Who’s Responsible for Curbing the Teen Vaping Epidemic?
A teenage girl vaping in a park.
E-cigarettes are big business. In 2017, American consumers bought more than $250 million in vapes and juice-filled pods, and spent $1 billion in 2018. By 2023, the global market could be worth $44 billion a year.
"My nine-year-old actually knows what Juuling is. In many cases the [school] bathroom is now referred to as 'the Juuling room.'"
Investors are trying to capitalize on the phenomenal growth. In July 2018, Juul Labs, the company that owns 70 percent of the U.S. e-cigarette market share, raised $1.25 billion at a $16 billion valuation, then sold a 35 percent stake to Phillip Morris USA owner Altria Group in December. The second transaction valued the company at $38 billion. While the traditional tobacco market remains much larger, it's projected to grow at less than two percent a year, making the attractiveness of the rapidly expanding e-cigarette market obvious.
While Juul and other e-cigarette manufacturers argue that their products help adults quit smoking – and there's some research to back this narrative up – much of the growth has been driven by children and teenagers. One CDC study showed a 48 percent rise in e-cigarette use by middle schoolers and a 78 percent increase by high schoolers between 2017 and 2018, a jump from 1.5 million kids to 3.6 million. In response to the study, F.D.A. Commissioner Scott Gottlieb said, "We see clear signs that youth use of electronic cigarettes has reached an epidemic proportion."
Another study found that teenagers between 15 and 17 were 16 times more likely to use Juul than people aged 25-34. In December, Surgeon General Jerome Adams said, "My nine-year-old actually knows what Juuling is. In many cases the [school] bathroom is now referred to as 'the Juuling room.'"
And the product is seriously addictive. A single Juul pod contains as much nicotine as a pack of 20 regular cigarettes. Considering that 90 percent of smokers are addicted by 18 years old, it's clear that steps need to be taken to combat the growing epidemic.
But who should take the lead? Juul and other e-cigarette companies? The F.D.A. and other government regulators? Schools? Parents?
The Surgeon General's website has a list of earnest possible texts that parents can send to their teens to dissuade them from Juuling, like: "Hope none of your friends use e-cigarettes around you. Even breathing the cloud they exhale can expose you to nicotine and chemicals that can be dangerous to your health." While parents can attempt to police their teens, many experts believe that the primary push should come at a federal level.
The regulation battle has already begun. In September, the F.D.A. announced that Juul had 60 days to show a plan that would prevent youth from getting their hands on the product. The result was for the company to announce that it wouldn't sell flavored pods in retail stores except for tobacco, menthol, and mint; Juul also shuttered its Instagram and Facebook accounts. These regulations mirrored an F.D.A. mandate two days later that required flavored e-cigarettes to be sold in closed-off areas. "This policy will make sure the fruity flavors are no longer accessible to kids in retail sites, plan and simple," Commissioner Gottlieb said when announcing the moves. "That's where they're getting access to the e-cigs and we intend to end those sales."
"There isn't a great history of the tobacco industry acting responsibly and being able to in any way police itself."
While so far, Gottlieb – who drew concerns about conflict of interest due to his past position as a board member at e-cigarette company, Kure – has pleased anti-smoking advocates with his efforts, some observers also argue that it needs to go further. "Overall, we didn't know what to expect when a new commissioner came in, but it's been quite refreshing how much attention has been paid to the tobacco industry by the F.D.A.," Robin Koval, CEO and president of Truth Initiative, said a day after the F.D.A. announced the proposed regulations. "It's important to have a start. I certainly want to give credit for that. But we were really hoping and feel that what was announced...doesn't go far enough."
The issue is the industry's inability or unwillingness to police itself in the past. Juul, however, claims that it's now proactively working to prevent young people from taking up its product. "Juul Labs and F.D.A. share a common goal – preventing youth from initiating on nicotine," a company representative said in an email. "To paraphrase Commissioner Gottlieb, we want to be the off-ramp for adult smokers to switch from cigarettes, not an on-ramp for America's youth to initiate on nicotine. We won't be successful in our mission to serve adult smokers if we don't narrow the on-ramp... Our intent was never to have youth use Juul products. But intent is not enough, the numbers are what matter, and the numbers tell us underage use of e-cigarette products is a problem. We must solve it."
Juul argues that its products help adults quit – even offering a calculator on the website showing how much people will save – and that it didn't target youth. But studies show otherwise. Furthermore, the youth smoking prevention curriculum the company released was poorly received. "It's what Philip Morris did years ago," said Bonnie Halpern-Felsher, a professor of pediatrics at Stanford who helped author a study on the program's faults. "They aren't talking about their named product. They are talking about vapes or e-cigarettes. Youth don't consider Juuls to be vapes or e-cigarettes. [Teens] don't talk about flavors. They don't talk about marketing. They did it to look good. But if you look at what [Juul] put together, it's a pretty awful curriculum that was put together pretty quickly."
The American Lung Association gave the FDA an "F" for failing to take mint and menthol e-cigs off the market, since those flavors remain popular with teens.
Add this all up, and in the end, it's hard to see the industry being able to police itself, critics say. Neither the past examples of other tobacco companies nor the present self-imposed regulations indicate that this will succeed.
"There isn't a great history of the tobacco industry acting responsibly and being able to in any way police itself," Koval said. "That job is best left to the F.D.A., and to the states and localities in what they can regulate and legislate to protect young people."
Halpern-Felsher agreed. "I think we need independent bodies. I really don't think that a voluntary ban or a regulation on the part of the industry is a good idea, nor do I think it will work," she said. "It's pretty much the same story, of repeating itself."
Just last week, the American Association of Pediatrics issued a new policy statement calling for the F.D.A. to immediately ban the sale of e-cigarettes to anyone under age 21 and to prohibit the online sale of vaping products and solutions, among other measures. And in its annual report, the American Lung Association gave the F.D.A. an "F" for failing to take mint and menthol e-cigs off the market, since those flavors remain popular with teens.
Few, if any people involved, want more regulation from the federal government. In an ideal world, this wouldn't be necessary. But many experts agree that it is. Anything else is just blowing smoke.
The Friday Five: Artificial DNA Could Give Cancer the Hook
In this week's Friday Five, artificial DNA could give cancer the hook. Plus, research suggests that this daily practice can improve relationships, social media could be good for finding factual information, injecting a gel may speed up recovery from injuries, and a blood pressure medicine is promising for a long healthy life.
The Friday Five covers five stories in research that you may have missed this week. There are plenty of controversies and troubling ethical issues in science – and we get into many of them in our online magazine – but this news roundup focuses on scientific creativity and progress to give you a therapeutic dose of inspiration headed into the weekend.
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Here are the promising studies covered in this week's Friday Five:
- Artificial DNA gives cancer the hook
- This daily practice could improve relationships
- Can social media handle the truth?
- Injecting a gel could speed up recovery
- A blood pressure medicine for a long healthy life
9 Tips for Online Mental Health Therapy
Research shows that, for most patients, online therapy offers the same benefits as in-person therapy, yet many people still resist it. A behavioral scientist explains how you can use it to improve mental health.
Telehealth offers a vast improvement in access and convenience to all sorts of medical services, and online therapy for mental health is one of the most promising case studies for telehealth. With many online therapy options available, you can choose whatever works best for you. Yet many people are hesitant about using online therapy. Even if they do give it a try, they often don’t know how to make the most effective use of this treatment modality.
Why do so many feel uncertain about online therapy? A major reason stems from its novelty. Humans are creatures of habit, prone to falling for what behavioral scientists like myself call the status quo bias, a predisposition to stick to traditional practices and behaviors. Many people reject innovative solutions even when they would be helpful. Thus, while teletherapy was available long before the pandemic, and might have fit the needs of many potential clients, relatively few took advantage of this option.
Even when we do try new methodologies, we often don’t do so effectively, because we cling to the same approaches that worked in previous situations. Scientists call this behavior functional fixedness. It’s kind of like the saying about the hammer-nail syndrome: “when you have a hammer, everything looks like a nail.”
These two mental blindspots, the status quo bias and functional fixedness, impact decision making in many areas of life. Fortunately, recent research has shown effective and pragmatic strategies to defeat these dangerous errors in judgment. The nine tips below will help you make the best decisions to get effective online therapy, based on the latest research.
Trust the science of online therapy
Extensive research shows that, for most patients, online therapy offers the same benefits as in-person therapy.
For instance, a 2014 study in the Journal of Affective Disorders reported that online treatment proved just as effective as face-to-face treatment for depression. A 2018 study, published in Journal of Psychological Disorders, found that online cognitive behavioral therapy, or CBT, was just as effective as face-to-face treatment for major depression, panic disorder, social anxiety disorder, and generalized anxiety disorder. And a 2014 study in Behaviour Research and Therapy discovered that online CBT proved effective in treating anxiety disorders, and helped lower costs of treatment.
During the forced teletherapy of COVID, therapists worried that those with serious mental health conditions would be less likely to convert to teletherapy. Yet research published in Counselling Psychology Quarterly has helped to alleviate that concern. It found that those with schizophrenia, bipolar disorder, severe depression, PTSD, and even suicidality converted to teletherapy at about the same rate as those with less severe mental health challenges.
Yet teletherapy may not be for everyone. For example, adolescents had the most varied response to teletherapy, according to a 2020 study in Family Process. Some adapted quickly and easily, while others found it awkward and anxiety-inducing. On the whole, children with trauma respond worse to online therapy, per a 2020 study in Child Abuse & Neglect. The treatment of mental health issues can sometimes require in-person interactions, such as the use of eye movement desensitization and reprocessing to treat post-traumatic stress disorder. And according to a 2020 study from the Journal of Humanistic Psychology, online therapy may not be as effective for those suffering from loneliness.
Leverage the strengths of online therapy
Online therapy is much more accessible than in-person therapy for those with a decent internet connection, webcam, mic, and digital skills. You don’t have to commute to your therapist’s office, wasting money and time. You can take much less medical leave from work, saving you money and hassle with your boss. If you live in a sparsely populated area, online therapy could allow you to access many specialized kinds of therapy that isn’t accessible locally.
Online options are much quicker compared to the long waiting lines for in-person therapy. You also have much more convenient scheduling options. And you won’t have to worry about running into someone you know in the waiting room. Online therapy is easier to conceal from others and reduces stigma. Many patients may feel more comfortable and open to sharing in the privacy and comfort of their own home.
You can use a variety of communication tools suited to your needs at any given time. Video can be used to start a relationship with a therapist and have more intense and nuanced discussions, but can be draining, especially for those with social anxiety. Voice-only may work well for less intense discussions. Email offers a useful option for long-form, well-thought-out messages. Texting is useful for quick, real-time questions, answers, and reinforcement.
Plus, online therapy is often cheaper than in-person therapy. In the midst of COVID, many insurance providers have decided to cover online therapy.
Address the weaknesses
One weakness is the requirement for appropriate technology and skills to engage in online therapy. Another is the difficulty of forming a close therapeutic relationship with your therapist. You won’t be able to communicate non-verbals as fully and the therapist will not be able to read you as well, requiring you to be more deliberate in how you express yourself.
Another important issue is that online therapy is subject to less government oversight compared to the in-person approach, which is regulated in each state, providing a baseline of quality control. As a result, you have to do more research on the providers that offer online therapy to make sure they’re reputable, use only licensed therapists, and have a clear and transparent pay structure.
Be intentional about advocating for yourself
Figure out what kind of goals you want to achieve. Consider how, within the context of your goals, you can leverage the benefits of online therapy while addressing the weaknesses. Write down and commit to achieving your goals. Remember, you need to be your own advocate, especially in the less regulated space of online therapy, so focus on being proactive in achieving your goals.
Develop your Hero’s Journey
Because online therapy can occur at various times of day through videos calls, emails and text, it might feel more open-ended and less organized, which can have advantages and disadvantages. One way you can give it more structure is to ground these interactions in the story of your self-improvement. Our minds perceive the world through narratives. Create a story of how you’ll get from where you are to where you want to go, meaning your goals.
A good template to use is the Hero’s Journey. Start the narrative with where you are, and what caused you to seek therapy. Write about the obstacles you will need to overcome, and the kind of help from a therapist that you’ll need in the process. Then, describe the final end state: how will you be better off after this journey, including what you will have learned.
Especially in online therapy, you need to be on top of things. Too many people let the therapist manage the treatment plan. As you pursue your hero’s journey, another way to organize for success is to take notes on your progress, and reevaluate how you’re doing every month with your therapist.
Identify your ideal mentor
Since it’s more difficult to be confident about the quality of service providers in an online setting, you should identify in advance the traits of your desired therapist. Every Hero’s Journey involves a mentor figure who guides the protagonist through this journey. So who’s your ideal mentor? Write out their top 10 characteristics, from most to least important.
For example, you might want someone who is:
- Empathetic
- Caring
- Good listener
- Logical
- Direct
- Questioning
- Non-judgmental
- Organized
- Curious
- Flexible
That’s my list. Depending on what challenge you’re facing and your personality and preferences, you should make your own. Then, when you are matched with a therapist, evaluate how well they fit your ideal list.
Fail fast
When you first match with a therapist, try to fail fast. That means, instead of focusing on getting treatment, focus on figuring out if the therapist is a good match based on the traits you identified above. That will enable you to move on quickly if they’re not, and it’s very much worth it to figure that out early.
Tell them your goals, your story, and your vision of your ideal mentor. Ask them whether they think they are a match, and what kind of a treatment plan they would suggest based on the information you provided. And observe them yourself in your initial interactions, focusing on whether they’re a good match. Often, you’ll find that your initial vision of your ideal mentor is incomplete, and you’ll learn through doing therapy what kind of a therapist is the best fit for you.
Choose a small but meaningful subgoal to work on first
This small subgoal should be sufficient to be meaningful and impactful for improving your mental health, but not a big stretch for you to achieve. This subgoal should be a tool for you to use to evaluate whether the therapist is indeed a good fit for you. It will also help you evaluate whether the treatment plan makes sense, or whether it needs to be revised.
Know when to wrap things up
As you approach the end of your planned work and you see you’re reaching your goals, talk to the therapist about how to wrap up rather than letting things drag on for too long. You don’t want to become dependent on therapy: it’s meant to be a temporary intervention. Some less scrupulous therapists will insist that therapy should never end and we should all stay in therapy forever, and you want to avoid falling for this line. When you reach your goals, end your therapy, unless you discover a serious new reason to continue it. Still, it may be wise to set up occasional check-ins once every three to six months to make sure you’re staying on the right track.