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By Bradley Allf
Gone are the days of the Marlboro Man, but the tobacco industry is finding new ways to lure young people. Though today’s youth smoke far fewer cigarettes than their counterparts did 20 years ago, an emerging market for electronic cigarettes is providing a new outlet for nicotine use among young people.
Despite a state law prohibiting the sale of these products to people younger than 18, a study by UNC-Chapel Hill researchers found that North Carolina minors can easily obtain electronic cigarettes over the internet.
“E-cigarettes,” as they are called, are a group of various battery-operated devices that allow users to inhale nicotine vapor.
Originally promoted as smoking cessation devices, the products are now exploding in popularity among teens, many of whom have never smoked conventional cigarettes. One recent study found that high school seniors are now twice as likely to use e-cigarettes as conventional cigarettes. Of the estimated 4.7 million middle and high-school students in the US that used tobacco products in 2015, 3 million were e-cigarette users.
The e-cigarette business, almost nonexistent 10 years ago, has burgeoned into a multi-billion-dollar industry. Effective policies have struggled to keep pace, leading one FDA official to label the market the “wild, wild West.”
North Carolina, for its part, outlawed the sale of e-cigarettes to minors in 2013. Researcher Rebecca Williams from UNC-Chapel Hill wanted to find out how effective this law was in preventing minors from purchasing e-cigarettes online.
To test this, her team recruited 11 teenagers from 14 to 17 years old to try to purchase e-cigarettes over the internet. The research is described in an article in JAMA Pediatrics.
The team identified 98 online e-cigarette vendors for the study. They then allowed the 11 teens, under supervision, to attempt to buy e-cigarette products from the different vendors.
Of the 98 purchase attempts, only 5 failed due to age-verification requirements.
In fact, more than 80 percent of vendors either did not attempt to verify age, or used clearly ineffective means of verifying age, such as offering a check box. The only consistently effective age-verification techniques that Williams and her team found were requirements to enter a date of birth in conjunction with a social security number.
Williams is a researcher at the UNC Lineberger Comprehensive Cancer Center and Center for Health Promotion and Disease Prevention. She has done similar studies on youth access to conventional cigarettes and anticipated these results.
“The rate of success with e-cigarettes is similar to what we found with cigarettes,” she said. “So it didn’t surprise me at all that it was easy to buy e-cigarettes online for teens.”
So why aren’t online vendors following North Carolina law? Williams explains that part of the issue is jurisdictional.
“When you’re making an online purchase, where is that purchase taking place? Is it taking place where the person who is ordering is located? Is it where the website is hosted? Is it where the business is located?” she asked. “Those all may be in different states and different countries.”
It can be tough to know where exactly the boundaries of enforcement fall when dealing with online purchases. It is also exceedingly difficult to track down these vendors, many of whom operate internationally.
Better than cigarettes?
According to a report released by the American Heart Association last year, “[e]- cigarettes are mostly unregulated and their health effects are not fully known, especially when associated with long-term use.”
Research on the effects of traditional cigarettes accumulated over decades. However, because e-cigarettes sprang quickly onto the US market in 2007, there hasn’t been enough time for researchers to determine how e-cigarettes affect the human body.
Despite this, there are already some known risks associated with e-cigarettes. One instance concerns the chemicals used to flavor the vapor. While these chemical products are approved by the Food and Drug Administration for ingestion, they have not been approved for inhaling.
“Safe to ingest does not mean safe to vaporize and inhale,” Williams says. “When they vaporize a product at a high temperature, it creates more and more dangerous chemicals that can be damaging to lung tissue and other tissue.”
Chemicals such as diacetyl (butter or popcorn flavor) and cinnamaldehyde (cinnamon flavor), both of which are found in many e-cigarette flavorings, pose known health risks.
In addition, nicotine itself is highly addictive and can have long-term consequences for brain development, particularly for young people.
Taken together, these health risks have many people concerned.
“I think we know they’re not safe and we’re still finding out how unsafe they are,” says Peg O’Connell of the North Carolina Alliance for Health. “I think that’s the public health message.”
At the national scale, the FDA announced in May that it will begin regulating the sale of e-cigarettes in August. This policy was partially informed by the Internet Tobacco Vendors Study, which based its suggestions on the research findings of Williams and her team.
Williams believes this is a step in the right direction. She said a national policy would address some of the jurisdictional problems associated with having different regulations in different states. She hopes that the FDA will end up enacting strict age-verification requirements for online vendors at both the point of order and the point of delivery to keep minors from getting access to e-cigarettes.
Locally, North Carolina health organizations are working on a number of fronts to enact policies designed to stem the rising number of young people who are using e-cigarettes.
O’Connell is working with the North Carolina Alliance for Health to bring back the state’s formerly award-winning youth tobacco prevention program. According to O’Connell, education initiatives such as the state’s previous anti-tobacco effort may be effective in keeping e-cigarettes away from minors.
The Orange County Board of Health, in concert with the Orange County Board of Commissioners and counties across the state, has been advocating other e-cigarette control policies.
Orange County health educator Coby Jansen Austin said those two bodies support a public policy of giving jurisdictions the right to raise the minimum sale age for tobacco and e-cigarettes from 18 to 21.
According to Austin, policy actions make a real difference in decreasing the number of young people who start using tobacco products.
“What we know has worked in tobacco control and contributed to a lot of the drop in tobacco use that we’ve seen over the last five or six decades are some of the policies around tobacco,” she says. “And so I think the FDA regulations are a good example of where we have the appropriate research and we take appropriate policy actions. It’s not just about education and sharing information, though those are also components.”
Correction: This article originally stated the research was published in the Journal of the American Medical Association.