Daniel Larson:
Hello, and welcome. My name is Daniel Larson and it is my pleasure to welcome you to today's program, featuring Connie Horgan, professor and founding director of the Institute for Behavioral Health at the Heller School for Social Policy and Management, Meredith Berkman, co-founder of Parents Against Vaping E-cigarettes, also known as PAVe and Alexandra F. Kritikos, a vaping researcher and doctoral candidate, PhD'20 of the Heller School for Social Policy and Management. Professor Horgan will serve as moderator for today's discussion on the topic of vaping in America. We are delighted to welcome you, our alumni, parents, Brandeis National Committee members, and friends around the world. Thank you so much for joining us.
Daniel Larson:
Now to introduce our speakers. Professor Horgan is a national expert on the organization financing and quality of behavioral healthcare. Her research is focused on how alcohol, drug, and mental health services are financed, organized, and delivered in the public and private sectors and what approaches can be used to improve the quality and effectiveness of the delivery system. Meredith Berkman is cofounder of Parents Against Vaping E-cigarettes, a national grassroots advocacy group formed by three New York moms that's response to the youth vaping epidemic. A former journalist, she wrote for magazines, including New York and entertainment weekly and was a columnist for newspapers, including the New York Post. Berkman is a graduate of Brown University and the Columbia Graduate School of journalism.
Daniel Larson:
Finally, Alexandra F. Kritikos, MA is a PhD candidate studying health and behavioral health policy at the Heller School for Social Policy and Management. She is a National Institute of Alcohol Abuse and Alcoholism pre-doctoral fellow for research. Her recent research includes work on cannabis regulatory policy commercialization, youth prevention, and polysubstance abuse, polysubstance use, I'm sorry. Kritikos received her MA in applied economics from Northeastern University and her BS in economics from the University of Patras. Now, onto you, Connie. Thank you.
Constance Horgan:
Okay. Thank you, and welcome to everyone to our very exciting dialogue today about vaping among the US youth. It is such an emerging crisis. We think of vaping maybe back in the start of this the century, that it was promoted as a healthy alternative to smoking. Here we are with vaping perceived as a problem. It is a cultural phenomenon you'll be hearing some phenomenally astounding statistics today about the fast pace of vaping in this country. But we're not just giving you statistics. We are going to be talking about, what are the solutions to this emerging problem? This is so key to be thinking more broadly and putting this in a broad public health perspective.
Constance Horgan:
To do that, we're sticking with our Heller byline, which is knowledge advancing social justice. To do that, we believe that there has to be the research, but there also has to be the policy and the advocacy to go along with it. So we're structuring our presentation today to have two perspectives brought together. We will be starting out with Alexandra Kritikos who is our stellar doctoral student at Heller who's been focusing her research on vaping who will give you an overview of the research particularly focused on adolescents. Then we will be moving on Meredith Berkman, who will be the activist here, bringing a different perspective, a much needed perspective because our argument is it's together with the research and the activists that we need to move forward in the policy world.
Constance Horgan:
Before we begin, I would just like to give you a game plan on the structure of today. We will start out with our two speakers, first, the researcher, Alexandra, second, Meredith, the perspective of the activist. Each has a set period of time, and we are not taking questions at that point. Then we will be moving into getting these two to talk. We're talking about research and the real world of activism. Let's have an exchange and a dialogue between the two of them. I will be moderating that discussion.
Constance Horgan:
Then the second half of our hour today will be spent with your audience asking questions, and there's ample time for questions in this period. Hopefully, you will be part of helping us think through solutions to this problem. So welcome to all who are now, I hope, on the line to alumni, parents and friends of the Brandeis National Women's Committee. Thank you for being here. I know we have a rather large audience, and I am so pleased that you're here. I'm so pleased to actually have gotten some messages from former students who've joined in. So this is a real treat for us. With that, I would just like to move right on to Alexandra to share with us the researcher perspective.
Alexandra Kritikos:
Great. Thank you so much. I will start sharing my screen at this moment. So just to know okay that you can see my screen, my slides. Yes. Okay. Thank you so much, Connie and Daniel for that great introduction. I'm so happy to be here. Thank you so much for having me. I am going to deep dive right into our topic for today, What is Happening With Vaping and Adolescents? Considerable progress has been made in reducing cigarette smoking among our nation's youth. However, the tobacco product landscape continues to evolve today and public health and medicine are currently facing a new challenge, e-cigarettes and vaporizers that were first developed in the early 2000s and have become an emerging phenomenon. So what are these new products? They are battery-operated nicotine delivery devices that resemble traditional tobacco cigarettes. Even though in the beginning, they were just used to vaporize nicotine, today, they're also used to vaporize flavoring marijuana as well as other substances.
Alexandra Kritikos:
So what are we concerned about? Well, first of all, many who are vaping just believe that they are inhaling and exhaling air, just water that evaporates. But we do know that these devices contain ingredients that are known to be toxic to the human body. Second of all, when we look at either nicotine or marijuana vaping, and we look at the nicotine and/or marijuana levels in these devices we do see that these levels approach those of traditional cigarettes and could even exceed a typical marijuana joint four to 30 times. We're going to talk about why that is problematic.
Alexandra Kritikos:
Third of all, and this is the focus of today's presentation, nearly one in four students report vaporizer use in the US today. Then finally, from the research perspective, as a researcher, we really are going through a social experiment. What does that mean? That these products are very, very new in the market. We don't have enough data to really talk about what's the health effects quite yet.
Alexandra Kritikos:
So why do we focus on adolescents as a focal point? Well, first of all, substance use, nicotine use, marijuana use, alcohol use, whatever that is typically begins in the middle to late adolescence and peaks in the early and middle twenties. Second of all, adolescents are more susceptible to environmental influences. So that means that if your friend is trying something out, if there's a new trend in school happening, if you are at a party, and your friends are engaging in some type of a behavior, then you might also be more susceptible as a young adult to engage in that behavior as well. Then finally, the most crucial piece is that adolescents brains have not fully matured.
Alexandra Kritikos:
So what does substance use have to do with the developing brain? Well, adolescents and teens are especially susceptible to the adverse effects of nicotine and marijuana use since their brains are still undergoing neurobiological maturation, which means that if a student is using a vape to consume nicotine and/or marijuana, they could develop a nicotine dependence. It could be likely that they develop a cannabis use disorder. It could affect their IQ levels. It could impair judgment, which might lead to other risky behaviors, such as driving under the influence. Then finally, a big part of my research is also looking into co-use. So our students who are vaping also engaging in other substance behaviors.
Alexandra Kritikos:
At this point, I'm just going to take a very, very brief second because I know that Meredith is going to talk a lot about this. But we know that these products enter the US market in 2007. Up until 2016, now that's almost 10 years after that, there were no regulations. So these products could be bought anywhere. You could find them all around the mall, in your convenience store down the street. There was no age restriction, and they were also freely advertised. So we can understand what implications that has on substance use.
Alexandra Kritikos:
So deep diving into the data. I'll start right here. This is just an overview of what has happened in the US. These products entered the US tobacco market in 2007, and sales have been exponential. Just looking at one year, 2012 to 2013, there was 150% increase in sales just within that year. If we look at those numbers today in 2020, they are much, much, much higher. Also very important, there are over 500 brands available in thousands of flavor, variations, ranging from juveniles flavors, such as bubblegum and cotton candy to very sophisticated flavors for adults. Then finally, if we look at who really started consuming these products, we see that the largest increase in consumption has happened specifically among youth. This is whatever we're talking about in the upcoming slides.
Alexandra Kritikos:
So right here on the right-hand side in this graph, we are looking at annual youth consumption rates across the US. This is data from the Monitoring the Future survey, which is a nationally representative survey of USU. What we see is that from 2015, where the survey started tracking vaping questions up until 2019, which are the most recent results, we see this increase in use among youth. It is quite a large percentage if we see that in 2018, it's about 30% for just this annual consumption. But what I would like you to focus on is on the two bars, 2017 and 2018, in that very large jump that we see there. So that jump from 2017 to 2018 translates into 1.3 million additional adolescents that vaped just in that year. If we look at the history of the Monitoring the Future survey in the US, that is the largest increase in a substance use question that has ever been asked on that survey. So that is very worrisome for many reasons.
Alexandra Kritikos:
So these were annual consumption rates. But here, I would also like to show you past month, specifically nicotine consumption rates because it's very important to look at past month to understand prevention from a better perspective. So what we see here happening on the right-hand side is a couple of things. First of all, again, we see that jump from 2017 to 2019. We see that increase in past-month nicotine consumption. But what we also see is that 12th graders who are in the dark bars are consuming more compared to the 10th graders who are consuming more compared to the eighth graders. That is something that we would expect.
Alexandra Kritikos:
Now, if we translate those numbers, that 25% that we see in past-month nicotine vaping among the 12th graders, that translates into one in four 12th graders has said yes to past-month nicotine vaping, one in five 10th graders and one in 10 eighth graders. I would like you to all think about that. If this is just past month vaping, then what would the ratios be if we asked about, have you ever used nicotine in a vape in your life? Those numbers, we can understand, are much, much higher.
Alexandra Kritikos:
One more point that I would like to focus on is going back to what I mentioned in the first slide, which is that these devices today are used to vape many different things, nicotine, marijuana, flavoring. A big focus today in the research is that youth are using more nicotine in these vaping devices, but they are also using more marijuana. This is what these graphs show. The gray is the year 2017. The light gray and the dark gray is the year 2018. So we see this continuous increase among eighth, 10th, and 12th graders for vaping nicotine, but we also see an increase in vaping marijuana. Again, the 12th graders are using more than the 10th graders and more than the previous.
Alexandra Kritikos:
Then finally, the last graph with data I will show is something that again, I've been talking about again and again, which is that it's important to not just ask, "Oh, are you vaping?" But what are they vaping? Because we see that almost 30% have said yes to vaping nicotine. 26% have said yes to vaping flavoring. 13% have said yes to vaping marijuana. Then there's also a percentage who don't even know what vaped, and that is problematic because you wouldn't want anyone not knowing what they are putting in their body. Correct.
Alexandra Kritikos:
So finally, I would like to just finish with two broad questions, just some food for thought. The first question is, are vaporizers the new gateway drug, even though we really don't talk about the gateway effect anymore? I would just like to pose if students do perceive these devices as less harmful, if they are appealing because of the various shapes, sizes, fun flavors, and colors that they come in. We know that youth are more likely to experiment with their friends at parties, and at the end of the day, these devices do contain nicotine and/or other substances.
Alexandra Kritikos:
So someone who might just be starting off because they think something is fun or cool could get hooked on a substance. The final question is I won't deep dive into this, but what is the policy concern? I know that we're going to have a great discussion with Meredith. So I'll just end here. Thank you so much.
Constance Horgan:
Thank you very much, Alexandra. That's wonderful background. Now, let's move right onto Meredith Berkman. Can you move us more into the policy work that's going on and tell us about what you have been doing. So thank you.
Meredith Berkman:
Thank you. Thank you so much.
Constance Horgan:
The activist perspective.
Meredith Berkman:
So funny, I think of myself as an advocate or a mom-vocate, a mom who advocates, we call ourselves mom-vocates because it seems less threatening sometimes. But I suppose you're right. It is activism. I think that we have a couple of polling questions that we were going to ask. If Daniel can put them on the screen because I don't see them. I'm not sure if others do. The first one, and just to give a perspective. So how many e-cigarette flavors remain on the market after what has been called the federal flavor ban of 2020, which we'll get into in a bit? So the choices are 200, 34, 15,000, or 5,000.
Meredith Berkman:
The reason that we're asking that question is because for our advocacy, we're completely focused on the flavors of e-cigarettes. Maybe we'll go to the next question, and then I'll go to my slides where I'll launch into how I ended up here. I think the next question, just the answer, and there you have it. How many flavors remain on the market after this year's "flavor ban" is actually 15,000. There were 15,000 flavors of e-cigarettes on the market before this flavor ban, and there are 15,000 still on the market. So I think that gives you a sense of some of the activist frustration with regulation.
Meredith Berkman:
The next question, let's see if we get the next question. How many states have banned the sale of all flavor e-cigarettes? The choices are two, none, 12, or four. Again, I think that gives you a bit of a guide to what we'll be talking about. So we're talking about how many states have banned the sale of all flavored e-cigarettes because that is at the key advocacy point for us because we're focused on kids because we're Parents Against Vaping E-cigarettes. We're not looking to ban devices or tobacco flavor, but we're looking to get rid of the flavors because the research has shown that it's the flavors that have hooked the kids.
Meredith Berkman:
So we can wait for that answer. The answer is actually four, and one of them is Massachusetts. In fact, there are four states that have banned the sale of all flavored e-cigarettes, and that right now is New York, where I live, Rhode Island, and New Jersey, and the fourth is Massachusetts. But Massachusetts is in a really wonderful position. That is the only state in the country that has so far ban the sale of all flavored tobacco products that hook young people, not just flavored e-cigarettes. We're very grateful for that.
Meredith Berkman:
I think there may have been one more question, which I only threw in there because I knew you would have the answer from listening to Alexandra's remarkable presentation, but it bears repeating. How many high school students report that they're vaping on a regular basis? One out of two, one out of four, one out of five, or one out of seven? So if you were listening to Alexandra, which you should have been, which I was, because I learned a lot, and I appreciated her presentation very much, you hopefully will know the answer. The reason that I'm repeating it also... Let's see if we get the answer. There it is. Everyone was listening. What a great audience, one out of four.
Meredith Berkman:
The reason, again, that I wanted to repeat that is if we had... I always joke if we had a dollar... You can take that down. Thank you. If we had a dollar for every parent that thanked us for our work and said, "Oh, it must be so awful. I'm just so glad that I have a great relationship with my kid and my kid doesn't do it," we would be running the world. So we use that statistic, one in four high school students when we go into schools around the country, now doing it digitally. You can see people thinking, "Well, I'm glad it's not me."
Meredith Berkman:
So I literally point to parents and I say, "Okay, just to give you the perspective, one, two, three, your kid, one, two, three, your kid," because we want people to understand with one out of four high school students doing this, it has been referred to by the former head of the FDA, by the surgeon general as the youth vaping epidemic, and that's really what it is.
Meredith Berkman:
So I'm going to ask Daniel, if you want to just quickly show the slides. Mine is not a formal presentation. That's not by design. That's by design of the role of the parent activist, I suppose. So our group is called Parents Against Vaping E-cigarettes or PAVe, and our website is parentsagainstvaping.org. You can go to the next slide, Daniel. But what we do is... This is our mission statement, which I'll let you read quickly. We're a national grassroots organization founded by me and two friends as a response to the youth vaping epidemic, which this was written pre COVID. But at that moment, it was and likely remains the most serious adolescent public health crisis that our country has faced in decades.
Meredith Berkman:
This is the part I want to get to as an introduction. The catalyst was our discovery about a Juul representative coming into our children's school and telling kids that Juul, while not for them, for adults, was totally safe. So I think we can go to the next slide. That will give you a sense of what catapulted us to do what we do. This slide represents the moment when... I'll just give quickly the backstory. In April of 2018, my son, I have three daughters and one son, and my then 16-year-old son came home from school and said, "I have to tell you about this anti-addiction talk." It was really strange. The teachers left the room, which is something that the teachers normally do in these situations, and the adult educator from an outside group began to talk to us about Juul. As my son said, and as we read there, while telling kids that this was not a substance that they should be using, and at that point in 2018, this was really below the radar for certainly most parents that we've come across, myself included. But there were lots of kids who were doing it, and including my own son.
Meredith Berkman:
My son said, "They kept saying it's totally safe." They told us that it would receive FDA approval any day. Both of those statements, to this day, remain untrue. Within 24 hours, I had called two friends, my cofounders, Dorian Fuhrman and Dina Alessi, and a little bit of digging because I was a journalist. We discovered that the school had no idea that the outside anti-addiction group, which interestingly came from Massachusetts naively was led to through a Google Analytics to the Juul website, where Juul had a named youth prevention education employee at that time who was all too happy when asked for an anti Juul speaker to send a Juul rep into the school. You can go to the next slide.
Meredith Berkman:
That moment when we made that discovery, my friends and I decided that we would have to essentially join whatever was out there, like a Mothers Against Drunk Driving of vaping. That's because, late at night, over the next weeks, we began researching this issue. What was Juul? What was vaping? How big of a problem? My co-founder, Dorian Fuhrman speaks quite a lot about having found Juul, which resembles... By design, it looked like a computer charger, right, and kids were using these things and hiding in plain sight stealth by design. When we realized that this was an enormous problem and that these products had been marketed by Juul on social media channels where parents were not going, we realized we had to get involved, and there was no group out there where parents could get information or could take action. So I like to joke that we're the necessary idiots that had to start the group we would have preferred to join.
Meredith Berkman:
Things happened very, very quickly for us. We started with a website, which we launched in the fall of 2018, which we intended to provide lots of information for parents like us. But very, very quickly, we realized that we would have to advocate. That's what the slide here... We can go to the next one. We began advocating. We started in our own state, in our own city because we realized as we reached out to researchers and we reached out to public health groups that we didn't even know existed on this point. We understood that we had to put a human face, a personal face on this issue.
Meredith Berkman:
The reason that I'm backtracking and showing you some of these slides just to give you a sense if you look. This all came out in our congressional testimony. Just to also back up for one moment, this event happened in 2018. We did not share it publicly because the school had no idea. We didn't want to make it about one school, as we did our own deep dive into the work of researchers like Alexandra and many others when we saw what was really just coming out there because of course, there's a gap between what's happening in real time on the ground and research and appropriately so, this is science and peer reviewed journals. So it takes some time for things to come to the public's awareness.
Meredith Berkman:
One of the problems with social media and Juul was the... This is something that has been said very, very widely. We used to call Juul Big Tobacco 2.0. But then Juul received billions of dollars in funding from Altria, the Big Tobacco company, and then it was very clear that this was Big Tobacco. You can see from this youth marketing slide the Juul, and you can just see the use of young influencers. The one with the ponytail seems to resemble Kim Kardashian. Can go to the next slide. The use of influencers and events that you see some of the other products like blu.
Meredith Berkman:
But when Juul came on the market and really made a splash, let's say in, I guess it was introduced in late 2015, early 2016, it was a complete game changer for the e-cigarette industry. You can go to the next slide. Because essentially, this was a product, and you can see again, the use of social media, the use of youth. This was the way in which youth were being targeted. Again, Juul itself has admitted to the use of young influencers, the use of... What we were a party to was at that point, they were using what they called a curriculum, and they would use that to go into schools and to teach prevention.
Meredith Berkman:
But certainly, in our case, to repeatedly tell kids, which my son, Caleb and my cofounder Dorian's son testified about was sending a really dangerous mixed message. I mean, these were kids who were hearing that this was not for them, and yet at the end of the presentation, when my son, Kayla went up to the educator with Dorian's and our third cofounder's son, Luke, to ask more questions, the Juul representative took out his own Juul, showed the boys how it worked and called it the iPhone of vapes.
Meredith Berkman:
I guess that's where the activism piece comes in. When it hits your child, when it hits your own family. I think for lack of a research technical term, I think we went into full mama bear mode, and we... You can go to the next slide. But this is just to give you a sense. The problem is so complex, and I have such great respect for the work of researchers like Alexandra and the work of people in social health as a public health research, like Connie and Heller Institute.
Meredith Berkman:
What we learned very quickly was we were going to have to advocate. As Alexandra said, there were no regulations on these products. I want to repeat that. We're talking about tobacco products that were allowed to proliferate in an unconscionable way without the federal government's full regulation. In fact, that could be a webinar in itself because the date by which products had to remove themselves on the market and then go back for full FDA regulation, it's called the pre-market review process, that date was pushed back and pushed back. It was adjudicated many times until finally after public health groups, like the campaign for tobacco free kids, one of our great partners, the American Academy of Pediatrics was actually... It was a case, I believe it was in federal court in Massachusetts. Ultimately, the date was pushed until 2021 and then finally to 2020, and all of the products, all of these disposables, the thousands of products that Alexandra mentioned, including Juul were going to have to be removed from the market by this past May to go through the regulation process. Because of COVID, it has been pushed back again until September.
Meredith Berkman:
But the problem for us as parents who are advocating to protect our kids from two things, first, the dangers of the youth vaping epidemic, the dangers of these tobacco products and the dangers of the predatory behavior of Big Tobacco. Why has our government allowed these products to remain on the market? Why have they allowed this to happen? So much of this was avoidable? So we became advocates. We have since also created an education initiative. So we are both advocating and educating.
Meredith Berkman:
So our goal is to advocate for a ban on all flavored e-cigarettes, again, because research has proven that the flavors have hooked our kids. And when we're working in coalition with our public health partners in cities and states around the country, we're in about 16 states now. We started here in New York, and we found out. We are in coalition with groups that include Campaign for Tobacco-Free Kids, the Heart, Lung, and Cancer Societies. One of our great partners also is the Truth Initiative. We work with, again, the American Academy of Pediatrics and local groups. We work in coalition for a ban on all flavored tobacco products, including all flavored cigarettes, but also all menthol cigarettes.
Meredith Berkman:
That makes things even more complicated. I can go into detail later about that. Again, the menthol cigarette piece, which is a real social justice piece relates to the predatory behavior of big tobacco the first time around, and the use of cigarettes. All flavored cigarettes were removed from the market in 2009, I believe, and yet menthol cigarettes remained on the market. If anyone has interest, I can recommend a short film on YouTube called Black Lives/Black Lungs that very powerfully talks about the preying upon communities of color by Big Tobacco and menthol cigarettes.
Meredith Berkman:
In some cases, when it's not possible, as it was in Massachusetts, the gold standard of removing all flavored products from the market, we will accept with our partners who will just a ban on flavored e-cigarettes. We came to the table for the flavored e-cigarettes, but we remained to fight in coalition to protect kids in all communities from flavored products. So I just want to go to the next slide. We mentioned here disposables. That is related and is a huge problem for us at this moment. The 2020 federal flavor ban, which literally, we went from sitting around my kitchen table, a group of moms, sort of figuring out how we could fight these products and protect our kids.
Meredith Berkman:
There are 5.3 million kids, according to the National Youth Tobacco Survey of 2019. Alexandra mentioned Monitoring the Future. This is the other national survey. This is wildly outdated at this point because the 2019 survey is looking back at what happened over a year ago. So by the time we get the next data, which will be delayed possibly because of COVID, this is growing in leaps and bounds. I mean, there was 178% increase over a two-year period in kids' use of these products.
Meredith Berkman:
The federal flavor ban inexplicably left out disposable products, these disposable products, the most popular, which is Puff Bar. You can see, again, they're stealth by design. There's something called Suorin, which looks... It's sort of pink and yellow. It looks like a highlighter. All these candied flavored products that are disposable are out there. Any product that can be refilled with a juice that relates to the 15,000 products, all of these are out there.
Meredith Berkman:
So we went from our kitchen table to sitting around the White House conference room table, which was one of the photos of my wearing a pink dress. Pink seems to be... It's a symbolic color to represent the power of moms. I know there's something cheesy and throw back to that, but I think the authenticity of our voices, because every single parent who advocates with us across the country is a volunteer, we are building, and we continue to build a serious national grassroots organization, but none of us are paying ourselves. What we're doing is fighting for our kids, and what we realized quickly in terms of advocacy and education is that parents listen to other parents.
Meredith Berkman:
We're not judging anyone because this happened to us. The level of nicotine addiction, again, that Alexandra talked about, the nicotine addiction from these products, because there is so much more nicotine in these e-cigarettes than in combustible cigarettes, because there have been no regulations. I think one of the really important facts you saw was about Juul, which you said that there is as much nicotine in one Juul pod as an entire pack of cigarettes, possibly up to one and a half packs of cigarettes, and there's even more in these disposable products.
Meredith Berkman:
So the flavors are cooking the kids, many of whom don't know there's nicotine. Alexandra talked about the brain issues, where there is emerging evidence about cardiovascular issues, and of course, the danger and the damage to our kids' precious developing lungs. I don't want to go past my time. You can go to, I think it's the final slide. But in addition to advocating at the federal level, we've testified multiple times before Congress. We have had multiple private listening sessions at FDA, where we've made our concerns known. We've just started a letter writing campaign of parents across the country complaining about the wildly egregious, particularly during the pandemic, predatory behavior towards teens of Puff Bar and all of these disposable products.
Meredith Berkman:
During this COVID time of digital pivot, we launched a podcast called Big Tobacco Messed with the Wrong Moms, where we interview moms whose children, for example, have suffered EVALI, lung injury. We've also interviewed Illinois Representative Raja Krishnamoorthi, before whom we've testified. We interviewed Dr. Nora Volkow, the head of the National Institute of Health, NIDA, National Institute of Drug Addiction. We've had up to 30,000 people listening, people who are parents and others who care about this. You could go to the last slide, and then finally education. We've just launched in the last few weeks a volunteer educator toolkit that's both in English and Spanish.
Meredith Berkman:
We do webinars both nationally and regionally, but our goal for this program, and I think there's one more slide is to empower parents like us all across the country to go into their own communities with this information and share it with their schools, with other parents. If you could go to the final slide, and this is how you can reach us. I guess, so to wrap up, we're parents who came to the table because Juul came into our school and marketed to our kids, and there was no way to elevate our voice.
Meredith Berkman:
So we reached out with all of the experts, and our goal is to give a human face to the problem and to amplify the really, really important, heavy lifting that people in the public health community, both as researchers and as policy people have done for decades. My final point is that you have to remember we're talking about an entire generation of kids potentially, 5.3 million. We won't know for some time how large that number is today. These are kids who would otherwise not have been initiated into the use of tobacco products.
Meredith Berkman:
How do we know that? Because all the heavy lifting that was done to make smoking not cool among kids, the youth smoking rate was at its lowest number ever, below 7% before Juul came on the market. We will not allow Big tobacco to take another generation of kids and turn them into lifelong customers. Thank you so much.
Constance Horgan:
Thank you, Meredith. I think that you have really proven that mama bears make great advocates.
Meredith Berkman:
So do daddy. Thank you. I don't know want to be... Just to be fair. Thank you.
Constance Horgan:
Thank you. Let's move on to having a discussion between the researcher and the parent activist, the parent advocate. I like to start out with a question and then just turn it over to you for 10 minutes or so and just exchange your perspectives on finding solutions. But I'd like to start out actually with... Alexandra did a great job showing about the prevalence of vaping particularly among adolescents. We certainly have stuck in our mind the popular press that vaping has positive aspects. It's a tool in quitting. It's better than using cigarettes.
Meredith Berkman:
There's no research. There's no research that proves that. Sorry.
Constance Horgan:
Okay. Alexandra said we're in the middle of an experiment really. Traditionally, health effects have a lag time in showing. So can you tell us, is vaping really bad for you since there are some positive aspects, or are there? What's the evidence. Alexandra, what do you want to start and then Meredith and then move on to whatever you want to talk about? Because I'm dying to hear you.
Alexandra Kritikos:
Great. So as an economist now, I'm thinking about point 1A, point 1B, but I'll keep it simple. So yes, these e-cigarettes and vapes, they basically heat nicotine flavoring to create an aerosol. Like I mentioned, many believe that that is just water that evaporates, but there are actually harmful toxins that do harm individuals. Are they less harmful than combustible cigarettes? In many ways, they are. So you touched on a really important point, Connie. You talked about adults and kids. So if we're talking about adults, and they're trying to switch from cigarettes to using an e-cigarette, that's one story. But like Meredith also mentioned, if there are kids that are picking up these devices, and we know that, first of all, they contain toxins that are harmful to the human body, that's very dangerous.
Alexandra Kritikos:
We've also seen in 2019, 2020, this huge long injury outbreak and deaths associated with vaping. That has a lot to do with a piece that Meredith was talking about, the flavorings and the juices that came from the black market. Kids can take these juices and then refill them on their own, or they could buy these products online. They're not from a credible source. Then finally, I also talked a lot about the marijuana vaping and a lot of the lung injury from there because when individuals are vaping marijuana, and specifically the THC that is the psychoactive component of marijuana in these devices, that also has harmful complications for humans.
Alexandra Kritikos:
Then these devices are addictive. They do contain nicotine. They could also contain marijuana. Meredith closed with a really important point. There were kids that would have never picked up a tobacco product before because the US had done such a great job with lowering the tobacco rates. If they would've never picked up these devices before, then if they do, it is harmful for them because they could become addicted to it.
Meredith Berkman:
So if I may, I want to just answer, first of all, and Alexandra, I certainly defer to you as a researcher, as a scientist, but I do have to take issue with one thing you just said. There is no evidence that... First of all, none of these products are healthy, right? None of these products are good. Is it healthier? There was one study that the pro vaping community, which is very outspoken, very well organized, very well funded, and I won't say the community, but I will say that many individuals go after us particularly on social media.
Meredith Berkman:
This is not a brag, but I've even received a named death threat on Twitter, and that's not fun and scary. But I will say that the one study that the pro vaping community has repeatedly pointed to as evidence that e-cigarettes are so much safer and healthier comes out of England out of the Royal College of Surgeons and Physicians. I want to just make the point that in fact, it's sort of like apples and oranges because the EU, they're doing a much better job. The rest of the world, not only the EU, they're doing a much better job of limiting the amount of nicotine in these devices.
Meredith Berkman:
Here, we have done nothing like that. That's one of the problems so that these products have been so wildly addictive. That study is really not relevant to whether or not these are healthier, whether or not these are quitting devices. There was one other study that the researchers themselves recently, and I can cite it for you. I can send that in an email because it just went out of my head, but there is one other study where the researchers themselves came out and said this study should not be seen as evidence. More information has come out about the harms, and that's no longer what we believe.
Meredith Berkman:
So number one, while there's certainly less tar, and there's so much research about lung cancer and tar and cigarettes, there has so far only been one study that has shown that when nicotine is injected into this at the cellular level into mice, it does cause cancer. Of course, that's the biggest fear, and that's done by a researcher at NYU. I'm sure that we will be seeing lots more like that. But we can't predict the future. You referred to this as a social experiment. Just to put it in our context, and I said this in Congress, that our children are being used as lab rats. They're being used as test tubes for the e-cigarette social experiment.
Meredith Berkman:
We don't advocate for adults in the sense that it is not our job to tell adults what they can and cannot do. I think that in addition to the vaping industry, there's the libertarian argument about encroaching on small businesses and the vape shops and the businesses that they would lose, and that's what brought us all to the table with the president and the health secretary. By the way, in that meeting, I bring it up, it was last November, someone made the point from the industry, these products are safer, Mr. President. They're safer. Of course, the public health groups, including ours were saying, there's no evidence, and the president turned to Health Secretary Azar and said, "So is that true?" He said, "Mr. President, there is not any conclusive evidence that these products are safer."
Meredith Berkman:
So I just want to bring that up. That also relates to the toxin issue. We mentioned the toxins. But just so people understand, we have that in our education slides, and I didn't share it. We're talking about propylene glycol, which something that you might ingest if you eat. We're talking about things that are used in antifreeze. We're talking about a host of toxins that when they're heated at a very, very high heat, often create a third chemical, a third toxin that we don't even know what that is.
Meredith Berkman:
So we're talking about a highly heated toxic cocktail. Because the flavors are private, we don't know what is in the flavors because they're not required to tell us. We don't even know what horrible toxins our kids are sucking into their lungs. The final thing that you may have mentioned, and I failed to have earlier, I want to also explain what nicotine salt technology is. Juul was a game changer for several reasons. The first was the patented nicotine salt technology, which is now used by really the entire industry as a standard.
Meredith Berkman:
What that was able to do was to make that first hit of the nicotine much less harsh and so much more potent, particularly for developing brains of adolescents. It's like a more... I'll let Alexandra, who is the researcher, explain it because I'm giving the sort of secular version. But one of the reasons that these products are so highly addictive and a game changer is because Juul patented this nicotine salt technology. The use of flavors, which Dr. Volkow, the head of NIDA, again, the flavors create a pleasant association.
Meredith Berkman:
We're talking about flavors like blueberry, Raz, grape soda, things like unicorns. These flavors that while adults may very well enjoy them and want them, there's absolutely no evidence they need them to quit through the use of e-cigarettes. Remember, there's also no evidence that people who are using e-cigarettes are actually quitting. In fact, some of the research has shown there's dual usage, and that's for adults.
Meredith Berkman:
So it's the nicotine salts. It's the use of enormous amounts of nicotine that are so much more potent. It's so highly addictive, and of course, stealth by design, kids were and many I'm sure continue to, though Juul is no longer as popular as it was because thanks to pressure from public health groups, including our own, Juul has taken a huge hit. They've been revealed for what they were doing. They self-corrected by removing some of their most popular kid flavors like mango, knowing full well, I would assert or suspecting, I suspect that they knew the kids would migrate to mint, which the numbers showed they did when mango wasn't available, and then they're allowed to keep menthol on the market. Again, menthol is just mint. So I'm going to let Alexandra jump in. Pardon me, but I do get very worked up.
Constance Horgan:
I'm wondering, if I could jump in, and thank you both for giving us the definitive answer. Yes, it is bad. What a crazy question, I would sum that up as. But I know we have a lot of people who have questions. So I'm wondering if we could just agree with a yes, and there's lots of more evidence that could be given. But I'd like to turn it over to Daniel Larson who will moderate the questions that have come in, curate the questions because I think we have far more than we can answer in the time that remains. So Daniel.
Daniel Larson:
Sure thing. Thank you. So we've had lots of questions come in, and we won't have time to get to all of them. But the first one here is, in the time of COVID-19, can you speak a bit more about the detrimental effects of what makes someone maybe more susceptible to COVID-19 against the backdrop of these e-cigarettes?
Meredith Berkman:
Alexandra, do you want me to answer that, or do you want-
Alexandra Kritikos:
I guess what I would say firsthand is that when we're thinking about youth consumption specifically, what's also really scary is that we know that usually, if you find a kid vaping, they're probably not going to be doing it on their own. They might be doing it with their friend. They might be using the same device among many. So what first comes to my mind is that during this pandemic where we shouldn't even be coming close to anyone, let alone sharing a vaping device, we can think about how that could really exacerbate the health effects and the health consequences. I'll hand it over to you, Meredith.
Meredith Berkman:
Well, this is the problem, right? There's no long-term research yet about vaping. There's certainly no long-term research about COVID. It's common sense that putting anything into your lungs other than fresh air is a huge mistake and risk in light of the COVID, the respiratory pandemic for anyone, particularly for kids. We do know, I mean, certainly we've referenced the EVALI, the lung injuries, some of them quite catastrophic that kids and some adults suffered. But yes. As you said, there is evidence that smoking and vaping, that that is clearly problematic. At the very beginning of the pandemic, FDA did also mention vaping in that category, and then we're sort of forced to walk it back.
Meredith Berkman:
So while there's no conclusive evidence about any of this, as you said, we do know that kids use these devices socially. So our fear is that as things open up, I see it on the street in here in New York. I see young people passing them back and forth, and that does put them at risk. In terms of the severity of symptoms, again, these are kids who've been compromising their lungs, whether they know they've been doing so or they have suffered a lung injury, and that's one of the reasons we're even serving all the people that reached out to us over the last couple of years whose kids were vaping and SurveyMonkey to say, are there any cases of severe COVID? So we can then go back to CDC and say, is this something that you should be researching because it's so new?
Alexandra Kritikos:
Actually, just one more point that came to mind is a few days ago, I was reading a long post in a journal, and it said that, I believe that a lot of the individuals that were diagnosed with COVID did have some type of a predisposition to vaping or having some type of lung, not injury, but bronchitis or something of that sort.
Meredith Berkman:
Can you share that with me after this because I'd love to see that?
Alexandra Kritikos:
Yes. Yes. So like Meredith said, the evidence is so, so, so new, but this is what we are hearing first off the bat, so yes.
Daniel Larson:
I have a question here about the link between vaping and marijuana decriminalization and legalization. The question is, does the successful political push for legalization and decriminalization of recreational marijuana in the states undercut the efforts of health advocates to reduce the vaping rates of adolescents in the United States?
Meredith Berkman:
So I'm just going to say straight out that there are groups, one of them that Alexandra probably called SAM, there are groups that focus solely on this issue. As a mom of four quarantines, as I like to say, believe me, this is something I think a lot about, and we don't advocate about marijuana. So I'm going to turn that over. We're focused on the vaping. But we do talk about nicotine and the use of these devices and that we know as a gateway drug. I mean, I know Alexandra said that that isn't used as much anymore, but we do in our advocacy. Nicotine is a gateway drug. So many kids, it's true, using these devices are using THC. So I'll let Alexandra who has an expertise in that answer.
Alexandra Kritikos:
Yeah. So I love this question. It's a great question, and I could go on and on about it. But I'll mention to two main points. So one is when we look at research around marijuana use specifically and marijuana vaping, what we see is that kids in states where the marijuana legalization has taken place, even for medical use or for adult recreational use, we do see, first of all, this shift in perception that, "Oh if it's legal, if adults can do it, then it's not that bad." So this shift in perception and this shift in their attitude has also shifted their perception when it comes to marijuana vaping, and that is really emerging research that is coming out right now.
Alexandra Kritikos:
The second piece that I'll talk about is if marijuana legalization is happening, then we do know that there are stores opening, cannabis stores, and there are dispensaries also opening. So if there are youth in a state that live close to any type of a dispensary or marijuana shop that does sell vapes, we can see how that could potentially affect youth... use, I'm sorry. So yes, that question really goes hand in hand. I do believe that marijuana vaping, or I'm sorry, marijuana legalization and vaping do kind of go hand in hand.
Meredith Berkman:
I just want to quickly jump on to add to your point. One thing we haven't talked about is the lack of enforcement. Parents reach out to us across the country every single day often saying, "I live in this town, and there is this store, and I have called..." I've heard this multiple times. "I have called the police. They say they're too busy." This was pre COVID, by the way. "I have called the local news, and they keep selling." As you said, kids go over the border. We know in Massachusetts, where all of these products are supposed to be banned, all flavored tobacco products, we think that there may be a store in New Hampshire, for example, where kids are going and getting these products and bringing them back in.
Meredith Berkman:
So what we say to parents is you should feel empowered report that store to your local health department. We put on our website, parentsagainstvaping.org the link to FDA, where you can report individual stores. The problem is that FDA has not prioritized enforcement, and no one's prioritizing enforcement. So on the local level, we encourage local groups, for example, in towns, in Massachusetts, in Livermore, California, where we're in a huge granular fight for the State of California, which is potentially... We're pushing for in the next two months, California, the entire state, we are trying to get... We got through the Senate, trying to get through the assembly to ban these products. But parents need to take if they feel it's important to them, an active role in policing these vape shops themselves and reporting them and then holding their elected officials accountable if no one does anything about it.
Constance Horgan:
Thank you. I just want to let the audience know that we've decided to go over by 10 minutes to get more audience questions. So we won't get everybody, but we hope that you can plan for an additional 10 minutes, and then we will have a very brief wrap-up. So Daniel, back.
Daniel Larson:
Sure thing. So we have a question here about the regional element of prevention efforts. So how are prevention efforts modified based on region in the United States. For example, in some areas, too much advocacy could be seen as a interference in our lives, as more of a libertarian streak. How do you modify that based on region and also in rural versus urban environments?
Meredith Berkman:
I guess that's the question for me, and I figured the very brief ending was also directed at me. So I apologize for speaking if I'm talking too much. So I will be brief. That's an interesting question. We're both following the parents that come to us because we're a grassroots group. So for example, if there are people in a state where there is no pending bill that we could join in supporting, then we focus on education, and we focus on building what we call our pods, which are our small membership groups, which is a bad pun intended on the Juul pods. So where there are places into deep into tobacco country, where they may not be ready for pushing for one of these bans for the local tobacco. Regulators and educators saying this is not the right time, or this is not the right bill. There are too many exemptions.
Meredith Berkman:
We focus on going in and educating if people are coming to us. Then places like Massachusetts, where we had a local mom who was involved there with the coalition, I mean, Massachusetts, or in California. California is a state that is a ripe for a statewide ban. I know we spent all of yesterday focusing on one assembly member and getting phone calls from moms just in this district. It was that granular. So we do follow the coalitions, and the coalitions are following again the climate for this kind of thing. So I guess that's my best answer to that.
Daniel Larson:
I have a question here about data. You mentioned the National Tobacco Survey. The questions to teenagers, when they're asked about vaping nicotine, are asked... Is it possible there'll be underreporting many teenagers don't realize that there is nicotine in products such as Juul.
Meredith Berkman:
So I'm going to answer quickly and then turn to Alexandra. That's a great question. In fact, when Juul first came on the market, there was a lag because the surveyors were going into the field and asking kids, do you use ENDS products, electronic nicotine delivery systems. So kids were like, "No, I don't even know what that is." The following year, when they were asked, "Do you Juul?" Well, you have to ask the right questions? That's the issue, right? Is that two things? One, our feeling is that the federal government has to come up with alternative and interim data collection. You can't wait a year, it's moving so quickly. if you're not using the correct lingo, you're going to get old data. If the surveyors who were only briefly in the field, they're in from March to May, so of course, because of COVID, those surveyors who were working with schools and kids, they weren't getting access. They got a very small sample.
Meredith Berkman:
If they weren't asking kids, "Do you use Puff Bar?" The new Juul, the disposable. "Do you use stead? Are you using disposables?" If they say, "Do you use disposables?" they're not going to get the right numbers. So that's the secular, that's the translation of what I think Alexandra may want to add onto as a researcher.
Alexandra Kritikos:
Yeah, no. Definitely, Meredith, you really covered a great point. Also, what researchers struggle with, we want to research and better understand vaping. But you really need to identify with what students consider vaping. Am I Juuling, am I using Puff Bar? Am I using this way using that? So what we see really happening with research is that we're trying to research A and B, but the kids are already at XYZ, and they're talking about other things. That's also a call to just researchers and whoever's constructing surly instruments that they need to be very, very careful to include the up-to-date lingo and really be ready to incorporate whatever is happening currently.
Daniel Larson:
We have a question here about, what efforts have been made to integrate advocacy and education efforts about the detrimental effects of vaping and e-cigarettes on adolescent health into existing school-based substance abuse programs, such as D.A.R.E? Have these efforts been successful, and if not, why not?
Meredith Berkman:
I will just say, I mean, I mentioned that we just launched our volunteer toolkit for parents in two different languages so that parents can go to their schools and say, "Yeah, there is no... I brought this up when we were asked to speak at a federal meeting overseen by the surgeon general last September, the inter-agency policy conference. They asked us to speak, and they asked a teen who had been to rehab because of his nicotine addiction that was so severe. One of the frustrations is why isn't this is such a pervasive problem, the department of education. There is not, and we would like to see a mandatory, or not even mandatory, but just really resource heavy education.
Meredith Berkman:
The FDA does have resources for schools. I think it depends also on the city department of education, the state department of education. So you could be in the city of Chicago, where we're also involved in pushing for a city council ban on flavored e-cigarettes, and you could be in a city school in Chicago, where you have a teacher who has accessed really important resources from some of our public health partners, and there are a couple of great curricula out there. Both partners of ours, the Stanford Tobacco Prevention Toolkit out of Stanford Medical School, one, Catch My Breath Foundation out of the University of Texas. But they're very few. I think because it's also new, I mean, ultimately, we would like to see that all schools be required to present this education. You might get it in a school in Chicago and just half an hour outside, the teachers say, "Oh, we talk about it, but we don't really have anything to tell the kids because we're that person or that educator just has chosen not to or really doesn't have the right resources." It's that granular again, even on the education level.
Alexandra Kritikos:
I think one point I'll also just add on, which is... It diverts a little bit from the question, but I think it's really, really important to mention is also when we talk about education, when we talk about educating teachers and parents and schools and teams in school, it goes back to what Meredith just mentioned, what schools have access to this information, which parents have access to this material. I think that really opens up to more of a kind of a social justice issue. Because we talk about... You can really think about what districts or what schools or who really has access to this information, so-
Meredith Berkman:
By the way, I'll just say, this was not the case in our school, but at that time, and Juul has since abandoned it. We discovered that there were school districts both in Massachusetts and in California. They were school districts that did not have a lot of funding, and Juul at that time, again, this all came out in Congress and was testified too publicly that they were offering grants, I think of up to $10,000 to schools that did not have a lot of resources saying, "We will give you $10,000 if you are willing to use our curriculum," which by the way, also came out of Congress. Some of the proprietary information without credit had been taken from the Stanford medical school researcher who Bonnie Halpern-Felsher the editor of that toolkit.
Meredith Berkman:
So that predatory behavior, in that case, they've abandoned that. But that's just sort of the tip of the iceberg of the social justice issue. So thank you for bringing that up.
Daniel Larson:
It's a good time for-
Constance Horgan:
Thank you.
Daniel Larson:
Oh, sorry.
Constance Horgan:
Do we have time for one more? Okay. The last-
Daniel Larson:
Yeah. Sorry. Last participant question here. This is speaking about schools, actually comes from a school board members. This individual says, as a school board member in the fourth largest school district in the nation, I realized that education is the key to everything. What suggestions do you have for specific policies that can be employed in places like bathrooms and other off-school properties, where perhaps vaping can take place?
Meredith Berkman:
So that's a really important topic. I'll say very quickly that one of the things that we do with some of the groups that we work with and we reached out to in Washington are things like these national school superintendent groups to share our resources and give them information they can share with their parents because as the school board member knows, this is a raging problem for teachers, for schools. They're spending so much time and energy trying to control this problem. They don't even have time to teach. So there's one device, patented device called the Fly Sense created by Soter Technologies that a lot of schools that afford it have been able to buy that cans sense in a school bathroom if someone has vaped. Obviously, they don't put cameras in the bathroom, but if the sensor goes off, schools can see who was come out of the bathroom. It's a very big brother is watching.
Meredith Berkman:
If you want more information about that, you can let us know. Then there's also a move among schools for alternatives to suspension, a lot of the pro vapors say we're just terrible parents. We're not setting rules. Our response is, "If I am a terrible parent, it's not because of this issue. Everyone tries their best." But we have to remember these were kids who were pretty much seduced through flavors and social media marketing into the use of these products, and we're talking in, not in every case, but in many cases about addiction. So alternatives to suspension is coming up with... I can provide more information about that. Someone can reach out to us on our website, parentsagainstvaping.org. But there is a move, instead of the one strike, you're out of school, you're off the team. If you talk about it as addiction and how do you work with kids to educate them or provide support and resources if they're addicted to nicotine and other products because of this, that's the way to approach it. Alexandra, do you have a thought about that?
Alexandra Kritikos:
I mean, you are definitely the expert when it comes to the prevention piece. But the only thing I guess that I would say is as a researcher, ... is kind of our best friend. So I would really look into what prevention policies were implemented to work around alcohol use and tobacco use, around child use. So we do learn from the past and since the US has been really, really successful with lowering the rates of tobacco use, combustible cigarettes and alcohol abuse, we can really also learn a lot from previous policies in the past.
Constance Horgan:
Right. Well, our time has come to an end. What a great, great discussion. I want to thank you both. But before the final thank yous, I'd like to end with a wrap-up by asking each of you to give one sentence. If you want this audience to walk away with one thing to remember, what is the one sentence. I went from one phrase to one sentence. But no more than one sentence because we are out of time. So Alexandra, would you like to kick that off?
Alexandra Kritikos:
Sure. I guess I would just say that youth are our future, and we have a responsibility to protect them and also to researchers that we need to conduct better research. So thank you.
Constance Horgan:
Turning to the parent advocate, also known as a mom activist.
Meredith Berkman:
A mom-vocate. My second line is what she said because I absolutely agree that's really important. What I would say coming from the parent perspective is parents voices really matter, and every small action a parent takes, whether it's a school board member going to the school and saying, what are we doing to educate our kids or writing a letter to the editor or signing a letter writing campaign to FDA. We have to make our voices heard to protect our kids. The government is failing us. They're not moving fast enough, and we've got to join in the chorus of wonderful researchers and public policy experts to make sure that we protect our kids. We don't want another generation of nicotine addicts.
Constance Horgan:
Thank you with that, I really would like to thank our speakers, both of whom have been fabulous. I think we've proved that there is a very useful conversation and mingling to join the researcher with the activist and together advanced policy solutions. So thank you both. I'd like to thank the audience, in particular alums, parents, and members and friends of the Brandeis National Committee. I also would like to give a shout-out to Brandeis' office of Institutional Advancement, and particularly Alison Saykin who has been the force behind this whole effort. So thank you all very much, and thank you for getting the word out that we are really facing another crisis in the US with our youth, and it is the vaping crisis. You've made great arguments from both the researcher perspective and the activist perspective. So thank you for that.
Meredith Berkman:
Thank you.
Constance Horgan:
Thank you, Daniel, for doing a fabulous job of moderating the questions.
Daniel Larson:
Well, thank you, Connie. Oh, thank you, Connie again, and thank you to all of you for joining us today, and thank you to our speakers, Alexandra and Meredith. It was a wonderful, fascinating discussion, and we're so delighted to see so many of our Brandeis community members coming together to continue this lifelong learning experience. We look forward to welcome you to future virtual events throughout the summer. We have a whole listing of all of our upcoming events on our website at alumni.brandeis.edu/events, and be sure also to follow @BrandeisUAlumni on social media to be attuned to all of our upcoming events. So thank you again so much.