In one state, students are walking the school halls smoking e-cigarettes; in the classroom, they're discreetly pulling them out of their backpacks for a quick pull when the teacher turns away from the class.
From left, Utah AFP members Peter Sundwall, M.D., and David Sundwall, M.D., pose with Utah AFP Executive Director Jennifer Dailey inside the state capital building during a recent meeting with legislators.
It's happening in Utah, a state historically known for low youth smoking rates. Between 2011 and 2013, rates of e-cigarette use among students in grades 8, 10 and 12 tripled, according to the Utah Department of Health(health.utah.gov). Only 3.8 percent of teenagers reported using traditional cigarettes compared with nearly 6 percent who said they used e-cigarettes.
Such a dramatic rise in e-cigarette smoking worries physicians and health professionals. In the absence of state or federal regulation, the increasing popularity of e-cigarettes has frustrated many people, including Jennifer Dailey, M.B.A., the Utah AFP's executive director.
"For 60 years, the tobacco companies swore up and down that smoking was not bad for your health," she told AAFP News. "Look how that turned out. Why we're going down the same road again, I don't know."
The chapter made a strong push during the 2014 legislative session to regulate the sale of e-cigarettes, only to fall short as the session ended. Both the house and senate voted in favor of legislation regulating e-cigarettes, but a final version had not been agreed on by the time the session concluded.
- The Utah AFP is working aggressively to enact legislation that regulates the sale and use of e-cigarettes.
- Teenagers are reporting much higher usage of e-cigarettes during the past two years.
- E-cigarette companies are actively promoting their product in the state, a development that worries health officials.
Not to be deterred, the chapter is gearing up for a second attempt during the 2015 session. The governor has indicated he would sign such a bill, according to Dailey.
Dailey is passionate about the issue and about politics in general. She has a personal reason for wanting to reduce e-cigarette smoking. Her mother, a lifelong smoker, now uses an oxygen tank yet continues to use e-cigarettes. She recalls sitting in a movie theater and watching a woman smoke an e-cigarette while sitting with her child.
"There is no smoke, no smell, no telltale sign," Dailey said. "It flies under the radar."
During the past legislative session, Dailey invited a chapter board member, Darlene Petersen, M.D., and other health experts to testify in support of legislation to regulate e-cigarettes and to meet with legislators individually.
"Some legislators said they wanted to wait until federal legislation was adopted, but we can't wait for that," Petersen said. "We need to do it at the state level."
The recent campaign focused largely on raising awareness and educating state officials. Some legislators thought that only smokers were using e-cigarettes and were unaware that children had such easy access to them.
"Kids should not have access to them because this is becoming a status thing," Petersen said.
Utah AFP members (from left) Andrew Sanders, M.D.; Lynsey Drew, D.O.; Phillip Brough, M.D.; Robert Mehl, D.O.; Michael Rhodes, M.D.; and David Grygla, D.O., pay a lobbying visit to the state capital.
Other health advocates have joined in the campaign, including the state medical association and a group of pediatricians. Public education efforts and greater awareness have advanced in the past year, Petersen noted. In the absence of state regulation, for example, more and more businesses are putting up signs informing customers that the facility's no smoking policy includes e-cigarettes.
Small retailers who sell the product have pushed back against state regulation of e-cigarettes, saying that it could drive them out of business. Some argue that these products are smoking cessation devices and, therefore, should be free of regulation.
"I told my patients there is no data to support that," Petersen said. "If you're using them to quit smoking, then you just need to quit."
Widespread distribution of e-cigarettes is another development that makes state health officials wary -- most notably, the emergence of "vape fests" where e-cigarette distributors sponsor events with live music, food vendors and, of course, e-cigarette booths. Unlike traditional tobacco products, for which advertising is prohibited, e-cigarettes have no such regulatory limits.
FACTS ABOUT THE UTAH AFP
Chapter executive director: Jennifer Dailey, M.B.A.
Number of chapter members: 800
Year chapter was chartered: 1946
2015 annual meeting: Scheduled for March; further details to come
"The industry has had free reign not being regulated," said Anna Guymon, a health educator with the Weber-Morgan Health Department Tobacco Prevention and Control Program. "Their intent is to grow market. We need to ensure that we don't have youth who become addicted to nicotine because of the lack of regulation."
Policymakers and retailers have become too accommodating to the industry, Dailey agreed.
"If you work with the industry, you are working against your interests," she said.
Dailey is troubled by the industry's presentation of e-cigarettes as a means of avoiding the greater harms of tobacco products and thinks e-cigarette products are every bit as addictive. Users inhale formaldehyde and other hazardous chemicals, she said, and with flavors modeled after cotton candy or cereal brands popular among children, distributors are clearly targeting a young audience.
A survey of 50,000 Utah students(dsamh.utah.gov) revealed that 60 percent said e-cigarettes are easy to obtain. Among teenagers who said they had used e-cigarettes within the past 30 days, one-third said they had never used traditional cigarettes.
Regarding marketing practices in the state, e-cigarettes are subject to sales tax but are not taxed as tobacco products, another issue the Utah chapter and health officials are working to change. Moreover, the legal age to purchase e-cigarettes in Utah is 19, but punishment for selling the product to minors is relatively light. Stores that sell to minors receive a ticket, but a violation does not jeopardize a store's license.
Guymon said when compliance checks on the sale of traditional tobacco products were introduced in 2001, the state saw an 82 percent reduction in access to the products by 2014.
Two major tobacco producers are providing dollar coupons for youth to purchase e-cigarettes at local convenience stores, and tobacco manufacturer Phillip Morris has hired salespeople to offer the coupons at the point of sale, according to Guymon.
"They are marketing their products as nonaddictive," Guymon said. "The general public is not questioning what they are told by the industry. The amount of advertising dollars that are being poured into the community is astounding."
Despite aggressive marketing by the industry, the presence of tobacco lobbyists in the state and the rising popularity of e-cigarettes, Utah chapter members are optimistic that change is coming.
"A lot of physicians are passionate about this," Petersen said. "I think we can get it passed next year."