Skyrocketing growth in the use of e-cigarettes threatens to unravel years of gains in the fight against teen smoking in Arkansas, health officials and advocates said.
The Arkansas Department of Health recently announced that e-cigarette use among Arkansas students is expected to match a national rate of just over 20 percent, or more than 1 in 5 teens, this year.
That figure has grown from less than 2 percent of teens (nationally and in Arkansas) who said they used e-cigarettes in 2010, state chronic disease director Dr. Appathurai Balamurugan said -- a tenfold rise in just a few years.
"We're all alarmed," he said. "Any Arkansas kid age 18 or younger shouldn't be using any of these products, period."
Combustible cigarette use among the state's high schoolers had fallen from around 40 percent to roughly 15 percent over the past few decades, he said, but the recent increase in e-cigarette use has caused consternation in the public health field.
It's thought that savvy marketing on the part of e-cigarette manufacturers stoked teens' desire for the devices, while a lax regulatory environment gave new products a foothold.
As a result, e-cigarettes have shown up at some Arkansas schools, where kids involved in student tobacco control programs report seeing other kids using them, particularly a device with the brand name JUUL, in bathrooms or even in classrooms, Arkansas Children's Hospital tobacco outreach specialist Laura Taylor said.
The new products have subverted campaigns that persuade young people not to smoke cigarettes, sometimes by presenting e-cigarettes as a safe alternative.
"The generation of students that are using the JUUL products would be the type of students that still think that smoking is gross. ... They've been raised to believe that it stinks, it's gross, it's bad for you," Taylor said. "I think that they really believe that this is not that big of a deal."
But in addition to carrying their own dangers, a growing body of research suggests that e-cigarette use functions as a "gateway" to other types of tobacco use, Balamurugan said.
What's feared is that e-cigarettes are priming a new generation of smokers, even of traditional cigarettes, which are linked to cancer, stroke, heart disease, lung disease and myriad health problems.
People working in public health have been working to curb tobacco use for 50 years, he said. Now new technologies and a teen fad may undermine those efforts.
"E-cigarette use is increasing in adults," he said, "[But] it's nothing compared to the exponential growth we see in the kids."
An uptick in teen e-cigarette use is attributed to a perfect storm of factors, health advocates said. Appealing products with poorly understood risks have been heavily marketed to young users.
For example, many e-cigarette manufacturers offer products in flavors that are perceived as child-friendly, such as "gummy bear" or "cotton candy."
Dr. Melissa Blythe Harrell, an associate professor at the Michael & Susan Dell Center for Healthy Living at the University of Texas at Austin, said her research substantiates the idea that flavorings are a key element of young people's enjoyment of e-cigarettes.
"We asked the kids straight out: If these products were not flavored, would you use them? And the large majority said no way, no how," Harrell said.
She said flavorings may contribute to "consolidation" of tobacco use, in which users switch from e-cigarettes to combustible cigarettes, by easing them into an activity that initially might be unpalatable.
The small size and minimal vapor of products like the JUUL mean they're easily overlooked by teachers and parents, Taylor said, so there are fewer opportunities to discuss relevant risks.
Among those dangers is nicotine, which is included in most e-cigarette cartridges and is "as addictive as cocaine," said Dr. Joe Thompson, president of the Arkansas Center for Health Improvement and a University of Arkansas for Medical Sciences professor.
This is a real problem for adolescent brains, which are unusually vulnerable to addiction, he said.
Balamurugan also points out that what's inside e-cigarette cartridges is not well-regulated, and they can contain harmful chemicals. In some research, he said, more than 7,000 ingredients were identified in some e-cigarette formulations.
Advocates also have been frustrated by e-cigarette marketing campaigns, which they say use cartoon characters and colorful images to target teens and preteens.
Parents might not be aware of the many venues in which e-cigarettes can be advertised on the Internet, Thompson noted, and strong evidence has connected tobacco advertising to youth cigarette uptake.
"In the e-cigarette space, you've got advertising practices that look very much like the cigarette companies did decades ago, to attract younger and younger users," he said. "It's almost like we didn't learn from our experience."
Tobacco use of any kind has long been a problem for Arkansans of all ages. The state has the third-highest percentage of adult smokers, according to the federal Centers for Disease Control and Prevention.
That department's 2017 Youth Risk Behavior Survey found that 13.7 percent of Arkansas high school respondents currently smoke cigarettes, compared with an 8.8 percent national average. Smokeless tobacco, or "dip," use rates among teens were more than twice the national average.
Greater cultural acceptance of smoking in the South and in rural areas, Taylor said, contributes to the state's persistent smoking rates. High poverty rates also play a part, as smoking can be a coping mechanism for people who are struggling economically, Balamurugan said.
Within this climate, parents encourage tobacco and nicotine use by modeling it in front of their kids, Taylor said. The presence of traditional tobacco and e-cigarettes in the home also makes it easier for kids to pick them up.
"There's a lot of data that shows that when parents use tobacco products and parents smoke, or dip, and now in this case vape, students, children, are much more likely to start as well," she said.
Widespread tobacco use also may explain lax enforcement of the state laws forbidding the sale of e-cigarettes to minors. Relative to national rates, twice as high a percentage of Arkansas teens who responded the CDC's survey said they were able to buy e-cigarettes in a store.
Thompson also noted the "exceedingly high proportion" of adults in the state who smoke, and said there hasn't been "a sense of urgency" about communicating the harms of e-cigarette use to young people.
"We're not telling parents how to sit down and talk about e-cigarettes with their kids. We need to be doing a better job at that," he said. "I think we are not at the peak."
In recent months, youth e-cigarette usage has emerged as a prominent conversation in public health, culminating in November with the Food and Drug Administration's release of National Youth Tobacco Survey findings on e-cigarettes.
Dramatic results, including a near-doubling of the number of high school students who said they were e-cigarette users between 2017 and 2018, prompted the federal agency to release survey results earlier than planned. The FDA has said it will move to ban the sale of flavored e-cigarettes in some contexts.
U.S. Department of Health and Human Services Secretary Alex Azar said in a statement that the data show "an epidemic of youth e-cigarette use, which threatens to engulf a new generation in nicotine addiction."
In Arkansas, Balamurugan said the department has a number of initiatives prepared to combat e-cigarette and general tobacco usage, including smoking cessation programs under Be Well Arkansas and the statewide Project Prevent coalition, which is a youth nicotine and tobacco prevention program run in partnership with Arkansas Children's Hospital.
But he said the work of parents will be critical in turning the tide.
"Kids are not going to take the word of an adult," he said. "I can't be a parent and say that 'You can't smoke,' while I sit back and smoke."
Taylor, who works on Project Prevent, said the program has pulled in close to 500 students around the state to work on tobacco control initiatives. Among other activities, the students give presentations in their communities and make signs to remind people not to vape or smoke in the parking lot at sports games or in the car around schools.
Michael Keck, Arkansas government relations director for the American Cancer Society Cancer Action Network, said one key policy could cut teen e-cigarette usage rates.
In Arkansas, e-cigarettes are subject to a regular sales tax, as opposed to the higher tobacco product tax. A change in taxation structure has "consistent[ly]" affected e-cigarette usage in other areas, he said.
"If it costs more, they're less likely to spend that discretionary income on an e-cigarette as opposed to going to the movies, or whatever else teenagers do these days," Thompson said.
Keck also supports a statewide rise in the legal age to purchase any kind of tobacco or nicotine product, rules that recently were adopted in Phillips County and the city of Harrison. Around six states and 200 municipalities nationwide have adopted such a law, he said.
He's spoken to several legislators about putting forth these types of proposals for the January legislative session, though no lawmaker is yet ready to step forward publicly.
"There's a lot of ideas with the word 'draft' set on it right now," he said.
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Print Headline: E-cigarette use by Arkansas teens stirs worry over health; U.S. Department of Health calls widespread teen use an 'epidemic'