14 | F RIDAY, AUGUST 2, 2019 THE NEW YORK TIMES INTERNATIONAL EDITION
Over 3.6 million middle and high
school students in the United States
used e-cigarettes last year, up by 1.
million over 2017. The use of Juul, the
most popular brand in the country,
appears to have led this alarming
increase among middle and high
school students. This should not be a
surprise.
The founders of Juul Labs say that
their product is not intended for young
people but was designed with the adult
smoker in mind. “We want to be part of
the solution to end combustible smok-
ing, not part of a problem to attract
youth, never smokers or former smok-
ers to nicotine products,” the company
says on its website.
That’s important, but it misses an
essential point: Based on what we
know about cigarettes, the unique
design of Juul may make it easier for
young people to use its product, which
delivers high-nicotine vapor. This is
known in public health circles as “fa-
cilitating initiation.” And that’s because
the blueprint for that e-cigarette could
easily have been taken straight out of
the tobacco industry’s playbook.
The makers of Juul and other e-
cigarettes are in the process of seeking
approval from the United States Food
and Drug Administration to continue
selling their products, as required by
new federal regulations. To win the
go-ahead as so-called new tobacco
products, the e-cigarettes must “pro-
tect the public health.” If Juul’s design
facilitates use by young nonsmokers, it
will likely fail under that standard.
The only other way Juul can remainon the market is to apply for status as
a smoking-cessation drug. Tobacco
products can be sold anywhere, includ-
ing gas stations and convenience
stores. But smoking-cessation drugs
can be restricted to prescription or
behind-the-counter sales.
Twenty-five years ago, the F.D.A.,
which I headed at the time, investi-
gated the tobacco industry to under-
stand what it knew about nicotine, its
addictive properties and how nicotine
was manipulated to make it more
pleasant for smokers. That inquiry led
to Congress giving the F.D.A. authority
to regulate both traditional cigarettes
and e-cigarettes.
The agency began
exercising authority
over e-cigarettes in
2016.
In internal tobac-
co industry memo-
randums that now
date back almost 50
years, cigarette developers discussed
how to design new brands that would
be particularly attractive to young
smokers while appealing to all smok-
ers.
The industry recognized that attract-
ing young smokers was critical to its
long-term success. It also understood
there were differences between
“presmokers,” “learners” and “con-
firmed smokers.”
For the presmoker and learner, the
physical effects of smoking were quite
unpleasant. But the addictive proper-
ties of nicotine could override the
unpleasantness. The key for a success-
ful youth brand was to reduce nico-
tine’s harshness and improve the
smoothness of the smoke.
As early as 1954, the industry tested
adding organic acids to burley tobaccoblends to reduce the harshness of the
nicotine, and found that many of those
acids significantly improved smooth-
ness. Smoothness became the focus in
designing a new cigarette for first-time
smokers. A published study of industry
documents concluded that “product
design changes which make cigarettes
more palatable, easier to smoke, or
more addictive are also likely to en-
courage greater uptake of smoking.”
Today, e-cigarettes are typically
made with nicotine from tobacco.
Before Juul, they generally contained 1
percent to 2.4 percent of nicotine ex-
tract that had not been treated with
acids. Juul increased the nicotine
“kick” by using up to 5 percent nico-
tine, and made that palatable by add-
ing organic acids to reduce the harsh-
ness, just as the industry had explored
doing decades earlier with cigarettes.
Other characteristics of Juul’s design
also make it easier for young people to
begin using e-cigarettes. They include
the use of flavor additives like mint
and fruit. Responding to criticism, Juul
recently stopped selling some flavors
in retail establishments and limited
them to online, age-verified sales. And
for young people at school, the size of
the vapor cloud — small but with high
nicotine — makes it less likely to be
detected.
Each Juul cartridge with 5 percent
nicotine delivers 200 puffs, compared
to the 10 to 15 puffs of a traditional
cigarette. As a pediatrician, I am very
concerned about the possibility of
increased daily nicotine consumption
among some young people.
I had hoped there could be a substi-
tute for traditional cigarettes that
offers a less risky nicotine delivery
system for those who are addicted to
nicotine, have not been able to quitsmoking and need an “off ramp.”
Juul is not that product. Its funda-
mental design appears to ease young
people into using these e-cigarettes
and ultimately, addiction. Those who
support the use of e-cigarettes to help
addicted adults quit cigarettes should
support clamping down on brands like
Juul that appeal to young people.
Last week, James Monsees, a co-
founder of Juul Labs, testified to Con-
gress that “our company has no incen-
tive to see minors use our products.
We know there is skepticism on this
point, but it is simply the truth.” If
that’s the case, then the company
needs to change the design of its prod-
uct. If it doesn’t, the F.D.A. should
reject it as a new tobacco product.
The company should also make public
any clinical studies and consumer
perception surveys. And now that the
tobacco giant Altria owns a 35 percent
stake in Juul Labs, which has an esti-
mated $38 billion valuation, it should
disclose what it knows from its own long
experience about reducing harshness
and increasing nicotine. This will help
the F.D.A. encourage products that help
smokers quit but do not initiate kids and
young adults into the habit.
The words of Addison Yeaman, the
general counsel for the tobacco com-
pany Brown & Williamson, written in
1963, are equally applicable today: “We
are, then, in the business of selling
nicotine, an addictive drug.” A long and
tragic history has taught us that nico-
tine addiction often begins as a pediat-
ric disease.David A. Kessler
DAVID A. KESSLER, a professor of pediat-
rics at the University of California, San
Francisco, was commissioner of the
Food and Drug Administration from
1990 to 1997.The e-cigarettes kids love
HAYLEY WARNHAMJuul’s devices
seem perfectly
adapted to
appeal to
young people.So, who won the Democratic debates?
My vote is for Elizabeth Warren and
Bernie Sanders. Sure they were both
on Day 1, but nobody on Day 2 came
close.
Unless you figure that Joe Biden
triumphed by failing to fall down. Some
of his answers might have been a bit
muddled, and he sort of faded off after
the first hour. But expectations were so
low, that was like clearing a high hur-
dle.
Everybody looked forward to his
meeting with Kamala Harris, who had
tortured him so effectively in Debate 1.
“Go easy on me, kid,” Biden told her
when they shook hands. It was either
typical nice-guy Joe or yet another
moment of Not Getting It by a former
vice president who doesn’t know you
don’t call a female member of the U.S.
Senate “kid.”
You pick.
Biden had a double challenge. The
progressives were laying into him
about his Mr. Moderate agenda, and
everybody was reminding him of his
sometimes-grimy decades of life as a
classic Senate deal-making insider. Allthat history, from Biden’s perspective,
was washed away in his eight years of
hanging around with Barack Obama.
“We’re in a battle for the soul of
America,” he said in one of his best
moments, which just involved repeat-
ing something he tells his audiences all
the time. If Donald Trump got re-
elected, Biden warned, “the America
we know will no longer exist.”
The specter of You Know Who was
looming behind everything. Everybody
knew that the only thing that really
mattered was getting rid of Donald
Trump, who was having a rather typi-
cal week of doing his best to ruin the
country.
For instance, the nation learned that
his pick for director of national intelli-
gence was an extremely conservative
congressman whose greatest qualifica-
tions were six months on the House
Intelligence Committee and a super
deep dedication to Trump.
And the president signed a bill fund-
ing care of 9/11 responders, taking the
opportunity to mention his own alleged
role post-terror attack.
“And I was down there also, and I’m
not considering myself a first respond-
er,” he said modestly. “But I was down
there. I spent a lot of time down there
with you.”
The man was looking out a window
from his luxury quarters uptown. And
bragging on radio that with the World
Trade Center gone, his building on
Wall Street was the tallest building
downtown.
And even that wasn’t true!
O.K., enough. We’re thinking aboutthe Democratic debates.
Twenty candidates over two days,
and only a handful of them had any
real business being on the stage. Lis-
tening to Bill de Blasio rant and preen,
the nation got a good hint of why no
mayor of New York has ever been
elected president. Harris totally failed
to live up to expectations, and sort of
floundered on the health care front.
The star of the first night was War-
ren. (“We’re not going to solve the
urgent problems that we face with
small ideas and
spinelessness.”) As a
result, some Biden
backers are talking
of recruiting her as
their vice-presiden-
tial nominee. This is
a problem both for
those who believe
Warren deserves to
be first and those
who believe a na-
tional ticket should ideally include at
least one person under the age of 70.
Anybody stand out on Night 2? Well,
Cory Booker did a good job of defend-
ing himself against Biden’s attacks on
his record as mayor of Newark. “Mr.
Vice President, there is a saying in my
community — you are dipping into the
Kool-Aid and you don’t even know the
flavor,” he rejoined at one point. It was
not the most impressive part of his
argument, but it was pretty much the
best quote of the night. Except for
Kirsten Gillibrand’s announcement
that the first thing she’d do as presi-
dent is “Clorox the Oval Office.”Let’s have another debate with just
Warren versus Biden. And maybe we’ll
throw in Booker and Bernie Sanders.
Sanders was the other top first-night
performer. And definitely the loudest of
the field of 20. Is that a good thing? If
voters are looking for change, will they
be excited about a guy who’s really
into shouting? It certainly made an
impact — Representative Tim Ryan
came out of the Tuesday round remem-
bered mainly for telling Sanders, “You
don’t have to yell.”
We’ve still got 10 more debates to go.
The next round is scheduled for Sep-
tember, in a week that begins with
Grandparents Day and ends with a full
moon. Perhaps Warren, Biden and
Sanders will show the audience pic-
tures of their grandchildren while Pete
Buttigieg will suggest that he is young
enough to be one of them. Then Biden
can point out that would happen only if
his parents and grandparents were
married in their teens.
Then comes the full moon. Who do
you think will be the surviving con-
tender most likely to howl?
At the end, two ways of looking at
this week’s debates. They weren’t, well... stirring. Viewers on CNN who
made it through the nearly five hours
deserved a medal reading, “I stayed
awake until Jake Tapper said good
night.”
On the other hand, you had 20 candi-
dates, and at least a dozen or so
seemed as if they’d be pretty good
chief executives. And 20 of whom
would be a huge improvement on the
status quo.
Fight night, er, debate night: Biden vs. the world
Two nights
of fighting:
One was one
versus one,
and the other
was nine
versus one.Gail Collins
opinion
A surge of migrants from Central America has over-
whelmed the border management system. Nearly a
million are expected to cross the southwestern border
by the end of year. Most hope to apply for asylum, add-
ing to a backlog already stretching back years.
It should be in the DNA of the American people, the
overwhelming majority of whom are themselves de-
scendants of immigrants who found refuge, opportunity
and happiness in the United States, to approach this
crisis with humanity. There must be a way to house the
migrants, accelerate the hearings and protect the bor-
der with respect for the dignity and rights of these des-
perate people.
And it should be a source of shame for all Americans
that their president has attacked the problem with cru-
elty and disdain for law and human rights, attempting
tactics that, one after another, have been blocked by
legislators or courts, and all the while trumpeting lies to
his followers that the migrants are gangsters, drug
smugglers and job stealers.
Outrageous consequences of this approach appear
with dismal regularity. The latest was the arrest and
23-day detention of an American-born United States
citizen because officers at one of many checkpoints in
South Texas didn’t believe that the documents he
showed were real. Francisco Erwin Galicia, 18, said he
had lost 26 pounds at the overcrowded immigrant de-
tention center, where men slept on the floor and were
not allowed showers. Mr. Galicia was released only
after The Dallas Morning News learned and told his
story.
There are valid reasons Customs and Border Protec-
tion agents might have wanted to take a closer look at
Mr. Galicia’s documents. His brother and another pas-
senger in the car in which he was stopped were undocu-
mented immigrants, as is his mother, who used a false
name on his birth certificate. These are the sad realities
of the lives of people who lack legal status in the United
States.
But his detention was hardly an isolated mistake —
hundreds of American citizens have now been detained
on suspicion that they are living illegally in the United
States, including a man held in custody for 1,273 days.
Mr. Galicia had sufficient proof of American citizenship
to rate a far speedier investigation.
The entire system of checkpoints, detention centers
and immigration agents hunting for Hispanics — along
with all the horror of children penned in disgusting
conditions and a cascade of immigration policies that
violate fundamental rights — perverts American values
and traditions. It is a victory for the xenophobic and
racist vision promoted by President Trump’s far-right
adviser Stephen Miller and exploited by Mr. Trump
from the day he announced his candidacy.
Among their latest sallies was a rule announced this
month that would deny asylum to anyone who had
failed to apply for — and be denied — protections in at
least one country they passed through on their way
north. That means Hondurans and Salvadorans would
have to apply for asylum in Guatemala or Mexico be-
fore they could apply in the United States. Mexico has
refused to go along with the scheme, but the White
House said last week that Guatemala had agreed to a
“safe third country” agreement, under which it would
require migrants heading north to seek asylum there.
Guatemala had balked at going along with the scheme
until Mr. Trump threatened the country with tariffs,
remittance fees and an unspecified “ban.”
The rule and arrangement could have effectively
denied asylum to anyone coming to the United States
by land other than Mexicans, who rarely seek it.
And so it goes, a relentless assault on the right to
asylum enshrined in international law — “ridiculous”
and “insane,” says Mr. Trump — and elemental decency.
In the administration’s view, most recently displayed by
Mr. Miller in an appearance with Chris Wallace on Fox
News, anyone who opposes the Trump policy on immi-
gration exhibits a “deep-seated hatred of the nation as it
exists” and doesn’t care “if American citizens lose their
jobs, lose their homes, lose their livelihoods, lose their
health coverage and lose their very lives.”
That accusation is not only false and offensive. It also
omits any hint of sympathy for the people who under-
take the perilous and uncertain trek north, usually to
escape poverty and violence in Honduras, El Salvador
or Guatemala. And it omits any optimism about the
contribution that such determined immigrants are
likely to make to the United States. Such people have
always been essential to creating and sustaining Ameri-
ca’s standing as a shining city upon a hill. A comprehen-
sive immigration law is long overdue. It must be based
on American tolerance and humanity and animated by
an American vision of a better future.Immigration
reform is long
overdue, but it
must be based
on inclusion
and humanity,
not on cruel
posturing.TRUMP’S WALL GETS THE U.S. NOWHERE
A.G. SULZBERGER,PublisherDEAN BAQUET,Executive Editor
JOSEPH KAHN,Managing Editor
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KATHLEEN KINGSBURY, Deputy Editorial Page EditorMARK THOMPSON,Chief Executive Officer
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