Nearly all e-cigarette flavorings can no longer be sold in convenience stores or any other brick-and-mortar store except adult-only vaping shops, according to new regulations announced by FDA Commissioner Scott Gottlieb this week. Only mint, menthol and tobacco flavorings can still be sold alongside unflavored e-cigarettes and traditional cigarettes in food and convenience stores, and any flavorings sold online must have stringent age verification requirements that are still being developed, as I reported here yesterday.
The new measures, along with restrictions on flavored cigars and continuing steps to ban menthol cigarettes, are part of Gottlieb’s stated commitment to address rapidly increasing rates of teen vaping, or e-cigarette use. But adults who have successfully used e-cigarettes to quit smoking worry the restrictions will make it harder for others to make the switch from traditional to electronic cigarettes and reduce harm to their health caused by nicotine dependence.
The research, both on vaping as a “gateway” to smoking and on e-cigarettes as an effective smoking cessation strategy, is growing but still far from definitive in either case. So in the midst of strengthening but still inadequate research, and the tension between protecting kids and helping adults quit the number one cause of cancer and other chronic diseases in the US, what do public health experts think about the FDA’s moves?
Understandably, most public health experts have been cautious about taking too strong a stance, recognizing the competing priorities and the ambiguities in the data. Some, however, such Stanton A. Glantz, PhD, director of the Center for Tobacco Research Control & Education at the University of California San Francisco, are vocal opponents of e-cigarettes and their potential as smoking cessation tools. He is among the voices who have criticized Gottlieb for being slow to act on rising teen vaping rates and risks of e-cigarettes.
Others see potential benefits and drawbacks to the FDA’s announcement. I communicated with two public researchers who generally believe in the value of vaping as a harm reduction alternative to smoking but don’t view e-cigarettes as harmless.
“I don’t envy FDA,” Kenneth Warner, professor emeritus of the University of Michigan School of Public Health, told me in an email. “Finding the ‘sweet spot’ of e-cigarette regulation is tough. Most anything they do to discourage youth vaping will risk reducing the usefulness of vaping as smoking cessation aid.”
Warner said it’s impossible to tell right now whether the new FDA measures specific to e-cigarettes will affect teen vaping rates, but his best educated guess is that they will have “a favorable impact,” though how much is anyone’s guess.
“Because kids are attracted to flavors (especially fruit flavors) and because the policy will reduce (not eliminate) their access to flavored products, it should reduce the attraction of vaping somewhat,” Warner said, but he then acknowledged the potential negative consequences for current adult smokers.
“E-cigarettes are now the number one aid to quitting among smokers—used more frequently than the FDA-approved nicotine replacement pharmaceuticals,” Warner said. He said reduced switching among adults from vaping to smoking cannot be an entirely “unintended” effect because Gottlieb himself acknowledged “the need to ‘slow the off-ramp’ from smoking [adults switching] in order to decrease ‘the on ramp’” [kids starting to smoke after vaping].
FDA Is Not Doing Enough About Smoking
Michael Siegel, MD, MPH, a professor of community health sciences at the Boston University School of Public Health, goes even further, calling out the FDA for perceived hypocrisy. Though he acknowledges that restricting e-cigarette sales to adult-only stores should help reduce youth access to them, he points to the far greater threat of traditional combustible cigarettes—still sold in ordinary stores—to teens’ health. An estimated 8% of high school students smoke traditional cigarettes, according to the CDC, and more than 3,000 adolescents try their first cigarette every day, he said.
“There is absolutely no valid public health rationale behind prohibiting the sale of most e-cigarettes, but allowing the real toxic cigarettes to remain on the shelves,” Siegel told me. “Although Juul use among youth clearly needs to be addressed, we have to be careful not to completely lose our sense of perspective. Smoking still kills more than 1,000 people every day. There is no evidence that vaping kills anyone.”
As a scientist who has long vocally supported the use of e-cigarettes to quit smoking, Siegel worries about a net negative impact on public health from the FDA’s actions.
“It is going to force many ex-smokers who stay smoke-free using e-cigarettes to return to smoking when their favored products are no longer available on retail store shelves,” he said. “Some will find alternate sources or will switch brands, but many will probably find it easier to must return to smoking.”
The decision to ban menthol cigarettes, however, appears much more clear-cut, with seemingly universal support from public health experts, especially considering the increased burden of nicotine addiction among black teens, menthol cigarettes’ biggest customer. Warner also considers it sensible to keep mint and menthol flavors available in e-cigarettes.
“If e-cigarettes are to have any utility in helping adults to quit smoking, they have to be consumer-attractive products,” Warner said. “Maintaining mint/menthol seems like a bare minimum,” though he noted other flavorings will still be available in vaping shops and online.
Experts also support strict age verification for online sales of e-cigarette products. It’s the question of their sales in ordinary stores, particularly in rural areas that may not have vaping shops, that becomes problematic.
Competing Priorities: Pay the Price Now or Later?
One of the challenges in balancing smokers’ right to have accessible flavored e-cigarettes as a cessation aid versus stopping a wave of new nicotine dependence in youth is the long delay in health effects of the latter compared to the former.
“Kids who might become addicted to nicotine by vaping and then become regular vapers or—much worse—smokers, are not going to begin to experience the most serious chronic disease consequences of their behaviors for 25-30 years,” Warner said. “In contrast, adult smokers 40 and older are very much at risk of those diseases now. Further, quitting smoking has immediate health benefits and can reduce the enormity of the toll of smoking right away.”
About a half million Americans die from smoking every year, Warner said, which translates to one death caused by smoking for every four or five deaths from other causes.
“We have to keep our eye on the prize: eliminating the use of combusted tobacco,” Warner said. “Smokers need to understand that it is not the nicotine per se that kills smokers. Rather it is the scores of serious toxins in the 7,000 chemicals in cigarette smoke that is responsible for all those deaths.”
The best thing any smoker can do for their health is to quit smoking, Warner said. But nicotine is one of the most addictive substances in the world. Contrary to what many still believe, quitting smoking nearly always requires more than simple willpower. It requires overcoming deeply tread physical and chemical pathways in the brain, and for an indeterminate number of smokers, vaping satisfies the same needs and cravings as smoking without as many of those 7,000 chemicals.
What Else Can Be Done to Reduce Teen Vaping?
The moves announced by Gottlieb aren’t the only options for reducing teen vaping, public health experts also say, and some of the measures he is taking are long overdue. Eliminating menthol cigarettes, for example, should have happened long ago, Warner says.
“The agency needs to focus on risk-proportionate regulation, focusing on discouraging use of the most dangerous tobacco products, those that are combusted [traditional],” Warner said. “The single most important [policy] would be establishing age 21 as the minimum age for purchase of e-cigarettes (and, especially, for cigarettes and other tobacco products).”
He also suggested much more punitive consequences for stores that sell to underage people, such as costlier fines for first offense and temporary or permanent loss of license for subsequent offenses.
Siegel described two other evidence-based approaches to reducing teen vaping:
“First is raising the price of e-cigarettes by imposing excise taxes on these products,” he said, though adding that “there should be an even higher tax imposed on tobacco cigarettes, so that the price advantage for e-cigarettes is maintained.”
The other is the same strategy that successfully helped turn the tide on smoking by de-glamourizing it: “run media campaigns to try to change social norms regarding vaping,” Siegel said. “I would argue that Juuling is what absolutely needs to be addressed, as this is the real threat in terms of youth addiction to nicotine, not other forms of vaping.”
Neither Dr. Warner nor Dr. Siegel receives funding from tobacco or e-cigarette companies or trade groups.