It’s Time to Stop E-Cigarette Manufacturers From Blowing Smoke About Youth Tobacco Use

The use of e-cigarettes among our nation’s kids is on the rise. This is why Senator Durbin has introduced bipartisan legislation to crack down on e-cigarette companies (https://www.durbin.senate.gov/issues/health-care) that target children with kid-friendly flavors and marketing tactics. SAFE Kids Act would give these companies one year to prove that their products do not result in more children vaping or smoking, do not harm the user, and actually help adults quit smoking cigarettes.

Then e-cigarettes arrived. Developed to support smoking reduction and cessation through a step-down program, the technology presented adults with an avenue to gradually end decades of addiction. But rather than reduce tobacco’s burden on society, e-cigarettes merely shifted it from adults to children. “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; these products can be used discreetly, have a high nicotine content, and come in flavors that appeal to youths,” the Centers for Disease Control and Prevention said (https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm).

E-cigarette manufacturers such as JUUL were quick to capitalize on the opportunity to market their products to hook those new, young users. “When JUUL first launched in 2015, the company used colorful, eye-catching designs and youth-oriented imagery and themes, such as young people dancing and using JUUL,” the Campaign for Tobacco Free Kids reported (https://www.tobaccofreekids.org/assets/factsheets/0394.pdf). “JUUL’s original marketing campaign included billboards in New York City’s Times Square, YouTube videos, advertising in Vice Magazine, launch parties, and a sampling tour.”

The marketing onslaught continues today as the companies turned to social media’s ubiquitous access to youth. In January 2023, the antitobacco group Truth Initiative published a research brief (https://www.frontiersin.org/articles/10.3389/fpubh.2022.1001115/full) that demonstrated the effects of social media influencers’ promotion of vaping products. Truth Initiative harkened the sites’ “endless onslaught of content that runs the gamut from personal artistic expression to branded product advertisements” and called for “clear, unambiguous guidelines to differentiate commercial content from organic content. The aim of a lot of vaping content on Instagram is not ambiguous including clearly branded and commercial-oriented promotion of specific vaping products.”

Regulation Is the First Step to Drive Down Dangerous Youth Tobacco Use

America’s youth hear tobacco marketing messages loud and clear. According to results (https://www.fda.gov/tobacco-products/youth-and-tobacco/results-annual-national-youth-tobacco-survey) of the U.S. Food and Drug Administration’s (FDA’s) 2022 National Youth Tobacco Survey, “more than 1 in 10 middle and high school students (3.08 million) used a tobacco product during the past 30 days—including 16.5% of high school and 4.5% of middle school students.”

In August 2022, FDA’s Center for Tobacco Products (CTP) issued the agency’s first warning letter (https://www.fda.gov/news-events/press-announcements/fda-warns-manufacturer-marketing-illegal-flavored-nicotine-gummies) of its kind to VPR Brands LP for marketing illegal flavored nicotine gummies. In a public announcement about the letter, CTP cited study results (https://www.fda.gov/news-events/press-announcements/fda-warns-manufacturer-marketing-illegal-flavored-nicotine-gummies) that demonstrated gummies’ particularly high use “among certain racial or ethnic, sexual or gender minority groups, and those with a history of nicotine use” and that flavored non-tobacco oral nicotine products like the gummies “present an increased risk to youth due to their resemblance to kid-friendly food or candy, availability in youth-appealing flavors, and the ability for teenagers to conceal use from adults.”

Just three months later, CTP sent warning letters (https://www.fda.gov/news-events/press-announcements/fda-warns-firms-selling-illegal-e-cigarettes-look-toys-food-and-cartoon-characters) to five additional manufacturers for unauthorized marketing of 15 different e-cigarette products packaged to look like toys, food, or cartoon characters. In a January 2023 announcement (https://www.fda.gov/tobacco-products/ctp-newsroom/looking-back-looking-ahead-fdas-progress-tobacco-product-regulation-2022), CTP Director Brian King, PhD, MPH, reinforced the agency’s commitment to “monitoring the continually changing product marketplace with a focus on protecting youth.” He specifically pointed to those two rounds of warning letters, emphasizing that (https://www.fda.gov/tobacco-products/ctp-newsroom/looking-back-looking-ahead-fdas-progress-tobacco-product-regulation-2022) “the designs and packaging of these types of illegal products were a flagrant attempt to target kids, and FDA will continue to hold companies accountable for illegally selling unauthorized e-cigarettes, particularly those that shamelessly target youth.”

Congress Cites FDA’s ‘Repeated Failures’ and Challenges Agency to Work Faster

But are FDA’s actions too little, too late? When it comes to youth tobacco use, U.S. Congress has a level of outrage rarely publicized in the policy arena. In a scathing February 2023 letter (https://www.durbin.senate.gov/imo/media/doc/Senate%20Ltr%20to%20HHS%20re_%20FDA%20E-Cigarette%20Delays.pdf) to U.S. Department of Health and Human Services Secretary Xavier Becerra, U.S. Senators Dick Durbin (D-IL), Jeff Merkley (D-OR), Lisa Murkowski (R-AK), and Mitt Romney (R-UT) wrote, “We need an FDA that stands on the side of public health and our children, rather than becoming mired in delays or cowering to Big Tobacco’s lawyers. Together, we’ve made incredible progress in reducing the toll of death and suffering caused by tobacco and those who peddle that poison. But we are at a crossroads now. We ask you do everything in your power to right the ship and take meaningful action to fix FDA’s persistent leadership failures and prevent youth from a lifetime of nicotine addiction.”

The letter worked: a true representation of real public health advocacy in action. In late February, FDA proactively took aggressive, extraordinary steps. For the first time, the agency filed civil money penalty complaints (https://www.hhs.gov/sites/default/files/2020-cessation-sgr-executive-summary.pdf) against four tobacco companies for violating the Federal Food, Drug, and Cosmetic Act of premarket review, claiming that the manufacturers are distributing tobacco products they are not authorized to sell. “Holding manufacturers accountable for making or selling illegal tobacco products is a top priority for the FDA,” King said (https://www.fda.gov/news-events/press-announcements/fda-files-civil-money-penalty-complaints-against-four-e-cigarette-product-manufacturers). “We are prepared to use the full scope of our authorities to enforce the law—especially against those who have continued to violate the law after being warned by the agency.” 

ONS Perspective

Tipping the scales toward public health awareness about tobacco’s future impact on cancer in a virtual world with new entertainment and lax oversight is a never-ending challenge, particularly when the work is underfunded. Nurses know and advocate for prevention, especially in the youth smoking cessation movement, but the message is a hard sell against a coordinated campaign that uses celebrity, notoriety, and swag as rewards for unhealthy behavior. “Healthcare professionals alone cannot solve this public health challenge,” former U.S. Surgeon General Jerome Adams, MD, MPH, said (https://www.hhs.gov/sites/default/files/2020-cessation-sgr-executive-summary.pdf). “Everyone has a role in helping to continue to reduce the burden of tobacco use on our society. It is critical that clinical interventions be adopted alongside broader efforts at the health system and population levels to promote and cultivate successful cessation and tobacco-free norms.”