Public health Program Paper 

Amber Shaikh 

-Electronic cigarettes have now become a major trend in the younger generation. What are the dangers of E-cigarettes to one’s health and what affect does marketing play in their spread?  How can we regulate its increased use?  

Define a Problem: 

Electronic cigarettes, or E-cigarettes, come in many shapes and sizes and have many names. Some of these names include: e-cigs, vape, juul, hookah, mods, vape pens, tanks, and ENDS (electronic nicotine delivery system). They come in many shapes such as: pipes, resembling cigarettes, or cigars, USB shape, and other regular items, most being rechargeable. No matter what they look like or what they are called; they function the same way; they act as a substitute to cigarettes by producing an aerosol that is created by heating up nicotine containing liquids. They are often flavored to appeal to the younger crowds. People use these by inhaling the aerosol into their lungs, therefore getting the satisfaction they would from a regular cigarette (CDC 2020). These aerosols contain potentially harmful substances such as nicotine, ultrafine particles, diacetyl flavorings, volatile organic compounds, cancer causing compounds, and heavy metals such as nickel, lead and tin (CDC 2020).  

Target audience for E-cigarettes: 

Due to their marketing as a “safer cigarette” alternative, different flavors, and high-tech appeal, teens and young adults are most affected by E-cigarettes. This trend has grown exponentially in the past 5 years, and as of now more high schoolers are using E-cigarettes more than cigarettes, and more then adults in general (c-cigarettes.surgeongeneral.gov 2018). A study done in the Journal of Adolescent health done on 444 students, over 46.5% of students learned about E-cigs from the internet, and 27.9% learned about it from their friends. Showing that adolescents are the most vulnerable to the pressures of e-cigarettes due to being easily influenced by the “new trend” (Cho et all 2011).  

Problem with marketing: 

Most of the problems with e-cigarettes start with the source of information. For this concern, marketing, whether it be Television commercials, internet advertisements, or radio announcements, has been a key player in the widespread trend of electronic cigarettes. An article in the journal of health communication explains how presentations of people smoking the various types of e-cigarettes (I.e vaping) in commercials, actually acts as a trigger for former smokers, increasing their urge, as well as attracting the younger population (Maloney 2015). The glamorization of these e-cigs in commercials, with groups of people partying and smoking together, mentally affects the youth and makes them want to be more like that. There are four main tactics that these marketing companies use to reel in new users (truth initiative 2018): 

1. certain e-cig companies offer scholarships to students who write essays about why vaping is better than cigarettes
2. they create a buzz on social media sites such asfacebook,instagram and tweeter by associating it with being cool, having freedom and sex appeal 
3. They sponsor major public events such as concerts and music festivals
4. The most important tactic is by using appealing flavors such as cotton candy, bubblegum etc.

Attempts at control: 

There have been attempts at regulating the spread of E-cigarettes in the past, with mixed results. The timeline of e-cigarette regulation starts in 2008 under the Bush administration, when the FDA detained certain e-cigarettes since they appeared to be unapproved devices delivering nicotine. At this moment the FDA had concerns about the ambiguous affects these electronic cigarettes would have to they body. In 2011, the Tobacco Control Act was created to oversee the e-cigarette production and vaping. It also aimed to remove flavors from e-cigs, since that was a major reason people used them. In May 2018, the Federal trade commission and the FDA took a stand against e-cigarette companies that made their products to look like candy or other treats, to attract the younger population. In 2017, Governor Cuomo signed a bill banning the use of electronic cigarettes from all places that regular cigarettes are prohibited. E-cig inhalant chemicals were also added to the NYS Indoor Clean Air Act. In September 2019, President Trump announced a ban on flavorings for vapes, but has not implemented it (Sharfstein 2019). Governor Cuomo also signed a bill in Nov 2019 that increases the age restriction to purchase e-cigarettes, or any tobacco containing products, from 18 to 21 in New York State (NYS 2019). With all these successes however comes failures, such as failure to put an excise tax on the sale or E-cigs, and failure to monitor who has access to these products. The age restrictions may be raised, which is a good start, but many adolescents find ways to purchase them online. We have come a long way in controlling this dangerous new trend, but there is still a lot to be done.  

Present evidence of problem (10 sources): 

Dangers of E-cigarettes to health: 

Considering E-cigarettes are still a new trend in our public health sphere, what we know about them and their dangers long term is sparse. The main concerning ingredient is Nicotine, which has dangerous affects such as: addictive properties, harmful to lungs, carcinogen, fatal to fetuses, and affects teenage brain development. They also contain other harmful chemicals that can reach deep into the lungs. These dangers are most concerns for adolescents, for it interferes with brain development, which typically is still happening till mid 20s. The addictive properties of nicotine tell the brain to release a substance called dopamine, which increases pleasure sensation, and causes a positive feedback loop (CDC 2020).  

In 2018, a study done by the National Academics of Science Engineering and Medicine produced a consensus report of 800 studies that showed that toxic substances the E-cigarettes emit cause long term cough, wheeze, and asthma exacerbation in youths, amongst other things. It was found that two ingredients: propylene glycol and vegetable glycerin, are toxic to our cells. Other chemicals emitted such as acetaldehyde, acrolein, and formaldehyde increases risk of lung and cardiovascular disease. Acrolein was also found to play a role in causing COPD (American lung association 2019). Other harms it can cause include airway hypersensitivity, increased airway resistance, increased cytotoxicity of the alveolus, and decreased immunity (Barry 2018).  

Harms and Benefits of E-cigarettes: 

Benefits of using E-cigarettes

Harms of using E-cigarettes

–less harmful then smoking cigarettes  -include less hazardous chemicals then the 7,000 toxic chemicals in cigarettes  -if used as a complete substitute for cigarettes, they can be effective for helping people taper down  -Recent Cochrane review found that the use of e-cigarettes can increase the chances of long–term quitting.   -if used at a quality controlled and regulated manor, e-cigarettes can provide hope for quitting when other methods have failed (Bond 2018).

–Still contain nicotine and other toxic chemicals  -appealing marketing and flavors target a young audience to start using e-cigarettes (when they never smoked before)  -studies have showed that smoking e-cigarettes can increase chances for smoking cigarettes in the future.   -Due to the added flavors, this causes people to want to smoke it for a longer period of time (accumulating nicotine damage)  -Their packaging similar to candy or in bright appealing containers can increase chances of kids accidently ingesting it (Barry 2018).  -inconclusive evidence of its actual long–term benefits and long term health hazards.

 

E-cigarettes are an additional danger because they can lead to smoking tendencies in those who never smoked before. In a study done by David Hammond and Jessica Reid, it was shown that smoking e-cigarettes in high school leads to a higher prevalence of smoking cigarettes 1 year after. In this experiment a cohort study and surveys were done at baseline and during a 1 year follow up, to test if there is a association amongst the two. It was found that there is a strong correlation between smoking e-cigarettes and starting cigarette smoking (Hammond et all 2017).  

 

Propose solution to problem (critical analysis of evidence): 

-develop and test community-level interventions to control of prevent the cause of the problem 

Interventions: 

Because this has become a multi-faceted public health concern, interventions for it must address several issues such as: sales and marketing concerns, tax concerns, enhancing education, limiting access and regulations.  

1. Limiting access to E-cigarettes:  
   1. E-cigarettes are a double-edged sword in our current generation. On one side they act as a harm reduction practice for those smoking cigarettes, looking to quit. However, on the other side, they can act as a “gateway drug” for the younger population causing them to start smoking. I believe one way to attack this by regulating and limiting access. Governor Cuomo started this by increasing the age restriction to 21 from 18 in NYS, but this needs to be implemented in all states. Also, due to the internet, people of all ages can find back routes to accessing e-cigarette products. Also there needs to be national laws that forbid the use of e-cigs in all places where cigarettes are forbidden (schools, workplaces, public stores, etc). The both emit nicotine and smoke and should be regulated the same way. Finally, there needs to be a excise tax placed on these products. Since they are rechargeable, the only parts people purchase are the inhalant refills. If there was an increased tax on these products, less and less people would have the desire to purchase them (Tremblay 2015). 

1. Regulating E-cigarette marketing 
   1. Marketing is at the center for the spread of e-cigarettes. Regulations need to be placed on how commercials depict e-cigarette use. It is often depicted as a trendy new habit, rather than what it is intended for, a harm reduction method to stop smoking. If e-cigarettes were presented more as medicine commercials, they would be more informative and less influential to vulnerable young minds. They also need to create a widespread ban on colorful packaging, made to look like candy or other everyday products. Warning labels need to be put at the forefront and highlighted. There also needs to be a age limitation warning on the front. Companies not following proper marketing guidelines should be fined a set amount.  

1. Putting an emphasis on educating younger generation on the harms of e-cigarettes 
   1. More importance needs to be put on educated young children and teens about the harms of e-cigarette use. Money made from potential tax on these products can be used to fund more mandatory assemblies and seminars in schools teaching middle and high schoolers about the harms of these products, along with regular cigarettes. There also needs to be an emphasis on banning the use of e-cigs on or near school properties.  

Assess for efficacy of intervention:  

Like any public health problem, when you put for interventions to address them, you also need to have methods to test and assess for the efficacy of such interventions and see whether they made a difference. The following are study methods I would use to test for the interventions listed above: 

1. Prospective cohort studies 
   1. For this study I would take 2 sets of groups, each with over 1,000 subjects such. For this I would use 2 sperate high schools (with 500 students each). High school group A would be exposed to the interventions mentioned above (limited access, increased school education, marketing regulations). High school group B will not be exposed. At baseline (or Day 1) I would have each student take a survey consisting of questions about smoking history, desire to smoke, knowledge of e-cig use, who they know smokes e-cigs, whether they ever have or will, etc. I will then follow these groups for 2 years and have them take the same survey again and will assess the differences in each group between each survey. This will be done with a cross sectional analysis. My hypothesis is that subjects of high school A will should a decreased desire to initiate or continue the use of e-cig, as per their survey results, whereas Group B will have a significant increase in use of e-cigarettes.  

1. Linear regression analysis 
   1. For this study I would assess the relationship between increased E-cigarette advertisements (continuous dependent variable) and the amount of people starting to use E-cigarettes (continuous independent variable) in a sample of 800 people between the ages of 17-20. For this I would use a quasirandom method of selecting my subjects, in that all of them will have no prior history of smoking cigarettes in the past. I will then assess the increase in smoking use in a 8 month period. My hypothesis is that there will be a positive correlation, in that the increased number of unregulated commercials will lead to an increased number of people starting to use E-cigarette products.  

1. Pre and post intervention surveys  
   1. Finally, I believe a cost friendly way to assess if interventions are effective, is by performing surveys. This gives us a qualitative analysis to see if the regulations we put in place made a difference. Surveys can come in many forms. We can simply ask people if they saw a decrease in use post interventions or have a questionnaire that assess ones desire to use such products, amongst others.  

 

 

Strengths and weakness of proposal: 

In order to oversee if these interventions are being enacted properly and whether or not the regulations are being enforced, there needs to be a group of people who are responsible for oversight and monitoring. They need to be proficient in e-cigarette history and behavior and need to be able to adjust regulations when need be.  

We also have to assess the advantages and disadvantages to each intervention proposal and study.  

Pros and cons of each proposal 

	Limiting access	Regulating marketing	Increased education
Advantages	-it will put a monetary fee on these products that will make less people want to buy them  -increasing the age restriction will prevent adolescent access  -banning use of these products in public areas will limit its use.	–decrease ads that make e-cig smoking appear cool, trendy and sexy.   -increase informative warning labels   -decrease potentials for children to ingest these products (due to their candy like packaging)	–increases knowledge of the hazards of smoking at an early age, when kids are most vulnerable and influenced  -increases communication about these dangerous products  -decreases use in schools
Disadvantages	–those who really want these products can find illegal back routes to obtaining them   -might increase crime rates for people trying to access them	–decreased compliance by marketing companies  -backlash and increased inappropriate advertisements  -increase cost for regulation and oversight	–mandating educational seminars can be costly and difficult to oversee.   -can potentially lead to increased disruptive behavior in young adults.

Pros and cons of the study mechanisms  

	Prospective cohort study	Linear regression analysis	Pre and post intervention surveys
Advantages	-follows a group of people into the future, while assessing changes in behavior  -can assess changes in behavior due to level of exposure to intervention (showing a correlation)	-looks at how one continuous value influences another   -less complicated study to perform due to less variables.	-uses quality measures to assess changes in behaviors and thought processes  -allows the public to express their concerns and thoughts
Disadvantages	-people may not be compliant in the future, and the data may not be accurate.  -need for a larger study sample can increase costs of the study	-other confounding variables can play into influencing the results of the data.   -need for a larger study size can be costly and difficult	-people may not answer truthfully or spend proper time thinking about the questions.

 

Sources: 

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html 

https://www.cmaj.ca/content/189/43/E1328.full 

https://www.sciencedirect.com/science/article/abs/pii/S1054139X11002734 

https://e-cigarettes.surgeongeneral.gov/ 

https://www.tandfonline.com/doi/abs/10.1080/10410236.2014.993496 

https://truthinitiative.org/research-resources/tobacco-industry-marketing/4-marketing-tactics-e-cigarette-companies-use-target 

https://www.statnews.com/2019/11/21/e-cigarettes-fda-hands-tied/ 

https://www.governor.ny.gov/news/governor-cuomo-announces-emergency-executive-action-ban-sale-flavored-e-cigarettes 

https://www.lung.org/stop-smoking/smoking-facts/impact-of-e-cigarettes-on-lung.html 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842051/ 

https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0370-z