Metropolitan Health District
Tobacco & Vaping

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111 Soledad, Suite 1000
San Antonio, TX 78205

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For the first time since 2000, overall youth tobacco use has increased in San Antonio. The boom of e-cigarettes and other vaping devices has reversed the trend of declining teen tobacco use. Tobacco 21 was introduced in San Antonio and by September 1, 2019 it became a state law in Texas. It is important to remind parents, teachers, and guardians to help children understand the risks of vaping and to take control of their health. If your child vapes and has symptoms such as coughing, shortness of breath, chest pain, nausea, vomiting, diarrhea, tiredness, fever or weight loss, call your doctor right away.

Know the Facts

Youth tobacco product use increased during 2017-2018.
In 2018, about 4.9 million middle and high school students used a tobacco product in the last 30 days, up from 3.6 million in 2017. This increase was driven by a startling increase in e-cigarette use—a 78% increase among high school students and nearly 50% increase among middle school students. Since 2014, e-cigarettes have been the most commonly used tobacco product among youth.

E-cigarettes come in many shapes and sizes.

What is an e-cigarette?
E-cigarettes are battery-powered devices that can deliver nicotine and flavorings to the user in the form of an aerosol. E-cigarettes come in many shapes and sizes. Some e-cigarettes look like regular cigarettes, cigars, or pipes. Some look like USB flash drives, pens, and other everyday items that are easy to conceal.

JUUL, an e-cigarette shaped like a USB flash drive, is now the most commonly sold e-cigarette in the United States. JUUL uses liquid nicotine refills called “pods,” which contain at least as much nicotine as a pack of cigarettes.

What is in the aerosol?
E-cigarette aerosol is not harmless water vapor. In addition to nicotine, the aerosol that users inhale and exhale from e-cigarettes can expose both themselves and bystanders to other harmful substances, including heavy metals, volatile organic compounds, and ultrafine particles that can be inhaled deeply into the lungs. Some of the flavorings used in e-cigarettes may also have health risks when inhaled.

Aerosols contain nicotine • volatile organic compounds • ultrafine particles • cancer-causing chemicals • heavy metals such as nicke, tin, and lead • Flavoring such as diacetyl, a chemical linked to a serious lung disease

Youth use of any tobacco product, including e-cigarettes, is unsafe.
Scientists are still learning about the long-term health effects of e-cigarettes, but we know enough to take action to protect kids from known risks of these products. Most e-cigarettes contain nicotine – the same addictive drug in regular cigarettes, cigars, and other tobacco products. Nicotine exposure during adolescence can harm the developing brain, and impact learning, memory, and attention. Using nicotine during adolescence can also increase risk for future addiction to other drugs.

Nicotine Levels: 1 JUUL Pod = 1 Cigarette Pack

All JUUL e-cigarettes contain a high level of nicotine.
These products also use nicotine salts, which allow particularly high levels of nicotine to be inhaled more easily and with less irritation than the free-base nicotine that has traditionally been used in tobacco products, including e-cigarettes. This is of particular concern for young people, because it could make it easier for them to initiate the use of nicotine through these products. But despite these risks, approximately two-thirds of JUUL users aged 15–24 do not know that JUUL always contains nicotine.

Other health risks for youth and young adults.
Young people who use e-cigarettes may be more likely to go on to use regular cigarettes. E-cigarettes also can be used to deliver other drugs, including marijuana; in 2016, approximately one-third of U.S. middle and high school students who have ever used an e-cigarette reported using marijuana in the device.

Also, defective e-cigarette batteries have caused fires and explosions, a few of which have resulted in serious injuries. Children have also been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes. Nationally, approximately 50% of calls to poison control centers for e-cigarettes are for kids 5 years of age or younger.

Advertising + Flavors = Youth e-cigarettes use

Flavors and marketing make e-cigarettes appealing to youth.
Many e-cigarettes come in fruit, candy, and other kid-friendly flavors, such as mango and crème. A majority of youth e-cigarette users report using flavored varieties, most youth e-cigarette users first start using e-cigarettes with a flavored variety, and flavors are a primary reason youth report using e-cigarettes.

E-cigarettes are also advertised using the same themes and tactics that have been shown to increase youth initiation of other tobacco products, including cigarettes. In 2016, about 8 in 10 middle school and high school students—more than 20 million youth—said they had seen e-cigarette advertising.

Refer to the Frequently Asked Questions section for additional information on youth and e-cigarettes.

Under 21: No sales of cigarettes, e-cigarettes, or tobacco products in Texas.

Tobacco

State Law

In 2019, the 86th Legislature passed Senate Bill 21, increasing the legal age from 18 to 21 for the sale, distribution, possession, purchase, consumption or receipt of cigarettes, e-cigarettes or tobacco products. The State Law became effective September 1, 2019. The City’s Tobacco 21 ordinance is no longer in effect.

Minors – Education and Prevention

The Texas Comptroller’s Office provides information for minors and their families. Please visit the Texas Comptroller’s Office for more information.

Information for Retailers

As of September 1, 2019, the State of Texas is now providing retailer education materials and enforcement for Senate Bill 21 (Tobacco 21). Please visit the Texas Comptroller’s Office for more information.

Take Action to protect youth

WHAT CAN PARENTS DO?
  • Set a positive example by being tobacco-free. Make their homes and cars tobacco-free. If they use tobacco products, they can visit Smokefree.gov or call 1-800-QUIT-NOW for free help to quit.
  • Read the E-Cigarettes and Youth: What Parents Need to Know fact sheet to educate themselves about e-cigarettes and the risks to youth.
  • Use the Talk with Your Teen about E-Cigarettes: Parent Tip Sheet to start a conversation with their child about tobacco products, including e-cigarettes.
  • Talk to school administrators to make sure their child’s school has a tobacco-free policy and teaches an evidence-based tobacco prevention curriculum that is not funded by the tobacco industry and includes information on e-cigarettes.
  • Ask their child’s health care provider to speak with their child about the health risks of using tobacco products, including e-cigarettes.
  • Learn more about the risks of youth e-cigarette use at the CDC Office on Smoking and Health e-cigarette web pages at www.CDC.gov/e-cigarettes.
teacher and students
WHAT CAN EDUCATORS DO?
WHAT CAN HEALTH CARE PROVIDERS DO?

QuitLine

Frequently Asked Questions

group of youth
WHAT IS AN E-CIGARETTE?
  • E-cigarettes are devices that heat a liquid into an aerosol that the user inhales. E-cigarettes come in many shapes and sizes. Most have a battery, a heating element, and a place to hold a liquid.
  • E-cigarettes produce an aerosol by heating a liquid that usually contains nicotine—the addictive drug in regular cigarettes, cigars, and other tobacco products—flavorings, and other chemicals that help to make the aerosol. Users inhale this aerosol into their lungs. Bystanders can also breathe in this aerosol when the user exhales into the air.
  • E-cigarettes are known by many different names. They are sometimes called “e-cigs,” “JUUL,” “e-hookahs,” “mods,” “vape pens,” “vapes,” “tank systems,” and “electronic nicotine delivery systems (ENDS).”
  • Some e-cigarettes are made to look like regular cigarettes, cigars, or pipes. Some resemble pens, USB sticks, and other everyday items.
  • E-cigarettes can be used to deliver marijuana and other drugs.
WHO IS USING E-CIGARETTES?
  • In the United States, youth are more likely than adults to use e-cigarettes.
  • In 2018, more than 3.6 million U.S. middle and high school students used e-cigarettes in the past 30 days, including 4.9% of middle school students and 20.8% of high school students.
  • In 2017, 2.8% of U.S. adults were current e-cigarette users.
Why are e-cigarettes the most commonly used tobacco product among U.S. middle and high school students?
  • Factors that have contributed to the increase in e-cigarette use among youth include the availability of these products in a variety of kid-friendly flavors, widespread advertising for these products, including via media for which advertising for conventional tobacco products is prohibited (e.g., TV), and the lower costs of some of these products relative to regular cigarettes.
  • Many youth also report using e-cigarettes because they are curious about these new products, and because they believe these products to be less harmful than regular cigarettes.
Why is nicotine unsafe for kids, teens, and young adults?
  • Most e-cigarettes contain nicotine—the addictive drug in regular cigarettes, cigars, and other tobacco products. Nicotine can harm the developing adolescent brain. The brain keeps developing until about age 25.
  • Using nicotine in adolescence can harm the parts of the brain that control attention, learning, mood, and impulse control.
  • Each time a new memory is created or a new skill is learned, stronger connections – or synapses – are built between brain cells. Young people’s brains build synapses faster than adult brains. Nicotine changes the way these synapses are formed.
  • Using nicotine in adolescence may also increase risk for future addiction to other drugs, and increases the likelihood that they will go on to smoke regular cigarettes.
How do e-cigarettes harm brain development?
  • The brain is the last organ in the human body to develop fully. Brain development continues to about the early to mid-20s.
  • E-cigarettes typically contain nicotine. Nicotine disrupts the development of brain circuits that control attention and learning, and young people who use e-cigarettes and other tobacco products are at risk for deficits in these areas.
  • Adolescence is a critical period for brain development, and brain development continues into young adulthood. Young people who use e-cigarettes and other tobacco products are uniquely at risk for long-term, long-lasting effects of exposing their developing brains to nicotine. In addition to learning and cognitive deficits, and susceptibility to addiction, these risks include mood disorders and permanent lowering of impulse control.
  • The nicotine in e-cigarettes and other tobacco products can also affect the development of the brain’s reward system, priming the adolescent brain for addiction to other drugs such as cocaine and methamphetamine.
What are the other risks of e-cigarettes for kids, teens, and young adults?
  • Scientists are still learning about the long-term health effects of e-cigarettes. However, we know that e-cigarette aerosol can contain harmful ingredients. For example, some flavorings used in e-cigarettes may have been approved as additives to food but are not safe to inhale.
  • Defective e-cigarette batteries have caused some fires and explosions, a few of which have resulted in serious injuries. Children and adults have been poisoned by swallowing, breathing, or absorbing e-cigarette liquid through their skin or eyes.
What is in e-cigarettes aerosol?
  • While e-cigarettes are less harmful than combustible cigarettes, e-cigarette aerosol is NOT harmless “water vapor.” The e-cigarette aerosol that users breathe from the device and exhale can contain harmful and potentially harmful substances, including:
    • Nicotine
    • Ultrafine particles that can be inhaled deep into the lungs
    • Flavoring such as diacetyl, a chemical linked to a serious lung disease
    • Volatile organic compounds
    • Cancer-causing chemicals
    • Heavy metals such as nickel, tin, and lead
  • It is difficult for consumers to know what e-cigarette products contain. For example, some e-cigarettes marketed as containing zero percent nicotine have been found to contain nicotine.
Can using e-cigarettes lead to future cigarette smoking among kids, teens, and young adults?
  • Many young people who use e-cigarettes also smoke cigarettes. There is a growing body of scientific evidence that young people who use e-cigarettes may be more likely to smoke cigarettes in the future than young people who do not use e-cigarettes.
  • A 2018 National Academies report found that among young people, there was some evidence that e-cigarette use increases the frequency and amount of cigarette smoking in the future.
  • But any e-cigarette use among young people is unsafe, even if they do not progress to future cigarette smoking.
Know the Risks: E-cigarettes typically contain nicotine, which is addictive and can harm brain development. E-cigarettes.SurgeonGeneral.gov
Do all e-cigarettes contain nicotine?
  • Most e-cigarettes contain nicotine, and all JUUL brand e-cigarettes contain nicotine. A recent CDC study found that 99% of the e-cigarettes sold in assessed venues in the United States contained nicotine.
  • Some e-cigarette labels do not disclose that they contain nicotine, and some e-cigarettes marketed as containing 0% nicotine have been found to contain nicotine.
  • Some of the new products, including JUUL, use nicotine salts, which allow particularly high levels of nicotine to be inhaled more easily and with less irritation than the free-base nicotine that has traditionally been used in tobacco products, including e-cigarettes. This is of particular concern for young people, because it could make it easier for them to initiate the use of nicotine through these products.
What is JUUL?
  • JUUL is a brand of e-cigarette that is shaped like a USB flash drive. Like other e-cigarettes, JUUL is a battery-powered device that heats a nicotine-containing liquid to produce an aerosol that is inhaled.
  • All JUUL e-cigarettes have a high level of nicotine. According to the manufacturer, a single JUUL pod contains as much nicotine as a pack of 20 regular cigarettes.
  • News outlets and social media sites report widespread use of JUUL by students in schools, including classrooms and bathrooms.
  • Although JUUL is currently the top-selling e-cigarette brand in the United States, other companies sell e-cigarettes that look like USB flash drives. Examples include the PHIX, a nicotine delivery device, and the PAX Era, a marijuana delivery device that looks like JUUL.
Are e-cigarettes regulated at the federal level?
  • Yes. In August 2016, the regulatory authority of the FDA was extended to cover e-cigarettes through the agency’s “deeming rule.”
  • Through authority granted by the Family Smoking Prevention and Tobacco Control Act (FSPTCA), FDA has authority over the manufacturing, marketing, and sale of e-cigarettes.
  • However, the FSPTCA does not prevent states and communities from adopting many strategies related to e-cigarettes. There are also many strategies that FDA does not have authority to implement and that states can do, such as including e-cigarettes in smoke-free policies, pricing strategies, and increasing the age of sale for tobacco products to 21.
Are there any national public education prevention campaigns focused on youth and e-cigarettes?
  • Yes. In 2018, the FDA expanded its successful youth tobacco prevention campaign, “The Real Cost,” to reach the more than 10 million youth aged 12–17 who have used e-cigarettes or are open to trying them. The campaign educates youth about the potential risks of using e-cigarettes.
  • The “Real Cost” reaches teens where they spend most of their time: in school and online. The campaign is also placing e-cigarette prevention materials in high schools across the nation, both in school bathrooms and on educational digital platforms accessed by students during the school day.
  • The Truth Initiative® launched the “Safer ≠ Safe” campaign in 2018, focusing on correcting youth misperceptions and providing accurate information about e-cigarettes and youth. The campaign is being promoted on digital and social media, including the Safer ≠ Safe website, which features videos, articles and interactive activities for youth.
What else can be done by public health to reduce youth e-cigarette use and initiation?
  • Regulating the sale, distribution, and marketing of tobacco products, coupled with proven population-based strategies, can reduce youth tobacco product use and initiation.
  • These proven strategies include increasing prices of tobacco products, protecting everyone from exposure to secondhand smoke and e-cigarette aerosol, and sustaining hard-hitting media campaigns like FDA’s “The Real Cost” campaign that warns youth about the dangers of tobacco product use, including e-cigarettes.
WHAT CAN PARENTS DO TO PROTECT AND PREVENT THEIR CHILD FROM USING E-CIGARETTES?
  • Parents can set a positive example by being tobacco-free, and ensuring that their kids aren’t exposed to the secondhand emissions from any tobacco products, including e-cigarettes.
  • We know e-cigarettes are now the most commonly used tobacco product among youth and that many youth aren’t aware of the dangers of these products, including the negative impacts of nicotine exposure on the developing adolescent brain. Therefore, ensuring that youth are aware of the risks of using all forms of tobacco products, including e-cigarettes, is critical.
WHAT DO WE KNOW ABOUT HEATED TOBACCO PRODUCTS?
  • Heated tobacco products (HTPs) like IQOS and Eclipse, sometimes marketed as “heat-not-burn” technology, represent a diverse class of products that heat the tobacco leaf to produce an inhaled aerosol. They are different from e-cigarettes, which heat a liquid that can contain nicotine derived from tobacco.
  • HTPs are available in at least 40 countries and several have recently been authorized for sale in the United States by the FDA. In 2018, few U.S. adults (2.4% of all surveyed, including 6.7% of current smokers surveyed) had ever used HTPs. Youth use of HTPs is unknown, but monitoring is underway.
  • Scientists are still learning about the short-term and long-term health effects of HTPs, but the available science shows they contain harmful and potentially harmful substances. Youth use of any tobacco products, including heated products, is unsafe.
  • It is important that we continue to modernize proven tobacco prevention and control strategies to include newer products entering the market such as HTPs.

Toolkit

For more resources visit the Center for Disease Control.