The Forum of International Respiratory Societies, a coalition of respiratory doctors and scientists, warns that there is mounting evidence to justify calling for a ban on flavourings and on marketing e-cigarettes as lower risk alternatives to children and adolescents.
The Forum of International Respiratory Societies is a collaborative of nine organisations from North and South America, Europe, Africa, Asia and Australia that was created to promote lung health worldwide.
The paper brings together a wide range of research findings on e-cigarettes. It highlights evidence that children and adolescents are highly susceptible to nicotine addiction, and that use of e-cigarettes has risen steeply in this age group to become the most commonly used tobacco-related product among adolescents in some countries.
The authors lay out a set of evidence-based recommendations for protecting youth from nicotine addiction and its harmful effects.
The paper was co-authored by Dr Thomas Ferkol, Alexis Hartmann professor of paediatrics and professor of cell biology and physiology at Washington University in St Louis. He said: "Until recently, the risks of e-cigarettes and their rising popularity with children and adolescents were under-recognised or ignored. We wrote this statement to address growing public health concerns over e-cigarette use among youths.
"Product design, flavours, marketing, and perception of safety and acceptability have increased the appeal of e-cigarettes to young people. These products are 'normalising' smoking and leading to new generations addicted to nicotine."
The authors found growing evidence that e-cigarettes act as a "one-way bridge" to cigarette smoking in adolescents. Ferkol added: "Some people truly believe e-cigarettes could be used as a smoking cessation technique, but these products also are an entry to nicotine addiction and tobacco use in young people."
Charlotta Pisinger, clinical professor of tobacco control at Bispebjerg and Frederiksberg Hospital and University of Copenhagen, Denmark was also a co-author. She said: "Although exposure to potentially harmful ingredients from electronic cigarettes may be lower than traditional cigarettes, this does not mean that e-cigarettes are harmless.
"And when we're talking about children and adolescents who are trying e-cigarettes for the first time, we should not be comparing their use to traditional cigarettes. We should be comparing them to no tobacco use."
The paper puts forward a series of expert recommendations that the authors say will protect this vulnerable group. They state that e-cigarettes should be regulated in the same way as tobacco products and included in smoke-free policies. They say that there should be a ban on sales to youths worldwide, which must be enforced. Advertising e-cigarettes as lower-risk alternatives directed to youths and young adults should cease.
The paper also calls for a ban on flavoured products, because there is evidence that flavourings draw young people to e-cigarettes. There are currently more than 7,500 different flavoured e-cigarettes and refills available. Finally, the authors recommended further research on the health effects of e-cigarettes as well as surveillance of use across different countries.
Regulation of e-cigarettes varies widely around the world. For example, legislation on a minimum age for buying e-cigarettes is non-existent or not enforced in most countries.
Dr Aneesa Vanker, a senior specialist in paediatric pulmonology, at the Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa, was also a co-author the paper. She added: "E-cigarettes are largely unregulated, particularly in low and middle-income countries. They are marketed as a smoking cessation tool and a safer alternative to tobacco cigarettes.
"However, there is growing evidence that nicotine has many acute and long-term adverse effects, including addiction. Young people are at particular risk for this.
"We want local, national, and regional decision-makers to recognise the growing public health threat that e-cigarettes pose to children and adolescents. Inhaling something other than air is never good for a child's lungs."
Children and adolescents are highly susceptible to nicotine addiction, which affects their brain development, even in those who smoke infrequently. Young people who become addicted to nicotine are at greater risk of becoming lifelong tobacco consumers. The use of nicotine-delivering electronic cigarettes has risen dramatically among youths worldwide. In addition to physical dependence, adolescents are susceptible to social and environmental influences to use electronic cigarettes. The product design, flavours, marketing, and perception of safety and acceptability have increased the appeal of electronic cigarettes to young people, thus leading to new generations addicted to nicotine. Moreover, there is growing evidence that electronic cigarettes in children and adolescents serve as a gateway to cigarette smoking. There can be no argument for harm reduction in children. To protect this vulnerable population from electronic cigarettes and other nicotine delivery devices, we recommend that electronic cigarettes be regulated as tobacco products and included in smoke-free policies. Sale of electronic cigarettes should be barred to youths worldwide. Flavouring should be prohibited in electronic cigarettes, and advertising accessible by youths and young adults be banned. Finally, we recommend greater research on the health effects of electronic cigarettes and surveillance of use across different countries.
Thomas W Ferkol, Harold J Farber, Stefania La Grutta, Frank T Leone, Henry M Marshall, Enid Neptune, Charlotta Pisinger, Aneesa Vanker, Myra Wisotzky, Gustavo E Zabert, Dean E Schraufnagel