September 19, 2018, 03:04 pm Scott Wilson – Mark Horowitz, M.D., is the kind of newspaper reader who still writes letters to the editor.
He's also a New York City family physician who specializes in adolescent health.
And so, the day after a story headlined "F.D.A., Alarmed by Teenage Use, Targets Vaping" hit the front page of The New York Times, the paper ran Horowitz's reply to the article in its Opinion section.
"Just this week, while taking a history from a 19-year-old young man, I asked him if he smoked cigarettes," Horowitz wrote. "The answer was no. I then asked him if he vaped."
The patient told Horowitz he vaped "continuously, all day," using a JUUL e-cigarette. And he said he wouldn't stop vaping, despite now having been told of the habit's risks.
Horowitz quoted the patient: "Everyone does it."
The federal government has noticed: Teenage use of e-cigarettes, FDA Commissioner Scott Gottlieb, M.D., said in a Sept. 12 statement, has reached "an epidemic proportion of growth."
"Epidemic" is a strong word, but Horowitz agrees. "Absolutely, no question about it," he told AAFP News.
"We have a new form of nicotine delivery marketed to youth in a way that allows the young people to initiate use of the drug without having to deal with the noxious flavor of the drug," he said.
The cartoonish array of flavors associated with vaping reminds Horowitz of the mentholated cigarettes that were advertised heavily in the East Harlem neighborhood where he completed an adolescent-medicine fellowship in the mid-1980s.
Adolescence, Horowitz said, is "a time of risk-taking and impulsive behavior, when kids think they're indestructible and being part of a cool group is important." These factors have always fueled teen smoking. What's different now, he says, is that the teenage patients he sees don't equate vaping with smoking.
"The way I take a history from a young person has changed, specifically with regard to substance use," he says. "We have a method of nicotine delivery that's flavored -- tooty-fruity JUULs -- and it means young people don't think they're smoking."
Because "the youth risk is paramount," as Gottlieb put it in his statement, the clock is now ticking for five major e-cigarette manufacturers, including the dominant JUUL Labs. The FDA has notified the companies -- JUUL, Vuse, Blu, Logic and MarkTen -- of a 60-day deadline to lay out how they plan to decrease underage vaping.
If the companies fail to reverse the youth-use trend, Gottlieb said, the FDA may move to take flavored products off the market. He also called attention to what he called an enforcement "blitz" aimed at brick-and-mortar and online retailers selling e-cigarettes to minors.
Critics of the agency, including a litigant in a lawsuit accusing the FDA of dragging its feet on implementing a rule regarding the regulation of new tobacco products, say these latest efforts still aren't enough.
Robin Koval, CEO and president of the anti-tobacco nonprofit Truth Initiative, said in a Sept. 13 statement, "The FDA's request that five e-cigarette manufacturers come up with plans to tackle the youth e-cigarette problem within the next 60 days is the equivalent of asking the fox to recommend plans for guarding the hen house."
For his part, Horowitz is lobbying his teenage patients one at a time.
"On first contact with a young person, by and large, they're completely in denial," he said. "I may say, 'Hey, there's stuff you're vaping that's not safe for you,' and they're probably thinking, 'Give me a break, doc.' But the degree to which I get through increases with time. My chances get better on subsequent visits."
Related AAFP News Coverage
ENDS Not Effective as Tobacco Cessation Method, Says Study
MMWR Report: Fewer Youth Say They Use Tobacco Products
AAFP Voices Support for FDA Tobacco Regulation
Academy Comments on Tobacco Flavors, Cigars, Nicotine in Cigarettes
More From AAFP
Tobacco: Preventing and Treating Nicotine Dependence and Tobacco Use (Position Paper)