FDA has been holding retailers and manufacturers accountable for marketing and sales practices that have led to increased youth accessibility and appeal of e-cigarettes. These declines resulted in an estimated 1.73 million fewer current youth tobacco product users in 2020 (4.47 million) compared to 2019 (6.20 million).8, Youth who use multiple tobacco products are at higher risk for developing nicotine dependence and might be more likely to continue using tobacco into adulthood.1, 2. 7. Nicotine is a toxic substance. Every day, almost 2,500 children under 18 years of age try their first cigarette, and more than 400 of them will become new, regular daily smokers. CDC twenty four seven. America's teens report a dramatic increase in their use of vaping devices in just a single year, with 37.3 percent of 12th graders reporting "any vaping" in the past 12 months, compared to just 27.8 percent in 2017. U.S. Department of Health and Human Services. We will continue to take vigorous compliance and enforcement actions aimed at ensuring e-cigarettes, and all tobacco products, are not being marketed or sold to youth. Thank you again for the opportunity to testify about FDAs comprehensive efforts to regulate ENDS, including our actions to prevent youth access to, and use of, these products. In 2021, about 11 of every 100 middle school students (11.3%) and about 1 of every 3 high school students (34.0%) said they had ever tried a tobacco product. We know how many deaths a year are caused by smoking, why don't we know how many people die each year from vaping? In addition, the nicotine in smokeless tobacco may increase the risk for sudden death from a condition where the heart does not beat properly (ventricular arrhythmias).5, Cigarette smoking causes about one of every five deaths in the United States each year.1,6Cigarette smoking is estimated to cause the following:1. Nearly one-third of deaths from heart disease are the result of smoking and secondhand smoke. Survey data shows 4.6% of adults currently used e-cigarettes or a similar device in 2017, compared with 4.7% in 2016. But what about the reverse? Congressional Testimony, Recalls, Market Withdrawals and Safety Alerts, An Epidemic Continues: Youth Vaping in America - 06/23/2021, House Committee on Oversight and Reform, Subcommittee on Economic and Consumer Policy, https://www.fda.gov/tobacco-products/market-and-distribute-tobacco-product/deemed-new-tobacco-product-applications-lists, https://www.fda.gov/tobacco-products/market-and-distribute-tobacco-product/tobacco-product-applications-metrics-reporting. E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs. The Agency will continue to work with the Administration to advance these efforts and implement regulatory policy on tobacco that improves the public health. Cigarette smoking causes about one of every five deaths in the United States each year.1,6 Cigarette smoking is estimated to cause the following:1 More than 480,000 deaths annually (including deaths from secondhand smoke) 278,544 deaths annually among men (including deaths from secondhand smoke) If FDA finds subsequent violations at a retail establishment after the issuance of a warning letter, it has the authority to seek a Civil Money Penalty (CMP) in accordance with the schedule published in the Tobacco Control Act. If current tobacco use patterns persist, an estimated 5.6 million of todays youth under age 18 eventually will die prematurely from a smoking-related disease. Vaping is even more common among high school students. Flavorings in tobacco products can make them more appealing to youth. FDA collaborates with the Centers for Disease Control and Prevention (CDC) to administer the National Youth Tobacco Survey (NYTS) to middle and high school students each year. As anticipated, FDA received thousands of tobacco product submissions covering millions of tobacco products, the vast majority of which are for ENDS products. Even nicotine free juice often contains nicotine 30. National Survey on Drug Use and Health, 2014. Smoking and Tobacco Control Monograph No. We will continue to allocate our resources with the goal of working as quickly as possible to transition the current marketplace for deemed products to one in which all new tobacco products available for sale have undergone a careful, science-based review by FDA. Cigarette smoking during childhood and adolescence causes significant health problems among young people, including an increase in the number and severity of respiratory illnesses, decreased physical fitness and potential effects on lung growth and function. This suite of free materials has been distributed to over 1.3 million educators to reach roughly 2.7 million students. This age gap is especially prevalent in Minnesota, where more than 11% of adults between 18 and 24 years old were current users in 2017, compared with the state average among adults of 3.7%. Tobacco Use Among Middle and High School Students United States, 20112015. We will focus resources on products where scientific review will have the greatest public health impact, including with respect to youth use of ENDS products, based on their market share, while also reviewing as many applications as possible from all companies regardless of size, prior to September 9, 2021, at which time they risk FDA enforcement. First, many teens believe vaping is less harmful than smoking. CDC WONDER On-line Database, Natality public-use data 2007-2014, 2016. Among US adults, millennials vape the most. Our service is free and we are here to help you. Regular survey efforts sponsored by the Centers for Disease Control and Prevention through the Behavioral Risk Factor Surveillance System and the Youth Risk Behavior Surveillance System capture trends in health behaviors at the state and national levels. Since 2009, we have enforced applicable laws and regulations and have issued over 1,000 warning letters to sites selling violative products and for online sales of products to kids. On April 29, 2021, FDA announced the Agencys commitment to advance two tobacco product standards to significantly reduce disease and death from cigarettes and cigars. Rates of overall tobacco use remain high, however. Men in the States are more than twice as likely to vape as women. This authority gave FDA comprehensive tools to protect the public from the harmful effects of tobacco use through science-based tobacco product regulation. Young people may be more likely to use tobacco products if a parent uses these products. Thank you for taking the time to confirm your preferences. Cookies used to make website functionality more relevant to you. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. The actions combined will truly benefit the public health and save hundreds of thousands of lives. Centers for Disease Control and Prevention. National Youth Tobacco Survey, 2014. Students who had vaped most commonly reported getting the last e-cigarette they had used from friends (63%), siblings (8%) or parents (7%). Smoking increases the risk of dying from coronary heart disease among middle-aged women by almost five times. Jan. 10, 2020 -- A 15-year-old Texas teen who died from vaping is the youngest victim so far in an outbreak of vaping-related deaths in the United States. Our key findings add to the evidence that a changing climate is making it harder to protect human health. National Center for Health Statistics. Since 2010, FDA has conducted more than 900 inspections of manufacturing establishments, some of which manufacture ENDS products (including e-liquids). . Lyon, (France): World Health Organization, International Agency for Research on Cancer, 2007 [accessed 2015 Aug 17]. During 20102014, almost 282,000 women (56,359 women each year) will die from lung cancer. If cigarette smoking continues at the current rate among youth in this country, 5.6 million of todays Americans younger than 18 will die early from a smoking-related illness. The CDC has identified vitamin E acetate as a chemical of concern among people with EVALI. Since July 2019, there have been over six million-page views regarding how to quit e-cigarette use, manage withdrawal and acquire tips for managing stress and anxiety. The site is secure. The way mass media show tobacco product use as a normal activity can make young people want to try these products. In 2022, about 4 of every 100 middle school students (4.5%) and about 1 of every 6 high school students (16.5%) reported current use of a tobacco product. You can review and change the way we collect information below. Your tax-deductible donation funds lung disease and lung cancer research, new treatments, lung health education, and more. 1 The Health Consequences of Smoking50 Years of Progress: A Report of the Surgeon General, 2014. It is important to keep working to prevent and reduce the use of all forms of tobacco product use among youth. Before inspections were suspended, however, FDA completed thousands of inspections focusing on the priorities identified in the final guidance issued in January 2020. 2014 Surgeon Generals Report: The Health Consequences of Smoking50 Years of Progress, Chapter 12, Table 12.4, The Health Consequences of Smoking50 Years of Progress. In fact, adults between 18 and 24 years old are three times more likely than average to use e-cigarettes or a similar vaping product, and adults between 25 and 34 years old are twice as likely. Can vaping lead to regular cigarette smoking later on? From 2010 to the present, FDAs Center for Tobacco Products (CTP) has funded more than 240 projects addressing ENDS use. The liquid can contain: nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, and other substances, flavorings, and additives. On Thursday, Dallas county health officials said a 15-year-old resident died from a vaping-related illness on New Year's Eve. High school athletes are more likely to use smokeless tobacco than those of the same age who are not athletes. The Tobacco Control Act also authorized FDA to deem other tobacco products (which include any product made or derived from tobacco that is intended for human consumption that is not a drug, device, or combination product under the FD&C Act, including any component, part, or accessory of that product) to be subject to the Agencys regulatory authority in Chapter IX of the FD&C Act. Tobacco product use is started and established primarily during adolescence. E-cigarettes have been the most commonly used tobacco product among youth since 2014. Vaping and e-cigarettes are sometimes promoted as ways to help cigarette smokers quit. We have worked for several years to prepare for premarket review of a large number of deemed products. FDAs final guidance (revised in April 2020) entitled, Enforcement Priorities for Electronic Nicotine Delivery System (ENDS) and Other Deemed Products on the Market Without Premarket Authorization, describes how FDA is prioritizing its enforcement resources with regard to the marketing of certain deemed tobacco products that do not have premarket authorization. There is evidence that youth may be sensitive to nicotine and that teens can feel dependent on nicotine sooner than adults. FDA generally issues a warning letter to a retailer the first time a tobacco retailer compliance check inspection reveals a violation of Federal tobacco law and regulation that FDA enforces. In July 2017, FDA announced a new plan for tobacco and nicotine regulation, and in August 2017, FDA published a compliance policy, which extended the compliance period for premarket review of deemed new tobacco products (that were on the market on August 8, 2016) to August 2022. In 2022, about 1 of every 7 high school students (14.1%) reported that they had used electronic cigarettes in the past 30 days. 2010; 12(Suppl 2):S136S146. In addition, almost 40 percent of high school students using e-cigarettes were using them on 20 or more days out of the month and almost a quarter of them used e-cigarettes every single day, indicating a strong dependence on nicotine among youth. FDA also conducts inspections of manufacturing establishments, which includes inspections of vape shop establishments, many of which mix and/or sell flavored ENDS products. Any flavored, cartridge-based ENDS products (other than tobacco- or menthol-flavored); All other ENDS products for which the manufacturer has failed to take (or is failing to take) adequate measures to prevent underage access; and. These cases appear to predominantly affect people who modify their vaping devices or use black market modified e-liquids. Trends reported by the CDC on the outbreak of lung injuries associated with vaping align with broader survey data. Since no ENDS product is known to have been commercially marketed in the U.S. as of February 15, 2007, all such products are understood to be new tobacco products. Nine months have now passed since that September 2020 deadline and we have received thousands of submissions for millions of new tobacco products. This policy became the subject of litigation and in May 2019, the U.S. District Court for the District of Maryland vacated FDAs August 2017 Compliance Policy. These cookies may also be used for advertising purposes by these third parties. But according to 2019 data from the Monitoring the Future survey, nearly 12% of high school seniors vape nicotine daily defined as vaping on 20 or more of the previous 30 days. and more than a quarter reported doing so within the past 30 days, up from just 11% in 2017. Bethesda (MD): U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 1998. No one. Questions also have swirled over whether e-cigarettes are effective as a smoking-cessation tool, or whether they merely offer another path to nicotine addiction. The same CDC report says disposable e-cigarette use has increased 1,000% among high school students and 400% among middle school students since 2019. All new tobacco products are required to obtain authorization from FDA before they can be legally marketed. There's very little information about him, but it's known that this case was also connected to vaping. Avoid using informal sources, such as friends, family or online dealers to obtain a vaping device. Nicotine is the primary agent in regular cigarettes and e-cigarettes, and it is highly addictive. Its quite another thing to start up nicotine use with vaping. For PMTAs, the review order for most of the products is determined using a computer-generated randomization process. In 1987, lung cancer surpassed breast cancer to become the leading cause of cancer death among U.S. women. Lee YO, Glantz SA. Between 1960 and 1990, deaths from lung cancer among women increased by more than 500%. The use of e-cigarettes spiked by a whopping 78% in 2018. There have been a few injuries due to battery safety issues, etc. In March 2020, FDA announced it would suspend all physical inspections and compliance checks due to health and safety concerns related to the SARS-CoV2 pandemic. In 2014, 10.2% of female teens aged 15 to 19 and 13% of women aged 20 to 24 smoked during pregnancy. California, meanwhile, had the lowest rate of vaping (3%) and the second-lowest rate of tobacco smokers (11.3%). In 2022, nearly 1 of every 100 middle school students (0.6%) reported that they had smoked cigars in the past 30 days. Cases and Deaths The Centers for Disease Control and Prevention and state agencies have reported 2,602. Because no one has ever died from causes attributable to vaping. FDA continues to remind retailers that they should discuss with their suppliers the current status of any particular tobacco products application and marketing authorization. Your Health is a FREE e-newsletter that serves as your smart, simple connection to the world-class expertise of Johns Hopkins. November 5, 2005; 116(5):1183-91. Nearly 41 million adults in the U.S. use combusted tobacco products, including cigarettes and cigars. In 2015, 2.3% of middle school students smoked cigarettes in the last 30 days. Putting the Pieces Together. In addition, FDA and the American Academy of Pediatrics (AAP) recently developed video interviews with pediatricians talking about the dangers of youth ENDS use. One-quarter of American high schoolers use tobacco products and one in five have used e-cigarettes (colloquially called vaping) in the last month a fourfold increase from 2013, according to CDC data. Menthol cigarette use is more common among younger and newer teen smokers. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Ensuring new tobacco products undergo a robust premarket evaluation by FDA is a critical part of our mission to protect the public health, particularly youth, and to reduce tobacco-related disease and death. Cases and Deaths The Centers for Disease Control and Prevention and state agencies have reported 2,506 lung injury cases. Accessed on June 9, 2008. The PATH Study may help identify and explain differences in use patterns (e.g., switching, dual use, polyuse), risk perceptions, and attitudes related to e-cigarettes. FDA continues taking appropriate actions that are guided by health and safety considerations and as outlined by the Agencys priorities. Do not use THC-containing e-cigarettes or vaping products. Emerging data suggestslinks to chronic lung disease and asthma, as well as associations between dual use of e-cigarettes and smoking withcardiovascular disease. T he Centers for Disease Control and Prevention (CDC) announced on Jan. 16 that, as of Jan. 14, the number of people who have died from a vaping-related illness has increased to 60, and. U.S. Cancer Statistics Data Visualizations Tool Thats about 1 of every 13 Americans aged 17 years or younger who are alive today.1. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. An estimated 28% of high school students and 11% of middle school students said they'd used e-cigarettes within the past month, according to a report based on a national survey conducted earlier . Currently, the CTP research portfolio includes more than 145 active research e-cigarette projects using a variety of research models (e.g., in vitro, animal models, human use studies). One study found that teens exposed to the greatest amount of smoking in movies were 2.6 times more likely to start smoking themselves compared with teens who watched the least amount of smoking in movies. [accessed 2015 Aug 17]. Learn about the American Lung Associations programs to help you or a loved one quit smoking, and join our advocacy efforts to reduce tobacco use and exposure to secondhand smoke. By identifying and ensuring review of these applications, we believe we can achieve the greatest public health impact most quickly. In 2019 9% of US 13-14 year olds had vaped nicotine; in 2017 it was only 3.5% 4. Among adults in 2017, men were more likely than women to use e-cigarettes or a similar device in all but one state: Tennessee. This is true for both men and women. CTP also supports two other national surveys in collaboration with CDC. That means overall tobacco use on the rise too. Opioid misuse at record lows with marijuana use remaining stable. but no deaths.. stols001, Eskie and Rossum Reply Report L LMP Senior Member ECF Veteran On May 20, 2021, FDA posted a list of deemed new tobacco products for which a PMTA was submitted by September 9, 2020.6 The list includes over 6 million products. According to the estimates of the IHME about 13% of deaths worldwide was the result of direct smoking in 2017; a further 2% was the result of secondhand smoke. Which States Vape, Use E-Cigarettes the Most? Prior to temporarily halting inspection activities due to the SARS-CoV2 pandemic, and then including the time period from October 2020 May 2021 when inspections resumed, FDA conducted inspections of over 170 tobacco manufacturing establishments and over 550 vape shops and conducted investigations involving thousands of websites. That's about 1 of every 13 Americans aged 17 years or younger who are alive today. Morbidity and Mortality Weekly Report. Surgeon General. Visit Lung.org or call the Lung HelpLine at 1-800-LUNGUSA (1-800-586-4872). In addition, in January 2021, FDA issued the first set of warning letters to firms that had not submitted premarket applications to FDA by September 9, 2020 and are continuing to market unauthorized ENDS after that deadline. Over time, increased exposure to the campaign is expected to increase population-level shifts in youth beliefs about e-cigarettes. Sales of nicotine pouches have increased rapidly in the U.S. 2011; 20(Supp 2):ii12ii19. Ever. You can review and change the way we collect information below. These include: In addition, under the deeming rule, the following regulatory provisions also apply to deemed tobacco products, including ENDS products: Following publication of the final deeming rule, FDA announced an enforcement policy with staggered timeframes. About Electronic Cigarettes (E-Cigarettes), Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults, Menthol Tobacco Products are a Public Health Problem, Menthol Smoking and Related Health Disparities, Unfair and Unjust Practices and Conditions, Asian, Native Hawaiian, and Pacific Islander People, Commercial Tobacco Product Use and Behavioral Health Conditions can Affect Each Other, Surgeon General's Reports on Smoking and Tobacco Use, 2016 SGRE-Cigarette Use Among Youth and Young Adults, Alaska Native Adult Tobacco Survey Guidance Manual, Morbidity and Mortality Weekly Reports (MMWR), Patient Care Settings and Smoking Cessation, Clinical Interventions to Treat Tobacco Use and Dependence Among Adults, Quitlines and Other Cessation Support Resources, Promising Policies And Practices To Address Tobacco Use By Persons With Mental And Substance Use Disorders, Tobacco Ingredient and Nicotine Reporting, U.S. Department of Health & Human Services. The American Lung Association is a 501(c)(3) charitable organization. *Current use is determined by respondents indicating that they have used a tobacco product on at least 1 day during the past 30 days. From its launch in February 2014 to November 2016, The Real Cost campaign, FDAs first public education cigarette prevention effort, prevented up to 587,000 youth ages 11 to 19 from initiating smoking, and over time those prevention efforts will save more than $53 billion in smoking-related costs for youth, their families, and society at largea cost savings of $180 for every dollar of the nearly $250 million invested. 35,825 will die of heart disease. The product would undergo FDA scientific review and need to meet the applicable statutory standard for marketing. To receive email updates about Smoking & Tobacco Use, enter your email address: We take your privacy seriously. I appreciate the opportunity to be here today to provide background on FDAs regulation of e-cigarettes and our efforts to prevent youth initiation and address this important public health issue. The Agency made the list available to the public to be transparent and increase stakeholder knowledge of these products; however, the list is only one source of information. Another effort the University of Michigan's Monitoring the Future survey, funded by the National Institute on Drug Abuse offers a more recent look at the issue among adolescent students. For the second day in a row, China is dismissing U.S. suggestions that the COVID-19 pandemic may have been triggered by a virus that leaked from a Chinese laboratory, Britains former health minister is denying wrongdoing after a newspaper published extracts of private messages he sent in the first weeks of the coronavirus pandemic. Vaping: From Safer Than Cigarettes to Public Health Crisis. Talk to your doctor about which smoking cessation program or tools would be best for you. National Youth Tobacco Survey. Our Tax ID is: 131632524. Prevalence of Tobacco Use among Children and Teenagers. In 2022, about 1 of every 100 high school students (1.5%) reported that they had smoked hookah in the past 30 days. Vitamin E acetate is a thickening agent often used in THC vaping products, and it was found in all lung fluid samples of EVALI patients examined by the CDC. 2016. All states last addressed the topics in BRFSS survey data for that year as well. Nearly 7 of 10 smokers say they want to stop. In 2015, 9.3% of high school students reported smoking cigarettes in the last 30 days, down 74% from 36.4% in 1997 when rates peaked after increasing throughout the first half of the 1990s. The PATH Study is a national, longitudinal cohort study of almost 46,000 youth and adults in the United States that collected its first wave of data in 2013 and follows study participants over time to learn how and why people start using tobacco products, switch tobacco products, use multiple tobacco products, quit using them, and start using them again after they have quit, as well as how different tobacco products affect health (such as cardiovascular and respiratory health) over time. Youth are more likely to use tobacco products if they see people their age using these products. Given the inherent toxicity of combusted tobacco products, decreasing their appeal will maximize the potential public health benefits of these regulatory actions. FDAs action was challenged and ultimately, the U.S. Court of Appeals for the D.C. Although theyve been promoted as an aid to help you quit smoking, e-cigarettes have not received Food and Drug Administration approval as smoking cessation devices. Secondhand smoke causes 7,333 annual deaths from, Secondhand smoke causes 33,951 annual deaths from. Targeting over 10 million teens who have used e-cigarettes or are susceptible to its use, FDA launched The Real Cost Youth E-Cigarette Prevention Campaign8a full-scale mass media effort in 2018, urging teens to know the real cost of vaping by highlighting the potential addiction and health risks. Find more COVID-19 testing locations on Maryland.gov. The continued marketing of these widely-used products has the potential to have the greatest public health impacteither positively or negativelyas they hold the largest overall market share and therefore are likely used by the largest number of people. Life expectancy for smokers is at least 10 years shorter than for nonsmokers. Im keeping a close eye on that.. The NYTS provides important data on current youth tobacco product use. At Another Johns Hopkins Member Hospital: Will Vaping Lead Teens to Smoking Cigarettes? National survey data sheds light on the epidemic of youth e-cigarette use and more. Second, e-cigarettes have a lower per-use cost than traditional cigarettes. A look at 373 reported cases found that nearly three-quarters of the cases were in males. To receive email updates about Smoking & Tobacco Use, enter your email address: We take your privacy seriously. It causes you to crave a smoke and suffer withdrawal symptoms if you ignore the craving. According to the 2021 National Youth Tobacco Survey, more than 2 million U.S. middle and high school students reported using e-cigarettes in 2021, with more than 8 in 10 of those youth using flavored e-cigarettes. As the Subcommittee considers the issues related to e-cigarette use today, it is important to remember that as of yet, no ENDS product in the United States is on the market legally. Vaping and E-Cigarettes: A New Public Health Problem, Iran's President Orders Probe of Poisoning at Girls' Schools, Cambodia Says Recent Bird Flu Cases Not Spread by Humans, China Dismisses FBI Statement on COVID-19 Lab Leak Theory, Ex-UK Health Chief Defends Record After COVID Messages Leak. Centers for Disease Control and Prevention. In 2021 7% of UK 11 - 15 year olds had vaped and 30% of 18 years old had vaped; in 2013 only 5% of 11-18 year olds had vaped 17. 2023 American Lung Association. As a result, FDA anticipated that many ENDS products would remain on the market without premarket authorization for up to three years. 2011; 20(Suppl 2):ii1ii7. In February 2020, the Centers for Disease Control and Prevention (CDC) confirmed 2,807 cases of e-cigarette or vaping use-associated lung injury (EVALI) and 68 deaths attributed to that condition. Learn more about trends in tobacco use among youth. They help us to know which pages are the most and least popular and see how visitors move around the site. Join over 700,000 people who receive the latest news about lung health, including COVID-19, research, air quality, inspiring stories and resources. Kentucky, for example, had the second-highest rate of both adults who vape (6.1%) and tobacco smokers (24.6%) in 2017. With no smell, e-cigarettes reduce some of the stigma of smoking. Quitting smoking is one of the best things you can do for your health smoking harms nearly every organ in your body, including your heart. Protecting our nations youth from the dangers of tobacco products is among the Agencys most important responsibilities, and we are taking aggressive steps to make sure tobacco products are not being marketed or sold to kids. FDA will continue to support and fund research to evaluate the health impacts of ENDS, both at the individual and population levels. KILO ELIQUIDS How Many People Die From Vaping Each Year. Nicotine pouches are microfiber pouches with flavored nicotine powder that users dissolve in the mouth without spitting. Kentucky, for example, had the second-highest rate of both adults who vape (6.1%) and tobacco smokers. https://www.fda.gov/tobacco-products/real-cost-campaign. Prevent and reduce the use of all forms of tobacco use among youth popular and see how move!: a Report of the products is determined using a computer-generated randomization process status of any particular tobacco can. Market modified e-liquids using these products so within the past 30 days nicotine.. We have worked for several years to prepare for premarket review of a large number of deemed.! Count visits and traffic sources so we can achieve the greatest public health of... Or call the lung HelpLine at 1-800-LUNGUSA ( 1-800-586-4872 ) survey on Drug use and more nearly one-third deaths. Primary agent in regular cigarettes and cigars aged 17 years or younger who are alive.! 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