Perspective

CDC: PCPs must help curb growing youth tobacco ‘crisis’

The CDC recently urged primary care physicians to step up their efforts to identify smokers among their patients aged younger than 18 years.

“One of the most important things for health care professionals who work with youth is to ask these young patients about e-cigarette use when they screen for tobacco product use,” Brian King, MPH, PhD, deputy director for research translation at CDC’s Office on Smoking and Health said in a recent conference call with reporters.

“They must also ask about the diversity of tobacco products that are out there and use current terminology like Juul or vape pad, since not all youth recognize that these are e-cigarettes. Clinicians must also warn about the risks of any kind of tobacco use in this population group,” he added.

The call to action came as 2018 National Youth Tobacco Survey data recently published in MMWR showed 27.1% of high school students and 7.2% of middle school students used any tobacco product, and that 20.8% of high school students and 4.9% of middle school students were using e-cigarettes.

The CDC said these numbers, combined with stagnant use of other tobacco products among U.S. youths during 2017 to 2018, wiped out the recent progress the U.S. had made in reducing overall tobacco product use among those patients.

In addition, data that recently appeared in JAMA Network Open indicated youths who reported e-cigarette use in a 2013 survey had more than four times the odds of ever using cigarettes than those who reported never using tobacco at all in the 2013 survey (OR = 4.09; 95% CI, 2.97-5.63). Prior use of other tobacco products was also linked to increased odds of ever cigarette use (OR = 3.84; 95% CI, 2.63-5.63).

King pointed some of the responsibility for the turnabout at a particular product.

Teenagers Smoking 
The CDC recently urged primary care physicians to step up their efforts to identify smokers among their patients aged younger than 18 years.


Source:Adobe

“The increase in e-cigarette use among youth that we’ve seen in the past year occurred at the same time as increases in sales of the e-cigarette Juul. ... Since December 2017 Juul has held the greatest market share of any e-cigarette in the United States,” he said.

King’s claim during the conference call that Juul has a “high nicotine content” was backed up in a recent Tobacco Control study that compared the nicotine levels in dozens of Juul-type products to Juul’s 5% nicotine level. These researchers found “more than 70 e-liquid brands sell high-nicotine products (5% or more) in bulk (30 mL or more), equivalent to 40 cigarette packs.”

Robert Jackler
Robert Jackler

The Tobacco Control study, which was not affiliated with the CDC, also noted the nicotine liquid found in the products studied put children at risk for food and skin poisoning and that the higher concentrations of nicotine via an aerosol can may make the impact of secondhand smoke worse, according to its co-author, Robert Jackler, MD, principal investigator of Stanford Research Into the Impact of Tobacco Advertising.

Like the CDC and other researchers, the FDA has also recently increased its attention towards Juul. In November, 1 month after it seized hundreds of Juul-related documents, the FDA announced it would revisit policies that oversee most flavored to electronic nicotine delivery systems that are sold online without additional, heightened age verification and other restrictions in place and also take another look at regulations that extend the premarket application compliance date for several products to electronic nicotine delivery systems and e-cigarettes to August 2022.

During the recent conference call, Mitch Zeller, JD, director of the FDA’s Center for Tobacco Products said more FDA efforts to curb tobacco and nicotine use among youth could be forthcoming.

Mitch Zeller
Mitch Zeller

“We continue to put the full scope of our regulatory tools against this mounting public health crisis [but] the reality is there are no FDA approved treatments for youth tobacco cessation. This is a gap in the treatment arsenal that needs to be closed but we are working to change that,” he said. – by Janel Miller

References:

Gentzke AS, et al. MMWR. 2019;published online ahead of print.

Jackler RK, Ramamurthi D. Tob Control. 2019;doi:10.1136/tobaccocontrol-2018-054796.

Stanford University School of Medicine. http://med.stanford.edu/news/all-news/2019/02/5-questions-robert-jackler-says-juul-spurs-nicotine-arms-race.html. “5 Questions: Robert Jackler says Juul spurs ‘nicotine arms race.’” Accessed Feb. 8, 2019.

Disclosures: Healio Primary Care Today was unable to determine relevant financial disclosures prior to publication.

The CDC recently urged primary care physicians to step up their efforts to identify smokers among their patients aged younger than 18 years.

“One of the most important things for health care professionals who work with youth is to ask these young patients about e-cigarette use when they screen for tobacco product use,” Brian King, MPH, PhD, deputy director for research translation at CDC’s Office on Smoking and Health said in a recent conference call with reporters.

“They must also ask about the diversity of tobacco products that are out there and use current terminology like Juul or vape pad, since not all youth recognize that these are e-cigarettes. Clinicians must also warn about the risks of any kind of tobacco use in this population group,” he added.

The call to action came as 2018 National Youth Tobacco Survey data recently published in MMWR showed 27.1% of high school students and 7.2% of middle school students used any tobacco product, and that 20.8% of high school students and 4.9% of middle school students were using e-cigarettes.

The CDC said these numbers, combined with stagnant use of other tobacco products among U.S. youths during 2017 to 2018, wiped out the recent progress the U.S. had made in reducing overall tobacco product use among those patients.

In addition, data that recently appeared in JAMA Network Open indicated youths who reported e-cigarette use in a 2013 survey had more than four times the odds of ever using cigarettes than those who reported never using tobacco at all in the 2013 survey (OR = 4.09; 95% CI, 2.97-5.63). Prior use of other tobacco products was also linked to increased odds of ever cigarette use (OR = 3.84; 95% CI, 2.63-5.63).

King pointed some of the responsibility for the turnabout at a particular product.

Teenagers Smoking 
The CDC recently urged primary care physicians to step up their efforts to identify smokers among their patients aged younger than 18 years.


Source:Adobe

“The increase in e-cigarette use among youth that we’ve seen in the past year occurred at the same time as increases in sales of the e-cigarette Juul. ... Since December 2017 Juul has held the greatest market share of any e-cigarette in the United States,” he said.

King’s claim during the conference call that Juul has a “high nicotine content” was backed up in a recent Tobacco Control study that compared the nicotine levels in dozens of Juul-type products to Juul’s 5% nicotine level. These researchers found “more than 70 e-liquid brands sell high-nicotine products (5% or more) in bulk (30 mL or more), equivalent to 40 cigarette packs.”

Robert Jackler
Robert Jackler

The Tobacco Control study, which was not affiliated with the CDC, also noted the nicotine liquid found in the products studied put children at risk for food and skin poisoning and that the higher concentrations of nicotine via an aerosol can may make the impact of secondhand smoke worse, according to its co-author, Robert Jackler, MD, principal investigator of Stanford Research Into the Impact of Tobacco Advertising.

Like the CDC and other researchers, the FDA has also recently increased its attention towards Juul. In November, 1 month after it seized hundreds of Juul-related documents, the FDA announced it would revisit policies that oversee most flavored to electronic nicotine delivery systems that are sold online without additional, heightened age verification and other restrictions in place and also take another look at regulations that extend the premarket application compliance date for several products to electronic nicotine delivery systems and e-cigarettes to August 2022.

During the recent conference call, Mitch Zeller, JD, director of the FDA’s Center for Tobacco Products said more FDA efforts to curb tobacco and nicotine use among youth could be forthcoming.

Mitch Zeller
Mitch Zeller

“We continue to put the full scope of our regulatory tools against this mounting public health crisis [but] the reality is there are no FDA approved treatments for youth tobacco cessation. This is a gap in the treatment arsenal that needs to be closed but we are working to change that,” he said. – by Janel Miller

References:

Gentzke AS, et al. MMWR. 2019;published online ahead of print.

Jackler RK, Ramamurthi D. Tob Control. 2019;doi:10.1136/tobaccocontrol-2018-054796.

Stanford University School of Medicine. http://med.stanford.edu/news/all-news/2019/02/5-questions-robert-jackler-says-juul-spurs-nicotine-arms-race.html. “5 Questions: Robert Jackler says Juul spurs ‘nicotine arms race.’” Accessed Feb. 8, 2019.

Disclosures: Healio Primary Care Today was unable to determine relevant financial disclosures prior to publication.

    Perspective
    Cristine Delnevo

    Cristine Delnevo

    Earlier this week, the CDC released a report on the patterns of youth tobacco use from 2011 to 2018. While the report contains incredible detail about the changing patterns of youth tobacco use, the findings were quickly reduced to soundbites like “tobacco use by teens soars, erasing past progress.” This pattern is driven by one type of product — electronic cigarettes — which is used sporadically.

    But the use of combustible tobacco, that is cigarettes and cigars, which remains the single largest preventable cause of disease and premature death in the U.S., is at an all-time low for our nation’s youth. Public health and medical professionals should be asking questions like “How did we get here?” and “How can we eliminate combustible tobacco use in young people?” The CDC report outlines some sound strategies like flavor bans and raising the legal age of tobacco sales to 21 years.

    One clear pattern emerges from the data, youth tobacco use is complex and spans the diverse tobacco marketplace. Moreover, there are notable demographic differences that warrant our attention. Poly-tobacco use, that is the use of more than one tobacco product, is common, with more than one out of 10 high school students reporting this behavior. E-cigarettes are overwhelmingly popular among white students, but among black high school students, cigars are the most popular. This differential pattern has the potential to exacerbate existing health disparities and we need to do better here. While neither the long-term health effects of e-cigarettes, nor the extent to which young e-cigarette users are addicted to nicotine is known yet, one thing is clear: cigars contain the same toxic and carcinogenic compounds found in cigarettes and are, without question, harmful to health.

    Much of the report focused on patterns of “current use” — which for youth is defined as any use, even one time, in the past 30 days. This broad definition includes first-time experimenters as well as regular, frequent use (defined as using the product on 20 or more days in the 30 days preceding the survey). A deeper dive into the data indicate that for cigarettes, frequent use in 2018 was extremely low (1.9% of all high school students). Compare this to 2 decades ago, when 16.8% of high school students smoked cigarettes frequently and of these, three out of four smoked daily. E-cigarettes were the product used most frequently with 5.8% of high school youth using e-cigarettes on 20 or more days in the past 30 days. It is important for us to understand who these youth are, and what their experiences are with other tobacco products. Answers to the questions “Are they naive tobacco users who became addicted to this new product?” or “Are they experienced tobacco users switching to lower-risk product?” are necessary to inform a sound public health and clinical response. Primary care physicians are well positioned to intervene to reduce youth tobacco use and should discuss the wide array of tobacco products with their patients and discourage their use.

    • Cristine Delnevo, PhD, MPH
    • Director, Center for Tobacco Studies at Rutgers School of Public Health
      Co-Leader, Cancer Prevention and Control Research Program at Rutgers Cancer Institute of New Jersey

    Disclosures: Delnevo reports receiving grant support from the National Cancer Institute and the FDA Center for Tobacco Products.

    Perspective
    Harold J. Farber

    Harold J. Farber

    The tobacco industry has long known that addicting youth is the key to their business, as 90% of smokers start before their 18th birthday, and 99% before their 26th birthday. The tobacco industry has a long history of designing products to maximize their addictiveness, such by as adjusting the pH to make the smoke more inhalable and adding menthol. The tobacco and nicotine industry have a long history of product design and promotion to appeal to young people from the infamous “Joe Camel” cigarette promotion to the fruit and candy flavors in cigars and e-cigarettes, vaping contests, etc. 

    Against this background comes the rise of Juul with a patented nicotine salt that is more addictive and less aversive than free-base nicotine which in turn was an innovation by the tobacco industry to make cigarettes more addictive. With its discreet design (looking like a flash drive for a computer, it is easy to use in class without attracting notice), appealing flavors, and a high concentration of a nicotine salt that can be delivered without the usual aversive impacts of nicotine, Juul has rapidly surged to dominate the e-cigarette market. Thanks in part to Juul, e-cigarette use is now epidemic among our young people.  Close to one out of four high school students in the U.S. report current e-cigarette use in 2019. In looking at current trends, we have not yet seen the peak of the epidemic, not even close. Without aggressive regulatory action, the toll of nicotine addiction among our young people will continue to rise. 

    The FDA was given authority adopt evidence-based tobacco product standards appropriate for the protection of the public health as part of the 2009 Family Smoking Prevention and Tobacco Control Act and in 2016 the FDA finalized a deeming rule to extend its regulatory authority over all tobacco products. Although the FDA has used tough language, they have yet to take much action against an industry that is rapidly addicting more and more young people to tobacco and nicotine. Rather, the FDA is calling on the tobacco and e-cigarette (vape) industry to regulate itself. To put it another way, the FDA is essentially asking the fox to guard the henhouse. In the absence of effective action from the FDA, the e-cigarette industry is targeting our youth and making billions in the process. There are a wealth of youth-appealing fruit and candy flavored products, product design and promotion has focused on appeal to young people, and now we are seeing innovations that are even more dangerous for our youth high nicotine products that do not have the usual aversive effects of nicotine on the uninitiated. That makes these products particularly dangerous as they are easy to start, but very hard to stop.

    The article by Jackler and Ramamurthi astutely highlights the consequences of this regulatory non-action by the FDA. Seeing the success of the Juul product with high nicotine concentrations, its competitors are attempting to get a piece of the action with similar products delivering high nicotine concentrations. Further, they document the increase in refillable high nicotine products characteristically packaged in brightly colored bottles with sweet and fruity flavors, design that leads to a substantial risk for nicotine poisoning of young children. 

    The e-cigarette and Juul epidemic could have been prevented if the FDA had lived up to its responsibility under the 2009 Family Smoking Prevention and Tobacco Control Act. The FDA has the authority to conduct premarket review of all tobacco products introduced in the United States after February 2007 and also gives the FDA the authority to reject these products if their introduction is not appropriate for the protection of the public health. Fruit- and candy-flavored e-cigarettes and the vast majority of flavored cigar products were introduced to the market after February 2007. Juul only hit the market in 2015. 

    The FDA has the authority to remove from the market any new tobacco product introduced after February 2007 until it has gone through pre-market review and to reject these products if their introduction is not appropriate for the protection of the public health this includes most e-cigarette products. The FDA has not started to conduct pre-market reviews, pushing the deadline back to August 2021 with the rationale that it, “will allow companies to develop higher quality, more complete applications.” The FDA’s current approach appears to be to talk big but do little, while deferring and delaying implementation of effective regulation. The current FDA approach protects the e-cigarette industry while leaving our children as fodder upon which they build their windfall profits.

    However, even without FDA action, there are actions that state and local governments can take to protect young people. Flavored tobacco and e-cigarette products can be banned.  Effective media campaigns and education focus on changing the image by telling the truth about nicotine and tobacco. Ineffective (and often industry sponsored or supported) efforts have focused on telling kids that it is acceptable for adults but not for them. Age for sale of tobacco and nicotine products can be increased to 21 years, which if enforced will protect middle and high school students by decreasing their social sources of tobacco and nicotine products. So far 425 cities and counties in 23 states have raised the age for sale of tobacco and nicotine products to 21 years. San Francisco has banned the sale of youth-appealing flavored tobacco and nicotine products. 

    The tobacco and e-cigarette industries are making billions by addicting our young people. When are the FDA, our policy makers, and our politicians going to say enough is enough? Our children are more important than the tobacco and e-cigarette industry’s profits.

    • Harold J. Farber, MD, MSPH, FAAP, ATSF
    • Associate professor of pediatrics, pulmonary section, Baylor College of Medicine and Texas Children's Hospital
      Associate medical director, Texas Children's Health Plan
      chair, Tobacco Action Committee, American Thoracic Society