Not so long ago, Laura Smith, senior public affairs manager for ClearWay Minnesota, was listening to the radio when she heard something confusing. It was an ad, titled ‘Make the Switch,” that featured former smokers of combustible cigarettes talking about how switching to the vaping device Juul helped them successfully move away from traditional cigarettes.
Smith, who is in the business of helping Minnesotans quit smoking, was taken aback. “When I first heard the ad,” she said, “I thought, ‘What?’ Is this a new quit-smoking program that’s not us?’ Then I realized it was Juul.”
Smith wasn’t the only one who had this reaction. In late September of this year, Juul announced that it would drop its broadcast, print and online advertising campaigns after the Food and Drug Administration (FDA) threatened it with fines for saying that its product was a safer alternative to combustible cigarettes.
“Juul is not an FDA-approved method for quitting tobacco products,” Smith said. She explained that the FDA gave e-cigarette manufacturers an opportunity to officially file for approval as a smoking-cessation device, but none pursued that route. Instead, she said, “Juul ran misleading campaigns that sounded like quit-plan ads.”
While the ads are gone from Minnesota’s airwaves and print publications for now, Smith and others in the state’s addiction community say that the company’s marketing efforts have already done plenty of damage.
E-cigarettes and other vaping devices have gained popularity in the state over the last several years. Drawn by claims that the devices can help long-time smokers wean themselves off combustible cigarettes, many see believe vaping to be a less-offensive alternative that may help them eventually quit.
But rather than seeing the total number of nicotine users in the state go down as many people had hoped, the popularity of e-cigarettes means that more young Minnesotans are becoming addicted.
Mike Sheldon, ClearWay Minnesota’s director of marketing, explained that the numbers are borne out in the Minnesota Adult Tobacco Survey, an extensive research project his nonprofit conducts every four years.
“In the last couple of years, we have asked people about e-cigarette use,” Sheldon said. “In 2014, we broke down the status of people who use e-cigarettes. Back then, 65 percent of people who used e-cigarettes were current smokers. The latest data from 2018 shows that number has decreased to 37 percent.”
Closer analysis of the survey results revealed a disturbing trend, Sheldon said: Vaping devices like Juul are attracting new people who were formerly nonsmokers. “In 2018, the percent of people who have never smoked combustibles and now use e-cigarettes was at 44 percent. … Those folks are not using Juul to quit.”
Because the nicotine level in Juul pods is much higher than the levels in combustible cigarettes, e-cigarettes are just as — or even more — addictive than combustible cigarettes, said Joseph Lee M.D., Hazelden Betty Ford Foundation medical director for the youth continuum.
“We are seeing young people in our programs who have developed a serious addiction from vaping Juul pods,” he said. “The nicotine levels [in the pods] are dangerously high and dangerously addictive — but nobody tells them that.”
Taylor Hays, M.D., director of the Mayo Clinic’s Nicotine Dependence Center, said that many e-cigarette users who come to his residential treatment program say they began vaping without understanding the dangers associated with the product. That ignorance has been intentionally cultivated by the devices’ manufacturers and distributors, he added.
“It took us about 50 to 60 years to figure that out that smoking tobacco causes lung cancer and other diseases,” Hays said. Because so many e-cigarette users started using a highly addictive product without realizing its larger health implications, he is concerned that we may be heading down a similar road.
“Are we OK with doing this natural experiment with our kids for the next couple of decades?” Hays asked. “When more of them start to get sick, will we shrug our shoulders and say, like we did with tobacco, ‘Oops. This wasn’t so good.’ I hope not.”
Highly addictive and deadly
The rash of recent news reports about serious lung injury and death connected to vaping devices has many people expressing concern about the long-term safety of e-cigarettes.
At ClearWay Minnesota, the organization’s official stance has always been that e-cigarettes are an unsafe and untested option for smoking cessation.
“We have always urged caution on using e-cigarettes,” Sheldon said. “We still don’t know what the long-term health impacts are. Plus, the FDA has never approved them as a quitting device. There is no evidence that e-cigarettes are more effective at helping people quit than proven options like patches, gum, lozenges, or counseling, and current media reports only underscore the importance of taking a cautious approach to using these devices.”
Hays said that the striking number of e-cigarette-related injuries and even deaths have rightfully drawn attention to the potential dangers of vaping.
“Vaping-related lung injury is a serious problem,” he said. “We are approaching 1,500 to 2,000 cases of serious lung injury and a number of deaths have already been reported in this country. It is an important public health issue that we need to tackle.”
But in some ways, Hays said, the issue of e-cigarettes distracts us from tobacco consumption, one of the most important public health issues in the world. “The traditional combustible cigarette is the cause of the overarching public health issue of tobacco, which accounts for 500,000 to 600,000 deaths in the United States every year, and 7 million deaths globally. If these trends continue, we will soon have seen 1 billion deaths from tobacco cigarettes in the world.”
Nicotine, contained in both vaping pods and combustible cigarettes, is the addictive substance that keeps users coming back, he explained. Combustion is what causes lung injury and eventual death. Because of tobacco’s vast reach, Hays continued, “It would be hard to find any family that is untouched. We’ve all been impacted by this horrible epidemic of tobacco-caused disease.”
Some clients at Mayo’s Nicotine Dependence Center arrive using e-cigarettes. In those cases, staff works to help them break their dependence using a combination of group and individual counseling, combined with pharmacological therapy, like smoking-cessation patches or lozenges.
“Our position about using vaping devices to help smokers quit is that we don’t know if it is helpful or not,” Hays said. “We do have ideas that it isn’t completely safe, which has been borne out by the recent tragic events. Our position is if you’re committed to a plan to quit we know from a lot of evidence that the best way to do that is a combination of behavioral therapy and safe and effective pharmacological therapy, which reduces withdrawal symptoms and reduces the urge to smoke.”
And Hays’ experience has been that most vaping habits aren’t exclusive. “Most adults who are using vaping devices in the U.S. are dual users,” he said. Despite what marketing campaigns would like consumers to believe, “they are still also using tobacco.”
Hays said he is concerned that the vaping-related injuries and deaths that are being reported in the news today are just “the tip of the iceberg. Are people who are using vaping devices regularly getting some subclinical lung injury, something that doesn’t come to light because the symptoms are mild and they never seek medical attention for it?” he asks. It reminds him of how, decades ago, Americans first responded to reports that tobacco was causing lung disease in smokers.
“The earliest inkling that cigarette smoking caused lung disease came in the 1940s when the guys who were in World War II started developing lung disease and heart disease and [in 1964] the surgeon general stood up and said, ‘We know that tobacco causes lung cancer,’” Hays said. “How long did it take the public to respond to that? How many people died?”
It is important for the public to understand that tobacco manufacturers are closely connected to e-cigarette manufacturers, Hays said.
“Why did Altria, the parent company of Philip Morris, buy a 35 percent stake in Juul?” Hays asked, adding that Philip Morris is also now marketing a new electronic heated tobacco device called IQUOS in the United States. “A former Phillip Morris’ executive is now CEO of Juul. They may state they want these products available so that tobacco smokers can switch to a ‘safer’ product, but they are in the business of selling tobacco. They are not a champion of the public health.”
It would appear that e-cigarette manufacturers are working from the same marketing playbook first used decades ago by combustible cigarette companies. Teens are the target market for these products, with slick designs and flavored options to appeal to young tastes, like watermelon, strawberry milk, grape and strawberry lemonade.
In the product’s early years, Hays said, teams of Juul staff spoke directly to young people in places where groups of them gathered.
“Juul cultivated the youth market,” he explained. “They were invited into schools.” The company also sponsored summer camps for children as young as 8 years old. During congressional hearings held in July 2019, “Students testified that they were told, ‘This is safe.’ Juul representatives equated them to water vapor, made it sound like, ‘No problem. You can use those things.’ They were pitching this device as something you can use completely safely.”
But, Smith said, research has found that use of nicotine in any form has a negative health impact on young people.
“There are a lot of things about the long-term health effects of e-cigarettes that we don’t know,” she said. “What we do know is that nicotine in any form is bad for the adolescent brain. It can disrupt attention. It can impact memory. It can prime the brain for addiction to other substances.” While there may be some unknowns about the long-term health effects of vaping, she continued, “We do know for sure that nicotine harms the adolescent brain.”
While use of combustible cigarettes is down among adolescents in the United States, Lee said that the number of teens who vape has risen dramatically.
“With the antismoking public service messages of the not-so distant past, we made decades of gains in getting young people to avoid smoking,” he said. “A lot of the ads were based on, ‘Don’t be a sucker. Look at what these companies are taking form you.’ But this is a different generation. We’ve lost a lot of those gains.”
Lee said he believes that tobacco companies are using nicotine-based products like Juul to hook the young people that had turned away from their combustible products. “It’s been a long-held playbook of the tobacco industry to get people to start early because nicotine is incredibly addictive,” Lee said. “They want to get you on the hook for the rest of your life.”
The recovery community has a complicated relationship with nicotine. For decades, many people in 12-step recovery programs smoked cigarettes. Many still do, and Minnesota-based recovery organizations like Hazelden Betty Ford accept that as part of their culture — to a point.
“We want to engage people no matter where they are at,” Lee said. “If they are using nicotine, we want to still try to engage them in our programs. But from a health perspective, we are going to give them plenty of off-ramps to stop. With young people, we tend to be more assertive. On our youth side, for instance, we don’t allow smoking.”
Even if you set aside recent reports of significant vaping-related lung damage, Lee said, there is clear evidence that e-cigarette use often translates to the use of combustible cigarettes. “Young people who vape are more likely to use combustible tobacco later. It is an on-ramp to traditional tobacco use. Young people who vape are getting indoctrinated into smoking.”
Lee explained that he likes to emphasize a more socially conscious approach when he’s talking to young e-cigarette users. “The industry is making suckers of young people, basically, but so many don’t see it,” he said. “What they are seeing is the flavors. They like the feeling they get from it. They don’t see that they might be hooked on it 10, 20 years later, but many of them will.”
Better options exist
If e-cigarettes are unsafe and addictive, what are the best options for Minnesotans who want to quit them for good?
The only one of its kind in the United States, Mayo Clinic’s nicotine addiction program is a weeklong residential option that combines a smoke-free environment with individual and group counseling, doctor-supervised care, medications to relieve withdrawal symptoms and long-term support. A portion of the cost of treatment is covered by many insurance plans.
ClearWay Minnesota’s smoking-cessation services are less intensive but also effective, Sheldon said. “We provide the free program to any Minnesotan who wants to quit. It is a scientifically backed program that uses things like patches, gum, lozenges, phone calls to help people quit smoking or using e-cigarettes.”
Teens seeking support for quitting nicotine products land in an unfortunate gray area, Smith allowed. While ClearWay offers free smoking-cessation aids to Minnesota adults, it can’t legally provide the same products to young people.
“From an addiction standpoint it is in interesting dilemma,” Smith said. “The FDA hasn’t approved nicotine replacement therapy for kids under 18.”
Because they can’t provide patches, gum or lozenges to teens, Sheldon said that ClearWay emphasizes counseling options when working with youth. “We do provide support for people under 18,” he said, “But we also encourage them to talk to their doctor for support to help them quit.”
Whatever form it takes, support is key to quitting nicotine, Lee said. “It’s not easy, but recovery is never easy.” That’s why he likes to arm people with knowledge when they make the decision to step away from nicotine addiction.
“Our angle is that the tobacco industry has not been moral,” Lee said. With flashy new products and marketing campaigns, he continued, tobacco companies are, “out to hook you in, and they are often seeking the most vulnerable populations to do that. We advocate on the side of regular people, of members of minority groups who have been consistently preyed upon by these companies. I want all people to realize this and take the next step.”