Health

HEALTH • Winter 2018 15 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 regu- lated 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-cig- arettes 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 nico- tine extracted from tobacco, along with flavorings and other additives. But specialty favors have led teenag- ers to jump on board, even selling them on the black market at schools. While there has been a significant decline in cigarette usage by teenag- ers, their use of e-cigarettes has sky- rocketed. 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-ciga- rettes are more likely to just transi- tion 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 outpa- tient services for the Harrington HealthCare System in Brimfield. She says that although the usage of e-cig- arettes 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 ques- tion 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 spe- cializes 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 expos- es users to cancer-causing chemicals, although it contains fewer toxic sub- stances than your normal cigarette. The Office of the Attorney General has also urged school officials to con- sider 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 operat- ed cigarettes on school buses, premis- es, and at activities. It also has a sepa- rate tobacco policy that considers the products to be contraband, punishable with disciplinary action, and repeated- ly, with suspension. In an effort to support students in curbing cigarette smoking, the school nurse offers voluntary smoking cessa- tion 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." H E-cigarette maker Juul has become such a big name in the industry that vaping, or smoking an e-cigarette, is sometimes simply called Juuling. The company is making changes under fire.

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