• Drug Free Cecil

A Youth Vaping Epidemic

Written by Jen Padgett


Tobacco Companies Need A New Generation of Nicotine Users

As part of a groundbreaking lawsuit in 1998, four of the largest U.S. tobacco companies were mandated to pay restitution for smoking related illnesses to 46 states, the District of Columbia and five U.S. territories. This was known as the Master Settlement Agreement which transformed tobacco control. For the first time in America’s history, the harm from tobacco use was nationally recognized and risks associated with use were elevated to the same level as other gateway drugs such as alcohol and marijuana. The dangers of tobacco use could no longer be dismissed, as a result tobacco became a separate field of prevention. With the traditional combustible tobacco no longer being accepted as safe by the main stream public and youth use dropping drastically, the tobacco industry had to create innovations to sell tobacco products to a new generation. Fast forward twenty years, vapes are threatening to addict a new generation to nicotine at epidemic proportions.


What is the problem with vapes?

Electronic Smoking Devices (ESD) are commonly referred to as “vapes”. ESD are a diverse group of devices that allow users to inhale an aerosol, which typically contains nicotine, flavorings, and other additives. The devices vary widely in design and appearance, but operate in a similar manner and are composed of similar components. Devices may be referred to as “e-cigarettes,” “vapes,” “e-hookahs,” “vape pens,” ”pods” “mods,” “tanks”, “JUUL”, or “electronic nicotine delivery systems (ENDS)”. There are nearly 500 brands.1 ESD devices resemble other tobacco products such as cigarettes; some resemble ordinary household items such as USB flash drives.2

ESD Graphic 3

JUice USB Lighting (JUUL) is the most popular form of ESD among youth. It looks like a USB flash drive and can be charged in the USB port of a computer. JUUL Pods (juices) and compatible pods come in tempting flavors: Cool Mint, Fruit Medley, Mango, Cool Cucumber, Blueberry, Strawberry, and Watermelon. All pods sold from JUUL do contain nicotine. 3 These pods contain 0.7 mL e-liquid with 5% nicotine by weight, which has the nicotine equivalent to a pack of cigarette.4


ESD vapor contains the addictive drug of nicotine, enticing flavorings, cancer-causing chemicals (formaldehyde, acetaldehyde, acrolein and diethylene glycol) and some may contain marijuana or other substances. The flavoring component of diacetyl has been linked to irreversible lung damage (bronchiolitis obliterans). Some other harmful substances are heavy metals (e.g., tin, lead, nickel, silver, aluminum, silicate and chromium) and volatile organic compounds.1 ,2, 3 Additionally, some ESD are used to deliver illicit substances that may be acquired on the street.2


“Dripping” or “dabbing” is a trend among users to modify ESD for a more potent drug hit which causes the user to inhale more of the harmful substances in the vapor. Dripping involves dropping e-cigarette liquid directly onto the hot coils of an e-cigarette which can result in high concentrations of compounds (e.g., nicotine, tetrahydrocannabinol [THC] and cannabinoid compounds). Dabbing involves superheating substances such as “budder”, butane hash oil and “710” that contain high concentrations of THC and other plant compounds (e.g., cannabidiol [CBD]). 2

Health Risks of Nicotine Use on a Developing Brain

Nicotine use among youth can have severe consequences. Evidence shows brain development continues to the age of 25, this is why teens form addiction more easily than adults. Early onset of use can increase the severity of addiction in adulthood. Nicotine use interferes with brain development by changing the way synapses are formed causing problems with: concentration, learning, mood disorders and impulse control. Adolescent nicotine use not only primes the brain for nicotine addiction but all types of addiction.1 According to the Monitoring Changing Tobacco Use Behaviors Report 2000-2016, youth tobacco users are: 3 times more likely to use alcohol, 4 times more likely to use marijuana, 5 times more likely to abuse prescription drugs, 11 times more likely to use injection drugs and 15 times more likely to use heroin.9


JUUL has found a way to use nicotine salts with a higher acidity than free-base nicotine in traditional cigarettes. Using salts can masks the harshness of nicotine’s potency.10 A barrage of physical symptoms stem from nicotine use in ESDs: dry mouth, mouth sores, gum bleeding, dry skin, rashes, headaches, dizziness, nose bleeds, heart palpitations, chest pain, coughing, muscle tremors, high blood pressure and sleep disturbances.11 Youth referred to these type of symptoms as “Nic Sick”. 12 Centers of Disease Control and Prevention (CDC) advises youth, young adults and pregnant women not use vapes for these reasons. 2


Unlawful Vape Marketing to Attract Youth


Packaging Graphic 5


While the tobacco industry claimed they were not targeting youth, they used aggressive marketing tactics to attract youth to use their products. They used a variety of flavors, colorful packaging, enticing names and labels similar to other popular products. Over 7,700 appealing flavors were placed on the market to tempt youth. 81% of youth vape users reported flavoring as the primary reason for use, according to the Surgeon General Report .1 Many e-liquids’ packaging labels were nearly identical to packaging of other kid-friendly products such as juice boxes, candy or cookies. In May 2018, the U.S. Food and Drug Administration (FDA) and the Federal Trade Commission issued warning letters to manufacturers and retailers for selling e-liquids with labeling that resembled kid-friendly food products.6 On September 12, 2018, the FDA announced they plan to halt sales of flavored ESD's if the major manufacturers were not making efforts to keep their products out of youths’ hands.7 Today, these flavored products are now considered illegal to sell by the FDA and the Maryland Comptroller’s Office.



With a nine billion dollar annual marketing budget, tobacco companies spared no expense to promote their products to youth.8 Vaping companies such as JUUL, had a merchandising line directed at youth with brightly colored classic cartoon skins and slogans like “JUUL kids are the CUUL kids”. Vaping companies and other companies continue to sell products that help youth disguise and conceal vape use such as vaprwear hoodies and vixen lipstick containers. Several e-cigarette companies offered scholarships to students, ranging from $250 to $5,000, for essays on the benefits of vaping. These companies took advantage of social media sites like Twitter, Instagram, and YouTube to market to youth. The first year of launch, JUUL spent more than one million dollars to market the product on the internet. The monthly average of JUUL-related tweets skyrocketed from 765 in 2015 to 30,565 in 2017. 5 From the growing amount of evidence, youth were the marketing target of the vape industry.


The Rise of Vape Use to Epidemic Proportions Among Youth

Between 2017 and 2018, the use of vapes among US high school students increased by 78%. JUUL use grew dramatically making it the most popular form of vape among youth. By 2018, more than 3.6 million U.S. youth, including 1 in 5 high school students and 1 in 20 middle school students, reported use of some type of vaping product. This led to the U.S. Surgeon General warning America that vape use among youth was now at epidemic proportions.13

According to the 2019 Monitoring the Future Survey by National Institute on Drug Abuse (NIDA) and the National Institutes of Health (NIH), 8th, 10th and 12th graders showed alarmingly high rates of vape use compared to the previous year, with rates doubling in the past two years. NIDA Director Dr. Nora D. Volkow declared, "With 25% of 12th graders, 20% of 10th graders and 9% of 8th graders now vaping nicotine within the past month, the use of these devices has become a public health crisis."14


Our statewide and county youth vape use trends showed similar increases which reflected national trends. Using the most recent Monitoring Changing Tobacco Use Behaviors Report, Cecil County vape use among middle and high school students was significantly higher than the State average in 2018. 39.5% of Cecil County public high school students reported using vapes compared to 23% of Maryland public high school students. 10.9 % of Cecil County public middle school students reported using vapes compared to 5.9% of Maryland public middle school students16. In school year 2019-2020, there were 207 tobacco violations in the Cecil County Public Schools. The epidemic had hit home.


Vape Health Advisories and Investigations



On August 30, 2019, the CDC issued a health advisory on severe pulmonary disease associated with vape use. As result of the advisory, the CDC, the FDA, state and local health departments, clinics, and other health partners investigated a multi-state outbreak of e-cigarette or vaping lung injuries referred to as EVALI. All patients reported using vapes before the onset of symptoms which would range from a few days to several weeks after use. In many cases, patients reported difficulty breathing, shortness of breath, and/or chest pain before hospitalization. Some cases reported mild to moderate gastrointestinal illness including vomiting and diarrhea, or other symptoms such as fevers or fatigue. While many of the patients, but not all, reported recent use of THC-containing products, some reported using both THC and nicotine containing products. A smaller group reported using nicotine only.2 As of February 18, 2020, a total of 2,807 hospitalized cases or deaths have been associated with EVALI. Vitamin E Acetate, an additive used in vaping products that contain THC, was identified as a primary cause of the EVALI outbreak. Other chemicals in either THC or non-THC vaping products, can not be ruled out as contributing factors to these EVALI cases.17

As part of a FDA investigation, information on injuries related to vape battery explosions is still being collected.18, 19 From 2015 to 2017, a total of 2,035 vape explosions and burn injuries were documented in US hospital emergency departments.20 Not all cases were remote and far away incidences. Several news reports featured cases in Maryland and Cecil County. On July 22, 2016, the Cecil Whig and Channel 2 ABC WMAR featured the same news story about a young lady from Perryville, Maryland who suffered burns to 15% of her body after her vape battery exploded.21, 22 On October 21, 2016, a Rising Sun High School student and his mother attended the Cecil County Tobacco Task Force to share their vape explosion story with the members. A vape explosion in a mouth, pocket, purse, or wallet can cause serious injuries including: burns, scarring, disfigurement and oral injuries. The individuals, often young people, who suffered these burn injuries find themselves undergoing expensive and painful wound care and skin graft procedures. These type of incidents continue to rise.


Tobacco 21: A Movement to Protect Our Youth

The alarming increase of youth vape use and reports of illnesses related to vape use started a national movement among the states to protect young people. Tobacco 21 (T21) laws prohibiting the sale of tobacco products, including ESDs, to those under the age of 21 years were adopted by states. As one of several states leading the way for the nation, Maryland passed T21 on April 3, 2019. On December 20, 2019, the President signed legislation raising the federal minimum age of sale of tobacco products from 18 to 21 years. 23


Youth-Led Community Movement

The tobacco industry greatly underestimates the youth of today. Tobacco companies have used billions of dollars and thousands of resources at their disposal to manipulate youth into addiction. They have attempted to hide their true intentions. As evidence increases from research and emerging ligations, the smokescreen from their propaganda can no longer control youth. Youth are now becoming armed with the facts. Within each youth, there is a burning amber ready to ignite. With the motivation to change our communities, states and nation for the better, they can “set the world on fire”. Through opportunities provided by Drug Free Cecil (DFC) and the Cecil County Tobacco Task Force, our youth are on their way to becoming a powerful army ready to combat the greed of the tobacco industry and make positive changes that will reverberate through our communities. They are leading the way by teaching their peers, our citizens and community leaders. With full support of the DFC coalitions, their voices have been and will continue to be heard all the way to Capitol Hill.


What you can do

If you want to be a part of the youth prevention movement or learn how to support Drug Free Cecil and the Cecil County Tobacco Task Force, please contact me, Jen Padgett at jenniferpadgett@maryland.gov.



Sources

  1. US Department of Health and Human Services. E-cigarette use among youth and young adults: a report of the Surgeon General pdf icon[PDF–8.47 MB]. Atlanta, GA: US Department of Health and Human Services, CDC; Released in 2016.

  2. Center of Disease Control and Prevention. Emergency Preparedness and Response. Severe Pulmonary Disease Associated with Using E-cigarettes Health Advisory. https://emergency.cdc.gov/han/han00421.asp; Released in 2019.

  3. Center of Disease Control and Prevention. Smoking and Tobacco Use. About Electronic Cigarettes (E-Cigarettes). https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html. [Accessed 2020, September 9].

  4. Campaign for Tobacco-Free Kids. JUUL and Youth: Rising E-Cigarette Popularity Factsheet. https://www.tobaccofreekids.org/assets/factsheets/0394.pdf. [Accessed 2020, September 9].

  5. Truth Initiative. Four Marketing Tactic E-cigarettes Companies Use to Target Youth. Introducing Appealing Flavors. https://truthinitiative.org/research-resources/tobacco-industry-marketing/4-marketing-tactics-e-cigarette-companies-use-target; Posted 2018, August 9.

  6. Food and Drug Administration. FDA, FTC Take Action Against Companies Misleading Kids with E-liquids That Resemble Children’s Juice Boxes, Candies and Cookies. https://www.fda.gov/news-events/press-announcements/fda-ftc-take-action-against-companies-misleading-kids-e-liquids-resemble-childrens-juice-boxes; Posted 2018, April 30.

  7. Food and Drug Administration. Statement from FDA Commissioner Scott Gottlieb, M.D., on proposed new steps to protect youth by preventing access to flavored tobacco products and banning menthol in cigarettes. https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-proposed-new-steps-protect-youth-preventing-access; Released in 2018.

  8. Truth Initiative. Tobacco Industry Marketing. https://truthinitiative.org/research-resources/topic/tobacco-industry-marketing [Accessed 2019, October 2].

  9. Maryland Department of Health. Monitoring Changing Tobacco Use Behaviors Report 2000-2016 https://smokingstopshere.com/wp-content/uploads/2019/02/MDH-Tobacco-Use-Summary-Report_2016_2.1.19.pdf [Accessed 2019, October 2].

  10. Centers of Disease and Prevention. Know the Risks: A Youth Guide about E-cigarettes. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Ecigarette-youth-deck-talking-points-508.pdf [Accessed 2019, October 2].

  11. Felman. Medical News Today. Everything you need to know about nicotine. Update 2018 January 11. https://www.medicalnewstoday.com/articles/240820.php [Accessed 2020, September 9].

  12. ABC Channel 7 WJLA. Are your kids JUULing at School? 7 On Your Side investigates. Aired 2018, August 6, https://youtu.be/NS5Dx8uOqpY [Accessed 2020, September 9].

  13. US Food and Drug Administration. Youth Tobacco Use: Results from 2018 National Youth tobacco Survey.2018 E cigarette Data. https://www.fda.gov/tobacco-products/youth-and-tobacco/youth-tobacco-use-results-national-youth-tobacco-survey; 2018.

  14. National Institute on Drug Abuse. Teen E-cigarette Use Double Since 2017. Researcher Sound Alarm on Potential Health Effects of Vaping. https://www.drugabuse.gov/news-events/news-releases/2019/09/teen-e-cigarette-use-doubles-2017; Posted 2019, September 18.

  15. Maryland Department of Health. Monitoring Changing Tobacco Use Behaviors Report 2000-2016. https://phpa.health.maryland.gov/ohpetup/Documents/2000%20-%202016%20Legislative%20Report%20Monitoring%20Changing%20Tobacco%20Use%20Behaviors.pdf; 2017.

  16. Maryland Department of Health. Monitoring Changing Tobacco Use Behaviors Report 2012-2018. MDH Released 2020.

  17. Center of Disease Control and Prevention. Smoking and Tobacco Use. Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html Posted September 27, 2019.

  18. .US Food and Drug Administration. Safety Reporting Portal for Tobacco Products. https://www.fda.gov/tobacco-products/tobacco-science-research/safety-reporting-portal-tobacco-products [Accessed 2020, September 9].

  19. US Food and Drug Administration. Tips to Help Avoid "Vape" Battery Explosions https://www.fda.gov/tobacco-products/products-ingredients-components/tips-help-avoid-vape-battery-explosions; 2017. UB 20

  20. Rossheim, Livingston, Soule, Zeraye, and Thombs. British Medical Journal: Vol 28, Issue 4 Brief Report: Electronic cigarette explosion and burn injuries, US Emergency Departments 2015–2017. https://tobaccocontrol.bmj.com/content/28/4/472; 2018

  21. July 22, 2016Carl Hamilton Cecil Whig Woman Burned in Bizarre Battery Explosion UB 22

  22. Hager. ABC WMAR-2 News. Baltimore. Vape Battery Explosion Sets Woman on Fire. Cecil County Victim Suffers Burns to 15% of Body. Posted 2016, July 22. https://www.wmar2news.com/news/region/cecil-county/vape-battery-explosion-sets-woman-on-fire [Accessed 2020, September 9].

  23. Maryland Department of Health. Maryland Responsible Tobacco Retailer Program https://health.maryland.gov/notobaccosalestominors/Pages/Home.aspx [Accessed 2020, September 9].

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