Declines in Adolescent Smoking Accelerated As Vaping Rose, Suggesting the FDA's Campaign Is Fatally Misguided
Even among teenagers, efforts to prevent underage e-cigarette use may do more harm than good.
In the midst of a federal campaign against underage vaping, a new study finds that downward trends in smoking among teenagers and young adults accelerated as e-cigarette use rose. The findings, based on data from five national surveys, suggest that the official panic about the "epidemic" of e-cigarette use by minors, which has led to restrictions that affect adult access to vaping products and government-sponsored propaganda that exaggerates their hazards, is fatally misguided.
"A long-term decline in smoking prevalence among US youth accelerated after 2013 when vaping became more widespread," Georgetown public health researcher David T. Levy and his co-authors report in the journal Tobacco Control. "These findings were also observed for US young adults, especially those ages 18–21. We also found that the decline in more established smoking, as measured by daily smoking, smoking half pack a day or having smoked at least 100 cigarettes and currently smoking some days or every day, markedly accelerated when vaping increased." While "it is premature to conclude that the observed increased rate of decline in smoking is due to vaping diverting youth from smoking," Levy et al. say, "it is a plausible explanation."
What about the concern that vaping is having the opposite effect, leading to smoking by teenagers who otherwise never would have used tobacco? As Levy and his colleagues note, the fact that teenagers who try vaping are more likely than teenagers who don't to subsequently try smoking does not necessarily mean that vaping is a "catalyst" for smoking. "The joint susceptibility hypothesis, also known as the common liability hypothesis, suggests that vaping is more likely to occur within a population with a propensity to use cigarettes due to shared common risk factors," they write. But "even if there is some validity to the catalyst hypothesis, its impact is dwarfed by other factors."
Since vaping is far less dangerous than smoking (at least 95 percent less dangerous, according to an estimate endorsed by Public Health England), the balance between these two possible effects is crucial in evaluating the public health impact of underage vaping and efforts to prevent it. "The divergent findings between individual-level cohort studies, which show a possible causal relationship between vaping and smoking, and those of population trends showing a negative association between vaping and smoking are not necessarily inconsistent," Levy et al. note. "Rather, it is possible that trying e-cigarettes is causally related to smoking for some youth, but the aggregate effect of this relationship at the population level may be small enough that its effects are swamped by other factors that influence smoking behaviour." The substitution of vaping for smoking is one of those factors.
This study did not include data for this year, when the National Youth Tobacco Survey (NYTS) found a sharp increase in vaping among teenagers, who mostly use Juul e-cigarettes, which offer better nicotine delivery than many competing products and might therefore be more addictive. But Levy says that development won't necessarily change the main thrust of his team's conclusions.
"The data that I have seen so far indicates that vaping has increased, but little has changed in terms of smoking rates," Levy told Gizmodo. "Much of the vaping is low-intensity use (less than 5 days in the last month), but some is more regular use as indicative of addiction. It is much too soon to say the combined effects, and I expect that we probably will not even have a good indication of the effects for at least another year." The 2018 NYTS results for smoking, unlike the results for vaping, have not been published yet, but they reportedly include an increase in past-month cigarette smoking among high school students from 7.6 percent to 8.1 percent, a change that was not statistically significant.
Notably, Food and Drug Commissioner Scott Gottlieb says his agency did not consider the inverse relationship between smoking and vaping among teenagers when it decided to ban almost all e-cigarette flavors from stores that admit minors, which account for the vast majority of outlets selling e-cigarettes. "I'm sure that there's a component in there of kids who are using e-cigarettes in lieu of combustible tobacco and otherwise would have used the combustible tobacco," Gottlieb told me in an interview last Friday. "But from our standpoint, that's a hard justification for us to use as a public health justification when our mandate is no child should be using a tobacco product."
In other words, the FDA is bound to do everything it can to curtail underage vaping, even if that means more smoking-related disease and death over the long term. When the goal of preventing e-cigarette use by minors conflicts with the mission of minimizing morbidity and mortality, public health loses.
The flavor restrictions are not the only way the FDA is undermining public health. Consider "The Real Cost" Youth E-Cigarette Prevention Campaign, which the agency proudly unveiled in September. "There's an epidemic spreading," says one of the TV spots, which shows worm-like parasites wriggling and spreading under the skin of young vapers and invading their brains. "Scientists say it can change your brain. It can release dangerous chemicals like formaldehyde into your bloodstream. It can expose your lungs to acrolein, which can cause irreversible damage. It's not a parasite, not a virus, not an infection. It's vaping."
A recent analysis of the aerosol generated by eight Juul pod flavors, commissioned by Juul Labs, found no acrolein and no quantifiable amount of formaldehyde. The tests also looked for 20 other potentially harmful constituents, and the results were similar: Either the constituent was not detected or the level was too low to quantify. Since Juul is by far the most popular e-cigarette in the U.S. market and the brand about which the FDA has expressed the most concern vis-á-vis underage consumption, the agency's warnings about acrolein and formaldehyde are more than a little misleading. In any case, the ad's over-the-top brain parasite imagery certainly leaves a false impression of the health risks posed by e-cigarettes.
The intent of these ads, I'm sure, is to convince teenagers that vaping is not as harmless as they might think it is. The FDA notes with alarm that, according to the Monitoring the Future survey, "about 80 percent of youth do not see great risk of harm from regular use of e-cigarettes." But regular use of e-cigarettes, as far as we can tell, doesn't pose a "great risk of harm," certainly not when compared to regular use of combustible cigarettes. If teenagers erroneously conclude from the FDA's icky, scaremongering ads that vaping is just as dangerous as smoking and maybe even more dangerous, they may be more inclined to smoke rather than vape, even though smoking is in fact much more dangerous than vaping.
Furthermore, as Competitive Enterprise Institute policy analyst Michelle Minton notes, teenagers are not the only ones who see these ads. The share of American adults who incorrectly believe that vaping is just as hazardous as smoking is already on the rise, thanks in no small part to overwrought, misleading, and sometimes flat-out inaccurate warnings from activists and public health officials. In one survey, the share of adults who incorrectly said vaping is as harmful as or more harmful than smoking tripled between 2012 and 2015, from 13 percent to 40 percent. Propaganda like the FDA's can only encourage that trend, making it less likely that smokers will switch to vaping and more likely that those who have switched will resume smoking.
On top of that discouragement, the FDA is now making it harder for adult smokers to get the e-cigarette flavors they prefer. Products that were once available in thousands of supermarkets and convenience stores will now be available only from tobacconists, vape shops, or online outlets that have age verification. At the margin, the added inconvenience is bound to deter some smokers from switching and lead some who already have quit to return to the cigarettes they used to smoke, which remain as readily available as they were before. Gottlieb presents that cost, which is unambiguously bad for public health, as a necessary tradeoff for reducing underage vaping. But if reducing underage vaping results in more smoking by teenagers, it is hard to see any way in which the tradeoff can be justified.
[This post has been updated with information about potentially harmful constituents in Juul aerosol.]