Teens hooked by vaping: FDA weighing a ban on flavored e-cigarette liquids

Jayne O'Donnell, Ken Alltucker and Josephine Chu, USA TODAY | USA TODAY

Show Caption Hide Caption FDA considers regulation to curb epidemic level teen vaping Teen vaping is reaching epidemic levels and FDA is considering regulation to curb it. One proposal would be banning flavoring of e-cigarette liquids.

Teen vaping is at the tipping point before possible epidemic levels, federal officials and public health advocates agree, but they're feuding over how fast and far to go to rein in the booming electronic cigarette industry.

Some of the health groups that sued the Food and Drug Administration for delaying regulation of vape products by four years charged last week that the agency let several new devices similar to the youth-favored Juul hit the market without approval.

Companies "have introduced new products at an alarming pace in total defiance of law, with no apparent concern for FDA enforcement,” the groups wrote.

More than 2 million middle school, high school and college teens use these battery-powered devices to heat liquid-based nicotine into an inhalable vapor. E-cigarettes were by far the most popular tobacco product among teens: Nearly 12 percent of high school students and 3 percent of middle school students used the device in the past 30 days, according to the 2017 National Youth Tobacco Survey released in June.

That puts hundreds of thousands of them at "exceedingly high" risk of developing nicotine addictions, FDA Commissioner Scott Gottlieb told USA TODAY. The nicotine, he said, "can rewire an adolescent’s brain."

The agency has hardly ignored the issue. It is reviewing more than a half million public comments as it mulls whether to restrict or even ban flavors in the liquid and is investigating youth marketing by Juul, which attracts young vapers with its nicotine-packed products, easily hidden USB size and alluring social media presence.

San Francisco-based Juul said it has worked to keep its products away from minors and has taken action against online retailers that sold devices to underage vapers.

This month, the FDA asked four e-cigarette companies for information about the appeal of their products to youths and said it could take enforcement action against the companies based on what it learns.

In mid-September, the FDA will launch a vaping prevention campaign targeting 10 million youths who vape or are open to trying it, Gottlieb said. It will continue enforcement against retailers that sell to minors.

"We are very concerned that we could be addicting a whole generation of young people," Gottlieb said. "We only have a narrow window of opportunity to address it."

Instead of committing to regulate flavor, the FDA solicited more research on flavor's role. Robin Koval, CEO of the anti-tobacco group Truth Initiative, said there is ample evidence that flavors attract teens.

"They understand the need for rapid response," Koval said. "Nevertheless, the (rulemaking approach) doesn't obligate them to any timetable or even to act."

Last year, the FDA delayed until 2022 the requirement that vaping products go through a rigorous approval process – filing a pre-market tobacco application – to remain on the market. Gottlieb said that will be a challenge for some to meet, so they "better start now."

Alternatives to cigarettes?

E-cigarettes are marketed as alternatives to traditional cigarettes because they can quell smokers' urges for nicotine without cancer-causing tobacco.

Federal health officials and other health experts said there's ample cause for concern about young people newly lured to nicotine and chemicals found in vaping juice. Vaping has not only usurped smoking tobacco among those under 20, it came along as youth smoking rates were declining and threatens to erase the health benefits from the gains.

Young adults who use e-cigarettes are more than four times as likely to begin smoking tobacco cigarettes within 18 months as their peers who do not vape, according to a study in December 2017 by the University of Pittsburgh Schools of the Health Sciences published in The American Journal of Medicine.

Teen and 20-something vapers interviewed described moving back and forth between vaping and smoking, sometimes simply because the battery on their device was dead and cigarettes were available. When heavy drinking was involved, it could be whatever was handy.

There's been a rapid increase in the number of kids caught vaping over the past school year, said Brian Maslowski, an alcohol, tobacco or other drugs instructor for the Fairfax County Public Schools in Northern Virginia. He attributed the trend to the popularity of Juul among high school students.

“It has exploded this past year,” he said.

Some kids have vaped in classrooms. Others got caught in bathrooms. In fact, there's a whole genre of Twitter memes about bathroom vaping.

"This isn't tolerable from a public health standpoint," Gottlieb said.

'Tingles for a couple seconds'

Smoke-filled rooms are gone in Washington, but a haze rose over Georgetown University's library during the spring semester. Across town at Catholic University, the vapers lined up in the back of large seminar halls to sneak hits. At George Washington University, even those who didn't own the trendy Juuls often took a few hits off friends at parties.

Inhaling the flavored vapor often starts as a lark before it becomes a habit or an addiction. It provides a "quick little head rush that is stronger than smoking a cigarette," said Emma Clary, a George Washington University sophomore who started vaping after a former boyfriend gave her a Juul as a gift.

"It's not like you lose control, but you feel a sort of a release in your body and tingles for a couple seconds," Clary said. "It's a de-stressor – almost like a break."

Whether they start because it satisfies an oral fixation, as consumer psychologist Kit Yarrow said, or a way to self-medicate for stress, as child psychologist Melissa Sporn suggested, harried young people increasingly turn to vaping.

"Let’s just say it’s a draw – no pun intended – to want to put things in your mouth and draw," said Yarrow, author of "Decoding the New Consumer Mind." "You thought that was only during infancy? It comes back during that initial period of separation from parents."

One pod, which can last a half day to more than two, has the same amount of nicotine as a pack of cigarettes and runs $4 to $5.

"It’s an expensive addiction," Clary said. "I didn’t work this past school year, so I would go through phases where I'd say, 'I'm not going to Juul for the next month,' and then I'd be ready to splurge on Juul pods."

Sporn, who practices in Fairfax County, said some parents refer their teenagers to her when they learn about their vaping or, more often, teens who are patients will disclose it.

Her discussions are "looking at what’s going on that they are self-medicating," Sporn said. Usually, she said, it's because they are anxious or depressed, and "it’s a numbing of those feelings."

That starts a dependence on a substance at a vulnerable age.

“Without having any exposure to nicotine before, they are now getting a little buzz,” said Maslowski of Fairfax County schools.

One girl tried to quit cold turkey from vaping up to five times a day before a family vacation and wound up moody, with the shakes and unable to sleep, Sporn said.

The buzz factor

Catholic University student Mike Venditti started vaping at the end of high school as a healthier alternative to the chewing tobacco and cigars he was using. More than two years later, he said he notices "most of the kids now just got into it because of the buzz." He described it as the same feeling you get when you bend over quickly and the blood rushes to your head.

Although some vapers described headaches and other withdrawal symptoms, Venditti said he generally just vapes in his house and doesn't "need it" in class.

Otherwise, he vapes "where kids are hanging out, mainly in the quads," he said. "It's more of a social thing."

Kevin Kee, 22, took up vaping to give up smoking when he was starting college but found himself going back to smoking again when he noticed the Juul was “more ingrained in my life than cigarettes ever were.”

“With the Juul, you can vape anywhere, 24/7. I went through pods way quicker – I could go through a pod in one day," Kee said. "My tolerance was higher, and I didn’t want that kind of life coming out of college.”

Spencer Re of Napa Valley, California, has been vaping for the past five years – since his senior year of high school when a friend gave him a vape with very little nicotine and watermelon-flavored "e-juice."

That led him to try smoking cigarettes in college, he said.

'"I was more just looking for new experiences in college, and someone offered me a cigarette, so I tried one," Re said. "But I think I was more likely to have taken the cigarette, because I vaped.”

Cigarettes eventually “completely replaced vaping," until he stopped smoking in early 2016 – with the help of vaping.

Even though he smoked, Re said he can't stand the taste of tobacco and cream flavors, so he vaped only fruity flavors.

Re's favorite flavors might help explain why health advocates support banning kid-friendly ones, such as Juul's fruit medley and mango. Kids are unlikely to like – if they even recognize – names such as "Creme Brulee," the thinking goes.

In a statement, Juul CEO Kevin Burns said restricting flavors “will negatively impact current adult smokers” who want to switch from smoking to vaping. He said the company would support “reasonable regulation” to restrict advertising and the naming of flavors such as cotton candy and gummy bear that target children.

Users such as Re said they doubt kids are drawn to vaping by fruity flavors

"I think that (flavoring) really misses the mark of children wanting to try nicotine – forbidden substances and the little bit of taboo that comes with it," he said.

Kee said he thinks people who vape to quit smoking are a minority and most people "vape just to vape." Out of college and working, he's given up cigarettes and vaping but fears a flavor ban would really hurt others.

"It’s become so ingrained in our culture that banning flavored nicotine would be like the prohibition," he said.

Weighing risk, benefit

At the FDA, Gottlieb is tasked with balancing the benefit to public health of flavored vape liquid enticing adults to quit smoking against the likelihood that a young person who has never smoked will become hooked. If it were, say, a five-adult-to-one-child ratio, Gottlieb said that probably wouldn't be acceptable.

Many of the more than 500,000 commenters to FDA about flavored tobacco and e-cigarettes would disagree. James Cherrette of Illinois is one of them.

“I started smoking when I was 12 years old, and guess what … it wasn’t because Marlboro had a fresh fruity flavor,” he scoffed.

But research suggests that flavors are pivotal for a large percentage of teen and younger vapers.

That helps explain why Juul, which has a $3 billion company valuation and sweeping appeal, has become so ingrained in social media and youth culture that "Juuling" became a verb. Kee said he doesn't even think of Juuling as vaping, as it's more concentrated, trendy and easier to use.

"It's a very convenient way to get a nicotine high anywhere you are," he said.

The Campaign for Tobacco Free Kids and other groups urged the FDA in a letter Tuesday "to take quick and aggressive action to enforce the law before one or more of these products become the next Juul phenomenon among our nation’s youth."

Altria, the company formerly known as Phillip Morris, said its MarkTen e-cigarettes were on the market before August 2016 when the FDA's rules changed, but the Campaign for Tobacco Free Kids said marketing materials suggest otherwise.

"Companies should know that the FDA is watching, and we will take swift action wherever appropriate," Gottlieb said in response to the letter.

A class-action lawsuit filed at U.S. District Court in San Francisco by Juul users alleged that the vaping giant used a two-pronged approach to target adult smokers and teens.

One San Diego teen said she was introduced to Juul by eighth-grade classmates. When her device broke last November, she obtained a warranty replacement through Juul’s website even though she was only 14, the lawsuit says.

The lawsuit alleges Juul targeted youth and nonsmokers through ads and “social media blitzes” using “alluring imagery.” Adult smokers were wooed with the promise of a lower or equal amount of nicotine compared with a cigarette even though the product is designed to be more potent and addictive than cigarettes, the lawsuit says.

“On a puff-for-puff basis, this was designed to be more powerful than the gold standard – the cigarette,” said Esfand Nafisi, a San Francisco Bay Area attorney representing Juul users. “That potency was either not disclosed or misrepresented continuously from the time of the company’s inception.”

In response to the San Francisco lawsuit and other civil lawsuits, Juul said it does not believe the cases have merit and will defend itself against them vigorously.

Ashley Gould, Juul's chief administrative officer, said the company has sent cease-and-desist letters to online retailers that resell its products and target minors. She noted that the company teamed with Iowa Attorney General Tom Miller to keep vaping products out of the hands of children.

Alex Bosman, who works at House of Vape in Vienna, Virginia, said Juul’s sleek design and ease of use are powerful lures for young vapers. A community of users share their vaping experience with others on social media sites such as Snapchat, Instagram and Twitter.

In that sense, Juul customers and influential social media users have become the company's biggest allies.

“I am not going to say Juul specifically targeted kids with their marketing,” Bosman said. “It was kind of an organic style of marketing that happened."

James Xu, owner of Avail, one of the largest vaping companies in the world, started the business when he saw how e-cigarettes helped his wife kick her smoking habit. Xu, who owns other businesses such as home goods retailer Plow and Hearth, said vaping doesn't "speak to me" like his other companies, "but I'm not ready to quit anytime soon because every day, I hear those moving stories touching people’s lives."

He's going to keep up the "fight for flavors" with the Global Vapor Standards Association run out of his Richmond, Virginia, headquarters where he makes about 100 flavors.

"The main reason people are able to switch away from tobacco is because of the flavors offered to them," Xu said. "If nobody uses it, why bother?"



