A resurgence of adolescent tobacco use has been on the radar of the pediatric community for some time. Now recent reports give additional credence to the trend and regulators are starting to take action.
The US Food and Drug Administration (FDA) recently announced it would be stepping up its efforts to cut marketing and sales of tobacco products to teenagers, but some stakeholders say these efforts fall short in that they place the burden of effort in these new campaigns on manufacturers rather than leveraging the regulatory power of the FDA.
Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, says his organization has been filing petitions with both the Federal Trade Commission (FTC) and the FDA over the advertising and marketing strategies of traditional cigarette companies as well as e-cigarette companies for some time. Myers says a 2-year investigation by the Campaign for Tobacco-Free Kids found that major social media campaigns are active in more than 40 different companies around the globe, and that these campaigns target teenagers.
It can be difficult to enforce marketing that originates in other countries where tobacco advertising regulations are different, but even on US soil, Myers says e-cigarette companies are marketing to young persons through veiled social media campaigns.
“They have a systematic set of campaigns where they fundamentally use young people as youth ambassadors. In some cases, they pay young people with high levels of followers [on social media platforms] and pay them to attend parties and post to their network about the parties, showing cigarette packs with young and glamorous people having a good time with cigarettes in their mouths or a pack in their hand,” Myers says. “In other cases, they don’t pay directly, but they host parties and invite people with high social media following. They use social media in the most sophisticated way. That’s troubling in so many ways.”
The Campaign for Tobacco-Free Kids’ petitions to the FTC suggest that changes need to be made to existing policies to better protect US teenagers from international social media campaigns.
“[Cigarette companies] have not initiated campaigns like this in the United States, but given the reach of social media, we tracked that these campaigns were viewed 8 billion times in the United States,” Myers says. “The cross-border ability of the industry to reach into countries that have done all they could to protect their young people needs to be revisited. This is a real eye-opener.”
The FDA has begun to dig in its heels, last year unveiling a broad final rule on antismoking policy that strengthened the Family Smoking Prevention and Tobacco Control Act of 2009. More recently, FDA Commissioner Scott Gottlieb, MD, writes in a September 12, 2018, statement that regulatory processes need to be strengthened even more than the recent efforts to fight what he calls an “epidemic” of e-cigarette use. Although the efforts initiated last year were a start, he writes, they can’t end there.
“We didn’t foresee the extent of what’s now become one of our biggest challenges. We didn’t predict what I now believe is an epidemic of e-cigarette use among teenagers. Today we can see that this epidemic of addiction was emerging when we first announced our plan last summer. Hindsight, and the data now available to us, reveal these trends. And the impact is clearly apparent to the FDA,” Gottlieb writes. “Unfortunately, I now have good reason to believe that it’s reached nothing short of an epidemic proportion of growth.”
To help fight this trend, Gottlieb says the FDA launched the Youth Tobacco Prevention Plan, which focuses on limiting access, curbing marketing to teenagers, and educating young persons on the dangers of e-cigarette use.
“E-cigs have become an almost ubiquitous—and dangerous—trend among teens. The disturbing and accelerating trajectory of use we’re seeing in youth, and the resulting path to addiction, must end. It’s simply not tolerable. I’ll be clear. The FDA won’t tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products,” Gottlieb writes.
Gottlieb also announced that 12 warning letters were sent to e-cigarette manufacturers about marketing and illegal sales to youths, and that 56 warning letters and 6 monetary penalties were issued last spring to retailers who were found selling and marketing JUUL products to underaged buyers. More recently, the FDA stepped up these efforts in what Gottlieb calls “the largest-ever coordinated initiative against violative sales in the history of the FDA” in which more than 1100 warning letters were sent to retailers, and 131 fines were levied.
The FDA is also giving manufacturers 2 months to present plans to the agency on how they will reduce use and access of their products to minors, and Gottlieb says additional FDA policies regulating e-cigarettes will be revisited and revised in order to stem the rise in teenaged use.
Victoria Davis, a spokesperson for JUUL, tells Contemporary Pediatrics that JUUL has always sought to offer its product as a way to eliminate cigarette smoking, and that the company condemns the use of the product by minors.
“We cannot be more emphatic on this point—no minor or non-nicotine user should ever try JUUL. Our packaging includes a prominent nicotine label and clearly states that it is intended only for adult smokers,” Davis says.
“Preventing underaged use of our product remains a top priority for the company, Davis reiterates. “We want to be a leader in seeking solutions, and are actively engaged with, and listening to, community leaders, educators, and lawmakers on how best to effectively keep young people away from JUUL.”
Davis says JUUL supports the FDA’s effort to curb underaged use of its products, and that the company supports “reasonable regulation and effective legislation to prevent the purchase and use of our products by minors,” including restricting advertising and naming of flavors that are directed at underaged users.
Davis adds that the company is investing $30 million over the next 3 years on its own initiative to reduce teenaged use. This spending will focus on new research, youth and parent education, and community engagement efforts, Davis says.
The announcement of this spending came just 1 day after the FDA ordered JUUL to turn over research and marketing data on the use of its products by adolescents.
Myers says the Campaign for Tobacco-Free Kids is also focused on JUUL as a major contributor to the e-cigarette problem with teenagers, noting the company holds 70% of the market share on e-cigarettes. The product is popular with adolescents, he says, and JUUL changed the game when it comes to vaping in several ways.
“I think the e-cigarette issue is enormous, and I think everything that happened before JUUL can be discounted, because JUUL changed the entire game, Myers says. “Many of the e-cigarettes that were on the market prior to JUUL delivered nicotine very inefficiently. JUUL delivers nicotine very efficiently and at very high levels, and therefore dramatically raises the risk that kids that use JUUL will become addicted.”
Myers says research by his organization has noted that teenagers who used JUUL for “fun” reported that they felt a “need” to use the product by the second week of use.
The FDA is in a unique position to intervene when it comes to e-cigarettes, Myers says, because it can control how the products look, how they are marketed, and to whom.
“This will only be stemmed with really strong action by the FDA,” Myers says. “The FDA has the authority to say to JUUL that they have to prove that it helps smokers quit, it does not appeal to kids, and that flavors don’t appeal to kids—and the FDA can pull the product if [these criteria aren’t] met.”
Whereas Myers says his organization has appealed to both the FDA and the FTC, and sent multiple letters to cigarette and e-cigarette manufacturers, he believes this will remain an ongoing battle, and one that must be fought on the front lines.
“I think we’re dreaming if we think they’re going to remove the products voluntarily that appeal to kids,” Myers says of tobacco companies. Clinicians can help, he adds, calling pediatricians “the most powerful voice in the room.”
Pediatricians need to document what they see in practice and speak up, become advocates, and keep educating children and their families.
“Since we’ve been fighting this cig battle for so long, even if we haven’t become complacent, we haven’t been making sure we’re educating enough,” Myers says. “What we discovered in the earlier stages of the JUUL epidemic was kids didn’t realize they were using an e-cigarette or getting nicotine.”
It took decades to convince the public that cigarettes weren’t “cool,” Myers says, but now there is a new kid on the block.
“We have to get out in front of that with e-cigarettes, too,” he says.