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Follow the Data Podcast: Protect Kids: Fight Flavored E-Cigarettes

On September 10th, 2019, Bloomberg Philanthropies announced the creation of a new $160 million initiative to end the youth e-cigarette epidemic. The three-year program, called Protect Kids: Fight Flavored E-Cigs, is led by the Campaign for Tobacco-Free Kids, which will partner with other leading organizations including parent and community groups concerned about the nation’s kids and health.

The day following the announcement, the Trump administration said it plans to ban the sale flavored e-cigarettes.

Just last Thursday, October 17th, Juul Labs Inc announced it will suspend sales of flavored nicotine pods nationwide, but they will continue to sell mint, menthol and tobacco flavors. Read Mike Bloomberg’s statement on Juul’s announcement here.

Approximately 5 million U.S. teens use e-cigarettes, including 1 in 4 high school students; 97% of kids who use e-cigarettes use flavored varieties. The new initiative launches on heels of 49 states investigating more than 1,299 cases of lung injury associated with vaping, many of which involve teens and young adults.

Dr. Kelly Henning, Bloomberg Philanthropies’ Public Health program lead, spoke to Matt Myers, President of Campaign for Tobacco-Free Kids, about the initiative, including the need to hold the federal government accountable for its stated intentions to ban flavored e-cigarettes.

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TRANSCRIPT

KATHERINE OLIVER: Welcome to Follow the Data, I’m your host, Katherine Oliver.

Electronic cigarettes, or E-cigarettes, have been prominently featured in the media over the past months. There has been much debate about the risks of these products, researchers with varying conclusions, scant evidence as to their safety and concerns from families about where to find the facts.

In today’s episode of Follow the Data, Dr. Kelly Henning, Bloomberg Philanthropies’ Public Health program lead spoke to Matt Myers, President of Campaign for Tobacco-Free Kids. They discuss the reality of e-cigarette use – that roughly 97% of the kids who use an e-cigarette use a flavor– and 70% report the flavors as the reason they use e-cigarettes. They talk about a new initiative to fight flavored e-cigarettes, called Protect Kids, which aims to ban flavored e-cigarettes, employing multi-faceted advocacy strategies in cities and states

Protect Kids seeks to prevent kids from becoming smokers; kids who smoke e-cigarettes are three to four times more likely to become cigarettes smokers.

To learn more, listen to their conversation now, and visit fightflavoredecigs.org

DR. KELLY HENNING:  Hi, Matt.  Thanks for joining today.  We launched a new initiative to fight flavored e-cigarettes. We’re really excited to talk with you today — about the initiative.  I wanted to start off by asking you if you could clarify what are these products, what are these e-cigarettes, particularly mention fighting flavored e-cigarettes, why are we talking about flavors?

MATT MYERS: This is a really important topic, because a growing number of adults and youth around the globe are using electronic cigarettes.  We are seriously concerned that instead of helping to reduce the number of people who smoke, it’s going to increase the number of kids who become addicted to tobacco and reverse many of the trends.  A critical question, what is an electronic cigarette? They come in a wide variety of products many look like cigarettes, pens, USB drives, even.  Instead of burning tobacco, e-cigarettes most often a battery coil to turn a liquid solution that contains nicotine and other substances, to deliver nicotine in a way that appears much cleaner and much safer to many consumers.

Unfortunately, the industry has also figured out how to turn these products into those that don’t have the harshness of cigarettes that make it much easier for young people to start. Normally when a young person smokes a cigarette the first time, it hurts, and many people don’t go beyond their first cigarette.  With an e-cigarette, they’ve eliminated the harshness.  By adding a host of flavors, from mint and mango, even things like cotton candy and gummy bear, young people use these products thinking they’re completely harmless.  They taste like candy; how they can cause harm?  They don’t have the smoke that you see in a cigarette.

Our concern is millions of young kids are starting these products thinking they’re safe, many of them don’t realize that they contain nicotine.  By the time they realize that they contain nicotine, by the time that they realize they contain nicotine, many of them are already hooked.  It’s the flavors that are the onramp.  Virtually every young person who uses an e-cigarette starts with a flavored product.

DR. HENNING:  Matt, when you say virtually everyone—what percent of kids are using flavors? Do you have a sense of that?

MYERS:  The best poll in the United States shows that in the United States, roughly 97% of the kids who use an e-cigarette use a flavored e-cigarette.  Many of them will be candid and tell you they actually use the e-cigarettes because of the flavors.  Seventy percent of kids say they use it precisely because of the flavors.  They think it’s cool.  And it doesn’t hurt their breath, unlike a cigarette.

DR. HENNING:  Those are pretty scary statistics.  I’ve heard you say that you’re concerned, that this could in fact result in a whole new generation of kids being addicted to nicotine. How are we going to prevent that?  What are we going to do in this initiative to really take that on?

MYERS:  The good news is that we think we have the tools to actually reverse this epidemic.We have to do it with urgency, given the extraordinary rise.  What many people don’t understand is, in the United States between 2017 and 2018, we saw a 78% increase in e-cigarette use among high school students, 50% increase among middle school students.  These are young kids.  The data shows that those kids are three to four times more likely to go on to become cigarette smokers.  The implications are both the harm of e-cigarettes and the threat of long-term reversal of our trends.

The good news is, we think we have some tools to do. First and foremost, we want to focus on eliminating the flavored products that have fueled the epidemic.  We have some experience of a number of cities in which we’ve already worked, such as San Francisco, Oakland, Minneapolis-St. Paul, where they have banned flavored tobacco products.  It’s too early to know the result, but we think we’ve seen a dramatic change in behavior in those places.  If you’re a smoker and you’re using an e-cigarette to quit, this won’t impact you.

Second thing that’s very important is, under U.S. law, the Food and Drug Administration should be reviewing these products for health and safety and potential to appeal to kids before they’re on the market.  The FDA hasn’t done that.  We’re going to use the new initiative to put additional pressure on the FDA to quickly review every product on the market.  We were seeing health problems in the U.S. even before the recent spate of very serious respiratory diseases.  We’ve seen an increase in the number of seizures among young people who use these products, and we don’t know why.  But most importantly, we have seen literally thousands of kids begin to suffer serious effects of addiction, overt signs of withdrawal.  They’ve lost their attention span.  A number of them have stopped athletics, because they simply can’t go that long without getting their hit.  This is an urgent problem.

The third thing we’re going to do is launch communications efforts.  We want to make sure that parents, teachers, and kids understand the actual health risks of these problems.  Equally as important, we want to mobilize their voices so that officials hear from those most affected.

DR. HENNING: Matt, the companies will often say that they’re part of the solution, that they are the solution, to the tobacco epidemic.  And they also will say that we’re seeing improvements in smoking trends because of their products.  Can you comment on that, we do hear that quite a bit.

MYERS:  Those are two important questions.  First, the claim that they’re part of the solution is the same thing that the tobacco industry has been saying since the very first surgeon general’s report: Trust us.If we’ve learned anything it’s, when you trust the tobacco industry, public health loses. The e-cigarette industry has said they don’t market to kids, and yet their advertising is clearly targeted to kids using the same images as before.

They developed a school curriculum claiming that they were going to be part of the solution.  And instead what we’ve learned is, first they eliminated all the effective parts of a good school curriculum.  And second, their emissaries went into schools and actually used it to market their products and mislead kids into thinking that they’re safer. As to the issue of are they helping or hurting to reduce cigarette smoking, their arguments don’t stand up to scrutiny.

Let me give you the best example.  Between 2009 and 2014, we saw dramatic declines every year in youth cigarette smoking.  Juul was introduced into the market in the United States in roughly 2015, began to be very popular in 2016.  What happened after Juul was introduced?  That progress came to a dead stop.  In the last three years, we’ve seen no decline whatsoever in youth cigarette smoking, even as the number of youth who use e-cigarettes and became addicted to e-cigarettes has skyrocketed.  What it says is, the e-cigarette companies are appealing to a different category of young people.

And in fact, by renormalizing smoking, they’re inhibiting our progress, not assisting it.  Interestingly, we see the same pattern with adults.  We saw a dramatic decline in the U.S. with adults beginning in 2009 as a result of an increase in the federal excise tax, additional public education, and the removal of flavored cigarettes.  What we also saw is that with the introduction of Juul, between 2016 and 2018, our progress with adults also slowed.

It shouldn’t be a surprise, because if you look at the data, between 2017 and 2018 we saw a dramatic increase, 78% increase, in youth use of e-cigarettes.  Between 2016 and 2018, there was no increase whatsoever in the percentage of adults who used e-cigarettes.  The growth market has been kids, and those people aren’t using it to quit.

Graph of Tobacco use in U.S. High School Students

DR. HENNING: I want to transition for a second into some work that we’ve been doing at Bloomberg Philanthropies with your group, the Campaign for Tobacco-Free Kids, and other partners around the world to address the smoking and tobacco issues outside of the United States, the Bloomberg Initiative to Reduce Tobacco Use.

This is something that we’ve been doing together since late 2006, with quite a bit of success.  Are there lessons from that global work that you think are important to touch on with regard to this e-cigarette epidemic that we’re experiencing right now in the U.S.?

MYERS:  I think there are very important lessons, and I think we should be applying the same tools to e-cigarettes that we have applied to cigarette smoking.

We’ve learned a number of things.  Kids in particular are very price-sensitive.  We should be taxing these products to increase their cost and decrease their availability to young people.

We should make sure that we apply the laws banning smoking indoors to e-cigarettes.  What we have seen is if you don’t do it, it renormalizes the entire act of smoking and undermines both our work on cigarette smoking and e-cigarettes.

Three, we’ve learned a great deal about how to do public education, both to communicate the risk of disease, but equally as important to do the kind of media that makes it uncool to use these products.

Fourth, it’s incredibly important to realize that government has a critical role. Government has to step in and ensure that it takes the necessary step to prohibit the tobacco industry and the e-cigarette industry from marketing their products.  We know that unless there are strong rules banning all forms of advertising and marketing, the industry will get around it.  We have seen that with the e-cigarette industry in the United States.We’re beginning to see the e-cigarette industry use the same tactics the tobacco industry used overseas.  They’re handing out free samples. They’re sponsoring events that young people to go to.  The only way to tackle that is to learn the same lesson we used from cigarette smoking, which is we simply need to ban all forms of that kind of marketing.

DR. HENNING:  You’ve touched on communications a couple of times. You’ve touched on the idea of marketing as an important strategy that the e-cigarette companies are using.  I think also, probably important to mention that a number of these companies are partially owned by tobacco companies.  Can you give us another example of deceptive strategies and communications tools that these companies are using to try to hook kids?

MYERS:  Absolutely.The e-cigarette industry has literally looked at the tobacco industry playbook. Marketing is perhaps the best example.  What we have seen is the e-cigarette industry has used social media marketing, and the images in the social media marketing are the kind of young adults in settings that are exactly what a young person wants.  The people pictured are having fun.  They’re engaged in social activity, it appears that the people who are using them are athletic, healthy, sexually and socially successful, and that the use of the product is a key link to that. It’s the exact same messaging we saw with the tobacco industry.

There’s another theme you see in e-cigarette marketing in the United States that’s identical, and that is, the individuals using them appear to be very independent, very strong-willed, and to some degree, quite rebellious.  It is the perfect image for a young person.  It’s not a surprise that the meteoric rise we saw in youth e-cigarette use in the United States followed the social media campaigns.  They use the exact same images.

What’s disturbing particularly is that we’re seeing social media and the same images being used in country after country around the globe. Even where one country bans them from doing so, they simply go somewhere else.  In the social media it’s particularly concerning, because there’s no borders.

The other thing that’s important to understand is that, when you ask young people about their understanding of the health effects, the social media imagery makes them believe that these products are safe.Not just safer, but safe.  It also misleads them into thinking that these products are not addictive, because these are very independent people in the images.

It’s the old industry playbook. Address all of the issues that an adolescent is concerned with.  Downplay the health effects of the product, and make it an integral part of becoming a young adult.

DR. HENNING:  Matt, I want to just wrap up by asking you about this plan to target 20 cities and states, localities.  What is the thinking around, first of all, looking at that level of government?  And secondly, how do you decide where to go, and how do you actually move forward with that plan?

MYERS:  We’ve decided to place a priority first on cities, because cities, in fact, often are the engines of innovation. It is the place where parent, teacher, youth voices are often most heard and most responded to. Our goal is to target at least 20 cities in the near future where there are active parent-teacher groups, youth groups, because we think we can make change fastest there.

We don’t see that as the end of the process.We see it as a building block.  We also plan to then very rapidly move on to state legislatures to talk about the growing problem there.  We’ve already seen progress. In the last several weeks we’ve seen two state governors either take action or say they were going to take action.And then we’ve also seen a number of state legislators who said that they’re deeply concerned.  We’re providing support to all of those.  The Food and Drug Administration has the authority to ban the sale of flavored e-cigarettes.  It has the authority to protect our kids. If you really care about our kids, you will ban flavored e-cigarettes to prevent another generation from becoming addicted.

DR. HENNING:  Matt, thank you so much for being with us today and talking about this need to protect our kids from flavored e-cigarettes.  It’s been great talking with you.

MYERS:  Thanks for having me.

OLIVER: Since we recorded the conversation between Dr. Kelly Henning and Matt Myers, the FDA announced that they would look into clearing the market of flavored e-cigarettes. We also have started to see governors and mayors across the country step up to say enough is enough and that they are taking action to ban the sale of flavors in their communities.

The initiative, Protect Kids: Fight Flavored E-Cigs, is still working to support those leaders who are taking action, bolster communications efforts to get the facts about the dangers of e-cigarettes to the public, and push the federal government to actually take action.

We hope you enjoyed this episode of Follow the Data.

Many thanks to Dr. Kelly Henning and Matt Myers for joining us. If you haven’t already, be sure to subscribe to Follow the Data podcast.

This episode was produced by Electra Colevas, Jean Weinberg, Jen Ellis and Ivy Li, music by Mark Piro.

Special thanks to Eric Sheppard and Tim Herro.

As our founder Mike Bloomberg says, if you can’t measure it, you can’t manage it. So until next time, keep following the data. I’m Katherine Oliver, thanks for listening.