The FDA recently announced that it considers a new surge in teen e-cigarette use to be an epidemic, and will give e-cigarette manufacturers 60 days to prove that they are not marketing to kids. This is a very welcome move for those of us who have been pushing to prevent teen tobacco use. Our city recently took on the makers of e-cigarettes and won. The FDA should take San Francisco's lead and do everything it can to protect kids from Big Tobacco.

"Big tobacco sees vaping as their future," these are the words of Patrick Reynolds, an anti-tobacco activist and executive director of Foundation for Smokefree America. He is the grandson of R.J. Reynolds, the man behind a namesake tobacco company largely responsible for the fact that millions of Americans continue to be hooked on cigarettes.

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Reynolds, like many local health departments, sees that a new generation is consuming new and different tobacco products at alarming rates.

Electronic cigarettes (e-cigarettes), are the main driver of this trend. They contain nicotine and harmful toxins, making them especially dangerous to youth, who are more susceptible to addiction because their brains are still developing. Cities like mine are taking action, because federal authorities have thus far failed to do so, leaving children and teenagers vulnerable to the effects of these deadly products.

“Vaping” is a new mode of nicotine delivery that includes e-cigarettes, e-pens, e-pipes, e-hookah, and e-cigars. “Vape” is a misnomer, as many assume the resulting product contains water vapor, when it indeed is an aerosol much like smog, and contains propylene glycol, a chemical base used in theater fog machines.

These e-products are easy to consume and simple to conceal, making them especially attractive to teens, which the industry is banking on. Juul, an extremely youth-popular San Francisco-based nicotine delivery device, in particular, is rising in popularity because it is arguably the most discreet e-cigarette product on the market, which comes in enticing flavors. The tobacco industry is again luring youth with flavors such as Gummi Bear and Cherry Crush, with the goal of creating a new generation of smokers — just in a different product.

The battle against vapes is like déjà vu for many of us in the public health community, who successfully fought to eliminate youth-attracting marketing tricks like colorful packaging and candy flavors in cigarettes decades ago. Much of the danger is fueled by the product’s seemingly innocuous presentation. Despite their sleek packaging, e-cigarettes still contain cancer-causing chemicals and highly addictive nicotine.

However, the aerosol emitted doesn’t smell like traditional cigarette smoke does, and resembles water boiled from a teapot. The aerosol inside has ultra-fine particles that contain heavy metals and other substances that are inhaled deep into the lungs. While originally thought to be a “harm reduction” mechanism, i.e. better for people than smoking traditional cigarettes, little is known about their long term effects, and many studies show dual use with cigarettes and reduced likelihood of quitting. Further, vaping may be an entry point to other drug/tobacco use.

Research shows that these sorts of features are devastatingly effective in attracting children, and Big Tobacco knows it. The ease of concealing e-cigarettes doubles their appeal. It’s no wonder new surveys show that the number of kids lighting up is spiking across America.

In the last year, San Francisco stood up to these tactics, enacting a ban on the sale of menthol cigarettes and all flavors in e-cigarettes and other tobacco products. Initially the local public health community worked with elected officials who unanimously adopted the ban.

Big Tobacco quickly challenged the local law with a signature-collecting campaign and referendum, which voters approved by a 2-to-1 margin in June 2018. San Franciscans effectively finished work that the U.S. Food and Drug Administration (FDA) and U.S. Congress left undone when flavors in traditional cigarettes were banned just a few years ago. The tobacco industry did not go down without a fight, however, as R.J Reynolds spent almost $12 million to defeat the city’s measure.

These corporations are fighting so hard to protect these products because their marketing is working, with devastating effects. E-cigarettes entered the market over a decade ago, and since then we’ve seen their popularity rise dramatically, especially among kids.

We conduct the California Healthy Kids Survey, and between 2013-2015 the study included questions about smoking electronic cigarettes or other vaping devices for the first time. Researchers found that students were significantly more likely to consume tobacco with this new method than to smoke cigarettes, especially among younger adolescents.

Among 7th graders, 13 percent identified themselves as lifetime users of e-cigarettes

Among 9th graders, 26 percent smoked e-cigarettes

Among 11th graders, 32 percent use these products

These rates were three times higher than for traditional cigarettes in 7th grade, twice as high in 9th, and 1.5 times higher in 11th. Students in all grades are also twice as likely to vape on school property (4 percent to 5 percent) than smoke cigarettes.

These rates of tobacco use are simply not acceptable, and right now, the tobacco industry is winning, continuing to grow their youth customer base almost unchecked.

Because the FDA and Congress have not acted to ban the flavors that help to lure a new generation of smokers, cities are left to fight Big Tobacco on their own to protect kids in their communities. Policymakers in Washington, must act now to ensure every kid in America, no matter where they live, is protected from the tobacco industry’s billions of dollars in marketing targeted to youth.

Tomás Aragón, MD, DrPH is the Health Officer and Division Director and Derek Smith, MSW, MPH is the Tobacco Free Project Director, at the Population Health Division of the San Francisco Department of Health. The health department is a member of the Big Cities Health Coalition, a forum for the leaders of America’s largest metropolitan health departments.