What you should know about vaping and e-cigarettes

"It gets easier, right?"

These are the words
I often hear from young parents

who are new to the game
of worrying about their children.

I tell them that it doesn't.

It gets different,

but there's always something
to worry about as parents.

I remember how I would lie
half-awake at night

listening to my son breathe

when he was young and had asthma,

and then, when he was a teen,

until I heard the front door chime open,

and I knew that he was home safe.

Worrying about our kids
comes with the territory.

Now, many of these worries
are about basic issues,

like what they eat,
where they are, who they're with.

But we also need to keep an eye on
new behaviors and fads.

The latest craze is something
that may not yet be on everyone's radar

as a serious health concern,

and that is the newfound
popularity of vaping,

or inhaling sweet aerosols

produced by vaporizing
e-liquids in e-cigarettes.

E-cigarettes, or "vapes,"
as they are commonly called,

are flying off the shelves like candy.

This year, the e-cigarette
market is expected to drive

26 billion dollars in sales worldwide.

Over the next six years,

that volume is expected to double.

We have a lot of serious concerns
about the health impact of vaping,

and unfortunately,
not nearly enough answers.

This becomes even more concerning
when you think of who uses e-cigarettes.

E-cigarette use, at least in the US,

has grown rapidly among youth
and young adults --

our kids,

our most vulnerable population.

There was a 900 percent growth
in the use of e-cigarettes by youth

between 2012 and 2015.

The most recent estimates suggest

that approximately 3.6 million
high school and middle school students

have used e-cigarettes in the US.

Now, e-cigarettes were originally created

to offer smokers a cleaner
form of nicotine

to help with their cigarette addiction.

In the US, these devices
come under the FDA's jurisdiction

as a tobacco product.

But the science on these devices
has not been able to keep up

with the rapid market growth,

so regulations on the components
of these devices and e-liquids

are lagging.

Current regulations do restrict
sales of these devices

to anyone under the age of 18,

but these do not seem
to have had much of an impact

on the explosion in the use
of these devices by teens.

You know, the first time
I heard of and saw an e-cigarette,

I knew right away
that teens would love it.

These devices are technology on a stick,

a perfect fit for
the smartphone generation --

small, rechargeable, easy to use,
easy to modify, nice smelling --

some even sync with your smartphone
to let you know how much you have vaped.

Even I was very drawn
to these very clever devices.

And since I had spent a long time
researching teen and adult addictions,

I immediately realized that these devices
fit perfectly into the teen psyche.

Teens are impulsive,
and they love to try new things.

They're also craving independence,
and they love to make things their own.

E-cigarettes meet these needs perfectly

by allowing them the chance
to both innovate and personalize

their vape experience.

They can choose from over 15,000
different e-liquid flavors

and multiple nicotine concentrations.

They can even create their own
nicotine flavor combination.

They can change how much vapor
is produced from these devices

by modifying the puff volume
and the constituents

and the power and temperature
of the devices.

They can even use these devices
for "cloud chasing."

Cloud chasing, also called vape tricks

or smoke tricks,

involves producing large vape clouds
with quirky shapes and names,

like rings, dragons, ghosts ...

Cloud chasers can even participate
in cloud competitions

and win prizes for creating
the most innovative shaped clouds.

Teens can also change the strength
and throat hit from the vapor

by either vaporizing the e-liquid
at higher temperatures

or dripping the e-liquid
directly onto a heated coil.

They can even use these devices
for marijuana vaping.

And since the devices
use lower temperatures

and do not combust or burn the marijuana,

they can do this very discreetly,

without the distinctive smell
of burnt marijuana.

So they can really make these vape
experiences their own,

which may explain the astounding rise
in the use of these devices by youth.

E-cigarettes are technically
a very simple device.

There is a receptacle for the e-liquid
which can be a tank, a pod or a plug.

There is a battery that charges the coil,
which then vaporizes the e-liquid.

And then there is a mouthpiece,

where the user can actually draw
from the e-cigarette.

In 2017, there were 466 e-cigarette
devices in the marketplace.

These range from cigarette-like devices
which are also called "cigalikes"

to tank systems,
which are also called "pens."

And then there are modified devices,
which are also called "mods."

Mods look nothing like a cigarette,

and they come in various shapes and sizes,

with different kinds of attachments
and user adjustments.

They're very popular for cloud chasing.

The most recent entrance
into the marketplace

are the pod devices,

which contain the e-liquid in a pod.

These are very popular,
by the way, among teens.

An example of this is the Juul,

which not only looks like a USB device

but can also be plugged
into a USB outlet to charge.

Many teens do not even think
that these are e-cigarettes,

which has led to the use of terms
like "juuling" instead of "vaping."

Many of these devices are so discreet
and produce so little vapor

that teens are using them in classrooms

and hiding them in objects
like Sharpie pens, their clothes,

their books.

Now, many teens think
that these devices produce water vapor,

and therefore, they are safe to use.

But this could not be
further from the truth.

What is produced is not even a vapor,

it's an aerosol,

and let me tell you, the difference
is quite pronounced.

Aerosols contain many finely suspended
particles of liquids and gases

that are created
from whatever is in the e-liquid.

So an aerosol could contain
propylene glycol and glycerin,

which are solvents in the e-liquid.

Now, these solvents are known
to be safe for edible use,

so for use in products that you eat,

but we know very little about their safety
following long-term inhalational exposure.

The e-liquids can also contain alcohol,

sometimes in high levels,

and inhaling alcohol is known
to have toxic effects on the brain.

I told you earlier that the e-liquids
contain over 15,000 different flavors.

Here are some examples,

some with very catchy but familiar names
like "Skittles" and "Fruit Loops,"

and others with more exotic names
like "Dragon's Milk" and "Tiger's Blood"

and "Unicorn Puke."

The e-liquid or the aerosol
can also contain metallic particles

like chromium, cadmium and lead.

These are generated
from the heating coil in the devices

and are also known to have
many toxic effects on vital organs.

So no, let me make this very clear:

what is produced is definitely
not water vapor.

Exposure of the teen brain to nicotine
through e-cigarettes

is also very concerning.

The teen brain is very sensitive
to even low levels of nicotine

and gets very easily addicted.

In fact, we have known for a long time

that 90 percent of smokers start smoking
cigarettes prior to the age of 18.

Those who start early are more addicted
and have a harder time quitting smoking.

In other words, and to quote
a past FDA commissioner,

"Nicotine addiction ...
is a pediatric disease."

E-cigarettes can expose teens
to a lot of nicotine.

Many of these devices contain
the amount of nicotine

that is in a full pack of cigarettes.

The more recent pod devices
contain a nicotine salt,

which has a smoother taste
and is much easier to use

and can produce rapid increases
in brain nicotine levels.

Teens who use e-cigarettes regularly
report symptoms of craving --

feeling anxious when they don't
have their e-cigarettes.

All these are hallmarks
of a behavioral addiction.

E-cigarettes are not only addictive

but they also affect
many other organs in the body.

So nicotine, which is
in e-cigarettes, for example,

binds to a receptor called
the nicotinic acetylcholine receptor,

which plays a key role in the functioning
of almost all organ systems

in the human body.

And chronic exposure to nicotine
changes the functioning of these systems.

So as an example,

chronic exposure to nicotine decreases
the flexibility of the blood vessels

and changes how the heart responds
to acute challenges like stress.

The teen brain is not only sensitive
to the addictive effects of nicotine

but also to its toxic effects.

In adolescent animals, nicotine
is a very well-established neurotoxin,

and it decreases learning,
memory and attention processes

and increases hyperactivity symptoms.

Teens who use tobacco products
are more likely to use

marijuana and alcohol

and also develop depression and anxiety
as a teen or as an adult.

So nicotine addiction through e-cigarettes
could be leading them down the path

of other addictions
and other mental health problems.

Now, in adolescent animals, nicotine
also produces epigenetic changes,

or heritable changes in gene expression,

for example, in the genes
involved in asthma.

So teens who use nicotine may not only
be harming themselves

but they could be harming
their future generations.

You know, the very existence
of e-cigarettes

could have led to an entire generation
of nicotine-addicted youth.

Easy access to these devices
could have led to more experimentation

with marijuana and many other
vaporizable substances by youth.

While there is no doubt that providing
smokers with a cleaner form of nicotine

is and should continue
to be a critical goal,

we still do not know if these devices
help smokers quit smoking,

and we know very little about
the long-term effects of these devices.

What we do know is that youth --
lots of youth -- are using these devices.

In fact, the FDA commissioner
recently used the term "epidemic"

to describe e-cigarette use in the US.

While trying to solve one huge
public health problem, cigarette smoking,

we may have created another colossal one.

Our lack of vigilance in the earlier years
around cigarette smoking

led to a cigarette epidemic and many,
many cigarette-related diseases.

We do not want to repeat
the same mistakes with e-cigarettes.

So now is the time for action,

for regulations that address the appeal
and access of these devices to youth.

Do smokers really need 15,000
kid-friendly flavors to quit smoking?

Do they need so many different
kinds of devices?

Is it a good idea to have devices
which are so easy to hide

and so easy to use?

We recently heard that the FDA plans
to introduce stricter regulations

on sales of these devices
that contain e-liquid flavors

in retail locations like convenience
stores and gas stations,

and also introduce stricter regulations

on sales of devices
to minors over the internet.

Is this going to be sufficient to change
this rapid increase in youth uptake?

We need to ask and answer
such critical questions.

Now is also the time for a serious
public education campaign.

Teens and their parents need to know

that while e-cigarettes may contain
less toxins than cigarettes,

they're certainly not benign.

Exposure of their bodies to the chemicals
produced by these devices

could be changing them in ways
they may not like

and setting them up for future
unknown toxicities and health problems.

You know, when I said earlier

that e-cigarettes were a perfect fit
for the smartphone generation,

I was not kidding.

We live in a technology-crazed world,

where the latest device
and technology gets a lot of attention

just because it is technology
and because it is the latest thing.

More and more over the next few years
and for the rest of our lives,

we are going to see technologies
coming into the marketplace

that may not raise
any health flags at first,

simply because they don't look unhealthy

or they're not a medical device.

For example, we could see devices

that may make it easier
to go longer without sleep

or help us lose weight --

a personal goal of mine --

or achieve any number of other goals

that we as consumers
are very, very interested in.

But many of these devices may come
with unacceptable risks to our own health.

So if we want to protect our health
and the health of our children,

perhaps we should get out of the habit

of automatically celebrating
such new technology

and get into the habit of looking
at them with a critical eye,

perhaps even through a medical lens.

Because, you know something?

Our health, the health of our children
and our future generations

is far too valuable
to let it go up in smoke --

or even in aerosol.

Thank you.

(Applause)