Colorado Looks to Educate Youth About the Public Health Consequences of JUUL

July 19, 2018 | ASTHO Staff

Colorado is in the midst of a challenging time addressing the e-cigarette and vaping epidemic among youth. Most popular among these products is the JUUL e-cigarette, a sleek, trendy, USB-shaped device created by JUUL Labs. Recently ranked the top state in the nation for high school vaping by the Youth Risk Behavior Surveillance Survey, Colorado is taking swift and decisive action to reverse these trends.

ASTHO spoke with Larry Wolk, MD, MSPH, executive director and chief medical officer of the Colorado Department of Public Health and Environment (CDPHE), about misconceptions surrounding the health impacts of e-cigarettes, encouraging regulatory actions, and the letter he sent to Colorado school partners urging caution around JUUL products.

To combat the spread of JUUL products, some schools have banned flash drives. How do you believe state public health leaders can help school districts and administrators educate students and parents about the dangers of nicotine and e-cigarette use?

In this moment, when so many schools are experiencing uncertainty and justified concern for their students, public health leaders can and should be sources of knowledge and partnership. In Colorado, we are working to help parents and teachers, coaches, and administrators to familiarize themselves with the many varieties of e-cigarettes so they can recognize these devices and not confuse them with legitimate educational tools. Additionally, we’re providing guidance on how to enforce the statewide Tobacco Free Schools Law, which includes vaping devices.

CDPHE is also funding two statewide media campaigns. One is aimed at educating parents, schools, and other adults who routinely work with youth about vaping and JUUL products. The other campaign, “Know the Facts,” is aimed at youth (under 18) and young adults, informing young people in Colorado about vaping and the risks.

In April, FDA Commissioner Scott Gottlieb announced several enforcement actions as part of a new Youth Tobacco Prevention Plan aimed at addressing the popularity of JUUL products and other e-cigarettes. What other regulatory steps would you like to see at the federal (or state) level?

FDA is right to hold retailers accountable for selling JUUL and other electronic nicotine products to children by curtailing online sales to underage youth and addressing misleading marketing claims. However, more can be done. FDA has regulation authority over these products, but they have not enforced any meaningful restrictions. Other proven tobacco control strategies should be applied to JUUL products and other nicotine products, including:

1. Taxing E-Cigarettes
   As tobacco products become more expensive, people are far less likely to use them. This is especially true for low-income people and kids. Because vapor products are not taxed equally with other products, they are often less expensive, which is an incentive for kids to use them.

2. Pushing Back Against the Normalization of Nicotine via E-Cigarettes
   People are allowed to use electronic cigarettes in many places where smoking is banned. This re-normalizes the use of nicotine and makes it more likely people will use the products.

3. More Strictly Enforcing Regulations on E-Cigarette Sales
   Even though it is illegal to sell tobacco products to kids, 68 percent of kids who attempt to buy tobacco products are able to make a purchase. More strict enforcement of regulations on the sale of tobacco products and increasing the legal age of purchase to 21 could reduce these problems.

In March, you sent a letter to Colorado school partners acknowledging the rising popularity of JUUL products among youth and urging caution. How would you characterize the response to that letter? What particular successes or challenges do you see for the future of state public health as it relates to this emerging issue?

We were very concerned when we heard the manufacturer of JUUL products had contacted a Colorado school. We acted swiftly, in partnership with the Colorado Department of Education, to alert schools to this specious activity. The letter contributed to an increase in schools asking for assistance with evidence-based prevention strategies and education for school staff, parents, and community members. RMC Health, which works with us to provide training, technical assistance, and resources to schools, has seen an increase in inquiries about what schools can do to address use of JUUL products and other electronic nicotine products in schools. Local health departments are also assisting schools in their area with educational resources.

Widespread marketing to young people—and the unproven notion that e-cigarettes are not harmful—has led to increased use. Most e-cigarettes, even those labelled “nicotine free,” contain nicotine. CDPHE is concerned any time a young person is using nicotine in any form. We know that nicotine impedes youth brain development and is highly addictive. There is substantial evidence that youth use of e-cigarettes increases the risk of transitioning to smoking cigarettes.

CDPHE is interested in how the introduction of e-cigarettes and similar vaping products have affected tobacco use and initiation in Colorado. While it is too soon to know the full range of health impacts, early data suggest that e-cigarettes have not led to a decrease in smoking in Colorado, meaning adult users are not smoking less while using e-cigarettes. National data concerning the rise in youth use is highly concerning, suggesting that the net effect may lead to an overall increase in nicotine addiction long-term.

The absence of regulation and the paucity of studies on e-cigarette products has allowed the tobacco industry to aggressively market these products, using traditional tobacco marketing strategies with little opposition. This is one of the many reasons the popularity of these products has exploded. Overcoming this lack of knowledge and resistance to public health messaging around vaping will take time, resources, and investment in comprehensive strategies.

JUUL Labs has taken steps to help schools remove its products from campuses. For instance, the company created a prevention curriculum to educate youth about JUUL ing and nicotine addiction, and came out in support of Tobacco 21. Do you believe there are opportunities for public health leaders and companies, such as JUUL Labs, to collaborate around tobacco cessation initiatives?

The tobacco industry has a long history of offering free “tobacco prevention” curricula to schools. Those programs have been proven not to prevent use of tobacco products among youth and instead increase goodwill for tobacco companies. We consider JUUL Labs to be a part of the tobacco industry and remain skeptical of their efforts to promote tobacco control efforts.

Do you see any potential for JUULing and other e-cigarette devices to be used as a harm-reduction strategy for adult cigarette smokers?

Again according to the National Academies of Science, Engineering and Medicine report, e-cigarettes have the potential for less risk to the individual than cigarettes. There is little known about the potential health effect or cessation benefits. While it’s too soon to know the full range of health impacts, early data suggest that e-cigarettes have not led to a decrease in smoking in Colorado. Adult users are not smoking less while using e-cigarettes. They may have a cessation benefit for adults, if users completely switch from combustible tobacco to electronic products. CDPHE recommends people who smoke talk to their doctor about quitting and rely on proven methods to quit smoking, including nicotine replacement therapy, behavioral counseling interventions, and calling the QuitLine.