Interview with Dr. Susan McDowell, MD, on the Vaping Crisis in Western North Carolina

February 24, 2020

1. Please introduce yourself (background/education/experience/current organization & role, etc.)

I grew up in a rural area of Southwest Virginia, drawing me towards rural health throughout my career. I’ve also always been interested in tobacco topics because I knew people whose parents were tobacco farmers and my hometown was greatly impacted by tobacco. I even had a friend who went to college on a tobacco scholarship designed to assist residents of the tobacco region in obtaining levels of education previously not promoted or available in the region

I graduated from the Medical College of Virginia and I currently work at MAHEC as a Substance Use Educator and served as the WCMS Foundation Chair last year. I initially educated about opioids mainly but have expanded into the vaping realm within the past year because of what we noticed happening in the community. Prior to this work, I was working in Madison county for 6 years with the Hot Springs Health Program as a Primary Care Physician. 

2. Please describe the extent of the vaping crisis in Western North Carolina and ways in which you measure that (include any common terms/phrases we should be aware of). Are there any statistics you think might surprise providers in our region regarding this issue?


The National Tobacco Survey that is released every 2 years recently showed that nearly 30% of 12th graders and 9% of 8th graders nationally have used e-cigarettes within the past 30 days. In 2017, the North Carolina Youth Tobacco Survey showed less than 20% of highschoolers had used e-cigarettes within the past 30 days and we’ve seen a steady rise since then. We typically see about 2-3% higher usage rates as a state in North Carolina than the national rate. If you ask highschoolers locally, they typically estimate that 50-60% of students are using e-cigarettes. Anecdotally, we’ve even heard of one 4th grader who's tried it. 90% of people using cigarettes later in life started before age 18 which is why this is particularly concerning. Being exposed to nicotine before the age of 18 primes your brain to use other substances in the future. There’s a strong link between nicotine exposure and opioids, methamphetamines, and other similar substance use. One student, Luka Kinard,  ended up in an inpatient rehab facility at age 16. 


One term they use is called “juul” or “juuling”, advertised online as “The Smoking Alternative, unlike any E-Cigarette or Vape”.  Sometimes students won’t say they’ve used tobacco because they don’t associate “juuling” with tobacco use. “Puff bars” is another term commonly used which refers to disposable, flavored e-cigarettes that are technically legal under new legislation that prohibits flavored juuls and raised the legal vaping age to 21. “Dabbing” means taking the e-cigarette apart to be able to inhale other substances. EVALI stands for E-cigarette or Vaping Product Use-Associated Lung Injury. 


“Juuling” was developed by Stanford graduates who used nicotine salts to make the product more potent, more addictive, and (perhaps intentionally) hook a new generation. Adult use hasn’t increased, but teen use has skyrocketed since 2011 in correlation with the amount of dollars spent on advertisements targeting youth. There’s a Netflix documentary describing this phenomenon in more detail called “Broken” that looks at four different popular consumer items, including vaping. 

3. What causes do you believe initiated and/or exacerbated this problem (and when)?

The first e-cigarette was invented in 2007 in China as a tobacco cessation tool. When it came to the US, due to a lot of lobbying from the tobacco and vaping industries, they decided to regulate it as a tobacco product instead of a tobacco cessation device, meaning it was less strictly regulated. The Juul product is owned by Altria, one of the world's largest producers and marketers of tobacco and the parent company of Philip Morris International, most recognized for selling Marlboro. 

There has been an 894% increase of highschoolers using e-cigarettes since 2011. Interviewing teenagers, about 66% thought it was just flavored air and didn’t contain nicotine or tobacco. When asking why teens use e-cigarettes in a survey conducted by the Truth Initiative, 39% said peer pressure, 31% said flavors, and 17% thought it was a less harmful alternative to cigarettes. 

Unfortunately, high schools tend to address e-cigarette use from a disciplinary approach instead of as a possible addiction to nicotine . Project Aspire created an in school suspension alternative model for kids who were caught vaping to help address this. Lack of government oversight is still a concern as well. In Europe, e-cigarettes are approved as a tobacco cessation device but the surgeon general disapproved of this idea in the US.  However, advertisements for e-cigarettes are now required to include a warning and are prohibited from targeting youth populations. 

4. Which populations/areas are most vulnerable and why?

While public health efforts are generally focused on middle school and high school populations due to the increased risks associated with being exposed to nicotine under the age of 18, all youth under the age of 25 are being impacted. The LGBTQ community has a higher rate of vaping use and has been targeted by Juul in previous campaigns. There is speculation that the African American community is also being targeted because the remaining legal flavors allowed by the Trump administration are tobacco and menthol, menthol being the most popular flavor among the African American community. 

5. What efforts/programs are currently in place to address the issue? How are they performing? Are there any gaps in those efforts?

  • Prevention efforts

  • Education efforts 

    • MAHEC Event on April 2nd: Pods, Mods and Vapes - Oh My!: E-cigarette Summit: What Adult Allies of Youth Can Do -2020 Update!

    • Buncombe County Substance Free Youth- highschoolers working on prevention efforts through a peer-to-peer curriculum 

    • MAHEC is planning to do a 1 hour CME event this spring designed for providers

  • Treatment

    • Medications for adults aren’t approved for kids [Wellbutrin (bupropion) & Chantix (varenicline)] 

    • Nicotine replacement therapy requires a prescription for minors 

    • The quitSTART app is a free smartphone app that helps you quit smoking with tailored tips, inspiration, and challenges

    • Behavioral efforts including motivational interviewing, cognitive behavior therapy, etc. have proven helpful 

  • Harm Reduction efforts

    • Encouraging people to not modify devices (“dabbing”) - EVALI has been linked to a filler used when dabbing (vitamin e acetate

    • Helping youth understand why flavors are approved for oral consumption but not for vaping 

6. What can providers and/or other concerned individuals in the region do to help support those efforts?

  • Seek education and connect with the Tobacco Prevention and Control Branch of the North Carolina Department of Health and Human Service

  • Ask the right questions with teens

    • CRAFFT 2.1 N is a questionnaire specifically designed to screen for substance use including e-cigarettes in 12 to 17 year olds

  • Treat it as an addition (substance use disorder) instead of as a disciplinary behavior

7. Is there anything else you think we should be asking or important information you’d like to share on the topic? 

My top three recommendations for resources are:


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