U.S. Surgeon General warns of youth vaping “epidemic”

December 18, 2018

The U.S. Surgeon General today issued an advisory on the health risks of vaping on youth and called on parents, health professionals and governments to curb their use.

“I am officially declaring e-cigarette use among youth an epidemic,” U.S. Surgeon General Jerome Adams said in a Tuesday press conference. “I don’t use that word lightly. We’re in the midst of a historic increase in youth use of any substance. Today we must protect our nation’s young people from a lifetime of nicotine addiction.”

Health Officer Dr. Jennifer Vines testifies on the health effects of nicotine and vaping on young people

Today’s advisory is the first federal health advisory on inhalant delivery systems and youth. The office used advisories in 2005 to warn of the risk of consuming alcohol while pregnant and the risks of breathing indoor radon, and earlier this year to encourage broader access to the drug Naloxone, which can reverse the effects of an opioid overdose.

It’s first warnings on the health risks of tobacco were issued more than 50 years ago, and the preceding decades marked a sharp decline in the number of Americans.

“Much has changed since then,”Adams said. “Technology has transformed our lives and the landscape has evolved to include electronic products, that are easily concealed, that most parents wouldn’t recognize as a way for youth to consume nicotine.”

Inhalant delivery devices, including electronic cigarettes, heat a liquid mix of nicotine and flavoring that is then inhaled. Largely unregulated, they allow people of any age to purchase them, and lack federal safety oversight. The liquids are sold in many kid-friendly flavors such as Gummy Bear, Sherbet Candy and Captain Crunch.

Tuesday’s advisory comes on the heels of findings released Dec. 17, 2018 by the Monitoring the Future project at the University of Michigan that show the percent of 12th graders who had vaped nicotine in the past 30 days had nearly doubled in a single year.

That translates into more than 1 million new nicotine vapers in 2018. That’s the largest increase for use of any substance among 12th graders since the project launched in 1975.

Members of the Beaverton High School's “Rebels for a Cause” program asked County in 2015 to regulate e-cigarettes

The soaring rates of youth vaping mirror soaring sales for vapor product companies. But almost none have dominated the market more than JUUL Labs, the Surgeon General and Centers for Disease Control and Prevention found. From 2016 to 2017, the company’s sales increased 641 percent — from 2.2 million devices to 16.2 million devices. By the end of 2017, one in every three inhalant delivery systems was a JUUL.

On Tuesday, Surgeon General Adams asked local governments to “implement evidence based strategies that we know work,” he said. Governments should consider policies and laws including:

  • Including inhalant delivery systems in indoor air quality laws prohibiting smoking.

  • Restricting use by minors.

  • Requiring vendors be licensed.

  • Establishing taxes on the sale of inhalant delivery systems.

  • Reducing access to flavored e-cigarette liquids.

  • Restricting advertising of inhalant delivery systems to youth.

“We've passed local regulations to keep e-cigarettes away for our kids, but we need solutions from Salem and Washington D.C. that make a deeper impact,”said Multnomah County Chair Deborah Kafoury. “Those include taxes, restrictions on kid-friendly flavors and advertising that targets young people. So I'll be pushing for those."

A long fight

Multnomah County began addressing health concerns about vaping in 2014.

In the fall of 2014, Health Officer Dr. Jennifer Vines warned the Board of an increasing number of youth using electronic cigarettes locally. The product was entirely unregulated by the state or county. Anyone, of any age, could purchase and use them. And they were not inspected or controlled by any safety authority. While tobacco use was declining among Oregon high school students, e-cigarette use was on the rise, Vines told the board.

That November, Environmental Health Director Dr. Jae Douglas recommended the county ban the sale of inhalant delivery systems to people under 18, and prohibit their use in places where cigarettes are banned under the Oregon Clean Air Act.

The Board followed with a series of 11 public meetings on vaping and inhalant delivery systems. Then in February 2015, Commissioners, acting as the Board of Health, adopted a policy to prohibit vaping in any place of employment where smoking is already prohibited. The order also banned sales to, and use and possession by, people under 18. A month later, the Board passed the ordinance to enact the health policy.

Alberto Moreno, then executive director of the Oregon Latino Health Coalition, testified in 2014.

In May, 2015, Gov. Kate Brown adopted the county’s ordinance, signing a state law that prohibited the sale of inhalant delivery systems to minors and prohibiting inhalant delivery systems in any indoor area that was smokefree under the Oregon Indoor Clean Air Act.

Health experts continued to urge County officials for tighter controls. Following a stunning spike in e-cigarette use by minors nationwide, Health Officer Vines in 2015 asked the Board of Commissioners to consider a tax on inhalant delivery systems as a tool to curb the explosion of vaping among teens.

County officials considered the proposal, but instead lobbied for a statewide solution. That year the Oregon legislature considered two bills that would have required the state collect excise taxes on inhalant delivery systems — HB 2134 and HB 2074. County leaders hoped the solution would come from Salem, and a statewide tax would pass. But both bills — opposed by industry groups — died in committee.

That November, the Board voted to require businesses selling tobacco and vaping products obtain a license. The license would support an education and enforcement program, allowing the county to monitor retailers who had helped earn Multnomah County one the nation’s highest rates of illegal tobacco sales to minors.  

Multnomah County officials also considered increasing the age to purchase tobacco and inhalant delivery systems from 18 to 21. Then in August, Gov. Brown signed SB 754 into law, raising the minimum legal sale age for nicotine products to 21, and including electronic cigarettes, vape pens and E-liquids in the law.

A second wind

Few states tax vaping supplies. Oregon lawmakers tried twice in 2015, but failed. Representatives Brian Clem (D-Salem) and Rob Nosse (D-Portland) tried again in 2017. Again the bill died. The 2019 legislature may get another chance to consider a tax, with the introduction of House Bill 2159. The bill would impose a tax equal to 95 percent of the wholesale price on some inhalant delivery systems.

Stateholders chatted following one of 11 public hearing on local regulation of inhalant delivery systems.

The Food and Drug Administration has had the authority to regulate inhalant delivery systems since 2016. And now they’re seeking to require age verifications for buying e-liquids. The agency will soon step up enforcement of sales to minors, targeting sites where kids can get access to flavorful e-liquids, FDA Director Dr. Scott Gottlieb said Tuesday.

“We have to limit the appeal to kids and that starts with flavors,” Gottlieb said. “Flavors are the primary vehicle by which youth start vaping.”

That’s particularly concerning because inhaling nicotine as a teen makes an adult’s brain more susceptible to addiction as an adult.

“Combustible cigarettes remain the leading cause of preventable death in the United States, and providing an effective off-ramp for adults who want to quit using them is a public health priority,” Health and Human Services Secretary Alex Azar said. “But we cannot allow e-cigarettes to become an on-ramp to nicotine addiction for younger Americans.”

Multnomah County Public Health Director Rachael Banks said she expects the local Public Health Advisory Board to recommend additional e-cigarette regulations when it appears before the board of Commissions next spring.

“In some ways we’ve talked about tobacco so much, that we forget, nicotine is a poison,” Banks said. “Our role is to protect youth from being exposed to substances that will harm them. From a public health perspective we can't stand by and let that happen.”