Youth ‘epidemic’ use of flavored tobacco products

From Tom Boo, MD, Mono County Health Department:

Adolescent and child use of addictive flavored tobacco products has reached epidemic levels in our communities and across the United States. Use of e-cigarettes (vaping) by high school students nearly doubled over the past year to over one in five kids, with
about one in ten middle school students also reporting current use of flavored
tobacco products.

Most of these kids are using flavored e-cigarettes, inhaling chemical aerosols
created by heating solutions containing nicotine and flavoring agents seemingly
developed for young people. With flavors such as Gummy Bear, Cotton Candy,
Berry Cobbler, Cherry Crush, Vivid Vanilla and host of others, e-cigarette liquids
are enticing to many youths.

Tobacco use is the leading cause of preventable disease, disability and death in
the United States, and the rapid rise in use by young people, driven by use of
flavored products, threatens to reverse recent progress in reducing tobacco use.

Among minors, e-cigarettes are the most commonly used tobacco product today
although child use of flavored cigars and smokeless tobacco (flavored snuff) is
unfortunately growing also.

Flavors are an essential part of the problem: Tobacco companies have long used
flavored products to entice new users because flavors improve taste and reduce
harshness. Congress banned flavored cigarettes (except menthol) in 2009
because the risks to minors was clear, but the Tobacco Control Act did not
address flavored cigars or e-cigarettes, which were little-known at that time.

Since then the tobacco industry has effectively exploited the shortcomings of this
federal law by developing countless flavored e-cigarette liquids, cigars and
smokeless (spit) tobacco, all of which are more popular among children and
young adults than they are with older tobacco users.

Over 80% of youth e-cigarette users say they use them “because they come in
flavors I like.” A government study found that 81% of 12-17 year old kids who had
used tobacco started with a flavored tobacco product.

Vaping is probably less harmful than smoking although e-cigarettes have not been
around long enough to understand long-term health risks. One risk is crystal clear:
e-cigarettes contain nicotine, which is highly addictive, and nicotine addiction too
often leads to smoking.

• Eighty percent of young smokers started vaping nicotine before they smoked.
• A 2016 study found that e-cigarette users are 6 times more likely to smoke
cigarettes compared to people who had never vaped nicotine. (Pediatrics,
Barrington-Trimis, et al., 2016)*.

• Almost all adult smokers began smoking when they were kids and close to 90%
started before they were 18 years old (

• JUUL’s phenomenal recent growth mirrors the alarming rise in child and
adolescent use • Kids 15-17 years old are SIXTEEN TIMES more likely to be
current JUUL users than young adults 25-34 years ( )
• Although JUUL liquid has a nicotine concentration about twice as high as most
other e-cigarettes a study found
that 63% of young JUUL users did not know that JUUL always contains nicotine ( )
• Products like JUUL, with higher nicotine levels, appear to pose greater risk:
studies show that young people vaping high nicotine products are more likely to
start smoking (Leventhal, et al, JAMA Pediatrics, 2018).

Nicotine is considered bad for young, developing brains. A 2016 report by the
U.S. Surgeon General noted that nicotine use in adolescence harms the parts of
the brain involved in attention, learning, mood and impulse control (E-cigarette
Use Among Youth and Young Adults: A Report of the Surgeon General
of Health and Human Services, CDC; 2016). Such neurobehavioral effects may
be lasting.

We do not know enough about other possible health effects of vaporized tobacco
products and flavorings.

E-cigarette aerosols have been found to contain at least ten chemicals that are on
California’s Proposition 65 list of chemicals known to cause cancer, birth defects
or other reproductive harm.

Little is known about the possible effects of inhaling aerosolized flavoring
chemicals. Most of these flavors are generally considered safe when ingested in
food but we simply do not know whether there are risks when such aldehydes and
ketones are heated and inhaled. Some of these chemicals cause harm to the
lungs of animals, and it seems reckless to permit human consumption of such
unstudied products (“Toxicological Concerns from Inhaled Food Flavorings Found
in Electronic (E-) Cigarette Aerosols: A Report from the Environmental
Health Investigations Branch”, CDPH, January 2017)

To combat rising child use of tobacco, in 2016 California raised the age for
purchasing tobacco products to 21 years (we are currently one of 6 states
requiring purchasers to be 21; in other states the age is 18).

But clearly the current approach is not working: three-quarters of teenage JUUL
users in a recent national survey reported that they had purchased JUUL products
at retail stores, over half had gotten it from friends or family, and 6% had
purchased JUUL over the internet.

Prompt actions at multiple levels are needed to reverse this addiction trend. U.S
Surgeon General Dr. Jerome Adams last month issued a warning about
e-cigarettes, with messages to parents, schools, healthcare providers and

The Surgeon General urges parents, teachers and healthcare providers to learn
more about flavored electronic nicotine delivery devices and the potential risks, to
talk to kids about the dangers and take other appropriate steps to discourage
use, including instituting school policies that more effectively deter all forms of
tobacco use.

Communities are advised to take steps to limit the access of minors to these

I endorse the Surgeon General’s advice but believe that even stronger action is
needed: We should ban the sale of flavored tobacco products completely, closing
the giant loopholes in the 2009 federal law. In 2018 Mono County
Mono County –
Healthy People, Healthy Communities became one of at least a dozen California
communities to prohibit the sale of flavored tobacco products in unincorporated
parts of the county. But the benefits of such bans are diminished by the continued
availability of these products in neighboring jurisdictions. I hope that the Town of
Mammoth Lakes and neighboring counties recognize that the exploding public
health threat of flavored tobacco products justifies making sales illegal, regardless
of age. …

Tom Boo, MD, FAAFP, Mono County Public Health Officer.

, ,

Oldest Most Voted
Inline Feedbacks
View all comments
4 years ago

Youth always have been and always will be easily influenced, back before we knew of the health risks Hollywood make smoking (cigarettes) appear cool and glamorous, way before my time.

4 years ago
Reply to  Tinner

You are right about kids being easily influenced. So when you tell them smoking marijuana is now legal, they see “cool”. And kids are also expert at spotting hypocrisy. If marijuana is cool, what’s wrong with e-cigs, which are less harmful to the brain than dope? You cannot expect to… Read more »

4 years ago
Reply to  vaguelynoble

If you think marijuana becoming legal made it look ‘cool’ to kids you aren’t the brightest candle on the cake.

3 years ago
Reply to  sugarmags

Maybe not the brightest candle on a cake with more than 50 candles. Sugar.

But I was referring to kids.

3 years ago
Reply to  vaguelynoble

Kids are experts at seeing hypocrisy? They don’t see anything beyond their iphones, let be real. As far as e-cigs being less harmful to the brain than weed, I don’t know, I know a whole lot of intelligent, educated, productive, successful, career driven people who are highly respected in society… Read more »

3 years ago
Reply to  Tinner

Wouldn’t be a good thing if everyone had health care so they could get to talk to a real doctor about their problems?
Maybe our taxes go up a little, but I know I’m paying 300 a month for lousy insurance right now.

Charles O. Jones
Charles O. Jones
3 years ago
Reply to  Trouble

The US is the only developed country that doesn’t provide some form of universal healthcare for its all of its citizens. In the US we pay an average of well over 8K per person annually for our healthcare, which over two times the average per capita cost for developed nations.… Read more »

4 years ago

You people need to turn this war on personal liberties off.
You ought to start focusing on making sure your kids get your house when you pass. Not our Hospitals and the IRS! Seriously!

4 years ago
Reply to  Trouble

Vote me down all you want, but you really should think about what our leaders keep shoving down our throats!
Do your kids and family a favor, support national health care for all. Look at Canada ,it works and they really have a middle class still!