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The Food and Drug Administration launched an advertising campaign on Tuesday aimed at keeping teenagers away from vaping using special effects.
The unusual campaign, which FDA officials described as "irreverent", will target teens on social networks and even in school bathrooms, while remaining under the radar of adult smokers who would like to use electronic cigarettes.
The message: e-cigarettes deliver nicotine to addicts and toxins that could have unexpected health effects.
"We are acting on very clear scientific evidence that an outbreak is underway," FDA Commissioner Dr. Scott Gottlieb told a meeting of "stakeholders" interested in tobacco control.
The FDA and other health organizations have also taken a strong stand in favor of e-cigarettes, calling them tobacco products.
"E-cigarettes are now the most popular tobacco product used by young people in the United States," said Mitch Zeller, director of the FDA's Tobacco Products Center.
"We need to raise awareness of the dangers of e-cigarette use among adolescents."
Last week, the FDA called the use of e-cigarettes among teenagers an epidemic and gave the five major manufacturers two months to develop a plan to keep their products out of reach of teenagers. The FDA has also threatened to ban flavored products at the vape, saying that flavors such as mango and chewing gum were clearly aimed at hooking up teens.
The Centers for Disease Control and Prevention also say that vaping is dangerous because it produces addictive nicotine, which can damage the brain of adolescents, as well as heavy metals such as lead and other potentially harmful chemicals.
The consumption of e-cigarettes by teens has increased from about 1.5% of high school students in 2011 to 12% in 2017, according to the CDC. In 2017, 2.1 million high school students used electronic cigarettes. More than 3% of college students reported having recently used an electronic cigarette.
Gottlieb said the numbers went up even more last year. "We have data showing a worrying increase in the number of teenagers using e-cigarettes last year," he said.
"We had to start taking action before the final results of this data could be made public. We will make these results public very soon. But we have an obligation to act on what we know. And what we know is very disturbing.
The ad campaign, said Kathy Crosby, of the FDA. It includes "snarky and irreverent" posters in school bathrooms, she said, with messages such as "Curiously, some children come here to take revenge".
Other ads will be shown on social media such as YouTube, while geographic targeting will try to target users aged 12 to 17 during their schooling. The ads will also go to the websites used by students to view their grades or get homework, Crosby said.
"When teenagers take a break, during lunch, when they release a video on YouTube, they will be served by our advertising," she said.
The ads describe nicotine as creeping through teenagers' bodies, disfiguring their faces. Previous research on anti-tobacco advertising has shown that adolescents are more affected by threats to their appearance than by threats to their health.
Crosby said the ads were shown to the focus groups, including a group of adult smokers who want to quit. She said that they had been cautious with these smokers when they were trying to use electronic cigarettes to quit smoking combustible cigarettes. The FDA will therefore not advertise on mainstream media such as television.
Gottlieb, who sat on the board of the Kure Vape Retailer, said it was still possible that e-cigarettes offer a less lethal alternative to adult smokers.
"To be clear, the FDA remains committed to the idea that e-cigarettes can help adult smokers avoid combustible cigarettes," he said.
"But we may have to reduce the ramp for adults to close the ramp for children."
Gottlieb said the FDA, which can regulate e-cigarettes but has not yet exercised this power, would explore ways to make tobacco products less toxic, less addictive and less appealing.
"We will examine the flavors and designs that appeal to children, as well as the packaging and labeling of products that protect children to prevent accidental exposure of children to liquid nicotine," he said.
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