Tuesday, December 18, 2018

Surgeon general issues national advisory on epidemic use of youth e-cig use; all agree it will take everyone to curb epidemic

By Melissa Patrick
Kentucky Health News

Electronic-cigarette use among teens is so widespread that the top U.S. public health official has issued a rare national advisory stressing the importance of protecting children from such devices, saying they are setting them up for a lifetime of nicotine addiction and associated health risks.

"We are in the midst of a historic and unprecedented increase in youth use of any substance," Surgeon General Jerome Adams said during a Dec. 18 news conference when he announced the advisory.

Federal research released in November showed a 78 percent increase in e-cigarette use among high-schoolers between 2017 and 2018, with the number of users surpassing 3 million. The same report showed use by middle schoolers increased 48 percent from the year before.

And this week, a National Institute on Drug Abuse study of 45,000 eighth, 10th and 12th graders found similar increases, with vaping among high school students near doubling from 11 percent in 2017 to 21 percent in 2018. In addition, this study found that nearly 8 percent of 12th graders used e-cigs to vape marijuana.

Elizabeth Anderson-Hoagland of Kentucky's Tobacco Prevention and Cessation Program said in a state-issued Facebook post about the surgeon general's advisory that while the latest research doesn't include state specific numbers, this uptick in e-cig use among teens is also a problem in Kentucky.

"Schools are saying that kids are using them in the classrooms, using them in the hallways, using them during games," she said. "It's just everywhere. It's really exploded"

Foundation for a Healthy Kentucky photo
E-cigarettes come in all shapes and sizes, but the most popular one is the Juul, which looks like a USB flash drive. Kids love them because they are easy to hide, are essentially odorless and come in flavors they like. Juul commands about 75 percent of the market.

Another problem is that youth don't realize e-cigs are harmful, and don't know they contain nicotine, which is highly addictive and harmful to brain development. In fact, one Juul pod can have as much nicotine as a pack of cigarettes and even products that are advertised as nicotine-free have been found to contain nicotine.

"Once they try the flavors, they get the nicotine hit -- and they don't realize that most products contain nicotine," said Anderson-Hoagland. "So they come because it taste good, and they stay because it's addictive."

Teens also have the misconception that they emit a harmless water vapor, when in fact they can contain harmful substances, including" ultrafine particles that are inhaled into the lungs, flavorings such as diacetyl, volatile organic compounds, heavy metals and cancer-causing chemicals," according to a Foundation for a Healthy Kentucky news release.

"So in those very important adolescent years when a child's brain is developing, these compounds can have very negative impacts," Dr. Jeff Howard, commissioner of the state Department of Public Health, said in the Facebook post.

The e-cigarette problem is so prevalent that the U.S. Food and Drug Administration has called it an epidemic, prompting the agency to implement and advise for stricter measures to keep the products out of teens' hands. They include, among other things, a crackdown on flavored products, which teens report is the main reason they start using the products.

The surgeon general said that while we are "late to the game" on this issue, everyone has a role to play in stopping this epidemic: parents and kids, teachers and administrators, health professionals, state and local governments and the federal government.

Juul has recently run large newspaper advertisements touting it as a device that helps smokers quit tobacco. Adams said neither he nor FDA Commissioner Scott Gottlieb "are against exploring the harm-reduction potential of these products, but we will not stand for another year of exponential, unprecedented, historic rises in youth use of these products."

At an e-cigarette conference held Dec. 10 in Louisville, Brian King, deputy director for the Office on Smoking and Health at the federal Centers for Disease Control and Prevention in Atlanta, pointed out that cessation is a necessary prerequisite for e-cigs to be considered a harm reduction product, and so far research does not support that this is the case.

"In the end, if we're going to have a benefit from e-cigarettes, the adult cessation has to outweigh youth initiation and that is simply not what we are seeing, particularly as we are seeing skyrocketing rates of use among youth. Remember, you have 2.8 percent of adults using the product and 21 percent of high school students. A seven- to eight-fold higher rate of use among kids compared to adults and that is why the public health community is so justifiably outraged over what we are seeing. We cannot leave kids behind in this discussion of harm and risk reduction among adults and we don't even have a product that has been effectively proven to help adult smokers quit," he said.

In Kentucky, about the same number of high-school students smoke cigarettes as use e-cigs, 14 percent. But health advocates warn that e-cig use is likely much higher among the state's youth because the survey was taken before the introduction of Juul and Juul-like products.

Howard echoed the surgeon general's call to action: "I'm very concerned about the use of electronic cigarettes and I encourage all parents, educators and community members to join me in making sure our teens and youth are aware of the risk of electronic cigarettes and doing as much as we can to prevent the use of electronic cigarettes in this population."

CDC image
Anderson-Hoagland was more specific in what needs to be done to stop this epidemic, calling for communities to enact tobacco-free smoke policies that include e-cigarettes, 100 percent tobacco-free school policies, and increased education about these products aimed a both adults and teens.

"We've been down this road before with regular cigarettes, so really we need to use the same playbook for e-cigarettes," she said.

King, of the CDC, added price increases, increased access to proven cessation products and mass media campaigns to this list of ways to stop this epidemic. As of now, Kentucky does not tax e-cigs, nor do they fall under the definition of tobacco in the state, though they are included in the federal definition.

"When it comes to tobacco control, prevention is key," King said. "We've got to stop those nine in 10 adults who began as youth from starting altogether. When you implement these [policies] in the context of effective regulation, you are going to get effective prevention measures that impact the population."

The American Cancer Society Cancer Action Network commended the surgeon general's advisory, but said more federal regulation is necessary to get in front of this epidemic.

“While a number of states and communities have begun to take action to address this epidemic across the country, community level action alone cannot solve this crisis. The most substantial way to begin reversing this epidemic of e-cigarette use among youth is for the [FDA] to exercise its full regulatory authority and conduct the legally required review of e-cigarettes and cigars, including prohibiting their use of flavoring, in order to be on the market," it said in a statement.

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