E-cigarette use rises in young adults as combustible cigarette use declines

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E-cigarette use is on the rise among young adults, but overall combustible cigarette use among teens is continuing on a downward trend, recent studies show.

One in five young adults regularly uses e-cigarettes and nearly one in four believes e-cigarettes are harmless and not addictive, according to a national cancer survey from the American Society of Clinical Oncology.

ASCO’s survey included questions about federal policy on e-cigarettes. In all, 71% of respondents supported FDA regulation of e-cigarettes, 68% supported raising the legal age to purchase e-cigarettes from 18 to 21, 46% supported banning the sale of flavored e-cigarettes, and 41% supported banning all e-cigarettes.

“No e-cigarette products are currently approved by the FDA as cessation aids, and more research to understand these products, the substances in them, and the acute and long-term effects of their use is urgently needed,” ASCO Chief Medical Officer Richard L. Schilsky said in a statement.

Overall tobacco product use among young adults has remained stable. But more importantly, the number of youths who vape e-cigarette versus those who smoke conventional cigarettes is changing, said Cliff Douglas, vice president of tobacco control at the American Cancer Society

“[The ASCO survey] underscores what we now understand to be widespread and increasing e-cigarette use by youth and young adults,” Douglas said to The Cancer Letter.

Preliminary data from the National Youth Tobacco Survey show that more than a quarter of high school students used an e-cigarette in the past 30 days in 2019. The majority of these were fruit and menthol flavors.

Fewer eighth, 10th and 12th graders are using conventional cigarettes, according to a study from the National Institute on Drug Abuse. In eighth graders, 13% reported using cigarettes in 2015, compared to about 9.1% in 2018. In 10th graders these rates fell from 19.9% to 16%, and in 12th graders these fell from 31.1% to 23.8%, respectively.

“Youth are really not smoking much anymore, and that bodes very well for public health and reduced cancers in America,” ACS’s Douglas said. Though cigarette use fell from 8.1% to 5.5% overall, vaping rates increased from 21% to 27% in high school students, he said.

“So, [there’s] a greater increase in vaping than the drop in smoking, and we don’t understand fully the dynamic around that,” he said.

High-prevalence of e-cigarette use and nicotine addiction among young adults in addition to a recent outbreak of vaping-related lung illness concerns Douglas, and has also led FDA to take action on e-cigarette products such as Juul.

There have been about 805 cases of lung injury reported from 46 states and 1 U.S. territory. Twelve deaths have been confirmed in 10 states. Most of those with the illness reported vaping THC, and many also reported vaping THC in addition to nicotine. Some reported just using nicotine, according to CDC.

FDA sent a warning letter to Juul Labs Inc. Sept. 9 for illegally marketing e-cigarettes, including labelling, advertising, and in one instance giving a presentation at a school. HHS pushed FDA to act, and the agency is expected to enact a policy on flavored e-cigarettes and related vaping products in the coming weeks, Acting FDA Commissioner Ned Sharpless said to reporters Sept. 25.

However, Douglas warned that media scrutiny on vaping could actually increase cigarette use among young adults. A memo from RBC Capital Markets, which Douglas sent to staff at ACS, said the Juul controversy will ultimately not affect Altria, the parent tobacco company behind Juul that has owned 35% of the organization since Dec. 2018.

“The issues with Juul has certainly cast a cloud over Altria’s capital allocation, but we remind investors that Juul’s current challenges will have no impact on Altria’s earnings or cash flow. We also believe the recent media scrutiny on vaping will help overall cigarette consumption. In fact, recent channel checks point to better cigarette volume trends in the first two weeks of September,” the memo states.

Essentially, the company believes vaping hysteria in the media will ultimately increase cigarette sales, Douglas said.

“And if that is an unintended consequence of our war on vaping — then that is a real problem for public health. We in the tobacco control community have got to find a sweet spot where we can substantially reduce e-cigarette use in kids.”

“We should do everything in our power to prevent a generation of young people from becoming addicted to nicotine, regardless of how it is delivered,” ASCO President Howard A. “Skip” Burris III said in a statement.

There isn’t enough advertising to counter the tobacco industry’s strong public relations campaigns that favor nicotine products, said Alan Blum, director of The University of Alabama Center for the Study of Tobacco and Society and professor and Gerald Leon Wallace Endowed chair in family medicine.

“There’s nobody on earth whose job depends on a decline in vaping,” Blum said to The Cancer Letter. “There are tens of thousands of new employees at Juul, at Philip Morris [Tobacco], at R.J. Reynolds’ [Vapor] Company … whose jobs depend on making sure that some stick with liquid nicotine gets stuck into the mouths of every person they can find.”

Juul halted all of its advertising Sept. 25.

Altria owns a 35% stake in Juul. In fact, Juul’s CEO Kevin Burns stepped down Sept. 25, and was replaced by Altria’s chief growth officer K.C. Crosthwaite. The transition further blurs the line between big tobacco organizations that are often behind e-cigarette companies, Douglas said.

“The positive public health vision for e-cigarettes for those who advocated [for them] is that they’d serve as a much less hazardous alternative to smoking conventional burn tobacco products,” Douglas said.

“It remains true that e-cigarettes remain less hazardous. The problem is the industry starting aggressively targeting kids and addicting several million of them to vaping products, exposing young brains to nicotine addiction and potential damage to young brain development,” Douglas said.

Flavored e-cigarettes are appealing to young adults, and social media campaigns using influencers to promote vaping products only increase that appeal, Campaign for Tobacco-Free Kids spokesperson Boot Bullwinkle said.

Nearly three in 10 young adults think flavored e-cigarettes are less damaging to a person’s health than non-flavored ones. In addition, nearly seven in 10 Americans support raising the legal age to purchase e-cigarettes from 18 to 21, according to the ASCO survey.

“We don’t want to see what happened with Juul happen with other nicotine companies … we saw them target kids with their flash social media campaigns,” Bullwinkle said to The Cancer Letter. “We want to make sure there’s guard rails in place so we don’t see the high rates of youth use.”

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