E-Cigarette Use is an Important Public Health Problem in the United States

The most prevalent form of nicotine product amongst middle and high school students in the United States are e-cigarettes. E-cigarettes are battery powered devices that include nicotine and other additives in the form of an aerosol.¹ E-cigarettes are different from cigarettes in that they come in different sizes and shapes and are comprised of multiple components (e.g., juice, device, battery). E-cigarette marketing claims (e.g. of product safety) are important drivers of e-cigarette uptake and use among young people.^2,3 E-cigarettes emit toxic substances, and their use leads to nicotine dependence and increased risk of cigarette smoking initiation among young people.^4,5 As a result, the FDA Commissioner declared in 2018 that e-cigarette use among youth reached “nothing short of an epidemic proportion of growth”.⁶

According to the National Youth Tobacco Survey in 2016, the most common reasons for e-cigarette use amongst youth include the assumptions that e-cigarettes are less harmful than cigarettes, the variety and availability of flavors, and the social exposure to e-cigarettes from friends and family.⁷ The National Youth Tobacco Survey (NYTS) assessed self-reported reasons for e-cigarette use among middle and high school students in the US. The most commonly selected reasons for US middle and high school students who reported having used e-cigarettes during the past 30 days were used by “friend or family member” (39%), availability of “flavors such as mint, candy, fruit, or chocolate” (31.0%) and the belief that “they are less harmful than other forms of tobacco such as cigarettes” (17.1%).⁸ During 2017-2018, e-cigarette use increased considerably among U.S middle and high school students.

The Importance of Communicating the Health Risks of E-Cigarette Use

Less evidence exists on the health risks of e-cigarettes, as it is a relatively new product that has emerged in recent years. Nonetheless, recent studies suggest that the use of e-cigarettes may have a negative impact on cardiovascular health.⁹ E-cigarettes are now the leading tobacco/nicotine product among young people in the US, where 27.5% of high school students in 2019 and 9.2% of young adults (18-24 years) in 2016 were current e-cigarette users.^10,11 According to national surveillance systems, between 2017 to 2018, E-cigarette use has increased by 46.2% among young adults, and 78% among high school students.^12,13 Young people are particularly prone to e-cigarettes due to their novelty, social acceptability, flavors, misperceptions of safety, and targeted industry marketing.^14,15

Flavorings on e-cigarette products are a largely unrecognized potential hazard that contain respiratory toxins. They create ultrafine aerosols that are inhaled deeply into the lungs, increasing the risk of developing lung disease.¹⁶ The liquid found in e-cigarettes contains nicotine, an addictive chemical, that can affect the development of the hippocampus a cerebral cortex among adolescents.¹⁷ Accumulating evidence shows that e-cigarette use is associated with nicotine dependence, acute respiratory symptoms, and increased risk of cigarette smoking initiation among young people.^18,4,5 

Accordingly, there is an urgent need to respond to the e-cigarette epidemic among US youth, with communicating e-cigarette risks to young people being a cornerstone of such response.¹⁹ Communicating the health risks associated with e-cigarettes is important in order to reduce tobacco related harms and the overall use of e-cigarettes amongst youth and has been endorsed by leading health organizations.^10,5 In order to assess the health warning labels developed for our project, the message impact framework will be utilized. The message impact framework, a successful model used in cigarette health warning labels research²⁰, assumes that feautures on health warning labels can lead to behavioral change and a chain of psychological events such as attracting users, influencing emotions (e.g attention, fear), affecting cognitive reactions such as thinking about the risk (harm perception), inducing intention to change the behavior (intention to quit), and ultimately behavior change (e.g reducing or quitting use).

References

1. Pratiti R, Mukherjee D. Epidemiology and Adverse Consequences of Hookah/Waterpipe Use: A Systematic Review. Cardiovasc Hematol Agents Med Chem. 2019;17(2):82-93. doi: 10.2174/1871525717666190904151856. PMID: 31483237.
2. Salloum RG, Thrasher JF, Getz KR, Barnett TE, Asfar T, Maziak W. Patterns of waterpipe tobacco smoking among US young adults, 2013− 2014. American journal of preventive medicine. 2017;52(4):507-512.
3. Wang TW, Gentzke A, Sharapova S, Cullen KA, Ambrose BK, Jamal A. Tobacco product use among middle and high school students—United States, 2011–2017. Morbidity and Mortality Weekly Report. 2018;67(22):629.
4. Florida Department of Health (2018). "Tobacco Use in Florida Youth Ages 11-17: 2012 - 2017." from http://www.floridahealth.gov/statistics-and-data/survey-data/florida-youth-survey/florida-youth-tobacco-survey/_documents/FYTS%20State%20Tables%202012-2017%20final.pdf
5. Florida Department of Health (2020). "Tobacco Use in Florida Youth Ages 11-17: 2014 - 2020." http://www.floridahealth.gov/statistics-and-data/survey-data/florida-youth-survey/florida-youth-tobacco-survey/FYTS2020StateLevelReport.pdf
6. Jawad, M., et al. (2013). "To what extent should waterpipe tobacco smoking become a public health priority?" Addiction 108(11): 1873-1884.
7. El-Zaatari, Z. M., et al. (2015). "Health effects associated with waterpipe smoking." Tobacco control: tobaccocontrol-2014-051908.
8. Waziry R, Jawad M, Ballout RA, et al. The effects of waterpipe tobacco smoking on health outcomes: an updated systematic review and meta-analysis. Int J Epidemiol 2017;46:32–43.
9. Monzer, B., et al. (2008). "Charcoal emissions as a source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke." Food and Chemical Toxicology 46(9): 2991-2995.
10. Nguyen, T., et al. (2013). "Charcoal burning as a source of polyaromatic hydrocarbons in waterpipe smoking." Journal of Environmental Science and Health, Part B 48(12): 1097-1102.
11. Center for Diseases Prevention and Control (CDC). Smoking and Tobacco Use. Hookahs. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/ hookahs/ 
12. Martin, J. (2009) Booming hookah biz links China, Iran, Egypt - and Texas CNNMoney
13. Center for Diseases Prevention and Control (2018). Hookahs. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/index.htm
14. Fromme, H., et al. (2009). "Indoor air contamination during a waterpipe (narghile) smoking session." Food and Chemical Toxicology 47(7): 1636-1641.
15. Awan KH, Siddiqi K, Patil S, et al. Assessing the effect of waterpipe smoking on cancer outcome - a systematic review of current evidence. Asian Pac J Cancer Prev 2017;18:495.
16. Aboaziza E, Eissenberg T. Waterpipe tobacco smoking: what is the evidence that it supports nicotine/tobacco dependence? Tob Control 2015;24(Suppl 1):i44–i53.
17. Kassem NO, Daffa RM, Liles S, et al. Children’s exposure to secondhand and thirdhand smoke carcinogens and toxicants in homes of hookah smokers. Nicotine Tob Res 2014;16:961–75.
18. Tamim H, Yunis KA, Chemaitelly H, et al. Effect of narghile and cigarette smoking on newborn birthweight. BJOG 2008;115:91–7.
19. Nuwayhid IA, Yamout B, Azar G, et al. Narghile (hubble-bubble) smoking, low birth weight, and other pregnancy outcomes. Am J Epidemiol 1998;148:375–83.
20. Jacob P, Abu Raddaha AH, Dempsey D, et al. Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe. Cancer Epidemiol Biomarkers Prev 2011;20:2345–53.
21. Cobb C, Ward KD, Maziak W, et al. Waterpipe tobacco smoking: an emerging health crisis in the United States. Am J Health Behav 2010;34:275–85.