“A Nicotine Arms Race”: Talking with Stanford Medicine’s Dr. Robert Jackler about e-cigarettes

Smoking remains the leading cause of preventable death in the US, killing more than 480,000 Americans each year—roughly one death every minute. Yet smoking is, in some respects, a public health success story in the US. Thanks to decades of sustained efforts across both the public and private sector, tobacco use is on the decline. In 2017, only 14 percent of American adults smoked cigarettes—in the 1960s, 42 percent of the country smoked.

On the rise, however, are electronic cigarettes. Once hailed as a tool to help adult smokers wean themselves off tobacco, e-cigarettes have become alarmingly popular among teenagers and now deliver just as much nicotine—and in some cases, much more—than a traditional cigarette. And while flavored tobacco cigarettes except for menthol were banned by the FDA in 2009, their electronic counterparts come in flavors ranging from mango to crème br?lée, making the products seem more like candy than nicotine-dispensing devices.

As the FDA signals its intent to aggressively regulate e-cigarette companies—amidst a growing epidemic of vaping among teenagers—I spoke with Dr. Robert Jackler, the Sewall Professor and Chair of the Department of Otolaryngology-Head & Neck Surgery here at Stanford Medicine to better understand the issues. Dr. Jackler, who is also the principal investigator of the Stanford Research into the Impact of Tobacco Advertising (SRITA) research group, talked to me about the disingenuous marketing behind e-cigarettes, the potential consequences of rampant e-cigarette use, and what interventions we should consider.

What effects do e-cigarettes have on our bodies?

We know that smoking traditional cigarettes deposits soot, nicotine, and lots of particles in the lungs. Vaping is different. It takes propylene glycol and glycerin, together with flavored chemicals and nicotine, and makes a mist of it. Nobody knows the effect even of the base vapor chemicals, the propylene glycol and glycerin. What happens when you breathe those in and out, over and over, for years? If you start smoking cigarettes today, it’s not until 30 years from now that you get emphysema and lung cancer. So, we really don't know the long-term effects of vaping yet. Some people have developed asthma from vaping. There are questions about it suppressing immunity of the lung, making you more prone to lung infections, for example.

But many of these vapor devices also have flavored products. Now, flavored chemicals are known to be safe in your gastrointestinal tract when you eat them, but the toxicity spectrum of the lung is different. We know that certain types of chemicals, the acid aldehydes, can be very damaging to the lung—in buttered popcorn factories, for example, workers developed chronic lung disease from inhaling the flavorant. But companies are placing many flavored chemicals of this type into e-cigarettes, even though they’ve never been tested for safety in the human lung.

Bottom line: Vaping is almost certainly not as damaging as regular smoking. But that’s not to say that it’s good for your health.

And yet these products were marketed as being good for smokers—a way for them to quit.

JUUL, the company that has about 76 percent market share of the e-cigarette business, has always claimed that their products are for adult smokers only. But fundamentally, the goal is not cessation. Quitting is a really bad business model, right? Their goal is for adults to transition over to their products and to use them for a long time. They also know, as the tobacco industry has known for decades, that the most lucrative market over the long term is not adults but young people.

Few adults decide to start smoking—smoking initiation happens almost entirely between the ages of about 12 to 20. Therefore, it makes sense to focus your marketing efforts on attracting new, life-long customers as opposed to winning over adults who are already loyal to other brands or are actively trying to quit. Here we see that JUUL has employed extraordinarily sophisticated advertising tactics that have been effective in targeting young people. JUUL says they are helping the lives of the billion smokers, but in fact they are creating nicotine addicts out of young people.

How dangerous is it for a young person to become addicted to nicotine?

Very. Once a teenager becomes addicted to nicotine, they are more likely to try other tobacco products. The literature also shows that young people who adopt e-cigarettes are much more likely to smoke traditional, combustible cigarettes than teenagers who never adopted vaping.

Also, nicotine addiction affects brain development and causes neurochemical and behavioral changes. It primes the brain for addictive sorts of behavior. There’s data that young people who start smoking are more likely to go on and use other drugs—not to say that there’s a high frequency, but those who become addicted to multiple substances tend to begin with tobacco.

And there’s real cause for concern, because JUUL has fundamentally changed the e-cigarette market. Most products used to have 1 to 2 percent nicotine. Now some e-cigarettes have 6+ percent nicotine. Keep in mind, when 3 percent came out, it was meant for the 2-pack-a-day smoker. That really high nicotine content, which is potent and addictive, has become ordinary. It may be effective for the heavy smokers to transition them to e-cigarette use, but in the hands of young people it’s very dangerous.

There is what I’ve called a “nicotine arms race” occurring. And it’s profitable for companies to win it. JUUL, which is now worth $15 billion, reached a $10 billion valuation faster than any other start-up. It replaced a company called Facebook in that category. 

Why do you think e-cigarettes have become so popular with teens?

Their marketing, for starters. E-cigarette companies have been very savvy at using social media channels and online influencers who reach young people to popularize vaping. It has been incredibly effective. But young people also have very different attitudes in looking at classical types of tobacco and vaping devices. Only about 4 in 10 young people perceive that using a vapor device is dangerous to their health. And really only about a third understand the devices contain nicotine. You interview teenagers, they think vapor is just water—that it’s harmless. They don't associate e-cigarettes with what they learned about the health consequences of smoking. If you interview a group of first-graders, they know smoking cigarettes is bad for you. By the time they reach their teenage years, they feel fairly immortal and don’t think long-term in that way. 

Education seems like an important first step, then.

Absolutely. When we educate young people about smoking, there are three ways of doing it. You can say to them, as the tobacco industry does when it has been forced by litigation, “You’re too young, smoking is an adult habit, and you won’t be permitted to do it.” Now, of course, that forbidden behavior is what kids are going to want to do, because they want to be like adults.

The second technique is to tell teenagers that if they smoke, they’re going to get sick and they may die young—you tell them the average smoker loses 10 years of life compared with a nonsmoker. That doesn’t really work, either.  

The most effective way we can educate teenagers is by showing them that these companies, both the classic tobacco industry as well as the vapor companies, are trying to get them addicted to their products so that they’ll use them for a long time; they’re trying to exploit young people as a way of making money. That tends to work. Kids get outraged. They realize that when they see a classmate smoking, that person has been manipulated and got hooked by these rich companies.

What about at a public policy level?

The policy so far towards e-cigarettes, in the US, has been no policy. Regulations have been put off until 2022. However, that’s changing because of the huge number of young kids adopting e-cigarettes—there’s a pressure to act.

You might say, “Let’s just ban all e-cigarettes,” but if you take away all vapor products, then the only choice that adult smokers have is standard cigarettes. What you want to do is come up with a regulatory framework that protects young people while allowing adult addicted smokers to be helped.

One of the key targets, which the FDA has rightfully taken aim at, is the combination of nicotine with youth-oriented flavors. High-nicotine devices should only be available in unsweetened tobacco flavors—a type that would not appeal to young people. And I think that selling high nicotine over the counter, as it is now, can be very toxic and makes it easier for young people to get access. One possible solution is to require a prescription from a doctor.

You mention doctors—what role do they have to play in this?

It’s important that physicians routinely bring it up—primary care doctors, specialists even. I’m an ear surgeon. If my patients smoke, I chat with them about it. If you simply ask people about smoking and encourage them to stop, there’s good data to say that it is the most important single intervention you can do to improve a person’s health on a preventive basis.

Obviously, we like exercise and fighting obesity, but smoking is number one.