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Op-Ed: Let’s call this youth vaping crisis what it is: A Juuling epidemic

Almost daily, educators across the country tell me that at least half of their students use e-cigarettes, mainly the Juul brand. Many of these young people show clear signs of addiction. They are agitated, emotional and unable to sit through an entire class period. They often need to leave class to “take a puff.”

National data about the pervasiveness of e-cigarettes show that it increased nearly 80% among high school students from 2017 to 2018. One in 5 report currently vaping.

But the vaping habit can start even earlier. Use among middle school students increased by almost 50% over the same time period, with 1 in 20 students reporting they had recently vaped.

Given that Juul Labs control about 70% of the e-cigarette market, allow me to borrow slang popular with teens and call this youth crisis what it is: A Juuling epidemic.

Vaping proponents would have you believe that e-cigarette use among youth is responsible for fewer of them smoking traditional cigarettes. This is simply not the case.

Statistics show significant declines in conventional cigarette use among youth from 1996 to 2016. But e-cigarettes weren’t sold in the U.S. until 2007, and Juul entered the U.S. market in 2015 as part of another company before becoming independent in 2017. The dramatic increase in youth vaping began that same year.

The e-cigarette industry has created this vaping epidemic among the young. It actively markets dangerous nicotine delivery devices to adolescents while trying to confuse the reality surrounding the use of these nicotine products.

The increase in e-cigarette use among young people has also been largely attributed to the youth-oriented flavors, misperceptions about nicotine levels and risk, and the patented and unique salt-based nicotine.

E-cigarettes are the entry point for adolescent tobacco use. The overwhelming majority of youth who use e-cigarettes have never smoked conventional cigarettes or used other forms of tobacco. As their need for nicotine increases, they are likely to incorporate conventional cigarettes into their routine.

Nicotine is highly addictive. Each Juul pod, which contains the nicotine liquid that is aerosolized and inhaled, has the same amount of nicotine as is found in one to two packs of cigarettes. And the changes occurring in the still-developing brains of youth make them especially susceptible to addiction.

Research also shows that the chemicals found in e-cigarettes and the flavors used in them are harmful and can result in heart and lung disease and be poisonous, among other health consequences. The products are so new the long-term consequences are unknown, a fact the CEO of Juul labs has admitted.

Vaping proponents also argue that the flavors in e-cigarettes play a role in helping adults switch from traditional cigarettes to e-cigarettes. However, studies have repeatedly shown that young people use e-cigarettes because of the flavors. If flavors didn’t exist, they say they wouldn’t vape.

Many of the more than 15,000 unique e-cigarette flavors have silly names, such as Honey Doo Doo, Booger Sugar and Barney Pebbles. Names that aren’t exactly aimed at an adult audience. Kids are also attracted to the mint and menthol flavors, long thought to be the purview of adults.

Cities and localities in California and at least five other states have restricted the sale of flavored tobacco products. In addition, the Food and Drug Administration and states including California and Hawaii have proposed statewide regulation to eliminate the sale of flavored cigars and flavored tobacco used in e-cigarettes and for hookah smoking. Unfortunately, mint and menthol are often exempted from these policies.

Juul continues to argue that its products are aimed at helping adults quit smoking. If executives at Juul, or any other e-cigarette company, truly viewed their products as “tobacco cessation aids,” they would try to help the user withdraw from nicotine by offering pods with increasingly lower nicotine levels, which could help them taper off use. No such products are offered. They also would apply to the FDA to obtain authorization to sell their products as a cessation device, rather than as a tobacco product. No such action has occurred.

Juul also claims that it is not targeting youth, but its actions say otherwise. During last month’s congressional hearings on Juul’s role in the youth vaping and nicotine epidemic, the company’s “prevention and education efforts” were shown to be an attempt to mislead and encourage youth to use its products.

Another concern is Juul’s recent hiring of Dr. Mark Rubinstein, an adolescent-medicine physician and prominent nicotine researcher I trained in tobacco control research. Rubinstein is known for his work on the dangers nicotine poses to the adolescent brain. Juul publicly says it hired Rubinstein to enhance its youth-vaping prevention efforts.

But given Juul’s history of deceptive marketing practices and educational efforts that promote rather than deter use, many in the research community are skeptical. Rubinstein, a specialist on the effects of nicotine in adolescents, is now working in an industry he recently took to task. His joining Juul is very surprising, disappointing and troubling.

E-cigarette companies seem to be following in the dishonest path of traditional cigarette companies by employing marketing that doesn’t accurately reflect the harm vaping can do. (Just last week, the FDA announced it was investigating 127 reports of seizures or other neurological symptoms possibly related to using e-cigarettes.)

The youth e-cigarette movement needs to be stopped. Doing so will require a complicated multistep process that should start with the FDA, states and local agencies enforcing strict policies that cut back on nicotine levels allowed in vaping pods, eliminate the sale of all e-cigarette flavors and ban marketing to youth.

Bonnie Halpern-Felsher is a professor of pediatrics at Stanford University and founder and executive director of the Tobacco Prevention Toolkit, an online curriculum that educates youth about tobacco products.

Tobacco‐21 laws reducing youth and young adult smoking

Parts of the United States that raised the legal age to buy tobacco from 18 to 21 have seen significant reductions in cigarette smoking among young adults.

Compared to other regions, those with tobacco-21 laws had a 39% decline in regular smoking among 18- to 20-year-olds who had previously experimented with cigarettes, a new study found.

In that age group, the reduction was even larger (50%) among those whose close friends smoked at age 16, according to the study published recently in the journal Addiction.

“This research indicates that a ‘social multiplier’ effect may amplify the impact of tobacco-21 laws,” said lead author Abigail Friedman, an assistant professor at the Yale School of Public Health in New Haven, Conn.

“As peer smoking is a critical predictor of youth smoking, this study suggests that tobacco-21 laws may help reduce smoking among those most susceptible to tobacco use,” she said in a Society for the Study of Addiction news release. “This result supports raising the age of sale to 21 as a means to reduce young adult smoking and improve public health.”

As of June, 16 states and more than 400 localities had adopted tobacco-21 laws.

Majority of Americans Support Tobacco 21 Legislation

Efforts to raise the legal minimum age to buy tobacco products are right in line with the opinion of many Americans.

According to recent Gallup poll, 73 percent of Americans said the minimum age to buy tobacco products should be raised to 21.

Support for Tobacco 21 efforts was strongest among adults 65 and older, though majorities of other age groups also support the policy change. Support is slightly lower among those aged 18 to 29; however, even within this demographic, two in three support the increase.

In addition, 76 percent women and 69 percent of men support hiking the minimum age to 21.

Nearly three quarters of nonsmokers support this change in age restrictions, while a smaller majority of 64 percent of current smokers agree, the poll found.

Gallup’s Tobacco 21 results
Looking at other tobacco-related issues, the same poll found that approximately six in 10 Americans support banning smoking in all public places, by three percentage points — the highest since Gallup first asked about this in 2011.

Much less popular is a proposal to ban smoking entirely in the United States. Strong majorities of Americans have opposed this idea in all polls since Gallup first polled on it in 1990. Though still unpopular, an outright national smoking ban has garnered more support on average since 2010 than before, with a high of 25 percent favoring it in 2018.

E-CIGARETTE RESTRICTIONS
Gallup also looked at regulatory moves around electronic cigarettes and found that nearly two-thirds of Americans say laws and regulations covering e-cigarettes should be made more strict, while 26 percent say the regulations should be kept as they are now. Only 5 percent say these laws and regulations should be less strict.

Digging deeper, support for stricter regulations was highest with women (71 percent) and Americans 65 and older (75 percent) — although majorities of most groups lean toward toughening regulations on e-cigarettes.

According to Gallup, the main exception is young adults. Among those 18 to 29, 49 percent say laws and regulations should be stricter and 42 percent say they should be kept as they are.

The data is from a July 1-12 Gallup poll.

Gallup poll results on electronic cigarette restrictions

FDA investigating 127 reports of seizures, neurological symptoms related to vaping

The US Food and Drug Administration has received 127 reports of seizures or other neurological symptoms possibly related to e-cigarettes, the agency announced Wednesday. Investigators have yet to determine, however, whether vaping was directly linked to the cases.

“The FDA is continuing its scientific investigation to determine if there’s a direct relationship between the use of e-cigarettes and a risk of seizure or other neurological symptoms,” said Dr. Ned Sharpless, the acting FDA commissioner.

The FDA said the reported cases occurred between 2010 and 2019, and in addition to seizures, some people reported fainting or tremors. Sharpless said that “we still don’t have enough information to determine if e-cigarettes are causing these reported incidents” but called on the public to continue submitting reports.
Additional information “may help us identify common risk factors and determine whether any specific e-cigarette product attributes, such as nicotine content or formulation, may be more likely to contribute to seizures,” he said.

In April, the FDA announced that it had received 35 reports of seizures related to vaping, particularly among younger users. “Seizures or convulsions are known potential side effects of nicotine toxicity,” the agency said at the time.

There have been 92 new reports since then, but the FDA didn’t announce any clear pattern across the cases.
Cases were reported in both first-time and experienced e-cigarette users, and “seizures have been reported as occurring after a few puffs or up to one day after use,” the FDA said in April. Several people had previously had a seizure diagnosis, the agency said at the time, and a few had also been using other drugs such as marijuana.

“Additional reports or more detailed information about these incidents are vital to help inform our analysis,” Sharpless said Wednesday. Cases can be reported to the FDA online, the agency said, and submissions are most helpful when they specify the product involved and any underlying medical conditions.

“It is imperative that health care professionals, consumers, parents, teachers and other concerned adults, as well as youth and young adult users, report detailed information about any past or future incidents of seizures following e-cigarette use to the FDA,” Sharpless said.

“We’re committed to monitoring this issue closely and taking additional steps as necessary to protect the public, especially our nation’s youth, from the dangers of e-cigarettes and other tobacco products,” he added.

Embattled Juul seeks allies in Washington

Juul Labs is spending big on campaign donations and a massive lobbying blitz as the e-cigarette maker faces growing threats from lawmakers and regulators, and with few allies in Washington.

The company spent $1.95 million on lobbying in the first two quarters of 2019, surpassing its 2018 total of $1.64 million. And Juul’s PAC has given nearly $100,000 to lawmakers this year, a pace that will blow past the $225,000 the company spent in the entire 2018 cycle.

Those moves have rattled Juul’s critics, who fear the efforts could slow momentum to combat teen vaping, and question if the company is serious about addressing the problem.

“Juul’s increased spending on lobbying and political donations is the latest example that the company says one thing and does another,” said Vince Willmore, vice president of communications at the Campaign for Tobacco-Free Kids.

“Juul claims it doesn’t want kids to use its products, yet it is doing everything it can to fight strong policies to prevent youth use, such as effective FDA regulation and prohibitions on flavored e-cigarettes,” he added.

Juul insists it is working with policymakers to reduce teen vaping.

“We have grown our team to engage with lawmakers, regulators, public health officials and advocates to drive awareness that JUUL exists to help adult smokers switch from combustible cigarettes and is committed to keeping JUUL products out of the hands of underage people,” Juul spokesperson Ted Kwong told The Hill in a statement. “That is why we have taken the most aggressive actions of anyone in the industry to combat youth usage.”

But influence world watchers expect the lobbying work to also intensify amid scrutiny from both the Food and Drug Administration (FDA) and House Democrats, who say Juul targeted its products to teenagers, leading to a spike in youth vaping.

“I would be surprised if they weren’t ramping up even more,” said David Williams, president of the Taxpayers Protection Alliance, a nonprofit group. “I think you’re going to see a lot more questions about their products that they’re going to have to answer from Republicans and Democrats. This is probably just the beginning for Juul.”

Juul is facing scrutiny over its marketing practices on multiple fronts.

At hearings last month, House lawmakers accused the company of deliberately targeting teenagers. At the state level, the attorneys general of Connecticut and Massachusetts are investigating the company and Juul faces a lawsuit from North Carolina alleging it marketed its products to young people. The FDA is also weighing tougher rules on e-cigarette sales.

Juul says it is trying to lower youth vaping, including by stopping the retail sale of some products critics say appeal to young people, shutting down their Facebook and Instagram accounts and beefing up online age verification. The company also backs legislation to raise the smoking age to 21.

But those efforts haven’t stopped Juul from also seeking help in Washington.

Its PAC has donated $74,000 to Democrats and $22,500 to Republicans so far in 2019, according to Federal Election Commission figures.

Rep. Cedric Richmond (D-La.) was the top recipient with $7,500. Democratic Sens. Kyrsten Sinema (Ariz.) and Jeanne Shaheen (N.H.) received $5,000, with the Congressional Black Caucus (CBC) and the Congressional Hispanic Caucus’ political action committees receiving the same, The Associated Press reported.

The wooing of minority Democratic lawmakers has rankled some anti-tobacco advocates.

“Going after at-risk communities is core to [tobacco companies’] business plan and has been for a long time,” said Stanton Glantz, director of the Center for Tobacco Control Research and Education.

“The CBC has grave concerns about the staggering rise in youth vaping, especially its impact on Black youth,” Gabrielle Brown, CBC spokeswoman, told The Hill in response. “Several of our members … have been very aggressive in providing the needed oversight to better understand the business practices of companies like JUUL.”

Juul’s in-house team has also brought on former aides as lobbyists and consultants, including Benjamin Branch, former senior policy adviser to Rep. Gregory Meeks (D-N.Y.), currently the chairman of the House Financial Services Subcommittee on Consumer Protection and Financial Institutions, and Ted McCann, a former assistant to ex-Speaker Paul Ryan (R-Wis.).

And the company has turned to prominent K Street firms, including KDCR Partners, which has a $180,000 lobbying contract, and S-3 Group with a $160,000 contract. The S-3 team includes Mike Ference, former senior policy adviser to ex-House Majority Leader Eric Cantor (R-Va.) and Matthew Bravo, former director of floor operations for House Majority Whip Steve Scalise (R-La.). Last week, Juul added the Nickles Group to their lobbying team, including former Sen. Don Nickles (R-Okla.).

Bruce Mehlman, a partner at Mehlman Castagnetti Rosen & Thomas, said it was no surprise Juul was “in need of significant government relations” help.

“When an industry is threatened, a lot of money is poured into lobbying,” said Beth Leech, director of graduate studies at Rutgers University’s Department of Political Science.

All of those resources are being put to the test.

“It’s self-preservation for them,” Williams said.

The company is pushing ahead, announcing new plans this week for a product that would monitor users’ vaping and include facial recognition technology to prevent youth smoking. But that could also bring the company new regulatory questions.

Juul insists it is working with regulators. CEO Kevin Burns wrote an op-ed in March highlighting the company’s actions to limit e-cigarette sales to young people. He also called for regulators to help crack down on other e-cigarette products he said could be less safe.

“We also need government agencies to take their own actions against counterfeit, knockoff and other illegal vapor products, which are often made with unknown ingredients, with unknown quality standards, and with youth-appealing flavors and packaging,” he wrote.

The company’s critics, though, are skeptical as Juul devotes more resources to its lobbying campaign, which is likely to fuel the fight.

“The tobacco companies, which include Juul, have a long history of using campaign contributions and fancy lobbyists to deter effective public health measures,” Glantz said.

Critics are vowing to keep pressure on the company.

“Policymakers shouldn’t be fooled and must hold Juul accountable,” said Willmore.