E-Cigarette Risks and Regulations

With more and more consumers affected by vaping-related lung illness -- otherwise known as EVALI -- experts continue to look for risk factors associated with smoking e-cigarettes. While recent studies have pointed to both vitamin E and THC as the primary sources of EVALI, a new study found that the vaping devices themselves could be to blame. 

According to researchers from the University of California at Irvine, the results from the earliest stages of a new study found that the heating source on vaping devices has been linked with an increased risk of lung damage. 

“While further research is needed, these results indicate specific devices and power settings may play a key role in the development of EVALI as much as the additives do,” said researcher Dr. Robert A. Kloner. “The harms associated with e-cigarettes and vaping simply cannot be overstated.” 

Analyzing vaping devices

The researchers didn’t set out to uncover this link between vaping devices’ heating sources and subsequent lung damage; they were initially studying the effect of vaping on consumers’ heart health. However, after the e-cigarette they had been using in their study was discontinued and participants were forced to use a different model, they observed some key differences. 

While the new vaping device was essentially the same as the first one, the heating element was different. The first device used stainless steel as the heating source, and the second device used a nickel-chromium alloy as the heating source. Though that change may not seem like it would make a massive difference, the researchers observed drastic changes to the participants’ health in a short amount of time. 

“Within an hour of beginning an experiment, we observed evidence of severe respiratory distress, including labored breathing, wheezing, and panting,” said researcher Michael Kleinman, PhD. “After analyzing lung tissue from subjects in the study, we found them to be severely compromised and observed other serious changes such as lung lesions, red blood cell congestion, obliteration of alveolar spaces, and pneumonitis in some cases.”  

Despite several studies that have pointed to the additives in e-cigarettes as the primary source of lung damage, the researchers explained that the devices they used contained no nicotine, vitamin E, or THC. The participants had been involved in the study for more than a year when they received the new vaping devices, and none of them had shown any signs of lung illness or similar health concerns up to that point. 

The researchers plan to do more work in this area to better understand how the heating element on vaping devices can be a risk to consumers’ health. However, they hope that consumers take these findings seriously and take steps to prevent severe health concerns. 

“The results were so impactful, we felt it imperative to release the initial findings early so that electronic cigarette users could be cautioned sooner, especially considering e-cigarette users are at an increased risk of COVID-19,” said Dr. Kloner. 

The number of children and teenagers who use e-cigarettes is slightly down this year, but not enough for health officials to stop calling it an “epidemic.” 

The Centers for Disease Control and Prevention (CDC) said in a release that 3.6 million youths have used e-cigarettes this year. That’s down from 5.4 million in 2019. 

"Although the decline in e-cigarette use among our nation's youth is a notable public health achievement, our work is far from over," said CDC director Dr. Robert Redfield. "Youth e-cigarette use remains an epidemic, and [the] CDC is committed to supporting efforts to protect youth from this preventable health risk."

Vaping still common among youth

The CDC, which drew its findings from the National Youth Tobacco Survey, found that 8 in 10 middle and high school students who currently vape said they use flavored e-cigarettes. The use of mint and menthol flavored vaping products was also common among the demographic.

Health officials have been attempting to curb the rise in teen vaping for several years now. Efforts to drive down the rate of vaping among youth have focused on cracking down on sales of flavored products, which have been found to appeal to minors. 

Unfortunately, researchers have found that teenagers who use e-cigarettes may be more likely to continue vaping. 

“While many children try e-cigarettes, not all become regular users,” said researcher Adam Leventhal, who worked on a 2019 study out of the University of Southern California “Teens who use e-cigarettes may be more inclined to continue vaping rather than just temporarily experiment with e-cigs.” 

“The longer and more frequently you vape, the more you’re exposing yourself to toxins in e-cigarette aerosol and put yourself at risk of nicotine addiction,” Leventhal said. 

Working to drive down the numbers

In the latest analysis of data, the CDC found that 19.6 percent of high school students and 4.7 percent of middle school students used e-cigarettes in 2020 -- down from about 27 percent and 10 percent, respectively, in 2019.

"These findings reinforce the importance of continuing to focus on the strategies that work to reduce youth tobacco product use while keeping pace with emerging trends in tobacco products," said Dr. Karen Hacker, director of CDC's National Center for Chronic Disease Prevention and Health Promotion. "Implementing these strategies at the national, state and local levels is integral to preventing and reducing youth tobacco product use, including e-cigarettes.”

In a statement, FDA Commissioner Dr. Stephen Hahn said the agency “remains very concerned about the 3.6 million U.S. youth who currently use e-cigarettes” and that it “will do everything possible” to stop the health crisis. 

"The findings come as we mark today's premarket review submission deadline, a milestone for ensuring new tobacco products, including many already on the market, undergo a robust scientific evaluation by the FDA,” Hahn said. “Scientific review of new products is a critical part of how we carry out our mission to protect the public -- especially kids -- from the harms associated with tobacco use.”

On Monday, a flavored tobacco product ban (SB 793) was unanimously approved by the California Assembly. 

SB 793 will prohibit the retail sale of flavored tobacco products, flavored e-cigarettes, and flavored vaping products in the state. The legislation is part of a larger effort to curb rates of flavored tobacco use among children, to whom the products tend to appeal.

Supporters of the legislation said it would help reduce rates of smoking and vaping among children and teenagers who use them specifically because they come in flavors like menthol, cotton candy, and gummy bears. 

Health experts have raised concerns that the high rate of flavored tobacco use among minors threatens to derail progress in curbing overall smoking rates. 

“These flavors are marketed to kids and people of color to ensure tobacco companies have a clientele on the hook for life,” said Assembly Speaker Anthony Rendon (D-Lakewood).

Exemption for some products 

During the legislative process, the bill was modified to include an exemption for some premium cigars. The bill defines “premium” as “any cigar that is handmade, is not mass produced by use of mechanization, has a wrapper that is made entirely from whole tobacco leaf, and has a wholesale price of no less than twelve dollars ($12). A premium cigar does not have a filter, tip, or non-tobacco mouthpiece and is capped by hand.”

“It’s the most deadly consumer product ever created,” Assemblyman Jim Wood (D-Healdsburg) said during Monday’s floor debate. “In a perfect world, there would be no exemptions to this bill, but we all know we don’t live in a perfect world.”

Assemblyman Heath Flora (R-Ripon) said exempting cigars, hookah products, and cannabis threatens to leave open a loophole that could put kids at risk. 

“If we actually cared about the kids, we would deal with some of the other industries as well,” he said.

The measure -- which is supported by the American Lung Association in California, American Heart Association, and American Cancer Society -- now faces one more vote in the Senate before heading to Gov. Gavin Newsom’s desk. 

Earlier this year, U.S. lawmakers crafted and passed a new policy that banned certain e-cigarette products that were popular with America’s youth. Now, regulators are asking for more e-cigarette products to be taken off the market -- but for a very different reason. 

Rep. Raja Krishnamoorthi (D-IL) sent a letter to FDA Commissioner Dr. Stephen M. Hahn this week to request that e-cigarette products be pulled from circulation due to additional risks they create in connection with the coronavirus. In the letter, Krishnamoorthi cites studies that suggest COVID-19 is even more dangerous for e-cigarette smokers.

“Today, we have the evidence that the FDA was waiting for, and it can no longer deny the danger e-cigarettes pose during the coronavirus crisis. The science is now in: e-cigarette users are much likelier to be diagnosed with COVID-19 and to experience symptoms,” Krishnamoorthi stated. 

Increased risk of infection

The evidence that the letter refers to is from a study conducted at Stanford University that gauged the risk of contracting COVID-19 in young e-cigarette smokers aged 13 to 24. The results suggest that this demographic is up to five times more likely to contract COVID-19 than those who don’t vape e-cigarette products. 

The statistics are even worse for those who vape e-cigarettes and smoke traditional cigarettes. These dual users were almost seven times more likely to be diagnosed with COVID-19 and nearly five times more likely to experience symptoms of the virus. Krishnamoorthi says that these numbers are putting a considerable burden on the nation’s COVID-19 testing system and leading to increased waiting times for results. 

“If we reduce the number of vapers in America, we will reduce the unnecessary stress we are putting on our testing system. People should not have to wait weeks for COVID-19 test results -- removing the risk posed by vaping will help,” he said.

The letter asks the FDA to confirm in writing within the next week whether or not will take e-cigarettes off the market. If the agency chooses to do so, it is also tasked with providing a description of its action plan. 

Several recent studies have highlighted the serious health risks associated with vaping. Because of how many young people have taken up the habit, lawmakers have worked to make it harder for minors to purchase e-cigarettes. 

Now, researchers from the European Society of Cardiology are focusing on how consumers’ heart health can be at risk due to vaping. The researchers are still citing large numbers of young people using e-cigarettes, and the habit has been linked with an increased risk of blood clots, high blood pressure, and heart attacks, among other risks. 

“Vaping is marketed towards teenagers and the tobacco industry uses celebrities to promote it as being healthier than smoking,” said researcher Maja-Lisa Løchen. “Action is urgently needed to halt the growing use in young people. The World Health Organization (WHO) states that e-cigarettes are harmful to health.” 

Risks to heart health

Though the risks associated with vaping continue to be documented by experts, the researchers focused specifically on cardiovascular health for this report. Because so many young people are using e-cigarettes, the long-term effects of vaping are cause for concern. The researchers analyzed several recent studies to explore how vaping is negatively affecting consumers’ heart health. 

While many were under the impression that vaping was healthier than traditional cigarettes, the researchers want to emphasize that this is not the case. Vaping can complicate heart health in countless ways. Ultimately, the consistent use of e-cigarettes can increase the risk of heart attack because vaping can lead to permanent damage to consumers’ blood vessels and arteries. The researchers say the habit can also increase the risk for blood clots. 

However, the risks don’t always start out so drastic. Oftentimes, consumers first experience changes to heart rate or blood pressure, which can lead to other, more serious, complications over time. Recent studies have also highlighted the stress vaping can put on the lungs and the harm caused by the chemicals used in e-cigarettes. 

Protecting consumers’ health

Moving forward, the researchers hope that future messaging about vaping is clear and that lawmakers do their part to enact measures that make it more difficult for young people to have access to e-cigarettes. 

“E-cigarettes are a relatively new product and the long-term health effects are unknown,” said Løchen. “Now is the time for politicians and regulators to act -- with public health campaigns to increase awareness and legislation to halt uptake in young people.” 

The U.S. Food and Drug Administration (FDA) is clamping down on a company selling a kind of fruity disposable e-cigarette product called Puff Bar e-cigarettes, which are popular among teenagers.

In warning letters to the manufacturer of Puff Bar vapes and nine other companies, the FDA said Puff Bar e-cigarettes -- which come in “youth-appealing” flavors like mango, pink lemonade, and strawberry -- must be pulled from the market within 15 business days. 

The FDA said the companies never received permission to sell the products in the United States. 

"We are concerned about the popularity of these products among youth and want to make clear to all tobacco product manufacturers and retailers that, even during the ongoing pandemic, the FDA is keeping a close watch on the marketplace and will hold companies accountable," FDA Commissioner Stephen Hahn said in a statement. 

Similar to Juul products

The agency added that it’s continuing to take action against companies selling unauthorized e-cigarette products, even in the midst of the pandemic. 

“These warning letters are the result of ongoing internet monitoring for violations of tobacco laws and regulations,” said Mitch Zeller, J.D., director of the FDA’s Center for Tobacco Products. 

The FDA’s action closes a loophole it left earlier this year when it cracked down on flavored e-cigarettes. Disposable vaping products like Puff Bar are similar to Juul products, but Puff Bar vaping products somehow evaded the FDA’s ban. 

The agency warned the companies that received letters that failure to correct violations could result in further action, such as civil money penalties, seizure, or injunction.

Juul, the maker of a popular e-cigarette product, has reportedly told federal regulators that it is willing to redesign its vaporizer so that it unlocks only for people 21 years of age or older.

The Wall Street Journal quotes people “familiar with the matter” as saying that the company is willing to make this accommodation in order to keep its products legal in the United States.

The Food and Drug Administration (FDA) has the authority to regulate e-cigarette products, as well as all tobacco products. For manufacturers of e-cigarettes, the companies must demonstrate that their products present a “net benefit to public health.” 

That’s widely interpreted as meaning the products help adult smokers kick their cigarette habit by switching to e-cigarettes, which deliver nicotine in vapor form. While that’s a noble objective, public health officials have sounded the alarm over a huge increase in young people getting hooked on nicotine through “vaping.”

Former Food and Drug Administration (FDA) Commissioner Dr, Scott Gottlieb has accused Juul, in particular, of luring young people into the nicotine habit through vaping.

Juul proclaims its innocence 

Juul, in which tobacco company Altria is a stakeholder, has professed its innocence. It says it intends to provide the FDA with more than 250,000 pages of scientific research and marketing materials, as well as an update on its efforts to curb illegal sales to minors, to prove that it has not been marketing to young people. 

Juul also says it plans to submit additional paperwork over the next three to five years, including an application to market its products as less harmful than cigarettes, to show that its mission has been to help smokers kick their smoking habit.

The company has reportedly submitted an application to the FDA that says its product can combat underage use of e-cigarettes by locking the cartridge where the vaping liquid is stored. That would prevent a user from replacing the liquid with one that is more desirable.

Juul has been working on this solution for some time. It has introduced products in the U.K. and Canada that allow the cartridge to be locked or unlocked using a Bluetooth connection to a mobile app. 

Users must submit a photo of themselves and government identification. The app also allows users to monitor their nicotine consumption.

The change addresses a new U.S. law that bans sweet and fruity e-cigarette cartridges because underage users tend to favor these flavors rather than the tobacco flavored liquids that are used to wean smokers away from cigarettes.

There has been no shortage of e-cigarette news as of late. Many experts say that the popular devices could be just as detrimental to consumers’ health as traditional cigarettes. 

While e-cigarettes contain a number of harmful chemicals, researchers from the University of California Riverside have now found that they also have harmful levels of metals. The researchers are most concerned about the levels of zinc, as exposure to the metal in these quantities can lead to several health concerns, including damage to consumers’ DNA. 

“Our study found that e-cigarette users are exposed to increased concentrations of potentially harmful levels of metals -- especially zinc -- that are correlated to oxidative DNA damage,” said researcher Prue Talbot. 

Harm to the body

To understand what effect these high levels of zinc can have on the body, the researchers analyzed how e-cigarettes affected 50 participants. The group was made up of cigarette smokers, e-cigarette smokers, and non-smokers so the researchers could best assess how e-cigarettes affect consumers with different smoking habits. 

The researchers tested the participants for certain biomarkers that are genetic indicators of disease or environmental exposures. They collected urine samples from all of the participants and evaluated their DNA responses. 

E-cigarette smokers were more likely than participants from the other two groups to present with genetic concerns related to metal exposure. The researchers found that e-cigarette smokers had higher levels of three biomarkers due to unsafe exposure to metals; each biomarker was related to oxidative damage to DNA. 

This is cause for concern, as damage to DNA can worsen if consumers use e-cigarettes over longer periods of time. This can increase their risk for any number of serious health conditions. According to researcher Shane Sakamaki-Ching, “prolonged use [of e-cigarettes] may lead to disease progression.” 

The researchers hope that consumers are mindful of these findings and that they understand the risks related to using e-cigarettes. 

“Given the recent deaths and pulmonary illnesses related to e-cigarette usage, everyone should be made aware of the potential health risks linked to e-cigarette usage,” said Talbot. 

Massachusetts’ Attorney General (AG) Maura Healey has filed a lawsuit against the e-cigarette company JUUL for its role in creating what she calls a “youth vaping epidemic,” and for its marketing ploys intended to lure youth to e-smoking.

The lawsuit demands that JUUL pay for all costs associated with Massachusetts's efforts in  countering the “public health crisis” that’s touched more than half of the state’s adolescents.

“JUUL, more than any other company, bears responsibility for the fact that millions of young people nationwide are now addicted to e-cigarettes, reversing decades of progress in combating underage tobacco and nicotine use and addiction,” Healey wrote in the complaint.

Going for the “cool crowd”

The new lawsuit is an interesting window into JUUL’s marketing plan. The strategy appears to be built around building awareness by targeting the “cool crowd” -- young people who are considered “fashionable, urban with a vibrant life,” and “enjoy[ed] going out to shows and events.” That includes a crowd, the AG points out, that’s not even of legal age to buy e-cigarettes. 

The complaint goes on to point out that JUUL paid little or no attention to how old the people it was marketing to actually were. Specifically, JUUL...

• Sold the under-18 market its product “even when (the youth) supplied dates of birth to JUUL that established they were younger than the local minimum legal sales age.” 

• Ignored the age verification tools it put in place when distributing marketing materials, according to the attorney general’s allegations. 

“Approximately 40,000 email addresses on JUUL’s email marketing list were associated with records of individuals who had ‘failed’ JUUL’s own age verification process,” read the complaint. On top of that, 83 percent of the estimated 420,000 email addresses on JUUL’s marketing list weren’t able to be matched with the record of someone at least 18 years old.

Advertising on youth networks

The lawsuit brings to light an onslaught of JUUL marketing on websites and TV networks that are “highly attractive to children, adolescents in middle school and high school, and underage college students.”

JUUL was found to have advertised on child favorites, such as Nickelodeon's Nick.com and NickJr.com. But the company didn’t stop there; it also bought ads on the Cartoon Network’s website and other websites generally designed for children such as allfreekidscrafts.com, hellokids.com, and kidsgameheroes.com. 

JUUL also reportedly purchased advertising on sites that younger girls favor such as dailydressupgames.com, didigames.com, forhergames.com, games2girls.com, girlgames.com, and girlsgogames.com. 

While most of what happens in Washington, D.C. happens at a snail’s pace, it was only a matter of months after the Trump administration called for a ban on e-cigarettes that it was put to work. Effective Thursday, that plan went into effect.

The ABC’s of the policy

The essential things consumers need to know about the policy are pretty straightforward:

• While it’s called a “ban,” it’s not a law and it’s not binding -- at least not at the moment.

• What’s covered is the manufacturing, distribution, and sale of flavored (e.g. fruit and mint) vaping cartridges or pods. An example of those would be what Juul was offering prior to the ban.

• Disposable vapes that use an open-tank system, and their respective flavored e-liquids, are not banned.

• Flavored “e-liquid” that’s not packaged in a cartridge is not banned, either.

If you happen to see an e-cigarette on the market, it’s there illegally. The Food and Drug Administration (FDA) has not given any e-cigarette manufacturer “premarket authorization” and it continues to put violators in its crosshairs. 

“Our review of premarket product applications will help evaluate the public health benefits and harms of a tobacco product to ensure that those authorized for marketing are appropriate for the protection of public health,” said Acting FDA Commissioner Ned Sharpless, M.D. 

“This will include understanding the likelihood that those who do not use tobacco products – such as kids – will start using them, as well as the likelihood that tobacco users will stop.” The FDA’s intention is to prioritize the shutdown of flavor cartridge-based vaping products. Menthol and tobacco flavors are not included in the policy.

Teens continue to be the focus

The number one goal of both the FDA and the U.S. Department of Health and Human Services (HHS) is keeping teens from falling into the e-cig trap. 

“The United States has never seen an epidemic of substance use arise as quickly as our current epidemic of youth use of e-cigarettes,” said HHS Secretary Alex Azar. “HHS is taking a comprehensive, aggressive approach to enforcing the law passed by Congress, under which no e-cigarettes are currently on the market legally.”

To that end, the FDA just rolled out “The Real Cost,” a video campaign featuring teenagers sharing cautionary tales about their e-cigarette addiction. In one of the series, called “My Vaping Mistake,” teenagers get personal about the physical and emotional effects vaping addiction had on their lives. 

“We will not stand idly by as this crisis among America’s youth grows and evolves, and we will continue monitoring the situation and take further actions as necessary,” Azar said.

Getting around the ban

Agencies behind the ban have their work cut out for them. The New York Times reported just last week that teens have already found a loophole in the ban and are working it to their advantage.

The wrinkle in the ban? Disposable vapes.

“Students were telling me that everybody had gone to Puff Bars, which are disposable,” Lauren W. Williams, a teacher at McCracken County High School in Kentucky told the Times. “The one we confiscated here this week is Banana Ice. Students are not using Juuls anymore because no one wants menthol or tobacco.”

Possible exceptions

It’s important to note that individual states may have their own vaping bans. Two examples are North Carolina and Missouri. According to Bloomberg Government, law-enforcement agencies in two states have told stores that sell cigarettes that state enforcement of tobacco rules isn’t changing yet, even though federal law prohibits the sale of e-cigarettes and vaping devices to minors. 

The reason isn’t a lack of desire. It has more to do with the layers and layers of getting statewide regulations into play. 

“You can’t just turn a battleship around on a dime,” Mike O’Connell, communications director for the Missouri Department of Public Safety, told Bloomberg.

The Centers for Disease Control and Prevention (CDC) is continuing to update consumers on the number of lung illness (EVALI) cases that are connected to vaping. In its latest advisory, the agency points to new evidence that devices containing THC are part of the problem. 

THC, or tetrahydrocannabinol, is the chemical in marijuana that produces a psychological “high.” The agency says that e-cigarette devices that contain THC were linked to 82 percent of EVALI cases as of January 14. Overall, 33 percent of consumers who developed EVALI reported that they only used a THC-containing device before becoming ill. 

With those numbers in mind, the CDC has adjusted its advisory to focus more on warning consumers to avoid THC-containing e-cigarettes.

“The EVALI outbreak primarily affects young adults, is driven by use of THC-containing products from informal sources and is strongly linked to vitamin E acetate,” the agency stated. “CDC and FDA recommend that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, or family, or in-person or online dealers.”

“THC use has been associated with a wide range of health effects, particularly with prolonged frequent use. The best way to avoid potentially harmful effects is to not use THC-containing e-cigarette, or vaping, products.”

Cases continue to decline

While the CDC continues to narrow down the factors related to these lung illnesses, the number of EVALI cases continues to decline. 

As of January 14, 2,668 consumers had been hospitalized nationwide due to lung illnesses linked to e-cigarette use. There have also been 60 reported deaths from 27 states and the District of Columbia, and officials say these cases are still under investigation. 

Consumers in Illinois and Texas have been hit hardest by this outbreak of illnesses, with each state experiencing between 200-249 hospitalizations. Cases of EVALI peaked last September but have slowed to a trickle in 2020. 

For more information, consumers can visit the CDC’s website here.

As e-cigarette-related deaths and illnesses affected dozens of consumers at the end of 2019, lawmakers tried doing their part to ensure that young people couldn’t continue the life-threatening habit. 

However, a new study conducted by researchers from the University of California at San Francisco found that products made by Juul have more nicotine than any other e-cigarette brand or even traditional cigarettes. 

“The comparison of cardiovascular health effects of Juul use with those of previous generation e-cigs and combusted cigarettes is an important issue for policymakers, including the FDA and comparable bodies outside the United States,” said researcher Matthew Springer, PhD. “Our findings show that the adverse effects of cigarettes on vascular endothelial function, which has been a known consequence of cigarette smoking since the 1990s, is not prevented using Juul.” 

Evaluating health effects

To see how Juul stacks up against other e-cigarette and regular cigarette brands, the researchers tested the vitals of rats after exposure to various kinds of nicotine. 

The researchers divided the rats into four testing groups and exposed them to vapor from e-cigarettes produced by Juul, traditional cigarette smoke, vapor from an e-cigarette with freebase nicotine, or clean air. The rats inhaled their substance 10 times over the course of five minutes, with each inhalation lasting two seconds. 

Following the trials, the researchers tested the rats’ blood vessel function and also collected blood samples to determine how their health was compromised, if at all, by their chosen supplement. 

The study revealed that inhaling Juul vapor was the most dangerous for the rats, as they were exposed to far more nicotine in that brand than in either the traditional cigarette or the other e-cigarette brand that was tested. 

Juul had five times more nicotine than a traditional cigarette and eight times as much nicotine as the other e-cigarette that was tested. 

The researchers explained that because of the varying nicotine levels in cigarettes and e-cigs, smokers who are new to e-cigarettes could try to keep their nicotine consumption the same on the device. However, this could become problematic for younger smokers who are new to the habit. The researchers urge consumers to understand how this could be detrimental to young people’s health. 

“...Adolescent non-smokers who are not familiar with the effects of nicotine may be more likely to chase higher levels of the drug’s effects,” said Dr. Springer. “The ease of over-consuming nicotine with Juul makes this likely, especially in light of reports of teenagers binging on Juul to the point of rapid addiction and behavioral consequences.” 

Reports in recent weeks have suggested that the Food and Drug Administration (FDA) was getting ready to ban a litany of flavored cartridge-based e-cigarettes. On Thursday, those speculations became reality as the agency finalized its enforcement policy on the issue.

In a press release, the agency said its decision is motivated by the desire to stem the tide of youth vaping in the U.S., which has been called an “epidemic” by officials.

“The United States has never seen an epidemic of substance use arise as quickly as our current epidemic of youth use of e-cigarettes,” said Health and Human Services (HHS) Secretary Alex Azar. 

“By prioritizing enforcement against the products that are most widely used by children, our action today seeks to strike the right public health balance by maintaining e-cigarettes as a potential off-ramp for adults using combustible tobacco while ensuring these products don’t provide an on-ramp to nicotine addiction for our youth.”

Policy takes place within 30 days

The FDA says that the new policy will be enforced within 30 days after it has been submitted to the Federal Register for publication. After that time, the agency says that it will begin enforcement actions against illegal electronic nicotine delivery systems (ENDS) that fit the following description:

• Any flavored, cartridge-based ENDS product (other than tobacco- or menthol-flavored ENDS product);

• All other ENDS products for which the manufacturer has failed to take (or is failing to take) adequate measures to prevent minors’ access; and 

• Any ENDS product that is targeted to minors or likely to promote use of ENDS to minors.

In other words, the agency will aggressively pursue legal action against companies who sell e-cigarettes or e-liquids that have flavors other than tobacco and menthol, and it will be paying special attention to how products are marketed to young people.

“Coupled with the recently signed legislation increasing the minimum age of sale of tobacco to 21, we believe this policy balances the urgency with which we must address the public health threat of youth use of e-cigarette products with the potential role that e-cigarettes may play in helping adult smokers transition completely away from combustible tobacco to a potentially less risky form of nicotine delivery,” said FDA Commissioner Dr. Stephen M. Hahn.

The Food and Drug Administration (FDA) spent the better part of 2019 stepping up the pressure on e-cigarettes. This year, the FDA may move from pressure to outright bans of certain types of “vaping” devices.

The Wall Street Journal cites “people familiar with the matter” as saying the agency will move within days to ban fruit-flavored cartridge e-cigarettes because they are believed to be most appealing to children and young adults. The move would allow the continued sale of tobacco and menthol-flavored tank system devices.

According to the Journal report, the FDA, which has expressed increasing concern about teen use of vaping devices, had to compromise with other elements of the Trump administration because of political concerns.

Political non-starter

An outright ban on e-cigarettes that some favored was seen as a political non-starter because it would cause too much discontent during an election year. An outright ban was also seen as a potential economic blow to small businesses.

Since the objective is to discourage teen vaping, the compromise was viewed as workable because teens prefer the flavored cartridge systems like Juu. Open tank devices are typically favored by older adults who are using e-cigarettes in an attempt to quit smoking.

The report says the FDA could announce the ban within days. It would follow a move by Congress two weeks ago to raise the legal age for purchasing both tobacco and e-cigarettes from 18 to 21.

Former commissioner began the campaign

The FDA’s campaign against e-cigarettes began under former FDA Commissioner Scott Gottlieb, who resigned in early March. At the beginning of last year, Gottlieb called the growing teen use of e-cigarettes “an epidemic” and first raised the possibility of an outright ban if surging teen use continued.

“I still believe e-cigs offer an opportunity for currently addicted adult smokers to transition off cigarettes and onto products that may not have the same level of risks,” Gottlieb wrote in a tweet last January. “But if youth use continues to rise, the entire category faces an existential threat.”

Gottlieb singled out Juul for special criticism as he left office in April, saying there is no question the company bears some responsibility for the surging levels of teen vaping. 

Gottlieb cited research showing that an estimated 37 percent of high school seniors have tried e-cigarettes. A quarter of youth users told researchers they didn’t realize the products contain nicotine.

In November, Juul voluntarily stopped selling mint-flavored products. Previously, it halted sales of its mango, creme, and cucumber flavors. With mint dropped from its offerings, Juul now only offers tobacco and menthol flavors. 

In the last few months of 2019, record numbers of vaping-related illnesses and deaths were plaguing consumers, and researchers ultimately made a connection between these incidents and the chemical vitamin E acetate. 

Now, researchers from Ohio State University Wexner Medical Center found that the connection between vitamin E acetate and vaping-related deaths could be stronger than initially anticipated. 

The role that vitamin E acetate plays

Experts have dubbed vaping-related illnesses EVALI. To better understand how vitamin E acetate contributes to the condition, the researchers tested lung fluid in participants. Having fluid in the lungs is typically associated with lung disease, so this process would give the researchers a clear picture of how consumers are affected by vaping and vitamin E acetate. 

The researchers worked hand-in-hand with the Centers for Disease Control and Prevention (CDC) to get these fluid samples from public health facilities, comparing nearly 100 patients with no history of EVALI with 51 patients who had been diagnosed with the condition. 

Based on the test results, the researchers discovered that all but three of the EVALI patients tested positive for fluid in their lungs, whereas those who didn’t vape and had no connection to EVALI were free of any lung fluid. 

Making change

As the vaping death toll continued to rise at the end of 2019, policymakers began getting involved in an effort to regulate the vaping industry. Moving forward, the researchers hope that these findings can help propel that momentum even further and ensure that the source of such health concerns can be targeted appropriately. 

“These findings support the conclusion that vitamin E acetate is a potential causative agent of EVALI, and that it is an important discovery as decisions are made about how to best regulate the rapidly evolving e-cig industry,” said researcher Dr. Peter Shields. 

The Centers for Disease Control and Prevention (CDC) released an update today on the number of hospitalizations and deaths associated with EVALI.

EVALI -- or “E-cigarettes or Vaping product use Associated Lung Injury” -- was a condition coined by the agency earlier this year after a rash of mysterious hospitalizations and deaths that were linked to vaping. After extensive investigations into the issue, the CDC connected these illnesses with the presence of Vitamin E acetate in certain e-cigarette products.

As of December 17, the agency says that there have been 2,506 hospitalizations in all 50 states and the District of Columbia that are linked to EVALI. The agency has also confirmed 54 deaths to these illnesses in 27 states and the District of Columbia.

“Adults who continue to use e-cigarette, or vaping, products, should carefully monitor themselves for symptoms and see a healthcare provider immediately if they develop symptoms like those reported in this outbreak,” the CDC stated.

Increasing legal age to buy

The number of deaths and illnesses brought on by EVALI may have been a huge part of the decision by lawmakers this week to increase the minimum age for buying tobacco and e-cigarette products to 21. 

The move was broadly supported by both Republicans and Democrats in the Senate and House of Representatives, and it is expected to be passed into law by the President’s signature in the near future. Lawmakers say passage of the bill will have important health implications for consumers of all ages in the U.S.

“By raising the age to buy tobacco products nationwide, we can save 223,000 lives and reduce youth tobacco use,” said Senator Tim Kaine (D-Va.), who was one of the bill’s co-sponsors.

Juul, the grand potentate of e-cigarettes, has taken another punch in the gut. 

In a study just released by Portland State University (Oregon), researchers found that the formula Juul uses for its e-cigarettes is almost a dead-ringer for both the addictive composition and the flavor of Marlboro cigarettes. Or, in their own words, Juul is nothing more than an “analog” version of Marlboro.

Déjà vu?

Previous research showed that the nicotine levels in tobacco-based cigarette smoke is “much higher than those in early e-liquids.”If this sounds familiar to the nicotine controversy of the ‘90s, there are some similarities. 

“The distribution of nicotine ... has been manipulated in tobacco smoke and now in electronic cigarettes by the use of acids to de-freebase nicotine and form ‘nicotine salts’” wrote the researchers. “The design evolution for e-cigarettes has made them more effective as substitutes to get smokers off combustibles. However, this evolution has likely made e-cigarette products vastly more addictive for never-smokers.”

“It becomes obvious why novice users, people who’ve never smoked before, find it easy to try Juul,” researcher David Peyton told Reuters. “And once you try it, you’re getting dosed with a high concentration of nicotine.”

The Goldilocks Principle

Maybe Marlboro didn’t want to see its $12.8 billion investment in Juul go up in smoke, but it had to know that this vaping thing could turn out bad for everyone involved.

“For Marlboro, by using additives and/or blend manipulation … [it accomplished] a Goldilocks principle solution (ie, not too harsh, not too mild),” the researchers wrote, further noting the “human affinity for the sensory bite” similar to carbonated beverages.

One of the key reasons why teens and young adults are drawn to e-cigarettes like Juul is the flavor. In a parallel study that was just released, researchers found that the “smoothness” of e-cigarettes is a “cross-cutting mediator” when compared to the bitter taste of tobacco. 

“Sweetness may also mediate appeal-enhancing effects of fruit and appeal-reducing effects of nicotine. Non-tobacco flavours may suppress appeal-reducing effects of nicotine in e-cigarettes through attenuation of nicotine’s aversive taste attributes,” the researchers concluded.

Where does Juul go from here?

Maybe it’s time for Juul to cut bait and go home. It was recenlty forced to give up its popular mint-flavored pods, and the FDA has repeatedly called the company out for playing a large role in the teen vaping crisis. Its CEO even apologized to the parents of teens hooked on its product.

Where the company is going is anyone’s guess, but it’s possible Juul can find a way out of the woods of woe it keeps walking into, primarily the one where all its teen consumers are.

“Youth use of vapor products is detrimental to our mission, and to our business,” the company recently wrote on its website. “Our target market is the one billion adult smokers globally, more than 70 percent of whom want to quit using combustible cigarettes (per CDC). Offering these adult smokers a real alternative to cigarettes is a public health and commercial opportunity of historic proportions, with over 7 million preventable deaths per year caused by cigarettes. Youth use puts this all at risk.”

“Through shared effort, we can significantly reduce youth access to, and usage of, all vapor products, including JUUL, while at the same time ensuring that adult smokers can access a product that is helping millions of them switch from combustible cigarettes – a goal we all share.”

Consumers who use e-cigarettes in hopes of quitting smoking may not be helping their cause. In fact, a recent study suggests that it could be raising their risk for respiratory disease.

While the products were originally created and marketed as an alternative to traditional cigarettes, study findings show that many consumers are using them in addition to traditional cigarettes. That, the research team says, demonstrates that the products should not be used as a stop-gap for consumers looking to quit smoking completely.

“Although switching from combustible tobacco, including cigarettes, to e-cigarettes theoretically could reduce the risk of developing respiratory disease, current evidence indicates high prevalence of dual use, which is associated with increased risk beyond combustible tobacco use,” the researchers concluded. 

“For most smokers, using an e-cigarette is associated with lower odds of successfully quitting smoking. E-cigarettes should not be recommended.”

Dangerous dual use

To come to their conclusions, researchers from the Center for Tobacco Control Research and Education collected data on e-cigarette use over a three-year period from consumers who used the devices. Participants, ranging in age from 18 to 74, answered questions about their e-cigarette use and health.

While the findings showed that participants who switched from using traditional cigarettes to exclusively using e-cigarettes could lower their risk for respiratory disease, the researchers say that less than one percent of participants at two checkpoints in the study were able to completely make that switch. Instead, they said the vast majority continued to use both traditional cigarettes and e-cigarettes after beginning to use the latter. 

To make matters worse, findings showed that consumers who used both e-cigarettes and traditional cigarettes were 3.3 times more likely to develop respiratory disease when compared to participants who had never used either product.

“Dual use of e-cigarettes and combustible tobacco (including cigarettes) is more dangerous than using either product alone,” the team concluded. 

Deaths and hospitalizations continue to rise

The findings come in the wake of a stark update from the Centers for Disease Control and Prevention (CDC). As of December 10, the agency estimates that over 2,400 hospitalizations linked to vaping and e-cigarette use had occurred in the U.S. Fifty-two deaths in 26 states have also been tied to the devices.

Unfortunately, the number of deaths and injuries have not stopped young people from using the devices. A report published earlier this month showed that over 6.2 million middle and high school students used tobacco within the previous 30 days, with much of that number being attributed to e-cigarette use. 

“Youth use of any tobacco product, including e-cigarettes, is unsafe. It is incumbent upon public health and healthcare professionals to educate Americans about the risks resulting from this epidemic among our youth,” said CDC Director Robert R. Redfield.

Around 6.2 million middle and high school students used tobacco in the past 30 days, according to data released Thursday in the 2019 National Youth Tobacco Survey from the CDC. The latest figures are up 3.6 million from last year and represent the highest level since 2000. 

CDC officials attributed the spike in tobacco use among teenagers to e-cigarettes. For the sixth consecutive year, e-cigarettes were the most commonly used tobacco product among teenagers, the survey found. 

More than half of students (55 percent) who took the survey reported using e-cigarettes only. Other tobacco products used by adolescents included cigars, cigarettes, smokeless tobacco, hookahs, and pipe tobacco. Around 31 percent of high schoolers and 12 percent of middle school students said they had used some type of tobacco product within the past 30 days. 

“Given the evolving variety and availability of tobacco products, surveillance for all forms of youth tobacco product use and associated factors is important to inform action at the national, state, and community levels,” the CDC said in a statement.

Increases in youth tobacco use

The CDC said curiosity and misperceptions of health risks have played a role in the growing popularity of e-cigarettes among adolescents. To counter their rise in use among teens, CDC Director Robert R. Redfield said it’s “incumbent” to increase education surrounding the health risks of the products.  

“Our Nation’s youth are becoming increasingly exposed to nicotine, a drug that is highly addictive and can harm brain development,” he said in a statement. “Youth use of any tobacco product, including e-cigarettes, is unsafe. It is incumbent upon public health and healthcare professionals to educate Americans about the risks resulting from this epidemic among our youth.”

E-cigarettes come in flavors that have been found to appeal to youth users. Nearly a quarter (22 percent) of middle and high school students who participated in the 2019 poll said they used e-cigarettes because “they are available in flavors, such as mint, candy, fruit, or chocolate.” 

The products have also been marketed in a way that health officials have deemed problematic, as it appeared to speak directly to youth users. Nearly 9 in 10 students reported having been exposed to tobacco product advertisements from at least one source.

Juul recently agreed to stop marketing its products altogether in an effort to minimize its appeal to teen users. Lawmakers are also considering banning flavored products and raising the minimum age to buy the products.  

In September, President Trump said the FDA would soon release some "very strong recommendations" regarding the sale of flavored e-cigarettes. An official policy has yet to be announced. 

The New York City Council has voted 42-2 to ban all non-tobacco flavored e-cigarettes. Mayor Bill de Blasio is set to sign the bill or allow its passage into law, according to his deputy press secretary. 

The bill was introduced in an effort to combat a surge in teen vaping. Federal health officials and regulators have expressed concern about the rise in teen vaping and have attributed it to the growing popularity of these products and the availability of fruity and minty flavors. 

“This bill would ban the sale of flavored electronic cigarettes and flavored e-liquids in New York City, including mint, menthol and wintergreen electronic cigarettes and e-liquids,” the ordinance states. 

Flavored products popular among teens

Studies have found that teenagers tend to prefer fruit, mint, and candy-flavored e-cigarette products. A National Institutes of Health-funded study published earlier this month found that less than two percent of teenagers who vape said their favorite flavor was tobacco. 

"New York City is finally addressing a public health crisis which has been mounting for years while state and local governments across the nation did next to nothing. We are finally taking action to address the resurgence of youth nicotine addiction caused by e-cigarette usage," Mark Levine, who introduced the legislation and is chair of the council's health committee, said in a statement to CNBC. 

"With this vote, the City Council is moving to ban the fruity, minty, candy-like flavors of e-cigarettes which were clearly designed to appeal to young people in the first place.”

Health concerns

The move to combat the rise in teen vaping comes amid growing concern about the health effects of the products. In recent months, a lung illness associated with vaping claimed 42 lives and sickened at least 2,100 people. 

The Trump administration is currently mulling whether or not to ban flavored vape pods or raise the minimum e-cigarette age to “21 or so” to reduce teen vaping numbers.

Attorneys general in New York, California, and Washington, D.C. have filed lawsuits claiming e-cigarette maker Juul used deceptive and illegal marketing practices to target young users. 

Juul has maintained that it’s committed to minimizing its appeal to youth users and “earning the trust of society by working cooperatively with attorneys general, regulators, public health officials, and other stakeholders to combat underage use and convert adult smokers from combustible cigarettes.” 

The company recently stopped sales of fruit and mint-flavored vape products and suspended all broadcast, print, and digital product advertising in the U.S.

New York is following the lead of other states, counties, and school districts in suing Juul for allegedly marketing to teenagers through the use of a “deceptive and illegal” campaign. 

The state’s Attorney General, Letitia James, announced the lawsuit on Tuesday and said she has no doubt that the company’s actions caused minors to become addicted to its products. In the complaint, James accuses Juul of marketing directly to teens by advertising its fruit flavored products on social media and downplaying the fact that the products contain nicotine. 

"Juul is putting countless New Yorkers at risk and compromising the health of millions of young people," James said at a press conference. "There is no doubt that Juul ... has caused this addiction."

Rise in teen vaping

Lawmakers have previously said they believe e-cigarette manufacturers like Juul must be held accountable for their role in creating and fueling the youth vaping epidemic. 

Meanwhile, Juul has said it’s just as concerned as regulators that its products are falling into the hands of underage users instead of its target demographic, “the world's 1 billion adult smokers.” James claims in the lawsuit that Juul “took a page from Big Tobacco’s playbook” when it allowed young consumers to purchase its products.

“JUUL’s advertising and social media posts misled consumers about the content of its products by failing to warn that they contain nicotine, a highly addictive chemical that is particularly dangerous for adolescents,” the complaint alleges.

Similar lawsuits

Earlier this week, California filed a similar lawsuit against Juul. The state’s Attorney General, Xavier Becerra, accused the e-cigarette maker of targeting minors through its marketing tactics and product design. 

The suit also accuses the company of using a “flawed” age-verification process for online sales and failing to properly warn consumers of the fact that they would be exposed to chemicals associated with cancer and birth defects.

“We’ve worked too hard, committed our hard-earned money for too long combatting harmful tobacco use to stand idly by as we now lose Californians to vaping and nicotine addiction,” Becerra said in a statement.

In May, North Carolina also filed a lawsuit against Juul, accusing the company of employing “deceptive and unfair” marketing practices to drive sales to minors.

In an effort to appease regulators and minimize its appeal to youth users, Juul recently stopped sales of fruit and mint-flavored vape products and suspended all broadcast, print, and digital product advertising in the U.S. 

Juul says it’s committed to “earning the trust of society by working cooperatively with attorneys general, regulators, public health officials, and other stakeholders to combat underage use and convert adult smokers from combustible cigarettes.” 

California has filed a lawsuit accusing Juul of deliberately targeting minors through its marketing tactics and product design. 

The complaint accuses the e-cigarette maker of failing to adequately warn consumers of the fact that they would be exposed to chemicals associated with cancer and birth defects. Additionally, Juul is accused of using a “flawed” age-verification process for online sales.

“We’ve worked too hard, committed our hard-earned money for too long combatting harmful tobacco use to stand idly by as we now lose Californians to vaping and nicotine addiction,” California’s Attorney General Xavier Becerra said in a statement.

“JUUL adopted the tobacco industry’s infamous playbook, employing advertisements that had no regard for public health and searching out vulnerable targets. Today we take legal action against the deceptive practices that JUUL and the e-cigarette industry employ to lure our kids into their vaping web. We will hold JUUL and any other company that fuels a public health crisis accountable.”

Teen vaping crisis 

The suit comes as lawmakers attempt to combat a surge in teen vaping. The Trump administration has proposed banning flavored e-cigarette products and/or bumping the minimum vaping age to “21 or so.”

Becerra noted that the number of high school students vaping in 2019 is 27.5 percent, up from 11.7 percent in 2017. He attributed the rise in teen vaping to the array of fruit-flavored products that were created. 

“JUUL has systematically targeted the teen market with everything from the design of their products to their advertisements,” said Supervisor Hahn. “With this lawsuit we are going to hold JUUL accountable for their hand in this public health crisis and do what we can to stop this company from creating a new generation of nicotine addicts.”

Juul has previously said it shares regulators’ concerns about its products getting into the hands of minors. In a statement, the company said it hasn’t yet reviewed the latest complaint but remains “focused on resetting the vapor category in the U.S. and earning the trust of society by working cooperatively with attorneys general, regulators, public health officials, and other stakeholders to combat underage use and convert adult smokers from combustible cigarettes.” 

Juul noted that it recently stopped sales of fruit and mint-flavored vape products and suspended all broadcast, print, and digital product advertising in the U.S. in an effort to minimize its appeal to youth users. 

“Our customer base is the world's 1 billion adult smokers and we do not intend to attract underage users,” Juul said. 

The lawsuit, which was announced on Monday, seeks monetary damages based on violations of California laws related to false advertising and unfair competition.

Apple has pulled all vaping-related apps from its App Store amid widespread concern over the health impact of the products. 

In a statement to Axios, the company said its App Store guidelines have been updated to prohibit software that encourages or facilitates vaping. 

"Experts ranging from the CDC to the American Heart Association have attributed a variety of lung injuries and fatalities to e-cigarette and vaping products, going so far as to call the spread of these devices a public health crisis and a youth epidemic," an Apple spokesperson said. "We agree, and we've updated our App Store Review Guidelines to reflect that apps encouraging or facilitating the use of these products are not permitted."

iPhone users who have already downloaded a vaping app will be able to continue using them, the company said. 

Vaping illnesses on the rise

The number of vaping-related lung illnesses has risen sharply in recent months, and investigators from the CDC, FDA, and elsewhere are still trying to figure out what exactly is causing the illnesses. 

To date, there have been 2,172 illnesses and 42 deaths tied to vaping. Health officials reported last week that vitamin E acetate has emerged as the likely culprit causing the lung illnesses, but investigations are ongoing. 

"Vitamin E acetate is used as an additive in the production of e-cigarette, or vaping, products," the CDC said in a report. "This is the first time that we have detected a potential chemical of concern in biologic samples from patients with these lung injuries."

CDC officials continue to recommend that consumers avoid any e-cigarette or vaping product that contains THC, “particularly from informal sources like friends or family, online dealers or the illicit market.” 

President Trump says the White House will soon unveil new minimum age requirements for vaping products in an effort to combat teen use. Speaking to reporters on Friday, Trump said his administration plans to implement a new policy that will raise the age limit for e-cigarettes from 18 to “21 or so.” 

“We’re going to be coming out with a very important position on vaping. We have to take care of our kids, most importantly, so we're going to have an age limit of 21 or so, but we'll be coming out with something next week very important on vaping," he said.

The Trump administration initially proposed banning all non-tobacco flavored pods back in September, saying the move would help reduce youth use of the products since flavored pods tend to appeal to teenage users. 

Critics of the plan have argued that the flavors on the market should remain because they help adult smokers quit. Government officials are now considering raising the minimum age requirement to counter rising levels of teen use. 

"We have a lot of people to look at, including jobs, quite frankly," Trump said. "Because, you know, it's become a pretty big industry."

He added that details on the potential minimum vaping age increase will be coming next week. CNBC points out that the FDA doesn’t have the authority to raise the smoking age, so it’s “unclear” how the Trump administration plans to go about implementing and enforcing a new minimum vaping age. 

Addressing health concerns

Word of the expected policy change comes as health officials continue to investigate an uptick in vaping-related lung injuries. Just a few days ago, the CDC said recent research appears to indicate that vitamin E acetate — which is present in many cannabis vaping products — is a likely culprit. 

Market leader Juul has been called out for its role in fueling what regulators have called a teen vaping “epidemic.” The e-cigarette maker has been a vocal supporter of bumping the minimum age of vaping to 21. 

In March, Juul said “raising the legal age to purchase tobacco products to 21 is not the only strategy for reducing underage use, we believe it is critical because it will prevent high-school seniors and recent high-school graduates from purchasing tobacco products and sharing them with underage users.” 

Several states have already enacted state-level regulations to counter teen use. Lawmakers have also pushed to limit the concentration of nicotine in e-cigarettes as a way to address concerns about the health effects of the products. 

Health officials have identified vitamin E acetate as the cause of a mysterious lung illness linked to vaping that has sickened more than 2,000 people over the past several months. 

In an advisory published Friday, the Centers for Disease Control and Prevention (CDC) announced that a majority of the lung fluid samples of 29 patients from 10 different states tested positive for the presence of the substance. 

"Vitamin E acetate is used as an additive in the production of e-cigarette, or vaping, products," the CDC noted in its report. "This is the first time that we have detected a potential chemical of concern in biologic samples from patients with these lung injuries."

The agency added that it continues to recommend that people refrain from using e-cigarettes or vaping products that contain THC, “particularly from informal sources like friends, or family, or in-person or online dealers.” 

“We will continue to provide updates as more data become available,” the CDC said. 

‘Strong culprit’

The FDA initially raised suspicion that the vitamin supplement was causing a surge in lung illnesses back in September, saying it had found it in cannabis products used by many people who had gotten sick over the summer. 

At the time, federal health officials stopped short of naming the substance as the definitive cause of the lung injuries. CDC officials say that the latest findings are a huge step toward finding the primary cause of the illness, although more tests are still needed for confirmation. 

“These new findings are significant," Dr. Anne Schuchat, the principal deputy director of the CDC, said during a press briefing on Friday. "We have a strong culprit."

The CDC said it hasn’t ruled out the possibility that other ingredients have caused the illness. However, the fact that 23 of the 29 lung fluid samples of people with the illness had vitamin E acetate in them is “noteworthy.” 

In total, the vaping-related lung illness — which was recently named “EVALI” -- has sickened 2,051 people and been tied to 39 deaths. The illness has been reported in every state except Alaska, as well as in Washington, D.C. and one U.S. territory.

Ahead of an expected announcement about the government’s plan to restrict e-cigarette flavors in an effort to reduce youth use, e-cigarette market leader Juul has announced that it has stopped selling mint-flavored pods. 

The action follows the release of a new study showing that mint flavors appeal to teenagers. Close to half of high school seniors polled by University of Southern California researchers said they almost always opt for mint Juul products. 

"These results are unacceptable," K.C. Crosthwaite, CEO of Juul Labs, said in a statement. "That is why we must reset the vapor category in the U.S. and earn the trust of society by working cooperatively with regulators, Attorneys General, public health officials, and other stakeholders to combat underage use."

Menthol still available

Juul has already halted sales of its mango, creme, and cucumber flavors. With mint dropped from its offerings, Juul now only offers tobacco and menthol flavors. Experts say allowing menthol to remain on the e-cigarette market could still leave a crack in the door to addiction for youth users, since menthol isn’t markedly different from mint. 

"It's just semantics," Bonnie Halpern-Felsher, a professor and expert in teen vaping at Stanford University told NBC News. "Young people are going to switch to menthol. It's really easy for companies to slightly change the formula or just re-name everything and kids won't know the difference."

The USC study, however, found that fewer than 6 percent of teenagers across all grades preferred menthol. Department of Health and Human Services (HHS) Secretary Alex Azar previously suggested that the expected federal ban on e-cigarettes would include mint, menthol, and all flavors except tobacco. 

“These products are still getting to kids and we cannot let a whole generation get addicted to them through mint and menthol and other flavors,” Azar said when the ban was initially proposed in September.

Vaping illnesses on the rise

The Centers for Disease Control and Prevention (CDC) reported on Thursday that the number of vaping-related lung injuries is up to 2,051. At least 39 deaths associated with the products have been confirmed, and additional deaths are under investigation.

Vaping or e-cigarette use has so far been “the only commonality among all cases” of the lung injuries, the CDC said. The current outbreak of lung illnesses tied to vaping hasn’t been linked to Juul specifically. 

Health officials are still trying to figure out what is causing the lung illnesses; no single product or ingredient has so far been linked to all the lung injuries.  

Federal regulators are expected to unveil new restrictions on e-cigarettes in an effort to reduce youth use of the products. However, vape shops could be exempted from those restrictions, Bloomberg reports. 

Speaking at the White House on Wednesday, presidential adviser Kellyanne Conway noted that teenagers like vaping mint and fruit-flavored products, but tobacco and menthol flavored products remain unpopular among youth users — a claim supported by a National Institutes of Health-funded study published Tuesday. 

“Kids report they use mint, and other flavors like mango, bubble gum, tutti frutti, unicorn milk -- pretty remarkable -- and that they don’t care for menthol,” Conway said Wednesday. 

That said, the Trump Administration may not include menthol in the flavored e-cigarette ban it proposed in September. Conway noted that the Department of Health and Human Services (HHS) has jurisdiction over e-cigarettes but not over vaping and vape shops. 

“This is a burgeoning health crisis; the difference is between kids and adults,” Conway said, according to Bloomberg. “So HHS and FDA have jurisdiction over cigarettes and e-cigarettes under the Tobacco Control Act. They do not have jurisdiction over vaping and vape shops, for example. So, if we’re talking about e-cigarettes, the president, yes, he’s been discussing this with his team and he will, or HHS, will make an announcement soon.”

Addressing teen use

HHS Secretary Alex Azar suggested last month that the soon-to-be-announced ban on e-cigarettes would include mint, menthol, and all flavors except tobacco. 

“These products are still getting to kids and we cannot let a whole generation get addicted to them through mint and menthol and other flavors,” Azar said when the ban was initially proposed.

Conway’s comments on Wednesday “indicate there may also be some kind of a reprieve for vape shops, who’ve mounted widespread pushback to a ban and warned it could cost both jobs and votes in 2020,” Bloomberg said. 

An announcement about the plan to restrict e-cigarette flavors to drive down youth use will be made by either the HHS or President Trump soon, Conway said. 

As the vaping death toll continues to rise among younger consumers, it may come as a surprise to many that the younger demographic has lessened its cannabis use. 

Researchers from the Columbia University Mailman School of Public Health found that the number of teens and young adults affected by cannabis use disorder declined between 2002 and 2016. 

“Contrary to expectations, the frequency of cannabis use disorder among people reporting daily/almost daily use decreased significantly between 2002 and 2016,” said researcher Dr. Silvia Martins. “The findings contradict the predominating hypothesis that the prevalence of DSM-IV CUD would be stable, or increase, among those using with regularity.” 

Lower rates of cannabis use

The researchers analyzed over 22,000 responses to the National Survey on Drug Use and Health to better understand the cannabis habits of those in three age groups: 12-17 years old, 18-25 years old, and over 26 years old. 

For the purposes of the study, the researchers used the DSM-IV definition for cannabis use disorder. While there are several factors that come into play, cannabis use becomes cause for concern when a person becomes dependent on the drug or uses it in a way that’s harmful to the body. 

The survey responses showed that every age bracket they observed had lowered their rates cannabis use disorder. Those 26 and older used the substance less than any others, dropping nearly 40 percent over the span of the study. 

Across the board, the motivation to quit wasn’t associated with any physical or mental health concerns. Those who dropped the habit said they didn’t do so out of necessity, and their health wasn’t compromised in any way. 

While the researchers noted that social and societal changes may have made an impact on some young people’s decision to stop using the drug, it is interesting to know that young people’s health -- either mental or physical -- was not on the line and didn’t affect their decision. 

“First, the new national cannabis policy environment, with 33 states legalizing medical use and 10 states allowing recreational use of cannabis may have played a role in reducing stigma and perceptions of risk associated with cannabis use,” said Dr. Martins. “Secondly, increasing legalization may be associated with changes in social attitudes resulting in fewer conflicts with relatives and friends around cannabis use.”

Vaping is a stark contrast

While the social aspect associated with cannabis use may be behind the sharp decline in use among young people, these findings do come in stark contrast to teens’ e-cigarette use, which has become problematic. 

Despite several warnings about health-related concerns, teens have not altered their vaping habits. One recent study found that flavored e-cigarettes, which have been under fire recently, are associated with higher teen use of vaping devices.

“While many children try e-cigarettes, not all become regular users,” said researcher Adam Leventhal. “Teens who use e-cigarettes may be more inclined to continue vaping rather than just temporarily experiment with e-cigs. Whether or not children continue vaping is important -- the longer and more frequently you vape, the more you’re exposing yourself to toxins in e-cigarette aerosol and put yourself at risk of nicotine addiction.”

The Federal Trade Commission (FTC) has launched an investigation into Altria and its role, if any, in the resignation of the CEO of Juul, its e-cigarette subsidiary that has come under close regulatory scrutiny in recent months.

According to a Securities and Exchange Commission (SEC) filing, Altria has received a demand from regulators seeking information about any role Atria played in the resignation of Juul’s CEO. At the end of September, Juul announced it was replacing its CEO Kevin Burns with Altria executive K.C. Crosthwaite.

Regulators are interested because within days of taking the top job, Crosthwaite hired Altria colleague Joe Murillo as Juul’s chief regulatory officer. 

Juul has been at the center of controversy over its marketing efforts and whether it targeted underage consumers with its vaping products. The company has also been in the crosshairs of the government’s efforts to stop underage use of vaping products.

In April, former Food and Drug Administration (FDA) Commissioner Scott Gottlieb accused Juul of being largely responsible for the spike in teen vaping. The FDA has cited research that shows an estimated 37 percent of high school seniors have tried e-cigarettes. A quarter of youth users told researchers they didn’t realize the products contain nicotine.

Attractive to minors

The agency has said products manufactured by Juul have been shown to be especially attractive to minors because they come in fruity flavors such as mango, mint, and fruit and creme. In January, Gottlieb warned that e-cigarettes could be taken off the market unless marketers made efforts to stop sales to minors.

Since then, Juul and its products have come under increasing scrutiny. In September, an official art the Centers for Disease Control and Prevention (CDC) called out Juul for allegedly using dangerous salts in its products.

In its SEC filing, Altria disclosed that the agency is conducting an antitrust review of Altria’s investment in the e-cigarette maker. Specifically, the agency is seeking information about any Altria role in the resignation of Juul’s CEO and his replacement with a long-time Altria executive.

In its filing, Altria also disclosed that the FTC and possibly other regulatory agencies are investigating Juul’s marketing practices. The company has been accused of targeting underage consumers -- something Juul vigorously denies.

In a lawsuit filed Tuesday, a former Juul executive accuses the e-cigarette maker of shipping a million contaminated pods earlier this year and not issuing a recall, according to BuzzFeed News.

The suit was filed by Siddharth Breja, Juul’s former senior vice president of global finance. Breja said he attended an executive meeting back in March, during which it came to his attention that Juul had shipped approximately 250,000 Juul “mint refills kits” (the equivalent of one million pods). 

The former executive claims that he pushed Juul to issue a product recall or public safety notice, but Juul allegedly dismissed the idea since doing so would cost it billions of dollars. Breja claims he was fired a week after expressing concern about the contaminated pods.

According to the lawsuit, former CEO Kevin Burns -- who was replaced by former Altria executive K.C. Crosthwaite in September -- responded to Breja’s concerns by saying: "Half our customers are drunk and vaping like mo-fo's, who the f*** is going to notice the quality of our pods?"

In a statement to BuzzFeed News, Breja's lawyer Harmeet Dhillon said that his client "became aware of very concerning actions at the company, and he performed his duty to shareholders and to the board by reporting these issues internally.” 

“In exchange for doing that, he was inappropriately terminated,” Dhillon continued. “This is very concerning, particularly since some of the issues he raised concerned matters of public safety."

Juul responds

Juul called Breja’s claims “baseless” and refuted the claim that he was fired after voicing concerns about the contaminated pods. 

“He was terminated in March 2019 because he failed to demonstrate the leadership qualities needed in his role,” a company spokesperson said in a statement issued to various media outlets. “The allegations concerning safety issues with Juul products are equally meritless, and we already investigated the underlying manufacturing issue and determined the product met all applicable specifications.” 

Juul added that it intends to “vigorously defend this lawsuit."

Juul has been singled out for fueling the current vaping epidemic, as its flavored products have been found to appeal to younger users. At this point, however, the current outbreak of lung illnesses tied to vaping hasn’t been linked to Juul specifically. Health officials say a majority of the more than 1,600 people who have gotten sick reported using THC-containing products.

The vaping industry itself is still under intense scrutiny as investigators seek to uncover a more specific cause behind the sudden rise in vaping-related lung illnesses and deaths. 

E-cigarettes have dominated the headlines recently, as more and more consumers are being diagnosed with vaping-related illnesses that healthcare professionals have been struggling to get to the root of. 

Health experts have pointed to additives in electronic cigarettes that can cause any number of health issues, and the sale of flavored e-cigarettes has been halted. However, the vaping death toll only continues to rise, and many young consumers continue to use e-cigarette devices.

Now, a new study conducted by researchers from the University of Southern California discovered that teens are more likely to stick to their vaping habits because of flavored e-cigarettes. 

“While many children try e-cigarettes, not all become regular users,” said researcher Adam Leventhal. “Teens who use e-cigarettes may be more inclined to continue vaping rather than just temporarily experiment with e-cigs. Whether or not children continue vaping is important -- the longer and more frequently you vape, the more you’re exposing yourself to toxins in e-cigarette aerosol and put yourself at risk of nicotine addiction.” 

How flavors play a role

The researchers created a survey to gauge teens’ vaping habits. They surveyed nearly 500 tenth graders every six months through their senior years of high school to see what changes -- if any -- took place over that time span. 

While a large majority of the students reported vaping at some point over the course of the study, the fruity or candy flavored e-cigarettes proved to be more popular and were often successful at getting students to stick with the habit long-term. While under 43 percent of students who vaped with the regular tobacco flavor continued the habit for an additional six months, over 64 percent of vapers who opted for sweeter flavors did the same. 

Overall, the researchers learned that 90 percent of the students had taken advantage of the wide variety of flavors available for e-cigarettes, and doing so often upped their typical day-to-day vaping habits. 

Federal regulation needed

As e-cigarettes remain unregulated by the government, the researchers are calling for federal intervention in an effort to keep young people healthy and reduce overall e-cigarette usage. 

“Regulations that reduce youth exposure to flavored e-cigarettes may aid in preventing young people who try e-cigarettes from becoming long-term e-cig users, and also from inhaling more aerosol into their lungs,” said Leventhal. “Regulations like these could also encourage the millions of U.S. adolescents who already use e-cigarettes to quit vaping, especially if they can no longer access e-cigs in the flavors they like.” 

The number of deaths attributed to the vaping-related illness recently named “EVALI” (short for “e-cigarette or vaping product use associated lung injury”) has risen to 34 people, the Centers for Disease Control and Prevention (CDC) reported Thursday. 

More than a hundred new cases of the illness have been reported over the past week, bringing the total number of cases to 1,604. The deaths and illnesses are spread across 49 states, as well as the District of Columbia and the Virgin Islands. 

While the severe lung illness responsible for these deaths and illnesses seems to have a clear link to vaping, health officials are still trying to find out exactly what is it to manifest. No one product or ingredient has so far been involved in all of the cases. However, a majority of patients have reported vaping THC.

“The latest national and state findings suggest products containing THC, particularly those obtained off the street or from other informal sources (e.g. friends, family members, illicit dealers), are linked to most of the cases and play a major role in the outbreak,” the CDC said. 

Though most people reported using a THC-containing product prior to getting sick, 10 percent of patients said they only used nicotine-containing products. Health officials still haven’t identified what in the products is making people sick.

“At this time, FDA and CDC have not identified the cause or causes of the lung injuries in these cases, and the only commonality among all cases is that patients report the use of e-cigarette, or vaping, products,” the CDC said. 

Testing for EVALI 

Symptoms of the lung injury connected to vaping include chest pain, shortness of breath, and vomiting. Last week, the CDC released guidance for clinicians on the diagnosis, management, and follow-up of the illness.

In the guidance, the CDC recommended that doctors consider testing all patients with symptoms of EVALI for influenza and other respiratory illnesses. 

“It is unknown if patients with a history of EVALI are at higher risk for severe complications of influenza or other respiratory viral infections if they are infected simultaneously or after recovering from lung injury,” the guidance says.

While state and federal health officials continue to investigate the illness, the CDC has urged people not to use e-cigarette or vaping products that contain THC.

Juul has ceased sales of its flavored nicotine products in the U.S. ahead of an expected order for it to do so from the U.S. Food and Drug Administration (FDA). 

The e-cigarette maker had previously pulled its flavored products from retail outlets, but its fruit-flavored e-cigarettes were still available online. Juul has now stopped selling flavored products, including mango, creme, fruit, and cucumber. The company is still selling tobacco, mint, and menthol flavored products.

The move comes as federal regulators seek to combat the rise in teen use of the products, which have been linked to severe lung illnesses and deaths. 

Cooperating with regulators 

Earlier this week, a parent whose son died after becoming “intensely addicted” to Juul’s products filed a wrongful death lawsuit against the company. Juul has previously been accused of targeting youth users through its marketing campaign and faces a number of similar lawsuits over its role in the vaping crisis. 

Juul announced last month that it would stop advertising its products in the U.S. and also stop fighting regulators over President Trump’s decision to remove all e-cigarette flavors from the market.

Going forward, Juul says it will continue to try to get its flavored products back on the market as an alternative to smoking for adults. The company said it’s also working on coming up with ways to prevent underage use of its products. 

“We must reset the vapor category by earning the trust of society and working cooperatively with regulators, policymakers, and stakeholders to combat underage use while providing an alternative to adult smokers,” Juul CEO K.C. Crosthwaite said in a statement.

Juul has been hit with a wrongful death suit following the death of a teenager who “became intensely addicted” to the e-cigarette maker’s nicotine products. 

The complaint, filed by the mother of 18-year-old Florida resident Daniel David Wakefield, accuses Juul of causing the teen’s death through its marketing campaign. The company has faced significant criticism over its marketing campaign, which lawmakers and health officials claim deliberately targeted youth users.

Juul recently agreed to stop advertising its products altogether in the U.S. while cases of a mysterious lung illness linked to vaping are being investigated. 

Years of Juul use

In the wrongful death suit filed on Tuesday, Wakefield’s mother claims her son’s behavior changed “dramatically” after being exposed to Juul advertising in 2015. She claims he gradually became “intensely addicted” to the company’s products. 

Within a year of starting to vape, the teen ended up hospitalized for three days. In August 2018, he was found in an unresponsive state by his father. The previously healthy teenager’s death was ultimately pinned on “breathing complications.” The complaint notes that the death occurred after a day that included moving boxes. 

The suit accuses Juul of “wrongful conduct in marketing, promoting, manufacturing, designing, and selling JUUL.” The plaintiff is seeking compensatory, punitive, and other damages related to Wakefield’s death, which Juul is accused of “substantially” contributing to.  

Lung illnesses under investigation

The CDC said last week that the vaping-related death toll in the U.S. had increased to 26, and the number of illnesses had been raised to 1,299. Health authorities are currently trying to find a specific cause of the illnesses, but vaping has so far been a common thread among all of the illnesses and deaths. 

Most of the confirmed cases of lung injuries have involved patients who reported using THC-containing products. However, some reported using only nicotine vaping products. 

Lawmakers and health officials are particularly concerned about the rise in youth use of the products over the past few years. Around 15 percent of those who either got sick or died are under the age of 18, and 21 percent are 18 to 20 years old, according to the CDC. 

Reacting to a finding drawn from a recent study involving mice, former FDA Commissioner Scott Gottlieb said he’s “skeptical that nicotine causes cancer.” 

“It might be a tumor promoter, [researchers] have said that there’s a potential that nicotine is a tumor promoter, but it doesn’t cause cancer,” Gottlieb said Monday on CNBC’s “Squawk Box.” 

Though skeptical of the claim that nicotine is carcinogenic, Gottlieb -- who stepped down from his position as FDA Commissioner in April -- said he did believe inhaling e-cigarette vapor would likely cause damage to the lungs.

“We had a signal when I was at the FDA of damage that vaping was causing to the lungs in an animal study,” Gottlieb told CNBC, adding that the results of the FDA study should be released soon. “You can’t inhale something into the lungs that way on a repeated basis and not cause some damage to the lung.”

Dangers of vaping

Last week, a New York University study found that e-cigarette vapor containing nicotine causes lung cancer and precancerous lesions on the bladder of mice. Researchers said 22 percent of the 40 mice involved in the study developed lung cancer. 

In light of the study’s findings, the researchers asserted that vaping is likely harmful to humans as well. Gottlieb, however, pointed out that the study was small and “isolated the effects of nicotine,” according to CNBC. 

The health impact of vaping is currently being studied extensively as health officials continue to report more cases of a lung illness linked to vaping. 

Last week, the CDC updated the official toll of lung illnesses and deaths linked to e-cigarette use. The death toll had risen to 26, and the number of vaping-related lung illnesses had been raised to 1,299.

The Centers for Disease Control and Prevention (CDC) has updated the official toll of lung illnesses and deaths linked to e-cigarette use. The death toll has increased to 26, and the number of illnesses has been raised to 1,299.

Health agencies across the U.S. have focused more intently in recent weeks on patients complaining of lung illnesses to determine if there could be a connection with vaping. Officials at the CDC say an alarming number of these illnesses and deaths have e-cigarette use in common.

Perhaps more alarming is the fact that many of the victims are young. According to CDC data, 15 percent of those who either got sick or died are under the age of 18, and 21 percent are 18 to 20 years old.

THC plays a role

The CDC said most patients reported a history of vaping THC products derived from cannabis. Approximately 70 percent of the patients are males, and the overwhelming majority are under the age of 35.

The health agency says there is still a lot that health authorities don’t know. For example, it isn’t known what chemical or combination of chemicals in the vapor is actually causing the illnesses. It says no single product or substance has been linked to all lung injury cases.

“The outbreak is occurring in the context of a dynamic marketplace for e-cigarette, or vaping, products, which may have a mix of ingredients, complex packaging and supply chains, and include potentially illicit substances,” the CDC said.

Because of the proliferation of illicit vaping products, the CDC says consumers may have no way of knowing what’s in them. Many of the products can be modified by users, which could also make them more dangerous.

More information needed

The CDC says more information is needed to know whether one or more e-cigarette or vaping products, substances, or brands caused the outbreak. The FDA recently launched a criminal investigation into vaping that will focus on uncovering the cause of the illnesses by looking at the chemical makeup of the products and how people use them. 

“We are in desperate need of facts," Mitch Zeller, the agency’s tobacco director, said in a statement last week. “The focus of their work is to identify what is making people sick, as well as a focus on the supply chain.”

The CDC continues to advise consumers to consider not using e-cigarette products. It says those who use the products should monitor themselves for symptoms such as shortness of breath, chest pain, nausea, vomiting, and cough. If any of these symptoms are present, regulators urge consumers to seek medical attention. 

A study published Monday is the first to connect e-cigarette vapor with several types of cancer in mice. Researchers say the results of the study suggest that vaping is also harmful to humans. 

Understanding the carcinogenic effect of e-cigarettes on humans could take another ten years, the study authors said. However, the latest research appears to strongly suggest that the products pose health risks that warrant further examination.

"Tobacco smoke is among the most dangerous environmental agents to which humans are routinely exposed, but the potential of E-cig smoke as a threat to human health is not yet fully understood," said Moon-Shong Tang, the study’s lead researcher, in a statement.

“Our study results in mice were not meant to be compared to human disease, but instead argue that E-cig smoke must be more thoroughly studied before it is deemed safe or marketed that way."

More research needed

Published Monday in The Proceedings of the National Academy of Sciences and funded by the National Institutes of Health, the study found that 22 percent of mice exposed to e-cigarette smoke with nicotine for 54 weeks developed lung cancer. 

By contrast, none of the 20 mice that were exposed to the same e-cigarette smoke without nicotine developed cancer -- a “statistically significant” figure, Tang said. The researcher and his team also found that 23 of 40 mice exposed to e-cigarette smoke developed precancerous lesions on the bladder and genetic changes that make cells more likely to multiply. 

The study authors estimated that the amount of smoke the mice were exposed to was equivalent to what a human would inhale in three to six years’ worth of regular vaping. 

The results of the study highlight the need for more research on the health effects of e-cigarettes. In the meantime, the researchers said the findings suggest that e-cigarette makers should refrain from marketing the products as safer than combustible cigarettes.

"Our results support the argument that the nicotine-derived DNA adducts are likely the main causes for carcinogenesis in mice exposed to E-cig smoke," said study author Dr. Herbert Lepor. "Our next step in this line of work will be to expand the number of mice studied, to shorten and prolong E-cigarette exposure time, and to further investigate the genetic changes caused by E-cigarette smoke."

The study comes as federal health officials continue to investigate a rise in lung illnesses linked to e-cigarette use. As of last week, the CDC said there were 805 confirmed and probable cases of lung injury associated with e-cigarette use in 46 states and the U.S. Virgin Islands. At least sixteen deaths have now been linked to e-cigarette use.

Congressman Raja Krishnamoorthi (D-Ill.) has unveiled a bill that would limit the amount of nicotine in e-cigarettes to no more than 20 milligrams per milliliter. 

The introduction of the “Ending Nicotine Dependence from Electronic Nicotine Delivery Systems Act” (or END ENDS Act) comes in the midst of ongoing concern about the health effects of e-cigarettes and a surge in teen use of the products.

Public health officials are continuing to investigate what’s behind the recent rise in vaping-related lung illnesses. As of last week, there were 805 confirmed and probable cases of lung injury associated with e-cigarette use in 46 states and the U.S. Virgin Islands. At least sixteen deaths have been linked to e-cigarette use.

Regulators have described the dramatic rise in teen vaping over the last few years as an “epidemic.” Krishnamoorthi, who himself is the parent of a teenager, said the issue is “deeply personal” to him.  

“More than 1 in four high school students are vaping, and as a concerned parent I am always working to do what’s best for my kids and future generations,” he wrote on Twitter. 

Creating less addictive products

If passed, the bill would require the amount of nicotine in e-cigarettes to be capped at about a third of the 59 milligrams per milliliter contained in standard Juul pods. Under the law, the FDA would be allowed to further lower the cap to make e-cigarettes minimally addictive or not addictive at all. 

“Capping the concentration of nicotine in e-cigarettes is integral to ending the youth vaping epidemic by making these products less addictive, less appealing to youth, and less harmful to public health,” Krishnamoorthi said in a statement. “After all, while flavors hook kids, it’s nicotine that nets them and pulls them on the boat into a lifelong vaping habit and addiction.”

Lawmakers on both sides of the aisle argue that e-cigarette manufacturers like Juul must be held accountable for their role in creating and fueling the youth vaping epidemic.

“We commend lawmakers for uniting on a bipartisan and bicameral basis to create the Congressional Caucus to End the Youth Vaping Epidemic,” Nancy Brown, CEO of the American Heart Association, said in a statement. “It is no secret that the tobacco industry has long preyed on young people with viral marketing and flavors intended to entice and addict a new generation to nicotine.” 

“Now we are in the midst of a public health crisis, and we need bold action from our nation’s leaders to keep e-cigarettes out of the hands of our youth. Together we can protect the health and safety of youth across the country and combat the mounting threat e-cigarettes pose to our population.”

The Food and Drug Administration (FDA) is stepping up its warnings to consumers about using e-cigarettes to “vape” THC products derived from cannabis.

The FDA is partnering with the Centers for Disease Control and Prevention (CDC) to investigate a growing number of lung illnesses -- including deaths -- that appear to be linked to vaping certain products. 

“We're strengthening our message to the public in an updated consumer alert stating that they should not use vaping products containing tetrahydrocannabinol (THC), the primary psychoactive component of the cannabis plant,” said Acting FDA Commissioner Ned Sharpless. 

“Additionally, consumers who choose to use any vaping products should not modify or add any substances such as THC or other oils to products purchased in stores and should not purchase any vaping products, including those containing THC, off the street or from other illicit channels.”

Last week, health officials in Virginia and New Jersey reported additional lung illness deaths that appear to be related to vaping. The deaths are part of hundreds of illnesses that have sent other consumers to the hospital.

E-cigarettes a common factor

The CDC said it knows for a fact that all patients used e-cigarettes or vaping devices prior to becoming ill; however, the exact cause of the illnesses is still under investigation.

“The specific chemical exposure(s) causing lung injuries associated with e-cigarette product use, or vaping, remains unknown at this time,” the CDC said in a statement late last week. “No single product or substance has been linked to all lung injury cases.” 

Sharpless said the lung ailments are at the center of what he called a complex, ongoing, and evolving investigation. The FDA is conducting its own analyses while also reviewing published literature of third-party analyses of samples and data.

“At this time, the FDA does not have enough data to identify the cause, or causes, of the lung injuries in these cases,” Sharpless said. “Additionally, while no one compound or ingredient has emerged as a singular culprit, we do know that THC is present in most of the samples being tested.”

Stop now

The amount of uncertainty linked to these illnesses is largely why the health agency has asked consumers to immediately stop using vaping products that contain THC or that have had any substances added to them, including those purchased from retail establishments. 

“Simply put, inhaling harmful contaminants in the lungs could put a patient's health at risk and should be avoided,” Sharpless said. 

Last month, the FDA said it suspected a chemical present in many varieties of marijuana liquid vaping products may be the underlying cause of some of the lung illnesses. Most patients reported vaping THC before becoming ill. At present, no single vaping product or ingredient has been found to have been involved in all of the cases. 

“For those who choose to continue the use of vaping products, particularly those containing THC, we urge you to monitor for symptoms and promptly seek medical attention if you have concerns about your health,” Sharpless said.

The Federal Trade Commission (FTC) has ordered six e-cigarette companies to submit documents containing their sales and advertising data, suggesting the federal agency could be close to launching a probe into their marketing practices. 

The orders were sent to Juul, Reynolds Vapor Company, Fontem US, Logic Technology Development, Nu Mark, and NJOY. The agency said its request is intended to help it gather information about e-cigarette sales, advertising, and promotional practices in the U.S. for the years 2015 through 2018. 

“The goal is to assist the Commission, policy makers, and the public to better understand the rapidly growing e-cigarette market,” the agency said in a statement on Thursday. 

An FTC official said the agency is seeking “annual data on the sales and give-aways of e-cigarette products; information about the characteristics of the companies’ e-cigarette products, such as product flavors; annual amounts the companies spent on advertising and promoting e-cigarette products; and information about e-cigarette product placement, the websites and social media accounts used to advertise or sell e-cigarettes, affiliate programs, influencer marketing, and college campus programs.” 

Rise in vaping-related deaths

According to the most recent data from the Centers for Disease Control and Prevention (CDC), 1,080 people in the U.S. are now affected by vaping-related lung illnesses, with 18 people having died as a result of their symptoms.

Regulators are actively seeking more information on e-cigarettes in an effort to uncover a more specific cause of the illnesses. 

At this time, health authorities suspect a chemical present in many varieties of marijuana liquid vaping products may be the underlying cause of some of the lung illnesses. Most patients reported using a THC-containing product before becoming ill. However, no single vaping product or ingredient has yet been linked to all of the cases. 

Juul, which previously sold flavored products that tended to entice youth users, recently agreed to stop advertising its products in the U.S. The Trump administration said it’s moving toward a ban on all flavored e-cigarette products in the U.S. 

While investigations into the matter are ongoing, the CDC has advised consumers to avoid using e-cigarettes or vaping products. 

The number of vaping-related deaths nationwide has now climbed to 16 following two additional death confirmations from health officials in Virginia and New Jersey. 

"I am deeply saddened to announce the first death of a Virginia resident related to this outbreak," Virginia's state health commissioner, Dr. M. Norman Oliver, said in a statement on Tuesday.

Officials from the New Jersey Department of Health said the tragedy in their state “underscores the potential dangers associated with vaping.”

E-cigarette use has been linked to fourteen other deaths in recent months, and the number of lung illnesses associated with vaping has grown by hundreds just within the past few weeks. 

Last week, the Centers for Disease Control and Prevention (CDC) announced that there are now 805 confirmed and probable cases of lung injury associated with e-cigarette use in 46 states and the U.S. Virgin Islands. 

Exact cause still unknown

The CDC said it knows for a fact that all patients used e-cigarettes or vaping devices prior to becoming ill; however, the exact cause of the illnesses is still under investigation.

“The specific chemical exposure(s) causing lung injuries associated with e-cigarette product use, or vaping, remains unknown at this time,” the CDC said. “No single product or substance has been linked to all lung injury cases.” 

Researchers currently suspect a chemical derived from vitamin E, which is present in many different types of marijuana liquid vaping products, may be behind some of the lung illnesses. A majority of patients have said they used THC-containing products. 

The FDA recently launched a criminal investigation into vaping that will focus on uncovering the cause of the illnesses by looking at the chemical makeup of the products and how people use them. 

“We are in desperate need of facts," Mitch Zeller, the agency’s tobacco director, said in a statement. “The focus of their work is to identify what is making people sick, as well as a focus on the supply chain.”

While health officials work to uncover a more precise cause of the illnesses, the CDC has advised consumers to consider not using e-cigarette products. Those who use the products should monitor themselves for symptoms such as shortness of breath, chest pain, nausea, vomiting, and cough. If any of these symptoms are present, regulators urge consumers to seek medical attention. 

Amid escalating concern over the health risks of e-cigarettes, Juul has announced that it will suspend all TV, print, and digital product advertising in the U.S. 

The e-cigarette maker also said it would stop fighting the Trump administration on its plan to remove flavored e-cigarettes from the market until they have received approval from federal regulators. Juul said it would fully support and comply with any new federal policy related to vaping policy when effective. 

The Trump Administration is currently finalizing a ban on all flavored e-cigarette products, including mint and menthol flavors. 

Juul CEO resigns

Wednesday’s announcement also included news that Juul’s CEO Kevin Burns is stepping down immediately and will be replaced by K. C. Crosthwaite. Crosthwaite previously held the title of Chief Growth Officer at tobacco giant Altria, which owns a 35 percent stake in Juul. 

“I have long believed in a future where adult smokers overwhelmingly choose alternative products like JUUL,” Crosthwaite said in the announcement. “That has been this company’s mission since it was founded, and it has taken great strides in that direction.” 

“Unfortunately, today that future is at risk due to unacceptable levels of youth usage and eroding public confidence in our industry,” he continued. “Against that backdrop, we must strive to work with regulators, policymakers and other stakeholders, and earn the trust of the societies in which we operate. That includes inviting an open dialogue, listening to others and being responsive to their concerns.”

Talks of a merger of Philip Morris and Altria have been called off. Both companies said Wednesday that they will remain separate entities. 

Health concerns under investigation

Last week, health officials said the number of illnesses associated with vaping has now climbed to 530. Since August, at least nine people in the U.S. have died following e-cigarette use. The CDC has not identified any one company or vaping product as responsible for all of the illnesses and fatalities.

Juul has been singled out for its role in the youth e-cigarette epidemic, as its flavored products have been shown to be particularly appealing to teens. Juul currently faces numerous lawsuits accusing it of deliberately targeting young consumers with its flavored nicotine products.

The FDA is considering banning all flavored e-cigarettes in an effort to curb use by teens while the health effects of the products are still being investigated.

At an emergency hearing regarding the recent surge in vaping-related lung illnesses, a CDC official said that Juul -- the manufacturer of an e-cigarette product that is especially popular among teens -- uses potentially dangerous salts in its vaping devices. 

“Juul products use nicotine salts, which can lead to much more available nicotine,” CDC Principal Deputy Director Dr. Anne Schuchat told the House Oversight and Reform Committee’s panel on consumer products on Tuesday.

She added that doctors believe the salts allow nicotine to “cross the blood brain barrier and lead to potentially more effect on the developing brain in adolescents.” 

High nicotine delivery

Last week, health officials said the number of illnesses associated with vaping has now climbed to 530. Since August, at least nine people in the U.S. have died following e-cigarette use. 

Amid escalating concern over the health impacts of the products, Juul has maintained that its sole mission is to serve as an “off-ramp” from smoking combustible cigarettes. 

Juul claims its nicotine salt formulation increases the rate and amount of nicotine delivered into the blood compared with other formulations. The formulation is intended to give users an experience similar to traditional cigarettes, which may help them quit. 

However, Schuchat said the nicotine salts could lead to higher quantities of nicotine being delivered. When used by teens, Juul’s devices could give way to a unique set of problems.

“The devices are very easy to conceal, between the high levels of nicotine and discreet use, we think that the use among teens is particularly concerning,” Schuchat said. She added that flavored e-cigarettes have been shown to appeal to youth users, which health officials and lawmakers have expressed concern about. 

“We really want to avoid another generation being addicted to nicotine so addressing flavors directly is a good idea,” she said. 

Avoiding e-cigarette use recommended

Schuchat echoed the CDC’s recent recommendation that consumers “consider not using e-cigarette products” while the investigation into the illnesses is ongoing. 

“We do not yet know the specific cause of these lung injuries,” the CDC said in a recent advisory. “The investigation has not identified any specific e-cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases.” 

Separately, the FDA is conducting an analysis of more than 150 vaping product samples in an effort to find a common thread behind the illnesses. 

“We are in desperate need of facts," Mitch Zeller, the agency’s tobacco director said in a statement. Zeller said the focus of the investigation is to “identify what is making people sick, as well as a focus on the supply chain.”

A Kansas man over 50 years old with preexisting health conditions died Monday from causes believed to be linked to vaping, bringing the total number of vaping-related deaths in the U.S. to nine.

The patient who died had begun using e-cigarettes just before his symptoms set in and hospitalization became necessary. Kansas health officials said they don’t know which type of e-cigarette product, device, and substances he used. 

In a press release announcing the latest fatality, officials from the state noted that the number of illnesses associated with vaping has now surpassed 500. Federal and state health officials are still investigating the cause of an outbreak of lung illnesses. 

“E-cigarettes are unregulated, which means that we don’t know what’s in them,” said Kansas Department of Health and Environment Secretary Dr. Lee Norman. “And, of great concern to me, is that in the midst of all these illnesses being reported, the amount of young people using them is significant.”

Cause of lung illnesses still under investigation

At this time, researchers suspect a chemical derived from vitamin E may be the underlying cause of some of the lung illnesses. 

“We know that in vaping solutions, there’s oils like Vitamin E acetate which is the one that’s thought to be probably contributing, there’s heavy metals, there’s poisons,” Dr. Norman said. “And we know that it looks like an oil infused into the lungs that is causing this, but the compound has not been 100% identified.”

The FDA recently launched a criminal investigation into vaping that will focus on uncovering the cause of the illnesses by looking at the chemical makeup of the products and how people use them. Researchers will conduct a forensic analysis of more than 150 vaping product samples to look for the presence of nicotine, THC, and other cannabinoids, opioids, cutting agents, additives, pesticides, poisons, toxins and any other substances.

“We are in desperate need of facts," Mitch Zeller, the agency’s tobacco director, said in a statement. “The focus of their work is to identify what is making people sick, as well as a focus on the supply chain.”

Avoiding use of e-cigarettes recommended

While the investigation into the illnesses is ongoing, the Centers for Disease Control and Prevention (CDC) has advised people to consider not using e-cigarette products. Those who use the products should monitor themselves for symptoms such as shortness of breath, chest pain, nausea, vomiting, and cough and seek medical attention for any health concerns. 

“We do not yet know the specific cause of these lung injuries,” the CDC said in an advisory. “The investigation has not identified any specific e-cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance that is linked to all cases.” 

The House Oversight and Reform Committee’s panel on consumer products is set to meet Tuesday for a hearing on the surge in illnesses tied to vaping.

The anti-vaping drumbeat is getting louder in Washington, as four members of the U.S. Senate have asked the Food and Drug Administration (FDA) to immediately ban the most popular kind of e-cigarette products from the market.

The senators -- Dick Durbin (D-IL), Lisa Murkowski (R-AK), Jeff Merkley (D-OR), and Richard Blumenthal (D-CT) -- cite the mysterious lung ailments that have been linked to e-cigarette use. In a letter to Acting FDA Commissioner Dr. Ned Sharpless, the lawmakers call for the immediate removal of all pod- and cartridge-based e-cigarettes from the market, unless or until they can prove that they benefit the public health.

The proposal is a sharp escalation of the steps currently under consideration. The FDA last week launched a criminal investigation into the 530 cases of lung illnesses, including eight deaths. The Trump administration is also reportedly considering a ban on flavored e-cigarette products.

Lawmakers fault the FDA

In their letter, the senators denounce what they say has been a lack of action from the FDA when it comes to e-cigarette products. 

“The proliferation of cartridge-based e-cigarettes—and their ever-increasing popularity with children—is primarily due to the FDA’s years-long refusal to regulate any e-cigarette devices or impose common-sense design standards preventing against adulteration, despite having the authority to do so,” they said. “Make no mistake: none of the e-cigarettes, including cartridge-based e-cigarettes, currently on the market have gone through the FDA approval process.  They have not demonstrated that they are safe and effective for helping adults quit smoking cigarettes.”

The lawmakers point to reports of the increasing use of e-cigarettes by people under the age of 18. They contend that five million children are now vaping, including one in four high school students.

In a recent one-year period, 2017 to 2018, the lawmakers say America saw a 78 percent increase in the number of high school students using e-cigarettes and a 48 percent increase in the number of middle school children using the products. 

The senators draw a distinction between cartridge-based systems and the open tank e-cigarettes that are typically sold in vape shops. They say cartridge-based products are often sold in convenience stores and other outlets where under-age consumers have freer access.

Walmart has announced that it will stop selling e-cigarettes and all related devices and accessories at its U.S. locations. 

The retailer said Friday that its decision to pull the products was made in response to “growing federal, state and local regulatory complexity and uncertainty” around e-cigarettes. Walmart said it will no longer stock the products once its current inventory is gone. 

Health officials said last week that more than 530 cases of a mysterious lung illnesses linked to vaping have now been reported. Since August, at least eight people who reported using e-cigarettes have died. 

“Given the growing federal, state and local regulatory complexity and uncertainty regarding e-cigarettes, we plan to discontinue the sale of electronic nicotine delivery products at all Walmart and Sam’s Club U.S. locations,” the company said in a memo to local managers, according to CNBC. “We will complete our exit after selling through current inventory.”

Health risks in question

Last week, the Trump administration announced that it’s moving toward a federal ban on all non-tobacco flavored e-cigarette products in response to mounting health concerns related to the products. The same week, New York announced that it would ban the sale of flavored e-cigarettes and other vaping products in an effort to address the same concerns.

The Food and Drug Administration (FDA) disclosed late last week that it has opened a criminal investigation into vaping and the illnesses it appears to have caused. The agency’s tobacco director, Mitch Zeller, said the probe is focused on uncovering the cause of the illnesses by examining the chemical makeup of the products and how people use them. 

“We are in desperate need of facts," Zeller said. “The focus of their work is to identify what is making people sick, as well as a focus on the supply chain.”

Walmart’s decision to stop selling e-cigarettes came several months after it ceased sales of fruit- and dessert-flavored e-cigarettes and raised the minimum age for tobacco purchases to 21.

Leaders in the vaping industry continue to assert that the products are less harmful than traditional cigarettes. Tony Abboud, executive director of the Vapor Technology Association, called Walmart’s decision to reduce adult smokers’ access to regulated vaping products “irresponsible.” 

"This will drive former adult smokers to purchase more cigarettes,” Abboud said in a statement.

The Food and Drug Administration (FDA) has launched a criminal probe into vaping as the number of lung illnesses and deaths linked to the products continues to climb. 

Health officials say more than 530 people have now been affected by the mysterious vaping-related lung illness, which has claimed eight lives. All patients have reported using either an electronic cigarette or vaping device prior to getting sick. 

The FDA’s tobacco director, Mitch Zeller, said the investigation is focused specifically on uncovering the cause of the illnesses by examining the chemical components of the products as it relates to how people use them. Zeller noted that the agency isn’t looking to prosecute people for their use of controlled substances through the probe. 

“We are in desperate need of facts," Zeller said. “The focus of their work is to identify what is making people sick, as well as a focus on the supply chain.”

Nationwide investigation

Health authorities suspect a chemical present in many varieties of marijuana liquid vaping products may be the underlying cause of some of the lung illnesses. Most patients reported vaping THC before becoming ill. At present, no single vaping product or ingredient has been found to have been involved in all of the cases. 

The FDA’s investigation will involve the forensic analysis of more than 150 vaping product samples, according to USA Today. Investigators will look for the presence of nicotine, THC, and other cannabinoids, opioids, cutting agents, additives, pesticides, poisons, toxin and any other substances in the samples.

“We are leaving no stones unturned," Zeller said.

Last week, the Trump administration announced that it’s moving toward a federal ban on all non-tobacco flavored e-cigarette products in an effort to address the rising tide of health concerns. New York announced earlier this week that it would implement an emergency ban on the sale of flavored e-cigarettes and other vaping products. 

Health officials in California have confirmed a seventh death connected to a vaping-related lung illness. 

The first death linked to vaping was confirmed in August in California and others were gradually reported in Kansas, Illinois, Indiana, Minnesota, and Oregon. Close to 400 cases of vaping-related lung illnesses have now been reported in 36 states. 

The man in California was reportedly sick for several weeks before dying of "severe pulmonary injury associated with vaping," said Karen Haught, the Tulare County public health officer, in a statement.

"Long-term effects of vaping on health are unknown. Anyone considering vaping should be aware of the serious potential risk associated with vaping,” Haught said. 

In the wake of the most recent death, the Centers for Disease Control and Prevention (CDC) activated its emergency operations center to help it respond to the health threat more effectively.

“CDC has made it a priority to find out what is causing this outbreak of e-cigarette or vaping-related injuries and deaths,” said CDC Director Robert Redfield, M.D. in a statement. “Activation of CDC’s Emergency Operations Center allows us to enhance operations and provide additional support to CDC staff working to protect our Nation from this serious health threat.”

Health effects in question

Lawmakers are currently lobbying to have flavored e-cigarettes banned, at least while investigations into the health effects of the products are ongoing. Last week, the Trump administration announced that it’s moving toward a federal ban on flavored vaping products amid persistent concerns over the “epidemic” of youth e-cigarette use.

Earlier this week, Governor Andrew Cuomo announced an emergency order to ban flavored e-cigarette products in New York. Sen. Richard Blumenthal (D-CT) also said this week that he wants flavored e-cigarettes to be banned in his state. Additionally, Blumenthal is pushing for a bill that would invest $500 million over the next 10 years to address e-cigarette use among teens.

"They should know these products are not harmless, they are not hip and cool, they can be severely damaging because of these compounds found in them," Blumenthal said on Monday.

The CDC recently recommended that young adults, pregnant women, and non-smokers avoid using e-cigarettes and vaping products while the agency investigates the outbreak of illnesses. 

"It is time to stop vaping," Kansas Department of Health and Environment Secretary Dr. Lee Norman said. "If you or a loved one is vaping, please stop. The recent deaths across our country, combined with hundreds of reported lung injury cases continue to intensify."

Over the weekend, New York Governor Andrew Cuomo announced he would issue an emergency order to ban flavored e-cigarette products. 

The announcement comes just a few days after the Centers for Disease Control and Prevention (CDC) said it had identified nearly 400 cases of lung disease associated with e-cigarettes. As of last week, six deaths have now been linked to vaping. 

Health officials have expressed deep concern over the “epidemic” of youth e-cigarette use that has unfolded over the past few years. Last week, the Trump administration announced that it’s moving toward a federal ban on flavored vaping products in an effort to reverse the trend. 

In a statement, Cuomo said New York is “confronting this crisis head-on” and taking a “nation-leading step to combat a public health emergency.”

"Vaping is dangerous. At a minimum, it is addicting young people to nicotine at a very early age,” Cuomo said on Sunday. 

‘Targeting young people’

Cuomo noted that there has been a 160 percent increase from 2014 on e-cigarette flavors such as bubble gum, cotton candy, and "Captain Crunch."

"Manufacturers of fruit and candy-flavored e-cigarettes are intentionally and recklessly targeting young people, and today we're taking action to put an end to it,” he said. 

Tobacco and menthol e-cigarette flavors wouldn’t be pulled from the market under the order, since these products can serve as a tool for adult smokers looking to discontinue their use of traditional cigarettes. However, "that could change in the future," Cuomo said.

Cuomo has also signed an order that would put educational awareness programs on vaping into school systems. In July, the Democratic governor announced that New York would also be raising the minimum age to purchase tobacco to 21 beginning in November. 

The Trump administration is reportedly gearing up to impose a ban on flavored e-cigarettes. 

The move comes as health officials continue to express concern over the number of teens who have picked up vaping in recent years. It also comes amid an ongoing national investigation into a surge in “severe” lung illnesses among e-cigarette users that has claimed six lives.

U.S. Health and Human Services Secretary Alex Azar said in a statement on Wednesday that the administration is “making it clear that we intend to clear the market of flavored e-cigarettes to reverse the deeply concerning epidemic of youth e-cigarette use that is impacting children, families, schools and communities.” 

“We will not stand idly by as these products become an on-ramp to combustible cigarettes or nicotine addiction for a generation of youth,” Azar continued. 

He said the Trump Administration wants to pull the products from the market entirely, at least until the FDA can thoroughly review their safety. 

Late last week, health officials reported that e-cigarette use is likely behind more than 450 cases of lung illnesses affecting users in 33 states. As of Tuesday, six people have died from causes believed to be linked to the use of e-cigarettes and other devices. 

FDA guidance coming soon

President Trump said on Wednesday that the FDA would be issuing "some very strong recommendations" regarding the use of flavored e-cigarettes in "a couple of weeks,” according to CNN.

The policy expected to be unveiled in the coming weeks would require manufacturers of flavored e-cigarette products to remove their products from the market within 30 days.

"It'll take several weeks for us to put out the final guidance that will announce all the parameters around the enforcement policy, and then there will likely be about a 30-day delay to effective date, as is customary," Azar said. “At that point all flavored e-cigarettes other than tobacco flavor would have to be removed from the market."

Applications seeking FDA approval to reenter the market could be submitted at a later date. 

“We strongly agree with the need for aggressive category-wide action on flavored products,” a Juul spokesman told CNBC. “We will fully comply with the final FDA policy when effective.”

The Centers for Disease Control and Prevention recently recommended that young adults, pregnant women, and non-smokers avoid using e-cigarettes and vaping products while the agency investigates the outbreak of lung illnesses. Those who use e-cigarette products are urged not to buy them off the street, modify them, or add any substances to the products that are not intended by the manufacturer. 

A sixth person has died from the mysterious vaping-related illness that is currently the subject of a national investigation.

Kansas health officials said on Tuesday that a woman over 50 with pre-existing health problems died after her symptoms were exacerbated by vaping. The woman died of acute respiratory distress syndrome less than a week after she began using e-cigarettes. 

Just a few days ago, health authorities announced that the number of vaping-related lung illnesses has increased to over 450. The CDC said those affected by the “outbreak of severe pulmonary disease” are spread across 33 states.  

The number of recent deaths believed to be linked to vaping has now risen to six. The other five vaping-related deaths were reported in Illinois, Indiana, Oregon, Minnesota, and California.

"It's time to stop vaping," Dr. Lee Norman, secretary for the Kansas Department of Health and Environment, wrote in a news release. "If you or a loved one is vaping, please stop."

Officials recommend avoiding use

On Friday, officials said they suspect a chemical derived from vitamin E may be the underlying cause of the lung illnesses. The chemical is present in many different types of marijuana liquid vaping products, which many patients reported using. 

While the investigation is ongoing, health officials have recommended that young adults, pregnant women, and non-smokers avoid using e-cigarettes and vaping products. Those who use e-cigarette products are urged not to buy them off the street, modify them, or add any substances to the products that are not intended by the manufacturer. 

“The severity of illness people are experiencing is alarming and we must get the word out that using e-cigarettes and vaping can be dangerous,” said Ngozi Ezike, director of the Illinois Department of Public Health, in an August statement. 

On Monday, the Food and Drug Administration (FDA) charged vaping industry leader Juul with illegally marketing its nicotine pods as “safe.” In a letter to the company’s CEO Kevin Burns, the FDA demanded that Juul change its marketing practices or risk being hit with a hefty fine or having its products seized. 

The letter was sent two days after the FDA reviewed testimony from a congressional hearing on Juul, which took place in July. The FDA said it found that Juul illegally sold or distributed its products as “modified risk tobacco products without an FDA order in effect that permits such sale or distribution.”

The agency stressed that regulatory approval is required before a company can market a specific product as being safer than traditional cigarettes. 

Federal regulators said Juul shirked that law by touting its products as carrying "a lower risk of tobacco-related disease” and being “less harmful than one or more other commercially marketed tobacco products.” Juul has never submitted its vaping devices for FDA review. 

“The law is clear that, before marketing tobacco products for reduced risk, companies must demonstrate with scientific evidence that their specific product does in fact pose less risk or is less harmful," acting FDA Commissioner Ned Sharpless said in a statement. "JUUL has ignored the law, and very concerningly, has made some of these statements in school to our nation's youth."

Health concerns raised

The FDA has given Juul 15 days to respond to the letter with a plan for maintaining compliance with the U.S. Federal Food, Drug, and Cosmetic Act. 

Alternatively, Juul may provide “reasoning and provide any and all scientific evidence and data, if any, that support that your statements and representations do not explicitly or implicitly convey that JUUL products pose less risk, are less harmful, present reduced exposure, or are safer than other tobacco products.”

A spokesperson for Juul said the company intends to “fully cooperate” with regulators.

Juul’s legal troubles come amid growing concern over the health risks of vaping products. On Friday, the Centers for Disease Protection and Control and Prevention (CDC) announced that it’s investigating hundreds of lung illness cases and five deaths that could be linked to chemical exposure while vaping.

While the investigation is ongoing, health officials have recommended that young adults, pregnant women, and non-smokers avoid using e-cigarettes and vaping products. Those who use e-cigarette products are urged not to buy them off the street, modify them, or add any substances to the products that are not intended by the manufacturer. 

On the heels of three more deaths believed to be associated with electronic cigarettes, federal health officials have issued a warning urging consumers to avoid using the products while they conduct an investigation into the matter. 

The Centers for Disease Control and Prevention (CDC) said on Friday that over 450 users of these devices have now reported symptoms of severe pulmonary disease.  

"CDC, US Food and Drug Administration (FDA), state and local health departments, and other clinical and public health partners are investigating a multistate outbreak of severe pulmonary disease associated with e-cigarette product (devices, liquids, refill pods, and/or cartridges) use,” the CDC said. 

“This investigation is ongoing and has not identified a cause, but all reported cases have a history of using e-cigarette products," the agency noted.

The illnesses have been reported from 33 states. With the addition of the three recent deaths, the number of deaths potentially linked with vaping has now risen to five. 

Chemical link suspected

Towards the end of August, the CDC announced that it was launching an investigation in response to “a cluster of pulmonary illnesses” in multiple states. Patients who had confirmed that they used e-cigarettes reported symptoms such as chest pain, fatigue, shortness of breath, and vomiting. 

The agency said there is no evidence that an infectious disease is causing the illnesses, which has led officials to believe the illnesses may be associated with chemical exposure. On Friday, health officials suggested that the lung illnesses were linked to a chemical derived from vitamin E that is present in many different types of marijuana liquid vaping products. 

All of the patients who have gotten sick have reported using e-cigarettes, but no specific substance or product was found to be linked to all the cases. However, many patients reported using e-cigarette products with liquids that contain cannabinoid products (such as THC), the CDC said. 

“These investigations are ongoing,” the agency wrote. “CDC will provide updates when more information is available.” 

In the meantime, health officials have recommended that young adults, pregnant women, and non-smokers avoid using e-cigarettes and vaping products. Those who use e-cigarette products are urged not to buy them off the street, modify them, or add any substances to the products that are not intended by the manufacturer. 

Federal health officials are making a case that a recent outbreak of lung illnesses may be linked to a chemical derived from vitamin E that is present in many different types of marijuana liquid vaping products.

The Washington Post reports information about the possible link was revealed this week in a conference call by the Food and Drug Administration (FDA) and health officials from various states.

Previously, the lung illnesses were linked to the vaping of a wide-ranging assortment of marijuana products. The chemical showed up in most of the cannabis samples from patients who got sick over the summer.

Vitamin E is harmless enough and millions of consumers take it daily in the form of a supplement. It’s also found naturally in certain food oils.

When ingested as a food, it’s not known to cause any problems -- but inhaling it may be another matter. Scientists say vitamin E’s molecular structure could cause problems if it is inhaled as a vapor.

The issue first came to light at least a year ago when health researchers claimed that vaping can damage important cells in the immune system and cause inflammation of the lungs. The researchers, writing in the journal Thorax, said that they "caution against the widely held opinion that e-cigarettes are safe.”

Official vaping death

Last month, the Centers for Disease Control and Prevention (CDC) for the first time officially attributed a death to vaping. Previously, some 200 cases of severe lung illnesses had been flagged as being potentially linked with vaping

In August, the agency said one adult patient in Illinois died over the summer after symptoms from an existing pulmonary illness were exacerbated or caused by e-cigarette use. 

Bureaucratic irregularities may make it harder for health officials to pin down the exact cause of these mystery lung ailments. At present, states don’t have to report suspected cases of vaping-related illnesses. Even if they did it might be difficult to pin down the ingredient in the many types of vaping liquids that is causing the problem.

Meanwhile, as of last week, state health department had reported 215 possible cases of vaping-related illnesses in 25 states.

A published report claims the Federal Trade Commission (FTC) is investigating Juul, the manufacturer of a popular e-cigarette product, to determine whether it has aimed its marketing efforts at minors.

The Wall Street Journal reports the regulator’s wide-ranging investigation is also focused on the company’s past use of paid influencers to help promote the product.

The Journal quotes a company spokesman as saying Juul used paid influencers in a “small, short-lived pilot” program that ended last year. Juul says it paid influencers less than $10,000 to post positive reviews about the e-cigarettes.

Juul is also under investigation by the Food and Drug Administration (FDA). A year ago the FDA seized more than a thousand pages of documents from Juul during an unannounced inspection of the company’s headquarters in San Francisco.

Then-FDA Commissioner Scott Gottlieb called the growing use of e-cigarettes among teens an “epidemic” and said easy access to the products was only fueling the trend.

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens," Gottlieb said last year. "The FDA won't tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products."

At the time, the FDA expressed concern that e-cigarette manufacturers, including Juul. were offering flavored products that appealed to teens. Since then, manufacturers have taken steps to discourage the use of their products by under-age consumers.

Smokers only

Juul has said that its products are for use by cigarette smokers to help them stop smoking. In an interview with CBS News Juul CEO Kevin Burns said people who don’t have a pre-existing  relationship with nicotine should not use his company’s products.

“Don't vape. Don't use Juul," Juul CEO Kevin Burns told the network. "Don't start using nicotine if you don't have a preexisting relationship with nicotine. Don't use the product. You're not our target consumer."

While Juul appears to be a favorite product of teens, the company says it never wanted to tap into that market. It recently introduced a bluetooth-enabled e-cigarette that requires consumers to submit a photo ID before the product can be used.

Juul Labs, which has been accused of fueling the teen vaping epidemic through its marketing campaign, has announced a new POS age-verification system that it hopes will reduce youth use of its products. 

“Today, we are implementing a series of new measures to combat the serious problem of youth access, appeal, and use of vapor products,” Juul said in a statement.

Juul says it’s partnering with retailers to implement the Retail Access Control Standards program (or RACS) -- “the strictest age-verification system ever required for age-restricted products,” said CEO Kevin Burns.

Under the new set of guidelines: 

• ID scanning to verify age is required

• Bulk purchasing is blocked to prevent social sourcing 

• Clerks can’t override the system manually 

Retailers who sell Juul must implement the new system by May 2021. More than 50 chains (totaling about 40,000 stores) have pledged to make the switch so far, and more than half of those outlets say they will comply with the system before the end of this year. 

Taking steps to curb youth use

Juul’s new plan to prevent youth use of its products comes about a month after CEO Kevin Burns apologized to parents whose children are addicted to the company’s e-cigarettes. 

“First of all, I’d tell them that I’m sorry that their child’s using the product,” Burns said in a documentary called “Vaporized: America’s E-cigarette Addiction.” 

“It’s not intended for them. I hope there was nothing that we did that made it appealing to them. As a parent of a 16-year-old, I’m sorry for them, and I have empathy for them, in terms of what the challenges they’re going through,” Burns said. 

In the RACS release, Juul said it’s aware that youth vaping in the U.S. has become a “serious and urgent problem” over the past few years. “At JUUL Labs, we have no higher priority than combating youth use,” the company said. 

The Centers for Disease Control and Prevention (CDC) has announced that it has recorded the first death believed to be linked to vaping. 

Nationwide, nearly 200 cases of severe lung illnesses have been flagged as being potentially linked with vaping, according to the CDC’s most recent figures. The agency said one adult patient in Illinois died over the summer after symptoms from an existing pulmonary illness were exacerbated or caused by vaping or e-cigarette use. 

The CDC said “severe unexplained respiratory symptoms” have been reported after vaping or e-cigarette use. Symptoms reported by patients have included breathing difficulties, vomiting, nausea, chest pain, and fatigue. 

Health officials have determined that an infectious disease isn’t causing the illnesses, but they have stopped short of naming vaping as the definitive cause. 

“While some cases in each of the states are similar and appear to be linked to e-cigarette product use, more information is needed to determine what is causing the illnesses,” CDC official Ileana Arias said in a statement. 

‘Alarming’ rise in illnesses

Last week, the CDC announced that it was investigating “a cluster of pulmonary illnesses” in five states (California, Illinois, Indiana, Minnesota and Wisconsin) that appeared to be linked with the use of e-cigarettes and other vaping devices. 

The agency said at the time that 94 cases of lung illnesses associated with e-cigarette use had been reported. Over the last week, the number of individuals who reported similar symptoms between June 28 and today increased to 193. 

Illinois has a particularly high concentration of the unknown lung illnesses among e-cigarette users. As of Friday, 22 people in the state have been hospitalized and 12 more cases are being reviewed. 

“The severity of illness people are experiencing is alarming and we must get the word out that using e-cigarettes and vaping can be dangerous,” said Ngozi Ezike, director of the Illinois Department of Public Health, in a statement.

The CDC said it’s working on developing a system to “collect, aggregate, and analyze data at the national level to better characterize this illness.”

​The Centers for Disease Control and Prevention (CDC) has announced that it’s looking into a possible link between severe lung diseases and e-cigarette use. 

The agency launched its probe in response to “a cluster of pulmonary illnesses” in five states -- California, Illinois, Indiana, Minnesota and Wisconsin -- that appear to be linked with the use of e-cigarettes and other vaping devices. 

The illnesses were mostly reported among adolescents and young adults, the CDC said. 

“Additional states have alerted CDC to possible (not confirmed) cases and investigations into these cases are ongoing,” the agency stated over the weekend. “There is no conclusive evidence that an infectious disease is causing the illnesses. While some cases in each of the states are similar and appear to be linked to e-cigarette product use, more information is needed to determine what is causing the illnesses.” 

Patients reported symptoms such as chest pain, fatigue, shortness of breath, and vomiting. Health officials said patients who experienced these problems were hospitalized after their symptoms worsened.

“All patients were hospitalized, with some needing assistance to breathe. While patients have improved with treatment, it is unknown whether there will be long-term health effects,” the Utah Department of Health said in a statement.

Nearly 94 cases of “severe” illnesses associated with e-cigarette use have so far been reported across 14 states since June 28, according to the CDC. 

Teen vaping raises alarm

Use of e-cigarettes among teenagers has skyrocketed in recent years, prompting both the FDA’s former chief and the Surgeon General of the United States to describe the issue as an “epidemic.” 

Studies have found that e-cigarette use among high schoolers grew by 78 percent between 2017 and 2018, and Juul has been singled out for its role in creating the problem. 

“The rise in e-cigarette use during 2017–2018 is likely because of the recent popularity of e-cigarettes shaped like a USB flash drive, such as JUUL,” the CDC said. “These products can be used discreetly, have a high nicotine content, and come in flavors that appeal to youths.”

In addition to carrying possible health risks, health officials have expressed concern that the recent surge in e-cigarette use among teens may lead to an increase in the use of combustible cigarettes. 

In a statement published in February, CDC Director Robert Redfield said the rise in teen vaping “threatens to erase progress made in reducing youth tobacco use and is “putting a new generation at risk for nicotine addiction.” 

The Vapor Technology Association, an industry group representing 800 vaping companies, has filed a lawsuit seeking to delay the FDA’s upcoming review of e-cigarettes.

The FDA originally set a 2022 deadline for submitting applications for e-cigarette approval, but it advanced it to May 2020 in response to a dramatic rise in teen vaping and pressure from anti-tobacco groups. In June, a judge ruled in favor of the new 2020 deadline, which prompted the vaping group to sue.

The lawsuit filed Wednesday claims the FDA’s new deadline will put many smaller vaping companies out of business. 

“It is time for FDA to stop moving the goalposts and changing the rules in the middle of the game to the detriment of our manufacturers and small businesses,” VTA executive director Tony Abboud said in a statement.

Health concerns

E-cigarette manufacturers have stressed that their products are intended to help adult smokers quit, but teens have gravitated toward them at a rate that has generated concern among health officials. 

Last month, the CEO of Juul -- which is among the members of the vaping association seeking to delay the government’s review of e-cigarettes -- issued a public apology to parents of children addicted to vaping products. 

“It’s not intended for them,” said Juul CEO Kevin Burns. “I hope there was nothing that we did that made it appealing to them. As a parent of a 16-year-old, I’m sorry for them, and I have empathy for them, in terms of what the challenges they’re going through.”

Researchers are still trying to get a clear picture of the health effects associated with e-cigarettes. The FDA is currently investigating nearly 130 reports of seizures in e-cigarette users, and regulators have expressed concern that the rise in e-cigarette threatens undo progress in reducing rates of tobacco use among minors.

The U.S. Food and Drug Administration (FDA) has sent warning letters to four companies to demand that they stop selling certain flavored e-cigarette and hookah products.

The agency says that a combined 44 products distributed by the four companies -- Mighty Vapors LLC, Liquid Labs USA LLC, V8P Juice International LLC, and Hookah Imports Inc. -- were not authorized to be legally sold in the U.S. The move comes shortly after a rule took effect that placed tobacco products under the jurisdiction of the FDA. 

“Today’s actions make clear that we will continue to keep a close watch on whether companies are breaking the law and will take swift steps when violations are found. Our work in this area has already resulted in a number of companies removing products from the market,” said Dr. Ned Sharpless, the FDA’s acting commissioner. 

The companies will have 15 days to respond to the FDA’s warning. If they fail to do so, the agency says it may have to take further action.

Addressing the youth vaping epidemic

The FDA’s decision follows several months in which regulators have sought to address the teen vaping crisis. Reports indicate that millions of teens currently use e-cigarettes, and regulators believe those high numbers may translate to future tobacco use. 

“The marketing of illegal tobacco products is particularly concerning given the epidemic of youth vaping that we’re facing, which we know has resulted in part from irresponsible practices from manufacturers importers and retailers who have targeted kids in their marketing of these products,” said Sharpless. 

“It is critical that we remain vigilant in our efforts to stem the increase in use and nicotine addiction in children driven by e-cigarettes, which threatens to erase the years of progress we’ve made combatting tobacco use among kids.”

In addition to its legal efforts, the FDA has launched its Youth Tobacco Prevention Plan to counter the teen vaping threat. It has also launched a new TV ad campaign designed to educate young people on the dangers of vaping.

What’s the “real cost” of vaping? The Food and Drug Administration (FDA) hopes to make it abundantly clear with a new television ad campaign aimed at the underage use of e-cigarettes.

It’s a dramatic expansion of the agency’s ”The Real Cost” Youth E-Cigarette Prevention Campaign launched in 2018 amid alarming statistics which showed large increases in teens’ use of e-cigarettes. Federal data showed e-cigarette use among high school students rose by 77 percent that year.

The initial campaign used hard-hitting advertising on digital and social media sites, as well as posters with e-cigarette prevention messages displayed in high schools across the nation. The new TV ads are intended to drive home public health messages about the risks of e-cigarette use.

Supposed to help smokers quit

E-cigarettes were initially introduced as a substitute for tobacco cigarettes. They produce a vapor from liquid that can be inhaled much like a cigarette. Because the liquid contains nicotine, the product is supposed to give a smoker the pleasures of smoking without using tobacco.

Many public health experts charge e-cigarette marketers of expanding their target beyond smokers who are trying to quit to teens who have never smoked. Former FDA Commissioner Scott Gottlieb, who resigned in April, was a particularly harsh critic of e-cigarette marketers.

“We don’t yet fully understand why these products are so popular among youth,” Gottlieb said in April 2018. “But it’s imperative that we figure it out, and fast.”

‘Troubling epidemic’

The FDA said the ad campaign has taken on heightened importance in light of what it says is an “emerging science” which suggests that teens who vape are more likely to start smoking cigarettes. The concern is that teens who get hooked on nicotine by using e-cigarettes will eventually graduate to tobacco in order to get a stronger dose.

“The troubling epidemic of youth vaping threatens to erase the years of progress we’ve made combating tobacco use among kids, and it’s imperative that our work to tackle this immensely concerning trend continues to include efforts to educate our nation’s youth about the dangers of these products,”  said Acting FDA Commissioner Ned Sharpless.

The new ads feature street magician Julius Dein, a YouTube star with 113 videos and nearly 800,000 subscribers. In the ads, the social media personality takes a young person’s e-cigarette  and transforms it into a cigarette in front of their eyes. The illusion is supposed to drive home the idea that teens who vape are more likely to start smoking cigarettes. 

The FDA says the new ads will run on TeenNick, CW, ESPN, and MTV, as well as on music streaming sites, social media networks, and other teen-focused media channels.

During an interview with CNBC’s Carl Quintanilla, Juul CEO Kevin Burns said he would apologize to parents whose children are addicted to Juul e-cigarettes. 

“First of all, I’d tell them that I’m sorry that their child’s using the product,” Burns said in a documentary called “Vaporized: America’s E-cigarette Addiction,” which is set to premiere Monday at 10 p.m. ET.

“It’s not intended for them,” he added. “I hope there was nothing that we did that made it appealing to them. As a parent of a 16-year-old, I’m sorry for them, and I have empathy for them, in terms of what the challenges they’re going through.”

Campaign for Tobacco-Free Kids President Matthew Myers called the apology “a deceptive, self-serving gesture by Juul given their complete refusal to take responsibility for creating the youth e-cigarette epidemic.”

“It is a blatant attempt to deflect attention from the company’s wrongdoing while it opposes meaningful government regulation to prevent it from continuing to addict kids,” Myers said in a statement on Monday, according to CNBC.

Juul’s role in the teen vaping ‘epidemic’

From 2017 to 2018, the number of youth e-cigarette users grew by 1.5 million, according to a survey conducted earlier this year by the Centers for Disease Control and Prevention (CDC).

In April, former FDA Commissioner Scott Gottlieb called out Juul -- a dominating force in the e-cigarette industry -- for fueling what they have called a teen vaping epidemic. Vaping products manufactured by Juul have been shown to be especially popular among teen users since they come in fruity flavors like fruit, creme, and mango. 

“I hope they recognize the problem that’s been created has been created largely by their product,” Gottlieb told Vox.

Juul has maintained that its intent was never to pull in youth users. To address the issue, the company has taken several actions to curb teen use of its products, including shuttering its social media accounts and eliminating its flavored products.

Controversial marketing campaign

Federal regulators have set out to reduce youth use of e-cigarettes in recent years, but critics say the damage caused by Juul may already have been done. Gottlieb noted that Juul’s early marketing campaigns appeared to speak directly to young people. 

“If you go back and look at their marketing campaigns from 2015 and 16, it’s hard not to look at that marketing and conclude that it's not going to be appealing to a youth, to a teenager,” Gottlieb said earlier this year. “It certainly in my view had some impact on creating the problem we have now.”

In the upcoming documentary, Burns refutes the claim that Juul’s initial marketing marketing campaign had any significant impact on sales. 

“When we launched Juul, we had a campaign that was arguably too kind of lifestyle-oriented, too flashy,” Burns said. “It lasted less than six months. It was in the early days of the product introduction. We think it had no impact on sales.”

Health impact in question

E-cigarette manufacturers have stressed that their products are intended to help adult smokers quit. However, teens have gravitated toward them at a rate that has sparked concern among health officials, who aren’t yet sure of the adverse health effects the products could cause down the line.

“Frankly, we don’t know [the impact of chronic vaping] today,” Burns said. “We have not done the long-term, longitudinal, clinical testing that we need to do.”

Additionally, regulators have expressed concern that the rise in e-cigarette could undo progress in reducing rates of tobacco use among minors.

"The skyrocketing growth of young people's e-cigarette use over the past year threatens to erase progress made in reducing youth tobacco use. It's putting a new generation at risk for nicotine addiction," CDC Director Robert Redfield said in a statement published in February.

Juul has said it supports the initiative to raise the minimum smoking age to 21 to prevent minors from buying its products.

On Tuesday, San Francisco became the first U.S. city to ban e-cigarettes when city officials passed an ordinance prohibits selling nicotine “pods” -- cartridges that contain nicotine and used in a vaporizer -- or electronic smoking devices that haven’t been approved by the Food and Drug Administration (FDA).

“There is so much we don’t know about the health impacts of these products, but we do know that e-cigarette companies are targeting our kids in their advertising and getting them hooked on addictive nicotine products,” San Francisco mayor London Breed said in a statement.

Who’ll be the next to step up?

It’ll be interesting to see if San Francisco’s ban catches fire and moves to other cities. Two other cities in the Bay Area --  the cities of Richmond and Livermore -- have already announced that they may follow in San Francisco’s footsteps.

On a state level, 48 states have laws in place prohibiting access to e-cigarettes for people up to 18 years old or older. 

On the federal level, the initiative has great support from the FDA. Last year, the agency carried out the largest coordinated enforcement effort in the FDA’s history when it issued more than 1,300 warning letters and fines to businesses that illegally sold e-cigarette products to minors.

Manufacturers say they’re on board, at least with teen use

Teens are the primary consumer target for e-cig companies. Close to 21 percent of U.S. high school students and 5 percent of middle schoolers say they’ve used electronic cigarettes in the past 30 days. Adding to that concern is an estimate that some addicted minors spend as much as $1,500 per year feeding their e-cig habit.

Juul -- the largest e-cig manufacturer, one owned in part by Altria, the parent company of Philip Morris -- has its white hat on and says it’s behind the prohibition to minors all the way. In its “commitment to youth prevention,” Juul promises it will:

• Suspend the distribution of non-tobacco and non-menthol-based flavored JUUL products to retail outlets;

• Enhance its e-commerce platform to ensure purchasers are 21+ and to prevent bulk purchases;

• Promote retailer compliance to ensure retail stores do not sell JUUL products to those underage;

• Exit its U.S. Facebook and Instagram accounts; and

• Develop technology-based solutions to prevent youth use.

Finding out the full impact will take time

It’s too early to predict the long-term effects of e-cigarette smoking. With tobacco, there were decades of use and diseases to draw from. But researchers are already seeing some similarity in how genes and proteins are affected. 

“While many of the chemicals found in e-liquids are FDA approved, they are approved for ingestion, not inhalation,” said UNC School of Medicine toxicologist Ilona Jaspers. “When you switch the route of exposure (inhaling instead on ingesting), and go through the lung, the lung is really not a good organ to metabolize foreign compounds.”

City supervisors in San Francisco are set to make the city the first in the country to prohibit all sales of e-cigarettes. The move comes as federal regulators continue to formulate ways to combat the alarming surge in teen vaping rates.

In addition to banning e-cigarette distribution and sales, city supervisors are expected to vote to impose a ban on manufacturing e-cigarettes on city property. The measures, which will receive a final vote next week, are each intended to prevent e-cigarettes from taking the place of traditional cigarettes.

Though vaping is considered to be less harmful than smoking cigarettes, researchers say the health risks of e-cigarettes may be more extensive than consumers may have been led to believe.

“This is about thinking about the next generation of users and thinking about protecting the overall health and sending a message to the rest of the state and the country: Follow our lead,” Supervisor Ahsha Safaí said in a statement to the media.

Addressing the rise in teen vaping

While vaping may be a useful tool in helping some smokers quit, former FDA Commissioner Scott Gottlieb has said that the agency “will not allow that opportunity to come at the expense of addicting a whole new generation of kids to nicotine.”

Just recently, the FDA reprimanded four vaping companies for failing to ensure that content posted by social media influencers contained the statement, “WARNING: This product contains nicotine. Nicotine is an addictive chemical.”

“Given the significant risk of addiction, the failure to disclose the presence of and risks associated with nicotine raises concerns that the social media postings could be unfair or likely to mislead consumers,” federal regulators said in letters sent to the four companies.

Juul, the leader in the e-cigarette industry, wasn’t among the companies that received a letter. However, the manufacturer was accused of reneging on its promise to serve only as an “off-ramp” for smokers to quit when it accepted a $12.8 billion investment from tobacco giant Altria.

The upcoming vote in San Francisco could have a big impact on Juul, which is headquartered in the city. Juul is currently backing a signature-collecting initiative for a November vote to overrule the measure.

Banning vaping products for all adults in San Francisco “will not effectively address underage use and will leave cigarettes on shelves as the only choice for adult smokers, even though they kill 40,000 Californians every year,” a spokesman for Juul told the Associated Press.

If imposed as expected, the ban would go into effect in around seven months.

A federal judge ruled Wednesday that the Food and Drug Administration (FDA) must speed up its review of the health impact of electronic cigarettes.

The ruling represents a victory for public health groups, who last year sued the agency after its delay in regulating e-cigarette products gave way to a rise in vaping among teens.

The groups that filed the lawsuit included the American Academy of Pediatrics, the Campaign for Tobacco-Free Kids, the American Cancer Society Cancer Action Network, and the heart and lung associations.  

Lack of regulation in the industry

In the complaint, the groups expressed deep concern that the FDA’s lack of written rules and product standards in the e-cigarette industry could threaten to get a new generation of Americans addicted to nicotine.

"It is now the FDA's responsibility to take immediate action to protect our kids and require manufacturers to apply to the FDA if they want to keep their products on the market," the groups said in a statement.

The lawsuit centers around the fact that the FDA postponed its review of the impact of e-cigarettes by several years -- a move that Maryland U.S. District Judge Paul Grimm, who issued the ruling, called “so extreme as to amount to an abdication of its statutory responsibilities.”

For its part, the agency has argued that both its staff and manufacturers need more time to prepare for regulation. Grimm has ordered the FDA to submit plans for speeding up the review process within two weeks.

E-cigarettes remain controversial within the Food and Drug Administration, which has expressed alarm at what it calls an epidemic of teen use of the nicotine-delivery device.

But the agency has flashed a green light for a new tobacco product that some critics argue is very similar to electronic cigarettes. The FDA has authorized the marketing of a new Phillip Morris product called a “tobacco heating system.” It consists of an electronic device that heats tobacco-filled sticks wrapped in paper to generate a nicotine-containing aerosol.

At the same time, the FDA said it is placing strict marketing restrictions on the products in an effort to prevent youth access and exposure.

The FDA said it is approving the product because, in the long run, it may be beneficial to public health by encouraging more cigarette smokers to quit. Following a review, it was determined that the new product produces lower levels of some toxins than regular cigarettes.

Marlboro brand

The FDA has cleared the way for marketing of the product, known as an IQOS device, sold under the brand names Marlboro Heatsticks, Marlboro Smooth Menthol Heatsticks, and Marlboro Fresh Menthol Heatsticks.

The agency makes clear that while it is approving the sale of this type of product in the U.S., it in no way is declaring it safe or ”FDA approved.”

“Ensuring new tobacco products undergo a robust premarket evaluation by the FDA is a critical part of our mission to protect the public, particularly youth, and to reduce tobacco-related disease and death,” said Mitch Zeller, J.D., director of the FDA’s Center for Tobacco Products.

May help smokers quit

Zeller said the agency paid particular attention to how the product may affect the use of nicotine and tobacco, a concern that has increased in recent years as young people who have never smoked have taken up “vaping,” inhaling nicotine vapor. In the end, the agency decided that with stringent controls to keep the new product away from teens it had potential to move smokers away from cigarettes.

“Importantly, the FDA is putting in place postmarket requirements aimed at, among other things, monitoring market dynamics such as potential youth uptake,” Zeller said. “We’ll be keeping a close watch on the marketplace, including how the company is marketing these products, and will take action as necessary to ensure the continued sale of these products in the U.S. remains appropriate and make certain that the company complies with the agency’s marketing restrictions to prevent youth access and exposure.”

Underscoring its concern, the FDA said all tobacco products are potentially harmful and addictive and those who do not use tobacco products shouldn’t start.

As he left office, Food and Drug Administration Commissioner Scott Gottlieb was highly critical of e-cigarette maker JUUL, charging the company has had a role in the increase of teen “vaping.”

But concern about the company is a bipartisan issue, with 11 Democratic members of the U.S. Senate now voicing their concern. In a letter to the company, the lawmakers asked for answers to questions about JUUL’s marketing practices.

The Democrats told JUUL they will not only look at how the company markets its product but also investigate its sale of a portion of the firm to Altria, a tobacco company.

“While JUUL has promised to address youth vaping through its modest voluntary efforts, by accepting $12.8 billion from Altria—a tobacco giant with such a disturbing record of deceptive marketing to hook children onto cigarettes—JUUL has lost what little remaining credibility the company had when it claimed to care about the public health.,” the senators wrote. “While you and your investors may be perfectly content with hooking an entire new generation of children on your tobacco products in order to increase your profit margins, we will not rest until your dangerous products are out of the hands of our nation’s children.”

Following FDA commissioner’s lead

On his way out the door, Gottlieb took another shot at JUUL, a company he has repeatedly pressed to limit access by underage consumers to their product.

“I hope they recognize the problem that’s been created has been created largely by their product,” Gottlieb said in an interview with Vox.

During his nearly two years as FDA head, Gottlieb made combating the rise in underage use of e-cigarettes one of the agency’s highest priorities. He’s previously called out JUUL for its role in creating what he’s called a public health crisis, which he’s previously described as an “epidemic.”

‘Public health epidemic’

Sen. Dick Durbin (D-Ill.), one of the senators signing the letter, noted that both the U.S. Surgeon General and the Food and Drug Administration (FDA) Commissioner have called youth use of e-cigarettes a “public health epidemic.”

Durbin cites data from the National Youth Tobacco Survey (NYTS) showing 20.8 percent of high-school students and 4.9 percent of middle-school students—more than 3.6 million children—currently use e-cigarettes. Durbin says in the last year children’s use of e-cigarettes has increased by 78 percent.

JUUL has defended itself from criticism by saying it makes its product for smokers who are trying to break their addiction to cigarettes. It said it agreed to the investment by Altria because the money it received allows the company to reach more smokers who are trying to quit.

FDA Commissioner Scott Gottlieb, who last month announced that he would be resigning from his position to spend more time with his family, said in an interview with Vox during his final week that e-cigarette manufacturer Juul is largely to blame for the “dramatic spike of youth [vaping].”

“I hope they recognize the problem that’s been created has been created largely by their product,” Gottlieb told Vox.

During his nearly two years as FDA head, Gottlieb has made combating the rise in underage use of e-cigarettes one of the agency’s highest priorities. He’s previously called out Juul for its role in creating the public health crisis, which he’s previously described as an “epidemic.”

Appeals to minors

The FDA has cited research that shows an estimated 37 percent of high school seniors have tried e-cigarettes. A quarter of youth users told researchers they didn’t realize the products contain nicotine.

The agency has said products manufactured by Juul have been shown to be especially attractive to minors because they come in fruity flavors such as mango, mint, and fruit and creme. In January, Gottlieb warned that e-cigarettes could be taken off the market unless marketers made efforts to stop sales to minors.

Gottlieb said in his interview with Vox this week that there’s “no question” that Juul -- which markets a device that looks like a USB drive -- “drove a lot of the youth use.”

“I’m not willing to concede the point that the Juul product was responsible — at least in part — for the sharp uptick in youth use,” he said.

Controversial marketing strategies

For its part, Juul has maintained that it’s dedicated to helping adult smokers quit by serving as an “off-ramp” for users of traditional cigarettes. However, Juul’s early marketing campaign often appeared to speak directly to young people.

“If you go back and look at their marketing campaigns from 2015 and 16, it’s hard not to look at that marketing and conclude that it's not going to be appealing to a youth, to a teenager,” Gottlieb said. “It certainly in my view had some impact on creating the problem we have now.”

Next steps

After Gottlieb steps down from his post, Ned Sharpless -- the current director of the National Cancer Institute -- will replace him as interim FDA commissioner.

Gottlieb says the surge in adolescent vaping has now reached the level of an “addiction crisis” which will “take time to reverse.” He said concerns about youth vaping should take priority over concerns about smokers if teen vaping rates continue to rise.

Gottlieb’s past moves to curb youth use of e-cigarettes have included restricting the sale of flavored e-cigarette products to young people and asking companies to take voluntary steps to withdraw them.

The Food and Drug Administration (FDA) is investigating dozens of reports that consumers using e-cigarettes have suffered seizures.

The agency said a search of its files revealed 35 reports of seizures, occurring between 2011 and 2019. In most instances, the victims were teens and young adults. In a joint statement, FDA Commissioner Scott Gottlieb and Deputy Commissioner Amy Abernathy said it’s another reason to be concerned about the growing vaping trend among young people.

“We know that nicotine isn't a harmless substance, especially in the developing brains of our youth,” the two officials said. “We know that initiation to, and addiction to nicotine by never-smokers – predominantly youth and young adults – raises public health concerns. These risks are among the many reasons why we so strongly believe that no child should be using any tobacco product.”

No established pattern

The FDA says the investigation has just begun and that so far, there doesn’t appear to be a pattern to the cases. In fact, Gottlieb and Abernathy say there isn’t proof of a direct connection, but the possibility of one requires the agency to investigate.

In some of the cases, the victims were vaping for the first time. In others, the victims were regular users. A few had a history of seizures and a few others had a history of drug use.

“While we believe that currently addicted adult smokers who completely switch off of combustible tobacco and onto e-cigarettes have the potential to improve their health, e-cigarettes still pose health risks,” Gottliieb and Abernathy said. “These include the possible release of some chemicals at higher levels than conventional cigarettes.”

They said there is also data to indicate there may be other potential health concerns with the product, especially since some e-cigarettes deliver a higher concentration of nicotine.

Other dangers

E-cigarettes use a small battery to heat nicotine-laced liquid into a vapor, which is inhaled much like a conventional cigarette. Some smokers have been able to give up cigarettes by vaping, but the FDA has expressed concern that many non-smoking teens have begun using e-cigarettes.

In addition to concerns about possible health risks, there are documented cases in which the products have caused serious injury when they exploded. A report last fall from researchers at George Mason University suggested the number of these cases has been underreported.

Analyzing data from the Consumer Product Safety Commission the researchers reported that approximately 2,035 people ended up in the emergency room due to e-cigarette burns or explosions between 2015 and 2017.

San Francisco city officials have introduced a measure to ban the sale of e-cigarettes within the city until the Food and Drug Administration (FDA) can rule on their safety.

It’s the first U.S. city to consider outlawing the sale of the electronic nicotine-delivery devices, which have come under fire because of their growing popularity among teens. The city has already outlawed the sale of flavored e-cigarettes because they are believed to be more popular with young people.

If the proposed ordinance is adopted in San Francisco, it would prohibit the sale of e-cigarettes within the city limits, either in retail stores or online. The measure was announced Tuesday by the city attorney, Dennis Herrera, and Supervisor Shamann Walton.

“San Francisco has never been afraid to lead and we’re certainly not afraid to do so when the health and lives of our children are at stake,” Herrera said.  E-cigarettes have wiped out the hard-fought gains we have made in curbing youth tobacco use. Today we are taking action to protect our kids.”

Would require FDA review

Herrera said the law requires a new tobacco product, before it goes on sale, to be reviewed by the FDA for its impact on health.

“Inexplicably, the FDA has failed to do its job when it comes to e-cigarettes,” Herrera said. “Until the FDA does so, San Francisco has to step up. These products should not be on our shelves until the FDA has reviewed the threat they pose to public health.”

Walton singled out Juul, an e-cigarette maker owned by Altria but based in San Francisco,  claiming it is contributing to increased numbers of people addicted to nicotine.

“Banning vaping products that target young people and push them towards addiction to nicotine and tobacco is the only way to ensure the safety of our youth,” he said.

‘Modern day prohibition’

In an interview with USA Today, Gregory Conley, president of the American Vaping Association, pointed out that actual tobacco products, such as cigars and cigarettes, are still legally sold in the California city.

"No youth should vape, but no politician should try to enact modern-day prohibition," Conley told the newspaper. "It is hard for San Francisco to get even more absurd, but this proposal and the rhetoric around it is absolutely insane."

If the San Francisco action weren’t bad enough for Juul and its parent company Altria, FDA Commissioner Scott Gottlieb disclosed that his meeting last week with Altria officials to discuss its e-cigarette business was “difficult.”

Gottlieb said the meeting left the firm impression with him that Altria’s decision to invest in the e-cigarette maker last year was purely a business decision and not an effort to offer a tobacco substitute.

The U.S. Food and Drug Administration (FDA) has proposed a new set of rules that would restrict sales of flavored e-cigarette products as part of its larger goal to counter the rise in teen vaping.

As flavored e-cigs have been shown to appeal to youth, the FDA has proposed prioritizing enforcement on sales of flavored products (other than tobacco-, mint-, and menthol-flavored).

“For instance, we’ll consider whether the products are sold under circumstances, whether at retail or online, without heightened age verification,” outgoing Commissioner Scott Gottlieb wrote in a statement.

In its draft guidance, the FDA also said it would be moving up the deadline to submit market applications to August 8, 2021.

“This is an important change in our expectations and enforcement priorities,” Gottlieb wrote of the new deadline, which is a year earlier than stated in a previous proposal.

“For all flavored ENDS [electronic nicotine delivery system] products, including any that continue to be offered for sale under circumstances involving heightened age verification, the FDA expects manufacturers to prepare and submit applications that demonstrate these products meet the public health standard by Aug. 8, 2021.”

Gottlieb, who announced recently that he plans to step down next month, has previously singled out Juul for offering fruity flavors that tend to appeal to underage users and contributing to “epidemic” levels of teen use.

He said the agency would consider taking further action if youth demand for “plain” e-cigarettes rises following the adoption of stricter rules for flavored products.

The proposal is open for public comment for the next 30 days.

In case you had any optism left that vaping could be a healthy alternative to smoking, a new study of nearly 100,000 Americans adds to the growing pile of evidence that e-cigarettes hurt smokers more than they help.

The new research, set to be presented next week at the American College of Cardiology's 68th Annual Scientific Session, is based on data about 96,467 people that was collected by the National Health Interview Survey, a federal government program that falls under the Centers for Disease Control and Prevention (CDC).

According to the findings, Americans who reported smoking e-cigarettes in the survey were 56 percent more likely to have a heart attack, 30 percent more likely to suffer a stroke, 10 percent more likely to suffer from coronary artery disease, and twice as likely to report depression or anxiety.

"These data are a real wake-up call and should prompt more action and awareness about the dangers of e-cigarettes," author Dr. Mohinder Vindhyal, a professor at the University of Kansas School of Medicine Wichita, told Environmental Health News in a statement.

“When the risk of heart attack increases by as much as 55 percent among e-cigarettes users compared to nonsmokers, I wouldn't want any of my patients nor my family members to vape," he added.

Mounting evidence

Experts say that the synthetic chemicals that create the seemingly harmless “puff” of fake smoke are the likely culprit.

The study follows three others published in recent years suggesting a link between e-cigs and cardiovascular problems and strokes. This particular report is significant because it also detected a link between e-cigs and circulatory problems, according to Dr. Stanton Glantz, a University of California, San Francisco researcher who has studied the dangers of smoking regular old cigarettes for decades, as well as e-cigarettes more recently.

On his website, Glantz writes that e-cigarettes are also harmful because they don’t actually encourage people to quit their cigarette addictions.

“Of course, most smokers who use e-cigs continue to be dual users, he writes, (i.e., continue using both products at the same time),” he writes, “which is substantially more dangerous than using either product alone.”

Citing thousands of tobacco-related violations, Food and Drug Administration (FDA) Commissioner Scott Gottlieb on Monday requested a meeting with Walgreens corporate leadership as part of the agency's ongoing crackdown on e-cigarette sales to minors.

E-cigarettes, like other tobacco products, can only be sold to people 18 and older under federal law. But in practice, critics and researchers say that the e-cig industry is intentionally marketing and selling their products to teens.

An estimated 37 percent of high school seniors have tried e-cigarettes. A quarter of those who did said they didn’t realize the products contain nicotine, according to a study published in December.  

Gas chains violate the law

The FDA says that convenience stores and other chains are also complicit in the e-cigarette epidemic among teens. Walgreens, in particular, has racked up more tobacco-related violations than any other chain, the agency says.

“Since the FDA began its retailer inspection program in 2010, FDA inspectors have found nearly 1,800 instances in which Walgreens stores failed to follow the law,” the agency wrote in a letter to Walgreens President Richard Ashworth on Monday.

“Among pharmacy chains that sell tobacco products, Walgreens is the top violator, with 22 percent of the stores inspected having illegally sold tobacco products to minors. These illegal sales must stop,” Gottlieb added.

In an accompanying press release, the agency says that Walgreens “isn’t alone” in the violations. Circle-K, 7-Eleven, and nearly every major gas station chain are also named by the agency as violating federal tobacco laws.

“We plan to similarly hold them accountable,” the FDA says.  “Ignoring the law and then paying associated fines and penalties should not simply be viewed as a cost of doing business.”

Electronic cigarettes have been dominating headlines recently, as experts continue to go back and forth on the risks associated with the devices.

Amidst countless headlines touting negative health effects, researchers from the University of Rochester Medical Center suggest that adults who are experiencing wheezing and other respiratory issues should look to their electronic cigarettes.

“The take-home message is that electronic cigarettes are not safe when it comes to lung health,” said researcher Deborah J. Ossip, PhD. “The changes we’re seeing with vaping, both in laboratory experiments and studies of people who vape, are consistent with early signs of lung damage, which is very worrisome.”

Discovering more dangers

To see the effect that e-cigarettes have on wheezing, the researchers evaluated responses from over 28,000 adults involved in the Population Assessment of Tobacco and Health (PATH) study.

While the PATH study relies on participants to report on their own behaviors, and doesn’t include information about the participants’ physical activity levels or eating habits, the researchers did find a correlation between adults who vape and those who experience wheezing.

Based on the responses, those who vape were nearly two times more likely to experience respiratory issues. The finding is significant because wheezing -- and difficulty breathing -- can lead to more serious health complications. While the researchers couldn’t prove a causal relationship between vaping and wheezing, they say the two are linked.

Teens at risk

As teens and young adults continue to be the primary users of electronic cigarettes, lawmakers have been working to make it harder for them to access the devices in an effort to eliminate any negative health effects.

The Food and Drug Administration (FDA) was working to ban online e-cigarette sales, as FDA Commissioner Scott Gottlieb called vaping an “epidemic” among teens. In late January, Gottlieb suggested that e-cigarettes could be taken off the market completely should use among teens continue to rise.

“I still believe e-cigs offer an opportunity for currently addicted adult smokers to transition off cigarettes and onto products that may not have the same level of risks. But if youth use continues to rise, the entire category faces an existential threat,” Gottlieb tweeted.

Food and Drug Administration Commissioner Scott Gottlieb has reportedly questioned whether or not Juul and Marlboro-maker Altria are truly committed to combating the rise in teen vaping. Gottlieb has asked to talk with the CEOs of these companies about "public statements that seem inconsistent" with the vows they made last year to curb youth use of e-cigarettes.

Gottlieb once again threatened to remove e-cigarettes from the market entirely if youth use continues to rise.

The FDA has previously called the alarming surge in teen vaping an “epidemic.” From 2017 to 2018, there was a 78 percent increase in current e-cigarette use among high school students and a 48 percent increase among middle school students, according to the 2018 National Youth Tobacco Survey.

“If youth use goes up 40 percent or 50 percent this year, we’re going to be having a very different discussion come this summer or fall,” Gottlieb said in an interview with Bloomberg.

Accused of backing off plan

In September, Gottlieb ordered the five largest e-cigarette manufacturers to submit their proposed plans for reducing use of e-cigarettes among minors.

Altria, Juul Labs, and other e-cigarette makers have all maintained that they fully support efforts to reduce youth access to e-cigarettes. In November, Juul said that it would halt sales of many of its flavored e-cig pods in retail stores, as fruity flavors have been shown to appeal to underage users.

Not long after these promises were made, Juul announced that it made a $12.8 billion deal with Altria, the parent company of Philip Morris USA and makers of Marlboro cigarettes. Altria said it planned to use its distribution experience to get Juul into more stores.

Questioning commitments

In an interview with CNBC on Thursday, Gottlieb stated that he’s "concerned."

"Did something change? Do they have new data? Do they have a new understanding? Because they just made a very big commitment to support the expansion of pod-based products, which they said contributes to the youth epidemic."

Altria said it still shares Gottlieb’s belief that "underage vaping has to be addressed” and that it’s still "committed to being part of the solution.”

"We look forward to meeting with the commissioner," Altria spokesman Steve Callahan told CNBC.

In December, Gottlieb expressed similar concerns over the lack of action from e-cig makers to curb teen use of their products. Gottlieb said he would be contacting e-cigarette makers “to meet to discuss commitments they made last month, and why some are changing course.”

“There’s no reason manufacturers must wait for [FDA] to more forcefully address the epidemic. Yet some already appear to back away from commitments made to FDA and the public,” Gottlieb tweeted.

The American Academy of Pediatrics (AAP) has called for the creation and implementation of new federal regulations that could help lower the rate of vaping among minors.

Citing its own data, the AAP pointed out that e-cigarette use among teens has jumped 75 percent since 2017. The group said that 20 percent of high school students and 5 percent of middle school students used e-cigarettes last year.  

“E-cigarettes are marketed to youths by promoting the products’ sweet and fruity flavors via media channels and advertising strategies used successfully by the tobacco industry to market conventional tobacco products to youths,” the AAP said in a new policy statement.

Combating the rise in teen vaping

To address what the FDA has declared an “epidemic” affecting young people, the AAP called for action on the part of federal regulators. On Monday, the organization called for new federal regulations, including:

• Setting a minimum age of 21 to buy the products;

• Banning online sales and youth-targeted marketing; and

• Stopping production of certain flavored e-cigarette products.

"Nicotine is highly addictive, and we know that the earlier that someone uses nicotine products in childhood, the more difficult it is to quit later," said Dr. Brian Jenssen, lead author of the new policy statement.

Earlier this month, FDA Commissioner Scott Gottlieb expressed similar concerns regarding the rise in teen vaping. Gottlieb warned that if e-cigarette makers fail to take sufficient measures to counter the teen vaping epidemic, e-cigarette products could be wiped from the market entirely.

“I still believe e-cigs offer an opportunity for currently addicted adult smokers to transition off cigarettes and onto products that may not have the same level of risks,” Gottlieb said. “But if youth use continues to rise, the entire category faces an existential threat.”

The AAP warned in its latest policy statement that the increasing use of e-cigarettes among minors “threatens five decades of public health gains.”

The Food and Drug Administration (FDA) is continuing to voice its concern on the alarming rise in e-cigarette use among teens.

Over the weekend, Commissioner Scott Gottlieb -- who has repeatedly called the surge in teen vaping “an epidemic” -- said that all e-cigarette makers face an “existential threat” if they fail to take sufficient measures to combat youth vaping.

“I still believe e-cigs offer an opportunity for currently addicted adult smokers to transition off cigarettes and onto products that may not have the same level of risks. But if youth use continues to rise, the entire category faces an existential threat,” Gottlieb tweeted on Saturday.

“I believe if every currently addicted adult smoker switched completely to e-cigs it would provide a tremendous public health gain. But that opportunity is in significant risk if kids use continues to rise,” he said.

Need for intervention by manufacturers

During a Friday public hearing on “Eliminating Youth Use of Electronic Cigarette and Other Tobacco Product Use,” Gottlieb noted that the number of teens using e-cigarettes (especially flavored e-cigarettes) has risen dramatically since 2017.

From 2017 to 2018, there was a 78 percent increase in current e-cigarette use among high school students and a 48 percent increase among middle school students, according to the 2018 National Youth Tobacco Survey.

Gottlieb emphasized that there’s a need for makers of e-cigarette products to take measures to mitigate the issue. If companies don’t stop marketing vaping products to youth, Gottlieb said the products could end up being removed from store shelves altogether.

“[I]f the epidemic continues to mount, I’m sure that the debate will change to one of whether these products should continue to be marketed at all without authorized pre-market tobacco applications,” Gottlieb said.

“It could be ‘game over’ for some these products until they can successfully traverse the regulatory process. I think the stakes are that high. And would be a blow for all of the currently addicted adult smokers who, I believe, could potentially benefit from these products,” he said.

Juul reacts

The FDA has previously singled out Juul for its significant role in the teen vaping epidemic, since underage users tend to gravitate toward flavored products such as those marketed by Juul. However, the company has maintained that it’s doing everything in its power to curb youth use of e-cigarettes.

“Underage use of JUUL and any other vaping products is completely unacceptable to us and is directly opposed to our mission of eliminating cigarettes by offering existing adult smokers a true alternative to combustible cigarettes," said Ted Kwong, a Juul Labs spokesperson.

"We are moving full steam ahead on implementing our action plan to limit youth usage, and this is unchanged since we announced our plan in November," he added. "We will be a transparent, engaged, and committed partner with FDA, state Attorneys General, local municipalities, and community organizations in the effort to combat underage use.”

Juul announced in November that it planned to pull some of its flavored pods from retail stores, shutter several of its social media accounts, and introduce stricter age-verification tools on its website as part of its effort to reduce youth use of its products.

The U.S. Food and Drug Administration (FDA) is planning to meet with the heads of e-cigarette companies to discuss ways to combat the alarming rise in teen vaping.

FDA Commissioner Scott Gottlieb, who has said previously that youth use of e-cigarettes has reached an “epidemic” proportion, said Thursday that he’s contacting e-cigarette makers “to meet to discuss commitments they made last month, and why some are changing course.”

“There’s no reason manufacturers must wait for [FDA] to more forcefully address the epidemic. Yet some already appear to back away from commitments made to FDA and the public,” Gottlieb tweeted.

“The vaping community that supports harm reduction for adults should also focus more of their efforts on select manufacturers that are primarily responsible for the youth epidemic if, like [FDA], they seek to preserve these opportunities as a way to transition adult smokers,” he said.

Last month, the FDA said it planned to roll out new restrictions on flavored e-cigarette products. The new restrictions included a ban on the sale of fruit and candy flavored e-cigarettes at convenience stores and gas stations, as well as stricter age verification rules for online sales of the products.

Efforts to limit youth access

Tobacco giant Altria, Juul Labs, and other e-cigarette makers have all said that they support efforts to reduce youth access to e-cigarettes. Juul said in November that it would no longer sell many of its flavored e-cig pods in retail stores, as these products have been shown to appeal to youth users.

The e-cigarette company also shuttered many of its social media accounts over concerns that teens were spreading and retweeting the company’s messages on platforms like Twitter.

Last week, the U.S. Surgeon General Jerome Adams issued a warning about e-cigarette use among teens, in which he urged aggressive steps to combat the “epidemic” of teen use. Adams specifically singled out Juul in the advisory when he said that it’s critical that strategies to curb tobacco use be applied to products “including USB flash drive-shaped products, such as Juul.”

In response to the advisory, Juul’s Senior Director of Communications Victoria Davis said in a statement that the company was “committed to preventing youth access of JUUL products.”

“We stopped the distribution of certain flavored JUULpods to retail stores as of November 17, 2018, strengthened the age verification of our industry leading site, eliminated our Facebook and Instagram accounts, and are developing new technology to further limit youth access and use,” Davis said.

“We are committed to working with the Surgeon General, FDA, state Attorneys General, local municipalities, and community organizations as a transparent and responsible partner in this effort,” she said.

Earlier this month, Juul Labs announced that it made a $12.8 billion deal with Altria, the parent company of Philip Morris USA and makers of Marlboro cigarettes. The deal brought Juul’s valuation to an estimated $38 billion.

Today, Juul Labs announced that it has made a deal with Altria Group, the parent company of Philip Morris USA and makers of Marlboro cigarettes.

The deal values Juul at $38 billion and “will put its products next to Marlboro cigarettes on American retail shelves,” according to Bloomberg. Under the deal, Altria will invest $12.8 billion in Juul in exchange for a 35 percent stake in Juul Labs.

“We understand the controversy and skepticism that comes with an affiliation and partnership with the largest tobacco company in the US. We were skeptical as well,” Juul Labs CEO Kevin Burns said in a statement. “But over the course of the last several months we were convinced by actions, not words, that in fact this partnership could help accelerate our success switching adult smokers. We understand the doubt. We doubted as well.”

Prior to the announcement, the deal had been rumored to be on the horizon. Altria announced earlier this month that it would be discontinuing MarkTen and Green Smoke, their two lines of e-cigarette brands. In their place, Altria will be buying a stake in Juul.

Anticipating change in tobacco industry

The deal comes after a year of Juul claiming that it’s taking steps to combat the alarming rise in the number of teenagers using its products.

In November, FDA Commissioner Scott Gottlieb announced a new plan of action for the e-cigarette industry intended to keep the products from being used by teens. One measure seeks to ban the sale of flavored e-cigarette products.

Juul has maintained that its primary goal is serve as an off-ramp for smokers to quit by providing an alternative to traditional cigarettes. Altria has reportedly agreed to several measures that would get information about Juul into the hands of adult cigarette smokers.

Altria said in a statement that the investment is largely rooted in the fact that the company understands that change is coming to the tobacco industry.

“We are taking significant action to prepare for a future where adult smokers overwhelmingly choose non-combustible products over cigarettes by investing $12.8 billion in JUUL, a world leader in switching adult smokers,” said Howard Willard, Altria’s Chairman and Chief Executive Officer.

“We have long said that providing adult smokers with superior, satisfying products with the potential to reduce harm is the best way to achieve tobacco harm reduction. Through JUUL,  we are making the biggest investment in our history to achieve that goal. We strongly believe that working with JUUL to accelerate its mission will have long-term benefits for adult smokers and our shareholders.”

The federal government is stepping up its war against e-cigarettes, used by some smokers to wean themselves off cigarettes but feared by public health professionals because they are exposing teens to nicotine.

U.S. Surgeon General Jerome Adams has issued a public health warning, saying he is concerned that there has been a large increase in teenagers using the products. E-cigarettes create vapor from liquid that contains nicotine, the addictive substance in cigarettes.

Public health officials are concerned that young people who get hooked on nicotine from their use of e-cigarettes will eventually begin smoking. They also worry about other chemicals in the vapor they say is harmful.

In his advisory, Adams said he is concerned about the increase in teen “vaping” because it isn’t clear what nicotine will do to a developing adolescent brain.

“Brain development begins during the growth of the fetus in the womb and continues through childhood and to about age 25,” Adams warned. “Nicotine exposure during adolescence and young adulthood can cause addiction and harm the developing brain.”

Rapid growth in use by teens

Adams said he is concerned that e-cigarette use has become popular among young people, noting its use has become exponentially widespread over the last five years. Adams says the use of e-cigarettes is higher among high school students than adults and that more young people use e-cigarettes than smoke cigarettes.

Adams singled out the e-cigarette product Juul for special condemnation because it appears to be highly popular with teenagers. In his advisory, Adams said Juul’s sleek design is easy to conceal and doesn’t emit much of an odor. Adams says parents should be vigilant and look for signs that teens are using e-cigarettes.

In October, the Centers for Disease Control and Prevention (CDC) documented a huge increase in sales of Juul products, noting that sales increased from 2.2 million devices sold in 2016 to 16.2 million devices sold in 2017. The study found that Juul was found to contain more nicotine than any other brand of e-cigarette.

‘No redeeming benefits’

“There are no redeeming benefits of e-cigarettes for young people,” Corinne Graffunder, director of the CDC’s Office on Smoking and Health, said at the time. “The use of certain USB-shaped e-cigarettes is especially dangerous among youth because these products contain extremely high levels of nicotine, which can harm the developing adolescent brain.”

Last month, the Food and Drug Administration (FDA) announced plans to restrict the sale of fruit and candy-flavored e-cigarettes at convenience stores and gas stations. FDA Commissioner Scott Gottlieb said expressed alarm at what he called the “disturbing and accelerating trajectory of use we’re seeing in youth and the resulting path to addiction.”

When the Food and Drug Administration (FDA) announced last month that it would crack down on e-cigarette companies that sell their products online or in convenience stores, citing research that e-cigs were getting teens and other non-smokers hooked, Juul steadfastly denied that its products were intended for anyone other than consumers trying to quit cigarette addictions.

That already questionable assurance from Juul just became a little more difficult to believe. Altria, the parent company of tobacco giant Philip Morris, has announced that it is discontinuing MarkTen and Green Smoke, their two lines of e-cigarette brands. In place of those, Altria is instead reportedly planning to buy a stake in Juul, sources familiar with the deal told CNBC.

Juul has yet to officially confirm the news. But it wouldn’t be the brand’s first partnership with a tobacco company. The e-cigarette brand, valued at $16 billion, partnered with Japan Tobacco International back in 2011.

The news comes as some consumers’ rosey views of legal cannabis also appears poised to get corrupted by tobacco interests. Altria is reportedly investing $1.8 billion in Cronos, a Canadian cannabis firm that is taking off with legalization up north.

"Investing in Cronos Group as our exclusive partner in the emerging global cannabis category represents an exciting new growth opportunity for Altria," Howard Willard, Altria's CEO, said in an announcement.  

A popular talking point for the e-cigarette industry is that vaping helps cigarette addicts quit smoking. But that doesn’t appear to be what e-cigarettes are actually designed to do.

The Food and Drug Administration (FDA) announced today that its own research found that vaping has increased by 80 percent in high schoolers and by 50 percent in middle schoolers, suggesting once again that non-smokers are an important target market to the vaping industry.

Those teens are then more likely to turn to traditional cigarettes -- some of which are sold by the same business interests that have entered the vaping market.

“The data show that kids using e-cigarettes are going to be more likely to try combustible cigarettes later,” FDA Commissioner Scott Gottlieb said in a lengthy statement Thursday about his agency’s plans for an industry-wide crackdown. “This is a large pool of future risk.”

While some proponents have claimed that cracking down on vaping will be a boon to Big Tobacco, the cigarette industry has actually invested heavily in e-cigarettes. Philip Morris is currently aggressively lobbying Australian regulators to overturn a country-wide ban on vaping.

The United States approach to regulating vaping would be less stringent.

Banning flavors

To combat what they say is an “astonishing” rise in teen vaping, the FDA is pursuing a ban on selling flavored e-cigarettes at any stores where people under the age of 18 are allowed.

Such a policy would ban flavored products from convenience stores and gas stations, though tobacco and vape shops would still be able to sell flavored pods.

The FDA will also make an exception to those rules for mint, menthol, and tobacco flavors because they say that people trying to quit traditional cigarettes have found those flavors helpful.

The agency is, however, following through on plans to crackdown on menthol cigarettes and flavored cigars.

Juul, a vaping brand that has gained a cult-like following among teens, said it has agreed to stop selling its Mango, Fruit, Cream, and Cucumber flavored pods at 90,000 retail stores, though the company claims it was never trying to get kids hooked.

“We launched flavors like Mango, Fruit, Creme, and Cucumber as effective tools to help adult smokers switch from combustible cigarettes, and we do not sell flavors like Gummy Bear or Cotton Candy, which are clearly targeted to kids,” the company said online.

Industry panic

But research has suggested otherwise. In 2016, researchers at the UCSF School of Medicine found that vaping actually made people 28 percent less likely to quit cigarettes. Experts say that cigarette addicts should stick to e-cigarettes with large cartridges if they are vaping to quit.

The FDA’s announcement appears to be sending chills through the vaping industry.

The Smoke Free Alternatives Trade Association, one of the vaping industry lobbying groups, is planning a meeting in December with other vaping trade groups to organize against “the many issues facing the vaping industry at the Federal level.”

“It's time for us all to stop viewing each other as the enemy and start working together -- or we will face dire consequences as an industry,” the group’s Executive Director Mark Anton wrote today on Facebook.

Juul has announced that it will temporarily halt sales of most of its flavored nicotine pods in over 90,000 brick-and-mortar stores. The move comes as the FDA is trying to reduce “epidemic” levels of teen use.

Juul said on Tuesday that it stopped taking retail orders for its mango, fruit, creme, and cucumber pods at convenience stores, vape shops, and other retailers that sell them. Sales of all of the company’s flavors will continue on its website, and sales of its four tobacco and menthol-flavored pods will continue in retail stores.

“We don’t want anyone who doesn’t smoke, or already use nicotine, to use JUUL products. We certainly don’t want youth using the product. It is bad for public health, and it is bad for our mission. JUUL Labs and FDA share a common goal – preventing youth from initiating on nicotine,” CEO Kevin Burns said in a blog post on the company’s website.

“To paraphrase Commissioner Gottlieb, we want to be the off-ramp for adult smokers to switch from cigarettes, not an on-ramp for America’s youth to initiate on nicotine. We won’t be successful in our mission to serve adult smokers if we don’t narrow the on-ramp,” Burns continued.

Suspending promotional activity on social media

As part of its effort to comply with regulators seeking to curb youth use of e-cigarettes, Juul will also shut down its Facebook and Instagram accounts and end promotional activity on Twitter.

A recent study found that a significant percentage of the company’s Twitter followers are teens, many of whom regularly spread the brand’s messages. Critics have said the advertising tactics of e-cigarette makers make the products seem glamorous.

Toward that end, Juul says it will use its Twitter account for “non-promotional communications only” going forward.

In September, FDA Commissioner Scott Gottlieb ordered Juul and four other e-cigarette producers to announce their proposed plans to reduce what he called "epidemic" levels of teen e-cigarette use.

Gottlieb said preliminary federal data showed a more than 75 percent surge in high school students using e-cigarettes. Juul’s product was the number one e-cigarette in the United States as of December 2017. Sales increased from 2.2 million devices sold in 2016 to 16.2 million devices sold in 2017.

Earlier this month, reports surfaced that the FDA is planning to issue a ban on the sale of fruit and candy flavored e-cigarettes at convenience stores and gas stations. The agency is also expected to introduce stricter age-verification requirements for online sales of e-cigarettes.

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens,” FDA Gottlieb said in September. “The disturbing and accelerating trajectory of use we’re seeing in youth, and the resulting path to addiction, must end. It’s simply not tolerable.”

To combat the “epidemic” of teen electronic cigarette use, the U.S. Food and Drug Administration (FDA) plans to issue a ban on the sale of fruit and candy flavored e-cigarettes at convenience stores and gas stations, The Washington Post reports.

The ban -- which is expected to be announced by FDA Commissioner Scott Gottlieb as soon as next week -- could hit Juul Labs the hardest, since it will mean that only tobacco, mint, and menthol flavors will be permitted to be sold at these stores.

In addition to restricting e-cigarette flavors, the FDA will introduce stricter age-verification requirements for online sales of e-cigarettes. The upcoming restrictions on flavors will not apply to vape shops or other specialty retail stores, officials said.

Surge in teen use

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens,” FDA Commissioner Scott Gottlieb said in September. “The disturbing and accelerating trajectory of use we’re seeing in youth, and the resulting path to addiction, must end. It’s simply not tolerable.”

The agency’s move to restrict e-cigarette flavors follows its warning to Juul and other top e-cigarette manufacturers to disclose their proposed steps to curb use among youth within 60 days.

Sales of Juul vaping devices surged from 2.2 million in 2016 to 16.2 million last year, according to the CDC. The products are especially attractive to minors because they come in flavors such as mango, mint, and fruit and creme (previously called creme brulee).

A recent study found that Juul’s Twitter account has amassed a large number of teen followers, many of whom regularly spread the brand’s messages.

Gottlieb has said that protecting children from tobacco-related disease is his first priority, and addressing the surge in underage e-cigarette use is crucial to achieving that goal. Research has shown that many e-cigarette users go on to become addicted to nicotine and will likely end up using regular cigarettes. Additionally, the health risks of e-cigarettes are still being studied.

“In order to firmly confront and reverse these trends – and fulfill the central premise of our public health mandate – we may need to take actions that might narrow the off-ramp from smoking for adults in order to close the on-ramp to nicotine addiction to kids,” Gottlieb said last month.

The U.S. Food and Drug Administration (FDA) has had “constructive” meetings with several e-cigarette manufacturers, Commissioner Scott Gottlieb said on Wednesday.

In recent months, the agency has called electronic cigarette use among youth an “epidemic” and has set out to address the dangerous trend. Gottlieb said he’s met with five companies over the past few weeks: Altria Group, JUUL Labs, Reynolds American, Fontem Ventures, and Japan Tobacco International USA.

“The companies acknowledged the serious public health consequences associated with youth use of tobacco products,” Gottlieb said. “They presented thoughtful proposals, consisting not only of what steps they would take themselves to restrict youth access to and appeal of these products, but also steps that they think the FDA and other policy-makers can take to reverse the trends in youth use of e-cigarettes.”

“Some stated explicitly that preventing youth use must be a priority, and that any potential benefits of e-cigarettes for adult smokers cannot justify significant increases in youth use and addiction,” he said.

Restricting youth access

E-cigarette use among high school students has risen by 77 percent this year, according to preliminary federal data.

“In order to firmly confront and reverse these trends – and fulfill the central premise of our public health mandate – we may need to take actions that might narrow the off-ramp from smoking for adults in order to close the on-ramp to nicotine addiction to kids,” Gottlieb said.

In meetings with manufacturers that collectively represent 97 percent of the market, Gottlieb said the companies “acknowledged the role that flavored e-cigarette products play in appealing to kids, as well as the role that flavored e-cigarettes can also play in helping adult smokers quit”

The companies offered several proposals for mitigating this problem. These include:

• That the FDA restrict distribution of certain flavored products to channels with enhanced age verification processes; and

• That the agency require certain products that are more appealing to kids -- such as those with fruity flavors -- to come off the market until these products receive premarket authorization from the FDA.

In a statement, Gottlieb said the FDA welcomes any voluntary steps the companies may take to address teen use.

Last month, the FDA ordered five e-cigarette manufacturers to submit plans to curb teen use of their products within 60 days.

Nearly a quarter of users who follow the electronic cigarette brand Juul on Twitter are under 18, according to a study published recently in the Journal of Adolescent Health.

The latest findings are raising concern not only because the products aren’t intended for underage use, but because many of these youth followers are retweeting the company’s messages.

For the study, researchers from the University of Pittsburgh School of Medicine and the University of Southern California analyzed users who engaged with the 3,239 tweets sent by @JUULvapor between February 2017 and January 2018. The team found that roughly 1 in 4 users spreading the brand’s messages are younger than 18.

Growing number of youth users

The study comes a month after Juul was called out by health officials for appealing to teens through its marketing. The FDA seized thousands of pages of documents following a surprise inspection of Juul’s headquarters as part of its investigation into whether the company is intentionally marketing to teens.

The FDA has previously described the explosion of e-cigarette use among teens as an “epidemic.” The authors of the latest study share the FDA’s concern over who Juul is actually appealing to through its advertising.

"Juul representatives have said the company is not trying to target adolescents with their advertising or sales, but our research clearly indicates that a sizable proportion of their Twitter audience is exactly this population," said study author Kar-Hai Chu, an assistant professor of medicine at Pitt's Center for Research on Media, Technology and Health.

"This is highly concerning because adolescents exposed to e-cigarette marketing are more likely to use e-cigarettes and, in turn, young adults who use e-cigarettes are four times as likely as their non-vaping peers to transition to smoking traditional tobacco cigarettes," Chu said in a statement.

Juul says it’s taking action

Juul says it’s aware of the problem and is taking steps to mitigate it. The company said it "has aggressively worked with social media platforms to remove posts and accounts that portray our product in unauthorized and youth-oriented manners. In just six months this year, we helped remove over 8,000 listings, 450 accounts, and 18,000 online marketplace listings."

Getting initiated with e-cigarettes at a young age can increase a teens’ risk of becoming an actual smoker, experts say. Additionally, most e-cigarettes contain nicotine, which can harm brain development in adolescents.

The authors of the study said the fact that Juul’s official Twitter account is being followed by such a large number of adolescents “presents a major public health concern because e-cig marketing exposure increases the adolescent risk of ever use of e-cigs.”

“In particular, adolescents exposed to e-cig messages online are more likely to initiate tobacco use later in life,” the authors said.

E-cigarettes have certainly been dominating the news cycle recently. Though a popular alternative -- particularly among youth -- to traditional cigarettes, the device comes with a rather long list of dangerous side effects and health risks for users.

Because e-cigarettes aren’t regulated, how the devices will impact users’ health later in life is still unknown. However, a team of researchers was interested in studying how the chemicals in e-cigarettes’ refillable cartridges affect users’ health.  

A new study examined the harmful effects found in the flavorings and additives that are used in e-cigarettes, as the researchers found they can alter lung function, cause inflammation throughout the body, and increase mucus production.

Negative effects similar to cigarettes

According to the Centers for Disease Control and Prevention (CDC), the aerosol found in e-cigarettes contains nicotine, cancer-causing chemicals, heavy metals, ultrafine particles, volatile organic compounds, and flavorings.

To test the effects of these chemicals, the researchers exposed mice to several different chemical combinations four times each day, with 30-minutes in between each exposure of smoke-free air.

Some of the mice were exposed for longer periods of time -- up to four weeks -- while others were removed after three days. The groups exposed to the chemicals were compared against another group of mice that were exposed to smoke-free air.

The different chemical combinations included:

• E-cigarette vapor that had propylene glycol (an additive found in pharmaceuticals, foods, and drinks) and vegetable glycerol (a liquid that comes from plants)

• Cigarette smoke

• Nicotine, tobacco flavoring, and propylene glycol

• Nicotine and propylene glycol

Because many people turn to e-cigarettes either to quit smoking or as a healthier alternative than regular cigarettes, the researchers were interested in comparing the results between the mice exposed to the cigarette smoke and those exposed to the e-cigarettes. The results proved to be surprising to them, as they found that the e-cigarette group experienced oxidative stress -- the state of oxidative damage in a cell -- at a rate either higher or equal to the cigarette group.

The researchers also found that in the mice exposed to the e-cigarette flavorings showed more adverse side effects in the short-term that appeared to go away over time. For example, the mice exposed to the e-cigarette vapors after just three days had impaired lung function, an increase in mucus production, and signs of inflammation. However, over the long-term, the e-cigarette group showed fewer negative side effects.

The researchers believe that further research is necessary in this area to really see how e-cigarettes are affecting people.

Dangerous side effects

A recent study done by George Mason University found that not only do many e-cigarettes cause severe burns, but some have lithium-ion batteries that have been known to explode or catch fire, leaving users with third-degree burns, loss of tongue, teeth or eyes, and some have led to death.

The researchers were particularly concerned because many people aren’t reporting these injuries and incidents. E-cigarettes aren’t regulated or monitored in any way nationally, and because of this, the researchers have reason to believe more injuries are occurring because of e-cigarettes.

Additionally, in late September, the Food and Drug Administration (FDA) was discussing banning the sale of e-cigarettes online. Commissioner Scott Gottlieb believes e-cigarettes have caused a “epidemic” among teens, and is looking to reduce the number of young people using e-cigarettes.

The Centers for Disease Control and Prevention (CDC) published a study in JAMA earlier this week detailing the sales of JUUL electronic cigarettes from 2013 through 2017, and the findings show a rapid increase in sales in just the last year.

While all e-cigarettes contain nicotine, JUUL was found to contain the most nicotine of any e-cigarette, though that didn’t stop teens from purchasing them. The USB-shaped e-cigarette was the number one e-cigarette in the United States by December 2017, and sales increased from 2.2 million devices sold in 2016 to 16.2 million devices sold in 2017.

“There are no redeeming benefits of e-cigarettes for young people,” said Corinne Graffunder, DrPH, director of the CDC’s Office on Smoking and Health. “The use of certain USB-shaped e-cigarettes is especially dangerous among youth because these products contain extremely high levels of nicotine, which can harm the developing adolescent brain.”

A market geared towards young people

Many people -- particularly young people -- turn to e-cigarettes because they perceive them to be a healthier alternative to traditional cigarettes. However, in addition to the countless chemicals found in e-cigarettes, the CDC warns against several other health risks that are associated with them.

Additionally, much of the marketing for e-cigarettes seems aimed directly at the younger generation, as the companies look to focus their attention on their prime audience. However, as the Food and Drug Administration (FDA) pushes its Youth Tobacco Prevention Plan, the agency is working to change the nature of these ads.

The FDA has also set its sights on over one thousand stores, as many retailers have been selling JUULs and other e-cigarettes to underage teenagers. The agency is looking for accountability from these establishments, and in addition to sending warning letters to known retailers selling to minors, has demanded answers about how these stores plan to combat this issue in future marketing materials.

“The popularity of JUUL among kids threatens our progress in reducing e-cigarette use,” said Robert Redfield, M.D., director of the CDC. “We are alarmed that these new high nicotine content e-cigarettes, marketed and sold in kid-friendly flavors, are so appealing to our nation’s young people.”

Recent concerns

JUUL hasn’t been able to escape the news cycle as of late.

Earlier this week, the FDA seized over one thousand pages of documents from the e-cigarette company as part of an unannounced inspection of the company’s headquarters in San Francisco.

The FDA reported that the investigation was an attempt to seek “further documentation related to Juul’s sales and marketing practices, among other things,” according to a statement. The investigation came shortly after the FDA announced it was looking to ban the sale of e-cigarettes online.

FDA Commissioner Scott Gottlieb said that the ease with which teens can access e-cigarettes has caused an “epidemic,” and the agency is working to minimize the use of tobacco by underage teens.

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens," Gottlieb said in a statement. "The FDA won't tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products."

The U.S. Food and Drug Administration (FDA) announced on Tuesday that it seized more than a thousand pages of documents from e-cigarette maker Juul during an unannounced inspection of the company’s headquarters in San Francisco on Friday.

The news comes a week after the agency announced that it was considering a ban on the online sale of e-cigarettes, which would primarily be an effort to drive down the number of minors who are able to acquire and use the products.

Commissioner Scott Gottlieb called the widespread use of e-cigarettes among teens an “epidemic” and said easy access to the products is only fueling the trend.

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens," Gottlieb said in a statement. "The FDA won't tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products."

Scrutiny of marketing practices

The agency has requested that e-cigarette manufacturers, including Juul, submit plans to curb youth use of their products within 60 days.

Last week, the FDA said it was looking into how e-cigarette manufacturers market their products -- especially flavored products, which tend to appeal to kids. Gottlieb said at an event hosted by Axios that the FDA will be releasing data in November that shows a “disturbingly sharp rise” in the number of teens using e-cigarettes.

That announcement came a month after the agency revealed that it had sent more than 1,300 warning letters to retailers who were found to have illegally sold Juul and other e-cigarette products to minors during “an undercover blitz" of both brick-and-mortar and online stores that occurred over the summer.

Friday’s surprise investigation was an attempt to seek “further documentation related to Juul's sales and marketing practices, among other things," the FDA said in a statement. The investigation “resulted in the collection of over a thousand pages of documents," the agency said.

The U.S. Food and Drug Administration (FDA) is reportedly mulling a ban on online sales of e-cigarettes.

During a panel discussion on vaping hosted by Axios earlier this week, Commissioner Scott Gottlieb said the move is “on the table” and is “very clearly something we are now looking at,” CNBC reports.

Gottlieb said easy access to vaping products has resulted in an “epidemic” of use among teens. The FDA says it will announce its next steps to combat underage use of e-cigarettes in November, when the agency will reveal data on teen vaping and invite public and corporate feedback.

Trend among youth

“E-cigs have become an almost ubiquitous ‒ and dangerous ‒ trend among teens," Gottlieb said in a statement earlier this month. "The FDA won't tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products."

Gottlieb said the FDA is also weighing a ban on flavored e-cigarettes, which he says tend to entice youth.

"One factor we're closely evaluating is the availability of characterizing flavors. We know that the flavors play an important role in driving the youth appeal. And in view of the trends underway, we may take steps to curtail the marketing and selling of flavored products," he said.

In May, the FDA (joined by the FTC) sent 13 warning letters to companies that advertise e-cigarettes in a way that causes them to “resemble kid-friendly food products, such as juice boxes, candy or cookies."

This month, the agency sent more than 1,300 warning letters to retailers who were found to have illegally sold JUUL and other e-cigarette products to minors during “an undercover blitz" of both brick-and-mortar and online stores that occurred over the summer.

"We're in possession of data that shows a disturbingly sharp rise in the number of teens using e-cigarettes in just the last year," Gottlieb said in a statement last week.

“The numbers of kids now using these products is unacceptable,” he said. “We can’t allow these trends to continue.”

Regulators and advocates have long spoken out against the use of e-cigarettes by young teens in middle school and high school. Now, a study conducted by the Centers for Disease Control and Prevention (CDC) shows that the problem may be worse than many may have thought.

The National Youth Tobacco Survey, which surveys young students in the U.S. in grades 6 through 12, shows that over 2 million young people have used e-cigarettes to vape marijuana. In all, the researchers say that one out of every eleven students have engaged in this activity across the country.

The CDC researchers say that the findings are dismaying because marijuana use has been associated with negative health effects in young people.

“The National Academies of Sciences has found cannabis use among youth can adversely affect learning and memory and may impair later academic achievement and education,” they said. “Strategies to reduce cannabis use in e-cigarettes are critical for protecting young people from these potential health risks.”

Stopping the e-cigarette youth epidemic

The findings, which were published in JAMA Pediatrics, come shortly after regulators announced a crackdown on selling e-cigarette devices to underage consumers.

Last week, the Food and Drug Administration announced that it would be taking action against over 1,300 retailers and five major manufacturers for their roles in making e-cigarettes available to young people. FDA Commissioner Scott Gottlieb went so far as to say that youth access to electronic cigarettes had reached “epidemic” levels.

“We must adjust certain aspects of our comprehensive strategy to stem this clear and present danger. This starts with the actions we’re taking today to crack down on retail sales of e-cigarettes to minors,” he said.

“While we remain committed to advancing policies that promote the potential of e-cigarettes to help adult smokers move away from combustible cigarettes, that work can’t come at the expense of kids. We cannot allow a whole new generation to become addicted to nicotine,” he concluded.

The Food and Drug Administration (FDA) has taken the epidemic of youth e-cigarette use by the horns, issuing a historic action against more than 1,300 retailers and 5 major manufacturers for their roles in leveraging youth access to the tobacco alternative.

It’s clear the FDA has done its homework on the matter. In serving its warning, the agency detailed specific dates and times minors were allowed to buy e-liquid products and that the agency will be watching offending retailers like a hawk.

“We will periodically inspect your establishment and review your promotional activities (e.g., website(s) related to FDA-regulated tobacco products to assess your compliance with all applicable laws and regulations, including access, marketing, labeling, and advertising restrictions,” wrote the FDA in its warning letter, which also gave the e-product vendors 15 days to let the agency know how they will address the violations and comply going forward.

The FDA’s commitment

“We’re committed to the comprehensive approach to address addiction to nicotine that we announced last year,” said FDA Commissioner Scott Gottlieb.

“But at the same time, we see clear signs that youth use of electronic cigarettes has reached an epidemic proportion, and we must adjust certain aspects of our comprehensive strategy to stem this clear and present danger. This starts with the actions we’re taking today to crack down on retail sales of e-cigarettes to minors. We will also revisit our compliance policy that extended the dates for manufacturers of certain flavored e-cigarettes to submit applications for premarket authorization.”

It’s been reported that nearly 12 percent of middle and high school students -- more than 12 million -- have used e-cigarettes, and Gottlieb believes that one of the chief lures for youth are the different flavors of e-vapor.

“While we remain committed to advancing policies that promote the potential of e-cigarettes to help adult smokers move away from combustible cigarettes, that work can’t come at the expense of kids. We cannot allow a whole new generation to become addicted to nicotine.”

Whether a user calls their vaping a harmless activity or an addiction, the notion is a front-burner health issue.

Researchers from the University of California say the use of e-cigarettes every day can nearly double the odds of a heart attack, according to a new analysis of a survey of nearly 70,000 people. The research also found that dual use of e-cigarettes and conventional cigarettes -- the most common use pattern among e-cigarette users -- appears to be more dangerous than using either product alone.

“Given the emerging data showing that e-cigarette use increased exposure to metal and other toxicants, FDA initiatives to reduce e-cigarette use among youth are urgently needed,” said Columbia University’s Mailman School environmental health scientist Ana Navas-Acien in a previous statement.

The warning signs are clear

The larger question of vaping is the possible connection between e-cigarettes and tobacco use. A report by the National Academies of Science, Engineering, and Medicine produces evidence that both teens and young adults who use e-cigarettes are at increased risk for trying cigarettes. As for adults, the report finds e-cigarettes can help them break a tobacco habit.

“You need a device that is sufficiently satisfying for those who want to quit,” says Navas-Acien, “but at the same time, one that doesn’t increase the risk of long-term addiction.”

Who’s in charge?

While federal law bans minors from purchasing e-cigarettes, state laws vary widely.

For example, how states define e-cigarettes runs the gamut. According to the Public Health Law Center, Indiana’s law on electronic delivery devices includes expected substances such as nicotine but throws in lobelia, a tropical or subtropical plant of the bellflower family, into the mix as well. In Rhode Island, the state included electronic hookahs into its definition, and some states -- including Michigan and Missouri -- have no anti-vaping laws in place at all.

But, it appears that the FDA’s proactive move into the vaping regulation arena signals that the agency is taking charge. “There is a clear need for strong federal enforcement of youth access restrictions,” said the FDA’s Gottlieb, “and the FDA will continue to hold retailers accountable by vigorously enforcing the law with the help of the agency’s state partners.