The federal government is expected to launch a nationwide ad campaign this week to warn teens about the dangers of e-cigarettes and nicotine addiction. It's the latest effort by the U.S. Food and Drug Administration to curtail what its commissioner has called an epidemic.
But as the federal government steps up enforcement, some tobacco control experts raise a critical point: Along with the feds, state public health agencies should have taken direct action sooner.
Instead, most states continue to act with indifference despite receiving more than $100 billion in payments from tobacco companies over the past 20 years.
An APM Reports analysis of state spending on tobacco control efforts has found that only 13 states are spending money directly on campaigns to discourage e-cigarette use among teens.
"The states have been asleep at the switch," said Matthew Myers, president of the Campaign for Tobacco-Free Kids. It's a problem states should have recognized and acted on earlier, he says.
Statistics show teens have been choosing e-cigarettes — also known as vaping — at a higher rate than other tobacco products for four consecutive years. A national survey of youth from 2017 shows 11.7 percent of students currently use e-cigarettes but FDA Commissioner Scott Gottlieb warned last week the percentage will be higher when new results are released later this year.
In Rhode Island, for example, studies show that it's in the top tier of youth vaping, but the state has spent just $232,000 in 2017 and 2018 on tobacco control programs overall. None of that money is used for e-cigarette prevention campaigns.
The stakes are high everywhere. If the federal government and states fail to reverse the vaping trend among youth, some worry a new generation of children could get hooked on nicotine, a highly addictive substance in tobacco products.
"These kids could become addicted for life, and they may not realize that the products they're using actually are addictive," said Alison Reidmohr, Tobacco Communications Specialist for the Colorado Department of Public Health and Environment.
Moreover, the popularity of e-cigarettes is expected to grow. The e-cigarette/vapor market size is estimated to be $5.5 billion and some analysts expect the devices to overtake traditional cigarettes within the decade.
It's driven in part by the popularity of JUUL, a device that has become the market leader in the e-cigarette universe. The slick, small device looks like a USB drive and has become popular among teens who share their "JUULing" experiences on social media. A starter kit — which includes the device and four pods — costs $50. Each pod, which includes a mix of chemicals, nicotine and flavors, delivers the same amount of nicotine as a pack of cigarettes.
The FDA has threatened JUUL and other manufacturers that it will pull products from the market if the industry doesn't take steps to limit use among children. The federal government has also requested JUUL's internal documents to determine whether the company engaged in youth marketing. Company officials have said they want to prevent underage use and help establish a task force to study how young people buy their products.
Colorado recently decided to take action.
The state has led the nation in e-cigarette use in a recent youth survey by the Centers for Disease Control. Among its high school students, 26.2 percent say they used e-cigarettes regularly in 2017, according to the survey. Today it's one of the 13 states spending money on ad campaigns, warning children and parents about the dangers of e-cigarettes.
Those figures — along with anecdotal evidence of JUUL's popularity among teens — prompted the ad campaign. "I think we saw something that really needs to be dealt with and that we have to invest in," said Reidmohr, whose state has $1.5 million supporting ad campaigns dubbed "Enough with the Puff" and "Tobacco is nasty."
The other 12 states have also varied their spending and approach when it comes to the e-cigarette campaigns. The lowest is Nebraska, which budgeted $13,000 for a digital media campaign. California has spent the most — $53 million since 2014.
Tobacco economists say anti-tobacco campaigns, along with educational outreach, have effectively lowered the number of teens using traditional tobacco products.
"The bottom line is, the more they spend, the lower smoking goes," said Frank Chaloupka, a research professor at the University of Illinois at Chicago School of Public Health.
But most states have done little outreach beyond including talking points about e-cigarettes among broader presentations on tobacco control.
Some states claim lack of funding, pointing to the economic downturn as a reason they gutted overall tobacco control spending.
Those funding decisions were made despite tobacco companies funneling $146 billion to states over the past 20 years. The annual payments are a result of a historic legal settlement in 1998 between the states and tobacco companies related to recovering health care costs caused by tobacco.
But instead of directing the money to tobacco control efforts, states used it in other ways.
Less than 8 percent of the $146 billion in tobacco payments sent to states between 1998 and 2017 — $11.4 billion — has gone to tobacco control and prevention, according to data compiled by the Campaign for Tobacco-Free Kids.
Instead, 20 states opted to sell the payments to investors for a one-time investment to erase a state's budget deficit.
Georgia and Alabama, for example, used the tobacco settlement money for economic development. North Carolina used a portion of its funds to help tobacco farmers. And in 2003 Minnesota scrapped an endowment aimed toward reducing youth tobacco use to erase the state's budget deficit.
"It's criminal that the states did not take the opportunity when they received literally billions of dollars to address the tobacco problem," Myers said. His organization, the Campaign for Tobacco-Free Kids, has lobbied the FDA and state governments to increase regulation and spend more on tobacco control, including e-cigarettes.
If states and the FDA fail to act responsibly when it comes to e-cigarettes, Myers said they'll "be paying the price for years to come."
Though there's considerable worry about children getting addicted to nicotine, several tobacco control experts say e-cigarettes are a safer alternative to combustible cigarettes. They say vaping could drive down the number of adults who use traditional cigarettes. It's a vexing problem for public health officials to encourage adults looking to quit smoking to use e-cigarettes while warning teens about the dangers of vaping.
Iowa Attorney General Tom Miller convened a task force in April to study teen e-cigarette use at the request of JUUL. Miller, who helped negotiate the 1998 tobacco settlement, has been a fierce advocate of e-cigarettes because it has the potential to limit adult smokers.
Before the FDA's announcement this month, Miller downplayed concerns over teen vaping, citing studies from the University of Michigan and elsewhere that teen vaping is "mostly experimental."
"They use them for a while, they don't become daily smokers, and then they move on to something else," he said.
Since e-cigarettes are relatively new, there have been no studies on the long-term health effects. Shorter-term studies have found that e-cigarettes are a safer alternative to combustible cigarettes but warn that the devices could be a gateway for teens to try other tobacco products.
Beyond spending, states have also struggled to increase their legal oversight of e-cigarettes.
Vaping falls under a different set of laws and regulations than traditional cigarettes, creating plenty of openings for the manufacturers. For example, only eight states tax vaping products, but every state has a cigarette sales tax.
Changing any laws related to vaping will also be tough. The tobacco industry continues to be strong and wields considerable clout in Congress and in state legislatures.
Chaloupka, who studies state tobacco control spending and regulation, says states should consider a mix of regulatory measures including taxation, increased spending on public awareness campaigns and raising the purchasing age of tobacco products to limit e-cigarette use among teens.
But, he said, most states have taken little action.
"The general conclusion is that e-cigarette use is going up and very little is being done about it," he said.
Will Craft and Kelly Busche contributed to this report.