IMPROVING PENNSYLVANIA HEALTH POLICY REGARDING ELECTRONIC
CIGARETTES
by
Ravi Indra Choudhuri
BA, BS, University of California, Riverside, 2012, 2012
Submitted to the Graduate Faculty of
Behavioral and Community Health Sciences
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2015
i
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Ravi Indra Choudhuri
on
April 21, 2015
and approved by
Essay Advisor:
Jeanette Trauth, PhD
Associate Professor, Behavioral and Community Health Sciences
Associate Professor, Health Policy and Management
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Brian Primack, MD, PhD
Associate Professor of Medicine, Pediatrics,
and Clinical and Translational Science
School of Medicine
University of Pittsburgh
ii
Copyright © by Ravi Indra Choudhuri
2015
iii
Jeanette Trauth, PhD
IMPROVING PENNSYLVANIA HEALTH POLICY REGARDING ELECTRONIC
CIGARETTES
Ravi Indra Choudhuri, MPH
University of Pittsburgh, 2015
ABSTRACT
Electronic cigarettes (i.e. e-cigarettes) are battery-powered devices that deliver nicotine and other
additives such as flavoring in an aerosolized form to an individual. Although originally
developed as a smoking cessation device, e-cigarettes are currently marketed as an alternative to
tobacco use. There has been a sharp increase nationwide in the use of e-cigarettes in recent
years—particularly among adolescents. This is of particular concern because of the adverse
health effects of nicotine on adolescent development. Currently, forty of the fifty states prohibit
the sales of e-cigarettes to minors. Pennsylvania is one of the ten states that do not restrict youth
access to e-cigarettes.
The purpose of this master’s essay is to present an argument for the
regulation of e-
cigarettes in Pennsylvania. In order to achieve this goal, I reviewed the current literature on: the
health consequences of e-cigarette use, attitudes and intentions of youth toward e-cigarette use
and the policy issues related to the regulation of this product. As a result of this review, I have
proposed a strategy for the development of an e-cigarette policy for Pennsylvania. The first step
in this strategy involves gathering information from policy makers in order to determine their
knowledge of: e-cigarettes, current regulations governing e-cigarettes and their thoughts on the
need for future policy in this domain. It is necessary for policy makers to have accurate
knowledge and an in-depth understanding of e-cigarette issues in order to inform the
iv
development of policies that will protect the health of Pennsylvania residents. This is the public
health significance of this study.
v
TABLE OF CONTENTS
1.0
INTRODUCTION………………………………………………………………………...1
2.0
BACKGROUND………………………………………………………………………….4
2.1
THE DEVELOPMENT OF ELECTRONIC CIGARETTES……………………..4
2.2
CURRENT USERS OF E-CIGARETTES………………………………………..5
2.3
THE CURRENT REGULATORY ENVIRONMENT……………………………6
2.4
UNDERSTANDING ADOLESCENT SMOKING BEHAVIOR………………...8
3.0
METHODS………………………………………………………………………………10
4.0
FINDINGS……………………………………………………………………………….11
5.0
4.1
HEALTH CONSEQUENCES OF E-CIGARETTE USE……………………….11
4.2
ATTITUDES AND INTENTIONS……………………………………………...12
4.3
POLICY ISSUES………………………………………………………………...13
DISCUSSION……………………………………………………………………………15
5.1
IMPLICATIONS OF THE RESULTS…………………………………………..21
5.2
A PROPOSED STRATEGY FOR THE DEVELOPMENT OF E-CIGARETTE
HEALTH POLICY FOR PENNSYLVANIA…………………………………...22
5.2.1
6.0
A PROPOSED STUDY SAMPLE………………………………………22
CONCLUSION…………………………………………………………………………..25
6.1
SUMMARY OF MAJOR FINDINGS…………………………………………..25
vi
6.2
STUDY LIMITATIONS………………………………………………………...26
APPENDIX A: PUBMED SEARCH LITERATURE...................................................................28
APPENDIX B: INTERVIEW SAMPLE QUESTIONS................................................................43
BIBLIOGRAPHY..........................................................................................................................44
vii
1.0
INTRODUCTION
The largest preventable cause of death and disease in the United States is smoking and related
tobacco use. Over 440,000 Americans die prematurely from smoking-related illness such as
cancer, COPD, heart disease, and stroke each year. An estimated 49,000 of these deaths are
related to secondhand smoke exposure1. The naturally addictive properties of tobacco are
delivered to
users in the form of nicotine—which is the underlying cause of long-term
dependence, morbidity and mortality.
According to the CDC, the prevalence of cigarette smoking among adults in the United
States ranges from 9.3% to 26.53%1,2. In Pennsylvania 21.3% of the adult population currently
smoke cigarettes. Among youth aged 12–17 years, the prevalence of smoking across the United
States ranges from 6.5% to 15.9%”1. In Pennsylvania, 11.8% of this age group smokes cigarettes.
Although there are states that have a higher percentage of adults who smoke, Pennsylvania still
has more adults who smoke compared to other states such as California and New York, where
only 13.7% and 18.1% of adults respectively smoke.
Research shows that nearly 90% of smokers started smoking by age 18, and 99% started
by age 261. Each day in the United States, more than 3,200 people 18 years of age or younger
smoke their first cigarette. And an estimated two thirds of this population become daily cigarette
smokers1. In order to reduce the total number of people who smoke, initiation rates among firsttime users must be reduced. This goal is problematic given the emergence in recent years of new
1
tobacco-free smoking products such as electronic cigarettes (i.e. e-cigarettes) and hookah vapes.
There has been a sharp increase nationwide in the use of e-cigarettes in recent years—
particularly among adolescents.
E-cigarettes are battery-powered devices that deliver nicotine in an aerosolized form to an
individual. Other additives such as flavoring can also be included in order to enhance the
acceptability and desirability of the product. Although originally developed as a smoking
cessation device, e-cigarettes are also currently marketed as an alternative to tobacco use. While
e-cigarettes can be beneficial to smokers who are trying to quit, there are still health
consequences associated with their use. Of particular concern are the adverse health effects of
nicotine on adolescent brain development3.
Currently, forty of the fifty states prohibit the sales of e-cigarettes to minors.
Pennsylvania is one of the ten states that do not restrict youth access to e-cigarettes. Although
clean indoor air policies and regulations related to the sale of cigarettes to minors do exist in
Pennsylvania, they do not address electronic cigarettes.
The purpose of this master’s essay is to present an argument for the regulation of ecigarettes in Pennsylvania which are currently not included under the existing tobacco regulatory
framework. In order to achieve this goal, I reviewed the current literature on: the health
consequences of e-cigarette use, attitudes and intentions of youth toward e-cigarette use and the
policy issues related to the regulation of this product. As a result of this review, I have proposed
a strategy for the development of an e-cigarette policy for Pennsylvania.
The first step in this strategy involves gathering information from policy makers (i.e.
legislators, tobacco-free organizations and local health department officials) in order to
understand how they are thinking about this issue. This can be accomplished by means of
2
qualitative interviews to explore their knowledge of electronic cigarettes, current regulations
governing e-cigarettes and their thoughts on the need for future policy in this domain. Policy
makers in Pennsylvania need to have accurate knowledge and an in-depth understanding of
electronic cigarette issues in order to inform the development of policies that will ultimately
decrease the initiation of electronic cigarette use and that will protect the health of all
Pennsylvania residents. Second paragraph.
3
2.0
2.1
BACKGROUND
THE DEVELOPMENT OF ELECTRONIC CIGARETTES
E- cigarettes were first developed and patented in 2003 by a Chinese pharmacist named Hon Lik.
They were originally created as a smoking cessation device rather than for recreational use4.
Lik’s original design of the electronic cigarette is still used today. It consists of a reusable
cigarette-like device, nicotine liquid extracted from tobacco plants, and an extremely small
piezoelectric ultrasound-emitting element that vibrates to produce heat and convert the liquid
nicotine into an inhalable aerosol4. Since 2003, the e-cigarette has undergone various design and
nicotine delivery modifications in order to adjust to users across the globe. Lik’s design is
currently referred to as the first generation of electronic cigarettes; a single unit resembling a
regular cigarette that contains a battery, heating mechanism, and nicotine liquid to be used and
disposed of after the battery dies or the liquid is depleted4, 5. In addition to being able to refill the
nicotine liquid, this design also allows users to change the battery or recharge it for continual
use.
A second-generation electronic cigarette has subsequently been developed. This device is
larger and deviates from the look and feel of a regular cigarette. It allows for a higher delivery of
nicotine liquid as well as extended use because of a larger rechargeable battery. This second
generation of the e-cigarette is used among more experienced electronic cigarette users and can
4
also be refilled with nicotine liquid at the user’s discretion4, 5. A third generation of e-cigarette is
also now available. This version of the product allows the user to tailor the device to meet their
own preferences rather than complying with standard operating procedures. This modification
process may involve the user adjusting the heat control of the internal heating mechanism in
order to produce a larger or smaller amount of nicotine aerosol delivery, change the flavoring of
the nicotine, or change the physical appearance of the device. This third generation is growing in
popularity because of the ability to adjust the heating device, allowing users to have control of
nicotine delivery4, 5.
2.2
CURRENT USERS OF E-CIGARETTES
Due to the fairly recent development of electronic cigarettes, there is limited research on user
demographics and projected future users. However, current evidence indicates that the largest
population of sustained electronic cigarette users are current smokers who believe that e-cigarette
use will help them quit smoking5. In addition, further evidence shows that the largest population
of first-time e-cigarette users are adolescents experimenting with tobacco products5. Although
current smokers predominantly use electronic cigarettes as a harm reduction tool, electronic
cigarette manufacturers are beginning to market and advertise their products commercially in a
way that targets adolescents and other younger populations4, 5. Because of the paucity of research
on this emerging product, health policies regulating the manufacture and marketing of ecigarettes are largely absent.
Furthermore, few studies have been undertaken on the long-term effects of continuous
electronic cigarette use. A number of smaller studies have explored whether electronic cigarettes
5
are a healthy alternative to regular tobacco products because of their lack of actual tobacco and
carcinogens5. However, studies have not been done examining the long-term health effects of ecigarettes. A number of emerging studies have shown that electronic cigarettes may still cause
lung cancer, as well as continuing the nicotine-dependence the user already has from other
tobacco products5. The overall health implications of electronic cigarette use is that users will
still be addicted to nicotine, and thus all forms of tobacco products that they may or may not use.
2.3
THE CURRENT REGULATORY ENVIRONMENT
In 1906 the Food and Drug Administration (FDA) issued the first federal level legislation within
the United States. Since then, many forms of legislation at the federal level have been passed to
control products that could be consumed by the American people. Specifically in tobacco
control, the FDA has regulated the distribution and marketing of tobacco products since the
1940s. More recently in 2009, the FDA has passed the Family Smoking Prevention and Tobacco
Control Act. This regulation has allowed the FDA to regulate all tobacco products. Although the
FDA does impose this federal regulation over defined tobacco products, it has not extended this
regulatory power over emerging tobacco products such as electronic cigarettes. Currently, the
FDA proposed to extended their Family Smoking Prevention and Tobacco Control Act to also
cover products such as electronic cigarettes3. Although this will help regulate e-cigarette use
substantially in the future, it currently does nothing in a regulatory capacity because it is only a
proposal.
State regulation of tobacco products differs from federal regulation in various forms.
States mainly regulate tobacco use through taxation of tobacco products, sales to minors,
6
licensure for those that sell tobacco products, and clean indoor air acts. States such as New
Jersey have imposed heavy taxes on tobacco products in order to increase state revenue as well
as tobacco desirability among users. Although this is effective in reducing tobacco use, not all
states tax tobacco products equally, which widens the tobacco user disparity across the nation.
Currently, only 40 states in the U.S. prohibit e-cigarette sales to minors while 10 other states
(including Pennsylvania) and DC have no regulation in this context3. Furthermore, states vary in
their use of clean indoor air acts. Some states regulate indoor air quality very strictly and prohibit
all forms of tobacco use while others regulate it loosely and only regulate indoor air in some
regards. The CDC reports that only 27 states, not including Pennsylvania, have a comprehensive
smoke-free air law in place at this point in time3.
Although municipal, county, and state clean indoor air policies and regulations related to
cigarettes are being rapidly introduced across the U.S, these laws have not adequately addressed
electronic cigarettes. For example, over two-thirds of the largest cities in the U.S. no longer
allow any smoking in bars, but electronic cigarette use is allowed in nearly all of these cities,
often related to various exemptions which are deeply embedded in legal codes. Because of this
variability and complexity, it is important to comprehensively characterize and better understand
U.S. policies as they apply to electronic cigarettes. Development of policies, which apply to
cigarette smoking but exempt electronic cigarette smoking, may unintentionally fuel increased
interest in and experimentation with electronic cigarettes. If increased electronic cigarette use is
an unintended consequence of current clean air legislation, this would have important
implications for current and future policies related to tobacco use.
As the prevalence of electronic cigarettes has increased in the U.S. and evidence of its
potential toxicity have emerged, many epidemiologic studies assessing prevalence of and
7
associations with electronic cigarettes have been conducted. While these reviews point out
important policy concerns related to the practice, systematic policy assessments have been
sparse.
2.4
UNDERSTANDING ADOLSCENT SMOKING BEHAVIOR
A number of theories have been used to help understand and explain adolescent smoking
behavior. In order to understand how smoking behavior is initiated and subsequently becomes a
long-term habit, research has focused on the individual’s biology and neuropharmacology as
well as social and behavioral factors. With regard to the latter issue, several theories from the
disciplines of psychology, sociology and public health have informed the design of studies of
smoking behaviors. With this in mind, smoking behavior and eventual addiction can be
explained through the lens of social-cognitive theory, theory of planned behavior, and the transtheoretical model.
Social-cognitive theory states that an individual derives their knowledge and thought
processes in accordance to their social surroundings and interactions that occur daily6,
7, 8
. In
regard to smoking among adolescents, interventions have discussed social-cognitive theory and
how adolescents who are exposed more in their daily routines to smoking cues will increase their
likelihood of initiating smoking as well8. Theory of planned behavior posits that one’s beliefs
will lead to an eventual action or behavior. Adolescents that are influenced by various external
cues such as social media and marketing strategies have undergone a shift in their beliefs about
smoking and therefore may initiate smoking behavior9, 10.
8
The trans-theoretical model assesses an individual’s motivation and openness to change
and lead a healthier lifestyle overall. This model has been used numerously throughout
interventions in order to effectively shift an adolescent’s mindset about smoking towards
healthier alternatives11. All of these various models and theories have been implemented over
time throughout interventions aimed towards reducing the amount of adolescents that initiate
smoking. By continuing this effort, science and health education can greatly increase the odds of
preventing the younger population in such risky behaviors and live a healthy lifestyle for future
generations to follow.
9
3.0
METHODS
In order to make an argument regarding the need for regulating youth access to e-cigarettes in
Pennsylvania, I reviewed the recent literature that has a bearing on this issue. Working with
faculty on my essay committee, a total of 21 articles published in 2014 and 2015 were identified
from the PubMed database.
After carefully reading each article, the following process was used to organize and
analyze this literature. Appendix 1 was created in WORD that contains the following
information: author(s) and year of publication, title of article, study methods, study results and
conclusions. The purpose of creating the table was to be able to synthesize the results across the
various studies. The results of this analysis are found in the following section of this essay.
10
4.0
FINDINGS
A total of 21 articles published in 2014 and 2015 pertaining to electronic cigarettes were
reviewed for this study. These articles generally fell into three categories. The first type of article
described the health consequences of e-cigarette use—both the positive and negative
consequences. These articles also addressed who uses e-cigarettes and why. There were 9
articles that fell into this category.
4.1
HEALTH CONSEQUENCES OF E-CIGARETTE USE
Various articles addressed the benefits of electronic cigarette use in the short term. Adrianes et al
conducted lab sessions to test how effective electronic cigarettes were in reducing normal
tobacco use among regular users12. They found that electronic cigarettes were effective in
immediately reducing cigarette cravings and over time lead to cigarette abstinence or reduction
in cigarette use among these regular users12. Biener & Hargraves found that daily use of
electronic cigarettes in just a month is associated with quitting tobacco use in general13.
Although Hummel et al reported that more long-term research on electronic cigarettes must be
done, they also reported that electronic cigarette use might be a safer alternative to cigarette
use14.
11
The article written by Dutra & Glantz found that use of electronic cigarettes were among
those that currently use or have ever used cigarettes as well as being associated with users that
want to quit cigarette use15. However, they also found that electronic cigarettes may encourage
cigarette use among adolescents in the United States15. Hamilton et al found that adolescents in
Ontario, Canada were using electronic cigarettes that contained nicotine and devices without
nicotine16. Electronic cigarette use has been shown to be used among those that want to quit their
normal cigarette use, but do not do so because the user is dissatisfied with the electronic cigarette
compared to their regular product17. Pepper et al say that to reduce the effect that electronic
cigarettes have as a gateway product, there needs to be a higher satisfaction rate among regular
tobacco users18. Shihadeh & Eissenberg discuss the flux, or inhalation amount done by users of
electronic cigarettes26. Their study shows that various devices can deliver different amounts of
nicotine and that this poses a challenge for regulation to be in place for electronic cigarettes26.
Willis et al reports that there is a high dual use among adolescent cigarette users and electronic
cigarettes, and that electronic cigarettes are most likely attracting averaged-risk adolescents into
tobacco use19.
4.2
ATTITUDES AND INTENTIONS
The second types of articles were those that described survey data on the attitudes and intentions
of current and future smokers. These articles described the attitudes and intentions of a range of
individuals along the spectrum from non-smokers to occasional to regular users. Berg et al
reported that the marketing strategies in place by electronic cigarette and hookah groups target
the idea that they are safe to use and are socially acceptable20. These authors state that future
12
studies need to be done in order to communicate the health risks involved with these emerging
tobacco products with adolescents20. Burnell et al surveyed over quarter million adolescents and
found that there is an association between electronic cigarette use and having a greater desire to
try normal cigarettes21. Coleman et al continued where Burnell et al was in reporting that
electronic cigarette use was associated with a more openness to smoke cigarettes22. Coleman et
al stresses the importance to conduct longitudinal research on the subject to understand emerging
tobacco products even more22.
4.3
POLICY ISSUES
Finally, a third type of article discussed policy issues and offered recommendations regarding
how e-cigarettes should be regulated. Brandon et al went through the health policy statements
released by the AACR and ASCO in regards to the lack of regulatory framework for electronic
cigarettes23. These authors discuss the importance of understanding the current regulations and
how we can improve them to reduce health effects among adolescents23. Kadowaki et al also
delve into the regulation side of electronic cigarettes and how electronic cigarettes over time can
cause adverse health effects if no regulation is instilled in the United States24. Lempert et al
discussed the health policy regulation in regard to electronic cigarette definitions and how these
definitions play an important role in how they are regulated state by state25. Lempert et al
continues their discussion of electronic cigarettes and how policymakers must create legislation
that has strict and careful definitions of all electronic cigarette products in a broad sense in order
to reduce any loopholes to being formed25.
13
Shihadeh & Eissenberg go on to discuss how flux of nicotine inhalation among users
must be regulated in order to stop increases of nicotine uptake, which can cause an increase in
addiction and other health effects26. Tan et al reports that research on electronic cigarette
advertising must be increased to find out if electronic cigarette media portrayal has an effect on
adolescents as well as bypassing current legislative rules for advertising27. Yong et al discuss
how the UK and Australia are affected by current policy that is in place for each respective
country28. These authors state that current smokers also use electronic cigarettes because there
are no federal regulations in place to reduce electronic cigarette28.
In summary, the policy articles discussed the current regulations and the need for
extended regulations on emerging tobacco products. The consensus of these articles shows that a
more strict regulation on electronic cigarettes must be in place in order to reduce e-cigarette use.
All the articles reviewed, their study methods, and results can be found in Appendix 1.
14
5.0
DISCUSSION
Cigarette smoking is still a difficult task to relinquish due to its very complex nature and constant
variation between individuals and context6. Smoking can be initiated by a myriad of variables
such social and physical environments, social groups, socioeconomic status, cognitive processes,
biological and genetic factors, exposure to tobacco and frequency of exposure, age of exposure,
family influence, and many other factors. The complexity lies in the interaction of all these
variables and how one may increase the effect of another.
Regardless of how the behavior is initiated, after habitual use, the nicotine content in the
cigarette forms a biological addiction within the brain, which makes it extremely difficult to stop.
After this initial addiction is formed and continued over a long period of time, habit is made to
smoke cigarettes even when one does not want to6. The cues related to smoking the cigarette can
now trigger a craving on their own in addition to withdrawal from nicotine deprivation between
cigarettes. In order to prevent this habit and addiction formation, resources must be concentrated
to target adolescents that initiate smoking and continue to smoke due to whatever reward
pathway is activated in their personal context.
Although e-cigarettes have been on an exponential rise in the past 10 years, little is still
known about their effects and their intended use. The CDC reports that the lack of e-cigarette
regulation across the United States could be caused by the lack of knowledge that policy makers
have in regard to e-cigarettes and their potential health effects3. As mentioned previously, the
15
formation of the e-cigarette was originally to be used as a type of nicotine replacement treatment
among current long-term users. However, tobacco marketing has advocated e-cigarette use to a
much wider population that encompasses not only current tobacco users, but also occasional and
non-users as well. Yet, because of its original idea to replace normal cigarettes among regular
users, this label as a type of health benefit has continued. Although this may seem promising at
first, this may be due to the labeling of e-cigarettes as a smoking cessation method when in
actuality it is not. The long-term cigarette using population might benefit from electronic
cigarette use, although it does not reduce their ability to quit the habit of smoking. Because the
perceived notion that using an e-cigarette means a user wants to quit, they may be more likely to
say they do want to abstain from smoking after repeated use.
Apart from the population of adult long-term smokers that want to quit but have not been
able to, a third of e-cigarette users are adolescent non-smokers17. With this population in mind,
an association is established between e-cigarette use and continuation to normal tobacco products
among non-smoking adolescents around the world. After the use of electronic cigarettes,
adolescents show an openness to try regular cigarettes if given the opportunity22. Adolescents
that partake in e-cigarette use tend to use them for the sake of trying a new emerging product
rather than its implied use of nicotine delivery16. A rationalization behind this may be that
adolescents that want to try and use something new and risky will try it, but will opt for a less
risky option when given one. However, in the context of the real world, when a non-smoking
adolescent is given an e-cigarette, that e-cigarette most likely contains nicotine because of its
wider availability in the market, which will then lead to addiction with consistent use.
Through these research findings, there appears to be two distinct groups of e-cigarette
users: non-smoking adolescents that are experimenting and long-term adult smokers that are
16
trying to quit smoking18. Because e-cigarettes have the notion of helping people quit their
cigarette smoking habits, adult smokers try them for said purpose; yet because e-cigarettes are
marketed towards adolescents they are also used among non-smoking populations.
The emergence of new tobacco products can have a great effect on the overall population,
not because of past knowledge on cigarette use, but the ignorance associated with these new
products. Without knowing what the risks or potential risks associated with products like ecigarettes are, more people will be willing to use the products even though they may have
detrimental health implications later on20. One associated risk with e-cigarettes is the potential to
ingest a large amount of nicotine from the cartridge delivery mechanism and overdose thereafter.
Current research has shown an increase in calls to poison control centers regarding nicotine
overdose, particularly young children29. An explanation to this increase in nicotine overdose
prevalence can be attributed to e-cigarette users leaving their nicotine cartridges out for children
to obtain and ingest because they are unaware of what it is they are ingesting.
Another risk associated with e-cigarette use is the nicotine delivery system itself. Because
users typically like to increase their nicotine delivery to match their normal tobacco product
amount, they can suffer toxic side effects or abuse the use of the device more frequently26.
Furthermore, adolescents and other users that use e-cigarettes may be compensating for their
inability to smoke tobacco products in public currently, but when able to do so they will continue
smoking their usual brands. This dual use can increase their overall nicotine dependence and
requirements to the point of either toxicity or long-term dependence of tobacco products19. With
these various risks in mind, and ones that are still under investigation, e-cigarette use may cause
more harm than what is understood by the general population.
17
The emergence of the electronic cigarette from China sparked an interest from tobacco
companies within the United States to add to their already extensive list of tobacco products.
However in 2008 the FDA responded to this increased interest from U.S. tobacco companies by
blocking all imports of the electronic cigarette under the Federal Food, Drug, and Cosmetic Act
of 1938 (FDCA), which states that the FDA can regulate all drug delivery devices within the
U.S25. However, a company that imports electronic cigarettes (Sottera, Inc.) argued in federal
court that electronic cigarettes are purely tobacco products because of their nicotine content and
are not meant for pharmaceutical purposes like it was originally intended when created in
China25. In 2010 the federal court sided with Sottera and classified the electronic cigarette as a
tobacco product, and therefore could not be blocked by the FDA under the FDCA (Sottera, Inc.
v. FDA 2010). After this ruling, the FDA would increase their regulatory power for tobacco
products to include emerging items such as hookah tobacco and electronic cigarettes under the
2009 Family Smoking Prevention and Tobacco Control Act (TCA)
25
. Although the FDA
strengthened their grip on overall tobacco product regulation, there are currently no federal laws
regulating electronic cigarettes in terms of sale, production, or usage25.
Although there is no federal regulation of electronic cigarettes, various states and
municipalities within the U.S. are passing restriction on public electronic cigarette usage. For
example, some states and counties ban use of electronic cigarettes in schools or county buildings
while others may include public parks as well. Clean indoor air acts, such as Pennsylvania’s,
enforce the rule of having bars, restaurants, workplaces, or a combination of the three to be
smoke-free. However, with emerging tobacco products such as the electronic cigarette and a lack
of updated regulation, these clean air acts are bypassed through various loopholes. Currently,
only New Jersey, Utah, and North Dakota have statewide bans on electronic cigarette usage in all
18
public places25. It is understood that statewide restrictions are more difficult to attain than lowerlevel legislative progression. While only a few states have varying degrees of electronic cigarette
bans in place, more municipalities are much more common25. Because of this bottom-up
approach of tobacco regulation within the states, large cities such as Chicago, New York City,
and Los Angeles all passed comprehensive bans on electronic cigarettes by adjusting their clean
air acts25.
One of the methods used by tobacco companies to avoid direct regulation on their
electronic cigarette products is by the stated definition of the product. Tobacco companies
collectively offer a myriad of brands, flavorings, and nicotine levels, which ultimately produces
varied terminology and definitions for a specific product. For example, a tobacco company can
alter the cartridge amount and design of all their electronic cigarette products and therefore have
many types of tobacco products that may or may not fall under the regulatory demands set by the
FDA. With the many combinations and permutations set by tobacco companies regarding
electronic cigarettes, state regulation efforts fall short because they are not all-inclusive
regarding tobacco products. Research has shown that even in countries such as Australia that
prohibit sale, possession, and/or use of nicotine-containing electronic cigarettes without a permit,
43% of electronic cigarette owners have nicotine in their devices without possession of a
permit28. This is another example of how tobacco companies shift the definition of their products
in order to increase use and sales.
To correct this issue, researchers have suggested that state regulation should include the
term “electronic smoking device or vapor product” anywhere the term “tobacco product” appears
in laws that have already been passed27. This change to already existing laws to include current
and future devices regardless of nicotine content will allow for tighter regulation and less
19
loopholes for electronic cigarette usage. By expanding existing definitions of electronic
cigarettes and other tobacco products to include “any product that requires inhaling or exhaling
of smoke and/or vapor from an electronic smoking device”, as New Jersey, Utah, and North
Dakota have, will ensure stronger regulation on electronic cigarettes without the need to expand
existing smoke-free laws completely27.
Another example of how health policy and regulations are avoided by tobacco companies
is how these electronic cigarette products are advertised and flavored. Currently there are more
than 7,700 electronic cigarette flavors available24, 26. Additionally, electronic cigarette television
advertising has increased youth exposure to electronic cigarettes by 257% and adult exposure by
321% from 2011 to 201324, 26. To combat this rising exposure and usage among adolescents, the
FDA has tried to prohibit the distribution of electronic cigarette free samples, sales to
adolescents, and sales through vending machines24, 26. Although this is a great step in the right
direction for the FDA, these restrictions do not impede the advertisement, marketing, or
promotion of electronic cigarette products in general, which can still be targeted towards
adolescents even if they are not explicitly done so. Flavors of electronic cigarettes have a similar
low threshold for regulation under the FDA even though flavor bans are in place for regular
tobacco products such as cigarettes25, 27.
The impact of media communication with the public has a significant role in forming
contrasting opinions about emerging tobacco products. Over the years, public interest in
electronic cigarettes has gained momentum with the increase of media coverage for electronic
cigarettes. With the original stigma and tobacco companies advertising electronic cigarettes as
healthy alternatives to regular tobacco, public opinion about electronic cigarettes have been
geared towards a safer option for people who want to smoke27. Studies have shown that this is
20
especially true in lower income and lower education populations because there is a higher
exposure rate to electronic cigarette media campaigns compared to areas of higher income and
education27. Furthermore, studies have shown that the public population has lower support for
electronic cigarette regulation due to the stigma that they are safe to use27. This increasing trend
in public opinion is directly related to the advertising techniques of tobacco companies as well as
a lack of policy to limit or ban these misguiding media campaigns.
5.1
IMPLICATIONS OF THE RESULTS
The purpose of this master’s essay is to argue that there is a need to develop health policies in
Pennsylvania to regulate electronic cigarettes, which are currently not regulated under the
existing tobacco regulatory framework. In order to develop such policies, it is recommended that
information be collected via in-depth interviews with policy makers, public health officials and
tobacco-free health advocates (Appendix 2).
The rationale for obtaining interview data is to explore the level of awareness and beliefs
regarding electronic cigarettes with individuals involved in tobacco-related legislation and/or
tobacco knowledge in Pennsylvania (PA). In order to attain this objective, the research staff and I
will conduct and qualitatively analyze individual interviews with legislators and/or staff; public
health officials who are familiar with tobacco use; and tobacco control advocacy group members.
The knowledge gained from these interviews will allow us to further enhance our understanding
of development and barriers involved in proposing regulations within PA that will impact those
within a societal and political context in regard to electronic cigarettes.
21
Qualitative interviewing methodologies have expanded in use over recent years to fully
assess information from a specific entity and/or organization. While quantitative measures have
been utilized for a large proportion of all scientific studies, quantitative analysis lacks the insight
that qualitative analysis provides when properly utilized. Qualitative interviews can provide the
researcher with comprehensive information regarding the subjects’ experiences and perspective
regarding a specific topic30. Because quantitative and qualitative analysis alone cannot
comprehensively find answers to a particular topic, using both in a mix methods approach can
provide the researcher with a broad collection of information to analyze further30.
Researchers use various forms of qualitative analysis to understand and extract the
correct type of data and responses from their subjects. For example, there are such interview
methods that fall under neopositivist, romanticist, or localist categories. For most qualitative
interview methods, researchers utilize the localist approach in order to obtain alternative28
understandings of the interview responses that are obtained from research subjects 30. Qualitative
interviewing allows a varying degree of freedom and flexibility in receiving information from
the study subject that normal conversations or quantitative analysis cannot provide30.
5.2
A PROPOSED STRATEGY FOR THE DEVELOPMENT OF E-CIGARETTE
HEALTH POLICY FOR PENNSYLVANIA
5.2.1 Proposed Study Sample
Our sample will be differentiated by PA’s regions in order diversify geopolitical ideologies
within PA. For each region, we will interview at least 3 different individuals within the specified
22
categories previously mentioned (policy maker and/or staff, public health official, and advocacy
group member), for a total of 24 interviews. The research team and I believe 24 interviews across
the state will be sufficient, but if deemed necessary we will continue to recruit and interview
individuals that pertain to the relative background categories. These individuals will be recruited
with the assistance of the research team’s connections and already established networks across
PA. If a legislator is unavailable for the interview, county staff members are appropriate
replacements because they tend to be very aware of any current legislative process.
Contrary to the standard quantitative methodology most health research undergoes,
qualitative methods provide researchers with the ability to describe the familiarity, concern, and
certainty of these interviewed individuals35, 36. With this method of data collect we can reduce
any limitations that other typical methods (first person surveys or questionnaires) may produce32,
33
.
In this qualitative interview portion of the study, interviewees will participate in two
separate interviews one month apart. The initial interview is to gather the majority of
information. The second interview of the study will be shorter and only a follow up because
policy makers, health officials, and advocacy members often review pertinent material brought
up in the initial interview to increase their understanding and awareness of the subject.
Furthermore, thoughts may change or new insights may be gained after individuals have had an
opportunity to consider issues introduced during initial interviews.
Each interview will be conducted via a recorded phone call to capture all verbal
communication. An important benefit of using this method is that it provides ideal data archiving
of all interview material so that interviews can be easily accessed at any time and analyzed
correctly. We have constructed a series of questions in the form of a template to conduct the in-
23
depth interviews. These questions may range from being broad, open-ended questions about
tobacco-control legislation to more detailed questions relating to tobacco awareness. We will
then ask about particular issues, such as (1) knowledge, attitudes, and beliefs related to electronic
cigarettes; (2) understanding of prior legislation related to tobacco products; and (3) perceived
consequences of any legislation passed. Because certain legislation varies between
municipalities, we will develop different templates based on findings prior to conducting a
specific interview. For example, for municipalities that have passed legislation, we will explore
issues related to enforcement of existing policies, whereas this will not be relevant to regions
with no relevant legislation. For the follow up second interview, we will assess changes since the
initial interview and revisit questions left unanswered. We will also explore participants’
perception of how participating in this study may have affected their knowledge, attitudes, or
beliefs regarding electronic cigarettes. We expect each initial interview to last between 20 to 30
minutes. Compensation will be made based on successful interviews with $50 for each
interviewee.
24
6.0
6.1
CONCLUSION
SUMMARY OF MAJOR FINDINGS
Overall, our research aims to control emerging tobacco products such as electronic cigarettes at a
direct source. By targeting health policy and communication between high-ranking individuals in
various municipalities across PA, we are able to direct our efforts of reducing electronic cigarette
use and exposure to the maximum percentage. Because various legislators, health officials, and
tobacco-free advocates already know the dangers of smoking and are aware of increasing
prevalence of electronic cigarettes, we do not need to entice them to enact change through
quantitative analysis and correlations. Rather, by performing qualitative interviews that target
each study subject’s immediate awareness and opinions on electronic cigarettes (Appendix 2),
we can fully understand the relationship that communication between officials have and how
legislation is passed at the county and eventually state level.
Communication between these officials is of utmost importance regarding municipality
legislation because if officials do not agree on a certain topic, legislation will not be passed.
Because state legislation regarding tobacco policy is a bottom-up approach, municipality
legislation is highly desirable in that it eventually leads to state legislation being passed that
concerns tobacco policy. PA must act like other states such as California and New York in the
sense that passing tobacco free legislation that includes new emerging tobacco products at the
25
county level will eventually spread to other counties in the state and cover all localities in the
future. Our study is geared towards understanding communication barriers and advantages that
these counties and municipalities have.
By assessing health policy at the local level that eventually leads to the state and federal
levels of tobacco control, our research endeavors hope to adjust PA’s tobacco legislation against
emerging tobacco products as a whole. If this is done, an array of public health objectives will be
met including but not limited to reducing smoking initiation rates among adolescents, increasing
education and information dissemination about electronic cigarettes, and reducing the amount of
infant mortalities related to nicotine liquid ingestion. Tobacco dependence still remains the
number one preventable cause of death in the U.S. and one of the leading tactics to combat this
statistic is a reform in health policy. If we act now we can reduce adolescent and adult exposure
to electronic cigarettes, which may prevent them from a lifetime of tobacco and nicotine
dependence.
6.2
STUDY LIMITATIONS
Various counties and municipalities are exempt due to a clause within the PA Clean Indoor Air
Act, however there are exceptions that allow us to still examine these municipalities in order to
affect statewide tobacco reform. For example, Philadelphia County has its own restrictions on
who can access tobacco products. In addition, youth access laws created before January 1st, 2002
are not exempt from the clause within the PA Clean Indoor Air Act, and therefore are subject to
change in the future without any legal conflicts. Because of these various problems within the
legal system regarding municipality legislation and tobacco reform exist, it may be difficult to
26
obtain relevant data. However, our research will offer insight to how federal, state, and municipal
regulations apply to electronic cigarettes.
Another possible limitation to our research study is that of actually obtaining responses
from the various individuals within each municipality and/or county. Legislators, county
officials, and health department heads tend to be very busy with many things and may not find
time right away to sit and exchange responses in the form of a qualitative interview. Although
this is currently the problem we are facing in our research study, we are still confident that we
will obtain responses from the various officials that we set out to find across the state because of
various reasons. One reason is that tobacco reform and control within PA is a very active issue
that tends to attract attention from legislators and health department officials alike. Secondly, we
have a list of names and contacts provided to us that have already shown interest in our study and
will participate when able to.
Another limitation that may occur is that of selection bias. Because we have a certain list
of officials that we have chosen to interview, this may create a bias of responses that are already
geared towards protecting public health via tobacco regulation. However, to avoid this bias, we
are utilizing the qualitative interview methodology in order to remain highly attuned to responses
that individuals make and analyze them accordingly.
27
APPENDIX A
PUBMED SEARCH LITERATURE
Authors
Article
Methods
Results
Conclusions
Title
Adriaen
Effectiven
s K, Van Gucht ess
of
the
D, Declerck P, electronic
Baeyens F.
cigarette:
An
eight-week
flemish study with
six-month followup on smoking
reduction, craving
and experienced
benefits
and
complaints.
After the lab
sessions, the control
group also received
an e-cig. The RCT
included
several
questionnaires,
which repeatedly
monitored
the
effect of ad libitum
e-cig use on the use
of
tobacco
cigarettes and the
experienced
benefits/complaints
up to six months
From the first lab session on, e-cig
use after four hours of abstinence resulted
in a reduction in cigarette craving which
was of the same magnitude as when a
cigarette was smoked, while eCO was
unaffected. At the end of the eight-month
study, 19% of the e-cig groups and 25% of
the control group were totally abstinent
from smoking, while an overall reduction
of 60% in the number of cigarettes
smoked per day was observed (compared
to intake). eCO levels decreased, whereas
cotinine levels were the same in all groups
at each moment of measurement. Reported
benefits far outweighed the reported
28
In a series of controlled
lab sessions with e-cig naïve
tobacco
smokers,
second
generation e-cigs were shown to
be immediately and highly
effective in reducing abstinence
induced cigarette craving and
withdrawal symptoms, while not
resulting in increases in eCO.
Remarkable
eight-month
reductions in, or complete
abstinence from tobacco smoking
was achieved with the e-cig in
almost half (44%) of the
participants.
after the last lab complaints.
session.
Berg CJ,
Stratton
E,
Schauer
GL,
Lewis M, Wang
Y, Windle M,
Kegler M.
Perceived
harm,
addictiveness, and
social
acceptability
of
tobacco products
and
marijuana
among
young
adults: marijuana,
hookah,
and
electronic
cigarettes win.
Authors
Article
10,000
students across two
universities in the
Southeastern region
of the United States
were recruited and
asked to complete
an online survey.
Out
of
these
students,
2,002
completed
the
survey
which
assessed
their
personal, parental,
and peer use of
tobacco
and
smoking products.
Methods
In the past month, marijuana was
the most commonly used smoking product
used at 19.2%, and hookah at second most
common at 16.4%. The least common
products used were smokeless tobacco
products at 2.6% and electronic cigarettes
were used among only 4.5% of surveyed
participants. Rates were high across all
participants
for
concurrent
usage,
especially electronic cigarette users.
Tobacco use was related to positive social
factors among those surveyed.
Results
Title
29
After surveying about
2000 college students, it seems
that marketing of electronic
cigarettes and hookah to be safe
and socially acceptable is
working. Further research needs
to be conducted on the health
risks from emerging tobacco
products like electronic cigarettes
and hookah to communicate risks
to targeted youth.
Conclusions
L,
JL.
Biener
A
Hargraves longitudinal study
of
electronic
cigarette
use
among
a
population-based
sample of adult
smokers:
association with
smoking cessation
and motivation to
quit.
Brandon
TH, Goniewicz
ML,
Hanna
NH, Hatsukami
DK, Herbst RS,
Hobin
JA,
Ostroff
JS,
Shields
PG,
Toll BA, Tyne
CA, Viswanath
K, Warren GW.
Electronic
Nicotine Delivery
Systems: A Policy
Statement
from
the
American
Association
for
Cancer Research
and the American
Society of Clinical
Oncology.
Representati
ve
samples
of
adults in 2 U.S.
metropolitan areas
were surveyed in
2011/2012
about
their use of novel
tobacco products.
In 2014, follow-up
interviews
were
conducted with 695
of
the
1,374
baseline cigarette
smokers who had
agreed to be recontacted.
This policy
statement
was
developed
by
members from the
Tobacco
and
Cancer
Subcommittee of
the
American
Association
for
Cancer
Research
(AACR)
Science
Policy
and
Government Affairs
(SPGA) Committee
and
American
Society of Clinical
Oncology (ASCO).
At follow-up, 23% were intensive
users, 29% intermittent users, 18% had
used once or twice, and 30% had not tried
e-cigarettes.
Logistic
regression
controlling for demographics and tobacco
dependence indicated that intensive users
of e-cigarettes were 6 times as likely as
non-users/triers to report that they quit
smoking (OR: 6.07, 95% CI = 1.11, 33.2).
No such relationship was seen for
intermittent users. There was a negative
association between intermittent ecigarette use and one of two indicators of
motivation to quit at follow-up.
Daily use of electronic
cigarettes for at least 1 month is
strongly associated with quitting
smoking at follow up. Further
investigation of the underlying
reasons for intensive versus
intermittent use will help shed
light
on
the
mechanisms
underlying
the
associations
between
e-cigarette
use,
motivation to quit and smoking
cessation.
The evidence regarding the risks
and benefits of ENDS in different
segments of the population such as current
smokers and nonsmokers is difficult to
interpret, because the marketplace of
ENDS products is evolving rapidly, and
data on the long-term consequences of
ENDS use are not yet available.
Additional studies are needed to inform
ENDS policy and regulation and to guide
the decisions of consumers and health care
providers related to ENDS use.
There is a lack of data on
the public health impact of
ENDS on both individuals and
the population as a whole, which
makes it difficult to develop a
comprehensive
regulatory
framework for these products at
the current time. Nonetheless, it
is prudent for policymakers to
take steps to minimize the
potential negative public health
consequences of these products,
particularly on youth, while
taking care not to undermine
their potential to reduce the harm
caused by combustible cigarettes
and other conventional tobacco
30
products.
Authors
Article
Methods
Results
Conclusions
Title
Bunnell
RE, Agaku IT,
Arrazola RA,
Apelberg
BJ,
Caraballo RS,
Corey
CG,
Coleman BN,
Dube SR, King
BA.
Intentions
to
Smoke
Cigarettes Among
Never-Smoking
US Middle and
High
School
Electronic
Cigarette Users:
National
Youth
Tobacco Survey,
2011-2013.
Analyzed
data from 2011,
2012, and 2013
National
Youth
Tobacco Surveys of
students in grades
6-12.
Youth
reporting
they
would
definitely
not smoke in the
next year, while all
others
were
classified as having
positive intention to
smoke conventional
cigarettes.
Demographics, protobacco
advertisement
exposure, ever use
of e-cigarettes, and
ever use of other
combustibles and
non-combustibles
were included in
assessing
associations with
Between 2011-2013, the number of
never-smoking youth who used ecigarettes increased three-fold, from
79,000 to over 263,000. Intention to
smoke conventional cigarettes was 43.9%
among ever e-cigarette users and 21.5%
among never users. Ever e-cigarette users
had higher adjusted odds of having
smoking intentions than never users
(Adjusted Odds Ratio: 1.70, 95%
Confidence Interval: 1.24-2.32). Those
who ever used other combustibles, ever
used non-combustibles, or reported protobacco advertisement exposure also had
increased odds of smoking intentions.
31
In 2013, over a quarter
million never-smoking youth had
used e-cigarettes. E-cigarette use
was associated with increased
intentions to smoke cigarettes.
Enhanced prevention efforts for
youth are important for all forms
of
tobacco,
including
ecigarettes.
smoking intentions
among
nevercigarette-smoking
youth.
Authors
Article
Methods
Results
Conclusions
Title
Chatha
m-Stephens K,
Law R, Taylor
E, Melstrom P,
Bunnell
R,
Wang
B,
Apelberg
B,
Schier
JG;
Centers
for
Disease Control
and Prevention
(CDC).
Notes
from the field:
calls to poison
centers
for
exposures
to
electronic
cigarettes--United
States, September
2010-February
2014.
E-cigarette
exposure calls were
compared
with
cigarette exposure
calls by proportion
of
calls
from
health-care
facilities. Over the
course of the study,
there was a reported
2,405
e-cigarette
and
16,248
cigarette exposure
calls from across
the United States,
the
District
of
Columbia, and U.S.
territories.
Colema
n BN, Apelberg
BJ,
Ambrose
BK, Green KM,
Choiniere CJ,
Associatio
n
Between
Electronic
Cigarette Use and
Openness
to
Data from
the
2012–2013
National
Adult
Tobacco
Survey,
characteristics
of
E-cigarettes accounted for an
increasing proportion of combined
monthly e-cigarette and cigarette exposure
calls, increasing from 0.3% in September
2010 to 41.7% in February 2014. A
greater proportion of e-cigarette exposure
calls came from health-care facilities than
cigarette exposure calls (12.8% versus
5.9%). Cigarette exposures were primarily
among persons aged 0–5 years (94.9%),
whereas e-cigarette exposures were mostly
among persons aged 0–5 years (51.1%)
and >20 years (42.0%). E-cigarette
exposures were more likely to be reported
as inhalations (16.8% versus 2.0%), eye
exposures (8.5% versus 0.1%), and skin
exposures (5.9% versus 0.1%), and less
likely to be reported as ingestions (68.9%
versus 97.8%) compared with cigarette
exposures.
Among young adults who had
never established cigarette smoking
behavior 7.9% reported having ever tried
e-cigarettes—14.6% of whom reported
current use of the product. Ever e-cigarette
32
Given the rapid increase
in e-cigarette-related exposures,
of which 51.1% were among
young
children,
developing
strategies to monitor and prevent
future poisonings is critical.
Health-care providers; the public
health community; e-cigarette
manufacturers,
distributors,
sellers, and marketers; and the
public should be aware that ecigarettes have the potential to
cause acute adverse health effects
and represent an emerging public
health concern.
Ever use of e-cigarettes,
as well as other tobacco products,
was associated with being open
to cigarette smoking. This study
does not allow us to assess the
Bunnell
King BA.
R, Cigarette
adults aged 18–29
Smoking Among who had never
US Young Adults. established
cigarette smoking
behavior
were
examined by ever
use of e-cigarettes,
demographics, and
ever use of other
tobacco products.
Authors
Article
Methods
Title
Dutra
Electronic
CrossLM, Glantz SA. cigarettes
and sectional analyses
conventional
of survey data from
cigarette
use a
representative
among
U.S. sample
of
US
adolescents:
a middle and high
cross-sectional
school students in
study.
2011 and 2012 that
completed the 2011
and 2012 National
Youth
Tobacco
Survey.
Experimentation
with, ever, and
current
smoking,
and
smoking
abstinence.
Hamilto
Ever Use
Data
for
n HA, Ferrence of Nicotine and 2892 high school
R, Boak A, Nonnicotine
students
were
Schwartz
R, Electronic
derived from the
use was associated with being open to
cigarette smoking as was being male, aged
18–24, less educated, and having ever
used hookah or experimented with
conventional cigarettes.
Results
In 2011, current cigarette smokers
who had ever used e-cigarettes were more
likely to intend to quit smoking within the
next year. Among experimenters with
conventional cigarettes, ever use of ecigarettes was associated with lower 30day, 6-month, and 1-year abstinence from
cigarettes. Current e-cigarette use was also
associated with lower 30-day, 6-month,
and 1-year abstinence. Among ever
smokers of cigarettes (≥100 cigarettes),
ever e-cigarette use was negatively
associated with 30-day, 6-month, and 1year abstinence from conventional
cigarettes.
directionality of this association,
so future longitudinal research is
needed to illuminate tobacco use
behaviors over time, as well as
provide additional insight on the
relationship between ENDS use
and conventional cigarette use
among young adult populations.
Conclusions
Use of e-cigarettes was
associated with higher odds of
ever or current cigarette smoking,
higher odds of established
smoking, higher odds of planning
to quit smoking among current
smokers,
and,
among
experimenters, lower odds of
abstinence from conventional
cigarettes. Use of e-cigarettes
does not discourage, and may
encourage, conventional cigarette
use among US adolescents.
Fifteen percent of high school
More students reported
students reported using e-cigarettes in ever using e-cigarettes without
their lifetime. Most students who ever nicotine than with nicotine in
used e-cigarettes reported using e- Ontario,
Canada.
This
33
Mann
RE, Cigarettes Among
O'Connor
S, High
School
Adlaf EM.
Students
in
Ontario, Canada.
Authors
Article
2013
Ontario
Student Drug Use
and Health Survey.
Analyses were used
to investigate the
factors associated
with use of ecigarettes. Use of ecigarettes
was
derived from the
question,
“Have
you ever smoked at
least one puff from
an e-cigarette?”
Methods
cigarettes without nicotine (72%), but
28% had used e-cigarettes with nicotine.
Male, White/Caucasian and rural students,
as well as those with a history of using
tobacco cigarettes, were at greater odds of
e-cigarette use. Seven percent of students
who had never smoked a tobacco cigarette
in their lifetime reported using an ecigarette. Five percent of those who had
ever used an e-cigarette had never smoked
a tobacco cigarette.
Samples of
smokers aged 15
years and older
from 2008, 2010,
2013, and 2014 as
part
of
the
International
Tobacco
Control
(ITC) Netherlands
Survey. Reasons for
use
and
characteristics
of
smokers
were
examined using the
sample from 2014.
Logistic regression
analyses
were
In 2014, 91.4% of Dutch smokers
reported being aware of e-cigarettes,
40.0% reported having ever tried them,
and 15.9% were currently using them. The
main reason given for using e-cigarettes
was to reduce the number of regular
cigarettes smoked per day (79%). Ever
trying e-cigarettes among those aware of
e-cigarettes was associated with being
young, smoking more regular cigarettes
per day, having made a quit attempt in the
last year, having used smoking cessation
pharmacotherapy in the last year, and
reporting high awareness of the price of
regular cigarettes. Smokers who kept
using e-cigarettes had a higher educational
background, had higher harm awareness
Results
underscores the need for greater
knowledge of the contents of
both nicotine and non-nicotine ecigarettes to better guide public
health policies.
Conclusions
Title
Hummel
K, Hoving C,
Nagelhout GE,
de Vries H, van
den Putte B,
Candel
MJ,
Borland
R,
Willemsen MC.
Prevalence
and reasons for
use of electronic
cigarettes among
smokers: Findings
from
the
International
Tobacco Control
(ITC) Netherlands
Survey.
34
E-cigarettes
are
increasingly used by Dutch
smokers. Commonly endorsed
motivations for current ecigarette use were to reduce
tobacco smoking and because ecigarettes are considered to be
less harmful than tobacco
cigarettes.
Kadowa
A review
ki J, Vuolo M, of the current
Kelly BC.
geographic
distribution of and
debate
surrounding
electronic
cigarette clean air
regulations in the
United States.
Authors
Article
conducted
to
evaluate
the
associations
between smokingrelated
variables
with ever trying ecigarettes
and
current e-cigarette
use.
The lack of
federal
guidance
leaves lower-level
jurisdictions
to
debate the merits of
restrictions on use
in public spaces
without sufficient
scientific research.
As
we
show
through
a
geographic
assessment
of
restrictions, this has
resulted
in
an
inconsistent
patchwork of ecigarette use bans
across the United
States of varying
degrees
of
coverage.
Methods
for the health of others, and were less
likely to have a total smoking ban at
home.
From a public health perspective,
if the lack of e-cigarette clean air acts
renormalizes the act of smoking, young or
uninformed users may be at risk of
developing nicotine addiction through the
use of e-cigarettes and may potentially
transition to tobacco use. Further, those
who currently reside in areas with
tobacco-specific clean air restrictions will
experience secondhand exposure to ecigarettes, adding toxins to the air that
would otherwise not be there.
Results
Title
35
The health effects of
vaping are largely unknown. This
leaves open the possibility that
users could suffer long-term
negative health effects from ecigarettes. However, preliminary
research
suggests
that
ecigarettes may be a much safer
alternative to smoking and could
possibly serve as an effective
smoking cessation therapy.
Conclusions
Krishna
n-Sarin
S,
Morean
ME,
Camenga DR,
Cavallo
DA,
Kong G.
E-cigarette
Use Among High
School
and
Middle
School
Adolescents
in
Connecticut.
Authors
Article
Crosssectional,
anonymous surveys
conducted in four
high schools (HS;
n=3614) and two
middle
schools
(MS; n=1166) in
CT in November
2013 examined ecigarette awareness,
use
patterns,
susceptibility
to
future
use,
preferences,
product
components used
(battery
type,
nicotine
content,
flavors),
and
sources
of
marketing
and
access.
Methods
Among MS students who were
lifetime e-cigarette users, 51.2% reported
that e-cigarettes were the first tobacco
product they had tried. E-cigarettes that
were rechargeable and had sweet flavors
were most popular. Smokers preferred ecigarettes to cigarettes. Current cigarette
smokers were more likely to initiate with
nicotine-containing e-cigarettes, and everand never- cigarette smokers to initiate
with e-cigarettes without nicotine. Primary
sources for e-cigarette advertisements
were televisions and gas stations and, for
acquiring e-cigarettes, were peers.
Examined
the text of 46 bills
that
define
ecigarettes enacted
in 40 states and
characterized how
e-cigarettes
and
similar
products
Definitions separating e-cigarettes
from other tobacco products are common.
Similar to past ‘Trojan horse’ policies, ecigarette 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
Results
Longitudinal monitoring
of e-cigarette use among
adolescents and establishment of
policies to limit access are
imperatively needed.
Conclusions
Title
Lempert
The
LK, Grana R, importance
of
Glantz SA.
product
definitions in US
e-cigarette laws
and regulations.
36
Definitions separating ecigarettes from other tobacco
products are common. Similar to
past ‘Trojan horse’ policies, ecigarette policies that initially
appear to restrict sales (eg, limit
youth access) may actually
undermine regulation if they
Authors
Article
were
defined.
Online survey data
was collected from
a
representative
sample of US adults
between
October
and December 2013
and weighted to
match the US adult
population.
They
fitted
multiple
regression models,
adjusting
for
demographic
variables,
to
examine
associations
between support for
policies to restrict
vaping
and
smoking in public
venues and selfreported frequency
of exposure to ecigarette
communications in
the
preceding
month.
Methods
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 preempt stronger regulations and explicitly
include e-cigarettes in smoke-free and
taxation laws.
Results
establish local pre-emption or
create definitions that divide ecigarettes 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.
Conclusions
Title
McMille
Trends in
MixedPrevalence of use increased
There has been rapid
n RC, Gottlieb Electronic
mode surveys were significantly across all demographic growth in ever and current
MA,
Shaefer Cigarette
Use used to obtain groups. In 2013, current use among young electronic cigarette use over the
37
RM, Winickoff Among
U.S.
JP, Klein JD.
Adults: Use is
Increasing in Both
Smokers
and
Nonsmokers.
representative,
adults 18–24 was higher than adults 25–
cross-sectional
44, 45–64, and 65+. Daily smokers and
samples of U.S. nondaily smokers were the most likely to
adults in each of 4 currently use e-cigarettes, compared to
years.
former smokers and never-smokers.
However, 32.5% of current electronic
cigarette users are never- or former
smokers.
Pepper
Reasons
JK, Ribisl KM, for starting and
Emery
SL, stopping
Brewer NT.
electronic
cigarette use.
In
March
2013, 17,522 U.S.
adult
TCME
participants
completed
an
online survey. For
this
study,
we
report data only
from the 3878
participants
who
reported
ever
having tried an ecigarette.
The most common reasons for
starting e-cigarette use were curiosity, a
friend or family member used, gave, or
offered an e-cigarette, and to quit or cut
back on smoking. Other common reasons
for trying e-cigarettes included believing
that e-cigarettes were less harmful to the
user than regular cigarettes, could be used
in places where smoking is not allowed, or
were less harmful to others. Nearly twothirds of those who had tried e-cigarettes
later discontinued use. People whose main
reason for trying e-cigarettes was not goaloriented were more likely to stop using ecigarettes than those whose main reason
was goal-oriented. However, among
participants who tried e-cigarettes in order
to quit or cut back on smoking, only 48%
discontinued use.
38
past 4 years. Use is highest
among young adults and current
cigarette smokers. Although
smokers are most likely to use
these products, almost a third of
current users are nonsmokers,
suggesting
that
e-cigarettes
contribute to primary nicotine
addiction and to renormalization
of tobacco use. Regulatory action
is needed at the federal, state, and
local levels to ensure that these
products do not contribute to
preventable chronic disease.
Those who try for goaloriented reasons are more likely
to continue using, but when they
do stop using, they do so for
reasons related to product
satisfaction. If e-cigarettes are to
serve as a harm reduction tool,
smokers who try for cessation
will need to be sufficiently
satisfied with the product so that
they switch completely and not
merely experiment with it. Future
research should build on this
study’s findings and explore
adolescents’ and young adults’
reasons for starting and stopping
e-cigarette use, as this could help
to design programs that prevent
e-cigarettes from serving as a
gateway to future smoking.
Authors
Article
Methods
Results
Conclusions
Title
Shihade
Electronic
h A, Eissenberg cigarette
T.
effectiveness and
abuse
liability:
predicting
and
regulating
nicotine flux.
This
framework employs
“nicotine flux” to
account for the total
dose and rate at
which
nicotine
reaches the user, 2
key factors in drug
abuse liability. The
nicotine flux is the
nicotine emitted per
puff second (e.g.,
mg/s) by a given
ECIG design under
given
use
conditions and can
be
predicted
accurately
using
physical principles.
Tan AS,
Sociodemo
Bigman
CA, graphic correlates
Sandersof
self-reported
Jackson A.
exposure to ecigarette
communications
and its association
with
public
Online
survey data was
collected from a
representative
sample of US adults
between
October
and December 2013
and weighted to
As a result, although its variable
voltage and variable nicotine features
allow Product A to occupy a large nicotine
flux surface, most of the ways that Product
A can be used will produce an
unacceptably low nicotine flux. Product B
is a fixed voltage device that is sold with
nonrefillable disposable cartridges of fixed
nicotine concentration. With long puff
durations, Product B allows the user to
obtain potentially unsafe nicotine fluxes
(red region). Product C is identical to
Product B. However, it is equipped with a
microchip that automatically terminates
power to the heater coil after a preset puff
duration has been reached and that does
not allow another puff to be executed prior
to the passage of a minimum interpuff
interval. As a result, the microchip
constrains operation of the product to the
desired range of nicotine flux.
Higher self-reported exposure to
advertising, other media, and interpersonal
discussion perceived as positive were
associated with lower support for vaping
restrictions, adjusting for covariates.
Exposure to e-cigarette communications
was associated with lower support for
smoking restrictions in bivariate analyses
39
ECIGs present a level of
complexity that is a challenge to
regulation. There clearly is great
variability in the marketplace
today, with some ECIGs
delivering little or no nicotine to
the user and others, under certain
conditions, yielding higher doses
of nicotine in a few puffs than
has been observed for an entire
single combustible cigarette.
With respect to nicotine yield, we
suggest that the concept of flux
and the critical functions Z p and
Z d will allow regulators to
navigate
this
complexity,
charting the range of possible
fluxes for various proposed rules.
Further research is needed
to assess whether messages
portraying e-cigarettes as a way
to
circumvent
smoking
restrictions from advertisements
and other media are influencing
public support for vape-free
policies. These findings provide
support
for
smoke-free
and
vape-free policies:
results from a
national survey of
US adults.
match the US adult but was not significant after adjusting for empirical evidence to inform the
population.
We covariates.
policy debate over regulating
fitted
multiple
specific e-cigarette advertising
regression models,
claims.
adjusting
for
demographic
variables,
to
examine
associations
between support for
policies to restrict
vaping
and
smoking in public
venues and selfreported frequency
of exposure to ecigarette
communications in
the
preceding
month. We fitted
separate models to
assess associations
between
policy
support
and
frequency
of
exposures weighted
by whether each
category of
ecigarette
communications
was perceived as
positive
or
negative.
40
Authors
Article
Methods
Results
Conclusions
Title
Wills
TA, Knight R,
Williams
RJ,
Pagano
I,
Sargent JD.
Risk
factors
for
exclusive
ecigarette use and
dual
e-cigarette
use and tobacco
use in adolescents.
Authors
Article
Schoolbased survey of
1941 high school
students in Hawaii;
data collected in
2013. The survey
assessed e-cigarette
use and cigarette
use, alcohol and
marijuana use, and
psychosocial risk
and
protective
variables. Analysis
of variance and
multinomial
regression
examined variation
in
risk
and
protective variables
across
the
following
categories of everuse:
e-cigarette
only, cigarette only,
dual
use,
and
nonuser.
Methods
Prevalence for the categories was
17% (e-cigarettes only), 12% (dual use),
3% (cigarettes only), and 68% (nonusers).
Dual users and cigarette-only users were
highest on risk status (elevated on risk
factors and lower on protective factors)
compared with other groups. E-cigarette
only users were higher on risk status than
nonusers but lower than dual users. Ecigarette only users and dual users more
often perceived e-cigarettes as healthier
than cigarettes compared with nonusers.
Results
This study reports a US
adolescent sample with one of
the largest prevalence rates of ecigarette only use in the existing
literature. Dual use also had a
substantial prevalence. The fact
that e-cigarette only users were
intermediate in risk status
between nonusers and dual users
raises the possibility that ecigarettes are recruiting mediumrisk adolescents, who otherwise
would be less susceptible to
tobacco product use.
Conclusions
Title
Yong
Trends in
Data
Across both waves, EC awareness,
EC awareness and use
HH, Borland R, E-Cigarette
analyzed
come trial, and use among current and former have risen rapidly between 2010
Balmford
J, Awareness, Trial, from Waves 8 and smokers were significantly greater in the and 2013 among current and
41
McNeill
A,
Hitchman
S,
Driezen
P,
Thompson ME,
Fong
GT,
Cummings KM
and Use Under the
Different
Regulatory
Environments of
Australia and the
United Kingdom.
9 (collected in 2010
and
2013,
respectively) of the
International
Tobacco
Control
surveys in Australia
and the United
Kingdom
(approximately
1,500 respondents
per
wave
per
country).
United Kingdom than in Australia, but all
3 of these measures increased significantly
between 2010 and 2013 in both countries,
and the rate of increase was equivalent
between countries. Seventy-three percent
of U.K. respondents reported that their
current brands contained nicotine as did
43% in Australia even though sale,
possession and/or use of nicotinecontaining ECs without a permit are
illegal in Australia. EC use was greater
among smokers in both countries, at least
in part due to fewer uptakes by exsmokers.
42
former smokers in both Australia
and the United Kingdom despite
different
EC
regulatory
environments.
Substantial
numbers in both countries are
using ECs that contain nicotine.
APPENDIX B
INTERVIEW SAMPLE QUESTIONS
1. Please tell me what you know about electronic cigarette smoking.





Mechanics of how it is used
Potential health harms (e.g., lead to smoking, toxin load)
Potential health benefits (e.g., help people stop smoking)
Marketing and industry (e.g., what traditional tobacco companies also market e-cigarettes)
Local establishments related to this form of substance use
2. Please tell me how current regulations may or may not apply to electronic cigarette
smoking.





Clean air
Taxation
Labeling/warnings
Flavoring
Age restrictions
3. Please tell me what you think should or should not be done in terms of future policy
related to electronic cigarette smoking.





Changes in state or local law
Changes in federal law
Changes in enforcement
Building of infrastructure
Changes in education
43
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