Summary and Commentary on the US Surgeon General’s Report, 2016 US Surgeon General Report: E-cigarette Use among Youth and Young Adults By Stephen Hamann
Introduction and Overview : The US Surgeon General’s Report (US SGR), E-cigarette Use among Youth and Young Adults, was released in December 2016.
The report comes amid alarming rates of youth e-cigarette use in the US in 2015 where about 1 in 6 high school students used an e-cigarette in the past month. The report emphasizes that youth and young adults are using e-cigarettes more than conventional cigarettes, and are uniquely vulnerable to the long-term consequences of nicotine exposure on the brain. It concludes that youth use of nicotine in any form is unsafe. The report also finds that secondhand aerosol that is exhaled into the air by e-cigarette users can expose others to potentially harmful chemicals.
Major Conclusions from the Report
E-cigarettes are a rapidly emerging and diversified class of products typically delivering nicotine, flavorings, and other additives to users via inhaled aerosol.
E-cigarette use among youth and young adults has become a public health concern.
E-cigarettes are now the most commonly used tobacco product among youth. E-cigarette use is strongly associated with the use of other tobacco products among youth and young adults, including combustible tobacco products such as cigarettes.
The use of products containing nicotine poses dangers to youth, pregnant women and fetuses. The use of products containing nicotine in any form among youth, including e-cigarettes, is unsafe.
E-cigarette aerosol is not harmless. It can contain harmful and potentially harmful ingredients, including nicotine.
E-cigarettes are marketed by promoting flavors and using a wide variety of media channels and approaches that have been used in the past for marketing conventional tobacco products to youth and young adults.
Action can be taken at the national, state and local levels to reduce youth and young adult use of e-cigarettes.
US Surgeon General Call to Action to prevent e-cigarette use and related harms to America’s young people includes: Continuing to regulate e-cigarettes at the Federal (national) level to protect public health,
Raising and strongly enforcing minimum age-of-sale laws for all tobacco products, including e-cigarettes, Incorporating e-cigarettes into smoke-free policies,
Regulating e-cigarette marketing, Sponsoring high-impact media campaigns to educate the public on the harms of e-cigarettes among young people, and Expanding research efforts related to e-cigarettes.
What are the arguments for and against e-cigarette use?
There continues to be controversy over e-cigarettes based on multiple arguments for and against their use. The main argument for e-cigarettes is that they are less harmful than conventional cigarettes, a fact agreed by both those for and against e-cigarette use, and supported by evidence of the chemicals emitted by the devices. However, since the devices are new and there are a wide variety of them, it is really not known how the chemicals from these devices will affect users after long-term use. In addition, the Surgeon General’s Report focuses on the potential adverse effects for youth and young adults, for which there is growing evidence. Those who favor e-cigarettes argue that they are not only less harmful but also useful for smoking cessation. They assert that e-cigarettes being less harmful is enough to support their use given that they are meant for adult use and not to be promoted to youth. Those who do not favor their use at this time, point to their likely harm both through product ingredients and emissions and the perpetuation of nicotine addiction and a culture of smoking that has so cleverly been manufactured by tobacco industry interests and which is exploitive of vulnerable consumers looking for a new, “safe” replacement for the conventional cigarette.
I have listed some perspectives on how e-cigarettes are presented in the US SGR. This is done to illustrate that there are several ways of looking at the role of e-cigarettes in tobacco control efforts.
>Every US SGR is rigorous, but finally, a consensus view of experts who balance evidence up to a given moment in time.
Some researchers might expect a more clear decision from the Surgeon General on the e-cigarette controversy, but this is unlikely in a US SGR considering the many experts involved and the use of a consensus process. UCSF Professor Stanton Glantz states, “The report was written and reviewed by more than 150 experts. I think that the Surgeon General report on e-cigarettes understated the evidence on some areas….” Others who support e-cigarette use maintain the evidence in the SGR was incomplete and/or overstated, specifically referring to the fact that 2016 findings were not included. A knowledge of the extensive review process and inclusion of experts with different views on e-cigarettes over 2 years makes these views of understatement and overstatement understandable. To illustrate the evolving nature of e-cigarette information, see a 2017 one hour lecture by Stanton Glantz on E-cigarettes to medical student at: https://tobacco.ucsf.edu/stan-glantz-lecture-ecigs-available-online
> A recent meta-analysis of e-cigarette use for smoking cessation finds that evidence is insufficient to find e-cigarettes effective based on results thus far (http://bmjopen.bmj.com/content/7/2/e012680). Thus, a central argument for e-cigarettes has not been confirmed using a systematic review with the conventional meta-analytic process.
Since evidence for effectiveness of e-cigarettes for smoking cessation is still inadequate, health authorities have taken a cautious approach so a product of uncertain utility for cessation does not become introduced and used widely. A precautionary approach is often taken given the universally accepted harm that inhaling smoke and chemicals into the lungs has had for centuries. In addition, research has shown that differences in the regulatory environment result in differences in success with cessation in different countries. A 2017 comparison of cessation success in countries with (Canada, Australia) and without (UK, US) major e-cigarette restrictions shows that quit attempts are more likely successful in countries with less restrictive e-cigarette policy environments. https://academic.oup.com/ntr/article-abstract/doi/10.1093/ntr/ntx056/3061874/Does-the-regulatory-environment-for-e-cigarettes?redirectedFrom=fulltext
The fate of e-cigarette use by adults is uncertain
Use of e-cigarettes has been declining even in the UK where e-cigarettes use for cessation is common. A recent news story notes, “Following studies linking e-cigarettes with cancer and infertility, the UK House of Commons science and technology committee will take evidence on how they affect human health. MPs will look at how to tackle e-cigarette addiction and if their use should be restricted. They will also examine how well ‘vaping’ works to help people give up smoking, as research shows fewer people are using the devices to quit.”
>Tobacco industry support for e-cigarettes as an alternative nicotine product calls into question the truthfulness of the industry’s stated harm reduction intentions.
The tobacco industry says health officials are hypocrites for suggesting the use of some nicotine replacement products while limiting the use of e-cigarettes which it portrays as a nicotine replacement product. However, it is quite clear that the tobacco industry has considered alternative nicotine products for many years and has viewed them as potential money-making avenues that will enhance continued nicotine dependence on a population level. In short, the goal is continued product use to maintain profits regardless of harm from e-cigarettes as an alternative product, or that product with conventional cigarette use (dual use). Recent promotion by the tobacco industry of alternative products, makes clear that the industry is strongly committed to portraying their move away from conventional combustible tobacco as a means to a more favorable public perception of their business, a view that they are a responsible industry, moving their customers to ‘safer’ products. It is impossible to ignore the fact that if tobacco companies were really sincere about harm reduction, they would just transition to making other non-nicotine products. It is clear that since they have invested so much in making nicotine addiction a ‘cash cow’ for huge profits, they do not intend to do any such thing. The movement to an “end game” for tobacco is primarily a realization that the tobacco industry must be forced to give up a dangerous product and move on.
A personal view: Youth are a crucial population to an end of tobacco use and it is important that this population be a major focus regarding e-cigarette use. It appears that evidence is being gathered for two different populations, one regarding use for adult cessation by smokers and the other about youth consequences of e-cigarette use. The SGR addresses the evidence in dealing with the youth population and presents its action plan to discourage youth use of e-cigarettes. While many questions remain on cessation for adults, especially with tobacco industry interests looking to expand profits through e-cigarette use, policy on youth use is clarified and the report is useful for those working to consider e-cigarettes as one of the ‘alternative products’ of importance to the future of tobacco control .
Clearly, the 2016 US Surgeon General Report is cautious in its evaluation, with an emphasis on the need to protect youth, a vulnerable population that now clearly has high use of e-cigarettes in the US.
On announcing the report, US Surgeon General Dr. Murthy emphasized, “We need parents, teachers, health care providers, and other influencers to help make it clear that e-cigarettes contain harmful chemicals and are not okay for kids to use. Today’s report gives them the facts about how these products can be harmful to young people’s health.”
He recommends information from his website containing key information from the report: https://www.surgeongeneral.gov/
This brief report and commentary is analysis by its author and does not reflect the views or position of the Tobacco Control Research and Knowledge Management Center or Mahidol University.