.

"Much like the fitness mobile app technology we have seen gain recent popularity, vaporizer users will soon be able to download their 'vaping' statistics through a corresponding mobile application in order to track exactly how often they use the device," said Kevin Frija, CEO of Vapor Corp.

Friends don't let friends drive drunk. And now, a new ad campaign tells us they don't let them smoke either. Ah, but there's a catch, as the NJoy ad has it: Friends do let friends vape. 

"For everything friends do for each other," a voiceover says. "This new year return the favor. Friends don't let friends smoke. Give them the only electronic cigarette worth switching to: the NJoy King." It concludes with the tagline: "Cigarettes, you've met your match."

Marketers are expecting 2014 to be the Year of the E-cig, as Big Tobacco moves into the business in a big way. And the NJoy ad takes more than a few leaves from Big Tobacco's playbook. 

Most obviously, it glorifies vaping, just as the Marlboro Man, before he succumbed to lung cancer, epitomized the rugged outdoorsish qualities of Marlboros.

It also comes tantalizingly close to making health claims for e-cigs, which could get a not-so-pleasant reaction from the Food and Drug Administration (FDA) and other agencies that regulate advertising, since the clear implication of the NJoy ad is that puffing away on an e-cig is healthier than smoking a traditional tobacco cigarette.

Story continues below video

It's illegal to make health claims that are not substantiated by scientifically sound evidence, which so far is somewhat scant in the case of electronic cigarettes. The NJoy ad is playing the same game Big Tobacco played for years, before broadcast tobacco advertising was finally banned altogether -- surrounding its products with happy, healthy, spirited young people.  

"We do not advertise e-cigs as a smoking cessation device," a company spokesman said in a statement to AdAge, an advertising trade journal. "However, a unique aspect of the NJOY video is that we are appealing to the friends & loved ones of smokers -- asking them to leverage the fundamental connection and emotional bond of love that bring us all together and strengthens our trust/intimacy. Everyone can identify with the desire to help our friends & loved ones become the best versions of themselves, and goal (especially in the new year!) to strive to be better versions of ourselves."

Whether that statement cuts much ice with regulators remains to be seen. Probably the exclamation mark won't help too much.

Big bucks

Just to be clear, the e-cig industry is not in this for its health, or anyone else's. Big bucks are at stake. E-cig sales are expected to hit $1.7 billion this year, assuming the FDA doesn't shut the market down or severely curtail it.

The agency has said for more than a year that it is considering new e-cig marketing regulations, possibly including new rules on television advertising, although an outright ad ban may not be in the cards without Congressional action.

Tobacco TV commercials have been banned for 40 years but the tobacco companies worked to build their brand identities before the ban took effect, and most of the major brands have survived to this day on the basis of history, habit and other forms of advertising and promotion.

Big Tobacco -- Altria, Reynolds American and Lorillard -- have waded into the e-cig market in a big way and are expected to use the same technique to build their electronic brands before the government bestirs itself.

Tired of waiting for the feds, New Jersey, North Dakota and Utah, among others, have already banned vaping indoors. As one of his final acts, former New York City mayor Michael Bloomberg signed a similar measure. But the states and cities have no effective way to control national advertising, so the indoor vaping bans are, at the most, petty annoyances to the e-cig industry. 

Promoters of e-cigarettes like to claim the devices are a good way to quit smoking, but a new study finds that they are more likely to get young people hooked on nicotine, causing them to smoke more, not less.

In the study, said to be the first of its kind, UC San Francisco researchers said the youths they studied using e-cigarettes were more likely to be trying to quit, but also were less likely to have stopped smoking and were smoking more, not less.

"We are witnessing the beginning of a new phase of the nicotine epidemic and a new route to nicotine addiction for kids," according to senior author Stanton A. Glantz, PhD, UCSF professor of medicine and director of the Center for Tobacco Control Research and Education at UCSF.

E-cigarettes are battery-powered devices that look like cigarettes and deliver an aerosol of nicotine and other chemicals. Promoted as safer alternatives to cigarettes and smoking cessation aids, e-cigarettes are rapidly gaining popularity among adults and youth in the United States and around the world. The devices are largely unregulated, with no effective controls on marketing them to minors.

In the UCSF study, the researchers assessed e-cigarette use among youth in Korea, where the devices are marketed much the way they are in the U.S. The study analyzed smoking among some 75,000 Korean youth.

The study appears online in the current issue of the Journal of Adolescent Health.

"Our paper raises serious concern about the effects of the Wild West marketing of e-cigarettes on youth," said Glantz.

Penetrating youth market

Despite industry claims that it markets only to adults, e-cigarettes have achieved substantial penetration into the youth market.

In the U.S., the Centers for Disease Control and Prevention recently reported that the majority of adolescent e-cigarette users also smoke regular cigarettes, and that the percentage of middle and high school students who use e-cigarettes more than doubled from 2011 to 2012. An estimated 1.78 million U.S. students had used the devices as of 2012, said the CDC.

In the UCSF study, the researchers report that four out of five Korean adolescent e-cigarette users are "dual" smokers who use both tobacco and e-cigarettes.

The authors conclude that young e-cigarette smokers "are more likely to have tried quitting smoking, which suggests that, consistent with cigarette marketing messages, some youth may be using e-cigarettes as a smoking cessation aid…Use of e-cigarettes is associated with heavier use of conventional cigarettes, which raises the likelihood that actual use of e-cigarettes may increase harm by creating a new pathway for youth to become addicted to nicotine and by reducing the odds that an adolescent will stop smoking conventional cigarettes."

If you’re an e-cigarette user who’s bought supplies from Vapor Corp. or Global Vapor Partners, which includes the brands Smoker 51, Krave, Green Puffer, VaporX, and EZ-Smoker, you might want to take a close look at your credit card statements — and, possibly, talk to an attorney.

Courthouse News Service reports that Vapor Corp. and Global Vapor are being sued for fraud in Cook County, Ill. The class-action suit, headed by lead plaintiff Jean-Francois Patterson, claims that the companies have not only been imposing fraudulent credit card charges – up to $100 per month for customers who only ever authorized an initial $4.95 shipping fee – but also made misleading claims on its websites.

Patterson claims that “"Vapor Corp. and GVP are careful to bury mention of the initial trial charges or the monthly charges in the Terms & Conditions, which never appear on the same page as the free trial offer. Defendants also obscure mention of these fees through the use of flashy graphics and misleading statements that tell consumers that they 'just pay shipping and handling' and that the 'Total' price for starter kit is '0.00' with a shipping and handling fee of '4.95.'”

However, customers who return the products are charged a $10 “restocking fee” and not refunded shipping costs, which means that under no circumstance does a “free” trial actually cost the consumer zero dollars, the lawsuit alleges.

The Better Business Bureau gives the company an F rating. We’ll admit we found no other scam reports when we did an online search for “Global Vapor Partners” – but then, our search on Nov. 27 brought back only three pages of any Google results, including the company’s own websites and the recent Courthouse News story.

Here’s a general rule for safely shopping on the Internet: you should definitely avoid a company whose search results yield page after page of scam complaints — but you should also avoid a company whose search results yield hardly anything at all.

Kids have been told for generations that cigarettes are no good for them. So, what are middle- and high-school students doing? According to a report in Center for Disease Control and Prevention's (CDC) Morbidity and Mortality Weekly Report, they're looking to so-called “emerging tobacco products” such as e-cigarettes and hookahs.

Data from the 2012 National Youth Tobacco Survey (NYTS) show that recent electronic cigarette use rose among middle school students from 0.6% in 2011 to 1.1% last year, and among high school students from 1.5% to 2.8%. Hookah use among high school students rose from 4.1% to 5.4% during the same period.

Marketing may be a factor

The report speculates that the increase in the use of e-cigarettes and hookahs could be due to an increase in marketing, availability, and visibility of these tobacco products and the perception that they may be safer alternatives to cigarettes.

Electronic cigarettes, hookahs, cigars and certain other new types of tobacco products are not currently subject to FDA regulation. However, the agency has said it intends to issue a proposed rule that would deem products meeting the statutory definition of a "tobacco product" to be subject to the Federal Food, Drug, and Cosmetic Act.

Cigar smoking worrisome

Another area of concern in the report is the increase in cigar use among certain groups of middle and high school students. During 2011-2012, cigar use increased dramatically among non-Hispanic black high school students from 11.7% to 16.7%, and has more than doubled since 2009. Further, cigar use among high school males in 2012 was 16.7%, similar to cigarette use among high school males (16.3%).

“This report raises a red flag about newer tobacco products,” said CDC Director Tom Frieden, M.D., M.P.H. “Cigars and hookah tobacco are smoked tobacco -- addictive and deadly. We need effective action to protect our kids from addiction to nicotine.”

The cigars category includes little cigars, many of which look almost exactly like cigarettes but are more affordable to teens because they are taxed at lower rates and can be sold individually, rather than by the pack. Little cigars also can be made with fruit and candy flavors that are banned from cigarettes. A CDC study published last month showed more than one in three (35.9%) middle and high school students who smoke cigars use flavored little cigars.

Kids at risk

“A large portion of kids who use tobacco are smoking products other than cigarettes, including cigars and hookahs, which are similarly dangerous,” said Tim McAfee, M.D., M.P.H., director of the CDC’s Office on Smoking and Health. “As we close in on the 50th anniversary of the first Surgeon General’s report on the dangers of smoking, we need to apply the same strategies that work to prevent and reduce cigarette use among our youth to these new and emerging products.”

Smoking remains the leading cause of preventable death and disease in the United States, killing more than 1,200 people every day. More than 8 million people live with a smoking-related disease. Each day, more than 2,000 youth and young adults become daily smokers. Smoking-related diseases cost $96 billion a year in direct health care expenses, much of which come in taxpayer-supported payments.

With new regulations looming, lobbyists for the electronic cigarette industry are heading to Capitol Hill, hoping to persuade lawmakers that the combustion-free devices shouldn't be treated like tobacco products.

“While our industry understands reasonable and appropriate regulation is needed, it is vital our young industry not be grouped with combustible cigarettes as federal guidelines are developed for these products," said Cynthia Cabrera, Executive Director of the Smoke Free Alternatives Trade Association (SFATA). "Excessive regulation could limit adult access to e-cigs and stifle growth and innovation in the segment.”

The U.S. Food and Drug Administration (FDA) has set an Oct. 31 deadline to issue a proposed rule that would expand its oversight of e-cigs. In response, Cabrera's group has summoned its members to Washington for a "day on the Hill" Nov. 4 and 5.

Trade associations for industries under pressure from the feds traditionally round up their members and bring them to D.C. to meet and greet lawmakers and their staffs, hoping to portray themselves as vital cogs in the economy and loyal supporters of their Congressional members.

Law being "misapplied"

Besides arguing the merits, if any, of e-cigs the group will be arguing that the law under which the FDA is issuing the new regulations -- the 2009 Tobacco Control Act -- doesn't give it the authority to do so.

"This law gave the FDA authority over cigarettes, smokeless tobacco and roll-your-own tobacco, and has been misapplied to allow the agency to expand its oversight to additional products, such as electronic cigarettes," Cabrera's group said in a press release.

The FDA has reportedly completed the drafting of its regulation and submitted it to the White House Office of Management and Budget (OMB) for review by OMB’s Office of Information and Regulatory Affairs (OIRA).

FDA has been saying for at least the last two years that it intends to include electronic cigarettes under its authority and it has come under increasing criticism from anti-smoking groups and some lawmakers for the plodding pace at which it has proceeded. In April, five senators, all Democrats, wrote to FDA Commissioner Margaret Hamburg, urging the agency to make haste.

“Unlike traditional tobacco products, e-cigarettes can be legally sold to children and are not subject to age verification laws,” the senators wrote. “E-cigarettes marketed to appeal to kids in candy and fruit flavors, like bubblegum and strawberry, are readily available to youth in shopping malls and online. These products risk addicting children to nicotine, which could be a pathway to cigarettes and other tobacco products.”

In a news release, SFATA said it is "encouraging the FDA and elected officials to refer to research established by credible health professionals who offer scientific evidence proving that e-cigarettes are a reliable, adult alternative to combustible cigarettes." It didn't cite any such evidence iin its release, however. 

The attorneys general of 40 states today urged the U.S. Food and Drug Administration (FDA) to ban the sale of e-cigarettes to minors and to regulate ingredients and advertising of the popular new products, which the AGs said are highly addictive.

The FDA has been studying the issue for more than a year and is expected to issue regulations shortly.

In a letter to the FDA, the 40 attorneys general called on the agency to take all available measures to regulate e-cigarettes as “tobacco products” under the Tobacco Control Act. E-cigs are battery-operated products that heat liquid nicotine, turning it into a vapor that is inhaled by the user.

Unlike traditional tobacco products, there are no federal age restrictions that would prevent children from obtaining e-cigarettes but the AGs say there should be. They urged the FDA to protect teens and children from becoming addicted to nicotine, citing a Centers for Disease Control and Prevention (CDC) survey that showed the percentages of youth who have tried or currently use e-cigarettes roughly doubled from 2011 to 2012.

The survey estimated that in 2012 nearly 1.8 million middle and high school students had tried e-cigarettes.

"Deceptive health claims"

“It’s widely known that most adult smokers start smoking at an early age, in part because manufacturers and advertisers have historically targeted young consumers with flashy marketing campaigns and deceptive health claims,” Illinois Attorney General Lisa Madigan said. “We’re seeing the same tactics at work in the e-cigarette industry. The FDA needs to put a stop to this before more teens take up this dangerous habit.”

The AGs' letter noted that e-cigarette manufacturers are using celebrity endorsements, television advertising, cartoons, attractive packaging and cheap prices to encourage young people to try e-cigs.

Some marketing, they said, has included claims that e-cigs do not contain the same level of toxins and carcinogens found in traditional cigarettes, cigars and other tobacco products.

"These claims imply that e-cigarettes are a safe alternative to smoking, when in fact nicotine is highly addictive, the health effects of e-cigarettes have not been adequately studied, and the ingredients are not regulated and may still contain carcinogens," Madigan said. "The lack of regulation puts the public at risk because users of e-cigarettes are inhaling unknown chemicals with unknown effects."

In 1998, the attorneys general of 52 states and territories signed a landmark agreement with the country’s four largest tobacco companies to recover billions of dollars in costs associated with smoking-related illnesses and restrict cigarette advertising to prevent youth smoking.

Manufacturers of electronic cigarettes -- or e-cigs -- like to say the devices help smokers quit while also dissuading non-smokers from taking up the tobacco-smoking habit.

But data published by the Centers for Disease Control and Prevention suggest the claims may be a smokescreen. The percentage of U.S. middle and high school students who use e-cigarettes more than doubled from 2011 to 2012, according to the findings from the National Youth Tobacco Survey.

The survey is likely to provide ammunition to critics who say the federal government is not moving quickly enough to regulate the e-cigs. In April, five U.S. Senators wrote to FDA Commissioner Margaret Hamburg, urging her agency to issue regulations for the devices. The letter was signed by Sens. Dick Durbin (D-Il.), Frank Lautenberg (D-N.J.), Richard Blumenthal (D-Conn.), Sherrod Brown (D-Oh.) and Jack Reed (D-R.I.). 

The FDA has left no doubt it intends to regulate e-cigs. The only questions are when and how.

“These data show a dramatic rise in usage of e-cigarettes by youth, and this is cause for great concern as we don’t yet understand the long-term effects of these novel tobacco products,” said Mitch Zeller, director of FDA’s Center for Tobacco Products. “These findings reinforce why the FDA intends to expand its authority over all tobacco products and establish a comprehensive and appropriate regulatory framework to reduce disease and death from tobacco use.”

Britian began regulating e-cigs in June, treating them as non-prescription medicine, allowing them to be sold widely by retailers but empowering the government to enforce quality and purity standards.  

The CDC survey found that the percentage of high school students who reported ever using an e-cigarette rose from 4.7 percent in 2011 to 10.0 percent in 2012. In the same time period, high school students using e-cigarettes within the past 30 days rose from 1.5 percent to 2.8 percent.  Use also doubled among middle school students. 

Altogether, in 2012 more than 1.78 million middle and high school students nationwide had tried e-cigarettes. 

Lifelong addiction

"The increased use of e-cigarettes by teens is deeply troubling," said CDC Director Tom Frieden, M.D., M.P.H.  "Nicotine is a highly addictive drug.  Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes."

The study also found that 76.3 percent of middle and high school students who used e-cigarettes within the past 30 days also smoked conventional cigarettes in the same period.

In addition, 1 in 5 middle school students who reported ever using e-cigarettes say they have never tried conventional cigarettes. This raises concern that there may be young people for whom e-cigarettes could be an entry point to use of conventional tobacco products, including cigarettes.  

“About 90 percent of all smokers begin smoking as teenagers,” said Tim McAfee, M.D., M.P.H., director of the CDC Office on Smoking and Health.  “We must keep our youth from experimenting or using any tobacco product. These dramatic increases suggest that developing strategies to prevent marketing, sales, and use of e-cigarettes among youth is critical.” 

No proof

Although some e-cigarettes have been marketed as smoking cessation aids, there is no conclusive scientific evidence that e-cigarettes promote successful long-term quitting, the FDA noted. However, there are proven cessation strategies and treatments, including counseling and FDA-approved cessation medications.

Cigarette smoking remains the leading preventable cause of dis­ease, dis­ability, and death in the United States, responsible for an estimated 443,000 deaths each year.  And for every one death, there are 20 people living with a smoking-related disease.  To quit smoking, free help is available at 1-800-QUIT NOW or www.cdc.gov/tips.

Major tobacco companies are showing enthusiastic interest in electronic, or e-cigarettes. And why not? These devices deliver the nicotine in a flavored vapor instead of smoke. To a large extent they are unregulated and untaxed.

Tobacco, on the other hand, is both highly regulated and heavily taxed. Most public areas now forbid cigarette smoking. That's not true, however, for e-cigarettes and may be one reasons smokers have been spending billions of dollars to buy them. It allows them to enjoy many of the pleasures of smoking in places where they can't light up a cigarette.

In June, Altria Group announced plans to introduce an e-cigarette called the Mark Ten. Reynolds American has already developed its line of e-cigarettes while Lorillard got into the business by acquiring an existing brand of e-cigarettes, Blu.

Increasing scrutiny

With the nation's three largest tobacco companies getting into the business of e-cigarettes, regulators and health researchers are taking a closer look. The Food and Drug Administration (FDA) is said to be preparing regulations for this new product, a move welcomed by some in the industry.

Meanwhile, the public interest health groups that have waged a long, hard war against tobacco are now viewing the booming sale of e-cigarettes with growing unease.

“The growing use of e-cigarettes and the unproven health claims being made about them underscore the need for the Food and Drug Administration to quickly assert authority over all tobacco products, including e-cigarettes,” Matthew L. Myers, President, Campaign for Tobacco-Free Kids, said in a February 2013 statement. “The FDA announced in December 2010 that it intended to do so, but over two years later, it has yet to act.”

It takes time to draft regulations, as well as conduct comprehensive health studies on these products. To date, that data isn't available. At the MD Anderson Cancer Center in Houston, cancer prevention experts Paul Cinciripini, Ph.D., director of the Tobacco Treatment Program, and Alexander Prokhorov, M.D., Ph.D., head of the Tobacco Outreach Education Program, caution that more research is needed to understand the potential role of e-cigarettes in smoking cessation.

Potential benefit

“Independent studies must rigorously investigate e-cigarettes, as there’s considerable potential benefit in these products if they’re regulated and their safety is ensured,” Cinciripini said. “But promoting the e-cigarettes already on the shelves as ‘safe’ is misleading and, if looked at as a harmless alternative to cigarettes, could potentially lead to a new generation of smokers more likely to become tobacco dependent.”

E-cigarettes are nicotine delivery vehicles, pure and simple. If a consumer is already hooked on nicotine, makers of e-cigarettes say their product is a safer way to get that nicotine fix than lighting up a cigarettes, which contains about 6,000 other chemicals besides nicotine.

Unlike anti-tobacco activists who pretty much view e-cigarettes as a threat, Cinciripini and Prokhorov don't rule out e-cigarettes as an effective and valuable tool to help people give up tobacco. But the problem, they say, is the unknowns. E-cigarettes might be safe, but no one really knows.

What users should know

Before using an e-cigarette, these researchers say consumers should understand that they are not yet regulated and there has been little research done on their effectiveness as a smoking-cessation tool. Consumers might be better off, they say, sticking to approved methods to quit smoking.

Even so, they say e-cigarettes might eventually prove to be a safe and effective alternatives to smoking.

“Reduced exposure to harmful chemicals warrants research of these products as a smoking cessation vehicle,” Cinciripini said.

But there could also be a downside. Branded as “safer,” marketed in a variety of colors and flavors and promoted by celebrities, Prokhorov and Cinciripini worry that e-cigarettes could become a hook for future smokers.

“E-cigarettes are a novel way to introduce tobacco smoking to young people, and their potential ‘gateway’ role should be a concern for parents and health officials alike,” Prokhorov said.

Millions of smokers worldwide have begun to embrace the electronic cigarette – or e-cig – as a way to wean themselves off tobacco. Some who have taken advantage of a “free trial” offer from a website selling the devices have reported bad experiences.

Free trial offers hardly ever work out well for a consumer. The company entices you with the free sample of their product, but requires you to supply credit card information so that you can pay a small shipping and handling charge. Many consumers see this as a good deal. It isn't.

Once a company has your credit card information, it can place other charges on your account as well. Free trial offers usually have very stringent terms. By accepting the sample you agree to place a full order – sometimes a full order each month. You can avoid the full charge only by cancelling within the required period of time.

Free samples rarely turn out well

In the past this marketing technique has been used on all sorts of products, from dietary supplements to teeth whiteners. Now a company, e-cig.com, is using it to market its e-cigarettes.

“My husband got their original sample for a S&H charge and now they keep charging my account for $80,” Lorraine, of Westford, Mass., wrote in a ConsumerAffairs post. “Tried to talk to someone and could not understand her and she would not give us to someone else. I finally got the return address and she continued to try to sell me the cigarettes. I spent 45 minutes on the phone trying to resolve this. They also did no good for my husband. Frustrated. Still don't know if we are out the money.”

John, of Bassett, Va., says he was charged $109 after ordering the free trial. He was confused so he called.

“They said I had 14 days to try product,” John writes. “Their 14 days started from the minute free tryout was ordered, not the five days later when it was received, so over one-third of the free tryout was expired before product was received. I called the company and received a runaround about the 14 days, basically my problem. I tried to go up the food chain and listened again to the canned answers. Finally they agreed to refund me $40.00 of the $109 then hung up. Fifteen minutes later, the original rep called me back and said they would be raising the refund to $59.00. They will still be retaining $50.00 of mine for nothing.”

Raymond, of Irving, Tex., said he ordered the product and was told he just had to pay the shipping charge. He thought he understood the terms.

Communication break-down

“I called to cancel future orders,” he writes. “I told two different people that I wanted to cancel and not receive any other charges. They kept telling me they were extending the trial period to July 2nd, 2013. I kept asking why - no clarity in answering my question. I told them over and over I did not want to be charged. They said they would not charge me. I just looked at my account today and much to my surprise, there is a charge for $19.95.”

Raymond says he is filing a complaint with the Texas Attorney General.

Generally, consumers should avoid accepting a free trial offer. In most cases there are just too many strings attached. While many companies comply with the law and post the terms and conditions of the trial, consumers don't always read them and in some cases they can be hard to find.

What to do

The Federal Trade Commission (FTC) requires companies engaging in “negative option” marketing – in which a sale is presumed to have occurred unless the consumer takes action to cancel it – to state the terms in a “clear and conspicuous” manner. Consumers can avoid many of the hassles and headaches associated with negative option marketing by not accepting any free trial offer.

Instead, simply purchase the smallest package of the product at the regular price. If you don't like the product, don't buy it again. Simple as that.

Britain has decided to regulate electronic cigarettes, treating them as non-prescription medicine. That means the popular e-cigs will still be widely sold in convenience stores and elsewhere but the government will enforce quality and purity regulations, just as it does with aspirin, sinus remedies and other widely sold products.

In the United States, the Food and Drug Administration (FDA) has been studying the matter and is expected to issue regulations one of these days, but more than 300 years after the Revolution, things move a bit more slowly on this side of the pond.

The decision was announced today by the UK's Medicines and Healthcare products Regulatory Agency (MHRA), which said it wanted to ensure that e-cigs "are safe, are of the right quality and work."  

Consistent quality

"Reducing the harms of smoking to smokers and those around them is a key government health priority. Our research has shown that existing electronic cigarettes and other nicotine containing products on the market are not good enough to meet this public health priority," Jeremy Mean, the MHRA’s Group Manager of Vigilance and Risk Management of Medicines, said.

“The decision announced today provides a framework that will enable good quality products to be widely available. It’s not about banning products that some people find useful, it’s about making sure that smokers have an effective alternative that they can rely on to meet their needs," Mean said.

The FDA's efforts to regulate e-cigarettes have bean hampered by a court decision that grew out of a 2010 effort by the agency to ban the devices, which deliver nicotine vapor without using tobacco.

In December 2010 the U.S. Court of Appeals for the District of Columbia ruled the FDA's attempt to classify e-cigarettes as drug delivery systems was incorrect. Instead, the court found that e-cigarettes were tobacco products, even though they contain no tobacco.

The FDA declined to appeal the ruling but has served notice that it might propose rules that would, in fact, regulate e-cigarettes as tobacco products. 

Howls of protest

Any talk of banning or regulating the use of the devices brings howls of protest from their users and manufacturers, who say the products are safe and do not emit fumes harmful to bystanders, unlike cigarettes.

Just a few days ago, R.J. Reynolds Co. jumped into the fray and announced it would launch a TV advertising campaign for its new e-cig brand, Vuse. TV ads for cigarettes have not been seen since 1971, when they were banned by Congress. Other large tobacco companies are also getting into the business in other countries and are expected to do so here, if the FDA permits it.

They're not cigarettes and they don't contain tobacco, so the ban shouldn't be a problem, is essentially the message R.J. Reynolds seems to be sending. Its initial marketing effort is restricted to Colorado.

It's not just the U.S. and Britain that have been trying to figure out what to do about the devices.  Brazil, Norway and Singapore have banned them outright while others have limited advertising and curbed the practice of "vaping" -- as adherents call it -- in public places.

Much safer

While some health authorities are dubious about the safety of e-cigs, the  MHRA's chief medical officer, Dame Sally Davies, made it clear she regards them as much safer than cigarettes.

“Smokers are harmed by the deadly tar and toxins in tobacco smoke, not the nicotine," she said. “While it’s best to quit completely, I realize that not every smoker can and it is much better to get nicotine from safer sources such as nicotine replacement therapy.

“More and more people are using e-cigarettes, so it’s only right these products are properly regulated to be safe and work effectively,” Dame Sallay said.

Unlike the U.S., where health and consumer advocates generally oppose wider use of e-cigs, the MHRA's decision is being greeted positively in the U.K. 

The non-profit public health group ASH said it "strong supports" the decision. 

"We think this is both proportionate and necessary," said Deborah Arnott, the group's chief executive. "Regulation will ensure that e-cigarettes meet the same standards for quality, safety and efficacy as medicines while remaining as readily available to smokers as they are today."

A physician's group, the General Council at the Royal College of General Practitioners, also said it was on board with the plan.

"The RCGP supports MHRA regulation of novel nicotine products such as e-cigarettes as this will ensure that they are of good quality and reliability and are effective in helping smokers who want to use them to cut down and quit,” Dr. Clare Gerada, the group's chair, said.

The MHRA's new rules don't go fully into effect until 2016.

The Food and Drug Administration (FDA) served notice some time ago that it will probably regulate electronic cigarettes but has yet to take the first step.

The FDA said it was preparing proposed regulations in 2011 but none appeared. It said the same thing the following year with the same results. Earlier this year it suggested a proposal would be offered in April.

Now the agency is coming under pressure from some lawmakers to get the process rolling. Five U.S. Senators have written to FDA Commissioner Margaret Hamburg, urging her agency to issue "deeming regulations" for the increasingly popular devices that some smokers have adopted in place of cigarettes.

The letter was signed by Sens. Dick Durbin (D-Il.), Frank Lautenberg (D-N.J.), Richard Blumenthal (D-Conn.), Sherrod Brown (D-Oh.) and Jack Reed (D-R.I.). They note that the number of people who have used e-cigarettes has doubled since 2010 but, to date, the nicotine delivery devices are currently not required to be evaluated or approved by the FDA.

Can currently be marketed to children

“Unlike traditional tobacco products, e-cigarettes can be legally sold to children and are not subject to age verification laws,” the Senators wrote. “E-cigarettes marketed to appeal to kids in candy and fruit flavors, like bubblegum and strawberry, are readily available to youth in shopping malls and online. These products risk addicting children to nicotine, which could be a pathway to cigarettes and other tobacco products.”

Earlier this month the CEO of an e-cigarette company also endorsed some regulation of his industry by the FDA. Eli Alelov, CEO of LOGIC Technology, told ConsumerAffairs that he wants to see manufacturing standards and age restrictions.

“I support raising the bar for the industry,” Alelov said. “Right now my biggest enemy is not the FDA, it's these 'me too' brands that come into the market with cheap electronic cigarettes, trying to make a buck, and they're putting lousy products on the market. That's hurting the entire industry.”

Alelov's company makes e-cigarettes in only two flavors – tobacco and menthol. He says the wide variety of fruit flavored e-cigarettes offered by other companies don't appeal to people who smoke cigarettes, but instead appeal to young people who don't smoke.

'Reasonable regulation'

The general counsel of FIN Branding Group LLC, another e-cigarette company, is also calling for "reasonable regulation."

"As the electronic cigarette industry continues to grow, it is important to work with stakeholders, including the FDA, to better understand how new regulations might alter our industry," said FIN Branding Vice President and General Counsel Rebecca Maisel. "We believe that some reasonable regulation that addresses quality control, product consistency, and a ban on selling products to minors is important."

State action

While the FDA ponders regulations, some states are considering action of their own. California is considering a measure that would ban the use of e-cigarettes in locations where smoking is banned. Currently e-cigarettes can be used in public spaces since they do not emit smoke, only water vapor.

The measure, SB 648, would ban e-cigarette use inside or within 20 feet of any public building or in a vehicle owned by the state. It would also allow landlords to ban e-cigarette use in private homes.

The Rhode Island legislature is currently debating a measure to ban e-cigarette sales to minors, but would also greatly restrict online sales of nicotine-containing products by treating e-cigarettes the same as traditional tobacco products.

E-cigarettes contain no tobacco but simulate the act of smoking by using heat to create water vapor that is inhaled. The flavored vapor contains nicotine and many smokers have said they find e-cigarettes an acceptable alternative to tobacco.

Anti-smoking groups, however, don't consider them acceptable. They have called for regulating e-cigarettes as tobacco products.

Several years ago, when the U.S. Food and Drug Administration (FDA) attempted to ban the import and sale of electronic e-cigarettes, a court stood in the way.

In December 2010 the U.S. Court of Appeals for the District of Columbia ruled the FDA's attempt to classify e-cigarettes as drug delivery systems was incorrect. Instead, the court found that e-cigarettes were tobacco products, even though they contain no tobacco.

The FDA declined to appeal the ruling but has served notice that it might propose rules that would, in fact, regulate e-cigarettes as tobacco products. The agency suggested it could issue a Notice of Proposed Rule Making sometime this month.

Welcomes regulation

Not all in the industry, it turns out, fear FDA regulation. Eli Alelov, CEO of LOGIC Technology, a maker of e-cigarettes, thinks some regulation is overdue. He told ConsumerAffairs that he wants to see manufacturing standards and age restrictions.

“I support raising the bar for the industry,” Alelov said. “Right now my biggest enemy is not the FDA, it's these 'me too' brands that come into the market with cheap electronic cigarettes, trying to make a buck, and they're putting lousy products on the market. That's hurting the entire industry.”

Alelov's company makes e-cigarettes in only two flavors – tobacco and menthol. He says the wide variety of fruit flavored e-cigarettes offered by other companies don't appeal to people who smoke cigarettes, but instead appeal to young people who don't smoke.

Children, he says, should not be using his product and he is in favor of restricting Internet sales.

“A 13-year-old girl should not have the option to buy electronic cigarettes just because she clicks on a button that says 'Yes, I'm 18' and then makes the purchase with her mother's credit card,” he said.

Passionate customers

E-cigarettes give smokers many of the same pleasures as smoking a cigarette. They are the same shape, they generate water vapor that can be inhaled and the water vapor contains nicotine, which satisfies an addictive craving. E-cigarette makers and their growing number of customers say the products are safer than smoking, a claim hotly denied by anti-tobacco groups. There is little scientific research so far to support either side.

The industry and its passionate customers have formed the Consumer Advocates for Smoke-Free Alternatives Association (CASAA) to try and head off what they view as onerous regulations that might relegate them once again to shivering in the cold outside buildings to have a smoke. Because there is no secondhand smoke with e-cigarettes, they are currently allowed in many public venues, in a practice called “vaping” instead of smoking.

When the FDA announced it was considering a rule making on e-cigarettes, more than 27,000 people signed an online White House petition to prevent it. CASAA launched a special website to keep track of the FDA's activities.

“At this time we do not know which regulations the FDA intends to apply to e-cigarettes, but statements made by the FDA in its letter to stakeholders raises some concerns for electronic cigarette consumers and tobacco harm reduction advocates,” the group says on the site.

Tobacco tax?

In its 2010 ruling, the U.S. Court of Appeals may have pointed the way, by classifying e-cigarettes as tobacco products. As such, it could be argued they could fall under the same tobacco taxes that make cigarettes so expensive, even though they contain no tobacco. Whatever the FDA decides to do, its impact could well be felt internationally.

“The FDA is a big player in the global market,” Alelov said. “I think some countries are waiting to see what the American FDA is going to say about this product.”

Whatever the decision may be, Alelov says he thinks within five to seven years, nearly half of today's smokers will be “vaping” instead.

You're in a nice restaurant when you look up from your menu and see a fashionably dressed young woman at the next table puffing away on a cigarette. Horrors! Smoking in a restaurant, in this day and age, in violation of who knows how many regulations and ordinances?

But on closer examination you see she is not smoking but “vaping,” enjoying most of the pleasures of smoking without breaking any rules – at least, not yet. That cigarette in her hand is actually an electronic cigarette, an e-cigarette. The smoke is actually water vapor, used to deliver flavored nicotine.

A growing number of smokers are giving up tobacco for e-cigarettes and for the most part, they're not using them as a way to stop their tobacco habit.

In fact, e-cigarette makers take great pains not to promote these devices as smoking-cessation aids. Were they to do so the products would be considered medicine and fall under the regulation of the Food and Drug Administration. (FDA).

Alternative to tobacco

Instead, consumers are embracing e-cigarettes as an alternative to tobacco cigarettes. They get the same hit of nicotine but avoid the thousands of chemicals found in cigarette smoke.

Electronic Cigarettes Inc. maintains a Facebook page where customers can post comments.

“I just celebrated my 11th month as a non-smoker and I have VaporKing E-Cigs to thank for that,” a customer named Anne wrote.

Note that she's been vaping for nearly a year and apparently doesn't miss cigarettes. It also sounds like she has no intention of kicking the vaping habit anytime soon.

That's what makes e-cigarettes such a booming business. Consumers aren't using them for a few months to ween themselves from cigarettes, then ending their use of the product. They enjoy vaping and apparently plan to keep doing it. After all, vaping is a lot cheaper than smoking.

“I just reordered the Vapor King after losing mine in a move,” a customer named Patrick posted on the Electronic Cigarettes Facebook page. “Ill be paying off my Camaro with the savings and funding my new hobbies!”

Saving money

He's not exaggerating. A pack of cigarettes can be more than $6 these days, thanks to the heavy federal and state taxes that are designed to discourage smoking. But these taxes also provide a significant revenue stream for governments. At least, until now.

A consumer who once smoked a pack of cigarettes a day but switches to e-cigarettes can literally save thousands of dollars a year. Governments, meanwhile, stand to lose billions.

Another reason smokers are gladly becoming vapers is they are no longer social outcasts, huddled in the cold outside a building getting a quick smoke. With e-cigarettes they can enjoy the ritual of smoking, along with the nicotine rush, in a restaurant, bar or other public place.

Anti-smoking groups

All of this has not escaped the notice of health advocates and anti-smoking groups, who are only now grappling with this new phenomenon. Some have raised questions about the health effects of vaping.

“The FDA is concerned about the safety of these products and how they are marketed to the public,” FDA Commissioner Margaret A. Hamburg said recently.

She expressed concern that e-cigarettes can increase nicotine addiction among young people and may lead kids to try other tobacco products, including conventional cigarettes. The World Health Organization said in 2008 that there's no evidence that e-cigarettes are harmless, but as yet, no solid evidence that they cause harm.

If, in the future, anti-smoking groups present studies suggesting e-cigarettes are harmful, you can expect vapers to present their own research that suggests they aren't.

Vapers have their own organization, the Consumer Advocates for Smoke-free Alternatives Association (CASAA), which recently began raising money to fund health reseach on e-cigarettes. It doesn't plan to sit by while the same curbs that were placed incrementally on tobacco are placed on e-cigarettes.

“CASAA will continue to be the leader in political actions to stop state and local anti-THR in the USA, and increasingly we are taking political action at the federal level,” the group said in a statement. “We will also continue to provide education internationally through our websites and other activities.”

Vapers appear to be passionate on the subject. When ConsumerAffairs recently reported on an anti-smoking group's attack on e-cigarettes, it produced a number of reader comments in defense of e-cigarettes.

“Find out how many people have quit smoking with these,” a reader named Jason posted. “Find out how many lives have been saved by electronic cigarettes. Tell people how well other smoking cessation devices work.”

A recent study by the Centers for Disease Control and Prevention (CDC) found that about 21% of adults who smoke traditional cigarettes had used e-cigarettes in 2011, compared with about 10 percent in 2010.

Overall, about six percent of all adults have tried e-cigarettes, with estimates nearly doubling from 2010. The study is the first to report changes in awareness and use of e-cigarettes between 2010 and 2011. 

While the jury is still out in the U.S., several countries, including Australia, Brazil and Canada have banned e-cigarettes while others have placed restrictions on their sale and use.  

If you are a cigarette smoker, would you give up the real thing for one of those electronic jobs? A lot of people have tried them.

A study released the Centers for Disease Control and Prevention (CDC) found that about 21% of adults who smoke traditional cigarettes had used e-cigarettes in 2011, compared with about 10 percent in 2010.

Overall, about six percent of all adults have tried e-cigarettes, with estimates nearly doubling from 2010. The study is the first to report changes in awareness and use of e-cigarettes between 2010 and 2011.

Moving to e-smokes

During 2010–2011, adults who have used e-cigarettes increased among both sexes, non-Hispanic whites, those aged 45–54 years, those living in the South, and current and former smokers and current and former smokers.

In both 2010 and 2011, e-cigarette use was significantly higher among current smokers compared to both former and never smokers. Awareness of e-cigarettes rose from about four in 10 adults in 2010 to six in 10 adults in 2011.

“E-cigarette use is growing rapidly,” said CDC Director Tom Frieden, MD, MPH. “There is still a lot we don’t know about these products, including whether they will decrease or increase use of traditional cigarettes.”

Is it safer?

Although e-cigarettes appear to have far fewer of the toxins found in smoke compared with traditional cigarettes, the impact of e-cigarettes on long-term health must be studied. Research is needed to assess how e-cigarette marketing could impact initiation and use of traditional cigarettes, particularly among young people.

“If large numbers of adult smokers become users of both traditional cigarettes and e-cigarettes -- rather than using e-cigarettes to quit cigarettes completely -- the net public health effect could be quite negative,” said Tim McAfee, MD MPH, director of the Office on Smoking and Health at CDC.

Everything else is electronic today, so why not cigarettes? That seems to be the thinking behind the growing use of electronic cigarettes, though whether this is a good thing is open to question.

If e-cigarettes replace traditional cigarettes, the net effect might be good, since the e-cigs emit fewer toxins than the real thing. But if people end up using both -- like avid readers who tote around both books and e-books -- it would be a different story, health officials say.

“If large numbers of adult smokers become users of both traditional cigarettes and e-cigarettes — rather than using e-cigarettes to quit cigarettes completely — the net public health effect could be quite negative,” said Tim McAfee, MD MPH, director of the Office on Smoking and Health at the Centers for Disease Control and Prevention (CDC).

Research is needed to assess how e-cigarette marketing could impact initiation and use of traditional cigarettes, particularly among young people, the CDC said.

Anti-smokers huff and puff

One group that's already made up its mind is Americans for Non-Smokers Rights. It's gone on a crusade against the marketers of e-cigarettes, claiming they are using press releases and social media to tout the benefits of their product, despite a lack of independent peer-reviewed scientific evidence demonstrating the safety or effectiveness.

E-cigarettes don't just produce harmless water vapor, the group claims. Instead, they say, they pollute indoor air with detectable levels of carcinogens and other toxic chemicals.

"What I find most egregious are the direct advertisements with false and misleading claims, including that e-cigarettes are effective smoking cessation devices, that e-cigarette use is permissible in all indoor environments, including venues that are smoke-free, and targeting pregnant women claiming that e-cigarettes are safer and healthier than other tobacco products," said Cynthia Hallett, executive director of Americans for Non-Smokers Rights.

Usage is up

One thing's sure: more people are trying e-cigarettes.

In 2011, about 21 percent of adults who smoke traditional cigarettes had used electronic cigarettes, also known as e-cigarettes, up from about 10 percent in 2010, according to a study released today by the CDC.  

Overall, about six percent of all adults have tried e-cigarettes, with estimates nearly doubling from 2010.

“E-cigarette use is growing rapidly,” said CDC Director Tom Frieden, MD, MPH. “There is still a lot we don’t know about these products, including whether they will decrease or increase use of traditional cigarettes.”

During 2010–2011, adults who have used e-cigarettes increased among both sexes, non-Hispanic Whites, those aged 45–54 years, those living in the South, and current and former smokers and current and former smokers.  In both 2010 and 2011, e-cigarette use was significantly higher among current smokers compared to both former and never smokers. 

Awareness of e-cigarettes rose from about four in 10 adults in 2010 to six in 10 adults in 2011.