The United States federal government, along with many state and local governments, have passed restrictions on electronic cigarette (“e-cigarette”) sales with the stated purpose of preventing youth use of these products.
The justification for these restrictions includes the argument that youth e-cigarette use will re-normalize youth smoking, leading to increased rates of cigarette smoking by teenagers.
However, in this paper, we propose an evidence-based version of this model based on several years’ worth of longitudinal and econometric research, which suggests that youth e-cigarette use has instead worked to replace a culture of youth smoking. From this analysis, we propose a re-evaluation of current policies surrounding e-cigarette sales so that declines in e-cigarette use will not come at the cost of increasing cigarette use among youth and adults.
Introduction
Since their arrival on the market, e-cigarettes have been the focus of measures taken by the United States federal, state, and local governments to decrease youth use of these products. A 2016 report by the US Surgeon General suggested that e-cigarette use among youth had the potential to lead to adverse health effects and increased cigarette use among youth, and thus called upon policymakers, practitioners, and community leaders to restrict e-cigarette use (Office of the Surgeon General, 2016). These concerns were heightened in August 2019, when an outbreak of what was erroneously called “E-Cigarette or Vaping Use-Associated Lung Injury,” or EVALI, sickened 2800 individuals across the United States, killing 68 (EVALI, 2020). While it was originally assumed that nicotine-containing e-cigarette use was responsible for this illness, by January 2020 it was understood that vitamin E acetate, found in some illicit vaporizable THC products but not in commonly-available e-cigarettes, caused this illness (Blount et al., 2020).
By 2021, the Campaign for Tobacco-Free Kids identified over 300 localities that enacted restrictions on the sale of flavored e-cigarettes, and some states, such as California, New York, New Jersey, Rhode Island, and Massachusetts, have restricted the sale of flavored e-cigarettes statewide (Bach, 2021). In addition, as of 2021, thirty states, along with numerous municipalities, have levied taxes on vaporizable nicotine products in order to curtail youth vaping (Vestal, 2020; States with Laws Taxing E-Cigarettes [Internet], 2021). Further, in January 2020, the US Food and Drug Administration announced measures to curb youth e-cigarette use, including a nationwide ban on any flavored vaping products (aside from tobacco or menthol flavors) that use pod or cartridge systems (FDA Press Announcements, 2020; US Food and Drug Administration, 2022). In 2020, an estimated 24.7% of 12th grade students and 10.5% of 8th grade students reported e-cigarette use in the 30 days prior to being surveyed, and trends from the Monitoring the Future Survey suggest that the rate of increase in youth e-cigarette use is starting to plateau (Miech et al., 2021).
Supporters of restrictive policies for e-cigarettes argue for these policies for many reasons, such as a concern that users would be exposed to nicotine, which is addictive, and the potential impact that exposure to nicotine and other substances in e-cigarette vapor could have on health (Adams, 2019). One major stated premise for measures intended to restrict e-cigarette use – and the main focus of this paper – is the apparent concern that youth e-cigarette use will lead to youth smoking, as the widespread popularity of vaping will re-normalize cigarette use, undermining years of progress in reducing it (Frieden, 2015; Chapman et al., 2019; Barrington-Trimis et al., 2020; Sarlin, 2018; Truth Initiative, 2020; Blaha, 2022). Both bans on e-cigarette sales and high taxes on vaping products are being enacted based on the argument that because teenagers are drawn to the flavored, trendy, sleek e-cigarettes and other devices, they will become “hooked” on the idea of nicotine consumption, regardless of form, and that this renormalization of youth nicotine consumption will lead to an increase in youth smoking. For example, the stated rationale for San Francisco’s ban on the sale of all e-cigarettes was that: “Each day, about 2,500 children in the United States try their first cigarette; and another 400 children under 18 years of age become new regular, daily smokers. 81% of youth who have ever used a tobacco product report that the first tobacco product they used was flavored. Flavored tobacco products promote youth initiation of tobacco use and help young occasional smokers to become daily smokers by reducing or masking the natural harshness and taste of tobacco smoke and thereby increasing the appeal of tobacco products.” (Article 19Q, 2017) This exact language also appears in flavored e-cigarette bans enacted in San Carlos (CA), Aspen (CO), Marin County (CA), Portola Valley (CA), Santa Cruz (CA), Edgewater (CO), Loveland (CO), San Mateo County (CA), Carbondale (CO), Golden (CO), Salida (CO), Fairfax (CA), Mill Valley (CA), and the state of Hawaii (Article 19Q, 2017; A Bill for An Act Relating to Flavored Tobacco Products, 2020; An Ordinance of the City Council for the City of Salida, 2020; An Ordinance of the City Council of the City of Golden, 2019; An Ordinance of the Town of Carbondale, 2019; An Ordinance Amending Title 5 of the Loveland Municipal Code and Creating Chapter 5.45 Concerning The Licensure of Tobacco Product Retailers and the Sale of Tobacco Products Including Flavored Tobacco Products, 2020; An Ordinance, 2021; An Ordinance of the City Council of the City of Santa Cruz Amending Chapters 6.06 “Tobacco Merchandising Regulation” and 6.07 “Tobacco Retailer Licenses” of the City of Santa Cruz Municipal Code to Restrict the Sale of Flavored Tobacco Products, 2018; Portola Valley Town Council, 2018; Prohibition Against the Sale or Offer for Sale of Flavored Tobacco Products, 2018; An Ordinance of the City Council of the City of Aspen, 2019; An Ordinance of the City Council of the City of San Carlos Amending San Carlos Municipa, 2019; An Ordinance of the City Council of the City of Mill Valley Amending Chapter 7.20 (Smoking Prohibitions and Tobacco Retailing Regulations) of the Mill Valley Municipal Code to Prohibit the Sale of Flavored Tobacco Products, 2020; Clean Indoor and Outdoor Air and Health Protection – Smoking Regulations, 2019; Palo Alto Daily Post, 2018). This conceptual model, which serves as a critical and widespread justification for the banning of flavored e-cigarette sales, is illustrated in Fig. 1.
Review of evidence
Supporters of restrictive policies for e-cigarettes often point to the high percentage of middle- and high-school students who report using e-cigarettes. However, these arguments rely on measures of any e-cigarette use without differentiating between “ever use” and habitual use, and a number of studies suggest that most youth e-cigarette use was among individuals who were likely to use other forms of tobacco regardless of e-cigarette use (US Food and Drug Administration, 2021a). Analyses of
Revised model of youth E-cigarette and cigarette use and policy implications
Given these findings, we believe that the currently-accepted conceptual model of e-cigarette and cigarette use among youth should be re-evaluated. It takes the form of a slippery-slope argument, as the undesired outcome (youth smoking) is predicated on a condition (widespread youth e-cigarette use) that, as the literature demonstrates, is not taking place (Fumagalli, 2020). Despite the lack of evidence of widespread, habitual youth e-cigarette use leading to youth smoking, proponents of this
Limitations
Although our review of the econometric studies suggests that e-cigarettes and tobacco cigarettes are economic substitutes, this does not necessarily imply that selective restrictions on vaping will lead to an increased prevalence of smoking. Since smoking is declining at such a high rate, it is possible that substitution of cigarettes for e-cigarettes would merely hinder the observed rate of decline. Because of the subtlety of such an effect, the results of the studies should be interpreted
Conclusion
Since e-cigarettes have emerged into the mainstream and became widely available, public health authorities have sought to regulate their availability not only to prevent youth vaping, but to prevent the re-normalization of youth smoking. The general driver of these policies has been the idea that youth e-cigarette use will re-normalize cigarette use, leading to increased rates of cigarette smoking among underage individuals. However, we demonstrate here that this thinking is unsupported, based
Dr. Michael Siegel and Amanda Katchmar – Preventive Medicine – 2022-04-20.
Want More Investigative Content?
