Importance The prevalence of e-cigarette use among US youth increased from 2011 to 2018. Continued monitoring of the prevalence of e-cigarette and other tobacco product use among youth is important to inform public health policy, planning, and regulatory efforts. Objective To estimate the prevalence of e-cigarette use among US high school and middle school students in 2019 including frequency of use, brands used, and use of flavored products. Design, Setting, and Participants Cross-sectional analyses of a school-based nationally representative sample of 19 018 US students in grades 6 to 12 participating in the 2019 National Youth Tobacco Survey. The survey was conducted from February 15, 2019, to May 24, 2019. Main Outcomes and Measures Self-reported current (past 30-day) e-cigarette use estimates among high school and middle school students; frequent use (≥20 days in the past 30 days) and usual e-cigarette brand among current e-cigarette users; and use of flavored e-cigarettes and flavor types among current exclusive e-cigarette users (no use of other tobacco products) by school level and usual brand. Prevalence estimates were weighted to account for the complex sampling design. Results The survey included 10 097 high school students (mean [SD] age, 16.1 [3.0] years; 47.5% female) and 8837 middle school students (mean [SD] age, 12.7 [2.8] years; 48.7% female). The response rate was 66.3%. An estimated 27.5% (95% CI, 25.3%-29.7%) of high school students and 10.5% (95% CI, 9.4%-11.8%) of middle school students reported current e-cigarette use. Among current e-cigarette users, an estimated 34.2% (95% CI, 31.2%-37.3%) of high school students and 18.0% (95% CI, 15.2%-21.2%) of middle school students reported frequent use, and an estimated 63.6% (95% CI, 59.3%-67.8%) of high school students and 65.4% (95% CI, 60.6%-69.9%) of middle school students reported exclusive use of e-cigarettes. Among current e-cigarette users, an estimated 59.1% (95% CI, 54.8%-63.2%) of high school students and 54.1% (95% CI, 49.1%-59.0%) of middle school students reported JUUL as their usual e-cigarette brand in the past 30 days; among current e-cigarette users, 13.8% (95% CI, 12.0%-15.9%) of high school students and 16.8% (95% CI, 13.6%-20.7%) of middle school students reported not having a usual e-cigarette brand. Among current exclusive e-cigarette users, an estimated 72.2% (95% CI, 69.1%-75.1%) of high school students and 59.2% (95% CI, 54.8%-63.4%) of middle school students used flavored e-cigarettes, with fruit, menthol or mint, and candy, desserts, or other sweets being the most commonly reported flavors. Conclusions and Relevance In 2019, the prevalence of self-reported e-cigarette use was high among high school and middle school students, with many current e-cigarette users reporting frequent use and most of the exclusive e-cigarette users reporting use of flavored e-cigarettes.

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e-Cigarette Use Among Youth in the United States, 2019

2005년 담배규제기본협약이 발효된 후 현재 2009년 현재 164개국이 그 협약에 비준한 상태이다. 비준국들은 기준 협약이 정한 기준에 맞추어 담배규제와 관련한 국내법적 조치들을 취하고 있다. 미국의 경우에도 2009년 6월 가족금연 및 담배규제법을 제정하여 통과시킴으로써 담배규제에 관한 새로운 전기를 맞게 되었다. 미국의 가족 금연 및 담배규제법의 중심적인 내용은 FDA에게 담배규제에 관한 포괄적인 권한을 부여하고, 담배수요를 억제하기 위한 조치로서 담배제조업자 및 수입업자로 하여금 보건부 장관에게 담배성분 및 첨가물 등에 대한 구체적인 정보를 제공하도록 하고 있다. 또한 담배포장 및 표시 규제와 관련하여 소비자를 오도할 수 있는 표시를 금지하는 한편, 담배광고 판촉 등에 대한 규제 권한을 연방의회에 부여하고 있다. 그리고 담배공급 감소조치로서는 불법담배의 거래를 방지하기 위해 라벨링, 검사, 기록 등을 유지하도록 하고 특히 기존의 법안들이 미성년자의 담배 구매 및 판매를 줄이기에는 미흡한 점이 있음을 인식하고 이 법안에서 보다 구체적이고 포괄적으로 규제를 강화하였다. 우리나라의 경우에도 기본협약의 비준국가로서 국내법적 조치를 취할 의무를 부담하고 있는데, 담배규제법안을 마련함에 있어 미국을 비롯한 다른 나라의 입법례들을 참고할 필요가 있다. 또한 담배규제법안의 규정방향을 정함에 있어서 몇 가지 고려해야 할 법적 쟁점들이 있다. 우선 흡연권의 기본권성 인정 여부와 관련하여 그 흡연권의 기본권성을 부정하는 입장에 섬으로써 담배와 관련한 규제의 정당성을 부여받을 수 있고, 또한 담배사업은 현 세대 뿐만 아니라 미래세대에 유해한 영향을 미치는 것으로 헌법적으로 보호받을 가치가 없는 것이다. 따라서 담배광고에 대한 포괄적인 금지 조치를 취하는 것이 우리 헌법적 원칙에 위배된다고 할 수 없다. 그리고 현행 담배사업법과 국민건강증진법으로 이원화되어 있는 법을 담배규제법안으로 일원화함으로써 담배규제를 효율적이고 통일적으로 수행해나갈 수 있을 것으로 기대된다. 이러한 기본적 사항들을 염두에 두고서 담배규제법안을 마련함에 있어서 미국 등 외국의 법들을 참고하여 보다 구체적이고 명확하게 담배규제를 할 수 있는 법안을 마련하여야 할 것이다.

미국의 가족금연 및 담배규제법(Family Smoking Prevention and Tobacco Control Act) 제정을 통해 본 우리의 입법과제

Objective Systematic review of research examining consumer preference for the main electronic cigarette (e-cigarette) attributes namely flavor, nicotine strength, and type. Method A systematic search of peer-reviewed articles resulted in a pool of 12,933 articles. We included only articles that meet all the selection criteria: (1) peer-reviewed, (2) written in English, and (3) addressed consumer preference for one or more of the e-cigarette attributes including flavor, strength, and type. Results 66 articles met the inclusion criteria for this review. Consumers preferred flavored e-cigarettes, and such preference varied with age groups and smoking status. We also found that several flavors were associated with decreased harm perception while tobacco flavor was associated with increased harm perception. In addition, some flavor chemicals and sweeteners used in e-cigarettes could be of toxicological concern. Finally, consumer preference for nicotine strength and types depended on smoking status, e-cigarette use history, and gender. Conclusion Adolescents could consider flavor the most important factor trying e-cigarettes and were more likely to initiate vaping through flavored e-cigarettes. Young adults overall preferred sweet, menthol, and cherry flavors, while non-smokers in particular preferred coffee and menthol flavors. Adults in general also preferred sweet flavors (though smokers like tobacco flavor the most) and disliked flavors that elicit bitterness or harshness. In terms of whether flavored e-cigarettes assisted quitting smoking, we found inconclusive evidence. E-cigarette users likely initiated use with a cigarette like product and transitioned to an advanced system with more features. Non-smokers and inexperienced e-cigarettes users tended to prefer no nicotine or low nicotine e-cigarettes while smokers and experienced e-cigarettes users preferred medium and high nicotine e-cigarettes. Weak evidence exists regarding a positive interaction between menthol flavor and nicotine strength.

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A Systematic Review of Consumer Preference for E-Cigarette Attributes: Flavor, Nicotine Strength, and Type

Introduction "Vaping" electronic cigarettes (e-cigarettes) is increasingly popular with youth, driven by the wide range of available flavors, often created using flavor aldehydes. The objective of this study was to examine whether flavor aldehydes remain stable in e-cigarette liquids or whether they undergo chemical reactions, forming novel chemical species that may cause harm to the user. Methods Gas chromatography was used to determine concentrations of flavor aldehydes and reaction products in e-liquids and vapor generated from a commercial e-cigarette. Stability of the detected reaction products in aqueous media was monitored by ultraviolet spectroscopy and nuclear magnetic resonance spectroscopy, and their effects on irritant receptors determined by fluorescent calcium imaging in HEK-293T cells. Results Flavor aldehydes including benzaldehyde, cinnamaldehyde, citral, ethylvanillin, and vanillin rapidly reacted with the e-liquid solvent propylene glycol (PG) after mixing, and upward of 40% of flavor aldehyde content was converted to flavor aldehyde PG acetals, which were also detected in commercial e-liquids. Vaping experiments showed carryover rates of 50%-80% of acetals to e-cigarette vapor. Acetals remained stable in physiological aqueous solution, with half-lives above 36 hours, suggesting they persist when inhaled by the user. Acetals activated aldehyde-sensitive TRPA1 irritant receptors and aldehyde-insensitive TRPV1 irritant receptors. Conclusions E-liquids are potentially reactive chemical systems in which new compounds can form after mixing of constituents and during storage, as demonstrated here for flavor aldehyde PG acetals, with unexpected toxicological effects. For regulatory purposes, a rigorous process is advised to monitor the potentially changing composition of e-liquids and e-vapors over time, to identify possible health hazards. Implications This study demonstrates that e-cigarette liquids can be chemically unstable, with reactions occurring between flavorant and solvent components immediately after mixing at room temperature. The resulting compounds have toxicological properties that differ from either the flavorants or solvent components. These findings suggest that the reporting of manufacturing ingredients of e-liquids is insufficient for a safety assessment. The establishment of an analytical workflow to detect newly formed compounds in e-liquids and their potential toxicological effects is imperative for regulatory risk analysis.

Formation of flavorant–propylene Glycol Adducts With Novel Toxicological Properties in Chemically Unstable E-Cigarette Liquids

Vaping is gaining popularity in the USA, particularly among teens and young adults. While e-cigs are commonly represented as safer alternatives to tobacco cigarettes, little is known regarding the health effects of their short- or long-term use, especially in individuals with pre-existing respiratory diseases such as asthma. Flavored e-cig liquids (e-liquids) and e-cig aerosols contain airway irritants and toxicants that have been implicated in the pathogenesis and worsening of lung diseases. In this review, we will summarize existing data on potential health effects of components present in e-cig aerosols, such as propylene glycol, vegetable glycerin, nicotine, and flavorings, and discuss their relevance in the context of asthma. Recent survey data indicate that adolescents with asthma had a higher prevalence of current e-cig use (12.4%) compared to their non-asthmatics peers (10.2%) and conveyed positive beliefs about tobacco products, especially e-cigs. Similarly, a study conducted among high school students from Ontario, Canada, indicated a greater likelihood of e-cig use in asthmatics as compared to their non-asthmatic peers. Availability of different flavorings is often cited as the main reason among youth/adolescents for trying e-cigs or switching from cigarettes to e-cigs. Occupational inhalation of some common food-safe flavoring agents is reported to cause occupational asthma and worsen asthmatic symptoms. Moreover, workplace inhalation exposures to the flavoring agent diacetyl have caused irreversible obstructive airway disease in healthy workers. Additionally, recent studies report that thermal decomposition of propylene glycol (PG) and vegetable glycerin (VG), the base constituents of e-liquids, produces reactive carbonyls, including acrolein, formaldehyde, and acetaldehyde, which have known respiratory toxicities. Furthermore, recent nicotine studies in rodents reveal that prenatal nicotine exposures lead to epigenetic reprogramming in the offspring, abnormal lung development, and multigenerational transmission of asthmatic-like symptoms. Comparisons of the toxicity and health effects of e-cigs and conventional cigarettes often focus on toxicants known to be present in cigarette smoke (CS) (i.e., formaldehyde, nitrosamines, etc.), as well as smoking-associated clinical endpoints, such as cancer, bronchitis, and chronic obstructive pulmonary disease (COPD). However, this approach disregards potential toxicity of components unique to flavored e-cigs, such as PG, VG, and the many different flavoring chemicals, which likely induce respiratory effects not usually observed in cigarette smokers.

Electronic Cigarettes: Their Constituents and Potential Links to Asthma.

The purpose of this study is to investigate how the use of flavored e-cigarettes varies between youth (12–17 years old), young adults (18–29 years old), and older adults (30 + years old). Cross-sectional surveys of school-going youth (n = 3907) and young adult college students (n = 5482) in Texas, and young adults and older adults (n = 6051) nationwide were administered in 2014–2015. Proportions and 95% confidence intervals were used to describe the percentage of e-cigarette use at initiation and in the past 30 days that was flavored, among current e-cigarette users. Chi-square tests were applied to examine differences by combustible tobacco product use and demographic factors. Most e-cigarette users said their first and “usual” e-cigarettes were flavored. At initiation, the majority of Texas school-going youth (98%), Texas young adult college students (95%), and young adults (71.2%) nationwide said their first e-cigarettes were flavored to taste like something other than tobacco, compared to 44.1% of older adults nationwide. Fruit and candy flavors predominated for all groups; and, for youth, flavors were an especially salient reason to use e-cigarettes. Among adults, the use of tobacco flavor at initiation was common among dual users (e-cigarettes + combustible tobacco), while other flavors were more common among former cigarette smokers (P = 0.03). Restricting the range of e-cigarette flavors (e.g., eliminating sweet flavors, like fruit and candy) may benefit youth and young adult prevention efforts. However, it is unclear what impact this change would have on adult smoking cessation.

Flavored e-cigarette use: Characterizing youth, young adult, and adult users.

Objective We aimed to determine the potential for reductions in the prevalence of young people's e-cigarette and tobacco use if characterizing flavors were not present. Methods Two parallel cross-sectional surveys of 2483 youth (TATAMS: Texas Adolescent Tobacco and Marketing Surveillance System) and 4326 young adults (M-PACT: Marketing and Promotions across Colleges in Texas) in Texas (Houston, Dallas/Ft. Worth, San Antonio, Austin). Current use of e-cigarettes and other tobacco (cigarettes, cigar products, hookah, smokeless tobacco). Users were asked: "When you use [product], do you usually use any of the following flavors?" Flavored product users were asked: "Would you continue using [product] if it were not flavored?" Results Over 80% of youth and young adult tobacco users reported using flavored tobacco. Three-fourths of flavored product users said they would no longer use the product if it was not flavored. This was highest for e-cigarettes and hookah and lowest for cigarettes. Few demographic differences in findings were observed. Conclusions Restricting flavors in tobacco products would not eradicate e-cigarette or other tobacco use among young people, but the potential for substantial reductions in the prevalence of young people's e-cigarette and other tobacco use seems high if flavors were removed.

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C. N. Marti

Papers

Flavored e-cigarette use: Characterizing youth, young adult, and adult users.

Flavored Tobacco Product Use among Youth and Young Adults: What if Flavors Didn't Exist?