Turning Off e-Cigarettes: Health Advocates Score a Victory

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Speaker 1 ( 00:04 ):
You've probably seen their ads. The Truth Initiative is America's largest nonprofit public health
organization committed to making tobacco use and nicotine addiction a thing of the past. Experts
credited for helping significantly reduce teen cigarette use in the last 20 years.
Robin Korval ( 00:25 ):
What we've also seen since the JUUL or ignited this, is that these products have become more and more
addictive. What JUUL did is introduced an innovation using these nicotine salts, which make the nicotine
much easier to inhale.
Speaker 3 ( 00:47 ):
Our guest is Robin Korval Truth's President, a nonprofit that now is facing new challenges because of
vaping and the tobacco industry's evolv ing tactics. And this is Conversations on Healthcare.
Speaker 1 ( 01:07 ):
Well, welcome Robin Korval to Conversations on Healthcare.
Robin Korval ( 01:12 ):
Thank you. It's a pleasure to be here.
Speaker 1 ( 01:14 ):
Yeah. You and your allies are celebrating a lot of victories right now in New York and California and several other states reached a settlement worth nearly a half a billion dollars against e - cigarette maker,
JUUL Labs. Our Attorney General, Tong, here in Connecticut, led one of the investigations in multi - state
negotiations as well. The states had accused the company of illegal advertising and marketing of teens. Maybe you could tell our listeners what exactly the company was doing.
Robin Korval ( 01:46
):
Well, in this case as well as in a number of cases that have been settled before. What we know through
multiple investigations is that JUUL targeted young people through their advertising, had many social media influencers working for them, young people. They hosted parties in cities all around the country, that in vited young, cool people to come to the party to make JUUL popular with young people. You can
look at all their ads that they ran during that time with sort of young, energetic people. Recruiting young
people to this product. They even, in some of the find ings that have come out, advertised digital ads on
cartoon, young people's programs, I mean kids programs. They tried to create programs for
underprivileged kids in, I believe it was Baltimore and camp programs. So this was not just an isolated
event here or there. It was a concerted effort to recruit a new generation of young people to nicotine.
( 03:18
):
They were very successful, unfortunately, in that effort. They ignited what became an absolute explosion of youth e - cigarette use. And now of course, because of their success, many, many, many
other brands have entered th e market and we continue to have a youth nicotine e - cigarette crisis. We
have almost 15% of high school kids who vape. 46% of the kids who vape are doing it regularly, which means they're really addicted. So, 20 or more times a month. What we've also seen since the JUUL or ignited this, is that these products have become more and more addictive. What JUUL did is introduced

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an innovation using these nicotine salts, which make the nicotine much easier to inhale. So it's not
irritating. You can use a lot more of it. And now these products have more and more nicotine.
( 04:26 ):
Of course, they come in and JUUL was responsible for this too. They launched all these flavored products and that has expanded as well. And the other thing that we have now is disposable vapes. So JUUL was a pod system you to... You bought a device and then you'd plug in new pods as you use them. But now we have disposable ones which are incredibly inexpensive. They can be loaded up with a lot of nicotine. So what happens is with a cigarette, when you smoke a cigarette, it's a dose. And how much you're goi ng to use and maybe you smoke a cigarette and then you do another one for hours later. And
especially for kids, they live at home, they go to school, they can't smoke a cigarette in those places. But with these vapes, especially the disposable high nicotin e flavored ones, you can use it sort of as much as
you want, wherever you want, whenever you want. So what we see is young people getting addicted really, really quickly.

Speaker 3 ( 05:37

):
Well Robin, thank you for all of that detailed information, disturbing as it is to hear. But you and the Truth Initiative are very familiar with the kinds of legal settlements that Mark was referencing as they initially funded your work. And I'd like you to comment on what can and should states do with these e -
cigarette funds that they will have to help make a big impact on young people ? Certainly to try and keep
them from starting. And also to help people stop. We have a lot of instances in the past of the settlement money going to things that really were not related to public health or to the issue of concern.
So what can the states do ? What should they do?

Robin Korval ( 06:24

):
Well, what's great abo ut these new settlements is, most of them in this new one, certainly are very
specific that the funds need to be used for youth tobacco use abatement. Which was one of, I would
agree with you, one of the flaws of the master settlement. The great thing abou t the master settlement
agreement is it created our organization. Originally known as the American Legacy Foundation, now
Truth Initiative. But a lot of the money went to and still goes because the states do get money in
perpetuity. We don't. Our funds end ed a long time ago in 2006, but the states still get money every year.
Last year I think was about $8 billion. But unfortunately that money gets used for all sorts of other
things, building roads, other state budgetary uses, and do not go into tobacco prevention or cessation
measures. So the great thing about this settlement is they are specified for that.
( 07:28 ):
And there are a few things, and I know this based on the work that we do and what we know is
effective. Youth public education programs like the Truth Campaign have been proven effective in
preventing young peop le from starting to vape. Our most recent evaluation shows that our campaign is
preventing millions of young people from starting to vape as well as helping them to make the decision
to quit. So public education programs like the Truth Campaign are very important. Also, as I said, we
have a lot of young people, 15% of high school students who are vaping, they want to quit. We know
that 60% of them want to quit. They don't realize what they're getting into. They don't realize how
quickly they'll become addic ted and they don't like it. So we have a program for example called This Is
Quitting. Which is a text - based program.
( 08:27 ):

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Kids do it on their phone, which is of course where they live. It's for teenagers and young adults. And we
segment you based on how old you are when you come into the program. Since that program wa s
launched, over 560,000 young people have enrolled. And by the way, the rate is not slowing down. We
have a lot of young people who want to quit. So this money should be used to help those people as well.
And finally, to get down into the community level, right? School curriculums work. We have a curriculum
called Vaping Know the Truth, that's in over 6,000 schools. 600,000 kids have been through it. And we
know from research evaluating the program, that prepost being part of this, using this curriculum, w hich
is digital also, that young people's knowledge and attitudes about vaping are shifted. And also their
understanding of where to go to get help. For instance, this is quitting if they need it.
( 09:30 ):
So I think those are the three most important things that need to be done with this money. And I have a lot of confid ence that the states will do it. For instance, we already work with New York State, and I
think we're about to work with Connecticut on This is Quitting. So the states know what they need to do, and now they have hard one funds to do that.
Speaker 1 ( 09:54
):
Well, I think it needs to be said one more time that your own research shows that when young people, 15 to 24 year old, are aware of your campaign, it lowers the likelihood that they'll vape. I wonder if you could just take us through some of the campaign tools that you use. And I was also fascinated as you walk thro ugh in your first answer, sort of the size and scope of what a JUUL has at its command in terms
of the resources it puts into the work. But tell us a little bit about your campaign as well?
Robin Korval ( 10:27

):
Sure, sure. So the Truth Campaign has been in existence since 2000. It's been proven incredibly effective. The underpinning of the campaign from the beginning through today, although there have
been many iterations of it, is really founded on the idea of telling young people the truth about tobacco. Used to be cigarettes, now it's vaping. Giving them the facts and engaging them in a way that isn't finger pointing, doesn't sound like your teacher or your parents, but really in a peer - to - peer voice. And trusting
young people that if you give them the facts and you do it in a way that feels engaging with them, A, they will hear you. And B, today what's so important, so much of what we do is through social channels
and digital channels is they will share the message themselves with their peers. And we love that.
( 11:28

):
So the work that we're doing right now about, I guess two years ago when we started thinking about this, you realize that the pandemic, everything that was going on in the country was creating a mental health crisis among not just young people, but widely, but of course a lot of it with young people.
( 11:53
):
And that we know from research that nicotine actually can amp lify depression, anxiety, makes stress
feel worse. And here's the funny thing, or I should say the sad thing, is the tobacco industry through years of marketing has put disinformation out there that makes young people believe that vaping, the use of nicoti ne will actually help alleviate their stress, which is in fact the exact opposite. So we began a
campaign in October of '21 called It's Messing With Our Heads, which is really helping young people to understand the very thing you might be using to help you cope in this very complicated world that they
are in is actually making it worse. The first thing we did is we launched a fake vape company and we called it depression stick. Much like a cigarette. Was known in common slang as a cancer stick. The reality is a vape is literally a depression stick.

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( 13:06 ):
So we launched this fake company to get attention and to call a vape exactly what it is. We've continued
that effort with something we now call Breath of Stress Air. Because again, we believe in telling the truth
and calling it like it is. And every time you take a hit off a vape, you are literally getting a breath of stress
air. It's been very, very successful. We also use a lot of influencers because it's not just what we say, but
we like to take advantage of the fact that there are a lot of young people out there who w ant to share
their stories and use their channels to talk to their peers. So for instance, we just did an effort with a
young woman, her name is McCall Mirabella. We found her because she actually... Organically, we didn't
even know who she was, decided to record her quit vaping story.
( 14:02 ):
She came to the attention of , I think it was Good Morning America. They put her on their show. She has
millions of followers. And we connected with her and said, "Hey, would you like to do something with us? Would you like to help others quit?" And it's been an incredibly successful effort. We're doing things
with other influencers now. We're just about to launch one with a gentleman named Eli Stone. So we, of
course, want to be in the culture. The other thing that we do is we really believe in telling the stories of
young people who are quitting. So we have a series of real life testimonials of young people who are
going through the, This is Quitting process. They sign up for the program, we record their journeys, they
share that with other people to show that, yes, it's hard to quit vaping.
( 14:55
):
No, I'm not going to kid around on that. But you can do it and you seek help, both in terms of a program that we know is effective. We know that this is quitting increases your odds of being able to quit by 40% versus the control that's from a randomized clinical trial. So if you commit to it and you use tools at help, your odds of success will go up and you can use the experience of other people to feel not so alone in the process.

Speaker 1 ( 15:26

):
You're a strategic thinker and I'm wondering, as you look at either having dollars or knowing culture, as you think about your campaign, what's more important for you? Becau se you were really relating to
young people and that campaign's important. And it sounds like you're using social media a lot, but how important is the financing for the work that you do as well?

Robin Korval ( 15:53

):
Well, I'd like to tell you, social media is free. It isn't. Our friends at the various social media chann els
from TikTok to Snapchat have figured out how to monetize their platform. So when I say social media, I
don't necessarily mean free social media. But I think the most important thing, I mean obviously we
need money to support the things we do. Big publi c education campaigns, no matter what platform
they're they are on, are very expensive. Fortunately, the funding that we've received from the MSA has
allowed us to do that for a very long time. Of course, we hope that will continue. But I think more
import antly is knowing how to shift culture. What we like to say we are doing. So the messages and we
craft those messages and being close to the ground with young people and listening to them, which we
do every single day is really important.
( 16:57 ):
What we like to say we're trying to do really is two big jobs. On the one h and, we want to de - normalized
vaping in culture, make it feel not so like everybody's doing it. And the other thing is to normalize quitting. Because if you don't see people around you trying to quit, if you don't know how to do it, if you

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don't understand that you can be successful, then it's very hard. So de - normalized, vaping, normalize
quitting. That's what we're trying to do in culture.

Speaker 1 ( 17:28 ):
Great.

Speaker 3 ( 17:28 ):
Well, it's incredible the way you've engaged young people. I have to say, I'm really curious whether
you've mobilized them to go to Washington and testify before Congress. And maybe you could tell us
about that in a minute too. But first, I wanted to ask you about your new report that showed that
tobacco imagery continues to influence youth vaping initiation through the onscreen entertainment that
our young people find the most popular. How are you working to combat this problem? Do you have
any new tools or legislative tools at your disposal? Tell us about that. Also love to hear whether you
have young people who've testified before Congress?

Robin Korval ( 18:06 ):
I will get to that. So we have for five years now, we've just published our fifth report taken on this issu e
of tobacco imagery on screens. At one point, it was all about tobacco in the movies, because in the olden days of network television, there was a prohibition of... I mean the networks respected it, of not showing smoking on TV. In the age of streaming, o bviously all that has changed. So we have been
publishing report for five years. We call it While You Were Streaming. We do a new edition every year. That really brings to light and what has become very pervasive when you think about the explosion of strea ming media and all the platforms that are available now, the portrayal of tobacco imagery in the
many, many programs across Netflix and Hulu and Amazon. And we go on and on and talk about all the platforms that are available to young people.
( 19:11

):
And it's very, very important. And we want the creative community to un derstand this and to
understand that they play a role. In peer reviewed research we know that onscreen exposure to tobacco imagery makes young people three times more likely to start vaping. It makes sense if the people you admire, if the shows that make y ou laugh or make you cry or that you're talking about continuously
normalize the use of tobacco, it's going to look normal to you even if way fewer people in the culture are actually doing it. And it's pretty pervasive. For instance, in this year's report, we found that 60% of
the 15 top shows that young people were watching across multiple platforms contain tobacco imagery.
We also see it, when you look at the movies, seven of this year's, 10 nominated for best picture award
shows had smoking imagery in th em.
( 20:20

):
There was one that was even PG rated, if you can believe that. And a lot of this imagery is in shows. As I
said, the top shows for young people and shown in ways that is very appealing to young people. So a number of these shows are animated. Things like The Simpsons and Bob's Burgers and other shows lik e
that, which are very appealing to young people. Or even if it's not an animated show, one of the worst
offenders over the years, although I will say Netflix did a little bit better this year, mostly because they
didn't have a new season of Stranger Thing s. But Stranger Things, one of the most popular shows with
the young people and has been one of the worst offenders over the year.

Speaker 3 ( 21:12
):

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And Robin, can I ask you -
Robin Korval ( 21:12 ):
Go ahead.
Speaker 3 ( 21:12 ):
Is industry paying for placement of the products in these shows?
Robin Korval ( 21:17 ):
We don't know. We have no knowledge of that. So I don't want to in insinuate that they all are. And
perhaps not. I mean, we've all often said, don't be an unpaid spokesperson. And in fact, what a lot of the
onscreen talent as well as all the creative people behind these shows, and of course the platforms that
put them out there is, if you are not being compensated, and let's assume they're not by the tobacco
industry, you are literally becoming an unpaid spo kesperson for this industry, which is, I mean just as
bad. And what I think we hope to enroll the creative community with us. One of the things we like to
make very, very clear.
( 22:07 ):
This isn't about prohibition or censorship and we believe in the freedom of artistic expression. But I think the question we would ask the creative community is, isn't there more creative way to show, oh, here's a person who's thinking really hard, so we show them smoking a cigarette, or here's a person, we want to show that they're a little rebellious, so we show them vaping. I mean, the re are many more creative ways to do that. And we hope that if the creative community understands that these images,... I mean they are literally the people who are creating culture. If they understand that these images have
power and we think they know th at they do, that they have an opportunity to help prevent another
generation of young people from spending a life addicted to nicotine.
Speaker 1 ( 23:02

):
Robin, we've talked so far a lot about advertising. Your background is in that industry. In fact, the
American Marketing Association named Truth as the most effective brand of the year. Congratulations.
But we have a lot of challenges in public health. I don't want to take you out of your lane, but I need to
get your thoughts about how well places like the CDC did in addressing the issues around Covid. You
obviously wer e in the same world that all of us were, and you have that unique perspective in terms of
marketing. How can they improve their messaging at this time, which is so critical, particularly given the
misinformation that's out there in the public health arena?
Robin Korval ( 23:52 ):
Well, that is a little out of my lane, but I will say as it pertains to what the CDC is doing in the tobacco
space and the FDA too. There's some good things and some areas where we need help. CDC runs a pretty effective effort called Tips for Former Smokers. That is all about helping adults to quit smoking. And through the years, they have helped a lot of the adult smokers find their ways to quitting. But that's an effort that is always at risk of being defunded. And so I think it is important. We know the public education works, we know it works for young people, we know it works for adults. And perhaps I would
say, thinking about your question about just public health issues in general, it is important to tell that story compellingly to the public so that they have the facts.
( 25:03

):

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Certainly in tobacco, we're going up against an industry that spends billions a year, and all of us in public
health, including these government campaigns, are a drop in the bucket compared to the messages of
others. So that's really important. And the other thing that I would say is we are looking for the FDA who
has authority over the regulation of tobacco. Two, there's a lot of important things on their plate that
we are really hoping that they can move this year. For instance, right now we're waiting for them to
issue a final rule to take menthol cigarettes off the market. That is one of the most important things we
can do to save people's lives. We know that menthol cigarettes make it easier to start smoking, easier to
get the bad stuff down. We know that menthol is, in this country, a social justice issue.
( 26:08 ):
Nine out of 10 black people who smoke smoke menthols, that's not an accident. It' s because the
tobacco industry aggressively has marketed that community over decades. So that's something we really
need the FDA to do. They have promised to get a rule out this year. We want to hold their feet to the
fire for that. Another thing we're rea lly, really pressuring FDA along with all of our partners in this space
to do, is we need to get rid of all of these flavors, not just menthol in cigarettes. We need to get rid of all
of these flavors in vape products. There is no strong evidence that flav ored vapes help adults to quit. On
the other hand, we know that 80% of kids who vape vape flavors. And it's not just menthol, of course,
it's flavors like Candy Crush and Rainbow Ice, and a lot of these flavors don't even sound like flavors.
( 27:18 ):
So they're these concept flavors. So yes, a flavor like Rainbow, rainbow b reeze, it's a way of getting
around rules of calling something menthol or mint or things that the FDA might not allow, but signaling, hey, this has a good taste and it's cooling too. So, there's a lot of things we're looking for FDA to do, to speed along t he PMTA process. It's supposed to be a pre - market approval process, so every e - cigarette
on the market is supposed to go through a pre - market approval process before they can put their
product on the shelves because of a lot of complications, which we don' t have time to talk about today, that has not been the case.
( 28:0 7

):
The number one product on the market right now, Vuse Alto, which is a product from RJ Reynolds, is illegally on the market. It has over, I believe, a 30% market share because it has not received FDA pre -
market approval yet. So yes, we have a lot of confidence in the FDA. They have a great new leader in the tobacco center named Brian King. We think he's on the right path, but he has a big job ahead of him.

Speaker 1 ( 28:36

):
Well, that's great. Thank you, Robin Korval for your many years of service and your leadership on these
important public health fronts. And thanks to our audience for joining us as well. They're more online
about conversations on healthcare, including a way to sign up for our email updates. Our address is
chcradio.com. Robin, thank you again for joining us today.

Speaker 3 ( 28:55 ):
That was spectacular.

Speaker 1 ( 28:57 ):
Yeah, thank you so much. Thank you. Thank you.

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