Commentary on Current Tobacco-Related Policies: Youth, E-Cigarettes and Flavored Nicotine Products

The following is a message from Erika Trapl, PhD, Co-Leader of the Cancer Population, Control & Population Research Program at the Case Comprehensive Cancer Center.

Earlier this month, the American Cancer Society reported the largest single-year decline in cancer deaths at 2.2% and attributed this decline to improvements related to lung cancer and melanoma. Lung cancer deaths for 2020 are estimated to reach roughly 136,000, with an estimated 80-90% of those deaths being attributed to smoking, a known modifiable lifestyle risk factor. Notably, nearly 9 out of 10 smokers begin smoking before the age of 18, and adolescents are more susceptible to the addicting effects of nicotine. It is an accepted premise within tobacco control that policy approaches to prevent youth use improve tobacco-related morbidity and mortality. To address youth access, President Donald Trump signed legislation on December 20, 2019, increasing the minimum legal age to purchase tobacco products, including cigarettes, e-cigarettes, and cigars, to 21 years. While this is seen as a win among tobacco control advocates, flavored tobacco products are still seen as a substantial threat to entice youth users.

Electronic cigarettes emerged in the US market in 2006 with the appeal of being a potential alternative to the health risks posed by cigarettes. However, by 2018, the Centers for Disease Control and Prevention, the US Surgeon General and other public health advocates noted significant rates of e-cigarette use among young adolescents. A single e-cigarette manufacturer, JUUL, held up to three-quarters of the market share and was found to be a preferred product of youth users, coining the term “JUULing”.  The initial outbreak of e-cigarette or vaping associated lung injuries (EVALI) escalated discussions on policy to curb adolescent use of e-cigarettes, culminating in statements made by President Trump in September 2019 that he would move to ban flavored e-cigarettes to discourage youth use. President Trump ultimately backed away from this broad endorsement of a flavored e-cigarette ban and, in its place, the US Food and Drug Administration announced on January 2, 2020, that companies producing flavored cartridge-based e-cigarettes (excluding tobacco or menthol flavors) would risk FDA enforcement action.

On its surface, it would appear that this policy has addressed the youth e-cigarette use problem. If a majority of youth report preference of a fruit-flavored JUUL, the presumed logic of the policy is that elimination of the fruit-flavored JUUL (a cartridge-based e-cigarette) will drive down the rates of youth use. This logic is much too simplistic for the complexity of human choice and the tobacco product market. The e-cigarette market alone includes cartridge-based products like JUUL as well as other types of e-cigarettes, such as refillable e-cigarettes or vapes such as the Suorin Air or SMOK, the second most preferred devices among adolescents, and disposable flavored e-cigarettes, such as the Puff Bar. The refillable devices and disposable devices are exempt from the current flavored e-cigarette legislation. So, while appealing flavors of cartridges for JUUL and other devices have been removed from the market, this has simply opened the market to other companies who are finding ways to capitalize on this loophole to be able to continue to market flavored nicotine products to youth.

And while this January 2, 2020, policy addresses some flavored e-cigarette products, there remains no movement on eliminating menthol cigarettes or flavored cigarillos, tobacco products known to be disproportionately marketed to African Americans and low-income communities.

The tobacco industry has been concerned since the 1970s with "replacement smokers." With the advent of new devices that shun the smoker moniker in place of more chic terms such as “vaping”, a “replacement smoker” becomes a “replacement nicotine addict.”

While policy change can have sweeping impact on a population, it oftentimes can create unintended consequences. The explicit message of this policy is that flavored cartridge-based e-cigarettes are a threat; the implicit message may be that all of the other products aren’t that bad. The potential impact of this implicit message among today’s youth continues to feed the pipeline of “replacement nicotine addicts” and slow, or worse, reverse, the downward trend of smoking-related lung cancer deaths.