Vaping and e-Cigarettes in Kids: An Unprecedented Epidemic

Medscape: On December 18, 2018, the US Surgeon General officially declared e-cigarette use among youth an "epidemic." While national data show that smoking rates are down, the rate of vaping in teens has skyrocketed. According to the 2018 Monitoring the Future survey, which included over 40,000 teens nationwide, 21% of 12th graders reported vaping nicotine during the past 30 days That is double the rate reporting use in 2017. Similar increases were seen in kids as young as sixth grade.

This comes on the heels of an announcement in September from the US Food and Drug Administration (FDA) that the agency is implementing actions to reduce the access and appeal that these products have to children younger than age 18 years, principally by targeting flavored e-cigarettes.

I am Laurie Scudder, editorial director at Medscape. I am at the offices of the Department of Health and Human Services and am honored to be joined by both the US Surgeon General, Vice Admiral Jerome Adams; and the FDA Commissioner, Dr Scott Gottlieb, to discuss this public health emergency.

Dr Adams, I would like to begin by asking you a fundamental question. Why is this so concerning? What are the health risks of e-cigs and why are they particularly harmful for kids?

Vice Admiral Jerome M. Adams, MD, MPH: As you noted, in December 2018 I released an advisory calling this an epidemic, and I really meant that. This was a sudden and unexpected increase over baseline in the number of youth using e-cigarettes and related products. When we look at data going back to 1975, we have never seen a jump in youth use of any substances even close to the order of magnitude of this increase. You ask what's concerning about it. I have three kids of my own—14, 13, and 9 years old. Like many kids, when I ask them what they know about e-cigarettes, they reply that it is harmless water vapor. Absolutely not. We know that many of these substances contain nicotine. As a matter of fact, the most popular product that children are using is JUUL, which cannot be obtained without nicotine. But we also know that a third of young people who do report that they are vaping are vaping marijuana. That substance is in addition to all of the other chemical substances that are included in vaping mixtures. Many of these mixtures are made bootleg and can harm youth in so many ways.

Scott Gottlieb, MD: We know that nicotine has direct effects on a developing brain. These products are not safe in children or adolescents. We also know that some percentage of teens using these products will become addicted to nicotine. Some percentage are going to migrate onto combustible tobacco products with all of the associated health risks. The common argument you will hear from proponents of vaping products are that at least these kids are not smoking regular cigarettes. When we look at the data, the kids who are using the vaping products are kids who see a stigma associated with combustible tobacco but don't see the same stigma associate with the vaping products. What is happening is that we are addicting a generation of kids on nicotine through these vaping products, some percentage of whom will go on to use regular cigarettes. All of the dramatic gains that we've made in reducing smoking rates in this country among youth will decline.

Adams: That is a great point that Dr Gottlieb makes. We have seen youth use of all tobacco products steadily going down. Unfortunately, now we're seeing that trend start to be reversed because of the epidemic and unprecedented rise in use of e-cigarettes. We see new-onset use of all tobacco products by youth starting to go back up again.

Medscape: Dr Adams, you noted that kids don't seem to get that this is a dangerous product that indeed contains nicotine. It would seem that that must be where we've got to target our efforts, by correcting that misperception that these products are not hazardous.

Adams: When we look back at the lessons learned from combustible cigarettes, we know that youth used combustible traditional cigarettes, first, because they thought they were cool. Second, they thought they were safe. They didn't think there was any harm. In 1964, one of my predecessors, Surgeon General Luther L. Terry, put out the first ever Surgeon General's report on smoking. That settled the issue of whether tobacco use was harmful to your health.

Both younger and older people out there think that because these electronic cigarette products are less harmful than combustible cigarettes, that this is the same thing as saying that they are harmless. They are not harmless. As Dr Gottlieb mentioned, they can affect learning, attention, and memory. Apart from the health effects, we know that this is also becoming a social problem in schools. You can't go into the bathrooms because so many people are JUULing. There are kids that have to leave classrooms to go out and support their nicotine addiction. So there are a bevy of effects that we are seeing that are negative for our youth.

The Case for e-Cigarettes in Adults

Medscape: Dr Gottlieb, you noted that one of the reasons kids do not smoke is the stigma associated with that activity. That is a direct result of the Surgeon General's report to which you referred, Dr Adams. I'd like to take a minute and talk about adult smokers. Some have advocated that these e-cigarette products are a good risk-mitigation strategy for adults who cannot or are unwilling to quit smoking. The argument is that they are not harmless but they sure beat combustible tobacco products. Is that true?

Gottlieb: We believe it is true. These products need to be put through an appropriate series of regulatory gates. We need to prove that proposition. However, at face value, we believe that these products pose less risk than combusting tobacco. If you can fully switch every currently addicted adult smoker who is using combustible tobacco products onto e-cigarettes, you will have a profound impact on public health. And some people are able to switch completely. We think that is a public health benefit.

However, we also see a lot of dual use. We are not certain that use of an electronic product to reduce overall use of combustible tobacco—without quitting completely—really does have a significant health benefit for that individual. These could be good smoking-cessation products to help currently addicted adult smokers—who want to achieve satisfying levels of nicotine but don't want all of the harmful effects of combustion—migrate off of cigarettes. Remember that nicotine, for the most part, while not a completely benign substance, is not what causes all of the death and disease associated with smoking; it is the combusting of the tobacco.

What we are seeing is a generation of kids getting addicted to nicotine through these e-cigarettes.

Adams: I think it is important, as Dr Gottlieb suggests, that we separate the two arguments out. The science is very clear that nicotine is uniquely harmful to the young, developing brain. It is also clear, based on the new data, that youth use is rising in an unprecedented way.

We want to separate that out from the fact that we still need to do more work in terms of making sure we can maximize the harm reduction potential of these products for adults. Most of the adult e-cigarette users in the United States are dual users. Unfortunately, we are finding out that, in some cases, people are consuming much more nicotine than what they would have if they were just smoking alone. Vaping products have so much nicotine in them. And smokers are stacking them on top of traditional cigarettes.

As Dr Gottlieb said, if you can switch over completely—and this is important for your listeners to understand—then, yes, we both fundamentally agree that vaping is less harmful than smoking a combustible cigarette. However, if you are smoking the same amount of combustible cigarettes and reinforcing your nicotine habit by vaping or JUULing when you cannot get to a regular cigarette, that is actually exposing users to more harmful chemicals and making it harder for them to eventually quit.

Gottlieb: That's why part of the FDA policy that we announced last fall was to regulate nicotine levels in combustible cigarettes—to render combustible cigarettes minimally addictive and lower the nicotine level. At the same time, we made accommodations to push off application deadlines on the electronic nicotine delivery systems like e-cigarettes. We saw a historic opportunity to use tobacco regulation to regulate nicotine combustible products so they could not sustain addiction. At the same time, we provided a regulatory path for these new products for use in adults who still wanted to get access to nicotine but no longer could do it through combustible products. That was the comprehensive plan. What we said at that time and have continued to say since is that that accommodation could not come at the expense of addicting a whole generation of kids to these electronic vaping products. In fact, what we are seeing is a generation of kids getting addicted to nicotine through these e-cigarettes.

Practical Advice for Clinicians

Medscape: You have both made it clear that clinicians certainly need to be addressing this with patients. Our smoking history with our patients must expand to also include vaping products. So, what other specific strategies would you recommend for clinicians to address this issue within their own practices?

Adams: An important opportunity lies in the annual physical that we offer to folks. When adults come in, we certainly should be asking about vaping. But we also have to ask that question of young people. We have heard stories of elementary schoolers JUULing. It is never too early to ask a child and parent about e-cigarettes. Do you know what they are? Are you familiar with these devices? Clinicians need to help them understand that they aren't just harmless water vapor. They do in fact contain nicotine, potentially marijuana, and a number of other dangerous substances. They can cause you to become addicted to nicotine for the rest of your life.

Gottlieb: Another key point I'd like to make: Kids don't necessarily think that some of these products are vaping products. If they are using a JUUL product, for example, they might not necessarily think that they're vaping. They might say that they are JUULing. For the first time, the National Youth Tobacco Survey, which will be launched this spring, will ask children not only whether or not they vape, but whether they are using JUUL or another specific brand. I would urge clinicians to not just ask questions about vaping but actually query kids about some of the common brands.

Adams: Exactly. Clinicians are important influencers [and need to be part of the conversation] as their communities begin talking about these products. We need to make sure that we are exploring the same evidence-based policies that have allowed us to lower smoking rates. This includes clean-air laws as well as making sure that local regulations and policies are appropriate—for example, that local schools have a no-tolerance policy for these products and can maintain an environment that allows our kids to grow up nicotine-free.

Regulatory Controls: What's in the Pipeline?

Medscape: Dr Gottlieb, you referred to some of the regulations that FDA has put in place. In September, you issued letters to the five major e-cigarette manufacturers who supply virtually the entire market and asked them to be a part of addressing this problem and reducing access for kids. Have they complied with that request?

One of the primary places where kids are getting access to these products are convenience stores.

Gottlieb: Some companies have taken certain voluntary steps that they have announced publicly. Some have made commitments privately to the agency. However, we are not dependent upon their voluntary action. This was an interim step while we put in place our regulatory framework for how we intend to try to reduce access and appeal of these products to kids. We are doing that primarily by putting in place significantly heightened age-verification requirements at the point of sale for flavored products. It will be much more difficult to sell a flavored product to a child. One of the big drivers behind the appeal of these products for youth are the flavors. And one of the primary places where kids are getting access to these products are convenience stores. So we are targeting these products at the point of sale.

If we are not successful in dramatically reducing youth use of these products and changing the trajectory of this epidemic, I worry that this potential opportunity for adults to use these products as smoking-cessation tools will be lost. If we can't adequately address the youth use of these products, it is an existential threat to this product category.

Adams. I could not agree more. The biggest threat to availability of these products for adults is a failure to act on this epidemic of young people accessing these products.

Medscape: Will these same restrictions be applied to online sales?

Gottlieb: Yes. We will also put in place these same age requirements, though, in some instances, you can actually conduct better age verification online. For example, think of wine-of-the-month clubs, which require an adult signature on delivery. There are ways to do online sales with pretty tight controls on the point of purchase to make sure that the customer is an adult. It is not 100% safe because nothing is. But we will put forward guidance on how to implement those measures for online sales as well. Only a small portion of the sales are online right now; most are at brick-and-mortar establishments.

Adams: It is important for providers to go to the FDA and Surgeon General's website just to familiarize yourself with what these products look like. In many cases, they look more like toys than electronic devices that deliver nicotine. It is important that you know not only what they look like but, as Dr Gottlieb mentioned, that their appeal is also due to flavors like cotton candy or, believe it or not, unicorn puke, and others that are designed to appeal to kids. Dr Gottlieb posted pictures on his Twitter feed of a juice box–flavored e-cigarette liquid. I visited a vape shop myself [to see these products] and they looked more like candy than like a nicotine delivery liquid.

Gottlieb: Kids are primarily using pod-based products with disposable cartridges rather than open-tank vaping systems, which are the more traditional device and skew more toward an adult population.

Practical Resources for Clinical Practice

Medscape: You referred to the Surgeon General website, Dr Adams. What kind of resources for clinicians are available there?

Adams: That's a great question. Yes, there are a number of tools on my site as well as links to FDA and CDC resources. We want providers to, first of all, know what these products look like. We also want them to understand that there are evidence-based methods out there to help both adults and young people quit smoking. This is the challenge that we face. Over 1.3 million youth used e-cigarettes last year. We now have young people who are addicted to nicotine. We have to lean on these evidence-based protocols and tools to get people off of nicotine.

We need providers to be part of the response team to turn around these unfortunate statistics.

Gottlieb: We're holding a workshop to look at how we develop evidence around the use of smoking-cessation tools and medicinal nicotine products in a pediatric population. We now have so many kids addicted to nicotine through these vaping products, that we need to develop science around cessation strategies in adolescents and younger children. These strategies will be different from the approach to the problem in adults. There are a lot of social factors that reinforce addiction in youth, so you're going to need more psychosocial support when using a medicinal nicotine product. You can't just give a medicinal nicotine product to a child.

Medscape: You both make a very compelling argument that we need to address this problem head-on. In conclusion, I'd like to ask you what is the one thing you want our clinician audience to take away from this interview?

Adams: I want them to take away that we are experiencing an epidemic rise in youth use. We have never seen anything like this before—a doubling in use rates by kids in 12th grade. Clinicians have a unique role to play. In regard to adults, we recognize the harm-reduction potential of these products. But we need to help adults understand that you only achieve harm reduction if you actually switch over from combustible cigarettes to e-cigarettes and vaping. We need to understand that these products are uniquely harmful to young people and can affect learning, attention, and memory. We don't want a new generation of young people to become addicted to nicotine. Unfortunately, public health comes late to the table far too often. We have a unique opportunity to jump in right as we're seeing this trend go up. We need providers to be part of the response team to turn around these unfortunate statistics.

Gottlieb: I think the Surgeon General got it right. I think that the one thing I would reinforce is that there is a perception among parents and children that these products are safe, much safer than cigarettes, and that has spread a certain complacency. Parents will be glad that at least their kid is not smoking. That is the wrong perception of these products. I think physicians need to reinforce that these products are dangerous to children.

Adams: Dr Gottlieb is better on Twitter than I am, but here's your tweet: Less harm does not equal harmless.

Medscape: That's the message. Thank you to you both. Thank you to our audience for being with us today. We hope we have provided some good information and tools for you to use in your own practices.

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