Let’s Teach Health – Chapter 5: E-Cigarettes Blow Up
November 25, 2019
The following is an excerpt from Let’s Teach Health, a forthcoming book from CATCH Global Foundation CEO, Duncan Van Dusen. The book will be available for purchase and digital download in Spring 2020. With a gift of $50 or more to CATCH Global Foundation this holiday season, you will receive a free signed copy of the book when it is published next year.
Let’s Teach Health
As If Each Child’s Life Depends On It, Because It Does
Chapter 5: E-Cigarettes Blow Up
How the epidemic of youth vaping happened and how health education can mitigate it
Q: What could possibly go wrong if we don’t take K-12 health education seriously?
A: The youth vaping epidemic.
As I write the seventh and final version of this chapter in the fall of 2019, it is clear from the daily news that the crisis of youth e-cigarette use, or vaping, is in full flame and a post-mortem is totally premature.
But we are far enough along to analyze the seeds of this ugly weed, and specifically how health education could have limited the problem and the role it can play in its eventual control and decline. Regardless of how the news proceeds, I bet the youth vaping tragedy will have a long shelf-life as a rallying cry for health education.
Where we are and why that’s a problem for youth
The FDA and CDC’s annual National Youth Tobacco Survey concluded that in 2019 5.3 million middle-and-high schoolers “currently” used e-cigarettes (i.e. in the past 30 days), up a staggering 152% from 2.1 million in 2017.
The health dangers of typical e-cigarettes to kids include nicotine’s known addictive properties, potential harm to brain development, and other effects, and the unknown long-term health impacts of inhaling the other chemicals that travel with it. I say “typical” because e-cigarettes and vaping were for a while synonymous with the delivery of nicotine, but have come to encompass THC, CBD, and many other chemicals that are aerosolized and inhaled. So although vaping is really a behavior and not a specific drug, we will focus here on nicotine since most school-age vapers use mass-market e-cigarettes which contain it (including all JUULs, their favorite brand).
Nicotine is uniquely dangerous to youth because the farther your brain is from reaching full development around age 26, the more susceptible you are to addiction to it. Almost ninety percent of adult tobacco users took up the habit before age 18, and 99% before age 26. (This fact should make everyone skeptical of claims from the nicotine business that they don’t want youth using their product. Without addicting youth, simple math will kill their business in a generation or two.)
In addition to being addictive, nicotine is believed by the Surgeon General to cause youth to have reduced impulse control, deficits in attention and cognition, and mood disorders. OK, all you parents and teachers out there, raise your hand if you’d like to have your teens use a product that would give them lower impulse control, less attention and cognition, and more mood disorders. . . Anyone?
The signal in the noise
The news in the second half of 2019 has buzzed with an outbreak of initially mysterious “E-cigarette and Vaping Associated Lung Injury” (EVALI) which according to CDC’s latest weekly update has recorded 2,172 cases and claimed 42 lives. The associated headlines that “vaping is dangerous,” are so far, when it comes to schoolchildren, the right news for the wrong reason.
EVALI has led to some 300 cases and 1-2 deaths for kids under 18, not to be ignored but a drop in the bucket in the big picture of health statistics. Research on its causes has pointed to Vitamin E acetate as the likely culprit, a thickening additive to THC and not an ingredient used in mass e-cigarette production. On the other hand, many unheralded consequences of youth vaping may indeed lead to long-term dangers at the level of population health. For example:
- Youth who vape are 4 times more likely to start smoking within 18 months than those who don’t.
- People addicted to nicotine are more likely to become addicted to other drugs, both illicit and prescription.
- There are acute risks of nicotine poisoning which have led to several child deaths and are suspected in 127 cases of seizures and other neurological problems reported to the FDA.
- Refillable vaping devices have inspired home-brew experimentation on a large scale with limited regulation – besides nicotine, many youth vape THC, CBD, and other concoctions. A student at a high school in Austin reportedly vaped Monster energy drink and ended up in the ER with holes in his lungs.
- Manufactured e-cigarettes, and especially these street products, contain many chemicals with unknown short- and long-term health effects. The current outbreak of EVALI may be only the first of many vaping-related diseases to come.
- Vaping is expensive, which may distort youth behavior and lead to crime. Another Austin-area high schooler was murdered this year in a presumed vaping sale stick-up, and teens are routinely caught stealing e-cigarette pods and devices, sometimes giving them criminal records for life.
- The more normalized youth vaping becomes, the greater the negative social effects for those who don’t participate, who may face bullying and exclusion.
- Importantly for our purposes here, vaping is a giant distraction to education because kids leave class to feed their addiction, sneak a hit right in the classroom when the teacher isn’t looking, miss school due to suspension, or are otherwise unable to properly concentrate on learning.
How we got here: supply-side
Considering the well-known dangers of tobacco and the hard-won social norms disfavoring its use, how is it possible that it could be so quickly repackaged and revisited on our youth with such grotesque success?
A proper answer to this question must address both the supply side (i.e. the product and its availability) and the demand side (i.e. how youth feel about its use).
E-cigarettes were introduced around 2007 as a potentially safer alternative to cigarettes and have already progressed through 3 product generations, each more devastating to youth than the last.
First and second generations
The first generation was disposable “cig-a-likes” with the size and shape of traditional cigarettes, in some cases even featuring a light on the tip which glowed during inhalation (a popular example was BLU with a blue light). These products were adopted mostly by middle-aged smokers in an effort to reduce the harm of their tobacco use or quit it entirely. Although there was mixed scientific evidence behind this strategy, the public health community initially sensed limited danger since these e-cigarettes attracted few new tobacco users and youth seemed to dismiss them as being “for old people.” Disposable e-cigarettes have now been almost completely eclipsed by newer types.
The second generation of e-cigarettes took hold around 2012 and consists of larger, more expensive, refillable devices known as “pens,” “tanks,” or “mods.” The ability to use your own “e-juice” (the suspension of a target drug in easily aerosolized propellant) in these devices led to a proliferation of thousands of flavored liquids, cooked up in your friendly and largely unregulated neighborhood vape shop. You could ask for apple, banana, crème brûlée, Dr. Pepper, energy boost, funfetti, grape ape, #sweet, incense, jujy fruit, kola, lemon lick, mild ‘n wild, nerds, OMG, pancakes & maple syrup, eye-Q, rhubarb, spearmint, t-bone steak, unicorn vomit, very berry, wonder thunder, x-success, yoohoo, zip line – or if none of those sounds tempting enough, any one of about 8,000 other delicious aromas.
The product innovations of the ability to customize nicotine strength, larger puff size permitting advanced smoke blowing tricks, and above all exotic flavoring attracted newcomers to tobacco who were not already using it. 81% of youth ages 12-17 report that their first experience with tobacco was with a flavored product, possibly because flavors mask the natural bitterness of nicotine and thus lower the barrier to initiation. The spike in youth use, and occasional reports of toxic e-juice ingestion and device explosion, started to attract public health concern.
Their main niche among youth at this point is as a delivery device not for nicotine but for cannabis-based oils containing THC and CBD.
Third generation: JUUL changes the game
In late 2016, the youth vaping landscape changed dramatically and tragically with the ascent of a third product generation of prefilled cartridge-based e-cigarettes pioneered by JUUL. A JUUL is a small, sleek device about the size and shape of a standard USB flash drive which uses a snap-in reloadable cartridge (“pod” or “cart”) containing flavored nicotine liquid. Sometimes called the “iPhone of e-cigarettes”, JUUL looks more like a product from Apple than Altria. This is no wonder since it was conceived at the Stanford Institute of Design where many Apple designers have studied.
JUUL’s appeal is more than skin-deep, as the device until recently was only compatible with the company’s patented e-juice in a nicotine strength of 5% by volume – much more than most other e-cigarettes or cigarettes and 2.5 times the generally-available maximum in the EU. JUUL created its elevated nicotine punch using previously uncommon nicotine salts, which are absorbed into the bloodstream more quickly and make higher nicotine concentrations tolerable thanks to a lower pH than traditional freebase nicotine. (Freebase nicotine is extracted from tobacco leaves using alkaline ammonia; such chemically basic substances typically have a very astringent taste.) JUUL knew this breakthrough was radical and trumpeted that its product delivered nicotine 1.25-2.7 times faster to the brain than other e-cigarettes. This uniquely stimulating and addictive product set off a nicotine arms race of sorts; upstart Blitz now offers 6.5% nicotine strength.
In addition to the youth-appealing characteristics of cool design and powerful nicotine punch, JUUL solved the distribution challenge of refillable e-cigarettes with simple packaging and standardized flavors intended to facilitate sales online and in corner gas stations and convenience stores, which are much more numerous and more accessible than the vape shops where previous product generations were sold. Many teens were suddenly able to fake their age and order online, find a corner store with lax age enforcement, or find an enterprising friend who had bought in quantity (legally or illegally) who would resell to them. And to top it all off, JUUL is easily concealed so most parents and teachers remained completely clueless about it until its use and addiction by middle and high schoolers had already reached alarming proportions.
Appeal, access, and furtiveness combined to rocket JUUL to a 76% e-cigarette market share within its first 3 years on the market, while introducing millions of new underage users to nicotine addiction. The correlation between exponential JUUL sales growth and current use of e-cigarettes among high schoolers shown in the Figure below is unmistakable.
Soaring youth usage rates and high nicotine strength inspired the FDA to label youth e-cigarette use an “epidemic” in September 2018, and cigarette giant Altria to buy 35% of JUUL for $13 billion in December. With a resulting value of $38B, JUUL reached the $10B mark 4 times faster than Facebook, and if public would have been the 354th largest company in the world by market cap, just ahead of eBay. Clearly JUUL had burst e-cigarettes into the mainstream of cool in both adult and teenage currency.
The vaping crisis has certainly triggered an evolution of tobacco regulation, though a fierce tug-of-war persists between those who point to the potential harm reduction of vaping as compared to other tobacco products and those who point to the soaring youth use and unknown health risks.
Vaping devices and their contents had few restrictions until the FDA deemed in 2016 that it had the authority to regulate e-cigarettes under the Tobacco Control Act of 2009, and started action by setting the minimum age for purchase at 18 and policing underage sale by both brick-and-mortar and online retailers.
Since that time, 18 states and hundreds of municipalities have raised the purchase age for all tobacco products, not just e-cigarettes, to 21, and seven states have enacted restrictions on flavored e-cigarettes. JUUL and other manufacturers have also pulled some flavored products off the market. Federal legislation with regard to both age and flavors has been discussed but not enacted.
However, in deference to the potentially lower health dangers of e-cigarettes compared to combustible tobacco, and despite its own characterization of the “epidemic” of youth use, the FDA has continued to “defer enforcement” of many health standards including pre-market review, effectively allowing e-cigarettes to stay on the market without meeting the usual burden of proof of product safety. As of this writing, no e-cigarettes on the US market have FDA approval.
How we got here: demand-side
Since it takes two to tango, we also need to consider why today’s youth have been so uniquely susceptible to vaping.
First, their teachers and parents didn’t grow up with JUULs or other e-cigarettes and simply don’t have the life experience, facts, or vocabulary to confidently discuss and bust myths about them. (What life experience we parents do have strongly argues for not taking up topics with our teens that we have not mastered!) So, most young people have not received the basic social inoculation about the dangers of e-cigarettes that they have for traditional cigarettes, marijuana, other drugs, drunk driving, pregnancy, and other common youth health risks.
The yawning generation knowledge gap was unmistakable for me when I brought a JUUL to the largest annual gathering of future health professionals (HOSA) in Dallas in the summer of 2018, after this product had already been around for a while. Of the hundreds of adults I presented to, only 2 or 3 hands went up when I asked what it was. Meanwhile my colleagues and I were unsuccessful in finding a single high schooler with any such uncertainty, and collected a few classic “no duh” looks along the way.
The second, compounding ingredient of this perfect storm was the advent of social media and micro-marketing, which allowed kids to be targeted with messages their parents weren’t seeing at all. If e-cigarette makers had taken ads in TIME magazine like tobacco peddlers of yore, adults would have cottoned on quickly. Instead, e-cigarette manufacturers, especially JUUL, exploited channels unmonitored by grown-ups through the use of paid social media “influencers” on Twitter, Instagram, and YouTube to portray their product as cool and evoke lifestyle emotions of relaxation, freedom, and sex appeal. These influencers’ posts often portrayed youth and easily reached underage consumers.
A third reason that parents and teachers were caught unaware is ironically the very success of youth smoking prevention policies and programs, including hard-hitting media campaigns like those from Truth Initiative. From the mid-1990s to 2018, the portion of 8th-12th graders smoking on a daily basis plunged 88%. Perhaps it is only natural that parents and schools shifted attention away from teen nicotine use, but in doing so we left our kids unguarded from the predatory enlistment of Big Tobacco and e-cigarette upstarts like JUUL. And when they hit, the decades of neglect of health education meant schools were without the staff skill, schedule time, parent engagement, and culture of health needed to mount a rapid response.
How health education could have helped, and can help
The dizzying rise of youth vaping shows that when it comes to health education parents can’t keep up, and without making it a core priority, schools don’t keep up.
Skills-based health education that applies Social Cognitive Theory could have, and can still, help in three ways.
First is knowledge. Youth familiarity with vaping does not equate to understanding it and in the absence of formal or informal education, teens bear the weight of dangerous myths. For example, 59% think e-juice is mostly water (it actually has none) and 41% think if e-cigarettes are flavored they don’t have nicotine (99% of mass-market products and all JUULs actually do). This latter untruth was passively stoked by the industry who did not clearly label their products as containing nicotine until required to do so in August 2018. A number of youth-initiated lawsuits have recently emerged claiming manufacturers’ deception on this score.
The second benefit health education could provide is to cultivate healthy attitudes and beliefs about e-cigarettes. Many youth, to some extent abetted by adults, have underrated the dangers of vaping due to whatever the opposite of “guilt by association” with cigarettes is; let’s say “innocent by dissociation.” School-age youth mostly still harbor social antibodies against smoking combustible tobacco, but see vaping as fundamentally different rather than as the same old drug (nicotine) in a different package. E-cigarettes are portrayed by their promoters as a potentially safer alternative to cigarettes (actually many have gone so far as to say safer and in September 2019 JUUL received a harsh cease & desist letter from the FDA on that subject). But “potentially safer” is hardly consolation when you are literally comparing something with an unquantified risk to the most deadly product of all-time, one that when used as designed has already accounted for 100 million deaths and adds another five planeloads of fatalities every day. And e-cigarettes can certainly not be thought of as a “safer alternative” by the millions of kids who never smoked and weren’t switching away from the more dangerous predecessors in the first place! A good health teacher can guide youth to re-frame unhealthy beliefs (like changing “this is safer” to “safer is not safe”), and thus significantly improve health behaviors.
Finally, health education can combat demand for vaping through youth empowerment. It’s unclear that the dogmatic “just say no” approach ever worked, and it certainly doesn’t work on today’s teens. Instead, teachers need to guide kids to an intrinsic decision about their health behaviors, and the social skills to back it up. For example, (1) instead of asking for a “pledge” about vaping, ask for a “choice” (2) structure peer-led small-group discussions and report-outs as part of the curriculum (3) rather than making declarative statements, ask open-ended questions about how vaping could hinder kids’ own goals (4) help youth name, preview, and practice refusal skills and (5) provide project-based learning opportunities for teens to explain, share, and advocate publicly for their healthy choice, which will help cement it in their own identity while potentially persuading some of their peers to follow.
These last two benefits of good health education, the development of healthy attitudes and empowering skills, are particularly important to combat the billions of dollars of advertising which are poured into making vaping look cool. If health educators are going to help kids replace marketers’ hollow images with an attitude that “health is cool,” a facts-only approach – especially when those facts are delivered by an adult – will not work. The strongest and most durable health choices are the ones cultivated by training youth to think and act for themselves.
CATCH My Breath: It works!
I’m pleased to report that the foregoing health education principles are not just theoretical – they are actually impacting kids’ lives through CATCH My Breath, the only evidence-based youth vaping prevention program. Evaluation of students who have completed the program has shown:
- Significant increases in knowledge about e-cigarettes and their health effects
- 79% say they are less likely to vape because of the program
- 81% say they are confident using a refusal skill learned in the program
- 82% think all middle and high schoolers should go through CATCH My Breath
- 46% fewer 7th graders tried e-cigarettes after getting CATCH My Breath, as compared to a similar control population
Pitfalls to Avoid
In addition to following these best practices, schools wanting to make an impact on student vaping through health education will need to break a few bad habits.
First, resist the temptation just to plug in e-cigarettes as a new topic in an already weak approach to school health. Schools need to acknowledge when they’re behind and remediate more actively. I have attended several parent presentations where a school triumphantly announced that vaping will be added as a topic in the (one-and-done) 6th grade health class next year! Invariably an irate parent will raise their hand and say, what about my 7th grader who will be in 8th grade next year, what are you doing for them? And if no one is saying it, they’re still thinking it. Attention educators: if that’s you answering parent questions, what are you going to say?
Second, don’t limit vaping education to students who are caught. Good youth health programs reform some kids, but their strength is in prevention not cessation – which for a bona-fide addict may need to go beyond education to behavioral and/or drug therapy. Moreover, making health education a punishment is a bad pedagogical precedent and a huge disservice to kids who with a dose of prevention might have avoided an infraction in the first place. A community service extension project on vaping can be an instructive disciplinary “learning experience,” but it can’t substitute for the educational core.
And finally, don’t let up when this particular crisis passes. To be a good educator means staying at the forefront, and the vaping epidemic has amply illustrated that health education topics and techniques evolve at least as fast as any other subject. Health needs to be made a part of schools’ educational core once and for all so that when the next threat begins to appear we are in front of it rather than playing catch-up with a generation of children.
Let’s Teach Health will be published in Spring 2020. You can receive a free signed copy of the book when it is released by giving $50 or more to CATCH Global Foundation this holiday season.
Chapter 5 Sources:
U.S. Food and Drug Administration and Centers for Disease Control, Youth Tobacco Use: Results From the National Youth Tobacco Survey(2019). https://www.fda.gov/tobacco-products/youth-and-tobacco/youth-tobacco-use-results-national-youth-tobacco-survey
Centers for Disease Control, Youth and Tobacco Use (2019).https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm
U.S. Department of Health and Human Services, Office of the Surgeon General, Preventing Tobacco Use Among Youths (2017).https://www.hhs.gov/surgeongeneral/reports-and-publications/tobacco/preventing-youth-tobacco-use-factsheet/index.html
Centers for Disease Control, Outbreak of Lung Injury Associated with the Use of E-cigarette, or Vaping, Products (November 19, 2019).https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
Brian A. Primack et al., “Initiation of Traditional Cigarette Smoking after Electronic Cigarette Use among Tobacco-Naïve U.S. Young Adults,” The American Journal of Medicine 131, no. 4 (2017): 443.e1 – 443.e92017, https://doi.org/10.1016/j.amjmed.2017.11.005
Arman Azad, “FDA Investigating 127 Reports of Seizures, Neurological Symptoms Related to Vaping,” CNN, August 7, 2019,https://www.cnn.com/2019/08/07/health/ecigarette-seizure-fda-investigation/index.html
Tony Plohetski, “Austin Student Killed Over Vaping Drugs, Sources Say,” Statesman, March 27, 2019, https://www.statesman.com/news/20190327/austin-student-killed-over-vaping-drugs-sources-say
The Tobacco Atlas, “JUUL from a Global Perspective,” July 12, 2018, https://tobaccoatlas.org/2018/07/12/juul-global-perspective/
Jeffrey G. Willett et al., “Recognition, Use and Perceptions of JUUL Among Youth and Young Adults,” Tobacco Control 28, no. 1 (2018), https://tobaccocontrol.bmj.com/content/28/1/115
Robert K. Jackler et al., “JUUL Advertising Over its First Three Years on the Market,” Stanford Research into the Impact of Tobacco Advertising (January 31, 2019), http://tobacco.stanford.edu/tobacco_main/publications/JUUL_Marketing_Stanford.pdf
Will Yakowicz, “These 4 Guys Just Made $3.4 Million Selling Nicotine Salt Juice,” Inc., 2018, https://www.inc.com/will-yakowicz/30-under-30-2018-solace-technologies.html
Nielsen sales data from various sources
Angelica LaVito, “Tobacco Giant Altria Takes 35% Stake in JUUL, Valuing E-cigarette Company at $38 Billion,” CNBC, December 20, 2018, https://www.cnbc.com/2018/12/20/altria-takes-stake-in-juul-a-pivotal-moment-for-the-e-cigarette-maker.html
Forbes, “The World’s Largest Public Companies, 2018 Ranking,” 2018, https://www.forbes.com/global2000/list/#header:marketValue_sortreverse:true
U.S. Food and Drug Administration, Testimony: Examining the Response to Lung Illnesses and Rising Youth Electronic Cigarette Use(November 13, 2019).
“Raising the Tobacco Age to 21,” Campaign for Tobacco-Free Kids, https://www.tobaccofreekids.org/what-we-do/us/sale-age-21
Sarah Rense, “7 States Have Moved to Ban Vapes. Is the Rest of America Next?” Esquire, October 4, 2019,https://www.esquire.com/lifestyle/health/a29067489/which-states-banned-flavored-e-cigarettes-vaping-juuls/
Lloyd D. Johnston et al., Monitoring the Future National Survey on Drug Use 1975-2018 (Ann Arbor: Institute for Social Research, University of Michigan, 2019). http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2018.pdf
CATCH Global Foundation, CATCH My Breath Youth E-Cigarette Prevention, 2018-19 Evaluation Report (2019).
Centers for Disease Control, Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults (2019). https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html
U.S. Food and Drug Administration, “Covered” Tobacco Products and Roll-Your-Own / Cigarette Tobacco Labeling and Warning Statement Requirements (2019). https://www.fda.gov/TobaccoProducts/Labeling/Labeling/ucm524470.htm
World Health Organization, WHO Report on the Global Tobacco Epidemic, 2008 (Geneva: World Health Organization, 2008). https://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf
Steven H. Kelder et al., “Rapid Response to a Child Health Epidemic: CATCH My Breath, A Middle School E-Cigarette Prevention Program,” Public Health Reports. (In press.)