Candy flavors. Feels cool. Seems harmless. Kills it on Instagram. Easily concealed from parents and teachers. For these reasons and more, electronic cigarettes have exploded in popularity among children and teens in the last few years.
“They honestly don’t think they’re using a nicotine delivery device,” Erika Westling says. Westling leads a study at Oregon Research Institute in Eugene that examines tobacco use among eighth graders in Woodburn and Creswell. E-cigarettes are ubiquitous, but kids told her they call them vape pens or mods.
The vaping devices seem to be hooking a new generation on tobacco — a substance that continues to be the leading preventable cause of death. Yet long-time tobacco foes aren’t willing to condemn e-cigarettes outright, because of the hope that, under the right circumstances, the devices may help adult smokers quit traditional combustible cigarettes.
There are success stories of quitting, but accumulating evidence tells a different tale. E-cigarettes actually may be diverting well-intentioned nicotine addicts from proven ways to quit. Instead, the vaping option expands the adult repertoire of tobacco products and makes it easy to sneak their nic-fix into places now forbidden to smokers, while inducting young people who otherwise may not have started the habit.
2018 was a year of reckoning. Nationwide, one in every four twelfth graders said they had vaped in the past 30 days, researchers reported in December. It was the second major national report of a sharp increase in e-cigarette use by teens and preteens. The U.S. surgeon general called it an “epidemic.”
Oregon reflects the nation, with a near tripling in teen use of e-cigarettes from 2013 to 2017.
“Adults can’t keep up with the trends,” Olivia Cooper, student body president at Crook County High School in Prineville, says. Cooper is a senior at the school and a tobacco-free advocate.
“Students are moving quicker than health professionals can counter,” Cooper says. “It has taken years for adults to understand and address the e-cigarette issue. By then, kids are addicted and don’t want to admit that they are.”
The 2018 surge in tobacco-vaping teens and young adults came as a double shock, because the numbers had appeared to dip for a couple of years, just after the U.S. surgeon general first issued a major report on e-cigarette use among youth in 2016. The apparent dip was probably false, because researchers did not ask specifically about use of new and emerging products such as Juul, says Jidong Huang, a health economist at Georgia State University in Atlanta. Many teens and young adults who vape do not identify as smokers or e-cigarette users.
E-cigarettes were introduced in 2004 as a less dangerous alternative to cigarettes. For those adults who haven’t knowingly encountered them yet, e-cigarettes are electric devices with nicotine dissolved in liquid that is often flavored. A coil boils the liquid, generating an aerosol of nicotine and other chemicals to inhale.
Then came Juul. Introduced in 2015, Juul packs its nicotine punch in a sleek design that looks like a computer memory stick and actually recharges in a USB port. Disposable pods originally came “in four absurdly-named flavors — tabaac, fruut, miint, bruulé — and cost $16 for a four-pack of cartridges (a cartridge is roughly equivalent to a pack of smokes),” enthused Wired magazine that year.
Juul soon cornered three-fourths of the e-cigarette market. Portland State University chemists recently worked out why Juul may be so appealing to inhale. The team analyzed 11 e-cigarette liquids. All had high levels of nicotine overall. The two Juul samples (in fruit medley and crème brulee flavors) had higher levels of a form known as protonated nicotine, also called nicotine salt. In the plant leaf, protonated nicotine acts as a natural pesticide against insect predation, says co-author and chemistry professor James Pankow, but in pods it makes Juuls more pleasant to inhale.
“It’s easier for naïve users,” says David Ashley, former director of the Office of Science at the Food & Drug Administration’s Center for Tobacco Products. “Getting over the hump of using cigarettes is terrible. Everyone who first smokes gags and gets sick.”
The PSU study found Juul had relatively less of the other form of nicotine, known as freebase. It gets into the blood and brain quickly, but is harsher on the throat. Cigarette makers credited freebase nicotine for Marlboro’s popularity decades ago. Ever since, the tobacco industry has considered it a necessary ingredient to satisfy smokers in the first few puffs, Ashley and Pankow say.
Juul was the first major retail e-cigarette brand to use social media in a big way. A combination of hashtags, celebrity endorsements and artsy images of hip young people flew under the radar of public health tracking systems, Huang and his colleagues reported in March. Quarterly sales of Juul tracked the skyrocketing number of tweets and retweets in 2017.
In April, the FDA announced a crack down on youth sales and marketing. In July, Juul added a lower nicotine pod (3 percent compared with 5 percent) to its lineup in mint and Virginia tobacco flavors. In November, Juul announced it was closing its Facebook and Instagram accounts and stopping distribution of certain flavors of pods that critics called appealing to teens. Juul maintains that it never intended youth use and instead aims to provide a less dangerous alternative to combustible cigarettes.
In December, one of the world’s largest tobacco producers and marketers, Altria (formerly known as Philip Morris), purchased a stake in Juul Labs for $12.8 billion in a deal that gave the 1,500 Juul Labs employees $2 billion in cash, the Wall Street Journal reported. On Jan. 18, the FDA will hold a hearing on reducing youth e-cigarette and other tobacco use, including the role for drug therapies to support quitting.
The tobacco industry has seen numbers of U.S. adult users steadily decrease since the mid 1960s and youth users drop since the mid 1990s. The drop is attributed in large part to prevention efforts to discourage smoking among teens. After all, nine out of 10 tobacco users say they began before age 19.
Of course, tobacco companies also lose customers to quitting and premature death.
As preventive health professionals like Brian King at the U.S. Centers for Disease Control in Atlanta are fond of saying, “When used as directed, tobacco kills half of its users.”
Heated tobacco is the next wave, King says. The FDA is reviewing an application to allow marketing of a tobacco-warming product called iQos (“I quit ordinary smoking”) that plugs into a device that looks like an iPhone, plus a claim that it’s safer than cigarettes. The device is popular in other countries, King says, but “a similar device failed miserably” in the U.S. earlier.
E-cigarettes may be not be as bad as smokes, especially for secondhand smoke, but the vapors still expose users to known harmful levels of certain chemicals, such as formaldehyde and ultrafine particles, Stanton Glantz, a long-time foe of tobacco use, said in an online lecture in August. Preliminary surveys and molecular studies implicate daily e-cigarette use with nearly double the risk of heart attacks and with increased risk of chronic lung disease. Dual users — people who both smoke and vape — have even higher risks.
People often associate smoking with cancer, Glantz said, but it accounts for only one-third the premature deaths, with heart disease and lung disease the major killers. “The risks are substantial,” he said. “No one knows yet how it compares to cigarettes, but they’re getting closer and closer.”
So what do you tell smokers who want to quit? “Always support a quit attempt,” Glantz said, but they need to know that “for most people, using e-cigarettes makes it harder to quit.” When used properly with counseling and support and a disciplined quit plan, as with FDA-approved cessation products, e-cigarettes may be effective in quitting, he said.
Prevention works better than trying to recover from a nicotine addiction. Nationally, policies to limit youth tobacco use have tended to start locally. In Lane County, “there’s evidence that use of e-cigarettes may be leading to use of other tobacco products,” says Christy Inskip, coordinator of the Lane County Tobacco Prevention and Education Program. In 2014, she and her colleagues documented tactics proven to target youth and vulnerable populations, such as people of color, those with lower incomes, disabilities and rural residents. They include varied pricing of flavored little cigars and cigarillos, which can be sold individually, which cost 69 cents in Florence, with higher tobacco use rates, and $1.18 in Eugene.
In another tactic, local stores get $10,000 a year to allow the tobacco company to place and advertise its products where it wants, such as near candy and at a child’s eye level, Inskip says. “The industry is exploiting local retailers,” she says.
The county and its cities are fighting back. In 2014, Lane County was the first in Oregon to require a license to sell tobacco and, in 2017, to raise the tobacco sale age from age 18 to 21. The state of Oregon followed within months. Cottage Grove was the first city to ban sales of e-cigarettes to minors. Eugene recently passed a smoke-free downtown ordinance, with ways for businesses to opt out, as well as ways for other organizations to opt in outside the prescribed smoke-free boundaries.
One of the most effective strategies is raising the price. In Oregon, the state Governor’s Budget includes a proposal to increase the price of tobacco by $2 per pack of cigarettes and also for the first time to tax inhalant delivery systems, which include e-cigarettes, says Delia Hernández, spokesperson for the Oregon Health Authority.