Electronic cigarette use and exposure in the pediatric population.
ABSTRACT: Electronic cigarette (e-cigarette) use has gained recent widespread popularity and acceptance in the general population. What effect e-cigarettes may have on pediatric health remains unknown. Although many jurisdictions have laws that prevent the sale of e-cigarettes to minors and the use of e-cigarettes in public places, infants, children, and adolescents are increasingly exposed to them. In this pediatric-focused review, we discuss the history of these devices, user demographics, known health effects, and current legislative efforts to protect minors from exposure.
Project description:To assess how easily minors can purchase cigarettes online and online cigarette vendors' compliance with federal age/ID verification and shipping regulations, North Carolina's 2013 tobacco age verification law, and federal prohibitions on the sale of non-menthol flavoured cigarettes or those labelled or advertised as 'light'.In early 2014, 10 minors aged 14-17 attempted to purchase cigarettes by credit card and electronic check from 68 popular internet vendors.Minors received cigarettes from 32.4% of purchase attempts, all delivered by the US Postal Service (USPS) from overseas sellers. None failed due to age/ID verification. All failures were due to payment processing problems. USPS left 63.6% of delivered orders at the door with the remainder handed to minors with no age verification. 70.6% of vendors advertised light cigarettes and 60.3% flavoured, with 23.5% and 11.8%, respectively, delivered to the teens. Study credit cards were exposed to an estimated $7000 of fraudulent charges.Despite years of regulations restricting internet cigarette sales, poor vendor compliance and lack of shipper and federal enforcement leaves minors still able to obtain cigarettes (including 'light' and flavoured) online. The internet cigarette marketplace has shifted overseas, exposing buyers to widespread credit card fraud. Federal agencies should rigorously enforce existing internet cigarette sales laws to prevent illegal shipments from reaching US consumers, shut down non-compliant and fraudulent websites, and stop the theft and fraudulent use of credit card information provided online. Future studies should assess whether these agencies begin adequately enforcing the existing laws.
Project description:Tobacco policies that limit the sale of cigarettes to minors and restrict smoking in public places are important strategies to deter youth from accessing and consuming cigarettes.We examined the relationship of youth cigarette smoking status to state-level youth access and clean indoor air laws, controlling for sociodemographic characteristics and cigarette price. Data were analyzed from the 2001 to 2002 U.S. Health Behavior in School-Aged Children survey, a cross-sectional survey conducted with a nationally representative sample of 13,339 students in the United States.Compared with students living in states with strict regulations, those living in states with no or minimal restrictions, particularly high school students, were more likely to be daily smokers. These effects were somewhat reduced when logistic regressions were adjusted for sociodemographic characteristics and cigarette price, suggesting that higher cigarette prices may discourage youth to access and consume cigarettes independent of other tobacco control measures.Strict tobacco control legislation could decrease the potential of youth experimenting with cigarettes or becoming daily smokers. The findings are consistent with the hypothesis that smoking policies, particularly clean indoor air provisions, reduce smoking prevalence among high school students.
Project description:This study aimed to gauge the Hong Kong's public support towards new e-cigarette regulation, and examine the associated factors of the support. We conducted a two-stage, randomized cross-sectional telephone-based survey to assess the public support towards the banning of e-cigarette promotion and advertisement, its use in smoke-free venues, the sale to people aged under 18, and regulating the sale of nicotine-free e-cigarettes. Adults (aged 15 years or above) who were never smoking (n = 1706), ex-smoking (n = 1712) or currently smoking (n = 1834) were included. Over half (57.8%) supported all the four regulations. Banning of e-cigarette promotion and advertisement (71.7%) received slightly less support than the other three regulations (banning of e-cigarette use in smoke-free venues (81.5%); banning of e-cigarette sale to minors (93.9%); sale restriction of nicotine-free e-cigarettes (80.9%)). Current smokers, and perceiving e-cigarettes as less harmful than traditional cigarettes or not knowing the harmfulness, were associated with a lower level of support. Our findings showed a strong public support for further regulation of e-cigarettes in Hong Kong. Current stringent measures on tobacco and e-cigarettes, and media reports on the harmfulness of e-cigarettes may underpin the strong support for the regulation.
Project description:Importance:Millions of Americans use electronic cigarettes (e-cigarettes). A growing number of state and local governments have started to draft and implement laws regarding the sale, marketing, and use of e-cigarettes. The association of US state regulations regarding e-cigarettes with e-cigarette use remains unknown. Objective:To examine the association of US state regulations regarding e-cigarettes with current e-cigarette use among adults in the United States. Design, Setting, and Participants:This cross-sectional study included adults aged 18 years or older from the 2016 and 2017 Behavioral Risk Factor Surveillance System, which is a nationwide, telephone-administered survey that collects state-representative data on health-related risk behaviors, chronic health conditions, and use of preventive services. Data analysis was performed from February 1, 2019, to April 31, 2019. Exposures:United States state laws regulating e-cigarette use, including prohibiting e-cigarette use in indoor areas of private workplaces, restaurants, and bars; requiring retailers to purchase a license to sell e-cigarettes; prohibiting self-service displays of e-cigarettes; prohibiting sales of tobacco products, including e-cigarettes, to persons younger than 21 years; and e-cigarette taxes. Main Outcomes and Measures:Current use of e-cigarettes. Results:Among 894?997 participants aged 18 years or older (503?688 women [51.3%], 679?443 non-Hispanic white [62.6%], 71?730 non-Hispanic black [16.3%], 69?823 Hispanic [11.4%], and 74?001 non-Hispanic other races [9.8%]), 28?907 (weighted prevalence, 4.4%) were currently using e-cigarettes. The age-standardized weighted prevalence of current e-cigarette use varied across US states and territories, from 1.0% in Puerto Rico to 6.2% in Guam. After adjustment for demographic, socioeconomic, and lifestyle factors, including conventional cigarette use, the odds ratios of current e-cigarette use were 0.90 (95% CI, 0.83-0.98) for state laws prohibiting e-cigarette use in indoor areas of private workplaces, restaurants, and bars; 0.90 (95% CI, 0.85-0.95) for state laws requiring retailers to purchase a license to sell e-cigarettes; 1.04 (95% CI, 0.99-1.09) for state laws prohibiting self-service displays of e-cigarettes; 0.86 (95% CI, 0.74-0.99) for state laws prohibiting sales of tobacco products, including e-cigarettes, to persons younger than 21 years; and 0.89 (95% CI, 0.83-0.96) for state laws applying taxes to e-cigarettes. Conclusions and Relevance:These findings suggest that several state regulations regarding e-cigarettes may be associated with reduced e-cigarette use among US adults.
Project description:We use difference-in-differences models and individual-level data from the national and state Youth Risk Behavior Surveillance System from 2005 to 2015 to examine the effects of e-cigarette minimum legal sale age (MLSA) laws on youth cigarette smoking, alcohol consumption, and marijuana use. Our results suggest that these laws increased youth smoking participation by about one percentage point and approximately half of the increased smoking participation could be attributed to smoking initiation. We find little evidence of higher cigarette smoking persisting beyond the point at which youth age out of the laws. Our results also show little effect of the laws on youth drinking, binge drinking, and marijuana use. Taking these together, our findings suggest a possible unintended effect of e-cigarette MLSA laws-rising cigarette use in the short term while youth are restricted from purchasing e-cigarettes.
Project description:BACKGROUND:Despite widespread age-of-sale restrictions on tobacco, adolescents continue to obtain cigarettes and experiment with smoking. This mixed-methods study aimed to understand how European adolescents access cigarettes and how the policy context may influence this process, using a realist evaluation approach. This is the first study to assess access to cigarettes across various European contexts. METHODS:A survey of 4104 students was combined with qualitative data from focus groups among 319 adolescents aged 14-19 across seven European countries. Data were synthesized to explore mechanisms via which young people obtain cigarettes despite age-of-sale restrictions. RESULTS:While purchasing cigarettes from supermarkets was widely regarded as difficult, many participants purchased cigarettes from noncompliant retailers (often in smaller shops or cafes). Other contra-mechanisms included circumventing age checks, proxy purchases, and/or social sources. Dominant forms of access differed across the seven contexts, with direct purchases more common where perceived enforcement was low (eg, Belgium) and proxy purchases more important where perceived enforcement of age-of-sale laws was high (eg, Finland). The effectiveness of age-of-sale restrictions in reducing youth access appears to be influenced by a range of contextual factors including retailer compliance, the availability of vending machines, and the specific minimum age-of-sale. CONCLUSIONS:Our findings illustrate the relevance of programme theory in understanding the contra-mechanisms that undermine the effectiveness of age-of-sale laws in discouraging youth smoking. Young people's access to cigarettes could be further limited by addressing these contra-mechanisms, including an increase in the legal sales age (particularly in Belgium), banning vending machines, and strengthening enforcement. IMPLICATIONS:Despite widespread implementation of age-of-sale laws, a substantial proportion of minors continue to access cigarettes. Young people use a number of contra-mechanisms to circumvent age-of-sale restrictions. These include accessing cigarettes via social sources, proxy sales or by circumventing age checks. Our findings show that in contexts where perceived enforcement of age-of-sale restrictions is high, young people are more reliant on irregular forms of access such as proxy sales. Young people's access to cigarettes may be further reduced by policy interventions that address these contra-mechanisms-for example, banning vending machines, strengthening enforcement of age-of-sale laws, and increasing the minimum age-of-sale.
Project description:BACKGROUND:According to the Juvenile Protection Act in Korea, no one is allowed to sell, rent, or distribute tobacco products to adolescents. Furthermore, the Framework Convention on Tobacco Control Article 16 prohibits the sale of tobacco products to minors. In this study, we investigated the trends in and associated factors of the ease of cigarette purchase among Korean adolescents from 2005 to 2016. METHODS:The analyses were based on the data of the Korea Youth Risk Behavior Web-based Survey. We estimated the trends in the ease of cigarette purchase from 2005 to 2016 and evaluated associated factors. Ease of cigarette purchase was defined as the proportion of adolescents who were able to purchase cigarettes from among those who had tried to purchase cigarettes in the past 30 days. RESULTS:The ease of cigarette purchase began decreasing since 2008 (81.3%) compared to 2005 (83.9%). It decreased to 76.5% in 2013 and further decreased to 71.4% in 2016. The ease of cigarette purchase increased for adolescents who were in higher grades, smoked larger amounts of cigarettes per day, lived in metropolitan cities, had problematic drinking in the past year, and had close friends who smoked. It decreased in adolescents who had current smokers among their family members. CONCLUSIONS:Although the proportion of adolescents who were able to purchase cigarettes significantly decreased starting in 2008, more than 70% of Korean adolescents can still purchase cigarettes. Enforcement of the Juvenile Protection Act must be strengthened in order to prevent cigarette use among adolescents.
Project description:Importance:Banning electronic cigarette (e-cigarette) sales to minors has been a key policy to protect children from e-cigarettes in the United States and Canada, but to date little is known about the outcome of such a ban. Objectives:To investigate the association of banning e-cigarette sales to minors in Canada with e-cigarette use among youths and the mechanisms through which a ban might be associated with their e-cigarette use. Design, Setting, and Participants:This quasi-experimental difference-in-differences and triple-differences study used data from the nationally representative Canadian Tobacco, Alcohol and Drugs Survey (2013-2017) and Canadian Student Tobacco, Alcohol and Drugs Survey (2014-2017). Study samples consisted of respondents aged 15 to 18 years (in difference-in-differences analysis; n?=?8212) and aged 15 to 25 years (in triple-differences analysis; n?=?20?934) in the Canadian Tobacco, Alcohol and Drugs Survey, and students in grades 6 to 12 (in difference-in-differences analysis; n?=?78?650) in the Canadian Student Tobacco, Alcohol and Drugs Survey. Interventions:Canada's provincial bans on e-cigarette sales to youths younger than 18 or 19 years (depending on province) implemented between 2015 and 2017. Main Outcomes and Measures:The primary outcome was past 30-day e-cigarette use among youths. Secondary outcomes were difficulty of access to e-cigarettes, perception of e-cigarette harm, and use of social sources of e-cigarettes. Results:After the bans, e-cigarette use among youths increased in all provinces, but the increase was 3.1 percentage points (95% CI, 0.2-6.0; P?=?.04), or 79%, lower in provinces with a ban than in provinces without a ban. Youths in provinces with a ban were 2.6 percentage points (95% CI, 1.5-3.7; P?=?.001), or 18%, less likely to believe that regular e-cigarette use poses no harm and 6.2 percentage points (95% CI, 1.1-11.4; P?=?.02), or 16%, more likely to self-report greater difficulty in obtaining e-cigarettes. Among youths who reported using e-cigarettes, the likelihood of obtaining e-cigarettes from social sources was 17.3 percentage points (95% CI, 5.2 -29.4; P?=?.01), or 29%, higher in provinces with a ban. These findings were robust to several sensitivity analyses. Conclusions and Relevance:Banning e-cigarette sales to minors was associated with a significant reduction in the rate of increase in e-cigarette use by youths, but this policy alone could not reverse the overall increase in e-cigarette use. The findings from this study suggest that this policy should be supplemented with other measures that can reduce young people's desire to obtain e-cigarettes through social sources, such as a ban on e-cigarettes with flavors that appeal to youths and children.
Project description:To determine the accuracy of the labeled quantity of the nicotine content of the e-liquids sold in unlicensed vape stores, whether the packaging of e-liquids sold within the vape stores was child-resistant, whether minors were present within vape stores, and whether sales to minors occurred. This study was conducted across North Dakota prior to implementation of a new e-cigarette state law and provided a baseline assessment before enactment of the new legal requirements.We tested samples of e-liquids and performed observations in 16 stores that were selling e-cigarettes but were not legally required to be licensed for tobacco retail. The e-liquids were analyzed for nicotine content using a validated high-performance liquid chromatography method for nicotine analysis.Of the 70 collected e-liquid samples that claimed to contain nicotine, 17% contained more than the labeled quantity and 34% contained less than the labeled quantity by 10% or more, with one sample containing 172% more than the labeled quantity. Of the 94 e-liquid containers sampled, only 35% were determined to be child-resistant. Minors were present in stores, although no sales to minors occurred.Mislabeling of nicotine in e-liquids is common and exposes the user to the harmful effects of nicotine. The lack of child-resistant packaging for this potentially toxic substance is a serious public health problem. E-cigarettes should be included in the legal definition of tobacco products, child-resistant packaging and nicotine labeling laws should be enacted and strictly enforced, and vape stores should be licensed by states.
Project description:BACKGROUND:How electronic cigarettes and similar products (e-cigarettes) are defined affects how they are regulated, particularly whether existing laws for cigarettes apply, including sales and marketing, youth access, smoke-free and taxation laws. METHODS:We examined the text of 46 bills that define e-cigarettes enacted in 40 states and characterised how e-cigarettes and similar products were defined. RESULTS:States enact laws creating new product categories for e-cigarettes separate from the 'tobacco product' category (eg, 'alternative nicotine product,' 'vapour product,' 'electronic nicotine device'), with four states explicitly excluding e-cigarettes from 'tobacco products.' Twenty-eight states do not include e-cigarettes in their definitions of 'tobacco products' or 'smoking,' eight include e-cigarettes as 'tobacco products,' three include e-cigarettes in 'smoking.' Sixteen states' definitions of e-cigarettes require nicotine, and five states pre-empt more stringent local laws. Tobacco and e-cigarette industry representatives tried to shape laws that benefit their interests. CONCLUSIONS:Definitions separating e-cigarettes from other tobacco products are common. Similar to past 'Trojan horse' policies, e-cigarette policies that initially appear to restrict sales (eg, limit youth access) may actually undermine regulation if they establish local pre-emption or create definitions that divide e-cigarettes from other tobacco products. Comparable issues are raised by the European Union Tobacco Products Directive and e-cigarette regulations in other countries. Policymakers should carefully draft legislation with definitions of e-cigarettes that broadly define the products, do not require nicotine or tobacco, do not pre-empt stronger regulations and explicitly include e-cigarettes in smoke-free and taxation laws.