Vaping has exploded in popularity in recent years — but not among the people it was intended for. Rather than adults trying to quit smoking, young people who’ve never picked up a cigarette are now vaping in record numbers.
According to a new Vital Signs report, published by the Centers for Disease Control and Prevention, in 2018, some 4.9 million high school and middle school students used tobacco in the last 30 days, an increase from 3.6 million in 2017. E-cigarettes were the most popular tobacco product among the children and adolescents.
The report follows a late 2018 National Institutes of Health survey, which tracked substance use among American adolescents. It found the number of high school seniors who say they vaped nicotine in the past 30 days doubled since 2017 — from 11 percent to nearly 21 percent. That was the largest increase ever recorded in any substance in the survey’s 43-year history. And it meant a quarter of 12th-grade students are now using, at least occasionally, a nicotine device that’s so new we have no idea what the long-term health impact of using it will be.
Young people’s extraordinarily rapid uptake of nicotine-delivery devices is one of the reasons Food and Drug Administration director Scott Gottlieb called for stronger regulations Monday. “Based on a growing body of evidence, I fear the youth trends will continue in 2019, forcing us to make some tough decisions about the regulatory status of e-cigarettes,” he said in a statement. “The signs that we’re seeing are not encouraging.”
The reason for the concern: Nicotine is a highly addictive substance and can cause immediate harmful side effects in young people’s developing brains and bodies. There’s some evidence that nicotine exposure may prime the developing brain to become more sensitive to substance use disorders later. Trying to quit nicotine can lead to serious withdrawal symptoms, including nervousness, restlessness, anxiety, sleepiness, and fatigue.
There’s also strong evidence of a potential long-term impact: that vaping may encourage kids to smoke. “After years of progress in reducing youth cigarette smoking, today’s report shows … a stall in progress in reducing youth cigarette use and possibly even an uptick among high school students,” Matthew Myers, president of the Campaign for Tobacco-Free Kids, said in a statement. (That’s because the high school smoking rate went from 7.6 percent in 2017 to 8.1 percent in 2018.)
“The kids using e-cigarettes are children who rejected conventional cigarettes, but don’t see the same stigma associated with the use of e-cigarettes,” Gottlieb added. “But now, having become exposed to nicotine through e-cigs, they will be more likely to smoke.”
This may be only the beginning. Like the cigarette industry before it, vaping companies have found effective ways to market their wares to young people. The way they design and pitch their products packs a dual punch: They are both high-tech and highly addicting. That’s left regulators scrambling to keep up, and a big question mark about what vaping nicotine might mean for the health outcomes of this new generation.
The way nicotine is marketed has changed
To understand the surge in vaping among youth, you need to understand Juul, the popular — and controversial — e-cigarette that many argue helped vaping nicotine go viral.
The company’s stated mission is “improving the lives of the world’s one billion adult smokers.” Created by two former smokers and Stanford design graduates (one of whom also worked as a design engineer at Apple), the duo wanted to make a device that looked sleek and attractive:
So they designed an e-cigarette that could easily be mistaken for a USB flash drive and can fit in the palm of the hand.
But here’s the thing: Not only is the device slick, but its pods pack as much nicotine as one to two packs of cigarettes. Juul also contains three times the nicotine levels permitted in the European Union, which is why Juul can’t be sold there.
So the appeal of Juul — with its high-tech design — is “compounded by its addictiveness,” said Michael Eriksen, dean of the school of public health at Georgia State University and a former director of the Centers for Disease Control and Prevention’s Office on Smoking and Health, “and I think that explains the rapidity of the uptake.”
In 2017, the US market expanded by 40 percent to $1.16 billion, with a lot of that growth driven by Juul.
As of March, Juul made up more than half of all e-cigarette retail market sales in the US, according to Nielsen data. Considering it has only been on the market since 2015 and there are hundreds of other devices available to consumers, Juul’s market share is staggering.
Marketing nicotine expressly to youth isn’t new. In the 1990s, when Eriksen was an expert witness for the Federal Trade Commission’s crackdown on Big Tobacco’s marketing of cigarettes to youth, he explained that tobacco companies like Reynold’s and Marlboro targeted their ads at young people. “They were consolidating around the imagery of the cowboy, [signaling] independence,” he said.
But what’s new, said Eriksen, is “this combination of innovation, social media spread, and the fact that it’s unfortunately addicting at the same time.”
A recent analysis of Juul’s early ads, out of Stanford, showed Juul employed social media influencers and ads that deliberately targeted youth.
An unscientific survey of high schoolers and teachers confirmed Juul’s virality. “I don’t recall any fad, legal or illegal, catching on in this way,” Meg Kenny, the assistant head of school at Burr and Burton Academy in Manchester, Vermont, who has worked in education for 20 years, told Vox in April. Students at her school were Juuling in bathrooms, in class, and on the bus. Because it’s against the school’s rules, they were also hiding the devices in ceiling tiles and in their bras and underwear.
Regulators are scrambling to keep up
The surge of teen vaping has left addiction specialists wondering how to best help young people who want to quit. It’s also left health regulators scrambling and sluggish in their response to the trend.
Here’s the conundrum: It’s true that e-cigarettes do hold potential to help adult smokers move on to a less deadly alternative. That’s why they’re widely viewed as potential harm-reduction tools. But regulators have been struggling with how to strike a balance between curbing the uptake of e-cigarettes in minors while also helping smokers quit. In the meantime, youth vaping exploded.
In July 2017, the FDA delayed the compliance deadline for the regulation of e-cigarette products to 2022. This gave the industry five more years to file public health applications that show that their products are safe alternatives to conventional cigarettes and that they weren’t unduly targeting minors.
Gottlieb positioned the delay as a way to give manufacturers time to get in step with the new laws while ensuring smokers had access to cigarette alternatives that could save their lives. But some health advocates viewed it another way: as a giveaway for the vaping industry, and a chance for e-cigarette makers to further expand their market share among kids at a time when e-cigarette use by teens has eclipsed conventional cigarette use.
It turns out those advocates may have been right. “I don’t want anyone to think I’m against the harm-reduction potential of these devices for adults,” Surgeon General Jerome Adams said on Politico’s Pulse Check podcast in December, explaining his call for new regulations that might curb youth vaping, including taxes and indoor vaping bans. “But 3 percent of adults are using these devices — [and] 20 percent of high schoolers are using these devices.”
More recently, the FDA has been taking action against Juul and teen e-cigarette use — but has stopped short of changing the compliance deadline. In April, the FDA took the unusual step of demanding Juul Labs submit documents about its marketing and research and what it knows about Juul use among young people.
In May, the agency followed up by sending requests for information to four other e-cigarette makers that also appear to be marketing to young people.
In November, the agency said it would restrict the sales of flavored e-cigarettes in stores and online — though it wouldn’t outright ban vape flavors in brick-and-mortar retailers, a move that was widely anticipated after leaked reports from the FDA ahead of the news.
And some wish the FDA would go further. “The mass marketing of cigarettes, a highly sophisticated, addictive, and defective nicotine delivery device that kills over 7 million people globally every year, is an abuse of corporate power and a human rights violation,” said Laurent Huber, Executive Director of ASH, an anti-tobacco nonprofit, in November. “Banning menthol is a step in the right direction, but it is time to go one step further and phase cigarettes out of the market to prevent millions of unnecessary deaths.”
I checked back with Meg Kenny, the assistant head of school at Burr and Burton Academy in Vermont, about Juuling on her campus. She says it appears to have cooled off this winter. While 95 percent of disciplinary infractions at the school were connected to Juul last fall and spring, 50 percent were this fall.
Maybe the awareness and crackdowns are having an impact. Or maybe the Juulers have moved on to cigarettes or have gotten better at hiding the habit. By next year’s youth tobacco surveys, we’ll have a preliminary answer.
For more on Juul and e-cigarettes, read our explainer, listen to the May 3, 2018, episode of Today, Explained, and watch our Vox video here.