“The FDA is prepared to use all of its authorities to ensure these, and other illegal and youth-appealing products, stay out of the hands of kids. We are committed to a multipronged approach using regulation, compliance, and enforcement action and education to protect our nation’s youth.” 

FDA is taking more hardline tactics to combat the marketing, distribution, and sales of all tobacco products, especially to minors. With Califf’s statement as its opening salvo, the agency issued warning letters in June 2023 to 189 retailers selling tobacco products to underage users (https://www.fda.gov/media/169692/download), specifically citing companies that market electronic cigarettes and tobacco flavors like bubble gum and cotton candy that are clearly designed for aggressive outreach to children.  

E-cigarettes have been the most commonly used tobacco product among U.S. youth since 2014, U.S. Surgeon General Vivek H. Murthy, MD, MBA, reported (https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/pdfs/2016_sgr_entire_report_508.pdf). Murthy pointed to fun, kid-friendly flavors as key drivers of that usage. According to the Campaign for Tobacco-Free Kids (https://www.tobaccofreekids.org/what-we-do/us/flavored-tobacco-products), “More than 46% of high school e-cigarette users are vaping at least 20 days a month, and 30% are daily users. In total, 700,000 middle and high school students are vaping every single day.” 

FDA Finally Gets Legal Authority to Kick Big Tobacco’s Butts 

In 1998, Big Tobacco CEOs finally admitted to a congressional committee (https://www.washingtonpost.com/wp-srv/national/longterm/tobacco/stories/incongress013098.htm) that their products were addictive and contributed to the development of lung cancer. It was a stunning admission, an actual reversal, from an industry that had scrupulously denied any knowledge of nicotine in a negative light (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879177/#:~:text=A%20striking%20event%20occurred%20in,own%20scientists)%20showing%20the%20opposite). The subsequent Master Settlement Agreement, which was “the largest civil litigation settlement in U.S. history, changed tobacco control forever (https://truthinitiative.org/who-we-are/our-history/master-settlement-agreement)” by launching the nation’s first wave of limits on tobacco advertising, marketing, and promotion. 

Yet it took another decade for the U.S. Congress to pass the Family Smoking Prevention and Tobacco Control Act (https://www.fda.gov/tobacco-products/rules-regulations-and-guidance/family-smoking-prevention-and-tobacco-control-act-overview) in 2009, which finally granted FDA’s Center for Tobacco Products broad authority to regulate the industry. Once the government had considerably more control to restrict and prevent tobacco use, the numbers of new smokers plummeted (https://www.cdc.gov/media/releases/2019/p1114-smoking-low.html)—until e-cigarettes, flavored tobacco, and vaping devices entered the market.  

A New Adversary Emerges 

According to the Centers for Disease Control and Prevention (CDC), “E-cigarette unit sales increased by 46.6% from January 2020–December 2022 (https://www.cdc.gov/mmwr/volumes/72/wr/mm7225a1.htm?s_cid=mm7225a1_w). After January 2020, sales of mint and other flavored prefilled cartridges ceased, and disposable e-cigarettes in fruit, sweet, and other flavors increased. Disposable e-cigarettes in youth-appealing flavors are now more commonly sold than prefilled units.” 

CDC concluded (https://www.cdc.gov/mmwr/volumes/72/wr/mm7225a1.htm) that the United States must enact “comprehensive restrictions” on all flavored tobacco nationally. It also suggested that raising public awareness (https://www.cdc.gov/mmwr/volumes/72/wr/mm7225a1.htm) through campaigns using evidence-based strategies, such as price increases, comprehensive smokefree policies that include e-cigarettes, and counter-marketing campaigns, can reduce youth smoking and tobacco-related disparities. 

Youth Tobacco Use Is a Global Challenge 

In 2003, the World Health Organization (WHO) negotiated its first-ever international treaty: the WHO Framework Convention on Tobacco Control. Now “one of the most rapidly and widely embraced treaties in United Nations history (https://fctc.who.int/who-fctc/overview),” it was created to address the global tobacco epidemic (https://www.who.int/news-room/fact-sheets/detail/tobacco#:~:text=The%20tobacco%20epidemic%20is%20one,%2Dhand%20smoke%20(1).), “one of the biggest public health threats the world has ever faced, killing over 8 million people a year around the world. More than 7 million of those deaths are the result of direct tobacco use while around 1.3 million are the result of non-smokers being exposed to second-hand smoke.” Article 13 of the framework requires all countries that sign the convention (https://fctc.who.int/publications/m/item/the-who-framework-convention-on-tobacco-control-an-overview) to “undertake a comprehensive ban of all tobacco advertising, promotion, and sponsorship within five years of entry into force of the convention, including a cross-border advertising ban.” To date, 168 countries have signed the convention (https://treaties.un.org/pages/ViewDetails.aspx?src=IND&mtdsg_no=IX-4&chapter=9&clang=_en), representing 183 territories. 

According to the Campaign for Tobacco Free Kids, at least 24 countries ban the sale of e-cigarettes altogether (https://www.tobaccofreekids.org/what-we-do/global/electronic-cigarettes) and another 47 strictly regulate sales and marketing (https://www.tobaccofreekids.org/what-we-do/global/electronic-cigarettes). But much more work needs to be done. In a study of Big Tobacco’s international advertising strategies (https://doi.org/10.1136/tobaccocontrol-2021-057095), the Campaign for Tobacco-Free Kids found that in 42 mostly low- and middle-income countries, tobacco companies: 

• Placed ads near schools and playgrounds  

• Incentivized retailers to display cigarettes at children’s eye level, near sweets and snacks 

“The evidence is clear that tobacco companies push their deadly products at points of sale frequented by kids because they know this strategy works to attract youth and their business depends on addicting new consumers,” Yolonda Richardson, the Campaign for Tobacco-Free Kids’ executive vice president of global programs, said (https://www.tobaccofreekids.org/press-releases/2022_06_01_tobacco-advertising-near-schools-playgrounds). “The findings of this analysis underscore the urgent need for more countries to implement proven tobacco control solutions, including comprehensive prohibitions on all tobacco advertising, promotion, and sponsorship.  Without urgent and comprehensive action to ban cigarette advertising, the world’s largest tobacco companies will continue to capitalize on weak regulations to market cigarettes to children and youth.” 

ONS Perspective 

Nurses lead smoking reduction and cessation awareness. ONS endorses the International Society of Nurses in Cancer Care Tobacco Position Statement (https://www.ons.org/make-difference/ons-center-advocacy-and-health-policy/position-statements/isncc-tobacco-position), which included among its many recommendations that nurses must:  

• Be recognized as and empowered to be critical enablers in the fight against the global tobacco epidemic. 

• Take an active role in initiating and supporting local, national, regional, and international tobacco control policy and legislation. 

• Collaborate with other healthcare organizations, public health, and tobacco-control groups to strengthen and fund tobacco control at all levels. 

In ONS’s own Position Statement on E-Cigarettes and Vaping (https://www.ons.org/make-difference/ons-center-advocacy-and-health-policy/position-statements/e-cigarettes-and-vaping), the Society recommended that nurses: 

• Advocate for e-cigarette regulation like other tobacco products. 

• Acquire knowledge and inform consumers about evidence-based tobacco cessation alternatives and the potential harm of e-cigarettes. 

The ONS Tobacco, E-Cigarettes, and Vaping Learning Library (https://www.ons.org/learning-libraries/vaping) has the tools you need to turn the tides on tobacco by raising awareness, helping patients with tobacco treatment, and advocating for change locally in your community and on a national level. Raise your voice with ONS—together we can eradicate e-cigarette marketing and use in minors and transform the trajectory of tobacco’s influence on cancer across the world.