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NYTS Survey: Youth Vaping Rates Drop Between 2019 and 2020

On September 9, the Centers for Disease Control and Prevention (CDC) published results from the 2020 National Youth Tobacco Survey (NYTS), which indicated that youth vaping declined by one-third from 2019 to 2020.

Published in the September 9, 2020 Morbidity and Mortality Weekly Report, data from the NYTS found that current e-cigarette and vapor product use – defined as using such products on at least one occasion in the 30 days prior to the survey – declined from 27.5 percent of high school students and 10.5 percent middle school students to 19.6 percent and 4.7 percent, respectively. Among middle school students, vaping rates declined by 55 percent.

Regarding frequent and daily use, among high school students, 7.62 percent of students reported using an e-cigarette on 20 or more days and 4.4 percent reported using e-cigarettes every day. Among middle schoolers, less than 1 percent reported using vapor products frequently and/or daily.

Youth reported using flavored e-cigarettes and different types of devices. Among all high school students, 9.4 percent reported using a cartridge-based closed system vapor product, 5 percent reported using a closed system disposable e-cigarette, and only 2 percent reported using an open-system, tank vapor product. Among all middle school students, 1.8 percent reported using a cartridge-based e-cigarette and less than 1 percent reported using tanks and/or disposables. 

This data should be contrasted with results from the 2019 Youth Risk Behavior Survey (YRBS), which were released by the CDC last month. In 2019, 32.7 percent of high school students reported current use of electronic cigarettes and vapor products. Further, 10.7 percent of high school students reported using e-cigarettes frequently and 7.2 percent reported daily e-cigarette use.

The 2019 YRBS also found that youth combustible cigarette use is at an all time low. Indeed, only 6 percent of high school students reported smoking on at least one day in the 30 days prior to survey. Moreover, only 1.3 and 1.1 percent of high school students reported frequent and daily combustible cigarette use, respectively.

This new data is promising for those hoping to keep vaping products on the market and available for adult smokers. It remains to be seen whether this progress will result in slowdowns of anti-vaping efforts at the local, state, and federal level, but we know that prohibitionist organizations like the Campaign for Tobacco-Free Kids are not backing down from their quest to ban all flavored tobacco and nicotine products.

As of September 2020, five states have passed laws banning the sale of flavored vapor products. Currently, New Jersey, New York, and Rhode Island prohibit the sale of flavored e-cigarettes. Massachusetts has banned the sale of all flavored tobacco products – including menthol cigarettes. California is the latest state that has banned flavored tobacco products, with the ban taking effect January 1, 2021, although a ballot initiative drive is underway that would put the ban on hold until voters approve or disapprove in November 2022. As predicted by many, black and gray market sources have replaced much of the legal market.

Many localities have also banned the sale of flavored tobacco and vapor products. On September 9, the Chicago City Council banned the sale of flavored e-cigarettes, after removing a ban on menthol cigarettes. A Phoenix City Councilman has recently voiced their intention to introduce a proposal to ban the sale of all flavored tobacco products, including menthol cigarettes and vapor products.

Policymakers have argued that banning flavors would reduce the appeal of vapor products to youth. Although youth do use flavored e-cigarette products, flavors are far from the number one cited reason as to why youth use such products. Indeed, data from surveys indicate that youth use vapor products due to social reasons and because a friend and/or family member uses such products. Furthermore, repeated surveys have found very high levels of flavor use by adults who have successfully switched to vaping.

It is important for policymakers to understand that while preventing youth e-cigarette use is laudable, policies should not restrict access to adult users of tobacco harm reduction products. Millions of Americans have used e-cigarettes to successfully quit smoking and rely on flavors to remain smoke-free, with youth e-cigarette use decreasing it is disingenuous to prohibit these products from adult consumers.

Research, Vaping News

Rutgers-Led National Survey Uncovers Doctors’ Misconceptions About Nicotine Risks

Researchers say physicians need to understand accurate nicotine risks better to assist patients addicted to the most harmful tobacco products

NEW BRUNSWICK, NEW JERSEY — Most physicians mistakenly believe that nicotine leads to cancer, and heart and respiratory diseases, according to a Rutgers-led national survey, even though it is the toxic substances in cigarette smoke and not the nicotine that causes the primary health risk. 

The study, published in the Journal of General Internal Medicine, surveying more than 1,000 doctors from six specialties between September 2018 and February 2019 about their knowledge of tobacco use, found that 80 percent of those surveyed believe it is the nicotine that directly causes cancer.

“Physicians must understand the actual risk of nicotine use as they are critical in the prescription and recommendation of FDA-approved nicotine replacement therapy products to help patients who use other dangerous forms of tobacco,” said Michael B. Steinberg, medical director of the Rutgers Center for Tobacco Studies and a professor and chief of the Division of General Internal Medicine at the Rutgers Robert Wood Johnson Medical School. “Doctors should be able to accurately communicate these risks, which may include low-nicotine cigarettes, which are not safer than traditional cigarettes.”

The Rutgers-led survey asked physicians in specialties ranging from family medicine, internal medicine, obstetrics and gynecology, cardiology, pulmonary and critical care and hematology and oncology about their understanding of tobacco treatment practices, harm reduction beliefs and tobacco and e-cigarette use.

Although nicotine’s primary risk is addiction or dependence on tobacco products, researchers found that 83 percent of doctors strongly believed that nicotine directly contributed to heart disease. In comparison, 81 percent thought it contributed to chronic obstructive pulmonary disease (COPD). Pulmonologists, who focus on the respiratory system, were less likely than other specialties to misperceive nicotine as a direct contributor to COPD. Family doctors were more likely than oncologists to misunderstand nicotine as a cancer-causing substance.

Less than one-third of the doctors surveyed correctly agreed that nicotine directly contributed to birth defects, while 30 percent did not answer the question, indicating they did not know the answer. Younger and female doctors were more likely than males to perceive correct nicotine risks causing birth defects, while OB/GYNs surprisingly misidentified them more than other specialties.

In the United States, an estimated 34 million people smoke cigarettes, according to the Centers for Disease Control. Nicotine replacement therapies include over-the-counter products like patches, gum and lozenges as well as prescription medications.

“Correcting misperceptions in medicine should be a priority given the FDA’s proposed nicotine-centered framework that includes reducing nicotine content in cigarettes to non-addictive levels while encouraging safer forms of nicotine like NRT, to help with smoking cessation or non-combustible tobacco, like smokeless tobacco for harm reduction,” said Cristine Delnevo, director of the Rutgers Center for Tobacco Studies and professor at the Rutgers School of Public Health.

Researchers recommend brief communication interventions that can effectively correct such nicotine misperceptions among doctors and the general public.

The study’s authors include Michael B. Steinberg MD, MPH; Michelle T. Bover Manderski PhD, MPH; Olivia A. Wackowski PhD, MPH; Binu Singh MPH; Andrew A. Strasser PhD; & Cristine D. Delnevo PhD, MPH.

Vaping News

PMTA Deadline Looms; Still A Major Threat to Thousands of Small Businesses

FDA Releases PMTA Guidance – Tobacco Plus Expo International

The deadline for the most serious regulatory hurdle to face the US vaping industry is just over a month away, and thousands of small businesses are still unsure whether they will be able to legally sell their products in the United States after September 9, 2020.

The premarket tobacco application (PMTA) was a component of the U.S. Food and Drug Administration’s (FDA) 2016 deeming regulations. This rule classified vapor products as ‘tobacco products’ and required manufacturers to follow a procedure to stay on the market. In the years that followed, vapor manufacturers complied with sensible requirements to register their products, open their manufacturing facilities to federal inspections, and submit ingredient listings to the FDA. It is the final step in the process — the PMTA — that is proving most difficult.

The PMTA is undoubtedly the most extensive of all the components of the deeming regulations. In order to prove that a product meets the FDA’s standard of “appropriate for the protection of public health,” it is not enough for a manufacturer of vapor products to merely describe their manufacturing process and present data showing that vaping is much less harmful than smoking. Each manufacturer is instead expected to conduct extensive testing on every product they sell.

Unfortunately, the testing component is a difficult task to complete. Demand has been sky high at the limited number of labs authorized by the FDA to conduct these tests and many small manufacturers have thousands of products. The FDA itself estimates that a single PMTA will cost “around $117,000 to around $466,000″ per product, although many believe that cost is underestimated.

In different hands, the FDA would have seen the PMTA process as an opportunity to help manufacturers of all sizes reassure the public that vapor products are fit for their intended purpose — to transition adult smokers away from cigarettes to a product that is much less hazardous than cigarettes. Regrettably, despite a pledge by Health & Human Services Secretary Alex Azar, the FDA has refused to streamline the process in any meaningful way.

The companies that seem most likely to be granted PMTAs are large tobacco or tobacco-affiliated companies like Juul, blu, and Reynolds. This is truly a great irony given that tobacco companies didn’t even introduce their own vapor products to US markets until 2012 – five years after e-cigarettes were first sold in the US.

Lawmakers and regulators should know that there are two different types of vapor products: open systems which include mods and tanks, and closed systems – often referred to as pod systems. When analyzing studies of vapor product usage, it is clear that while adults have found great success in using closed systems to quit smoking, teens also utilize closed systems at greater rates than open systems.

In 2019, former FDA Commissioner Dr. Scott Gottlieb tweeted that increases in youth vaping were “largely driven by use of Juul, the most popular e-cig among kids. The vape industry needs to differentiate open systems used by adults vs closed systems like Juul preferred by kids.” It remains to be seen whether the FDA, now under the leadership of Dr. Stephen Hahn, will recognize this difference when assessing PMTAs.

With a little over a month away from the PMTA deadline, it is important that regulators understand the enormous cost of submitting a PMTA. Dr. Gottlieb is correct that there needs to be a differentiation between the different types of vapor products. Open systems shouldn’t be shut down due to draconian regulations that are impossible for small businesses to afford.

Without further delays and reforms to the PMTA system, it is likely that the current diverse marketplace for legal vapor products will undergo radical change for the worst. Open systems — the products used least by youth but most at risk of being banned by the FDA — will continue to be sold, but in new illicit markets with limited or no safety controls instead of in regulated vape shops. Meanwhile, legal and deadly cigarettes will remain on the shelves of every convenience store.

It would be a great travesty to see a technological innovation — one created by former smokers that has helped millions of Americans quit combustible cigarettes — be needlessly destroyed by bad regulations.

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Vaping News

S.1253 Will Harm Adult Vapers and Will Not Reduce Youth E-Cigarette Use

Last Thursday, the United States Senate passed S.1253, the Preventing Online Sales of E-Cigarettes to Children Act, which has been pitched to the public as a way of requiring online e-cigarette retailers to verify ages of customers, including requiring a signature and ID upon delivery.

As is often the case, the words of politicians often conflict with the language in the bills they support. This legislation would also ban the USPS from shipping vaping products — forcing consumers and businesses to use more expensive and less reliable options offered by FedEx and UPS — and require even the smallest of vaping product companies to comply with a byzantine set of rules laws and rules set by both the federal and state governments.

The United States is in the middle of an epidemic that has effectively transformed the way that products are delivered. COVID-19 has directed many companies to offer contactless delivery and this Act would require drivers and the public to interact – undoubtedly ignoring social distancing practice. Moreover, this Act comes at a time when more and more American adults are relying on mail delivery for household goods and will simply add more burden to an already-burdened mail system.

Although seeking to reduce youth e-cigarette use is laudable, this Act ignores data that indicate most youth utilize “social sources” to obtain tobacco products, including legal-age friends and family. Indeed, a study by the United States Food and Drug Administration found 89 percent of 15 to 17 years, relied on giving money to someone else to purchase e-cigarettes. These social sources mentioned included “older siblings, friends, parents and even strangers.”

Simply, S.1253 would burden the US mailing system and is unlikely to reduce youth usage. It would also unnecessarily put delivery drivers and the public at a greater risk of COVID-19. 

The Consumer Advocates for Smoke-free Alternatives Association’s Call to Action for S.1253 remains open for vapers and harm reduction advocates to take action.

Research, Vaping News

Yale Study Finds That Vaping Flavors Help Adults Quit

File:E-liquid Bottles (9832492693).jpg - Wikimedia Commons

Evidence collected over the last decade indicates that flavors are essential for adults looking to use vaping products to quit smoking. Indeed, a new study published finds flavored vapor products to be more effective than tobacco-flavored e-cigarettes in helping adults remain smoke-free.

A new study published by JAMA Network Open examines the role of flavors in electronic cigarettes and vapor products and their influence on subsequent smoking initiation and cessation by both youth and adults. The use of flavored e-cigarettes was associated with more than twice the odds of smoking cessation among adult users compared to those using tobacco flavors. And despite a decade of hype about a supposed ‘gateway’ effect from vaping to cigarettes for young people, the researchers found no evidence to support the claim that flavors increase the chances of youth beginning to smoke.

The authors identified 17,929 respondents aged 12 to 54 years old, with data collected between 2013 and 2018. The study examined “differences in smoking initiation and cessation subsequent to vaping uptake among those who used flavored vs unflavored e-cigarettes, separately by age group.”

The study concluded that flavored e-cigarette use “was no more associated with youth smoking initiation than vaping tobacco-flavors.” Further, adults that used flavored vapor products “were more likely to subsequently quit smoking than those who used unflavored e-cigarettes.”

The findings are significant as the results indicate that flavors in e-cigarettes have no association with subsequent youth smoking initiation.

Co-author Abigail S. Friedman, PhD., of the Yale School of Public Health, told United Press International, “Our findings are consistent with the claim that non-tobacco-flavored e-cigarettes are more strongly associated with adult smoking cessation than tobacco-flavored e-cigarettes.”

The new study adds to the growing literature that flavors are essential for adult e-cigarette users. At this time four states – Massachusetts, New Jersey, New York and Rhode Island – ban the sale of flavored vapor products. Other states including California, Florida and Montana are have introduced and/or are introducing similar bans.

Although lawmakers have pushed forward with flavor bans to stem youth e-cigarette use, this study adds to growing literature that youth are not using vapor products solely due to flavors. In analyses of youth vaping surveys, youth are overwhelmingly using e-cigarettes out of curiosity and because friends and/or family members use them.

Moreover, studies on youth vapor product use indicate that many youth e-cigarette users are using such products once or twice a month, often in social settings.

Removing flavors from vapor products is unlikely to reduce youth e-cigarette use, but such bans will greatly harm both current adult e-cigarette users and current combustible cigarettes users by eliminating tobacco harm reduction options.

The American Vaping Association continues to fight against flavor bans and draconian prohibitions that threaten adult access to vapor products.