Tobacco Use by Youth is Rising

OPERATOR: Welcome and thank you for standing by. At this time all participants are in listen-only mode until the question-and-answer session for today’s conference call, at that time you may press “star” “one” to ask a question over the phone. Today’s conference call is being recorded, if you have any objections you may disconnect at this time. I would now like to turn the call over to Kathy Harben. Thank you. You may begin ma’am.

KATHY HARBEN: Thank you, Dulana and thank you everyone for joining us today for the release of a new CDC Vital Sign. This one is on Tobacco Product Use Among Middle and High School Students.

We’re joined today by Dr. Anne Schuchat, Principal Deputy Director of CDC; Mitch Zeller, Director of FDA’s Center for Tobacco Products; Dr. Brian King, Deputy Director of CDC’s Office on Smoking and Health; and Laura Oliven, Tobacco Control Manager for the Minnesota Department of Health.

I’ll turn the call over now to Dr. Schuchat.

ANNE SCHUCHAT: Thank you for joining us today.

CDC works 24/7 to protect the health, safety, and security of all Americans. One of the ways we do this is by identifying health threats and working to address them. This Vital Signs Report contains an important update focused on youth and their use of all tobacco products. Tobacco use is the leading cause of preventable death and disease in the United States and almost all tobacco product use begins during adolescence. Today’s Vital Signs Report highlights annual data from the National Youth To bacco Survey collected in 2018, it provides national estimates of tobacco product use amongst middle and high school students.

Let me give you the bottom line. In 2018, 27.1 percent of high school students and 7.2 percent of medical — middle school students currently use any tobacco product that equates to 4.9 million of our nation’s youth who reported currently using tobacco product, a substantial increase over 2017. The increase is being driven in a surge e-cigarette use in these young people. There were 1.5 million more youth using e-cigarettes in 2018 compared to 2017.

From 2017 to 2018 e-cigarette use increased from 11.7 percent to 20.8 percent among high school students and from 3.3 percent to 4.9 percent among — middle school students. There was no change in the use of other tobacco product including cigarettes from 2017 to 2018. E-cigarettes are still the most commonly used tobacco product among middle and high school student, reported for the fifth year in a row but within the past year use of e-cigarettes among our nation’s youth has reached unprecedented and epidemic proportions and those who are using them are using them more often as we reported in November.

Teens should not use any tobacco products including e-cigarettes. They shouldn’t be using these products routinely or even experimenting with them.

At CDC we are concerned about this increase in tobacco product use. Let me be clear that any use of any tobacco product is unsafe for teens. Our report finds many are using multiple products; these products typically contain nicotine and several other harmful ingredients. We want everyone particularly parents and teachers to know how dangerous use of nicotine in any form is for kids. Nicotine is highly addictive and can harm brain development including harmful effects on learning, memory, and attention.

Before we start taking questions Mitch Zeller who is the Director of FDA’s Center for Tobacco Products will share a few remarks followed by Laura Oliven, the Tobacco Control Manager with the Minnesota Department of Health, she’ll describe what she’s seeing in Minnesota and what the state has done in response. Then Dr. Brian King from CDC’s Office of Smoking on Health will give additional details from today’s report.

Now here’s the FDA’s Mitch Zeller.

MITCH ZELLER: Thanks, so much Dr. Schuchat.

Protecting our nation’s youth from the dangers of tobacco products is among the most important responsibilities of the Food and Drug Administration. To help address this concerning rate of e-cigarette use amongst kids, highlighted in the NYTS data, FDA has taken a rigorous enforcement stance over the past year. This has included a number of actions to combat the illegal sale of e-cigarettes to youth, we’ve also taken steps to target companies engaged in kid-friendly marketing that increases the youth appeal of these products, and we launched “The Real Cost” Youth E-Cigarette Prevention Campaign, a new comprehensive effort that targets nearly 10.7 million at-risk youth with advertising on Digital and Social Media and even in schools.

We’re also committed to meaningful policy changes. Notably this past November, FDA Commissioner Gottlieb announced proposed new steps to protect youths by preventing access to flavored tobacco products including e-cigarettes. This policy framework aims to ensure these products are sold in ways that make them less accessible and appealing to youth and include issuing proposed rules to ban menthol in cigarettes and all characterizing flavors in cigars. We have several other efforts we’ll be announcing this year as we continue put the put the full scope of our regulatory tools against this mounting public health crisis.

I’d like to thank CDC for having FDA join this call.

And now I’ll turn it over to Laura Oliven, Tobacco Control Manager with the Minnesota Department of Health.

LAURA OLIVEN: Thanks Mitch.

E-cigarette use is the rapidly escalating and widespread phenomena here in Minnesota. Similar to the national numbers one in five high school youths here are using e-cigarettes and exposing their brains to potentially intense levels of highly addictive nicotine.

At the Minnesota Department of Health, we are responding rapidly to this crisis and using our public health platform, tools, and partnerships to try to stem the tide and prevent further expansion of use.

We have issued an MDA Health Advisory and send It to a Public Health network to warn providers of the health harms of early nicotine exposure on the adolescent brain and the increased susceptibility for future addiction.

We’ve collaborated with the Minister of the Department of Education to issue a joint letter to over 8,000 school officials including school nurses, school health counselors and more. Along with it we provided a toolkit with an array of new resources and actions that school staff can take to protect their students.

We are partnering with physician groups and the healthcare community to educate providers and increase their capacity to protect their patients and warn parents. We’ve activated our network of local Public Health and — officials and community grantees to disseminate information at the local level.

And finally, we have highlighted a series of policy actions that communities can take to better protect youth and make sustainable change. This is a full-court press and we are moving forward on this comprehensive approach with urgency and alacrity.

Now I’d like to turn it over to Brian – Dr. Brian King.

BRIAN KING: Thank you, Laura.

So the report we’re releasing today is based on data from the 2018 National Youth Tobacco Survey which is an annual survey of over 20,000 students in grades 6 through 12 and in 2018 more than one in four U.S. high school students and approximately one in 14 middle school students reported currently using any tobacco product.

Although e-cigarettes are the most commonly used tobacco product among youth, 13.9 percent of high school students and 3.3 percent of middle school students currently report using a combustible tobacco product such as the conventional cigarette, cigars, hookah, pipe tobacco, or bidis.

As Dr. Schuchat noted, the substantial increase in e-cigarette use was the primary driver of this overall increase in tobacco product use from 2017 to 2018 which was previously reported by CDC and FDA November of last year so you may be asking yourself what’s new today and there are several new findings in today’s study.

First the findings from this new study show that use of other tobacco products including cigarettes did not change during this period. We also found that use of multiple tobacco products was common among middle and high school youth, among current tobacco products use is about two in five high school students and one in three middle school students currently used two or more tobacco products. E-cigarettes and cigarettes were the most common combination of products that were use among youth.

The report also notes changes in frequency of tobacco product use among our nation’s youth specifically related to e-cigarettes. Among current tobacco product users frequent use which we consider youths who use the product on 20 or more days in the past 30 days increased significantly among current school e-cigarette users from 20 percent to 27.7 percent.

However, in contrast to what we saw in e-cigarettes no change in frequent use was observed for other tobacco products including cigarettes. This means that in addition to there been 1.5 million more youth who are using e-cigarettes in 2018 compared to 2017, youths who are using e-cigarettes are using them more frequently.

Today’s report also shows differences in tobacco product use across population groups with any use being higher among male, white, and older students. In 2018 e-cigarettes were the most commonly used among all racial ethnic groups except for black high school students, among whom cigars were the most common product.

So a question you may also be asking yourself, is do we know why youth tobacco product uses increasing. The answer to that is yes. As I noted before the advertising will bring a horse to water, the flavors will get them to drink, and the nicotine will keep them coming back for more. We know that exposure to tobacco product advertising and imaging through various media including retail stores, the Internet, television, and other sources can cause youth to start using tobacco products.

Additionally, some new types of e-cigarettes have become popular particularly among kids in this country, the increase in e-cigarette use among youth we’ve seen in the past year occurred at the same time as increases in sales of the e-cigarette Juul. Juul entered the U.S. market in 2015 and since December 2017 has held the greatest market share of any e-cigarette in the United States. We know that Juul devices are being used among kids in schools including inside bathrooms and classrooms and we also know that similar to many other e-cigarettes, Juul comes in a variety of flavors which can appeal to teens.

Juul also has a high nicotine content, among the highest of the any cigarette – e-cigarette on the U.S. market. The devices also use nicotine salt which can allow high amounts of nicotine to be inhaled more easily and with less irritation than the free-base nicotine that’s used in most other e-cigarettes on the market.

So although e-cigarettes are the most commonly used tobacco product among youths, today’s report also shows that they are not the only product being use; we have over 4 million high school student and 840,000 middle school students who are currently using any tobacco product, this includes the variety of smoked, smoke less and electronic product and many youths are using multiple product which can increase the risk of addiction and dependency.

So in conclusion today, the bad news is that there is an epidemic of e-cigarette use among our nation’s youth but the good news is that we know what works to combat this epidemic, using a proven evidence-based strategy. The sustained implementation of these strategies in coordination with FDA regulation of tobacco product will result in reducing tobacco product use including e-cigarettes and initiation among youth.

We can and we should protect our nation’s youth from this completely preventable health threat.

I’d now like to turn it over to a moderator who will ask the operator to open the line for some questions from those who have called in today.

KATHY HARBEN: Thank you, Dr. King.

Dulana, we’re now ready for questions.

OPERATOR: Thank you. If you would like to ask a question over the phone please press “star” “one,” unmute your phone and record your name clearly when prompted. Your name is required to introduce your question. If you need to withdraw your question press “star” “two.” Again, to ask a question over the phone, please press “star” “one.” It will take a few moments for questions to come through so please stand by.

Mike Stobbe from Associated Press, your line is open.

MIKE STOBBE: Hi, thank you for taking my call. This is a question for Laura Oliven. Laura could you tell us what the trend is with conventional cigarette use in Minnesota? I may have a follow-up.

LAURA OLIVEN: Yes. We have reached a historic low in our cigarette use rates here in Minnesota and were very pleased of course with that decline.

MIKE STOBBE: Has it been flat the last few years or has it been steadily declining?

LAURA OLIVEN: It’s been steadily declining and I credit our Comprehensive Tobacco Control interventions, like clean indoor air, high tax rates, and advance comprehensive tobacco control efforts but the e-cig use of course is a disruptor to this success just as smoke – tobacco-free generation was within reach, this is compromising and undermining our efforts.

MIKE STOBBE: Why do say it’s compromising your efforts if the smoking rate is still going down in Minnesota?

LAURA OLIVEN: We consider this overall tobacco use and nicotine exposure is particularly damaging to the early adolescent brain development so from a public health perspective this is a threat that we are very concerned about.

MIKE STOBBE: OK. Thank you.

KATHY HARBEN: Next question please.

OPERATOR: Yes. One moment.

Our next question comes from Sarah Wheaton from Politico. Your line is open.

SARAH WHEATON: Hi, thank you. I wanted to ask if you had asked the youth which brand of e-cigarette they were using or if you would consider doing that in the future? And kind of related to that, I know some pro-vaper groups have argued that this survey would include other types of products under the e-cigarette category like marijuana-based for instance and that they think that that’s kind of conflating the numbers, what would you say to that?

BRIAN KING: Yes. So this is Brian King from CDC. With regard to the brand question we do include questions on the individual brand in terms of both cigarettes as well as e-cigarettes. Of note the 2017 and 2018 survey did not include Juul and we’re in the process of working with our FDA colleagues to update the survey so they will include the specific brand descriptor around Juul but nonetheless this suggests that we are capturing a large portion of Juul use among kids, given now that Juul command 75 percent of the U.S. market share of e-cigarettes and the increase in use among youth has corresponded with skyrocketing rates of sales of these products with a six hundred percent increase between 2016 and 2017 alone with further increases in the 75 percent of the market share.

So this specific study today did not present any information on brands but the survey does include questions on brand and moving forward we will have more data specifically in Juul.

And in terms of your second question, with regard to the e-cigarettes and the use of other products, we do ask the question about the use of other substances in e-cigarettes and CDC released a study last year that found that one third of U.S. middle and high school students who are using e-cigarettes reported using marijuana in the device and that’s consistent with the findings of the 2016 Surgeon General’s Report which also concluded that these products are being use to accommodate other psycho active substances.

So in terms of this particular study, it’s likely that we could have some underestimation in terms of Juul use and there are variants of Juul including PAKs (ph) that are specifically used to administer marijuana but we do have questions that capture the use of other psychoactive substances and basically right now, it suggests about a third of kids are using marijuana in these devices but we’re still actively capturing kids who are using other things besides marijuana, most notably nicotine which h we know can be highly addictive but also can harm the developing adolescent brain which continues to develop into young adulthood and so we are concerned not only among youth but also the increasingly prominent use of these products among young adults as well that’s been captured in other surveys.

QUESTION: So sorry, just to clarify, a third of the e-cig users that are already captured in the survey are also using it for marijuana, like a third about 28 percent?

BRIAN KING: That’s correct. So among those who currently use e-cigarettes in the past 30 days, one third of those report that they’ve used marijuana in and e-cigarette.

SARAH WHEATON: Got it. Thank you.

KATHY HARBEN: Next question please.

OPERATOR: Betsy McKay from Wall Street Journal, your line is open.

BETSY McKAY: Hi, I had a couple of questions, if that’s OK? One for Mitch Zeller if he’s still on the call, which is not anecdotally you know, parents report that flavored e-cigarettes are still pretty easy for their kids to get so what progress is you know, is being made on restricting access after the FDA’s announcements in November I believe?

And then the second question I guess for Dr. King, following up on what Mike Stobbe was asking about use of combustible cigarettes, nationally why do you think use of combustible cigarettes is not declining in this — you know, is there a relationship with the increased exposure – nicotine exposure from e-cigarettes?

MITCH ZELLER: This is Mitch, I’ll answer your first question.

When we issued our policy announcement in November, we said that we were going to take steps, drawing a line between flavors other than mint and menthol tobacco flavors so cherry, and strawberry, grape, bubble gum, cotton candy, the idea being that for those kinds of flavored product whether they are sold in a brick-and-mortar store, a gas station, a convenience store, or sold online that they need to be accompanied by heightened age restrictions so if it’s a brick-and-mortar establishment and w e’ll be getting additional information guidance out very shortly on this, there needs to be an age-restricted location, either the entire establishment is off-limits to kids or there is some age-restricted location inside the store which is the only place that adults would be able to purchase those other flavored products.

We are extraordinarily concerned about the ongoing appeal that all flavored tobacco products have to kids, all policy options are on the table and as I said in my remarks and it’s that the Commissioner announced in November, this goes beyond e-cigarettes; we know how incredibly popular menthol is still being present in cigarettes so we have announced the first time in the Agency’s history the intention to issue a Proposed Rule To Ban Menthol in Cigarettes and a separate rule To Ban All Character izing Flavors, including menthol in Cigars so the problem of flavors being an attractive aspect of all tobacco products including e-cigarettes when it comes to kids is across the board and something that needs to be addressed in a comprehensive way.

BETSY McKAY: OK and but you know, I know it’s only been a couple of months but do you, you know, is access being restricted yet, I their other you know, some of these voluntary actions actually taking effect do you think or there’s more need to be done?

MITCH ZELLER: Well the proof will be in the — in the next round of surveys that take place both NYTS and other surveys that are in the field. As you said it’s only been a couple of months since the November announcement and we’re close to getting additional guidance out for brick-and-mortar and online retailers so it may be too early to tell the impact that purely voluntary actions have had since.

But the Commissioner has also made clear that, we’ll go back to the drawing board and revisit where we drew the line in November depending upon the 2019 results and we are concerned that the 2019 results will continue to show an upward increase in kid’s use of e-cigarettes especially flavored e-cigarettes at which point we will be more than willing to reconsider our policies.

BETSY McKAY: OK. Thank you.

And then the question…

BRIAN KING: Yes, so this is Brian King. To answer your question about why are combustibles not declining.

So there’s multiple factors that could be contributing to this. Of course, in the field of Tobacco Control we have the luxury of over a half a century of science showing us what works, whether that be price increases, comprehensive smoke-free laws, hard-hitting mass-media campaigns, youth access restrictions, we know what works. That being said not everyone is implementing these proven strategies that we know work and there’s a lot of variability particularly across state and so when you look at state-level estimates we are — prominent use of cigarette-smoking rates particularly among kids, it’s still 8 percent nationally but when you look at state levels there’s also some variability as well and it’s no surprise that the higher rates of smoking are in the places where people are not protected by the evidence-based strategies that we know work.

So these findings are really an important kick in the pants in terms of reminding us that we don’t want to play a game of public health Whac-A-Mole where we allow certain products to go up and others to go down, we want all forms of tobacco product use to go down among kids because there is no redeeming aspect of any form of tobacco product use when we’re talking about kids.

That being said it’s important to note that the landscape of tobacco products has diversified significantly within the past several years and we have new products including e-cigarettes and so e-cigarettes could be playing a role in the patterns of use we’re seeing among kids in terms of cigarette smoking and a very important finding from today’s study is that there is two in five high school students are using two or more tobacco products and one in three middle school students are and irrespective of whether middle or high school students, the most common combination is e-cigarettes and cigarettes and so that it is possible that we are reinforcing and perpetuating dependency in terms of nicotine and when it comes to the diverse array of products that youths are using.

It’s also important to note that there is an emerging body of science showing that kids who use e-cigarettes are more likely to smoke conventional cigarettes in the future. We now have over two dozen studies from multiple countries including the United States, the U.K., and Canada showing that kids who use e-cigarettes are more likely to smoke cigarettes in the future.

So although it’s not conclusive and we still need more science on this issue, the science is certainly pointing to a direction that e-cigarette use can influence future conventional cigarette smoking and so it’s possible that we’ve now have a high enough rate of e-cigarette use among youth that’s now starting to influence the rates that we’re seeing in terms of conventional smoking among kids.

And so taken altogether, the science suggests that there’s multiple factors that could be influencing this but the bottom line is that the direction that we want tobacco product use to go is down and irrespective of whether it’s increasing among e-cigarettes or its staying the same among all tobacco products, we need to redouble our efforts to protect our nation’s use from this completely preventable health threat; any form of tobacco product is unsafe among kids a respective of whether it is smoked, smokeless or electronic.

MITCH ZELLER: This is Mitch. Let me — let me call out one other really important finding from these results which Brian included in his opening remarks. In an

In past years when the National Youth Tobacco Survey data was released, going back now three years showing the increase – the extraordinary increase in kid’s use of e-cigarettes one of the responses was, “Yeah, but it’s really very infrequent use,” say five days per month in the past 30 days down to one. Well one of the most important and concerning findings in this release is the extraordinary increase in frequent use which is typically defined as using 20 or more days in the past 30 days and that number went up considerably almost 40 percent from 2017 to 2018 and from a public health perspective we should be very concerned about what that might mean especially with the popularity of these pod-based products, with incredibly high levels of nicotine in them, which is not to say that all these kids are becoming addicted but there is — there’s nothing good from a public health perspective that comes from more frequent use of any tobacco product and an almost 40 percent increase in frequent use of e-cigarettes by kids in one year is cause for concern.

BETSY McKAY: Thank you.

KATHY HARBEN: Next question please.

OPERATOR: Our next question comes from Salynn Boyles, from MedPage Today, your line is open.

SALYM BOYLES: Thank you very much, appreciate it. I have a couple of questions. My first one for Dr. King. So these are data from the last few years but doesn’t this reflect actually the first significant increase in youth tobacco usage in more than a couple of decades?

BRIAN KING: So it’s — it’s — it’s tricky to do an apples-to-apples comparison because the survey has changed over time so our best baseline when we’ve assessed all these products is 2011 where we started assessing the diversity of product including hookah and e-cigarettes and we did actually see a slight decline in the earlier years, from 2011 to 2013 but then it up ticked, it declined again in 2015 and ’16 but this is the greatest single year-over-year increase that we’ve ever seen in terms of any tobacco product use.

And of course, going back we’ve seen consistent declines in tobacco product use for two decades, since the mid-90s.

SALYM BOYLES: Right.

BRIAN KING: … cigarette smoking has been declining among kids but as the landscape has diversified, it’s complicated our ability to do an apples-to-apples but this is a single most year-over-year increase in any tobacco use that we’ve seen from the National Youth Tobacco Survey since we began monitoring back in 1999.

SALYM BOYLES: OK.

So the single biggest increase in any single year for…

BRIAN KING: Correct.

SALYM BOYLES: … sure. OK.

And also, you point out in the report, this is the first reflect a rise in Juul usage, can you elaborate on that a little bit, how — why is that?

BRIAN KING: Yes, so certainly. So it ultimately comes down to looking at the diversity of different surveys that collect data on this issue and one of the most useful rapid-response surveillance systems is retail sales data and they have been instrumental and be able to monitor what the current landscape is in terms of product being sold nationally and so CDC published a study in the Journal of the American Medical Association last year which found that there was a six-hundred percent increase in the use of — in the sales of Juul in particular between 2016 and 2017.

It’s important to note that that study ended by December 2017 but if you look at the sales data one of the most pronounced upticks after that time period was during the summer, between ’17 and ’18 and so the youth – the National Youth Tobacco Survey is fielded in the spring and so the last time that we conducted the survey, we weren’t necessarily capturing the time period where the majority of that sales increase occurred nationally and so if I had my crystal ball I would suspect that we surveyed the kids in 2017 and many of them went home for the summer, and went to camp and they met with their friends and they went on YouTube and found all about this hot new product called Juul and then they subsequently came back to school in 2018 and then we collected our data in spring and we noted a significant increase in the use reported among youth and so that sales data coupled with the emerging body of other surveys which have assessed self-reported use of Juul among kids confirms what we’re seeing in the National Youth Tobacco Survey, demonstrating that you know, the only modifiable factor during this period was primarily these USB pod-mod devices including Juul which skyrocketed in sales at the same point that we saw this increase in use among youth.

KATHY HARBEN: Next question…

SALYM BOYLES: Thank you.

OPERATOR: Richard Harris from NPR. Your line is open.

RICHARD HARRIS: Thanks. I’ve got two quick questions for, I guess for Dr. King both.

One of which is you said a couple of times two in five high school kids are using two or more products, that’s 40 percent. If the overall rate is 27 percent, and I’m a little bit confused for any high — for any tobacco product so I’m a little confused what that two in five really means?

BRIAN KING: Yes. So the two in five is actually among current tobacco product users so the denominator, the bottom of the fraction, and so it’s among youths who are currently using tobacco product, two and five high school students and one in three middle school students are using two or more products and so those other numbers that we’re recording among all the kids but that multiple product use, the bottom denominator line is just the kids who are using tobacco not all kids.

RICHARD HARRIS: So two in five high school users are using two or more products, is that right?

RICHARD HARRIS: And the other question is, just curiosity, is nicotine coming from tobacco still or is it — is it synthesized so the — I’m just wondering why you call these tobacco products?

BRIAN KING: Yes. So in terms of the actual nicotine that’s used in the vast majority of tobacco products including e-cigarettes it is derived from the tobacco plant. Nicotine is naturally occurring in tobacco, it’s traditionally extracted from the tobacco plant using ammonia, although there are certain things that can be done during the manufacturing process as well to change the acidity of the nicotine and like an example of that is with Juul, uses nicotine salt so it’s still nicotine but it’s a different type of nicotine that can make it to go down easier, which is certainly concerning to us in terms of nicotine naive-populations such as youth and young adults but in terms of CDC we categorize these products as tobacco products because the FDA regulates them as such.

And so it is possible to create synthetic nicotine but it would be extremely expensive in the current market, it would not be lucrative to you know, sell you know, using synthetic nicotine although the — there are certainly a lot of people that are researching that and looking at alternative avenues in which to obtain nicotine but for the most part the vast majority of tobacco products as well as e-cigarette product on the U.S. market do in fact include nicotine which is derived from the tobacco plants in which case it is under the regulatory purview of FDA.

I’ll note that you can also obtain nicotine from vegetables but I can assure you that it is hundreds of pounds of potatoes and egg plants in order to get even the equivalent of one pack of cigarettes so the likelihood of someone using either vegetable-derived nicotine or other sources is simply not financially or even reasonably possible in the current environment.

RICHARD HARRIS: OK. Thanks.

KATHY HARBEN: We have time for two more questions. Next question.

OPERATOR: Andrew Siddons from Congressional Quarterly. Your line is open.

ANDREW SIDDONS: Thanks for doing this today. First for CDC, you said – you said the most frequent combination cigarettes and e-cigarettes, could you just say what proportion of the dual users are using that combination? And second for Director Zeller, last week Commissioner Gottlieb sent a letter to Juul talking – expressing concern that their commitments – that they’re sliding back on their commitments, could you specify what actions they have been taking that are concerning to you all? Thank you.

MITCH ZELLER: This is Mitch. I’ll go first. I would refer anybody interested in this to any of the public statements that either Juul or Altria put out in the aftermath of the meetings that they had at our request with them last October and November and that’s why last week’s letters went out to have both companies come back in to basically explain so that we can better understand how things that were said last fall, especially as regards the marketing of flavored pod-based products, how that squares with their positions today and I’ll just leave it at that.

BRIAN KING: And then in turn — this is Brian, the answer to your other question so among the high school students who currently use two or more tobacco products, the proportion of use, e-cigarettes and cigarette was 14.8 percent and among middle school students it was 14.4 percent so it’s important to remember that there’s a lot of different combinations, there can be two products, it can be three or more, it could be you know, all five you know, products that were assessed but in terms of the percentage of multiple products’ users and the prevalence of the combination, it was about 15 percent among high school students and about 14 percent among middle school students.

ANDREW SIDDONS: Thank you.

KATHY HARBEN: Final question please.

OPERATOR: Janel Miller from Healio. Your line is open.

JANEL MILLER: Yes. Thank you for taking my call and having the conference call with us today. Can you talk a little bit about what clinicians can do to curb this epidemic because they are not going to have the effort — they’re not going to be able to affect media campaigns or campaign to lower the prices as much as some of the other stakeholders you mentioned so I was hoping you could specifically talk to what the primary care physician should be doing to curb this epidemic? Thank you.

BRIAN KING: So this is Brian King. And I think it’s important to reinforce and this Vital Sign does so in the supplemental fact-sheet information that’s provided along with today’s report, the fact that there is a variety of people that play a critical role in terms of addressing the epidemic of e-cigarette use in this country.

And consistent with the Surgeon General’s Advisory which was released last year we know that there is a variety of individuals who can take action, it’s not just you know, the national, state, and local you know, policymakers and decision-makers, it’s also parents and educators, healthcare providers, individuals, schools as well as states and communities.

And when it comes to healthcare providers, there are several things that they can do. One of the most important is asking specifically about e-cigarettes when they screen for tobacco products use, and it is extremely important for pediatricians, but any healthcare professionals that’s working with youth and we need to make sure that you know, we don’t have to reinvent the wheel here but we have to grease the squeaky wheel to ensure that we’re addressing the diversity of tobacco products that kids are using.

So first and foremost, identify the use of the product and ask kids whether they are using them and that may include using the current terminology, and saying, “You know, do you use the Juul?” “Do you use,” you know, a, “Vape Pod?” The kids may not necessarily identify the product as an e-cigarette but identifying use, is particularly important using the terminology that the kids are using. And it’s also most important that once they identify whether they are using them but even if they’re not ensuring that they’re warned about the risks of tobacco products use.

We know that an ounce of prevention is worth a pound of cure and that the vast majority of adult tobacco users begin during adolescence and so this is a critical period in terms of intervention to ensure that we prevent kids from using all forms of tobacco products use.

So the bottom line is when it comes down to healthcare professionals ask them about the product using relevant terminology and if they are using it, warn them to stop using it completely including the risk of nicotine on their developing brain and its impact on learning and memory and cognition, and helping to work with them to get off of these products. And we do know that behavioral counseling has shown to be effective by healthcare professionals, to help kids quit tobacco product and as a critical lever in coordination with right reminders from parents and other use influencers to reinforce the dangers of these products among youth.

MITCH ZELLER: This is Mitch. Let me add a point from a different FDA perspective and that is treatment and pharmacotherapy, the reality is there are no FDA-approved medications to treat use tobacco cessation of any type; there never have been and this is a gap and we convened a public hearing just a few weeks ago to bring in researchers, clinicians, folks working at the community level, to inform our thinking about what can be done to address the role of medicines when it comes to treatment.

The increasing number of reports that we’re hearing albeit anecdotally of kids who are either becoming addicted or showing signs of addiction to especially these pod-based products is really concerning. In the past when we had lots of kids smoking cigarettes, there were no FDA approved medicines, they’re still aren’t so this remains a gap in the treatment arsenal that needs to be closed and we are working closely with colleagues to try to do that.

OPERATOR: OK.

KATHY HARBEN: Thank you to all of our participants both their opening remarks and for the Q&A. If reporters have follow-up questions you can call the CDC Press Office at 404-639-3286 or you can send us an email at media@cdc.gov.

Thank you everyone for joining us. This concludes our call

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