Vaping and e-cigarettes have exploded in popularity in recent years. Now the practice is in the hot seat for safety concerns. As of Sept. 19, the Centers for Disease Control and Prevention had reported 530 confirmed or probable cases of vaping-related lung injury or illness. The Trump administration is already moving to ban flavored e-cigarettes, siding with those who believe the flavors attract too many young users and hook them to an unsafe practice. Some voices in health care, however, worry that banning the flavors will make the practice less appealing to those who rely on e-cigarettes to kick their smoking addiction.
The Inquirer turned to health-care experts and researchers to ask: Should flavored e-cigarettes be banned from the market?
A new product has been unleashed on the market. No one knows what’s in it, but we do know that it has enticed one in four teenagers, sickened hundreds of young people, and killed a few. Shouldn’t we do something about that?
E-cigarettes deliver drugs to users through their lungs. They’re filled with liquids that vaporize when heated, enticing “flavors,” and nicotine, a drug as addictive as heroin. While e-cigarettes have been around for years, in the last two years the company Juul has overwhelmed the market with candy flavors and extraordinarily high nicotine levels. Because of Juul, between 2017 and 2019, the percentage of teenagers using e-cigarettes skyrocketed from 11.7% to 27.5%. And, as we are learning painfully, it is easy for users to replace the liquids in e-cigarettes with bootlegged “juice” containing THC, the active ingredient in marijuana, and toxic chemicals.
Until recently, my biggest worry about e-cigarettes was that the effect of the vapors on the lung —
when used hours a day for years — were unknown. Lung tissues are very sensitive, so it was difficult to imagine there wouldn’t be at least some damage. Chemical “flavors” are scientifically evaluated as to whether they are safe to be eaten in food, not delivered directly to the lung.
The Food and Drug Administration has a mandate to regulate both drugs and drug-delivery devices. It’s not supposed to allow them to be sold in the United States unless they are proven both safe and effective. So far the FDA not only hasn’t taken action to regulate e-cigarettes, it hasn’t even got a clue what’s in them, because it hasn’t required manufacturers to report ingredients. Until recently, the strongest defense one could make for the FDA was that there were no proven health risks from e-cigarettes.
But now that we’re facing a national epidemic of “vape lung,” no one can say that the safety of these drug-delivery devices is unknown. It’s high time that the FDA keep e-cigarettes off the market unless and until they are proven both safe and effective at helping smokers quit.
If the FDA dithers, then state and local governments should step in to protect people from these products. That includes both prohibiting the flavorings in e-cigarettes and limiting the nicotine levels.
The flavorings are important because they seem to be what attract kids to start. Nearly two-thirds of teenagers vaping e-cigarettes today are using fruit- or mint-flavored products, and more than one-third are using candy-flavored products. Using candy flavors to attract kids is an old tactic — akin to the candy-flavored cigarillos we’ve seen in Philadelphia to get teens smoking.
Nicotine is important because that’s what gets users hooked. Juul uses nicotine “salts” that deliver a higher level of nicotine to the brain than other e-cigarettes, which is probably why Juul has captured the market.
E-cigarette manufacturers say they are helping adult smokers quit. But if they really want to help, they can design products that are safe and tamper-proof, conduct more studies to show whether they actually help smokers quit, and market proven products only to adult smokers.
If the e-cigarette manufacturers were to take this responsible path, I would be their biggest supporter. But sales to teenagers and young adults bring big money, and the manufacturers have shown that they are willing to risk these lives to make a profit. As long as e-cigarette companies’ business model is getting our youth addicted to devices that could kill them, we must step in.
Thomas Farley is health commissioner of the city of Philadelphia.
The myth of vape flavors designed for kids is believable because it is intuitive. It targets natural emotional concern for kids, and exploits the fact that most people know little about vaping or the role of flavors in harm reduction and its central importance to public health. The myth of evil flavors is an appeal to seeming common sense that discourages us from questioning its flawed basis.
Flavored e-cigarettes were not invented by “Big Tobacco,” nor are they an unscrupulous marketing plot from the thousands of small, independently owned vape companies in the United States to addict kids. Non-tobacco vape flavors are a user innovation.
My own research examines the substantial contribution of users to vaping innovation, including the development of a commercial flavor market. From examining thousands of early e-cigarette forum posts, I’ve discovered that fruit, candy, bakery, mint, and beverage flavors were introduced to vaping in 2008 by pioneering users of the technology who were desperate to use e-cigarettes to replace smoking. Dissatisfied with the taste of products from online Chinese vendors at that time, these users began experimenting with water-soluble flavorings from specialty flavor houses traditionally used in confectionary applications. The commercial flavor market emerged to meet the demands of these users.
In 2018, the largest flavor preference survey of adult vapers in the United States found fruit and dessert flavors to be the most popular by far. The same survey found that only a minority of the nearly 70,000 participants used tobacco flavors, and their use decreased over time. These results are consistent with several large-scale consumer surveys and peer-reviewed studies, where adults who vape overwhelmingly reported that non-tobacco flavors and flavor variability matter to them and help keep them off tobacco.
Importantly, youth vaping didn’t peak at the same time flavor options did. The vape flavor market expanded until 2016, after which the FDA prohibited new products from being introduced without marketing approval. There were an estimated 7,764 flavors available on e-cigarette brand websites in 2013. By 2016 that estimate had more than doubled to 15,586. If flavors cause youth to vape, we’d expect youth vaping to have increased steadily with the proliferation of flavors. CDC data show vaping rates among youth increased every year between 2011 (when the behavior was first measured) and 2015. But in 2016, right when the United States vaping market reached “peak flavor,” national data showed youth vaping decline for the first time. This low rate remained stable in 2017. Increases in 2018 and 2019 happened when the flavor market was frozen in its 2016 state.
While national surveys of youth do show that youth experiment with flavors, this hardly shows that flavors are the main driver of youth vaping. It more likely reflects what is popular overall.
Given the morally and politically charged context of the e-cigarette debate, and the genuinely concerning news of lung poisonings believed to be caused by contaminants in illicit THC oil cartridges (and not nicotine vaping products targeted by this ban), it is easy to forget that tobacco use is endemic among youth, that teenagers still smoke cigarettes, and 5.6 million kids alive under the age of 18 today will ultimately die prematurely as a result of smoking.
No youth should use nicotine, but the reality is that teenagers experiment with adult things. There is overwhelming evidence that the adult things they are experimenting with now are vastly and demonstrably safer than cigarettes, which kill nearly 500,000 Americans annually. Allowing vaping to replace smoking at the population level has enormous benefits for future generations.
Flavors reflect the preferences of the people who use these products to stop smoking. E-cigarettes don’t work when people don’t like them, and flavors are what the people who need e-cigarettes like about them.
Amelia Howard is a Ph.D. candidate in sociology at the University of Waterloo studying vaping innovation and the politics of technological change. @Amelia_RH