E-cigarettes ‘more harmful than we think’

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Vaping can damage vital immune system cells and may be more harmful than previously thought, a study suggests.

Researchers found e-cigarette vapour disabled important immune cells in the lung and boosted inflammation.

The researchers “caution against the widely held opinion that e-cigarettes are safe”.

However, Public Health England advises they are much less harmful than smoking and people should not hesitate to use them as an aid to giving up cigarettes.

The small experimental study, led by Prof David Thickett, at the University of Birmingham, is published online in the journal Thorax.

Previous studies have focused on the chemical composition of e-cigarette liquid before it is vaped.

In this study, the researchers devised a mechanical procedure to mimic vaping in the laboratory, using lung tissue samples provided by eight non-smokers.

They found vapour caused inflammation and impaired the activity of alveolar macrophages, cells that remove potentially damaging dust particles, bacteria and allergens.

They said some of the effects were similar to those seen in regular smokers and people with chronic lung disease.

They caution the results are only in laboratory conditions and advise further research is needed to better understand the long-term health impact – the changes recorded took place only over 48 hours.

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An independent review of the latest evidence on e-cigarettes was published by Public Health England in February.

The review concluded there was “overwhelming evidence” they were far safer than smoking and “of negligible risk to bystanders” and advised they should be available on prescription because of how successful they had been in helping people give up smoking.

Prof Thickett said while e-cigarettes were safer than traditional cigarettes, they may still be harmful in the long-term as research was in its infancy.

“In terms of cancer causing molecules in cigarette smoke, as opposed to cigarette vapour, there are certainly reduced numbers of carcinogens,” he said.

“They are safer in terms of cancer risk – but if you vape for 20 or 30 years and this can cause COPD [chronic obstructive pulmonary disease], then that’s something we need to know about.

“I don’t believe e-cigarettes are more harmful than ordinary cigarettes – but we should have a cautious scepticism that they are as safe as we are being led to believe.”

Martin Dockrell, tobacco control lead at Public Health England, said: “E-cigarettes are not 100% risk-free but they are clearly much less harmful than smoking.

“Any smoker considering e-cigarettes should switch completely without delay.”

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Are we living in a ‘nanny state’?

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Whether it is forcing restaurants in England to print calorie counts on menus or banning energy drinks for under-18s, the government is full of ideas about how to protect people from themselves.

Conservative politicians used to hate this kind of stuff. They called it the “nanny state” – conjuring images of a finger-wagging, bossy government forever telling us all what to do.

Margaret Thatcher – to her critics the epitome of a bossy, finger-wagging prime minister – often took aim at the “nanny state”.

But one of the earliest uses of the phrase in Parliament came in 1980 during a debate on plans to make the wearing of car seatbelts, for drivers and front seat passengers, compulsory.

Former World War One fighter ace, and Conservative peer, Lord Balfour of Inchrye argued with great passion that seatbelts “can kill”.

But his main objection to the plan was that it was “yet another state narrowing of individual freedom and individual responsibility”.

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Image caption Lord Balfour is strapped into a glider – with a seatbelt – on a visit to the Air Training Corps in 1942

Where would it all end, he wondered in a speech in the House of Lords.

“There are I believe 60,000 deaths a year from lung cancer. I cannot remember the starting of any pressure group formed of the medical community for compulsion on this matter.

“Regarding alcohol, there is possible legislation to limit the amount and conditions in which alcohol is taken which may reduce the terrible tragedy of bodies broken and constitutions wrecked by alcohol. I do not believe that the medical people have lobbied for compulsion there.

“Therefore, if we are to have what I term the ‘nanny state’… why do not the medical lobby go for compulsory wearing of life jackets for people who swim, sail and row in boats?”

How times have changed.

Restrictions on the sale and advertising of cigarettes, like the compulsory wearing of seatbelts, have long since become law, spurred on by the medical lobby that was invisible to Lord Balfour, with curbs on alcohol consumption, through minimum unit pricing, coming down the track.

In some cases, these laws were passed by Conservative governments.

Swimmers have yet to be made to wear life jackets – but the idea that the state can, and should, use its power to force people to make better choices about their health and safety is accepted as a good thing across the political spectrum.

Supporters can point to the many lives that have been saved and how the public has, by and large, accepted curbs on what now seem like reckless, or downright dangerous, behaviours.

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Media caption‘Wood burning Gove’: Truss fumes at cabinet colleague

Indeed, health campaigners and opposition parties argue that Theresa May’s government – for all its commitment to cutting smoking rates and tackling childhood obesity – remains far too fond of industry self-regulation and not willing to take the tough legislative action needed to make a real difference.

But are there signs that the tide is turning on the Conservative benches? Is the ghost of Lord Balfour, who died in 1988, aged 90, haunting the corridors of power?

In the run-up to the Conservative Party conference, former minister and leading Brexiteer Priti Patel criticised the prime minister for leading a “nanny state government”, which she claimed was more interested in banning things than implementing Conservative policies.

Chief Secretary to the Treasury Liz Truss – who has criticised the restaurant menu plan and called for motorway speed limits to be increased to 80mph – grabbed headlines in June when she took a swipe at cabinet colleague Michael Gove’s proposed ban on wood burning stoves.

It is not the government’s job “to tell us what our tastes should be”, she said in a speech.

“Too often we’re hearing about not drinking too much, eating too many doughnuts or enjoying the warm glow of our wood-burning Goves – I mean stoves.

“I can see their point: there’s enough hot air and smoke at the environment department already.”

Christopher Snowdon, of the Institute for Economic Affairs, a free market think tank which is reported to have received funding from the tobacco industry, said other Conservative MPs were similarly uneasy about what they see as the bossy tone of government initiatives, although few have been willing to go on the record about it.

Mr Snowdon is a longstanding campaigner against the “nanny state”. He even compiles an annual league table of the most “nannying” countries – which last year saw the UK coming second behind Finland as the “worst country in which to eat, drink, smoke and vape in the EU”.

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Image caption Smoking in pubs was banned in 2007 by a Labour government

His ultra-libertarian views – he says he would have no problem with legalising all drugs, for example – puts him at odds with Theresa May and the rest of the Tory leadership, as well as mainstream opinion in Labour and just about every other party at Westminster.

He argues that they have all misread the mood of the public, who, he claims, are growing increasingly “fed up” with being told how to live their lives.

“I think there is a public backlash but it may not always be reflected in the media,” he says.

It is mostly the poor and marginalised – people who don’t always have a voice at Westminster – who bear the brunt of increased taxes on food, alcohol and tobacco, he argues.

Banning things is “very easy and cheap to do”, he says, and it makes an immediate impact on people’s lives – an irresistible combination for politicians looking to make a name for themselves.

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Image caption But the Conservatives have continued to crack down on tobacco

Dolly Theis, a Conservative candidate at last year’s general election, and a policy expert in public health, says that far from restricting freedom of choice, the government’s childhood obesity strategy, which aims to ban the sale of fatty and sugary foods at supermarket checkouts among other things, is about increasing choice.

Few people decide “I want to be obese” but their choices can be limited by their economic circumstances, she says.

“By the age of five, children in poverty are twice as likely to be obese as their least deprived peers, and by the age of 11 they are three times as likely,” she wrote in a paper for the Bright Blue think tank.

“They are also more likely to live in an area with more takeaway and fast food outlets; more likely to live in poor, unsuitable or overcrowded housing; and more likely to experience a combination of family breakdown, stress, mental health issues and financial problems – all factors which can impair parents’ ability to make rational and compassionate decisions.”

The childhood obesity strategy, she claims, marks a significant shift “away from viewing childhood obesity as an issue of poor personal choice, towards understanding that our environment, socioeconomic circumstances, education and the influence of the food and drinks industry, dictate the choices we are presented with”.

Cutting obesity will also save the NHS millions in the longer term, reducing the need to increase taxes – another key Conservative priority, she adds.

But cabinet tensions over how far the government should go in its efforts to improve public health, and what tone it should adopt, suggests the debate in the party is far from settled.

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Juul and the vape debate: Choosing between smokers and teens

(CNN)The year was 2004, and James Monsees and Adam Bowen couldn’t stop taking smoking breaks during a brainstorming session for their joint master’s thesis at Stanford University’s design school. It was during one of these breaks that they decided: Why not create a better way to deliver nicotine?

Eleven years later, they unveiled Juul, a device that gives users a flavored nicotine fix without the smell and smoke of combustible cigarettes. It’s an e-cigarette, which means it doesn’t burn tobacco but rather generates an aerosol by heating a liquid that contains nicotine.
Juul, along with many other e-cigarette products, has found a place in a multibillion-dollar market. According to a Bloomberg report from late June, Juul controls 68% of the e-cigarette market. In 2016, 3.2% of US adults were current e-cigarette smokers while 15.5% smoked combustible cigarettes according to the National Health Interview Survey. Younger adults were more likely to vape than older ones.
    That even holds true for underage users: Youths are more likely than adults to vape, according to the US Centers for Disease Control and Prevention. For high school and middle school students who used a tobacco product in 2016, e-cigarettes were the most commonly used; 11.3% of high schoolers and 4.3% of middle schoolers used e-cigs, according to data from the 2011-2016 National Youth Tobacco Surveys.
    The act of vaping has even become a verb among youth: Juuling.
    Today, Monsees and Bowen are the chief product officers for the company. Ashley Gould, the chief administrative officer for Juul Labs, said they designed Juul for adult smokers trying to switch from combustible cigarettes, but data show the product’s startling popularity among youth.
    “It’s been devastating to us,” Gould said. “This is not a product for youth. It’s a product for adult smokers.”
    According to a 2017 national online survey by the Truth Initiative, a nonprofit tobacco control organization,7% of teens 15 to 17 reported having ever used a Juul.
    “The evidence is overwhelming today that these products appeal to kids,” said Matt Myers, president of the nonprofit organization Campaign for Tobacco-Free Kids.
    But Juul Labs argues that, by helping people give up cigarettes completely, the company provides a potentially life-saving service to current smokers, two-thirds of whom will die from smoking-related illnesses. The scientific consensus, however, is still out on the long-term health effects of vaping. And new research, combined with lawsuits against Juul Labs, threatens to undermine the company’s argument.
    “We need to talk to our kids, and at the same time, we can’t forget about the 38 million American adult smokers in our country who need and deserve our support,” Gould said.
    New research on the health effects of vaping and lawsuits against Juul Labs threaten to undermine the company’s argument.

    Juul gone viral

    At Jonathan Law High School in Milford, Connecticut, Principal Francis Thompson pulled from his pocket a sleek device resembling a USB drive. It’s the Juul, the most popular vape students used, he said.
    Vaping among teens took off so rapidly at Jonathan Law, the school had to take drastic measures.
    “Being a relatively new phenomenon, we didn’t know a lot about vaping and its impact and its danger and, quite frankly, its popularity that continues to rise among teenagers,” Thompson said. “It was causing several issues in our school bathrooms.”
    Thompson closed all but one of the school’s bathrooms. But then, kids began to brazenly vape in hallways and classrooms instead, recalls Andrew Paulus, an 18-year-old recent graduate.
    “It was a party setting. I saw everyone was doing it, so I was like, ‘Let me just try it once just to see what this fuss is about,’ ” Paulus said.
    Emma Hudd, one of Paulus’ classmates, said that teachers who didn’t know any better would allow kids to plug their vapes into classroom computers to charge them.
    Hudd, 18, likened Juul to her generation’s version of cigarettes.
    “We need to understand this more, because no usage of our product by youth is acceptable to us,” Gould said.
    “I can tell you certainly though, it was not designed to look like a USB device. It was not designed to be hid by kids,” she said. “This is a product that was designed by smokers for adult smokers, and that is the design ethos of the product.”
    Bella Kacoyannakis saw the Juul on social media sites, where people would post about how “awesome” it was, she said. The first time the 20-year-old tried it, she said she was immediately drawn to its small size, simple upkeep and fruity flavors.
    “I like the Juul better than cigarettes because the taste is so much more pleasant. And, like, the nicotine content isn’t really that much different,” Kacoyannakis said.
    The nicotine in one Juulpod, a small disposable e-liquid cartridge that’s inserted into the vaping device, is equal to that of an entire pack of cigarettes, according to the company. The rate at which a Juulpod is consumed varies among users, but can last about 200 puffs.
    Since Kacoyannakis switched from cigarettes to the Juul, she says, she vapes more than she used to smoke because of how convenient the device is.
    Gould said the company’s data do not show that Juulers who switched from cigarettes are taking in more nicotine than they did when they smoked. Independent research hasn’t yet confirmed Juul Labs’ data.
    Kacoyannakis recently picked up the box of her Juul and for the first time read the warning label.
    “This product contains chemicals known to the state of California to cause cancer and birth defects or other reproductive harm,” she read aloud. She had never noticed the California Proposition 65 warning before.
    Neither had Paulus or his friends.
    “On the front [of the packaging], it’s big letters, J-U-U-L Juul, or it has the flavoring in the color of the pod, but no one really looks at the side to see this really small writing saying, ‘Oh, caution, this is bad for you or whatever,’ ” he said.
    The Truth Initiative survey reported that 63% of young Juul users did not know that the product always contains nicotine.
    Gould said Juul Labs has added larger warning labels that now announce that the product contains nicotine across 20% of the space showing on a package.

    What’s in the vape?

    Nicotine isn’t the only ingredient in e-cigarettes, though. Studies from Harvard and Johns Hopkins researchers found that e-cigarette users wind up inhaling dangerous chemicals and toxic heavy metals along with their nicotine fix.
    “There’s a lot that’s happening with an e-cigarette besides just the nicotine and the carrier fluid. You’re also inhaling these flavoring chemicals like diacetyl or cousins of diacetyl, which have been found to be harmful,” said Joe Allen, an assistant professor at the Harvard T.H. Chan School of Public Health and the first author of a study on the presence of diacetyl in e-cigarettes.
    Much of what’s known about diacetyl’s effects on the lungs comes from studying the workers in a microwave popcorn packaging plant, Allen said. Twenty years ago, these workers developed a disease called bronchiolitis obliterans, or popcorn lung, after inhaling the fumes of artificial butter flavoring from open vats in their workplace.
    “You see a slow onset of some symptoms like wheezing, shortness of breath or coughing,” Allen said. “This is a disease that is irreversible, often requiring a lung transplant.”
    But David Abrams, a professor at the NYU College of Global Public Health who has researched smoking cessation for 40 years, doesn’t see diacetyl inhalation as much of a threat for vapers.
    “I think this whole story of diacetyl and popcorn lung, which is true only in popcorn workers who were exposed for eight to 10 hours a day has been completely exaggerated, and it’s part of what’s led the public into thinking e-cigarettes are as dangerous as cigarettes,” he said.
    Nevertheless, Abrams said the public can’t be reassured completely until the US Food and Drug Administration regulates vaping products.

    The future of regulation

    Last year, the FDA announced that it would delay regulations that could have halted the sales of many e-cigarettes. Instead, the agency gave extensions to new and existing vaping products, giving them until August 2022 to submit information to support their products’ safety and efficacy as switching devices.
    The organization decided on this timeline to “make certain that the FDA is striking an appropriate balance between regulation and encouraging development of innovative tobacco products that may be less dangerous than cigarettes,” according to the news release announcing the extensions.
    Michael Felberbaum, an FDA spokesman, said the agency does not have any additional information regarding a regulatory timeline once these applications are submitted. Meanwhile, the agency plans to propose a series of product standards to address some of the known public health risks of these products, which includes taking a close look at flavors, he said.
    Greg Conley, president of the American Vaping Association, said the question facing the American public and the FDA is not whether there should be regulations but whether they should be so strict as to wipe out competition from independent vape companies.
    “Reasonable product standards that actually help make the products better, help instill consumer confidence, that would be fine,” he said. “But what the FDA has proposed is not regulation; it is prohibition for 99% of products on the market today.”
    Gould says reasonable regulation would entail banning candy flavoring for e-cigs like cotton candy and gummy bear, cracking down on marketing to youth and restricting purchase to buyers 21 and older.

    Protecting kids

    Even as it announced the extensions last year, FDA Commissioner Dr. Scott Gottlieb said the agency would “redouble our efforts to protect kids from all nicotine-containing products.”
    Felberbaum said the agency’s goal is to balance public health concerns alongside the innovation of the e-cigarette industry, which “can’t come at the expense of kids,” he added.
    In April, after telling CNN Chief Medical Correspondent Dr. Sanjay Gupta that the organization would be taking enforcement actions “very soon” against companies believed to be marketing products to young people, Gottlieb announced a “blitz” on retailers for violations related to sales of e-cigarettes to minors. The agency said it sent Juul Labs a request to submit documents related to product marketing and research, including information about “youth initiation and use.”
    In July, the company was hit with multiple lawsuits that allege Juul Labs intentionally targets teens in its marketing. Prior to the lawsuits, Gould said the company took seriously the criticism of its 2015 launch campaign, which used young-looking models. The company had also announced that it would no longer use models on social media platforms, instead focusing on testimonials from adult smokers who switched to Juul.
    “That campaign in the end, we felt, did not help us achieve our mission of speaking to adult smokers to provide them information about an alternative to cigarettes,” she said.
    Juul uses age verification measures on its website, but Gould said 90% of the company’s sales are at the retail level, which is more difficult to regulate.
    Paulus, the recent high school graduate, says enforcing stricter age laws won’t stop underage users from getting their hands on Juuls.

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    “I’m 18, and a freshman, sophomore, junior — if they really want to smoke or use a Juul, they could ask me or ask anyone in the senior class that’s over 18, and they could easily just give them money, go to a store, pick it up for them,” he said.
    Other approaches target the schools where the Juuling problem is prevalent.
    One independent organization that has developed an e-cigarette prevention program for middle and high school students is the Coordinated Approach to Child Health, or CATCH. It includes four lessons with topics that include e-cigarette ingredients, marketing techniques and skills for refusing e-cigarettes.
    Ashley Monteiro, a student at Wareham Middle School in Massachusetts, said that before taking the class, she thought e-cigarettes looked “pretty cool” and the flavors might taste good. But since learning about the use of artificial flavorings and chemicals in vapes, she’s no longer interested.
    For Hudd, a 2018 grad ofJonathan Law High School, the solution to the vaping craze is to escape its epicenter.
    “I’m happy I’m leaving high school so that I can get out of here and away from all the Juuling,” she said.

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    FDA expands investigation of illegal e-cigarette marketing to kids

    (CNN)The US Food and Drug Administration pressed forward with its investigation of e-cigarette companies Friday, sending letters to 21 companies in an effort to uncover whether they are marketing products illegally and outside the agency’s compliance policy.

    This latest phase of the investigation addresses more than 40 e-cigarette products and is part of the agency’s ongoing efforts to combat e-cigarette use among youth. It also comes less than two weeks after the agency conducted a surprise inspection of e-cigarette maker Juul’s corporate headquarters in San Francisco, seizing thousand of documents, many of which relate to its sales and marketing practices.
    “Companies are on notice,” FDA Commissioner Dr. Scott Gottlieb said in a statement Friday. “The FDA will not allow the proliferation of e-cigarettes or other tobacco products potentially being marketed illegally and outside of the agency’s compliance policy, and we will take swift action when companies are skirting the law.”
      In September, Gottlieb called the increasing teen use of e-cigarettes “an epidemic,” adding that teen nicotine use is dangerous to young people’s health and brains.
      Federal law prohibits the sale of e-cigarettes to people under the age of 18, but more than 2 million middle and high school students were current users of e-cigarettes in 2017, according to the FDA. The US Centers for Disease Control and Prevention says it’s the most common nicotine product used by middle and high schoolers.
      Also last month, the FDA requested that five major e-cigarette manufacturers, including Juul, explain how they plan to combat the use of their products by minors. The agency said it was looking into steps to eliminate the sale of flavored products and unveiled a public education campaign about e-cigarettes.
      The FDA said it’s considering civil and criminal avenues to enforce these regulations, including fines, seizures and injunctions, according to Friday’s announcement.
      CNN reached out to some of the companies that received letters for comment but did not immediately receive a response.

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        “We’re going to address issues related to the access kids have to e-cigarettes, as well as the youth appeal of these products,” Gottlieb said Friday. “We know flavors are one of the principal drivers of the youth appeal of e-cigarettes and we’re looking carefully at this.
        “No reasonable person wants to see these products reaching epidemic use among kids,” he said.

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        Teens who vape or use hookah are more likely to use marijuana later, study finds

        (CNN)Teens who used e-cigarettes and hookah were up to four times more likely to use marijuana later, according to a study published Monday in the journal Pediatrics.

        Researchers from the University of Pennsylvania and the University of Southern California surveyed 2,668 students at 10 public high schools in Los Angeles beginning in fall 2013, when they were 14 years old and in ninth grade.
        The students answered a paper-and-pencil, phone or internet survey that asked whether they had ever used (or had used in the past 30 days) e-cigarettes, combustible cigarettes or a hookah water pipe. They were also asked whether they had used any type of marijuana product. The use of less popular tobacco products such as smokeless tobacco and cigars was not studied.
          In a followup survey in fall 2015, when the students were 16 years old and in 11th grade, the survey asked whether they had used three types of marijuana products: combustible, vaped or edible.
          The researchers found that the students who had tried e-cigarettes when they were freshmen had a more than three-fold greater likelihood of ever using marijuana and using marijuana in the past 30 days than students who hadn’t tried e-cigs.
          “When we were thinking about this topic, we were kind of just reflecting on the fact that we have more tobacco products on the market now than ever,” said Janet Audrain-McGovern, an associate professor in the Department of Psychiatry at the University of Pennsylvania’s Perelman School of Medicine and lead author of the study. “And we’ve seen cigarette smoking decline among young people, but we’ve seen increase in use of these other tobacco products. At the same time, we’ve also seen in many areas of the country a lessening of the restrictions surrounding marijuana use.”
          The researchers controlled for factors that could be associated with an increased risk of marijuana use, including family history of both tobacco and marijuana use, peer use, depression and impulsivity.
          “That doesn’t mean necessarily that the association is causal,” cautioned Dr. Ana Navas-Acien, a professor of environmental health sciences at Columbia University’s Mailman School of Public Health, who was not involved with the study. “I think we need to be very careful with interpreting these relationships. But it seems that the use of these tobacco products, including combustible cigarettes and e-cigarettes, seems to precede the use of marijuana somehow.”
          Students who had used hookah at the time of the first survey had a more than three-fold increase in the odds of having tried marijuana two years later and over a fourfold increase in the odds of using marijuana in the previous 30 days.
          One potential reason for the strong tie between hookah and marijuana use is that hookahs allow the mixing of multiple combustible products and could be used with marijuana itself, said Navas-Acien, who also studies e-cigarettes and hookah usage.
          Along with the potential of addiction to nicotine and the substances in marijuana, there are toxicants in hookah that can lead to increased health concerns, she said. Smoking hookah can result in 1.7 times more nicotine exposure than a regular cigarette, the researchers said.
          Nicotine changes the brain and enhances the pleasure experienced from subsequent drug exposures, Audrain-McGovern said. The changes in the airway from hookah smoking and e-cigarette vaping could also make smoking and vaping marijuana easier because of decreased sensitivity to irritation.
          “Once you start vaping, I think you become known as the person who vapes, who’s cool,” said Richard Miech, a professor at the University of Michigan and principal investigator of Monitoring the Future, an ongoing study of adolescent drug use. He was not involved with the new study. “You get invited to parties where people are going to smoke cigarettes and smoke marijuana because you vape already. So there’s that social component.”
          Students probably develop peer groups that they wouldn’t otherwise, and that is a possible link between vaping and future cigarette and marijuana smoking, Miech said.
          “And I think there are probably other social pathways as well, other than just friendship networks,” he added. “It probably changes your attitude. You probably vaped for a while and say ‘I don’t see any problem. I’m not dropping dead. I guess it’s not as dangerous as they’re telling me it is.’ “
          More than 11% of high schoolers use e-cigarettes, and between 5% and 11% smoke hookah, according to the authors of the study.

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          “The brain is still developing during the teen years,” Hongying Dai,an associate professor at Children’s Mercy Hospital and the University of Nebraska Medical Center, who researches tobacco use and health disparities, wrote in an email. She was not involved in the study.
          “Nicotine exposure might lead to changes in the central nervous system that predisposes teens to dependence on other drugs of abuse. Experimenting with e-cigarettes might also increase youth’s curiosity about marijuana, reduce perceived harm of marijuana use, and increase the social access to marijuana from peers and friends.”
          Teens had about 3.5 times greater likelihood of using marijuana in the previous two years for each additional tobacco product used, the study found.
          “And we know that these two drugs sort of go together,” Audrain-McGovern said. “So if you smoke cigarettes and then you later try marijuana, you’re more likely to quickly progress to using marijuana again.”
          The surveys did not measure the frequency of marijuana use, so whether e-cigarette or hookah use aligns with specific levels of marijuana use is unknown, researchers said. More data demonstrating a relationship between e-cigarettes and hookah use and marijuana use would be useful in determining policies to protect teen health, they said.

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          FDA threatens stores that sell Juul and flavored e-cigarettes to kids

          (CNN)The head of the US Food and Drug Administration took aim Wednesday at Juul and other e-cigarette manufacturers, warning that they must show in the next two months how they’ll keep the devices out of the hands of young people.

          Noting an “epidemic” surge in teen use of e-cigarettes, FDA Commissioner Dr. Scott Gottlieb warned the FDA might require companies to change their sales and marketing practices; stop distributing products to retailers who sell to kids; and remove flavored e-cigarette products from the market.
          “I use the word epidemic with great care,” Gottlieb said. “E-cigs have become an almost ubiquitous — and dangerous — trend among teens. The disturbing and accelerating trajectory of use we’re seeing in youth, and the resulting path to addiction, must end. It’s simply not tolerable.”
            Juul, MarkTen, Vuse, Blu and Logic control 97% of the e-cigarette market, the FDA said. In the next 60 days, the FDA plans to investigate the five e-cigarette companies’ marketing and sales practices, with possible “boots on the ground inspections,” Gottlieb said.
            The agency will also be increasing federal enforcement actions on e-cig sales to minors in convenience stores and other retail sites, Gottlieb said. On Wednesday, it announced “historic action” against more than 1,300 retailers who illegally sold Juul and other e-cigarettes to minors during a crack down on retailers this summer. Gottlieb called the action the largest coordinated enforcement effort in the agency’s history.
            The FDA will also look closely at “straw purchases,” in which adults visit web-based stores and buy in bulk to resell to minors. Federal law prohibits the sale of e-cigarettes to people younger than 18.
            “If young adults go online and buy 100 units of a product to sell to teens, that activity ought to be easy for a product manufacturer to identify,” said Gottlieb. If manufacturers aren’t willing to do the research, he said, the FDA will do it for them, with appropriate consequences.
            “Let me be clear: Everything is on the table,” said Gottlieb. “This includes the resources of our civil and criminal enforcement tools.”

            A generation addicted?

            E-cigarette makers argue the devices help adult smokers give up cigarettes — potentially saving them from related illnesses — by giving a nicotine fix without the smoke and smell of combustible cigarettes. The scientific consensus, however, is still out on the long-term health effects of vaping.
            The FDA recognized the impact its actions might have on adults trying to stop smoking, Gottlieb said, but emerging research on how flavored products encourage excessive use by young people shows action must be taken.
            More than 2 million middle and high school students were current users of e-cigarettes in 2017, the FDA said, and e-cigarettes were the most commonly used tobacco product by youth. Youths are more likely than adults to vape, according to the US Centers for Disease Control and Prevention.
            “I’ll be clear. The FDA won’t tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products,” Gottlieb said Wednesday.
            “We’re especially focused on the flavored e-cigarettes. And we’re seriously considering a policy change that would lead to the immediate removal of these flavored products from the market.”
            Juul Labs, which controls about 70% of the market, said in its statement that “appropriate flavors” play a role in adults changing their smoking habits, but added that they “are committed to preventing underage use of our product, and we want to be part of the solution in keeping e-cigarettes out of the hands of young people.”
            Several other manufacturers targeted by the FDA — MarkTen, Vuse, Blu and Logic — also issued statements agreeing with the need to limit access to minors and announcing their willingness to work with the FDA to reach a solution.
            The Vapor Technology Association, which says it represents over 600 vaping manufacturers and distributors, also supports limiting teen access, but added that the new actions by the FDA ventured “into dangerous territory” by not being in the best interest of public health.
            In a statement, VTA Executive Director Tony Abboud asked: “Does FDA really want millions of Americans to return to smoking cigarettes?”

            A change of plan

            Last year, the FDA announced that it would delay regulations that could have halted the sales of many e-cigarettes. Instead, the agency gave extensions till August 2022 to new and existing vaping products. The agency said it allowed the extra time to strike an appropriate balance between regulation and encouraging the development of innovative tobacco products that may help older smokers quit.
            At that time of the extension, Gottlieb said Wednesday, the agency didn’t foresee the “epidemic'”of adolescent use that has become one of the plan’s biggest challenges.
            “Today we can see that this epidemic of addiction was emerging when we first announced our plan last summer,” said Gottlieb. “Hindsight, and the data now available to us, reveal these trends.”

            Sign up here to get The Results Are In with Dr. Sanjay Gupta every Tuesday from the CNN Health team.

            Since Wednesday’s action did not change the current 2022 timeline for regulatory review, some said the agency’s action fell short.
            “We need to go further,” said Michael Bloomberg, the billionaire philanthropist who has worked for years to reduce tobacco use.
            “The FDA should immediately move to regulate flavored e-cigarettes, instead of waiting until 2022, as it is currently planning to do,” Bloomberg said in a statement.
            The Campaign for Tobacco-Free Kids also called for stronger action.
            In a statement, Matthew Myers, the campaign’s president, said the FDA’s action would only represent a turning point if it “reverses its policy and requires that all of these products undergo agency review now, not four years from now.”
            The American Medical Association’s Dr. Barbara McAneny also said the FDA could do much more, pledging that the association would “continue to advocate for more stringent policies.”
            U.S. Senate Democratic Whip Dick Durbin and Republican Sen. Lisa Murkowski also asked the FDA to end delays. In a statement, they called for support for their bipartisan legislation, introduced in July, which would ban flavored cigars and place stringent controls on e-juice flavorings.

            FDA actions so far

            In April the agency launched a Youth Tobacco Prevention Plan, designed to address some of the known public health risks, such as flavors, that contribute to adolescent use of e-cigarettes.
            Shortly after the launch, the FDA cracked down on e-liquids marketed to resemble kid-friendly foods like juice boxes, candy and cookies. As part of today’s action, the agency sent an additional 12 warning letters to another 12 companies that continue to sell the products.
              The FDA also targeted Juul retailers this spring, issuing 56 warning letters and six civil monetary penalties. Today’s effort notches up that action, becoming, said Gottlieb, the “largest ever coordinated initiative against violative sales in the history of the FDA.”
              The agency said it plans to unveil a new e-cigarette public education campaign targeted to youth next week, and will soon announce wider access to new nicotine replacement therapies to help more adult smokers quit cigarettes.’

              Read more: http://edition.cnn.com/

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              Love and heroin don’t mix: how these newlyweds survived a harrowing romance

              Augusta, Georgia (CNN)There’s nothing sweet or adorable about the way newlyweds Brittany and Ryan Coleman first met — no “meet cute” like in rom-com movies or romance novels.

              It was 2015, and Brittany bought heroin from Ryan in a parking lot, and Ryan cheated her. Brittany called him some choice names, and Ryan shrugged his shoulders and walked off.
              Despite that inauspicious beginning, and the many years of drug abuse that precededit, the Colemans want to get out this message: There is life and love after drug addiction.
                They want to give hope to those whose lives have been ravaged by the opioid epidemic, which kills more than 115 people every day in the United States.
                “You just have to find the right people to get connected to to kind of show you the way out,” said Brittany, 29.

                Addiction, rehab and relapse

                When Brittany Hokrein was 11 years old, her parents divorced, and she and her brothers and mother moved from Georgia to Pennsylvania.
                She struggled emotionally, and at age 14 she started to use marijuana and alcohol so she wouldn’t feel the hurt. Soon, pain pills became her drug of choice, and by age 18 she was addicted.
                Ryan, now 37, was born into a military family, moving from Georgia to Germany to Texas and then back to Georgia. Like Brittany, he had a loving family, but as a teenager, he felt like he didn’t fit in, and he started to smoke pot at age 14.
                “I found that I could medicate that feeling. Life was great once I got high,” he said.
                By the time Ryan was 17, he was smoking pot every day, and he dropped out of high school senior year. He moved on to LSD and cocaine. By the time he was 20 he was hooked on painkillers.
                His father, an Army drill sergeant, and his mother, a high school teacher, begged him to go to recovery. They told him a recovery program had saved his mother from alcoholism when Ryan was a child. But he rebelled and rejected everything his parents stood for.
                By 22, he was strung out on heroin. “I had to have it,” he said.
                Over the next 10 years, Brittany and Ryan unknowingly led parallel lives. Hopping from city to city, they both used heroin, methamphetamines, prescription opioids, Xanax, cocaine and alcohol.
                Brittany overdosed three times, and Ryan overdosed five times. Ryan got arrested 16 times, mostly for stealing so he could get money to buy drugs. Brittany stole, too, and had a stint at prostitution.
                Their parents loved them and helped get them into rehab programs. Each stint ended in a relapse.
                By 2016, both Ryan and Brittany had moved back to Augusta, Georgia.
                They happened to end up at the same recovery group meeting. Eight months had passed since they’d met at that drug deal in the parking lot.

                A forbidden love (and with good reason)

                He’s cute, Brittany thought when she met him again at rehab.
                She’s beautiful, Ryan thought. Really beautiful. And she looked so familiar.
                He realized she was the woman he’d cheated in the drug deal.
                “I thought, ‘This was fate.’ I walked right up to her and told her I needed to apologize for ripping her off,” Ryan remembered. “I did want to make amends, but I also had an ulterior moment. I wanted to date her.”
                Dating was discouraged in their recovery program — and Brittany and Ryan found out why.
                As they fell in love, they spent all their time together and their lives became intertwined. At first they both stayed sober but then slowly, imperceptibly, Ryan slipped away, taking Brittany with him.
                After about four months of dating, one Friday morning Ryan told Brittany he was going down to a park by the Savannah River to think about his life.
                But instead, he drove two hours to Atlanta to buy heroin and cocaine.
                He called her on the way and told her the truth. Brittany stood there with her phone in her hand. She wrote out a text that she knew she shouldn’t send.
                It said that Ryan needed to bring back some drugs for her. She stared at the text for a while. Then she hit send.
                And everything fell apart.

                Giving up heroin — and each other

                For the next week, Brittany and Ryan went right back to heroin, right back to cocaine, right back to meth, sometimes all at the same time.
                “I even romanticized it, saying f*** all the rules, we’re going to be heroin junkies together, all that ‘Trainspotting’ bull****,” he said, referring to the 1996 film about young Britons on heroin. “Addicts have a sick way of romanticizing their drug use.”
                Then on October 3, 2016, they both overdosed on meth and heroin. Medics found Brittany lying on the floor of a gas station bathroom, and Ryan right outside, unconscious in his car.
                The medics gave them doses of Narcan, the drug that reverses overdoses. Brittany had done so much heroin she needed two doses.
                Ryan was wracked with guilt. He felt personally responsible for Brittany’s near death in that gas station bathroom. He was the one who’d driven to Atlanta to get drugs when they were both working so hard to be clean. He was the one who said ‘yes’ when she asked him to bring some back for her.
                “I had almost killed the person I loved the most,” he said.
                Brittany returned to Hope House, a treatment center for women in Augusta.
                Ryan visited here there. Surrounded by his sponsor from his recovery group and Brittany’s counselors, he got down on his knees — and apologized.
                “He held my hand and apologized to me in front of all those people,” Brittany said, crying at the memory of it. “He was shaking and I was shaking. He said how sorry he was for putting me through all this and how scared he was to almost lose me.”
                They then had to do something they describe as just as hard as giving up heroin: They had to give each other up. For a month, they had no contact at all.
                “The only way for us to survive was to focus only on our recovery, and not on each other,” Brittany said. “It was the only way it would work.”
                Brittany then left Hope House, and the two met up at their recovery group’s Thanksgiving dinner. They started back dating slowly, and then a year and a half later, on February 24, 2018, they were married.

                Two years sober

                Next month marks two years of sobriety for both Brittany and Ryan, and today they live in a small house with four cats in Augusta. Ryan works at a vape store, where he’s advanced from part-time clerk to assistant manager to manager. Brittany works at a rehab center, helping others overcome their addictions.
                They volunteer to help others in recovery and have also spoken at programs that train people how to use Narcan, the drug that saved both of them so many times.
                When asked how they survived addiction where so many have died, they say it was the grace of God and to a large degree luck — luck that those Narcan doses were available right when they needed them.
                They also say they let other people guide them: their families, who never gave up on them; the rehab counselors who stuck with them; and their recovery mentors who showed them the way, including that they needed to focus on their individual recoveries and not on each other in order to survive.

                Sign up here to get The Results Are In with Dr. Sanjay Gupta every Tuesday from the CNN Health team.

                All of those people joined them on their wedding day.
                “It was really a culmination of all the good things going on in our lives finally really coming together,” Ryan said.
                Sometimes Brittany can’t believe she’s alive, much less in a loving, stable relationship.
                “It’s unbelievable. I don’t think that I would have ever imagined that I would be married and happy and just planning a future with another human,” she said. “I didn’t ever picture that for myself.”
                  They want people in the throes of addiction to see that despite the dire statistics, there can be hope.
                  “I want them to see people like us and realize that we were in that same place at one point in our lives — and we got out,” Ryan said.

                  Read more: http://edition.cnn.com/

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                  FDA Cracks Down On Juul And E-Cigarettes Sold To Teens

                  The Food and Drug Administration on Wednesday issued a dire warning to Juul and four other manufacturers of popular e-cigarettes, giving the companies 60 days to submit plans showing how they will do a better job keeping the devices out of minors’ hands. 

                  FDA Commissioner Scott Gottlieb said in a statement his agency has seen “clear signs” that use of vaping devices has reached an “epidemic proportion.” Of specific concern are tobacco products flavored to resemble “kid-friendly” foods, the agency said.

                  The FDA specifically targeted Vuse, Blu, Juul, MarkTen XL and Logic devices, which together represent the vast majority of the U.S. e-cigarette market. If the brands fail to comply with the order, the FDA may order their products taken off shelves.

                  Although vaping exposes users to far fewer toxic chemicals than traditional cigarettes, the addictive component used in such devices ― nicotine ― is present in greater amounts. Juul, a product so popular it became a verb, offers nicotine pods with flavors such as mint, mango, cucumber and creme brulee. 

                  E-cigarette advocates argue that the flavors help adult smokers switch to the electronic alternative. 

                  While e-cigarettes have proven to be a means of weaning adults away from traditional cigarettes, the devices’ popularity among teens has spiked, introducing a new generation of young people to nicotine.

                  In its sweeping declaration, the FDA stated that it “won’t allow the current trends in youth access and use to continue, even if it means putting limits in place that reduce adult uptake of these products.”

                  “It’s an unfortunate trade-off,” Gottlieb told The New York Times.

                  The agency has already issued 1,300 warnings and fines to retailers it says have sold the vaping devices to minors, including 7-Eleven, Circle K and Walgreens stores, and shops at Shell and Mobil gas stations. Fines imposed on some locations ranged from approximately $280 to $11,200. 

                  The regulator’s so-called enforcement blitz was conducted from June through August and targeted both brick-and-mortar and online stores. Gottlieb said it was the largest such effort in the FDA’s history. 

                  More than 2 million middle school and high school students used e-cigarettes in 2017, the agency said. 

                  Juul was quick to express support for the government’s action on Wednesday. 

                  “We are committed to preventing underage use of our product, and we want to be part of the solution in keeping e-cigarettes out of the hands of young people,” the company said in a statement. 

                  Manufacturers of Blu and MarkTen devices emphasized commitments to keeping tobacco products out of kids’ hands, as well.

                  Efforts to curtail the products’ availability to teens could mean the companies cut off sales to retailers with a history of selling to minors. The FDA also suggested eliminating online sales entirely, or removing the flavored products until they are vetted by the agency.

                  The crackdown on e-cigarettes comes more than a year after the FDA announced a new plan to combat tobacco-related deaths in the U.S., which stand at 480,000 annually, according to the Centers for Disease Control and Prevention.

                  This article has been updated to note comments by Blu and MarkTen.

                  Read more: http://www.huffingtonpost.com/

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                  Weed Growers Not High On Vicente Fox’s Goal To Add Pot To NAFTA

                  Former Mexican President Vicente Fox is planting a seed as far as trade agreements go: He wants to add marijuana to North American Free Trade Agreement.

                  Fox currently sits on the board of Vancouver-based medical marijuana producer Khiron Life Sciences Corp., and he believes cannabis should be treated like any other form of produce, according to Bloomberg.

                  Mexico legalized medical marijuana in 2017, and Fox predicts recreational weed will become legal in the country next year. He’s high on the idea, saying it could help curb drug cartel violence.

                  “We can change criminals for businessmen, we can change underground, illegal non-taxpayers into an industry, a sector of the economy,” Fox told Bloomberg on Thursday. “I think it should be part of NAFTA and that’s what I’m pursuing.”

                  But that possibility gets marijuana growers like Jamie Warm all out of joint.

                  Warm, the CEO of Henry’s Original, a Mendocino, California-based cannabis company, believes making pot part of NAFTA could be devastating to American agriculture.

                  “U.S. farming has collapsed as it has been outsourced everywhere,” he told HuffPost. “How is that fair? But cannabis is one crop that small farms have relied on for income.”

                  Although the cannabis industry is growing, Warm said it’s also become more corporate, making the barriers to entry into the market more difficult for small farmers.

                  Allowing cannabis from other countries could nip the industry in the bud since “U.S. farmers have to deal with environmental regulations and worker protections that other countries don’t have.”

                  Lex Corwin, the founder of Stone Road Farms in Los Angeles, also sees big problems with Fox’s proposal.

                  “NAFTA is a federal trade agreement and marijuana is federally illegal, therefore marijuana can’t be included until it’s federally legalized,” he told HuffPost.

                  But even if cannabis does become legal on a federal level, Corwin doesn’t think it should be included in international trade agreements.

                  “Small cultivators and manufacturers are struggling enough with California’s excessive regulation and constantly changing legal framework,” he argued. “If we add foreign-grown, low-cost marijuana to the equation, it would be a death sentence for many American marijuana businesses and the tens of thousands of well-paying jobs this industry provides.”

                  Kenny Morrison, president of the California Cannabis Manufacturers Association, holds out hope that pot smokers will ultimately prefer quality above cheap weed, but he added that legally available Mexican marijuana could impact the industry.

                  “There will always be a market for California craft cannabis, but could Mexico disrupt it to a large degree? Yes. it happened to kale, why not cannabis?”

                  Some pot industry people think a NAFTA deal could be considered in the future, but not in the current climate.

                  Matthew Nathaniel, the general manager of Heavy Grass, a Los Angeles-based vape company, said trade agreements could be the future of cannabis production, but he added that Mexico, Canada and the U.S. are just too far apart on legality.

                  “Additionally, none of the three have a proven regulatory system, with all three having struggles in the early stages of market development,” he told HuffPost. “There’s still much to do before a deal of this scale can be a reality.”

                  But while many in the pot industry are hesitant about including marijuana crops in NAFTA, some investors believe the benefits outweigh the potential downside.

                  Wil Ralston, the president of SinglePoint, a publicly-traded cannabis and technology holding company, believes allowing the import and export of legal cannabis would create huge growth in the industry.

                  “While I understand that there might be concerns from U.S. cultivators, I do see an agreement like the one Vicente Fox proposes greatly expanding the potential U.S. market size for exports, in addition to opening a new and lucrative supply chain between U.S. and Mexican companies,” he told HuffPost.

                  Meanwhile, Leslie Bocskor, President of Electrum Partners, an advisory services firm specializing in medical and recreational cannabis, said he’s certain that marijuana won’t be added to NAFTA anytime soon ― and so is the guy who is suggesting it.

                  “President Fox knows that the Trump Administration will never add Cannabis to NAFTA at this time,”Bocskor told HuffPost. “However, he does know that the timing to have this conversation for the first time is now.”

                  CORRECTION: An earlier version of this story incorrectly cited a quote from Leslie Bocskor as being from Erik Knutson.

                  Read more: http://www.huffingtonpost.com/

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                  FDA takes ‘historic action’ on youth e-cigarette ‘epidemic’

                  (CNN)Concerned with an “epidemic” surge in teen use of e-cigarettes, the head of the US Food and Drug Administration announced today a “historic action” against more than 1,300 retailers and five major manufacturers for their roles in perpetuating youth access to the devices in the US.

                  “I use the word epidemic with great care,” said FDA Commissioner Dr. Scott Gottlieb. “E-cigs have become an almost ubiquitous — and dangerous — trend among teens. The disturbing and accelerating trajectory of use we’re seeing in youth, and the resulting path to addiction, must end. It’s simply not tolerable.”

                  A ‘historic’ action

                    Gottlieb announced the agency sent 1,100 warning letters to stores for the illegal sale of e-cigarettes to minors under the age of 18, and issued 131 fines to stores that continued to violate the restrictions on sales to minors.
                    Gottlieb called the action “historic” and said it was the largest coordinated enforcement effort in the agency’s history.
                    Juul and four other manufacturers, which Gottlieb said control 97% of the market, are now required to provide plans to mitigate youth sales within 60 days or face potential criminal or civil action.
                    Gottlieb warned action may require companies to change their sales and marketing practices; stop distributing products to retailers who sell to kids; and remove “some or all of their flavored e-cig products from the market.”
                    “We’re especially focused on the flavored e-cigarettes,” said Gottlieb. “And we’re seriously considering a policy change that would lead to the immediate removal of these flavored products from the market.”
                    Gottlieb said the FDA recognized the impact this might have on adults trying to stop smoking, but said that emerging research on how flavored products encourage excessive use by young people shows action must be taken.
                    “I’ll be clear. The FDA won’t tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products,” Gottlieb said.
                    Several of the manufacturers targeted by the FDA — Juul, MarkTen, Vuse, Blu and Logic — issued statements agreeing with the need to limit access to minors and announcing their willingness to work with the FDA to reach a solution.
                    Juul Labs, which controls about 70% of the market, said in its statement that “appropriate flavors” play a role in adults changing their smoking habits, but added that they “are committed to preventing underage use of our product, and we want to be part of the solution in keeping e-cigarettes out of the hands of young people.”
                    The Vapor Technology Association, which says it represents over 600 vaping manufacturers and distributors, also supports limiting teen access, but added that the new actions by the FDA ventured “into dangerous territory” by not being in the best interest of public health.
                    In a statement, VTA Executive Director Tony Abboud asked: “Does FDA really want millions of Americans to return to smoking cigarettes?”
                    During the 60-day waiting period, the FDA plans to investigate the five companies’ marketing and sales practices, with possible “boots on the ground inspections,” Gottlieb said.
                    The agency will also be increasing federal enforcement actions on e-cig sales to minors in convenience stores and other retail sites, Gottlieb said, and would look closely at a practice called “straw purchases,” in which adults visit web-based stores and buy in bulk to resell to minors.
                    “If young adults go online and buy 100 units of a product to sell to teens, that activity ought to be easy for a product manufacturer to identify,” said Gottlieb. If manufacturers aren’t willing to do the research, he said, the FDA will do it for them, with appropriate consequences.
                    “Let me be clear: Everything is on the table,” said Gottlieb. “This includes the resources of our civil and criminal enforcement tools.”

                    ‘Need to go further’

                    While applauding the FDA for today’s actions, some said the agency should increase its efforts to protect the nation’s youth from the dangers of vaping.
                    “We need to go further,” said Michael Bloomberg, the billionaire philanthropist who has worked for years to reduce tobacco use.
                    “The FDA should immediately move to regulate flavored e-cigarettes, instead of waiting until 2022, as it is currently planning to do,” Bloomberg said in a statement.
                    The American Medical Association’s Dr. Barbara McAneny also said the FDA could do much more, pledging that the association would “continue to advocate for more stringent policies.”
                    U.S. Senate Democratic Whip Dick Durbin and Republican Sen. Lisa Murkowski also asked the FDA to end delays. In a statement, they called for support for their bipartisan legislation, introduced in July, which would ban flavored cigars and place stringent controls on e-juice flavorings.

                    A change of plan

                    Last year, the FDA announced that it would delay regulations that could have halted the sales of many e-cigarettes. Instead, the agency gave extensions to new and existing vaping products, giving them until August 2022 to submit information to support their products’ safety and efficacy as switching devices.
                    The agency said it allowed the extra time to strike an appropriate balance between regulation and encouraging the development of innovative tobacco products that may help older smokers quit.
                    At that time, Gottlieb said, the agency didn’t foresee the “epidemic'”of adolescent use that has become one of the plan’s biggest challenges.
                    “Today we can see that this epidemic of addiction was emerging when we first announced our plan last summer,” said Gottlieb. “Hindsight, and the data now available to us, reveal these trends.”

                    Sign up here to get The Results Are In with Dr. Sanjay Gupta every Tuesday from the CNN Health team.

                    In April the agency launched a Youth Tobacco Prevention Plan, designed to address some of the known public health risks, such as flavors, that contribute to adolescent use of e-cigarettes.
                    Shortly after the launch, the FDA cracked down on e-liquids marketed to resemble kid-friendly foods like juice boxes, candy and cookies. As part of today’s action, the agency sent an additional 12 warning letters to another 12 companies that continue to sell the products.
                      The FDA also targeted Juul retailers this spring, issuing 56 warning letters and six civil monetary penalties. Today’s effort notches up that action, becoming, said Gottlieb, the “largest ever coordinated initiative against violative sales in the history of the FDA.”
                      The agency said it plans to unveil a new e-cigarette public education campaign targeted to youth next week, and will soon announce wider access to new nicotine replacement therapies to help more adult smokers quit cigarettes.

                      Read more: http://edition.cnn.com/

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