The Danger of Flavored Nicotine Products Marketed to Young People

Tobacco and nicotine use among young people has plagued the United States for decades. The recent introduction of e-cigarettes has only allowed this substance abuse to gain traction again after years of declining usage among adolescents.

The American Academy of Pediatrics (AAP) says tobacco and nicotine use is so dangerous, it requires "urgent action" to protect children. That's why the organization has released a report calling for policy changes to be implemented and is issuing recommendations to help prevent children and teens from picking up the habit, one that is shown to have serious health implications.

"The vast majority of tobacco use starts in the teenage years," says Brian Jenssen, M.D., FAAP, one of the report's lead authors. "We're seeing the shifting landscape where there's more and different new tobacco and nicotine products that continue to emerge that are targeted towards kids."

One particular category of products causing concern: E-cigarettes. Many of them are flavored, making them appealing to tweens and teens. In 2020, nearly 1 in 4 high school students and 1 in 14 middle school students reported using a tobacco product. In just one year, from 2019 to 2020, the use of e-cigarettes among high school students increased by 11%.

Policy Changes to Combat Youth Nicotine Use

The AAP's new policy statement, titled "Protecting Children and Adolescents From Tobacco and Nicotine," is an update to its report from 2015. It outlines the need for increased prevention efforts and early intervention in reducing tobacco use and nicotine exposure in children and adolescents.

"One message [in the report] is that parents can play a pivotal role in helping protect their kids from tobacco products, period," Dr. Jenssen explains.

Some of the policy suggestions outlined by the AAP include:

• Asking the FDA to regulate all tobacco and nicotine products.
• Funding for tobacco use prevention.
• Screening and treatment for pediatric populations.
• An increase in price for tobacco and nicotine products to deter potential young buyers.
• Enacting more preventative measures against secondhand smoke and aerosol exposure.

The report also outlines more specific guidelines for pediatricians as the first line of defense with their patients. These include:

• Screening all adolescents for tobacco and nicotine use.
• Asking about parents' use of tobacco and nicotine.
• Referring youth who want to quit using nicotine and tobacco to behavioral interventions.
  

"I believe our role is to engage in honest face-to-face discussions with our patients regarding the dangers of all nicotine-related products, including smokeless tobacco products," Dr. Shaumberger says. "Any actions by the AAP that prevent adolescents from starting to use tobacco products are welcome. As a pediatrician, watching first-hand the epidemic of teen vaping—driven by direct social media marketing of flavored products—was very upsetting."

The Rise (and Crackdown) of E-cigarettes

Dr. Jenssen and his colleagues published their series of reports just days after the e-cigarette company Juul was ordered to pay a monumental settlement of $462 million to six states. The company, known for its sleek design and playful nicotine flavoring, was accused of contributing to the rise of vaping in young people.

E-cigarettes first came on the market in 2007, but really took off around 2014 when they became the tobacco product most used by U.S. youth. Through aerosol, users inhale nicotine with flavors, a practice commonly referred to as vaping. Along with the dangers of nicotine consumption, the use of aerosol in e-cigarettes causes potential harm from the added exposure to substances like heavy metals, volatile organic compounds, and ultrafine particles.

"It's easy, in a way, to show that anything is safer than cigarettes because [they're] so harmful. E-cigarettes might be safer on some level than cigarettes," Dr. Jenssen says. "[But] e-cigarettes have been in the market just for a couple of years. And it took us about 30 years, if not longer, to really figure out how bad cigarettes were for your health. As we get longer-term data [on e-cigarettes], approaching almost 10 years in the marketplace, we've learned more and more about the harms."

Juul and other e-cigarette brands have been at the center of controversy for marketing practices that some argue target youth. Last year, the Food and Drug Administration (FDA) ordered Juul products be pulled from shelves while the agency investigated its health effects, particularly for young people who were facing serious health problems after the alleged use of e-cigarettes. The FDA had previously ordered Juul to stop selling their mint and fruit-flavored devices specifically.

The company claims its products, originally made to help adults quit smoking, were never intentionally marketed toward adolescents. But experts point to their use of young people for a multitude of advertising campaigns, as well as the fruity flavors offered, which appeal to new or young smokers.

"There has always been this playbook by tobacco companies targeting kids because they are more vulnerable than adults in terms of their risk factors," Dr. Jenssen explains. "[Those factors include] the likelihood to experiment, that their developing brain is more susceptible to some of the marketing tactics, and the addiction potential of nicotine products. What made e-cigarettes so enticing was a combination of technology and use of social media, especially by Juul, to really take the same sort of tobacco company playbook and then bring it into the 21st century."

Under Juul's settlement terms, co-led by New York Attorney General Letitia James and California Attorney General Rob Bonta, retailers will be obligated to keep Juul products behind counters and the buyers' age must be verified before purchase. The company will also not be allowed to use people under 35-years-old in its marketing materials targeted, whether directly or indirectly, toward young people.

The Risks of Tobacco Use

All tobacco products contain nicotine, an addictive substance with well-documented damaging effects. The risk of serious, long-term health effects is increased for young people. Exposure to nicotine during adolescence has been shown to hinder developing brains impacting learning, memory, and attention. It can also lead to future addiction to other drugs.

"The health effects of tobacco usage have been well documented for the last 50-plus years," says David Schaumberger, M.D., a pediatrician in New Jersey. "Cigarette smoking is the leading cause of preventable disease in the U.S.."

Long-term tobacco use has also been linked to various other health issues including cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD), among others.

"Cigarettes are the only legal product on the marketplace that, when you use them as intended, will kill you," Dr. Jennssen says. "That's a pretty damning indictment. The average cigarette user dies 10 years earlier than their non-smoking peers."

The problem isn't just an issue for those young people who do the smoking—secondhand smoke is also a major issue for unborn babies and young children. According to the AAP, almost 40% of kids between ages 3-11 are exposed to secondhand smoke on a regular basis. In addition, prenatal exposure can affect lung development and the risk of respiratory illness.

There was a small window of time, between 2015 and 2017, when tobacco and nicotine use among young people had actually decreased and all of those prevention methods seemed to work. While e-cigarettes were one factor that caused a rise in tobacco use in adolescents again, Dr. Jenssen and his colleagues hope their calls for policy change will contribute to a future with decreased demand for tobacco products from young people.

"I'm always an optimist and good things are always possible," says Dr. Jenssen. "We can't let up. I would love, as a tobacco researcher and tobacco use treatment expert, to be out of a job in that space. All these things that we're recommending are really focused on helping children, adolescents, parents, and families live tobacco-free lives."