Last week President Joe Biden signed legislation that allows the Food and Drug Administration to regulate synthetic nicotine, used in vape products popular among teens.

Kentucky advocacy groups say the state's high level of vape product use among young people is setting the stage for a serious public health crisis.

E-cigarettes or vapes typically contain as much or more nicotine than traditional cigarettes, but until now manufacturers have skirted government regulations by using a synthetic version of the chemical.

Dr. Scott Bickel - assistant professor of pediatrics in the Division of Pediatric Pulmonology, Allergy, and Immunology at the University of Louisville School of Medicine - explained that the nicotine and other toxic substances found in vape products can have substantial health consequences.

"Can lead to impulsivity, difficulties with brain development, and so on," said Bickel. "And then certainly the respiratory consequences of starting those things early can't be overstated."

Congress moved to give the FDA the authority to regulate synthetic nicotine in the $1.5 trillion spending bill that funds the government through September. Biden signed the legislation into law last week.

More than one in four Kentucky high schoolers use e-cigarettes. According to the Centers for Disease Control and Prevention, e-cigarette sales hit a record high last June, with more than 22 million units sold nationwide.

Allison Adams - vice president for policy with the Foundation for a Healthy Kentucky - said the experience of the coronavirus pandemic highlighted how tobacco can make individuals more susceptible to respiratory illnesses such as COVID-19.

She added the Commonwealth has one of the highest rates of tobacco use in the nation.

"And so knowing that we weren't coming into this pandemic as a healthy state," said Adams, "we were on a trajectory for loss and less ability to fight it off quickly and rapidly."

Adams said the state could allow local communities to make their own decisions about how tobacco products are marketed, sold and distributed at the local level to help protect the health of young people.

Hannah Abdon is a senior at Boone County High School. She said she believes her classmates have gravitated toward vape products because of heavy advertising in her community.

"On my drive to school," said Abdon, "I think I pass three different places, and these places all sell vapor products, and they have advertisements in their storefronts that I can see when I'm driving past."

Tobacco and e-cigarette industries spent more than $788,000 lobbying Kentucky lawmakers in 2020, according to state data.

The American Lung Association has released its 2022 State of Lung Cancer report, which shows Indiana has some work to do.

The leading cause of lung cancer is smoking, and the state ranks high in the Lung Association report with 19% of Hoosiers doing so. Indiana also ranks high with the second leading cause of lung cancer, as 40% of home radon tests are at or above the Environmental Protection Agency action level. With early detection, the five-year lung cancer survival rate is 61%.

Tiffany Nichols, Indiana director of advocacy for the American Lung Association, said many people don't realize treatments are possible.

"Many Hoosiers don't understand that there are lifesaving treatments out there," Nichols observed. "I think we need to do a better job at letting people that are at risk of getting lung cancer know there are things out there. They don't necessarily have to die from lung cancer."

She encouraged people to ask their doctors to find out if they are eligible for a lung-cancer screening.

Indiana ranks 20th in the nation in early screenings, but it still represents only 7% of high-risk patients, and nationally only 5% are screened. The Lung Association maintains states should mandate coverage of lung-cancer screenings "in all fee-for-service and managed-care plans without any financial or administrative barriers in their Medicaid programs."

Nichols added health professionals need to advocate for screenings.

"I think health professionals need to make it known that there are screening things that are out there that can help to diagnose and to check for lung cancer early," Nichols urged.

In March of last year, the U.S. Preventive Services Task Force updated the recommendations around lung cancer screenings to include a larger age range and more current and former people who smoke.

A new report from Stanford University finds tobacco companies continue to directly target African Americans, women, and young people with their advertising, creating a larger market for a product which has been linked for years to cardiovascular disease and cancer.

It comes as efforts are underway at the state and federal levels to remove menthol cigarettes from the market.

Dr. Robert K. Jackler, professor at the Stanford University School of Medicine and the report's lead author, said the preference among the targeted groups for menthol cigarettes is the product of a concerted campaign.

"Urban heavily Black-populated areas got carpeted by billboards and signs in store windows, discount coupons," Jackler explained. "The companies would have vans that would give out free samples of cigarettes in poor neighborhoods."

In 2020, the California Legislature prohibited most flavored tobacco products, but the law was put on hold when the industry gathered signatures to force a referendum. In November, voters will consider Proposition 31, which upholds the restrictions. And the industry is funding the "No on 31" campaign, arguing blocking adults from buying menthol products would lead to a drop in sales-tax revenue and create an illegal market, increasing crime.

Jackler predicted voters will pass the ballot initiative, reaffirming the California Legislature's intention to remove most forms of flavored tobacco from the market.

"The tobacco industry is very cynical," Jackler asserted. "They used the initiative petition to buy a couple of more years of profit off of California. They knew they were going to lose this, I think, in the election."

The report finds tobacco companies market menthol to youth because it makes it easier to smoke, masking the taste and numbing the throat. It also noted menthol encourages deeper inhalation and thus, greater exposure to nicotine.

Dr. Jessica Sims, medical director of managed care at UCLA Health and an American Heart Association volunteer expert, thinks removing menthol cigarettes and flavored vaping products from the market will improve public health.

"Nicotine itself has been demonstrated to cause permanent harm to the teenage brain that's still developing," emphasized. "It causes difficulties with attention and memory, and can impact someone's trajectory in life."

In April, the FDA proposed to remove menthol cigarettes and flavored cigars from the market but no final rule has been issued. In 2009, Congress passed the Family Smoking Prevention and Tobacco Control Act, which prohibited all flavors other than tobacco and menthol in cigarettes.

After an investigation found the e-cigarette maker Juul Labs deliberately targeted young people using a variety of marketing practices, Tennessee is among the states that will benefit from the court settlement.

Juul has said its aim has been to "transition adult smokers away from cigarettes," but states argued that its advertising showed otherwise. Tennessee is one of 34 states that will share more than $438 million.

In addition to explicit advertising to kids, said Tennessee Attorney General Jonathan Skrmetti, the company is required to stop even so-called "subtle" forms of marketing through social media and other avenues "such as funding education programs, which let them put their name and the existence of their product in front of kids. They're not allowed to use people under the age of 35 in their marketing. So, they can't pay influencers; they can't use celebrities who are younger, who appeal to younger people."

He added that the company can no longer sell flavors that aren't approved by the Food and Drug Administration, or misrepresent the nicotine content in its products. Juul also will have to verify the age of its followers on Twitter and Instagram. Skrmetti said the settlement money will go into the Office of the Attorney General's Reserve Fund, to support ongoing consumer-protection efforts.

Skrmetti said the company's tactics, like those of big tobacco in previous generations, were aimed at creating a new crop of long-term customers.

"If they're adults and they choose to use these products, that is their choice," he said. "But when they're younger - when they're more vulnerable, when they're not in a position to make that informed decision - this settlement will protect them from the subtle manipulation that could otherwise turn them into lifelong consumers."

According to the Centers for Disease Control and Prevention, as of last year, around 2 million middle- and high-school students said they recently had used e-cigarettes.