By Danielle Jones
Author's Note: The 2018 National Youth Tobacco Survey results were published after this article went to print. Click here to view them.
On September 12th FDA Commissioner Dr. Scott Gottlieb publicly declared that youth usage of vapor products had reached “epidemic” proportions. The FDA sent out over 1,000 warning letters to businesses for the illegal sale of e-cigarettes to minors and issued 131 fines to repeat offenders. They also sent letters to 5 large vapor manufacturers whose products were sold to minors during the “enforcement blitz” and whom the FDA believes collectively represents the majority of the vapor market – Juul, Vuse, MarkTen, Blu, and Logic. “They’re now on notice by the FDA of how their products are being used by youth at disturbing rates,” said Gottlieb in his statement. The FDA is demanding these five companies present them with a plan in the next 60 days to curb youth usage drastically. He threatened that, if the plans aren’t convincing enough, he’ll consider removing flavored vapor products from the market – regardless of the negative consequences to adult smokers and vapers.
WHERE’S THE “EPIDEMIC?”
If you’re looking at the 2015-2017 data from the CDC’s National Youth Tobacco Surveys (NYTS) and scratching your head in confusion, you are not alone. Youth usage has been declining since it spiked in 2015. The latest available data, from 2017, shows around 12% of high schoolers and 3% of middle schoolers used an electronic cigarette (even one puff) in the last 30 days before the survey. In 2015 high school usage was at 16% and middle school usage at around 5%. However, reports have indicated that the FDA is referencing unpublished NYTS data for 2018, which they are declining to share with the public as of yet. The Washington Post reports that this latest survey purportedly shows a 75% increase in usage among high schoolers, compared with last year.
It’s unusual that Gottlieb and the FDA would take such drastic measures and draw conclusions based on data that isn’t published, peer-reviewed, or available to the public. In the medical community, announcements relative to new unpublished data or analyses are typically released to the general public in conjunction with a medical meeting or event to allow for objective and unbiased review. However, in this case, we are simply supposed to trust the government on blind faith.
INTO THE WEEDS
Let’s overlook the odd fact that this data isn’t yet available, and operate under the assumption that it’s correct, and that usage has increased by 75% over last year. Where exactly does that put us? First, let’s look at what the CDC data actually measures.
The NYTS questionnaire given to students is a daunting 80+ question survey that asks a multitude of questions about various tobacco products, including vapor products. The NYTS collects data on the frequency of usage (meaning how many days exactly in the last month did students use the products), but they don’t publish that data. The tables, graphs, and statistics you’ll find only report how many students took even a single puff from a vape device in the last 30 days. This is a very important detail to understand because the frequency of usage matters, especially in adolescents who are prone to experimentation. If a student tried vaping once, and never touched an e-cig again, but it happened to be in the month prior to them taking this survey, the CDC counts them in this data as a vaper. Consider this: if 1 million people in the U.S. had a beer once, or even twice, but never drank again, would we call that an “alcoholism epidemic?” No. Because frequency matters.
COMPARE AND CONTRAST
Other reputable scientific institutions recognize this dynamic as well. For example, when the United Kingdom wanted to assess youth vaping trends and the alleged “gateway effect” to smoking, they conducted the country’s “largest ever data analysis.” The study was a collaboration between UK Centre for Tobacco and Alcohol Studies, Public Health England, Action on Smoking and Health, and the DECIPHer Centre at the University of Cardiff. This study analyzed five large-scale surveys done over the course of 2015-2017 involving over 60,000 adolescents (3 times more than the annual CDC NYTS sample size).
The UK surveys used a variety of different collection methods including in-home interviews, internet surveys, and school-based surveys. The authors of the UK study note that each collection method has limitations, for example, “school-based surveys are more likely to miss those adolescents who are most at risk of taking up smoking,” [due to being absent or dropping out]. By combining multiple methods, they greatly reduce the chances of selection bias. Selection bias can happen when a certain group is targeted based on, for example, access to the survey. What you’re left with is data from a group that does not accurately represent everyone. This can skew the study results. The fact that the UK study used several recruitment platforms, including in-school, in-home, and internet, allowed them to achieve a broader study population. The CDC NYTS limits its sample group to school-based surveys only.
Let’s circle back to the importance of frequency. One of the most critical things the UK study did was to clearly categorize and analyze the data based on usage frequency and cigarette smoking status. They had clear distinctions between “ever use” and “regular use” as well as whether the kids were smokers or non-smokers. Instead of just stating that ever use rates of vapor products were up to 32% (which is true) they also point out that regular use is only 1-3%. Going further, non-smoker ever use was up to 14% but regular use was a mere 0.1-0.5%, suggesting a high propensity for experimentation with vaping, but not necessarily habitual use. They also found that the highest rates of ever use and regular use came from smokers. With all this information they were able to conclude that “…around a tenth to a fifth of 11-16 year olds report having tried e-cigarettes, only 3% or less report using them at least weekly, most of whom are regular smokers, with less than 0.5% of never smokers reporting weekly e-cigarette use … [this data] suggests that, for now, experimentation with e-cigarettes does not necessarily translate into regular use, particularly among never smokers … Our findings indicate that there is no evidence of e-cigarettes driving smoking prevalence upwards. This is important, and suggests that fears about e-cigarettes as a gateway to more youth becoming smokers are not currently justified…”
TAKING A CLOSER LOOK
The CDC NYTS data pales in comparison to the robust and more in-depth data collected by the UK, which is likely why we allegedly have a youth vaping “epidemic” and they do not. What if we could use the same parameters to analyze some of the CDC data? After all, they do collect the information; they just don’t use it.
Professor of Medicine Brad Rodu from the University of Louisville had the same idea. He analyzed the 2017 frequency usage data and found that while ever 30-day use rates for vapor products were around 12%, regular use rates (students who vaped 20 or more days in the previous month) were only 2.4%, and of those, only 1.2% were non-smokers. If you apply this percentage of non-smokers regular use to the entire population of high schoolers, it will amount to 184,000 out of 14.9 million who are potentially “addicted to vaping,” according to Rodu.
Their 2017 data reports that 42.2% of students tried vaping at least once in their life, 13.2% of students tried vaping at least once in the past 30 days (similar to the NYTS 11.7%), but only 3.3% of students frequently vaped (20+ days), and only 2.4% of students vaped every day. All of this data had not significantly changed, or had decreased, from their previous 2015 findings.
In many cases they’ve devoted their entire careers to this mission, but, what happens to them if they actually succeed in eradicating smoking? They’re out of a job. So wouldn’t it be convenient for them if another “epidemic” came along that needed their constant attention? Something similar to smoking, but new and modern, requiring money for studies and programs. The NYTS results are used specifically for evaluating their own tobacco prevention and control programs, so naturally it’s in their best interests to cherry-pick the data and report inflated usage rates so they can continue to fund themselves and their programs. Take, for example, a statement made at a Beverly Hills City Council hearing by Carol McGruder, an anti-tobacco activist from the University of California, San Francisco (UCSF). She claimed that for every adult vaper that quits smoking with vaping, 100 children start vaping. There are at least 9 million adult vapors in the United States, and if we say, conservatively, that 4 million of them quit smoking completely, that would mean that according to her math, 400 million children are vaping. The entire population of the United States is less than 400 million, so that statement is impossible, illogical, and wholly unscientific. As long as the CDC continues to be allowed to report the data used to fund their own programs, there will always be some kind of “epidemic.”