New data suggest that vaping isn’t a passing fad: Teenagers across the country are doing it in record numbers.
More than one-third — or 37.3 percent — of 12th-graders reported vaping at least once in the past 12 months, according to a survey released Monday by the National Institute on Drug Abuse. That’s an increase of nearly 10 percentage points over 2017, when 27.8 percent of high school seniors reported vaping.
The students surveyed said they had vaped nicotine, marijuana or simply flavoring. Researchers say it’s unclear whether teens know what’s in their vape, and that some may be misguided about vaping only “flavoring.”
The findings are “a remarkable wake-up call for public health officials, and for parents and communities who are responsible for raising healthy children,” said Dr. Wilson Compton, the deputy director of the institute, which funded the survey.
The data also showed that the number of high school seniors who reported vaping nicotine within the previous 30 days nearly doubled from 11 percent in 2017 to 20.9 percent this year.
E-cigarettes, also known as vapes, are battery-operated devices that heat nicotine-laced liquid to generate an aerosol that users inhale. The liquids come in kid-friendly flavors — from watermelon to the more exotic “unicorn puke” — that release fruity and sweet vapors, making e-cigs easier to disguise than traditional cigarettes.
While the vape industry insists that its products are only for — and advertised to — adults, teens can easily get their hands on them.
Health experts fear that the high nicotine content of vaping liquids can be extremely addictive for teenagers and ultimately lead them to traditional cigarettes. Nicotine is known to raise blood pressure and has been linked to heart disease.
“We know that nicotine affects brain development,” said Stanton Glantz, a professor of medicine and director of the Center for Tobacco Control Research and Education at University of California-San Francisco who was not involved in this study.
The heated e-liquids, he added, “tear up your lungs.”
Researchers at the University of Michigan in Ann Arbor, who conducted the annual survey, asked 44,482 students from 392 private and public schools across the country about their use of tobacco, opioids, marijuana and alcohol.
They found that the use of traditional cigarettes is still at a record low, with 3.6 percent of high school seniors smoking daily, compared with 22.4 percent two decades ago. Teenage opioid use is also decreasing: 3.4 percent of seniors reported using prescription opioids in 2018, down from 4.2 percent in 2017 — and significantly lower than its peak of 9.5 percent in 2004.
Alcohol use and binge drinking also continue to decline among teens, according to the survey.
Vaping is the outlier.Email Sign-Up
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The steady decline in teens’ use of other drugs makes the growth in vaping all the more concerning, Compton said. “It’s really important that we keep an eye on this.”
In response to this trend, hundreds of cities, towns and counties across the country are restricting the sale of flavored tobacco products, including vape liquids. California legislators recently introduced proposals to ban the sale of such products in stores and vending machines statewide, and to make it harder to buy them online.
The vape craze exploded when the Juul, an electronic cigarette brand with a sleek design resembling a flash drive, started popping up on school campuses. Students even take hits from their Juuls in class or school restrooms.
In vapes like the Juul, nicotine comes in “pods” or cartridges in flavors such as mango, cucumber and crème. Other e-cigarettes use “e-juice” or nicotine liquids that not only come in appealing flavors but are often packaged to look like candy.
“Our intent was never to have youth use Juul products,” said company spokesman Ted Kwong. Juul has taken steps to reduce teenage vaping, he said, such as ending the sales of certain flavored pods at retail stores starting last month, strengthening the age verification process on its website and eliminating its Facebook and Instagram accounts.
The restrictions proposed by the state legislature follow San Francisco’s ban on the sale of flavored tobacco products, including vaping liquids and menthol cigarettes, which took effect in July.
Twenty-four other California counties or cities have restricted the sale of these products, according to the Campaign for Tobacco-Free Kids. In Massachusetts, 136 communities have restrictions on the sales of flavored tobacco. In Minnesota, nine communities do. Chicago bans sales of flavored tobacco products within 500 feet of schools.
California state Sen. Jerry Hill (D-San Mateo), lead author of the state bills, said his proposals would curb the “epidemic proportion” of vaping among teens.
“This is something that requires immediate action to protect our youth,” Hill said.
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Sarah Witter couldn’t get a break even though her leg had gotten several.
As she lay on a ski trail in Vermont last February, Witter, now 63, knew she hadn’t suffered a regular fall because she could not get up. An X-ray showed she had fractured two major bones in her lower left leg.Send Us Your Medical Bill
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A surgeon at Rutland Regional Medical Center screwed two gleaming metal plates onto the bones to stabilize them. “I was very pleased with how things came together,” the doctor wrote in his operation notes.
But as spring ended, the wound started to hurt more. In June, Witter returned to the doctor. “He X-rayed it and said it broke,” she said. “And I was thinking, what broke? And he said, the plate. He said they do sometimes.”
The doctor performed another operation, removing the cracked plate and replacing it with a larger one.
Witter said she had been dutifully following all the instructions for her recovery, including going to physical therapy and keeping weight off her leg.
“I was, of course, thinking, ‘What did I do?’” Witter said. “The doctor said right off the bat it was nothing I did.”
Then the bill came.
Patient: Sarah Witter, a retired teacher and ski buff who had moved from Pennsylvania to Vermont for the outdoorsy lifestyle.
Total bill: $99,159 for emergency services, therapy and hospital care, including $52,587 for the first surgery and $43,208 for the second surgery. Altogether, Witter’s insurer, Aetna, paid $76,783. Witter paid $18,442 — including $7,808 for the second surgery. About half of Witter’s total expenses were copayments; another $7,410 was the portion of hospital charges that Aetna considered unreasonably high and refused to pay.
Service provider: Rutland Regional Medical Center, the largest community hospital in Vermont, performed the surgeries. Emergency services, anesthesia and physical therapy were done by other providers.
Medical service: In February, two metal plates called bone fixation devices and manufactured by Johnson & Johnson’s DePuy Synthes division were surgically attached to two lower leg bones Witter had fractured in a skiing accident. These plates are long, narrow pieces of metal with holes drilled in them at regular intervals for screws to attach them to the bones. A crack had developed in one of the plates running from the side of one of those holes to the edge of the plate. A second surgery was required to remove the plate and replace it.
What gives: When devices or treatments fail and need to be replaced or redone, patients (and their insurers) are expected to foot the bill. That may be understandable if a first course of antibiotics doesn’t clear a bronchitis, requiring a second drug. But it is more problematic — and far more expensive — when a piece of surgical hardware fails, whether it’s a pacemaker, a hip that dislocates in the days after surgery or a fractured metal plate.More From Our Bill Of The Month Series
Warranties, standard features at an electronic store or a car dealership, are rare for surgeries and in the medical device industry.
Dr. James Rickert, an orthopedic surgeon in Indiana and president of the Society for Patient Centered Orthopedics, said a plate like the one implanted in Witter’s leg can fail if the surgeon does not line it up correctly with the bone, although usually that causes the screws to break or back out. A plate also can fail if the patient puts too much weight on it or doesn’t follow other recovery instructions.
“When the plate breaks, it’s usually from overworking it, or a defect in the plate itself,” Rickert said. “The vast majority of people follow their instructions and are honest about it. If a person comes in and tells you they’ve been following their instructions and the surgery’s done properly, to me that’s a hardware failure.”
Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, said sometimes hospitals will not charge for a second surgery “if they were aware that it was something they did that caused the patient to need follow-up care.”
Rutland Regional, Witter’s hospital, would not discuss Witter’s care or bills, even though she gave it permission to do so. “The organization is not comfortable in getting into the specifics of an individual patient’s case,” a spokeswoman wrote. The hospital also declined to discuss under what circumstances, if any, it would discount a second surgery’s cost because of the first’s failure.
Hospitals do not consider it their responsibility if a medical device failure is the problem, Foster said. But manufacturers are reluctant to take the blame for an unsuccessful surgery.
AdvaMed, the trade group for medical device manufacturers, said some companies will provide replacement devices if theirs failed, but others do not, especially if the failure of a procedure cannot “easily be attributed” to the device, the group said in a written statement.
“There are numerous factors outside of a manufacturer’s control — and unrelated to the safety of the device as designed — that could result in a device not performing as intended,” AdvaMed said.
These devices aren’t cheap: Witter’s hospital billed $9,706 for the first set of plates. It billed $12,860 for the replacement and an extra piece of equipment to attach it.
DePuy Synthes, which manufactured Witter’s plates, said in a written response that “in rare circumstances” metal plates “may fracture under normal weight-bearing or load-bearing in the absence of complete bone healing.” Even then, the company said, that is a chance patients have to take.
AdvaMed said it does not keep statistics on device performance, and DePuy did not respond to questions about how often its plates fail.Email Sign-Up
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Resolution: The second surgery delayed Witter’s recovery by four months and prevented her from gardening, golfing, hiking, biking and motorcycling through the summer and fall, as she usually does. “I was pretty much chair-bound for 20 weeks,” she said.
In November, she was not able to join her husband and son on a trip to Iceland. Instead of volunteering at a nearby ski resort, as she had done for six years — and which carries the benefit of a free season pass — Witter said she tried selling hand warmers and lip balm out of a small kiosk and watching the skiers through a window. She said she had to quit after six days because of the pain in her feet.
“The biggest annoyance with this whole thing, even though it took eight months out of my life, is I hate to pay for it again, and the doctor clearly said it wasn’t anything I did,” she said.
Aetna said in a statement that while it does not allow providers to charge for indisputably inept medical mistakes such as leaving a surgical sponge in a patient or operating on the wrong limb, a broken plate does not qualify for such protection.
After reviewing Witter’s records, Aetna said it concluded the hospital had billed Witter for the portion of charges Aetna had considered excessive —a practice known as “balance billing.” While Aetna cannot reject those charges because the hospital does not have a contract with it, the spokesman said Aetna would try to negotiate with the hospital on Witter’s behalf to reduce the bill.
Rutland Regional, however, indicated in its statement that the only reason it would discount a bill was for people who had inadequate insurance or were suffering financial hardship from the size of the bills. Witter said she does not meet the hospital’s criteria.
The hospital invited her to meet with her surgeon and its chief financial officer.
The Takeaway: Witter brought up the seeming unfairness of the double charges to the hospital’s billing department as well as to her doctor, who, she said, was “charming,” but told her “he had no wiggle room to do anything.”
Patients are usually out of luck when a second surgery is needed because of the failure of a medical device or a surgeon’s mistake. A few places, most prominently the Geisinger health system in Pennsylvania, offer warranties for hip and knee, spine and coronary artery bypass surgeries, among other procedures.
AdvaMed says that if a company provides a replacement, the hospital or surgeon is not supposed to bill Medicare or the patient for the equipment — even if the operation incurs charges.
Patients should scrutinize their bills and question their doctor and hospital or surgical center about charges for replacement devices.
If the doctor or hospital is partially at fault for the failure of the first procedure, request that part or all of the costs of the second surgery be waived. Get it in writing so you can make sure the billing department follows through. Also, in a medical market where insurers want to pay only for value-based care, let your insurer or employer’s human resources department know that you are being charged twice for the same surgery. Let them fight the battle for you.
Do you have an exorbitant or baffling medical bill? Join the KHN and NPR Bill-of-the-Month Club and tell us about your experience.
More Americans are now employed in health care than in any other industry.
The Bureau of Labor Statistics, which tallies job creation, says that for most of this year the health sector outpaced the retail industry. Only government, on all levels, employs more people. One of the consistent features of the BLS reports is that health care has reliably added thousands of jobs to the economy each month.
November was no different. The health care industry created 32,000 jobs, adding to the 328,000 health care positions created since early 2017.
But what kinds of jobs? Were they highly paid doctors and hospital executives or were they positions on the other end of the pay scale, such as nursing home aides and the people who enter data for billing in hospitals and clinics?
It’s hard to know for sure, because the BLS monthly data measure industries not occupations and what information it does have on occupations is overly broad. For instance, it says hospitals accounted for about 13,000 jobs in November. Another 19,000 jobs were for “ambulatory” care, which is a broad term for services delivered outside of hospital systems, like in clinics and private doctors’ offices.
But another set of BLS data offers additional insights. Every two years, BLS puts out a wonky set of numbers called “industry-occupation matrices,” which more finely slices job categories and predicts which will grow or shrink over the next 10 years.
The most recent, from 2016, still provides a pretty accurate snapshot, according to Joanne Spetz, a professor at the University of California-San Francisco’s Institute for Health Policy Studies.
Registered nurses are the fastest-growing occupation. They account for more than 25 percent of jobs in hospitals. If that share remained the same last month, 3,289 of the new hospital jobs added in November went to RNs.
It’s likely that many of the hospital jobs went to medical assistants, who currently make up only 1.5 percent of the industry. Medical assistants are usually the people taking your vitals and helping the doctor take notes. The BLS expects about a 16 percent increase in these jobs in the next decade.
“There will be a fair amount of growth in physician and surgeon employment in the next decade, but so many more medical assistants than physicians,” Spetz said.
The national median pay of a registered nurse is $70,000 a year, according to more BLS data. For medical assistants, it is $32,480. Doctors’ median pay is more than $200,000.
Far more of those medical assistants found work outside the hospital in the ambulatory sector: almost 1,300.
There is also a good chance that in these ambulatory settings many of the newly created jobs were filled by non-medical staff.Email Sign-Up
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As of 2016, fewer than 30 percent of staff in ambulatory settings were workers whom Spetz calls “paper pushers.” If the trend held up, around 5,700 of the hires in November, or 30 percent of ambulatory jobs, fall into these categories. These jobs can pay as much as medical assistants. The BLS says the median income of “medical record and health information technicians” is about $39,000 a year. BLS is predicting around a 20 percent increase in “information and record clerks” and another 22 percent increase in “secretaries and administrative assistants.”
But the idea that hospitals and doctors’ offices are hiring only lower-paid support staff might be overblown. The BLS figures “health care practitioners and technical occupations” still make up more than 37 percent of the ambulatory industry, and “health diagnosing and treating practitioners” are almost 23 percent.
So nearly 70 percent of ambulatory hires last month were probably physicians or other skilled professionals like registered nurses, licensed practical nurses, social workers and personal care aides.
“What we have seen over the past couple years is with the job growth in health it is not dominated by back office,” said Ani Turner, an economist who focuses on health sector labor trends with Altarum, a nonprofit health research and consulting organization.
Another thing hiding in the numbers? A dissipating distinction between ambulatory and hospital care. Traditionally, hospital jobs were pretty straightforward; they referred to the doctors, nurses and support staff who worked in hospitals.
But as business models shift, more care is given outside of hospital walls, something not reflected in employment numbers that split health into two distinct categories. Employees who staff the clinics, surgery centers, labs and imaging centers run by hospitals are counted as hospital staff, Turner said, though they work in outpatient settings.
So those 13,000 new hospital jobs the BLS cited last month may not reflect real-world trends about where hiring happens.
“Whether in physicians’ offices, free-standing clinics or hospital outpatient clinics, you’ll see it as the two separate settings, but the same trend,” Turner said.
Podcast: KHN’s ‘What The Health?’ What Just Happened To The ACA And What Happens Now? A Special Bonus Edition
Kaiser Health NewsRead Julie's Stories Stephanie Armour
The Wall Street JournalRead Stephanie's Stories Joanne Kenen
PoliticoRead Joanne's Stories Paige Winfield Cunningham
The Washington PostRead Paige's Stories
Federal District Judge Reed O’Connor again thrust the Affordable Care Act into uncertainty with his ruling Friday that eliminating the tax penalty for not having insurance renders the entire law unconstitutional.
The panelists for this special bonus episode of KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Stephanie Armour of The Wall Street Journal and Paige Winfield Cunningham of The Washington Post
Among the takeaways:
- Because Judge Reed O’Connor did not issue an injunction after ruling the ACA unconstitutional, supporters of the law cannot file immediately for an appeal. The process will be more complicated.
- Although conservative legal scholars likely might agree with the judge that the mandate to have coverage cannot stand without the penalty — based on Chief Justice John Roberts’ landmark ruling in the first challenge to the law — many did not expect that other broad aspects of the ACA would also be thrown out in this case.
- Although the issue will play out in the courts, Congress will face pressure on how to handle the decision. Lawmakers could easily remedy this situation by instituting a 1-cent penalty against people who don’t have insurance. But finding consensus on a plan forward looks difficult.
- Much of the focus by the public after the decision has been on the 10 million people who buy insurance through the ACA marketplaces and the 12 million who are covered through their states’ Medicaid expansion. But the law had much broader reach, including protections for people with preexisting conditions, an end to lifetime caps for all consumers, requirements on how much of their revenue insurers must spend on customers’ coverage and efforts to improve quality at hospitals, nursing homes and doctors’ offices.
To hear all our podcasts, click here.
Julie Rovner, KHN’s chief Washington correspondent, was featured on NPR’s “Up First” podcast Monday morning to discuss a federal judge’s ruling late Friday invalidating the Affordable Care Act. She also joined NPR’s Michel Martin on Saturday on “All Things Considered” to talk about the case.
Rovner was also a guest on MSNBC’s “Kasie DC” on Sunday, where she discussed the case and its implications with host Kasie Hunt. That interview can be found here.