Responding to the Increased Presence of E-Cigarettes on School Campuses

During the 2012-2013 school year, one school district in Texas confiscated e-cigarette products on nearly a daily basis9. This is one of the many issues schools face as the number of U.S. students who try electronic cigarettes for the first time steadily increases19. Approximately 263,000 6-12th grade public and private school students reported trying e-cigarettes in 2013 compared to only 79,000 students in 20112. Of these first-time e-cigarettes users, as many as 43.9% report an intention to smoke conventional cigarettes in the future, according to a publication from the Nicotine & Tobacco Research journal2. There are concerns that e-cigarette use may encourage, or serve as a gateway toward conventional cigarette use amongst youth1.

E-cigarettes, also known as vapor pens and cloud pens, are the most popular form of electronic nicotine delivery systems18. These battery-powered devices vaporize liquid forms of nicotine and other chemicals, and are usually packaged in the shape of a sleek cigarette or pen3. The prevalence of e-cigarette advertisements and the lack of knowledge about the long-term effects of e-cigarette use may lead some students to perceive e-cigarettes as less harmful than conventional cigarettes and may contribute to an increase in e-cigarette use amongst youth1.

E-cigarette advertisements have been criticized for using marketing strategies directed at youth-strategies similar to those currently banned for conventional cigarettes6. For example, e-cigarettes are produced and advertised in flavors that are appealing to youth including Kool-Aid, Fruit Loops, and Skittles. They have been named after popular cartoon characters such as Curious George and Daisy Duck, and may be accompanied by celebrity endorsements. Decades of research has demonstrated that exposure to cigarette advertising causes conventional smoking amongst youth6. Similarly, in current studies, students that have been exposed via the internet, magazines, retail environments, and television to advertisements promoting tobacco products reported higher rates of intention to smoke conventional cigarettes when compared to those students who were not exposed to pro-tobacco advertisements2.

It is more crucial than ever to help prevent early tobacco use that could lead to a lifetime of nicotine addiction.

Students who reside in one of the 41 states with regulations that prohibit the sale of e-cigarettes to minors may alternatively have access to these products through online markets. For example, in a study conducted in North Carolina between February and June 2014, youth who tried to purchase e-cigarettes through online markets were blocked only 5 out of 80 times by vendors trying to verify age19. The state of Texas is one of nine states with no regulations prohibiting the sale of e-cigarettes to minors12, however several bills seeking to regulate e-cigarettes have been introduced in the current legislative session14. The variation in state's regulations of e-cigarettes is a result of a lack of federal regulations by the FDA1, due in some part to the limited data regarding the effects of long-term e-cigarette use16. In April 2014, the FDA proposed a rule to classify e-cigarettes as tobacco products under its "deeming" authority, which would make e-cigarettes and liquid nicotine subject to FDA regulations and oversight17. Until then, consumers in today's unregulated market can never be certain about what exactly they are smoking1.

A lack of federal oversight means that e-cigarette users cannot be certain that the label on the fluid bottle accurately indicates the levels of nicotine actually in the fluid8. In 2014, researchers in the U.S. examined levels of nicotine in e-cigarette cartridges and found that as many as 46 out of 50 fluid bottles contained higher levels than indicated on the label5. In a separate study, researchers found that e-cigarette cartridges labeled as 'nicotine-free' actually contained some traces of nicotine7.

A high concentration of nicotine in e-cigarette fluid has the potential to be extremely dangerous if the liquid is accidentally or intentionally ingested orally or is absorbed by the skin13. The number of e-cigarette exposures reported to Texas poison centers increased from 2 in 2009 to 123 in 2013 with almost half of these exposures occurring unintentionally at home to children under the age of five13. Although most of the reported poisoning cases have not resulted in death, it is important to note that consumption of high doses of the liquid-form of nicotine by any person (or pet), either by ingesting it orally or it being absorbed through the skin, eyes, nose, and mouth, can lead to nicotine overdose poisoning and death4, 11.

The general lack of knowledge available about e-cigarettes is concerning given reports that for the first time, more teenagers are using e-cigarettes than conventional cigarettes10. Tom Frieden, director of the CDC, said, "[the] data shows a dramatic rise in use of e-cigarettes by youth, and this is cause for great concerns as we don't yet understand the long-term effects of these novel tobacco products3." Margaret Hamburg, former commissioner of the FDA stated in 2014, "It is more crucial than ever to help prevent early tobacco use that could lead to a lifetime of nicotine addiction." Schools can play a part in helping prevent the use of tobacco products by its students.

While some schools have already incorporated policies against e-cigarettes in their student code of conducts, other schools await FDA regulations or state legislation to serve as guidelines for their own regulations16. For example, in Texas proposed Senate Bill 96 would amend tobacco-free school laws to include e-cigarettes5, thereby requiring all schools to treat the possession of e-cigarettes as they would any other tobacco product. In the absence of federal or state legislation, however, schools can begin the process of implementing e-cigarette policies by ensuring that educators are aware of the rising popularity of e-cigarettes amongst youth. Administrators should ensure that teachers are equipped with procedures for dealing with students in possession of e-cigarettes or related products. Students should be educated about school policies on e-cigarettes, the possible consequences if found in possession of these items, and the adverse effects that nicotine can have on their health16. Given the false belief amongst many that what they are inhaling is just water vapor, student should also be informed of the various ingredients that have been found in e-cigarette fluids1,18.

Efforts to educate students should be implemented at school in order to prevent students from attempting to acquire or use e-cigarettes. Such a program at school could include counter advertising, mass media campaigns, community programs, school-wide policies, interventions, and the promotion of tobacco-free social norms. The CDC noted that collaborative efforts by national, state, and local agencies have been shown to prevent and reduce tobacco use among youth. The Texas School Safety Center offers resources to support schools in their anti-tobacco initiatives.

Efforts to educate students should be implemented at school in order to prevent students from attempting to acquire or use e-cigarettes.

The Texas School Safety Center houses various tobacco prevention programs. The Say What! Movement (Students, Adults and Youth Working Hard Against Tobacco!) offers information related to statewide tobacco prevention efforts and serves as an umbrella organization to connect, learn, share, and inspire others to make a positive difference in their schools and communities. Resources, information, and tools are provided to groups on the Say What! Website. The Texas School Safety Center also coordinates the Annual Synar Tobacco Survey which measures the state's retail violation rates of tobacco sales to minors by conducting inspections of randomly selected tobacco retail outlets; the FDA Compliance Check Inspection Program in which inspectors conduct undercover buys with minors and report the findings of these operations to the FDA; and the Statewide Tobacco Enforcement Program which conducts controlled buys/stings of tobacco retailers in conjunction with local law enforcement who issue citations to clerks that sell tobacco products to minors.

References

1 American Lung Association. 2015. American Lung Association statement on e-cigarettes [statement]. Retrieved from http://www.lung.org/stop-smoking/tobacco-control-advocacy/federal/e-cigarettes.html.

2 Bunnell, R.E., Agaku, I.T., Arrazola, R. Apelbreg, B.J., Caraballo, R.S., Corey, C.G., Coleman, B., Dube S.R., King, B.A. (2014). Intentions to smoke cigarettes among never-smoking U.S. middle and high school electronic cigarettes users: National Youth Tobacco Survey, 2011-2013. Nicotine & Tobacco Research 17, 2, 228-235. doi: 10.1093/ntr/ntu166

3 Centers for Disease Control and Prevention (CDC). (2014a). E-cigarette use more than doubles among U.S. middle and high school students from 2011-2012 [press release]. Retrieved from http://www.cdc.gov/media/releases/2013/p0905-ecigarette-use.html.

4 Centers for Disease Control and Prevention (CDC). (2014b). The national institute for occupational safety and health (NIOSH), nicotine, systemic agent. Atlanta, Georgia: Education and Information Division. Retrieved from http://www.cdc.gov/niosh/ershdb/EmergencyResponseCard_29750028.html.

5 Davis, B., Dang, M., Kim, J., and Talbot, P. 2015. Nicotine concentration in electronic cigarette refill and do-it-yourself fluids. Nicotine & Tobacco Research, 17, 2, 134-144. doi: 10.1093/ntr/ntu080.

6 Dutra, Lauren M., and Glantz, S.A. (2014). E-cigarettes and conventional cigarette use among US adolescents: A cross-sectional study. JAMA Pediatrics, 168(7), 610-617. doi:10.1001/jamapediatrics.2013.5488

7 Goniewicz, M., Gupta, R., Lee, Y., Reinhardt, S., Kim, S., Kim, B., Kosmider, L., and Sobczak, A. 2015. Nicotine levels in electronic cigarette refill solutions: a comparative analysis of products from the US, Korea, and Poland. International Journal of Drug Policy [in press], http://dx.doi.org/10.1016/j.drugpo.2015.01.020

8 Grana, R., Benowitz, N. and Glantz, S.A. (2014). E-cigarettes: a scientific review. Contemporary Reviews in Cardiovascular Medicine, 129, 1972-1986.

9 McPhate, Christian. 2014. E-cigarettes draw minors: efforts made in area to restrict product use to people 18 years and older. Denton Record-Chronicle. Retrieved from http://www.dentonrc.com/local-news/local-news-headlines/20140924-e-cigarettes-draw-minors.ece.

10 Minnesota Department of Health. (2015). Electronic cigarettes. St. Paul, Minnesota: Alcohol and Tobacco Prevention and Control. Retrieved from: http://www.health.state.mn.us/divs/hpcd/tpc/topics/ecig_docs/ecigarettes_w.pdf

11 Mowry, J. B., Spyker, D.A., Cantilena, L.R., McMIllan, N., and Ford, M. (2014). 2013 Annual report of the American association of poison control centers' national poison data system (NPDS): 31st annual report. Clinical Toxicology, 52, 1032-1283. doi: 10.3109/15563650.2014.987397

12 National Conference of State Legislatures. (2015). Alternative nicotine products: electronic cigarettes. Denver, Colorado: NCSL. Retrieved from: http://www.ncsl.org/research/health/alternative-nicotine-products-e-cigarettes.aspx

13 Ordonez, J.E., Kleinschmidt, K.C., and Forrester, M.B. (2015). Electronic cigarettes exposures reported to Texas poison centers. Nicotine & Tobacco Research, 17, 2, 209-211.

14 Texas Legislature Online. 2015a. Bills in the 84th legislative session. Retrieved from http://www.legis.state.tx.us/Search/TextSearchResults.aspx?CP=1&LegSess=84R&House=true&Senate=true&TypeB=true&TypeR=false&TypeJR=true&TypeCR=false&VerInt=true&VerHCR=true&VerEng=true&VerSCR=true&VerEnr=true&DocTypeB=true&DocTypeFN=true&DocTypeBA=true&DocTypeAM=true&Srch=custom&Custom=e-cigarettes&All=&Any=&Exact=&Exclude=.

15 Texas Legislature Online. 2015b. Senate Bill 96 bill analysis. Retrieved from http://www.legis.state.tx.us/Search/DocViewer.aspx?ID=84RSB000962A&QueryText=%22e-cigarettes%22&DocType=A.

16 Ulrich, Amanda. (2014). E-cigarettes cloud schools' anti-smoking policies. Bethesda, Maryland: Education Weekly. Retrieved from http://www.edweek.org/ew/articles/2014/07/29/37ecigarettes.h33.html?qs=ulrich.

17 U.S. Food and Drug Administration. 2015. Issue snapshot on deeming: regulating additional tobacco products. Retrieved from http://www.fda.gov/downloads/TobaccoProducts/NewsEvents/UCM397724.pdf.

18 World Health Organization. 2014. Noncommunicable diseases and mental health: backgrounder on WHO report on regulation of e-cigarettes and similar products. Geneva, Switzerland. Retrieved from http://www.who.int/nmh/events/2014/backgrounder-e-cigarettes/en/.

19 Williams, R.S., Derrick, J., and Ribisl, K.M. (2015). Electronic cigarettes sales to minors via the internet. JAMA Pediatrics, 169, 3:e 1563. doi: 10.1001/jamapediatrics.2015.63