E-cigarette use is flaring up across the United States, according to a new study by the US Centers for Disease Control and Prevention.
Monthly e-cigarette unit sales surged by 46.6% from January 2020 to December 2022—from 15.5 million to 22.7 million units, according to report published Thursday in the CDC’s Morbidity and Mortality Weekly Report. During that time period, purchases of tobacco and mint-flavored e-cigarettes fell, but sales of the fruit- and candy-flavored e-cigarettes that appeal to youth shot up.
“The dramatic spikes in youth e-cigarette use…showed us how quickly e-cigarette sales and use patterns can change,” said Deirdre Lawrence Kittner, director of CDC’s Office on Smoking and Health, in a news release. “Retail sales data are key to providing real-time information on the rapidly changing e-cigarette landscape, which is essential to reducing youth tobacco use.”
According to the 2022 National Youth Tobacco Survey, over 2.5 million middle and high school students reported using e-cigarettes. E-cigarettes contain high concentrations of nicotine, a highly addictive chemical that can harm adolescents’ brains.
Thursday’s study was conducted by the CDC, the CDC Foundation (the CDC’s nonprofit, charitable arm), and the Truth Initiative. To investigate the trends behind e-cigarette use, the researchers analyzed retail scanner data from 2020-2022 to look at e-cigarette products, flavors, and top-selling brands.
The report’s data only include sales from brick-and-mortar retailers. E-cigarette sales from tobacco-specialty stores, such as vape shops, and online sellers were not examined.
During the study’s time frame, the increase in e-cigarette sales was accompanied by a spike in the number of e-cigarette brands, which shot up by 46.2% from 184 to 269 brands.
Among those, the five top-selling e-cigarette brands were Vuse, JUUL, Elf Bar, NJOY, and Breeze Smoke. The study found that Elf Bar was the top-selling disposable brand in the United States and has been responsible for driving sharp recent increases in e-cigarette use among youth in England.
While sales of pre-filled e-cigarette devices decreased from 75.2% to 48.0%, the share of disposable e-cigarettes climbed from 24.7% to 51.8%. The report attributes these changes to a 2020 announcement by the FDA, which prioritized enforcement against prefilled e-cigarette cartridges that were not tobacco or menthol flavored.
After the announcement, however, sales of tobacco and mint-flavored prefilled cartridges slowed. Sales of fruit, sweet, and mint-flavored disposable e-cigarettes, however, shot up: from 2020 to 2022, sales of “other-flavor” e-cigarettes—including fruit, sweet, and chocolate flavors-–increased by 29.2% to 41.3%.
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Now, the study noted, disposable e-cigarettes in these “youth-appealing flavors” are more commonly sold than prefilled ones.
“Nicotine addiction shouldn’t taste like candy,” wrote Robin Koval, CEO and president of the Truth Initiative, in an email to CNN. “These data speak volumes to the urgency of closing the gaping flavored tobacco product loophole to protect our nation’s youth– no matter the e-cigarette form – pods, refillable, and now especially disposables.”
While total e-cigarette sales increased during the study period, they decreased during the last months of the study period from May to December 2022. According to the report, that decline may be due to a number of factors, including local and state restrictions on flavored tobacco product sales, FDA regulations, and Covid-19-related supply chain disruptions.
While seven states and 378 counties, towns, and cities have an e-cigarette restriction in place, the study recognized that more needs to be done.
E-cigarette poisoning cases also on the rise among kids
A separate report from the US Food and Drug Administration published by the CDC Thursday found that from April 2022 to March 2023, 7,043 e-cigarette exposure cases were reported to poison centers in the United States, representing a 32% monthly increase during the study period.
Nearly 90% of the cases occurred among children under 5 years old.
Warning against the dangers of youth e-cigarette use, the report recommends “comprehensive restrictions” on the sale of all flavored tobacco products.
“These strategies, when coupled with longstanding evidence-based strategies to prevent youth tobacco use such as price increases, comprehensive smokefree policies…and counter-marketing campaigns, are expected to reduce youth initiation and use as well as reduce disparities in tobacco product use,” the study said.
On Thursday, the FDA announced that it had issued warning letters to 189 retailers for selling unauthorized Elf Bar and Esco Bars e-cigarettes, highlighting their dangerous appeal to adolescents.
Following a nationwide “inspection blitz” of e-cigarette vendors by the FDA, the warnings cite the CDC reports’ findings of Elf Bar as the most popular disposable e-cigarette sold in the U.S., including among teenagers.
Elf Bar and Esco Bars e-cigarettes also lack marketing authorization from the FDA, the agency added. The FDA has only authorized 23 tobacco-flavored e-cigarettes and products; any other e-cigarettes cannot be legally sold in the U.S.
According to Thursday’s previous FDA report, Elf Bar products were the most cited e-cigarette involved in cases reported to poison control centers. Almost all Elf Bar cases occurred in children under five, as well.
Last month, the FDA issued import alerts for products under the Elf Bar and Esco Bars brands, which placed them on a “red list” and allowed the FDA to detain the products without individually examining them.
“The FDA is prepared to use all of its authorities to ensure these, and other illegal and youth-appealing products, stay out of the hands of kids,” said FDA Commissioner Robert M. Califf, M.D, in a news release. “We are committed to a multipronged approach using regulation, compliance and enforcement action and education to protect our nation’s youth.”
Correction: A previous version of this story misstated the name of the Truth Initiative.