The 'Epidemic' of Underage Vaping Does Not Justify the FDA's E-Cigarette Restrictions
The health burden on adults who continue smoking far outweighs the risks for teenagers who vape.
Today Food and Drug Commissioner Scott Gottlieb, who has been talking for months about an "epidemic" of underage vaping, finally released the survey data to which he was referring, along with his agency's plan to reverse the trends that trouble him. As expected, the plan includes a ban on e-cigarette flavors other than menthol, mint, and tobacco in stores that admit minors, along with a complete ban on menthol cigarettes and flavored cigars.
In the National Youth Tobacco Survey (NYTS), which is conducted by the U.S. Centers for Disease Control and Prevention (CDC), the share of high school students who reported using e-cigarettes in the previous month rose from 11.7 percent in 2017 to 20.8 percent in 2018, a 78 percent increase. The share of those e-cigarette users who reported vaping on 20 or more days in the previous month rose from 20 percent to 27.7 percent, a 39 percent increase. In other words, 5.8 percent of high school students, about 845,000 teenagers, could be considered frequent vapers, up from 2.3 percent (346,000) last year.
The share of middle school students who reported using e-cigarettes in the previous month rose from 3.3 percent to 4.9 percent, an increase of 48 percent. The share of those e-cigarette users who reported vaping on 20 or more days in the previous month rose from 12.9 percent to 16.2 percent, an increase that was not statistically significant. In other words, 0.8 percent of middle school students, about 92,000 kids, are frequent vapers.
A large majority of adolescent vapers presumably are using Juul e-cigarettes, which account for more than 70 percent of the market. The 2017 NYTS questionnaire did not mention Juul as an example of an e-cigarette, an omission that some critics said may have led to an underestimate of vaping that year. The CDC has not posted the 2018 NYTS questionnaire yet. But assuming that the CDC added Juul to its list of e-cigarette brands, that change may account for some of the increase in reported use.
Leaving that point aside, do those 937,000 or so frequent vapers constitute an "epidemic"? Yes, in the sense that their numbers have risen sharply. But to the extent that the term implies disease, disability, and death, no. E-cigarettes, which do not contain tobacco and do not burn anything, are far less hazardous than the combustible kind—on the order of 95 percent less hazardous. Smoking rates among teenagers have continued to decline as e-cigarette use has surged, and that may be more than a coincidence. To the extent that teenagers who would otherwise be smoking are vaping instead, that should count as a public health victory.
Gottlieb worries that "some proportion" of adolescent vapers who "otherwise might never have initiated on tobacco" will "become long-term users of combustible tobacco." But while teenagers who try e-cigarettes are more likely than teenagers who don't to later try the conventional kind, that does not mean vaping causes smoking. In a world without e-cigarettes, those teenagers might eventually have started smoking anyway. Maybe some of them would not have tried tobacco had they not been introduced to nicotine via e-cigarettes. But there is no reason to believe that group is large enough to justify Gottlieb's fear that "all the great gains that we've made in this country [in] reducing smoking rates…will be reversed or lost if we can't address the youth use of e-cigarettes."
Cigarette smoking was more common than vaping among high school students until 2014. The previous year, 12.7 percent of high school students reported past-month cigarette smoking in the NYTS, nearly three times the share who reported vaping. This year 20.8 percent reported past-month vaping, more than two and a half times the percentage who reported past-month cigarette smoking in last year's survey. (The CDC has not reported the smoking numbers for 2018 yet.) If you are concerned about the health hazards associated with nicotine consumption, as opposed to nicotine consumption itself, the current situation is clearly preferable to the situation five years ago.
In short, I think Gottlieb is overreacting to a problem that is not nearly as dire as he makes it out to be. Even allowing that underage vaping is a legitimate concern that should be addressed, the restrictions that the Food and Drug Administration is imposing, which will make e-cigarettes less accessible and less appealing to adult smokers who might be interested in switching to vaping (or have already switched), impose a cost in terms of smoking-related disease and death that Gottlieb seems reluctant to acknowledge. He talks about putting "speed bumps" in the way of smokers who might want to switch (or narrowing the "off-ramp" for them) as a necessary cost of reducing underage vaping. But leaving aside the ethics of that tradeoff, I can't see how it makes sense from a public health perspective.
On one hand, we can be pretty confident that some adults will continue to smoke or return to smoking as a result of the FDA's restrictions and will therefore face more disease and shorter lives. On the other hand, Gottlieb worries that some teenagers who move from vaping to smoking otherwise never would have tried tobacco and that they will eventually become regular, long-term smokers, facing more disease and shorter lives than they would have if e-cigarettes had never been invented. He hopes some of that smoking-related health cost can be averted by restricting e-cigarette flavors. If he is trying to minimize morbidity and mortality, Gottlieb must think that remote and speculative public health benefit outweighs the imminent and all but certain public health cost. That conclusion seems highly implausible to me.
Gottlieb says the FDA is striking "a careful public health balance between our imperative to enable the opportunities to transition to non-combustible products to be available for adults" and "our solemn mandate to make nicotine products less accessible and less appealing to children." Yet he also says he will take "whatever steps I must" to prevent nicotine addiction among teenagers. That is not striking a balance, since it could justify removing e-cigarettes from the market entirely, which would prevent teenagers from using them but also prevent smokers from switching to them, resulting in more smoking-related morbidity and mortality.
Total prohibition is the approach the FDA is taking with menthol cigarettes and flavored cigars, which it says are so appealing to teenagers that they cannot be tolerated at all, even in age-restricted outlets. Those bans, which will take longer to implement than the restrictions on e-cigarettes, are more extreme, but they make more sense from a public health perspective, which attaches no value to pleasure or individual choice. The e-cigarette rules, by contrast, manage to limit consumer choice while also undermining public health.