E-Cigarette Messages: Exploring Messages on E-Cigarettes Aimed at Women and Youth

Good afternoon, everyone. My name is Ellen
Pliska, and I’m the director of family and child health at the Association of State and
Territorial Health Officials. Hi, everyone. My name is Diana Karczmarczyk
and I am the senior analyst at the Association of State and Territorial Health Officials
and I focus on tobacco and chronic disease prevention. We would like to welcome you to
today’s interactive webinar exploring messages on e-cigarettes, aimed at women and youth.
In 1964, the U.S. surgeon general released a milestone report that formally addressed
the severe health risks of smoking and tobacco years. In the 50 years since the report’s
release, the United States has made considerable progress in reducing the tobacco use epidemic.
However, public health agencies are now facing new challenges due to the emergence of smokeless
tobacco products such as electronic cigarettes, or e-cigarettes Today’s webinar, hosted by
the Association of State and Territorial Health Officials, or ASTHO, in partnership with the
Association of Maternal and Child Health Programs, the National Association of County and City
Health Officials and the Children’s Safety Network, we will explore messages that have
been developed regarding the poisonous threat that e-cigarette liquids pose to young children
and the negative effects that nicotine has on brain development in adolescents.
Furthermore, we will explore public health messages aimed at women before and during
pregnancy on the use of e-cigarettes. We will introduce each of our speakers before they
present on the call today. All phone lines for participants have been muted during this
webinar. If you have a question for one of our speakers,
please post it on the chat box on your screen at any time during the webinar. These questions
will be used during the Q&A after today’s presentation. At the conclusion of the webinar,
you will be directed to an evaluation survey. Please take a few moments to provide us with
feedback on today’s webinar. We really look forward to hearing your comments.
Also, a recording of this webinar will be posted to the ASTHO website within the next
week. The website address will be provided on the last slide today. Thank you, Diana, for giving us some background
information on the webinar. We are joined today by an esteemed panel of experts who
will be telling you individually more about their specific role in tobacco control. Before
each speaker, we’ll be providing a brief introduction and we will anticipate that there will be
many questions for each speaker. So we’ve made an effort to allot time for that at the
conclusion of the panel presentation. Our first speaker today is Desmond Jenson.
Desmond Jenson is a graduate of William Mitchell College of Law and is a staff attorney with
the Tobacco Control Legal Consortium. He works primarily on shaping federal tobacco control
policy by encouraging the Food and Drug Administration to enact strong tobacco control regulations
based on its authority under the Family Smoking Prevention and Control Act. Desmond also educates
the public health and scientific communities about rulemaking processes and highlights
opportunities to engage the FDA to create better regulations.
He helps the public health community in its efforts to close regulatory gaps and enact
novel regulations that anticipate further regulatory issues. Desmond provides legal
technical assistance to members of the public health community who wish to participate in
the regulatory process. He also provides litigation support to defend tobacco control policies
that are challenged by the tobacco industry. We are thrilled to have Desmond with us today.
Desmond, I’ll turn it over to you. Thanks, Ellen, and thank you again for inviting
me to speak on this webinar about a really important topic. I have a lot of ground to
cover so I’ll try to move quickly. But if you have any lingering questions that don’t
get answered today, feel free to contact me at any time in the future.
First off, if you aren’t familiar with the Tobacco Control Legal Consortium, we are a
national network of legal centers providing legal technical assistance to tobacco control
professionals and advocates around the country. The consortiums team of legal and policy specialists
provide legislative drafting and policy assistance to community leaders and public health organizations.
Feel free to contact us at any stage as you develop and implement tobacco control policy.
Before we start discussing how to regulate them, it might be useful to talk about what
exactly an e-cigarette is. Up until the last couple years, almost every e-cigarette on
the market looked pretty much like an ordinary combustible cigarette. In order to coax smokers
to switch, the idea was to mimic a cigarette as much as possible.
On the inside, an e-cigarette is nothing like a combustible cigarette. You can see in the
diagram below that each device holds a cartridge filled with a nicotine solution that is heated
by a heating element powered by a battery. The solution is aerosolized and inhaled into
the lungs, much like cigarette smoke. These “cig-a-like” devices come in two varieties:
the rechargeable that allows the user to buy additional nicotine cartridges and recharge
the battery, which means the device can be used as long as the electronics continue to
work. The other type is the disposable, which comes
with a pre-charged battery and prefilled cartridge. Once the battery dies or the nicotine solution
is consumed, the entire device is disposed. Regulating the disposal of e-cigarette is
a topic for another day. Now, if we were conducting this webinar a few years ago, there wouldn’t
be much else to say about these devices. But over the last few years the market for e-cigarettes
has changed dramatically and the version of the product that is growing the fastest in
popularity looks nothing like a combustible cigarette.
These are often referred to as pink systems or tank mods. These devices are customizable
in almost every way from the size of the tank that holds the liquid nicotine, the temperature
of the heating element to the voltage of the battery. They range in appearance from the
most ordinary in the top left to the most opulent next to it. That device was purchased
by a Russian oligarch for his girlfriend and it’s covered and 500 carats of diamonds.
Even on the cheap, these devices are customized to fit anyone’s hobbies, adults and children
it seems, including Nintendo, Hello Kitty, Game of Thrones and even Star Wars. Now, because
these devices are not disposable, they have to be refilled which requires the user to
buy liquid nicotine. Nicotine dissolved in propylene glycol and vegetable glycerin can
now be purchased in almost every city and town across the country. It is often sold
in fruit, candy, dessert and alcohol flavors. The solutions vary in nicotine concentrations
from those that are alleged to contain no nicotine at all to the gallon jug that you
see at the bottom that can be purchased by anyone over the Internet which is concentrated
to 100 milligrams per milliliter and because I’m sure you’re wondering, that jug contains
enough poisonous nicotine to kill over 300 adults weighing about 200 pounds, yours for
just $350. It’s also worth noting that many of the mom-and-pop
shops out there that sell the stuff will mix your preferred concentration and flavor onsite.
The picture here of a woman wearing gloves while she mixes is definitely not the rule,
which is another huge health hazard as nicotine can be absorbed readily through the skin.
One last category that I want to mention is the “Vape Pen,” sometimes called the “e-hookah.”
This is a much more fluid category although most to the products are disposable. Some
aren’t. They are almost always filled in youth-attractive flavors and the devices are usually very small.
Many youth are entering the e-cigarette market with these devices because they’re easy to
conceal so that they can be hidden from teachers and parents.
Because they are rarely labeled as e-cigarettes, kids often don’t know that they contain harmful
and addictive chemicals. There’s also a growing overlap between these types of devices and
marijuana vaporizers. In the center you see a picture of a vaporizer endorsed by the rapper
Snoop Dogg. Moving on to the why’s and how’s of regulation,
particularly when it comes to maternal and child health, all of the looming unknowns
as to the public health effects of these products should be an indicator that the precautionary
principle should guide as we think about how to regulate them. It’s often the case that
we have to remind the public that a lack of a scientific finding that a product is harmful
is not the same as the finding that a product is safe.
And in the past, even drugs that have been approved by the FDA for use by pregnant women
have had tragic consequences down the road. We really still know very little about the
long-term health effects of these products. And unfortunately that will remain the case
until people have been using them for many years. What we do know about nicotine is that
it is highly addictive and that it can be devastating on the developing brain.
A good summary of the information about the effects of nicotine can be found in chapter
five of a for 2014 surgeon general’s report. There’s also a very real risk that these products
can be a gateway to other tobacco products. Kids are experimenting with them at alarming
rates. And while there are hundreds of anecdotal
stories of people using e-cigarettes to quit smoking, we don’t yet know the population
level effect on cessation and it’s also important to remember that the manufacturing of these
products is completely unregulated. No one is ensuring that there’s consistency in the
production of liquid nicotine or that the devices meet any sort of quality control standards
whatsoever. So who is regulating e-cigarettes and how
are they protecting maternal and child health? Currently not the FDA. You’ve probably heard
a lot about the FDA’s future regulation of e-cigarettes and the so-called deeming regulation
that will bring the products under the FDA’s authority. Currently the FDA only regulates
a few types of products and e-cigarette are not one of them. After the FDA finalizes and
implemented its deeming regulation, it would begin regulating e-cigarettes and other currently
unregulated tobacco products. What will FDA regulation look like? In addition
to a variety of information reporting and more global authority over the products, the
FDA’s rule would establish a minimum age, prohibit vending machine sales except in adult-only
facilities, prohibit sampling and establish warning labels. If you haven’t seen it already,
it’s worth looking at the proposed warning label for e-cigarettes.
Obviously these are the current warning labels for cigarettes and smokeless tobacco and they’re
fairly short and direct. Smoking can kill you. Smokeless tobacco is addictive. This
is the proposed warning label for e-cigarettes: Warning: This product contains nicotine derived
from tobacco. Nicotine is an addictive chemical. It’s incredibly benign and could barely be
considered a warning. There are also a number restrictions that
apply to cigarettes and smokeless tobacco that the FDA did not propose to extend to
e-cigarettes like prohibiting self-service displays, establishing the minimum package
sizes, prohibiting flavors, prohibiting brand new sponsorships and requiring notice for
advertising. While there are a number of things that the FDA proposed to do to regulate e-cigarettes,
there are many others that they have not proposed to do and I also want folks to understand
that the FDA has only just begun a very long process with a lot of red tape.
It is almost certain that the tobacco industry will challenge some aspect of the agency’s
final rule and that ensuing litigation would delay FDA action even further. We are years
away from FDA regulation of e-cigarettes. So the message for state and local governments
is do not wait for the FDA. If you want to regulate e-cigarettes to protect maternal
and child health in your community, do it now. Do not wait.
Now, what can state and local governments do to regulate e-cigarettes? Here’s a list
of FDA do’s and don’ts and with very few exceptions state and local governments have the authority
to do with the FDA proposed to do and the things that the FDA left on the table. It’s
a long list of policies, all of which would have a positive impact on public health. I
want to focus on just two that are particularly important for maternal and child health: flavored
product sales restrictions: and mandating child-resistant packaging.
Starting with child-resistant packaging, I’m sure that you all heard about the tragic poisoning
death of a toddler in upstate New York just last month. I’ve been describing the potential
for poisoning from liquid nicotine as a public health time bomb and unfortunately it seems
as though the clock may be running out. This death was entirely preventable and if no action
is taken it will likely not be the last. As I said earlier, the nicotine content of
these refill containers varies widely from nothing or next to nothing to incredibly high.
Many retailers classify a 12 to 18 milligrams per milliliter dose as medium and most packages
come in quantities of 10 to 15 milliliters, which means that the majority of the refill
containers have more than 100 milligrams of nicotine in each bottle.
This is estimated to be enough to kill a toddler. In addition to being fatal, these chemicals
have packaging with bright colors and often have pictures of fruit or candy. It’s no wonder
that calls to poison control centers reporting nicotine ingestion have skyrocketed from just
a couple hundred in 2011 to almost 4,000 in 2014.
So what do we do now? I’m sure that everyone on this webinar has encountered this. Almost
every over-the-counter drug comes in a bottle that requires you to either line up the cap
and the bottle of push down on the lid while turning. Both of these methods are simple
for adults to open but very difficult for children. These types of bottles are already
widely available for liquid nicotine and some companies are beginning to utilize them voluntarily.
They actually look virtually identical to bottles that are not child-resistant, which
is why it is not enough to rely on voluntary action.
Many state and local governments are not waiting for the FDA. Minnesota, Vermont, Illinois
and David County, Utah have all implemented laws requiring child-resistant packaging for
nicotine. There is also a growing list of communities that are considering something
similar and this list is probably outdated. We fully expect to see more of these laws
passed during the current legislative session and this will likely continue to build momentum
for this policy. Now, while the policy in general is an obvious
one, how it gets implemented can be tricky, which products are covered and how exactly
a jurisdiction determines whether a package is child-resistant can be much more complicated
and jurisdictions have gone in different directions on these questions and none of them have been
challenged in court yet. If you’re considering implementing a child-resistant packaging policy,
we would encourage you to contact the consortium to discuss your options.
Lastly I want to discuss flavored tobacco products. I’m sure I don’t need to convince
all you that flavored tobacco products are much more attractive to youth and are often
viewed by youth as being less harmful than non-flavored products. They represent a clear
danger to young people and the ubiquity of flavors in the e-cigarette market in particular
is leading many jurisdictions to seriously consider prohibiting the sale of all flavored
tobacco products. New York City, Providence, Rhode Island and Chicago have all passed laws
that restrict the sale of flavored tobacco products.
New York and Providence allow the products to only be sold in specific types of tobacco
bars while Chicago prohibits the sale of flavored products, including menthol-flavored cigarettes,
within 500 feet of schools. Providence and Chicago’s laws do cover e-cigarettes while
New York’s does not. Each city was sued. New York City and Providence successfully defended
their laws well Chicago’s litigation is still pending but looking positive so far.
This policy is also likely to increase in popularity as the FDA has not proposed to
limit flavors and communities are tired of the industry targeting youth with flavored
products. Unfortunately, there isn’t time to talk about some of the other policies that
will also have a large public health impact, such as including e-cigarettes into clean
indoor air laws or taxing them at the same rate as other tobacco products.
But the thing to remember is that there are a variety of options available to communities
that want to take action. And just to remind you one more time, if you are considering
a policy you can contact us to seek free legal technical assistance. We can help you at any
stage as you develop and implement your policy. Our website also has lots of resources on
not just tobacco control but healthy food, active living policies as well as other public
health topics. Thank you for your attention and I look forward to any questions that you
might have Thank you so much, Desmond, for all of your
comments today. We appreciate you sharing such a great overview on e-cigarettes, and
examples of the regulations to improve maternal and child health. I would now like to introduce
our next speakers, Laura Oliven and Parker Smith. Laura Oliven serves as the tobacco
control manager for the Minnesota Department of Health. She had been with the agency for
four months and brings with her over a decade of successful health promotion and tobacco
prevention and control experience in Rhode Island and Minnesota, working at the state
and local level. Parker Smith serves as the tobacco communications
coordinator for the Minnesota Department of Health. He’s been with the department for
over a year-and-a-half and leads communication planning and strategy for the agency’s tobacco
work. He holds an MPH from the University of Minnesota. We are thrilled to have Laura
and Parker with us today. Laura and Parker, I will now turn it over to you. Thank you. Let me just advance the slide.
We are pleased to preset to you today and share our experience in working on e-cigarette
policy and communication at the Minnesota Department of Health. in the next 25 minutes,
we will give you a brief background on the Minnesota tobacco prevention and control landscape
so you have a context for this presentation, share the major findings from our 2014 Minnesota
youth tobacco survey, talk about the communication goals and key messaging we developed to accompany
our youth e-cigarette use findings from the survey and describe the rollout and response
of our messaging. As mentioned, Parker Smith, who leads our tobacco control communication,
will help tell our story. So let’s start with a quick background on
the tobacco control landscape in our state. Since 2007, the Minnesota Clean Indoor Air
Act has restricted smoking in nearly all indoor public places. However until 2014 this did
not include e-cigarette use. Showing prescience in 2010, the legislature passed the Tobacco
Modernization Law, which prohibited the sale of nicotine delivery products to minors and
in that respect Minnesota was ahead of their time.
In 2013, new tobacco tax laws significantly increased excise taxes rates on cigarettes
and other tobacco products. The legislature increased the cigarette tax by $1.60 to a
total of $2.83 per pack, the tax on other tobacco products to 95 percent of wholesale
price and the tax increase also covered nicotine cartridges of e-cigarettes, one-time-use e-cigarettes
and e-juice containing nicotine. In 2014, the law changes were introduced related
to e-cigarettes. E-cigarettes are now prohibited in Minnesota, in some schools, hospitals,
government buildings and universities. There were further prohibitions on sales to minors
and it requires stores selling e-cigarette delivery devices to have a tobacco license.
It also required behind-the-counter sales of e-cigarette products with the exception
of adult tobacco product shops. And as I’ll describe more in a minute, it
required child-resistant packaging which, by the way, just went into effect on January
1st, 2015. So these changes did stop short of prohibiting e-cigarette use in all indoor
places. One other word on Minnesota, we’re lucky to have the statewide health improvement
program which funds 38 local public health authorities to work on obesity and tobacco
prevention as well as nine tobacco-free community grantees and nine tribal grantees.
We also work closely with the Blue Cross Blue Shield Center for Prevention in Clearway,
Minnesota grantees. So as a result, we have a comprehensive tobacco control network to
help disseminate the messaging we will talk about today. And we recognize how fortunate
we are to have that infrastructure. Part of the impetus for some of the 2014 law changes
on e-cigarettes was the release of 2013 data on the spike of e-cigarette poisonings in
Minnesota. We worked closely with our Minnesota poison
control system to analyze tobacco-related poison reports. In 2013, they reported 74
e-cigarette poisonings overall with 50 reports involving kids and teens. This was a tenfold
increase from 2012. Keep in mind that e-cigarette poisonings were virtually unheard of prior
to 2013. Several of those calls involved toddlers and infants less than two years of age who
swallowed the e-juice. Some calls involved teenagers who had been using e-cigarettes.
One other aspect I wanted to highlight from the 2014 law is Minnesota’s new child-resistant
packing requirement, which recently went into effect. We are one of only three states — three
plus another that Desmond just highlighted, so it’s updated — to have such a law in effect.
It requires our retailers to have child-resistant packaging on the sale of liquids use for electronic
delivery devices. The way the law is structured enforcement of this requirement is on our
city and county licensing authorities. I want to give a plug for the Public Health
Law Center, who has recently posted on their website a legislative spotlight piece highlighting
the key provisions of this law, if you’d like to know more about it. Now that you have the
Minnesota context, we can talk about the results of the 2014 Minnesota youth tobacco survey.
The MYTS, as we call it, is one of the most important public health monitoring tools that
we have. We conduct it every three years and it collects in-depth data on youth tobacco
use. The 2014 survey include many questions about
new products, especially electronic cigarettes as well as conventional tobacco products.
Public schools and classrooms across the state were selected at random and invited to participate.
Overall, we have 4,243 students in grades six through 12 that took the survey. The survey
was recent and went into the field in early 2014.
Well, what did we find? We are very pleased to report that the rate of cigarette use among
high school students during the past 30 days dropped from 18.1 percent in 2011 to 10.6
percent in 2014. That was the largest decline in the history of the survey. Such success
has many mothers. There’s a strong evidence base that price increases are the most effective
strategy to reduce tobacco use. We believe that cigarette tax had a major
impact on youth tobacco use as well as our clean indoor air laws that I’ve just described.
We have also built an impressive community capacity through our grant programs to empower
disparately impacted populations to advance policy systems and environmental change and
promote health equity. The percent of students who used any conventional
products, including cigarettes, cigars, chew and the like also dropped from 25.8 to 19.3
percent. The survey however was not all good news. For the first time, the survey asked
about e-cigarette use. They found that a whopping 28 percent of high school students reported
ever having tried an e-cigarette. The survey also found that 12.9 percent of high school
students used or tried an electronic cigarette in the past 30 days. One note, that unlike
conventional cigarette use data and reporting, e-cigarette 30-day use may reflect experimental
or occasional use. We’re also seeing that tobacco companies are
taking advantage of a lack of e-cigarette marketing regulations as an opportunity to
market to youth. Tobacco companies are using old and well-tested marketing techniques to
introduce children to nicotine and the new product. The survey found that more than half
of high school students, 57 percent, saw an e-cigarette ad on TV in the past 30 days.
About half, 48 percent, saw one in a convenience store.
One of the other concerning findings in the level of youth menthol use at 44.3 percent.
In 2014, we changed the wording for the youth menthol use question which may explain the
slight drop. Overall however, the number remains high. A note is the contrast between the high
percentage of youth smoking menthol and the adult menthol use rate at 25 percent. Like
the flavorings in e-cigarettes and other tobacco products, menthol masks the harsh taste of
tobacco, making it even more attractive to youth.
One other note worth mentioning to this audience with a focus on maternal and child health,
the new MYTS also reflected in what our grantees are observing all over the state is the changing
landscape of tobacco use. As cigarettes have become more expensive and less attractive
for youth, they are experimenting with novel and often flavored tobacco products that are
dangerous and continue to expose them to nicotine. So as we prepared to roll out the YTS data,
we developed four strategic goals for our communication plan. We wanted to inform stakeholders
of the new findings in the data. We wanted to alert parents and community members about
youth e-cigarette use. We wanted to educate the public on the health risks of nicotine
and reinforce the importance of clean indoor air and other proven tobacco control strategies.
Those goals guided all of the activities that I’ll now describe.
So our messaging celebrated out state success in reducing youth tobacco use, underscoring
the effectiveness of tobacco control policies like price increases and comprehensive clean
indoor air. In describing the data and findings, we noted that man of the youth using e-cigarettes
were also using conventional tobacco products, so dual use.
Additionally, we were concerned to find that one-quarter of youth who tried e-cigarettes
had never used a conventional tobacco product. For them, e-cigarettes may be a dangerous
introduction to nicotine. Because of the advent of youth e-cigarette — because the advent
of youth e-cigarette use is relatively new and the body of research is still developing,
we spent a great deal of time thinking about how to characterize the health risks of youth
e-cigarette use. I’d like to say that we are certainly aware
of the emerging body of research relating to particulates in the aerosol and the danger
of inhaling flavorings. So after reviewing the body of research, which I constantly evolving,
and upon consulting with the CDC, we decided to firmly base our messaging on the findings
in the 2014 surgeon general’s report. With this as our guide, we concluded that where
the science and the research is the most definitive is on the health risks of nicotine to youth.
So we made nicotine the centerpiece of our health risk messaging. We focused our messaging
around the four concepts listed in this slide. We emphasized repeatedly in the rollout of
this data that e-cigarette use puts our youth at risk, that no amount of nicotine is safe
for youth and that nicotine is addictive and harmful to the adolescent brain development.
We further emphasized that e-cigarettes are not regulated by the FDA and that e-cigarette
use may be especially harmful if it leads to ongoing use of nicotine and other tobacco
products. The YTS also asked new questions about exposure
to e-cigarette advertising. We emphasized that cigarettes advertising hasn’t been allowed
on TV, radio or billboards for decades. E-cigarettes may be harmful if they glamorize or renormalize
tobacco use, including exposing children to images of tobacco use. Finally, we used the
decline in youth cigarette use to emphasize the effectiveness of proven tobacco control
strategies like price, ease of access and compliance. We especially highlighted the
importance and effectiveness of clean indoor air policies, which serve as a key opportunity
to highlight the critical importance of prohibiting public indoor e-cigarette use.
Now I’d like to introduce Parker Smith, who will highlight our communication and dissemination
strategy for the messaging we developed. Thanks, Laura. As part of our communication
strategy, we compiled our new nicotine focused-messaging to create a comprehensive toolkit that would
enable our grantees and partners to talk about the new data as well as the health risks of
e-cigarettes. So what we packaged together ended up being our set of talking points and
new messages, a summary of significant data points from our new report on youth data to
help provide at a glance a set of data that is organized by topic.
We also included an infographic to visually summarize some of these main points and our
key messages, which could easily then be shared on social media. I’ll show you that in a minute.
We included our e-cigarette fact sheet for some background information as well as the
executive summary from our new youth report which highlighted some of the significant
findings in more detail. And lastly, we included a question-and-answer document to prepare
local spokespeople for questions about the data.
And one example in particular, a question we anticipated and did happen to get was isn’t
it a good thing that more kids are using e-cigarettes instead of conventional cigarettes? And using
the messaging that we developed, our answer would be that this new data indicates most
of or more than 60 percent of youth who use e-cigarettes are also using conventional tobacco.
So regardless, no amount of nicotine is safe for youth and kids should not be exposed to
nicotine in any form. And here’s the infographic I promised. We
included this with the toolkit and it was developed in collaboration with our state
partners and as you can see incorporates our main messages. For a closer look, you can
find this on our website. So just before the broad release of our new youth data, we invited
our tobacco control partners to a heads-up call. On the call, we briefly discussed the
new findings and provided an overview of our key messaging. But at the same time, we distributed
our toolkit to these partners and also our local grantees.
Then, just hours after our heads-up call, the new data was released broadly during our
scheduled press conference. And at this conference, we featured Dr. Ehlinger, Minnesota’s commissioner
of health, as well as our lead epidemiologist who worked on the Minnesota youth tobacco
survey as well as a youth representative from the Minneapolis Youth Congress. And despite
enduring one of our typical Minnesota snowstorms, nearly all of our local news networks, including
the Associated Press and Minnesota Public Radio, were in attendance.
Afterward, we held a Q&A with our panel and offered the media a chance to ask the youth
about their experiences with e-cigarette use in school. And as we anticipated, our release
gained significant media coverage. Since November, our story received almost 22.5 million views
or impressions through media coverage, which also includes many other outlets from out
of state. And in addition to the headlines, many of these news stories did indeed pick
up on our messaging on the danger of nicotine as well as the health risks to youth.
In the end though, the release of our data served as an important platform for our agency
and our network of tobacco control partners to inform the public on the health risks of
e-cigarette use and that message continues to spread even today. And that’s all we have
now. Thank you for your time and we look forward to answering your questions later on. Also,
you’re welcome to contact either of us directly after the webinar with questions about any
of our messaging. Thank you so much, Laura and Parker, for your
comments today. We really appreciate both of you sharing all the great work that you’re
doing in Minnesota. We know that there will be a lot of questions about your work and
want to remind today’s participants that you can submit questions for speakers at any time
into the chat box on the screen. We have provided for speakers to answer these questions at
the conclusion of the presentation portion of today’s session. We will also be sending
out all of the slides to the participants within the week. So look forward to those.
I want to welcome our next speaker, Dr. Jonathan Klein. Dr. Klein is a pediatrician and a health
services researcher and is the founding director of the American Academy of Pediatrics Julius
B. Richmond Center of Excellence, which is dedicated to the elimination of children’s
exposure to tobacco and secondhand smoke. He was on the faculty at the University of
Rochester in New York for 18 years in adolescent medicine and as an associate chair for community
and government affairs in the department of pediatrics. Dr. Klein joined the academy as
associate executive director in 2009, where his oversight responsibilities include research,
tobacco control, publishing and international health. We’re pleased to have Dr. Klein with
us today. Dr. Klein, I’ll turn it over to you. Thank you, Ellen, and thank you, Diana. And
thanks to ASTHO for sponsoring today’s event. I’m going to spend a couple of minutes talking
about e-cigarettes and the electronic nicotine delivery systems from a clinical perspective
and from some of the work that we’ve been engaged with at the academy.
I think you’ve all heard the background so far that these are products that are designed
and are appealing to adolescents and young adults. And actually every one of the things
in that crayon box of e-cigarette products, none of those are actually crayons or markers.
And so they really are mimicking things that are going to be very difficult to detect in
many settings for young people. And as we heard in the first presentation,
the flavorings, bubble gum, fruit-flavored things are designed to be palatable and attractive
to youth. Obviously this is a big concern for us as pediatricians for several reasons.
And the marketing, as we’ve heard, there are very few restrictions on the advertising or
no restrictions on the advertising. And you can see the advertisements are using themes
of sexuality and imagery that is again designed to appeal to different youth audiences. And
on the right there is from the same Sports Illustrated issue that had the swimsuit models
on the cover. And so again, the marketing designed to promote
the products as being associated with youth and sexuality in the same way that the tobacco
industry did for many, many years for traditional compatible cigarettes. We’ve heard new data
from Minnesota on both the great impact they had from their campaign but also the rise
of the e-cigarette data. And I think what we see from data from CDC and from other surveys
as well as from state tobacco surveillance is that every time you look, the prevalence
of these products continues to rise. And we’ve gone from less than 1 percent in
most places only three or four years ago, to five and fix and now up into the mid-20s,
28 percent in the Minnesota data for high school-aged students and that’s for that students
who actually recognize that the products they are using are e-cigarettes or e-hookahs or
vape pens. Again, the confusion over what to call them and what is used continues to
be an underreport when it comes to much surveillance. And so, we have increasing numbers of users.
We have young people responding to the advertising. Among adults, the numbers also continue to
rise with, again, low numbers in 2011 and ’12 and an increasing proportion. And again,
the most concerning thing is, as our colleagues in Minnesota reported, 25 percent of the youth
users were never smokers when it came to traditional combustible tobacco products. We find the
same kind of proportion among adult users of e-cigarettes as well where significant
numbers of e-cigarette users are never smokers. The other group of e-cigarette users that’s
concerning is that again a substantial number are what we’ve defined at the academy’s Richmond
Center as distant former smokers. They have not smoked a traditional cigarette product
in more than five years and yet they report recent electronic cigarette use. And I think
that number becomes equally important because of the industry’s use of the claim that, oh,
well smokers are using these to try to quit or to use a less harmful product even though
the evidence base for cessation with e-cigarettes is minimal to nonexistent.
The fact that many of the e-cigarette users are these distant former smokers, people who
long ago quit but are becoming re-addicted to nicotine directly refutes that and some
of the publications from our center, led by Robert McMillen at University of Mississippi
Social Research Center have some of the data there in recent publications. We’ve got some
of those citations on our website as well. So what are the health effects of these products?
Relative to combustible tobacco, there is less tar and less of the particulates that
are present in combustible tobacco. There are however measurable and variable levels
of nicotine. Whether these in fact provide a step down in dosage similar to cessation
methods is an unproven claim that the manufacturers make. It may be less harmful than smoking
tobacco products but compared to not smoking at all or using medical grade prescription
or over-the-counter replacement therapy with nicotine, there clearly is an increased amount
of harm from these products. And our belief is that if people are going
to be responsible in addressing tobacco control, the responsible position is to say that one
has to first regulate the advertising and the promotion to youth before one talks about
whether there might be a positive benefit to harm reduction or to cessation and that
the evidence that it’s a benefit would need to be demonstrated just like any other therapeutic
use might be to be generated. The evidence is emerging mainly from animal
models right now that exposure to e-cigarette vapor and in fact secondhand exposure to e-cigarette
vapor actually causes a decrease in lung function and slower lung growth and slower lung development
mostly in mouse models. Sharon McGrath-Morrow at Johns Hopkins, another one of our center’s
investigators, has been seeing this in a model that already existed for prenatal and newborn
mice that was a secondhand tobacco smoke exposure model. They’ve exposed these newborn mice
and the prenatal exposure of these mice to secondhand e-cigarette vapor and not only
does it address and harm their lung function and growth, in fact the vapor without nicotine
in it also harms developing lungs because of the propylene glycol when it’s heated and
what effect that has on lung growth. And infant mice exposed prenatally and during
their first two weeks of life — and again they can do this experiment in mice — actually
have measurable effects on their behavior as adults. Now, mice become adults a lot more
quickly than our children do. But if we have evidence emerging from animal models that
the harm of nicotine exposure is just as measurable as it is from traditional combustible tobacco
products, it would seem that the prudent course of action would be to protect our children
from them and not to allow the products to remain unregulated.
Again, there’s a quality control issue in the e-cigarette products because of the way
the solution is mixed and the fact that adulterated products are in the market and are not in
any way controlled or safe. Again, it results in new nicotine addiction and we’ve talked
about the toxicity of nicotine, the safety of the flavorings and of some of the other
agents that affect the way it feels when you use it when they’re heated and inhaled is
unknown. But some of the flavorings actually have proven
toxicity and there’s evidence that’s emerged that some of the flavors create the same kind
of lung damage that the hot oil from popcorn machines can create. And so, it’s known as
a popcorn lung effect. But you can get that from some of the e-cigarette flavors as well.
And again, this may impact the smokers who have tried to quit in terms of their overall
trajectory. The public health effects, again, secondhand
e-cigarette vapor is not just harmless water vapor. It emits measurable and variable levels
of nicotine. They are less than that of combustible cigarettes but you actually can identify measurable
adsorption of nicotine from secondhand exposure to the e-cigarette vapor just as you can measure
that in people exposed to traditional cigarettes. The particulates also can be harmful and again
the toxins — we’re seeing increasing evidence. Some of you may have seen California’s public
health declaration yesterday that the e-cigarette vapor also contains formaldehyde and some
of the other toxic chemicals that are present in traditional cigarette smoke as well.
And the fact that this is beginning to renormalize imagery of smoking, that people are using
them in places where smoking is not allowed, that we’re seeing them in TV and other video
and billboard settings again for the first time since the early 1970s and that they pretty
much look like cigarettes in many of the imagery in the media is a significant concern when
it comes to addicting young people to tobacco in this generation.
We’ve heard a little bit about the liquid itself. This is a list of some of the things
that can be in the liquid. All of these are not in all of them. But as some of you know,
the refillable products can be refilled with liquid or wax products that are used for marijuana
rather than for nicotine as well. And it’s indistinguishable in its use from the nicotine
products. What the long-term health impact of the various products are and their inhalation
really remains to be seen. But again, actually prudently would seem to
make some sense there. This is just a graph of the poison control calls. We’ve talked
and heard a little bit about the safety packaging and the number of calls and the number of
children potentially harmed as well as the number who will wind up harmed like the deaths
that occurred in New Jersey remains to be seen. The academy was a vigorous sponsor at
the federal level of the Child Nicotine Poison and Prevention Act of 2014 that Senator Nelson
and Representative Esty had sponsored. This was a very narrow bill designed to allow the
consumer Product Safety Commission to regulate the packaging of e-cigarette liquid. Because
it’s a tobacco product, it is exempt from CPSC rules. The bill died at the end of the
session. There was a hold on it from the current majority side in the Senate but there was
pretty good bipartisan support for moving this forward and we’re hoping this will move
in the current session as well. From a clinical practice perspective, pediatricians
and other clinicians need to be sure we’re asking the right questions about tobacco use
and about secondhand smoke and these need to include asking about e-cigarettes and other
electronic nicotine devices as well as exposure to secondhand vapor from these devices. We
know that we have a long way to go in getting all of the adult clinicians who care for adults
with chronic illness or getting any of the folks caring for kids to really be asking
these questions very consistently. But recognizing that this is an opportunity
to enhance the referral to quit lines, to enhance the cessation messaging and clinical
practice with parents and other adults who are highly motivated to protect their children
from their harm and so the route of referral to quit lines through pediatric sources of
care is an important component of state tobacco control programs and it’s one that we’ve asked
our state chapters to be active in advocating for as well as to do their part in addressing
the clinical education of health care providers. Until we know more about any of the e-products
and cessation evidence, we really need to be recommending only approved NRT and quit
lines and other evidence-based interventions for smokers who want to stop smoking or to
stop their nicotine addiction. And electronic cigarettes should not be used in any setting
in which there are nonsmokers, pregnant women or children who need to be protected from
their exposure. The easiest way to do this is to include them in all traditional cigarette,
clean indoor and outdoor air control regulations. But this requires action at state and local
levels throughout the country. The other policy implications, the FDA often
moves a little more quickly with their deeming in order to actually establish the authority
over the products. We understand why they are moving slowly but the pace is really somewhat
depressing when we realize how quickly this epidemic has connoted to the tobacco epidemic
for our society. We do need research about the effect of secondhand vapor as well as
the addiction potential and the dual use issues. But again, the research needs to err on the
side of protection of our young people, not on the side of a free and unrestricted market
until we have demonstrated the harm. Childproof packaging is obviously a critical component
of safety for children and again including all of these devices in all smoke-free air
laws and purchase and sale laws is an important set of actions.
The academy has a variety of resources both to help our members but also to help in the
public health arena with these issues. The Julius B. Richmond Center of Excellence at
the academy is a center dedicated to the elimination of tobacco and secondhand smoke from children’s
lives. Our main sources of support come from the Flight Attendant Medical Research Institute
and from the Legacy Foundation but also from other grants and donations. We have a set
of resource materials for clinicians, for parents. Some of them deal with emerging products.
There are about 30 different PowerPoint sets that can be pulled down and used from the
Richmond Center website and there are a bunch of webinar series including a few on e-cigarettes
that summarize some of this evidence in a bit more detail again that can be used as
an enduring resource. And we have a set of resources that have been
designed specifically for states that address some of the state policy issues that we’ve
worked on with our state chapters and with our community health advocates. The center
also has a network of tobacco control champions around the country who have been part of mobilizing
the voices of pediatric clinicians to help provide a pediatric perspective on why it’s
important to protect children from tobacco. And if you’re working on these issues in your
states or your communities, we’re very happy to connect you with local experts who can
be spokespeople about the importance of child health issues.
So let me stop there. I’m looking forward to the questions. The pictures by the way
that bookended my presentation are children’s artwork about clean air and secondhand smoke.
There’s a library of sort of the top 40 of them from an art contest that we’ve sponsored
over a couple of years that are available for use in other settings. That’s also on
our website if people would like to use them. And if you have any questions, please feel
free to email us. Again, on our website are links to do that. Thanks again. Thank you, Dr. Klein, for such useful information
on e-cigarettes and sharing the clinical perspective on this topic. We would now like to share
some resources available from ASTHO, NACCHO, AMCHP and the Children’s Safety Resource Network
related to e-cigarettes. ASTHO has several resources on our website that may be helpful
to states. The first is a booklet highlighting recommendations
about smoking cessation strategies for women before, during and after pregnancy. This publication
includes examples of the work that several states are currently doing in these areas
of tobacco control and prevention. And it was a collaboration through our tobacco and
MCH projects at ASTHO. We’ve also written comment letters on proposed
tobacco control regulations including issues like menthol and e-cigarettes. In addition,
you will find on our website a collection of our webinar recordings, state resources
about e-cigarettes including our recently released issue brief on e-cigarettes and a
spreadsheet of resources that have been compiled and organized by ASTHO.
The web address for ASTHO’s tobacco website where you can access more information about
all of these resources is up on the screen now and it will also be provided on the last
slide of the presentation along with our contact information. Our child health project, the
Healthy Baby Clearinghouse, a website of state case studies and emerging, promising and best
practices around improving birth and maternal outcomes.
The clearinghouse compiles state stories, tools and other resources like time and impact,
preconception, inter-conception, prenatal, birth to 28 days and the first year of life
and by socioeconomical model, policy, organizational, data, community, provider and self-management.
It also features a section on specific state strategies to improve birth outcomes including
smoking cessation. ASTHO also collaborates with NCSL, the National
Conference of State Legislatures, and we wanted to share their website as it also contains
valuable information for states and local health agencies. NACCHO, the National Association
of County and City Health Officials, also has a section on their website dedicated to
e-cigarettes. There you will find their policy statement on e-cigarettes. AMCHP, the Association
of Maternal and Child Health Programs also has a place on their website that features
the AMCHP innovation station. This is a place where AMCHP encourages states
to submit examples of innovative work in the area of e-cigs and maternal and child health.
The Children’s Safety Resource Network hosted a webinar in e-cigarette poisoning last month.
The recording and slides are available on their website. We also did a blog post about
e-cigarette poisoning last year which is also available on their site. Just as reminder,
the slides of this webinar will be posted to the ASTHO website along with a recording
within a few days. And within the next day, all participants will also receive an email
with a copy of these slides for your reference. At this time, we will begin the question-and-answer
session. If you would like to ask a question, please type it into the chat box located on
your screen. We’ve received many questions already so I’ll start with those as we wait
for more to come in. The first is just a comment. This comes from someone who works in the poison
control calls. As a veterinarian this person is seeing an increased number of calls and
emergency room presentations of dog and cat poisonings that also mimic those seen in children
and so they just wanted to see if anyone had any comments about that. That could be to
any of the speakers. Diana, I don�t know anything specific about
cats and dogs. But we have undertaken — we’re about to undertake an analysis of the poisoning
reports for this last year to see who is being poisoned, how many and the nature of the poison
reports. So we’ll tabulate that data and produce an eventual report around that or at least
release the findings. So stay tuned. Glad to know about it. Great. Thank you. Okay, we’ve received another
question. This is one is requesting a general response about the best way to go about policy
implementation. They’re wondering if it is recommendations to address e-cigarettes by
community, district or at the state level and where’s the best place to get started.
That would be for anyone. If no one wants to start, I can. I would strongly
recommend to start at the state level. Then you don�t have to worry about the local
level. However, that’s not always easy to do. So sometimes if you begin at the local
level and you can build momentum that way to the point where you can attain enough support
and mobilize enough communities and stakeholders to get state level policy change. This is John. I really think it also depends
on where you got the political will to move it forward. I think we got the evidence base
in hand and we have the strategies that can be implemented and it really requires having
the support of your elected officials as well as your health department focus on taking
some action. I think that again all of the organizations and the websites that were talked
about have websites to think about what are the strategies you can take.
Certainly we have policy tools online as do most of the others that can talk about the
specifics of what to put in regulation or legislation. But I think what we learned with
the communities putting prevention to work and with some of the programs that have succeeded
them, CDC has actively supported, there also needs to be that political will in the local
or state communities. So looking at the public health and advocacy community and assessing
sort of what’s the feasible step has got to be part of the equation and working towards
the goal of protecting people from products. This is Desmond. I would echo what everyone
else has aid and then just add, like others have said, if you have an ambitious state
legislature and you can do something at the state level, that’s great. But if you don�t,
if you have a local coalition that’s strong and doing that is also good. At the local
level, county or city, you also need to look at if you’re intending to do policy work and
to make sure that your jurisdiction has the authority to do what you’re hoping to do and
also that you’re not preempted by state law. So if you’re doing something at the local
level, there are a couple other little things to iron out but that doesn’t mean that you
can’t get something done. We do have a follow-up question that’s along
the same lines. Someone is looking for any advice for local jurisdictions or states that
may be up against exclusions for vape shops and indoor clean air acts allowing for sampling
in stores, if any states or counties or even cities that have had this exclusion and what
are you seeing. This is Desmond again. I was just waiting
to see if anyone else was weighing in. When you’re looking at your clean indoor air law,
that can be tricky and complicated and difficult depending on what you want to do. And if you’re
intending to go back and revisit any exemptions, if you already have prohibited the use of
e-cigarettes in various places and you want to go back and target vape shops and sampling
and that sort of thing is always a great thing to do.
But you always want to be careful that in opening up that law you don�t accidentally
undo something you didn’t want to do. We see in a lot of communities the tobacco industry
and e-cigarette companies have lobbyists and they will send experts in and try to undo
things if they can. So it’s always important to be very careful.
If you haven’t yet prohibited the use of e-cigarettes, if you haven’t included them into your clean
indoor air laws, thinking about doing it and working ahead of time to ensure that you can
message that properly and make sure that you can properly state the problem and why you
want to solve it is going to be really important because when there are people who want to
target that law and create exemptions, vape shops and cigar bars and things like that
are a pretty common target. So if you want to be very comprehensive, make sure that you
have your resources in order long before you start putting pen to paper. Thank you so much. We’ve received another
question and could any of you comment on how or whether communities or states can restrict
youth-targeted monitoring and advertising of electronic nicotine delivery devices or
electronic nicotine delivery services and how they could go about doing that? Desmond, I think you’re probably the best
one here. I was afraid so. Advertising is very difficult.
I am not a naysayer by any means. But when you are targeting advertising in particular,
you have to be very, very, very, very cautious because the First Amendment is a very powerful
tool for the tobacco industry to challenge tobacco control policy and we’ve seen that
at all levels of government. So you have to be careful to craft a policy that will withstand
litigation because any time you are attempting to restrict advertising, the likelihood of
litigation is very, very high. So if you are targeting things like outdoor
advertising or point of sale, limiting it, the policies to areas like schools or using
the local authority zoning and licensing to limit the places and the time, place and manner
of advertising is going to be easier to overcome a litigation challenge but certainly not guaranteed.
I would say that if you have local will to do something to limit e-cigarette advertising,
you may have a better bet going after a thing like a sales restrictions like limiting flavors
or limiting sales near schools. And so, in limiting those products, the retailers won’t
be able to advertise them because they can’t offer them for sale. So it’s sort of you do
get at advertising through another avenue but as I said in my presentation, New York
City and Providence were able to limit flavored products and that held up in court. So it
is easier to overcome litigation than if you were purely regulating advertising. Thank you. Our next question is coming from
a little more of a personal place. There’s this person has a daughter whose friends are
using e-cigarettes and wants to know how they can be better educated since these students
believe that e-cigarettes are just vapor and water and don’t think that there’s anything
else in them. So she’s looking for a way to educate teenagers on the facts of e-cigarettes
at a family level or if there are any family or community resources out there that may
be beneficial for families. This is John. I think that if you look at
some of our educational material for families and teens or some of the other groups, the
evidence for the addictive nature of the products, especially for young people who are nonsmokers
and who are not addicted to nicotine are really quite clear and the harm of nicotine is quite
clear. And so, I think like with any other adolescent
behavior that parents need to set expectations, explain why their expectations are based and
the concern for their teen and work with their clinicians to try to help guide teens towards
safe and healthy behaviors. You can provide the same kind of information
to your teenaged kids or to younger children and I think the other thing, again, that’s
been strongly evidenced with regard to tobacco advertising is that the media imagery that’s
shown is false when it comes to the impact of the products on health and on lifestyle.
And I think Legacy’s truth campaign has made that case elegantly with combustible cigarettes.
Much of the same messaging is true around e-cigarette products, try to deliver the entire
message by parent communication. Perhaps looking at some of that content together may in fact
help get that message through in the family setting. But I think again for parents to
remember that their ability to influence their teen’s behavior through setting expectations
and addressing health issues is quite strong. Even if it apparently is not received, it
actually is well-received when it comes to teens’ behavioral choices. Thank you for your response to that. We do
have a question around what kinds of behavioral differences were noted in some the mice studies
where the mice were exposed in infancy. Dr. Klein, I believe that’s for you. Yes, I’m sorry. What about the exposure? Absolutely. What are some of the kinds of
behavioral differences that were noticed in the mice exposed in infancy? Were you able
to see any longer term from the offspring of the nice and any differences there? So the study which is currently in press and
should be out in the next couple of weeks actually from the folks at Hopkins, what they
have is they had mice that were exposed during the pregnancies of the mice. And the exposure
was sort of the equivalent to 10 minutes of e-vapor secondhand exposure a day. And then
the same mice, once they had been born, their exposure continued for about two weeks while
the pups were still breastfeeding with their moms.
They then took some of the mice, once they had grown to adulthood, and I’m sorry, I don�t
remember how many months it is for a mouse to become an adult but it’s not all that many
and they put the mice through some standard behavioral tests that look at some of the
impulsivity and some of the correlates of hyperactivity and behavior disruption that
are measurable in mice. And again, I’m not expert in this area. But
the mice who had been exposed to nicotine through the e-cigarette vapor demonstrated
behavioral changes and consistent differences from mice that had not been exposed. The human
data in the surgeon general’s report, I believe it’s from the 2012 surgeon general’s report,
but the surgeon general’s report on the effect of smoke and secondhand smoke on children
has shown us pretty clearly that there are behavioral correlates to traditional cigarette
exposure, secondhand exposure in early school-aged children.
There are more disruptive behaviors, more behavioral problems in early education and
more hyperactivity symptoms in children with tobacco exposure. And so, it’s interesting
and concerning that some of the animal model data is suggesting that some of the same kinds
of effects in the same direction are there with e-cigarette nicotine exposure as well. Thank you, Dr. Klein. Our next question is
how would you respond to somebody that says should we embrace e-cigarettes which support
replacing traditional cigarettes or combustible cigarettes for adults? We’ve been talking
a lot about kids. So how would you respond to those questions, and that can be for anybody. This is John again. I think I addressed it
a little bit in my original comments that it’s possible that as a harm reduction, these
might have a use. But until we have first completely addressed marketing to young people
and the addiction of nonsmokers or the re-addiction of smokers who have quit, to say that because
they might have a benefit is an irresponsible position from a public health point of view.
If we believe that they might have a benefit, then let’s put them in controlled settings
and study that question of benefit rather than call for them to be unregulated in the
marketplace and allow them to be flavored and marketed in a way that we know is likely
to addict young people who are nonsmokers. Our next question � Diana? Go ahead, please. Sorry, I just want to add one thing. That
as beautifully said, John. I would also add we always say that e-cigarettes are unregulated
and that’s entirely true. But if any of the e-cigarette manufacturers chose to, they could
apply to the FDA Center for Drug Evaluation Research as a cessation product and try to
get their products approved for cessation purposes and none of them have done that yet.
From a manufacturer’s standpoint, it’s pretty clear that they’re out to make a buck. They’re
not out to protect public health. So that’s also an important thing to keep in mind. Thank you. So our next question kind of goes
along the line with some of the discussions around online purchases for e-cigarettes and
other associated products. Since there’s man that have no age verification or if it’s just
a check box that says they’re 18 or older and paying by debit card is hard to verify.
So what can be done legally about these online sales in individual states or beyond? I’ll weigh in and anybody else is free to
weigh in as well. At the state and local level, I won’t say there’s no way to do it. It would
certainly be challenging. At the federal level, obviously the ability to regulate interstate
commerce and how products are moved throughout the country and sold over the internet is
much simpler and it’s well within the FDA’s authority to do anything from completely prohibit
the sale of e-cigarettes online or to create an actual age verification system that would
work. The FDA did propose a regulation to require
minimum age of purchase and that would include online sales. So it remains to be seen exactly
how that will be implemented and enforced. Hopefully that would at least get at part
of the problem. The FDA has been very aggressive at their retail enforcement. So hopefully
they would treat internet sales the same way. At the state level, I don�t recall which
state and I want to say California, and if anyone’s from California and I’m wrong, I
apologize. But I think that California had proposed to
address this problem at the state level and to either prohibit or limit internet sales
by the shipment of the product into the states and I don�t recall if they were prohibiting
the product from coming in once it’s been purchased over the internet or if they were
requiring age verification at the point of delivery.
But those would both certainly be options for a state to undertake. How that gets enforced
and implemented is probably going to be challenging and I would assume costly. So it would have
to be a state who is really ambitious and wants to take that on. At the local level,
city or county, that difficulty is multiplied I’m sure by a lack of resources and potentially
a lack of authority. So it’s probably difficult to do at the local level. But it is something
that a state could certainly look into and there are regulatory options at the state
level. Desmond, this is John. Is there any opportunity
or any route that the attorneys general could take to address the online sale within the
context of state enforcement of age of sale restriction? Yeah, that’s a good point as well. I was just
thinking of that after I finished speaking. Yeah, certainly there are on the books in
almost every state some form of a consumer protection law. and if there’s enough evidence
that it’s very easy for youth to purchase e-cigarettes within a state and receive them
without any real age verification, it would be within — most likely in most states it
would be within the attorney general’s authority to enforce laws that are already on the books.
And at the very least, some sort of civil action against whoever is shipping the product
to the state. There could be problems if the product is being shipped from overseas and
I don�t know how many of the websites operate overseas. I’m sure there are some. I know
that most of the product is manufactured overseas and then over the intent I’m not sure.
But that certainly also is an avenue that states could consider. And if it’s a problem
you want to address at the local level, writing a letter to your attorney general and gathering
evidence about the problem would certainly be something you could do at the local level
to put pressure on a state to act. Our next question is around what are some
of the consequences or outcomes of women who are pregnant or breastfeeding or who have
recently delivered while using e-cigarettes. We’ve talked a lot about youth and some adults
and then we talked about mic studies. What are we starting to see or what are some of
the things you’re hearing around pregnant or recently pregnant populations? I’m not aware of any data about e-cigarettes
and pregnancy. I think it’s a good question. But I don�t know that anyone’s actually
done that surveillance and it doesn’t sound like it’d be terribly ethical to study. Thank you. Our next question is a few states
and a city have recently launched media campaigns addressing e-cigarette harm, including vapor
pollutants, poison risks and addiction. In your opinion, what are some of those top priorities
that messaging that states or communities could emphasize in thinking about future campaigns? This is Parker. In Minnesota, we’ve found
it important to keep our messaging focused on youth and the harms of nicotine. We know
that nicotine is harmful for youth and adolescent brain development. And additionally, when
it comes to tobacco prevention, we know which strategies are proven, such as increasing
the price of tobacco as well as restricting indoor use. And our final question, and we’ll certainly
do our best to see if we can answer some of those that have come through that we haven’t
been able to get to, but can anyone comment on e-cigarettes or e-juice on the global market?
I know we’ve been focusing this webinar particularly internally to the United States and its jurisdictions.
But they’re wondering if we’re the only country where usage of e-cigarettes and related products
is up, if that’s anything that you’ve looked at. From our experience in the pediatric and adolescent
area, this is a global problem. The industry has been marketing these heavily in all countries
where tobacco products are already in use. And that’s pretty much a global phenomenon. Thank you. Diana, I’m going to turn it back
to you. Thank you so much, Ellen. We want to take
the opportunity to thank all of you for joining us today. As we mentioned earlier, you will
be immediately directed to an evaluation at the conclusion of today’s webinar. Please
take a few minutes to complete our survey as it really does provide us with useful information
for our future products. ASTHO would like to thank the CDC Office on Smoking and Health
and the Health Resources and Services Administration, Maternal and Child Heath Bureau Office on
Policy and Coordination for cosponsoring this webinar.
We would like to thank NACCHO, AMCHP and the Children’s Safety Resource Network for helping
to plan and promote this webinar. We would also like to thank NCSL for their input on
today’s webinar. Most of all, we would like to thank our speakers, Desmond Jensen from
the Tobacco Control Legal Consortium, Laura Oliven and Parker Smith from the Minnesota
Department of Health and Dr. Klein from the American Academy of Pediatrics.
A recording of today’s webinar will be available on our website within the next few days at
the Web address on your screen now. We hope that you will use this webinar as a resource
and will share the link with others once it is available. If you have any follow-up questions
about today’s webinar, please don’t hesitate to either contact myself, Diana Karczmarczyk
or Ellen Pliska at ASTHO. Thank you and enjoy the rest of your day. Thank you. Ladies and gentlemen, this does
conclude today’s conference call. You may now disconnect your lines. Presenters, please
hold. [End of Audio]