More Action on e-Cigarettes Needed, AACR Tells Lawmakers

Alicia Ault

July 24, 2018

WASHINGTON — Federal regulatory and public health authorities need to gather more information on the potential for short- and long-term harm from e-cigarettes and should take stronger steps to restrict youths from accessing the tobacco products, panelists said at a Washington briefing aimed at congressional staff.

The briefing was convened by the American Association for Cancer Research (AACR), which is pushing for faster and stronger action on e-cigarettes.

The US Food and Drug Administration (FDA) has the authority to regulate e-cigarettes in the same way as cigarettes. Last year, the agency delayed enforcement, giving manufacturers until 2022 to comply.

In the United States, persons younger than 18 years are prohibited from buying e-cigarettes, but an FDA crackdown on retailers earlier this year found multiple violations, especially in sales of the Juul device, which has a growing share of the youth market.

"I think it's important to keep a very close eye on this," said Roy S. Herbst, MD, PhD, chief of medical oncology at the Yale Cancer Center, New Haven, Connecticut.

"That's why we're here in Congress today," Herbst told Medscape Medical News.

Senator Dick Durbin (D-IL), who spoke at the briefing, said he would soon introduce legislation to "ban kid-friendly e-cigarette flavors" unless manufacturers could prove that the devices don't cause young people to begin smoking and that they help adults quit.

He also inserted language into the FDA's fiscal 2019 appropriations bill that would require the agency to do the following: quickly finalize and implement a proposed rule to ban flavors in cigarettes, cigars, and e-cigarettes; enforce an existing FDA rule that prohibits new e-cigarette flavors from coming to market without agency review; and to establish rules within a year that would more closely regulate how manufacturers verify the age of online purchasers.

That appropriations bill is still being negotiated, which means that Durbin's provisions might not survive.

Durbin said adolescent use of e-cigarettes should receive more attention. "If the heads of every single federal public health agency are worried, why isn't Congress?" he asked.

Confusion and "Cool"

e-Cigarettes continue to cause confusion among users, school officials, teachers, and even clinicians, said Herbst, who is also the chair of the AACR's Subcommittee on Tobacco and Cancer and is Ensign Professor of Medicine at Yale School of Medicine.

A few studies have shown that e-cigarettes may be useful aids in helping current smokers quit, but more studies are needed, said Herbst.

Even the number of users is unclear. The Centers for Disease Control and Prevention (CDC) has reported that in 2016, some 2 million American middle and high school students said that they had used e-cigarettes in the past 30 days. But that number is a moving target, said AACR panelist Rachel Grana Mayne, PhD, MPH, program director at the National Cancer Institute's Tobacco Control Research Branch. She said that the challenge for CDC is, "How do we adapt our surveillance system to capture this rapidly evolving landscape?"

The overriding concern is that adolescents are taking up a habit that could lead to a lifelong nicotine addiction, said Herbst. A lengthy inquiry by the National Academies of Sciences concluded that although e-cigarettes may have fewer toxic substances than combustible cigarettes, they still present a danger, and teens who use e-cigarettes are likely to start smoking conventional cigarettes.

Teens only take in the message that e-cigarettes are "safer," said Brian Maslowski, a school instructor on alcohol, tobacco, and other drugs for the Fairfax County, Virginia, school system. His job is to intervene with students who use illicit substances by educating them and, if the behavior continues, recommending disciplinary action.

Maslowski, who spoke on the AACR panel, said the Juul device — a slim black stick that is expensive, easy to conceal, and can be recharged on a laptop — gives teen users a higher social status among peers. It also appeals to the teen brain, he said.

"It's very attractive for me to try to use this as a teen and get away with it," Maslowski said. He noted that teen e-cigarette use appeared to be on the rise in his schools. "We saw three times as many students for vaping as for all other drugs this year," he said. "It was a huge explosion."

Being "cool" is a big part of the appeal of e-cigarettes and that this is particularly so with the Juul device, said Jia Tolentino, a staff writer with the New Yorker who interviewed and observed teen e-cigarette users for an article for the magazine.

Tolentino, who also spoke on the AACR panel, said that use of the Juul device was intertwined with social media and that, unwittingly, teens are doing Juul's marketing. "Most Juul advertising is effectively what teens are doing to each other," she said, noting their use of Instagram and Snapchat to post memes, selfies, or ludicrous tricks.

Unlike cigarettes, which they find disgusting, teenagers consider use of the Juul to be a fun "party thing," Tolentino said. "It is a kind of joke, and they know it's a stupid behavior, but because it's a stupid behavior, it's a joke," said Tolentino.

But, she said, "Teens aren't stupid. Many of them understand that Juul, even if it's safer than cigarettes, is a problem for their age group. They know that it's not good to develop an addiction. They also are interested in seeing long-term data about their age group," she said.

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