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October 20, 2020

Commenting on Flavor Bans: What Should You Discuss?

The deadline for public comment on the proposed Michigan flavor ban is this Friday, Oct. 23. Please see our article on the ban for details on how to leave your comment.

Flavor bans are probably the most common current threat to vaping in states and municipalities—and next year we’ll probably see more of them. Usually they’re laws passed by state legislatures or city councils. Sometimes, as with the Rhode Island flavor ban or the currently proposed Michigan flavor ban, they’re presented as health department rules.

CASAA does a great job of alerting vapers to threats in states and local governments [disclosure: I’m on the CASAA board], and CASAA chief executive Alex Clark writes terrific responses that you can send to your state or local officials. What could be better than sending CASAA’s well-written takedown of a proposed law, and signing your name to it?

Better would be adding something uniquely yours to the prewritten response, or even replacing the prewritten text altogether and sending your own complete comment. An individual response stands out in a legislator or regulator’s office. It may get attention when a stack of duplicate comments doesn’t (although in some cases, simply flooding the office with opposition letters—no matter what they say—can be the most important thing).

While doing research for my own comment on the proposed Michigan flavor ban, I decided to offer some general suggestions for others making comments on the Michigan ban—or any other flavor ban. This is not by any means all the topics you could write about; it’s just the outline I used for my comments. There are many other ways you might approach the issues.

Depending on how much time you have, you might just want to address one or two aspects of a flavor ban. Or you might choose to get into topics I haven’t even mentioned. Below my suggested talking points, I added a list of academic papers and non-academic articles to draw from when making comments on flavors and other kinds of vape bans and restrictions. I recommend these resources for additional topic ideas. I hope this helps others organize their own ideas. (Note: please don’t copy/paste my exact words or cite Vaping360 as a scientific source!)

Flavor ban comments: suggested topics

Flavors are important for adult vapers who have quit smoking

  • The claim that adult vapers “don’t need” flavored products is a political position, not a scientific one. E-liquid is flavored because the flavor is a key feature of the product. It’s an advantage vaping has over smoking
  • Surveys of adult vapers who have quit smoking show that successful experienced vapers prefer fruit, dessert and candy flavors above all others. (Russell 2018, Farsalinos 2017)
  • Research shows that former smokers who now vape are more likely to use fruit flavors than tobacco flavors

Vaping wasn’t invented by “Big Tobacco” as a trick to hook kids

  • Vaping was invented in 2003 by a Chinese pharmacist whose father died of lung cancer. According to University of Waterloo (Ontario) sociologist Amelia Howard—an expert on vaping market innovation—the U.S. e-liquid industry was started in 2008 by vapers who were dissatisfied with existing flavors sold by Chinese manufacturers
  • The tobacco industry took no interest in vaping until Lorillard bought an existing e-cigarette maker (blu) in 2012. Even now, tobacco companies control less than half of the vaping market (and have no position in the vape shop sector)
  • Vape shops and e-liquid manufacturers are independent businesses, not affiliated with the tobacco industry. For them, selling a product that drives youth (or anyone) to cigarettes would hurt their businesses, not help them

Flavored vape availability doesn’t “cause“ teens to vape

  • The claim that flavors are the primary reason that teenagers vape is often based on a 2015 study that used 2013-14 FDA PATH study data in which 81.5% of 12- to 17-year-olds reported they vaped because “they come in flavors I like”—supposedly the top answer. However, University of Pittsburgh/PinneyAssociates addiction researcher Saul Shiffman found that when he aggregated the four separate harm reduction answers chosen by vaping teens, harm reduction jumped past flavors as the top reason (88.2%) given for vaping. In fact, of those 81.5% who chose flavors, 92% also chose a harm reduction answer—and just 1.8% of all youth surveyed chose flavors as their only reason for vaping
  • The most recent national survey that asked about flavors (the 2019 National Youth Tobacco Survey) found that just one in five middle- and high school students listed flavors as a reason for vaping
  • Adolescents initiated nicotine use for more than a century with the harshest, most unpalatable flavor of all: burning tobacco

Teen vaping declined by almost a third from 2019 to 2020

  • Preliminary results from the 2020 National Youth Tobacco Survey show a 29% drop in past-30-day vaping among middle- and high school students this year—down to 19.6% from 27.5% in 2019
  • The 2019 NYTS also showed the largest one-year decline ever in the rate of teenage smoking—and that was a decline over what had already been the lowest rate ever. CDC didn’t release smoking results with the early 2020 numbers. What will happen to smoking numbers when school-age vaping declines?
  • We don’t know how many of the NYTS survey participants were THC (and not nicotine) vapers, because the CDC doesn’t ask, but merely assumes they’re all vaping nicotine and reports the results as though they are. So the number of nicotine vapers could be much lower
  • Since 2019, a federal Tobacco 21 law has taken effect, and the FDA has updated its enforcement priority guidance to eliminate flavored pod-based vaping products. Those products (especially JUUL) have been the most popular among teenagers experimenting with vaping, and now they’re federally banned

Vaping isn’t a cessation product, but it does help smokers quit

If flavored vaping products are banned, expect a black market

  • If a flavor ban is implemented, adult-only vape shops, which sell FDA-regulated products, will close and be replaced by a black market. There will be no manufacturing or ingredient standards, and no state or federal age compliance checks
  • E-liquid is easy to make. The ingredients are widely available and mostly unregulated. It will be impossible to control in an underground vaping market
  • How is the state government able to enforce minimum age laws to its satisfaction with respect to alcohol and cannabis sales, but not nicotine products?
  • The effects of a flavor ban will include many adult and youth vapers switching to cigarettes, current smokers prevented from accessing an effective, safer consumer alternative to cigarettes, and legal small businesses shuttered during a recession. It will also protect the tobacco industry—whose products are sold in every convenience store and gas station—and indeed will protect cigarette sales
  • Drug prohibition has never worked. Why will this prohibition model be successful when no other has succeeded?

Resources

Academic sources

Farsalinos K, Russell C, Lagoumintzis G, Poulas K.
Patterns of flavored e-cigarette use among adults vapers in the United States: an internet survey.
Submission to FDA Docket No. FDA-2017-N-6565 for “Regulation of Flavors in Tobacco Products,” 2018.
https://www.dropbox.com/s/b8uwoxay6i2fzb2/Docket%20No.%20FDA-2017-N-6565_FARSALINOS.pdf

The second major survey (2018) of American vapers was submitted as a comment to the FDA, with careful analysis by Dr. Farsalinos. The survey measured the preferences of more than 69,000 adult vapers.

The survey showed that among vapers who had successfully quit smoking, just 7.7% were current users of tobacco-flavored vaping products, but 83.2% used fruit flavors, 72.3% used dessert flavors, 47.7% used candy flavors, and 40.3% used beverage flavors. Many vapers switch between multiple flavors

Russell C, McKeganey N, Dickson T, Nides M.
Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA.
Harm Reduction Journal, 2018.
https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-018-0238-6

The first major survey (2016) of U.S. vapers looked at the flavor preferences of more than 20,000 frequent vapers. (The paper was published in 2018—after the Farsalinos survey—but this survey was completed first.)

CONCLUSION: “Adult frequent e-cigarette users in the USA who have completely switched from smoking cigarettes to using e-cigarettes are increasingly likely to have initiated e-cigarette use with non-tobacco flavors and to have transitioned from tobacco to non-tobacco flavors over time. Restricting access to non-tobacco e-cigarette flavors may discourage smokers from attempting to switch to e-cigarettes.”

Warner KE, Mendez D.
E-cigarettes: Comparing the Possible Risks of Increasing Smoking Initiation with the Potential Benefits of Increasing Smoking Cessation.

Nicotine and Tobacco Research, 2018.
https://academic.oup.com/ntr/article/21/1/41/4956222

Two respected University of Michigan tobacco control researchers modeled the number of life-years gained or lost under a variety of circumstances to assess whether vaping uptake among young people will have a net benefit or a net loss to public health.

“Results: With base-case assumptions, the population gains almost 3.3 million life-years by 2070. If all people who quit smoking by vaping lose 10% of the benefit of quitting smoking, the net life-year gain falls to 2.4 million. Under worst-case assumptions, in which vaping increases smoking initiation by 6% and cessation by 5%, and vaping-induced quitters lose 10% of the health benefits, the population gains over 580000 life-years.

“Conclusion: “Potential life-years gained as a result of vaping-induced smoking cessation are projected to exceed potential life-years lost due to vaping-induced smoking initiation. These results hold over a wide range of plausible parameters.

“Implications: Our analysis strongly suggests that the upside health benefit associated with e-cigarettes, in terms of their potential to increase adult smoking cessation, exceeds their downside risk to health as a result of their possibly increasing the number of youthful smoking initiators. Public messaging and policy should continue to strive to reduce young people’s exposure to all nicotine and tobacco products. But, they should not do so at the expense of limiting such products’ potential to help adult smokers to quit.”

Wang TW, Gentzke AS, Creamer MR, Cullen KA, Holder-Hayes E, Sawdey MD, et al.
Tobacco Product Use and Associated Factors Among Middle and High School Students — United States, 2019.

CDC Morbidity and Mortality Weekly Report (MMWR) Surveillance Summaries – December 6, 2019.
https://www.cdc.gov/mmwr/volumes/68/ss/ss6812a1.htm

TABLE 5. Reasons for e-cigarette use* among middle and high school students who reported ever using e-cigarettes,† by school level, sex, and race/ethnicity.
National Youth Tobacco Survey, United States, 2019. [Table from CDC paper above.]
https://www.cdc.gov/mmwr/volumes/68/ss/ss6812a1.htm#T5_down

CDC analysis of the 2019 National Youth Tobacco Survey shows that middle- and high school students who vape do not do it primarily because of flavors.

The question allowed multiple reasons to be listed, but only 22.3% of youth vapers chose “They are available in flavors, such as mint, candy, fruit, or chocolate” as a reason for vaping. The most popular reason (56.1%) was curiosity, and the second-most cited reason (23.9%) was “friend or family member used them.” Nearly as many (21%) selected harm reduction reasons for vaping—”They are less harmful than other forms of tobacco, such as cigarettes” and “To try to quit using other tobacco products, such as cigarettes”—as selected flavors.

Fairchild A, Healton C, Curran J, Abrams D, Bayer R.
Evidence, alarm, and the debate over e-cigarettes.

Science, 2019.
https://science.sciencemag.org/content/366/6471/1318/tab-article-info

Five well-known public health academics—including three deans of American schools of public health—hash out the pros and cons of vaping, and come down on the side of a well-regulated market that includes flavored products.

“We share strong concern about the large surge in youth vaping (some call it an epidemic and point to studies of a possible but unproven causal gateway into smoking) and we promote harm minimization and management. Yet we suggest that careful analysis of all the data in context indicates that the net benefits of vaped nicotine products outweigh the feared harms to youth.”

“Vaping flavors with or without nicotine may appeal to youth, but flavors also appeal to adult smokers and help them switch. Evidence suggests that the vast majority of smokers who successfully switch completely from smoking combustible products to vaping do so—after weeks, months, or years of dual use—by transitioning from vaping tobacco, or menthol flavored liquids, to other flavors and often to lower nicotine concentrations or even to no nicotine in order to reduce the triggers that remind them of their prior smoking product.”

Glasser AM, Johnson AL, Niaura RS, Abrams DB, Pearson JL.
Youth Vaping and Tobacco Use in Context in the United States: Results from the 2018 National Youth Tobacco Survey.

Nicotine and Tobacco Research, 2020.
https://academic.oup.com/ntr/advance-article-abstract/doi/10.1093/ntr/ntaa010/5701081?redirectedFrom=fulltext

Analysis of 2018 National Youth Tobacco Survey, in which well-known tobacco control researchers break down the eye-popping “past-30-day” use number, and find that very few youth vapers are doing anything but experimenting. Most teen vapers had used other tobacco products already, and of the small number that hadn’t, only a tiny fraction were frequent vapers.

“Implications: Results underscore the importance of including the full context of use patterns. The majority of vapers (60.0%–88.9% by use frequency) were concurrent p30d or ever tobacco users. About 4% of students were tobacco naïve and vaped in the p30d, but few (0.4%) vaped regularly on 20 or more days. Reporting youth vaping data with frequency and tobacco product co-use will give public health decision-makers the best possible information to protect public health.”

Du P, Bascom R, Fan T, Sinharoy A, Yingst J, Mondal P, Foulds J.
Changes in Flavor Preference in a Cohort of Long-Term Electronic Cigarette Users.

Annals of the American Thoracic Society, 2020.
https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201906-472OC

Adult e-cigarette users surveyed by Penn State University in 2012-14 were re-surveyed in 2017 to assess changes in their vaping preferences, including flavor preferences. Most tobacco-, menthol- and mint-flavored users migrated to other flavors.

Results: “Participants’ age averaged 44 ± 12 years; 86% were exclusive e-cigarette users, and 13% reported “poly-use” (i.e., e-cigarette and other tobacco product use). E-cigarette flavor preference migration occurred in all demographic groups: only 36–44% maintained a preference for their original flavor. Preference for tobacco and menthol or mint decreased over time (40% baseline vs. 22% follow-up); preference for fruit remained stable (23% baseline and follow-up), but chocolate/candy or other sweets preference significantly increased (16% baseline vs. 29% follow-up), and other flavors increased slightly. Migration to sweet flavors was more noticeable in younger adults (18–45 yr); exclusive e-cigarette users preferred sweet flavors more commonly than poly-users did (31% vs. 19%). Flavor-associated adverse reactions, mainly respiratory irritations, were reported by 26 (6.9%) participants. Nearly 50% of the participants reported that they would “find a way” to buy their preferred flavor or add flavoring agents themselves if nontobacco flavors were banned.”

Yang Y, Lindblon EN, Salloum RG, Warda KD.
The impact of a comprehensive tobacco product flavor ban in San Francisco among young adults.

Addictive Behaviors Reports, 2020.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186365/

Small survey of tobacco users in San Francisco after that city’s first-in-country 2019 flavor ban. The researchers found that banning flavors does reduce vaping. It also increases cigarette smoking.

“Conclusions: These findings suggest that comprehensive local flavor bans, by themselves, cannot sharply reduce the availability or use of flavored tobacco products among residents. Nevertheless, local bans can still significantly reduce overall e-cigarette use and cigar smoking but may increase cigarette smoking.”

Friedman AS, Xu S.
Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation.

JAMA Network Open, 2020.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2766787

Two Yale researchers analyzed longitudinal survey data from the FDA Population Assessment of Tobacco and Health (PATH) study (collected from 2013 to 2018). The goal was to discover whether uptake of flavored vaping products was associated with smoking initiation in youth or cessation in adults.

Conclusion: “In this study, adults who began vaping nontobacco-flavored e-cigarettes were more likely to quit smoking than those who vaped tobacco flavors. More research is needed to establish the relationship between e-cigarette flavors and smoking and to guide related policy.”

Gravely S, Cummings KM, Hammond D, Lindblom E, Smith DM, Martin N, et al.
The Association of E-cigarette Flavors With Satisfaction, Enjoyment, and Trying to Quit or Stay Abstinent From Smoking Among Regular Adult Vapers From Canada and the United States: Findings From the 2018 ITC Four Country Smoking and Vaping Survey.

Nicotine and Tobacco Research, 2020.
https://academic.oup.com/ntr/article/22/10/1831/5843872

A group of highly respected American, Canadian and Australian tobacco control researchers recently studied flavor preferences among vapers. They found that a majority of frequent vapers prefer non-tobacco flavors.

CONCLUSION: “A majority of regular vapers in Canada and the US use nontobacco flavors. Greater satisfaction and enjoyment with vaping are higher among fruit and candy flavor users. While it does not appear that certain flavors are associated with a greater propensity to attempt to quit smoking among concurrent users, nontobacco flavors are popular among former smokers who are exclusively vaping. Future research should determine the likely impact of flavor bans on those who are vaping to quit smoking or to stay quit.”

Wang TW, Neff LJ, Park-Lee E, Ren C, Cullen KA, King BA.
E-cigarette Use Among Middle and High School Students — United States, 2020
.
CDC Morbidity and Mortality Weekly Report (MMWR), September 18, 2020.
https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6937e1-H.pdf

The 2020 National Youth Tobacco Survey shows that vaping among middle- and high school students dropped 29% since last year—from 27.5% to 19.6%.

Smokers created vaping without any help from the tobacco industry or anti-smoking crusaders, and vapers have the right to keep innovating to help themselves. My goal is to provide clear, honest information about the challenges vaping faces from lawmakers, regulators, and brokers of disinformation. I recently joined the CASAA board, but my opinions aren’t necessarily CASAA’s, and vice versa. You can find me on Twitter @whycherrywhy
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