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A new report suggests that lowering the age to purchase electronic cigarettes from 18 to 16 years of age in order to combat returns to conventional smoking among adolescents.
Electronic cigarette (e-cigarette) use among adolescents-and liquid nicotine poisoning among children-is increasing, but a new report suggests that lowering the age to purchase e-cigarettes from 18 to 16 may help prevent traditional cigarette smoking.
“Since e-cigarettes entered the US market in 2007, policy makers have been trying to figure out how to regulate them, given their potential health effects,” says lead author Abigail Friedman, assistant professor of health policy at the Yale School of Public Health in New Haven, Connecticut. “Current evidence indicates that e-cigarettes are not harmless, but that they are far less harmful than conventional cigarettes.”
Friedman’s research found that, in states with bans on e-cigarette sales to minors, downward trends in cigarette smoking have actually reversed.
“State bans on e-cigarette sales to minors increase recent use of conventional cigarettes among 12- to 17-year-olds by 0.9%, relative to the states without these bans. The impact is not evident among older adolescents, and only present once the bans go into effect,” she says.
Overall smoking rates, however, continue to fall in both types of states, Freidman reports.
“Among adolescents, conventional smoking has been falling rather steadily for more than a decade. This downward trend is the product of many factors, not just e-cigarettes, and such drivers shift over time,” she says.
The 0.9% increase is significant, because in the 8 years before the ban went into effect in the states studies, adolescent smoking rates were dropping by 1.3% every 2 years.
“So a relative increase of 0.9% would counteract 70% of the expected decline in a 2-year period. Given the youth-population in states that implemented these bans during the study period, this finding suggests that tens of thousands of teenagers took up conventional cigarettes who would not have done so if their states had not instituted these bans,” Freidman says.
The answer to how to improve this trend is not an easy one, Freidman says. Reversing existing bans could lead people in those 40 states that have already implemented bans to believe that e-cigarettes are safe, she explains. One suggestion may include changing the age restriction to 16 years rather than 18 years.
“Nicotine use is bad for adolescents, but conventional cigarettes appear far worse than e-cigarettes,” Friedman explains. “So we would like a policy that leads teenagers who are likely to smoke conventional cigarettes to choose e-cigarettes instead, without inducing nicotine use among teenagers who would not otherwise smoke. The fact that conventional smoking rates first spike at age 16 years suggests that one way to target e-cigarettes towards those at higher risk of cigarette use is to allow teenagers aged 16 years and up to purchase e-cigarettes, but retain the restriction for younger adolescents.”
The debate over the use and regulation of electronic cigarettes is a hot debate in public health policy, and Friedman’s recommendation is not congruent with that of other public health agencies.
While e-cigarettes still deliver nicotine, they do so without the same addictive qualities and possible reduce overall smoking rates. However, there is concern that the use and acceptance of e-cigarettes results in increased smoking by introducing users who would not have used traditional cigarettes, and reducing the stigma around smoking.
There is also some indication that e-cigarette use may be used as a gateway to cigarette smoking, but the study suggests that people who are willing to experiment with e-cigarettes may also be more likely to enjoy experimentation in general and are more likely to try both products regardless of its effect.
Friedman suggests that 16 years is an appropriate age to lower the e-cigarette ban to because that’s the age when conventional smoking spikes. The most important finding of this research, she writes, is the causal evidence that e-cigarette access reduces teens smoking.
“Policy discussions to date have not considered that banning e-cigarette sales to minors might increase teenaged smoking. Assuming that e-cigarettes are indeed less risky to one’s health than traditional cigarettes, as suggested by existing evidence on the subject, this result calls such bans into question. Yet it is not a straightforward guide to regulation: beyond the fact that the market had not reached equilibrium by 2013, an US Food and Drug Administration decision not to ban e-cigarette sales to minors after having announced this intention could be seen as sanctioning teen vaping, introducing distinct costs not addressed here,” Friedman says. “A middle ground that recognizes the potential for yet unknown long run costs of e-cigarette use might involve banning sales to those aged younger than 16 years instead of 18 years, as initiation of regular smoking first spikes at the former age.”
Tobacco use usually starts in adolescence, with 90% of smokers first trying before age 18 years. Overall, 24.6% of high school students and 7.7% of middle school students reporting using some type of tobacco in 2014, and 46% of high school students and 17.7% of middle school students admitted at least trying a tobacco product in 2013. According to the American Academy of Pediatrics (AAP), more than 3800 adolescents try their first cigarette every day, and 2100 become daily smokers. Most start with some type of flavored tobacco, according to AAP, and more students report trying e-cigarettes before traditional cigarettes. According to AAP, 2.5% of middle school students and 9.2% of high school students reported trying cigarettes in the past 30 days in 2014–down 4.3% and 15.8%, respectively, from 2011. On the other hand, 3.9% of middle school students and 13.4% of high school students reported trying e-cigarettes in 2014-an increase of 0.6% and 1.5%, respectively, from 2011. Hookah use has increased, as well, up 1% in middle school students, and 4.1% in high schoolers.
The Centers for Disease Control and Prevention (CDC) recommends combatting tobacco use among adolescents by increasing costs and taxes, raising the minimum age to purchase tobacco products to 21 years, promoting participation in school and community groups, and more. Advertising to children and childrens should also be targeted, CDC says, and while cigarette advertisements have been limited, AAP found that exposure to e-cigarette advertisements among 12- to 17-year-olds increased by 256% from 2011 to 2013 with ads appearing on the 100 highest-rates youth programs.
Electronic cigarette use is increasing, according to another AAP report, which reported e-cigarette used at 29% among Hawaiian high school students in 2013-a figure much higher than previously estimated.
The AAP has called for increased regulation of e-cigarettes, particularly through improved child-proof packaging, citing increased instances of nicotine poisoning among children. The American Association of Poison Control Centers (AAPCC) reported 3353 year-to-date exposures related to e-cigarettes and liquid nicotine in 2013. These products are appealing to children because of their bright colors and candy-like flavors, says AAP. The AAP says the exposure figures reported by AAPCC in 2013 have more than doubled in 2014, and most exposures occurred in children aged younger than age 6 years. The AAP reports 2689 liquid nicotine exposures for 2015 as of October 31. Just 1 teaspoon of liquid nicotine can be lethal to a child, and smaller amounts could cause serious illness, says AAP.