KMA Resolution on E-Cigarettes

Resolution 15: Regulation of the Marketing, Packaging, and Sale of Electronic Nicotine Delivery Systems, Electronic Non-Nicotine Delivery Systems and Associated Products in Kentucky
This resolution was submitted by medical students from the University of Kentucky and the University of Louisville. A resolution submitted by the Greater Louisville Medical Society was merged into this resolution. This resolution was approved by the Kentucky House of Delegates on September 22, 2019.

WHEREAS, an electronic cigarette (e-cigarette) is a disposable or reusable device that operates by heating a liquid solution to create an aerosol that is inhaled, and can come in a variety of designs, resembling regular cigarettes, cigars, pipes, pens, and USB flash drives (1); and
WHEREAS, e-cigarette use among teens is on the rise across the United States, with the number of teen e-cigarette users increasing by nearly 1.5 million from 2017 to 2018 (2); and
WHEREAS, the rates of e-cigarette use among Kentucky youth exceeds the national average, and use among Kentucky middle and high school students has nearly doubled from 2016 to 2018 (3,4); and
WHEREAS, 43 percent of young adults who tried e-cigarettes reported that they first tried them because of their appealing flavors4, including cotton candy, gummi bear, mango, cucumber (4); and
WHEREAS, it is estimated that nicotine levels found in the e-cigarette brand JUUL are equivalent to 20 times that of other electronic and traditional cigarettes, and the product labels sometimes do not list the true nicotine content (5); and
WHEREAS, the brain does not fully develop until mid to late 20’s, thus young adults are at increased risk of harm from nicotine, as it impairs adolescent brain development and can cause long lasting effects, including impulsivity and mood disorder (2,4); and
WHEREAS, the aerosol in e-cigarettes contain chemicals, such as formaldehyde and acrolein that can cause irreversible lung damage and have been associated with cancer, lung disease, airway irritation, and heart disease6,7, and at least 10 chemicals identified in e-cigarettes are on the list of carcinogens and reproductive toxins from the Safe Drinking Water and Toxic Enforcement Act of 1986 (5,8); and
WHEREAS, e-cigarette aerosol has a higher concentration of ultrafine particles than that in conventional tobacco cigarette smoke, and exposure to these particles can worsen respiratory illnesses like asthma and constrict arteries, causing cardiovascular effects such as myocardial infarction (8); and
WHEREAS, the US Surgeon General concluded in 2016 that second-hand smoke from e-cigarette aerosol contains volatile organic compounds, heavy metals, and flavorings such as diacetyl, all of which are associated with negative health consequences (9); and
WHEREAS, smoke-free laws are designed to reduce second-hand smoke harm but also have been shown to reduce smoking, increase the success of smoking cessation, and may decrease smoking initiation in youth (10); and WHEREAS, in 2016, nearly 4 out of 5 middle and high school students and over 20 million young adults reported that they saw at least one e-cigarette advertisement during the year11; and
WHEREAS, e-cigarettes are often marketed as an alternative to smoking cigarettes; however, 40% of users aged 18-24 had never been regular cigarette smokers and the use of e-cigarettes increase the risk of using traditional cigarettes (2,9,4); and
WHEREAS, few restrictions regarding e-cigarette marketing exist, allowing companies to promote their products through traditional and modern outlets (including radio, television, magazines and social media) that target adolescent audiences11; and
WHEREAS, tobacco advertising bans showed a reduction in tobacco use and initiation, especially among the youth12; and
WHEREAS, increasing the price of tobacco products has been shown to decrease tobacco consumption and reduce initiation of tobacco use (13,14); and
WHEREAS, smoking-related health care costs in Kentucky are approaching $2 billion per year (15); and
WHEREAS, at the time of this resolution’s submission, there are no regulations or excise taxes in place on the sale, packaging, and advertising of e-cigarettes in Kentucky (16); now, therefore, be it

RESOLVED, that the Kentucky Medical Association supports regulation of marketing and packaging of e-cigarettes, in a way that mirrors the regulation of traditional cigarettes; and be it further,
RESOLVED, that the Kentucky Medical Association supports a ban on e-cigarette use in locations where tobacco use is prohibited; and be it further,
RESOLVED, that the Kentucky Medical Association supports the extension of laws prohibiting tobacco advertising to e-cigarettes; and be it further,
RESOLVED, that the Kentucky Medical Association supports federal and state bans on flavorings for electronic nicotine delivery systems, electronic non-nicotine delivery systems and associated products; and be it further
RESOLVED, that the Kentucky Medical Association support legislation to tax electronic nicotine delivery systems, electronic non-nicotine delivery systems and associated products at rates similar to conventional, combustible cigarettes; and be it further
RESOLVED, that KMA educate the public, especially youth, of the dangers of using electronic nicotine delivery systems, electronic non-nicotine delivery systems and associated products, and so discourage the use of them.

References

1 E-cigarettes: Facts, stats and regulations. Truth Initiative. https://truthinitiative.org/research-resources/emerging-tobaccoproducts/e-cigarettes-facts-stats-and-regulations. Accessed August 17, 2019.
2 Tobacco Use By Youth Is Rising: E-cigarettes Are the Main Reason. Centers for Disease Control and Prevention. https://www.cdc.gov/vitalsigns/youth-tobacco-use/index.html. Published February 215, 2019. Accessed August 19, 2019.
3 Foundation Statement: Kentucky Youth Vaping Doubled from 2016-2018. Foundation for a Healthy Kentucky. https://www.healthy-ky.org/newsroom/news-releases/article/317/foundation-statement-kentucky-youth-vaping-doubled-from2016-2018. Accessed August 17, 2019.
4 Products C for T. 2018 NYTS Data: A Startling Rise in Youth E-cigarette Use. FDA. April 2019. http://www.fda.gov/tobaccoproducts/youth-and-tobacco/2018-nyts-data-startling-rise-youth-e-cigarette-use. Accessed August 17, 2019.
5 How Much Nicotine is in JUUL? Truth Initiative. https://truthinitiative.org/research-resources/emerging-tobacco-products/howmuch-nicotine-juul Accessed August 19, 2019.
6 Ogunwale MA, et al. Aldehyde Detection in Electronic Cigarette Aerosols. ACS Omega. 2017;2(3):1207-1214. doi:10.1021/acsomega.6b00489
7 Jin, L, et al. Formaldehyde Induces Mesenteric Artery Relaxation via a Sensitive Transient Receptor Potential Ankyrin-1 (TRPA1) and Endothelium-Dependent Mechanism: Potential Role in Postprandial Hyperemia. Frontiers in Physiology. 2019;10:277. doi: 10.3389/fphys.2019.00277
8 Electronic Smoking Devices and Secondhand Aerosol. American Nonsmokers’ Rights Foundation | no-smoke.org. https://nosmoke.org/electronic-smoking-devices-secondhand-aerosol/. Accessed August 17, 2019.
9 E-Cigarettes and Lung Health. American Lung Association. https://www.lung.org/stop-smoking/smoking-facts/e-cigarettesand-lung-health.html. Accessed August 17, 2019.
10 CDC Tobacco Free. Smoke-Free Policies Reduce Smoking. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/protection/reduce_smoking/index.htm. Published December 1, 2016. Accessed August 17, 2019.
11 4 marketing tactics e-cigarette companies use to target youth. Truth Initiative. https://truthinitiative.org/researchresources/tobacco-industry-marketing/4-marketing-tactics-e-cigarette-companies-use-target. Accessed August 17, 2019.
12 WHO | Ban tobacco advertising to protect young people. WHO. https://www.who.int/mediacentre/news/releases/2013/who_ban_tobacco/en/. Accessed August 17, 2019.
13 Chaloupka FJ, Straif K, Leon ME. Effectiveness of tax and price policies in tobacco control. Tobacco Control. 2011;20(3):235238. doi:10.1136/tc.2010.039982
14 CDC – Prevention Status Reports (PSR) – National Summary – Tobacco Use. https://wwwn.cdc.gov/psr/NationalSummary/NSTU.aspx. Accessed August 17, 2019.
15 2019 Kentucky tobacco use fact sheet. Truth Initiative. https://truthinitiative.org/research-resources/smoking-region/tobaccouse-kentucky-2019. Accessed August 17, 2019
16 E-Cigarette Regulations – Kentucky | Public Health Law Center. https://www.publichealthlawcenter.org/resources/us-ecigarette-regulations-50-state-review/ky. Accessed August 17, 2019

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