Tagged Children’s Health

Joe Camel Was Forced Out Of Ads. So Why Is Juul Allowed On TV?

Why does e-cigarette maker Juul advertise its product on TV when cigarette ads are banned? The short answer: Because it can.

For nearly 50 years, cigarette advertising has been banned from TV and radio. But electronic cigarettes — those battery-operated devices that often resemble oversized USB flash drives with flavored nicotine “pods” that clip in on the end — aren’t addressed in the law.

Since launching its product in 2015, Juul Labs, based in San Francisco, has taken the e-cigarette market by storm, and now accounts for roughly 75% of e-cigarette sales at convenience stores and mass retail outlets. Until recently, TV ads haven’t played a role in Juul’s marketing, which relied primarily on social media.

But this year, the company launched a $10 million TV advertising campaign, “Make the Switch,” that it said was aimed at helping adults find a healthier alternative to smoking cigarettes. The campaign also features print and radio ads.

Many public health advocates are skeptical of the company’s repeated assertions that adult smokers are its target audience. When the company launched its sleek e-cigarette four years ago, it relied on social media outlets such as Facebook, Instagram and Twitter to promote its product in ads that, especially at the beginning, featured playful, partying 20-somethings.

As the product caught on, young people helped spread the word to other young people using hashtags like #juul. Social media influencers who posted content praising Juul amplified the message.

“There’s overwhelming evidence that the behavior of Juul contributed to the product being sold to youth,” said Dr. Robert Jackler, a professor and the principal investigator at Stanford Research Into the Impact of Tobacco Advertising (SRITA) at the university’s medical school.

Juul said it is not targeting children and teens and supports efforts to limit tobacco products to people under age 21. “We recognize that youth use of vapor products is a problem that requires an effective and appropriate response from industry and regulatory bodies,” said Ted Kwong, a Juul Labs spokesman. “We strongly support restrictions on social media marketing of vapor products.”

In recent years, the number of high schoolers and even younger kids who say they’ve used e-cigarettes has grown rapidly, alarming parents and public health advocates.

Last year, almost 21% of high school students reported using e-cigarettes in the previous 30 days, according to an analysis of National Youth Tobacco Survey data published by the federal Centers for Disease Control and Prevention. In 2011, the proportion was just 1.5%. Between 2017 and 2018 alone, the number of high school students who said they were current e-cigarette users grew by 78%, to more than 3 million students overall. The CDC said 1 in 20 middle school students, those in grades 6 through 8, reported vaping in the previous 30 days.

In contrast, 3% of adults said they used e-cigarettes in 2017, according to the CDC.

E-cigarettes, also called vapes, were introduced in the United States in the mid-2000s. Some early versions resembled actual cigarettes. Juul’s product can be plugged into a USB port to recharge and fits inconspicuously into the palm, often frustrating parents and teachers seeking to stop teens from using it.

There’s evidence that smoking e-cigarettes may act as a “gateway” that leads young people to try cigarette smoking. And cigarette smoking remains the leading cause of preventable death, killing more than 480,000 people in the United States every year.

E-cigarettes don’t produce tar, in which most of the cancer-causing and other harmful chemicals from tobacco smoke are found. But both products contain nicotine, which is highly addictive and can harm the developing brains of adolescents.

In addition, the vapor that people inhale when the liquid nicotine in e-cigarettes is heated may contain cancer-causing chemicals, heavy metals and other dangerous substances.

Nevertheless, e-cigarettes are often touted as a healthier alternative to cigarette smoking, and that’s the premise of Juul’s “Make the Switch” campaign. The testimonial ads feature adults describing the positive changes in their lives after they gave up smoking cigarettes to use Juul.

“We want adult smokers to hear directly from former adult smokers that Juul Labs provides a true alternative to combustible cigarettes and is showing unprecedented success, with studies showing 40 to 56 percent of adult smokers fully switching within 90 days of use,” said Kwong.

Although adolescents may be more likely to see ads in social media than traditional broadcast and print ads, the Juul TV ads probably have an impact on them, said Bonnie Halpern-Felsher, a professor of pediatrics at Stanford University School of Medicine who developed a tobacco prevention toolkit for teachers.

“When you say that a product is for an adult, the message is not ‘Don’t use,’ it’s ‘Use these products and you’ll appear to be adult or mature,’” Halpern-Felsher said.

Anti-smoking advocates would like to see the same marketing limits applied to e-cigarettes that apply to so-called combustible cigarettes, including banning them from advertising on TV and radio.

They would also like to see the changes that were put in place under the Master Settlement Agreement in 1998 between the largest cigarette manufacturers and the attorneys general of 46 states applied to e-cigarettes. The states had sued the cigarette makers to recover their costs for treating sick and dying smokers. Among other things, the agreement banned most transit and billboard advertising of cigarettes, branded merchandise, free product samples and sponsorships of events, such as concerts and sporting events.

E-cigarette makers, such as Juul, have used some of those advertising methods over the years.

Last year, after the federal Food and Drug Administration said it was cracking down on an “epidemic” of teen vaping, Juul announced changes to its marketing activities.

The company shut down its Facebook and Instagram accounts and limited Twitter communications to non-promotional posts, Kwong said.

That’s like closing the door to the barn after the horse has left, said public health advocates. Young people, they added, are continuing to post about Juul on those sites.

“It’s too late,” said Dave Dobbins, chief operating officer at the Truth Initiative, an anti-tobacco advocacy group. “The kids are doing their work for them.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

DIY Tech Gives People More Freedom In Managing Diabetes

When Sam Mazaheri was 9, he was diagnosed with Type 1 diabetes. That means Sam’s body makes little or no insulin, a hormone that turns food into energy.

“All of a sudden I had to manage everything he was going to take, including the insulin,” said Sam’s mom, Nasim Mazaheri.

It was frightening, she said, and it felt like bringing home a newborn all over again.

“If I give him too much, it can actually kill him, or if I don’t give him enough, it will eventually kill him.”

Nasim and Ali Mazaheri, Sam’s dad, didn’t sleep much, scared of the worst-case scenario.

Type 1 diabetes is a lifelong condition that can be managed with medication. But without insulin, the body can no longer move glucose from the blood into the cells and, eventually, will stop working. More than 1 million people in the U.S. have been diagnosed with Type 1 diabetes, according to a 2017 report from the Centers for Disease Control and Prevention.

The Mazaheris, who live in Irvine, Calif., say adjusting to their new normal was tough for the whole family.

Sam, now 14, began wearing an insulin pump attached to his stomach. The pump is a computerized device that is programmed to deliver small doses of the hormone. He also had a separate glucose monitor on the back of his arm that beeped when his insulin levels needed attention.

Sam had to learn to count carbs and pay close attention to his food intake so he could calculate how much insulin he needed at mealtimes — a lot for a 9-year-old to manage.

Sam and his father, Ali, have lunch together at home in Irvine, Calif.(Heidi de Marco/KHN)

Plus, Sam was tethered to his parents. The first few months, they needed to stay close to track his glucose levels and make the appropriate corrections.

“I was checking on him constantly throughout the night,” Nasim said.

Sam was a sound sleeper and wouldn’t hear the beeping of the low-insulin alerts in the middle of the night. Worried, Nasim eventually moved into Sam’s room and slept in the bed with him.

Frustrated and fed up, Sam’s dad ― who works at Microsoft ― decided he could use his tech skills to make his son’s life more manageable.

Ali discovered an online community of people also looking for ways to live better with diabetes. After scouring Twitter and networking with others in the tech industry, he stumbled onto something called “looping.”

Using instructions freely available online, do-it-yourselfers ― who belong to what’s known as the “open-source community” ― close the loop between an insulin pump and a continuous glucose monitor. It creates a new system that connects the two separate devices, allowing them to talk to each other with the help of a transmitter, and deliver insulin to the body automatically. They call that “looping.”

Sam tracks his glucose levels on his phone with the help of an open-source code called Open Artificial Pancreas System (OpenAPS), known in the diabetes community as “looping.” (Heidi de Marco/KHN)

Sam uses a continuous glucose monitor on the back of his arm.(Heidi de Marco/KHN)

The system sends commands based on frequent glucose readings, adjusting Sam’s insulin throughout the day.

Looping works only on older-model insulin pumps because the wireless technology is different on newer pumps. So Ali scoured the internet and found a few on Craigslist for about $600 each.

“There was a black market,” he said.

Ali and Nasim are able to monitor Sam’s glucose levels using their smartphones and smartwatches, no matter where he is.

That first time he tried it out on Sam, Ali said, there was one more sleepless night.

Ali, the interim director at the Microsoft Technology Center in Irvine, Calif., monitors his Type 1 diabetic son’s glucose levels on his smartwatch using a DIY looping system. DIY systems combine insulin pumps and continuous glucose monitors (CGMs), with open-source software to deliver different doses of insulin.(Heidi de Marco/KHN)

The closed-loop concept began with people who were frustrated that there aren’t more ready-made, commercial options. And some people have rallied around the hashtag #WeAreNotWaiting to express their impatience for better health-data innovations to manage their diabetes.

Looping advocate Dana Lewis, who lives near Seattle, says she knows of about 1,500 people experimenting with looping to control their diabetes.

In 2015, Lewis was one of the first to provide open-source code to others online. Now people go to her website, OpenAPS, for step-by-step instructions.

The Mazaheris have been looping for four years and Ali says they haven’t had any issues.

Nasim checks 14-year-old son Sam’s glucose levels on his phone before he heads out to tennis practice.(Heidi de Marco/KHN)

But in May, the Food and Drug Administration issued a warning.

“Use of unauthorized devices could result in inaccurate glucose level readings or unsafe insulin dosing, which can lead to injury requiring medical intervention or death,” it said.

An FDA spokesperson said the warning was issued after the agency received a report that a patient using an unauthorized device experienced an accidental insulin overdose that required medical attention.

Endocrinologist Dr. Irl Hirsch said several of his patients use looping systems to manage their diabetes.

“To date, the patients I’ve cared for who are looping have done amazingly well,” said Hirsch, who is with the Diabetes Institute at UW Medicine in Seattle.

But Hirsch has his own warning.

“I tell my patients who do this, it has to be at their own risk. There isn’t a pump manufacturer that will take care of them if something goes wrong, and I can’t be held responsible if there is a problem,” he said.

The FDA also wants people to be aware that certain recalled devices are susceptible to cybersecurity risks. The FDA said there are no documented cases, but it’s possible that someone other than a patient could change a pump’s settings wirelessly.

Those warnings haven’t deterred Ali Mazaheri, who said looping allows Sam to be independent and just be a kid.

There is an FDA-approved medical device that closes the loop between an insulin pump and blood sugar monitor, and similar devices in the pipeline. But open-source users say they’ll continue to program their own devices because that gives them more flexibility to personalize their diabetes management.

While at tennis practice, Sam wears a fanny pack around his waist that holds his insulin pump, cellphone and a credit-card-sized device that transmits commands to the pump.(Heidi de Marco/KHN)

Sam starts high school in September. He’s an amazing tennis player and an avid collector of Star Wars memorabilia. He also wears a SPIbelt around his waist, a fanny pack that holds his insulin pump, his phone and a credit-card-sized device that transmits commands to the pump.

“Now the pump won’t go off in the middle of the night as much as it did,” Sam said.

These days, his blood sugar is almost always in a healthy range.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

At This Summer Camp, Struggling With A Disability Is The Point

A summer camp for children with disabilities in Nashville does things a little differently. Rather than accommodate the campers’ physical challenges, therapists make life a bit tougher, in hopes of ultimately strengthening the kids’ ability to navigate the world.

Priceless Garinger’s left arm is wrapped from shoulder to fingertips in a neon-pink cast on the day I visit. The left one is the 12-year-old’s strong hand. It’s her other arm and hand that have been the problem since she was born with cerebral palsy. She can move her right arm but has difficulty grasping anything.

“Right there, where you bend your arm, it itches right there,” she said, using a plastic spoon to scratch her elbow, which is out of reach.

This day camp is organized by Vanderbilt Children’s Hospital. Some campers, like Priceless, have cerebral palsy; others have had a brain tumor removed or had a stroke. All of them have a weak side of the body they rarely use. At High Five Constraint Camp, the children are forced to try to strengthen that weak side.

“Yeah, there it is,” Priceless said as she bumps bare arms with a fellow camper — an improvised fist bump.

This kind of rehab is known as constraint-induced movement therapy. Similar camps are run by children’s hospitals around the U.S. during the summer months. The approach is based on research by Edward Taub and his team at the University of Alabama. He hypothesized years ago that the affected limbs suffer from “learned nonuse.”

Priceless takes her turn on the indoor obstacle course at the hospital’s pediatric rehab facility, located at a Vanderbilt satellite campus on Nashville’s outskirts. She rides a modified zip line, wrapping her long legs around the swinging seat — swooping along and then dropping into a pit of overstuffed pillows.

The occupational therapists prompt her to climb out. They cheer her on but don’t immediately help. The struggle is the point.

Priceless finds her way out, and next plops down on a scooter. She grunts as she tries to propel herself with a hand that she can barely control.

“I’m not going anywhere,” she said.

Her therapist gives her a boost toward the finish line, where Priceless hits a buzzer that sounds an alarm and draws cheers from the other campers.

Constraint-Induced Therapy

The restrictive rehab techniques are increasingly used with kids who have cerebral palsy, though there hasn’t been much research to show the approach is better than traditional physical therapy. And some kids become overly frustrated or even refuse to cooperate.

To outsiders, the strategy can seem mean.

“If the families have never heard of it before, it’s kind of like, ‘What? You’re going to cast their good arm and take away their really functional hand?’” said occupational therapist Stephanie Frazer.

This particular day camp started a decade ago as part of a research project at Vanderbilt University. When the study concluded, the camp shut down. But Frazer revived it in recent years because she believes the approach and the setting are effective.

“Whenever we’re casting that good arm, the brain is like, ‘I have this other arm here.’ And they start using it more and it starts creating pathways,” she said. “They actually make a lot of progress in a short amount of time.”

The kids’ temporary casts end in a mitten shape to minimize any wiggle room and attempts to rely on that stronger hand while at camp.(Blake Farmer/Nashville Public Radio)

Even snack time can turn into a therapeutic experience. Playing with food is required at this camp. The kids take pretzels and stab them into blocks of cheese.

Some blow bubbles in their juice, partly out of frustration. Some resort to using the arm that’s in a cast to feed themselves.

Seeking Independence

This is the third summer of camp for Priceless, who wasn’t exactly enthusiastic when she started. But she’s beginning to see how helpful it would be to be able to rely on both hands to do things like manipulate a remote control.

“I want to play with my iPad and watch TV,” she said.

The parents of the campers are even more motivated because they understand how the use of two hands could make independence in adulthood much more feasible for their children.

“She talks about wanting to drive,” said Laura Garinger, Priceless’ mom.

From past experience, Garinger said, she suspects that for the first few months after this camp session, Priceless will use her weak hand more often. But in past summers, she eventually has reverted to relying on her strong side.

Still, Garinger said, she has witnessed other, permanent successes.

Garinger, a special education teacher, met Priceless when the little girl was 3; she adopted Priceless two years later. The preschooler needed to use a walker at the time. Now she walks on her own.

Being able to rely on both hands would go a long way toward helping Priceless achieve her dreams, her mom said.

“She hopes to be a police officer, so the sky’s the limit. We’ll see,” Garinger said, pausing as her voice shook with emotion. “I mean, it’s probably not realistic, but I always tell her she can do what she wants when she grows up.”

The first step for Priceless, Garinger said, is strengthening her arm enough to give a high-five — or a two-arm hug.

This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.