Perspective from Cristine Delnevo, PhD, MPH
Perspective from Harold J. Farber, MD, MSPH
February 11, 2019
8 min read

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

Perspective from Cristine Delnevo, PhD, MPH
Perspective from Harold J. Farber, MD, MSPH
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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.


“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


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. “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.