Your Role in Truth Initiative’s New Vape Battle 

(00:00)
[instrumental music plays]

Mark Masselli (00:04)
The Truth Initiative is trying to help make 2026 the year Americans quit vaping. In fact, their polling shows a
huge majority, 67%, plan to give up their nicotine addiction this year, but there are personal, as well as policy
challenges, to achieve that goal.

Kathy Crosby (00:23)
We are all-day, every-day behavior change to help people live healthier lives, and that's what, that's what I get
up every day doing is like knowing that we're helping people. In just one month, between middle of December
to middle of January, over 50,000 people enrolled in EX Program to ask for help in quitting.

Margaret Flinter (00:46)
Our guest today is Kathy Crosby. She is the CEO and president of the Truth Initiative, the nation's largest non-
profit public health organization dedicated to achieving a culture where all young people reject smoking, vaping,
and nicotine.

Kathy (01:01)
I would say, you know, as, as wonderful a job as the public health groups have done in driving down smoking,
the industry continues to innovate in a way that's very appealing to youth.

EX Program Commercial (01:11)
Quitting vaping on your own can get hated. But with EX Program, you can outsmart nicotine and increase your
odds of quitting. Join EX Program for free.

Margaret (01:25)
This is Conversations on Healthcare.

Mark (01:38)
Well, Kathy, welcome to Conversations on Healthcare.

Kathy (01:41)
Thanks so much for having me. I really appreciate it.

Mark (01:43)
You know, we had your predecessor on, Robin Koval, 2020, so it's been a while, so we have a lot to catch up
on. Maybe we can start by asking for the latest details about nicotine addiction. and I know a Truth Initiative
report highlighted that the nicotine product market, especially s- smart vapes, flavored nicotine pouches, and
disposable e-cigarettes, that market is really evolving very quickly, and perhaps many of us assumed we were
winning the war against tobacco because of the successes in the past with cigarettes. Tell us what's gone off
track.

Kathy (02:21)
Sure. So, so first of all, I think that we have seen a significant public health victory in that we genuinely have the
lowest smoking rates for adults and the lowest smoking rate for teens ever, which is huge. But as you know, the
industry continues to reinvent themselves, and we saw a huge uptick in youth use of e-cigarettes starting in 19-
2015 all the way into like 2019, where we saw a, a total of 5.6 million youth addicted to vaping. And so, at the
time, it was really a crisis, and we've done a significant amount of good, the public health community, in driving
down, youth vaping rates. They're now at the lowest rates they've been in a decade. But still, the industry
continues to change itself. And so, if you look at, the, the amount of flavored vapes in the market, if you look at
smart vapes, so vapes are designed now with screens. They're designed to be games. They're designed to be held
in your hand, and it, it tells you if, you've gotten too far away from your vape. It'll beep you. So, I feel like the,
the way that these, products continue to evolve, they're very, interesting and appealing to youth. The flavors
they come in are, are a huge attraction. And the vast majority of these products are illegal to be sold in the
United States. The Food & Drug Administration has said that they are illegal. They're not appropriate for
the protection of public health when it comes to, talking about teens and youth use. And so, the industry evolves,
and now we have a massive increase in the amount of, they're called pouches. And they're, they're literally,
literally, nicotine that you put in your lip. And the- there's been tremendous amount of growth in that one

category of product. And so, I would say, you know, as, as wonderful a job as the public health groups have
done in driving down smoking, the industry continues to innovate in a way that's very appealing to youth.

Margaret (04:13)
Well, clearly, we're up against quite a bit, here, and, innovate seems to be the name of the game, I think, in
terms of addressing it. So, I understand there's new research in the Journal of Adolescent Health, that found that
messages that focused on mental health were very successful when trying to help young people, quit e-
cigarettes. I found that a little bit surprising, so tell us more about that.

Kathy (04:35)
Sure. So, one of the things that we know through our research is that the reason why young adults wanna quit,
over 67% say they wanna quit this year, is because they're very worried about their mental health and their
physical health. And we know that once you're addicted to nicotine, going through the cycle of dependence can
make you more anxious and more depressed. And so, there is a link between nicotine dependence and symptoms
of anxiety and depression. And so, I think that this, this cohort of young adults are especially interested in being
healthy, and mental health is talked about in a way that it hasn't been talked about in generations past. And so, I
think that they really do wanna quit because they recognize that while they, they might have started to use these
products because they were feeling stressed, these products actually make it, make their lives much more
stressful because they are a part of an addiction loop that, is incredibly hard to break.

Mark (05:37)
You know, Kathy, you're calling for stronger enforcement and regulatory action to protect young people,
including federal oversight, and retailer accountability. Tell us a little more about what the legislation would
look like and where does it stand now in Congress? And maybe you can add onto that, where someone like
Secretary, Kennedy is on all of this.

Kathy (06:02)
Sure. So, so FDA currently has the authority, complete authority to regulate these products and as I mentioned
earlier, they go through a, a comprehensive process of scientific evaluation of each and every product
application, and FDA has denied almost nine- over 90% of e-cigarette applications and novel product
applications because they cannot be found as being appropriate for the protection of public health. That is the
legal bar that FDA must, basically, set. It's a legal bar that they set to ensure that products, do not cause harm.
And so, these products, FDA has said are not legal to be sold, but yet retailers continue to sell them. And I think
they would say there's confusion in the marketplace about what is l- able to be sold, but any convenience store
you walk into, most likely over 85% of those products that they are selling are illegal. FDA has only authorized
over 34 products that are, allowed to be sold that are e-cigarette products. So, all the flavored products that you
see out there, with the exception of a few menthol products, are not legal to be sold. So, so much can be done if,
retailers will, will be responsible in selling only products that FDA has said are authorized to be sold and if the
manufacturers themselves, do not ship products into the United States. I mean, the majority of these products are
coming in illegally from China, so if, manufacturers are responsible and retailers are responsible, it would make
it so much easier to close the youth access and what they're able to, to get in this marketplace. So, so much
could be done. I do think the FDA is doing their job in reviewing and analyzing these products, deciding
whether or not they can stay on market. They have authorized, as I said, I think 34 different e-cigarette products.
They have started to authorize a few of the, of the novel pouch products like Zyn. but those products are the
only ones that should be sold, and they are really only beneficial for adult smokers who are trying to leave
smoking completely behind. And if they switch and use these products exclusively, FDA has said that their risk
will be lessened. But, but for a youth who has never used a product, these problem- these products only pose
risks for them.

Mark (08:15)
Tell me, are there, is there any state regulatory action, any best practices happening in states until, in terms of
monitoring retailers?

Kathy (08:25)
Sure. And, and a lot of states have what are called, voluntary compliance laws, and those laws were really
created for cigarettes. And now that new and novel products, you know, are- have been exploding in the last
decade, they need to update their laws to ensure that voluntary compliance with the retailers also includes things
like e-cigarettes and novel nicotine pouches. So that's one thing they're doing. I mean, the states are doing a
phenomenal, job, but enforcement is everybody's problem. It's a federal problem, and it's also a state problem.

And so, you know, honestly, more could be done to try to get these illegal products off the market. And it, it
would also-

Mark (9:00)
Any, any best practices, any best practices in a particular state that we could point to?

Kathy (09:06)
Sure. I think California has done a phenomenal amount, in terms of, like, making the sale of flavored products
completely illegal at a state level. S- so has the state of Massachusetts. And so, when the states are putting in
flavor bans, you can really see the impact because sales go down. Sales to, you know... Well, first of all, these
products are illegal to be purchased by anybody under the age of 21, so they shouldn't be on the market in the
first place. They should definitely not be sold. But states like Massachusetts and, California have some
significant laws that are also helping to drive down youth access.

Margaret (09:42)
Well, that's good to hear 'cause I'm having a little cognitive dissonance here, hearing that they're evaluated,
they're found, to be harmful, they're not legal, and, the last time I looked, I thought that was problematic for-

Mark (09:55)
And what we hear, coming from China is only the fentanyl issue.

Margaret (09:58)
Right.

Mark (09:58)
We don't, we're not hearing about this issue as-

(09:59)
We haven't heard about this. So maybe just, just sort of level set, for our, audience some, some facts we've
gleaned, from you, Kathy, and wanna ask a little bit about, that between 2017 and 2022, disposable e-cigarettes
nearly tripled in nicotine strength. We didn't see that with cigarettes. Quintupled in e-liquid capacity, and most
surprising to me dropped in price by nearly 70%. You add to that do not have FDA, authorization, making their
presence illegal, and you're really gonna have to explain to us maybe again how can this be possible? And right
in front of our noses. Right in front of us. That they are illegal and that people have a choice about selling illegal
things. You couldn't sell marijuana back in the day over the counter when it was illegal, and now there's a whole
industry and, and shops. You know, whether you agree with it or not, that's a, a legalized industry. Maybe just
shed some more about who's fighting this. Where's, where's the advocacy coming from to say you are creating
an addiction in our young people under our noses?

Kathy (11:05)
So, so, so I think the advocacy is really coming from public health groups like Truth Initiative, the Campaign for
Tobacco-Free Kids, American Heart Association, American Lung Association. You know, there are, American
Academy of Pediatrics. I think the problem is, is, very widespread. And so how, how it goes is that FDA got
authority, they deemed authority over e-cigarettes in 2016. At that time, there were probably hundreds of
thousands of products on the market. FDA gave them a length of time to be able to get their applications to the
FDA, so it was a brand-new process for them. And then FDA received millions of these applications, and, and
you can imagine what it takes to go through millions of a- applications. So, for a window of time, these products
were allowed to stay on the market unauthorized while FDA was going through their complete review process.
fast-forward to s- like 2021, 2022, I forget the exact year, FDA had gone through the majority of applications,
the vast majority of applications, and they look for a very strenuous scientific bar, and they found that these
products did not meet the scientific bar that is appropriate for the protection of public health. So, a lot, the vast
majority of these products were deemed to be non, marketable-But then the, the onus falls on the retailers to pull
them off the shelves. And so, you know, the, the industry would immediately sue the FDA, and then during a
pending lawsuit, no action can be taken, so that further confounds why these products remain on the market.
And so, FDA's trying to do their job. They're trying to go through all the litigation proces- process. Many of
these, have a- actually gone to the Supreme Court, these cases. So, it is a long process, and during that process,
the products are allowed to stay on the market. and then you have a lot of illegal products coming in from China.
they are prim- primarily ma- manufactured in one area within China, and it is a really hard problem to, to catch
these products at the border, so that further compounds the problem. And so, the ... I know there's a federal task
force, whether it's, ATB, whether it's, I'm gonna forget all the acronyms. I'm so sorry. But that works with a

combination of DOJ, ATF, and other agencies, as well as Customs and Border Patrol, to try to stop these
products from coming in. and then we have to work with all of the manufacturers to make sure that they're not
getting, shipped across state lines. So, it is a very complex problem. And in the meantime, I think people don't
understand that these products, by and large, are illegal. There are some products that are v- vaping products and
that are nicotine patches that FDA has said are legal to stay on the market, but they are in the small minority.
And so where are retailers? Where are the retail associations? Where are parents? Where are schools? Like, it's
so hard to have this issue rise to the top and make people care about it because think about everything that
parents have to worry about. Sure. Think about everything that schools have to worry about. You mentioned
fentanyl, and when you talk to parents, they say in the, in the continuum of things they have to worry about their
children being exposed to, sadly, nicotine has fallen more towards the bottom of that. And so, it is a systemic
issue. It's a systemic problem and trying to figure out how to solve it would require everybody to be a good
actor. It would require the retailers to take these products off the market. If they have any shred of doubt
whether or not they're legal, take them off the market. They shouldn't be allowed to stay. FDA needs to stay and
continue to do their job with enforcement actions. The states play a role. It's just, it's combined. But if you think
about everything that people have to worry about, everything that legislators have to worry about, and
enforcement agencies have to worry about, this probably pales in comparison.

Mark (15:04)
Margaret, I was thinking, Kathy was talking about states, playing a role, probably a disincentive 'cause of all the
tax dollars they might be bringing in here because of the volume that's being done. But let's stick with the FDA.
Last year, the FDA gave regulatory authorization to Juul for its tobacco and meth- menthol e-cigarettes, and the
company's saying that's a great move because they're helping people give up cigarettes. I'm wondering what's
your view on that statement.

Kathy (15:32)
So, I think, I think, there is truth in that statement. So, one of the things that FDA has to do, and I personally
believe that they do well, is they follow the science very closely, and they, they have a very high bar. But in the
case of, Juul tobacco flavor and Juul menthol flavor, FDA felt that they, they met the bar to be called
appropriate for the protection of public health, that they could be actually legally marketed. So, w- the intention
for that is for adult smokers who can't quit or have tried so many times in the past and failed to transition
completely away from the most deadly product, which is c- is a cigarette to an FDA-authorized product like,
Juul, you know, tobacco or menthol. If the, if the data shows that if a smoker transitions completely away from
smoking and uses one of those products, their risks decline and, and, and it could be better for them long term.
So obviously what FDA says is the best thing to do is never start. If you start, the best thing to do is quit. If you
need help on that journey and you can't quit completely, these products, if you substitute and use them
completely, are less harmful for you. So, there is a place, in my opinion, for products that have been found to be
less harmful, but they're only less harmful for smokers. They're not less harmful for someone that's nicotine
naive, someone that's never used a tobacco product. Then they induce risk and harm to them. So, this discussion
is very complex and nuanced depending on who the end user of the product is. So, I'm just kinda sharing with
you a little bit o- of the conundrum that FDA is in.

Margaret (17:17)
Yeah. Wow. And, and quite a challenge as the leader of your organization to make these messages clear in the
60 seconds you may have to talk. As you can see, it's taking us more than 60 seconds to have it be clear to us.
but I wanna go back to both the kids and the adults really. you know, in, in healthcare we have some evidence-
based strategies for helping people, to quit. part of it is behavioral. Part of it's counseling. But really a big part of
it is also medication that's been shown, to be effective. Is there an equivalent in the vaping side of the house in
terms of helping people to quit, both adults and kids?

Kathy (17:57)
Sure. So, we have been running EX Program, which is a free digital clinical intervention. It was developed in
2008 in partnership with the Mayo Clinic and the Mayo Clinic's Nicotine Dependence Center, and we have
been, literally been helping millions of people to quit all forms of nicotine, over, the past 15 years. The, the
amazing thing about EX Program is that it's completely evidence-based, and we have some significant, clinical
control trials among both teens and young adults that show that, uh-Anybody that's going through X program, it
increases their likelihood of quitting by up to 40%. So, if we can get people in a data-driven, evidence-based
program that, includes both counseling and medication, it can really help their, their likelihood of being able to
succeed. And what we know is that sometimes it can take an- anybody that's trying to quit, it could take five
times, it could take 10 times it could take up to 30 times to be able to successfully quit because this nicotine
Right as a drug is so highly addictive, and the younger you start to use a product, the harder it is to quit. But it,

there is, there is the opportunity, and you can be successful. And so, what we try to show through our, national
public education campaign, which is called Outsmart Nicotine, that drives people to X program, that you
absolutely can quit, and that even if you fail this time, trying again, will make you stronger the next time. And
so, it's really about, counseling in the moment, helping people to overcome their, their cravings. It's like if we
can get someone through a craving just five minutes, then that makes them stronger. And if we can get them
through 24 hours, that makes them stronger. And so, it is a, a behavioral coach. We like to talk about it a- it's
the, the friend they keep in their pocket. It's, X program is there to help them overcome their cravings and
sustain a long-term quit, which is really what it's all about. So, there is help. And, and, one of the areas that
we're really asking FDA to focus on is, you know, you see the proliferation in nicotine products, but you don't
see the proliferation in medicines. There hasn't been a new medicine actually introduced and authorized in 20
years. So, we're even asking, the Center for Drug Evaluation and Research to please, help the prol ... If, if, if the
proliferation of nicotine is happening on the tobacco side, cannot the proliferation of medicine also help? So,
you know, X program shows up where people are. We have a tremendous amount of research. We understand
the quit cycle. We understand what young people are going through, and we need to give them everything that
can help them to quit.

Mark (20:43)
Kathy, I'm sure your, research shows that nicotine use and health outcomes vary by community. Tell us how
you address these differences in effective ways.

Kathy (20:54)
Yeah. So, I mean, that's such an important question. So, we know that, and primarily with smoking here,
because the data has not necessarily caught up with e-cigarettes yet, but, you know, there are communities that
are smoking that are disproportionately harmed. There are communities that are smoking that are
disproportionately targeted with marketing, and so I'm speaking specific of the African American community, of
the LGBTQ community. And so, you've got a significant marketing engine trying to reach these populations in
very culturally relevant ways. And you see in the prevalence data that there, there has been significant,
populations that are using it at disproportionate rates, compared to their white peers. And so, the ... What I
would say easily to answer your question is what our program tries to do is ensure that we understand who's
coming into the program, what walks of life they're coming from, demographically, psychographically, and we
try to tailor a pro- our program in culturally relevant and reasonable and responsible ways. We also look to
develop significant partnerships, with, people that are trusted within that community. So, we just, developed a
partnership with NAACP, and they're gonna be helping us to distribute, our, tobacco prevention and cessation
messaging among their audience, as a trusted, as a trusted advocate for their health. And so, we try to approach
diversity from a, a number of ways, both understanding the prevalence, understanding the populations that have
high prevalence and why, and then developing culturally rel- relevant and responsible messages to those
audiences, and then bringing in partners to help us deliver the message.

Margaret (22:39)
Well, I think you would, find a lot of common ground with the community health center movement on this, and
we were, chatting just be- before the show. The good news is rates of smoking have fallen so much, around the
country. They have not fallen with the populations that you speak of, and today we're looking at data that
showed about 24% of the adult men in our ... of, of adult, of all the adults, are, are smokers, and maybe 18% of
women are smokers. Those are huge compared to the national rates now. So really applaud you for that and, and
hope there's some seams of opportunity there. But on the, on the list of the things that we all, have worried about
for years, decades now, certainly, the opioid addiction crisis, has also been very much there. And I understand
that your organization is now also taking on the opioid addiction issue. So, we'd like to give you a chance to talk
with us about how you're approaching that, particularly with youth.

Kathy (23:36)
Sure. So very, very carefully. And, and we had what I would call, you know, more of a complex and, and
complete advertising campaign, which was really trying to help people understand that if they're using their
product, it could be deadly for them. And, and one of the ways in that we've really found to be more successful
is in school-based programs, so trying to reach youth before they are actually using these products and just
helping them to understand, you know, that the medicine that they're using might be laced with fentanyl. Like,
that's a new thing. Like, I don't think kids really want to actually take fentanyl. They don't understand that it's
oftentimes hidden within other products. And so with, with this drug in particular, we've been trying to go
younger, and we're really focusing on school-based peer-to-peer curriculum to help to drive the, the, the issue
home, that these products are not, not at all safe, but doing it in a way that, you know, high sensation-seeking

youth will, will hopefully respond to. So that, that's a really hard one, honestly. I would say it's a, it's, it's a
difficult one to do in, a traditional ad.

Mark (24:44)
So, talk to us a little bit about your creative approach, which is so important in this era of TikTok, video games,
and so many other changes that are happening, particularly with AI, co- coming out. So, what's the secret sauce,
for your team in terms of making sure you're reaching the, this important population?

Kathy (25:05)
Yeah. So, I mean, first of all, I think, for anybody that markets to a young audience, you have to be so in touch
with the insights about who they are, what makes them tick what makes them work, what's aspirational to them.
You know, so, so there's a, a very definitive theory of behavior change that we follow, and it basically starts
with understanding who your audience is and really doing a, a complex, research analysis of their current
thoughts, beliefs, attitudes, intentions towards using products. Then you understand who is most at risk in that
population, and then you develop basically conceptual ideas about how to talk to that audience. And then you
take those ideas out, and you do research among the audience. You find what sticks, what doesn't stick, what's
appealing, what's not appealing. Then you produce e- the advertising, and then you find where they are. You
used to call it fish where the fish are. And if you're reaching, trying to reach a middle school, a high school, or a
young adult audience, if you're not in social media, you will not reach them. It's like the days of the television
ad, I hate to say this, I grew up on television, the days of television, traditional linear television reaching, uh- ...
a young audience- Right ... isn't reaching them. They're not listening. They're watching the Super Bowl, they're
watching the Final Four, but, and they're watching college football. But honestly, the way to reach them, as you
said, is in, in the social channels, the social platforms, TikTok, Instagram, Snapchat, YouTube. Those are the
deliverers of the messages now, and they can work for you, or they can work against you. Just like we're
advertising in all of those spaces and trying to catch the attention and catch the eyes of young audiences, the
behaviors that are being modeled on TikTok, for example, are really, really problematic too because what they
see, they adapt. And so those who are putting out messages about how not to use a product are completely
consumed by those putting out messages to use a product. And honestly, one of the things that, I think is so
critically important for anybody that's thinking about, a health behavior and a healthy behavior right now is that
you cannot ignore the role of pop culture. If we ignore the role of pop culture, we're ignoring the most powerful
channels where, nicotine companies never have to pay for an ad. It's like the, the social media influencers that
are influencing and, and showing how they're using a product, they're, they're unpaid spokespeople for tobacco
companies or other companies that are, you know, wanna sell a product. And so, you know, I just saw a recent
cover of Vanity Fair where a very popular influencer is lighting up a cigarette. I mean, it looks really cool. It
looks fantastic, but, but does she understand the number of youths that will consider smoking now because of
that? And so, I mean, with such, with such power comes such responsibility, and I- I'm talking to the Tikto-
TikToks and the Instagrams of the world. What they allow to populate on their program, could really be very
harmful for the audiences that are so, inspired by them.

Margaret (28:30)
Well, Kathy, you were named, CEO almost three years ago. clearly you signed up for a, a daunting and yet very,
very, uh- Important ... important challenge. share with all of us, what's your long-term vision for Truth Initiative
under your leadership?

Kathy (28:47)
So, what I, what I love about this job is the ability to, help shape hearts and minds, to really give young people
the, the truth and the knowledge about the products that they are considering using or are currently using, and to
help them to quit. And so, we are all-day, every-day behavior change to help people live healthier lives, and
that's what, that's what I get up every day doing, is like knowing that we're helping people. In just one month,
between middle of December to middle of January, over 50,000 people enrolled in EX program to ask for help
in quitting.

EX Program Commercial (29:28)
There are a lot of ways to curb cravings while quitting vaping. Or you could outsmart nicotine with EX program
and find what works best for you. Join for free. Text EXPROGRAM to 88709.

Kathy (29:39)
And so, you know, when I think about my life, and I think about the stuff that I've been trying to, to do, it's
always been about helping people lead he- healthier, happier, safer lives. And you know, when 50,000 people in

one month are coming saying, "I need help in quitting," you know that you're doing some good, and that, that's
what keeps me here and I, and I love it.

Mark (30:02)
Well, thank you, Kathy, for joining us, and thank you to our audience for being here. Just a reminder to be sure
to subscribe to our videos on YouTube and find us on Facebook and X. You can also share your thoughts and
comments about this program. Take care and be well.

(30:19)
[instrumental music plays]

Margaret (30:22)
This copyrighted program is produced by Conversations on Healthcare and cannot be reproduced or
retransmitted in whole or in part without the express written consent from Community Health Center, Inc. The
views expressed by guests are their own and they do not necessarily reflect the opinion of Conversations on
Healthcare or its affiliated entities.

(30:43)
[instrumental music plays out]