
US Surgeon General Declares E-cigarette Epidemic Among Youth [pdf] - Pulcinella
https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth-2018.pdf
======
md224
We should be clear what the actual object of this "epidemic" is. It isn't
really about vaping. It's about Nicotine. And this fight is just one battle in
a larger war: the societal struggle to define the proper moral dimensions of
chemical dependency.

Many people have a knee-jerk reaction to "chemical dependency"... they assume
it must be a bad thing. That somehow sobriety is the "natural" state of human
beings, and that any dependence on a mind-altering chemical is a weakness, a
deviation.

You can see this in the way we mix up terms like "dependency" and "addiction".
People treat the former as if it were equivalent to the latter, but it isn't:
"addiction" is when the harms of a dependency outweigh the benefits, when it
becomes "maladaptive" (a vague, value-laden term). But a dependency by itself
isn't necessarily maladaptive. Sometimes it's a positive adaptation.

Consider this, one of my favorite essays, about a woman whose relationship
with Nicotine appears to have enriched her life:

[https://www.nytimes.com/2016/03/06/opinion/sunday/can-
nicoti...](https://www.nytimes.com/2016/03/06/opinion/sunday/can-nicotine-be-
good-for-you.html)

There are certainly chemicals that cause far more harm than good... there's no
denying that. I'm not saying we should embrace Fentanyl. But it would be a
mistake to treat every chemical dependency as an obvious evil. The moral
valence of Nicotine dependency is far from black-and-white. Sometimes we
depend on something because it's good for us. (Notice how nobody's complaining
about a coffee epidemic.)

~~~
winchling
Yes to the moral dimension -- obscured by the health issue.

It's also about children. Most parents won't allow young kids to drink coffee,
for instance. Childhood ought to be a preparation for freedom and addictions
have the potential to limit that freedom before it even gets started.

Adults may weigh the benefits for themselves. Sometimes the result is indeed
positive.

~~~
cwkoss
Do any states prohibit selling caffeine to minors?

~~~
ungzd
In Russia, "energy drinks" are forbidden for minors (< 18 years), but coffee,
tea and coca-cola-like drinks (which AFAIK can have caffeine too) don't have
such restriction.

~~~
p10_user
Dosage and sweetness is surly part of the rationale. Coffee is not a cool,
sweet, refreshing drink. Soda is but has around 50 mg of caffeine, while
energy drinks have between 80-160 mg. Probable harm from high levels of
caffeine much easier to hit with energy drinks.

------
mullingitover
The fun part about the e-cigarette epidemic: states have a perverse incentive
to keep cigarette smoking rates from dropping too quickly. The Tobacco Master
Settlement Agreement gave states an annuity from tobacco profits, and many
states took a lump-sum payment instead. That money has already been spent. If
cigarette smoking rates (and thus, profits) drop too much, they have to pay
back the money.

Everything with e-cigarettes was fairly hunky-dory and not an 'epidemic' until
2014, the year teen smoking rates plummeted and e-cigarettes took off. Most of
those teen smokers who took up vaping instead of cigarettes will likely never
become cigarette smokers. This alters the math on the annuity payments that
were already cashed in for up-front money, and thus the states could end up in
the red on their bond payments. Thus they have a financial incentive to keep
e-cigarettes from fully replacing combustible cigarettes, even if they are a
definite harm reduction tool.

~~~
dragonwriter
> Everything with e-cigarettes was fairly hunky-dory and not an 'epidemic'
> until 2014, the year teen smoking rates plummeted and e-cigarettes took off.

Yes. E-cigarette usage wasn't an epidemic until usage “took off”.

That's just the definition of “epidemic”; everything else you try to associate
is irrelevant.

~~~
mullingitover
Don't epidemics usually create sick people? I realize the counter-argument
will of course be "we don't know the long-term effects," but people have been
exposed to aerosolized glycerine/propylene glycol for decades in the form of
fog machines at concerts and clubs. Surely if this was the next asbestos we'd
be seeing _something_ by now.

~~~
vel0city
How many people spend a significant percentage of their time right next to a
fog machine breathing in highly concentrated amounts?

------
gehwartzen
Just my personal take but as an adult who just quite smoking a few weeks ago
the availability of vaps has been tremendously helpful. I feel night and day
better in terms of health despite consuming probably similar levels of
nicotine.

And while I don't view nicotine (or vaporized VG, PG) as particularly harmful
it probably should be reserved for those 18+. What doesn't seem to be helpful
is that vaping comes in all sorts of flavors (beyond synthetic tobacco
flavor)that would probably appeal to people minors (mango, cotton-candy, etc).
In contrast any flavorings of those types in cigarettes was banned a decade
ago (with the notable exception of menthol).

> Currently, no flavors are banned from other tobacco products, although
> research suggests flavors may also make these products more enticing to
> youth and young adults. Data from FDA’s Population Assessment of Tobacco and
> Health found that nearly 80 percent of youth ages 12-17 and nearly 75
> percent of young adults ages 18-25 who were current tobacco users in 2014
> reported that the first tobacco product they ever used was flavored.25
> Alternatively, FDA is aware of self-reported information suggesting that the
> availability of flavors in some noncombusted tobacco products such as
> e-cigarettes and other ENDS may help some adult users reduce cigarette use
> or switch to potentially less harmful products.

[https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredi...](https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm2019416.htm)

~~~
stefan_
Nicotine is little different from caffeine. Either you ban both, none, or you
decide your policy is arbitrary moral posturing supported by no evidence.

Ultimately, there is little in the way of physical dependency; nicotine is as
addicting as sugar and fat loaded burgers and fries, and the health risk to
the population of those blow any risk from nicotine out of the water. In fact,
the evidence probably shows we could promote the use of vaping instead of
overeating on junk-food, and should ban minors from entering fast food places.

~~~
solomatov
>Nicotine is little different from caffeine. Either you ban both, none, or you
decide your policy is arbitrary moral posturing supported by no evidence.

They are quite different in their mechanism of action. Caffeine works via
Adenosine, Nicotine works via Nicotinic Acetylcholine receptors.

~~~
stefan_
Yes, they are both nerve agents, harmless to humans beyond some nootropic
effect. No physical dependency.

~~~
inscionent
> Nicotine on direct application in humans causes irritation and burning
> sensation in the mouth and throat, increased salivation, nausea, abdominal
> pain, vomiting and diarrhea.[17] Gastrointestinal effects are less severe
> but can occur even after cutaneous and respiratory exposure.[18] Predominant
> immediate effects as seen in animal studies and in humans consist of
> increase in pulse rate and blood pressure. Nicotine also causes an increase
> in plasma free fatty acids, hyperglycemia, and an increase in the level of
> catecholamines in the blood.[19,20] There is reduced coronary blood flow but
> an increased skeletal muscle blood flow.[20,22] The increased rate of
> respiration causes hypothermia, a hypercoagulable state, decreases skin
> temperature, and increases the blood viscosity.

Nicotine is one of the most toxic of all poisons and has a rapid onset of
action. Apart from local actions, the target organs are the peripheral and
central nervous systems. In severe poisoning, there are tremors, prostration,
cyanosis, dypnoea, convulsion, progression to collapse and coma. Even death
may occur from paralysis of respiratory muscles and/or central respiratory
failure with a LD50 in adults of around 30-60 mg of nicotine. In children the
LD50 is around 10 mg.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363846/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363846/)

~~~
stefan_
You can also die from caffeine. What is your point, beyond "the dose makes the
poison"?

~~~
klodolph
The fact that a risk _exists_ is irrelevant, and it was never the point. If
you want to understand the risks associated with nicotine and caffeine, you
measure them. There are a number of metrics we can use as a proxy for risk,
like margin of exposure or margin of safety, but these give us an incomplete
understanding of the risks. The problem with electronic cigarettes is that
children are particularly prone to the following things:

\- Eating or drinking inappropriate things,

\- Eating or drinking things which are colorful or have a pleasant aroma, and

\- Being more sensitive to certain chemicals (e.g. nicotine) than adults.

So if you told me, "Let's put nicotine in a mango-scented liquid and put it in
reach of children," I think we should be alarmed. Likewise, when we took iron
supplements and put them in the shape of colorful pills or animals with a
sweet taste like candy, and then children started eating them and getting iron
poisoning, we got concerned.

------
snek
I read an article the other day about how juul modifies the nicotine to make
it less painful so they can put more in each pod. An interesting side effect
of this is that people who don't smoke can start smoking easier because it's
less painful. That information combined with this report just makes me so
upset on so many levels...

~~~
wbronitsky
Can you cite the article? I cannot find any reference to Juul modifying
nicotine to make it more palatable.

~~~
g45y45
Juul uses nicotine salts, where as standard vape juice is just freebase
nicotine. The salts are said to be 'milder' or easier to consume. In the US,
vape juice comes in 0, 3 and 6mg/mL doses. Juul does not publish nic levels,
but its probably closer to 48+mg/mL.

~~~
mcguire
Most vape liquids I've seen come in 0-24 mg/ml (in 6mg increments, except for
3).

------
tsmarsh
Is this more serious than the sugar epidemic?

Or exposure to traffic pollution?

Or reduced freedom to roam?

It would seem that there are many social threats to my children, and vaping is
maybe in the top 10? Should it be higher?

~~~
jtr_47
I wonder if the big tobacco companies are behind this.

They have much to lose because e-cigs are not used for tobacco, in my
experience.

So they (tobacco corps) will lose future tobacco addicts to e-cigs and vaping
liquid producers.

peace.

~~~
friedman23
The nicotine in e-cigs are produced using tobacco and I'm pretty sure big
tobacco doesn't care if kids are smoking actual cigarettes or e-cigs, only
that they are smoking.

~~~
LyndsySimon
> I'm pretty sure big tobacco doesn't care if kids are smoking actual
> cigarettes or e-cigs, only that they are smoking.

I disagree.

Tobacco is an industry with high regulatory barriers to entry and decades of
very effective marketing behind it. "Big Tobacco" makes money at the wholesale
and retail levels pretty much unopposed.

Vaping is effectively unregulated, and there really aren't any truly big
players in e-liquid market. Everyone who vapes seems to have their favorites,
but even a small vape shop will have a dozen or more brands on the shelves.

Vaping isn't going to kill tobacco use, because as you said, the nicotine
ultimately comes from tobacco - but its rise is cutting significantly into the
revenue of "Big Tobacco".

------
LyndsySimon
> approximately two-thirds of JUUL users aged 15-24 do not know that JUUL
> always contains nicotine.

I find this very, very difficult to believe.

~~~
brianwawok
How many people do you know aged 15-24? It would not surprise me one bit.

~~~
dorchadas
I'm a high school teacher (and kids have no concept of privacy and talk openly
about everything), and I completely agree. Not sure if it's 2/3, but I'd say
definitely over 50% don't realize that most probably contain nicotine.

------
dpflan
Juul is cited many times in that document. I am generally intrigued by Juul.
Their intention to "end combustible smoking" and help "adult smokers" smoke
with less pain/more easily seems good for the target user (create a system
with fewer toxins-to-nicotine ratio). The side-effect of engineering a better
system is that it's easier for all users to smoke, i.e. intended for adults,
but tech-savy kids will devour this concept).

~~~
russley
Juul is reported to have higher nicotine levels though.

~~~
dpflan
I see. I'm not very familiar with their product. I would think that their
product is good for weening "adult smokers" off of nicotine through tapered
usage (e.g. reducing nicotine intake over a timeline by using specific dosage
cartridges). Which of course go against a sustainable business?

~~~
owlninja
They actually did just introduce lower level nicotine packs of their pods. The
device worked for me because if you look into the world of vaping, it is
almost like another hobby. So many parts, batteries, coils, juices, etc... the
juul was dead simple and really just replaced my 13 year pack-a-day habit. It
is a little unfortunate how it took off in schools and I do truly believe that
was never their intention. It really works as a "cigarette replacement" if you
aren't ready to quit cold turkey.

~~~
dpflan
Thanks for sharing! That's an interesting point regarding simplicity of design
and how the complexity of vaping can actually create a hobbyism that keeps you
in the realm.

If you don't mind me asking (and you sharing): How long did it take to stop
smoking? Can you describe the weening process?

~~~
owlninja
Sorry for late reply. It was literally overnight....I didn't wean myself off
the real thing it just sort of changed. It felt good and certainly has social
benefits, but the downside is I can smoke the juul basically anywhere,
including indoors. I would still recommend it for some who "wants" to quit
(but doesn't really want to). No more smells or coughing up gunk every
morning.

------
Shivetya
fwiw, vaping is treated the same as tobacco use by most insurance companies
with regards to what is provided to employees.

I have been amazed at how some who vape think it is acceptable indoors in
public places that other tobacco use is not. At work it had to be reminded
more than once it was not acceptable outside of designated areas. It simply is
an addiction that is easier to partake of and hide than most.

~~~
elhudy
People who vape are under the impression that exhalation only releases water
vapor into their immediate surroundings; I've heard this on multiple occasions
from smokers. The question then of course becomes, how does it have a scent if
it is just water vapor?

~~~
cgag
I've heard people say this but it's never even been water vapor. It's
vegetable glycerin and/or propylene glycol even if there were no other
flavorings or nicotine.

------
johnlehnertz
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years since treatment, i feel great and breath well

------
sctb
Recent related discussion:
[https://news.ycombinator.com/item?id=18712622](https://news.ycombinator.com/item?id=18712622).

------
juulia
Ecigs are this generations 70's cigarette moment, thanks to social media. It
has been glamorized and thus cool:

[https://vsco.co/search/images/juul](https://vsco.co/search/images/juul)

------
mruts
E-cigs haven't shown to be harmful in the least bit, in fact, there's a lot of
evidence that nicotine is a nootropic with neuro-protective properties.
Increases cognitive performance and decreases the likelihood of developing
Parkinson's or Alzheimer's.

Also while nicotine is addictive, there is some research showing that it is
addictive only in the presence of MAOI's (present in normal cigarettes not but
E-cigs).

EDIT: I'm getting downvoted, and maybe you guys are right, E-cigs haven't been
shown to "not be harmful in the least bit." But their risk profile is more
akin to eating junk food than tobacco, which is on a whole different level
(disclosure: I don't smoke E-cigs, but I do smoke tobacco)

~~~
diminoten
Alright, so dealer's choice on who you want to believe:

* cancer.net? [https://www.cancer.net/navigating-cancer-care/prevention-and...](https://www.cancer.net/navigating-cancer-care/prevention-and-healthy-living/stopping-tobacco-use-after-cancer-diagnosis/health-risks-e-cigarettes-smokeless-tobacco-and-waterpipes)

* CDC? [https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Q...](https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html)

* Harvard? [https://www.health.harvard.edu/blog/electronic-cigarettes-go...](https://www.health.harvard.edu/blog/electronic-cigarettes-good-news-bad-news-2016072510010)

* Stanford? [https://med.stanford.edu/content/dam/sm/tobaccopreventiontoo...](https://med.stanford.edu/content/dam/sm/tobaccopreventiontoolkit/documents/ecigarettes/Risks%20of%20E-Cigarette%20Factsheet.pdf)

I think it's pretty far from "harmless".

~~~
tsmarsh
Thank you for the links. I did read them, but failed to reach the conclusion
“pretty far from “harmless””.

It sounds like an understudied but potentially very safe mechanism for
nicotine delivery. The big issue seams to be poor behaviour from companies
like JUUL, and large quaestions around dosing for adolescents.

I honestly couldn’t tell you from those links if I should be more concerned
about nicotine, sugar, caffeine, THC, or alcohol.

At this point I suspect that I should be more worried about soda than vaping.

~~~
diminoten
> Even still, the mounting evidence shows that these devices are not harmless.

> Chronic nicotine exposure may lead to insulin resistance and type 2
> diabetes, although this risk may be offset by the well-known appetite
> suppressant effects of nicotine. Inhaled nicotine increases heart rate and
> blood pressure. Nicotine is highly addictive in its own right, and it may
> lead to changes in the brain that increase the risk of addiction to other
> drugs, especially in young people. Nicotine may also impair prefrontal brain
> development in adolescents, leading to attention deficit disorder and poor
> impulse control. These potential harms of nicotine are particularly
> worrisome in view of soaring rates of e-cigarette use in U.S. teenagers.

> Using nicotine in adolescence can harm the parts of the brain that control
> attention, learning, mood, and impulse control.

> Many people incorrectly believe that these devices produce a water vapor
> when in fact they create aerosols that contain harmful chemicals, and ultra-
> fine particles that are inhaled into the lungs and out into the environment,
> making them harmful to the user and others nearby.

I guess you're assuming people aren't going to read the actual links?

Further, this isn't a zero sum game; you can be worried about soda _and_
e-cigs.

It bothers me more than it probably should, your attitude. You're letting this
stuff ruin lives all because you want to get high.

~~~
mruts
What about the positive effects of nicotine? Are you saying that the negative
effects out weight the good? Or are you just opposed to anything that gets you
"high."?

~~~
diminoten
PCP also gives you immense strength. Let's give our kids PCP!

Short term advantages don't make up for long term consequences.

Edit: I'm sorry, that was overly snarky. I should be clear, I don't give a
shit what adults do to themselves. My sole concern is this normalization of
nicotine reaching kids. They're being marketed to very strongly with this
"it's safe!" argument, which doesn't hold up to scrutiny.

~~~
mruts
I mean, maybe not. But it's a personal decision.

------
nulagrithom
Why are there conflicting reports on the stats from the CDC?

The CDC's website[1] says there's been a 0.6% increase in vaping in middle
school and 1.5% increase in high school since 2011. This advisory however says
"E-cigarette use among U.S. middle and high school students increased 900%
during 2011-2015, before declining for the first time during 2015-2017." Was
there a nearly 899% drop in 2015-2017?

[https://www.cdc.gov/tobacco/data_statistics/fact_sheets/yout...](https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm)

~~~
dragonwriter
> Why are there conflicting reports on the stats from the CDC?

There aren't.

> The CDC's website[1] says there's been a 0.6% increase in vaping in middle
> school and 1.5% increase in high school

No, it doesn't. The 0.6% and 1.5% numbers appear, but as the base incidence in
2011 from which an increase occurred, not the percent increase. Quoting the
relevant passage of your own source (emphasis added):

“Nearly 5 of every 100 middle school students (4.9%) reported in 2018 that
they used electronic cigarettes in the past 30 days— _an increase from 0.6% in
2011_.”

“Nearly 21 of every 100 high school students (20.8%) reported in 2018 that
they used electronic cigarettes in the past 30 days— _an increase from 1.5% in
2011_.”

There is a difference between an “an increase FROM _x_ % IN 2011” and “an
increase OF _x_ SINCE 2011”; you seem to have confused the former for the
latter.

The middle school increase reported is 717%; the high school increase reported
is 1287%. There is nothing obviously inconsistent with aggregate 900% increase
2011-2015 with a slight aggregate decline thereafter.

~~~
nulagrithom
Yes, yayana explained my error pretty succinctly before you did...

------
ProAm
Epidemic seems a little strong...

~~~
happytoexplain
Because you feel it's not widespread enough or not damaging enough (or both)?

~~~
RosanaAnaDana
I think it would be about rates of increase or decrease rather than overall
numbers. If it were about overall numbers, well, its pretty clear we've ended
a tobacco epidemic over the past 60 years.

Not sure if any one else here remembers cigarettes in restaurants, but imagine
spelling camels while getting your salad bar refill at Sizzler.

We've come a long way.

~~~
snek
That doesn't mean we're finished. Pretending this problem is solved will just
result in it getting out of hand again.

~~~
RosanaAnaDana
What do you mean by 'finished' and 'solved'? You speak as if there is some
sort of societal goal in mind here. You've clearly got an agenda here and I
think you should make it clear that you've got a goal in mind here regarding
whats 'right' and 'wrong' for other people to do with their time, lives, and
money.

If people want to smoke, let them smoke. Is it bad for them? Yeah. Does it
have a negative cost against society? Yeah. But its a slight cost that I'm
willing to bear to uphold personal liberty and freedom of choice.

Overall, smoking rates are pretty low, and we're probably on the other side of
the overall costs smoking writ-large will have on society. So its fine. If
people still want to smoke, warn them of the negatives, then let them smoke.

~~~
snek
I assume the societal goal is to help young people, whose brains aren't yet
able to make sound decisions
([https://www.aacap.org/aacap/families_and_youth/facts_for_fam...](https://www.aacap.org/aacap/families_and_youth/facts_for_families/fff-
guide/the-teen-brain-behavior-problem-solving-and-decision-making-095.aspx))
and keep them from doing things which might really hurt them in life like
developing nicotine or alcohol dependency.
([https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4519837/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4519837/))

~~~
ApolloFortyNine
They already require people be over 18, maybe the punishment should be higher
on those who are supplying children with them?

The reason I'm so against more regulation is that the current trend in the war
against ecigs is to ban pretty much any good tasting flavors (all but
menthol), and I don't like that what entails for our future. I don't even
vape, but the idea that the majority will go around banning what they don't
like "for the good of the children" is something I refuse to support.

It's not going to stop if it gets started.

------
badrabbit
ELI5: what makes vaping more dangerous or concerning than say coffee or energy
drinks?

~~~
hannasanarion
The withdrawal symptoms are far worse, for one.

If you go off caffeine, you're drowsy for a few days, no big deal.

If you go off nicotine, you're condemning yourself to months or years of
craving that never fully goes away: the physiological components of nicotine
addiction are more or less permanent.

That's just off the top of my head. I wouldn't be surprised if there are
detrimental dosage effects of nicotine that caffeine doesn't have.

~~~
badrabbit
I quit smoking daily (at least half a pack per day) for 3 years straight,and
it was "cold turkey" as they say.

Once I quit,I felt a bit uncomfortable like a very mild headache(almost
background annoyance) for about two weeks and that was all there was to it.
Now,I've never been addicted to caffeine even though I drink espresso shots
daily for weeks and for a few more weeks might not drink any caffeine,so I
have no frame of reference for comparison.

Stress does still cause me to be tempted but it's no worse than being tempted
to eat fast food.

