Anti-tobacco harm reduction campaigners backed by US Federal and state authorities, supportive media and large wodges of Bloomberg cash are about to deliver the worst possible news for millions of American smokers who wish to continue using nicotine while significantly reducing the risk of a premature and painful death.
On 11th September that bastion of common sense – the Trump administration - announced a projected ban on all e-liquid flavours except tobacco (and possibly mint, menthol and wombat). Worth noting that in the US, flavoured e-liquids are technically illegal anyway, because Donald has yet to taste all estimated 7000 flavours to give them a yummy rating (sorry, I misread The Federal Drug Administration (FDA) Regulation 2302, para 494, subsection 78b something about pre-market authorisation).
Clive Bates has done a detailed break-down on why this is a seriously bad idea, so what follows is a potted version with the odd thought of my own. To read the full blog with lots of diagrams and evidence, go to: https://www.clivebates.com/the-us-vaping-flavour-ban-twenty-things-you-should-know/
Apart from the fact that the anti-vaping Taliban have been looking to kill the industry from the get-go, why now?
It comes off the back of the cynical attempt by US ‘health’ authorities to conflate regular e-liquid vaping with the outbreak of serious lung injuries arising from the use of adulterated ‘Breaking Bad’ cannabinoid products. This served to ramp up the already febrile moral panic surrounding vaping and triggered several states into emergency action against vaping products.
Whither a risk assessment?
You could be forgiven for thinking the FDA have conducted a robust and independent risk assessment before undertaking the prohibition of a product whose absence is likely to pose a serious threat to getting smokers off the smoking treadmill. How wrong you would be. Questions like these below remained unanswered as the FDA plunges forward with a major intervention born in an evidence-free zone:
- Is the cause for concern an actual flavour or the way it is described (or both)?
- Is the cause for concern all flavours or some flavours?
- How will these concerns be identified?
- Does a flavour preference create a behaviour change leading to increased e-cigarette use?
- Would youth uptake of e-cigarettes caused by flavours be harmful or beneficial to health?
- How are trade-offs between potential harms and potential benefits to youth addressed?
- How will beneficial impacts for adults be reconciled with any potential impacts on youth?
It seems now that any and all flavours are aimed at trapping our kiddies into a lifelong smoking habit. It may be true that naming flavours ‘gummy bear’ and ‘cotton candy’ was not a smart move. But Americans consume more sugar per capita than any other population on the planet, so zillions of American adults are also attracted to sweet flavours of just about anything. In his latter days that icon of the American Dream, Elvis Presley, consumed a 30-cm long bread roll, crammed with peanut butter, strawberry jam and bacon. It contained 42,000 calories and he ate two – every day
There is no evidence that calling an e-liquid ‘Squidgy Ice Cream’ has any impact on youth vaping choices; until they withdrew them, those pied pipers of doom, Juul, were offering: creme, fruit, mango, and cucumber. But ‘kiddie flavours’? Really? This whole kiddie flavour narrative is just a ‘get out of jail free’ card for those who hate the vaping industry and are looking to destroy it without actually instigating Prohibition, as that would be so un-American. And incidentally, there is little convincing evidence that non-smoking youth are attracted to vaping by flavours either.
Won’t somebody think about the adults?
Crucially though, flavours are an important part of the appeal to adults while interest in tobacco flavour has been declining over time. Consumers see the vaping experience increasingly as a different and better way to consume nicotine, and flavours are integral to that experience. For many smokers looking to switch, the fact that they can enjoy nicotine without being reminded of smoking is crucial. And it is harder for older smokers who have been smoking for decades to switch away from tobacco flavour. To make tobacco the only flavour available to smokers looking to move away from smoking, you might as well only serve beer during the refreshment break at an AA meeting.
Clive iterates a whole evidence base to show why young people might want to vape and, as you might imagine, it is way more variegated than the chance to inhale teddy bear flavour. But as he shows, drawing conclusions on why young people do things by simply asking them (especially with self-report surveys) depends hugely on the questions asked, the way results are scored and interpreted, and the questions not asked. So easy to get the answers you are looking for.
It is certainly true that incidents of vaping among American youth have increased in the past few years, but can it be categorised as a “youth vaping epidemic” or an “epidemic of youth nicotine addiction”? As Clive points out, you cannot really say anything credible about youth vaping without knowing in detail the frequency distribution (how many days in the past 30 did each student use e-cigarettes) and what their wider pattern of tobacco is (especially whether they are smokers or like to smoke). How many adolescent vapers show signs of dependence? Simply using a vaping product does not make the user a ‘nicotine addict’. British experts analysing official US data concluded that the data “Do not support claims of a new epidemic of nicotine addiction stemming from use of e-cigarettes, nor concerns that declines in youth tobacco addiction stand to be reversed after years of progress. Among current e-cigarette users who had never tried tobacco products, responses consistently pointed to minimal dependence”.
Flavour bans worse for adolescents too?
Official stats show that by a large majority, the frequent vapers are also the ones who are already using tobacco. For them, vaping may be beneficial; it can help them quit smoking; it can divert them from starting smoking; it might reduce how much they smoke, and it’s there for them if they want to quit smoking by switching to vaping later.
The ‘don’t care’ gummy bears
The total lack of understanding of these issues by those who should care was starkly revealed by former FDA Commissioner Gottlieb:
Even if the trends are moving in a more positive direction of reduced overall use of tobacco products. Even if kids are using ENDS instead of cigarettes — and that migration in part accounts for the decline in youth cigarette use — that’s still not an acceptable trade.
In effect the FDA doesn’t care if measures they take against vaping have the effect of increasing smoking among adolescents. What it clearly demonstrates is an elitist bias.
There is a justifiable suspicion that the political storm is being created by the worried well-off for the sake of kids who have never smoked and are unlikely to become regular vapers. We hear little from poor families whose kids are more likely to smoke and for whom vaping could be a protective alternative.
Professor Lynn Kozlowski observes that the FDA emphasises the minor risk to what he terms the ‘good’ kids and ignores the potential benefit to the ‘bad’ kids:
“Disgust at contaminating the “purity” of youth, especially “good,” low-risk youth, with any tobacco/nicotine products opposes harm reduction, as does contempt for violating so-called community values and disrespecting authority. Support for harm reduction arises from anger at failing to provide reduced harm to “bad,” high-risk individuals and denying them the “liberty” to decide”.
And incidentally, those ‘bad kids’ will be living in ‘bad families’ where smoking is likely to be more prevalent affecting the lives of both adults and kids. How much better off would these families be if the smokers who couldn’t give up switched to vaping? Why would anybody deny them the chance to make the safer choice? Unless of course, you didn’t care because these families are not petitioning politicians. They are ‘not like us’.
Likely consequences of a flavour ban?
- The closure of thousands of small to medium-sized businesses (vape stores and manufacturers) as the products they make and sell are predominantly flavoured. Many of these also provide a market-based supportive service to smokers wishing to take up vaping as an alternative to smoking;
- The development of a new and flourishing black market in flavoured nicotine e-liquids manufactured by amateurs, opportunists, and criminal enterprise;
- Migration of users to the existing unregulated sub-culture of DIY mixing of nicotine and food flavours;
- Vapers or dual users may revert to smoking or the use of other tobacco products and current smokers who would otherwise switch to vaping in the future may remain as smokers;
- Some may switch to tobacco flavoured e-liquids (although this experience is nothing like smoking);
- Some may quit vaping and smoking altogether (though may increase other risk behaviours).
Astonishingly, the FDA has already recognised the downside of a rapidly disappearing vaping market. Mitch Zeller of the FDA said:
“[…] mass market exit of such products would limit the availability of a potentially less harmful alternative for adult smokers seeking to transition or stay away from combustible tobacco products. Dramatically and precipitously reducing availability of these products could present a serious risk that adults, especially former smokers, who currently use ENDS products and are addicted to nicotine would migrate to combustible tobacco products, even if particular ENDS products ultimately receive marketing authorization and return to the market later.“
He is predicting that having pushed people back to smoking, they might not return to vaping even if the products made a comeback.
And the winners are.....
- Tobacco company vaping sales risks are to some extent hedged by cigarette sales and, in Altria’s case, by iQOS. There is no equivalent hedge for pure vaping companies;
- The vaping flavour ban will wipe out nearly all of Big Tobacco’s competitors in the recreational nicotine space – vapour is a flavours business. State and local bans that go further serve the same cause;
- Only Big Tobacco will be able to wade through the hideously expensive bureaucratic treacle to bring products to market;
- If the trope of Bloomberg and others is that there is no difference between smoking and vaping and you act to kill off the vaping industry, what is the likely scenario for smoking rates? And who will benefit?;
- Market analysts have concluded that a flavour ban only helps Big Tobacco while putting at risk those kids and adults who seek underground alternatives.