What's worrisome to public health officials is that these young users will remain addicted to nicotine, even though they're not smoking.

By Sarah Ovaska-Few

Tobacco use among teens is at what the FDA is calling “epidemic “ with the escalating popularity of the flavored packets that plug into Juul and other e-cigarettes undoing years of preventative health work.

North Carolina, where golden leaves of tobacco long served as one of the state’s economic pillars, is far from immune to the effects of the mounting public health crisis.

E-cigarettes, which use liquid nicotine that is heated and then vaporized before the user sucks the vapor into their lungs, has seen escalating use among youth just as teenage cigarette use in the state reached record lows.

“We saw a steady decline in the use of cigarettes, traditional cigarettes, which was great,” said Kathy FitzJefferies, the program manager for Winston-Salem/Forsyth County Schools ’ Safe and Drug Free Schools program. “But then the vaping devices came on.”

Only 1.7 percent of high school youth had tried e-cigarettes in 2011 when the state first asking about the vaping in a biennial survey of tobacco use. Usage rates were up to nearly 17 percent in 2017, with no signs of it abating as vaping, Juuls and other e-cigs are making footholds in popular culture and social media. Middle-school use was at 9 percent.

Use is highest among white teenagers, with nearly 23 percent of white high-schoolers reporting e-cigarette use, while 15 percent of their Hispanic cohorts and fewer than 8 percent of black youth reporting vaping in the last 30 days.

Juul a particular threat

One brand in particular – Juul – is so popular it’s become a verb, with teens “juuling” and national reports showing the start-up company making up 72 percent of the e-cigarette market less than four years after its inception. The start-up reached a $15 billion valuation mark this spring just months after it began fundraising from venture capitalists, an accomplishment that took Facebook and Google many more years to accomplish, according to Bloomberg analyses.

The sleek, rectangular devices are used by inserting a pod of liquid nicotine, available in teen-friendly flavors like mango or cucumber. A starter pack of a Juul device and four pods retails for $40 to $50 and is available online as well as in vaping, convenience and tobacco stores. Replacement pods cost about $3 to $4 each, a little less than the $5.29 that a pack of Marlboros was selling for in a North Carolina tobacco shop this week.

The company claims it’s focused on adult smokers hoping to quit smoking but those assertions have come under tough scrutiny from federal regulators. The FDA seized thousands of documents from Juul Labs’ New York headquarters earlier this month as part of a broad inquiry into whether underage users are illegally being targeted by the company, according to a report from the New York Times.

The dangers are real, with the nicotine levels in Juul higher than in traditional cigarettes and other e-cigarettes, said Jim Martin, the director of the state Tobacco Prevention and Control Branch for the N.C. Department of Health and Human Services.

A single pod, which offers about 200 puffs and can easily be consumed in a day’s time, has the same amount of nicotine as a pack of cigarettes, Martin said. Recent research has found high-schoolers are four times more likely to try cigarettes after using e-cigarettes.

“The nicotine level in the Juul is basically double any other cigarette on the market,” he said.

Teens have been reporting waking up in the middle of the night craving nicotine, Martin said, or vomiting in school settings from the sudden rush of nicotine.

Detection by parents and school officials is difficult. Gone as well are the tell-tale signs of cigarettes such as smoke or lingering scents of tobacco, making it near impossible for parents or school officials to detect except for the faint scents left behind by flavored varieties.

Juuls charge through USB ports and look, to the uninitiated, like a technology device. In a recent meeting of the state Child Fatality Task Force, Martin recalled a story where a woman turned a Juul into her agency’s information technology department, thinking it was a computer device. She didn’t learn it was a Juul until her teenage daughters spotted it and asked her if she’d started Juul-ing.

Beyond nicotine

Research shows that nearly all tobacco users started when they were teenagers, with 90 percent of tobacco users indicating they started before the age of 18, according to the U.S. Surgeon General’s Office. That means the current surge of e-cigarette users could very well lead to a whole new generation of persistent tobacco users, Martin said.

Most worrisome about the e-cigarette trend is what else the vaping devices can be used for.

Nicotine-based pods for e-cigarette devices can be swapped out for off-brand ones containing tetrahydrocannabinol (THC) oils, the ingredient in marijuana that brings on the high and is legal for adults in states like California and Colorado. Also being used are the significantly more dangerous synthetic cannabinoids manufactured in China from unknown substances, FitzJefferies said.

While these can’t be bought at local convenience stores, teenagers can order them online to be delivered or find ways to tamper with pods to infuse them with THC oil or other substances, FitzJefferies said.

“Kids are creative, if they want to find it, they’ll find it,” she said.

Synthetic cannabinoids are especially concerning, given that there’s little disclosed about what’s used to manufacture the chemical concoctions, and with overdoses and deaths reported elsewhere.

E-cigarettes aren’t as much a gateway to other tobacco or drugs, but more of a highway, FitzJefferies said, pointing to the fast entry into dangerous territory that can occur if teens begin inserting potent THC oils or synthetic cannabinoids in devices.

Also making it difficult for school officials is the fact that there’s no easy way to tell if a vaping device has a nicotine-based pod in it, or something more illicit. That lead to inconsistencies in how different schools were treating Juuls and other vaping devices, with some likening it to cigarettes and others to marijuana pipes.

That reality prompted the Winston-Salem/Forsyth Schools to reclassify vaping devices as drug paraphernalia in their policies this year. When teenagers are found with them on campus, it prompts an assessment for substance abuse issues among other disciplinary measures, FitzJefferies said.

Early intervention into problematic substance abuse, whether its vaping or drugs, is key for teenagers who are more susceptible to addiction given that their brains are still developing, she said.

“We want to address the issue,” she said. “If we don’t provide them the support to address it, it’s going to be a revolving door.”