Growing e-cigarette use among young people threatens decades of progress in shrinking tobacco use, top US health officials warned in a report released on Thursday.

The US surgeon general’s report is the first federal government review of the public health impact of e-cigarettes on young people across the country.

“Preventing tobacco use in any form among youth and young adults is critical to ending the tobacco epidemic in the United States,” said surgeon general Vivek Murthy.

E-cigarettes don’t contain tobacco, but do contain nicotine and are considered “tobacco products” by the US government.

Advocates say e-cigarettes could replace traditional cigarettes, while critics are concerned they are a gateway to tobacco use – especially in young people, who are more vulnerable to the addictive impact of nicotine.

The debate over the potential harms and benefits of e-cigarettes is a live one in the US and the UK. Many public health professionals in the UK believe that vaping is the best available option for those who would otherwise smoke tobacco, and that it is saving thousands of lives by enabling hardened smokers to quit. Public Health England has said it is 95% safer, and that the young people experimenting with e-cigarettes are the same people who try smoking tobacco.

“Evidence from the US is the same as in the UK in crucial respects,” said Professor John Britton, director of the UK Centre for Tobacco and Alcohol Studies at Nottingham University. “Children experimenting with e-cigarettes are by and large those who are already experimenting with cigarettes or are smokers.”

The surgeon general’s report said e-cigarettes are the most commonly used tobacco product among the young and are more popular than cigarettes, cigars and hookahs in the US. The use of e-cigarettes and other nicotine products by under-18s has jumped significantly after decades of declining rates of cigarette smoking.



Young people are not using the products for the same reasons as adults, the report said: “Although adults report using e-cigarettes as a cessation device, the evidence supporting the effectiveness of e-cigarettes as an aid for quitting conventional cigarettes remains unproven and nonexistent among youth.”

The most common reasons for young people to use e-cigarettes are curiosity, to avoid indoor smoking restrictions and as a less harmful alternative to conventional cigarettes, according to the report.

In 2014, use of e-cigarettes by young adults aged 18 to 24 surpassed that of adults aged 25 and older.

Sylvia Burwell, the US Department of Health and Human Services secretary, said the US must ensure progress in combatting traditional cigarette use isn’t compromised by the use of new tobacco products like e-cigarettes.

“The findings from this report reinforce the need to support evidence-based programs to prevent youth and young adults from using tobacco in any form, including e-cigarettes,” Burwell wrote. “The health and wellbeing of our nation’s young people depend on it.”

Kevin Fenton, national director of health and wellbeing at Public Health England, said the group recognised the concern in the US, where it had proved difficult to impose restrictions on the marketing of e-cigarettes. By contrast, England had put in place a ban on marketing to under-18s, advertising controls and quality standards. But, he said, “our review of the evidence found e-cigarette use carries a fraction of the risk of smoking, a conclusion reiterated by the Royal College of Physicians earlier this year. No new evidence has been published to contradict this, however we are closely monitoring any emerging evidence.”

The US report’s findings pull from existing research on e-cigarette use among people aged between 11 and 24 to show patterns of use and how it affects health.



This report was crafted in a similar vein to earlier surgeon general reports on youth tobacco use. The most recent of those was released in 2012, when e-cigarettes were less popular than they are now.

E-cigarette sales in the US grew to an estimated $3.5bn in 2015, according to Nielsen, but have been falling significantly since the end of last year.

The e-cigarette industry is dominated by traditional tobacco companies, who were targeted in the report for using similar tactics as those used to lure young users to tobacco. “Companies are promoting their products through television and radio advertisements that use celebrities, sexual content, and claims of independence to glamorize these addictive products and make them appealing to young people,” said Centers for Disease Control and Prevention director, Thomas Frieden, in the report’s foreword.

The report concludes with recommendations for combatting e-cigarette use among young people, including incorporating e-cigarettes into smoke-free policies, preventing youth access to e-cigarettes and significant increases to taxes and prices affiliated with e-cigarettes.

Murthy said: “Preventing tobacco use in any form among youth and young adults is critical to ending the tobacco epidemic in the United States.”

The report was launched on Thursday morning in Washington DC at an event where the surgeon general unveiled a new e-cigarette website and public service announcement. Speakers included Murthy, 16-year-old health activist Tyra Nicolay and American Academy of Pediatrics president Benard Dreyer.

Tyra, a member of the Navajo Nation, described how she was first introduced to e-cigarettes with a sour green apple flavored product but has since quit using e-cigarettes. “Today, I call on my peers to reject tobacco products, including e-cigarettes,” she said.

Dreyer said e-cigarette use “has raised alarm among pediatricians, tremendously”.

In October 2015, the AAP issued recommendations for e-cigarette public policy and regulations and guidance for physicians on how to speak with families about tobacco and “nicotine delivery devices” such as e-cigarettes.

“That’s why this report is so necessary and welcome at this time,” Dreyer said. “Because as you’ve heard, e-cigarettes have the potential to addict the next generation of children. It’s a major public health crisis, as far as we’re concerned.”

The British campaigning organisation Action on Smoking and Health said it was puzzled by the surgeon general’s concerns. “In the US as in the UK, young people are experimenting with e-cigarettes but vaping has not been associated with an increase in smoking, a point which is not made sufficiently clear in the report,” it said.



“While nicotine is not completely harmless, it is smoking that is lethal. In the UK we have a regulatory system that restricts advertising and controls sales to young people. There is no evidence of significant regular use by non-smoking children and, as in the US, smoking rates are going down, not up.”

Britton, the Nottingham University academic, attributed a drop in the UK smoking rate, down three percentage points in three years, to people taking up e-cigarettes in order to quit. “It is falling fast in the UK, almost certainly related to e-cigarettes.”