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TDH Public Health Advisory

The Tennessee Department of Health has updated its January 2017 public health advisory to reflect recently published research of importance to the health of Tennesseans. Since the first TDH advisory on ENDS was issued in February, 2013 accumulating evidence has increased the level of concern regarding the risks posed by these products to the health of all persons involved, especially children. Most importantly:

• Nicotine is highly addictive and dangerous to the developing brain. Nearly 90 percent of adult smokers started before age 18.1

• There is now substantial evidence that use of END products by youth places them at increased risk of becoming future smokers of combustible products.2,3,4

• In Tennessee, 40 percent of high school students have used an END product, and 11.5 percent report current use.5

• Those who use ENDS as cessation devices often continue to smoke cigarettes as well and may be less likely to quit using tobacco than those who do not use END products.

6,7 While electronic nicotine delivery systems, or ENDS, are promoted as smoking cessation devices, the safety and efficacy of these products has not been demonstrated. ENDS are known to expose users and bystanders to harmful chemicals and metals.4 ENDS use as smoking cessation devices does not provide clear benefit over the numerous other Food and Drug Administration-approved products available to smokers who would like to end their use of tobacco.8 Many private health insurance plans, as well as TennCare, cover the cost of these FDA-approved and evidence-based cessation products.

The U.S. Preventive Services Task Force concluded that evidence is insufficient to recommend e-cigarettes for smoking cessation in adults.9 ENDS products continue to evolve in ways that are appealing to teens, and young people often fail to understand the dangers associated with their use. Products such as Juul™ provide high-dose nicotine via devices that are similar in appearance to USB devices. These devices combine attractive flavorings such as crème brulée and mango with minimal vapor production, making them attractive to youth and easy to conceal, even in school. According to the 2018 National Youth Tobacco Survey, more than 3.6 million U.S. middle (one in 20) and high school (one in five) students had used an ENDS product in the 30 days prior to the survey, representing a 78 percent increase in use among high school students and a 48 percent increase among middle school students.10 The majority of these youth would never have used combustible tobacco products. FDA Commissioner Scott Gottlieb stated, “We now have evidence that a new generation is being addicted to nicotine, and we can’t tolerate that.” Commissioner Gottlieb has called for a ban on the selling of all flavored ENDS (with the exception of mint and menthol flavors) outside of age-restricted, in-person locations and for heightened practices for age verification for online sales.11 Juul™ has been banned in other nations, citing them as a danger to public health. 12 The Tennessee Department of Health supports the regulation of flavorings and further urges that no flavorings of any kind, including menthol, be used with tobacco and nicotine products.

Nicotine is highly addictive and dangerous to the developing brain. Youth who use ENDS are more likely to begin use of combustible cigarettes and are at higher risk for increasing the frequency and intensity of subsequent combustible tobacco smoking.2,13 A recently published study also revealed that ENDS use predicts subsequent marijuana use among youth, especially among younger adolescents.

14 The Tennessee Department of Health continues to urge caution to consumers using or considering the use of electronic nicotine delivery systems including Juuls™, electronic cigarettes, e-cigs, e-cigars, e-pipes, e-hookahs, personal vaporizers and similar emissions-producing devices. Consumers should understand there are still significant unknowns as to the short- and long-term health impacts upon individuals of any age who use these devices and for those exposed to second-hand emissions, in addition to the known increased risk to youth for the development of nicotine addiction and future chronic tobacco and substance use.

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