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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.

National Health Organizations Oppose Florida HB1299

March 25, 2019

The undersigned strenuously oppose HB1299, a measure that would preempt locally-elected Florida office holders from raising the minimum legal tobacco sales age or enacting local licensure for tobacco and nicotine products.  This unwelcome, top-down proposal would remove the ability of local governments to protect the health and safety of their constituents, especially children.

HB1299 is especially egregious in light of the Juul e-cigarette addiction epidemic that has swept through Florida’s adolescent population – with estimates that a quarter of underage teens use these slick devices.  A single Juul pod delivers highly-addictive nicotine equivalent to a pack of cigarettes.

Many public health policy interventions such as Tobacco 21 begin at the local level. As of today, over 450 localities in 25 states, including Florida, have enacted these common-sense regulations.  Alachua County recently demonstrated its health leadership by passing the first Tobacco 21 policy in the state.  The effectiveness of the policy is dependent on local enforcement and a local license.  As a result of Alachua’s leadership, several other Florida municipalities are considering the measure.

Both state and local elected officials have the responsibility to act on urgent matters of public health and safety like that of the adolescent e-cigarette epidemic. Good health policy must be evidence-based, have public support and, above all, not be set by tobacco industry lobbyists in backrooms of the statehouse.

We urge that HB1299 be rejected.

Sincerely,

The Preventing Tobacco Addiction Foundation/Tobacco 21.org

The American Heart Association/The American Stroke Association

The American Lung Association

Campaign for Tobacco-Free Kids

Tobacco-Free Alachua

Cancer advocates say tobacco bill is flawed, encourage lawmakers to vote no

SALT LAKE CITY — A bill to incrementally raise the age for tobacco products, including electronic cigarettes, to 21 passed through the Utah Legislature Wednesday with a 15-12 vote in the Senate and a 55-16 concurrence vote in the House.

HB324, sponsored by Rep. Steve Eliason, R-Sandy, changes the age from 19 to 20 on July 1, 2020, and to 21 one year later. The bill raises the age for “obtaining, possessing, using, providing, or furnishing of tobacco products, paraphernalia, and under certain circumstances, electronic cigarettes.”

Arguments around this bill has centered on the debate of preemption, with cancer advocates speaking against an early version of the bill. The bill that passed made only one amendment to preemption language in current code, adding the minimum age of sale to what cannot be modified by cities and counties.

Sen. Curt Bramble, R-Provo, the Senate sponsor of the bill, said this compromise would allow cities that have already raised the age for sale of tobacco, including Lehi and Cedar Hills, to keep the age at 21 instead of following the incremental age increase in the state.

She said addiction should not be shamed or criminalized, especially for youth. If youth get in trouble while they are building who they are as a person, they could define themselves as thugs or criminals.

“This is not about smokers, this is about protecting youth from having access to these addictive materials that the tobacco industry is pushing,” Tischler said.

According to Tischler, 800 youth in Utah each year become daily smokers, and vaping is especially a problem for youth because they have more access to it and it’s easier to hide from parents.

Jordan Osborne was part of an anti-tobacco youth group in Utah County and helped change laws to make parks tobacco free. But when he was 18, a friend a few years older bought him a vape pen and he became a smoker. He still vapes and occasionally smokes cigarettes. He said he doesn’t feel like he is addicted, but he gets aggravated when he hasn’t smoked.

“If they had the smoking age at 21 back then it would have made it even harder for me to even get (tobacco),” Osborne said.

He said if he had never started using tobacco he would be a lot healthier and wouldn’t have to have something to help him relax.

Cedar Hills and Lehi both passed ordinances in the last few weeks raising the age to buy tobacco to 21. But opponents to HB324 say language in the bill could stop other cities from making changes to local tobacco laws.

Vaping isn’t working at cessation; it is working at hooking our teens

By  and  | Guest Commentary
PUBLISHED:  | UPDATED: 
When electronic cigarettes first came on the market, we hoped they might help reduce the tremendous harm caused by tobacco cigarettes. If smokers inhaled a vapor containing nicotine, flavorings and other additives rather than the multitude of cancer-causing chemicals in tobacco smoke, there might be some benefit.

While some adults have used e-cigarettes to wean themselves from tobacco, research indicates that e-cigarettes are really just another nicotine delivery device with its own unique hazards that addict users to nicotine. This is especially concerning for teens and young adults who are using e-cigarettes with alarming frequency.

One recent study did suggest that e-cigarettes helped adults stop smoking. However, those who quit tobacco continued to consume e-cigarettes and nicotine a year later. More common appears to be the experience of smokers studied by Dr. Russell Bowler, a professor of medicine at National Jewish Health. He found that most of the tobacco smokers who started using e-cigarettes in hopes of quitting tobacco continued to smoke tobacco at similar or higher levels five years later. Former smokers who began using e-cigarettes were more than 16 times as likely to resume tobacco smoking.

Additional research at National Jewish Health has shown that, while less harmful than tobacco smoke, e-cigarette vapor itself is harmful. It injures cells lining the airways and blood vessels in the lungs, and increases susceptibility to respiratory viruses.

E-cigarette use, or vaping, by teens and young adults is especially worrisome. After decades of decline, the consumption of tobacco products has taken a U-turn and begun a precipitous climb. Vaping among middle and high school students increased 900 percent from 2011 to 2015 and nearly doubled in just the last year.

Today, one in 20 middle schoolers and one in five high school students use e-cigarettes. College students and young adults vape at similar or even greater rates.

Research has shown that youth who try an e-cigarette are more likely to begin smoking tobacco. The Surgeon General and the Food and Drug Administration have both called e-cigarette use by teens and young adults a serious public health threat.

Nicotine in e-cigarettes poses unique threats to young users’ health. Adolescence is an important period of brain development when learning capacity, decision making, working memory, reward processing and emotional regulation all grow and mature. Nicotine use during adolescence profoundly alters this process, priming the brain for future addictions and increasing the risk of mood disorders, intellectual problems and impulsiveness.

E-cigarettes have become immensely popular, fueled by flavors and marketing targeted at young people. Peer pressure to vape is bearing down on those who don’t. Many don’t even realize they are vaping nicotine and mistakenly believe they are inhaling simple water vapor. Teenage brains are especially susceptible to nicotine’s addictive and rewarding effects, yet many fail to recognize the threat e-cigarettes pose to long-term mental and physical health.

After decades of fighting to reduce harm from tobacco, it is astounding that a new generation faces a renewed threat from tobacco. We must help young people avoid nicotine and quit e-cigarettes. Teens can call the Colorado QuitLine (1-800-QUIT-NOW), which recently lowered the age of eligibility for services to 12.

As the operator of the Colorado and many other state quitlines for 17 years, National Jewish Health has extensive experience treating nicotine addiction with personalized plans to avoid nicotine, navigate peer pressure and manage nicotine withdrawal. At the same time, the FDA must tighten regulation of e-cigarettes and follow through on promises to close down manufacturers who don’t meaningfully limit youth access to e-cigarettes.

JUUL, the dominant company in the market, must follow through on its action plan to cease marketing to youth and limit their access to its products.

We urge Colorado legislators to pass the recently introduced bill to raise the age for legal purchase of e-cigarettes.

Together, we can protect our youth from the dangers of e-cigarettes and vaping.

Dr. Michael Salem is president and CEO of National Jewish Health. Thomas Ylioja, PhD, is an assistant professor of medicine and clinical director of health initiatives at National Jewish Health.

Brian Donohue column: Tobacco 21: Addressing the right problem the wrong way

Nearly 95 percent of adults who smoke started before age 21, so we applaud our state legislators for wanting to reduce the use of tobacco, including e-cigarettes, for those younger than 21. However, the proposed bill as it is drafted will not provide the public policy results legislators are looking for and will not have support from the American Cancer Society Cancer Action Network (ACS CAN).

It is important to closely evaluate each proposed Tobacco 21 bill as the tobacco industry has a history of using age of sale laws to weaken restrictions on sales to youth, penalize youth, create carve-outs for certain products, and to interfere with other effective tobacco control policies.

ACS CAN has been working to advance effective Tobacco 21 legislation across the nation for several years. What we have learned from these debates is that the legislative focus needs to be on the sale — not the purchase — of tobacco and e-cigarette products. We have also seen that penalizing and fining youth who purchase tobacco and e-cigarettes has proven not to be an effective way to reduce consumption. Therefore, as this bill is drafted, it will not have support from ACS CAN.

The Tobacco 21 legislation needs to address three critical areas of concern in order to have the greatest impact: focus on the sale of tobacco and e-cigarettes rather than the purchase, require licensing for all retailers that sell tobacco and e-cigarette products, and fund prevention and cessation programs to help reduce youth tobacco use.

This bill retains penalties for youth who purchase, use, and possess tobacco and e-cigarette products. We have learned from working Tobacco 21 bills across the states that laws that focus on the purchaser rather than the seller fail to reduce youth consumption. Virginia’s current law unfairly penalizes youth, many of whom became addicted at an early age due to tobacco industry marketing campaigns. This takes the spotlight off Big Tobacco and retailers and shifts it onto the victims — our youth.

Not licensing retailers makes enforcement and holding retailers accountable next to impossible. For Tobacco 21 laws to be effective, there must be strict enforcement to ensure a high rate of compliance. We recommend the proposed bill be amended to require retailers to be licensed, designate an enforcement agency, identify a dedicated funding source for enforcement, require annual unannounced compliance checks, increase fines and penalties including license suspension and revocation for retailers found out of compliance, provide for citizen complaints of violations, require appropriate signage at retail stores, and, lastly, provide retailer education.

Our final concern is that many young people who smoke are already addicted. Some research suggests that penalizing youth could deter them from seeking support for cessation. Promoting and increasing funding for tobacco prevention and cessation resources for teens interested in quitting would be a more beneficial alternative to fines and punishment.

Without the amendments outlined above, this bill will prove to be ineffective, feel-good legislation that allows the tobacco and e-cigarette industries to support this measure while presenting themselves as good corporate citizens who are doing the right thing.

We urge lawmakers to oppose this bill as drafted and work to seize this opportunity to pass meaningful legislation that has proven to effectively reduce youth consumption of all tobacco and e-cigarette products. ACS CAN stands ready to work with legislators on amendments needed to make this bill an effective vehicle for protecting our young people from a lifelong addiction to tobacco and e-cigarette products.