P5. Youth Materials: ENDS KEY FACTS

ELECTRONIC NICOTINE DELIVERY SYSTEMS KEY FACTS
Youth use of ENDS continues to rise rapidly in the U.S.

Nearly 3 million U.S. middle and

From 2011 to 2015, past 30-day use of e-cigarettes
increased

high school students were past 30-day
e-cigarette users in 2015

10x

more than
for high school
students (1.5% to 16.0%)

9x

for middle
and nearly
school students (0.6% to 5.3%)

including about

1 in 7 high school students.

1

In 2013, more than a quarter of a million (263,000) middle and high school
students who had never smoked cigarettes had ever used e-cigarettes.2

Most adult ENDS users also smoke conventional
cigarettes, which is referred to as “dual use.”
In 2012/2013, 1.9% of adults were past 30
day e-cigarette users, including
of conventional cigarette smokers.3

Among adult past 30 day e-cigarette users,

9.4%

76.8% were also current cigarette
smokers (i.e., “dual users”) in 2012/2013.3

Nicotine poses dangers to pregnant women and fetuses, children, and
adolescents. Youth use of nicotine in any form, including ENDS, is unsafe.4,5

•
•
•

Nicotine is highly addictive.4

•

Nicotine is toxic to developing fetuses and impairs
fetal brain and lung development. 4,5
Poisonings have resulted among users and non-users
due to ingestion of nicotine liquid, absorption
through the skin, and inhalation.6 E-cigarette
exposure calls to poison centers increased from one
per month in September 2010 to 215 per month in
February 2014, and over half of those calls were
regarding children ages 5 and under.6

•

Because the adolescent brain is still developing,
nicotine use during adolescence can disrupt the
formation of brain circuits that control attention,
learning, and susceptibility to addiction. 5

According to the Surgeon General, the evidence is
already sufficient to warn pregnant women, women
of reproductive age, and adolescents about the use
of nicotine containing products such as smokeless
tobacco, dissolvables, and ENDS as alternatives to
smoking.4

www.cdc.gov/tobacco
CS2606251-B

Any combusted tobacco use at any age is dangerous.

burden of death and disease

The
from tobacco use in the U.S. is overwhelmingly caused
by cigarettes and other combusted tobacco products.4

no safe level

There is
of exposure
to secondhand tobacco smoke.7

In order for adult smokers to benefit from ENDS, they must
completely quit combusted tobacco use. Smoking even a few
cigarettes per day is dangerous to your health.
Smokers who cut back on cigarettes by using ENDS, but who don’t completely quit
smoking cigarettes, aren’t fully protecting their health:

• Smoking just 1- 4 cigarettes a day doubles the risk of dying from heart disease.
• Heavy smokers who reduce their cigarette use by half still have a very high risk for early death.
8

9

Benefits of quitting smoking completely:

• Heart disease risk is cut in half 1 year after quitting and continues to drop overtime.
• Even quitting at age 50 cuts your risk in half for early death from a smoking-related disease.
4

4

ENDS are not an FDA-approved quit aid.
Currently the evidence is insufficient
to conclude that ENDS are effective

for smoking cessation.

Seven medicines are approved by the FDA
for smoking cessation, and are proven safe and
effective when used as directed.10

ENDS aerosol is NOT harmless “water vapor”
and is NOT as safe as clean air.18

• ENDS generally emit lower levels of dangerous toxins • Some ENDS manufacturers claim that the use of
than combusted cigarettes. However, in addition to
nicotine, ENDS aerosols can contain heavy metals,
ultrafine particulate, and cancer-causing agents
like acrolein.11

• ENDS aerosols also contain propylene glycol or
glycerin and flavorings.

propylene glycol, glycerin, and food flavorings is safe
because they meet the FDA definition of “Generally
Recognized as Safe” (GRAS). However, GRAS status
applies to additives for use in foods, NOT for
inhalation. The health effects of inhaling these
substances are currently unknown.

www.cdc.gov/tobacco

ENDS are aggressively marketed using similar tactics
as those proven to lead to youth cigarette smoking.
Although the advertisement of
cigarettes has been banned from
television in the United States since
1971, ENDS are now marketed on
television and other mainstream
media channels.2

Spending on advertising of ENDS
tripled each year from 2011 to
2013.12,13 Sales of ENDS also increased
dramatically over a similar period.14

ENDS marketing has included unproven claims of
safety and use for smoking cessation, and statements
that they are exempt from clean air policies that
restrict smoking.4 These messages could:
§

§ Undermine clean indoor air standards, smokefree
policy enforcement, and tobacco-free social norms.

In a randomized controlled trial,
adolescents who viewed e-cigarette TV
advertisements reported a significantly
greater likelihood of future e-cigarette
use compared with the control group.
They were also more likely to agree
that e-cigarettes can be used in places
where smoking is not allowed.15
Some ENDS companies are using techniques similar
to those used by cigarette companies that have
been shown in the 2012 Surgeon General’s Report to
increase use of cigarettes by youth, including: candyflavored products; youth-resonant themes such as
rebellion, glamour, and sex; celebrity endorsements; and
sports and music sponsorships.13,16

Visual depictions of ENDS use in
advertisements may serve as smoking
cues to smokers and former smokers,
increasing the urge to smoke and
undermining efforts to quit or
abstain from smoking.17

Given the currently available evidence on ENDS, several
policy levers are appropriate to protect public health:

• Prohibitions on marketing or sales of ENDS that
result in youth use of any tobacco product,
including ENDS.

§ States laws prohibiting sales of ENDS to
minors that feature strong enforcement
provisions and allow localities to develop
more stringent policies are more likely to
help prevent youth access.18

• Prohibitions on ENDS use in indoor areas where
conventional smoking is not allowed could:18

• When addressing potential public health

harms associated with ENDS, it is important to
simultaneously uphold and accelerate strategies
found by the Surgeon General to prevent and
reduce combustible tobacco use, including
tobacco price increases, comprehensive smoke-free
laws, high-impact media campaigns, barrier-free
cessation treatment and services, and
comprehensive statewide tobacco control
programs.4,18

§ Preserve clean indoor air standards and
protect bystanders from exposure to secondhand
ENDS aerosol.
§ Support tobacco-free norms.

www.cdc.gov/tobacco

References
1

Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students — United States,
2011–2015. MMWR 65(14);361-367.

2

Bunnell, Agaku, Arrazola, Apelberg, Caraballo, Corey, Coleman, Dube, and King. Intentions to smoke cigarettes among neversmoking U.S. middle and high school electronic cigarette users, National Youth Tobacco Survey, 2011 -2013 Nicotine Tob Res.

3

King, Patel, Nguyen, and Dube. Trends in Awareness and Use of Electronic Cigarettes among U.S. Adults, 2010 -2013
Nicotine Tob Res ntu191 first published online September 19, 2014 doi:10.1093/ntr/ntu191

4

USDHHS. The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA.:
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for
Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

5

England, L. et al. Nicotine and the Developing Human: A Neglected Element of the E -cigarette Debate. Am J Prev Med.
2015 Mar 7. [Epub ahead of print].

6

Centers for Disease Control and Prevention. Notes from the field: calls to poison centers for exposures to electronic
cigarettes—United States, September 2010 – February 2014. MMWR 63(13):292-3.

7

USDHHS. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General.Atlanta, GA.:
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Office on Smoking and Health, 2006.

8

Bjartveit K, Tverdal A. Health Consequences of Smoking 1-4 Cigarettes per Day. Tobacco Control 2005; 14(5):315-20.

9

Tverdal A, Bjartveit K. Health Consequences of Reduced Daily Cigarette Consumption. Tobacco Control. 2006; 15(6): 472–80.

10 FDA 101: Smoking Cessation Products. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm198176.
htm#learn

11 Goniewicz, ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, Prokopowicz A, Jablonska -Czapla M,
Rosik-Dulewska C, Havel C, Jacob P, Benowitz N. Levels of selected carcinogens and toxicants in vapour from
electronic cigarettes. Tobacco Control 2014,23(2): 133–9.
12 Kim AE, Arnold KY, Makarenko O. E-cigarette advertising expenditures in the U.S., 2011–2012. Am J Prev Med 2014;46:409–12.
13 Legacy. Vaporized: E-cigarettes, advertising, and youth. May 2014. Available at: http://legacyforhealth.org/content/
download/4542/63436/version/1/file/LEG-Vaporized-E-cig_Report-May2014.pdf.
14 Loomis B et al. National and State-Specific Sales and Prices for Electronic Cigarettes—U.S., 2012–2013. Am J Prev Med 2015
July 7 [Epub ahead of print].
15 Farrelly MC et al. A Randomized Trial of the Effect of E-cigarette TV Advertisements on Intentions to Use E-cigarettes.
Am J Prev Med 2015 July 8. [Epub ahead of print].
16 U.S. Department of Health and Human Services (2012). Reports of the Surgeon General. Preventing Tobacco Use Among
Youth and Young Adults: A Report of the Surgeon General. Atlanta (GA), Centers for Disease Control and Prevention (US).
17 Maloney EK, Cappella JN. Does Vaping in E-Cigarette Advertisements Affect Tobacco Smoking Urge, Intentions, and
Perceptions in Daily, Intermittent, and Former Smokers? Health Commun. 2015 Mar 11:1-10.
18 Centers for Disease Control and Prevention. State Laws Prohibiting Sales to Minors and Indoor Use of Electronic Nicotine
Delivery Systems — United States, November 2014. MMWR 63(49);1145-1150.

www.cdc.gov/tobacco