Perspective from Clayton Cowl, MD, MS
June 28, 2019
4 min read

San Francisco bans sale of e-cigarettes, other vaping products

Perspective from Clayton Cowl, MD, MS
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Laura E. Crotty Alexander, MD
Laura E. Crotty Alexander

The San Francisco Board of Supervisors unanimously passed an ordinance to amend the city’s health code to prohibit sale of electronic cigarettes and flavored tobacco products whose marketing has not received FDA approval.

Currently, the ordinance effectively bans the sales of all e-cigarettes and liquid nicotine and nicotine-containing e-liquids in San Francisco, as none are authorized for marketing by the FDA.

“Because the FDA failed to act on e-cigarettes over the last several years, states and local governments have been forced to fill the void left by the FDA. On the national level, the American Thoracic Society supports any effective policy to regulate e-cigarettes, and we are all hoping that the FDA takes note of San Francisco’s actions and that maybe other cities and states will follow suit,” Laura E. Crotty Alexander, MD, associate professor of medicine in the division of pulmonary critical care and sleep at the University of California, San Diego, and staff physician in the VA San Diego Healthcare System, told Healio Pulmonology.

Importantly, the city’s decision highlights the fact that e-cigarettes are not necessarily safe, although they are marketed as a less dangerous alternative to conventional tobacco products, Crotty Alexander noted.

“The bottom line is that e-cigarettes will cause disease, so vaping e-cigarettes on a regular basis is not healthy and will be harmful to the lungs, the cardiovascular system, kidneys and more,” she said.

E-cigarettes likely will not be as harmful as conventional tobacco in terms of the amount of injury and disease that they induce, Crotty Alexander added. Further, they are considered to be a possible transitional tool for long-term smokers with severe nicotine addiction who would benefit from decreasing their use of conventional tobacco. However, they are not always effective in this manner.

“Unfortunately, what researchers have found is that when smokers add e-cigarettes when they’re trying to stop smoking, it ends up reinforcing the nicotine addiction,” Crotty Alexander said. “So, in the end, smokers aren’t free of tobacco; they’re just smoking conventional tobacco less and have replaced it with vaping.”

E-cigarette use among children, teens

Concern over the surge in e-cigarette use, particularly among children and adolescents, has served as one impetus behind San Francisco’s decision. For example, Dennis J. Herrera, the city attorney, referred to youth vaping as “an epidemic” in a statement on the ordinance.


According to a report published in MMWR, e-cigarette use increased by 78% in high schoolers and by 48% in middle schoolers from 2017 to 2018.

“We now have a new generation of nicotine addicts who are just using tobacco in a different form,” Crotty Alexander told Healio Pulmonology.

Currently, the most popular e-cigarettes are Juuls, which are highly addictive, she added, noting that their e-liquids contain some of the highest levels of nicotine. As a result, children and adolescents have large amounts of nicotine deposited into their bloodstreams and brains when they vape.

“Any child or teenager who starts vaping gets this amazing dopamine reward surge in their brain, which causes a high with which nothing else can compete, including going to school, spending time with their friends and family or even playing with their puppy,” Crotty Alexander said. “Kids are getting addicted to nicotine through these e-cigarettes; are starting to disengage from family and society; and are acting like addicts because that’s what they are.”

The concept of e-cigarettes did arise from a desire to help, according to Crotty Alexander, but the need for profit likely became an issue for manufacturers.

“I do think the intention was to help smokers quit — that was the origin of the device — but these companies want their product to sell, so their intent became reaching the largest population possible, which is why they targeted children and teenagers by developing these flavored products,” she said.

Notably, efforts to curb conventional tobacco use among children and adolescents appear to be effective, according to Crotty Alexander. For instance, many children and adolescents consider smoking and regular cigarettes to be unhealthy and “gross.” The concern is, though, that they believe vaping is healthy and clean, suggesting that they do not understand what e-cigarettes contain. She also noted that vaping has the potential to normalize smoking.

“However, if we can prevent vaping among kids and teenagers who haven’t ever tried e-cigarettes, then that would be the better part of valor,” Crotty Alexander said.

Moving forward

Importantly, the FDA has taken steps toward regulation of e-cigarettes and other vaping products. On June 11, the agency finalized its guidance for manufacturers submitting new tobacco product applications through the premarket tobacco product application pathway for electronic nicotine delivery systems. The guidance indicates that manufacturers must demonstrate “that the new tobacco product would be appropriate for protection of public health,” according to an FDA press release.


At the same time, Herrera noted that the ordinance does not “ban e-cigarettes outright,” pointing out that the legislation “takes a reasoned approach.”

“It simply says that if a tobacco product is required to have FDA approval to be on the market, it can’t be sold in San Francisco until it receives that approval. ... If their product is actually a benefit to public health, rather than a lure to addict another generation, they have the opportunity to get certified before this legislation takes effect,” he said in the statement.

While physicians await the outcome of the FDA’s regulatory efforts and similar legislation that could be adopted in other cities, Crotty Alexander highlighted the importance of being proactive.

“We want all pediatricians to be asking their patients about e-cigarette use and advising and counseling them about it,” she told Healio Pulmonology. – by Melissa Foster


Cullen KA, et al. MMWR. 2018;doi:10.15585/mmwr.mm6745a5.

Herrera statement on e-cigarette legislation passing. Available at: Accessed June 27, 2019.

San Francisco Board of Supervisors Meeting Minutes. Available at: Accessed June 27, 2019.

For more information:

Laura E. Crotty Alexander, MD, can be reached at; Twitter: @crottyalexander.

Disclosure: Crotty Alexander reports no relevant financial disclosures.