Roy S. Herbst, MD, PhD

IN 2015, THE AMERICAN ASSOCIATION FOR CANCER RESEARCH (AACR) and the American Society of Clinical Oncology (ASCO) issued a joint statement raising the alarm about a sudden 400% rise in middle and high school student use of electronic nicotine delivery systems (ENDS), including e-cigarettes, between 2012 and 2014 as reported by the National Youth Tobacco Survey.

Youth use rose another 46% between 2014 and 2020, with up to 3.6 million middle and high school students reporting using ENDS within the past 30 days. The continued growth in ENDS use halted decades of consistent declines in the number of American youth and young adults using tobacco products, prompting AACR and ASCO to release an updated statement in fall 2022.

A key driver of the ENDS epidemic among youth and young adults has been the widespread availability of flavored products, which youth are much more likely to try. A study in the journal Tobacco Control found that adolescents 13 to 17 years old are more than six times as likely to try fruit-fla vored ENDS as tobacco-flavored ENDS. In fact, 83% of youth who used ENDS in 2020 used flavored products, with fruit flavors being the most popular. Therefore, a central recommendation of the updated joint policy statement is for the Food and Drug Administration (FDA) or Congress to comprehensively prohibit all flavored tobacco products, except for research purposes or FDA-approved smoking cessation therapies.

Every health care provider should support their patients who use tobacco products by encouraging them to use FDA-approved tobacco cessation therapies. Many high-quality studies demonstrate that counseling, medications to treat addiction, and nicotine replacement therapies like gum and patches greatly improve the chances of successfully quitting these incredibly addictive products. While ENDS have been billed as a new method to help adults quit smoking, the evidence about their effectiveness remains inconclusive. This is primarily because no ENDS manufacturers have applied to the FDA to develop their product as a cessation therapy, a prerequisite for conducting clinical trials in the United States.

The new AACR-ASCO statement also details advances in understanding how ENDS impact human biology. While ENDS emit far fewer carcinogens than traditional cigarettes, a growing body of evidence links ENDS use to known steps in cancer development: DNA damage and promotion of uncontrolled cell growth. Cancer can take decades to develop, however, and long-term studies are needed to better understand the relationship between ENDS use and cancer risk. Nicotine itself also harms individuals by raising blood pressure, weakening the immune system, and impairing memory and learning abilities of youth and young adults. It is especially concerning that some ENDS products expose individuals to nicotine levels similar to traditional cigarettes.

The FDA took initial steps in 2022 to reduce the availability of flavored tobacco products. First, the FDA required all ENDS products to undergo a scientific review to prove that each product on the market is “appropriate for the protection of public health.” So far, the FDA has issued marketing orders that allow a small number of tobacco-flavored ENDS to be sold, while not making decisions on several other types of flavored ENDS. These products can stay on the market until a decision on the applications is reached. Second, the FDA issued two new draft rules in April 2022 that would prohibit menthol cigarettes and all flavors of cigars, but ENDS were not included in either rule. AACR submitted public comments strongly supporting these rules, and if finalized, they would be powerful tools to reduce youth and young adult use of combustible tobacco.

AACR will continue to advocate for effective tobacco control policies and support evidence-based smoking cessation treatment.

Roy S. Herbst, MD, PhD, is chairman of the AACR Tobacco and Cancer Subcommittee and chief of medical oncology at Yale Comprehensive Cancer Center​ in New Haven, Connecticu​t.