FDA Commissioner Scott Gottlieb says he still believes that e-cigarettes offer "a tremendous public health opportunity" to reduce the harm caused by smoking but felt compelled to impose restrictions on them because of a surprising surge in underage vaping. Had the FDA not acted, he said in an interview with Reason today, political pressure could have led Congress to intervene, presenting "an existential threat" to the vaping industry.
"We were shocked when we saw the data," Gottlieb said, referring to results from the National Youth Tobacco Survey showing a sharp increase in e-cigarette use by high school and middle school students between 2017 and 2018. "It doesn't matter what you think or what I think. We're going to have congressional legislation that's going to foreclose and supersede anything we can do. We're at 20 percent of high school kids using vaping products, based on the data. You have another year of 50 percent growth on top of that, we'll be at levels that will be intolerable to the general public. The political consensus tilts pretty heavily in favor of restrictions on these things. I worry about the existential threat that comes with continued growth in youth use if we do believe that this is an opportunity to really shift the trajectory of smoking-related disease and get more adults off of combustible tobacco."
Gottlieb acknowledged that the new FDA rules, which ban the sale of most e-cigarette flavors in locations open to minors, will make it harder for adult smokers to get the e-cigarettes they prefer, which might make it less likely that they will switch to vaping or more likely that they will switch back to smoking. "I'm accepting the fact that steps that we take to provide additional restrictions on access to these products [by] kids are going to have an impact on adult access," he said. "We tried to strike a balance. There is no free lunch here. Anything we do to try to foreclose the rampant use by kids is going to also have some impact on adult access." That seems like an overstatement, since better enforcement of the minimum purchase age could reduce access by minors without creating significant barriers for adults.
In addition to his concern about possible congressional action, Gottlieb said he is personally worried by the increase in underage vaping and has a legal mandate as head of the FDA to reduce it. "I'm in a position where we simply have to respond to the youth use," he said.
Gottlieb has repeatedly said he worries that some teenagers who otherwise never would have tried tobacco will start smoking after being introduced to nicotine via e-cigarettes. Today he said proprietary industry survey data he has seen indicate that teenagers who view smoking with disgust do not have the same reaction to vaping. "We've been relatively successful in this country at stigmatizing traditional cigarette smoking among kids," he said. "That stigma doesn't attach to e-cigarettes."
At the same time, Gottlieb acknowledged that some teenagers who vape might otherwise be smoking, a substitution effect that seems plausible given that the surge in e-cigarette use by teenagers has coincided with a continued decline in smoking. "It's probable," he said. "It's implausible for me to say that there aren't kids out there who are using e-cigarettes instead of combustible tobacco and probably, if they never had this opportunity, would have used combustible tobacco." But he added that it's hard for the FDA to consider that as "a public health justification" when "our mandate is that no child should be using a tobacco product." That suggests the FDA's mission to reduce underage vaping may conflict with the public health goal of minimizing morbidity and mortality.
Yesterday Gottlieb said the FDA would consider additional restrictions on e-cigarettes if the upward trend in underage consumption is not reversed. But today he said he is determined to keep e-cigarettes on the market as a harm-reducing alternative for smokers. "I think there's a tremendous public health opportunity," he said. "These things do have risks associated with them…but certainly not any risks on the same level as combustible products….It wouldn't be my intent to ever impose a complete ban on e-cigarettes. I've said repeatedly that we see a public health opportunity here, and I think it would be an unfortunate day if there ever was a ban imposed on e-cigarettes. I wouldn't foreclose the possibility that Congress could contemplate more restrictive measures in a world where youth trends continue at the same rate they are right now, and I do worry about that."