E-cig marketing finds a ready teenage audience, and preventive messaging isn't keeping up; risks of nicotine are largely forgotten

                                             Medscape photo

By Melissa Patrick
Kentucky Health News

RICHMOND, Ky. -- Marketing messages for electronic cigarettes are resonating with Kentucky's teenagers, who said in focus-group interviews that teens use e-cigs because they are safer, non-addictive, and cool.

"Overwhelmingly, those first responses were about safety and less harm," Amy Jeffers, director of Pathways Regional Prevention Center, said May 2 at an e-cig prevention conference in Richmond. "What we know is the messages that the manufacturers and sellers are getting out is getting through to kids and unfortunately, for a lot of kids, when they hear 'safer,' the 'er' drops off and it just becomes 'safe'."

Ramakanth Kavuluru, an assistant professor in the division of biomedical informatics at the University of Kentucky, told the conference that his research found 71 percent of e-cig tweets convey a positive message about the products and that 50 percent have a "marketing theme." He also noted that reputable news sources and federal agencies, such as the Food and Drug Administration, send only 5 percent of the tweets about e-cigs.

The focus groups, conducted by five of the regional prevention centers last year, involved 82 middle- and high-school students who were asked about their perceptions and observations about teen use of e-cigarettes in their area.

In addition to the aforementioned reasons, the student participants said teens use e-cigs because they are "less harmful" than traditional cigarettes, and because they are "fun" and "different."

"Kids think these are safe because they don't hear negative things about them like they do all the time with regular cigarettes and stuff," said one of the students.

When asked why they are so appealing, once again the students said teens perceive them to be "less harmful" than traditional cigarettes, but they also added that they are "cleaner," the "lesser of two evils," and can be used as a cessation product. Others noted that they were "easier to hide."

                            Huffington Post photo

Jeffers said these responses show that while teens are getting the message from the vaping industry that e-cigs are safe, they earlier got the message that tobacco products are bad for them. Teen smoking rates in Kentucky have dropped greatly, to 16.9 percent in 2015 from 47 percent in 1997. Nationally, the rate dropped to 10.8 percent from 36.4 percent.

More teens are using e-cigs. In 2015, 23.4 percent of Kentucky high school students said they had used an electronic vapor product in the past 30 days and 41.7 percent said they had ever used them, according to the Youth Risk Behavioral Surveillance Survey. Nationally, these rates are 24.1 percent and 44.9 percent, respectively.

"Prevention messages about the dangers of smoking cigarettes have worked," Jeffers said."But unfortunately, in our efforts, the villain became smoke, and not the nicotine addiction, and so we need to change that."

E-cigarettes deliver nicotine through an aerosol by using a battery to heat a solution of propylene glycol or vegetable glycerin, with flavoring and other additives.

Nicotine is highly addictive and can pose a danger to the developing brains of children and pregnant women.

"Human brain development continues far longer than was previously realized, and nicotine use during adolescence and young adulthood has been associated with lasting cognitive and behavioral impairments, including effects on working memory and attention," says the American Lung Association.

"No use of nicotine is safe during pregnancy," said Kristin Ashford, associate professor and assistant dean of research at the UK College of Nursing.

Nicotine exposure in pregnancy can harm the developing fetus, and cause lasting consequences for the developing brain and lungs, the lung association says. Exposure can also result in low birth weights, pre-term delivery, stillbirth and sudden infant death syndrome.

And while many teens and adults alike often think that the vapor from an e-cig is nothing more than a water-based vapor, it is actually an aerosol that contains ultra-fine particles and varying amounts of nicotine and toxins, including benzene, formaldehyde and tobacco-specific nitrosamines, which are all carcinogens. This is why health advocates want e-cigs covered by all smoke-free laws and other policies, as Louisville is planning to do.

Jeffers said teens don't like the word "e-cigarettes" because they don't want to be associated with anything connected to the word cigarettes. Instead, they use the word "vape" or "vaping."

The students said they weren't allowed to use e-cigs in schools or other public places, but also said teens often do so with little repercussion, or their communities had no restrictions. As for their parents, they said parents don't approve of smoking, but some may not care about e-cigs because they think they are "safer" and don't know much about them, "so they don't care."

While e-cigs can be an alternative to smoking, they also lead teens to tobacco. "The odds of transitioning from vaping to smoking when compared with never-smokers transitioning to smoking, they are six times more likely, " Kavuluru said. "A six times higher odds ratio is really high."

Ad for e-liquid (tobaccostanford.edu)

Students were asked why e-cigs are so appealing to teens who have never smoked. They answered that it is because of the "flavors" and because they have a desire to "fit in" and "look cool."

The liquid used in e-cigarettes comes in thousands of flavors, with many of them marketed toward youth, though the industry denies this, including cotton candy, bubble gum, cookie dough, unicorn puke and unicorn poop, to name a few.

"It smells better than regular tobacco and they don't make your breath smell and your teeth nasty to look at," said one of the students.

But, alarmingly to health advocates, the students also said "peer pressure" was one of the reasons teens who have never smoked are using e-cigarettes.

"Peer pressure is a word we had not heard in a long time," Jeffers said, adding that teens in previous focus group discussion about traditional cigarettes have said no-one ever pressured them to smoke traditional cigarettes "because we all know it's bad."

"I haven't ever felt peer pressure to use regular tobacco and dip and stuff, but everybody wants you to try this," a student said.

Students also said marketing makes the products appealing to teens. Jeffers noted that kids see these products everywhere and pointed out that Kentucky's towns are full of vape shops.

                                                                            Vaporferver photo

Other questions revealed that teens prefer the tank style or "mods" when they are with friends, but use the smaller devices when they want to hide them from parents and adults. Asked how they got them, they said teens either get them from older teens, who often sell them for a profit, buy them on the internet or steal or borrow them from their parents. The discussion revealed that adults who use e-cigarettes typically have a collection of them, so they are seldom missed.

The teens were well aware that e-cigs are used to smoke marijuana, as well as hash oil and bath salts. Some of the students said they had heard of adults using them for heroin, crack and methamphetamine.

All speakers at the conference said more research is needed on these products. Kavuluru told the group that 90 percent of scientific papers on e-cigs have been done since 2014.

And while recognizing that these products are likely safer than traditional tobacco products, they said it is misleading to call them safe, adding that most research does not support the claim that they are an effective cessation tool, and most e-cig users are dual users. All agreed they are not meant for teen use.

Jeffers encouraged communities to do similar assessments to determine the scope of teen e-cig use in their communities. She called for more education and more preventive messaging. She also called for policy support, through increased regulation, taxation and 100 percent smoke free laws that include e-cigs.

"What we know, even going into schools and talking to adults -- principals, teachers -- nobody wants to talk about e-cigarettes because they say they don't know anything about them," she said.