After decades of drops in the youth smoking rate, e-cigarettes are now the most popular tobacco product among young people — and their popularity is growing.

“E-cigarettes may be turning back the clock on the tremendous progress we’ve made in the fight against tobacco,” said Robin Koval, CEO and president of Truth Initiative®, at the most recent installment of the Kenneth E. Warner Series, “The Youth E-cigarette Epidemic: Unintended Consequences or Strategic Marketing?”

A group of public health experts, researchers, youth and education professionals gathered at the event to discuss youth e-cigarette use and the health risks confronting an entire generation. Here are five takeaways from the discussion, facilitated by USA Today reporter Jayne O'Donnell.

Youth e-cigarette epidemic is growing.

Is youth e-cigarette use an epidemic?

Food and Drug Administration Commissioner Scott Gottlieb recently declared that youth e-cigarette use has reached “nothing short of an epidemic proportion of growth” and cited new, unpublished federal data that show a 77 percent increase in e-cigarette use among high school students.

“I think it’s really hard not to call it an epidemic when you see a 77 percent increase in prevalence in 12 months,” said Donna Vallone, chief research officer at Truth Initiative. “That level of uptake and popularity at a population level is almost unprecedented.”

Nicotine is harmful to developing brains: younger users are more likely to become addicted, have more difficulty quitting and are at higher risk for addiction to other substances in the future. Additionally, young people who use e-cigarettes are more than four times as likely to begin smoking tobacco cigarettes within 18 months compared with their peers who do not vape.

JUUL is the main culprit.

How popular is JUUL?

The most popular e-cigarette, JUUL, has experienced explosive growth, tripling its market share in just over a year from about one-quarter to three-quarters of the e-cigarette market.

While the maker of JUUL claims it is “only for adults,” new Truth Initiative research published in Tobacco Control shows that teenagers are more likely to use the device than older age groups. In fact, 15- to 17-year-olds have over 16 times greater odds of being current JUUL users compared with those between 25 and 34 years old. Additionally, a May 2018 Truth Initiative survey found that nearly one in five middle and high school students have seen JUUL used in school.

“My high school, for example, took the first door out of the bathroom to discourage the students from using [JUUL] in the bathroom,” said Mila Milagros Vascones-Gatski, a substance abuse counselor at Yorktown High School in Arlington, Virginia, who added that many students and parents are unaware that the product contains nicotine. “It’s about education — educating parents and educating kids.”

Results from a Truth Initiative study published in April 2018 found that 63 percent of JUUL users did not know that the product always contains nicotine, even though all types of JUUL pods sold on the market have nicotine in them.

Jack Waxman, founder of Juulers Against Juul and a student at Cornell University, said he has also seen a lack of awareness about the addictive chemical nicotine. “This is one of the biggest problems affecting our generation because it will stay with us for the rest of our lives,” he said.

Flavors are attracting youth.

Would teens use JUUL if it didn't come in flavors?

JUUL, as well as a slew of copycat products that have emerged in recent months, come in a variety of flavors proven to attract young people.

“If the flavors weren’t fruit and things I like, I wouldn’t JUUL. I personally hate the tobacco flavor,” said high school junior Stephanie Aquino, referring to JUUL flavors like mango and fruit. JUUL also comes in a creme, mint and tobacco flavor.

Many e-cigarette makers say flavors can help smokers use e-cigarettes to quit, but more research is needed to support that claim, said Vallone.

“Here’s what we do know: we know that flavors are incredibly enticing for youth and young adults,” Vallone said. “We’ve always known that.”

Truth Initiative has called for the FDA to issue product standards eliminating flavors from all tobacco products, with a narrow exception for products like e-cigarettes that have been demonstrated to help smokers completely switch from combustible tobacco. The manufacturer must also show that the product is not marketed to attract youth, and that claim must be verified with careful post-marketing surveillance of actual use patterns.

E-cigarettes have not yet proven to be successful quit tools.

Do e-cigarettes help people quit smoking?

A smoker who switches completely from combustible cigarettes to e-cigarettes will substantially reduce exposure to toxic chemicals and health risks. However, Georgia State University School of Public Health Professor David Ashley notes that most e-cigarette users are not completely switching to e-cigarettes and are instead using the products in addition to combustible products.

“These products are not very effective at accomplishing what they are supposedly trying to accomplish,” Ashley said. “I’m encouraged that e-cigarettes may be part of the answer. I don’t think they are the answer right now. I think the way they are being marketed and the products that are out there right now are not getting us where we want to go.”

We need policies and practices that protect youth.

How can we stop the e-cigarette epidemic?

“We really need some standardized way of regulating this product that makes sense for everyone,” Vallone said.

The FDA has taken recent actions on e-cigarettes, including cracking down on retailers selling e-cigarettes to minors, doing a surprise inspection of JUUL Labs and developing plans for regulatory actions. The FDA also asked that five e-cigarette manufacturers come up with plans to tackle the youth e-cigarette problem.

“I think the real responsibility falls on the companies who have created this issue” said Ashley, noting that companies can alter the product’s appeal, marketing and technology to clearly target adults and decrease youth use. “The problem we run into is that companies are not going to do that. There is a history of companies not taking that objective on.”

Truth Initiative is taking several actions to address the e-cigarette epidemic, including calling for a comprehensive public health strategy. truth®, the national youth tobacco prevention campaign from Truth Initiative, recently launched a new digital campaign about the risks of e-cigarettes called “safer ≠ safe.” The effort shares key facts, including that one standard JUUL pod delivers the amount of nicotine equivalent to a pack of cigarettes.  

The Warner Series regularly brings together leaders across tobacco control, public health and youth service communities to engage in thought-provoking conversations about ways we can innovate and inspire action to save lives. Watch the entire event, “The Youth E-cigarette Epidemic: Unintended Consequences or Strategic Marketing?”

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