James Loy:

This is Reframe, The podcast from the College of Education, Health and Society on the campus of Miami University in Oxford, Ohio.

Electronic cigarettes are spreading like a wave across this country. Just three years after hitting the market, e-cigarettes are being used by teenagers almost everywhere. Even the FDA has recently called it an “epidemic.”

Lauren Bartoszek:

They're being used at just astronomical rates among youth.

So in this episode, we’ll speak more with Dr. Lauren Bartoszek, Miami University visiting assistant professor of public health.

And we’ll hear more about important information that parents and teachers should know, and how we might stop the momentum of this phenomena now.

(MUSIC FADE)

Lauren Bartoszek:

I think when you said phenomena that really is truly what it is. It started on the west coast. And right around 2015, is when it sparked the interest of the many young-ins out on the west coast. And that was just in 2015. We're only three years past that. So it made its way across the nation. There have been reports from the west coast and then it hit to, like, the Texas Central Plains area and then it hit to the East Coast and then to the south, and then really recently up to the Northeast. So it just sort of . . . the wave kind of happened across the nation, but so quickly.

James Loy:

Dr. Bartoszek is among the many public health professionals moving quickly to address this problem now, because in a lot of ways, their concerns are very valid.

According to the U.S. Surgeon General, e-cigarettes – or also known as e-cigs or vaping -- are now the “most commonly used form of tobacco by youth in the United States.” They use a battery operated electronic nicotine delivery system to inhale a vaporized aerosol.

And data shows that more than 40% of high schoolers have used e-cigarettes at least once. Over 15% of youth have reported ongoing use in the past 30 days. And in some areas, that number is approaching 20%. And when compared to 2017, usage is up 78% among high schoolers and nearly 50% among middle schoolers this year alone.

And many public health professionals believe it will only get worse before it gets better.

In a time when the battle against smoking has largely been won, it's surprising to see another nicotine threat emerge so quickly, especially one that can be so alluring to some, and yet so mysterious to others.

So, Dr. Bartoszek, do a lot of people not yet even know what vaping or e-cigarettes are? Is this still a mysterious issue to some? Like, maybe, especially to parents and teachers who are like what are kids are doing now?

Lauren Bartoszek:

Yes, 100%. So as you kind of think about the traditional cigarette, sort of was the initial … and then you've got those bigger, those large-scale vaping units that billow the smoke out. And so, everyone knows what that is. It's really easy to see. But the newest ones are these really super sleek, electronic devices that charge in a USB Drive. Literally. Not figuratively. Literally charge a USB Drive. And so, teachers and parents may not recognize it. 

I actually heard kind of an anecdote, a story, a couple of weeks ago, about how kids at a school --and I don't have any . . . there's no . . . it was just a through a friend through a friend, “Oh my God, I heard this” -- that kids were starting to play a game, seeing which teachers they could get to charge their e-cig for them. Like, “Hey, can you charge my USB?” Which, I don't know, I mean, if you just don't know much about it. “Sure thing I'll plug it in.” And the kids were playing game, like, which teachers they could get to charge their e-cig for them. Because you just don't know. 

So, as far as what teachers and parents should look for, I mean, the device itself is really the number one thing. Like, trying to start, you know, Googling and recognizing. Go into vape shops. Go into stores and start looking at what the devices look like, so that you can recognize what it is. The other thing is just the simple fact that it does charge in a USB. So, you know, not trying to call out students necessarily, right. You don't want to assume that that's what it is. But knowing that it could be, right.

So it's just a matter of education. This is going to be health education at its finest, for both parents, teachers, professionals, and our youth, in terms of what to do.

James Loy:

Do you have a sense of why electronic cigarettes are becoming so popular among teenagers today? I even saw a report . . . an article in U.S. News and World Report that called it the “mark of teenage a coolness that's developed a cult following” among adolescence. Now, I imagine that feeling of being able to get away with something must be part of it. But that can’t be the whole story, right?

Lauren Bartoszek:

Yeah. I think it pretty much can be locked into about three things. The first would be that kids nowadays, this generation, they don't they don't smoke cigarettes. Most of them will say, “Eww.” Right. We have done, as prevention measures, have done a great job of saying, “Cigarettes are bad. Cigarettes are bad. Cigarettes are bad.” The problem with that is just the one word. “Cigarettes.” So what that immediately signifies is that if it's not a cigarette, well, then it can't be bad. The problem . . . Cigarettes are bad. That's true. Nicotine, though, is also bad. It is a toxic substance.

And so, I think the first thing is that e-cigarettes have claimed to be -- and there's a huge thought process -- that they are “healthier” or “not harmful.” The hard part, from a public health standpoint, is that the fact is they are “safer” than cigarettes. Well, yeah, you're not inhaling smoke. So the tar and the actual blackened lung thing, from what we know, is not there. Because you're not inhaling smoke. So, true, they are safer. But let's . . . I mean . . .

James Loy:

Right, I’ve heard the saying that saying they're safer than cigarettes is not setting the bar very high.

Lauren Bartoszek:

Right. And so, that becomes a really big problem. That becomes a really big problem. So this perception of harm is really low.

The second thing is the perception about risk of dependence and addiction. A lot of studies have -- particularly in talking to younger kids -- a lot of them don't think that nicotine is in some of the products. “Oh, this doesn't have a nicotine. It's just it's just flavored water vapor.” About 99 percent of products tested have nicotine in them. Even ones that say “zero percent nicotine.” So that's just completely unprecedented. But they don't think, generally speaking, that they're harmful. They don't think that there's a high addiction potential.

The third thing, really, comes down to the fact that e-cigs are cool. They are flavors. French vanilla. Cherry pie, right. Kiwi strawberry. They're literally on billboards and websites and magazines that have celebrities, concerts, you know, all the traditional … if you think back to before the 1998 Master Settlement Agreement, which was where Big Tobacco basically got called out. One of the biggest things apart in that agreement was that cigarette marketing couldn't be towards youth anymore. So no flavors. No TV ads. No, you know, youth appealing things. So that's why you don't see cigarettes like that. Electronic products were not a part of that piece of legislation, because they didn't really exist, right. So they fall into that quote “loophole” of they're allowed to do that type of marketing. 

That's really the third thing. They are 100% marketed . . . and when you read on the websites, you know, all these big companies will say things like, you know, these are meant for adult smokers. Adults want flavors too. But I'm gonna be honest, again, anecdotally. But the few adults that I've spoken to that use e cigs say, “No, I don't want flavors because I want it to taste poorly because I want to quit completely, right.

But kids, it's the opposite, right. It tastes good. It's cool. It's sleek. Everyone's doing it. There's just this general perception that if we don't know the outcomes are bad, it must be good, right. But there's no research.

James Loy:

So do we know how dangerous they are or even potentially could be?

Lauren Bartoszek:

Yes. So, with the ever so lovely spike in the last handful of years, immediately the CDC and the FDA started to do some really interesting studies.

While we don't know completely what's in the aerosol, as far as the ingredients, we know that there are carcinogenic materials. There's heavy metals that have been found to be in that aerosol. Nicotine, which in itself is just a problem in a variety of ways -- I can talk about here in a second -- as well as the flavor. So the problem with the flavor is that the flavorings are approved by the FDA for ingestion, which means that the stomach can handle them. The stomach has acid. The lungs, however, are not the stomach, right. And so, that's where it gets really gray, I think for kids and for some people, is that the flavors that oftentimes are used in these e-cigs . . . I don't know if you heard about popcorn lung. Have you ever heard about that?

James Loy:

No.

Lauren Bartoszek:

So there was a case maybe, or two, of people using e-cigarettes getting something that they were calling popcorn lung.Okay. And scientifically, I haven't done my full-fledged biological research on what's happening. But it's something with the bronchi in the lungs. All the little parts that help you breathe in your lungs. They call it popcorn lung though because the only other place that they've seen this health outcome was in people who worked in factories that made popcorn, that were inhaling the fake butter. So, again, fake butter is totally okay for your stomach. But when you inhale it, your lungs cannot process that.

So there haven't been a ton of health outcomes. That's only been a handful of cases that I can even think about in the news. But that's one of them. And the reason we don't have a ton is because, again, this really was 2015. It's been three years. It took us 22 years, well, actually about 50 years since the first time we said, “cigarettes cause lung cancer,” back in the 50s, to really have a firm body of research.

So we're trying to fit in the last three to five years all this stuff. So there haven't been any super, super big long-term studies. But the few that there are, the health outcomes are not great. The stuff that we found.

Really quickly on nicotine, what I don't think people know is how toxic it truly is. So nicotine, when inhaled and when used in a cigarette, gives you that buzz, gives you that short-term quick onset feeling of intoxication. But you're typically taking on very small amounts, right, in the cigarette. The way that the e-cig works is something called a nicotine salt. And what it does is it creates a smoother inhalation, right. But the problem is it's so concentrated that -- this porous skin -- it can actually be toxic.

So there was actually a story of -- I want to say it was Wisconsin or Minnesota -- where a school administrator had confiscated an electronic product, and had gotten some on his skin and actually was rushed to the hospital. So there's a slew of other problems, like from exposure to the skin that can be super, super toxic, all the way up to, you know, potentially fatal. Depending on the dose.

James Loy:

So these problems seem like they are all part of a growing list of bad news. But it also seems like there's good news too. There's a strong resistance that seems to be rising. Because there are already massive efforts underway to curb these new trends. It's encouraging to see how the CDC, for example, is already on this so quickly. So do we not necessarily have to re-learn all the hard lessons that we learned in the past with cigarettes all over again? That took a while for people to wake up and realize that those were bad. But now it seems like we don’t have to wait 20 years to do that. People can use what we learned back then to mobilize quickly now, before it becomes a problem at that scale.

Lauren Bartoszek:

And I think that's exactly true, right. We have all of this really amazing information from cigarettes, and we don't necessarily need to reinvent the wheel in terms of prevention, because all we need to do is just reframe it, right. We've got prevention cigarette messaging down. And we have results over the last 20 years that show it worked! It worked! So how can we take that same structure, and change it to e-cigs? And actually I just saw, for the very first time, a commercial this weekend about Juuling. It was the first one I've ever seen, and what's great is that they just really used the same tactics that they've used and just changed the product.

James Loy:

Juuling is actually a reference to JUUL Labs, the dominate e-cig manufacture.

And while the CDC continues to conduct in-depth medical research, the FDA has cracked down hard on JUUL Labs. Alongside an aggressive scrutiny of marketing and advertising practices, and more, the FDA just enacted expansive new anti-tobacco measures aimed prominently at underage vaping. Soon, the FDA also plans to ban flavored e-cigarette sales in stores.

And additional efforts are also coalescing in local communities all around the nation.

At Miami, Dr. Lauren Bartoszek, along with her research colleagues Rose Marie Ward, Phillip Smith, and Paul Branscum, have received funding to examine e-cigarette use among college students. And Bartoszek also serves as the advocacy coordinator for Activating Substance Abuse Prevention or ASAP, a coalition in Norwood, OH, which recently acquired $75,000 from Interact for Health to support a policy called Tobacco21.

Tobacco21 is designed to help local citizens to push back against the spread of e-cigarettes and other tobacco-related products. The goal is to raise the age required to purchase such products from 18 to 21. 

Lauren Bartoszek:

This Tobacco 21 is really beautiful because it is local, right. The government -- in terms of FDA and CDC -- are doing their due diligence. They're doing all that scientific work that we need to say “this is bad. Here's what's in it.” But until we get a blanket policy, it's got to come from below, which is pretty awesome to hear that people could actually change this. You just . . . you can go do it which is really, really great.

James Loy:

The policy is now active in over 360 cities across the country. In Ohio, Cleveland and Columbus have already passed Tobacco21, and support is building in the Cincinnati and Oxford areas.

As a community-led ordinance, it only takes a local city council vote to pass. So health professionals strongly encourage local residents to get involved, and supporting Tobacco21 is a great way to begin. But there are a few more things people can do.

Lauren Bartoszek:

I think the two main things is: Number one. People should just start doing their research. There are some amazing fact sheets and amazing informational tools from the Surgeon General. They did an entire report, it's hundreds of pages long -- they have fact sheets for it. The CDC, the FDA, right. Like know the truth. And the truth is that they are a “safer” option. But they're not an FDA-approved cessation tool. They are not safe. And they are very unknown, right, there's a lot we still don't know about them.

James Loy:

And number two. Parents should talk with their children about e-cigarettes.

Lauren Bartoszek:

It stems to more of that broad spectrum substance abuse prevention -- we have a lot … this is a lot of high school kids, who are really under their parents roof still. So just encouraging parents to ask their kids, right, and in a non-judgmental open conversation. Like, “Hey, who does e-cigs? Do you do you know what it is? Do you know if it's good for you?” And we find typically, and the research suggests that, right, better parent-child communication tends to lend itself to being a protective factor. So kids are less likely to report using drugs of any kind. So, really trying to just keep an open line of communication, as opposed to looking for something, trying to find their “source.” Just trying to ask, trying to say, “Hey, this e-cig thing is really taking over.”

So just really start basic questions until . . . Because it doesn't’t look or smell like a cigarette.

James Loy:

Alright, well, thank you so much for speaking about this topic today, and for all the great information.

Lauren Bartoszek:

Thank you so much. Yeah, I could talk about this all day, so if you have any other questions, don’t hesitate to ask. Because they are so new and so sneaky.

James Loy:

Dr. Lauren Bartoszek is Miami University visiting assistant professor of public health, and if you do have any questions, or if you’d would like more information, you can email us at reframe@miamioh.edu.

And thank you for listening.