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House examines JUUL’s role in the youth nicotine epidemic

The U.S. House Committee on Oversight and Reform held the first of a two-part hearing on Wednesday titled “Examining JUUL’s Role in the Youth Nicotine Epidemic.” The hearings are led by the Economic and Consumer Policy Subcommittee with the purpose of examining “JUUL’s: (1) role in the youth nicotine addiction epidemic, (2) appeal to youth, (3) marketing, (4) health claims, and (5) relationship to traditional tobacco companies.”

Subcommittee Chairman Rep. Raja Krishnamoorthi’s, D-IL, opening statements acknowledged that youth nicotine use has reversed course after years of steady decline, with youth e-cigarette use rising 78% between 2017 and 2018. The result is that 20% of high school students now vape.

“The lingering question is why?” Krishnamoorthi said. “And what was the role of Juul, the country’s dominant maker of e-cigarettes with almost 80% of e-cigarette market share, in the dramatic rise in vaping?”

The day’s panel addressing these questions included Meredith Berkman, co-founder of Parents Against Vaping E-cigarettes; Robert Jackler, a professor of head and neck surgery at Stanford University; Raymond Niaura, a psychologist and professor in the  College of Global Public Health at New York University; Rae O’Leary, a public health analyst at Missouri Breaks Industries Research and member of the Cheyenne River Sioux Tribe; and Jonathan Winickoff, a member of the American Academy of Pediatrics.

Berkman began panel statements by explaining that Parents Against Vaping e-cigarettes (PAVe) was founded by three concerned mothers and has expanded nationwide with “groups of activated parents across the country from California to New York.”

“Our goal today is to give voice to the 3.6 million teens who are vaping, most of them Juuling,” Berkman said. “This most recent figure from the CDC is already outdated. … Experts believe that the new figures due this fall will likely be much higher because nothing has happened to have them go down.”

In line with PAVe’s work, Berkman shared the stories of parents who contact the organization seeking help for their “JUUL-dependent, nicotine-addicted kids,” noting that there is not yet any FDA-approved treatment for this kind of teen nicotine addiction.

One mother from Massachusetts told PAVe that her son, a hockey-player, developed a cough and couldn’t breathe while skating. In addition, he became moody and irritable, with extreme bouts of anger. After smoking one JUUL pod a day for three years, her son has restrictive lung disease and now requires inhalers and oral steroids. 

Berkman shared the story of another mother, Kelly Kinard from North Carolina, whose son’s grades dropped from straight A’s to F’s. His nicotine addiction due to Juuling became so severe that he spent 39 days in rehab in California. Kelly Kinard told her story to EducationNC here.

Even Berkman explained that she discovered her own child had been Juuling right under her nose without her knowing. 

“It doesn’t mean you’re a bad parent if your kids are Juuling,” she said. “It’s stealth by design. We knew that nicotine was harmful to our kids’ brains, and as we researched and put pieces together, we learned that Juul’s deceptive behavior seemed to be part of its marketing strategy.”

Berkman told the story of how a Juul representative gave a talk at her son’s high school in 2017. Her son told her about the anti-addiction talk where the teachers left the room and a Juul representative “gave a confusing talk about Juul, telling them it was not for kids but for adults. It was much safer than cigarettes. The FDA would approve it any day.”

Another panelist, Rae O’Leary, also pointed to another Juul marketing strategy — this time directed at Native Americans. O’Leary is the founder of the Canli Tobacco Coalition, a grassroots anti-tobacco coalition of the Cheyenne River Sioux Tribe (CRST).

“The Canli Coalition opposes all commercial tobacco products because of the tobacco industry’s historical targeting of American Indians, which has contributed to the health disparities and death on the Cheyenne River Reservation,” O’Leary said. 

She described an instance in February of this year where three representatives from Juul handed out free product to tribal decision-makers and offered a switching program for those 21 and older to the health committee. Juul also proposed to sell starter kits valued at $50 to the tribe for $5 each. 

“Throughout Juul’s presentation, they made multiple claims that their product is effective for smoking cessation and less harmful than tobacco products,” O’Leary said. “These claims as well as Juul’s actions to hand out free product are all clear violations of the Family Smoking Prevention and Tobacco Control Act.” (More on this Act here). 

O’Leary said that health committee members were initially interested in Juul’s switching program and requested written documentation of the program’s proposal. Instead, the tribe received a mutual nondisclosure agreement, which was not signed.

“As a result, Juul has not returned to the Cheyenne River Sioux Tribe,” she said. “Earlier this month, the CRST health committee unanimously approved a resolution that declares, ‘CRST shall neither solicit nor accept any tobacco, electronic smoking device, or nicotine-related funding or sponsorship.'”

While the cessation program was intended for adults, it was rejected for potential and unknown long-term health risks as well as the chance the product would fall into the hands of the tribe’s youth.

“The Canli Coalition has great concern that our American Indian youth will begin using Juul due to increased access and a highly concealable and flavorful product,” O’Leary said. “This concern is supported by the data that American Indian middle school students in South Dakota are using e-cigarettes three times more than their white counterparts.”

The topic of tobacco companies and targeting of minority groups came up again during the hearing. When House representatives had the chance to pose questions to panelists, Rep. Ayanna Pressley, D-MA, brought up the history of tobacco marketing to African Americans.

“I’d be remiss not to highlight how similar many of Juul’s tactics seem to be right out of the Big Tobacco playbook,” Pressley said. “For decades Big Tobacco targeted black communities to the point where almost 90% of all black smokers used menthols. Nearly 45% of black menthol smokers state they would quit smoking if menthols were all together banned.”

This brings up another issue commonly discussed when it comes to youth vaping: attractive flavors. 

“The flavor crisis is even worse for children, 66% of whom the National Institute on Drug Abuse found believed e-cigarettes only contained flavors,” Pressley said. “It seems obvious that the elimination of flavors would help eliminate this confusion, so Dr. Winickoff, why are menthol-flavored tobacco products particularly exploitive in the context of e-cigarettes?”

Winickoff, a pediatrician, responded that the tobacco industry has a long history of targeting mint and menthol products to African Americans, and specifically African American children. 

Mint and menthol are just two Juul pod flavors available, along with Virginia Tobacco, Classic Tobacco, Mango, Cucumber, Creme, and Fruit. Last year, the FDA contended that certain flavors are a particular draw for youth

New legislation

Sen. Richard Durbin, D-IL, served as the sole panelist on a second panel, with closing statements to the day, including on recently proposed legislation.

“Juul and other e-cigarette companies like to claim that their products are only meant for adults looking to quit cigarettes,” Durbin said. “But a look at the facts quickly dispels that notion. Here’s the starting point: there is no clinical trial proving that Juul devices help adults quit smoking cigarettes. None.”

Durbin’s point was a firm cap to a back-and-forth in the morning’s discussion on regulations of Juul for youth while keeping avenues open for adult smokers who wanted to use Juul to quit. Much of the pushback by some House representatives in cracking down on Juul hinged on this issue of adult smoking cessation.

“Despite all the marketing claims and all the paid testimonials, there is no credible medical evidence of Juul’s most fundamental marketing claim. None,” Durbin said. “Further, more than 20% of children under the age of 18 are using e-cigarettes compared with less than 3% of adults.”

To combat the youth vaping epidemic, Durbin shared that he has introduced bipartisan legislation along with Sen. Lisa Murkowski, R-AK; Rep. Diana DeGette, D-CO; and Rep. Jamie Raskin, D-MD, called the SAFE Kids Act

“Our SAFE Kids Act would give e-cigarette companies one year to prove their products meet three criteria,” Durbin said. “First, companies would have to prove that their products actually help adult smokers to quit. Second, they’d have to prove that products don’t harm the people using them. Third, e-cigarette companies would have to prove their products do not cause children to start using nicotine.”

It’s not the only tobacco legislation proposed. Earlier this year, Senate Majority Leader Mitch McConnell, R-KY, introduced legislation to raise the age of purchasing tobacco products, including e-cigarettes, to 21.

Durbin’s proposed legislation is also far from his first anti-tobacco proposal. After losing his father to lung cancer due to smoking at the age of 15, Durbin devoted himself to curbing tobacco use, including proposing legislation to ban smoking in commercial airline flights. The bill was signed by President Reagan in 1988 and paved the way for laws restricting smoking and preventing exposure to secondhand smoke in public spaces.

“Congress waited far too long to start protecting children from cigarettes,” Durbin said. “History is now repeating itself with e-cigarettes. Our inaction, combined with FDA’s complacency, is dooming an entire new generation of children to nicotine addiction. Most parents care when their teenager is lost in a cloud of vape smoke. Does Congress?”

Part two of the House committee hearing takes place Thursday afternoon and features leading officers from Juul Labs. Stay tuned to EducationNC for that recap. For more on youth e-cigarette use, follow our series here

Yasmin Bendaas

Yasmin Bendaas is a Science writer.  A North Carolina native, she received her master’s degree in Science & Medical Journalism at UNC Chapel Hill, where she was a Park Fellow. She received her Bachelor of Arts in anthropology in 2013 from Wake Forest University, where she double-minored in journalism and Middle East and South Asia studies. As an undergraduate student, Bendaas gained insight into public health when she interned at the Kate B. Reynolds Charitable Trust, a statewide grantmaker focused on rural health, including access to primary care, diabetes, community-centered prevention, and mental health and substance abuse. 

As a journalist, Bendaas has been funded twice by the Pulitzer Center on Crisis Reporting for fieldwork in Algeria — first to cover a disappearing indigenous tattoo tradition, and again to look at how climate change affects rural sheepherding practices.