For the second time in two years, a U.S. surgeon general has sounded an alarm about the use of electronic cigarettes by youths.
Dr. Jerome Adams issued an advisory Tuesday to parents, teachers, health care and government officials encouraging them to stop children and teens from using e-cigs.
“I am emphasizing the importance of protecting our children from a lifetime of nicotine addiction and associated health risks by immediately addressing the epidemic of youth e-cigarette use,” Adams said.
Adams joined Dr. Scott Gottlieb, commissioner of the Food and Drug Administration, in referring to the surge in youth e-cig consumption as an epidemic. Adams cited many of Gottlieb’s recent recommendations about banning most e-cig flavors and targeting top-selling e-cig Juul in his presentation.
“The recent surge in e-cigarette use among youth, which has been fueled by new types of e-cigarettes that have recently entered the market, is a cause for great concern,” Adams said.
Juul, made by Juul Labs Inc., entered the mainstream retail marketplace in 2015, and is sold in the form of a pen or a USB device. That design makes it easy to hide, which Gottlieb has said is a contributing factor to teenage use.
Juul has a 76 percent market share, according to the latest Nielsen survey of convenience stores. Adams said the majority of Juul consumers between ages 15 and 24 do not realize most varieties contain nicotine.
Adams’ advisory came a day after an annual national report found that rates of traditional and e-cig use by youths continue to go in opposite directions.
The Monitoring the Future study by the University of Michigan found that 12th-graders’ consumption of traditional cigarettes — measured as at least once over a 30-day period — dropped again to a historic low of 7.8 percent compared with 9.7 percent in 2017.
Meanwhile, 26.7 percent of 12th graders said they vaped at least once during a 30-day period. That’s up from 16.3 percent when researchers began reviewing vaping in 2015.
Adams acknowledged the progress made in reducing traditional cigarette use by high schoolers in his report, but expressed concern that “the tobacco product landscape continues to evolve.”
“I don’t want anyone to think I’m against the harm-reduction potential of these devices for adults,” Adams said in a pre-release interview with Politico.
“But 3 percent of adults are using these devices — 20 percent of high schoolers are using these devices.”
Less confusion on e-cigs?
In December 2016, Dr. Vivek Murthy, the Obama administration’s surgeon general, was a little more cautious with his advisory. His main comment was that there’s no safe use of the products for people younger than 25.
“There is confusion around e-cigs and youths, are they safe to use?” Murthy said at that time.
“We know enough right now to say that youth and young adults should not be using e-cigarettes or any other tobacco product, for that matter.”
Murthy acknowledged his report didn’t aim to resolve the bigger public-health questions of whether e-cigs and vaporizers offer smokers — particularly adults — a reduced-risk alternative to traditional cigarettes, or whether they should be regulated like traditional cigarettes.
Some studies, including one by the Royal College of Physicians, have claimed e-cigs and vaporizers are up to 95 percent less harmful than traditional cigarettes. The Royal College’s study on traditional cigarettes played a key role in the landmark 1964 surgeon general’s determination.
Adams said the level of public health confusion has decreased around e-cigs in the past two years.
“Nicotine exposure during adolescence can harm the developing brain, which continues to develop until about age 25,” Adams said. “Nicotine exposure during adolescence can impact learning, memory and attention.”
Adams said that “using nicotine in adolescence can also increase risk for future addiction to other drugs,” although there are several studies that have shown e-cigs are not proving to be a gateway to traditional cigarette use.
Kimberly Wagoner, assistant professor of public health sciences at Wake Forest Baptist Health, said Monday in response to the Monitoring the Future report that her main concern with the increase in youth e-cig use is that “many of these products contain high levels of nicotine, which can lead to dependence.”
Gottlieb unveiled steps Nov. 15 that would ban all e-cig cigarette flavors except tobacco, menthol and mint, ban menthol traditional cigarettes, restrict flavored cigars and tighten online age-verification systems.
It is projected it will take years for the FDA to go through the regulatory process to implement the heightened restrictions, and the agency likely will face multiple lawsuits from tobacco manufacturers and anti-smoking groups.
Adams wants federal, state and local government entities to “implement evidence-based, population-level strategies to reduce e-cigarette use among young people that include: requiring e-cigs to meet smoke-free indoor air policies; restricting young peoples’ access to e-cigs in retail settings; licensing retailers; implementing price policies that could include excise tax increases on the products; and developing educational initiatives targeting young people.
Adams said he supports additional restrictions on e-cig marketing.
Juul said Nov. 14 it would temporarily only sell tobacco, mint and menthol flavors at more than 90,000 convenience stores and vape shops. The creme, cucumber, fruit and mango flavors being removed remain available at www.juul.com, but with heightened age-restriction policies and age-21 verification.
“Juul Labs shares a common goal with the surgeon general and other federal health regulators — preventing youth from initiating on nicotine,” the company said in a statement Tuesday.
“We are committed to preventing youth access of Juul products. We cannot fulfill our mission to provide the world’s 1 billion adult smokers with a true alternative to combustible cigarettes if youth use continues unabated.”
Altria Group Inc. has said it is exiting the e-cig business, which analysts say represents a precursor to a potential multi-billion-dollar investment in Juul.
Warning draws criticism
Adams’ advisory, much like Murthy’s, drew criticism from anti-smoking advocates for downplaying what they say is the positive public-health role e-cigs are playing with adult smokers.
“When the Surgeon General focuses only on the downsides of any alternative to cigarettes without the context of 500,000 annual deaths from smoking, we see the abstinence-only agenda winning out,” said David Sweanor, an adjunct law professor at the University of Ottawa and the author of several e-cigs and health studies.
“Instead, we need a rational policy discussion that focuses on reducing deaths and disease while pragmatically identifying and limiting unintended consequences. We need to focus on empowering rather than confusing the public.”
Scott Ballin, past chairman of the anti-smoking alliance Coalition of Science or Health, said he was not surprised by Adams’ advisory “given the position of other agencies within the federal government, FDA, CDC, National Institutes of Health.”
“The statement will actively be used by those in the tobacco control community to continue the hysteria against e-cigarettes.”
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