Why Teens Just Can't Quit Nicotine

Welcome to Chasing Life. You know, one day, about six years ago, I sat down for a conversation with all three of my daughters. I wanted to talk to them about something that was weighing on my mind in the minds of just about every parent I knew at the time. Vaping. What did you think was in these vapes, Ole? I thought it's just a lot of chemicals, and some chemicals can, like, damage you. Are you comfortable with this conversation? No. Why not? Because I'm only 10. At the time, my youngest, who you just heard from, Sole, she wasn't even a teenager yet. But I wanted her to be part of the conversation anyway, because the numbers back then, and also what her big sister, 14-year-old Sage, already gone through, suggested to me that vaping was probably something she was going to run into in middle school. How would you describe the vaping situation in your school? It got kind of bad last year. Some people did it too much. Like, a lot too much. In 2019, the CDC found that 27.5% of high school kids admitted to vaping. It's more than a quarter. And that's the ones who actually admitted to it. But here's the thing. By 2024, just five years later, that number had dropped to 7.8%, the lowest in a decade. Before Sole could even get her driver's license, it looked like vaping was already on the way out. And it seemed like the same tools and lessons that had driven down teen cigarette smoking were also successfully beating back this new threat. But today, I wanted to talk about something else that was happening in 2024 as well. This half hour, a new type of nicotine product in the U.S. is going viral. ZIN is taking over the market. That's right. ZINs. They're the most popular brand of nicotine pouches. And if you haven't heard of them, you probably will. Between 2023 and 2024, teen use of nicotine pouches nearly doubled. In one year, thanks in part to boosts from social media influencers who are in fact called ZIN influencers. Once you try this, you're going to get a lot richer. ZIN? Is that their advertising campaign? ZIN is not a ZIN. That's the advertising campaign. So today, I wanted to talk about teen smoking, vaping, and ZIN. What is the truth about nicotine? How does it affect our children's health? And why does it seem like every time we get a handle on one product, a new one comes along? My guest today is Dr. Pamela Ling. She's an expert in tobacco marketing and the director of the University of California, San Francisco Center for Tobacco Control Research and Education. She's going to help us figure out why tobacco and nicotine are such moving targets for public health. I'm Dr. Sanjay Gupta, CNN's chief medical correspondent, and this is Chasing Life. Okay, Dr. Ling. Hi. How are you? Doing good, hanging in there. I've been really looking forward to some. I'm curious. Let me ask you a basic question. I feel like most people recognize that nicotine is highly addictive. And I don't want to overstate this, but I think it's one of the most addictive, right? I mean, some say even more addictive than heroin, for example. Do young people recognize that? I think young people do recognize that nicotine is addictive. But-- That addictive. Yeah, but I think that tobacco companies have been on a campaign since the 1988 Surgeon General's report came out that said nicotine is addictive, right? Nicotine is the reason why people can't quit smoking. And the tobacco companies have been on a campaign for 50-plus years to try to minimize nicotine and say, you know, nicotine is like caffeine in your coffee. It's not a big deal. But when you take care of patients who, you know, continue to smoke, even though they've had their larynx removed or continue to smoke even though they have cancer, because they can't quit, you're talking about a really serious addiction. And that, I think, young people are maybe sort of aware of it, but there's an active campaign to get them to forget about it. I want to get a sort of snapshot of where we are as a country with regard to nicotine and tobacco use. I just want to read you some numbers. And tell me-- correct me if any of these numbers are wrong. But teen cigarette smoking peaked in the late 1990s when 37% of teens at that point reported smoking. By 2021, that number had fallen to just 3.9%. But in the 2010s, after cigarettes were already in steep decline, vaping sort of really-- it was already there, but it really started to surge in popularity. Peaking in 2019, when about 5 million teens were using e-cigarettes. So you seem like you had two things happening simultaneously. Cigarette smoking dropped precipitously among teenagers, but at the same time, vaping increased significantly in popularity. So what are we to make of all that? What was the impact of all that? Yeah, so we did have big decreases in teen smoking. You're right, because we had national campaigns, we had warning labels, we had taxes on cigarettes, we had clean and/or air laws. So there were lots of things happening in the U.S. to drive down those smoking rates. And then e-cigarettes were introduced, and actually teen smoking continued to decline, but at a slower rate after that. But now, by far, the most popular tobacco product used by young people is vaping. And do you anticipate, as a result of this, that teen smoking may go back up? Is there a transition point between vaping and starting to smoke again? That is one of our concerns. So there have been longitudinal studies of young people who are vaping, and they really consistently find that teens that vape are about three times more likely to start smoking later in their life. So we are concerned that the popularity of vaping could lead to a resurgence of smoking. Before I get into the real harms of this, which I think for a lot of people may be intuitive, but there is a success story in here. Again, in terms of how much teen smoking did drop over the over the couple of decades, and you said it was several things. What do you attribute it to more than anything? Is there something that sort of stands out as a lesson learned in terms of really bringing down teen smoking? I mean, we in the U.S., we had some of the most effective mass media campaigns to educate young people about the dangers of smoking. So probably before your kids' time was the Truth Campaign, which is now run by the Truth Initiative. But this campaign started in the '90s, right? Why I like it is because it really, rather than telling teens that this cigarette smoke is going to kill you, the campaign was really focused on holding tobacco executives responsible for their role in perpetuating a lie to the American public about the dangers of smoking. So you may have remembered they had these ads where you would have teenagers bringing a lie detector to the Philip Morris offices to like interrogate the CEO of Philip Morris. Because, you know, when they were doing the research for this campaign, they found out that like teens did not really care that much about getting lung cancer 50 years from now, right? What they cared about was adults lying and getting away with it and making money off of their lies because teens can relate to adults not following the rules that they themselves are subject to. So that energy around saying, you know, the tobacco industry is responsible for this. They've been lying. They've been making all this money off of it. And you, as teens, can actually hold these adults accountable for their actions was the core message of the Truth Campaign in the '90s. And that was actually very relatable and energizing for rebellious teens who have the highest rates of youth smoking. You know, I find this really interesting because I think we're both doctors. But the idea of effective communication, I think for a lot of doctors, people who went to medical school, it's this idea that, look, if you don't do this, this may happen to you. If you don't exercise, you don't eat right. You may get heart disease. You may develop problems later in life. But this point that you're making is you've got to understand what's really going to resonate with people. So for these young people, imagining lung cancer 50 years from now bad, but not immediate enough to maybe spur them to action. But the idea that these tobacco executives were taking advantage of them in some way, lying to them in some way, that was enough to spur action. It is more thinking like a marketer, right? And it's a little less thinking about in medicine. You know, we tend to be very logical. And very much like if you give people the facts, they'll respond. They'll learn and they'll change their behavior, which is true. But sometimes the facts you need to share are not just changing your individual behavior. Sometimes getting people energized about, you know, we need to hold this industry accountable is a better message. Going back to vaping nicotine. So what do we know now over the last couple of decades in terms of the potential harms associated with this? There are some health harms associated with vaping for young people, particularly for like if young people have asthma, it can exacerbate asthma. It is associated with respiratory problems. I think the biggest harm from vaping is really exposing yourself to an addictive substance, which is the nicotine. So while the nicotine doesn't cause cancer, the nicotine is very addictive and can then lead you to move on to other tobacco products. And it's not a trivial thing. So people who are addicted to nicotine, you know, then experience especially, I mean, you have teenage girls, so you know I do too, right? Like the mental health challenges in teen girls is like a real thing. And adding nicotine addiction to someone who's already trying to navigate, you know, strong and complex emotions or anxiety, depression, stress, that is a really bad combination for young people. That's interesting because I was going to ask if there was any redeeming qualities to vaping because I think when, you know, they started to really become quite popular, I think one of the things that they were touted as doing was helping people quit smoking. Yes, and actually there is now better evidence than before that there are some randomized controlled trials that show that when you give people vapes and counseling in a randomized controlled trial situation, they do quit smoking at rates equal to or a little bit better than nicotine replacement therapy. Problem is that, you know, life is not a randomized trial, right? So the highly controlled conditions that we do for RCTs are not like go down to 7-eleven, get a geek bar and do the best you can. And that's what people are mostly using vapes. And we have lots of population based studies and the studies show that people actually don't quit at higher rates. And in some cases, they actually are less likely to quit if they're using vapes. Quit at higher rates compared to, I mean, other nicotine replacement therapy? Quit at people who didn't use vapes, yeah. So where do we land on this then? You know, because I think, again, the redeeming quality, if there was one of vaping, was that it can help people quit smoking. Now that we're in 2025, was that a failed experiment? Did it work? Well, how would you describe it? I would say that you potentially can use vapes to quit smoking, but it needs to be in a very controlled environment, right? You need to have counseling. You need to have a doctor's supervision. You need to have really close follow-up the way you would give a medication, right? As a commercial product, this is a failure because the highest rates of use are by young people. Now, most of the young people using vapes have never smoked cigarettes. So they're just an entry point into nicotine addiction. And the real-world way that people are mostly using vapes isn't effective for cessation. After the break, Dr. Ling breaks down why vapes and nicotine pouches are actually more addictive than they've ever been before. Stay with us. Have I Got News For Your Ears, the podcast. I am your host, Michael Ian Black. We're building a ballroom. They've wanted a ballroom for 150 years, and the ballroom's going to be beautiful. I'm not sure it's a terrible idea, but it's problematic for other reasons. That's not his house. No. He's not allowed. It's like when you live in a development, like there's HOA rules. Yeah. You can't just do whatever you want. Where are the HOA rules of the way else? I know one of them is that you can't tear down the East Wing. Have I Got News For Your Ears releases new episodes every Wednesday. Don't miss an episode. Follow us wherever you get your podcasts. Are we doing enough as a society in terms of regulation around vaping? I think we could do more. Because correct me, so flavors were a big concern. And it seemed like a lot of flavors were sort of designed to be attractive to young people. I mean watermelon and bubble gum and flavors like that. Some of those have gone away. Is that right? And I think menthol was still allowed to exist. But just give us a little bit of the landscape in terms of where the regulation is. Yeah. So when the vaping epidemic was at its peak in 2018, 2019, that was really driven by the product called Juul, a little one that looked like a USB port. Juul voluntarily withdrew their flavors except for mint and menthol and tobacco flavor. So some of the products that had the most scrutiny got rid of some of the flavors. And they did that voluntarily, you said? They voluntarily did that, I think, to avoid having flavors be banned across the board. But what you see if you look on the marketplace or if you go online and look around is that there are still hundreds to thousands of e-cigarette products available in a wide variety of flavors because those products are, I mean, they're officially under the auspices of the FDA, but they're just very difficult to enforce. And they're just tons and tons of flavored products still really easily available. They're also now getting much bigger and stronger. So Juul really dominated the market because they put salts, they put acids into their liquid, which allowed them to deliver a lot of nicotine. And the Juul pod had about 200 puffs in it, which was the equivalent of a pack of cigarettes worth of nicotine. You know, now you can get vapes that contain 6,000 puffs, 10,000 puffs. So they're like 20 times stronger than what was in the Juul pod. And you can buy them for, you know, 10 bucks or certainly under 20. And so you can walk around with like a couple of cartons worth of nicotine, you know, in your handheld device. And the problem for that for young people is that you often don't know how much nicotine is in the vape. And, you know, because you can kind of stealthfully use it all day long in different situations without realizing it, you can become very addicted to the nicotine. I mean, again, I think if there's any good news, I like to celebrate good news. So if there's any good news here, I think that the vaping sort of surged in popularity peaking, it seemed like right in 2019. So just just before the pandemic and by 2024 has dropped to about a third of that peak, which was the lowest level in a decade. So potentially some good news there. But at the same time, a new product sort of emerged. I'm not even sure how to say the ZYN. How do you say that Zen? Yes. Oh, the nicotine pouches. Yes. The nicotine pouches. Yeah. These pouches that contain nicotine. Yes. And ZYN is the most popular brand. So it's like if you were imagining a graph over time, cigarette smoking peaks starts to come down, vaping starts to go up, that starts to come down. And now ZYN, these nicotine pouches, is that just the way it is, Doc? Like every time we sort of start to get a handle on one product, another one comes along. You know, I will tell you that that is the tobacco company's plans. So we talked about in the beginning about the tobacco industry. Twenty years ago, the cigarette company said we have a problem. People are quitting smoking. How do we stay alive as a business? And their plan was basically to transform themselves into like nicotine pharmaceutical companies. And so all of this rolling out the next new products, whether they're heated tobacco products, e-cigarettes, nicotine pouches, other smokeless products. I mean, some tobacco companies also own nicotine replacement therapy pharmaceuticals because as long as they get people addicted to nicotine and they can keep producing a new product, right, they're still making money. So it's not a surprise that as vaping drops off in popularity, the nicotine pouches are coming up because there's a whole arsenal of new products that are rolling out. Along with these campaigns to say it's not a big deal, right? Maybe it's good for you. Don't worry about it. Cool, whatever it might be. Yeah, nicotine pouch is really easy to hide, right? Really easy to hide. They look like candy. And so much of this used to be sort of TV advertisements. And now the other thing that has changed tremendously is social media. And there are these folks that are called ZIN influencers. So they are literally influencers around ZIN, largely sort of credited for the rise of these nicotine pouches. Has that surprised you, just sort of the rise of nicotine pouches? I was a little surprised because, you know, we've had smokeless tobacco products in this country for a long time. And they've never been very popular. I mean, it's been popular among like young men, macho young guys. But for like women and other people, it's like disgusting. And so for a while, the nicotine pouches were kind of associated with chew. But now, because the companies that are promoting the nicotine pouches, a lot of them are vape companies. So they're kind of using all of the techniques that made vapes popular and translating even some of the same brands over to the pouches. And I think that's opened up the market or the audience. The concern I have about pouches not only is the concealability, but they're also getting bigger and stronger. So even in the pouches you can buy this year compared to last year, the milligrams of nicotine. So, you know, when we prescribe nicotine replacement, you know, the low dose is two milligrams and the high dose is four milligrams, right? Zin starts at three and has six. So it already starts out stronger than nicotine replacement. And now you can get nine milligrams, 12 milligrams, 15 milligrams. So all the newer pouches coming out have higher and higher amounts of nicotine in them. So the whole market is going kind of bigger, stronger, cheaper, which again really facilitates addiction. I really resist being preachy at all in life and certainly on this podcast. But what would you say to parents who -- because, you know, I do talk to parents whose kids are vaping and the parents know it. And sometimes I get this sense, doctor, that they are kind of kind of like just let them. You know, like what am I -- it seems insurmountable for them, nicotine so addictive. And then kids go off to college and you don't have eyes on them all the time. And I think it's frightening, but I think there's almost this sense of like despair. Like there's nothing I can do about it. What would you say to those parents? I would say there's always something you can do, right? So parent, you can talk to your kids, but also, you know what parents can do? Parents can do things like put in public comment to the FDA, right? The FDA is taking comments right now on approving ZIN. So if you are worried about your kid using these products, tell your story. Go to the FDA website. Anyone can put in a public comment and say, you know, "My kid is addicted to vaping." And I don't want, you know, the ZINs to be the next wave of nicotine addiction. You can tell the FDA don't approve ZIN or you can say limit the nicotine. Like why does anyone need 15 milligrams of nicotine in a pouch, right? Yeah, I think parents definitely have a voice. And if you're talking to your kid one-on-one, again, I think the way we started this conversation was this idea that what we've learned from big tobacco marketing was that they were selling a product by extolling the virtues of it, obviously not emphasizing the harms. If you reverse engineer that message as a parent talking to a kid, is the message, "Hey, imagine your life without vaping. Imagine your life without these nicotine pouches." As opposed to saying, "Hey, this is so bad for you." Is there a different approach, do you think, in terms of that conversation that parents should be having with their kids that would be more effective in getting them to quit? I think the answer is there might be, right? It might be for some young people knowing the harms, but for some young people, the harms of what they're doing is not going to be the thing that resonates. So it might be, yes, focusing on the positive thing that they do want and seeing how vaping or using pouches interferes with that or thinking about a different reason that might not even be health-related. Sometimes when we get kids involved in these campaigns that are anti-industry, they will quit smoking or vaping on their own, even not for health reasons. They'll just say, "You know, I'm really passionate about this and I just feel like it's not the right thing to do because, you know, I'm part of this campaign." And so sometimes just making a real connection with your kids, no judgment and helping them to connect with things that have meaning can be more effective. And hey, look, these campaigns have worked in the past. We can end the podcast there. There's been some good news, right, in terms of the effectiveness of these campaigns. Maybe we learned it from big tobacco initially, but it doesn't mean that it can't be applied for good. That's right. And we can do more. We can always do more. Hey, I was really looking forward to this. You know, we're both parents and, you know, I think that this is something that a lot of parents are thinking about. So I really appreciate your guidance. Thank you. For sure. It's been a pleasure. I want to thank Dr. Pam Ling for coming on the show and I want to thank you for listening to Chasing Life. 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