MARC FISHERWelcome back. I'm Marc Fisher of the Washington Post, sitting in for Kojo Nnamdi. E-cigarettes have been touted as a safer alternative to traditional cigarettes, and many smokers have used them to help break the smoking habit. But the increased popularity of e-cigarettes has boosted the number of young people who are vaping, and that is alarming parents, educators, and now that the surgeon general has declared youth vaping an epidemic, it's alarming the federal government, as well. Maryland is now considering banning tobacco sales to people under 21, a move that the District has already made.

MARC FISHERToday, we explore the popularity of vaping among young people, and joining me for the discussion are Sheila Kaplan. She's public health reporter for the New York Times. Welcome.

SHEILA KAPLANHi. Thank you.

FISHERAnd Robin Koval is CEO and President of the Truth Initiative, a nonprofit tobacco control organization. Good to have you.

ROBIN KOVALAh, great to be here.

FISHERAnd joining us on the phone is Alex Clark. He's CEO of the Consumer Advocates for Smoke-Free Alternatives Association. That's a trade group for the industry. Welcome.

ALEX CLARKThank you for having me.

FISHEROkay. Sheila Kaplan, maybe you can start us off. Last year, the surgeon general declared e-cigarette use to be a national epidemic among youth. What lead to that announcement, and how widespread is vaping these days?

KAPLANWell, youth vaping has been going up very, very quickly, and right now, according to the last CDC report, 3.6 million middle and high school kids report vaping regularly.

FISHERAnd is that -- is there a direct one-to-one relationship in the decline of traditional cigarette smoking and the increase in vaping? Is it a clear replacement that's going on?

KAPLANNo, it's not. Regular combustible cigarettes are going down, but the people who are starting, the largest users of JUUL are people who've never smoked at all, and that's the problem.

FISHERAnd just so we have our terminology right, can you take us through e-cigarettes, vaping and JUUL? What are those different terms? Tell us.

KAPLANOkay, sure. These are all devices that the Food and Drug Administration calls electronic nicotine delivery devices. And you've got e-cigarettes. There are different types, but the most popular one by far is JUUL, which is a pod of liquid nicotine that's put into a device that looks like a flash drive. And, you know, people can vape on it and get a very high burst of nicotine, more than -- actually equal to a whole pack of cigarettes.

FISHEROh, and JUUL is the primary brand delivery, then.

KAPLANRight. Yeah, they've got 72 percent of the market, which is astonishing, considering they just launched in 2015.

FISHERRobin Koval, why are we seeing this increase particularly in teen vaping?

KOVALWell, there's a number of things going on to talk about JUUL specifically, because they do have so much of the market. This is a product perfectly tailored for young people to experiment with, when you think about it being very cool and techy looking. As Sheila said, it looks like a USB device. It comes in flavors, and we know the flavors are the number one reason why young people say they're interested in vaping. So, mango and fruit medley, other things like that. And you can hide it. So, many parents and teachers don't know what it is. They literally do think it's a USB device. It's small. You can hold it in your hand. Kids sit in class and, you know, suck on it, and then blow the vapor into their hoody, or whatever.

KOVALSo, you know, it's easy for them to experiment with. And what JUUL did was launch it in a way that made it very popular with young people, with cool colors and young, hip-looking models and fancy launch parties in New York and Los Angeles and places like that. And then, of course, what happens is what always happens now, the internet took over, social media took over, and young people began spreading it virally themselves.

FISHERAlex Clark, the same question to you: why are we seeing this increase in teen vaping? Is it incidental to the marketing of these products, or has it been the target?

CLARKWell, first of all, thank you. I wanted to clarify something. CASAA is not an industry trade group. We represent the interests of consumers. I don't advocate on behalf of businesses. As far as why youth would be picking up these products, I think, to some extent, it's expected that young people will sort of mimic what's going on in the adult population. These are new and very interesting tech products, and so some adoption, I think, is to be expected. It's also -- you know, we know that young people are prone to seeking out risky behaviors. It is a natural part of adolescence to try new things and experiment. So, I think a lot of those are the driving factors.

CLARKAnd, of course, you know, all of the other things. We have to consider socioeconomic influences, peer pressure, you know, trauma, things that young people are experiencing as teenagers, you know, motivate them to try things to, you know, resolve those issues. And sometimes, they are in destructive ways.

FISHERWell, do you think that JUUL or other companies bare any responsibility to ensure that young people don't take advantage of this product? I mean, you seem to be saying that you're not seeking those customers. If you don't want them, what's the role of the industry in pushing them away?

CLARKI think all manufacturers of adult products have some responsibility to make sure that their products are getting to the intended audience. And I think, actually, if you look at the response that JUUL provided to FDA about the ways in which they'd be dealing with the youth access issue, I think they provided a very thoughtful response, leveraging their contractual agreements with retailers, leveraging technology. These are all things that companies have at their disposal to make sure that young people are not able to purchase these products.

FISHERThe CDC put out some numbers just recently, saying that in the past month -- high schools were asked about their behavior in the past month. Eight percent of them said that they'd smoked cigarettes in the past month, and 21 percent said that they had vaped in the past month. So, clearly, a major social change is going on here. Sheila Kaplan, when you hear a representative of the industry discussing the teen adoption of vaping in this sort of distanced fashion, does that comport with the reality that you're aware of?

KAPLANNot one bit. I've interviewed two people who were among the original marketing officers at JUUL. So, these were the people who helped create the plan to market JUUL and make it popular. And they said they did not deliberately target teens, but they absolutely knew what they were doing was going to appeal to teens. And they looked at them as either collateral damage or as a brilliant way to get customers for life, because if they could addict teens, then they would stay with JUUL.

FISHERAnd, Robin Koval, does that question of intent in marketing -- we're aggressively going after a teen market or we're not going after a teen market and it just happens to occur -- does that matter?

KOVALWell, yes. You have to look at it holistically. Just because they didn't write down on a piece of paper, our intended target market is young people, doesn't absolve you from understanding how the marketplace works. And if your primary means of introducing your product and launching it is through all of the channels that young people gravitate to -- YouTube, Instagram -- then you are going to attract those people. We know from our own research, for example, that when we talk to 15 to 34-year-olds, 15 to 17-year-olds were 16 times more likely to be JUUL users than the 25 to 34-year-olds. So, if we know that data, JUUL knows that data. They know exactly who their market is.

FISHERA lot of kids and teachers say that vaping is a -- whatever you think of it, it's at least a better -- it's better for them than traditional cigarette smoking. They justify it in that way. Alex Clark, if that's true, then why not market these products as a way for kids who perhaps had been smoking traditional cigarettes to move to a healthier status?

CLARKWell, I don't think anybody's going to touch that with a ten foot pole (laugh). You know, this is...

FISHER(overlapping) That's why we ask.

CLARKYeah, exactly. The intended target here are adults who smoke, you know. And I think, you know, actually, looking back over some of Ms. Kaplan's reporting about the JUUL marketing, you know, originally, they had selected kind of a young adult age group, between the ages of 20 and 30. And, you know, I think, you know, obviously, there was some inexperience involved there. There's a mistake being made that there is possibly going to be some spillover into younger groups. But, you know, in having this conversation about appropriate interventions for young people who smoke, I think, you know, right now a lot of people -- we're all gearing up for a hearing at FDA regarding, you know, is it appropriate to start thinking about medications for youth nicotine addiction?

CLARKYou know, one of the interesting things about vapor products is that the sort of self-administered step-down program is actually part of the product. It's kind of shocking and very concerning to me that we would be talking about jumping to medication as a form of intervention for young people who are possibly, by and large, experimenting with these products.

FISHERWell, they're experimenting with a product that contains something that's addictive, so the experimentation, I would imagine, becomes something different in fairly short order. Is that your primary objection, Robin Koval?

KOVALWell, you know, yes, youth do experiment. But what the most recent data says is they're not experimenting. They're using. So, a significant portion of that 21 percent of young people who say they've used a product in the last 30 days are using these products 20 or more times a month. And so, yes, they are addicted. This is a very high level of nicotine and I've heard story after story -- and I'm sure Sheila has, as well -- from parents and also from young people who are beside themselves with just how quickly they've become addicted, and now they don't know what to do.

KOVALPediatricians are seeing addicted young people in their offices, and they don't know what advice to give. So, you know, we have a whole new challenge here in terms of how do we create cessation methods for young people.

FISHERLet's hear from Michael in Ashburn, Virginia. Michael, you're on the air.

MICHAELHi. Thanks for taking my call, and I appreciate the panelists, there. The gentleman from the association, what's it called, the vaping association, what is it?

FISHERConsumer Advocates for Smoke-free Alternatives.

MICHAELHuh. Okay. Are you an attorney, a lobbyist for the group, or are you an employee of the group? What's your role there?

CLARKI am a paid -- the paid CEO.

MICHAELOkay. So, you do public relations, and I imagine you do that from a perspective, you know, an advisor from a legal and regulatory perspective? Would that be correct?

CLARKWell, you know, I don't have a background -- I'm not a lawyer by training. My story is that I was a smoker for 21 years, and I quit practically overnight by switching to vapor products. And that's how I got involved in all of this. I am really coming at this from the consumer perspective.

FISHERMichael, what's your question?

MICHAELYes, thank you. Are you still -- so, here's my question. I think Altria, if I'm not wrong, or maybe it was Philip Morris, one of the two big -- two or three big tobacco companies in the world just put $2 billion into JUUL and gives that company now a market valuation of $12.1 billion, with a B. And it seems to me that, you know, the intention is to go after a replacement market, because their US revenues are declining for tobacco, while their world revenues are holding steady or growing.

MICHAELBut frankly, you know, if Joe Camel taught us anything, it's that the stated intent of marketing is not typically what plays out in the field. And until there are financial penalties and regulatory restrictions on the sale and resale of such products that are significant enough, it doesn't really matter what the intention of marketing is. What matters is availability, pricing and height. And right now, those three things are playing in favor of young people taking on a new drug.

FISHEROkay. Thanks, Michael. Sheila Kaplan, is there -- tell us about the role that Altria -- which is the former Philip Morris -- has played in entering the vaping market. What's the significance of that?

KAPLANWell, right now the Food and Drug Administration is, I think, fair to say, very, very angry at Altria, and also angry at JUUL, because in September and October, under pressure from FDA to reduce youth vaping, both companies promised that they would develop measures to really keep these e-cigarettes away from kids. Altria announced that they would take their most popular flavored pods off the market. But what the FDA has found out is that while Altria and JUUL were negotiating these new terms with the FDA, they were secretly negotiating their financial deal which gives JUUL access now to 230,000 stores and gives Altria a big financial stake in the business they told the FDA they were getting out of.

FISHERAlex Clark, your organization has what's called a harm reduction approach to tobacco. What does that mean?

CLARKWell, harm reduction is all about meeting people where they're at. You know, there's only so far that you can go by restricting access to products or beating people over their heads or pushing people who use substances to the fringes of society. Really, what we want to see is providing effective, enjoyable products that people will choose, on their own time, to use. And that's where vaping has really made leaps and bounds, in that these are enjoyable products that people who smoke have voluntarily chosen to use. And millions of people have quit smoking by switching to them.

FISHERRobin Koval, what's wrong with that?

KOVALWell, you know, my organization and many of those in tobacco control do support the concept of harm reduction for, you know, those who are unable or unwilling to quit on their own, e-cigarettes could be part of that. We've had nicotine patches and lozenges for years and years, which is also part of a harm reduction strategy. So, in theory, that does work, but it can only work in an environment that's well-regulated.

KOVALAnd one of the things that we've seen happen is with the sort of unbridled opportunity that e-cigarettes have had in the marketplace, without sufficient taxes or other kinds of restrictions, without the FDA fully regulating these products before they get on the market so we know what we're getting, we have a lot of unintended consequences. JUUL being the primary example of a product that the company said was supposed to help smokers quit, but, in fact, has addicted an entire new generation of young people to nicotine.

FISHERRobin Koval is CEO of the Truth Initiative, a nonprofit tobacco control organization. We're also talking with Alex Clark from the Consumer Advocates for Smoke-Free Alternatives Association, and Sheila Kaplan, public health reporter for the New York Times. I'm Marc Fisher, and this is the Kojo Nnamdi Show. When we come back after a short break, what to do about e-cigarettes and the people who use them. More of your calls and your suggestions at 1-800-433-8850.

FISHERI'm Marc Fisher of the Washington Post sitting in for Kojo Nnamdi, and we are talking about vaping, especially among young people, with Alex Clark from the Consumer Advocates for Smoke-Free Alternatives Association, Robin Koval from the Truth Initiative and Sheila Kaplan, reporter for New York Times. And let's go right to Laura in Hagerstown, who is actually a consumer of the product. Laura.

LAURAHi, there. I just wanted to add that e-cigarettes did help me, well, assisted me in quitting. I quit, and I think it was maybe a month or so, and I started vaping. I'm not one of those people that have the giant vape carrying around with me. I'm kind of discreet with it. But I am addicted to it, but I also feel that I could quit the vaping just like a did the cigarettes. And I feel that it's probably better for me than a pharmaceutical pill for anxiety or something. Because as I do use it, you know, it calms me down. I know that sounds crazy, but it does.

LAURABut kids are always going to do everything you tell them not to do. It's the say-no-to-drugs thing, alcohol, whatever it is, kids are going to do. And I don't know that you can keep it (word?). I guess it doesn't help with a giant former cigarette manufacturer and corporation pushing it, which I kind of disagree with, but you're always going to have the capitalism involved there, too. Am I correct?

FISHERAnd Laura, I take it you're over 21. What...

LAURAYes, sir. I'm 56.

FISHEROkay. So what would be your attitude toward the vaping that we see among high school kids and even younger kids? What would you want the government to do about it, if anything?

LAURAWell, everything, it seems, has an age limit, with the exception of pharmaceuticals, I guess. But there's -- they're going to get things from their friends that are -- they just find a way to do it. I don't know what the government will do. Will they have fines? You know, I'm not exactly sure how to answer that.

FISHEROkay. Well, let's see what our panelists think about that. Alex Clark, should there be a difference between the way government approaches vaping as compared to how it approaches smoking? They both involve addictive material of nicotine. Should they be regulated and taxed in the same fashion?

CLARKNo. Regulation should be proportionate to risk, and considering that these products are very low risk, the regulation should reflect that. I think that a lot can -- you know, we haven't done all that we can do in enforcing the existing laws. The federal minimum legal purchase age is 18 years old. There are already, you know, compliance inspections that happen for retailers of tobacco products. Those compliance inspections should be carried out with retailers who sell vapor products. And, like I said earlier, we have this opportunity to leverage technology. Manufacturers can leverage contractual agreements with retailers and make sure that these products are not being sold to young people.

FISHERWe have a Tweet from Suzette, who says, yes, they should raise the age for tobacco products. Just look where nicotine ranks in the order of addictive substances, not to mentioned the additional healthcare costs Americans end up paying for to treat the havoc nicotine does to the body. And, Sheila Kaplan, what is the government's distinction, if any, between smoking and vaping, and what are some states, such as Maryland, thinking of doing about that?

KAPLANWell, I know that Maryland and some other states are raising the age of, you know, being able to buy e-cigarettes to 21. And the industry is actually going along with that. But I take issue with Alex's comment that e-cigarette products are very low risk. I think there is no evidence to show that right now. According to the FDA and the CDC, they are likely lower risk than smoking, but not necessarily low risk.

FISHERLet's hear from Alex, in Washington. Alex, you're on the air.

ALEXHi. Yes, I kind of have a suggestion, and then also a question that goes along with that suggestion.

FISHEROkay.

ALEXSo, I'm only 22, so I have an interesting perspective about smoking and JUULs, because I went to college when smoking was not cool. Society has been told for decades that it's horrible for you. People shame other people who smoke cigarettes. Like, I had a friend, if someone was smoking a cigarette at a party, would go ask for a hit and the throw it out if they gave them the cigarette, because as a society, we don't accept cigarettes.

ALEXAnd then I saw the transition personally of vaping coming in, and people -- it's not just that people who didn't used to smoke cigarettes are now vaping on occasion. My friends who started vaping as I got to be an upperclassman in college, are vaping all day long. Like, it's not an occasional thing, it's throughout the entire day. And so, I was curious, what kind of studies are being done to show the damaging effects that that amount of smoking has, because I feel like there's no way that that could possibly be good for you.

ALEXAnd the excuse that a lot of my friends who are young, 18, 17, 20 years old give is, oh, it's not that bad for you. You can't shame me into not doing it. So, that would be my suggestion would be to have studies that show is it, in fact, not that bad for you, because I find that hard to believe. And I think the societal pressure that would come along with recommending how bad it is for you would help with that trend.

FISHERAnd you think your friends who vape would react to a study showing how harmful it was by stopping?

ALEXYes.

FISHEROkay. Well, let's see...

ALEXI don't know if they'd stop, but I definitely think they would do it significantly less frequently, and other people around them would pressure them to do so, as well.

FISHEROkay. Let's hear from Robin Koval on that question.

KOVALWell, there is a lot of lack of information out there. And it is a new area, so we don't have the years and years of studies that we have on combustible tobacco. But here's what we know, and we say this at Truth Initiative when we talk about vaping to young people: safer does not equal safe. And there are studies that say there are health effects. And whether an e-cigarette is not as deadly as a combustible cigarette, I mean, that's a pretty low bar, given how deadly cigarettes are.

KOVALAnd we do know that nicotine is a highly addictive substance. The younger you are when you become addicted to nicotine, the easier it is for you to get addicted, the harder it is for you to quit later. There are cognitive effects, and there's also evidence that becoming addicted to nicotine makes you more vulnerable for other addictions, as well. So, if you're a young person who is not a smoker, who is not trying to find a way to quit smoking 100 percent, there is absolutely no reason for you to start using nicotine.

FISHERWe have an email from Bill, who says, I visit friends who now live in DC because they're potheads. Some are switching to vaping. The other night I suggested to them that teens have JUUls to help hide their other vape containing THC, but we've heard no statistics about this. Sheila Kaplan, is there any research on that question?

KAPLANThere's a research that's begun. I haven't seen anything that really can say definitively whether that's happening. But there's a lot of anecdotal evidence that people are re-jiggering pods and using them for THC.

FISHERAlex Clark, is this something the industry is aware of, and does it have a position on it?

CLARKWell, from the nicotine vaping side of things, most of the people in the industry want to keep their distance as far as they can from any cannabis vaping or anything like that. There are products that are specific to each category, so nicotine vaping products tend to be a little bit different than the cannabis vaping products. I do understand that there is some crossover in terms of the technology, but as far as people -- you know, the position seems to be from nicotine vapor manufacturers. They have their own -- they have their own customer base. That's who they want to stick with.

FISHERLet's hear from Sandy, who has a question on that point. Sandy, you're on the air.

SANDYHello, everyone. Yeah, so mine is actually right along that last comment. And in addition to the THC, which is, you know, obviously, a little bit more taboo, but that is going to be eliminating, there's also what you call the CBD oil. And I am -- I really do believe that we probably -- I could even say 50, or more than 50 percent of the vaping that you might see by eye and look at as exemplifies, could very well be CBD oil. And you have athletes that use CBD oil. It's a cannabin oil. People that, you know, work out hard because it's a nice way to sort of relieve pain.

SANDYOne of my friends who has fibromyalgia who also, you know, uses the other oil, but he has been using the CBD oil as sort of a daily, just, in like his pain has been relieved so much. So, I do understand the tobacco element, but just from my social circles and my experience, the chances of it actually being tobacco in a vape seems super, super low. But that could just be a lifestyle thing. Thank you very much.

FISHERThank you. Robin Koval, does the fact that the same technology is used for nicotine and for marijuana-related products confuse the whole question of whether and how to regulate?

KOVALWell, first of all, I would say inhaling anything into your lungs, you know, is not as good as breathing air (laugh). So, while we don't necessarily...

FISHER(overlapping) We could probably find agreement depressive. Go ahead.

KOVAL...have, you know, all of the evidence we'd like to have on what are the effects of whether you're smoking it or vaping marijuana. You are inhaling something into your lungs. But I think what we do know is that if you look at the size of the industry, for instance, how large the JUUL business is, most of the vaping -- I would take issue with your caller -- most of the vaping that is going on is nicotine vaping. There is, of course, another market, legal and probably not-so-legal, for THC products. But the issue we really have to deal with here is a whole generation of young people becoming addicted to nicotine.

FISHERWe have a Tweet from someone who's at least upfront in his handle, Vaping Legion, who says: in the UK e-cigarettes are pushed by Public Health England. The Royal College of physicians has stated that vaping is 95% less harmful. Why is the UK embracing this industry and the US and health organizations are fighting against it? Sheila Kaplan.

KAPLANSure. I was recently at the World Health Organization tobacco control meeting in Geneva. And there were folks from the UK there, and representatives from, I think, over 100 countries. And a lot of people take issue with the UK's decision. They feel that it has been made in haste, and that future research will not -- in future research, that point will not hold up.

FISHERAlex Clark, same question to you. Why do you see this different approach to regulation between US and Britain?

CLARKWell, I think that the UK recognizes that these products do not represent a massive public health threat, and that there is a net public health benefit to be gained by allowing these products to remain on the market, allowing people who smoke to choose these products voluntarily and quit in very large numbers. Something that just has not happened with the pharmaceutical products that are available.

CLARKIn conjunction with that, there's a very important element of the vaping community that we don't see with medicalized nicotine replacement therapies, which is you sort of have this built-in peer-to-peer support network, which is something that the UK recognized and started promoting these products through their stop smoking services in the UK. So that's something that, you know, state governments have tried to replicate, funding through taxpayer dollars, by providing 1-800 quit lines. And it's just not something that the government has actually been able to replicate, whereas in the vaping community, it happens naturally in a vape shop.

FISHERA couple of emails about this question of the minimum purchase age. AJ emails: less than a week ago, a teenager came up to my car window in a convenience store parking lot and asked me to go into the store to buy JUUL pods for him. I don't think he could've been older than 16, and he was hanging out in a parking lot trying to get people to buy him nicotine. It was very depressing to see. And Arianna emails, I graduated from high school two years ago, now in college. More than half of my friends in high school owned a JUUL or vape being under 18 and having never smoked cigarettes before. There was a culture at my private Catholic high school for seniors to buy JUULs for underage underclassmen, so I don't think raising the tobacco purchasing age to 21 would be effective. Robin Koval, would it be effective?

KOVALYes, it would. There is a study that was published in 2015 from the National Academies that got to that very point, that raising the age from 18 to 21 would produce a significant reduction in underage smoking, as well as smoking between those 18 and 20 years old. And one of the reasons for that, to your comment before -- listener's comment before, is if you're 15, you probably know someone who's 18, but you may not know someone who's 21. So, if we raise the age and it's properly enforced, it has a significant impact on the ability of those underage to get access.

FISHEROkay. We have to leave it there. Robin Koval is the Chief Executive Officer of the Truth Initiative, a nonprofit tobacco control organization. We're joined by Alex Clark, CEO of the Consumer Advocates for Smoke-Free Alternatives Association, and by Sheila Kaplan, public health reporter for the New York Times. Today's conversation on vaping was produced by Mark Gunnery. Our conversation earlier on Virginia's teacher strike proposal was produced by Julie Depenbrock.

FISHEROn Thursday, we're doing a deep dive into DC's opioid crisis. Have you, a family member or a friend dealt with addiction? How did it start? What has or hasn't helped with recovery? Record a voice memo and send it to Kojo at WAMU.org, with the subject line Opioids. And coming up tomorrow, we'll discuss the evolution of the Washington Post's $20 Diner column, and take a look at guardianship laws across the Washington region. Thanks very much for listening. I'm Marc Fisher from the Washington Post, sitting in for Kojo Nnamdi.