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In this issue, Liu et al. posit a novel comorbidity in neonates born to women prenatally exposed to second-hand smoke. The authors found an approximate 10% difference in telomere length in infants born to mothers with second-hand smoke exposure and intriguingly suggest possible gender differences in the in utero susceptibility to maternal prenatal second-hand smoke exposure. The pediatric comorbidities associated with second-hand smoke exposure are well documented and include Sudden Infant Death Syndrome, wheezing, lower respiratory tract infection, pneumonia, bronchiolitis and otitis media. Infant urine cotinine levels—a nicotine metabolite—are inversely related to infant lung function. Second-hand smoke exposure is also a significant source of increased healthcare utilization and a risk factor for decreased school attendance. Exposed children wct 2utilize the emergency and urgent care facilities and are hospitalized more frequently than those unexposed to second-hand smoke. Fortunately, decades of public health messaging and increased understanding of these effects have contributed to reduced rates of combustible tobacco use in both women of reproductive age and pregnant women. In sharp contrast to this decline however, the use of electronic cigarettes and nicotine delivery systems has exponentially increased in all age groups. Rates of e-cigarette use in adults of reproductive age doubled to 4.2% from 2012 to 2014. More than 10% of these adults vape exclusively, having never used combustible tobacco. Yet youth vaping and e-cigarette use may be a pathway to traditional cigarette smoking, particularly in previously low-risk children. Exclusive e-cigarette users are at high risk of beginning combustible cigarette use within 2 years of initiating vaping. Currently, 27.5% of United States youth report using an electronic cigarette within the past 30 days and rates of use in children have increased by over 100% in the past 2 years. Though popularly conceived as a safer alternative to combustible cigarettes, these products contain toxicants such as formaldehyde, propylene glycol, acetylaldehyde, vegetable glycerin and acrolein. These substances also have the potential to cause oxidative stress, promote inflammation, induce mutagenesis and may be associated with increased cancer risk. Further, the outcome of prenatal vaping on birth outcomes is unknown. The potential for youth use to fuel a burgeoning increase in use of these products in women of reproductive age within several years, accompanied by the known association of vaping with combustible tobacco use, is significant. Across the spectrum of nicotine delivery systems, flavored vape products are extremely appealing to youth. Among current tobacco users, 80% of youth and 73% of adults 18–24 years use flavored products and 60% of specifically cite flavors as a reason for continued use. Many teen and young adults are unaware these products contain nicotine. Based on these findings, the United States government has engaged in several actions aimed at reducing youth electronic cigarette use, specifically targeting flavored products. In 2016, the FDA Center for Tobacco Products asserted regulatory authority over electronic nicotine delivery systems, and restricted their sale to anyone under 18 years of age. The agency has issued warning letters and leveled civil complaints to retailers who sell to minors and has prohibited the distribution of free tobacco products samples. The agency also required, as of June 2019, for these products to state they contain nicotine and to have the ingredients listed. However, the most effective strategy to restrict sale of flavored vape products and curb youth use may be via use of the FDA’s requirement that these products undergo FDA approval prior to sale. In July of 2019, a US Federal Court ordered electronic cigarette manufacturers to submit applications for FDA premarket review by May of 2020. The FDA would then have the ability to limit or prohibit sale of these products if the agency feels they do not have a legitimate public health role. Such a public health role may include the use of flavored tobacco products to reduce the use of combustible cigarettes in adults who currently smoke. Yet, even if flavored vape devices are shown to provide a benefit to current smokers, the FDA could still substantially restrict use if the agency deems the threat of youth tobacco initiation outweighs potential benefits to current adult smokers. However, given the politicization of federal regulation in the current administration, it remains unclear what level of permissiveness the agency will allow in evaluating these products, including to what extent and scrutiny industry-sponsored research will be reviewed. Hence there is little assurance FDA actions will be comprehensive. Like state laws and Presidential executive actions, these measures are limited in scope and finite. In the absence of a rapid, comprehensive federal response, states and municipalities have been regulating tobacco flavors locally. For example, to address the vaping epidemic, California’s governor recently signed an executive order that earmarks funds for education and increases enforcement of underage sales. Though San Francisco was the first major city to prohibit the sale of flavored tobacco products, several states and New York City have followed—motivated by over 1200 vape-related hospitalizations nationwide, the rapid uptake of these products by children and concerns of child-health advocates, including pediatricians, parents and teachers (Table 1). Preliminary data have shown prohibiting the sale of flavored vape products may be effective in reducing teen vaping. In comparing two local communities, Kingsley et al. demonstrated a flavor ban reduced current use of both flavored and unflavored tobacco products in children within 6 months after implementation. This result is promising; however, flavor prohibitions in states are too new to determine their longterm and sustained impact on youth vaping beyond the 6-month study period. These policies will provide a natural long-term experiment for public health researchers to evaluate if sales prohibitions in flavored nicotine, as a policy tool, reduce teen use, and if so, to what extent. However, the immediacy of this threat to child health, in conjunction with the meteoric rise in the use of these products, necessitates a “Do No Harm” approach which underlies the need for flavor prohibitions. Similar studies provided data illustrating the compelling role of “Tobacco 21” laws—which