AAP policy calls for reforms to combat rise in youth e-cigarette use
Brian P.Jenssen, M.D., M.S.H.P., FAAP and Susan C.Walley, M.D., CTTS, FAAP
E-cigarettes have exploded in popularity among teens over the last decade, making
them the most common tobacco product used by youths. According to 2018 data, one in
five high school students and one in 20 middle school students use e-cigarettes, a
75% increase from 2017.
As a trusted source of health information, pediatricians can educate patients and
parents about the harms of these products to prevent youth initiation and guide treatment
options for tobacco users. Implementation of proven population-based strategies, in
coordination with Food and Drug Administration (FDA) regulation of tobacco products,
is key to reducing all forms of tobacco product use, including e-cigarettes, among
The updated AAP policy statement E-Cigarettes and Similar Devices summarizes the latest evidence on the health harms of e-cigarettes and supports both
clinical interventions by pediatricians and policy strategies to protect youths from
the epidemic of e-cigarette use. The policy, from the Section on Tobacco Control,
is available at https://doi.org/10.1542/peds.2018-3652 and will be published in the February issue of Pediatrics.
What is known about youths and e-cigarettes
E-cigarettes encompass a wide variety of devices known as vapes, mods, tanks and pod
systems, including popular brands like JUUL.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.E-cigarette advertising is associated with current e-cigarette use by youths.
E-cigarette solutions contain numerous toxicants and carcinogens. Nicotine, the major
psychoactive component of e-cigarette solution, is a highly addictive drug that can
damage brain development and has been linked to adverse health outcomes. Adolescents
and young adults who use e-cigarettes are at high risk of transitioning to traditional
cigarettes. The increasing use of e-cigarettes among youths threatens five decades
of public health gains in deglamorizing, restricting and decreasing use of tobacco
JUUL is a brand of e-cigarette known as a pod system with solution contained in prefilled
pods. JUUL is extremely popular with adolescents and young adults and holds 70% of
the market share. Its popularity is thought to be due in part to the discreet design
(i.e., looks like a flash drive) and sweet flavors. The nicotine concentration in
JUUL is higher than other e-cigarette brands, with each pod containing the same amount
of nicotine as a pack of cigarettes.
Significant gaps remain in e-cigarette regulation. At press time, federal laws and
regulations have not appropriately restricted the advertising of e-cigarettes to youths.
Furthermore, child-friendly flavors are available and marketed to youths.
In November 2018, the FDA announced steps to protect young people by restricting the
availability of some flavored e-cigarettes in certain locations. This was preceded
by a warning letter to JUUL and other e-cigarette manufacturers in September 2018
to voluntarily take actions to curb youth appeal.
The Academy continues to advocate for stronger regulation to protect youths from e-cigarettes.
Regulation, legislative action and counter promotion are critically needed to minimize
the potential public health harm from e-cigarette use and help youths live tobacco-free
Key actions for pediatricians
Screen for e-cigarette use and exposure and provide prevention counseling in clinical
Counsel that e-cigarettes and combustible tobacco products should be banned from homes,
cars and places where children and adolescents live, learn, play, work and visit.
Do not recommend e-cigarettes to treat tobacco dependence.
Public policy recommendations
Reduce youth access to e-cigarettes:
The FDA should act immediately to regulate e-cigarettes like traditional cigarettes
to protect public health.
Ban the sale of e-cigarettes to individuals younger than 21 years.
Ban internet sales of e-cigarettes and e-cigarette solution.
Reduce youth demand for e-cigarettes:
Ban all flavors, including menthol, in e-cigarettes.
Ban all e-cigarette product advertising and promotion that are accessible to children
Tax e-cigarettes at rates comparable to conventional cigarettes.
Incorporate e-cigarettes into tobacco-free laws and ordinances where children and
adolescents live, learn, play, work and visit.
Drs. Jenssen and Walley are lead authors of the policy statement. Dr. Walley is chair
of the AAP Section on Tobacco Control Executive Committee, and Dr. Jenssen is the
committee’s policy chair.