Transcript for CDC press briefing: E-cigarette use triples among middle and high school students in just one year

OPERATOR: Welcome and thank you for standing by. At this time all participates are on the listen and only mode. During the question and answer session please press star one on your touch tone phone. This conference is being record. If anyone has any objections, you may disconnect at this time. I would like to go ahead and turn today's call to Tom Skinner, Senior Public Affairs Officer, CDC. Sir, you may begin.

TOM SKINNER: Thank you Julie and thank you all for joining us today for the release of an MMWR by CDC on tobacco use among middle and high school students, United States, 2011 to 2014. Before we begin the call I want to remind reporters we have sent out a notice this morning regarding an errata to the report we're talking about. Please check your e-mails to make sure that you have the errata that we sent out regarding this report. We're joined today by the director of the Centers for Disease Control and Prevention, Dr. Tom Frieden who is going to provide some opening remarks and then he'll be joined by Dr. Brian King, Deputy Director for Research Translation in CDC's Office of Smoking and Health to help answer your questions. Dr. Frieden.

TOM FRIEDEN: Thank you very much for joining us. The MMWR report we're releasing today outlines tobacco use among middle and high school students. It contains a very alarming finding. There are now 2.5 million kids using e-cigarettes and 1.5 million using hookah. In just one year, the number of kids using hookah doubled, and the number of kids using e-cigarettes appears to have tripled. Furthermore, these increases are driving an uptick in the total number of our children who are using tobacco products for the first time in a generation. There's been an increase of 400,000 in the number of middle and high school kids who are using one or more tobacco product.

It's important that everyone, parents and kids, understand that nicotine is dangerous for kids at any age, whether it's an e-cigarette, hookah, cigarette, or a cigar. In fact, these trends are particularly worrisome because human brain development is still in process in these years. Parts of the prefrontal cortex continue to develop and there's substantial neural remodeling that includes changes in how the brain works and how the cholinergic system works. Its maturism plays a central role in cognition and executive functions. Smoking cigarettes during adolescence has been associated with lasting cognitive impairments, including memory and attention, and although accurate quantification in humans is difficult, animal studies have compelling additional evidence that nicotine exposure causes both long-term structural and functional changes to the brain. These are substantial and in many different parts of the brain.

Today it's important to know we're talking about use of e-cigarettes in kids. Let me spend a moment on the issue of e-cigarette use in adults. For adults who have tried to quit smoking combustible-cigarettes with FDA-proven methods and failed and have tried using e-cigarettes and have been able to be get off cigarettes using e-cigarettes. That's a good thing. Unfortunately, that's not what we're seeing in general in adults. Three quarters of the adults who are using e-cigarettes are continuing to smoke, and some of those who are using both might well have quit if they had tried an FDA-approved and proven method rather than e-cigarettes.

But leaving that aside, the issue today is about kids. In the case of kids, e-cigarettes are harmful all by themselves because of the effects of nicotine on children's brains. In fact, we're concerned that there are multiple aspects of e-cigarette use that are concerning that includes addiction to nicotine, effects on the developing brain, and the significant likelihood that a proportion of those who are using e-cigarettes will go on to use combustible-cigarettes. That this is happening is alarming, but should not be very surprising. We have seen that the tobacco companies have bought up many of the leading e-cigarette companies. Hookah is being aggressively promoted in a variety of settings, and hookah smoke is just as dangerous as tobacco smoke and causes cancer and a variety of other problems. What we've seen in the marketing is essentially "Mad Men" come to e-cigarettes.

Marketing that we're seeing for e-cigarettes looks just like tobacco marketing did in the 1950s and tobacco marketing -- I'm sorry e-cigarette marketing expenditures tripled each year from 2011 to 2013. Marketing is about sex, free samples, flavors, aggressive marketing promotion and distribution. It's straight out of the playbook of what was done for cigarettes in the 1950s. Although cigarette ads are no longer on TV and haven't been since 1971, kids are now seeing e-cigarettes advertised on TV using the same tactics that the Surgeon General found appealed to kids including themes, glamour, rebellions, celebrities, sports, music events, candy, and fruit flavors. The tobacco industry spends more on marketing and promotion in just a couple of days than we spend in a year educating the public, parents, and kids about tobacco. We know that nicotine is harmful to the developing brain and we could be seeing another generation getting hooked. So many of the smokers I've met and cared for as patients are so desperate to quit and so much wish they have never started. We need to stop before another generation gets hooked on nicotine.

Comprehensive programs work. Smoke-free laws should apply to e-cigarettes as well. Hard-hitting ads about tobacco need to continue and we need to ensure that programs like minimum age requirements for purchase of e-cigarettes and comprehensive tobacco control programs are implemented at the state and local level. It's important that the FDA is moving forward that it exercises its authority on regulating all forms of tobacco products including e-cigarettes. So big picture here is we're seeing a striking increase. It's very concerning. It more than counter balances the decrease in cigarette smoking, which we've seen occurring over the last few years. The decrease in cigarette smoking, of course, it's a good thing when fewer kids are smoking cigarettes. On the other hand, it would be a mistake to suggest there is a causal relationship between the increase in e-cigarette use and the decrease in child tobacco use. That child tobacco use decrease preceded the big increase in e-cigarette use, and began after 2009, accelerated after 2009 when it was a federal tax which we know decreases tobacco use and accelerated further in 2012 and 2013 when the FDA and CDC began running hard-hitting campaigns for the first time ever. In addition the Legacy Foundation has had its ads as well. I'll stop there and look forward to answering your questions.

TOM SKINNER: Julie, I believe we're ready for questions, please.

OPERATOR: Thank you. We will now begin the question and answer session. If you would like to ask a question on the phone press star one. Please unmute your phone and record your name clearly when prompted. Your name is required to introduce your question. If you would like to ask a question press star one. To withdraw your question please press star two. One moment please for the first question over the phone.

OPERATOR: Thank you. The first question comes from Mike Stobbe from the Associated Press. Your line is open.

MIKE STOBBE: Thank you. Thank you for taking my question. Two questions. Dr. Frieden, you said hookah is aggressively promoted in a variety of settings. I guess I haven't seen those ads. Do you mind saying a little bit more about what you meant by that in what way is hookah advertised or promoted to teens? And my second question was, you said it would be a mistake to suggest a causal relationship between the growth of e-cigarette use and decline in traditional smoking, and you mentioned a couple of other things going on. But do you attribute -- can we include the e-cigarette boom at all? Is it at least partly a factor in the decline in e-cigarette use or completely has nothing to do at all with the decline in cigarette use. Those are my questions. Thank you.

TOM FRIEDEN: I'll make two points, then turn it over to Brian to comment further and then back to me for some final comments. The first is that in terms of hookah, in many jurisdictions, hookahs are not included in smoke free laws. And that is something that we know is important to reduce the likelihood that children will begin or continue to use a tobacco product. The second is that there's no evidence in teens that suggests that e-cigarettes are in any way necessary to or are actually protecting kids from tobacco use. Brian?

BRIAN KING: Yes, I would like to add in terms of the hookah they are actively advertised by the point of sale. There's a wide availability of these products. It's particularly noted that currently hookah like e-cigarettes are not regulated. Although, they are proposed to be regulated. They're still available in flavors, and particularly kid-friendly flavors that can increase appeal and access. So in terms of the targeted marketing, there is wide availability and particularly at the point of sale advertising for these products.

TOM SKINNER: Dr. Frieden, anything more to add? Shall we go to the next question?

TOM FRIEDEN: Let's go to the next question.

TOM SKINNER: Next question Julie, please.

OPERATOR: The next questions comes from John Tozzi with Bloomberg Business Week. Your line is open.

JOHN TOZZI: Hi, thanks for taking my question. Dr. Frieden, you mentioned that the marketing of e-cigarettes including television ads is one of the factors. I believe it's driving this increase and that, also, they're using --

TOM FRIEDEN: Hello? Hello? Hello?

TOM SKINNER: He may have dropped off. Hopefully he'll come back.

TOM FRIEDEN: While we're waiting for him to come back, I would like to say one more thing about the previous question that was asked. What we saw from 2013 to 2014 was an expansion by 400,000, which is a large, all though it's only a one-year trend, we don't know that it's statistically significant. But it's the first uptick we've seen in a generation. So if the argument was that they're replacing the use, we wouldn't see the total expansion in the number of kids smoking. So I just wanted to make that point and let's see if the questioner is back on.

TOM SKINNER: Next question, Julie?

OPERATOR: The next question comes from Dennis Thompson with HealthDay. Your line is open.

DENNIS THOMPSON: Thank you for taking my question. I wanted -- I couldn't find in the report more information on the overall increase in tobacco use. You had mentioned that it had been an increase of 400,000 kids. Is that between 2013 and 2014? Or 2011 and 2014? I just like to be able to report that accurately.

TOM FRIEDEN: That's between 2013 and 2014. We can send you that data separately, if you'll call the number that Mr. Skinner provides after the call.

DENNIS THOMPSON: Thank you very much, sir.

TOM SKINNER: Next question, Julie.

OPERATOR: Thank you. The next question comes from Toni Clarke from Reuters. Your line is open.

TONI CLARKE: Yes, hi. I wondered if you could tell me, did you ask or do you have the data on how many of the e-cigarette users were previously smokers, and how many were --

TOM FRIEDEN: Brian?

BRIAN KING: This is Brian. We did not report that in this survey, we have reported it in previous ways of the National Youth Tobacco Survey. And so those data aren't currently available in the study. What we have seen is that there's a large preponderance of never using the conventional cigarettes that are using e-cigarettes. And so, for example, in 2012 it was about one in five middle school students who had never used conventional cigarettes were using e-cigarettes. We do know from the data in recent years that we've seen increases in the exclusive use of e-cigarettes, particularly between 2013 and 2014. So all though we didn't present it in this particular report because it was beyond the scope of the standard descriptive statistics we report each year. We have data from past years that demonstrate this. There is a large proportion of the dual use of the products. Most noticeably dual use between conventional cigarettes and e-cigarettes.

TONI CLARKE: And can I just ask one more question? Just going back to Dr. Frieden to pick up on an earlier question where you say there's no evidence that the e-cigarettes is a contributing factor to the decline in conventional cigarettes. But what evidence do you have to sort of declaratively rule it out? You've got between 2013 and 2014 the biggest ever -- as far as I can see, the biggest ever year on year decline in smoking. Do you attribute that entirely to conventional tobacco control measures?

TOM FRIEDEN: Well, we know that conventional tobacco control measures worked. We know that the FDA youth-directed tobacco campaign was released and really -- there's a lot that we don't know. We don't have certainty about aspects of the trends, but we do know that an increase in the number of kids using an addictive substance that's likely to harm their brains is not a good thing. And we do know that with addiction the possibility of progression to other forms of tobacco is significant. We further know that although there was a great deal of hope that most adults who use e-cigarettes would be able to quit regular cigarettes. That is not what we've seen at this point. Brian, would you like to add to that?

BRIAN KING: I would like to reiterate that we really reject the notion we need to protect kids from cigarettes by allowing them to use a product like e-cigarette which is addictive and could harm their brain. The standard really should be that you should not be using any tobacco products because we know that it's unsafe, irrespective of its combustible, non-combustible, or electronic.

TONI CLARKE: Okay. So you don't' see any benefit basically in getting toward 30 percent reduction in smoking. You see that the equivalent -- an equivalent risk for kids smoking e-cigarettes as they would smoke traditional cigarettes -- you don't buy any kind of reduced harm argument in all of this?

TOM FRIEDEN: I think you have to look at the broader picture here. The question of reduced harm is a question of are more people going to be smoking dangerous products in the future? And the fact that kids in increasing numbers are using an addictive product that is harmful to their brains is a real problem. And I think if you look at the long history of tobacco products, filters, and low tar. There's the hope we're going to be able to figure out a way to make an addictive substance less harmful. And while it's likely the case with someone who only uses e-cigarettes compared to someone who uses conventional cigarettes. You have to reduce risk. For the life of the individual and the group of people at risk when that resulted in actual increase in the number of people who are using combustible products. It's something that is a major risk and certainly not something that we should count on not happening.

TONI CLARKE: Thank you.

TOM SKINNER: Next question.

OPERATOR: We're going back to John now.

JOHN TOZZI: Okay. Can you hear me?

TOM SKINNER: Yes.

JOHN TOZZI: Hi. Thank you for taking my question. My understanding is that the FDA's proposed rule would not restrict advertising or marketing flavors of e-cigarettes. In your view, given the evidence you're presenting today had the FDA reconsidered that policy?

TOM FRIEDEN: We would have to refer any questions about FDA regulations to the FDA.

TOM SKINNER: Next question, Julie.

OPERATOR: Thank you. The next question comes from Kathleen O'Brien with the Star-Ledger.

KATHLEEN O'BRIEN: Hi. I know this doesn't appear to be in the actual survey, but do you have any sense of what kids believe the harm to be? Do they think that e-cigarettes are safer because they will not -- they don't have the carcinogenic properties of conventional tobacco? Do they think they're doing something that is safer?

TOM FRIEDEN: I'll ask Brian to comment further based on the studies in the literature. I think anecdotally, there's a sense that e-cigarettes are -- there's not a recognition that e-cigarettes are a tobacco product and not a recognition they're highly addictive and potentially dangerous for the brain.

BRIAN KING: Yes, I would concur with that. There's also an emerging body of literature documenting that among both adults and youth demonstrating that people do perceive them as less safe. And a lot of this is -- as safer, I'm sorry-- and a lot is founded as a result of advertising. There's advertising claims by a lot of companies essentially alluding to the fact that these are potentially more safe than conventional products. So the studies that have been released to date do demonstrate that youth as well as adults perceive them as less harmful and this isn't surprising considering there's marked advertising by several companies that are alluding to this.

TOM SKINNER: Julie, one more question and then we will have Dr. Frieden provide some concluding remarks.

OPERATOR: One moment. The next question comes from Kimberly Leonard with the U.S. News and World Report. Your line is open.

KIMBERLY LEONARD: Hi. Thank you so much for taking my call. Dr. Frieden, earlier in the call you said there was some likelihood that teens would then switch to combustible option of tobacco. Are you saying that e-cigarettes are a gateway to smoking or can be?

TOM FRIEDEN: There are more studies underway that will help elucidate with what is happening with teens who use e-cigarettes. And in some sense, time will tell because the numbers are so unprecedented. We're now seeing 2.5 million kids using e-cigarettes and 1.5 million using hookah, and regardless of whether they then progress to using other combustible products, they're using the products that likely damage their brain and is highly addictive and it may route in combustible tobacco use in the future.

I want to thank everyone for joining us and just make a couple of last comments. E-cigarettes and hookah are a new product or new in the sense of the extent of use we're seeing from the U.S. And unfortunately, we're having to play whack-a-mole with different tobacco products, and it's important to keep the bottom line clear. Nicotine addiction is often a lifelong challenge. Usually starts in childhood and the longer -- the less likely someone is to use tobacco as a child the less likely they are to use it as an adult. Tobacco remains the leading preventable cause of death in this country, and all forms of tobacco containing nicotine are addictive. And that addiction is a struggle which most smokers wish they didn't have to fight. As someone who worked on tobacco control for many years, seeing this uptick in the number of our kids who are using tobacco products in just one year and seeing a doubling in hookah use and tripling in e-cigarette use in just one year is deeply alarming. I want to thank you all for your interest and Tom Skinner will give information on how people can get follow up information or reach our press office.

TOM SKINNER: Thank you, Dr. Frieden and Dr. King for joining us today as well as reporters. If you have follow up questions you can call the press office at 404-639-6386. Thank you joining us and this concludes our call.

OPERATOR: Thank you very much for participating in today's conference call. You may disconnect your lines at this time. Thank you and have a great day.

**This transcript is not edited and may contain errors**

###
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES