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E-cigarette sales still strong even without flavored products: Study

Before COVID-19 was dominating headlines, many Americans were concerned about another deadly epidemic: vaping.

It’s been linked to more than 2,800 hospitalizations and deaths, though health officials haven’t linked any specific substance or products to the illnesses, and no single product has been associated with all of the cases.

E-cigarette sales in the United States steadily rose from 2016 to 2018, with youth-friendly, candy- and fruit-flavored products that critics say targeted teens fueling most of that growth. Facing mounting criticism as reports of vaping-associated lung disease rose, the popular vaping brand JUUL ended in-store sales of fruit- and candy-flavored products in November 2018.

But, according to a new study, those actions have had little effect. Sales of e-cigarettes remain strong even after the measures taken to curb purchases of youth-friendly products, raising questions about federal regulations and how to best protect American youth from harming themselves by vaping.

After companies stepped in to self-regulate, e-cigarette sales dropped for about two months but quickly rebounded, soon exceeding previous highs, according to the study by the American Cancer Society published in the American Journal of Public Health.

The study’s authors said the data show a glaring shortcoming in allowing e-cigarette companies largely to self-regulate in lieu of coordinated federal regulations. In December, more than a year after JUUL stopped selling fruit- and candy-flavored products, Congress did ban the sale of all tobacco and e-cigarettes to anyone younger than 21.

A spokesperson for JUUL told ABC News that the company is working closely with regulators, attorneys, public health officials and other stakeholders to combat underage use of its products and “will continue to reset the vapor category in the U.S. and seek to earn the trust of society.” Juul has also long maintained its products are intended for adults looking to switch from combustible cigarettes.

The Food and Drug Administration, which regulates tobacco products, said it was reviewing the findings of the recent study, which will be evaluated as part of a larger body of evidence.

The study, based on sales figures from the market research firm Nielsen, only collected data from brick-and-mortar retailers and may not show the whole picture. Online sales of vaping products could be much higher, especially among younger buyers, according to experts.

“The trends being reported in this paper are likely to be an underestimate of the total volume of sales across the country,” said Dr. Andy Tan, a public health researcher at Dana-Farber Cancer Institute.

The study didn’t track purchases by individual customers and wasn’t broken down into age groups. Nevertheless, the data offers a “snapshot” of e-cigarette sales over time in certain stores and suggests vaping continues to be popular despite the voluntary removal of fruit- and candy-flavored products by e-cigarette companies, Tan noted.

Outside surveys have corroborated the idea that many middle school and high school students simply switched to mint, menthol and tobacco flavors. Believing that the removal of a few flavors of a highly successful product would make a significant dent in usage is “highly naive,” Tan added, “because these products are highly addictive.”

Alex Liber, one of the study’s lead scientists, added: “JUUL was able to transition sales of other flavors easily by simply swapping which flavors were being displayed in stores.”

JUUL’s sales also likely got a boost, Liber added, thanks to new part-owner Altria, a massive distributor of tobacco products that also owns Philip Morris USA, the producer of Marlboro cigarettes.

From 2016 to 2019, according to a National Youth Tobacco survey, flavor preferences among high school students shifted, with those vaping menthol or mint flavors increasing to 57% from 16%.

Ultimately, the researchers concluded that JUUL’s self-regulation was insufficient to curb the use of these products, although it’s too soon to determine how big of an impact changing the legal purchasing age to 21 may have.

“Business acts to serve its own interests,” Liber said, “while well-constructed government regulation can serve the public interest.”

Heather J. Kagan, M.D., an internal medicine resident physician at The Johns Hopkins Hospital, is a contributor to the ABC News Medical Unit. Sony Salzman is the unit’s coordinating producer.

Are Smokers or Vapers More at Risk for COVID-19? Here’s What We know

Investigating the potential danger to those who use tobacco products or e-cigarettes calls for a look at the lungs

Pandemics seem to have a way of reminding us about things we might normally take for granted: The feel of a hug or handshake. The number of times we touch our faces or wash our hands each day. Even our intake of breath—and what it might feel like if COVID-19 blocked our ability to breathe as effortlessly as we normally do.

This is a moment in history that has many of us thinking more about our lungs than we ever have before.

Lungs do amazing things invisibly. They contain an array of around 1,200 miles of capillaries and 300 million tiny sacs. When we breathe, our heart circulates blood past those tiny gas exchangers to fuel every cell in the body.

As the SARS-CoV-2 pathogen spreads across the world, researchers are racing to figure out how this new viral foe steals that ability from us. Part of the work involves finding preexisting health factors that might allow the disease it causes to change from a bad—but beatable—respiratory bug to a deadly threat.

Early pathological studies from the pandemic have revealed some risk factors for the most severe forms of COVID-19. Among the most important: being older and having a chronic underlying illness.

Smoking and vaping are also being actively investigated as risk factors. A wealth of research already suggests that smoking suppresses immune function in the lungs. It is also known to increase the risk  of influenza. And while there are very little data on e-cigarette use and infectious disease risk, the recent outbreak of deadly vaping-related lung illnesses sensitized both the scientific world and the public to the potential harms associated with that practice.

In this video by Scientific American’s reporting partner Retro Report, we see that while COVID-19 is brand-new, the scientific approach to treating people who get it cannot rely on understanding SARS-CoV-2 in isolation alone. Treatment must also take into account the unique history and susceptibility of each patient’s airway. Doing so means understanding, and factoring in, personal habits, including smoking and vaping.

The younger kids are when they start smoking, the more likely they’ll still be smoking in middle age, says U of M study

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Children and teens who smoke — even if they have tried it only a few times — are more likely to be smoking daily during their 20s and less likely to have quit smoking by their 40s, according to a University of Minnesota study published Wednesday in the Journal of the American Heart Association.

Furthermore, the younger children are when they begin experimenting with cigarettes or the more often they smoke, the greater their chance of becoming full-fledge smokers during adulthood.

Children who first try smoking around the ages of 14 and 15 are, for example, six times more likely to be smoking in their 20s than those who puff on their first cigarette at age 18 or 19, the study found.

“We really should be doing everything we can to keep cigarettes out of the hands of children,” said David Jacobs, the study’s senior author and an epidemiologist at the U of M, in a phone interview with MinnPost.

“You have to keep never smoking until you are of age in order to have the real minimal risk of never becoming an adult smoker,” he added.

Although the prevalence of smoking has dropped dramatically among American teens in recent years — from 40 percent of 12 graders in 1995 to about 10 percent in 2018 — a still significant number of young people smoke. Each day, some 1,600 children and teens light up their first cigarette, according to the Centers for Disease Control and Prevention. And the number of young people using electronic cigarettes has risen rapidly recently — from 3.6 million in 2018 to 5.4 million in 2019.

Those discouraging figures formed the impetus behind legislation passed late last year by Congress and signed into law by President Trump that increased the minimum age for the sale of tobacco products from 18 to 21.

The current study isn’t the first, of course, to report that smoking during childhood raises the risk of continuing the habit during adulthood. In the United States, for example, it’s long been known that 9 in 10 adult smokers began smoking when they were kids. This study is the first, however, to follow the smoking habits of people from childhood into midlife. Most other studies have not been prospective, but have, instead, asked people to look back and recall when they started smoking. Such recollections can be inaccurate.

How the study was done

For the study, Jacobs and his co-authors analyzed smoking information on more than 6,600 people from the United States, Australia and Finland who were followed from childhood into midlife as part of the International Childhood Cardiovascular Cohort Consortium. The researchers looked specifically at smoking data collected at three points in the participants’ lives: when they were 6 to 19 years old (in the 1970s and 1980s), when they were in their 20s, and then again when they were in their 40s.

The analysis revealed that the age at which someone began smoking during childhood made a significant difference in whether they continued to smoke into their adulthood. Half of those who first tried smoking by age 14 were smoking daily in their 20s, compared to 33 percent for those who first tried at age 15 to 17 and 8 percent of those who first tried at 18 to 19.

Very few — 2.6 percent — of the participants began smoking when they were out of their teens.

“There’s a very small probability that you will become an adult smoker if you don’t start by adolescence,” said Jacobs.

The analysis also found that the intensity with which young people smoked — how often they lit up a cigarette — also predicted whether they became daily smokers in adulthood. For example, 86 percent of the participants who smoked daily between the ages of 15 and17 went on to do the same in their twenties, and 59 percent were still smoking daily in their 40s. By comparison, 49 percent of the participants who were regular, but non-daily, smokers between the ages of 15 and 17 went on to become daily smokers in their 20s, and 29 percent of them were still smoking daily in their 40s.

Yet, even children who only dabbled in smoking — puffing on a few cigarettes here and there — were at risk of becoming adult smokers. And the younger they were when they started such experimenting, the greater the risk. For example, 45 percent of the 13- to 14-year-old “triers” became daily smokers by young adulthood compared to 9 percent of 18- to 19-year-old ones.

“We’ve known for a long time that it’s much harder for a heavy smoker to quit smoking than for a light smoker,” said Jacobs.

“It’s very interesting that the intensity of the adolescent smoking is still visible in the quit rates during the 40s,” he added.

Limitations and implications

The study comes with several caveats. For example, the questionnaires used for the various groups of participants did not solicit uniform sets of information about childhood smoking, a factor that may have affected the findings. Also, young people, particularly young children, can have difficulty filling out questionnaires and therefore may not have provided accurate information about their early smoking behaviors.

In addition, the study did not consider smoking products other than cigarettes — most notably, electronic cigarettes. Jacobs believes, however, that when such research is done, the results are likely to be similar to those of the current study.

As Jacobs and his colleagues emphasize in their paper, their findings underscore the need to discourage young people from using any tobacco products, including banning the sale of such products to anyone under the age of 21.

“We really should do everything we can to keep them out of the hands of children, said Jacobs.

“If you have any influence with your child, the best thing you can do is give strong advice to not smoke,” he added.


For more information:  The study, which was funded in part by the National Heart, Lung, and Blood Institute, can be read in full on the Journal of the American Heart Association’s website.


Letter: Defending vaping puts kids’ health at risk

Posted Mar 17, 2020 at 4:11 AM


Recently The Dispatch took the highly unusual step of printing side-by-side op-eds both expressing the same opinion in opposition to a bill in Congress that would restrict kid-friendly flavors in nicotine and tobacco products.

Both pieces were shocking in their denial of facts and their blithe repetition of tobacco industry talking points. The Centers for Disease Control report that 6 million middle school and high school kids are using addictive nicotine, nearly three times the rate of just a few years ago. Vaping is fueling this epidemic with cheap, disposable, sweet-flavored products loaded with nicotine chemically altered to make it a more palatable starter for kids.

The Reversing the Youth Tobacco Epidemic Act has strong support of the American Association of Pediatrics, the American Medical Association, the American Cancer Society, the American Heart Association, the American Lung Association, the Campaign for Tobacco Free Kids, Truth, the American Public Health Association and hundreds of other organizations trying to stem the epidemic of teen vaping. That the new dean of OSU’s College of Public Health publicly disputed their position is alarming.

This important bill has passed the U.S. House, and it now moves to the Senate where the lead sponsor is Ohio’s Senator Sherrod Brown.

Let me add as a footnote that early analysis shows tobacco users are 14 times more likely to suffer serious illness and death from COVID-19 than non-smokers. Any inhaled nicotine paralyzes the lungs’ cleansing system. There was never a better time to quit smoking and vaping.


Rob Crane, MD,

Professor of Clinical Family Medicine, Ohio State University, Columbus


What happens to people’s lungs when they get coronavirus?

Respiratory physician John Wilson explains the range of Covid-19 impacts, from no symptoms to severe illness featuring pneumonia

Respiratory physician John Wilson explains the range of Covid-19 impacts. This image shows a CT scan from a man with Covid-19. Pneumonia caused by the new severe acute respiratory coronavirus 2 can show up as distinctive hazy patches on the outer edges of the lungs, indicated by arrows.
Respiratory physician John Wilson explains the range of Covid-19 impacts. This image shows a CT scan from a man with Covid-19. Pneumonia caused by the new severe acute respiratory coronavirus 2 can show up as distinctive hazy patches on the outer edges of the lungs, indicated by arrows. Photograph: AP

What became known as Covid-19, or the coronavirus, started in late 2019 as a cluster of pneumonia cases with an unknown cause. The cause of the pneumonia was found to be a new virus – severe acute respiratory syndrome coronavirus 2, or Sars-CoV-2. The illness caused by the virus is Covid-19.

Now declared as a pandemic by the World Health Organisation (WHO), the majority of people who contract Covid-19 suffer only mild, cold-like symptoms.

WHO says about 80% of people with Covid-19 recover without needing any specialist treatment. Only about one person in six becomes seriously ill “and develops difficulty breathing”.

So how can Covid-19 develop into a more serious illness featuring pneumonia, and what does that do to our lungs and the rest of our body?

How is the virus affecting people?

Guardian Australia spoke with Prof John Wilson, president-elect of the Royal Australasian College of Physicians and a respiratory physician.

He says almost all serious consequences of Covid-19 feature pneumonia.

Wilson says people who catch Covid-19 can be placed into four broad categories.

The least serious are those people who are “sub-clinical” and who have the virus but have no symptoms.

Next are those who get an infection in the upper respiratory tract, which, Wilson says, “means a person has a fever and a cough and maybe milder symptoms like headache or conjunctivitis”.

He says: “Those people with minor symptoms are still able to transmit the virus but may not be aware of it.”

The largest group of those who would be positive for Covid-19, and the people most likely to present to hospitals and surgeries, are those who develop the same flu-like symptoms that would usually keep them off work.

A fourth group, Wilson says, will develop severe illness that features pneumonia.

He says: “In Wuhan, it worked out that from those who had tested positive and had sought medical help, roughly 6% had a severe illness.”

The WHO says the elderly and people with underlying problems like high blood pressure, heart and lung problems or diabetes, are more likely to develop serious illness.

How does the pneumonia develop?

When people with Covid-19 develop a cough and fever, Wilson says this is a result of the infection reaching the respiratory tree – the air passages that conduct air between the lungs and the outside.

He says: “The lining of the respiratory tree becomes injured, causing inflammation. This in turn irritates the nerves in the lining of the airway. Just a speck of dust can stimulate a cough.

“But if this gets worse, it goes past just the lining of the airway and goes to the gas exchange units, which are at the end of the air passages.

“If they become infected they respond by pouring out inflammatory material into the air sacs that are at the bottom of our lungs.”

If the air sacs then become inflamed, Wilson says this causes an “outpouring of inflammatory material [fluid and inflammatory cells] into the lungs and we end up with pneumonia.”

He says lungs that become filled with inflammatory material are unable to get enough oxygen to the bloodstream, reducing the body’s ability to take on oxygen and get rid of carbon dioxide.

“That’s the usual cause of death with severe pneumonia,” he says.

How can the pneumonia be treated?

Prof Christine Jenkins, chair of Lung Foundation Australia and a leading respiratory physician, told Guardian Australia: “Unfortunately, so far we don’t have anything that can stop people getting Covid-19 pneumonia.

“People are already trialling all sorts of medications and we’re hopeful that we might discover that there are various combinations of viral and anti-viral medications that could be effective. At the moment there isn’t any established treatment apart from supportive treatment, which is what we give people in intensive care.

“We ventilate them and maintain high oxygen levels until their lungs are able to function in a normal way again as they recover.”

Wilson says patients with viral pneumonia are also at risk of developing secondary infections, so they would also be treated with anti-viral medication and antibiotics.

“In some situations that isn’t enough,” he says of the current outbreak. “The pneumonia went unabated and the patients did not survive.”

Is Covid-19 pneumonia different?

Jenkins says Covid-19 pneumonia is different from the most common cases that people are admitted to hospitals for.

“Most types of pneumonia that we know of and that we admit people to hospital for are bacterial and they respond to an antibiotic.

Wilson says there is evidence that pneumonia caused by Covid-19 may be particularly severe. Wilson says cases of coronavirus pneumonia tend to affect all of the lungs, instead of just small parts.

He says: “Once we have an infection in the lung and, if it involves the air sacs, then the body’s response is first to try and destroy [the virus] and limit its replication.”

But Wilson says this “first responder mechanism” can be impaired in some groups, including people with underlying heart and lung conditions, diabetes and the elderly.

Jenkins says that, generally, people aged 65 and over are at risk of getting pneumonia, as well as people with medical conditions such as diabetes, cancer or a chronic disease affecting the lungs, heart, kidney or liver, smokers, Indigenous Australians, and infants aged 12 months and under.

“Age is the major predictor of risk of death from pneumonia. Pneumonia is always serious for an older person and in fact it used to be one of the main causes of death in the elderly. Now we have very good treatments for pneumonia.

“It’s important to remember that no matter how healthy and active you are, your risk for getting pneumonia increases with age. This is because our immune system naturally weakens with age, making it harder for our bodies to fight off infections and diseases.”

  • Due to the unprecedented and ongoing nature of the coronavirus outbreak, this article is being regularly updated to ensure that it reflects the current situation at the date of publication. Any significant corrections made to this or previous versions of the article will continue to be footnoted in line with Guardian editorial policy.

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