Electronic Cigarettes Targeting Kids

Juul Now A Public Health Threat

Introduced in 2015, Juul electronic cigarettes have quickly skyrocketed in popularity among teens and college students across the United States, according to widespread news reports. Educators and students report an alarming level of Juul use in middle and high schools, making this an urgent public health problem.

JUUL Labs produces the JUUL device and JUULpods, which are inserted into the JUUL device. In appearance, the JUUL device looks quite similar to a USB flash drive, and can in fact be charged in the USB port of a computer. According to JUUL Labs, all JUULpods contain flavorings and 0.7mL e-liquid with 5% nicotine by weight, which they claim to be the equivalent amount of nicotine as a pack of cigarettes, or 200 puffs. JUULpods come in five flavors: Cool Mint, Crème Brulee, Fruit Medley, Virginia Tobacco, Mango, as well as three additional limited edition flavors: Cool Cucumber, Classic Tobacco, and Classic Menthol. Other companies manufacture “JUUL-compatible” pods in additional flavors; for example, the website Eonsmoke sells JUUL-compatible pods in Blueberry, Silky Strawberry, Mango, Cool Mint, Watermelon, Tobacco, and Caffé Latte flavors. There are also companies that produce JUUL “wraps” or “skins,” decals that wrap around the JUUL device and allow JUUL users to customize their device with unique colors and patterns (and may be an appealing way for younger users to disguise their device).

According to data from Wells Fargo, JUUL’s popularity has grown dramatically in the last year, with unit sales increasing more than 600 percent in 2017. In mid-2016, dollar sales share for JUUL products was less than 5 percent, the lowest compared to products sold by the main companies in Nielsen-tracked channels. But by the end of 2017, JUUL sales had surpassed all other companies’ products (see adjacent graph). As a result, JUUL is now more popular than the e-cigarette brands manufactured by the major tobacco companies (blu, Vuse, and MarkTen).

More recently, JUUL has updated its marketing code with the purported goal of limiting youth exposure to its advertising. Its current marketing materials focus primarily on its popular flavors and on messaging that encourages smokers to “make the satisfying switch.”

teen smoking and vaping

E-cigarettes are a diverse group of products containing a heating element that produces an aerosol from a liquid that users can inhale via a mouthpiece, and include a range of devices such as “cig-a-likes,” vape tank systems, and vape mods.  Millions of Americans use e-cigarettes, and e-cigarette use is generally greatest among young adults and decreases with age.  Use varies substantially across demographic groups, including age, gender, race, and ethnicity.  For example, among youth and adults, use is typically greater among males than females.

Juul sales have grown dramatically and now make up more than half of the e-cigarette market. According to the most recent data from Wells Fargo, JUUL sales currently represent 68 percent of the market share. 

Several factors have contributed to Juul’s rising popularity with teens:

  • Juul e-cigarettes are sleek, high tech and easy to hide. They look just like USB flash drives and can be charged in the USB port of a computer. They don’t look like a traditional tobacco product. A Juul is small enough to fit in a closed hand;
  • Juul comes in sweet flavors that appeal to youth, including mango, fruit medley, crème brulee, cool mint and cool cucumber. Research has shown that flavors play a key role in youth use of tobacco products, including e-cigarettes; and
  • Juul appears to deliver nicotine more quickly, more effectively and at higher doses than other e-cigarettes, increasing users’ risk of addiction. The manufacturer claims each Juul cartridge of nicotine liquid (called a “Juul pod”) contains as much nicotine as a pack of cigarettes (about 200 puffs). However, research has found that many Juul users don’t know the product always contains nicotine, and many teens call use of the product “juuling,” indicating they may not realize it is an e-cigarette or tobacco product.

According to the National Youth Tobacco Survey, 11.7 percent of high school students and 3.3 percent of middle school students—over 2.1 million youth—were current e-cigarette users in 2017. However, a study from Truth Initiative found that a quarter of youth and young adult JUUL users don’t refer to JUUL use as “e-cigarette use” or “vaping,” but rather as “JUULing.” Therefore, it is possible that existing surveys may not be capturing the full spectrum of youth e-cigarette use. News articles, letters from school officials, and anecdotal evidence indicate that JUUL has gained popularity among youth and young adults across the country, from middle schools to college campuses. A 2018 study found that nearly one-fifth of youth (ages 12-17) surveyed reported having seen JUUL used in their school.

While smoking cigarettes among high school students has dropped, vaping nicotine continues to increase–in some states more than others. For example, according to the 2017 Healthy Kids Colorado Survey, only 7 percent of high school students currently smoke cigarettes, while 27 percent said they vape nicotine. The statewide school survey shows 87 percent of Colorado high school students think cigarette smoking is risky, but only 50 percent think those risks apply to vaping nicotine.

teen vaping

The availability of flavors may also contribute to JUUL’s popularity among youth. A national survey found that that 81 percent of youth aged 12-17 who had ever used e-cigarettes had used a flavored e-cigarette the first time they tried the product, and that 85.3 percent of current youth e-cigarette users had used a flavored e-cigarette in the past month. Moreover, 81.5 percent of current youth e-cigarette users said they used e-cigarettes “because they come in flavors I like.”

The number of youth using e-cigarettes, including JUUL, is alarming and raises serious concerns that E-cigarettes could be an entryway to nicotine addiction and use of regular cigarettes for some kids. Though there is insufficient research on the long-term effects of using e-cigarettes in general, and certainly not specific to JUUL, the use of such products still raises concerns because they contain nicotine. The company claims that the nicotine in JUUL is from “nicotine salts found in leaf tobacco, rather than freebase nicotine,” which they claim “accommodate cigarette-like strength nicotine levels.” 12 The health impact of that specific form of nicotine is yet unknown.

Juul is putting kids at risk of nicotine addiction and threatens to undermine decades of progress in reducing youth tobacco use:

The alarming increase in youth use of Juul requires strong and immediate action by the Food and Drug Administration to protect kids. The FDA is responsible for regulating tobacco products, including e-cigarettes, and the FDA must take action to address the skyrocketing youth use of Juul.

A congressionally mandated report from the National Academies of Sciences, Engineering, and Medicine takes a comprehensive look at evidence on the human health effects of e-cigarettes. Although the research base is limited given the relatively short time e-cigarettes have been used, the committee that conducted the study identified and examined over 800 peer-reviewed scientific studies, reaching dozens of conclusions about a range of health impacts.

Whether e-cigarettes have an overall positive or negative impact on public health is currently unknown, the report says. More and better research on e-cigarettes’ short- and long-term effects on health and on their relationship to conventional smoking is needed to answer that question with clarity.

“E-cigarettes cannot be simply categorized as either beneficial or harmful,” said David Eaton, chair of the committee that wrote the report, and dean and vice provost of the Graduate School of the University of Washington, Seattle. “In some circumstances, such as their use by non-smoking adolescents and young adults, their adverse effects clearly warrant concern. In other cases, such as when adult smokers use them to quit smoking, they offer an opportunity to reduce smoking-related illness.”

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Are e-Cigarettes A Healthy Way To Quit Smoking

Cigarette Smoking Losing Its Appeal To Teens

Smoking accounts for more than 480,000 deaths every year in this country, or about one of every five deaths, according to the Centers for Disease Control and Prevention. An additional 16 million Americans live with a smoking-related disease, it says. Clearly more needs to be done to get Americans to quit smoking.

Some people say electronic cigarettes can help wean smokers off tobacco, at little risk to their health. For others, both of those assertions are false.

Jed E. Rose, a professor of psychiatry and behavioral sciences and director of the Duke Center for Smoking Cessation at Duke University, makes the case for e-cigarettes as a smoking-cessation tool. Arguing against it is Pamela Ling, a professor of medicine with the Center for Tobacco Control Research and Education at the University of California, San Francisco.

teen smoking e-cigarette

YES: they appear to be effective — and safer

By Jed E. Rose

In evaluating the potential public-health impact of e-cigarettes, we need to bear in mind the staggering toll of death and disease caused by cigarette smoking throughout the world. In this context, we should not discourage promising new approaches that might change this picture.

As with any new potentially therapeutic approach, we must evaluate e-cigarettes based on the information currently available, while recognizing that an exhaustive analysis of all of the potential long-term effects will require many years of study. And the information we have now shows that electronic cigarettes can safely help people quit smoking.

The U.S. Surgeon General and other experts have linked the vast majority of smoking-related disease to the combustion products of smoke, not to the nicotine that is present both in tobacco and in electronic cigarettes.

Nicotine is a powerfully addictive substance, but it is not the cause of cancer, lung disease or vascular disease seen in smokers. While quitting all nicotine-containing products may be an ideal goal, smokers who try to stop on their own have less than a 5% chance of long-term success, and only about a 10% chance with the assistance of a medical provider.

In this setting, the ability to switch from tobacco cigarettes to e-cigarettes that contain nicotine but do not burn offers enormous promise as a means to save lives.

Researchers from highly credible organizations, among them the U.K. Center for Tobacco and Alcohol Studies and the University of Geneva’s Institute of Social and Preventive Medicine, have concluded that e-cigarettes are helpful in reducing or eliminating tobacco use. And recently the British government’s drug regulatory authority approved an e-cigarette as a quit-smoking medicine.

This position is also supported by common sense, considering that every other form of nicotine replacement studied to date has been shown to help people stop smoking, including nicotine patches, gum, lozenges, nasal spray and inhalers.

What’s more, compared with those treatments, e-cigarettes can more effectively satisfy a smoker’s craving by delivering nicotine as rapidly as a cigarette, while also satisfying the habitual aspects of smoking. As e-cigarette technology improves, these devices will almost certainly become more-effective tools to aid smokers in breaking their addiction to combustible cigarettes.

Available evidence also overwhelmingly supports the view that e-cigarettes are reasonably safe and — most important — far less risky than cigarettes.

Despite expert consensus to that effect, some researchers have focused their attention on exaggerated health concerns. These reports have a sensational quality and often gain wide coverage by the press. For example, some early reports suggested that e-cigarettes produce formaldehyde, a toxic substance found in cigarette smoke. More recent research, however, has shown that under normal operating conditions, e-cigarettes release far less formaldehyde than tobacco cigarettes.

Moreover, because there are numerous carcinogens in cigarette smoke, the formaldehyde component of cigarette smoke has been estimated to raise smokers’ risk of cancer by less than 1 part in 1,000. Thus the overall cancer risk presented by formaldehyde in e-cigarette vapor is likely to be insignificant.

Still, it will take many years to fully establish the long-term safety of electronic cigarettes—during which time millions of tobacco smokers will needlessly die if they are discouraged from using alternatives that are almost certainly far less harmful.

Another report examining population data suggested that e-cigarettes may not be effective for smokers who want to quit. This report gained wide press coverage but was flawed because smokers who turn to e-cigarettes may be a self-selected group that finds it especially difficult to quit smoking.

The gold-standard scientific method for assessing effectiveness is the randomized clinical trial, and two trials to date have shown e-cigarettes can help smokers quit.

Having worked my entire career to develop effective smoking-cessation treatments, I have realized that current approaches are ineffective for the vast majority of smokers. Alternative approaches are urgently needed. The World Health Organization predicts a billion deaths will be attributable to smoking during the 21st century.

Electronic cigarettes have an unparalleled potential to reduce the public-health impact of smoking, by allowing smokers to replace the habit and nicotine of smoking without the toxic effects of combustion.

lung cancer and smoking tobacco

NO: There are better and safer ways to quit smoking

By Pamela Ling

Doctors should support their patients in every effort to quit smoking. But doctors are also expected to recommend treatments that are safe and effective. Electronic cigarettes are neither.

While there are numerous anecdotes of people using e-cigarettes to help them quit smoking and e-cigarettes have been widely promoted as an effective way to quit, the medical evidence supporting these claims is extremely sparse.

There is only one randomized clinical trial — the type of study considered most reliable — comparing e-cigarettes with a nicotine patch. It showed low quit rates and virtually no difference: 7% of nicotine e-cigarette users and 6% of nicotine patch users quit.

cigarettes cause lung cancer

No other randomized clinical trial has compared e-cigarettes with the most effective treatment regimens widely recommended for health-care providers and approved by the Food and Drug Administration (which include the medications bupropion and varenicline, and nicotine replacement therapy through gum, nasal spray, inhaler, lozenge or patch—all of which should be combined with counseling for greatest effect).

Expert opinion is arrayed against e-cigarettes as a quitting aid. The U.S. Preventive Services Task Force, the best independent panel of national experts in prevention and evidence-based medicine, concluded a major review of the medical evidence, finding that there is insufficient evidence to recommend use of e-cigarettes for tobacco cessation. And major medical and health organizations including the World Health Organization, the American Medical Association, the American College of Physicians and the American Public Health Association do not recommend using electronic cigarettes for smoking cessation, because the quality of the purported evidence for their effectiveness is poor.

So-called common sense—the idea that e-cigarettes should be effective because other forms of nicotine replacement have been, and more so because they mimic smoking—simply doesn’t stand up when we look at the scientific evidence.

It gets worse. Most people who use e-cigarettes continue to smoke — so now they have simply added e-cigarettes to their tobacco use.

Many people have tried using electronic cigarettes for smoking cessation based on advertising, news reports and word-of-mouth. Studies that have been done of people who used e-cigarettes on their own — as opposed to those who participated in randomized trials — reflect the various devices and ways consumers in the real world are trying to use them to quit smoking.

At least 20 such studies have examined whether people using e-cigarettes quit smoking tobacco over time, compared with tobacco smokers not using e-cigarettes.

A comprehensive review of all these controlled studies found that people using electronic cigarettes were less likely to quit smoking tobacco. In the real world, most e-cigarette users continue to smoke tobacco — which suggests that electronic cigarettes may actually keep people smoking traditional cigarettes.

The rapid evolution of the e-cigarette market further undermines the argument for them.

Most of the studies on electronic cigarettes have been conducted on first-generation products, which are rapidly being replaced by a dizzying array of new products, most of which have not been studied.

While some of these newer devices may deliver nicotine more effectively than first-generation devices — which should make them better quitting tools — they also generate more heat and produce more chemicals and fine particles, which may have adverse health effects.

Even assuming they are still safer than smoking tobacco, asking that e-cigarettes be safer than the world’s most deadly consumer product sets the bar extremely low.

Further skepticism about electronic cigarettes as a way to quit smoking might be prompted by the simple question, who profits?

While e-cigarette advocacy organizations position themselves as independent of tobacco companies, all of the major U.S. cigarette companies have acquired electronic-cigarette subsidiaries, and the electronic-cigarette brands with the largest market share are owned by cigarette companies.

It is hard to believe that these companies would churn out products that they believe would damage the tobacco market, which is many times bigger than the e-cigarette market.

We have treatments that work for smoking cessation. E-cigarettes are not one of them, and it’s long past time to stop selling them as such.

Tobacco News via http://www.marketwatch.com/story/are-e-cigarettes-a-healthy-way-to-quit-smoking-2016-04-30

Selling Poison To Addicted Smokers

Nicotine Addiction Profitable In Any Form 

A dangerous new form of a powerful stimulant is hitting markets nationwide, for sale by the vial, the gallon and even the barrel. The drug is nicotine, in its potent, liquid form — extracted from tobacco and tinctured with a cocktail of flavorings, colorings and assorted chemicals to feed the fast-growing electronic cigarette industry.

tobacco lung cancer
Tobacco users are more expensive to insure.

These “e-liquids,” the key ingredients in e-cigarettes, are powerful neurotoxins. Tiny amounts, whether ingested or absorbed through the skin, can cause vomiting and seizures and even be lethal. A teaspoon of even highly diluted e-liquid can kill a small child.

But, like e-cigarettes, e-liquids are not regulated by federal authorities. They are mixed on factory floors and in the back rooms of shops, and sold legally in stores and online in small bottles that are kept casually around the house for regular refilling of e-cigarettes.

Evidence of the potential dangers is already emerging. Toxicologists warn that e-liquids pose a significant risk to public health, particularly to children, who may be drawn to their bright colors and fragrant flavorings like cherry, chocolate and bubble gum. It sounds like a familiar formula for tobacco companies.

Source: http://www.nytimes.com/2014/03/24/business/selling-a-poison-by-the-barrel-liquid-nicotine-for-e-cigarettes.html?smid=tw-share&_r=0

E-Cigarettes Under Fire

E Cigarettes More Harmful Than Tobacco Products

Editor’s Note: E-cigarettes are being marketed as a safer alternative to traditional smoking methods. The chemical used to create the vapor that companies put into these electronic smoking devices contains propylene glycol, more commonly known as anti-freeze (read below). It’s a poison and a carcinogen. 

You may have already seen e-cigarettes — electronic cigarettes — for sale on the Internet or at one of at least 62 kiosks at malls across the U.S. It’s implied that e-cigarettes are safer than cigarettes. But until e-cigarettes are proven safe, the FDA is refusing to let them into the country and may soon ban their sale, as major U.S. medical associations have asked.

E-cigarettes don’t help people quit smoking. They are not safe, according to critics.

“We have an open investigation into this issue,” FDA spokeswoman Rita Chappelle tells WebMD. “What is happening right now is FDA has reviewed several e-cigarettes, e-cigars, and e-pipes, and have refused entry of these products into the country. We acted because these products appear to require FDA approval for marketing, and have not been reviewed by the agency.”

An informal FDA review of some of these products “indicated that these products are not currently approved,” Chappelle says.

If the FDA bans e-cigarettes, an action many observers believe imminent, it won’t be the first North American agency to do so. Last month, Canada’s health agency banned the importation or sale of e-cigarette products.

What’s all the fuss about? At the heart of the issue is a debate over what the e-cigarette really is.

The e-cigarette comes in many shapes and sizes. Many look more or less like long cigarettes; others look like cigars or pipes. They all work the same basic way:

  • The user inhales through a mouthpiece.
  • Air flow triggers a sensor that switches on a small, battery-powered heater.
  • The heater vaporizes liquid nicotine in a small cartridge (it also activates a light at the “lit” end of the e-cigarette). Users can opt for a cartridge without nicotine.
  • The heater also vaporizes propylene glycol (PEG) in the cartridge. PEG is the stuff of which theatrical smoke is made.
  • The user gets a puff of hot gas that feels a lot like tobacco smoke.
  • When the user exhales, there’s a cloud of PEG vapor that looks like smoke. The vapor quickly dissipates.
  • E-cigarettes contain no tobacco products; even the nicotine is synthetic.

The devices retail for $100 to $200. Refill cartridge packs vary in price depending on nicotine content, and liquid for do-it-yourself refills are sold, too. Each cartridge is good for several uses.

Different e-cigarette marketers stress different points:

  • For smokers who don’t plan to quit tobacco, some firms point to e-cigarettes as a way to “smoke” in smoke-free environments such as airplane lounges, restaurants, and workplaces.
  • For smokers who don’t want to give up their nicotine addiction, some firms suggest that switching to e-cigarettes will reduce the harm of their habit.
  • For smokers who want to quit, some firms suggest that e-cigarettes may help people transition from smokers to nonsmokers (the World Health Organization has asked marketers not to make this claim).

Craig Youngblood, president of the InLife e-cigarette company, says that since regular tobacco is very bad for you, something that assuages your nicotine habit without smoke must be less bad.

“In our product you have nicotine or no nicotine, PEG, and some flavoring. In cigarettes you have nicotine, PEG, and 4,000 chemicals and 43 carcinogens,” Youngblood tells WebMD. “There are 45 to 50 million people already addicted to nicotine. Should they have the choice to satisfy their addiction by other means? … I am a proponent of harm reduction. People have rights and choices and should be allowed to make them.”

Youngblood says his company makes no health claims. He rejects the idea that his product is a smoking cessation device and says his company does not make that claim. He also says his product is not sold to minors.

E-cigarettes Deadly, But Green

“There is no pollution of the environment with this product,” he says. “The vapor is not the same as smoke. And for every odor-free e-cigarette cartridge people throw in the trash, smokers throw 20 smelly cigarette butts out their car windows.”

Some firms do suggest that e-cigarettes are safer than tobacco cigarettes. Most point to a Ruyan-funded study by tobacco researcher Murray Laugesen, MBChB, of Health New Zealand, a private research firm.

Laugesen analyzed Ruyan e-cigarettes and found nothing inherently bad in them — that is, they contained what they said they contained and posed little threat of immediate harm. But this was not a clinical study, notes Norman Edelman, MD, chief medical officer of the American Lung Association, one of the organizations that has called for an FDA ban on e-cigarettes.

“Laugesen is trying to project what the effects of e-cigarettes might be, but he doesn’t really know,” Edelman tells WebMD. “There are no clinical studies of long-term use of these products.”

And some firms do claim that e-cigarettes help people quit smoking. After all, there’s an FDA-approved nicotine inhaler already in drug stores — Pfizer’s Nicotrol. It doesn’t look much like a cigarette, but it doesn’t look much different than some e-cigarette products.

“The Nicotrol inhaler is an approved smoking cessation device,” says the FDA’s Chapelle. “Because these e-cigarette products haven’t been reviewed by the agency, their labeling has to be reviewed, their intended use has to be reviewed, and all of their ingredients and components have to be reviewed.”

Edelman says nicotine addiction is bad and that people with the habit need help quitting, not help continuing their habit in more socially acceptable ways.

And there’s no proof that e-cigarettes don’t cause long-term harm. That’s what bothers all the health experts who discussed e-cigarettes with WebMD.

“We cannot say they are good or bad because we don’t have any scientific proof,” says Eliana Mendes, MD, a pulmonology researcher at the University of Miami.

“What happens to someone who stops inhaling the tars of cigarettes and just inhales nicotine? We don’t know,” Edelman says. “We are talking about use that might be three years, five years, 10 years, we just don’t know. Once you have the nicotine habit, you are not likely to quit.”

Rather than quit, e-cigarettes might worsen users’ nicotine habits, says Michael Eriksen, ScD, director of the institute of public health at Atlanta’s Georgia State University and former director of CDC’s office of smoking and health.

“I have seen no evidence that people switch from tobacco cigarettes to e-cigarettes or other smokeless tobacco products,” Eriksen tells WebMD. “If you look at how smokeless products are marketed, they are sold as something to use at times you can’t smoke. The implication is you will increase nicotine exposure, not reduce smoking. We’ll just be encouraging people to use more nicotine.”

Youngblood says his e-cigarette products are being marketed only to people who already smoke and already have a nicotine addiction. But Eriksen says the unregulated sale of these products might get new users hooked — users who might then start smoking.

“Will e-cigarettes get fewer people smoking? Or will people start with e-cigarettes and graduate to tobacco cigarettes? It is unknown whether these things are good, bad, or indifferent,” he says. “If for every person who used e-cigarettes there was one fewer person smoking tobacco cigarettes, that would be good. But there is no evidence that will occur.”

And there’s one more issue that troubles doctors. University of Miami pediatrician and lung specialist Michael Light, PhD, says underage users will get their hands on e-cigarettes — even if marketers like Youngblood refuse to sell them to minors.

“It will be easy for kids to get the product,” Light tells WebMD. “It could be a way to get kids into the nicotine habit to get them to smoke. It is a ploy.”

Source: http://www.webmd.com/smoking-cessation/features/ecigarettes-under-fire