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NC sued Juul over its impact on the meteoric rise of youth vaping. How is the state spending $40M in settlement money?

A person holding a Juul vape pen.
Sarah J
A person holding a Juul vape pen.

Thousands of North Carolina teens and young adults have taken part in programs in the past year that are aimed at helping them to quit vaping or to prevent them from starting.

Funding for the programs comes from a $40 million settlement the state won in 2021 against e-cigarette maker Juul. In December, Attorney General Josh Stein announced that Juul would pay another $7.8 million to the state.

Stein, who is the Democratic nominee in the upcoming governor’s race, sued Juul in 2019 over its role in growing nicotine use among the state’s youth. More teens use e-cigarettes than regular cigarettes, according to the latest state Youth Tobacco Survey in 2022. 

The $40 million paid by Juul when they settled the case will pay for e-cigarette cessation and prevention programs, data monitoring, evaluation of programs, a documents depository and litigation costs.

In January, Stein announced the launch of a searchable database of Juul documents that can be used by the public and researchers. The depository will be housed by UNC Chapel Hill’s University Libraries and the University of California-San Francisco, which houses a similar database about legacy tobacco companies.

The state is in the first full year of spending money from the settlement, said Adam Goldstein, director of Tobacco Intervention Programs at the UNC School of Medicine, which received $887,431 in Juul settlement funds for a two-year contract to research e-cigarette use among the state’s youth and young adults.   

“They’re doing a really good job of trying to design a comprehensive program,” Goldstein said of the state’s efforts so far. “I’m proud of that work. I’m happy we’re in a state that’s willing to do that.”

It’s too early to see if those efforts have paid off.

“What we do know is that [vaping] continues to be a problem, which we know because of our ongoing work,” he said.

Tobacco use among youth

In North Carolina, one in eight high school students uses a tobacco product, according to the Youth Tobacco Survey. That is equal to three students in every classroom.

Nationally, e-cigarettes took over as the No. 1 tobacco product for youth in 2014 after years of decline in the use of traditional cigarettes. E-cigarettes remain the favored product today, including in North Carolina.

E-cigarettes, or electronic cigarettes, are also called by other names, such as vape pens, e-hookahs and mods. Most have a battery, a heating element and a place to hold liquid. When the liquid is heated, users inhale the vapors, which carry nicotine and other additives or flavors.

The state Youth Tobacco Survey showed that overall, about 57,300 high school students and 18,600 middle school students currently use tobacco products. Nearly three in 10 high school students and five in 10 middle school students reported they use more than one type.

Cigarettes are the third most popular tobacco product among the state’s youth. Cigars, cigarillos and little cigars come in second, according to the survey.

E-cigarettes — the top product — are used by 43,800 high school students and 12,500 middle school students in North Carolina. 

Nearly 91 percent of high school students and 95.6 percent of middle school students in the state who are current users report using flavored e-cigarettes.

Enticing flavors

The Juul e-cigarette first entered the market in 2015. At its height, Juul claimed about 75 percent of the e-cigarette market share in the United States. By last year, Juul’s share had dropped to 24.4 percent.

At the same time, e-cigarette sales continued to grow as other players entered the market. Sales nearly tripled from 7.7 million units in a four-week period in 2014 to 22.7 million in a four-week period in 2022, according to reports by the Centers for Disease Control and Prevention. 

More recently, Elf Bar has become a favorite brand among youth. More than half of middle and high school students who vape used an Elf Bar product in the past 30 days, according to the 2023 National Youth Tobacco Survey.

Elf Bar products seized during a joint federal operation that resulted in the seizure 41 shipments containing e-cigarettes.

Elf Bar offers such exotic flavors as citrus sunrise, nana coconut and watermelon ice. None have been approved for sale in the U.S.

Nonetheless, nearly nine in 10 youth e-cigarette users use flavored products, according to the Campaign for Tobacco-Free Kids. The nonprofit says fruit, candy/desserts/other sweets, mint and menthol are reported as the most popular flavors.

“Kids have shifted dramatically to disposable and menthol e-cigarettes, two categories of products that were left on the market under current federal restrictions,” the group said on its website. “These shifts show that the only way to end this crisis is to eliminate all flavored e-cigarettes.”

In an effort to cut down on youth vaping, federal legislation limits the use of flavors in e-cigarettes and requires that new products be approved before being marketed in the U.S. Only 23 e-cigarette products, all tobacco-flavored, have been approved

Congress also passed a law in 2019 that increased the smoking age limit from 18 to 21.

Those changes haven’t stopped stores from selling to minors or selling flavored vaping products that haven’t been approved.

Last month, the U.S. Food and Drug Administration sent warning letters to 19 online retailers accused of illegally selling vaping products meant to appeal to youth.

In North Carolina, the FDA sent warning letters or fined more than 200 stores last year over violations connected to vaping products sold to someone younger than 21.

Twenty civil money penalty complaints that the FDA issued nationally last month involved Elf Bar, which not only offers a large variety of flavors, but also sells products with different levels of nicotine.

“The new products are so easy to become addicted to,” Goldstein said.

Addressing addiction

In the initial round of Juul settlement money, the General Assembly designated $4.4 million for media campaigns, resources and programs to help youth and young adults quit vaping.

State health officials last year approved contracts with several programs geared toward that goal.

In the first month of the “This is Quitting” texting campaign, more than 1,000 youth signed up, according to a Feb. 23 report by the North Carolina Department of Health and Human Services.

“This demonstrates strong demand from young adults in NC who likely first became addicted to e-cigarettes because of Juul,” DHHS wrote in the report, which was delivered to the Joint Legislative Oversight Committee on Health and Human Services and Fiscal Research Division.

Money from the fund can only be spent after being appropriated by the General Assembly, and it can only be spent on issues connected to youth nicotine use.

How to get help

The following programs are geared toward helping youth quit vaping:

QuitlineNC: Go online, call 800-784-8669 or text VAPEFREENC to 873373.

Quit the Hit: Go online to find out more or sign up for this vaping cessation program that uses Instagram Groups to connect youth interested in quitting. 

This is Quitting: Go online or text DITCHVAPE to 88709 for this text-to-quit program through the Truth Initiative.

Another program, “Quit the Hit,” ran from April to July last year. More than 200 teens ages 13-17 participated in the Instagram-based group sessions out of an initial 1,500 who registered, according to the report.

No residential treatment programs are listed on the report, but that’s not unusual, according to Goldstein. Very few places in the country have established residential treatment programs for anyone struggling with nicotine addiction, let alone youth, he said.

With the programs in place so far, the state may be targeting the easiest to reach, said Goldstein, whose research focuses on tobacco regulatory science and its relationship to health policy, disparities in tobacco use and patient-centered tobacco cessation.

“Our challenge will be how do we reach those with the greatest needs,” he said.

What’s next?

The state budget approved last year releases another $22.5 million from the Juul settlement to cover continuing research as well as prevention and cessation programs over the next two years.

Flexibility will be key as North Carolina uses the Juul settlement money to tackle youth vaping, Goldstein said. For example, one of the texting programs on quitting vaping had a large number of people interested and a decent number that enrolled, but relatively small numbers finished it, he said.

“We have to be prepared to pivot based on data. We need real-time data on what’s working and what’s not working,” he said.

Goldstein said the state is doing different things, and some will work better than others. Next steps include seeing if there is enough data to scale up what is working and figuring out where the gaps are and plugging them.

“I think the outcome data should show improvements. But this isn’t a static industry,” he said, noting the fall of Juul and the rise of brands like Elf Bar.

This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.

North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.

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