23 September 2018:

By Sarah Milov

Source: The Washington Post

It’s time to stop them.

Last week, the Food and Drug Administration described teenage e-cigarette use as an “epidemic,” echoing the firsthand observations of teachers, social media watchers and the public health community.

Juul Labs, the leading e-cigarette manufacturer, responded with the industry’s well-worn, lawyer-approved denial. “We are committed to preventing underage use of our product,” said Kevin Burns, Juul’s chief executive.

But just like their traditional counterpart, e-cigarettes have always been marketed to kids. And as a result, millions of American teens have become addicted to nicotine before they reach the age of consent, while their brains are still developing.

In the late 19th century, at the dawn of the cigarette age, cigarette firms began placing stiff cardboard inside packaging to prevent cigarettes from getting crushed. Soon, the baseball card was born as a gimmick to entice boys into collecting the roster of their favorite team.

A few decades later, the marketing gurus at R.J. Reynolds saw the back-to-school season as an opportunity to expand their reach. “School days are here. And that means BIG TOBACCO BUSINESS for somebody. Let’s get it,” read one 1927 memo sent to division managers in advance of preparatory school openings in the fall.

In more recent decades, the industry refined these techniques, for the simple reason that it knows that the vast majority of smokers become addicted before they are 18. By the time young smokers have reached the age of majority, they already have strong preferences for a favorite brand and are not likely to switch.

Internal industry documents, now public through litigation, reveal a far-reaching strategy to hook underage teens, even after the dangers of smoking had become well-known. As one 1978 memo from a Lorillard official put it: “The base of our business is the high school student.” As another report elaborated, the company’s goal was to design packaging “to attract the youthful eye” rather than “the ever-watchful eye of the Federal Government.”

Joe Camel was the most infamous testament to the industry’s savvy in recruiting young smokers. By the early 1990s, after three years of an advertising blitz centered on the “smooth character,” Camel’s slice of the under-18 market surged from 0.5 percent to 33 percent. At the same time, a study found that 90 percent of kids over 6 recognized the smirking dromedary, including nearly one-third of 3-year-olds.

Much has changed in the intervening decades. Joe Camel has been retired for over 20 years. Today’s Juulers were born after the Master Settlement Agreement prohibited cigarette manufacturers from even indirectly targeting kids.

And Juuls aren’t your dad’s Marlboros. Juul Labs is not owned by any legacy cigarette company, and Juuls themselves don’t look like a tobacco product at all. Instead, they resemble an extra-long USB drive, and they can charge in a laptop port. The devices are so sleek that kids get away with using them in class.

In fact, many users see no connection between cigarettes and e-cigarettes. You don’t “smoke” or even “vape” a Juul. You simply “Juul.”

At least on the surface then, Juul is no throwback to the age of Big Tobacco. But from its product design to marketing strategies to corporate disavowals, Juul is following a well-trodden path.

In the 1970s, Brown and Williamson, the makers of Kool, flirted with the idea of a youth cigarette. “It is a well-known fact that teenagers like sweet products,” read one marketing report under the heading “Youth Cigarette-New Concepts.” Cola, apple and “sweet flavor” cigarettes were considered.

Juul takes this insight into the youthful palette to new extremes. Crème, mango, cucumber and fruit medley are a few of the most popular flavors of Juul pods. The existence of these masking flavors ought to give regulators pause, especially because each pod contains as much nicotine as one or two packs of cigarettes.

In fact, the Juul pods with the highest nicotine content are the sweetest and most attractive to younger users. Tobacco- and mint-flavored pods have lower nicotine levels, perhaps to attract smokers seeking a less-harmful nicotine fix.

And therein lies the fundamental contradiction of Juul Labs’ public face. On the one hand, Juul presents itself as offering a potentially lifesaving device, enabling smokers to switch to a less deadly product. “No minor or non-nicotine user should ever use JUUL,” a spokesperson recently told The Washington Post.

But the company has seen incredible growth not as a harm-reduction or a cessation tool, but as a form of recreation that creates addiction in minors. And far from being an effective tool for quitting, evidence is emerging that young people who Juul may actually be more likely to smoke conventional cigarettes. Juul’s sales are up more than 700 percent from a year ago, as the Internet fuels its popularity among the underage. (Juul Labs has surged past competitors in part on the strength of its presence on Twitter and Instagram.)

Juul has implemented some admirable age-verification strategies on its website. But like a giant cigarette vending machine, researchers have found, the Juul website is easy to circumvent. A determined 15-year-old, armed with trial-and-error wisdom culled from a Juul subreddit, can secure her purchase faster than you can say “glycerol, propylene glycol, nicotine, benzoic acid and flavoring” — the five primary ingredients in a Juul.

But Internet verification does little to address the 74 percent of underage Juul users who obtained them from physical retail locations like gas stations and convenience stores. Just 6 percent reported purchasing Juuls on the Internet.

In response, the FDA recently issued 1,300 warning letters and fines to retailers who sold Juuls to kids. However, given the magnitude of demand, this sporadic enforcement is unlikely to drastically reduce sales at the tens of thousands of convenience stores where kids buy Juuls along with legal vices like Slurpees and Snickers.

The FDA has been late to regulate e-cigarettes, even as the agency admits that the nation faces an “epidemic” of nicotine-addicted youths. FDA Commissioner Scott Gottlieb has given makers of e-cigs 60 days to devise a strategy to keep their products out of the hands of minors. History suggests that voluntary action by tobacco manufacturers is unlikely to substantially reduce youth-smoking rates and may even give Juul Labs a defense when addicted Americans bring suit against Juul and other retailers — as they have already begun to do.

Fortunately, the history of tobacco also contains many lessons for public health and e-cigarettes.

Local initiative is a crucial and underappreciated resource for public health. The anti-tobacco movement of the 1970s and 1980s helped create a right to smoke-free air by passing local ordinances that restricted where cigarettes could be smoked. Cigarettes became more difficult to smoke, and fewer people smoked them.

Today, local governments can use zoning laws to restrict the location of e-cigarette retailers, prohibiting vaping establishments near high schools. Such a regulation would be even more powerful if Juuls were banned from 7-11s and restricted to licensed retailers that sold products only to adults.

Public health officials have known for decades that kids are the most price-sensitive tobacco consumers. For this reason, discounts and promotions on e-cigarette products should be prohibited, and state taxes on the devices should be raised so as to bring their prices in line with cigarettes.

The stakes for curtailing teen use of Juuls are high: If trends continue, a generation of young people will enter adulthood addicted to nicotine. If they are anything like the smokers of generations past, they will experience profound regret at ever picking up their first vaporizer. Just how profound that regret might be is not yet known: While e-cigarettes may be less carcinogenic than cigarettes, researchers do not know the long-term consequences of Juuling on the heart and lungs.

But we do not need to wait for perfect scientific knowledge. We’ve been here before. We know enough to act.