December 3, 2018
Central Massachusetts Health

Vaping policies evolving with rising use

Rising vaping use has spurred officials to take action. Gov. Charlie Baker signed statewide legislation into law in July, making Massachusetts the sixth state to increase the age of sale for tobacco products from 18 to 21.

Across Central Massachusetts, teenagers are "Juuling." Juul electronic cigarettes are named after the company that's both a household name and a target of health advocates.

The size of a flash drive, these e-cigarettes are all the rage for high schoolers, even though they started out as alternatives for adults who want to minimize smoking traditional cigarettes.

One Juul cartridge alone lasts about 200 puffs, or about the nicotine equivalent of a pack of cigarettes. The vape pen can be charged in a laptop's USB port, and handily slipped into a back pocket.

But Juuling might be harder to do soon.

Gov. Charlie Baker signed statewide legislation into law in July, making Massachusetts the sixth state to increase the age of sale for tobacco products from 18 to 21. Once the state law goes into effect on Dec. 31, every city and town in Massachusetts will be covered.

Around 135 municipalities, including many in Central Massachusetts, have changed their local regulations and ordinances to ban e-cigarette use in smoke-free locations, according to data from the Massachusetts Municipal Association.

Worcester, Gardner and Leominster are among that group, which encompasses over 57 percent of the state's population. Parents, health providers and educators are increasingly becoming concerned about the potential repercussions of vaping.

Popularity forces changes

Vaping may still be relatively new, but high schoolers appear to have quickly taken to it. Close to a quarter of Massachusetts high school students have vaped, said Marc Hymovitz, the Massachusetts government relations director for American Cancer Society Cancer Action Network.

"What we've seen in the last few years is across state is a huge increase in youth use of vaping products," Hymovitz said. "Several towns in Worcester County and elsewhere are limiting that," he continued.

The American Cancer Society is working to make sure people are aware of the potential dangers of vaping. Lung cancer is the leading cause of cancer death, accounting for one in four. Around 154,000 people will die of the disease in 2018. Nicotine has long been known as a cancer causing agent.


Legal steps on several fronts are changing the way Juul and other companies can sell e-cigarettes.

In July, Attorney General Maura Healey announced an investigation into Juul and other online e-cigarette retailers over marketing and selling to minors. The office sent cease and desist orders to three websites that sell Juul products with inadequate age verification systems.

Around 220 municipalities in Massachusetts have banned the sale of e-cigarettes to minors and regulated retail services.

The Centers for Disease Control and Prevention is taking regulatory action that includes issuing 1,300 warning letters and fines in September to retailers who illegally sold e-cigarette products to minors.

Juul took its own action in November, coming just days before the FDA announced a plan to limit e-cigarettes that are flavored to appeal to youngsters. Juul said it would shut down its social media sites, stop selling mango, fruit, creme, and cucumber flavored e-cigarettes in any stores and limit sales online to those verified by a third-party site to be over 21.

The Dangers

E-cigarettes contain heated nicotine extracted from tobacco, along with flavorings and other additives. But specialty favors have led teenagers to jump on board, even selling them on the black market at schools.

While there has been a significant decline in cigarette usage by teenagers, their use of e-cigarettes has skyrocketed. A teen survey by the U.S. Food and Drug Administration and the CDC showed 3.6 million middle and high school students are users, an increase of more than 1.5 million since last year. Only 1.5 percent of high school students said they vaped in 2011, but by this year, that had risen to more than 20 percent. By last year, e-cigarettes had even eclipsed traditional cigarettes in popular use among high schoolers.

Flavored e-cigarettes may be a key reason why. From 2012 to 2016, the share of e-cigarette sales that were for flavored products rose fourfold to 44 percent, according to the CDC.

Research shows that compared to non-users, teenagers who use e-cigarettes are more likely to just transition to traditional cigarettes.

Flavored varieties were especially targeted by regulators, not only for their youth appeal but because of their ingredients.

According to research by the American Lung Association, vaping with flavored varieties can cause something called "popcorn lung."

Popcorn lung was discovered when workers in a microwave popcorn factory were sickened from breathing in diacetyl, a buttery-flavored chemical in the product. The chemical has been linked to hundreds of cases of bronchiolitis obliterans (commonly known as popcorn lung), an irreversible lung disease. The tiny air sacs in the lungs become scarred from narrowing airways.

Diacetyl still exists in e-cigarette vapor. Some flavorings like vanilla and maple have diacetyl added to their e-juice liquids. Juul does not have diacetyl, but Harvard University researchers found that 39 out of 51 e-cigarette brands contain the chemical.

The Appeal

Dr. Ruth Benet works in outpatient services for the Harrington HealthCare System in Brimfield. She says that although the usage of e-cigarettes started as adults trying to "step down" from smoking so much, she's seeing it in more and more of the teenagers in her care. It's a trend that has been on the uptick for a couple of years.


"What worries me is that it tends to be something they don't think is a big deal," Benet said. If she asks a teenager if they smoke, "they'll say no," she said. "They don't see it as bad like cigarettes."

Benet tries to ask specifically about vaping, and hopes that a question about the topic will be added to a formal health questionnaire. Benet said parents who visit her practice are aware of the dangers of vaping and ask her "What can you say to get my child to stop vaping? I try to explain, but they don't listen to me."

Dr. Katherine Fitzgerald, who specializes in osteopathy and addiction medicine, at Heywood Family Medicine in Gardner, says she's already getting notices from her 12-year-old's school calling vaping "an epidemic."

Fitzgerald's practice uses a screening tool during pediatrician visits that asks teens about tobacco product usage, and now includes vaping in the list of questions.

"Kids who vape think smoking is disgusting," she said. "When you try to tell the child, 'you know your chances of smoking actual cigarettes is higher because you're doing this,' they fight you because they think it's disgusting."

Fitzgerald says that e-cigarettes are dangerous because they are still introducing "a highly addictive product" to a young brain.

That product is dopamine, a "feel good" neurotransmitter.

The CDC warns that vaping exposes users to cancer-causing chemicals, although it contains fewer toxic substances than your normal cigarette. The Office of the Attorney General has also urged school officials to consider educating students on vaping.

Tantasqua Regional High School in Sturbridge recently had a mandatory meeting for students and parents about vaping.

"We have tried to educate both our students and parents so that they are aware of the harmful impacts," Tantasqua Principal Mike Lucas said.

Vaping is also being discussed in health classes, Lucas said. The 2018-2019 student handbook for the school prohibits electronic or battery operated cigarettes on school buses, premises, and at activities. It also has a separate tobacco policy that considers the products to be contraband, punishable with disciplinary action, and repeatedly, with suspension.

In an effort to support students in curbing cigarette smoking, the school nurse offers voluntary smoking cessation programs to interested students.

Fitzgerald thinks it's difficult to change the minds of teenagers who want Juul pens.

"They're marketed on Snapchat — Instagram," she said. "They're made to look sexy and cute."


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