First E-Cigarette Ban: Mark a Win for Public Health

Recently, the sale and distribution of e-cigarettes without FDA approval was banned in San Francisco. The ban is expected to go into effect early next year and will also affect other flavored tobacco products. The ordinance will make it illegal for tobacco shops to sell any flavored tobacco products or electronic cigarettes that have not been approved by the FDA. Still, many users when surveyed feel e-cigarettes are harmless, simply because they are a heat not burn method like combustible cigarettes. Unfortunately, this myth is pervasive. Discover how tobacco companies have found a new mask to hide behind, the dangers of e-cigarettes, how e-cigarette companies are targeting youth and how you can make a difference.

First E-Cigarette Ban: Mark a Win for Public Health

Recently, the sale and distribution of e-cigarettes without FDA approval was banned in San Francisco. The ban is expected to go into effect early next year and will also affect other flavored tobacco products. The ordinance will make it illegal for tobacco shops to sell any flavored tobacco products or electronic cigarettes that have not been approved by the FDA. According to Ned Sharpless, who became Acting Commissioner of Food and Drugs in April of this year, “There are no authorized e-cigarettes currently on the market.”

Beverly Hills also passed a similar law in early June, which will go into effect in 2021. Historically, California has blazed the trail for other states on tobacco-related bans. They were the first to prohibit indoor smoking in public places more than two decades ago.

However, tobacco companies remain vehemently committed to gaining new customers no matter the cost. While the 2009 Family Smoking Prevention and Tobacco Control Act restricts marketing to youth through advertising and adding flavors in combustible cigarettes (except menthol), e-cigarette companies found themselves in the comfort of a gap in regulation. In fact, they can concoct any flavor imaginable. Despite claiming to market to adults, many flavors appear to be designed to tempt young users and particularly appeal to those willing to try for the first-time.

Using data from the 2016 National Youth Tobacco Survey, the Centers for Disease Control and Prevention and the Food and Drug Administration found the “availability of appealing flavors” was one of the top self-reported reasons for using e-cigarettes among middle and high school students.

It is very reminiscent of the old tactics tobacco companies used for decades prior to the development and enforcement of regulations. Juul, the largest e-cigarette company has always positioned itself as anti-tobacco. In fact, the company’s mission is “to improve the lives of the world’s one billion adult smokers by eliminating cigarettes.” They go a step further stating, “We don’t want anyone who doesn’t smoke, or already use nicotine, to use Juul products. We certainly don’t want youth using the product. It is bad for public health, and it is bad for our mission.” (Juul website) E-cigarettes are often marketed to help individuals wean off combustible cigarettes, which aligns with Juul’s mission. However, as the old adage says, actions speak louder than words. And e-cigarette companies are behaving strikingly like well-known tobacco giants.

Juul spent more than $1 million dollars in marketing their products on the internet, according to one research study. They focused on YouTube, Instagram, and Twitter which promoted ads conveying having fun, relaxing, sex appeal, and being cool with those who use Juul. In fact, the strategic campaign to drastically increase their social media presence equated to growing their Juul-related tweets from 765 (on average) per month in 2015 to 30,565 per month just two years later. And it worked. The number of tweets highly correlated with retail sales enabling Juul to control more than half of the e-cigarette market share by the end of 2017.

Additionally, the gap in regulation allows e-cigarette companies to sponsor music festivals and sporting events, something that is strictly prohibited for cigarettes and smokeless tobacco. However, thanks to the loophole, sponsors can set up vaping rooms, charging stations, samples, and even host surprise guest appearances from performers to lure in a bigger crowd.

E-cigarette companies have gone as far as offering college scholarships to teens in exchange for essays. It’s a way for the companies to get their brand name on college websites which looks to many like an endorsement. Some of scholarship topics seem innocuous while others outright ask for students to write about the benefits of vaping or why people still choose to smoke. If all e-cigarette companies strictly market to adults and primarily existing smokers, why would teens applying for college be in that demographic?

Even when their mission statement claims they are not targeting teenagers, their actions are telling a much different story. Juul, which touts one of their core values is “mission first” still ironically claims, “Switching adult smokers and eliminating cigarettes are at the center of all we do.” Yet, in December of 2018, Altria (owner of Marlboro) invested $12.8 billion in Juul. In fact, the deal made them owners of 35 percent of the company. It appears like a large investment to place in an e-cigarette company who claims to be on a mission to eliminate your primary product and revenue.

Consequently, another mask emerges for tobacco companies to hide behind. E-cigarette companies proclaiming to the public that their product will improve their health by helping them quit smoking. Akin to the disturbing marketing images that were used to peddle tobacco products plastered in print and television through the 1950s. Despite e-cigarettes being marketed only to adults, the U.S. Surgeon General has declared that vaping by teenagers is at epidemic levels. We know that nicotine is as addictive as heroin, and once young users are addicted, they will likely become long-term users.

Still when surveyed, many users feel e-cigarettes are harmless, simply because they are a heat not burn method like combustible cigarettes. Unfortunately, this myth is pervasive. E-cigarettes produce an aerosol by heating a liquid that contains nicotine, flavorings and other chemicals. Users and second-hand bystanders inhale harmful substances directly and deeply into their lungs through the aerosol that include nicotine, ultra fine particles, flavorings such as diacetyl (known to cause popcorn lung), heavy metals (nickel, tin, and lead), cancer-causing chemicals and volatile organic compounds like benzene, ethylene oxide, acrylonitrile, acrolein, and acrylamide.

The recent bans in California should lead the way for other cities and states to pass similar policies. I urge you to contact your local representatives and advocate for proposing similar legislation in your state to hold e-cigarette companies accountable to the same regulations as cigarettes and smokeless tobacco. Without such action, we will likely find ourselves repeating history with the newest face of tobacco companies once again padding their pockets as the public pays the heavy price of preventable health conditions.

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Jill Weberding MPH

About Jill Weberding MPH, BSN, RN

Jill Weberding, MPH, BSN, RN, OCN is an Oncology Nurse Consultant She has worked as an oncology nurse for more than 20 years. Her career has been spent in the community practice setting, including inpatient, outpatient infusion, clinical research, and management. She is an experienced speaker and trainer of seasoned and novice oncology healthcare professionals. With her passion for patient education and advocacy, she has spent years speaking to support groups obtaining feedback from patients and family members to understand where the gaps lie in teaching. She now spends her career working to simplify cancer education for patients and families, as well as training and speaking to health care professionals to facilitate improving oncology patient care.

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Specializes in ICU, trauma, neuro.

A take a "counter position" in that I believe there is research to show that ecigarettes are considerably safer than smoking https://www.sciencedaily.com/releases/2017/02/170207104358.htm , and https://www.theguardian.com/society/2018/dec/28/vaping-is-95-safer-than-smoking-claims-public-health-england and other studies have shown that they may be twice as effective as nicotine replacement patches, gum and lozenges at helping smokers quit smoking https://www.nejm.org/doi/10.1056/NEJMoa1808779 . However, they also play a role in getting kids to start smoking. Still as someone who lost both of his parents to cancer and who was exposed to massive amounts of tobacco smoke as a child (I was diagnosed with chronic bronchitis at 12, and the MD was mortified because my parents were 3-4 pack per day smokers), I believe that almost anything that can save lives and get people off of a more dangerous product is a net positive. I also have a problem with millions (billions?) in tax revenue being made off of a product that kills so many. Perhaps it is time that we as a society move towards banning nicotine products.

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I mean the ban isn’t the issue. The problem is that San Francisco is the same s-hole that has Homeless defecting and shooting drugs up on every corner. But yes, let’s ban e-cigs. Makes a ton of sense

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Specializes in Nurse Business Mentor, Healthcare Consultant.

@myoglobin I do see your counter position. And while yes, I agree that e-cigarettes are safer than combustible cigarettes-they still pose health threats. The first article you mentioned was from the UK, where they also note that they have stricter regulations on the limit of nicotine allowed in e-cigarettes, unlike the U.S. Juul products can be found in both countries, but the level of nicotine in U.S. products is higher than the UK. The same article noted that e-cigarettes helped as many as 65% smokers quit in a smoking cessation program, but in the NEJM article you also linked...the cessation rate was 18%. Which is quite a difference depending on the source.

The World Health Organization (WHO) recommended that e-cigarettes should be banned in indoor areas or where smoking is prohibited, back in 2016. They didn't feel there was sufficient evidence to prove that they help smokers quit and they certainly encourage youth to experiment due to the available flavors. There's plenty of evidence noting the spike in youth using e-cigarettes (which now is 1 in 3 in high school).

I'm not sure why my table didn't publish with the article but the real struggle for me is the blatant marketing to our youth in order to START them on nicotine products. Flavors like: Fruity Circle (cereal), S'mores, Sweet Tart, Atomic Cinnamon, Donut, Gummy, Pink Chewing Gum, Snickerdoodle, Marshmallow, Buttered Popcorn, Taffy, Orange Dreamsicle, and every fruit flavor you can imagine just to name a few. You will never convince me that these are "adult" flavors. Developing flavors that mimic every sugary cereal, pastry, candy and kid treat is very intentional. This is exactly like what tobacco giants did decades ago which led to the current regulations. They are going after our youth to create new customers for tobacco companies. And those companies are so sure of the link...that they are now buying at least partial ownership in the e-cigarette companies.

I simply think that e-cigarettes should be put in the same category as smokeless tobacco & cigarettes. They should be accountable to the same regulations regarding flavors & marketing. I too, was a child who grew up with a smoking parent. When I was young (8-9yrs old), I was so scared they would kill my dad that I used to steal cigarettes out of his pack and hide them under the couch just so he wouldn't smoke them. It didn't dawn on me at that age, that he would just buy more. As a cancer nurse, I would love for the U.S. to ban nicotine-products. However, I don't see that ever happening. My hope is that it at least will be regulated so the warnings are on products and they cannot target our youth.

There are many countries that have restrictions on vaping: Australia, Canada, Hong Kong, India, Norway & Japan. And even more that have banned either the sale and/or the possession of nicotine-containing liquid: Argentina, Brazil, Brunei, Cambodia, Egypt, Indonesia, Jordan, Lebanon, Malaysia, Mexico, Panama, Phillipines, Qatar, Singapore, Taiwan, Thailand, Uruguay, Venezuela, & Vietnam. @Mini2544 Yes, San Fran has a lot of public health issues right now that need to be addressed. But I don't think continuing to allow a company to target our teens to START nicotine products (much less anything else they want to put in their Juul/e-cigarette) should be ignored either. I'll take a win when I see one.

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Specializes in ICU, trauma, neuro.

I am much less concerned about vaping than smoking. Here's a "thought experiment" if you could replace every smoker with a "vapor" by snaping your "cosmic" fingers what would be the impact on public health. Let's say it would only reduce deaths by 70% rather than the 90% plus that many authorities speculate. The WHO estimates that around 8 million die each year from smoking, thus a 70% reduction would save around 5 million lives each year. This is to say nothing of the reduced impact from so called "side stream smoke. I wasn't calling for outlawing ecigs, but for outlawing cigerettes. They are by far the biggest threats. I weep for all the kids who like me dreamed of breathing clean air. If my parents had done ecigs instead my lungs would have been in much better shape.

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Specializes in Nurse Business Mentor, Healthcare Consultant.

@myoglobin Of course, we'd all like cigarettes to be banned, but that's not realistic. We'd love to reduce the millions of deaths (and health complications) caused by smoking every year. I'm just not convinced that vaping is doing that....the study you cited in the NEJM said 18% were still using e-cigarettes at one year. That equated to about 80 people in the study. That's a 72% failure rate at 1yr. I'm all for e-cigarettes helping adults wean of cigarettes if it actually does that, even if it is only 18%. However, what I'm not a proponent of is creating an entire generation that would not otherwise have used nicotine products. There is clear evidence about the significant increase in the use of nicotine products in teens as a direct result of vaping. They cite the flavors as being one of the most common reasons for trying and the thought that they're not harmful. Kids who never used nicotine products before....are now using e-cigarettes by the thousands. I have family members and close friends as teachers and I've heard them talk about this "epidemic." There is a loop hole for these companies to market to kids, create flavors of any imagination, promote at concerts providing celebrity guests and give college applicants. It's ridiculous, quite frankly. We stopped cigarette companies from targeting our kids so why wouldn't we put e-cigarette companies in the same category? What will those smoking & death rates look like when we have a significant surge in teens "experimenting" & being addicted to nicotine in high school. And with 1 in 3 users...those are going to be pretty high numbers. Nicotine is addictive and harmful. We know it and there's plenty of evidence. So why is it ok to target our youth? This ban is just the first step to move the e-cigarette companies to be forced to comply with the same existing regulations. It bans non-FDA approved products, which currently is all of them. But they have deeper pockets now that many are at least partially owned by tobacco companies, so they'll file for approval. But then one would expect that FDA will force them to comply with existing marketing/flavoring regs for other nicotine products. And why shouldn't they?

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Specializes in ICU, trauma, neuro.
1 hour ago, Jill Weberding MPH said:

@myoglobin Of course, we'd all like cigarettes to be banned, but that's not realistic. We'd love to reduce the millions of deaths (and health complications) caused by smoking every year. I'm just not convinced that vaping is doing that....the study you cited in the NEJM said 18% were still using e-cigarettes at one year. That equated to about 80 people in the study. That's a 72% failure rate at 1yr. I'm all for e-cigarettes helping adults wean of cigarettes if it actually does that, even if it is only 18%. However, what I'm not a proponent of is creating an entire generation that would not otherwise have used nicotine products. There is clear evidence about the significant increase in the use of nicotine products in teens as a direct result of vaping. They cite the flavors as being one of the most common reasons for trying and the thought that they're not harmful. Kids who never used nicotine products before....are now using e-cigarettes by the thousands. I have family members and close friends as teachers and I've heard them talk about this "epidemic." There is a loop hole for these companies to market to kids, create flavors of any imagination, promote at concerts providing celebrity guests and give college applicants. It's ridiculous, quite frankly. We stopped cigarette companies from targeting our kids so why wouldn't we put e-cigarette companies in the same category? What will those smoking & death rates look like when we have a significant surge in teens "experimenting" & being addicted to nicotine in high school. And with 1 in 3 users...those are going to be pretty high numbers. Nicotine is addictive and harmful. We know it and there's plenty of evidence. So why is it ok to target our youth? This ban is just the first step to move the e-cigarette companies to be forced to comply with the same existing regulations. It bans non-FDA approved products, which currently is all of them. But they have deeper pockets now that many are at least partially owned by tobacco companies, so they'll file for approval. But then one would expect that FDA will force them to comply with existing marketing/flavoring regs for other nicotine products. And why shouldn't they?

I would favor a law which "diverted" tobacco taxes towards ecigs/ and nicotine replacement products (in other words these would be very cheap almost free) while at the same time making tobacco products more expensive. I have no problem with age restrictions on ecigs, I just don't want to see them be more expensive and therefore less utilized by adults who smoke. As for flavors I think adults should be able to buy whatever flavors they choose. Probably half the patients in the ICU that I care for are there from ETOH or diabetes related conditions are we going to regulate cola flavors or alcohol flavors? Also, I think that smoking around children should be automatic grounds for losing custody to your kids and facing neglect charges.

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Should be interesting to see if Healthy people 2030 addresses e-cigarette use.

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Specializes in Nurse Business Mentor, Healthcare Consultant.

Agree! I think it will definitely be addressed..but we’ll see.

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On 7/4/2019 at 10:46 AM, Mini2544 said:

I mean the ban isn’t the issue. The problem is that San Francisco is the same s-hole that has Homeless defecting and shooting drugs up on every corner. But yes, let’s ban e-cigs. Makes a ton of sense

I take the stance that people have the right to choose a healthy lifestyle or unhealthy one. I also think that kids shouldn't smoke. I have completed a community study in my county about youth smoking, I interviewed police officers, teachers, and school nurses among many other people that are connected to the youth in the area. The pervasive factor in kids smoking was low income and poor parenting. One thing that surprised me was parents buying their own children tobacco being rather commonplace.

Tobacco companies tell lies to make money, just like many other businesses and just like hospitals saying that patients come first, when we know that they don't. Only savvy people have a chance of not getting suckered in. It is a sad reality.

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Wow. This is so arguable. our own government did a comprehensive study in 2018 and concluded that vaping is in there words "SIGNIFICANTLY LESS HARMFUL."

Regulate the products and ingredients, regulate marketing, and stop using kids as shields. Talk to your kids. Give them education like we do with any other substance. Ban vaporizers, seriously. Another example of policies being made off emotion instead of science.

Even if a smoker goes to a vaporizer and stays there, it is SIGNIFICANTLY safer than analog cigarettes. Not SAFE (nothing belongs in lungs but air), but LESS HARMFUL. Not only to the user, but to those around them.

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Specializes in Nurse Business Mentor, Healthcare Consultant.

@Jakehose I appreciate you reading the post and your comment. Yes, I did see a couple conflicting articles...however, The WHO (that previously "didn't have enough evidence") recently came out and said "e-cigarettes do not help reduce cancer. Electronic cigarettes, containing nicotine but not tobacco, have been promoted as a way to quit smoking. But there was no evidence to justify the claim, and evidence from the U.S. has shown that it has increased the prevalence of young people smoking."

The Lancet Respiratory Medicine published a report back in 2016 stating the same thing. However, it seemed to get lost in the constant media buzz and epidemic level of popularity among youth. The most concerning issue is the irrefutable fact that e-cigarettes is increasing nicotine users in our youth...new users that would have never started. So yes, I agree they're NOT SAFE...and for this group of new users....not even "safer" because they would have never started smoking.

And those existing smokers that tried to quit by switching to vaping...not only are they still vaping a year later...a significant portion are "dual-users" which means they vape and are still smoking. I completely agree that they need to regulate the products, ingredients, marketing and stop using our kids as shields...but when it's already on the market..there has to be a ban first which pulls it off the shelves. Then the regulations are put in place (or possibly they simply amend existing tobacco regulations to include e-cigarettes) and those who comply, can put it back out there. The goal is regulation...the first step in the process is the ban to pull it off the shelves. Again, we're by no means leading this charge against e-cigarettes with 1 ban in San Fran...19 other countries have banned them. Nineteen. And 6 additional countries have restrictions on these products. On top of that....the U.S. currently has the most lax restriction already on the nicotine level allowed in the e-juice. They couldn't even sell in other countries what they're pedaling to our citizens. I'm wondering why on earth is San Fran the only ones who have raised their voice? If tobacco companies weren't convinced that e-cigarettes were leading consumers back to combustible cigarettes....they wouldn't be investing BILLIONS in them and grabbing ownership shares. There's nothing "safer" about millions of new users addicted to nicotine. What percentage do you think will convert? I'm quite certain Altria (Marlboro owner) has that formula already calculated.

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