White Paper: Electronic Nicotine Delivery Systems & Smoke Free Laws 2020 Revised
White Paper on
ELECTRONIC NICOTINE DELIVERY SYSTEMS & SMOKE FREE LAWS
January 17, 2018
Revised January 27, 2020
Revised January 14, 2022
E-cigarettes or electronic nicotine delivery systems (ENDS) come in a variety of shapes, sizes, and forms. They may resemble tobacco products such as cigarettes, pipes, or everyday items such as flashlights or pens, but all have the same purpose—to deliver a concentrated dose of intensely addictive nicotine to the consumer.
ENDS products are now the most commonly used tobacco product among youth. In 2020, more than 3.5 million United States middle and high school students used e-cigarettes in the past 30 days.1 About 4 of every 100 middle school students (4.7%) and 19 of every 100 high school students (19.6%) reported the use of e-cigarettes in the past 30 days 2020.1 ENDS products also offer appealing flavors, intriguing designs, and often, a means by which nicotine users can circumvent smoke-free policies.
Although they have been touted as “safer” alternatives to smoking, or even a way to quitsmoking cigarettes, the nicotine solutions and aerosols produced by them have been shown to contain potentially harmful chemicals and carcinogens that may pose a threat to those inhaling them secondhand. But because ENDS products are relatively new to the market, the long-term health effects of ENDS use remains to be determined.3
Tennessee has a well-documented history of protecting its citizens—particularly its youth—from the harmful effects of secondhand smoke inhalation, beginning in 1994 with the Prevention of Youth Access to Tobacco Act and the Children’s Act for Clean Indoor Air the following year. Subsequent protections allowed for smoke-free state buildings and gave opportunities for hospitals, colleges, and religious institutions to determine for themselves whether to allow smoking on their campuses.
Twenty years of scientific study has illuminated just how detrimental secondhand smoke is to public health. These facts have prompted local advocates to seek stronger standards to reduce the exposure of children, youth, and non-smoking adults. Unfortunately, under current Tennessee law, municipalities are preempted by state law and are unable to decide for
themselves whether stadiums, playgrounds, picnic areas, entrances to building, etc., should be smoke free zones.
To further augment the policies in place to protect Tennesseans from secondhand smoke or vapor/aerosol produced by any nicotine-delivery product, the Prevention Alliance of Tennessee recommends the following actions:
1. Allow for more exemptions that return control to localities to reduce the exposure of children, youth, and non-smoking adults to secondhand smoke.
2. Encourage people to use CDC-approved methods for smoking cessation.
Table of Contents
I. Electronic Nicotine Delivery Systems (ENDS) II. Youth Use
III. Tobacco Cessation
IV. Secondhand Smoke Comparison
V. Accidental Poisonings
VI. Exemptions to Preemption
VII. Case for Restricting Advertising of ENDS products VIII. Solutions
IX. Authors
X. References
Electronic Nicotine Delivery Systems (ENDS)
Electronic nicotine delivery systems (ENDS) are known by many different names. They are sometimes called electronic cigarettes, e-cigarettes, e-cigs, vape pens, e-hookahs, mods, and tank systems.2 Due to the variability in the different types available and in the terminology used to describe ENDS products, translating ENDS research into evidence-based regulatory policy poses a difficult challenge.4
ENDS products contain liquid nicotine, an addictive stimulant with a risk of poisoning. “Poisoning related to e-cigarettes involves the liquid containing nicotine...and can occur in three ways: by ingestion, inhalation or absorption through the skin or eyes...e-cigarette liquids containing nicotine have the potential to cause immediate adverse health effects and represent an emerging public health concern.”5 Currently, there is inadequate scientific information about the health effects caused by the chemical suspension containing the nicotine. However, research shows that the liquid nicotine solution does contain cancer-causing chemicals such as formaldehyde, propylene glycol, acetaldehyde, acrolein, and tobacco-specific nitrosamines.6
Nicotine is absorbed through inhalation and reaches the brain within ten seconds of inhalation.6 Nicotine acts on the brain by activating the circuitry which regulates feelings of pleasure through the dopamine pathway—our brain’s natural reward system. The acute effects of nicotine dissipate within a few minutes, which causes the user to feel a need to repeat intake throughout the day. Repeated exposure to nicotine results in a tolerance to the drug, a condition in which higher doses of a drug are required to produce the same initial effect.7
Nicotine is a highly addictive drug and can harm adolescent brain development, which continues into the early to mid-20s.2 To further complicate things, tobacco and nicotine addiction is usually established during adolescence. Despite cigarette smoking declining in recent years, ENDS use among adolescents has grown at alarming rates—shown in many local and national U.S.
datasets.2
Youth Use
ENDS use now exceeds cigarette smoking among youth in the United States.3 In 2011, 1.5% of high school students used an ENDS product in the past month: that figure increased to 16.0% of high school students in 20153 and on to 27.5% in 2019.21 Studies have been ongoing for several years and recent studies show youth who initiate tobacco with ENDS products are more likely to smoke traditional combustible cigarettes.22
Flavored tobacco products are known to be extremely appealing to youth;8 however, the safety of inhaled flavorings is largely unknown.9 Adding flavorings was a marketing tactic used by tobacco companies to appeal to younger audiences. Even though they are illegal to promote to youth, flavored ENDS products claim more than 466 brands and 7,764 unique flavors.10 On December 20, 2019, President Trump and his administration, upon advice from the Food and Drug Administration (FDA) and Department of Health and Human Services (DHHS) enacted the Tobacco-21 act, also banning all vape flavorings, excluding menthol and tobacco flavors(flavored cartridges could reemerge on the market if the FDA approves applications by companies proving they are not targeting youth).20,23
In addition to the complications with flavors, vape liquids rely on pH for nicotine absorption. The higher the pH, the faster the rate of nicotine absorption: studies show vape brands rely on the higher pH to achieve several goals 1) increase rate of absorption of nicotine, 2) make nicotine salts more “comfortable” to inhale. Nicotine salts are found naturally in leaf tobacco and are more stable than traditional freebase nicotine, but require a higher temperature for combustion. Nicotine salts can be harsh to inhale, so chemicals are added to make the experience more “pleasurable.” These chemicals include PG, glycerol, lactic acid, and benzoic acid, which allow salts to vaporize at lower temperatures, lower pH levels in salts (makes it more smooth), and cause reactions allowing salts to be absorbed as easily as freebase nicotine.24
Tobacco Cessation
In the first analysis of the relationship between ENDS use and smoking among youth in the United States, University of California, San Francisco (U.C.S.F.) researchers in the Center for Tobacco Control, Research, & Education found that adolescents who used the devices were more likely to smoke cigarettes and less likely to quit smoking. “Despite claims that e-cigarettes are helping people quit smoking, we found that e-cigarettes were associated with more, not less, cigarette smoking among adolescents,” said lead author Lauren Dutra, a postdoctoral fellow at the U.C.S.F.
Center for Tobacco Control Research and Education, in a news release.11
Although no randomized control trials or observational studies examining the efficacy of ENDS for quitting smoking in youth exist, prospective studies among youth have shown that ENDS use among smokers did not change the frequency of smoking one year later.3
Secondhand Smoke Comparison
While aerosol from ENDS products is presumed to be less harmful than secondhand smoke, a recent study “measured levels of potential e-cigarette pollutants in a ventilated room while volunteers consumed e-cigarettes with and without nicotine for two hours and found a change in air quality. The concentration of polycyclic aromatic hydrocarbons (PAH) in the indoor air increased by 20%, while particulate numbers also increased.”11 The authors concluded that exposure to e-cigarette pollutants might be a health concern, as fine and ultra-fine particles might be deposited in the lung.11 ENDS are designed to generate nicotine aerosol; when the user puffs on the device, they exhale an aerosol. A study published by the Oxford University Press
concluded that e-cigarettes are “a source of secondhand exposure to nicotine.” In addition, passive smoking or exposure to secondhand smoke remains a public health concern, especially to vulnerable populations, including children, pregnant women, and those with cardiovascular conditions. While the study did not find considerable evidence for exposure to toxic compounds, it did note the possibility of exposure to carbonyls, nitrosamines, and heavy metals, identifying the need for accurate methodology to assess indoor concentrations of ENDS aerosol. The study also noted the particles may be deposited onto surfaces (resulting in third-hand exposure).25 Ultimately, the policy recommendation in the study states:
E-cigarettes are promoted to circumvent smoke-free policies. Exempting e- cigarettes from smoke-free regulations, besides creating second-hand exposure to nicotine, might have additional implications for public health.25
Accidental Poisonings
The potential for poisoning exists; refill bottles for typical ENDS products can contain up to 72 milligrams of nicotine (the fatal dose is 10 milligrams for children, 30-60 milligrams for adults). When smoking a regular cigarette from the U.S. market, the average smoker takes in 1 to 2 milligrams of nicotine per cigarette—in stark contrast to the potential exposure from an ENDS product.7 The common adverse effects of nicotine poisoning resulting from ENDS toxicity are ocular irritation, nausea, lethargy, tachycardia, and vomiting.11 Severe events include apnea, muscular fasciculations,seizures, coma, or cardia arrest. Poisonings would be most likely to occur in children drinking the refill liquid or individuals inhaling the aerosol of liquids.12
Calls to poison control centers about ENDS toxicity, especially in children, and case reports of toxic exposures have increased over the past 3 years.13 A recent study from the CDC looked at calls to Poison Centers for exposures to electronic cigarettes and regular combustible cigarettes (January 2012 to April 2015) and found 29,141 calls for nicotine and tobacco product exposures among children younger than 6 years. E-cigarettes accounted for 14.2% of exposure calls, and the monthly number of exposures associated with e-cigarettes increased by 1492.9% during the study period. Additionally, Children under 2 years old accounted for 44.1% of e-cigarette exposures.13
Since the popularity of vaping has risen, there have been several problems identified by the Center for Disease Control and Prevention (CDC). On November 8, 2019, the CDC conducted a laboratory experiment analyzing bronchoalveolar Lavage (BAL) fluid samples. The CDC examined the BAL samplesfrom 29 participants from 10 statesfound the presence of vitamin E acetate that has been linked to the ever-growing illnesses and deaths associated with vape products.19 As of February, 2020, a total of 2,807 cases of hospitalization due to complications to vaping, or e cigarette products had been reported to the CDC from 50 states, the District of Columbia, and two U.S. territories. With this information, 68 deaths had been confirmed in 29 states and the District of Columbia. In Tennessee, 78 vaping-related lung injury cases have been reported to the Tennessee Department of Health: 69 of the 78-required hospitalization and two deaths have been reported.26
To minimize these incidents, a 2016 law mandated that liquid nicotine refills must be marketed in child-resistant packaging. Yet, increasing popularity and insufficient regulation have resulted in nicotine toxicity in children.12
Exemptions to Preemption
In the late 1800s, Tennessee was adamant about protecting its citizens from the harms of tobacco. These attitudes changed in the 1920s, as tobacco farming spread across the state and cigarettes could be sold again, but they would also be taxed.
By the 1990s, attitudes about tobacco began shifting again and Tennessee chose once again to protect some of its citizens from tobacco with the Prevention of Youth Access to Tobacco law. The tobacco industry conceded on preventing youth access by achieving their primary strategy - state preemption of tobacco regulation. Thus, Tennessee legislators voted “to occupy and preempt the entire field of legislation concerning the regulation of tobacco products. Any law or regulation of tobacco products enacted or promulgated after March 15, 1994, by any agency or political subdivision of the state or any agency thereof is void; provided, that cities, counties, and counties having a metropolitan form of government may regulate the use of tobacco products in buildings owned or leased by such political subdivisions; and provided further, that airport authorities created pursuant to the provisions of title 42; utility districts created pursuant to the provisions of title 7; and special school districts may regulate the use of tobacco products in buildings owned or leased by such entities. Notwithstanding any other provision of the law to the contrary, individual owners or operators of retail establishments located within an enclosed shopping mall shall retain the right to determine the policy on the use of tobacco products within such person's establishment" (TN CODE ANN. § 39-17-1551).14
State preemption as a legislative power precludes any lower level of government from creating its own authority over a topic. “In the area of smoke-free policy, preemption typically takes the form of a state law that prevents communities from adopting local smoking restrictions.”15
Because these constraints remove the rights of localities to designate their properties as smoke free campuses, children, youth and non-smokers are exposed to secondhand smoke. While hospitals are allowed to take measuresto enforce smoke-free campuses to promote health, local health departments lack the same ability. At local parks where youth sporting events are held, where children play on playgrounds or where families eat at picnic tables, local government is prohibited by the state to make decisions locally.
A decade after the Prevention of Youth Access to Tobacco, other exemptions were slowly introduced, allowing more control at the local level.
• 2005—Higher education institutions could regulate their own campuses • 2006—Smoke-free state buildings
• 2007—Smoke-free state vehicles
• 2008—Churches were allowed to decide their own policy
• 2016—A pool in Sullivan County and an amphitheater in Davidson County were allowed to designate themselves as smoke free. Two decades after preemption was put in place, more is known about the health hazards of secondhand smoke. The Prevention Alliance of Tennessee recommends that more exemptions be allowed to reduce the exposure of children, youth and non-smoking adults to secondhand smoke by allowing localities to decide if their stadiums, playgrounds, picnic areas and entrances to building should be smoke free zones.
• 2017—Municipalities located in Putnam County authorized to prohibit, by local ordinance, smoking on the grounds of an urban park center.
Case for Restricting Advertising of ENDS products
E-Cigarette Advertising to Youth
It is well understood that frequent exposure is a major determinant in use of tobacco and related nicotine delivering products by minors. A recent study indicated that there is a link between greater exposure to e-cigarette advertising and use of e-cigarette use among US adolescents. Advertising exposure via Internet, newspapers/magazines, retail stores, and TV/movies were all associated with elevated use of ENDS products among middle and high school students.15,16
Therefore, exposure to ENDS advertisements may play a significant role in adolescents’ use and perception of ENDS products.17
Solutions
In Tennessee, it is already illegal to sell or distribute any electronic cigarette to another person who has not yet reached the age of 21; persons under the age of 21 may not purchase electronic cigarettes. (TN CODE ANN. § 39-17-1504; affected by 2020 effective date of federal Tobacco 21 ruling). The Prevention Alliance of Tennessee recommends that children and non-smokers be
protected from nicotine and other pollutants by the addition of “vapor/aerosol products” to the definitions of the Children’s Act for Clean Indoor Air and the Non-Smoker’s Protection Act and allow for more exemptions that return control to localities to reduce the exposure of children, youth, musicians, and non-smoking adults to secondhand smoke.
Authors
Melony Ison, Prevention Coordinator, Sullivan County Anti-Drug Coalition Alice McCaffrey, Director, Sullivan County Anti-Drug Coalition
Justin Sweatman-Weaver, Executive Director, Sumner County Anti-Drug Coalition Stephanie Strutner, MPH, CPSII, Executive Director, ASAP of Anderson
Amanda Letheren, Doctoral Student, University of Tennessee Department of Public Health Edited: Nicholas Edwards, Masters Student, Ashford University School of Public Health Edited: Dana Reno, BSW, Project Director, STARS Nashville
References
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2 Centers for Disaese Control and Prevention. Electronic Cigarettes. 2017; (https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm). 3Drope J, Cahn Z, Kennedy R, et al. Key issues surrounding the health impacts of electronic nicotine delivery systems
(ENDS) and other sources of nicotine. CA: a cancer journal for clinicians. 2017;67(6):449-471. 4Barrington-Trimis JL, Gibson LA, Halpern-Felsher B, et al. Type of E-Cigarette Device Used Among Adolescents and Young Adults: Findings From a Pooled Analysis of Eight Studies of 2166 Vapers. Nicotine & tobacco research: official journal of the Society for Research on Nicotine and Tobacco. 2018;20(2):271-274.
5Centers for Disease Control and Prevention and the U.S. Food and Drug Administration’s Center for Tobacco Products
(CTP). Morbidity and Mortality Weekly Report 2015.
6The truth about: Electronic nicotine delivery systems. 2015;
http://truthinitiative.org/sites/default/files/The_Truth_About_Electronic_Nicotine_Delivery_Sy stems.pdf
7Nicotine 2014; psychologytoday.com/conditions/nicotine.
8Harrell MB, Weaver SR, Loukas A, et al. Flavored e-cigarette use: Characterizing youth, young adult, and adult users.
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9Schraufnagel DE. Electronic Cigarettes: Vulnerability of Youth. Pediatric Allergy, Immunology, and Pulmonology. 2015;28(1):2-6.
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11Fernandez ME. E-cigarettes are gateway to nicotine addiction for teens. 2014; http://universityofcalifornia.edu/news/e-cigarettes-are-gateway-nicotine-addiction-teens. 12Tegin G, Mekala HM, Sarai SK, Lippmann S. E-Cigarette Toxicity? Southern medical journal. 2018;111(1):35-38.
13Payne JD, David M, Menfil O-B, Kenneth N. Electronic Cigarette Toxicity. Journal of Primary Care & Community Health.
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14Mamudu, M H, Dadkar, et al. Tobacco Control in Tennessee: Stakeholder Analysis of the Development of the Non¬Smoker Protection Act, 2007. 2011.
15Mowery PD, Babb S, Hobart R, Tworek C, MacNeil A. The Impact of State Preemption of Local Smoking Restrictions on Public Health Protections and Changes in Social Norms. Journal of Environmental and Public Health.
2012;2012:8.
16Singh T, Agaku IT, Arrazola RA, et al. Exposure to Advertisements and Electronic Cigarette Use Among US Middle and High School Students. Pediatrics. 2016;137(5).
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18Bomey, N. (2019, October 17). Juul suspends all US sales of fruity e -cigarettes amid scrutiny. Retrieved December 18, 2019, from https://www.usatoday.com/story/money /2019/10/17/juul-e-cigarette-flavors/4009168002/.
19Center for Disease Control and Prevention. (2019, December 12). Outbreak of Lung Injury Associated with the Use of E
Cigarette, or Vaping, Products. Retrieved December 18, 2019, from
https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#map cases.
20American Lung Association. (2020, January 3). Tobacco 21 Laws: Raising the Minimum Sales Age for All Tobacco Products to 21. Retrieved January6, 2020, from https://www.lung.org/our initiatives/tobacco/cessation-and- prevention/tobacco-21-laws.html.
21Center for Disease Control and Prevention. Youth Tobacco Fact Sheet. Retrieved Janaury 27, 2020 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data /tobacco_ use/index.htm.
22RAND Corporation: News Release. Youth Who use Vaping Products More Likely to Smoke Cigarettes, Increase in Both Over Time. October 2, 2018.
23National Public Radio. Trump Administration Issues Partial and Temporary E-Cigarette Ban. Aired January 2, 2020 on All Things Considered, 4:10 pm.
24National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems; Eaton DL, Kwan LY, Stratton K, editors. Washington (DC): National Academies Press (US); 2018 Jan 23.
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26Tennessee Department of Health: Vaping-Associated Pulmonary Illness report. Retrieved from https://www.tn.gov/health/cedep/vaping-illness.html, January 27, 2020.