N.C. middle and high school current users of any tobacco product. Data source: N.C. Youth Tobacco Survey, 2013
N.C. middle and high school current users of any tobacco product. Data source: N.C. Youth Tobacco Survey, 2013


New statistics show more teens are using devices such as e-cigarettes and hookahs, even as the rate of cigarette smoking drops.

By Rose Hoban

Fewer young people in North Carolina are picking up the smoking habit, according to new statistics released last week. But at the same time, an accelerating number of high-schoolers in the state are becoming addicted to nicotine by using e-cigarettes and other forms of tobacco.

According to the latest Youth Tobacco Survey, a nationwide survey sponsored by the Centers for Disease Control and Prevention, the number of high-schoolers in North Carolina who are current cigarette smokers dropped from 15.5 percent in 2011 to 13.5 percent in 2013, an all-time low.

N.C. current tobacco users by gender. Data source: N.C. Youth Tobacco Survey, 2013
NC current tobacco users by gender. Current use is defined as someone who self-reports as using a tobacco product in the past 30 days. Data source: N.C. Youth Tobacco Survey, 2013

At the same time, the number of high school students using any tobacco product – including e-cigarettes, small flavored cigars and tobacco smoked in hookahs – rose from 25.8 percent in 2011 to 29.7 percent in 2013.

Use of tobacco products among middle-schoolers has remained relatively stable, decreasing slightly from 9.9 percent in 2011 to 8.6 percent last year.

Penny Slade-Sawyer, head of the North Carolina Division of Public Health, said this rise in the use of tobacco products among young people is a “huge problem.”

“This new generation is growing up in a world where we have tobacco companies spending millions and millions of dollars to bring them into their fold with flavored cigarettes and e-cigarettes,” Slade-Sawyer said.

Youth focus

According to acting U.S. Surgeon General Boris Lushniak, who was in North Carolina last week to speak to the N.C. Public Health Association, the problem is that the world of regulators has been slow to respond to the explosive growth in the e-cigarette industry.

After years of pressure from anti-smoking advocates, the Food and Drug Administration – which has the power to regulate cigarettes – came out in April 2014 with a proposed rule that would regulate e-cigarettes.

Lushniak said neither he nor the FDA has enough scientific data to say that e-cigarettes are harmful, but he stopped just short of doing so in his presentation to the public-health association.

“Do I want to substitute one addictive product for another addictive product?” he asked during his presentation.

Lushniak said there are many unanswered questions, and that he can’t condone e-cigarette use. He also said he had a hard time seeing e-cigarettes as a way to help cigarette users quit, as many e-cigarette advocates, and some in the industry, claim.

“There was a study from the United Kingdom recently that viewed it as a potential tool [for quitting],” Lushniak said. “But the reality is that when you look at the harm-reduction model, if it’s an intermediary to drop all nicotine use, I’d be all for it. But now, that’s not how it’s being marketed.”

N.C. middle and high school current users of any tobacco product. Data source: N.C. Youth Tobacco Survey, 2013
NC middle and high school current users of any tobacco product. Data source: N.C. Youth Tobacco Survey, 2013

Slade-Sawyer and Lushniak pointed to the myriad of e-cigarette “juices” with flavors such as cherry cordial and watermelon that would appeal to youth as evidence that the industry is targeting young people.

“You want bubble gum flavor, you can have bubble gum. You want cotton candy, you can have cotton candy,” said Slade-Sawyer. “We are having our children being brought into an addictive culture, and it’s our job to try to stop that.”

She said the evidence is that even though e-cigarette users don’t get exposed to the thousands of chemicals created when a smoker inhales cigarette smoke, the nicotine and other chemicals in e-cigarettes are not without harm.

And she dismissed the idea that liquids vaporized in e-cigarettes are not tobacco products.

“Let me ask you, where does nicotine come from?” Slade-Sawyer asked. “Tobacco.”

Research has shown that nicotine contributes to heart disease, narrowing of the arteries and increased blood pressure, which increases the risk of stroke. There’s also research that shows that nicotine can affect the adolescent brain, increasing attention deficits and making young users more susceptible to addiction. And new research shows that patients with tobacco-related cancers increased their use of e-cigarettes, rather than quitting the nicotine habit altogether.

Research from Duke University is also showing nicotine might have profound effects on developing fetuses.

‘Wild West’

Several of the officials who commented on the survey numbers Friday compared the state of regulation in the e-cigarette industry to the “Wild West.”

One of the issues with e-cigarettes is that the substances and amounts used in the devices are unregulated, according to Erin Sutfin, a public-health researcher at Wake Forest University. She said there’s little standardization in how e-cigarette manufacturers extract nicotine from tobacco plants, and the process could result in harmful chemicals remaining in the mix.

Some of the e-cigarette liquids for sale in N.C. today. Flavors from left to right: watermelon, Irish Cream and appletini.
Some of the e-cigarette liquids for sale in NC today. Flavors from left to right: chocolate-covered strawberry, Irish Cream and appletini. Photo credit: Rose Hoban

“We need to know more about the chemical composition of the aerosol,” Sutfin said. “You see the array of products there and there’s no standard composition in the products, and right now there’s no regulation.”

Sutfin showed a vial of watermelon-flavored “juice” on which the label read “0 mg nicotine” and also had the warning, “May contain nicotine.” She said preliminary evidence from her lab on that particular vial indicated there was nicotine in the mix.

“These are the types of things that we hope that once the FDA has the final rule in place, they can set product standards that will require disclosure of what’s in the product and make sure the products are labeled clearly,” she said.

“We at the Division of Public Health and at the Department of Health and Human Services believe and know that e-cigarettes are tobacco products and need to be regulated in the same way that tobacco products are regulated,” Slade-Sawyer said.

No money for education

Pam Seamans from the N.C. Alliance for Health bemoaned the fact that funding for youth prevention activities in North Carolina was eliminated in the 2011 budget.

“North Carolina gets about $140 million a year from the Master Settlement Agreement and the money is coming to the state for tobacco cessation, and instead it’s going to the general fund,” she said, referring to the 1999 class-action settlement in which tobacco companies agreed to pay states for the public costs of treating tobacco-related diseases.

Lushniak pointed out that tobacco companies spend about a million dollars an hour on marketing tobacco products, but most states only use a fraction of their Master Settlement money, if any, on reducing use.

“What’s so distressing about North Carolina is that they did have a well-funded program that was having an impact,” said Amy Barkley, the Southeast regional director for the Campaign for Tobacco-Free Kids. “We had proven impacts about what was being done, and then the funding is completely stripped away.”

“There are many, many legislators who care a lot more about what the tobacco industry thinks than what health advocates think,” Barkley said. “And when you have politicians dictating public-health policy, that’s a problem.”

This story has been updated with a link to research published on Sept. 22, 2014. 

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